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Traumatic Spinal Cord Injury
Marnie Quick, RN, MSN, CNRN
A. Pathophysiology/etiologyNormal spinal cord as it relates to SCI Spinal cord begins at
the foramen magnum in the cranium
Cord ends at the L1-L2 vertebra level
Spinal nerves continue to the last sacral vertebra
Normal protection of spinal cord from injury: Bones- vertebral column
Protection of spinal cord from injury Disc between
vertebra Internal and external
ligaments
Protection of Spinal Cord from Injury Meninges CSF in subarachnoid
space allow for movement within spinal canal
Normal spinal cord as relates SCI: Autonomic Nervous System & Cord ANS can be affected
by SCI Sympathetic chains
on both sides of the spinal column
Parasympathic nervous system is the cranial-sacral branch
Normal spinal cord: White tracks send messages to and from the brain Pyramidal- Voluntary
movements Posterior column
(Dorsal)- touch, proprioception, and vibration sense
Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord)
Normal spinal cord: Reflex ark in center of the spinal cord Where sensory and
motor nerves arise from cord
Sensory fibers enter posterior
Motor fibers leave from anterior
Once outside cord join form spinal nerve
Normal spinal cord: Dermatones Skin innervated by
sensory spinal nerves
Normal spinal cord: Spinal cord level When referring to spinal
cord level, it the reflex arc level not the vertebral or bone level.
Note that the thoracic, lumbar & sacral reflex arcs are higher than were the spinal nerves actually leave through the opening of there respective vertebral bone
Etiology of traumatic spinal cord injury MVA- most common cause Other: falls, violence, sport injuries SCI typically occurs from indirect injury
from vertebral bones compressing cord SCI frequently occur with head injuries Cord injury may be caused by direct
trauma from knives, bullets, etc
Hemorrhage and edema occur in the cord post injury, causing more damage to cord
Extension of the cord injury from cord edema can occur over the first few days- watch the phrenic nerve!
Initially SCI experience spinal shock- depression of all cord & ANS function below injury. Lasts from few min to wks
Patho: Forces resulting in SCI Flexion (hyperflexion) Most common
because of natural protection position.
Generally cause neck to be unstable because stretching of ligaments
Patho/forces: Hyperextention Caused by chin
hitting a surface area, such as dashboard or bathtub
Usually causes central cord syndrome symptoms
Patho/forces: Compression Caused by force from
above, as hit on head Or from below as
landing on butt Usually affects the
lumbar region
Classification of spinal cord injury:1. Complete (transection) spinal cord inj After spinal shock: Motor deficits-
spastic paralysis below level of injury
Sensory- loss of all sensation perception
Autonomic deficits- vasomotor failure and spastic bladder
2. Incomplete spinal cord injury- what white tracks are working after spinal shock is over?
Incomplete spinal cord injury: Central cord Syndrome Injury to the center of
the cord by edema and hemorrhage
Weakness in both upper extremities- legs are spared
Varied loss of sensation
Incomplete spinal cord injury: Anterior Cord Syndrome Injury to anterior cord Loss of voluntary
motor (Pyramidal track) below
Loss of pain and temperature perception
Retains posterior column function
Incomplete spinal cord injury: Brown-Sequard Syndrome Hemisection of cord Ipsilateral paralysis Ipsilateral superficial
sensation, vibration and proprioception loss
Contralateral loss of pain and temperature perception
Incomplete cord injury: Horner’s Syndrome Injury to the cervical
sympathetic nerves Ipsilateral ptosis of
the eyelid Constriction of the
pupil (miosis) Facial anhidrosis
Horner’s Syndrome
Classification of spinal cord injury- 3. by level of spinal cord injury In addition to complete or
incomplete- Spinal cord injuries are
also described by the level of the injury– the cord segment or dermatome level
Such as C6; L4 spinal cord injury
B. Common Manifestations and Complications by body systems Skin: pressure ulcers Neuro: pain; sensory loss; upper/lower
motor deficits; autonomic dysreflexia Cardio: dysrhythmias; spinal shock; loss of
sympathetic nervous system control over blood vessels (vasomotor control)- dec venous return, orthostatic hypotension, poikilothermic (takes on temp of room)
Body system cont. Resp: decrease chest expansion; cough reflex &
vital capacicty; diaphragm function-phrenic nerve GI: stress ulcers; paralytic ileus; bowel-
impaction & incontinence GU: upper/lower motor bladder; impotence;
sexual dysfunction Musculoskeletal: joint contractures; bone
demineralization; osteoporosis; muscle spasms; muscle atrophy; pathologic fractures; para/tetraplegia
Common manifestations/complications:Spinal shock- depression of cord & ANS Motor loss- flaccid paralysis below level injury Sensory loss- loss touch, pressure, temperature
pain and proprioception perception below injury Sympathetic NS loss results in parasympathic
dominance with vasomotor failure- Neurogenic shock, bradycardia, orthostatic
hypotension and poor temperature control (poikilothermic- takes on temp of environment)
Parasympathetic NS loss of the S 2,3,4 reflex arks results in flaccid bladder
Lasts from few minutes to weeks How do you know spinal shock is over? Clonus is one of the
first signs Hyperreflexia of foot Test by flexing leg at
knee & quickly dorsiflex the foot
Rhythmic oscillations of foot against hand
Common manifestation/complications: Upper and Lower Motor Deficits Upper motor deficits
results in spastic paralysis
Lower motor deficits are flaccid paralysis and muscle atrophy
Common manifestation/complications: Terms used to describe motor deficits Prefix: para- meaning two extremities;
tetra- or quadra- all four extremities Suffix –paresis meaning weakness; -plegia
meaning paralysis Quadraparesis means what?
Common manifestations/complications: Functional Goals for Spinal Cord Injury C1-3 usually fatal- loss phrenic innervation;
ventilator dependent; no B/B control; spastic paralysis; electric w/c with chin/mouth control
C6- weak grasp; has shoulder/biceps to transfer & push w/c; no bowel/bladder control. Considered level of independence
T1-6- full use of upper extremity; transfer; drive car with hand controls and do ADL’s; no bowel/bladder control
C. Therapeutic Interventions for SCI: Diagnostic tests
X-ray of spinal column
CT/MRI Blood gases
Therapeutic interventions: Emergency care at scene, ER & ICU Transport with
cervical collar Assess ABC’s; O2;
tracheotomy/vent IV for life line NG to suction Foley
Therapeutic interventions: Medications IV metylprednisone (Solu-Medrol) within 8 hrs to
decrease cord edema Medications to control or to prevent
complications SCI and immobility: Vasopressors treat bradycardia or hypotension Histamine H2 blockers to prevent stress ulcers Anticoagulants Stool softeners Antispastomotics
Therapeutic interventions: Stabilization/immobilization Traction with
Gardner-Wells tongs
Traction
External traction Halo device For patients who do
not have motor deficits
Experience less immobility complications
Therapeutic interventions: Casts; splints; collars; braces
Therapeutic interventions: Special Beds for SCI To decrease
immobility complications
Rotorest is a common one used- rotates 23 hrs a day
Therapeutic interventions: Surgery for SCI Manipulation to
correct dislocation or to unlock vertebrae
Decompression laminectomy
Spinal fusion Wiring or rods to
hold vertebrae together
D. Nursing Assessment specific to SCI Health History Description of how and when injury occurred Other illnesses or disease processes Ability to move, breath, and associated injury
such as a head injury, fractures
Nursing Assessment specific SCI Physical exam LOC and pupils- may have indirect SCI
from head injury Respiratory status- phrenic nerve
(diaphragm) and intercostals; lung sounds Vital signs Motor Sensory Bowel and bladder function
Nursing assessment: Motor assessment Movement, strength
and symmetry Hand grips Flex and extend arm
at elbow- with and without resistance
Nursing assessment: Motor assessment lower extremity Flex and extend leg at
knee with and without resistance
Planter and dorsi flexion of foot
Nursing assessment: Motor assessment- Clonus Clonus- hyperreflexia Flex knee and quickly
dorsiflex the foot with your hand
If has return of reflex function the foot will have repetitive movements against you hand
Spinal shock is over
Nursing assessment: Sensory assessment With the sharp and
dull ends of a paperclip have the individual, with their eyes closed identify
Use the dermatome as reference to identify level
C6 thumb; T4 nipple; T10 naval
E. Pertinent nursing problems/interventions 1. Impaired physical mobility
Log roll as a single unit; provide assistance as needed to keep alignment; teach patient
Care traction, collars, splints, braces, assistive devices for ADL’s
Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)
Spastic paralysis- assess for clonus Prevent spasms by avoiding; sudden movements or
jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue
Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmotic medications
Assess skin break down thrombophlebitis; remove TED hose at least every shift
Prevent/treat orthostatic hypotension Abdominal binder, calf compressors, TED hose when
individual gets up Assess BP, especially when rising Assist Physical Therapy with tilt table as individual
gradually gets use to being in an upright position
Use of transfer board
2. Impaired gas exchange Phrenic nerve (C3-5) controls the diaphragm
bilaterally. If nerve is nonfunctioning then individual is ventilator dependent.
Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing
Phrenic nerve
Monitor vital capacity, respiratory effort, ABG’s, O2 saturation
Assess for signs of impending extension of SCI up cord to phrenic nerve level (C3-5)
Quad cough (assistive cough) as needed
3. Ineffective breathing patterns Assess respiratory rate, rhythm, depth, and breath
sounds Assess need for ventilatory assistance,
tracheotomy, ventilator
4. Autonomic Dysreflexia SCI above T6 Results in loss of normal
compensatory mechanisms when sympathetic nervous system is stimulated
Life threatening- if goes unchecked BP can result in cerebral hemorrhage
Autonomic Dysreflexia- assess
Vasodilatation
symptoms above SCI Vasoconstriction
symptoms below SCI The cause of SNS
stimulation
Autonomic Dysreflexia- treatment Elevate head of bed- causes orthostatic
hypotension Identify cause/alleviate- if full bladder- cath; if
skin- remove pressure, if full bowel- empty, etc Remove support hose/abdominal binder Monitor blood pressure- can get > 300 S Give PRN medication to lower BP If above not effective– call physician
5. Altered urinary elimination/constipation Bladder
Bladder reflex ark- sacral 2,3,4 Flaccid bladder (lower motor neuron lesion) has
no reflex from S2,3,4. Have automatic empting of bladder. Urine fills the bladder and dribbles out. Need foley or freq intermittent self catherization
Spastic bladder (upper motor neuron lesion) has reflex ark, but no connection to or from brain. Reflex fires at will. Bladder training- trigger points to stimulate empting; self catherization
Upper/lower motor bladder
Bladder functioning: http://www.rnceus.com/course_frame.asp?
exam_id=56&directory=uro
Use bladder scan to see amount of urine in bladder
Goal- residual <100ml/20% bladder capacity Some individuals may need suprapubic catheter Assess effectiveness of medication
Urecholine to stimulate the parasympathic S 2,3,4 reflex to fire and cause bladder contraction
Urinary antiseptic
Bowel Bowel rely more on bulk than on nerves Stimulate bowels at the same time each day. Best
after a meal when normal peristalsis occurs Individual may progress from ducolax
suppository to glycerin then to gloved finger for digital stimulation
Assess bowel sounds prior to giving food for the first time– paralytic illus!
6. Sexual dysfunction Assess readiness/knowledge/your ability Male sexual function- reflexogenic (S2,3,4)
erections; psychogenic erections (psychological stimulation) Ejaculation/fertility may be affected
Female- hormones more than nerves regarding fertility. C-section because of chance for autonomic dysreflexia during labor. Lack of sensation/movement affects sexual performance
Suggestions: empty bladder before sex; withhold fluids and antispasmodics; certain positions may increase spasms; explore new erogenous zones; penile implants
7. Low self-esteem Assess thoughts on ‘quality of life’; body image;
role changes Physical and psychological support Most common SCI is 15-30 yeas old and
generally a risk taker– this greatly affects their perception of life and rehabilitation progress
8. Home care Assess psychological, physical resources, need
for rehabilitation (in-house or outpatient); need for community resources
Home evaluation
Case Study PDS– Spinal Cord Injury
http://www.softwarefornurses.com/access/index.asp
LeMone- Blackboard Case Study & Media links
http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html
http://www.apacure.com/
http://spinalcord.org/
Nursing Care Plan: A Client with a SCI LeMone p. 1334
http://wps.prenhall.com/wps/media/objects/737/755395/sci.pdf
Additional Critical thinking questions LeMone p 1334: Nursing Care Plan: A Client with a SCI 1. Why does Jim have flaccid paralysis on
admission to ICU? 2. What symptoms indicate that he is in spinal
shock? What was done about these symptoms? 3. How will we know when he is out of spinal
shock? 4. How does progressive mobilization assist with
orthostatic hypotension? What else can be done? 5. What are realistic functional goals for Jim?
Case Study SCI
http://www.pitt.edu/~rhe001/ugcs96.htm