- 1. By Dr Imran Javed. Associate Professor Surgery. Fiji
National University.
2. Vertebrae 7 cervical (flexion, extension, lateral flexion,
rotation) 1st-atlas 2nd-axis 12 thoracic (little movement) 5 lumbar
(less flexion than extension, some rotation 5 sacral (fused) 3-4
coccyx (fused) 3. Each vertebrae has a nerve that exits either
below or above it 31 pairs of spinal nerves 8 cervical nerves 12
thoracic nerves 5 lumbar 5 sacral 1 coccygeal 4. Part of the CNS
along with brain Contained within vertebral canal Extends from
cranium to 1st-2nd lumbar vertebrae Lumbar roots & sacral
nerves for a horse-like tail called cauda equina 2 plexuses
Brachial, lumbosacral 5. L1,2,3-iliopsoaship flexion
L2,3,4-Quadsknee extension L4-tibialis anterior
dorsiflexion/inversion at ankle L5-Extensor hallicus longus,
extensor digitorum longus/brevis, extension/inversion at ankle
S1-peroneus longus/brevis-eversion S1,2-gastroc/soleus plantar
flexion C5-deltoidshoulder abduction C5-6-bicepselbow Flexion
C6-wrist extensors extension C7-triceps & wrist/finger
flexorselbow extension, wrist/finger flexion C8-finger
flexorsfinger flexion T1-finger Abductors-- abduction 6. Whos at
risk? ADULT MEN BETWEEN 15 AND 30 YEARS Anyone in a risk-taking
occupation or lifestyle SCI in older clients increasing largely due
to MVAs Causes (in order of frequency) MVA Gunshot wounds/acts of
violence Falls Sports injuries 7. Airway & Cervical Spine.
Breathing. Circulation. Disability. Environment & Exposure.
Fluids. 8. Below site of injury: Total lack of function Decreased
or absent reflexes and flaccid paralysis Lasts from a week to
several months after onset. End of spinal shock signaled by
muscular spasticity, reflex bladder emptying, hyperreflexia. 9.
Flexion (bending forward) Hyperextension (backward) Rotation
(either flexion- or extension- rotation) Compression (downward
motion) 10. Complete transection Total paralysis and loss of
sensory and motor function although arms or rarely completely
paralyzed Incomplete (partial transection) Mixed loss of voluntary
motor activity and sensation Four patterns or syndromes 11. Central
cord syndrome More common in older clients Frequently from
hyperextension of spine Weakness in upper and lower ext, but
greater in upper. Anterior cord syndrome Posterior cord syndrome
Brown-Sequard syndrome 12. Compression of the ant. Cord, usually a
flexion injury Sudden, complete motor paralysis at lesion and
below; decreased sensation (including pain) and loss of temperature
sensation below site. Touch, position, vibration and motion remain
intact. 13. Assoc with cervical hyperextension injuries Dorsal area
of cord is damaged resulting in loss of proprioception Pain,
temperature sensation and motor function remain intact. 14. Damage
to one half of the cord on either side. Caused by penetrating
trauma or ruptured disk. ischemia (obstruction of a blood vessel),
or infectious or inflammatory diseases such as tuberculosis, or
multiple sclerosis. BSS may be caused by a spinal cord tumor,
trauma (such as a puncture wound to the neck or back),. a rare SCI
syndrome which results in weakness or paralysis (hemiparaplegia) on
one side of the body and a loss of sensation (hemianesthesia) on
the opposite side. 15. Depend on the LEVEL and DEGREE of the
injury! Quadriplegia occurs with C-1 through C-8 injuries.
Paraplegia occurs with T-1 thru L-4. Respiratory C1 C3: Absence of
ability to breathe independently. C4 poor cough, diaphragmatic
breathing, hypoventilation C5 T6: decreased respiratory reserve T6
or T7 L4: functional respiratory system with adequate reserve.
Cardiovascular: C1 T5 shows decreased or absent SNS influence.
BRADYCARDIA AND HYPOTENSION (due to vasodilation) 16. The phrenic
nerve stimulates the diaphragm to contract. Two phrenic nerves
(right and left) - injury to one or the other paralyzes contraction
of only one half of the diaphragm but even hemi- (half) paralysis
can significantly interfere with breathing for patients with lung
disease. The nerve arises from branches of the C3,4, and 5 nerve
roots. The phrenic nerve can be damaged by procedures exploring the
neck & upper back Loss of the phrenic nerve on either side
results in paralysis of the diaphragm on that side. Paralysis of
the diaphragm on one side results in less inflation of the lung on
that side. Whether this is physiologically significant (producing
respiratory distress, hypoventilation/hypercapnia) depends on other
aspects of a patient's pulmonary physiology (namely underlying
chronic obstructive pulmonary disease [emphysema, bronchitis],
pneumonia, etc.). 17. The longest of the cranial nerves- exits out
of the medulla and ends in the abdomen It supplies sensory and
motor function to the pharynx Supplies motor function to the
muscles of the abdominal organs Provides parasympathetic activity
to the heart, lungs, and most of the digestive system 18. Atonic
bladder with RETENTION in spinal shock. Post acute phase
irritability causing dribbling or frequent urination. Urinary
infection and calculi from retention and distention. INTERMITTENT
CATHETERIZATION! 19. Decreased motility Paralytic ileus Gastric
distention intermittent NG suctioning Increased H2 administer H2
inhibitors such as Zantac or Pepcid in initial stages Carafate and
antacids later as prophylaxis Intra-abdominal bleeding! Remember,
no pain or tenderness to warn you. Watch for impactions. 20.
Pressure ulcers! Muscle atrophy in flaccid paralysis Contractures
in spastic paralysis Poikilothermism the adjustment of body temp to
room temperature Decreased ability to sweat below lesion 21. DVT
common but not detected easily Pulmonary embolism a significant
cause of death. Doppler studies, measurement of extremity girth,
impedance plethysmography (what the heck is this?) 22. Goals are to
Sustain life Prevent further cord damage Assessment of muscle
groups; motor status Against gravity Against resistance Both sides
of the body Ask to move legs, hands, fingers, wrists, then shrug
shoulders Thorough motor examination including position sense and
vibration. Sensory examination Pinprick starting at toes and
working upward ALWAYS HAVE CLIENT CLOSE EYES OR LOOK AWAY! If he
can see what youre doing, he will answer accordingly. Assess for
head injury and ICP X-ray, CT scan, EMG 23. MRI provides Better
Evaluation of Spinal cord. CT Scan is good for Bony Injury but
radiation exposure is involved. X-Ray is still good for initial
evaluation & Screening purposes with multiple views. Myelogram
is outdated but still may be used where MRI is not available.
Tomograms may be of little value. Continuous Imaging (Fluoroscopy)
may be used during surgery & Manipulation of Spine. 24.
Surgical Therapy: Reduces injury and stabilizes the SC Done for
Compression, Bony fragments in the cord, Compound fracture,
Penetrating trauma Vasopressors: to keep mean arterial pressure
greater than 80mm to 900mm/Hg so that PERFUSION TO CORD is
improved. MethylPrednisolone: Increases the recovery of function.
IV bolus then continuous IV over a 23 hour period. Improves blood
flow and reduces edema in the SC. GI problems - zantac, tagamet,
pepcid Bradycardia - atropine bladder spasticity - anticholinergics
autonomic dysreflexia blood pressure reduction
