Etiology of Traumatic Spinal Cord InjuryMVA- most common causeOther: falls, violence, sport injuriesSCI typically occurs from indirect injury from

vertebral bones compressing cord SCI frequently occur with head injuriesCord injury may be caused by direct trauma

from knives, bullets, etc

Etiology of Traumatic Spinal Cord Injury78% people with SCI are maleTypically young men – 16-30Number of older adults rising (>61 yr)Greater complicationsLife Expectancy 5 years less than same age

without injury90% go home

Pathophysiologyanatomy of the spine

PathophysiologyNormal Spinal Cord

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

PathophysiologyNormal Spinal Cord

Vertebral Column

8 Cervical12 Thoracic5- Lumbar5- Sacral

Protection of Spinal Cord from Injury

Bones- vertebral column

Discs- between vertebra

Internal and external ligaments

Dura

Protection of Spinal Cord from Injury

Internal and external ligaments

DuraMeningesCSF in

subarachnoid space allow for movement within spinal canal

Nervous System and the Spinal Cord

ANS can be affected by SCI

Sympathetic chains on both sides of the spinal column

Parasympathetic nervous system is the cranial-sacral branch

Normal Spinal Cord

Normal spinal cord

DermatonesSkin innervated by

sensory spinal nerves

Normal Spinal Cord

Reflex Arc Where sensory and

motor nerves arise from cord

Sensory fibers enter posterior

Motor fibers leave from anterior

Once outside cord join form spinal nerve

reflex movement

Normal Spinal CordWhite tracts 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)

voluntary movement

Spinal Cord Injury- SCICompressionInterruption of blood supplyTractionPenetrating Trauma

Spinal Cord InjuryPrimary

Initial mechanism of injurySecondary

Ongoing progressive damage Ischemia Hypoxia Microhemorrhage Edema

Spinal Cord InjuryHemorrhage 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

Classifications of SCI1. Mechanism of Injury2. Skeletal and Neurologic Level3. Completeness (degree) of Injury

Classifications of SCIMechanism of Injury1. Mechanism of Injury

FlexionHyperextensionFlexion RotationCompression

Classifications of SCIMechanism of Injury

Flexion (hyperflexion)Most common because

of natural protection position.

Generally cause neck to be unstable because stretching of ligaments

Classifications of SCIMechanism of Injury

HyperextentionCaused by chin hitting a

surface area, such as dashboard or bathtub

Usually causes central cord syndrome symptoms

Classifications of SCIMechanism of Injury

CompressionCaused by force from

above, as hit on headOr from below as

landing on buttUsually affects the

lumbar region

Classifications of SCIMechanism of Injury

Flexion/RoatationMost unstableResults in tearing of

ligamentous structures that normally stabilize the spine

Usually results in serious neurologic deficits

Classification of SCI- Level of InjurySpinal cord levelWhen referring to

spinal cord level, it is the reflex arc level not the vertebral or bone level.

Note that the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of there respective vertebral bone

Classification of SCI- Level of Injury

Spinal cord injuries are described by the level of the injury– the cord segment or dermatome level

Such as C6; L4 spinal cord injury

Classifications of SCICompleteness (Degree) of Injury

CompleteIncomplete

Central cord syndromeAnterior Cord syndromeBrown-Sequard SyndromePosterior Cord SyndromeCauda Equina and Conus Medullaris

Classification of SCI Completeness (degree) of InjuryComplete (transection)After spinal shock: Motor deficits- spastic

paralysis below level of injury

Sensory- loss of all sensation perception

Autonomic deficits- vasomotor failure and spastic bladder

Classification of SCI Completeness (degree) of InjuryIncompleteCentral 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

Classification of SCI Completeness (degree) of InjuryIncomplete

Brown-Séquard Syndrome

Hemisection of cordIpsilateral paralysisIpsilateral superficial

sensation, vibration and proprioception loss

Contralateral loss of pain and temperature perception

Classification of SCI Completeness (degree) of InjuryincompleteAnterior Cord Syndrome

Injury to anterior cord Loss of voluntary motor

(Pyramidal track) below Loss of pain and

temperature perceptionRetains posterior column

function

Classification of SCI Completeness (degree) of InjuryincompletePosterior Cord Syndrome

Least frequent syndromeInjury to the posterior

columns results in proprioceptive loss (dorsal columns)

Pain, temperature, touch are preserved. Motor function is preserved to varying degrees.

Classification of SCI Completeness (degree) of InjuryincompleteConus Medullaris

Syndrome Injury to the sacral cord

(conus) and lumbar nerve roots within the spinal canal, usually results in are-flexic bladder and bowel, and lower limbs (in low-level lesions)

Cauda Equina Syndrome Injury to the lumbosacral

nerve roots within the neural canal, results in areflexic bladder, bowel, lower limbs

Common Manifestations/ComplicationsTerms used to describe motor deficitsPrefix: para- meaning two extremities; tetra-

or quadra- all four extremitiesSuffix –paresis meaning weakness; -plegia

meaning paralysisQuadraparesis means what?

Common Manifestations/Complications

C1-3 usually fatal- Loss of phrenic

innervation ventilator dependent

No B/B controlSpastic paralysisElectric w/c with

chin/mouth control

Common Manifestations/Complications

C6- weak graspHas shoulder/biceps to

transfer & push w/cNo bowel/bladder

control.

Considered level of independence

Common Manifestations/Complications

T1-6- full use of upper extremity

TransferDrive car with hand

controls and do ADL’sNo bowel/bladder

control

Clinical Manifestations of SCISkin: 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)- decreased venous return, orthostatic hypotension, poikilothermic (takes on temp of room)

Clinical Manifestations of SCIRespiratory: decrease chest expansion; cough

reflex & vital capacity; 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

Spinal and Neurogenic shockSpinal Shock

Decreased reflexes and loss of sensation below the level of injury

Motor loss- flaccid paralysis below level injurySensory loss- loss touch, pressure, temperature

pain and proprioception perception below injury

Lasts days to months

Spinal and Neurogenic ShockNeurogenic shockDue to loss of vasomotor tone

SNS loss results in parasympathetic dominance with vasomotor failure

Loss of SNS innervation causes peripheral pooling and decreased cardiac output

Hypotension and Bradycardia Orthostatic hypotension and poor

temperature control (poikilothermic- takes on temp of environment)

How do you know spinal shock is over?

Clonus is one of the first signs

Hyperreflexia of footTest by flexing leg at

knee & quickly dorsiflex the foot

Rhythmic oscillations of foot against hand

clonus

Common Manifestation/ComplicationsUpper and Lower Motor Deficits

Upper motor deficits result in spastic paralysis

Lower motor deficits result in flaccid paralysis and muscle atrophy

Diagnostic Studies for SCI

X-ray of spinal columnCT/MRIBlood gases

Collaborative CareEmergency Care at Scene, ER & ICU

Transport with cervical collar

Assess ABC’s; O2; tracheotomy/vent

IV for life lineNG to suctionFoley

Therapeutic Interventions MedicationsIV methylprednisolone (Solu-Medrol)

within 8 hrs to decrease cord edema

Therapeutic InterventionsMedications To control or to prevent complications of

SCI and immobility:Vasopressors to maintain perfusionHistamine H2 blockers to prevent stress ulcersAnticoagulantsStool softenersAntispastomotics

Therapeutic InterventionsStabilization/immobilizationTraction with Gardner-Wells tongs

Therapeutic InterventionsExternal tractionHalo device For patients who do not

have motor deficits Experience less

immobility complications

Therapeutic InterventionsCasts; splints; collars; braces

Therapeutic InterventionsSpecial Beds for SCITo decrease immobility

complicationsRotorest is a common

one used- rotates 23 hrs a day

Therapeutic InterventionsSurgery for SCI

Manipulation to correct dislocation or to unlock vertebrae

Decompression laminectomy

Spinal fusionWiring or rods to hold

vertebrae together

Nursing Management AssessmentHealth HistoryDescription of how and when injury occurredOther illnesses or disease processesAbility to move, breathe, and associated

injury such as a head injury, fractures

Nursing Management AssessmentPHYSICAL EXAM

LOC and pupils- may have indirect SCI from head injury

Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds

Vital signsMotorSensoryBowel and bladder function

Nursing ManagementAssessmentMotor Assessment Upper Extremity

Movement, strength and symmetry

Hand grips

Flex and extend arm at elbow- with and without resistance

Nursing Management Assessment Motor Assessment Lower Extremity

Flex and extend leg at knee with and without resistance

Planter and dorsi flexion of foot

Nursing Management AssessmentMotor assessment- ClonusClonus- hyperreflexiaFlex 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 Management AssessmentSensory 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

Nursing Problems/Interventions

1.Impaired mobility2.Impaired gas exchange3. Impaired skin integrity4. Constipation5. Impaired urinary elimination6. Risk for autonomic dysreflexia7. Ineffective coping

1. Impaired Physical MobilityLog roll as a single unit; provide assistance

as needed to keep alignment; teach patient Care traction, collars, splints, braces,

assistive devices for ADL’sFlaccid paralysis- use high top tennis shoes

or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)

1. Impaired Physical MobilitySpastic 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

1. Impaired Physical MobilityPrevent/treat orthostatic hypotension

Abdominal binder, calf compressors, TED hose when individual gets up

Assess BP, especially when risingAssist Physical Therapy with tilt table as

individual gradually gets use to being in an upright position

1. Impaired Physical MobilityUse of transfer board

2. Impaired Gas ExchangePhrenic 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

2. Impaired Gas ExchangeAssess respiratory rate, rhythm, depth, and

breath soundsMonitor vital capacity, respiratory effort,

ABG’s, O2 saturationAssess for signs of impending extension of

SCI up cord to phrenic nerve level (C3-5)Assess need for ventilatory assistance,

tracheotomy, ventilator Quad cough (assistive cough) as needed

3. Impaired Skin IntegrityChange position frequentlyRemoval of TED hose every 8 hoursNutritional statusProtection from extremes in temperature

3. Impaired Skin IntegrityInspect skin at least 2x/day especially over

boney prominences Avoid shearing and friction to soft tissue

with transfers

4. ConstipationBowel rely more on bulk than on nervesStimulate bowels at the same time each day.

Best after a meal when normal peristalsis occurs

Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation

Assess bowel sounds prior to giving food for the first time– paralytic illus!

5. Impaired Urinary EliminationBladder function SCI

Upper/Lower MotorBladder reflex arc-

sacral 2,3,4

5. Impaired Urinary EliminationFlaccid bladder (lower motor neuron lesion)

No reflex from S2,3,4Automatic empting of bladder Urine fills the bladder and dribbles outNeed foley or freq intermittent self catherization

Spastic bladder (upper motor neuron lesion) Reflex arc but no connection to or from brain Reflex fires at will Bladder training- trigger points to stimulate empting;

self catherization

5. Impaired Urinary EliminationUse bladder scan to see amount of urine

in bladder Goal- residual <100ml/20% bladder

capacitySome individuals may need suprapubic

catheterAssess effectiveness of medication

Urecholine to stimulate bladder contractionUrinary antiseptic

6. Risk for Autonomic DysreflexiaSCI 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

Vasodilatation symptoms above SCIVasoconstriction symptoms below SCIThe cause of SNS stimulation

6. Risk for Autonomic Dysreflexia

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 binderMonitor blood pressure- can get > 300 SGive PRN medication to lower BPIf above not effective– call physician

7. Ineffective Coping

Grief and DepressionSexuality

7. Ineffective CopingGrief and Depression

Assess thoughts on ‘quality of life’; body image; role changes

Physical and psychological supportMost common SCI is 15-30 yeas old and

generally a risk taker– this greatly affects their perception of life and rehabilitation

7. Ineffective CopingSexualityAssess 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

Home CareAssess psychological, physical resources,

need for rehabilitation (in-house or outpatient); need for community resources

Home evaluation

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NCLEX questions/ case study

Case study- Jim Valdez1. 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?