lOMoARcPSD|4531903

Spinal Cord Injury - Dr. Wiles Lecture

Adult Health Nursing Iii (Old Dominion University)

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Spinal Cord Injury

 A&P Review
o Vertebrae
 7 cervical
 MVAs
 12 thoracic
 Hardest to break due to ribcage
 5 lumbar
 Falls
 5 sacral fused as 1
 4 coccygeal fused as 1
o 31 pairs of spinal nerves
o ★ Dorsal root carries sensory from the body to the posterior part of the SC
 In injury, lose sensation
o ★ Ventral root carries motor info from the anterior part of the SC to the body
 In injury, lose motor ability but still have sensation
 Hallmark Assessment Areas
o C 3-4—Respiratory function
o C 5—Top of shoulder
o T 4—Nipple line
o T 10—Umbilicus
o L 4—Great toe
 SCI Mechanism of Injury
o Hyperflexion
 Deceleration (head-on collisions)
 Compresses cord, dislocates vertebral bodies
 Unstable neck
 Self-splinting
o Hyperextension
 Backward & downward
 Rear end collisions & diving accidents
 Cord generally stretched and distorted rather than boney involvement
o Axial loading
 Vertical force along the SCI
 Falls landing on feet or buttocks
o Rotation
 In conjunction with hyperextension or hyperflexion
 Tearing of ligaments
o Penetrating
 Anatomically penetrate or transect cord
 Injury Types
o Concussion
 A temporary loss of function lasting from 24-48 hours
 Pathologic changes are not identifiable
o Contusion
 Bruising of the SC with edema and possible necrosis of tissue from cord compression
o Transection
 The complete or incomplete severing of the SC
o Interruption of Vascular Supply
 Results in cord ischemia & necrosis
 Temporary deficits may be caused by ischemia
 Prolonged ischemia will result in necrosis and permanent loss of function
 SCI Pathophysiology
o Mechanical force that disrupts the neurological tissue, vascular supply, or both
o Primary Injury
 Occurs at the moment of impact
 Microscopic hemorrhage into gray matter
 Hemorrhage overflows from gray matter into white matter
 Impeded circulation

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 SCI Pathophysiology (cont’d)

o Secondary Injury
 Complex biochemical process that affect cellular function
 Ischemia
 ↑ intracellular Ca
 Inflammation
 Spinal Cord Injury
o Functional Injury
 The degree of disruption of normal spinal function
 Complete vs. Incomplete
o Complete SCI
 Total loss of sensory and motor function below the level of the injury
 Quadriplegia / Tetrapelegia
 C1 – T1
 Paraplegia
 T2 – L1
o Incomplete SCI
 Mixed loss of voluntary & involuntary motor activity & sensation below the level of the injury
 Types of Incomplete SCI
 Central Cord Syndromes
o Etiology
 C-spine hyperextension /flexion injuries
 Hematoma or swelling in the center of the cervical cord
o Symptoms
 Deficit of motor and sensory function below the level of the lesion
with loss greater in the arms than the legs
 Varying degrees of B&B function
o Greater loss in arms than in legs
 Anterior Cord Syndromes
o Etiology
 Disruption to blood flow to the anterior cord
 Generally flexion injuries or herniation of intravertebeal disc
o Symptoms
 Lost: motor function, pain, temp
 Intact: position sense & sensations of pressure and vibrations
 Posterior Cord Syndromes
o Etiology
 Acute posterior cord compression
 Hyperextension injuries
o Symptoms
 Lost: position, pressure, & vibration
 Intact: motor function, pain, & temp
 Brown-Sequard Cord Syndromes
o Etiology
 Damage to only 1 side of the cord
o Symptoms
 Lost: voluntary motor function on the side of injury
 Lost: pain & temp & sensation on the opposite side of the injury
 Spinal Shock
o Complete loss of all muscle tone and reflexes below the level of the injury
o Symptoms last several hours to a few months
 Flaccid paralysis
 Loss of DTRs and perianal reflexes
 Squeeze butt cheeks, finger up the butt
 Loss of motor and sensory function

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 Neurogenic shock
o Distributive shock
 Sympathetic blockade
 Assoc. with injuries above T 6
 Onset minutes
 Duration- days to ~1 month
o Signs & Symptoms
 Hypotension
 Bradycardia
 Warm dry skin
 Poikilothermy
 Take on temperature of the environment
o Treatment
 Fluid resuscitation
 Midodrine
 Be cautious of position changes
 Autonomic Dysreflexia
o Life threatening
o Massive sympathetic response to a noxious stimuli
o Signs/Symptoms
 Bradycardia
 Hypertension
 Facial flushing
 HA
 Acute pulmonary edema
o Precipitating cause
 Bowel or bladder distention
 Pressure points
 Line insertion
o Treatment
 Relieve noxious stimuli
 Treat BP prn
 SCI Diagnosis
o Assessment findings
 “clinically clearing” neck
o Plain X rays
 Cross table lateral films
o CT scan
o MRI
 SCI Nursing Dx
o Ineffective airway clearance
o Ineffective breathing pattern
o Hypothermia
o Dysreflexia r/t excessive response to noxious stimli
o Decreased CO r/t sympathetic blockade
o Powerless
o Impaired mobility
o Self-esteem disturbance
o Ineffective individual coping
o Anxiety
o Sleep pattern disturbance
o Skin integrity
o Pain
 SCI Therapeutic Management
o Goals
 Prevent further neuro deficit
 Stabilize the spine!
 Prevent life threatening complications
 Maximize function of all body systems

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 SCI Therapeutic Management (cont’d)

o Minimizing Deficit
 High dose Methyl-prednisolone
 Steroid to reduce inflammation
 Prevents post-traumatic ischemia
 30 mg/kg bolus over 15 minutes
 5.4 mg/kg/hr for 23 hours beginning 45 minutes after the bolus ends
o Start within 8 hours of the injury
o May be given for 47 hours if started 3-8 hours post injury
 Clinical Management
o Assessment
 Airway with c-spine precautions
 Breathing
 Circulation
 Temperature control
o Immobilization
 Cervical collar
 Back board
 Halo
 C-spine injury
 Trach and PEG
o Surgical Immobilization
 Laminectomy
 Decompression
 Spinal Fusion
 Provides stability
 Rodding
 Provides stability
o Pulmonary
o Source of frequent complications
 Resp status depends on level of injury
 Vent or independent
 Require pulmonary toilet
 Cough assistance
o Cardiovascular
 Sympathetic tone
 Too much or too little?
 Orthostatic hypotension
 Thermoregulation
 DVT prophylaxis
o Neuro status & checks
 Dermatone evaluation
 Hourly assessment
o Muscle Strength Scale
 Active movement against maximal resistance
 Active movement against resistance
 Active movement against gravity
 Active movement with gravity eliminated
 Flicker or trace of contraction
 Flaccid, no movement
o GI System
 Ileus
 NG tube
 Bowel training
 Constipation
 Impaction
 Distended abdomen
o Genitourinary system
 Bladder training
 High risk for UTI
 Sexuality

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 Clinical Management (cont’d)

o Skin Integrity
 Pressure sores
 Turning & moving
 Specialty beds/mattresses
 Padded wheelchairs
o Musculoskeletal
 Turn patients
 Logroll until stabilized
 ROM to prevent contracture
 Positioning
 Adaptive devises
 Foot drop splints
 Hand splints
 Maximize mobility
o Psychosocial effects
 Need dedicated emotional support
 Grief process
 SCI has not affected cognitive ability
 Need to learn new self-care routines
 4 D syndrome
 Drinking, depression, drug addiction, divorce

SCI Functional Level

Level Respiratory Function Comment

C1 – C2 Paralysis of the diaphragm Ventilator dependent
C3 – C5 Varying degrees of diaphragm May need vent
paralysis Some diaphragm control
C6 – T11 Varying degrees of impaired Compromised respiratory function
intracostal & abd muscle ↓ inspiratory ability
Ineffective cough & sneeze

Level of Injury Functional Ability

C1 – C4 Requires electric WC w/ breath, head, or should controls
C5 Electric WC w/ hand control/manual with rims, adaptive
devises for ADLS
C6 Independent manual WC on level surfaces
May need hand controls, adaptive devices for ADLs
C7 Manual WC for most surfaces, may need adaptive
devices

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