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SPINAL CORD INJURY A.

) Description and Assessment Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function. The International Standards for Neurological and Functional Classification of Spinal Cord Injury is a widely accepted system describing the level and extent of injury based on a systematic motor and sensory examination of neurologic function. The following terminology has developed around the classification of SCI:

Tetraplegia (replaces the term quadriplegia) - Injury to the spinal cord in the cervical region, with associated loss of muscle strength in all 4 extremities

Paraplegia - Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris

SCI can be sustained through different mechanisms, with the following 3 common abnormalities leading to tissue damage:

Destruction from direct trauma Compression by bone fragments, hematoma, or disk material Ischemia from damage or impingement on the spinal arteries

Edema could ensue subsequent to any of these types of damage. The different clinical presentations of the above causes of tissue damage are explained further below.

Spinal shock Spinal shock is a state of transient physiologic (rather than anatomic) reflex depression of cord function below the level of injury, with associated loss of all sensorimotor functions. An initial increase in blood pressure due to the release of catecholamines, followed by hypotension, is noted. Flaccid paralysis, including of the bowel and bladder, is observed, and sometimes sustained priapism develops. These symptoms tend to last several hours to days until the reflex arcs below the level of the injury begin to function again (eg, bulbocavernosus reflex, muscle stretch reflex [MSR]). Neurogenic shock Neurogenic shock is manifested by the triad of hypotension, bradycardia, and hypothermia. Shock tends to occur more commonly in injuries above T6, secondary to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal tone, leading to a decrease in vascular resistance, with associated vascular dilatation. Neurogenic shock needs to be differentiated from spinal and hypovolemic shock. Hypovolemic shock tends to be associated with tachycardia. Autonomic dysreflexia In a study showing a high incidence of autonomic dysfunction, including orthostatic hypotension and impaired cardiovascular control, following SCI, it was recommended that an assessment of autonomic function be routinely used, along with American Spinal Injury Association (ASIA) assessment, in the neurologic evaluation of patients with SCI.

Motor strengths and sensory testing The extent of injury is defined by the ASIA Impairment Scale (modified from the Frankel classification), using the following categories:

A - Complete: No sensory or motor function is preserved in sacral segments S4-S5.

B - Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5.

C - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3.

D - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3.

E - Normal: Sensory and motor functions are normal.

Perform a rectal examination to check motor function or sensation at the anal mucocutaneous junction. The presence of either is considered sacral-sparing. Definitions of complete and incomplete SCI are based on the above ASIA definition with sacral-sparing.

Complete - Absence of sensory and motor functions in the lowest sacral segments

Incomplete - Preservation of sensory or motor function below the level of injury, including the lowest sacral segments

Sacral-sparing is evidence of the physiologic continuity of spinal cord long tract fibers (with the sacral fibers located more at the periphery of the cord). Indication of

the presence of sacral fibers is of significance in defining the completeness of the injury and the potential for some motor recovery. This finding tends to be repeated and better defined after the period of spinal shock. With the ASIA classification system, the terms paraparesis and quadriparesis now have become obsolete. The ASIA classification using the description of the neurologic level of injury is employed in defining the type of SCI (eg, C8 ASIA A with zone of partial preservation of pinprick to T2). Other classifications of SCI include the following:

Central cord syndrome often is associated with a cervical region injury and leads to greater weakness in the upper limbs than in the lower limbs, with sacral sensory sparing.

Brown-Squard syndrome, which often is associated with a hemisection lesion of the cord, causes a relatively greater ipsilateral proprioceptive and motor loss, with contralateral loss of sensitivity to pain and temperature.

Anterior cord syndrome often is associated with a lesion causing variable loss of motor function and sensitivity to pain and temperature; proprioception is preserved.

Conus medullaris syndrome is associated with injury to the sacral cord and lumbar nerve roots leading to areflexic bladder, bowel, and lower limbs, while the sacral segments occasionally may show preserved reflexes (eg, bulbocavernosus and micturition reflexes).

Cauda equina syndrome is due to injury to the lumbosacral nerve roots in the spinal canal, leading to areflexic bladder, bowel, and lower limbs.

Muscle strength is graded using the following Medical Research Council (MRC) scale of 0-5:

5 - Normal power 4+ - Submaximal movement against resistance 4 - Moderate movement against resistance 4- - Slight movement against resistance 3 - Movement against gravity but not against resistance 2 - Movement with gravity eliminated 1 - Flicker of movement 0 - No movement

Muscle strength always should be graded according to the maximum strength attained, no matter how briefly that strength is maintained during the examination. The muscles are tested with the patient supine. The following key muscles are tested in patients with SCI, and the corresponding level of injury is indicated:

C5 - Elbow flexors (biceps, brachialis) C6 - Wrist extensors (extensor carpi radialis longus and brevis) C7 - Elbow extensors (triceps) C8 - Finger flexors (flexor digitorum profundus) to the middle finger T1 - Small finger abductors (abductor digiti minimi) L2 - Hip flexors (iliopsoas) L3 - Knee extensors (quadriceps) L4 - Ankle dorsiflexors (tibialis anterior)

L5 - Long toe extensors (extensors hallucis longus) S1 - Ankle plantar flexors (gastrocnemius, soleus)

Sensory testing is performed at the following levels:


C2 - Occipital protuberance C3 - Supraclavicular fossa C4 - Top of the acromioclavicular joint C5 - Lateral side of antecubital fossa C6 - Thumb C7 - Middle finger C8 - Little finger T1 - Medial side of antecubital fossa T2 - Apex of axilla T3 - Third intercostal space (IS) T4 - Fourth IS at nipple line T5 - Fifth IS (midway between T4 and T6) T6 - Sixth IS at the level of the xiphisternum T7 - Seventh IS (midway between T6 and T8) T8 - Eighth IS (midway between T6 and T10) T9 - Ninth IS (midway between T8 and T10) T10 - 10th IS or umbilicus T11 - 11th IS (midway between T10 and T12) T12 - Midpoint of inguinal ligament L1 - Half the distance between T12 and L2 L2 - Midanterior thigh

L3 - Medial femoral condyle L4 - Medial malleolus L5 - Dorsum of the foot at third metatarsophalangeal joint S1 - Lateral heel S2 - Popliteal fossa in the midline S3 - Ischial tuberosity S4-5 - Perianal area (taken as 1 level)

Sensory scoring is for light touch and pinprick, as follows:


0 - Absent 1 - Impaired or hyperesthesia 2 - Intact

A score of zero is given if the patient cannot differentiate between the point of a sharp pin and the dull edge. Motor level - Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5) Motor index scoring - Using the 0-5 scoring of each key muscle, with total points being 25 per extremity and with the total possible score being 100 Sensory level - Most caudal dermatome with a normal score of 2/2 for pinprick and light touch Sensory index scoring - Total score from adding each dermatomal score with possible total score (= 112 each for pinprick and light touch)

Neurologic level of injury - Most caudal level at which motor and sensory levels are intact, with motor level as defined above and sensory level defined by a sensory score of 2. Zone of partial preservation - All segments below the neurologic level of injury with preservation of motor or sensory findings (This index is used only when the injury is complete.). Skeletal level of injury - Level of the greatest vertebral damage on radiograph Lower extremities motor score (LEMS) - Uses the ASIA key muscles in both lower extremities, with a total possible score of 50 (ie, maximum score of 5 for each key muscle [L2, L3, L4, L5, and S1] per extremity). A LEMS of 20 or less indicates that the patient is likely to be a limited ambulator. A LEMS of 30 or more suggests that the individual is likely to be a community ambulator. Etiology/Causes Common causes of spinal cord injury The most common causes of spinal cord injuries in the United States are:

Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for more than 40 percent of new spinal cord injuries each year.

Acts of violence. As many as 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife wounds, according to the National Institute of Neurological Disorders and Stroke.

Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause about one-quarter of spinal cord injuries.

Sports and recreation injuries. Athletic activities, such as impact sports and diving in shallow water, cause about 8 percent of spinal cord injuries.

Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Signs and Symptoms


Loss of movement Loss of sensation, including the ability to feel heat, cold and touch Loss of bowel or bladder control Exaggerated reflex activities or spasms Changes in sexual function, sexual sensitivity and fertility Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord

Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms of spinal cord injury after an accident may include:

Extreme back pain or pressure in your neck, head or back Weakness, incoordination or paralysis in any part of your body Numbness, tingling or loss of sensation in your hands, fingers, feet or toes Loss of bladder or bowel control Difficulty with balance and walking

Impaired breathing after injury An oddly positioned or twisted neck or back

B.) Diagnostic Exam/Tests

X-rays. Medical personnel typically order these tests on all people who are suspected of having a spinal cord injury after trauma. X-rays can reveal vertebral (spinal column) problems, tumors, fractures or degenerative changes in the spine.

Computerized tomography (CT) scan. A CT scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other problems.

Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is extremely helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may be compressing the spinal cord.

Myelography. Myelography allows the doctor to visualize the spinal nerves more clearly. After a special dye is injected into the spinal canal, X-rays or CT scans of the vertebrae can suggest a herniated disk or other lesions. This test is used when MRI isn't possible or when it may yield important additional information that isn't provided by other tests. If the doctor suspects a spinal cord injury, he or she may prescribe traction to

immobilize spine.

A few days after injury, when some of the swelling may have subsided, the doctor will conduct a neurological exam to determine the level and completeness of the injury. This involves testing the muscle strength and the ability to sense light touch and a pinprick. C.) Anatomy and Physiology

The Spinal Cord The spinal cord has two functions:


Transmission

of nerve impulses. Neurons in the white matter of the spinal

cord transmit sensory signals from peripheral regions to the brain and motor signals from the brain to peripheral regions.
Spinal

reflexes. Neurons in the gray matter of the spinal cord integrate

incoming sensory information and respond with motor impulses that control muscles (skeletal, smooth, or cardiac) or glands. The spinal cord is an extension of the brain stem that begins at the foramen magnum and continues down through the vertebral canal to the first lumbar vertebra (L1). Here, the spinal cord comes to a tapering point, the conus medullaris. The spinal cord is held in position at its inferior end by the filum terminale, an extension of the pia mater that attaches to the coccyx. Along its length, the spinal cord is held

within the vertebral canal by denticulate ligaments, lateral extensions of the pia mater that attach to the dural sheath.

The following external features on the spinal cord (see Figure 1 ).

Figure 1

External features of the spinal cord.

Spinal

nerves emerge in pairs, one from each side of the spinal cord along its

length.

The

cervical enlargement is a widening in the upper part of the spinal cord (C 4

to T1). Nerves that extend into the upper limbs originate or terminate here.
The

lumbar enlargement is a widening in the lower part of the spinal cord (T9

to T12). Nerves that extend into the lower limbs originate or terminate here.
The

anterior median fissure and the posterior median sulcus are two grooves

that run the length of the spinal cord on its anterior and posterior surfaces, respectively.
The

cauda equina are nerves that attach to the end of the spinal cord and

continue to run downward before turning laterally to other parts of the body. A cross section of the spinal cord reveals the following features, shown in Figure 2 :
Roots

are branches of the spinal nerve that connect to the spinal cord. Two

major roots form:

A ventral root (anterior or motor root) is the branch of the nerve that

enters the ventral side of the spinal cord. Ventral roots contain motor nerve axons, transmitting nerve impulses from the spinal cord to skeletal muscles.

A dorsal root (posterior or sensory root) is the branch of a nerve that

enters the dorsal side of the spinal cord. Dorsal roots contain sensory nerve fibers, transmitting nerve impulses from peripheral regions to the spinal cord.

A dorsal root ganglion is a cluster of cell bodies of a sensory nerve. It is

located on the dorsal root.

Gray

matter appears in the center of the spinal cord in the form of the letter H

(or a pair of butterfly wings) when viewed in cross section.

The gray commissure is the cross-bra of the H. The anterior (ventral) horns are gray matter areas at the front of each

side of the H. Cell bodies of motor neurons that stimulate skeletal muscles are located here.

The posterior (dorsal) horns are gray matter areas at the rear of each

side of the H. These horns contain mostly interneurons that synapse with sensory neurons.

The lateral horns are small projections of gray matter at the sides of H.

These horns are present only in the thoracic and lumbar regions of the spinal cord. They contain cell bodies of motor neurons in the sympathetic branch of the autonomic nervous system.

The central canal is a small hole in the center of the H cross-bar. It

contains CSF and runs the length of the spinal cord and connects with the fourth ventricle of the brain.
White

columns (funiculi) refer to six areas of the white matter, three on each

side of the H. They are the anterior (ventral) columns, the posterior (dorsal) columns, and the lateral columns.
Fasciculi are bundles of nerve tracts within white columns containing neurons

with common functions or destinations.


Ascending (sensory) tracts transmit sensory information from various

parts of the body to the brain.

Descending (motor) tracts transmit nerve impulses from the brain to

muscles and glands.

Figure 2 A cross-section of the spinal cord.

D.) Pathophysiology

Damage to the spinal cord ranges from transient concussion (from which patient fully recovers) to contusion, laceration, and compression of the cord substance (either alone or in combination), to complete transaction (severing) of the cord (which renders the patient paralyzed below the level of the injury). SCIs can be separated into two categories: primary injuries and secondary injuries. Primary injuries are the result of the initial insult or trauma and are usually permanent. Secondary injuries are usually the result of a swell and disintegrate. A secondary chain of events produces ischemia, hypoxia, edema, and hemorrhagic lesions, which in turn result in destruction of myelin and axons. These secondary reactions, believed to be principal causes of spinal cord degeneration at the level of injury, are now thought to be reversible during the first 4 to 6 hours after injury. Therefore, if the cord has not suffered irreparable damage, some method of early treatment is needed to prevent partial damage from developing into total and permanent damage. E.) Medical Management & Medications Unfortunately, there's no way to reverse damage to the spinal cord. But, researchers are continually working on new treatments, including innovative treatments, prostheses and medications that may promote nerve cell regeneration or improve the function of the nerves that remain after a spinal cord injury. In the meantime, spinal cord injury treatment focuses on preventing further injury and empowering people with a spinal cord injury to return to an active and productive life.

Emergency Actions Urgent medical attention is critical to minimizing the effects of any head or neck trauma. So treatment for a spinal cord injury often begins at the scene of the accident. Emergency personnel typically immobilize the spine as gently and quickly as possible using a rigid neck collar and a rigid carrying board, which they'll use to transport the patient to the hospital. Early (acute) stages of treatment In the emergency room, doctors focus on:

Maintaining ability to breathe Preventing shock Immobilizing neck to prevent further spinal cord damage Avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular difficulty, and formation of deep vein blood clots in the extremities

Patient may be sedated so that they don't move and sustain more damage while undergoing diagnostic tests for spinal cord injury. If patient do have a spinal cord injury, they'll usually be admitted to the intensive care unit for treatment. They may even be transferred to a regional spine injury center that has a team of neurosurgeons, orthopedic surgeons, spinal cord

medicine specialists, psychologists, nurses, therapists and social workers with expertise in spinal cord injury.

Medications. Methylprednisolone (Medrol) is a treatment option for an acute spinal cord injury. If methylprednisolone is given within eight hours of injury, some people experience mild improvement from their spinal cord injury. It appears to work by reducing damage to nerve cells and decreasing inflammation near the site of injury. However, this is not a cure for a spinal cord injury.

Immobilization. Patient may need traction to stabilize his spine, to bring the spine into proper alignment or both. Sometimes, traction is accomplished by securing metal braces, attached to weights or a body harness, to patients skull to keep his head from moving. In some cases, a rigid neck collar also may work. A special bed also may help immobilize the body.

Surgery. Often, surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity.

Ongoing care After the initial injury or disease stabilizes, doctors turn their attention to preventing secondary problems that may arise, such as deconditioning, muscle contractures, pressure ulcers, bowel and bladder issues, respiratory infections and blood clots.

The length of patients hospitalization depends on his individual condition and what medical issues hes facing. Once hes well enough to participate in therapies and treatment, he may transfer to a rehabilitation facility. Rehabilitation. Rehabilitation team members may begin to work with the patient while hes in the early stages of recovery. His team may include a physical therapist, occupational therapist, rehabilitation nurse, rehabilitation psychologist, social worker, dietitian, recreation therapist and a doctor who specializes in physical medicine (physiatrist) or spinal cord injuries. During the initial stages of rehabilitation, therapists usually emphasize maintenance and strengthening of existing muscle function, redeveloping fine motor skills and learning adaptive techniques to accomplish day-to-day tasks. Patient be educated on the effects of a spinal cord injury and how to prevent complications, as well as be given advice on rebuilding his life and increasing his quality of life. He'll be taught many new skills, and will use equipment and technology that can help him live on his own as much as possible. He'll be encouraged to resume his favorite hobbies, participate in social and fitness activities, and return to school or the workplace. Medications. Medications may be used to manage some of the effects of spinal cord injury. These include medications to control pain and muscle spasticity, as well as medications that can improve bladder control, bowel control and sexual functioning. New technologies. Inventive medical devices can help people with a spinal cord injury become more independent and more mobile. Some devices may also restore function. These include:

Modern wheelchairs. Improved, lighter weight wheelchairs are making people with a spinal cord injury more mobile and more comfortable. For some, an electric wheelchair may be needed. Some wheelchairs can even climb stairs, travel over rough terrain and elevate a seated passenger to eye level to reach high places without help.

Computer adaptations. For someone that has limited hand function, computers can be very powerful tools, but they're difficult to operate. Some examples of computer adaptations range from simple to complex, such as key guards or voice recognition.

Electronic aids to daily living. Essentially any device that uses electricity can be controlled with an electronic aid to daily living (EADL). Devices can be turned on or off by switch or voice-controlled and computer-based remotes.

Electrical stimulation devices. These sophisticated devices use electrical stimulation to produce actions. They're often called functional electrical stimulation (FES) systems, and they use electrical stimulators to control arm and leg muscles to allow people with a spinal cord injury to stand, walk, reach and grip.

F.) Nursing Interventions The Patient with Acute Spinal Cord Injury 1.) 2.) Promoting adequate breathing and airway clearance Improving Mobility

3.) 4.) 5.) 6.) 7.) 8.) 9.)

Promoting adaptation to sensory and perceptual alterations Maintaining skin integrity Maintaining urinary elimination Improving bowel function Providing comfort measures Monitoring and managing potential complications Promoting home and community based care

The Patient with Long- Term Complications of Spinal Cord Injury 1.) Increasing mobility 2.) Preventing disuse syndrome 3.) Promoting skin integrity 4.) Improving bladder management 5.) Establishing bowel control 6.) Counselling on sexual expression 7.) Enhancing coping mechanism 8.) Monitoring and managing potential complications 9.) Promoting home and community- based care

Prognosis In general, patients with complete injuries recover very little lost function and patients with incomplete injuries have more hope of recovery. Some patients that are initially assessed as having complete injuries are later changed to incomplete injuries. Recovery is typically quickest during the first six months, with very few patients experiencing any substantial recovery more than nine months after the injury. Tetraplegia The ASIA motor score (AMS) is a 100 point score based on ten pairs of muscles each given a five point rating. A person with no injury should score 100. In complete tetraplegia, a recovery of nine points on this scale is average regardless of where the patient starts. Patients with higher levels of injury will typically have lower starting scores. In incomplete tetraplegia, 46 percent of patients were able to walk one year after injury, though they may require assistance such as crutches and braces. These patients had similar recovery in muscles of the upper and lower body. Patients who had pinprick sensation in the sacral dermatomes such as the anus recovered better than patients that could only sense a light touch. Paraplegia In one study on 142 individuals after one year of complete paraplegia, none of the patients where the initial injury was above the ninth thoracic vertebra (T9) were able to recover completely. Less than half, 38 percent, of the studied subjects had

any sort of recovery. Very few, five percent, recovered enough function to walk, and those required crutches and other assistive devices, and all of them had injuries below T11. A few of the patients, four percent, had what were originally classified as complete injuries and were reassessed as having incomplete injuries, but only half of that four percent regained bowel and bladder control. Of the 54 patients in the same study with incomplete paraplegia 76 percent were able to walk with assistance after one year. On average, patients improved 12 points on the 50 point lower extremity motor score (LEMS) scale. The amount of improvement was not dependent on the location of the injury, but patients with higher injuries had lower initial motor scores and correspondingly lower final motor scores. A LEMS of 50 is normal, and scores of 30 or higher typically predict ability to walk.