Spinal Cord Injuries

Becca MaddoxN2205

Spring 2002

SPINAL CORD INJURY (SCI)

FAST FACTS Occurs primarily in young males (> 75% of cases) Half of these injuries result from MVAs 2/3 of patients are < 30 years old Other sources of SCI: Falls, sporting and industrial

accidents, gunshot wounds. Most common vertebrae involved are C5, C6, C7, T12,

and L1 because they have the greatest ROM The estimated cost of these injuries exceeds $2 billion

annually.

Type of Injury

Transient concussion - is due to extreme vibration of the cord and may cause temporary loss of function lasting 24 to 48 hours. No neuropathologic changes are present.

Contusion - is a bruising that includes bleeding, subsequent edema, and possible necrosis from the edematous compression. • The neurological involvement depends on the severity of

contusion and necrosis Laceration Compression of cord substance Complete transection of the cord

Pathophysiology

Hemorrhage: Blood flows into the extradural, subdural, or subarachnoid spaces of the spinal cord

Injury to spinal cord vasculature causes nerve fibers to swell and disintegrate

Blood circulation to the gray matter of the spinal cord is impaired

Secondary chain of events: Ischemia, hypoxia, edema, and hemorrhagic lesions

These secondary events result in destruction of

myelin and axons.

Pathophysiology Cont’d

These secondary reactions, are believed to be the principal causes of spinal cord degeneration .

The damage may be reversible within the first 4 to

6 hours after the injury. The consequence of spinal cord injury depends

on• The type of injury (concussion, contusion,

laceration, compression, transection) • The neurologic level (lowest level at which

sensory and motor functions are normal)

Management of Spinal Cord Injuries

Immediate management at the scene is critical. Improper handling can cause further damage and

loss of functioning Always assume there is a spinal cord injury until it

is ruled out• Immobilize

• Prevent flexion, rotation or extension of neck

• Avoid twisting patient

If conscious, patients will usually mention acute pain in back or neck which may radiate along the involved nerve

Management cont’d

Management is aimed at preventing further injury and observing for progression of neuro deficits

Consists of emergency treatment following an A-B-C-D-E sequence.

Airway Management

First priority. Open airway with jaw-thrust maneuver. Use bag-valve-mask devise initially for

airway compromise and if necessary to prepare for intubation.

High concentration of 02 will prevent bradycardia or asystole for patients exhibiting signs of neurogenic shock.

Breathing

Lesions above C5 level will cause partial to complete diaphragmatic paralysis (recall the diaphragm is innervated at C3-5 levels).

Any lesion above T12 may cause some airway compromise.

Lesions at C5 and below will allow full diaphragmatic movement, but intercostal muscles (innervated at T1) and abdominal muscles (innervated at T12) are affected.

Circulation

Cardiac output is affected by external or internal hemorrhage and neurogenic shock.

To determine external bleeding, turn the patient in log-roll fashion and quickly note the site of injury.

Two signs of internal bleeding from abdominal trauma are abdominal pain and muscular rigidity. However, these signs may be masked in a patient with sensory and motor deficits.

Other usual signs of shock from internal bleeding are absence of urine and/or classic signs of shock (decreased BP and increased HR)

Disability

Neurological Examination Lateral C-Spine X-ray CT scan Telemetry - bradycardia and asystole are

common with acute cervical injury Search for other injuries - spinal trauma is

often accompanied by other injuries, particularly of the head and chest

Exposure

Patients with SCI become poikilothermic, meaning that their body temperature will increase and decrease with the temperature of the environment.

Because they lose the ability to regulate core body temperature through vasodilatation and vasoconstriction, they can become dangerously hyperthermic or hypothermic.

Medical Management

High dose corticosteroids (Methylprednisolone) - improves the prognosis and decreases disability if initiated within 8 hours of injury. Patient receives a loading dose and then a continuous drip.

High dose steroids, Mannitol, Dextran Naloxone - has shown promise in use on

humans, minimal side effects, may promote neurological improvement

Neurogenic Shock

Neurogenic shock may complicate the assessment because it masks the typical signs of hypovolemia - tachycardia, cold and clammy skin.

Vasomotor tone is lost, producing hypotension from vasodilatation.

Increased vagal tone causes bradycardia. The skin stays warm and dry because the

sympathetic nervous system cannot initiate the usual compensatory mechanism for hypovolemic shock (shunting blood from periphery to core).

Neurogenic vs. Spinal Shock

Neurogenic Shock- loss of vasomotor tone and impairment of autonomic function.• Tx - close monitoring of HR, use of vasoactive drugs. • Typically it lasts from 3 days to 3 weeks after injury.

Spinal shock - loss of spinal reflexes resulting in flaccid paralysis below the level of the injury. • Tx - monitor patient for respiratory difficulty, bladder

and bowel management, abrupt onset of fever (as patient loses ability to perspire in areas of paralysis).

• May last from weeks to months. When it ends, flaccid muscles become spastic.

Neurological/Orthopedic Management

Neurological/orthopedic management includes methods a surgeon may use to treat unstable spinal cord injuries: • Reduction• Fixation• Fusion

Reduction

With reduction, the spine is realigned through the application of a skeletal traction devise, such as Gardner-Wells tongs or Halo traction.

5 to 10 pounds of weight are usually added for each involved vertebral interspace, beginning at C1.

Be careful - too much weight can pull the spine apart, causing a distraction injury.

Check traction regularly for free-hanging weights and correct amount of weight.

Pins should fit tightly against the cranium. The patient should not be able to shake his head.

Assess pin sites for infection and clean according to policy.

Fixation and Fusion

Fixation involves stabilizing vertebral fractures with wires, plates, and other types of hardware.

Fusion involves attaching injured vertebrae to uninjured vertebrae with bone grafts, and steel rods to help maintain structural integrity.

Complications of SCI - Pulmonary

Pulmonary complications - Function compromise, Airway compromise, infection, decreased vital capacity, atelectasis, retention of secretions, respiratory failure, pulmonary edema

Acute respiratory failure is the leading cause of death in high cervical injuries

Management of pulmonary complications: Chest physiotherapy & postural drainage, frequent suctioning, quad cough technique, incentive spirometry, assessing breath sounds, monitoring ABG’s and chest x-rays.

Deep Vein Thrombosis (DVT)

The incidence of DVT is extremely high in SCI patients due to pressure on their calf muscles, loss of the skeletal muscle pump, and the hypercoagulability of their blood.

Treatment consists of hospital’s choice of DVT prophylaxis - pneumatic compression hose, low dose Heparin or Lovenox, ROM exercises, and vena cava filters.

May require Coumadin long term. Measure thighs and calves daily.

Orthostatic Hypotension

May develop in the acute or transitional phase. Caused by venous pooling in the legs and abdomen,

loss the skeletal muscle pump, and impaired sympathetic nervous system control of BP.

May occur with position changes and can result in syncope, bradycardia, or asystole.

Treatment consists of quickly returning the patient to a supine position, administering oxygen, and if necessary, atropine to increase heart rate.

Preventive measures include TED stockings, elastic bandages, and abdominal binders that promote

venous return from the extremities.

GI and GU dysfunction

Assess for bowel distention, ileus or gastrointestinal bleeding - may require an NGT

Monitor patient’s bowel function and establish bowel routine.

During acute injury phase, the bladder is atonic so the patient is unable to void voluntarily or spontaneously - also increases risk of UTI

Maintain strict Intake and Output

Begin bladder training

Skin Integrity

Below the level of SCI, the patient cannot sense discomfort from pressure, skin irritants, or temperature extremes.

Patient will remain at high risk for pressure ulcers, serious skin injury and infection.

During acute phase, inspect skin for redness or other signs of breakdown - pressure ulcers can occur within 6 hours

May use special bed as roto-rest or striker frame to turn patient.

Autonomic Dysreflexia

An acute emergency It is an exaggerated response to stimuli Classic signs are pounding headache, marked

hypertension, diaphoresis (particularly of the forehead), bradycardia, flushing, piloerection, nausea, and nasal congestion

Occurs only after spinal shock has resolved The increase in ICP and blood pressure can lead

to cerebral hemorrhage

Autonomic Dysreflexia Pathophysiology

Occurs with spinal cord lesions above the thoracic sympathetic outflow (T6 or T7). The feedback system between the sympathetic and parasympathetic branches of the ANS is disrupted.

The parasympathetic response is partially disabled and the sympathetic response is dominant.

As a result, the sympathetic response produces profound vasoconstriction thus producing a rapid rise in blood pressure.

Normally, baroceptors in the cerebral vessels, carotid sinus, and aorta detect the rising blood pressure and attempt to trigger visceral and peripheral vasodilatation, but these impulse are blocked by a damaged cord.

The parasympathetic response is limited to vagal slowing of the heart rate and vasodilatation, flushing, and diaphoresis above the level of spinal cord injury.

Autonomic Dysreflexia cont’d

Anything that can cause discomfort to a neurologically intact person can trigger autonomic dysreflexia in a patient with a spinal cord injury.

The most common stimulus is a distended bladder or rectum.

Other causes include: Stimulation of the skin from pressure, pain, heat or cold.

The goal of treatment is to identify and remove the cause of the dysreflexia and thus lower the BP.

Sit patient with feet down to promote orthostatic reduction of blood pressure. (If patient unable to sit, elevate head of bed to 90 degrees).

Quadraplegics and Paraplegics

Quadraplegics - results from a cervical impairment

Paraplegic - results from impairment at the thoracic, lumbar, or sacral root area.

Can result from accidents, spinal cord lesions, tumors, vascular lesions, multiple sclerosis, infections or abscesses of the spinal cord or congenital defects

You will see these patients in the hospital for all of the other things you see patients for

Rehab and Long-Term Issues

Mobility - initially may require a brace or halo. Needs to bear weight as soon as possible because it helps decrease disuse atrophy, decrease the opportunity for osteoporosis, decrease the possibility of renal calculi, and enhances metabolic processes

Exercise - to strengthen unaffected parts and promote self-care

Skin Integrity - needs to be taught the importance of being responsible for own skin integrity

Rehab and Long-Term Issues cont’d

Urinary and Bowel Programs - will have to develop and maintain programs. Will need to learn how/when to self-cath, check residual urine. Will need to know how to stimulate a bowel movement. Will need to be able to recognize an impaction or ileus.

Prevent and Manage Complications Spastic Muscles - maximum spastic activity is

usually 2 years out and then minimizes some. May require long-term use of anti-spasmodic drugs such as valium, baclofen or dantrium

Rehab and Long Term Issues cont’d

Contractures - Needs to understand the importance of exercise and maintaining function

UTI’s and sepsis - needs to recognize signs and symptoms of UTI and sepsis.

Heterotropic ossification - overgrowth of bone in hips, knees, shoulders elbows. This causes pain and decreased ROM for pain, thus decreasing mobility

Self-Esteem - May need counseling to deal with changes in self-identity, sexual function, social and emotional roles. Needs to feel strong, lovable and loved.

Psychosocial Behavior

Denial, anger and depression are common reactions to SCI.

Manipulative behavior and emotional times are managed by setting mutually reasonable expectations of the patient and nursing staff.

Ultimately the SCI patient will ask the question of walking again. Often this question cannot be answered in the immediate post-injury phase. The goals are to provide honest and realistic communication about the nature of the injury and help the patient develop short-term goals.

Intraspinal Tumors

Tumors within the spine are classified according to their anatomic relation to the spinal cord

Intramedullary lesions (within the spinal cord)

Extramedullary- intradural lesions (within the subarachnoid space)

Extradural lesions (outside the dural membrane)

Symptoms Associated with Intraspinal Tumors

Weakness Loss of reflexes above the tumor level Localized or shooting pains in the area that is

innervated by the spinal roots that originate in the cord near the tumor site

Progressive loss of motor function and paralysis below the level of the lesion

Diagnosis is made by neurological exam and myelogram plus CT scanning and Magnetic Reasoning Imaging (MRI)

Preoperative Management

Assess patient for weakness, muscle wasting, spasticity, and sensory or sphincter disorders.

Important areas in patient’s history include: pulmonary system(especially when a cervical lesion is present), hx of coagulopathies, any anticoagulants taken recently including aspirin or anti-inflammatory drugs.

Importance of pulmonary toilet (cough and deep breathing exercises and use of incentive spirometer) is taught prior to surgery.

Surgical Management of Intraspinal Tumors

Excision of the tumor while sparing the uninvolved portions of the spinal cord is the most desirable form of treatment/cure.

Prognosis is related to degree of neurologic impairment at the time of surgery, the speed with which symptoms occurred, and the tumors origin.

Other treatment modalities include partial removal of the tumor, decompression of the spinal cord, chemotherapy, and radiation therapy.

Spinal cord compression from metastatic Ca is treated with

high dose dexamethasone and radiation to help relieve pain

Postoperative Nursing Interventions

Monitor patient for deterioration in neurological status Note: a sudden onset of neurological deficit is an

ominous sign and should be treated as an emergency. It may be due to vertebral collapse associated with

spinal cord infarction. Respiratory function: Assess for rate and quality of

breath sounds, manage artificial airway if present, and encourage pulmonary toilet.

Bladder: Palpate for urinary retention or urinary incontinence. Monitor intake and output.

Assist with pain management.

Postoperative Nursing Interventions cont’d

Positioning - keep flat, log roll when turning. Patient may be more comfortable on side. Avoid extreme knee flexion.

Monitor wound for CSF leakage - can lead to serious infection and severe pain

Herniation of an Intervertebral Disc

The intervertebral disc is a cartilaginous plate that forms a cushion between vertebral bodies.

This tough, fibrous material is incorporated in a capsule.

A ball-like cushion in the center of the disc is called the nucleus pulposus.

Herniation occurs when the nucleus of the disc protrudes into the fibrous ring causing nerve compression.

Can occur related to degenerative changes or trauma

Herniation of an IV Disc cont’d

Manifestation depends on:• location• rate of development (acute vs. chronic)• effect on surrounding structures

Herniation of a Cervical IV Disc

The cervical spine is subjected to stresses that result from disc degeneration (from aging, occupational stresses), and spondylosis (degenerative changes occurring in disc and adjacent vertebral bodies).

Cervical disc herniation usually occurs at the C5-C6 and C6-C7 interspaces.

Pain and stiffness may occur in the neck, the top of the shoulders, the region of the scapulae, in the upper extremities, head, and may be accompanied by numbness of the upper extremities.

Diagnosis of cervical disc herniation is confirmed on MRI.

Management of Herniation of a Cervical IV Disc

The goals of treatment are (1) rest and immobilization of cervical spine and (2) reduce inflammation of supportive tissue and affected nerve roots

Management may include:• Immobilization• Traction• Pain Relief - moist heat, analgesics, sedatives,

muscle relaxants, anti-inflammatories, corticosteroids

• Surgical repair of injured spine

Herniation of a Lumbar Disc

Most lumbar disc herniations occur at the L4-L5 or L5-S1 interspaces.

Typically produces low back pain accompanied by various degrees of sensory and motor impairment.

Patient presents with low back pain and muscle spasms, followed by radiation of the pain into one hip and traveling down the leg (sciatica).

Pain is aggravated by actions that increase intraspinal fluid pressure

Pain is usually relieved by bed rest. Diagnosis by MRI - if symptoms and pathology don’t

match, then confirmation with CT or myelogram

Management of Herniation of a Lumbar Disc

The goals of treatment are (1) reduce pain, (2) slow progression of the disease, and (3) increase functional abilities.

Management may include:• Bed rest - firm mattress• Position of comfort - usually semi-fowler’s

with modest hip and knee flexion• Muscle relaxants, anti-inflammatories,

corticosteroids• Moist heat

Disc Surgery

Surgical excision of a herniated disc is performed when there is evidence of a progressing neurological deficit (muscle weakness and atrophy, loss of sensory and motor function, loss of sphincter control), and continuing pain and sciatica that is not responsive to medical management.

The goal of surgical management is to lessen the pressure on the nerve root to relieve pain and reverse neurological deficits.

Disc Surgery cont’d

Diskectomy - removal of herniated or extruded fragments of intervertebral disc.

Laminectomy - removal of the lamina to expose the neural elements in the spinal canal; allows the surgeon to inspect the spinal cord, identify and remove tissue for pathology, and relieve compression of the cord and roots.

Laminotomy - division of the lamina of a vertebra Diskectomy with fusion - a bone graft (from iliac crest or

bone bank) is used to fuse the vertebral spinous processes; the object of spinal fusion is to bridge over the defective disc to stabilize the spine and reduce the rate of recurrence.

Disc Surgery cont’d

Preoperative Management includes evaluation of movement in extremities plus bowel and bladder function.

Patient is taught useful techniques such as log-rolling, pulmonary toilet, and muscle-setting (isometric) exercises, which will help to maintain muscle tone postoperatively.

Disc Surgery cont’d

Post-operative Management includes:• Frequent neurological checks, along with

vascular supply checks to extremities.• Sitting is discouraged• Position patient using a pillow under the head,

and the knee rest is slightly elevated. When patient lying on side, avoid excessive knee flexion

• Encouraged to move from side to side by log rolling

Complications of Disc Surgery

Arachnoiditis - inflammation of the arachnoid membrane. Causes diffuse frequent burning pain in lower back radiating to buttocks

Failed Disc Syndrome - recurrence of sciatica after surgery

Bleeding and hematoma formation Fixing one level may cause problems at other

levels Recurrence of herniation