Spinal cord injury

my post graduate report on SCI

1.  Spinal cord injury (SCI) is a traumatic injury to the spinal cord that may vary from a mild cord concussion with
transient numbness to immediate and complete tetraplegia.
 Injury to the spinal cord may result in loss of function below
the level of cord injury
 Either caused by trauma(MVA) or disease (Cancer).
Statistics (WHO 2013)
 Every year, around the world, between 250 000 and 500 000 people
suffer a spinal cord injury (SCI).
 The majority of spinal cord injuries are due to preventable causes
such as road traffic crashes, falls or violence.
 People with a spinal cord injury are two to five times more likely to
die prematurely than people without a spinal cord injury, with worse
survival rates in low- and middle-income countries.
 Spinal cord injury is associated with lower rates of school enrollment
and economic participation, and it carries substantial individual and
societal costs.

2. Common causes of spinal cord injury
 Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for more than
35 percent of new spinal cord injuries each year.
 Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause more than one-quarter of spinal cord
injuries.
 Acts of violence. Around 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife
wounds, according to the National Spinal Cord Injury Statistical Center.
 Sports and recreation injuries. Athletic activities, such as impact sports and diving in shallow water, cause about 9 percent of
spinal cord injuries.
 Alcohol. Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
 Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

3. The International Standards for Neurological Classification of Spinal Cord Injury, promoted by the American Spinal Injury
Association (ASIA), are used (available at http://www.asia-spinalinjury.org/publications/index.html). The ASIA Impairment
Scale is based upon completeness of injury and motor/sensory function.
ASIA A = Complete; absent sensory and motor function at S4-5.
ASIA B = Incomplete; intact sensory but absent motor function below the neurologic level of injury (LOI) and includes level
S4-5.
ASIA C = Incomplete; intact motor function distal to neurologic LOI, and more than half of key muscles distal to LOI have
muscle grade less than 3.
ASIA D = Incomplete; intact motor function distal to neurologic LOI, and more than half of key muscles distal to LOI have
muscle grade greater than or equal to 3.
ASIA E = Normal; intact motor and sensory function.

Risk factors
Although a spinal cord injury is usually the result of an accident and can happen to anyone, certain factors may predispose you to a
higher risk of sustaining a spinal cord injury, including:

4.  Being male. Spinal cord injuries affect a disproportionate amount of men. In fact, females account for only about 20 percent
of traumatic spinal cord injuries in the United States.
 Being between the ages of 16 and 30. You're most likely to suffer a traumatic spinal cord injury if you're between the ages of
16 and 30.
 Being older than 65. Falls cause most injuries in older adults.
 Engaging in risky behavior. Diving into too-shallow water or playing sports without wearing the proper safety gear or taking
proper precautions can lead to spinal cord injuries. Motor vehicle crashes are the leading cause of spinal cord injuries for people
under 65.
 Having a bone or joint disorder. A relatively minor injury can cause a spinal cord injury if you have another disorder that
affects your bones or joints, such as arthritis or osteoporosis.
Pathophysiology
 The pathophysiology of spinal cord injury can be categorized as acute impact or compression.
 Acute impact injury is a concussion of the spinal cord. This type of injury initiates a cascade of events focused in the gray matter,
and results in hemorrhagic necrosis. The initiating event is a hypoperfusion of the gray matter. Increases in intracellular calcium
and reperfusion injury play key roles in cellular injury, and occur early after injury. The extent of necrosis is contingent on the
amount of initial force of trauma, but also involves concomitant compression, perfusion pressures and blood flow, and
administration of pharmacological agents. Preventing or quelling this cascade of events must involve mechanisms occurring in
the initial stages.

5.  Spinal cord compression occurs when a mass impinges on the spinal cord causing increased parenchymal pressure. The tissue
response is gliosis, demyelination, and axonal loss. This occurs in the white matter, whereas gray matter structures are
preserved. Rapid or a critical degree of compression will result in collapse of the venous side of the microvasculature, resulting
in vasogenic edema. Vasogenic edema exacerbates parenchymal pressure, and may lead to rapid progression of disfunction.
Signs and Symptoms
According to the Severity of the Injury
 Complete. If almost all feeling (sensory) and all ability to control movement (motor function) are lost below the spinal cord injury,
your injury is called complete.
 Incomplete. If you have some motor or sensory function below the affected area, your injury is called incomplete.
According to the Paralysis affected
 Tetraplegia. Also known as quadriplegia, this means your arms, hands, trunk, legs and pelvic organs are all affected by your
spinal cord injury.
 Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.
Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:
 Loss of movement
 Loss of sensation, including the ability to feel heat, cold and touch
 Loss of bowel or bladder control

6.  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
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
Complications
 Bladder control. Your bladder will continue to store urine from your kidneys. However, your brain may not be able to control
your bladder as well because the message carrier (the spinal cord) has been injured. The changes in bladder control increase
your risk of urinary tract infections. They also may cause kidney infections and kidney or bladder stones.

7.  Bowel control. Although your stomach and intestines work much like they did before your injury, control of your bowel
movements is often altered.
 Skin sensation. Below the neurological level of your injury, you may have lost part of or all skin sensations. Therefore, your skin
can't send a message to your brain when it's injured by certain things such as prolonged pressure, heat or cold.
 Circulatory control. A spinal cord injury may cause circulatory problems ranging from low blood pressure when you rise
(orthostatic hypotension) to swelling of your extremities. These circulation changes also may increase your risk of developing
blood clots, such as deep vein thrombosis or a pulmonary embolus. Another problem with circulatory control is a potentially
life-threatening rise in blood pressure (autonomic hyperreflexia).
 Respiratory system. Your injury may make it more difficult to breathe and cough if your abdominal and chest muscles are
affected. These include the diaphragm and the muscles in your chest wall and abdomen.
 Muscle tone. Some people with a spinal cord injury experience one of two types of muscle tone problems: uncontrolled
tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
 Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility may lead to
a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes.
 Sexual health. Sexuality, fertility and sexual function may be affected by spinal cord injury. Men may notice changes in erection
and ejaculation; women may notice changes in lubrication.
 Pain. Some people experience pain, such as muscle or joint pain, from overuse of particular muscle groups. Nerve pain, also
known as neuropathic or central pain, can occur after a spinal cord injury, especially in someone with an incomplete injury.

8.  Depression. Coping with all the changes spinal cord injury brings and living with pain causes some people to experience
depression.
Medical Management
 X-ray of spinal column include open mouth studies for adequate visualization of C1 and C2.
 MRI of spine to detect soft tissue injury, hemorrhage, edema, bony injury; syringomyelia (cystic degeneration in spinal cord)
may present as cord compression, syrinx (cavity) at the fracture site, and kyphosis at fracture site.
 Electrophysiologic monitoring to determine function of neural pathways.
 Urodynamic studies may include urine flow to detect bladder outlet obstruction and/or impaired bladder contractility;
cystometrogram to determine bladder sensation, compliance, and capacity; sphincter EMG and other studies. The gold
standard in urodynamics is to measure bladder and urethral pressure under fluoroscopy monitoring.
 If DVT or pulmonary emboli are suspected, an ultrasound of the lower extremity or ventilation/perfusion scan is performed
 Heterotopic ossification may be diagnosed in the inflammatory stages using ultrasound. Alkaline phosphatase and ESR are
typically elevated.
 Nutritional status should be assessed using nutritional history, anthropometric measurements, pre-albumin (half-life 12 to 36
hours) and transferrin (half-life 6 to 10 days).
 Total lymphocyte count and creatinine height index are also used to establish nutritional risk.

9. Therapeutic Plan
 Patients with spinal cord injuries typically are brought to the
emergency department. They should be kept immobilized
until they are assessed by a physician.
 If injury to the spinal cord is detected, the patient needs to remain immobilized.
Emergency Management
 involves careful monitoring of vital signs and airway and keeping the patient immobilized.
 Intubation and mechanical ventilation may be necessary
 Intravenous normal saline may be used for fluid replacement.
 Various medications to reduce the extent of injury, including intravenous methylprednisolone (a steroid), are currently being
researched.
Respiratory Management
 Patients with injuries above C4–5 have some degree of respiratory impairment.
 The patient may require a tracheostomy and continuous mechanical ventilation or require a ventilator only at night or when
fatigued.
 Some patients are able to breathe by using a phrenic nerve stimulator. This device, similar to a pacemaker, artificially stimulates
the phrenic nerve, causing the diaphragm to move.

10.  These patients use a mechanical ventilator at night. This lessens the stress on the phrenic nerve and removes the risk of the
system failing while the patient is asleep.
 Elective intubation and mechanical ventilation protect the patient from expending huge amounts of energy trying to breathe
 Feeling their breathing becoming more labored is terrifying to these patients, and they need to be reassured that it is
probably a temporary setback.
 As the edema recedes and the accessory muscles become stronger, the patient is weaned from the ventilator.
Gastrointestinal Management
 Absence of bowel sounds is a common finding on examination.
 Oral or enteral feedings are not started until bowel function resumes.
 The metabolic needs of the patients are influenced by the work of breathing and the extent of other injuries.


Genitourinary Management
 An indwelling urinary catheter is placed to prevent bladder distention and protect skin integrity until spinal shock resolves.
Immobilization

11.  The cervical spine may be immobilized with skeletal traction such as Crutchfield or Gardner-Wells tongs
 Some patients have a halo brace, a device that attaches to the skull with four small pins.
 The device keeps the head and neck immobile while fusion and healing take place.
 The advantage over traction is that the patient is not confined to bed.
Surgical Management
 The goal of surgery following spinal cord injury is to stabilize the bony elements of the spine and relieve pressure on the spinal
cord.
 Stabilization of the spine allows for earlier mobilization of the patient.
 This decreases the risk of complications from immobility and quickens the transition to a rehabilitation setting.
 Unstable thoracic and lumbar fractures may also be treated with surgical implantation of rods to stabilize the spine.
 It is more difficult to stabilize these areas in the postoperative recovery period.

NURSING CARE PLAN for the Patient with a Spinal Cord Injury

12. Nursing Diagnosis: Ineffective airway clearance related to ineffective cough and decreased muscle control
Expected Outcome Patient will maintain a clear airway as evidenced by clear breath sounds and SaO
2
90%.
Evaluation of Outcome Are breath sounds clear? Is SaO
2
90%?
Nursing Interventions Rationale Evaluative Outcomes

1. Monitor cough and lung sounds.

Patient may not have adequate muscle
strength to cough effectively
Is patient able to cough up secretions? Is
there evidence that secretions are
retained?
2. Suction patient PRN if unable to
cough effectively.
To keep the airway clear
Is suctioning effective in clearing
airway?
3. Once the patient is stable, try
assisting the patient to cough to
clear secretions. Gently push
upward and inward on the
patient’s chest while the patient
coughs as strongly as possible
This may help the patient clear secretions
without invasive suctioning.

This is similar to the Heimlich maneuver
but not as forceful
Does the assisted cough technique help
the patient to clear the airway?

13. Nursing Diagnosis: Total urinary incontinence related to spinal cord damage and no sensation to void and/or
inability to control flow of urine
Expected Outcomes Patient’s skin will be dry and free of urine; urine elimination will be controlled.
Evaluation of Outcomes Patient will be continent of urine, free of urinary infection (urine clear, yellow,
without burning on urination), and have dry and intact skin.
4. Provide humidified air and oral or
enteral fluids.
Humidification helps keep secretions thin
and mobile.
Are secretions thin and easily
expectorated?
Nursing Interventions Rationale Evaluative Outcomes
1. Assess patient’s ability to control
urination.
If patient has some control, a bladder
training program may be effective.
Is patient able to sense need to urinate? Is
any degree of control present?
2. Monitor appearance of urine,
temperature, and white cell count.
Cloudy urine, and an increase in
temperature and white cell count indicate
urinary tract infection.
Is urine clear, and temperature and white
blood cells within normal limits?
3. Implement a bladder training program Following a voiding schedule can help Is patient able to avoid incontinence with

14. Discharge Planning
Goal: to reduce hospital length of stay and unplanned readmission to hospital, and improve the co- ordination of services following
discharge from hospital.

Medications
 Anti-Hypertensive drugs and Vasodilators to reduce BP and heart rate especially in case of Autonomic Dysreflexia
utilizing set times for voiding. reduce incontinence. regular voiding?
4. Use bladder ultrasound to scan bladder
for residual urine
Incomplete voiding can increase risk for
urinary tract infection
Is patient effectively emptying
bladder?
5. Teach the patient or caregiver
self-catheterization as ordered, if bladder
training is not effective.
Intermittent self-catheterization is
associated with fewer complications than
an indwelling catheter.
Is patient able to perform
selfcatheterization correctly?
6. Consult with physician re Foley catheter
if patient is not a candidate for intermittent
self catheterization.
An indwelling catheter can increase risk
for infection, but may be necessary as a
last resort for some patients.
Is Foley catheter necessary? Are signs of
infection avoided?

15.  Antibiotics if infections are noted during hospitalization
 Muscle Relaxants are given to reduce spasticity of muscles
 NSAIDS are given to reduce pain and inflammation
Exercise
 Follow the exercise or rehabilitation treatment plan your healthcare provider prescribes. You may need to do special exercises to
keep muscles from shrinking.
 If your spinal cord injury has not affected your ability to move, follow activity restrictions, such as not driving.
 You may need to make arrangements for someone to be with you to help you with your daily activities.


Treatment
 You may need to continue a rehabilitation program after you leave the hospital to help you adjust to some of the functions you
may have lost due to the injury.
 Get plenty of rest while you’re recovering. Try to get at least 7 to 9 hours of sleep each night.
Health Teachings

16.  Teach family members and significant others how to manage the patient especially in the early stages that he/she needs total
dependence from them
 Instruct them for follow-up check ups and routine re-assessment of the patient especially at home
Observable Signs and Symptoms
 Call your healthcare provider right away if you have new or worsening:
 Trouble with muscle movements, such as swallowing, moving arms and legs
 Loss of bladder or bowel control
 Numbness
 Tingling
 Depression
 Redness, bumps, blisters, or sores on your skin
 Signs of infection around your surgical wound if you had surgery. These include:
o The area around your wound is more red or painful
o The wound area is very warm to touch
o You have blood, pus, or other fluid coming from your wound area
o You have a fever higher than 101.5째 F (38.6째 C)
o You have chills or muscle aches

Diet

17.  If your spinal cord injury has affected your ability to chew or swallow, you will need to make some changes in the foods you eat.
Ask your provider about the benefits of talking to a dietician to learn what foods you will be able to eat in a healthy diet.
 High-fiber diet for proper defecation.
Safety
 You may need to make changes to your home in order to use special equipment that will help you with your daily activities.
 Siderails at the bathroom and other non-dry places at the house.