Spinal cord injury

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1. Spinal cord injury RATHEESH R L

2. definition A spinal cord injury refers to any injury to the spinal cord that is caused by trauma instead of disease.

3. etiology Trauma (automobile or motor cycle accidents, gunshot or knife wounds, falls and sports mishaps) Vertebrae most commonly involved are the 5 th , 6 th and 7 th cervical vertebrae, 12 th thoracic vertebrae and 1 st lumbar vertebrae

4. classification Mechanism of injury Level of injury Degree of injury

5. Mechanism of injury Flexion rotation injuries Hyper extension injuries Compression injuries

6. Flexion rotation injuries Occurs when the head strikes the steering wheel, the spine is forced into acute hyper flexion Rupture of posterior ligaments results in forward dislocation of the vertebrae Cervical spine usually affected are the C5 to C6 level

7. Hyper extension injuries Results after a fall in which the chin hits an object and the head is thrown back Anterior ligament is ruptured with fracture of the posterior elements of the vertebral body Greatest area of stress is at the C4 and C5

8. Compression injuries Caused by falls or jumps in which the person lands directly on the head, sacrum or feet Force of impact fractures the vertebrae and the fragments compress the cord Lumbar and lower thoracic vertebrae are usually affected

9. Level of injury Skeletal level Neurologic level

10. Degree of injury Complete cord injury - Results in total loss of sensory and motor function below the level of injury Incomplete cord injury - mixed loss of voluntary motor activity and sensation and leaves some tracts intact

11. Incomplete injury Central cord syndrome Anterior cord syndrome Brown sequard syndrome Posterior cord syndrome Conus medullaris and cauda equina syndrome

12. Central cord syndrome Damage to central spinal cord Occurs most commonly in the cervical region Motor weakness and sensory loss are present in both upper and lower extremities

13. Anterior cord syndrome Caused by damage to anterior spinal artery Results from injury causing compression of anterior portion of the spinal cord(flexion injury) Paralysis and loss of pain and temperature sensation below the level of injury Sensation of touch, position and vibration remains intact

14. Brown sequard syndrome Result of damage to one half of the spinal cord(knife or missile injury) Ipsilateral paralysis with ipsilateral loss of touch and pressure and contralateral loss of pain and temperature

15. Posterior cord syndrome Results from damage to the posterior spinal artery Dorsal columns are damaged resulting in loss of proprioception Pain, temperature and motor function below the level of lesion remains intact

16. Conus medullaris and cauda equina syndrome Result from damage to the very lowest portion of the spinal cord ( conus ) and the lumbar and sacral nerve roots( cauda equina ) Flaccid paralysis of the lower limbs and areflexia (flaccid bladder and bowel)

17. Clinical manifestations Respiratory system Injury below the level of C4 diaphragmatic breathing hypoventilation Cervical and thoracic injuries paralysis of abdominal and intercostal muscles patient cannot cough effectively to remove secretions atelectasis and pneumonia Neurogenic pulmonary edema

18. Clinical manifestations… Cardio vascular system Injury above the level of T6 decreases the influence of sympathetic nervous system bradycardia occurs peripheral vasodilation reduces return of blood to the heart Decreases cardiac output hypotension

19. Clinical manifestations… Urinary system Urinary retention (loss of sensation and decreased reflexes)

20. Clinical manifestations… Gastrointestinal system Injury above the level of T5 decreased gastro intestinal motility development of paralytic ileus and gastric distension Development of stress ulcers Intra abdominal bleeding Less voluntary control over the bowel neurogenic bowel(bowel is arereflexic and sphincter tone is decreased)

21. Clinical manifestations… Problems with thermoregulation Poikilothermism is lost in spinal cord injuries Decreased ability to sweat or shiver below the level of the lesion Patients with high cervical injury have a greater loss of ability to regulate temperature

22. Clinical manifestations… Peripheral vascular problems Deep vein thrombosis(during the first 3 months)

23. Clinical manifestations… Spinal shock and neurogenic shock Spinal shock - Temporary loss of neurologic function characterized by decreased reflexes, loss of sensation and flaccid paralysis below the level of injury - syndrome lasts days to months

24. Neurogenic shock - Effects are associated with cervical or high thoracic injury - Due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia - peripheral vasodilation decreased cardiac output

25. Diagnostic measures History and physical examination X ray spine CT scan MRI scan Vertebral angiography

26. complications Neurologic deterioration Pressure sores Pulmonary complications - Atelectasis - Increased work of breathing - Decrease cough retained secretions Pneumonia - Muscle fatigue

27. Complications…. Neurogenic bladder - Include urgency, frequency, incontinence, inability to void and high bladder pressure resulting in reflux of urine into the kidneys Neurogenic bowel - Voluntary control of bowel evacuation is lost

28. Complications…. -Hypertension - Throbbing headache - Marked diaphoresis above the level of the lesion - Bradycardia - flushing of the skin above the level of the lesion - pale extremities below the level of the lesion

29. complications Loss of circulatory control Muscle tone problems - Spastic and flaccid muscles

30. management Initial care Neck should be stabilized in a neutral position without flexion or extension Place the affected person on a spine board and secure the spine with a hard collar around the neck

31. Initial care…… Log rolling technique Maintain a patent airway Mechanically assisted ventilation patients with severe cervical injury, placed in skeletal traction

32. management Drug therapy Methyl prednisolone (effective if given within 8 hours of injury) Loading dose of 30mg|kg given within 3 hours of injury followed by 24 hours of 5.4mg|kg IV methyl prednisolone drip Vasopressor agents (dopamine) Histamine 2 receptor blocking agents

33. management Managing respiratory dysfunction If the injury is at or above C3 endotracheal intubation and mechanical ventilation Chest physiotherapy, adequate oxygenation and pain management Use of incentive spirometry

34. management Managing cardiovascular instability In case of bradycardia, administer anticholinergic (atropine) Hypotension managed with dopamine infusion Compression gradient stockings to prevent DVT If severe blood loss has occurred, blood should be administered according to protocol

35. management Fluid and nutritional balance First 48 to 72 hours after SCI GI tract may stop functioning (paralytic ileus ) NG tube insertion for gastric decompression Introduce oral foods and fluids once the bowel sounds returns In patients with high cervical injuries swallowing capacity must be evaluated Increased dietary fiber

36. management Temperature control Monitor body temperature Monitor the environment closely to maintain appropriate temperature Patient should not be overloaded with covers or unduly exposed

37. management Managing stress ulcers Stool and gastric contents are tested daily for blood Give corticosteroids along with antacids H2 receptor blockers or proton pump inhibitors

38. management Bladder and bowel management Insertion of indwelling catheter After patient is stabilized, start intermittent catheterization Suppository should be inserted daily Increased fiber intake

39. Nursing diagnosis Ineffective breathing pattern related to weakness or paralysis of abdominal and intercostal muscles Impaired physical mobility related to motor and sensory impairments Disturbed sensory perception related to motor and sensory impairment Impaired urinary elimination related to inability to void spontaneously Constipation related to presence of atonic bowel

40. Nursing diagnosis Risk for impaired skin integrity related to immobility Risk for autonomic dysreflexia related to reflex stimulation of sympathetic nervous system after spinal shock resolves