Spinal cord injury

Spinal cord injury

1. SPINAL CORD INJURY

2. Spinal cord syndromes??? Causes of spinal cord injury??? Spinal plexus???? Immediate management??

3. CASE A 42-year-old male was admitted to emergency department after a motor vehicle accident. His complaint was back pain and was unable to move both lower limbs. Upon physical examination, the patient was not ambulatory. Sensory examination revealed the absence of sensation below the T12 level. The strength of the bilateral lower limbs was grade 0. The patient received a radiographic evaluation. The initial diagnosis was T11 fracture with complete paraplegia of the lower limbs. Sagittal MRI demonstrated an isointense lesion on T1-weighted imaging and a high-signal spindle-like lesion on T2-weighted imaging of the spinal cord adjacent to the T11 vertebra. The patient was ultimately diagnosed with complete paraplegia with a T11 butterfly vertebra. He underwent urgent posterior decompressive and fixation surgery from T10 to T12. His postoperative recovery was uneventful.

4. Butterfly vertebra

5. DEFINITION Spinal cord injury (SCI) is caused by trauma or damage to the spinal cord. It can result in either a temporary or permanent alteration in the function of the spinal cord.

6. INCIDENCE AND PREVALENCE In India, approximately 1.5 million people live with SCI. Approximate 20,000 new cases of SCI are added every year and 60-70% of them are illiterate, poor villagers. Majority of them are males in the age group of 16-30 years, signifying higher incidence in young, active and productive population of the society.

7. RISK FACTORS OF SPINAL CORD INJURY Gender- Male > Female (80:20) Age – 16 to 30 years and older than 65 years Diving into too-shallow water or playing sports without wearing the proper safety gear or taking proper precautions Motor vehicle accidents Having a bone or joint disorder

8. CAUSES OF SPINAL CORD INJURY Tumours Falls Infections Gunshot Injuries Blunt Assault Road traffic accidents Vertebral fractures secondary to osteoporosis Stab Wounds Sport Injuries Vascular disorders Development disorders

9. The initial mechanical disruption of axons as a result of stretch or laceration is referred to as the primary injury.

10. CLASSIFICATION OF SPINAL CORD INJURY SCIs are classified by the: (1) Mechanism of injury (2) Level of injury (3) Degree of injury

11. JEFFERSON FRACTURE

12. CLINICAL MANIFESTATIONS The manifestations of SCI are generally the direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection. Manifestations of SCI are related to the level and degree of injury. The patient with an incomplete injury may demonstrate a mixture of manifestations. The higher the injury, the more serious the sequelae because of the proximity of the cervical cord to the medulla and brainstem

13. OTHER TYPES OF INJURY

14. RESPIRATORY SYSTEM- Respiratory insufficiency, hypoventilation, decrease in vital capacity and tidal volume, impairment of the intercostal muscles. CARDIOVASCULAR SYSTEM- Decreased cardiac output, resulting in hypotension. IV fluids or vasopressor drugs may be required to support the BP. URINARY SYSTEM- The bladder is atonic and becomes over distended.

15. GASTROINTESTINAL SYSTEM- Decreased or increase GI motor activity contributes to the development of paralytic ileus and gastric distention. INTEGUMENTARY SYSTEM- Skin breakdown over bony prominences in areas of decreased or absent sensation. THERMOREGULATION- Spinal cord disruption there is also decreased ability to sweat or shiver below the level of injury, which also affects the ability to regulate body temperature.

16. METABOLIC NEEDS- The person with an SCI has greater nutritional needs than other patients who are immobilized. A high-protein diet helps prevent skin breakdown and infections and decreases the rate of muscle atrophy. MUSCLE SPASM- Emotion and cutaneous stimulation may initiate spastic movement. AUTOGENIC DYSREFLEXIA- It is a cluster of clinical manifestation that result in multiple spinal cord autonomic response discharge simultaneously.

17. DIAGNOSTIC TEST History collection Physical examination Neurological examination CT and MRI Cervical X-ray CT angiogram

18. COLLABORATIVE CARE Immediate post injury goals include maintaining a patent airway, adequate ventilation, and adequate circulating blood volume and preventing extension of cord damage (secondary injury).

19. Emergency management of the patient with an SCI- Assessment Findings • Pain, tenderness, deformities, or muscle spasms adjacent to vertebral column • Numbness, paraesthesia • Alterations in sensation: temperature, light touch, deep pressure • Weakness or heaviness in limbs • Weakness, paralysis, or flaccidity of muscles

20. Spinal shock Cuts; bruises; open wounds over-head, face, neck, or back Neurogenic shock: hypotension, bradycardia, dry, flushed skin Bowel and bladder incontinence Urinary retention Difficulty breathing Diminished rectal sphincter tone

21. Interventions • Ensure patent airway. • Immobilize and stabilize cervical spine. • Administer O2 via nasal cannula or non-rebreather mask. • Establish IV access with two large-bore catheters to infuse normal saline or lactated Ringer’s solution as appropriate. • Assess for other injuries. • Control external bleeding. • Obtain CT scan or cervical spine x-rays. • Ongoing Monitoring

22. • Monitor vital signs, level of consciousness, O2 saturation, cardiac rhythm, urine output. • Keep warm. • Monitor for urinary retention, hypertension. • Anticipate need for intubation if gag reflex absent. • Systemic and neurogenic shock must be treated to maintain BP. For injury at the cervical level, all body systems must be maintained until the full extent of the damage can be evaluated.

23. NON-OPERATIVE STABILIZATION Traction or realignment Stabilization methods eliminate damaging motion at the injury site. These methods are intended to prevent secondary spinal cord damage caused by repeated contusion or compression.

24. DRUG THERAPY Methylprednisolone Low-molecular-weight heparin (e.g., enoxaparin) is used to prevent VTE unless contraindicated. Vasopressor agents such as dopamine (Inotropic) are used in the acute phase as adjuvants to treatment. Analgesic (Tramadol) to reduce the pain.

25. SURGICAL THERAPY Criteria used in the decision for early surgery include : (1) Evidence of cord compression (2) Progressive neurologic deficit (3) Compound fracture of the vertebrae (4) Bony fragments (may dislodge and penetrate the cord) (5) Penetrating wounds of the spinal cord or surrounding structures

26. A fusion procedure involves attaching metal screws, plates, or other devices to the bones of the spine to help keep them properly aligned.

27. NURSING DIAGNOSIS Ineffective breathing pattern related to respiratory muscle fatigue, neuromuscular paralysis, and retained secretions as evidence by altered respiratory rate. Chronic pain related to spinal cord injury as evidence by immobilization, facial expression and verbal explanation of client. Impaired physical mobility related to spinal cord injury as evidenced by inability to move upper or lower extremities, secondary to paralysis.

28. Impaired skin integrity related to immobility and poor tissue perfusion as evidence by presence of bed sore. Impaired urinary elimination related to spinal injury and/ or limited fluid intake as evidence by decreased urine output.

29. COMPLICATIONS OF SPINAL CORD INJURY • Urinary tract infection or urinary incontinence • Bowel incontinence • Pressure sore • Lung infection • Blood clot • Muscle spasm • Chronic pain and depression • Breathing difficulty • Impaired activities of daily living

30. Rehabilitation of spinal cord injury Initiate range of motion exercises of all joints within the first week after injury and continue throughout the acute phase. Strengthening Exercises. Seating and Positioning. Mobilization, including bed mobility, transfer training, relevant locomotion (gait or wheelchair). Splinting - Upper and Lower Extremity. Respiratory Interventions including percussion, vibration, suctioning, postural drainage, mobilization, training of accessory muscles, cough, and deep breathing exercises.

31. Functional communication. Assessment of swallowing. Assessment of cognitive and/or language deficits from concomitant traumatic brain injury. Nutritional Status including anthropometric measurements, dietary intake and losses, nutrition- and hydration-related blood work, ability to self-feed or dependence on others for eating and drinking and other barriers to optimal food and fluid intake Educate patients and families about the rehabilitation process and encourage their participation in discharge planning discussions.

32. Contextualizing the lived experience of quality of life for persons with spinal cord injury: A mixed-methods application of the response shift model A mixed-method study, applying the Schwartz and Sprangers response shift (RS) model was conducted to gain greater insight into individuals’ quality of life (QOL) definitions, appraisals, and adaptations following spinal cord injury (SCI) in community dwelling participants. RS is a cognitive process wherein, in response to a change in health status, individuals change internal standards, values, or conceptualization of QOL. A purposive sample of 40 participants with SCI completed semi-structured interviews and accompanying quantitative measures. Four RS themes were identified. The themes ranged from complete RS, indicating active engagement in maintaining QOL, to awareness and comparisons redefining QOL, to a relative lack of RS. The study concluded that the RS model contextualizes differences in QOL definitions, appraisals, and adaptations in a way standardized QOL measures alone do not.

33. A Cross Sectional Study of Spinal Cord Injury-Induced Musculoskeletal Pain A cross-sectional study was conducted by Mohammad Kamrujjaman in 2019 to determine the spinal cord injury-induced musculoskeletal pain in Dhaka city on 90 spinal cord injury subjects. Numerical Pain Rating Scale was used to assess the grade of musculoskeletal pain and American Spinal Injury Association scale was used to find out the types of injury. The study concluded that more than two-third of the person with spinal cord injury complained to musculoskeletal pain. Neck, shoulder, and back were the more prevalent site of musculoskeletal pain. Road traffic accident and fall from height were the common causes of injury. Cervical and thoracic levels were the vulnerable site in person with spinal cord injury. However, there was a highly significant relationship found between the level of injury and musculoskeletal pain. The prevalence of musculoskeletal pain is extremely high in person with spinal cord injury. Some factors like spinal levels and causes of injury are significantly accountable for musculoskeletal pain. Adequate physiotherapy might help to reduce the incidence and intensity of spinal cord injury-induced musculoskeletal pain.

34. CONCLUSION Brain and spinal cord injury are most complex injuries the human can endure. Nurses who have to look after neurologically impaired patients must develop and maintain assessment skills to detect the suitable signs of neurologic deterioration. The physical and psychological impairment vary with the degree of damage as well as the client response to and ability to cope with the body changes. It is imperative that nurse comprehend the severity of the client dysfunction as it relates to quality of life as well as its impact on family dynamics.