Spinal cord injury (SCI)

A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury.

1. SPINAL CORD INJURY BY SACHIN DWIVEDI KING GEORGE’S MEDICAL UNIVERSITY, COLLEGE OF NURSING, LUCKNOW

2. ANATOMY AND PHYSIOLOGY Originates in the brainstem, passes through the foramen magnum, and continues through to the conus medullaris near the L2 before terminating in filum terminale . Contains cerebrospinal fluid . 45 cm (18 in) in men ,43  cm (17 in) long in women. 13 mm (1⁄2 in) in the cervical and lumbar regions to 6.4 mm (1⁄4 in) in the thoracic area .

3. Cont.… 31 pairs of spinal Nerve.( C1–C8 ),( T1–T12 ), (L1–L5 ), (S1–S5 ) and Co1. Spinal meninges: Dura, Arachnoid. And Pia matter. External surface: Conus medularis (L1-L2) cauda equina   (L3-L5) Spinal Tissue: Gray Matter (neuronal cell bodies, dendrites, axons and glial cells ) White Matter (Myelinated Axon) Dorsal Root (afferent sensory root ) Ventral Root(Efferent motor root ). Important Function: Conduction pathway for impulses.(Efferent and Afferent Root) Serving as a reflex center.(Reflex Arc)

4. Nerve Plexus N erve plexus is a network of intersecting nerves. Cervical Plexus(C1-C4)— Serves the Head, Neck and Shoulders. Brachial Plexus(C5-T1)—Serves the Chest, Shoulders, Arms and Hands. Lumbar Plexus(L1-L4)— Serves the Back, Abdomen, Groin, Thighs, Knees, and Calves. Sacral Plexus(L5-S4)— Serves the Pelvis, Buttocks, Genitals, Thighs, Calves, and Feet. Coccygeal Plexus(S5-Co1)—Serves a Small Region over the Coccyx.

5. DEFINITION Spinal cord injury (SCI) is damage to the spinal cord that results in a loss of function such as mobility or feeling. A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury.

6. Incidence SCI is highest among persons age 16-30, in whom 53.1 percent of injuries. Males represent 81.2 percent of all reported SCIs and 89.8 percent of all sports-related SCIs. Among both genders, auto accidents, falls and gunshots are the three leading causes of SCI. Sports and recreation-related SCI injuries primarily affect people under age 29.

7. Causes

8. TYPES OF SPINAL CORD INJURY

9. INCOMPLETE SCI

10. Complete Spinal Cord Injuries Tetraplegia(Quadriplegia):- Spinal cord injury above the first thoracic vertebra, or within the cervical sections of C1-C8. result is some degree of paralysis in all four limbs—the legs and arms . Paraplegia : Spinal cord injuries below the first thoracic spinal levels (T1-L5). Paraplegics are able to fully use their arms and hands, but the degree to which their legs are disabled depends on the injury. Complete paraplegia: It is described as permanent loss of motor and nerve function at T1 level or below, resulting in loss of sensation and movement in the legs, bowel, bladder, and sexual region .

11. CENTRAL CORD SYNDROME Cause: Injury or edema of the central cord, usually of the cervical area and cervical lesions . Characteristics: Motor deficits (in the upper extremities sensory loss varies in the upper extremities).

12. ANTERIOR CORD SYNDROME Cause: acute disk herniation associated with fracture-dislocation of vertebra and also occur injury to anterior spinal Artery and lesion. Characteristics : Loss of pain, temperature, and motor function is noted below the level of the lesion or injury; light touch, position, and vibration sensation remain intact.

13. POSTIRIOR CORD SYNDROME Cause: an infarct in the posterior spinal artery and is caused by lesions on the posterior portion of the spinal cord, Characteristics: loss of proprioceptive sensation, fine touch, pressure, and vibration below the lesion; deep tendon areflexia .

14. Brown- Sequard syndrome Known as Lateral Cord Syndrome. Cause : The lesion is caused by a transverse hemisection of the cord, as a result of a knife or missile injury, fracture dislocation of a unilateral articular process. Characteristics: Ipsilateral paralysis or paresis is noted, together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature.

15. Conas Medularis syndrome Known as Lateral Cord Syndrome. Cause : blow to the back- such as Gunshot and spinal tumor. Characteristics: Bowel and bladder dysfunction, Flaccid lower extremities. Sexual dysfunction.

16. Cauda Equina Syndrome Known as Horse tail Syndrome. Cause : Injury or lesion at the lumbosacral nerve root below the conus medulararis . Characteristics: Areflexia loss of reflexes(Lower Extremities). Leg weakness Bladder/bowel dysfunction

17. PATHOPHYSIOLOGY

18. SIGNS AND SYMPTOMS

19. CLINICAL MANIFESTATION Spinal Shock Autonomic Dysreflexia Pain Breathing difficulty Sensitivity to stimuli Muscle spasms Loss of sensation Loss of reflex function Loss of autonomic activity Loss of bowel control Loss of bladder control Sexual dysfunction Loss of function, such as mobility or sensation

20. CERVICAL (NECK) INJURIES Breathing difficulties Loss of normal bowel and bladder control Numbness Sensory changes Spasticity (increased muscle tone)

21. THORACIC (CHEST LEVEL) INJURIES Loss of normal bowel and bladder control Numbness Sensory changes Spasticity (increased muscle tone) Weakness , paralysis

22. LUMBAR SACRAL (LOWER BACK) INJURIES Loss of normal bowel and bladder control (you may have constipation, leakage, and bladder spasms ) Numbness Pain Sensory changes Weakness and paralysis

23. ASSESSMENT

24. DIAGNOSTIC TESTS  Complete blood count (e.g. Hb, RBC, WBC)  Arterial blood gas level PaO2:85-95 mm of Hg PaCO2:35-45 mm of Hg

25. X- RAYS:

26. COMPUTERIZED TOMOGRAPHY (CT) SCANS

27. MAGNETIC RESONANCE IMAGING (MRI):

28. MYEL O GRAP H Y :

29. MEDICAL MANAGEMENT:  Whole blood  NS  RL  Hydrocortisone: Action : steroids

30.  Nor epinephrine action: adrenergic drug  Epinephrine action: α and β adrenergic drug  Dopamine action: adrenergic, anti shock drug

31. EMEGENCY MANAGEMENT Initial treatment of patients with cord injury focuses on two aspects -preventing further damage and resuscitation . I mmobilization with a hard cervical collar (in case of cervical spine injuries) and care in transportation of patient is of paramount importance if the spine is unstable . Resuscitation is aimed at airway maintenance, adequate oxygen saturation of peripheral blood, restoring blood pressure to acceptable limits, preventing bradycardia , done simultaneously to prevent any ischemic damage to the already compromised cord.

32. SURGICAL MANAGEMENT

33. NURSING MANAGEMENT:

34. NURSING DIAGNOSIS Impaired physical mobility related to loss of motor function Fluid volume deficit related to decrease LOC Risk for injury related to loss of motor function. Urinary retention related to level of injury Risk for Impaired skin integrity related to trauma Knowledge deficit regarding the treatment modalities and current situation. Anxiety related to outcome of diseases as evidenced by poor concentration on work, isolation from others, rude behavior

35. NURSING MANAGEMENT OF PATIENT WITH SPINAL CORD INJURY Goal Resuscitation according to ATLS guidelines Determination of neurological injury Prevention of neurological deterioration Ongoing assessment and treatment of associated injuries Prevention of complications Initiation of definitive management for vertebral column injury.

36. Respiratory management Closely monitor the patient’s respiratory rate, depth, and pattern, staying alert for paradoxical breathing. Maintain  continuous pulse oximetry ; when possible, use end-tidal capnography  as part of routine monitoring . Intubation.  Patients with respiratory failure require mechanical ventilation. If your patient needs intubation, take care to maintain spinal alignment by using a cervical collar, manual inline traction,  Many patients with injuries at the C3 vertebral level or higher are ventilator dependent. Those with an intact phrenic nerve may qualify for diaphragmatic pacer implantation, which may allow weaning from mechanical ventilation.

37. Cardiovascular management Patients with significant cervical and high thoracic injuries (T6 level and above) may develop N eurogenic  shock. Caused by loss of sympathetic tone, this distributive shock state results in vasodilation, profound  bradycardia , and hypothermia. Hypotension ,  temperature dysregulation , venous stasis, and autonomic   dysregulation (AD) may occur .

38. GI management Acute GI problems in SCI patients may include paralytic ileus with associated abdominal distention, gastric ulcers, and constipation . Monitor the patient’s bowel sounds and abdominal distention at least every 4 hours. If indicated and ordered, insert a decompressive  gastric tube to reduce aspiration risk and restore diaphragm position and lung size to normal . To aid bowel regulation , the patient may need a bowel regimen of stool softeners and a high-fiber diet along with low-volume enemas, glycerin, or bisacodyl suppositories or digital rectal stimulation to cause reflexive evacuation after the morning meal.

39. Genitourinary management A patient in neurogenic shock experiences abrupt loss of voluntary muscle control and reflexes, resulting in acute urinary retention . An indwelling urinary catheter must be placed to decompress the bladder and allow close urinary output monitoring. SCI can cause neurogenic or  aneurogenic bladder. • In  neurogenic  bladder, reflex-initiated voiding may occur when the patient has a full bladder. • In  aneurogenic   bladder, such voiding doesn’t occur, potentially causing overflow urine leakage. Planned intermittent catheterization  can reduce incontinence. Longterm  bladder management varies with the patient’s bladder type, needs, and lifestyle.

40. Musculoskeletal management Patients with SCIs typically experience muscle spasticity as spinal shock recedes and reflexes return.  Nonpharmacologic strategies to manage spasticity include R ange- ofmotion  exercises , P ositioning techniques, W eight-bearing exercises,  electrical stimulation , and orthoses  or splinting to prevent loss of muscle length and contractures. Pharmacologic  therapy may include baclofen, benzodiazepines, alpha2-adrenergic agonists, and regional botulism toxin or phenol injection.

41. Dermatologic management Prevention and early detection are the cornerstones of pressureulcer  management. an established skin risk assessment tool, such as the Braden scale.    turning the patient every 2 hours or more (depending on risk assessment findings) avoiding positioning the patient on bony prominences , such as the trochanters, sacrum, and  heels minimizing moisture frequently inspecting the skin under braces and splints establishing a pressure-release regimen (manual or automated) for wheelchair sitting

42. REHABILITATION  Cognitive Rehabilitation Therapy  Speech Therapy  Mental Rehabilitation  Physical Exercise  Occupational Therapy

43. POSSIBLE COMPLICATIONS  Blood pressure changes - can be extreme (autonomic hyperreflexia)  Chronic kidney disease  Complications of immobility: Deep vein thrombosis Pulmonary infections Skin breakdown  Contractures

44. Increased risk of urinary tract infections Loss of bladder control Loss of bowel control Loss of sensation Loss of sexual functioning (male impotence) Muscle spasticity Paralysis of breathing muscles Paralysis (paraplegia, quadriplegia) Pressure sores

45. THANK YOU