INTRODUCTION: Injuries affecting the spinal cord commonly results from trauma, gunshot wounds and motor vehicle

accidents. Many cases of SCI are caused by falls, sports-related injury and minor trauma. The principal risk factors for SCI include age, gender, and alcohol and drug use. Males are affected four times more often than females. Over half of the victims are 16 to 30 years of age. The most common vertebrae involved in SCI are the 5th, 6th and 7th cervical, the 12th thoracic, and the 1st lumbar. These vertebrae are the most vulnerable because there is a greater range of mobility in the vertebral column in these areas. Damage to the spinal cord ranges from transient concussion, to contusion, laceration and compression of the cord substance, to complete transection of the cord. Injury can be categorized as primary which is usually permanent or secondary wherein nerve fibers swell and disintegrate as a result of ischemia, hypoxia, edema, and hemorrhagic lesions. The type of injury on the other hand, refers to the extent of injury to the spinal cord itself. Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central, lateral, anterior, or peripheral. A completespinal cord injury can result in paraplegia, which is paralysis of the lower body or quadriplegia which is the paralysis of all four extremities.

INCIDENCE: Most spinal cord trauma happens to young, healthy individuals. Men ages 15 - 35 are most commonly affected. The death rate tends to be higher in young children with spinal injuries.

RISK FACTORS: Participating in risky physical activities, not wearing protective gear during work or play, or diving into shallow water. Older people with weakened spines (from osteoporosis) may be more likely to have a spinal cord injury. Patients who have other medical problems that make them prone to falling from weakness or clumsiness (from stroke, for example) may also be more susceptible.

CAUSES: Motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial accidents, gunshot wounds, assault, and other causes. Minor injury can cause spinal cord trauma if the spine is weakened (such as from rheumatoid arthritis or osteoporosis) or if the spinal canal protecting the spinal cord has become too narrow (spinal stenosis) due to the normal aging process. Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or the disks have been damaged. Direct damage can also occur if the spinal cord is pulled, pressed sideways, or compressed. This may occur if the head, neck, or back are twisted abnormally during an accident or injury. The accumulation of blood or fluid can compress the spinal cord and damage it.

SIGNS AND SYMPTOMS: Neurologic Level: The neurologic level refers to the lowest level of the injury of the cord. Total sensory and motor paralysis below the neurologic level Loss of bladder and bowel control (usually with urinary retention and bladder distention) Loss of sweating and vasomotor tone below the neurologic level Marked reduction of blood pressure from loss of peripheral vascular resistance If conscious, patient reports acute pain in back or neck; patient may speak of fear that the neck or back is broken Respiratory Problems: Related to compromised respiratory function; severity depends on level of injury Acute respiratory failure is the leading cause of death in high cervical cord injury

ANATOMY AND PHYSIOLOGY:

Cervical: Cervical (neck) injuries usually result in full or partial tetraplegia (Quadriplegia). However, depending on the specific location and severity of trauma, limited function may be retained.

Injuries at the C-1/C-2 levels will often result in loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing. C3 vertebrae and above : Typically results in loss of diaphragm function, necessitating the use of a ventilator for breathing. C4 : Results in significant loss of function at the biceps and shoulders. C5 : Results in potential loss of function at the shoulders and biceps, and complete loss of function at the wrists and hands. C6 : Results in limited wrist control, and complete loss of hand function. C7 and T1 : Results in lack of dexterity in the hands and fingers, but allows for limited use of arms.

Thoracic Complete injuries at or below the thoracic spinal levels result in paraplegia. Functions of the hands, arms, neck, and breathing are usually not affected.

T1 to T8 : Results in the inability to control the abdominal muscles. Accordingly, trunk stability is affected. The lower the level of injury, the less severe the effects. T9 to T12 : Results in partial loss of trunk and abdominal muscle control.

Lumbosacral: The effects of injuries to the lumbar or sacral regions of the spinal cord are decreased control of the legs and hips, urinary system, and anus.

Bowel and bladder function is regulated by the sacral region of the spine. In that regard, it is very common to experience dysfunction of the bowel and bladder, including infections of the bladder and anal incontinence, after traumatic injury. Sexual function is also associated with the sacral spinal segments, and is often affected after injury. During a psychogenic sexual experience, signals from the brain are sent to spinal levels T10-L2 and in case of men, are then relayed to the penis where they trigger an erection. A reflex erection, on the other hand, occurs as a result of direct physical contact to the penis or other erotic areas such as the ears, nipples or neck. A reflex erection is involuntary and can occur without sexually stimulating thoughts. The nerves that control a man's ability to have a reflex erection are located in the sacral nerves (S2S4) of the spinal cord and could be affected after a spinal cord injury.

PATHOPHYSIOLOGY: Spinal Cord Injury Classification: Quadriplegia :

injury in cervical region all 4 extremities affected Paraplegia :

injury in thoracic, lumbar or sacral segments 2 extremities affected Injury: Complete: Incomplete: Some function is present below site of injury More favourable prognosis overall Are recognisable patterns of injury, although they are rarely pure and variations occur Loss of voluntary movement of parts innervated by segment This is irreversible,Loss of sensation Spinal shock

Injury defined by ASIA Impairment Scale: A Complete: no sensory or motor function preserved in sacral segments S4 S5 B Incomplete: sensory, but no motor function in sacral segments C Incomplete: motor function preserved below level and power graded < 3 D Incomplete: motor function preserved below level and power graded 3 or more E Normal: sensory and motor function normal

Muscle Strength Grading: 5 Normal strength 4 Full range of motion, but less than normal strength against resistance 3 Full range of motion against gravity 2 Movement with gravity eliminated 1 Flicker of movement 0 Total paralysis

DIAGNOSTIC EXAM: Diagnosis of SCI is based on physical examination, radiologic examination, CT scan, MRI and myelography. Diagnostic x-rays such as lateral cervical spine x-rays CT scanning are usually performed initially. MRI scan may be ordered as a further work up if a ligamentous injury is suspected, since significant spinal cord damage may exist even in the ansence of bony injury. Continuous electrocardiographic monitoring may be indicated if a cord injury is suspected since bradycardia and asystole are common in acute spinal injuries.

NURSING INTERVENTION: Promoting Adequate Breathing

Detect potential respiratory failure by observing patient, measuring vital capacity, and monitoring oxygen saturation through pulse oximetry and arterial blood gas values. Prevent retention of secretions and resultant atelectasis with early and vigorous attention to clearing bronchial and pharyngeal secretions. Suction with caution, because this procedure can stimulate the vagus nerve, producing bradycardia and cardiac arrest. Initiate chest physical therapy and assisted coughing to mobilize secretions. Supervise breathing exercises to increase strength and endurance of inspiratory muscles, particularly the diaphragm. Ensure proper humidification and hydration to maintain thin secretions. Assess for signs of respiratory infection: cough, fever, and dyspnea. Discourage smoking. Monitor respiratory status frequently.

Improving Mobility

Maintain proper body alignment; place patient in dorsal or supine position. Turn patient every 2 hours; monitor for hypotension in patients with lesions above the midthoracic level. Assist patient out of bed as soon as spinal column is stabilized. Do not turn patient who is not on a turning frame unless physician indicates that it is safe to do so. Apply splints to prevent footdrop ans trochanter rolls to prevent external rotation of the hip joint; reapply every 2 hours. Perform passive range-of-motion exercises within 48 to 72 hours after injury to avoid complications such as contractures and atrophy. Provide a full range of motion at least every four or five times daily to toes, metatarsals, ankles, knees & hips.

Maintaining Skin Integrity

Change patients position every 2 hours and inspect the skin, particularly under cervical collar. Assess for redness or breaks in skin over pressure points; check perineum for soilage; observe catheter for adequate drainage; assess general body alignment and comfort. Wash skin every few hours with a mild soap, rinse well, and blot dry. Keep pressure sensitive areas well lubricated and soft with bland cream or lotion; gently perform massage using a circular motion. Teach patient about pressure ulcers and encourage participation in preventive measures.

Promoting Urinary Elimination

Perform intermittent catheterization to avoid overstreatching the bladder and infection. If this is not feasible, insert an indwelling catheter. Show family members how to catheterize, and encourage them to participate in this facet of care. Teach patient to record fluid intake, voiding pattern, amounts of residual urine after catheterization, quality of urine, and any unusual feelings.

Promoting Adaptation to Disturbed Sensory Perception

Stimulate the area above the level of the injury through touch, aromas, flavorful food, conversation, and music. Provide prism glasses to enable patient to see from supine position. Encourage use of hearing aids, if applicable. Provide emotional support; teach patient strategies to compensate for or cope with sensory deficits.

Improving Bowel Function

Monitor reactions to gastric intubation. Provide a high-calorie, high-protein, and high-fiber diet. Food amount may be gradually increased after bowel sound resume.

Administer prescribed stool softener to counteract effects of immobility and pain medications, and institue a bowel program as early as possible.

Providing Comfort

Reassure patient in halo traction that he/she will adapt to steel frame. Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening; keep a torque screwdriver readily available. Assess skull for signs of infection, including drainage around halo-vest tongs. Check back of head periodically for signs of pressure. Massage at intervals, taking care not to move the neck. Shave hair around tongs to facilitate inspection. Avoid probing under encrusted areas. Inspect skin under halo vest for excessive perspiration, redness, and skin blistering, especially on bony prominences. Open vest at the sides to allow torso to be washed. Do not allow vest to become wet; do not use powder inside vest.

REFERENCE

Smeltzer, S. Et Al.. Brunner & Suddarths Textbook of Medical-Surgical Nursing (Lippincott Williams & Wilkins. 10th edition,2004) Huether, S. Et Al. Understanding Pathophysiology (Mosby, Inc. 2nd edition. 2000) Evans RW, Wilberger JE, Bhatia S. Traumatic disorders. In: Goetz CG, ed. Textbook of Clinical Neurology. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007:chap 51. Ling GSF. Traumatic brain injury and spinal cord injury. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier; 2007:chap 422. Tator CH. Recognition and management of spinal cord injuries in sports and recreation. Neurol Clin. 2008 Feb;26(1):79-88; viii. [PubMed: 18295085]