Spinal Cord Injury:  is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor,

sensory, or autonomic function Statistics:  40 cases per million or 12,000 spinal cord injuries per year  Incidence o 80.7% males o 50% occur in 16-30 years of age o 66.5% are white o Greater mortality in older patients  Common causes o MVC (50%) o Falls (22%) o Acts of violence (15%) o Sports injuries/Recreation (8%) o Diseases (5%) Causes of Death: 1. Pneumonia 2. Non-ischemic heart disease 3. Septicemia 4. Ill-defined Conditions 5. Pulmonary embolus 6. Ischemic heart disease 7. Suicide Anatomy Review: The Spine o Cervical Spine o 7 vertebrae o very flexible o C1: also known as the atlas o C2: also known as the axis o Thoracic Spine o 12 vertebrae o ribs connected to spine o provides rigid framework of thorax o Lumbar Spine o 5 vertebrae o largest vertebral bodies o carries most of the body s weight o Sacrum o 5 fused vertebrae o common to spine and pelvis o Coccyx o 4 fused vertebrae o tailbone Spinal Cord: A. Functional Anatomy 1. Ascending Tracts (Sensory) a. dorsal columns (posterior funiculi) : deep touch, proprioception, vibratory b. lateral spinothalamic tract: pain and temperature, site of chordotomy to alleviate intractable pain c. anterior spinothalamic tract : light touch 2. Descending Tracts (Motor) a. lateral corticospinal tract : voluntary motor cervical pathways more medial which explains why a central cord injury affects the upper extremities more than the lower extremities

b.

ventral corticospinal tract: voluntary motor

Spinal Cord Injury: Assessment 1. Determine sensory levels for right and left sides. o lowest segment where sensory function is normal on both sides Determine motor levels for right and left sides. o lowest segment with normal motor function Determine neurological level. o defined as lowest segment where motor and sensory function is normal on both sides Determine whether the injury is COMPLETE or INCOMPLETE o COMPLETE defined as:  no voluntary anal contraction (sacral sparing) AND  0/5 distal motor AND  0/2 distal sensory scores (no perianal sensation) AND  bulbocavernosus reflex present (patient not in spinal shock) o INCOMPLETE defined as  voluntary anal contraction (sacral sparing) OR  palpable or visible muscle contraction below injury level OR  perianal sensation present Determine ASIA Impairment Scale (AIS) Grade:

2. 3.

4.

5.

ASIA Impairment Scale A Complete No motor or sensory function is preserved in the sacral segments S4S5. Sensory function preserved but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3. Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more. Motor and sensory functions are normal.

B Incomplete

C Incomplete

D Incomplete

Normal

Assessment: 1. Level of spinal cord injury 2. Respiratory changes 3. Motor and sensory changes below the level of injury 4. Loss of reflexes 5. Loss of bladder and bowel control 6. Presence of sweat 7. Spinal Shock and autonomic dysreflexia a. Spinal shock/Neurogenic shock:

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b.

Sudden depression of reflex activity in the spinal cord below the level of injury y Occurs in the first hour of injury and can last to days or months y Muscles are completely paralyzed and flaccid, absent reflexes Autonomic dysreflexia / Autonomic hyperreflexia: y Occurs after a period of spinal shock is resolved and occurs when lesions are above T6 and cervical lesions y Commonly caused by by visceral distention from distended bladder or impacted rectum y Neurological emergency and must be treated immediately to prevent hypertensive stroke y Autonomic dysreflexia Sudden onset, severe throbbing head ache Severe HPN Flushing above the lesions Pallor below the lesion Nasal stuffiness Nausea Mydriasis or blurred vision Sweating Piloerection Restlessness and a feeling of apprehension

Spinal shock  Flaccid paralysis  Loss of reflex activity below the lesion  Bradycardia  Paralytic ileus  hypotension

         

B.

Clinical Classification of Injury: 1. Complete cord injury

Anterior cord syndrome a. Damage in the anterior portion of gray and white matter b. Motor function, pain and temperature sensations are lost below the level of injury, however proprioception, vibrations and touch remain intact

2.

Incomplete cord injury A.     Central Cord syndrome Occurs from a lesion in the central cord Loss of motor function is more pronounced in the upper extremity, and varying degrees and patterns of sensation remain intact Most common incomplete cord injury Good prognosis

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C.

Posterior cord syndrome a. Damage to the posterior portion of the gray and white matter b. Motor function remains intact, however there is loss of vibratory sense, crude touch and proprioception

E.

F.

Conus medullaris  Damage on the lumbar nerve roots and conus medullaris  Client experiences bowel and bladder areflexia and flaccid lower extremities  If damage is limited to the upper and sacral segments of the spinal cord, bulbospongiosus penile and micturition reflexes will remain intact Cauda Equina Syndrome  Occurs from the injury to the lumbosacral nerve roots below the conus medullaris  The client experiences areflexia of the bowel, bladder and lower reflexes

Effects of Spinal Cord Injury 1. Quadriplegia:C1 C8, paralysis in all four extremities 2. Paraplegia: T1 L4, paralysis on the LE Signs and Symptoms Symptoms vary somewhat depending on the location of the injury. Spinal cord injury causes weakness and sensory loss at and below the point of the injury. The severity of symptoms depends on whether the entire cord is severely injured (complete) or only partially injured (incomplete). A. CERVICAL (NECK) INJURIES When spinal cord injuries occur in the neck area, symptoms can affect the arms, legs, and middle of the body. The symptoms may occur on one or both sides of the body. Symptoms can include:

D.

Brown Sequard syndrome  Results from penetrating injuries that cause hemi section of the spinal cord  Motor function, vibration, proprioception, and deep touch sensations are lost on the same side of the body (ipsilateral) as the lesion or cord damage  Contralateral of the lesion or cord damage, the sensations of pain, temperature and light touch are affected

y y y y y y y
B.

Breathing difficulties (from paralysis of the breathing muscles, if the injury is high up in the neck) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis

THORACIC (CHEST LEVEL) INJURIES When spinal injuries occur at chest level, symptoms can affect the legs:

y y y y y y y

Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis

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Injuries to the cervical or high thoracic spinal cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining normal body temperature. C. LUMBAR SACRAL INJURIES When spinal injuries occur at the lower back level, varying degrees of symptoms can affect one or both legs, as well as the muscles that control your bowels and bladder:

y y y y y y

Loss of normal bowel and bladder control (you may have constipation, leakage, and bladder spasms) Numbness Pain Sensory changes Spasticity (increased muscle tone) Weakness and paralysis

Interventions during Hospitalization: 1. Respiratory system  Assess respiratory status  ABG s  DBE and incentive spirometer  Assess for pnemonia 2. Cardiovascular system  Assess for dysrrhymthmias  Assess for signs of shock  Prevent orthostatic hypotension 3. Neurovascular system  Neuro status  Motor and sensory status  Monitor for spinal shock and autonomic dysreflexia  Immobilize  Assess and treat pain  Collaborate with PT 4. Gastrointestinal  Assess bowel distention, bowel sounds and paralytic ileus  Assess for bowel retention and initiate bowel control program  Maintain adequate nutrition and increased fiber diet 5. Renal system  Prevent urinary retention  Initiate bladder control program  Maintain fluid intake of 2l/day  Prevent UTI and calculi 6. Integumentary system  Assess skin integrity  Turn patient using log roll technique 7. Psychosocial integrity  Encourage expression of feelings  Discuss sexual concerns  Promote self care, setting goals based on functional levels  Referral to community services

Medical and Surgical Interventions 1. Cervical spine Traction a. Skeletal traction is used to stabilize fractures or dislocations of the cervical and upper thoracic spine b. Skull tongs  Inserted into the outer aspect of the skull, and traction is applied  Maintain body alignment  Turn the client every two hours  Assess insertion tongs for infection  Provide sterile pin site care c. Halo traction  Static traction device that consists of a headpiece with four pins, two anterior and posterior, inserted in the skull  Monitor neurological status for changes in movement or decreased strength 2. Surgical intervention for thoracic, lumbar and sacral injuries a. Decompressive laminectomy  Removal of one or more laminae  Allows for cord expansion from edema b. Spinal fusion  Used for thoracic spinal injury  Bone is grafted between the vertebrae for support and to strengthen the back 3. Medications a. Dexamethasone (decadron)  Anti - inflammatory b. Dextran  Plasma expander used to increase capillary blood flow within the spinal cord and to prevent and treat hypotension c. Dantolene (Dantrium), Baclofen (Lioresal)  Used for client s with upper motor neuron injuries to control muscle spasticity Goals of SCI Rehabilitation and Treatment: Researchers, many of whom are supported by the National Institute of Neurological Disorders and Stroke (NINDS), are focused on advancing our understanding of the four key principles of spinal cord repair: Protecting surviving nerve cells from further damage Replacing damaged nerve cells Stimulating the regrowth of axons and targeting their connections appropriately Retraining neural circuits to restore body functions

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