Chapter 20: Acute Spinal Cord Injury
Anterior Cord (Incomplete SCI)
Fxn Lost: Motor fxn below lvl of injury, pain, temperature, touch Fxn Present: proprioception, pressure, vibration
Brown Sequard
Fxn Lost: loss of voluntary movement on the same side of injury, loss of pain, temperature, and sensation on opposite side Fxn Present: side of the best motor ctrl has little to no sensation
Posterior cord
Fxn Lost: proprioception, vibration sensation below site of injury Fxn Present: motor fxn, sense of pain, & light touch
Central cord
Fxn Lost: variable motor fxn of LE's, sensory deficit in UE's, often spastic Fxn Present: motor, sensory pathways in LE's, some bladder/bowel fxn
Neurogenic Shock (True distributive form of shock)
This can happen in patients with an injury above T6. What happens in neurogenic shock is MASSIVE VASODILATION and pooling of blood in the periphery. - patient will look hypovolemic because the fluid has all leaked out of the vascular space. - unchecked parasympathetic stimulation/loss of sympathetic control. HOW TO TELL THIS IS NEUROGENIC SHOCK: the patient will have BRADYCARDIA along with low blood pressure. - Treatment involves fluid resuscitation and vasopressors to vasoconstrict the vessels
Distraction injury
from excessive stretching of cord (hanging)
Braces
- A hard cervical collar and molded plastic body jacket (sometimes called a clambshell) brace may be all that is needed for some injuries. - The Jewitt orthosis is often used with thoracic and lumbar spine injuries. - Clambshell braces
Impaired Urinary Elimination and Constipation
- An indwelling catheter is best in the acute phase during spinal shock/when fluid resuscitation is needed. Outside of that, removing the catheter as a potential source of infection is important. - Renal disease,complications can develop. - Intermittent catheterization (IC) is one of the safest forms of bladder management. - Urinary tract infections are a common problem for the SCI patient.
Diagnosis of SCI
- Begins with a detailed history of events surrounding the incident - Includes radiographic and other imaging studies of the spine - Includes assessment of sensory, motor, and reflex function - baseline, ABG's, respiratory assessment
Surgical Stabilization
- Closed or open reduction is indicated as soon as possible in patients with bilateral cervical facet dislocation, a complete displacement of the anterior vertebral body. - Decompression surgery significantly improves outcomes! Preferably within 24 hours. EARLY promotes better outcomes! - Spinal segments are fused and spinal canal decompression is accomplished. Rods are used to stabilize.
Pulmonary Dysfunction
- Complications include pneumonia, atelectasis, aspiration, and respiratory failure. - Pneumonia is the other leading cause of death in patients with SCI. - Aggressive pulmonary hygiene! Implementation of ventilator bundle if indicated.
Heterotopic Ossification
- Ectopic bone formation occurs below the level of the SCI, restricting joint mobility. Hip is most frequently affected site. - Hallmark sign that warrants further investigation is loss of range of motion in a joint, localized swelling, warmth, and fever.
Complications Related to Altered Mobility Skin Breakdown
- Frequent repositioning, foot and heel protectors and specialty beds, daily or twice-daily skin inspection
An MRI
- Identifies injuries to the spinal cord, ligaments, and disks - Used to detect tumors, inflammation, infection, degenerative disorders, and vascular interruptions in the spinal cord and brain
Reflex Activity
- If DTRs are intact below the level of injury in the immediate post-injury period, there is an incomplete lesion. Perineal reflexes, if present, may mean that bowel and bladder training is possible. - Perineal reflexes include priapisim which may be present in males, and anal "wink" initiated by a pinprick in the perianal area, and the bulbocavernosus reflex (contraction of the rectal sphincter if, for example, the urinary cateter is pulled).
Imbalanced Nutrition
- In the early phases, paralytic ileus is common so an NG tube to prevent distention may be necessary. - Ensure the patient's nutritional needs are met -- initiate dietary consult. - Nursing care includes monitoring intake, changes in the patient's weight, assessing electrolyte balance, and administering total parenteral nutrition, or enteral feedings as ordered.
Interventions for bowel function
- Include initiating the defecation reflex by inserting a suppository or doing a digital stimulation. - If the patient has a LMN lesion below the sacral level, the bowel loses its reflexes and digital stimulation won't help. Manual removal of stool may be necessary. - Establishing a daily bowel routine is critical.
Trauma-Related Injuries
- Including MVAs, falls, acts of violence such as gunshot wounds, and recreational sporting activities. - Causes of death in this population includes pulmonary emboli, pneumonia, and septicemia.
Ineffective Thermoregulation
- Interruption between the spinal cord and the hypothalamus results in the loss of temperature control. - Body temp is dependent on the environmental temp, meaning temperature extremes can be dangerous. - Loss of SNS of the sweat glands below the level of injury prevents sweating. - Patient may need to be kept warm with passive warming devices, but CAUTION to avoid burns!
Secondary Injury
- Just as with TBI, there can be secondary injury to the cord that occurs after the initial trauma. - This is caused by cellular damage (particularly from elevated intracellular calcium), inflammation, and ischemia. - The more swelling there is, the less blood flow can get to that area, making a vicious cycle of inflammation and ischemia.
Motor Status
- Keep in mind that voluntary movement requires both upper and lower motor neuron activity. Motor activity is assessed for strength, beginning at the head and moving down. - Passive movement is tried first, followed by active. Movement is also compared side to side.
Thromboembolism
- Leading cause of mortality and morbidity following acute SCI. - Failure of venous muscle pump. Apply mechanical compression devices early after injury. - Begin LMWH or UFH plus intermittent pneumatic compression in all patients when they are not actively bleeding after the trauma. - Consider prophylactic vena cava filter in unstable patients with active bleeding who can't be started on anticoagulants.
A CT:
- May be ordered after completion of x-rays if the spine is not well visualized - Provides superior visualization of bony structures of the spine and identifies spinal fractures. - If radiopaque contrast is used, check for allergies to dye or seafood, and assess for underlying kidney disease.
Labs f/high acuity spinal pt's
- Obtain CBC, coagulation profile, comprehensive metabolic profile, cardiac enzyme profile, urinalysis, and toxicology screen.
Spinal Shock (not normal)
- Occurs within 30-60 minutes after the injury, marked by absence of all reflexes, motor activity, and sensation below the level of the injury. - While it often resolves within 24 hours, it can last 7 to 20 days. - HOW YOU KNOW IT IS OVER: Return of DTRs below the level of the injury. - It is difficult to fully classify an injury until spinal shock has resolved.
SCI patients are at high-risk for decreased cardiac output because of:
- Orthostatic hypotension - Spinal and neurogenic shock - Venous pooling - Emboli - Bradycardia.
NI's f/high acuity pt's
- Patients with SCI require close monitoring of respiratory drive, ventilation, ability to cough, pulse oximetry, and arterial blood gases. - Aggressive respiratory therapy and careful monioring required. - Humidified oxygen, incentive spirometry - "Hemilich-assisted quad cough" technique. - Bronchodilators and mucolytics beneficial in mobilizing secretions, along with chest physiotherapy if tolerated and indicated. - Frequent position changes whenever possible, consider specialty beds (log-rolling & maintaining alignment)
Sensory Status
- Pinpointing the exact point where sensation is intact is critical. Sensation is tested along dermatomes using a cotton swab and pinprick -- beginning distally and working up. - Proprioception is tested by moving the big toes and thumbs up and down and asking patient to confirm direction.
TREATMENT PRIORITIES INCLUDE (AD)
- Put the head up and loosen any restrictive clothing. - Determine cause of the autonomic dysreflexia (AD). MOST COMMON CAUSE IS DISTENDED BOWEL OR BLADDER!!!! - Control blood pressure with short-acting antihypertensive agent if cause cannot be immediately identified.
Susceptibility f/abnormal heart rhythms
- SCI patients can have unopposed vagal stimulation, so they are always at risk for bradycardia! - Consider very high risk during intubation, suctioning, NG tube insertion, etc. - If bradycardia is life-threatening, may need a pacemaker early in treatment. - The patient may need to have CVP readings for close monitoring of preload. Inotropic and vasopressor medications may be needed to maintain adequate cardiac output and tissue perfusion. - MAP should be maintained at 85-90 to ensure that the cord is getting enough perfusion!
Decreased Joint Mobility
- Spasticity from UMN damage may contribute to this problem. Must be maintained through ROM!!!!
SCI Classification
- Spinal cord injuries can be either complete (loss of all voluntary motor and sensory function below the level of the injury caused by damage to the entire level of the spinal cord) or incomplete (preservation of some sensory or motor function below the level of injury because only part of the level has been damaged). - The cervical region is the most vulnerable region of the spine because of poor stability. Complete injuries at C1 or C2 are often fatal because patients are unable to breathe spontaneously. There is a lot more stability to the thoracolumbar regions because of the ribs. - More force is required to cause a complete injury.
Steroid Therapy
- Steroid therapy has been very controversial in the last 1-2 decades. The theory makes sense -- reduce early inflammation, and we may have less injury/disability. -- usually admin w/in the first 8 hrs
Physical Assessment
- The American Spinal Injury Association (ASIA) Standard Neurological Classification of SCI assessment form is used to document sensory and motor function. - Serial neurologic exams are performed hourly for at least the first 24 hours after SCI. - The patient is monitored closely for respiratory failure in the first few days.
Neuronal function and spinal cord organization
- The main blood supply to the spinal cord is provided by the anterior spinal artery and the posterior spinal arteries. - The spine contains gray and white matter. - The parasympathetic nervous system originates in a group of neurons located in the brainstem.
Impaired Gas Exchange, Ineffective Breathing Patterns
- The patient's airway and breathing may be compromised, particularly with a cervical injury. C1-C2 injuries, if survived, will require mechanical ventilation for life. - C3-C5 have varying degrees of diaphragm weakness/paralysis. - Injuries below C6 may have some impaired intercostal and abdominal muscle function, making it difficult to cough and sneeze to clear the airway.
Halo Device
- This is an external fixation device that keeps the spine aligned, prevents flexion, extension, and rotational movement of head and neck, and allows for early mobilization! - Secured with 4 pins inserted in the skull; halo ring attached to a rigid plastic vest. (DO NOT PULL ON THE STRUTS!!!!) - There are a few things to keep in mind about caring for someone in a halo device: NAMELY, MUST HAVE A WRENCH ON THE FRONT OF THE VEST IN CASE THE PATIENT CODES!!!!!!
Manual Stabilization (Skull Tongs)
- Tongs may be used, such as Gardner-Wells (shown above) or Vinke. Skrews are placed in the patients skull and sequential weights are added. - Ten pounds of traction is applied if no fracture. If there is a fracture, 5 pounds per interspace beginning with C1 to the level of the lesion is required.
Nontrauma-Related Injuries
- Traumatic injuries cause the most, but degenerative changes, ankylosing spondylitis, rheumatoid arthritis, space-occupying lesions, lymphoma, multiple myeloma all can cause SCI. - Acute spinal infarction is rare but does happen. SCI can also happen as a result of pressure decompression/gas emboli formation in scuba diving. I once saw a quadriplegic who had sustained the injury secondary to a large aortic aneurysm!
Magnetic Resonance Angiography (MRA)
- a noninvasive diagnostic test for assessing vertebral artery injury.
Autonomic Dysreflexia
- a potentially LIFE-THREATENING complication that involves an exaggerated sympathetic response in patients with SCI at T6 or above. - Result of SNS stimulation below the level of SCI where CNS control of spinal reflexes is lost. - HYPERTENSION due to severe vasoconstriction (often 200mmHg or more!), Sweating, piloerection, sudden headache, blurred vision, and anxiety. - Vasodilation above the level of injury, resulting in flushing of skin, pupil constriction, increased nasal secretions, and a decreased heart rate (due to vagal nerve stimulation).
What causes AD?
- bladder distention/spasm - bowel impaction - decubitus ulcer - ingown toenails - labor - pain - stimulation of anal reflex - temp change - tight irritating clothes - UTI's
Flexion-Rotation injury
- caused by excessive twisting movement, causing shearing and tearing of the posterior ligaments and rotation of the spinal column.
Hyperextension injury
- caused by forward-backward motion of the head, such as a rear-end collision. (Whiplash is a mild form)
An x-ray may be needed for patients who have:
- have changes in level of consciousness as a result of injury - complain of neck tenderness and have some obvious symptoms
Compression injury
- is also called axial loading and is caused by a vertical force such as diving into shallow water or falling from a distance onto feet or buttocks
Hyperflexion injury
- most often caused by a sudden deceleration of the motion of the head, such as a head-on collision.
Primary injury
- occurs when excessive force is applied to the cord. The damage occurs at the moment of impact - initial irritation - influx of Ca
NI's f/pt's w/HALO devices
- tape a halo vest wrench to anterior portion of the vest - inspect f/loose pins - don't move the struts to move or posn the pt - assess motor & sensory fxn every 2 to 4 hrs - perform pin care per unit protocol; chk f/signs of infection - turn every 2 hrs; chk f/skin breakdown - provide skin care
Unstable spinal cord injury
- the vertebral and ligamentous structures are unable to support and protect an injured area. You can see above that the spinal cord is divided into the anterior, middle, and posterior columns. THE INJURY BECOMES UNSTABLE WHEN TWO OF THE THREE STRUCTURAL COLUMNS ARE INJURED AND CANNOT SUPPORT THE SPINAL COLUMN
Somatosensory-Evoked Potentials (SEPs)
- used to establish a functional prognosis after resolution of spinal cord edema. - The response of the cerebral cortex to stimulation (evoked potential) is recorded using scalp electrodes.
