Spinal Cord Injury

SCI urinary manifestations:

Acute phase - Urinary retention - Bladder atonic, overdistended, fails to empty - Indwelling catheter Postacute phase - Bladder may become hyperirritable - Loss of inhibition from brain - Reflex emptying and failure to store urine

A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to a. breathe with respiratory support. b. drive a vehicle with hand controls. c. ambulate with long-leg braces and crutches. d. use a powered device to handle eating utensils.

Answer: B Rationale: A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; use wheelchair independently; and drive a car with powered hand controls (in some patients); attendant care 0 to 6 hours/day.

A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for a. Return of reflexes. b. bradycardia with hypoxemia. c. effects of sensory deprivation. d. fluctuations in body temperature.

Answer: B Rationale: Neurogenic shock is due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia, which are important clinical clues. These effects are generally associated with a cervical or high thoracic injury (T6 or higher).

During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? a. A heart rate of 92 b. A reddened area over the patient's coccyx c. Marked perspiration on the patient's face and arms d. A light inspiratory wheeze on auscultation of the lungs

Answer: C Rationale: Autonomic dysreflexia is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It occurs in response to visceral stimulation once spinal shock is resolved in patients with spinal cord lesions. The condition is a life-threatening situation that requires immediate resolution. If resolution does not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/min), piloerection (erection of body hair) as a result of pilomotor spasm, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea.

neurogenic bladder:

Bladder dysfunction related to abnormal or absent bladder innervation.

SOMI brace

•The need for surgery is determined after the spine is reduced. •After cervical fusion or other stabilization surgery, the patient may wear a hard cervical collar or sternal-occipital-mandibular immobilizer brace

Halo vest

•When a patient can begin to mobilize after a stable injury (for which surgery is not needed), the halo frame can be attached to a special vest (Halo vest). •This allows the patient to mobilize and ambulate while cervical bones fuse. •However, the halo is not indicated if the patient has ligament instability from the injury. That patient will require surgery.

Potential for infection at sites of tongs or halo pin insertion. Preventive care based on hospital protocol. Common protocol involves:

▪ Cleansing with ½ strength peroxide and normal saline twice a day ▪ Applying antibiotic ointment (Bacitracin) as a mechanical barrier to the entrance of bacteria

SCI is classified by

▪ Mechanism of injury ▪ Level of injury ▪ Degree of injury

Nociceptive Pain

▪ Musculoskeletal pain dull or aching, worsens with movement ▪ Visceral pain in thorax, abdomen, pelvis - dull, tender, or cramping

Neuropathic Pain

▪Located at or below level of injury ▪ Hot, burning, tingling, pins and needles, cold, shooting ▪ May be extremely sensitive to stimuli

____________________ injury is the most unstable because ligaments that stabilize the spine are torn. This injury most often contributes to severe neurologic deficits.

Flexion-rotation

flexion injury

Forward dislocation ruptures posterior ligaments and damages the spinal cord

thoracic vertebrae

T1-T12 -they articulate with the 12 pairs of ribs to form the outward curve of the spine

Edema secondary to the inflammatory response creates compression of the spinal cord and extends

above and below the injury, thus increasing the ischemic damage. *Extent of the injury and prognosis for recovery are most accurately determined at least 72 hours or more after injury

Dermatomes

areas of sensation innervated by spinal nerves

detrusor muscle

bladder wall

The degree of spinal cord involvement may be

complete or incomplete (partial).

Compression fractures

crush the vertebrae and force bony fragments into the spinal canal.

Patients with stable thoracic or lumbar spine injuries may be immobilized with a

custom thoracolumbar sacral orthosis (TLSO or body jacket) to limit spinal flexion, extension, and rotation.

most common precipitating factor of Autonomic Dysreflexia

distended bladder or rectum

Patients with complete SCI above C5 should be

intubated at once

Nasogastric suctioning may lead to

metabolic alkalosis. *It is important to especially monitor sodium and potassium until suctioning is discontinued and a normal diet is resumed.

neurogenic (vasogenic) shock can cause

peripheral vasodilation, venous pooling, and decreased cardiac output.

Apoptosis is

programmed cell death

if a pt were to sustain a cervical fracture, a ______________ assessment is a priority

respiratory

Hyperextension injury of the cervical spine

ruptures the anterior ligaments

Histamine (H2)-receptor blockers (e.g., ranitidine) or proton pump inhibitors (e.g., pantoprazole, omeprazole) given prophylactically decreases the

secretion of HCl acid and prevents ulcers.

Flexion-rotation injury of the cervical spine often results in

tearing of ligamentous structures that normally stabilize the spine

Cervical and lumbar injuries are most common because these levels are associated with

the greatest flexibility and movement.

Complete cord involvement results in

total loss of sensory and motor function below the level of injury

Spinal cord injury (SCI) is caused by

trauma or damage to spinal cord, that can result in either a temporary or permanent alteration in the function of the spinal cord

Skeletal vs. neurologic level of injury

-Skeletal level of injury is the vertebral level with the most damage to vertebral bones and ligaments. -Neurologic level is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body.

Spasms may be controlled with the use of antispasmodic drugs such as:

-baclofen (Lioresal) -dantrolene (Dantrium) -tizanidine (Zanaflex) *Botulism toxin injections may also be given to treat severe spasticity.

In contrast to spinal shock, neurogenic (vasogenic) shock:

-can occur in cervical or high thoracic injury (T6 or higher). -occurs from unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation - can continue for 1 to 3 weeks

Five major syndromes are associated with incomplete injuries:

-central cord syndrome -anterior cord syndrome -Brown-Séquard syndrome -cauda equina syndrome -conus medullaris syndrome

Primary injury results from

-direct physical trauma to the spinal cord due to blunt or penetrating trauma. -Trauma can cause spinal cord compression by bone displacement, interruption of blood supply, or distraction from pulling. -Penetrating trauma, such as gunshot and stab wounds, can cause tearing and transection. -The initial mechanical disruption of axons as a result of stretch or laceration

spinal shock occurs shortly after an acute SCI and is characterized by:

-loss of deep tendon and sphincter reflexes -loss of sensation -flaccid paralysis below the level of injury. This syndrome lasts days to weeks. It often masks postinjury neurologic function.

Autonomic Dysreflexia

-massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system -life-threatening condition if uncorrected can lead to status epilepticus, stroke, MI, and death

Incomplete cord involvement results in a

-mixed loss of voluntary motor activity and sensation -some tracts intact

SCI is usually a result of trauma. The 4 most common causes are

-motor vehicle collisions (38%) -falls (30.5%) -violence (13.5%) -sports injuries (9%).

Paraplegia

-paralysis and loss of sensation -damage to the thoracic, lumbar, or sacral spinal cord

Tetraplegia (quadraplegia)

-paralysis of all four extremities -injury from C1 to T1 -degree of impairment in the arms following cervical injury depends on the level of injury -The lower the level, the more function is retained in the arms.

Vasopressor agents

-phenylephrine -norepinephrine *Dopamine has more complications than phenylephrine in SCI

Neurologic damage caused by SCI occurs in 2 phases:

-primary injury: initial physical disruption of the spinal cord -secondary injury: from processes, such as ischemia, hypoxia, hemorrhage, edema

neurogenic (vasogenic) shock: Manifestations

-significant hypotension (< 90 mmHg) -bradycardia -temperature dysregulation.

Common problems with a neurogenic bladder include

-urgency -frequency -incontinence -inability to void -high bladder pressures resulting in reflux of urine into the kidneys.

Use of vasopressors has significant risk of complications, including:

-ventricular tachycardia -troponin elevation -metabolic acidosis -atrial fibrillation.

Depending on the injury, a neurogenic bladder may

1) have no reflex detrusor contractions (flaccid, hypotonic) 2) have hyperactive reflex detrusor contractions (spastic) 3) lack coordination between detrusor contraction and urethral relaxation (dyssynergia).

coccyx

4 fused vertebrae

Sacrum Vertebrae

5 fused vertebrae

The American Spinal Injury Association (ASIA) Impairment Scale is recommended for classifying the severity of impairment resulting from spinal cord injury:

- A: complete, no sensory/motor func. preserved in sacral segments S4-S5 - B: incom., sensory but no motor func. preserved below neuro level and extends through S segments - C: incom., motor func. preserved below neuro level, majority of key muscle grps below neuro level have muscle grade less than 3/5 - D: same as above but muscle grade >or = 3/5 - E: normal, sensory and motor func. normal

SCI prehospital care:

- ABCs - Prevent extension of spinal cord damage - Immobilization: - Spinal immobilization with penetrating trauma not recommended - Maintain systolic BP >90 mm Hg

Intervene to maintain ventilation

- Administer oxygen - Provide ventilator support - Chest physiotherapy - Assisted (augmented) coughing - Tracheal suctioning - Incentive spirometry - Appropriate pain management

SCI Diagnostic Studies

- CT scan - Cervical x-rays (done when a CT scan is not readily available) - MRI - Comprehensive neurologic examination - CT angiogram

Level of injury may be

- Cervical - Thoracic - Lumbar - Sacral

SCI Pain management

Musculoskeletal nociceptive pain ▪ Antiinflammatory drugs ▪ Opioids Visceral nociceptive pain ▪ Diagnostic imaging to evaluate cause Neuropathic pain ▪ Gabapentin (Neurontin) or pregabalin (Lyrica) ▪ Teach about pain triggers and relaxation therapy

Kinetic therapy:

- Continual side-to-side rotation - Prevent pulmonary complications - Prevent pressure ulcers

SCI G.I manifestations

- Decreased GI motor activity - Gastric distention - Development of paralytic ileus - Gastric emptying may be delayed - Excessive release of HCl may cause stress ulcers - Dysphagia may be present - Intraabdominal bleeding may be difficult to diagnose - Neurogenic Bowel - Constipation - Possible impaction - Ileus

Autonomic Dysreflexia: nursing interventions

- Elevate head, sit upright - Notify HCP - Assess for and remove cause - Immediate catheterization - Remove stool impaction if cause - Remove constrictive clothing/tight shoes - Monitor and treat BP - Patient and caregiver teaching

Major mechanisms of injury are

- Flexion - Hyperextension - Flexion-rotation - Extension-rotation - Compression

Secondary injury refers to the ongoing, progressive damage that occurs after the primary injury due to vascular changes:

- Free radical formation - Lipid peroxidation - Release of glutamate - Uncontrolled calcium influx. - Apoptosis- for weeks after injury, lead to scar tissue formation, irreversible nerve damage, and permanent neurologic deficit

Acute care: immobilization

- Maintain neutral position - Stabilize to prevent lateral rotation - Hard cervical collar - Backboard - Keep body in correct alignment - Turn as a unit (logrolling) - Trendelenburg position - Reverse Trendelenburg position - Skeletal traction

SCI surgical therapy

- Used following acute SCI to fix instability and decompress the spinal cord - Surgery within first 24 hours associated with improved neurologic outcome - Posterior approach - Anterior approach - Fusion

Acute care: Bowel management

- stool softeners - laxatives - bowel program started during acute care - Daily rectal stimulant - Suppository or small-volume enema - Digital stimulation or manual evacuation - Adequate fluid and fiber intake - Increased activity and exercise

Poikilothermia

- the inability to regulate core body temperature - Interruption of SNS - ↓ Ability to sweat or shiver below the level of injury - More common with high cervical injury

SCI respiratory manifestations:

-Closely correspond to level of injury - Above level of C4: Total loss of respiratory muscle function - Below level of C4: Diaphragmatic breathing → respiratory insufficiency -Cervical and thoracic injuries: Paralysis of abdominal and intercostal muscles → ineffective cough → risk for aspiration, atelectasis, pneumonia - Risk for neurogenic pulmonary edema

Autonomic Dysreflexia manifestations:

-Hypertension (up to 300 mm Hg systolic) - Throbbing headache - Marked diaphoresis above level of injury - Bradycardia (30 to 40 beats/minute) - Piloerection - Flushing of skin above level of injury - Blurred vision or spots in visual field - Nasal congestion - Anxiety - Nausea

SCI cardiovascular manifestations:

-Injury above T6 leads to dysfunction of sympathetic nervous system - Leads to neurogenic shock (Bradycardia, Peripheral vasodilation, Hypotension)

Skeletal traction

-Realignment or reduction of injury - Crutchfield, Gardner-Wells, or halo - Rope, pulley, and weights - Traction maintained at all times - If displacement occurs, hold head in neutral position and get help

cervical vertebrae

C1-C7; first set of seven bones, forming the neck

lumbar vertebrae

L1-L5

SCI drug therapy

Low-molecular-weight heparin: - Prevent VTE Vasopressor agents - Maintain mean arterial pressure >85-90 mm Hg