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PathophysiologyNormal Spinal Cord
Spinal cord begins at the foramen magnum in the cranium
Cord ends at the L1-L2 vertebra level
Spinal nerves continue to the last sacral vertebra
The Human Spine
Spinal CordGray matter-
cell bodies of voluntary and autonomic motor neurons
White matter axons of ascending and descending motor fibers
Upper Motor NeuronsUMN Originate in cerebral cortexProject downwardResult in skeletal muscle movementInjury = SPASTIC paralysis
Lower Motor NeuronsLMNOriginate at each vertebral levelProject to specific parts of the bodyResult in movement /sensationInjury = FLACCID paralysis
Normal Spinal Cord
DermatonesSkin innervated by
sensory spinal nervesMyotome- muscle group
innervated by motor neurons
Nervous System and the Spinal CordANS can be
affected by SCISympathetic
chains on both sides of the spinal column (T1-L2)
Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)
Spinal Cord ProtectionBones- vertebral column7 Cervical12 Thoracic5- Lumbar5- Sacral
Discs- between vertebra
Spinal Cord Protection
Internal and external ligaments
DuraMeningesCSF in
subarachnoid space allow for movement within spinal canal
Etiology of Traumatic SCIMVA- most common causeOther: falls, violence, sport injuriesSCI typically occurs from indirect injury from
vertebral bones compressing cord SCI frequently occur with head injuriesCord injury may be caused by direct trauma
from knives, bullets, etc
Etiology of Traumatic SCI78% people with SCI are maleTypically young men – 16-30Number of older adults rising (>61 yr)Greater complications
Spinal Cord Injury- SCICompressionInterruption of blood supplyTractionPenetrating Trauma
Spinal Cord InjuryPrimary
Initial mechanism of injurySecondary
Ongoing progressive damageIschemiaHypoxiaMicrohemorrhageEdema
Spinal and Neurogenic ShockSpinal Shock
Decreased reflexes and loss of sensation below the level of injury
Motor loss- flaccid paralysis below level injury
Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury
Lasts days to months
Spinal and Neurogenic ShockNeurogenic shockDue to loss of vasomotor tone
peripheral pooling and decreased cardiac output
Hypotension and Bradycardia Orthostatic hypotension and poor
temperature control (poikilothermic)
How do you know spinal shock is over?
Clonus is one of the first signs
Hyperreflexia of footTest by flexing leg at
knee & quickly dorsiflex the foot
Rhythmic oscillations of foot against hand
clonus
Classifications of SCIMechanism of InjurySkeletal and Neurologic LevelCompleteness (degree) of Injury
Mechanism of InjuryFlexionHyperextension CompressionFlexion /Rotation
Classifications of SCIMechanism of Injury
Flexion (hyperflexion)Most common because
of natural protection position.
Generally cause neck to be unstable because stretching of ligaments
Classifications of SCIMechanism of Injury
HyperextentionCaused by chin hitting a
surface area, such as dashboard or bathtub
Usually causes central cord syndrome symptoms
Classifications of SCIMechanism of Injury
CompressionCaused by force from
above, as hit on headOr from below as
landing on buttUsually affects the
lumbar region
Classifications of SCIMechanism of Injury
Flexion/RoatationMost unstableResults in tearing of
ligamentous structures that normally stabilize the spine
Usually results in serious neurologic deficits
Skeletal levelVertebral level
where the most damage to the bones
Neurologic levelThe lowest segment
of the spinal cord with normal sensory and motor function on both sides of the body
Levels of Function in Spinal Cord Injury
Classification of SCI- Level of InjurySpinal cord level
When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level.
the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone
Classifications of SCICompleteness (Degree) of Injury
CompleteIncomplete
Central cord syndromeAnterior Cord syndromeBrown-Sequard SyndromePosterior Cord SyndromeCauda Equina and Conus Medullaris
Classification of SCI Completeness (degree) of InjuryComplete (transection)After spinal shock: Motor deficits-
spastic paralysis below level of injury
Sensory- loss of all sensation
perceptionAutonomic deficits-
vasomotor failure and spastic bladder
Classification of SCI Completeness (degree) of InjuryIncomplete
Central Cord Syndrome
Injury to the center of the cord by edema and hemorrhage
Motor weakness and sensory loss in all extremities
Upper extremities affected more
Classification of SCI Completeness (degree) of InjuryIncomplete
Brown-Séquard Syndrome
Hemisection of cordIpsilateral paralysisIpsilateral superficial
sensation, vibration and proprioception loss
Contralateral loss of pain and temperature perception
Classification of SCI Completeness (degree) of InjuryincompleteAnterior Cord Syndrome
Injury to anterior cord Loss of voluntary motor,
pain and temperature perception below injury
Retains posterior column function (sensations of touch, position, vibration, motion)
Classification of SCI Completeness (degree) of InjuryincompletePosterior Cord Syndrome
Least frequent syndromeInjury to the posterior
(dorsal) columns Loss of proprioceptionPain, temperature,
sensation and motor function below the level of the lesion remain intact
Classification of SCI Completeness (degree) of Injuryincomplete
Conus MedullarisInjury to the sacral
cord (conus) and lumbar nerve roots
Cauda EquinaInjury to the
lumbosacral nerve roots
Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs
Clinical Manifestations of SCISkin:
pressure ulcers
Neuro: pain sensory lossupper/lower motor
deficitsautonomic
dysreflexia
Cardio: dysrhythmiasspinal shockorthostatic
hypotension,
Respiratory-decrease chest
expansion, cough reflex & vital capacity
diaphragm function-phrenic nerve
GIstress ulcersparalytic ileusbowel- impaction &
incontinence
GUupper/lower motor
bladdersexual dysfunction
Musculoskeletaljoint contracturesbone
demineralizationosteoporosismuscle spasmsmuscle atrophypathologic fracturespara/tetraplegia
Common Manifestation/ComplicationsUpper and Lower Motor Deficits
Upper motor deficits result in spastic paralysis
Lower motor deficits result in flaccid paralysis and muscle atrophy
Common Manifestations/ComplicationsSpinal cord injuries are described by the level of the injury–
the cord segment or dermatome levelSuch as C6; L4 spinal cord injury
Terms used to describe motor deficitsPrefix:
para- meaning two extremities tetra- or quadra- all four extremities
Suffix : -paresis meaning weakness
-plegia meaning paralysis
Quadraparesis means what?
Immediate CareEmergency Care at Scene, ER & ICU
Transport with cervical collar
Assess ABC’s; O2; tracheotomy/vent
IV for life lineNG to suction
Diagnostic Studies for SCI
X-ray of spinal columnCT/MRIBlood gases
Therapeutic Interventions MedicationsIV methylprednisolone (Solu-Medrol)
within 8 hrs to decrease cord edema
Therapeutic InterventionsStabilization/Immobilization
Traction-Gardner-wells tongsHalo
CastsSplintsCollarsBraces
Therapeutic InterventionsSurgery for SCI
Manipulation to correct dislocation or to unlock vertebrae
Decompression laminectomy
Spinal fusionWiring or rods to
hold vertebrae together
Nursing Management AssessmentHEALTH HISTOYDescription of how and when injury
occurredOther illnesses or disease processesAbility to move, breathe, and associated
injury such as a head injury, fractures
Nursing Management AssessmentPHYSICAL EXAM
LOC and pupils- may have indirect SCI from head injury
Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds
Vital signsMotorSensoryBowel and bladder function
Nursing ManagementAssessmentMotor Assessment Upper Extremity
Movement, strength and symmetry
Hand grips
Flex and extend arm at elbow- with and without resistance
Nursing Management Assessment Motor Assessment Lower Extremity
Flex and extend leg at knee with and without resistance
Planter and dorsi flexion of foot
Assess for Clonus
Nursing Management AssessmentSensory assessment
With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify
Use the dermatome as reference to identify level
C6 thumb; T4 nipple; T10 naval
Nursing Problems/Interventions
1.Impaired mobility2.Impaired gas exchange3. Impaired skin integrity4. Constipation5. Impaired urinary elimination6. Risk for autonomic dysreflexia7. Ineffective coping
1. Impaired Physical Mobilityprovide assistance as needed to keep
alignment; teach patient Care traction, collars, splints, braces,
assistive devices for ADL’sFlaccid paralysis- use high top tennis shoes
or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)
1. Impaired Physical MobilitySpastic Paralysis
Prevent spasms by avoiding; sudden movements or jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue
Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications
Assess skin break down thrombophlebitis; remove TED hose(compression stockings) at least every shift
1. Impaired Physical MobilityPrevent/treat orthostatic hypotension
Abdominal binder, calf compressors, TED hose when individual gets up
Assess BP, especially when rising
Teach use of transfer boardAssist Physical Therapy with tilt table as
individual gradually gets use to being in an upright position
2. Impaired Gas ExchangePhrenic nerve (C3-5) controls the diaphragm
bilaterally. If nerve is nonfunctioning then individual is ventilator dependent.
Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing
2. Impaired Gas ExchangeRespiratory rate, rhythm,
depth, breath sounds, respiratory effort, ABG’s, O2 saturation
Need for ventilatory assistance tracheotomy, ventilator
Quad cough (assistive cough) as needed
3. Impaired Skin IntegrityChange position frequentlyProtection from extremes in temperatureInspect skin at least 2x/day especially over boney
prominences Avoid shearing and friction to soft tissue with
transfersRemoval of TED hose every 8 hoursNutritional status
4. Constipation
Bowels rely more on bulk than on nervesStimulate bowels at the same time each day.
Best after a meal when normal peristalsis occurs
Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation
Assess bowel sounds prior to giving food for the first time– paralytic ileus!
5. Impaired Urinary EliminationFlaccid bladder (lower motor neuron lesion)
No reflex from S2,3,4Automatic empting of bladder Urine fills the bladder and dribbles outNeed Foley or freq intermittent self catheterization
Spastic bladder (upper motor neuron lesion) Reflex arc but no connection to or from brain Bladder training- trigger points to stimulate empting;
self catheterization
5. Impaired Urinary EliminationUse bladder scan to see amount of urine
in bladder Goal- residual <100ml/20% bladder
capacitySome individuals may need suprapubic
catheterAssess effectiveness of medication
Urecholine to stimulate bladder contractionUrinary antiseptic
6. Risk for Autonomic Dysreflexia
Elevate head of bed- causes orthostatic hypotension
Identify cause/alleviate- if full bladder- cath; if skin- remove pressure, if full bowel- empty, etc
Remove support hose/abdominal binderMonitor blood pressure- can get > 300 SGive PRN medication to lower BPIf above not effective– call physician
7. Ineffective Coping/Grief and Depression
Assess thoughts on ‘quality of life’; body image; role changes
Physical and psychological supportMost common SCI is 15-30 yeas old and
generally a risk taker– this greatly affects their perception of life and rehabilitation
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