Against All Odds
Maximizing Outcomes in SCI
Mary Kay Bader RN, MSN, CCNS,
FAHA, FNCS, CCRN, CNRN
Neuro Critical Care CNS
Mission Hospital
Badermk@aol.com
Disclosures
• American Association of Neuroscience
Nurses
– Immediate Past President
• Medical Advisory Board
– Brain Trauma Foundation
– Neuroptics
• Honorarium
– Bard
– Neuroptics
– The Medicines Company
• Causes
– MVAs 42%
– Interpersonal violence
24%
– Falls 27%
– Acts of violence (15%)
– Sports 8%
• (diving=cervical vs
parachuting =
thoracolumbar)
– Industrial (crush) 2%
• Location
– majority c-spine
– thoracic-lumbar 2030%
Epidemiology
Epidemiology
• Incidence: 12,000/year
– 50% age 16-30 mean (age 40)
– 81% male
– Alcohol intoxication present 17-19%
• Prevalence
– 259,000 survivors in US
– Average life expectancy
• High tetraplegics 36 years after injury
• Low tetraplegics 40 years after injury
• Paraplegics 45 years after injury
Factors that Impact Outcome
•
•
•
•
Age at time of SCI
Level of injury
Grading of Injury (ASIA)
Increased mortality
– Higher lesions
– Advanced age
Description
• Primary Injury
– A temporary or permanent loss of
function as a result of injury produced
from compression, tearing, lacerations
or ischemia
• Secondary Injury
– Further compromise to cord function
• spinal cord edema
• hemorrhage
– Results in a decrease in perfusion to
cord
Vertebral
Column
Spinal
Cord
Meninges
Vertebral
Column
• Ligaments
– Anterior support
• ant. long lig
• post. long. lig
– Posterior
support
• interspinous
• supraspinal
• cruciform
SCI: Degree of Stability
• Stable
• Unstable ligamentous injury
Intervertebral
Discs
•Ruptured discs
can manifest
motor/sensory
or both
Blood Supply to SC
• Anterior and posterior spinal arteries
• Radicular arteries
Spinal Cord
• C1-L2
– max movement
C5-6
– greatest flexion
L4-5
• Gray matter: cell
bodies/dendrites
• White matter:
myelinated axons
Etiology
• Causes
– MVAs 44%
– Interpersonal violence 24%
– Falls 22%
– Sports 8%
• Location
– majority c-spine
– thoracic-lumbar 20-30%
Mechanism of Injury
• Hyperflexion
• Hyperextension
• Compression
• Rotation
• Penetrating
Characteristics of Injury
• Rotational Injuries
– caused by extreme lateral flexion or twisting of
neck
– tears posterior ligamental structures causing
dislocation and instability
Soft Tissue Injury
Vertebral
Trauma
• Simple-single break
– Usually spinous/transverse
processes, pedicles or facets
• Compression: cause
flattening/wedging of VB
– wedge, burst or teardrop
(hyperextension)
– Amenable to orthosis
• Dislocation
– ligaments damage
Crush injury
Atlas and Axis Injuries
C1 burst: disruption of ant and post arch of C1. Results from force
to vertex of head/rarely causes neuro injury. Usually managed with
external orthosis.
http://www.google.com/url?sa=i&rct=j&q=spinal+cord+hangmans+fracture&source=images&cd=&cad=rja&docid=t1ZbAjMq9m0oEM&tbnid=Itidkkw8ILzSyM:&ved=0CAQQjB0&url=http%3A
%2F%2Fdermatologic.com.ar%2F4.htm&ei=8cBYUeDZNJGu8QTurICoCg&bvm=bv.44442042,d.dmQ&psig=AFQjCNFQbyZny2YNQztNSvOlBeULzzAAvg&ust=1364857224911192
Types of C2 Fractures
1: usually
stable
2. Transverse
or oblique fX
thru dens:
Unstable
Usually involves
ligament.
Stable. May be
ass. with
antlantooccipital
dislocation
Often displaced
anteriorly or
posteriorly.
Associated with
high nonunion
rate when
managed
conservatively
3. Base of Dens:
May require light traction for initial
reduction with Halo
Atlas and Axis Injuries
Hangman’s
Fracture
Fx through bilateral pedicles
Separates C2-C3 and posterior elements
CT Spine
Floating
Dens (C2)
Anterior C1
Posterior
C1
Chance Fractures
• Mechanism
– a flexion-distraction injury (seatbelt injury)
• may be a bony injury
• may be ligamentous injury (flexion-distraction injury)
– more difficult to heal
• middle and posterior columns fail under tension
• anterior column fails under compression
• Associated injuries
– high rate of gastrointestinal injuries (50%)
Chance Fractures
• Result from hyperfexion
of the spine around an
anterior fulcrum in
combo with a posterior
vertical distraction force
• Horizontal fractures of
the pedicles with
extension through
vertebral body
• Associated with visceral
injuries
Fracture-Dislocations
Subluxation
Rotary sublux: caused by abnormal
rotation at C1-C2; Seen on CT; exhibit
torticollis
Sublux: facet malignment; may be no
bony fx, only ligament –unstable; aka
locked, perched, jumped facets.
Spinal Cord Injury
• Concussion
– Transient loss of SC function
• Contusion
– Intramedullary hemorrhage &
edema
• Laceration
– Cut in the cord
Spinal Cord Injury
• Transection
– Complete cut through SC; very
rare
• Hemorrhage
– Parenchyma of SC or within one
of meninges (can lead to SC
compression)
• Vascular
– Damage to vessels perfusing the
cord lead to ischemia
• Cellular Dynamics
Complete Injury: Anatomical Levels
http://www.google.com/url?sa=i&rct=j&q=spinal+cord+injury+assessment&source=images&cd=&cad=rja&docid=Jacvj9YwLVXwTM&tbnid=rgb8iZ7PUkifCM:
&ved=0CAQQjB0&url=http%3A%2F%2Fwww.yourshealthy.com%2F&ei=IbpYUeOvGIuA9QSyo4CoCA&bvm=bv.44442042,d.dmg&psig=AFQjCNEy75p04w
3B9O-NUeu-HR2uRK82Yg&ust=1364855704791603
Cord Injury
• Level of lesion and functional
impairment
– C 1-4 tetraplegia with loss of respiratory
– C 4-5 tetraplegia with possible phrenic nerve
– C 5-6 tetraplegia with gross arm/diaphragm
– C6-7 tetraplegia with biceps intact
– C7-8 tetraplegia with triceps, biceps, & w.e.
– T1-L2 paraplegia with loss of intercostals and
abdominal muscle function
– Below L2: Cauda equina vs. conus medullaris
Cord Injury
• Level of lesion and functional
impairment
– Below L2: Cauda equina
–Compression of lumbosacral nerve
roots below L1 vertebrae
–Variable motor loss
–Absent Achilles reflex
–Radicular pain
–Variable sensory loss
–Areflexive bowel and bladder
–No upper motor neuron findings
Cord Injury
• Below L2: conus medullaris
• Compression of conical termination
of cord with damage to lower
lumbar/sacral gray matter and
nerve roots
• Causes
–Fractures
–Disc herniation in the T12/Lumbar
region of vertebral column
Cord Injury
• Below L2: conus medullaris
• Urinary retention
• Impotence
• Constipation
• Lax anal sphincter
• Saddle anesthesia (variable)
• Loss of anal/bulbocavernosus reflex
• Minimal to no motor weakness –
varies may have lower motor neuron
impairment
Cord Injury
• Horner’s syndrome
– Ptosis
– Miosis
– Anhidrosis on affected side
– Associated with spine lesions
above T1 that disrupts the cervical
sympathetic chain or it central
pathways
Incomplete
Injury
• Central cord
• Anterior cord syndrome
• Brown Sequard
• ipsilateral loss of motor
and position/vibratory
sense
• contralateral loss of pain
and temperature
Cord Injury
• Pathophysiology
– decreased blood supply to cord
– progressive edema
– decrease tissue oxygenation
Cord Injury
• Spinal shock –primary injury to
cord
– Areflexia
– flaccid paralysis
– loss of sensation
– Loss of autonomic function
– Loss of bowel/bladder function
Cord Injury
• Neurogenic shock –secondary to
autonomic dysfunction especially
injuries above T6
• Interrupts normal sympathetic outflow
from T1-12 region of SC
– Peripheral dilatation & unopposed vagal
tone
– S/S
• hypotension/bradycardia
• Hypothermia
• lose ability to sweat below level of lesion
Assessment
• History
– How did injury
occur?
• Remember your P’s
– Pain
– Paralysis
– Paresthesias
– Position
– Ptosis
– Points
– Priapism
Assessment Principles
• Upon arrival
–Rapid, thorough evaluation
–Airway patency, ventilation,
and circulation
–Gross neurologic assessment
• Repeat at regular intervals
Assessment Principles
• Why do patients deteriorate?
– Early clinical deterioration (<24 hours)
• Usually due to treatment
• Application or removal of traction
• Inadequate immobilization
– Delayed deterioration (24 hours-7days)
• Often associated with hypotension in
patients with fracture dislocations
– Late deterioration (> 7 days)
• Associated with vertebral artery injuries
• Maintain neck in neutral position
– Immobilization
• ABC
– Airway-Intubation and airway support
– BP and Heart rate
• Disability
– GCS and pupils
– Motor 0-5 scale
– Sensory
– Reflex
Assessing Motor Function
• Upper extremities
– C5 Deltoids: Raise arms
– C5-6 Biceps: Flexion of elbow
– C6-7 wrist extensors: Extension of wrist
– C7 Triceps: Extension of elbow
– C8-T1 Hand intrinsics:
• Finger flexion
• Hand squeeze
• Finger abduction
Assessing Motor Function
• Lower extremities
– L2 Iliopsoas: Hip flexion
– L2-4 Hip adductors: Adduct hips
– L4-S1 Hip abductors: Abduct hips
– L3-4 Quadriceps: Knee extension
– L4-5 S1-2 Hamstrings: Dorsiflex foot
– L5 EHL: Extend great toe
– S1 Gastrocnemius: Plantar flex foot
Assessing Sensory Function
• Sensation: Sharp vs dull distinction in
each dermatome
– Lateral spinothalamic tract mediates pain
and temperature
– Tongue depressor (dull) and pin (sharp)
– Compare side to side
• Porprioceptioin (position sense)
– Dorsal column
– Toe and Thumb positions
Sensory
Dermatomes
AANS Guidelines 2013
• Published 2013 by
AANS/CNS
Hospital Based Protocol
• Collaboration
• Protocol
– ED
• Maintain spine stabilization
• Assess/intervene:
–Airway protection and stabilization
• Assess/intervene:
–Hemodynamic assessment
–Interventions: VS/2 large bore IVs
Hospital Based Protocol
• ED
– Maintain Systolic BP
• Infuse NS
• Start vasopressors: Dopamine #1
– Secondary Survey
– Radiographic evaluation
Medical Surgical Recommendations
Consult
Neurosurgery
or Ortho
Spine
stabilization
Hospital Based Protocol: ICU Care
• Respiratory
– Cervical lesion: loss of C3-4-5 and
diaphragm
• loss of intercostals with thoracic level
dysfunction
• abdominals assist with expiration and blow
off CO2
• cough reflex is diminished
– Acceptable parameters for quad
• VC 1 - 1.2 liters/ NIF -25/ CO2 45-50
– Aggressive pulmonary toilet
Hospital Based Protocol: ICU Care -
Ongoing Care Respiratory
• Airway maintenance
– Intubated, trached, non-intubated
– Ventilator dependent vs independent
– Secretion control
• Assisted cough: cough reflex intact but loss of
respiratory muscles impact cough
• Manually assisted quad cough
• In-exsufflator cough machine: helps clear secretions
by delivering a positive pressure deep breath and
shifting rapidly to a negative pressure high
expiratory flow (via a mask or trache)
• Electrical stimulation of abdominal wall
Hospital Based Protocol: ICU Care -
Ongoing Care Respiratory
• Airway maintenance
– Chest PT
– Bronchoscopy
– Glossopharyngeal breathing (gulping several
breaths then exhale for bigger tidal volumes)
– Mucolytics
– Hydrating agents
– Positioning and mobilization
– 5% of all SCI patients are ventilator dependent
at 1 year
Hospital Based Protocol
• Optimize Spinal Cord Perfusion
– MAP > 85-90
• Crystalloid/colloid IV
• Packed RBCs
• Dopamine and/or Dobutamine
• Administer Methylprednisilone???
– Absolutely NOT!
Hospital Based Protocol ICU Care
• Maintain OG tube
• Assess nutritional
needs through
indirect
calorimetry
– Begin feedings
– H2 blockers
– Bowel program
Hospital Based Protocol ICU Care
• Maintain foley until spinal
shock resolves
– D/C foley
– In/Out catheterization
schedule
Hospital Based Protocol ICU Care
• Musculoskeletal
– Spasticity
– Contractures
– Osteoporosis
– Heterotrophic
ossification
– Interventions: ROM,
positioning important
with PRAFO or splints,
and turn frequently
Hospital Based Protocol: ICU Care
• Skin
– Frequent inspection
– Frequent turning
• Psychological
• Rehab
Effects of Injury on systemic function
• Motor
– Upper motor neuron: motor strip to sc
•
•
•
•
loss of voluntary function
increase in muscle tone and hyperreflexia
reflex arc is intact
spasticity
– Lower motor neuron: spinal nerve
roots/reflex
• loss of voluntary function
• decrease in resting voluntary function
• wasting of muscle and loss of reflexes
Effects of Injury on systemic function
Autonomic Dysreflexia
– Lesions above T6
– Triggered by #1 bladder distention, #2bowel
distention, skin breakdown, stimulation of pain
receptor
– Signs and Symptoms of Autonomic Dysreflexia
Effects of Injury on systemic function
Autonomic Hyperreflexia TX:
1. Sit the patient upright
2. Loosen any tight clothing
3. Search for the cause!
4. If SBP > 150 mm Hg, start pharmacologic treatment
NO
Pre-Hospital
• 51 year old male backseat passenger in
auto
– TC hit from behind
– Paramedics arrived
•
•
•
•
•
GCS 1-1-1
BP 170
Agonal respirations
Pt intubated
IV initiated
Emergency Department
0921
• ABC
– Intubated
– HR 92 BP 129/53 RR assisted
– BP decreased to systolic 80s within 30
minutes of arrival
• IV fluids
• Vasopressor: Dopamine started
• Neuro: No motor movement
• To Radiology
Neurosurgical Consultation
• Pt intubated on ventilator
– No spontaneous respirations
– No motor movement on arrival
– No sensation
– Diagnostics
•
•
•
•
C1-C2 fractures
C5-6 dislocation
T2-3 fracture
Ankylosing spondylitis with extensive fusion
of entire spine
Diagnostics
C1
posterior
C1
anterior
C2 type 2
fracture
Dens of
C2
C5 fracture
Cord Contusion C1-2
CT Spine
Floating
Dens (C2)
Anterior C1
Posterior
C1
CT Spine
Space between
C5-6
T2 Fracture
Odontoid
Screw
Neurosurgical plan Postop
SICU Nursing Care
• Implement the
hypothermia protocol
– Stabilize Airway and
breathing
– Assure MAP adequate
for spine perfusion
– Assess neurologic
status prior to induction
– Stabilize spine for
further operative
interventions
Close Tabs on Vital Info
Hospital Course
Day 8
Spinal Cord Injury
Flowsheet
Ongoing SCI Assess
Outcome
• On PCSU
– Moving arms/legs
• Transferred to ARU and Discharged
– Ambulating
– Weakness in arms 4/5
Emerging Treatment/Research
• Early decompression surgery
• Use of lumbar drains to reduce spine
pressure
• Augmenting Spinal perfusion
– Lumbar drains
– Combination studies (drug + drain +
MAP enhancement)
Emerging Treatment/Research
• Neuroprotection
– Targeting decreasing ionic deranangements,
limiting excitatory neurotransmittors,
stabilizing blood brain barrier, lessening
immune response and inhibiting apoptosis
• Pharmacologic
– Minocycline: decreases inflammation and
inhibits apoptosis
– Riluzole (used in ALS) blocks activation of
sodium channels and reduces glutamate
• Hypothermia
• Regeneration of nerves
• Stem cell
Questions