Focus on Spinal Cord Injury
(Relates to Chapter 63, Spinal Cord Injury in the textbook)
• Prognosis for life ~5 years less than persons without spinal cord injuries
– Cause of premature death usually related to compromised respiratory function
• Spinal cord injuries can cause major problems
– Economic loss
– High cost of rehabilitation and
long-term health care
– Spinal Cord Injuries
• Estimates from CDC
– 11,000 Americans suffer spinal cord injuries each year
– 222,000 to 285,000 Americans live with spinal cord injuries
• Cost of spinal cord injury care is high
• For patient with high cervical injury
– First year: $682,957
– Subsequent years: $122,334
– Etiology and Pathophysiology
• Young adult men between ages 16 and 30 are at greatest risk
• 78% of spinal cord injury patients are 19-year-old males
Causes
– 50% Motor vehicle crashes
– 24% Falls
– 11% Violence
• In large urban areas, gunshot wounds may surpass falls
– 9% Sport injuries
– 6% Other miscellaneous
Etiology and Pathophysiology
Initial Injury
• Spinal cord is wrapped in tough layers of dura
• Spinal cord injury due to cord compression by
– Bone displacement
– Interruption of blood supply to cord
– Traction resulting from pulling on cord
• Penetrating trauma (gunshot wound or stab wounds)
• Primary injury
– Initial mechanical disruption of axons as a result of stretch or laceration
• Secondary injury
– Ongoing, progressive damage that occurs after initial injury
• Cell death occurs and may continue for weeks or months after initial injury
• Complete cord damage in severe trauma related to autodestruction of cord
– Petechial hemorrhages are in central gray matter of cord shortly after injury
– Appear within 1 hour
– 4 hours later may be infarction in gray matter
• Resulting hypoxia, ↓ oxygen tension below level that meets metabolic needs of spinal cord
• ↑ Vasoactive substances
– Norepinephrine, Serotonin, Dopamine
•
At high levels, vasoactive substances cause
– Vasospasms, Hypoxia
• Leading to subsequent necrosis
• By ≤24 hours, permanent damage may occur because of edema
• Edema secondary to inflammatory response is harmful because of lack of space for tissue expansion
• Resultant compression of cord and extension of edema above and below injury increase ischemic damage
• Extent of neurologic damage caused by spinal cord injury results from
– Primary injury damage
• Actual physical disruption of axons
– Secondary damage
• Ischemia, hypoxia, microhemorrhage, and edema
(will not know the exact extent of the injury for at least 72hrs or more)
Spinal and Neurogenic Shock
Spinal shock
– Temporary neurologic syndrome
– Characterized by
• ↓ Reflexes
• Loss of sensation
• Flaccid paralysis below level of injury
Spinal shock resolves – Will see return of reflex activities (spinal shock usually last 7-20 days)
The transient nature of spinal shock is unknown
– Experienced by ~50% of people with acute spinal cord injury
Neurogenic shock
– Loss of vasomotor tone caused by injury
– Characterized by hypotension and bradycardia (important clinical cues)
– Loss of sympathetic nervous system innervation causes
• Peripheral vasodilation
• Venous pooling
• ↓ Cardiac output
– Spinal shock patients will also have neurogenic shock.
– Mechanisms of Injury
• Major mechanisms of injury are
– Flexion or Hyperflexion
– Hyperextension
– Compression or Axial loading
– Rotational
• Hyperflexion
• Cervical: (usually seen in c5-c6)
– Sudden forceful forward acceleration of the head.
• Lower thoracic/lumbar:
– Trunk is suddenly flexed on itself.
• Compression.
• Dislocation.
• Instability.
• Hyperextension
• Head accelerated & decelerated.
•
•
•
•
•
Vertebrae may fracture or subluxate (subluxation).
SC stretched & distorted.
Contusion & ischemia of SC.
Axial Loading / Compression
Vertical force along SC.
– Fall  Landing on feet, buttocks or head.
• Vertebrae shatter.
– Wedge, burst or teardrop fractures.
• Bone fragments damage SC.
• Rotational Injury
• Occurs in conjunction with a flexion or extension injury.
– Sudden twisting of the body.
• Tearing of posterior ligaments.
• Displacement (rotation) of the spinal column.
Level of Injury
• Skeletal level
– Injury is the vertebral level where there is most damage to vertebral bones and ligaments
• Neurologic level
– Lowest segment of spinal cord with normal sensory and motor function on both sides of the body
• Cervical and lumbar injuries are most common
• Paralysis of all four extremities occurs (tetraplegia [quadriplegia]) if cervical cord is involved
• When damage is high in cervical cord, arms are rarely completely paralyzed
• Paraplegia results if thoracic or lumbar cord is damaged
Degree of Injury
• Degree of spinal cord involvement may be
– Complete cord involvement
• Results in total loss of sensory and motor function below level of lesion (injury)
– Incomplete (partial) cord involvement
• Results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact
• Four syndromes are associated with incomplete lesions
– Central cord syndrome
– Anterior cord syndrome
– Brown-Séquard syndrome
– Posterior cord syndrome
SEE HANDOUT GIVEN IN CLASS!
Central Cord Syndrome
• Damage to central spinal cord
• Occurs most commonly in cervical cord region
• More common in older adults
• Motor weakness and sensory loss are present in both upper and lower extremities
Anterior Cord Syndrome
• Caused by damage to anterior spinal artery
• Results in compromised blood flow to anterior spinal cord
• Typically results from injury causing acute compression of anterior portion of spinal cord
– Often a flexion injury
Brown-Séquard Syndrome
• Result of damage to one half of spinal cord
• Characterized by a loss of motor function and position and vibration sense on same side of injury
• Vasomotor paralysis on the same side as lesion (loss of deep touch)
• Opposite side has loss of pain and temperature sensation below level of lesion
Posterior Cord Syndrome
• Results from compression or damage to posterior spinal artery
• Very rare condition
• Usually dorsal columns are damaged
– Results in loss of proprioception
• Pain, temperature sensation, and motor function below level of lesion remain intact
Clinical Manifestations
• Generally direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection
• Related to level and degree of injury
• Patient with an incomplete lesion may demonstrate a mixture of symptoms
• Loss of voluntary control below the lesion
• Higher the injury, the more serious the sequelae
– Proximity of cervical cord to medulla and brainstem
• Movement and rehabilitation potential related to specific locations of spinal cord injury
• Immediate postinjury problems include
– Maintaining a patent airway
– Adequate ventilation
– Adequate circulating blood volume
– Preventing extension of cord damage (secondary damage) – maintain C-spine stability
Respiratory System
• Respiratory complications closely correspond to level of injury
• Cervical injury
– Above level of C4
• Presents special problems because of total loss of respiratory muscle function
• Mechanical ventilation is required to keep patient alive
–
Below level of C4
• Diaphragmatic breathing if phrenic nerve is functioning
• Spinal cord edema and hemorrhage can affect function of phrenic nerve and cause respiratory
insufficiency
• Hypoventilation almost always occurs with diaphragmatic breathing
• Cervical and thoracic injuries cause paralysis of
– Abdominal muscles
– Intercostal muscles (c6-t8)
• Patient cannot cough effectively
– Leads to atelectasis or pneumonia
Cardiovascular System
• Any cord injury above level T6 greatly ↓ the influence of the sympathetic nervous system
• Peripheral vasodilation results in hypotension
• Cardiac monitoring is necessary
• Peripheral vasodilation
– ↓ Venous return of blood to heart
– ↓ Cardiac output
Urinary System
• Urinary retention common
• Bladder is atonic and overdistended
• Indwelling catheter inserted
– Increased risk of infection
• Bladder may become hyperirritable
– Loss of inhibition from brain
– Reflex emptying (good thing – even with total loss of function, they will be able to get rid of the cath)
Gastrointestinal System
• If cord injury is above T5, primary GI problems related to hypomotility
• Stress ulcers common
• Intraabdominal bleeding may occur
– Difficult to diagnose
– Indications of bleeding
• Continued hypotension despite treatment
• Decreased hemoglobin and hematocrit
• Less voluntary neurogenic control over bowel results in a neurogenic bowel
• Injury level of T12 or below
– Bowel is areflexic
– ↓ Sphincter tone
• As reflexes return
– Bowel becomes reflexic
– Sphincter tone is enhanced
– Reflex emptying occurs
– Clinical Manifestations
Integumentary System
• Consequence of lack of movement is skin breakdown
• Pressure ulcers can occur quickly
• Can lead to major infection or sepsis
Thermoregulation
• Poikilothermism
– Adjustment of body temperature to room temperature
• With spinal cord disruption, there is also
– Decreased ability to sweat
– Decreased ability to shiver
• Degree of poikilothermism depends on level of injury
– Clinical Manifestations
Metabolic Needs
• Nasogastric suctioning may lead to metabolic alkalosis
• ↓ Tissue perfusion may lead to acidosis
• Monitor electrolyte levels until suctioning is discontinued and normal diet is resumed
• Loss of body weight is common
• Nutritional needs much greater than expected for immobilized person
• Positive nitrogen and high-protein diet
– Prevents skin breakdown and infection
– Decreases rate of muscle atrophy
Peripheral Vascular Problems
• Deep vein thrombosis (DVT) problem
• DVT assessments
– Doppler examination
– Measurement of legs and thigh girth
Diagnostic Studies
• Complete spine films are performed to assess for vertebral fracture
• CT scan may be used to assess stability of injury, location, and degree of bone injury
• MRI used where there is unexplained neurologic deficit
• Comprehensive neurologic examination
Collaborative Care
• Initial goals are to
– Sustain life
– Prevent further cord damage
• Systemic and neurogenic shock must be treated to maintain BP
• At cervical level, all body systems must be maintained until full extent of damage is known
• Thoracic and lumbar vertebrae injuries
– Systemic support less intense
– Specific problems treated symptomatically
• After stabilization, history is obtained
– Emphasis on how injury occurred
– Extent of injury as perceived by patient immediately after event
– Collaborative Care
Assessment
– Test muscle groups with and against gravity
– Note spontaneous movement
– Sensory examination
– Position sense and vibration
– Brain injury may have occurred—assess history for
• Unconsciousness
• Signs of concussion
• Increased intracranial pressure
– Musculoskeletal injuries
– Trauma to internal organs
Nonoperative Stabilization
• Focused on stabilization of injured spinal segment and decompression
• Through traction or realignment
• Eliminate damaging motion at injury site
• Intended to prevent secondary damage
Surgical Therapy
• Criteria for early surgery
– Cord decompression may result in
↓ secondary injury
– Evidence of cord compression
– Progressive neurologic deficit
– Compound fracture
– Bony fragments
– Penetrating wounds of spinal cord or surrounding structures
Common surgical procedures
– Decompression laminectomy by anterior cervical and thoracic approaches with fusion
– Posterior laminectomy with use of acrylic wire mesh and fusion
– Insertion of stabilizing rods
Drug Therapy
• Methylprednisolone (MP)
– Administered early and in large doses there is greater recovery of neurologic function
– Was a standard of care, but MP increases risk of complications, cost, hospital stay
– Now a treatment option
– No benefit 8 hours postinjury
• Vasopressor agents
– Used in acute phase
– Maintain mean arterial pressure
• Drug interactions may occur
Pharmacologic agents
– Used to treat specific autonomic dysfunctions
Nursing Assessment
• Subjective data
– Past health history
– Health perception–health management
– Activity-exercise
– Cognitive-perceptual
– Coping–stress tolerance
• Objective data
– General: Poikilothermism
– Integumentary: Neurogenic shock
– Respiratory: Lesions at C1-3
– Cardiovascular: Lesions above T5
– GI: Decreased or absent bowel sounds
– Urinary: Retention, flaccid bladder
Planning
• Overall goals
– Maintain an optimal level of neurologic functioning
– Have minimal to no complications of immobility
– Learn skills, gain knowledge, and acquire behaviors to care for self
– Return to home and community
Nursing Implementation
• Nursing interventions
– Education
– Counseling
– Maintaining appointments
– Referral to programs
•
•
•
Recreation and exercise programs
Alcohol treatment programs
Smoking cessation programs
Immobilization
• Proper immobilization involves maintenance of a neutral position
• Stabilize neck to prevent lateral rotation of cervical spine
– A blanket or towel
– Hard cervical collar
– Backboard
• Skeletal traction
– Realignment or reduction of injury
– Provided by rope from center of tongs over a pulley that has weights attached at end
– Traction must be maintained at all times
– Stabilize head if dislodged and then call for help
• Kinetic therapy
– Uses a continual side-to-side slow rotation
– Decreases pressure ulcers and cardiopulmonary complications
• Thoracic or lumbar spine injuries
– Custom thoracolumbar orthosis (“body jacket”)
– Meticulous skin care is critical
Respiratory Dysfunction
• During first 48 hours, spinal cord edema increases level of dysfunction
• Respiratory distress may occur
• Injury at or above C3
– Mechanical ventilation
• Other potential problems
– Pneumonia and atelectasis
• Aggressive chest physiotherapy
• Proper pain management
Cardiovascular Instability
• Heart rate is slow (<60 beats per minute) because of unopposed vagal response
• Any ↑ in vagal stimulation can result in cardiac arrest
– Turning
– Suctioning
• Temporary/permanent pacemaker
• Compression gradient stockings
– Remove every 8 hours for skin care
• Prophylactic heparin or low-molecular-weight heparin
Fluid and Nutritional Maintenance
• During first 48 to 72 hours, GI tract may stop functioning
• Nasogastric tube may be inserted
• High-protein, high-calorie diet
• Evaluate swallowing in high cervical cord injuries before starting oral feedings
• Bladder and Bowel Management
• Immediately after injury
– Urine is retained
–
–
–
Loss of autonomic and reflex control of bladder and sphincter
Bladder overdistention can result in reflux into kidney with eventual renal failure
Intermittent catheterization program
• Urinary tract infections
Bladder and Bowel Management
• Constipation
– Problem during spinal shock
– No voluntary or involuntary evacuation of bowels occurs
– Rectal stimulant (suppository or
mini-enema) inserted daily
Temperature Control
• Below level of injury, no
– Vasoconstriction
– Piloerection
– Heat loss through perspiration
• Temperature is largely external to patient
• Nurse must monitor environment and body temperature
Stress Ulcers
• Physiologic response to severe trauma or physiologic stress
• High-dose corticosteroids
• Peak incidence occurs 6 to 14 days after injury
Sensory Deprivation
• Stimulate patient above level of injury
• Conversation, music, strong aromas, and interesting flavors
• Prism glasses to read and watch TV
• Every effort should be made to prevent patient from withdrawing
Reflexes
• Return of reflexes may complicate rehabilitation
– Hyperactive
– Exaggerated responses
– Spasms
• Patient or family may see this as return of function
Autonomic Dysreflexia
• Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system
• If reflexes return after spinal shock and injury level is T6 or ↑
• Occurs in response to visceral stimulation
• Life-threatening
• Most common precipitating factor is distended bladder or rectum
Manifestations
– Hypertension
– Blurred vision
– Throbbing headache—take BP
– Marked diaphoresis above lesion level
– Bradycardia
– Piloerection (erection of body hair) resulting from pilomotor spasm
– Flushing of skin above lesion
– Spots in visual field
– Nasal congestion
– Anxiety
– Nausea
– Autonomic Dysreflexia
Nursing interventions
– Elevate head of bed at 45 degrees or sit patient upright
– Notify physician
– Assess cause
– Immediate catheterization
• Teach patient and family causes and symptoms
Rehabilitation and Home Care
• Organized around individual patient’s goals and needs
• Patient expected
– To be involved in therapies
– To learn self-care
• Can be very stressful
• Frequent encouragement
Respiratory Rehabilitation
• Phrenic nerve stimulators or electronic diaphragmatic pacemakers increase mobility
• Teach cervical-level injury patients who are not ventilator dependent
– Assisted coughing
– Regular use of spirometry or deep breathing exercises
Neurogenic Bladder
• Any type of bladder dysfunction related to abnormal or absent bladder innervation
• Common problems
– Urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux to
urine into kidneys
Neurogenic Bowel
• Voluntary control may be lost
• High-fiber diet and adequate fluid intake
• Suppositories, small-volume enemas, or digital stimulation by patient or nurse
• Carefully record bowel movements
Neurogenic Skin
• Prevention of pressure ulcers and other types of injury to insensitive skin is essential
• Teach these skills and provide information about daily skin care
• Careful positioning and repositioning should be done every
2 hours with gradual ↑ in time
Sexuality
• Important issue regardless of patient’s age or gender
• Injury level and completeness of injury is needed to understand the male patient’s potential for orgasm,
erection, fertility, and patient’s capacity for sexual satisfaction
• Treatments for erectile dysfunction include drugs, vacuum devices, and surgical procedures
Grief and Depression
• May feel an overwhelming sense of loss
• May believe they are useless and burdens to their families
•
•
•
•
Working through grief is a difficult, lifelong process
Needs support and encouragement
Patient’s family may also require counseling
Patient should be
– Treated in an adult manner
– Involved in decision-making process
Summary
•
•
•
•
Spinal cord injury patients are living much longer life spans
Aging has serious impact on the older adult with a spinal cord injury
Health promotion and screening are important
SEATBELTS and HELMETS