The incidence of DVT is extremely high in SCI patients due to pressure on their calf muscles, loss of the skeletal muscle pump, and the hypercoagulability of their blood.
Treatment consists of hospital’s choice of DVT prophylaxis - pneumatic compression hose, low dose Heparin or Lovenox, ROM exercises, and vena cava filters.
May require Coumadin long term.
Measure thighs and calves daily.
May develop in the acute or transitional phase.
Caused by venous pooling in the legs and abdomen, loss the skeletal muscle pump, and impaired sympathetic nervous system control of BP.
May occur with position changes and can result in syncope, bradycardia, or asystole.
Treatment consists of quickly returning the patient to a supine position, administering oxygen, and if necessary, atropine to increase heart rate.
Preventive measures include TED stockings, elastic bandages, and abdominal binders that promote venous return from the extremities.
GI and GU dysfunction
Assess for bowel distention, ileus or gastrointestinal bleeding - may require an NGT
Monitor patient’s bowel function and establish bowel routine.
During acute injury phase, the bladder is atonic so the patient is unable to void voluntarily or spontaneously - also increases risk of UTI
Maintain strict Intake and Output
Begin bladder training
Below the level of SCI, the patient cannot sense discomfort from pressure, skin irritants, or temperature extremes.
Patient will remain at high risk for pressure ulcers, serious skin injury and infection.
During acute phase, inspect skin for redness or other signs of breakdown - pressure ulcers can occur within 6 hours
May use special bed as roto-rest or striker frame to turn patient.
An acute emergency
It is an exaggerated response to stimuli
Classic signs are pounding headache, marked hypertension, diaphoresis (particularly of the forehead), bradycardia, flushing, piloerection, nausea, and nasal congestion
Occurs only after spinal shock has resolved
The increase in ICP and blood pressure can lead to cerebral hemorrhage
Autonomic Dysreflexia Pathophysiology
Occurs with spinal cord lesions above the thoracic sympathetic outflow (T6 or T7). The feedback system between the sympathetic and parasympathetic branches of the ANS is disrupted.
The parasympathetic response is partially disabled and the sympathetic response is dominant.
As a result, the sympathetic response produces profound vasoconstriction thus producing a rapid rise in blood pressure.
Normally, baroceptors in the cerebral vessels, carotid sinus, and aorta detect the rising blood pressure and attempt to trigger visceral and peripheral vasodilatation, but these impulse are blocked by a damaged cord.
The parasympathetic response is limited to vagal slowing of the heart rate and vasodilatation, flushing, and diaphoresis above the level of spinal cord injury.
Autonomic Dysreflexia cont’d
Anything that can cause discomfort to a neurologically intact person can trigger autonomic dysreflexia in a patient with a spinal cord injury.
The most common stimulus is a distended bladder or rectum.
Other causes include: Stimulation of the skin from pressure, pain, heat or cold.
The goal of treatment is to identify and remove the cause of the dysreflexia and thus lower the BP.
Sit patient with feet down to promote orthostatic reduction of blood pressure. (If patient unable to sit, elevate head of bed to 90 degrees).
Quadraplegics and Paraplegics
Quadraplegics - results from a cervical impairment
Paraplegic - results from impairment at the thoracic, lumbar, or sacral root area.
Can result from accidents, spinal cord lesions, tumors, vascular lesions, multiple sclerosis, infections or abscesses of the spinal cord or congenital defects
You will see these patients in the hospital for all of the other things you see patients for
Rehab and Long-Term Issues
Mobility - initially may require a brace or halo. Needs to bear weight as soon as possible because it helps decrease disuse atrophy, decrease the opportunity for osteoporosis, decrease the possibility of renal calculi, and enhances metabolic processes
Exercise - to strengthen unaffected parts and promote self-care
Skin Integrity - needs to be taught the importance of being responsible for own skin integrity
Rehab and Long-Term Issues cont’d
Urinary and Bowel Programs - will have to develop and maintain programs. Will need to learn how/when to self-cath, check residual urine. Will need to know how to stimulate a bowel movement. Will need to be able to recognize an impaction or ileus.
Prevent and Manage Complications
Spastic Muscles - maximum spastic activity is usually 2 years out and then minimizes some. May require long-term use of anti-spasmodic drugs such as valium, baclofen or dantrium
Rehab and Long Term Issues cont’d
Contractures - Needs to understand the importance of exercise and maintaining function
UTI’s and sepsis - needs to recognize signs and symptoms of UTI and sepsis.
Heterotropic ossification - overgrowth of bone in hips, knees, shoulders elbows. This causes pain and decreased ROM for pain, thus decreasing mobility
Self-Esteem - May need counseling to deal with changes in self-identity, sexual function, social and emotional roles. Needs to feel strong, lovable and loved.
Denial, anger and depression are common reactions to SCI.
Manipulative behavior and emotional times are managed by setting mutually reasonable expectations of the patient and nursing staff.
Ultimately the SCI patient will ask the question of walking again. Often this question cannot be answered in the immediate post-injury phase. The goals are to provide honest and realistic communication about the nature of the injury and help the patient develop short-term goals.
Tumors within the spine are classified according to their anatomic relation to the spinal cord
Intramedullary lesions (within the spinal cord)
Extramedullary- intradural lesions (within the subarachnoid space)
Extradural lesions (outside the dural membrane)
Symptoms Associated with Intraspinal Tumors
Loss of reflexes above the tumor level
Localized or shooting pains in the area that is innervated by the spinal roots that originate in the cord near the tumor site
Progressive loss of motor function and paralysis below the level of the lesion
Diagnosis is made by neurological exam and myelogram plus CT scanning and Magnetic Reasoning Imaging (MRI)
Assess patient for weakness, muscle wasting, spasticity, and sensory or sphincter disorders.
Important areas in patient’s history include: pulmonary system(especially when a cervical lesion is present), hx of coagulopathies, any anticoagulants taken recently including aspirin or anti-inflammatory drugs.
Importance of pulmonary toilet (cough and deep breathing exercises and use of incentive spirometer) is taught prior to surgery.
Surgical Management of Intraspinal Tumors
Excision of the tumor while sparing the uninvolved portions of the spinal cord is the most desirable form of treatment/cure.
Prognosis is related to degree of neurologic impairment at the time of surgery, the speed with which symptoms occurred, and the tumors origin.
Other treatment modalities include partial removal of the tumor, decompression of the spinal cord, chemotherapy, and radiation therapy.
Spinal cord compression from metastatic Ca is treated with high dose dexamethasone and radiation to help relieve pain
Postoperative Nursing Interventions
Monitor patient for deterioration in neurological status
Note: a sudden onset of neurological deficit is an ominous sign and should be treated as an emergency.
It may be due to vertebral collapse associated with spinal cord infarction.
Respiratory function: Assess for rate and quality of breath sounds, manage artificial airway if present, and encourage pulmonary toilet.
Bladder: Palpate for urinary retention or urinary incontinence. Monitor intake and output.
Assist with pain management.
Postoperative Nursing Interventions cont’d
Positioning - keep flat, log roll when turning. Patient may be more comfortable on side. Avoid extreme knee flexion.
Monitor wound for CSF leakage - can lead to serious infection and severe pain
Herniation of an Intervertebral Disc
The intervertebral disc is a cartilaginous plate that forms a cushion between vertebral bodies.
This tough, fibrous material is incorporated in a capsule.
A ball-like cushion in the center of the disc is called the nucleus pulposus.
Herniation occurs when the nucleus of the disc protrudes into the fibrous ring causing nerve compression.
Can occur related to degenerative changes or trauma
Herniation of an IV Disc cont’d
Manifestation depends on:
rate of development (acute vs. chronic)
effect on surrounding structures
Herniation of a Cervical IV Disc
The cervical spine is subjected to stresses that result from disc degeneration (from aging, occupational stresses), and spondylosis (degenerative changes occurring in disc and adjacent vertebral bodies).
Cervical disc herniation usually occurs at the C5-C6 and C6-C7 interspaces.
Pain and stiffness may occur in the neck, the top of the shoulders, the region of the scapulae, in the upper extremities, head, and may be accompanied by numbness of the upper extremities.
Diagnosis of cervical disc herniation is confirmed on MRI.
Management of Herniation of a Cervical IV Disc
The goals of treatment are (1) rest and immobilization of cervical spine and (2) reduce inflammation of supportive tissue and affected nerve roots
Surgical excision of a herniated disc is performed when there is evidence of a progressing neurological deficit (muscle weakness and atrophy, loss of sensory and motor function, loss of sphincter control), and continuing pain and sciatica that is not responsive to medical management.
The goal of surgical management is to lessen the pressure on the nerve root to relieve pain and reverse neurological deficits.
Disc Surgery cont’d
Diskectomy - removal of herniated or extruded fragments of intervertebral disc.
Laminectomy - removal of the lamina to expose the neural elements in the spinal canal; allows the surgeon to inspect the spinal cord, identify and remove tissue for pathology, and relieve compression of the cord and roots.
Laminotomy - division of the lamina of a vertebra
Diskectomy with fusion - a bone graft (from iliac crest or bone bank) is used to fuse the vertebral spinous processes; the object of spinal fusion is to bridge over the defective disc to stabilize the spine and reduce the rate of recurrence.
Disc Surgery cont’d
Preoperative Management includes evaluation of movement in extremities plus bowel and bladder function.
Patient is taught useful techniques such as log-rolling, pulmonary toilet, and muscle-setting (isometric) exercises, which will help to maintain muscle tone postoperatively.
Disc Surgery cont’d
Post-operative Management includes:
Frequent neurological checks, along with vascular supply checks to extremities.
Sitting is discouraged
Position patient using a pillow under the head, and the knee rest is slightly elevated. When patient lying on side, avoid excessive knee flexion
Encouraged to move from side to side by log rolling
Complications of Disc Surgery
Arachnoiditis - inflammation of the arachnoid membrane. Causes diffuse frequent burning pain in lower back radiating to buttocks
Failed Disc Syndrome - recurrence of sciatica after surgery
Bleeding and hematoma formation
Fixing one level may cause problems at other levels