Spinal cord injury


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Spinal cord injury

  1. 1. Spinal cord Injury This unit aims at helping learners understand the physical, physiological and psychological sequel of spinal cord injuries. Unit will also focus on preventive and curative care of patients with intervertebral disc herniations.
  2. 2. OBJECTIVES: By the end of this unit the learners will be able to: 1. Review basic anatomy and physiology of spinal cord and its protective structures. 2. Describe various mechanisms of injury that may be involved in spinal cord injury. 3. Relate pathophysiological changes that take place after a partial or complete cord transaction. 4. Identify life threatening complications that may result from spinal cord injury. 5. Appreciate the need for prompt interventions incase of a patient with spinal shock and autonomic dysreflexia. 6. Describe the nursing care of a patient with spinal cord injury in an emergency and acute care setting. 7. Explain briefly the rehabilitative needs of patients with Spinal cord injury. 8. Identify the causes and mechanism of injury involved in intervertebral disc herniaition. 9. Describe the role of nurses in surgical and non surgical management of a patient with intervertebral disc herniation. 10. Discuss the importance of maintaining proper body mechanics in preventing Intervertebral disc herniation.
  3. 3. Introduction • Continuation of medulla oblongata • 31 segments each with pair of spinal nerves • Protected by meninges - dura mater, - arachnoid, - pia mater
  4. 4. Functions of spinal cord • Conveys sensory impulses to the brain • Integrates reflexes • Spinal nerves connects at roots - Dorsal root: sensory - Ventral root: motor • All 31 pairs arise from union of dorsal and ventral roots • Mixed nerves consisting of motor and sensory fibers • Most exit vertebral column between vertebrae
  5. 5. • Named and numbered according to region and level of spinal cord • Cervical: 8 pairs • Thoracic: 12 pairs • Lumbar: 5 pairs • Sacral: 5 pairs • Coccygeal: 1 pair
  6. 6. Physiology and function • Dorsal root- sensory fibres • Ventral root- motor fibres • Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve
  8. 8. TRACTS 1- Posterior column: • Fine touch • Light pressure • Proprioception 2- Lateral corticospinal tract: • skilled voluntary work 3- Lateral spinothalamic tract: • Pain and temperature sensation
  9. 9. • Posterior column and lateral corticospinal tract crosses over at medulla oblongata • Spinothalamic tract crosses in the spinal and ascends on the opposite side
  10. 10. MECHANISM OF INJURY Mechanisms: 1. Direct trauma 2. Compression by bone fragments/hematoma/disc material 3. Ischemia from damage/ impingement on the spinal arteries
  11. 11. Other causes: • Vascular disorder • Tumors • Infectious conditions • Spondylosis • Latrogenic • Vertebral fractures secondary to osteoporosis • Developmental disorders
  12. 12. MECHANISM OF SCI: • Hyper flexion: injuries in which the head strikes against steering wheel and flexion results in forward dislocation of the vertebrae • Hyperextension: injuries in which head is thrown back and hyperextension of sc leads to transection of the cord • Compression: injuries caused by falls or jumpsthe force of impact fractures the vertebra
  13. 13. PATHOPHYSIOLOGY OF SCI • The spinal cord is injured by compression, pull or tear of tissues. Microscopic bleeding occurs in grey matter. Edema develops within the first hours and peaks within 2 to 3 days and subsides within the first 7 days after injury. Fragmentation of axonal covering loss of myelin, tissue necrosis are the later changes. • Also leads to bleeding, hematoma and compression of the nerve roots. The cord server either partially or completely. The client experiences motor and sensory dysfunction below the site of injury. Physiologic response extends beyond SC • decreased GI perfusion, respiratory arrest spasticity of muscles.
  14. 14. Myotomes • • • • • • • • Segmental nerve root innervating a muscle Again important in developing level of injury Upper limbs: C5- deltoid C6- wrist extensors C7- elbow extensor C8- long finger flexors T1- small hand muscles
  15. 15. • Lower limbs: L2- hip flexors L3,4- knee extensors L4,5- S1- knee flexion L5- ankle dorsiflexion S1- Ankle plantar flexion
  16. 16. Muscle strength grading: • 5-normal strength • 4- full range of motion, but less than normal strength against resistance • 3- full range of motion against gravity • 2- movement with gravity eliminated • 1- flicker of movement • 0- total paralysis
  17. 17. CONSEQUENCES OF SCI • C1-C3- paralysis below neck and no sensation below neck c4c5- ventilation support is required; no sensation below clavicle c6-8- possible diaphragmatic breathing; some elbow to wrist movements possible. Sensation in chest is impaired T 1-6 – paralysis below waist; no sensation below mid chest • T7- 12- varying degrees of trunk and abdominal control; varying sensation below waist L 1-2- hip adduction impaired; no sensation below lower abdomen L3-5- knee and ankle movement impaired; no sensation below upper thighs S1-5- varying degrees of bowel and bladder control and sexual dysfunction; no sensation in perineum
  18. 18. Spinal cord Injury classification • Quadriplegia: injury in cervical region, all extremities affected • Paraplegia: injury in thoracic, lumbar or sacral segments 2 extremities affected. Injury either: 1) complete 2) incomplete
  19. 19. Complete: • loss of voluntary movement of parts innervated by segment, this is irreversible • Loss of sensation • spinal shock
  20. 20. Incomplete: 1. Some function is present below site of injury 2. More favorable prognosis overall 3. Are recognizable patterns of injury, although they are rarely pure and variations occur
  21. 21. Common cause of SCI
  22. 22. SCI Type Incomplete/partial SCI: • Spinal cord is able to convey some messages to or from the brain. Therefore, retain some sensation and possibly some motor function below the affected area Complete injury: • • • • • Complete loss of motor function and sensation below the area of injury Even in a complete injury, the spinal cord is almost never completely cut in half. Doctors use the term complete to decrease to describe a large amount of damage to the spinal cord It’s a key distinction because many people with partial spinal cord injured are able to experience signification recovery, while those with complete injuries are not. Most trauma to the spinal cord causes permanent disability or loss of movement (paralysis) and sensation below the site of the injury Paralysis can involve all four extremities, a condition called quadriplegia or tetraplegia or only the lower body, a condition called paraplegia
  23. 23. SCI Casual categories • Traumatic spinal cord injury may stem from: sudden, traumatic blow that fractures, dislocates, crushes or compresses one or more of vertebrae • Gunshot or knife: wound that penetrates and cuts your spinal cord • Additional (secondary) damage usually occur over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around spinal cord • Non-traumatic spinal cord injury may be cause by arthritis, cancer, blood vessel problems or bleeding, inflammation or infection or disk degeneration of the spine
  24. 24. Risk factors: • Gender- spinal cord injury affects a disproportionate amount of men • Age- (young adults and seniors) - Between ages 16 and 35 / MVA(motor vehicle accident) leading cause - Another peak in people older than 60/ falls leading cause • People active in sports- high risk athletic activities include football, rugby, wrestling, gymnastics, diving, surfing,ice hockey and downhill skiing • Predisposing conditions- a relatively minor injury can cause spinal cord injury in people with conditions that affect their bones or joints, such as arthritis or osteoporosis
  25. 25. Priorities: • Maintaining ability to breathe • Preventing shock • immobilization to prevent further spinal cord damage(backboard & c-collar)
  26. 26. Complications: • The following list of complications that can follow a spinal cord injury is not exhaustive. The very nature of spinal cord lesion usually means some of the secondary complications below may follow the initial injury. Every injury is unique and these complications will not affect everyone • Skin breakdown Pneumonia Osteoporosis and fracture Spasticity Urinary tract infections Autonomic dysreflexia deep vein thrombosis Pulmonary embolism Orthostatic hypotension Cardiovascular disease Neuropathic/spinal cord pain Medication problems Hyperthermia/hypothermia
  27. 27. Life threatening complication • Spinal shock • Autonomic dysreflexia
  28. 28. Autonomic dysreflexia • Is a life threatening syndrome in which a cluster of clinical manifestation results, when multiple spinal cord autonomic reponses discharge simultaneously. The manifestations results from an exaggerated sympathetic response to stimuli like bladder/ bowel distention cause the blood vessels below the injury to constrict. • S/S: • Hypertension,headache,diaphoresis,piloerection, restlessness,nausea,blurrerd vision and bradycardia
  29. 29. Spinal shock • It is the immediate response to cord transection(damage to cord due to trauma). S/S • Complete loss of skeletal muscle function, bowel and bladder tone, sexual function and autonomic reflexes. Body assumes environmental temperature. It is most severe in clients with high levels of SCI and it lasts for 1-6 wks.
  30. 30. Immediate management • Move only with adequate personnel. Stabilize head and neck before transferring. Perform logrolling maneuver. Cut off clothing provide oxygen support. open a IV port, insert a indwelling catheter, vasoactive drugs, insertion of NG tube
  31. 31. SURGICAL MANAGEMENT: • Depending on the extent of injury –removal of bone fragments – repair of dislocated vertebrae –stabilization of spine – external immobilization with a brace and cast
  32. 32. MEDICAL MANAGEMENT: • Immobilize head & neck in neutral. Stabilize vital functions and manage shock. Corticosteroids to reduce SC edema-short term high dose methyl-prednisolone within 8 hrs. other therapies-neuro peptides, thyrotropin releasing hormones and H2 receptor antagonists; urinary antiseptic, laxatives, anticoagulants and antispasmodics
  33. 33. 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 • The 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 Manifestation depends on : • Location • Rate of development(acute vs. chronic) • Effect on surrounding structures
  34. 34. 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 occurs 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
  35. 35. 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 tissues and affected never roots Management may include: • immobilization • Traction • Pain relief-moist heat, analgesics, sedatives, muscle relaxants, anti- inflammatory, corticosteroids • Surgical repair of injured spine
  36. 36. Disc surgery • Surgical excision of a herniated disc is performed when there is evidence of a progressing neurological deficit (muscle weakness and atropy, 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 relive pain and reverse neurological deficits
  37. 37. Surgical management • The surgery usually includes removing the part of the disc that has squeezed outside its proper place called a discectomy. • The surgeon also may want to remove the back part of the vertebrae called the lamina, in a laminectomy or laminectomy- removal of the lamina to expose the neutral elements in the spinal canal; allows the surgeon to inspect the spinal cord, identify and remove tissue for pathology, relieve compression of the cord and roots
  38. 38. • Diskectomy- removal of herniated or extruded fragments of intervertebral disc. • Laminotomy- division of the lamina of a vertebrae • Diskectomy with fusion- a bone graft(from a 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
  39. 39. Preoperative management • 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 musclesetting(isometric) exercises, which will help to maintain muscle tone postoperatively
  40. 40. Postoperative management Postoperative management includes: • Frequent neurological checks, along with vascular supply checks to extremities. • sitting is discouraged • Position 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
  41. 41. Complications of disc surgery • Arachnoiditis- inflammation of the arachnoid membrane. Cause diffuse frequent burning pain in lower back radiating to buttocks • Failed disc syndrome- recurrence of sciatica after surgery • Bleeding and hematoma fromation • Fixing one level may cause problems at other levels • Recurrence of herniation.
  42. 42. Baseline assessment of scene & upon arrival to ER • ABCs/ATLS assessment includes vital signs & Glasgow coma scale • Neck/ spine stabilization • Maintaining BP • Multisystem support • May be sedated
  43. 43. Be vigilant! • Spinal cord injury isn’t always obvious • Numbness or paralysis may result immediately after a spinal cord injury or gradually as bleeding or swelling occurs in or around the spinal cord • In either case, time between injury and treatment is a critical factor that can determine the extent of complications and the level of recovery • It’s safest to assume that trauma victims have a spinal cord injury until proved other wise • If you suspect that someone has a back or neck injury Spinal immobilization STAT!
  44. 44. History of injury • Loss of consciousness • Other victims seriously hurt? • Mechanism of injury? - Driver/passenger/seat belt? - Fall height/what caused fall? - Hit where and with what? - Gunshot/impaled object?
  45. 45. NURSING PROCESS ASSESSMENT: Obtain information about the injury. Perform neurological assessment. Assess vital signs with a focus to respiratory function. Ongoing monitoring-neurologic, motor, sensory abilities, bowel and bladder pattern and signs of respiratory distress and spinal shock NURSING SDIAGNOSIS: • Ineffective breathing pattern • ineffective airway clearance • risk for impaired gas exchange • pain-neuropathic • impaired physical mobility • risk for impaired skin integrity • altered elimination • imbalanced nutrition
  46. 46. • Respiratory support: mechanical ventilation, chest physical therapy, suctioning, kinetic bed, tracheotomy, abdominal binder to facilitate abdominal breathing, incentive spirometry • THERMOREGULATION: rectal or core temperature monitoring. Environment control. prevention of cool draughts top linen to protect hypothermia blanket • Physical mobility: position to avoid contractures and foot drop. Maintain skin integrity by 2 hrly position change, massaging bony prominences, keep skin clean and dry and use pressure relieving devices. Assist to perform isometric, active and passive exercise
  47. 47. • SPINAL REHABILITATION: rehabilitation begins on admission. During acute stage care should focus on prevention of infection , pressure sore and contractures facilitates rehabilitation and reduce the sufferings, disability and expense . Establish functional goals and motivate client and family and involve them in all phases of rehabilitation. • GOALS OF REHABILITATION: Promote mobility, Reduce spasticity. Improve bladder and bowel Control. Prevent pressure ulcers. Reduce respiratory dysfunction. Promote expression of sexuality. Control pain nutritional management and weight gain control. Effective health maintenances