Spinal cord injury

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Spinal cord injury

  1. 1. Spinal Cord Injury: What Now? Expected Outcomes. <ul><li>Maura Nee RNP </li></ul><ul><li>Elizabeth Tammaro RN, CRRN </li></ul><ul><ul><li>VA Boston Healthcare System </li></ul></ul><ul><ul><li>SCI Out Patient Clinic </li></ul></ul>
  2. 2. Objectives: <ul><li>Discuss Anatomy and Physiology of the Spinal Cord </li></ul><ul><li>Understand the Impact of Neurologic Level of Injury (LOI) and ASIA Classification </li></ul><ul><li>Discuss Expected Functional Outcomes Specific to LOI </li></ul><ul><li>Understand Role of the Nurse in Achieving Functional Outcomes </li></ul>
  3. 3. SCI Statistics (2002) <ul><li>250,000 in USA </li></ul><ul><li>Paraplegic: 52% </li></ul><ul><li>Quadriplegia: 47% </li></ul><ul><li>New SCI/yr: 11,000 </li></ul><ul><li>Male: 82% </li></ul><ul><li>16yr-30yr: 56% </li></ul><ul><li>Causes </li></ul><ul><ul><li>MVA: 37% </li></ul></ul><ul><ul><li>Violence: 28% </li></ul></ul><ul><ul><li>Falls: 21% </li></ul></ul><ul><ul><li>Sports: 6% </li></ul></ul><ul><ul><li>Other: 8% </li></ul></ul><ul><li>89%: D/C’d home </li></ul>
  4. 4. Anatomy of the Spine <ul><li>Vertebrae </li></ul><ul><ul><li>Body </li></ul></ul><ul><ul><ul><li>Front section, shaped like drum </li></ul></ul></ul><ul><ul><ul><li>Supports weight </li></ul></ul></ul><ul><ul><li>Lamina </li></ul></ul><ul><ul><ul><li>Towards the back </li></ul></ul></ul><ul><ul><ul><li>Boney arch surrounds spinal canal </li></ul></ul></ul><ul><ul><li>Spinous process </li></ul></ul><ul><ul><ul><li>Boney process from arch </li></ul></ul></ul><ul><ul><ul><li>Points of attachment for muscles and ligaments </li></ul></ul></ul><ul><li>Discs </li></ul><ul><ul><ul><li>Cushions between vertebrae </li></ul></ul></ul>
  5. 5.                                                                  
  6. 6. Anatomy of the Spine <ul><li>Vertebrae: </li></ul><ul><ul><li>7 Cervical </li></ul></ul><ul><ul><ul><li>Flexion, extension, bending and turning of head </li></ul></ul></ul><ul><ul><li>12 Thoracic </li></ul></ul><ul><ul><ul><li>Chest region, allows mostly for rotation </li></ul></ul></ul><ul><ul><li>5 Lumbar </li></ul></ul><ul><ul><ul><li>Larger boney structures to support added wgt </li></ul></ul></ul><ul><ul><li>5 Sacral </li></ul></ul><ul><ul><ul><li>Fused together </li></ul></ul></ul><ul><ul><li>Coccyx </li></ul></ul>
  7. 7.                                                          
  8. 8. Anatomy of the Cord <ul><li>Cervical Cord </li></ul><ul><ul><li>C1-C2: </li></ul></ul><ul><ul><li>C3-4: Phrenic nucleus </li></ul></ul><ul><ul><li>C4: Deltoids </li></ul></ul><ul><ul><li>C4-5: Biceps </li></ul></ul><ul><ul><li>C6: Wrist extensors </li></ul></ul><ul><ul><li>C7: Triceps </li></ul></ul><ul><ul><li>C8: Wrist extensors </li></ul></ul><ul><ul><li>C8-T1: Hand muscles </li></ul></ul>
  9. 9. Anatomy of the Cord <ul><li>Thoracic Cord </li></ul><ul><ul><ul><li>Intercostal muscles and associated dermatones </li></ul></ul></ul><ul><li>Lumbarsacral </li></ul><ul><ul><ul><li>Starts at T9 and continues to L2 </li></ul></ul></ul><ul><ul><ul><li>Innervates hips, legs, buttocks and anal region </li></ul></ul></ul><ul><li>Cauda Equina (horses tail) </li></ul><ul><ul><ul><li>Spinal cord ends at L2 </li></ul></ul></ul><ul><ul><ul><li>Tip called conus, below conus a spray of spinal roots </li></ul></ul></ul>
  10. 10.                                                           
  11. 11. Dermatomes/Sensory Level <ul><li>Dermatome: </li></ul><ul><ul><li>patch of skin innervated by a given spinal cord level </li></ul></ul>
  12. 12.                                                                                      C2 to C4. The C2 dermatome
  13. 13. Myotomes/Motor Level <ul><li>Myotome: </li></ul><ul><ul><li>Spinal nerve roots which innervates muscles groups </li></ul></ul><ul><ul><li>Most muscles are innervated by more than one root </li></ul></ul>
  14. 14.  
  15. 16. ASIA Impairment Scale <ul><ul><li>ASIA A: Complete: no motor or sensory function is preserved in the sacral segments S4-S5 </li></ul></ul><ul><ul><li>ASIA B: Incomplete: sensory but NOT motor function is preserved below the neurological level and includes the sacral segments </li></ul></ul><ul><ul><li>ASIA C: Incomplete: motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade <3 </li></ul></ul><ul><ul><li>ASIA D: Incomplete: motor function is preserved w/ muscle grade > 3 </li></ul></ul><ul><ul><li>ASIA E: Normal </li></ul></ul>
  16. 17. Definition of Disability <ul><li>Tetraplegia (preferred to quadriplegia) </li></ul><ul><ul><li>Refers to impairment or loss of motor/sensory function in cervical segments of the spinal cord </li></ul></ul><ul><ul><li>Impairment of function in arms, trunk, legs and pelvic organs </li></ul></ul><ul><ul><li>ASIA Scale vs quadriparesis </li></ul></ul>
  17. 18. Definition of Disability <ul><li>Paraplegia </li></ul><ul><ul><li>Refers to impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord </li></ul></ul><ul><ul><li>Arm function spared </li></ul></ul><ul><ul><li>Possible impairment of function in trunk, legs and pelvic organs </li></ul></ul><ul><ul><li>ASIA Scale vs paraparesis </li></ul></ul>
  18. 19. Clinical Syndromes <ul><ul><li>Central Cord Syndrome: </li></ul></ul><ul><ul><ul><li>lesion occurring almost exclusively in the cervical region </li></ul></ul></ul><ul><ul><ul><li>Sacral sensory sparing </li></ul></ul></ul><ul><ul><ul><li>Weakness > UE vs LE </li></ul></ul></ul><ul><ul><li>Brown-Sequard Syndrome: </li></ul></ul><ul><ul><ul><li>Lesion that produces ipsilateral, proprioceptive and motor loss and contralateral loss of sensitivity to pain and temp </li></ul></ul></ul>
  19. 20. Clinical Syndromes <ul><ul><li>Anterior Cord Syndrome: </li></ul></ul><ul><ul><ul><li>Lesion that produces variable loss of motor function and of sensitivity while preserving proprioception </li></ul></ul></ul><ul><ul><li>Cauda Equina Syndrome: </li></ul></ul><ul><ul><ul><li>Injury to the lumbosacral nerve roots w/ in the neurocanal resulting in areflexive bladder, bowel and lower limbs </li></ul></ul></ul>
  20. 21. Achievement of Functional Goals <ul><li>Age </li></ul><ul><li>Body type </li></ul><ul><li>Comorbidities </li></ul><ul><li>Prior athletic sense </li></ul><ul><li>Fatigue level </li></ul><ul><li>Type of stabilization </li></ul><ul><li>HX HO/POA </li></ul><ul><li>Spasticity </li></ul><ul><li>Psychosocial factors </li></ul><ul><li>Nutrition </li></ul>
  21. 22. Functional Outcomes <ul><li>Motor/sensory recovery </li></ul><ul><li>Ability to perform or direct ADLs </li></ul><ul><li>Social reintegration </li></ul><ul><li>Quality of life </li></ul>
  22. 23. Functional Outcomes <ul><li>LEVEL C1-C3 </li></ul><ul><ul><li>Limited head/neck movement </li></ul></ul><ul><ul><li>Rotate/flex neck (sternocleidomastoid) </li></ul></ul><ul><ul><li>Extend neck (cervical paraspinals) </li></ul></ul><ul><ul><li>Speech and swallowing (neck accessories) </li></ul></ul><ul><ul><li>Total paralysis of trunk,UE and LE </li></ul></ul>
  23. 24. LEVEL: C1-3 <ul><ul><li>24 hr care needs </li></ul></ul><ul><ul><li>Able to direct care needs </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Ventilator dependent </li></ul></ul><ul><ul><li>Impaired communication </li></ul></ul><ul><ul><li>Dependent for all care needs </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Power wheelchair </li></ul></ul><ul><ul><li>Hoyer lift </li></ul></ul>
  24. 25. LEVEL: C1-C3 <ul><li>Equipment Needs </li></ul><ul><ul><li>Adapted computer </li></ul></ul><ul><ul><li>Bedside/portable ventilator </li></ul></ul><ul><ul><li>Suction machine </li></ul></ul><ul><ul><li>Specialty bed </li></ul></ul><ul><ul><li>Hoyer </li></ul></ul><ul><ul><li>Reclining shower chair </li></ul></ul>
  25. 27. Functional Outcomes <ul><li>LEVEL: C4 </li></ul><ul><ul><li>Head and neck control (cerv paraspinals) </li></ul></ul><ul><ul><li>Shoulder shrug (upper traps) </li></ul></ul><ul><ul><li>Inspiration(diaphragm) </li></ul></ul><ul><ul><li>Lack of shoulder control (deltoids) </li></ul></ul><ul><ul><li>Paralysis of trunk, UE and LE </li></ul></ul><ul><ul><li>Inability to cough, low respiratory reserve </li></ul></ul>
  26. 28. LEVEL: C4 <ul><ul><li>24 hr care needs </li></ul></ul><ul><ul><li>Able to direct care needs </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>May or may not be vent dependent </li></ul></ul><ul><ul><li>Improved communication </li></ul></ul><ul><ul><li>Assisted cough </li></ul></ul><ul><ul><li>Dependent for all care needs </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Power wheelchair </li></ul></ul><ul><ul><li>Hoyer lift </li></ul></ul>
  27. 29. LEVEL: C4 <ul><li>Equipment Needs </li></ul><ul><ul><li>Adapted computer </li></ul></ul><ul><ul><li>Bedside/portable ventilator as needed </li></ul></ul><ul><ul><li>Suction machine </li></ul></ul><ul><ul><li>Specialty bed </li></ul></ul><ul><ul><li>Hoyer </li></ul></ul><ul><ul><li>Reclining shower chair </li></ul></ul>
  28. 32. Functional Outcomes <ul><li>LEVEL: C5 </li></ul><ul><ul><li>Shoulder control (deltoids) </li></ul></ul><ul><ul><li>Elbow flexion (biceps/elbow flexors) </li></ul></ul><ul><ul><li>Supinate hands (brachialis and brachioradialis) </li></ul></ul><ul><ul><li>Lack elbow extension and hand pronation </li></ul></ul><ul><ul><li>Paralysis of trunk and LE </li></ul></ul>
  29. 33. LEVEL: C5 <ul><ul><li>10hrs personal care need </li></ul></ul><ul><ul><li>6 hrs homemaking assistance </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Set-up/equipment: eating, drinking, face wash and teeth </li></ul></ul><ul><ul><li>Assisted cough </li></ul></ul><ul><ul><li>Dependent for bowel, bladder and lower body hygiene </li></ul></ul><ul><ul><li>Dependent for bed mobility and transfers </li></ul></ul>
  30. 34. LEVEL: C5 <ul><li>Mobility </li></ul><ul><ul><li>Hoyer or stand pivot </li></ul></ul><ul><ul><li>Power wheelchair w/ hand controls </li></ul></ul><ul><ul><li>Manual wheelchair </li></ul></ul><ul><ul><li>Drive motor vehicle w/ hand controls </li></ul></ul><ul><li>Equipment Needs </li></ul><ul><ul><li>Power and manual wheelchairs </li></ul></ul><ul><ul><li>Adaptive splints/braces </li></ul></ul><ul><ul><li>Page turners/computer adaptations </li></ul></ul>
  31. 36. Functional Outcomes <ul><li>LEVEL: C6 </li></ul><ul><ul><li>Wrist extension (extensor carpi ulnaris and extensor carpi radialis longus/brevis) </li></ul></ul><ul><ul><li>Arm across chest (clavicular pectrocialis) </li></ul></ul><ul><ul><li>Lack elbow extension (triceps) </li></ul></ul><ul><ul><li>Lack wrist flexion </li></ul></ul><ul><ul><li>Lack hand control </li></ul></ul><ul><ul><li>Paralysis of trunk and LE </li></ul></ul>
  32. 37. LEVEL: C6 <ul><ul><li>6 hrs personal care needs </li></ul></ul><ul><ul><li>4hrs homemaking assistance </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Assisted cough </li></ul></ul><ul><ul><li>Set-up for feeding, bathing and dressing </li></ul></ul><ul><ul><li>Independent pressure relief, turns and skin assessment </li></ul></ul><ul><ul><li>May be independent for bowel/bladder care </li></ul></ul>
  33. 38. LEVEL: C6 <ul><li>Mobility </li></ul><ul><ul><li>Independent slide board transfer </li></ul></ul><ul><ul><li>Manual wheelchair </li></ul></ul><ul><ul><li>Drive with adaptive equipment </li></ul></ul>
  34. 40. Functional Outcomes <ul><li>LEVEL: C7 </li></ul><ul><ul><li>Elbow flexion and extension (biceps/triceps) </li></ul></ul><ul><ul><li>Arm toward body (sternal pectoralis) </li></ul></ul><ul><ul><li>Lack finger function </li></ul></ul><ul><ul><li>Lack trunk stability </li></ul></ul>
  35. 41. LEVEL: C7 <ul><ul><li>6hrs personal care needs </li></ul></ul><ul><ul><li>2hrs homemaking assistance </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>More effective cough </li></ul></ul><ul><ul><li>Fewer adaptive aids </li></ul></ul><ul><ul><li>Independent w/ all ADLs </li></ul></ul><ul><ul><li>May need adaptive aids for bowel care </li></ul></ul>
  36. 42. LEVEL: C7 <ul><li>Mobility </li></ul><ul><ul><li>Manual wheelchair </li></ul></ul><ul><ul><li>Transfers without adaptive equipment </li></ul></ul>
  37. 44. Functional Outcomes <ul><li>LEVEL: C8-T1 </li></ul><ul><ul><li>Increased finger and hand strength </li></ul></ul><ul><ul><ul><li>Finger flexion (flexor digitorum) </li></ul></ul></ul><ul><ul><ul><li>Finger extension (extensor communis) </li></ul></ul></ul><ul><ul><ul><li>Thumb movement (policus longis brevis) </li></ul></ul></ul><ul><ul><ul><li>Separate fingers (introssi separates) </li></ul></ul></ul>
  38. 45. LEVEL: C8-T1 <ul><ul><li>4hrs personal care needs </li></ul></ul><ul><ul><li>2hrs homemaking assistance </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Independent w/ or w/o assistive devices </li></ul></ul><ul><ul><li>Assist w/ complex meal prep and home management </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Manual wheelchair </li></ul></ul>
  39. 47. Functional Outcomes <ul><li>LEVEL: T2-T6 </li></ul><ul><ul><li>Normal motor function of head, neck, shoulders, arms, hands and fingers </li></ul></ul><ul><ul><li>Increased use of intercostals </li></ul></ul><ul><ul><li>Increase trunk control (erector spinae) </li></ul></ul>
  40. 48. LEVEL: T2-T6 <ul><ul><li>3hrs personal care needs/homemaking </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Independent in personal care </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Manual wheelchair </li></ul></ul><ul><ul><li>May have limited walking with extensive bracing </li></ul></ul><ul><ul><li>Drive with hand controls </li></ul></ul>
  41. 50. Functional Outcomes <ul><li>LEVEL: T7-T12 </li></ul><ul><ul><li>Added motor function </li></ul></ul><ul><ul><li>Increased abdominal control </li></ul></ul><ul><ul><li>Increased trunk stability </li></ul></ul>
  42. 51. LEVEL: T7-T12 <ul><ul><li>2 hrs personal care needs/homemaking </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Independent </li></ul></ul><ul><ul><li>Improved cough </li></ul></ul><ul><ul><li>Improved balance control </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Manual wheelchair </li></ul></ul><ul><ul><li>May have limited walking with bracing </li></ul></ul><ul><ul><li>Driving with hand controls </li></ul></ul>
  43. 53. Functional Outcomes <ul><li>LEVEL: L2-L5 </li></ul><ul><ul><li>Added motor function in hips and knees </li></ul></ul><ul><ul><ul><li>L2 Hip flexors (iliopsas) </li></ul></ul></ul><ul><ul><ul><li>L3 Knee extensors (quadriceps) </li></ul></ul></ul><ul><ul><ul><li>L4 Ankle dorsiflexors (tibialis anterior) </li></ul></ul></ul><ul><ul><ul><li>L 5 Long toe extensors (ext hallucis longus) </li></ul></ul></ul>
  44. 54. LEVEL: L2-L5 <ul><ul><li>May need 1hr personal care/homemaking </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Independent </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Manual wheelchair </li></ul></ul><ul><ul><li>May walk short distance with braces and assistive devices </li></ul></ul><ul><ul><li>Driving with hand controls </li></ul></ul>
  45. 56. Functional Outcomes <ul><li>LEVEL: S1-S5 </li></ul><ul><ul><li>Ankle plantar flexors (gastrocnemius) </li></ul></ul><ul><ul><li>Various degrees of bowel, bladder and sexual function </li></ul></ul><ul><ul><li>Lower level equals greater function </li></ul></ul>
  46. 57. LEVEL: S1-S5 <ul><ul><li>No personal or homemaker needs </li></ul></ul><ul><li>ADLs </li></ul><ul><ul><li>Independent </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>Increased ability to walk with less adaptive/supportive devices </li></ul></ul><ul><ul><li>Manual w/c for distance </li></ul></ul>
  47. 59. Functional Outcomes <ul><li>Achieving maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life </li></ul>
  48. 60. Functional Outcomes <ul><li>Power Point presentation can be found: </li></ul><ul><li>www1.va.gov/spinalcordboston/ </li></ul>

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