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4. CNS Spinal cord injury.pptx
1. SPINAL CORD INJURY
MANOJ M.G
MANOJ M.G.
LECTURER (MEDICAL SURGICAL
NURSING)
DEPARTMENT OF NURSING AND
MIDWIFERY
WOLLEGA UNIVERSITY
2. DEFINITION
•Spinal cord injury (SCI) is damage to the
spinal cord that results in a loss of function
such as mobility or feeling.
Common locations of spinal cord injuries
•Flexion-extension injuries are commonly
located at C4 - C7.
• T11, T12, and L1 are frequent sites of spinal
cord injury resulting rom falls.
3.
4. Mechanisms of spinal cord injury.
•Flexion-extension: whiplash(is a non-medical term
describing a range of injuries to the neck caused
by or related to a sudden distortion of the neck,
associated with extension)
• Subluxation: incomplete or partial dislocation.
•Torsion: twisting of the spinal cord.
•Compression.
6. RISK FACTORS
Gender - Spinal cord injury affects a
disproportionate amount of men
Age – (Young adults and seniors)
- Between ages 16 and 35 / MVA 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
8. •Road Traffic Accident
•Sports injury
•Fall
•Bullet or stab wound
•Traumatic injury
•Electric shock
•Extreme twisting of the middle of the body
•Landing on the head during a sports injury
•Fall from a great height
9.
10. Types of Spinal Cord Injury
•Complete Spinal Cord Injuries
• Complete paraplegia is described as
permanent loss of motor and nerve function
at T1 level or below, resulting in loss of
sensation and movement in the legs, bowel,
bladder, and sexual region. Arms and hands
retain normal function.
•Complete loss of motor function and
sensation below the area of injury
11. •Even in a complete injury, the spinal cord is
almost never completely cut in half. Doctors
use the term "complete" to describe a large
amount of damage to the spinal cord.
•many people with partial spinal cord injuries
are able to experience significant recovery.
While those with complete injuries are not .
12. Incomplete / Partial spinal cord injury
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
16. •Anterior Cord Syndrome
Damage of front 2/3 of spinal cord, loss
of pain and temperature sensation, and
motor function below level of injury
Light touch (pressure) and position and
vibration sensation preserved
Possible for some people with this injury
to later recover some movement
16
17.
18. •Central Cord Syndrome
Usually with unbelted Motor Vehicle
Accidents and falls of elderly
Typically results greater weakness in arms vs
lower extremities
Sensory loss varies but more severe in upper
extremities
Control over the bowel and bladder varies and
may be preserved
Possible for some recovery from this type of
injury, usually starting in the legs, gradually
progressing upwards
18
20. •Brown-Sequard Syndrome/lateral
Usually stab or Gun Shot Wound
Damage is towards one side of the
spinal cord
Ipsilateral (same side as the cord
injury) Impaired or loss of movement,
touch, pressure and vibration (Hemi
paraplegia)
Contralateral (opposite side of cord
injury) loss of pain and temperature
sensation (Hemiparasthesia)
20
21.
22. •Posterior Cord Syndrome
Damage is towards the back of the
spinal cord
May leave the person with good
muscle power, pain and temperature
sensation
However they may experience
difficulty coordinating movement of
their limbs
22
23.
24. •Cauda Equina Syndrome:
Due to bony compression or disc
protrusions in lumbar or sacral region
Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle paresthesia(loss of sensation
restricted to the area of buttocks, perineum
and inner surface of the thighs)
25. Spinal Cord Injuries Causal 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
occurs over days or weeks because of
bleeding, swelling, inflammation and fluid
accumulation in and around spinal cord
26. Non-traumatic spinal cord injury may be
caused by :
• Arthritis
• Cancer
• Blood vessel problems or bleeding
• Inflammation or infections
• Disk degeneration of the spine
31. PATHOPHYSIOLOGY
Due to the etiological factor
Damage to the cord may be a concussion, contusion, laceration,
compression, or complete, incomplete of the cord.
Cord's response to injury includes hemorrhage, ischemia, and edema
SCI Involves loss of:
Motor function
Sensory function
Reflexes
Control of elimination
32. CLINICAL MANIFESTATIONS
•Patients with tetraplegia (formerly called
quadriplegia) have damage to the cervical
segments of nerves (C1-C8) in the spinal canal.
Function may be impaired in the upper
extremities, trunk, pelvic organs, and lower
extremities.
•Patients with paraplegia have damage to the
thoracic, lumbar, or sacral segments of nerves
in the spinal cord. The arms are unaffected, but
function may be impaired in the trunk, pelvic
organs, and lower extremities.
33. •Sacral sensation is intact if there is deep sensation
and sensation at the anal mucocutaneous junction;
sacral motor is intact if the patient has voluntary
contraction of the external anal sphincter with
digital stimulation.
•The Zone of Partial Preservation (ZPP) indicates
areas of partial sensory/motor innervation below
the Level Of Injurie; the ZPP is applicable only to
complete injuries.
34. •The neurologic level of injury is the lowest neural
level with normal sensory and motor function on
both sides of the body. When describing the level
of involvement, the neurologic level is noted
unless stated specifically that the skeletal level of
involvement, which is the level of greatest
vertebral damage, is being discussed.
•Various syndromes (incomplete injuries) may
characterize the clinical presentation
35. • Patient's symptoms will mirror the level of the
cord injury.
•There will be total sensory loss and motor
paralysis below level of the injury.
• Cervical spinal cord injuries will produce
quadriplegia--loss of function of all four
extremities.
• Injuries to the thoracic spinal cord below the level
of T1 will produce paraplegia--paralysis of the
lower extremities.
• Loss of bowel and bladder control; usually urinary
retention and bladder distention.
36. •Loss of sweating and vasomotor tone below
the level of the cord injury.
•Marked reduction of blood pressure due to
loss of peripheral vascular resistance.
•Neck/back pain.
•Priapism--persistent, painful erection of the
penis.
37.
38. CERVICAL (NECK) INJURIES
•Breathing difficulties
•Loss of normal bowel and bladder control
•Numbness
•Sensory changes
•Spasticity (increased muscle tone)
39. THORACIC (CHEST LEVEL) INJURIES
•Loss of normal bowel and bladder control
•Numbness
•Sensory changes
•Spasticity (increased muscle tone)
•Weakness, paralysis
40. LUMBAR SACRAL (LOWER BACK)
INJURIES
•Loss of normal bowel and bladder control (you may have
constipation, leakage, and bladder spasms)
•Numbness
•Pain
•Sensory changes
•Weakness and paralysis
47. MANAGEMENT
•Requires a multidisciplinary approach because of
multiple systems involvement and the
psychosocial aspects of catastrophic injuries.
Immediately After Trauma (Less Than 1
Hour)
•Immobilization with rigid cervical collar,
sandbags, and rigid spine board to transport from
the field to acute care facility.
49. Acute Phase (1 to 24 Hours)
•Maintenance of pulmonary and cardiovascular
stability.
•Intubation and mechanical ventilation, if needed.
•Vasopressors to maintain adequate perfusion to
sustain mean arterial BP at 85 to 90 mm Hg.
•Medical stabilization before spinal stabilization and
decompression.
50. •Spinal cord immobilization use of skeletal
tongs.
•Crutchfield and Vinke tongs( used for
immubilization) require predrilled holes in the
skull under local anesthesia; Gardner-Wells and
Heifitz tongs do not.
•Weight is added to traction gradually to reduce the
vertebral fracture; weight maintained at a level to
ensure vertebral alignment.
51. •Rigid kinetic turning bed to immobilize patients
with thoracic and lumbar injuries.
•Surgical interventions are considered when the
patient has vertebral instability that may result in
further neurologic damage; an injury that is
incomplete at onset may become complete if
instability exists. The objectives are to remove all
of the bony and soft tissues that are compressing
the spinal cord, thereby minimizing the possibility
of a deteriorating neurologic status, and stabilize
the vertebra surrounding the spinal cord so that
rehabilitation may begin as soon as possible.
52. •Decompression, typically using the anterior
approach in cervical instances, may be
accomplished by removing the bony structures
and soft tissues (eg, fusion, decompression
laminectomy). Realignment of the soft tissues
and vertebral column is required.
•Stabilization, typically done using the posterior
approach, involves the use of wires, bone grafts,
plates, screws, and other fixation devices to
prevent movement at the damaged bony site (eg,
fusion, Harrington rods). Harrington rods, used
for thoracolumbar SCI, extend approximately
one to three levels above and below the fracture.
53. •Methylprednisolone sodium succinate( to
improve neurological recovery) should be
administered within 8 hours of injury.
•Bolus 30 mg/kg administered over 15 minutes;
maintenance infusion of 5.4 mg/kg/hr infused for 23
hours
•Additional benefit may be achieved by
administering the maintenance dose for 48 hours.
•Management of neurogenic bladder( dysfunction
caused by neurologic damage, symptoms may
include over flow, urgency, frequency) Foley
catheter
•Pressure ulcer prevention pressure reduction
mattress or kinetic turning frame.
54. Sub acute Phase (Within 1 Week)
•Halo traction is the primary treatment for cervical
injuries
•ganglioside sodium salt I.V., begun within 72
hours after injury, and continued for 18 to 32 days,
is believed to enhance neuronal regeneration.
•H2-receptor blockers to prevent gastric irritation
and haemorrhage.
•Early mobilization and passive exercise as soon as
patient is surgically and medically stable.
•Hyper alimentation( intravenous supply of
nutrients) to retard negative nitrogen balance.
55. •Interventions to prevent thromboembolism
(intermediate risk) are based on motor
completeness of injury:
•Motor Incomplete ,compression hose; compression
boots in addition to unfractionated heparin (UH) 5,000
units every 12 hours.
•Motor Complete compression hose; compression boots
in addition to UH with the dosage adjusted to high
normal or low-molecular-weight heparin 30 mg bid.
•If the patient is at high risk (ie, motor complete with
other risk factors such as fractures of lower extremities
or previous DVT), an inferior vena cava filter should be
considered.
56. Chronic Phase (Beyond 1 Week)
•Harrington rods, used in conjunction with a body
jackets, are used for patients with thoracolumbar
injuries.
•To prevent thrombophlebitis in the chronic phase,
compression boots should be continued for 2
weeks; anticoagulants should also be continued
based on motor completeness of injury:
•Motor Incomplete until discharged from hospital (or 8
weeks
•Motor Complete 8 weeks.
•If the patient is at high risk, anticoagulants should be
continued for 12 weeks or until discharged from
hospital.
57. •Management of complications may include
treatment of infections with antibiotics; treatment
of respiratory compromise with phrenic nerve
pacing, mechanical ventilation, and other methods;
pressure ulcer treatment; management of
heterotopic ossification (is the presence of bone in
soft tissue where bone normally does not exist)
with calcium chelators( which bind calcium) and
anti-inflammatory agents; drainage of
syringomyelia( cyst in spinal cord); management
of spasticity with oral or intrathecal
antispasmodics, surgical procedure, or spinal cord
stimulation; and management of central
neuropathic pain with anticonvulsants, minor
sedatives, antidepressants, nerve block, or surgical
procedure.
58. •Spasticity should be managed by:
•Maintaining calm, stress-free environment.
•Allowing ample time for activities such as
positioning and transferring.
•Performing joint ROM exercises with slow,
smooth movements.
•Avoiding temperature extremes.
•Administering muscle relaxants, such as
baclofen (Lioresal) (via pump or orally),
diazepam (Valium), and dantrolene (Dantrium),
as prescribed.
59. •External sphincterotomy may be used for detrusor-
sphincter dyssynergia (Insufficient relaxation of the
sphincter during a voiding contraction prevents effective
bladder emptying and can lead to high pressures in the
bladder) Other options include urethral stents and balloon
dilatation.
•Clonidine has been used to manage spasticity and
facilitate ambulation in patients with incomplete injuries.
•Resistive inspiratory muscles training shows promise in
promoting respiratory muscle strength and reducing sleep-
induced breathing disturbances in patients with
tetraplegia. Resistive training devices are used to perform
respiratory maneuvers at scheduled times during the day.
•Rehabilitation includes medical and psychosocial support,
physical therapy, urologic evaluation, occupational
therapy, and multiple other interventions to facilitate an
increased level of function and community participation.
61. Nursing Assessment
•Assess cardiopulmonary status and vital signs to
help determine degree of autonomic dysfunction,
especially in patients with tetraplegia.
•Determine LOC and cognitive function indicating
Traumatic Brain Injuries or other pathology.
•Perform frequent motor and sensory assessment of
trunk and extremities extent of deficits may
increase due to oedema and haemorrhage. And it
may increase the neurologic deficit and pain.
62. •Note signs and symptoms of spinal shock, such as
flaccid paralysis, urine retention, absent reflexes.
•Assess bowel and bladder function.
•Assess quality, location, severity of pain.
•Perform psychosocial assessment to evaluate
motivation, support network, financial or other
problems.
•Assess for indicators of powerlessness, including
verbal expression of no control over situation,
depression, nonparticipation, dependence on
others, passivity.
63. Nursing Diagnoses
•Ineffective Breathing Pattern related to paralysis of
respiratory muscles or diaphragm
•Impaired Physical Mobility related to motor
dysfunction
•Risk for Impaired Skin Integrity related to
immobility and sensory deficit
•Urinary Retention related to neurogenic bladder
•Constipation or Bowel Incontinence related to
neurogenic bowel
64. •Risk for Injury: autonomic dysreflexia (is a
syndrome in which there is a sudden onset of
excessively high blood pressure) and orthostatic
hypotension ( is defined as a decrease in
systolic blood pressure of 20 mm Hg or a
decrease in diastolic blood pressure of 10 mm Hg
within three minutes of standing when compared
with blood pressure from the sitting or supine
position)
•Powerlessness related to loss of function, long
rehabilitation, depression
•Sexual Dysfunction related to erectile dysfunction
and fertility changes
•Chronic Pain related to neurogenic changes
65. Nursing Management
Objectives of care:
•Reduce the fracture/dislocation and obtain
immobilization of the spine as soon as possible
to prevent further cord damage.
•Observe for symptoms of progressive
neurological damage.
Patient with cervical spine injury will have
some form of skeletal traction. Maintain
traction and provide nursing care local policy.
66. Continuously observe patient's breathing pattern.
•Patients with injuries at high levels are at risk for
respiratory failure.
•Observe strength of cough effort.
Be alert for signs of spinal shock ( is the temporary
reduction of or loss of reflexes following a spinal
cord injury (SCI) )and report immediately.
•(Spinal shock represents a sudden loss of continuity
between the spinal cord and higher nerve centers.
•It is characterized by a complete loss of motor,
sensory, reflex, and autonomic activity below the
level of the injury.
•Though temporary, spinal shock may last for several
weeks.
67. Continuously observe patient for motor and
sensory changes due to cord edema or
hemorrhage, which may further compromise
cord function.
•Test patient's motor ability by asking him/her to
spread fingers, grip your hands, shrug
shoulders, etc.
•Test sensory level by gently pinching the skin at
shoulders and progressing down sides; ascertain
level at which patient can no longer feel pinch.
•Note presence/absence of sweating.
•Carefully record findings in patient's clinical
record; report changes in patient's
motor/sensory level immediately to professional
nurse.
68. If turning is allowed and patient is not on a turning
frame or turning bed, the patient must be carefully log-
rolled with the spine maintained in alignment.
Surgery, depending upon the injury and pathological
findings, may have to be performed to stabilize the
spine before rehabilitation can begin.
Patient will require passive range of motion exercises.
Assist with active rehabilitation procedures when
patient is stable.
•Program is designed according to neurological deficit.
•Usually involves 6 weeks of gradual mobilization with
brace or cast, depending upon level of injury.
Provide constant encouragement and psychological
support to the patient with a spinal cord injury.
69. Possible Complications
•Blood pressure changes - can be extreme
(autonomic hyper reflexia)
•Chronic kidney disease
•Complications of immobility:
Deep vein thrombosis
Pulmonary infections
Skin breakdown
•Contractures: A muscle contracture is a
permanent shortening of a muscle or joint
70. •Increased risk of urinary tract infections
•Loss of bladder control
•Loss of bowel control
•Loss of sensation
•Loss of sexual functioning (male impotence)
•Muscle spasticity
•Paralysis of breathing muscles
•Paralysis (paraplegia, quadriplegia)
•Pressure sores
•Shock
