Review of spinal cord injuries in medicine

1. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Interferences to Rest and Activity
Needs Due to Trauma and
Degenerative Disorders, Spinal
Cord Injuries/Developmental
Alterations, Amputations

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Lumbosacral Back Pain (Low Back
Pain)
 Herniated nucleus pulposus

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Health Promotion and
Maintenance
 Good posture
 Proper lifting
 Exercise
 Ergonomics

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Patient-Centered Collaborative
Care
 Assessment
 Diagnostic assessment

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Nonsurgical Management
 Positioning
 Drug therapy
 Heat therapy
 Physical therapy
 Weight control
 Complementary and alternative therapies

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Surgical Management
 Minimally invasive surgery:
 Percutaneous lumbar diskectomy
 Thermodiskectomy
 Laser-assisted laparoscopic lumbar
diskectomy
 Conventional open surgical procedures:
 Diskectomy
 Laminectomy
 Spinal fusion

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Postoperative Care
 Prevention and assessment of
complications
 Neurologic assessment; vital signs
 Patient’s ability to void
 Pain control
 Wound care
 CSF check
 Patient positioning and mobility

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Community-Based Care
 Home care management
 Health teaching
 Health care resources

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Cervical Neck Pain
 Conservative treatment is the same as
described for back pain except that the
exercises focus on shoulder and neck.
 If these treatments do not work, soft collar
may be used at night for a period of no
longer than 10 days.
 If conservative treatment is ineffective,
surgery such as an anterior cervical
diskectomy and fusion is commonly
performed.

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Spinal Cord Injuries
 Hyperflexion injury
 Hyperextension injury
 Axial loading injury or vertical compression
such as those that occur in jumping
 Excessive rotation of the head beyond its
range
 Penetration injury, such as those wounds
caused by a bullet or a knife

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Spinal Cord Injuries (Cont’d)

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Spinal Cord Injuries (Cont’d)

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Common Spinal Cord Syndromes
 Complete lesion
 Anterior cord syndrome
 Posterior cord lesion
 Brown-Séquard syndrome
 Central cord syndrome

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Common Spinal Cord Syndromes
(Cont’d)

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Anterior Cord Syndrome
 Damage to the anterior portion of both
gray and white matter of the spinal cord
 Usually a result of decreased blood supply
 Motor function and pain and temperature
lost below the level of the injury
 Sensations of touch, position, and
vibration remain intact

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Posterior Cord Lesion
 Damage to the posterior gray and white
matter of the spinal cord
 Motor function remains intact
 Patient experiences loss of vibratory
sense, touch, and position sensation

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Brown-Séquard Syndrome
 Results from penetrating injuries that
cause hemisection of the spinal cord, or
injuries that affect half of the spinal cord.
 Motor function, proprioception, vibration,
deep touch sensations are lost on the
same side (ipsilateral) of the body as the
lesion.
 Opposite side (contralateral) of the body
sensations of pain, temperature, light
touch are affected.

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Central Cord Syndrome
 Lesions of the central portion of the spinal
cord.
 Loss of motor function is more pronounced
in the upper extremities than in the lower
extremities.
 Varying degrees and patterns of sensation
remain intact.

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SCI: Etiology
 Trauma is the leading cause
 Incidence/prevalence

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Patient with SCI: Initial
Assessment
 First priority is assessment of the patient’s
airway, breathing pattern, and circulation
status
 Assessment for indications of intra-
abdominal hemorrhage or hemorrhage or
bleeding around fracture sites
 Assessment of level of consciousness
using Glasgow Coma Scale

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Initial Assessment (Cont’d)
 Establishment of level of injury: tetraplegia,
quadriplegia, quadriparesis, paraplegia,
and paraparesis

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Spinal Shock/Spinal Shock
Syndrome
 This condition occurs immediately as a
concussion response to the injury. The
patient has:
 Flaccid paralysis
 Loss of reflex activity below the level of the
lesion
 Usually resolves within 24 hours
 Muscle spasticity begins in patients with
cervical or high thoracic injuries

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Assessment of Sensory and Motor
Ability
 Hypoesthesia
 Hyperesthesia

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Cardiovascular and Respiratory
Assessment
 Cardiovascular dysfunction is usually the
result of disruption of the autonomic
nervous system especially if the injury is
above the 6th thoracic vertebra.
 Cardiac dysrhythmias may result.
 Systolic BP below 90 requires treatment
because lack of perfusion to the spinal
cord could worsen the patient’s condition.
 Hypothermia.

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Cardiovascular and Respiratory
Assessment (Cont’d)
 Patients with cervical SCI are at risk for
respiratory problems resulting from
immobility or from an interruption of spinal
innervations to the respiratory muscles.
 Continued respiratory assessment
including vital capacity and minute volume.

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Gastrointestinal and Genitourinary
Assessment
 Assess abdomen for indications of
hemorrhage, distention, or paralytic ileus.
 Assess for reflex or hypotonic bowel.
 Assess for areflexic bladder, which later
leads to urinary retention.
 Assess for neurogenic bladder.

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Other Assessments
 Lower motor neuron assessment
 Upper motor neuron assessment
 Skin assessment
 Heterotrophic ossification assessment
 Psychosocial assessment
 Laboratory assessment
 Imaging assessment

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Nonsurgical Management
 Constant assessment
 Assess for neurogenic shock. Neurogenic
shock is spinal shock with:
 Bradycardia
 Decreased or absent bowel sounds
 Warm, dry skin
 Hypothermia
 Hypotension

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Immobilization for Cervical Injuries
 Fixed skeletal traction to realign the
vertebrae, facilitate bone healing, and
prevent further injury
 Halo fixation and cervical tongs
 Stryker frame, rotational bed, kinetic
treatment table
 Pin site care and monitoring of traction
ropes

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Immobilization of Thoracic and
Lumbosacral Injuries
 For patients with thoracic injuries—bedrest
and possible immobilization with a
fiberglass or plastic body cast
 For patients with lumbar and sacral
injuries—immobilization of the spine with a
brace or corset worn when the patient is
out of bed; custom-fit thoracic lumbar
sacral orthoses preferred

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Drug Therapy
 Methylprednisolone (controversial)
 Dextran
 Atropine sulfate
 Dopamine hydrochloride
 Tizanidine
 Intrathecal baclofen

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Surgical Management
 Emergency surgery necessary for spinal
cord decompression
 Decompressive laminectomy
 Spinal fusion
 Harrington rods to stabilize thoracic spinal
injuries

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Ineffective Airway Clearance and
Breathing Pattern
 Interventions for the patient with spinal
cord injury:
 Airway management is the priority.
 Patients with injuries at or above the 6th
thoracic vertebra are especially at risk for
respiratory complications.
 Provide measures to maintain airway.

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Ineffective Airway Clearance and
Breathing Pattern (Cont’d)
 Assisted coughing, quad cough, cough assist
 Use of incentive Spiro meter

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Impaired Physical Mobility; Self-
Care Deficit
 Interventions include:
 In patients with spinal cord injury, monitor for
risk of pressure ulcers, contractures, and deep
vein thrombosis or pulmonary emboli.
 Proper positioning, skin inspection, ROM
exercises, heparin, and graduated
compression stockings.

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Impaired Physical Mobility; Self-Care
Deficit (Cont’d)
 Prevent orthostatic hypotension.
 Promote self-care.

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Impaired Urinary Elimination;
Constipation
 Interventions include:
 A bladder retraining program
 Spastic bladder—manipulating external area
 Flaccid bladder—Valsalva maneuver
 Encouraging consumption of 2000 to 2500 mL
of fluid daily to prevent urinary tract infection

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Impaired Urinary Elimination;
Constipation (Cont’d)
 Long-term renal complication
 Signs and symptoms of urinary tract
infection not perceived by the patient

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Autonomic Dysreflexia
 Commonly seen in patients with upper
spinal cord injury
 Severe hypertension
 Bradycardia
 Severe headache
 Nasal stuffiness
 Flushing
 Treatment

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Establishing a Bowel Retraining
Program
 Consistent time for bowel elimination
 High fluid intake
 High-fiber diet
 Rectal stimulation (with or without
suppositories)
 Stool softener medications, as needed

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Impaired Adjustment
 Interventions include:
 Invite patients to ask questions about
significant life changes; reply openly and
honestly.
 Encourage patients to discuss their
perceptions of their situation and coping
strategies that can be used.
 Begin a patient education program to clarify
misconceptions.

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Community-Based Care
 Home care management
 Health teaching
 Health care resources

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Multiple Sclerosis
 Chronic autoimmune disease affecting the
myelin sheath and conduction pathway of
the CNS
 Characterized by periods of remission and
exacerbation
 Inflammatory response resulting in random
or patchy areas of plaque in the white
matter of the CNS

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Multiple Sclerosis (Cont’d)
 Etiology
 Genetic risk
 Incidence
 Prevalence

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Major Types of Multiple Sclerosis
 Relapsing-remitting
 Primary progressive
 Secondary progressive
 Progressive-relapsing

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Patient-Centered Collaborative Care
 Patient history
 Physical assessment/clinical
manifestations
 Fatigue

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Common Physical Assessment
 Findings include:
 Flexor spasms at night
 Intention tremor
 Dysmetria
 Blurred vision, diplopia, decreased visual
acuity, scotomas, nystagmus
 Hypalgesia, numbness, tingling, or burning
 Bowel and bladder dysfunction

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Assessment
 Psychosocial assessment
 Laboratory assessment
 Other diagnostic tests

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Drug Therapy
 Therapies include:
 Interferon beta
 Monoclonal antibodies
 Copaxone
 Novantrone
 Immunosuppressive therapy
 Methylprednisolone

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Drug Therapy (Cont’d)
 Muscle relaxants
 Treatment of paresthesia
 Treatment of bladder dysfunction

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Other Interventions
 Promoting mobility
 Managing symptoms
 Complementary and alternative therapies

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Community-Based Care
 Home care management
 Health teaching
 Health care resources

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Guillain-Barré Syndrome
 Demyelination of the peripheral nerves,
progressive motor weakness and sensory
abnormalities
 Ascending paralysis
 Result of a variety of related immune-
mediated pathologic processes

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Clinical Manifestations
 Muscle weakness and pain have abrupt
onset; cause remains obscure.
 Cerebral function or pupillary signs are not
affected.
 Cranial nerve involvement.
 Autonomic dysfunction.

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Clinical Manifestations (Cont’d)
 Weakness and paresthesia begin in the
lower extremities and progress upward
toward the trunk, arms, and cranial nerves
in ascending GBS.

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Interventions
 Drug therapy
 Plasmapheresis
 Monitoring respiratory status and
managing the airway
 Managing cardiac dysfunction
 Improving mobility and preventing
complications of immobility
 Managing pain

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Interventions (Cont’d)
 Promoting communication
 Providing emotional support

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Plasmapheresis
 Plasmapheresis removes the circulating
antibodies assumed to cause the disease.
 Plasma is selectively separated from
whole blood; the blood cells are returned
to the patient without the plasma.
 Plasma usually replaces itself, or the
patient is transfused with albumin.

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Myasthenia Gravis
 Chronic disease characterized by
weakness primarily in muscles innervated
by cranial nerves, as well as in skeletal
and respiratory muscles
 Thymoma—encapsulated thymus gland
tumor

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Myasthenia Gravis (Cont’d)
 Progressive paresis of affected muscle
groups that is partially resolved by resting
 Most common symptoms—involvement of
eye muscles, such as ocular palsies,
ptosis, diplopia, weak or incomplete eye
closure

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Tensilon Testing
 Within 30 to 60 sec after injection of
Tensilon, most myasthenic patients show
marked improvement in muscle tone that
lasts 4 to 5 minutes.
 Prostigmin is also used.
 Cholinergic crisis is due to overmedication.

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Tensilon Testing (Cont’d)
 Myasthenic crisis is due to
undermedication.
 Atropine sulfate is the antidote for Tensilon
complications.

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Nonsurgical Management
 Respiratory support
 Promoting mobility
 Drug therapy:
 Cholinesterase inhibitor drugs
 Immunosuppression
 Plasmapheresis

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Cholinesterase Inhibitor Drugs
 Drugs include anticholinesterase and
antimyasthenics.
 Enhance neuromuscular impulse
transmission by preventing decrease of
ACh by the enzyme ChE.
 Administer with food.
 Observe drug interactions.

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Emergency Crises
 Myasthenic crisis—an exacerbation of the
myasthenic symptoms caused by
undermedication with anticholinesterases
 Cholinergic crisis—an acute exacerbation
of muscle weakness caused by
overmedication with cholinergic
(anticholinesterase) drugs

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Myasthenic Emergency Crisis
 Tensilon test is performed.
 Priority for nursing management is to
maintain adequate respiratory function.
 Cholinesterase-inhibiting drugs are
withheld because they increase respiratory
secretions and are usually ineffective for
the first few days after the crisis begins.

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Cholinergic Emergency Crisis
 Anticholinergic drugs are withheld while
the patient is maintained on a ventilator.
 Atropine may be given and repeated, if
necessary.
 Observe for thickened secretions due to
the drugs.
 Improvement is usually rapid after
appropriate drugs have been given.

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Management
 Immunosuppression
 Plasmapheresis
 Respiratory support
 Promoting self-care guidelines
 Assisting with communication
 Nutritional support
 Eye protection
 Surgical management usually involving
thymectomy

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Health Teaching
 Factors in exacerbation include infection,
stress, surgery, hard physical exercise,
sedatives, enemas, and strong cathartics.
 Avoid overheating, crowds, overeating,
erratic changes in sleeping habits, and
emotional extremes.
 Teach warning signs.
 Teach importance of compliance.

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Trigeminal Neuralgia
 Affects trigeminal or fifth cranial nerve
 Nonsurgical management of facial pain—
drug therapy
 Surgical management—microvascular
decompression, radiofrequency thermal
coagulation, percutaneous balloon
microcompression
 Postoperative care—monitoring for
complications

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Trigeminal Nerve

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Facial Paralysis or Bell’s Palsy
 Acute paralysis of seventh cranial nerve
 Medical management—prednisone,
analgesics, acyclovir
 Protection of the eye
 Nutrition
 Massage; warm, moist heat; facial
exercises

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Amputations
 Surgical amputation
 Traumatic amputation
 Levels of amputation
 Complications of amputations—
hemorrhage, infection, phantom limb pain,
neuroma, flexion contracture

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Common Levels of Amputation

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Phantom Limb Pain
 Phantom limb pain is a frequent
complication of amputation.
 Patient complains of pain at the site of the
removed body part, most often shortly
after surgery.
 Pain is intense burning feeling, crushing
sensation, or cramping.
 Some patients feel that the removed body
part is in a distorted position.

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Management of Pain
 Phantom limb pain must be distinguished
from stump pain because they are
managed differently.
 Recognize that this pain is real and
interferes with the amputee’s ADLs.

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Management of Pain (Cont’d)
 Opioids are not as effective for phantom
limb pain as they are for residual limb pain.
 Other drugs include beta blockers,
antiepileptic drugs, antispasmodics, and IV
infusion of calcitonin.

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Exercise After Amputation
 ROM to prevent flexion contractures,
particularly of the hip and knee
 Trapeze and overhead frame
 Firm mattress
 Prone position every 3 to 4 hours
 Elevation of lower-leg residual limb
controversial

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Stump Care

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Prostheses
 Devices to help shape and shrink the
residual limb and help patient adapt
 Wrapping of elastic bandages
 Individual fitting of the prosthesis; special
care

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Complex Regional Pain Syndrome
 A poorly understood complex disorder that
includes debilitating pain, atrophy,
autonomic dysfunction, and motor
impairment
 Collaborative management—pain relief,
maintaining ROM, endoscopic thoracic
sympathectomy, and psychotherapy

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Cerebral Palsy
 Copy and past the URL below to see a
video ppt presentation on CP
 http://www.authorstream.com/Presentation
/laqueitaowens23-388993-cerebral-palsy-
power-point-presentation-education-ppt-
powerpoint/

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Spina Bifida
 The most common, permanent and
disabling birth defect in the United
States

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What are the effects of Spina
Bifida?
 Ongoing medical challenges
 Full or partial paralysis
 Nervous system complications
 Bladder and bowel control difficulties
 Learning disabilities
 Depression
 Social and sexual issues
 Latex allergy

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 Latex allergy
 70% of children and adolescents with Spina
Bifida are sensitive to latex
 Items made with latex include:
• Promotional items like stress balls
• Balloons
• Rubber bands
• Rubber erasers

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How does Spina Bifida
happen?
 First month of pregnancy
 Before most women know they are
pregnant
 The spine does not close
 Causes an opening or lesion
 Damaged nerves may result in varying
degrees of paralysis

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What happens after birth?
 Surgery
Reduces risk of infection
Further damage to the spinal
cord
 Life-long treatment and care

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Can Spina Bifida be prevented?
 Exact cause is not known
 Medical research confirms link between
folic acid and Spina Bifida*
 Women who take 400 mcg of folic acid
every day reduce the risk by up to 70%.
 BEFORE becoming pregnant
 During first three months of pregnancy
* (and other birth defects)

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What is folic acid?
 B-vitamin that builds healthy cells
 In most multivitamins
 Foods
 Leafy green vegetables (broccoli and spinach)
 Fruits and juices (orange juice)
 Folic acid-fortified breakfast cereals and other
bread and grain products
The surest way to get enough folic acid every day
is to take a vitamin with folic acid.