includes spinal cord injuries

1. Spinal cord injury
DR.BHARTI PAWAR (PT)

2. definition
 A spinal cord injury refers to any injury to the spinal
cord that is caused by trauma instead of disease.

3. etiology
 Trauma (automobile or motor cycle accidents, gunshot
or knife wounds, falls and sports mishaps)
 Vertebrae most commonly involved are the 5th, 6th and
7th cervical vertebrae, 12th thoracic vertebrae and 1st
lumbar vertebrae

4. classification
 Mechanism of injury
 Level of injury
 Degree of injury

5. Mechanism of injury
 Flexion rotation injuries
 Hyper extension injuries
 Compression injuries

6. Flexion rotation injuries
 Occurs when the head strikes the
steering wheel, the spine is forced
into acute hyper flexion
 Rupture of posterior ligaments results in forward
dislocation of the vertebrae
 Cervical spine usually affected are the C5 to C6 level

7. Hyper extension injuries
 Results after a fall in
which the chin hits an
object and the head
is thrown back
 Anterior ligament is ruptured with fracture of the
posterior elements of the vertebral body
 Greatest area of stress is at the C4 and C5

8. Compression injuries
 Caused by falls or jumps in which
the person lands directly on the
head, sacrum or feet
 Force of impact fractures the
vertebrae and the fragments
compress the cord
 Lumbar and lower thoracic
vertebrae are usually affected

9. Level of injury
 Skeletal level
 Neurologic level

10. Degree of injury
 Complete cord injury
- Results in total loss of sensory and motor function below the level of
injury
 Incomplete cord injury
- mixed loss of voluntary motor activity and sensation and leaves some
tracts intact

11. Incomplete injury
 Central cord syndrome
 Anterior cord syndrome
 Brown sequard syndrome
 Posterior cord syndrome
 Conus medullaris and cauda equina syndrome

12. Central cord syndrome
 Damage to central spinal cord
 Occurs most commonly in the
cervical region
 Motor weakness and sensory loss
are present in both upper and
lower extremities

13. Anterior cord syndrome
 Caused by damage to anterior spinal
artery
 Results from injury causing
compression of anterior portion of
the spinal cord(flexion injury)
 Paralysis and loss of pain and
temperature sensation below the
level of injury
 Sensation of touch, position and
vibration remains intact

14. Brown sequard syndrome
 Result of damage to one half
of the spinal cord(knife or
missile injury)
 Ipsilateral paralysis with
ipsilateral loss of touch and
pressure and contralateral
loss of pain and temperature

15. Posterior cord syndrome
 Results from damage to the posterior spinal artery
 Dorsal columns are damaged resulting in loss of
proprioception
 Pain, temperature and motor function below the level
of lesion remains intact

16. Conus medullaris and
cauda equina syndrome
 Result from damage to the very lowest
portion of the spinal cord (conus) and
the lumbar and sacral nerve roots(cauda
equina)
 Flaccid paralysis of the lower limbs and
areflexia(flaccid bladder and bowel)

17. Clinical manifestations
Respiratory system
 Injury below the level of C4
 diaphragmatic breathing hypoventilation
 Cervical and thoracic injuries paralysis of abdominal and intercostal
muscles patient cannot cough effectively to remove
secretions atelectasis and pneumonia
 Neurogenic pulmonary edema

18. Clinical manifestations…
Cardio vascular system
 Injury above the level of T6 decreases the influence of
sympathetic nervous system
bradycardia occurs
peripheral vasodilation
reduces return of blood to the heart
Decreases cardiac output hypotension

19. Clinical manifestations…
Urinary system
 Urinary retention (loss of sensation and decreased
reflexes)

20. Clinical manifestations…
 Gastrointestinal system
 Injury above the level of T5 decreased
 gastro intestinal motility development of paralytic ileus and
gastric distension
 Development of stress ulcers
 Intra abdominal bleeding
 Less voluntary control over the bowel
neurogenic bowel(bowel is arereflexic and sphincter tone is
decreased)

21. Clinical manifestations…
Problems with thermoregulation
 Poikilothermism is lost in spinal cord injuries
 Decreased ability to sweat or shiver below the level of
the lesion
 Patients with high cervical injury have a greater loss of
ability to regulate temperature

22. Clinical manifestations…
 Peripheral vascular
problems
 Deep vein
thrombosis(during the first
3 months)

23. Clinical manifestations…
Spinal shock and neurogenic shock
 Spinal shock
- Temporary loss of neurologic function characterized by
decreased reflexes, loss of sensation and flaccid
paralysis below the level of injury
- syndrome lasts days to months

24.  Neurogenic shock
- Effects are associated with cervical or high thoracic
injury
- Due to loss of vasomotor tone caused by injury and is
characterized by hypotension and bradycardia
- peripheral vasodilation decreased cardiac output

25. Diagnostic measures
 History and physical examination
 X ray spine
 CT scan
 MRI scan
 Vertebral angiography

26. complications
 Neurologic deterioration
 Pressure sores
 Pulmonary complications
- Atelectasis
- Increased work of breathing
- Decrease cough retained secretions
Pneumonia
- Muscle fatigue

27. Complications….
 Neurogenic bladder
- Include urgency, frequency, incontinence, inability
to void and high bladder pressure resulting in reflux of
urine into the kidneys
 Neurogenic bowel
- Voluntary control of bowel evacuation is lost

28. Complications….
-Hypertension
- Throbbing headache
- Marked diaphoresis above the level of the lesion
- Bradycardia
- flushing of the skin above the level of the lesion
- pale extremities below the level of the lesion

29. complications
 Loss of circulatory control
 Muscle tone problems
- Spastic and flaccid muscles

30. management
Initial care
 Neck should be stabilized in a neutral position
without flexion or extension
 Place the affected person on a spine board and
secure the spine with a hard collar around the
neck

31. Initial care……
 Log rolling technique
 Maintain a patent airway
 Mechanically assisted
ventilation
 patients with severe
cervical injury, placed in
skeletal traction

32. management
 Drug therapy
 Methyl prednisolone(effective if given within 8 hours of
injury)
 Loading dose of 30mg|kg given within 3 hours of injury
followed by 24 hours of 5.4mg|kg IV methyl
prednisolone drip
 Vasopressor agents (dopamine)
 Histamine 2 receptor blocking agents

33. management
 Managing respiratory dysfunction
 If the injury is at or above C3 endotracheal intubation and
mechanical ventilation
 Chest physiotherapy, adequate oxygenation and pain management
 Use of incentive spirometry

34. management
 Managing cardiovascular instability
 In case of bradycardia, administer anticholinergic(atropine)
 Hypotension managed with dopamine infusion
 Compression gradient stockings to prevent DVT
 If severe blood loss has occurred, blood should be administered
according to protocol

35. management
 Fluid and nutritional balance
 First 48 to 72 hours after SCI GI tract may stop functioning
(paralytic ileus)
 NG tube insertion for gastric decompression
 Introduce oral foods and fluids once the bowel sounds returns
 In patients with high cervical injuries swallowing capacity must be
evaluated
 Increased dietary fiber

36. management
 Temperature control
 Monitor body temperature
 Monitor the environment closely to maintain
appropriate temperature
 Patient should not be overloaded with covers or unduly
exposed

37. management
 Managing stress ulcers
 Stool and gastric contents are tested daily for blood
 Give corticosteroids along with antacids
 H2 receptor blockers or proton pump inhibitors

38. management
 Bladder and bowel management
 Insertion of indwelling catheter
 After patient is stabilized, start intermittent
catheterization
 Suppository should be inserted daily
 Increased fiber intake

39. Nursing diagnosis
 Ineffective breathing pattern related to weakness or
paralysis of abdominal and intercostal muscles
 Impaired physical mobility related to motor and sensory
impairments
 Disturbed sensory perception related to motor and
sensory impairment
 Impaired urinary elimination related to inability to void
spontaneously
 Constipation related to presence of atonic bowel

40. Nursing diagnosis
 Risk for impaired skin integrity related to immobility
 Risk for autonomic dysreflexia related to reflex
stimulation of sympathetic nervous system after spinal
shock resolves

41. THANK YOU!