Spinal Cord Injury

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Spinal Cord Injury

• Nursing 335
• C. Fehr
• Fall 2005

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SCI Facts

• SCI can happen to anyone, anytime
• Affects gt 41,000 Canadians
• 1,100 new injuries/year
• Major risk factors male, less than 34 years
  old, involvement in risky activities
• Many d/t motor vehicle collisions, sports
  injuries
• Unemployment rate of those with SCI gt62
• Cost to health care system between 1.25 25
  million over each injured persons life
• Annual costs to Canada - 750 million
• Source Canadian Paraplegic Association Rick
  Hansen Mon In Motion Foundation

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Causes of SCI

• Traumatic
• MVAs, falls, sports injuries, objects falling
  onto head, assault
• Non-traumatic
• Degenerative, infective, oncogenic spinal lesions

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• Vertebral Foramen (provide bony protection for
  spinal cord by forming vertebral canal)
• Transverse Process

Source Christopher Dana Reeve Paralysis
Resource Center
Source Allrefer.com http//health.allrefer.com
/health/cervical-spondylosis-skeletal-spine.html
Source Christopher Dana Reeve Paralysis
Resource Center
5
Definition

• Damage to spinal cord with disruption of
  communication to/from brain body, resulting in
  loss of sensation function to varying degrees
• Most often permanent effects and currently there
  is no cure, although research proves that spinal
  cord repair regeneration is possible
• Prevention is the key to limiting SCI and its
  devastating effects

• The effects of Spinal Cord Injury vary depending
  on the type and level of injury sustained. 
• Complete and Incomplete 
• Complete injury - no function below the level of
  the injury (no sensation and no voluntary
  movement) and both sides of the body are equally
  affected 
• Incomplete injury - some functioning below the
  primary level of the injury One limb may be able
  to be moved more than the other, the person may
  be able to feel parts of the body that cannot be
  moved and there may be more functioning on one
  side of the body than the other.

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• spinal cord is divided into five sections the
  cervical, thoracic, lumbar, sacral, and coccygeal
  regions
• level of injury determines the extent of
  paralysis and/or loss of sensation
• No two injuries are alike.
• diagram at left illustrates the connections
  between the major skeletal muscle groups and each
  level of the spinal cord

Source Christopher Dana Reeve Paralysis
Resource Center
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• In addition to the control of voluntary movement,
  the CNS contains the sympathetic and
  parasympathetic pathways that control the "fight
  or flight" response to danger and regulation of
  bodily functions
• hormone release, movement of food through the
  stomach and intestines, sensations from and
  muscular control to all internal organs.
• The diagram at left illustrates these pathways
  and the level of the spinal cord projecting to
  each organ. 

Source Christopher Dana Reeve Paralysis
Resource Center
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ANS
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Dermatomes
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• The Miami Project to Cure Paralysis
• http//www.miamiproject.miami.edu/x12.xml -
  Heroes Video (15 min)

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Paraplegia Quadraplegia

• Paraplegia loss of sensation movement in legs
  and in part or all of the trunk usually d/t
  damage to spinal cord below the neck
• Tetraplegia (Quadraplegia) paralysis of all
  four limbs d/t injury to the neck C1-T1
• Both may lead to loss of sensation, movement,
  pain management, bladder bowel control, sexual
  function disturbances

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Spinal Neurogenic Shock

• Spinal Neurogenic shock commonly occur together
• Terms often used interchangeably however, there
  is a concrete difference between the two
• Spinal Shock
• the temporary suppression of all reflex activity
  below the level of cord injury (somatic
  autonomic reflex activity)
• SCI ?loss of conduction d/t migration K ions
  from inside cells into extracellular spaces
• Neurogenic Shock
• bodys response to the sudden loss of sympathetic
  control (only above T6 injury)
• Hypotension d/t ? SNS outflow
• Bradycardia d/t unopposed PNS
• Hypothermia d/t bodys inability to conserve
  heat d/t passively dilated vascular bed loss of
  thermoregulation poikilothermia ? loss of sweat
  gland activity

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Upper Lower Motor Neurons

• Spinal nerves provide common pathways for
  controlled movement, sensory input, reflex
  activity link between body CNS
• 31 pairs spinal nerves convey both sensory
  motor two way communication between spinal cord
  body
• dependent on connection of CNS PNS
• Connection accomplished through synaptic
  transmission between UMN (CNS) LMN (PNS) at
  each spinal segment

Source Christopher Dana Reeve Paralysis
Resource Center
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UMN Versus LMN Injury

• UMN Lesion
• Spastic paralysis
• Spastic bowel
• Spastic bladder
• Reflex erections in males
• hyperreflexia

• LMN Lesion
• Flaccid paralysis
• Loss of bowel tone
• Loss of bladder tone
• Reflex erections not possible
• hyporeflexia

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Motor Sensory Tracts of Spinal Cord

• Posterior Column ascending tract responsible
  for proprioception, light touch, vibration
  sensation
• Lateral Corticospinal Tract descending tract
  responsible for voluntary motion
• Lateral Spinothalamic Tract ascending tract
  responsible for pain and temperature sensation
• Anterior Column descending tract responsible
  for voluntary movement
• Gray matter

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Mechanisms of Progressive Damage

• Primary injury to cord
• d/t vascular change direct damage to neural
  tissue at time of trauma
• Secondary injury
• result from chain of events which leads to
  ischemia, hypoxia, edema, infarction
  hemorrhagic necrosis of cord (begins immediately
  after injury progresses for hours)
• Edema of cord
• ? perfusion pressure to damaged area
• Structural changes of gray white matter
• Biochemical changes from release of vasoactive
  substances ? toxic vasospasm
• Aim of health care members is to interrupt or
  reverse secondary processes that further damage
  cord could ? function even further
• Methylprednisolone (Solumedrol) within first 8hrs
  post-injury

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Complete Incomplete SCI

• Neurological level of injury is determined as
  most caudal segment (lowest spinal segment) that
  tests normal or intact for both sensory motor
  function
• E.g., a C4 injury indicates loss of M S
  function below C4
• Complete Injury
• Functional transection of spinal cord (cord
  seldom physically transected)
• Total areflexia, absence of motor sensory
  function below level of injury
• Only fully confirmed after spinal shock subsides
  remember spinal shock can cause complete
  areflexia and last hours to days
• Incomplete Injury
• Sparing or preservation of some motor or sensory
  function
• Five distinct patterns of neurological deficit

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ASIA Impairment Scale
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Neurological Level of Injury
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Incomplete Injury Clinical Syndromes

• Central Cord Syndrome
• Central portion cervical cord damaged
• Often seen with older adults, hyperextension
  injury
• Motor sensory deficits gt in upper extremities
• Functional sparing to lower extremities

Area of Cord Damage

• Brown-Séquards Syndrome
• Transverse hemisection of cord
• Motor deficit Ipsilateral (same side as cord
  damage) below level of lesion
• Sensory deficit Contralateral (opposite side as
  cord damage) pain, temp, position, vibration,
  touch sense below level of lesion

Area of Cord Damage
Source of pictures University of Wisconsin
Anatomy Department
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Source of pictures University of Wisconsin
Anatomy Department

• Anterior Cord Syndrome
• Anterior ? cord damaged
• Sparing posterior columns
• Complete motor deficit below lesion sensory
  deficit of pain, temperature below level of
  lesion
• Sensory sparing position, vibration, touch
  sense
• Fairly rare

Area of Cord Damage

• Posterior Cord Syndrome
• Rare
• Dorsal column (posterior) pathways damaged
• Motor function spared
• Sense deficit - light touch, vibration,
  proprioception
• Sense sparing - pain temperature
• Difficult to mobilize walking plegia

Source Zedjlik, 1992
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• Conus Cauda Equina Injuries
• Cone-shaped end of cord (conus) or spinal nerves
  (LMN injury) forming cauda equina
• Often involves injuries below L1
• Motor deficit variable with asymmetrical
  involvement
• Sensory deficit often not markedly impaired
• Flaccid paralysis of bowel, bladder, sexual
  function b/c those centers located in conus

• Sacral Sparing
• Major part of cord /or bld supply damaged
  radicular arteries spare outer circumference of
  cord
• Motor deficit complete below level of injury
• Sensory deficit complete below level of injury
  except sacral area

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Initial Assessment Management

• A airway with C-spine control
• C-spine maintained until cleared (X-ray, CT, MRI)
• Close monitor HR minimize bradycardia
  (unopposed vagal stimulation)
• Preoxygenation hyperventilation with bag 100
  O2
• Nuromuscular blocking agents if difficult
  intubation

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Initial Assessment Management cont.

• B breathing
• Mildly to severely compromised depending on level
  of neurological injury
• C1-3 injury loss phrenic nerve innervation ?
  loss spontaneous ventilation

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Ventilatory Dysfunction
Source Sheerin, 2005
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Ventilatory Dysfunction
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Initial Assessment Management cont.

• C circulation
• Hypotension may represent nurogenic shock,
  hemorrhagic shock or combination
• Neurogenic Shock only in SCI above T6
  (hypotension with SCI below T6 or spinal no
  cord injury probably d/t hemorrhage)
• Triad of symptoms
• Hypotension d/t ? SNS outflow
• Bradycardia d/t unopposed PNS
• Hypothermia d/t bodys inability to conserve
  heat d/t passively dilated vascular bed

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Pathophysiology of Neurogenic Shock
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Goals of Therapy for Neurogenic Shock

• Maintain u/o gt 30 cc/hr
• Maintain systolic BP 90-100 mmHg without
  overhydration ? severe prolonged hypotension
  treated with vasopressor (Dopamine)
• Maintain heart rate 60-100/min
• Avoid hypothermia

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Initial Assessment Management cont.

• D delicate spine disability (Neurological
  Status)
• Immobilization of spine use to use Stryker
  frame not as common today
• Level of injury documented ASAP after admission
  to ED
• Determined by pain tenderness _at_ injury site,
  motor strength to extremities, sensory function
  over body
• C3 means loss of motor sensory function below
  C3
• Neuro impairment ? complete OR incomplete
• ASIA impairment scale
• Clinical syndromes

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• Sensory Assessment is determined by testing each
  of 28 dermatomes on each side using light touch
  pin prick
• Labeled as 0absent, 1 impaired (hypo/hyper
  sensation), 2normal, NTnot tested

Source Spinal Cord Injury Resource Center
http//www.spinalinjury.net/index.html
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Other Body Systems Affected

• GI
• Paralytic ileus NG inserted in all with acute
  SCI
• Stress ulcers H2 antagonists, cytoprotectants,
  antacids, early nutritional support
• Cholelithiasis
• Bowel changes
• Reflex bowel
• Areflexic bowel

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Other Body Systems Affected cont.

• GU
• Temporary or permanent loss of bladder function
• Indwelling catheter ? intermittent
  catheterizations
• Reproductive
• ? can alter fertility sexual function
• above conus reflex erections, no ejaculate
• below conus few achieve erection or ejaculation
• ? remain capable of sexual intercourse
  conception
• 50-70 can achieve orgasm
• menses can be disrupted initially
• with pregnancy, close monitoring
• no hormonal contraceptives
• Skin
• Pressure sores

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Other Body Systems Affected cont.

• Psychosocial
• Anger, fear, anxiety
• Need simple, concise, factual info many times
  over no speculations re condition long term
  prognosis
• Simple objective facts
• Respiratory
• Depends on level of injury for all,
  immobilization initially
• Higher injury impacts diaphragm intercostals
• Some ventilator dependant with tracheostomy

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Other Complications Associated with SCI

• Osteoporosis Fractures
• Very common
• d/t non-weight bearing muscle strengthening
• No way to reverse ? prevention key
• Heterotropic Ossification
• Not well understood ? laying down of bone outside
  skeleton
• Causes stiffening fusion of joints
• Prevention regular ROM

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Other Complications Associated with SCI

• Overuse Injuries
• Upper extremity joints
• Overuse syndrome, chronic pain, rotator cuff
  problems, nerve entrapments
• Muscle Spasms or Spasticity
• Exaggeration of normal reflexes d/t Nerve cells
  below level of injury disconnected from brain
• Occur anytime body below level of injury is
  stimulated
• Prevention regular ROM, ? risk factors, meds
  such as Baclofen, Valium, and Dantrium
• Benefits warning system of problems, helps
  maintain muscle size bone strength, circulation
  to legs can aid with dressing transfers

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Other Complication Associated with SCI

• Autonomic Dysreflexia
• Only those with injury above T6
• r/t disconnections between body below injury and
  control mechanisms for BP HR ? stimuli sets in
  motion
• Causes BP rise dangerous levels
• Common stimuli full bladder, bladder infection,
  constipation, turned up/down toes, sitting on
  scrotum, decubiti/pressure area, tests/treatments
  (IV) done below level of injury
• SS
• pounding H/A, spots before eyes, blurred vision
  (direct result of high BP occurs when BV below
  injury constrict)
• Body response dilating BV above injury ?
  flushed skin, sweating, goosebumps, nasal
  stuffiness, anxiety diaphoresis, pallor,
  coolness below level of injury
• If uncontrolled can lead to stroke body will
  severely ? HR to try to ? BP
• Tx remove stimulus, sit as straight up as
  possible (natural ? BP), check foley for kinks,
  catheterize, check bowel, check skin prevention
  is key

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Other Complication Associated with SCI

• DVT PE -
• r/t changes to normal neurologic control of BV ?
  stasis or sludging
• r/t ? movement of limbs for sustained periods of
  time, particularly if in ill-fitting w/c for long
  periods of time without weight shifts ? poor
  venous return
• Very common in lower legs during phases of
  recovery/rehab
• Prevention regular ROM, proper fitting w/c,
  antiembolic stockings/pneumatic compression
  devices, prophylactic LMW heparin
• Cardiovascular Disease -
• Generally sedintary
• Increase in adipose tissue, decrease muscle mass
  tone
• Prevention exercise programs tailored to
  abilities passive ROM to paralyzed areas
• Wheelchair sports racing w/c, monoskis ? lots
  opportunities organized thru paraplegic
  association
• T6 or above more common to suffer orthostatic
  hypotension ? change position gradually,
  abdominal binder if occurs, lie back or tilt w/c
  back

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Other Complication Associated with SCI

• Neuropathic/Spinal Cord Pain -
• Significant problem of varying degrees types
• Nerve root pain ? sharp, electric shock-type
  quality
• Phantom limb pain pain radiating from level of
  lesion in specific pattern
• Tx ant-depressant type medications, nerve block
  procedures
• Respiratory Dysfunction -
• Pneumonia (common complication), atelectasis,
  aspiration
• Particularly affecting those with injury above T4
  ? innervation muscle atrophy
• restrictive lung disease 5-10 years post injury
  progressive
• Monitoring pulmonary function tests q 1-2 years
• Prevention pneumonia pneumococcal vaccine
  percussion drainage using gravity assist,
  assisted coughs, abdominal binders, mobilization

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• Remember that SCI is just one obstacle or hurdle
  who you are caring for is a person who can still
  dream, still live a full and productive life
• http//www.rickhansen.com/Story/story_video.htm

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References

• http//www.paralysis.org/ - Christopher Dana
  Reeve Paralysis Resource Center
• http//www.apacure.com/ - Christopher Reeve
  Paralysis Foundation
• Video - Toughest Break by Christopher Reeve Man
  in Motion Foundation
• Chen, D., Nussbaum, S. (2002). Gastrointestinal
  disorders. In Kirschblum S et al. (eds) Spinal
  cord medicine. Philadelphia PA Lippincott
  Williams Wilkins
• Gibson, K.L. (2003). Caring for a patient who
  lives with a spinal cord injury. Nursing 2003,
  33(7), 36-41.
• Sheerin, F. (2005). Spinal cord injury acute
  care management. Emergency Nurse, 12(10), 26-34.
• Zejdlik, C. (1992). Management of spinal cord
  injury (2nd ed.) Boston MA Jones Bartlett.