Professional Documents
Culture Documents
The Cord
* Two views
The Cord
* Whats in the cord? * 33 vertebrae to protect and support * 7 cervicals-neck, most unstable * 12 thoracics- chest * 5 lumbars- support back- again pain * 5 sacrals
* Coccyx * Vertebrae separated by discsshock absorbers * Inner core of disc is NP * Cord has CSF & meninges * Contains ascending sensory & descending motor tracts
Cord in sections
* 4 basic divisions * Cervical * Thoracic * Lumbar * Sacrococcygeal
* Intervertebral discs wh
Cord Problems
* From progressive neuropathy,Osteoporosis * Cancer,Lower back pain with muscle strain- pain worse oft at rest * So get locus, radiation, duration of pain, paresthesias, muscle weakness and report anything rapid or worsening
Cord Psychosocial
* Will always give change in
issues
* What about self concept &
powerlessness
* Anxiety * Can also alter family
Congenital Problems
* Will also be addressed in
Pedi
Meningomyelocele
* Congenital deficits of neural
closure
* Normal bones and
no cord herniation
* Not visible except as a dent
of pimple
* Few physical
motor problems
* If below L2 are flaccid,
Meningocele
* Sac is filled with spinal fluidlooks like a cyst * Mass will transilluminate * May see this on prenatal ultrasound * Will also see > AFP so now know ahead of time
Meningomyelocele
* This is worse with protrusion of meninges, fluid and cord * Very disrupted * Will have neurogenic bladder & oft ongoing UTIs
* May need intermittent cath programs * Surgery later with artificial sphincters * Probanthine, urecholine as pt ages
Care in these
* Genetic c viral trigger* so counseling
psych
Care in these
* Keep sac sterile & moist * Saline towels to cover-occ
silver nitrate
* Q 2 hr checks -? leak,
for bonding
Hydrocephalus
* See c previous- if before suture close, then skull can expand and will not herniate * As usual worse danger is if CSF accumulates too rapidlyfrom blockage or defective reabsorption * See with trauma, infection, genetics * Will need to shunt this- place ventriculostomy
close
* Sudden weakness, anesth, bowel/bladder stuff get MRI * Recent trauma with back injuryhad films * Ca or infection> get CBC, UA
Sciatica
* Pain in lower back, radiating down posterior, lateral thigh * Only 45% will have herniation detectable on xray- pain can be severe, functionally limiting- usu worse in leg
* Straight leg test is most sensitive- supine or seated- pain at 30-70 degrees of hip flexionthen do crossed leg- lift opp leg & get pain in affected leg
locus
* L3-4> ankle dorsiflexion,
Sciatica
* Improves in 90% at 6
weeks
* Bed rest is out- mobility in * No steroids, opiates initially
get MRI
nerves, bones
* Disk is shock absorber to provide a cushion & give flexibility, distributed load * Gelatinous center surrounded by fibro cartilage ring * Disk can get weak with age, excess movement * A rupture will allow gelatinous center to pour out, exude & compress root
Anatomy
* many processes protruding from vertebral segments. * The facet joints are held together with capsular ligaments.
Anatomy
* The facet joints > held together capsular ligaments.
HNP happens
* Could be at any level but in general where the spine has most movt- at L4-5 or L5-S1 * Other issues are at C5-7 * In anyone with active life, falls * Poor abdominal tone * Risk factors
* Sx: low back pain radiating down thigh oft down 1 dermatome * Pain is sharp, numbing, stabbing, burning oft with paresthesias * Oft a while after injury * See muscle spasm * If herniate centrally may get issues with urination, incontinent or impotence * Aggrav with strain, cough, straight leg raising,
diagnostics
* Can tell best with MRI- hi res, contrast or not but what will insurance company bear- super details of nerves * SPECT- can distinguish benign from malignant lesionstechnetium or gallium scan that gets uptake in hydroxyapatite crystals in new bone- tells tumors, fx, mets
Tests
* XRAY-lateral ray of lumbar spine - e cellent for determining alignment > tells !ompression fractures, collapse of the disk spaces
* Myelogram>LP c dye if MRI inconclusive shows lateral or central herniation - also if cannot do MRI- contrast into subarachnoid space- can irritate
Discogram
* A discogram " study of radio opa#ue dye injected into the disk space. * both anatomical study & functional study.
* looks at anatomy of disk space > can show when dye leaks through rents in the annulus fibrosis. * Also functional test > patient reports, on a scale from $ to $%, how much pain has been produced.
hands/fingers
* Neck movement restricted
Dermatomes
* Levels of nerve distribution * Damage follows the levels
Feet issues
* Sensory loss * Paresthesias * Motor problems
thru cord
IDET
* IDET =intradiscal
fissures in the disc wall, thus reducing bulging of inner disc material & impingement on nerve diminishes
* done outpatient c local
anesthesia
Other treatments
* http://www.spineandscoliosi
s.com/animation.php? pn=artificialdisc
* http://www.spineandscoliosi
s.com/animation.php? pn=discmicro
Red Flags
* Fecal incontinence, saddle
osteoprorosis
The PE
* Diminished reflexes * Paresthesias in
dermatomes
* Cannot straight leg raise
Or Lumbar Stenosis
* Under pressure
* narrowing of space thru wh nerves go to legs * Gets smaller if bone there grows * Causes leg pain, mobility problems * Arthritis, falls, wear cause itget back pain,leg pain, weakness * Pain worse with activity- tx exercise, PT, surgery to open up canal
Spinal stenosis
* Affects 1.2 million- oft from degeneration
* Pain described as problem when exercise- pain is burning, cramped, weak, a neural claudication- may feel better if get in fetal position- to open space * Few studies but epidurals do not help- expect surgery in moderate pain or at least a neurogenic regional block
Spinal stenosis
* Can treat with pain meds or
decompression surgery
* Local anesthetic block * Seems best results after
surgery
m/the-mild-procedure.html
Mild procedure
* http://www.youtube.com/wa
tch?v=fE8BJMJmjM0
* http://www.youtube.com/wa
tch?v=QMee68ZuRIo
Tx Disc
* Conservative Tx is best & firstno longer a long time of bed rest now up and moving * Deep ultrasonic heat, exercise, progressive muscle work, energy, massage, ice to reduce spasm * Bed avoid prone and pillows * Williams position * PT for back class and exercises * Roll to move- log roll
Back Class
* Stretch- proper body
mechanics
* The way to bend
hips
* Steroids * Facet joint injections * Epidurals * Trigger point injections * Lidoderm patches
Back Surgery
* For scoliosis, tumors, HNP,
now in Canada
approvals
Laminectomy
* Remove posterior arch of vertebrae * Fusion = to ensure stability by inserting bone grafts into interspace and immobilize the area * Will do this when conservative Tx ineffective * Pre-Op> usu now is EMA so will need good teaching
* assessment is get baseline of pain, motor, sensory function
Post Op Laminectomy
* Vitals, movement, voiding, pain, sensation * Cervical
* Flat, worry for laryngeal nerve damage * Hoarse, difficulty swallowing, signs of dependent bleeding
* Lumbar
* Oft flat in bed for period of time, log roll * Check for bleeding, paresthesias
* Will log roll in 1st 2 hrs- flat minimizes CSF leakage * Keep pillow between legs, arms across chest
Post op Laminectomy
* Care is changing and oft varies with surgeon- may stay 48 hrs or go home at 24 * Always get OOB on 1st day so need to pay close attention to body mechanics * You need specific positioning orders * Log roll with extra help
* Cervical fusion will need to watch swallow, increasing edema, stridor, distress
* Can also get pain and spasm wh is depressing to pt as thought this would end with surgery * Import of maintaining alignment
Teaching Laminectomy
* Body mechanics * Seat belts * Wt loss * Williams exercises- pelvic
Disc surgeries
* http://www.youtube.com/wa
tch?v=EvQPZxXr3Rs
* http://www.youtube.com/wa
* Every year there are 14,000. Esp in age 16-30 group more in men, risky business * 35% are MVA, 20% are falls, 30% violence * 33% are thoracic/cervical * Mostly young men in July * Cervicals become quadriplegics or tetraplegics- these are most common * Also related to knives, guns, osteoporosis, tumors, vasc disease with infarcts
* Whiplash to complete transections * Any level but particularly Cspine C1-2, C4-6, T11-12 where spine is most mobile * Trauma to tissue and then tissue death * This then becomes a chronic illness or disability
Christopher Reeves
* Got a lot of money from NIH and his foundation so things are moving * Private money, Medicaid or whatever it will bear
* Group homes - mobilize- can they live alone * Care is complex, overwhelming, and demanding * Cost for a quad in 1st year is over $500,000
At Risk
* Those with feelings of immortality, PSA * Bikes, motorcycles * Prevention is oft lost on those who need it but better with helmets, seat belts * Secondary prevention-stabilize cord on scene- so may need to hold traction & avoid twisting
The spine
* So any * Or all * What is innerv * How impacted
Injury from
* Transection * Compression * Infarction
* Look at motor and sensory loss
* C1-C4= Quadriplegia- loss of resp * C4-C5= Quadriplegia- phrenic involved * C5-6= gross arm movt, diaphragm breathing * C7-8= Quad> triceps & biceps, no hand * T1-2= Paraplegia- some intercostal & abd
ASIA classifications
* A= complete lesion- no
* B=incomplete lesion-
Terms
* Paraplegia- both lower extremities * Quadriplegia- involves all 4 extremities
* Complete lesion- above C6 with no potential for independence * Use of dermatomes to describe the loss- sensory loss to the spinal nerve
* Could be a different level for sensory and for motor
* Damage can be primary or from edema & inflammation > idea of ischemic penumbra again
cord and comprises anterior, lateral and posterior hornssensory fx arises from dorsal gray matter- ventral gray matter is motor function
* Viscera and body get
innervated from this- and activation of symp and paraasym autonomic ns occur in white and gray matter
SNS
matter of cord and go from thoracic to lumbar- damage to cord affects sns response
activity transmission- orig in brain and crosses over in brainstem to innervate opp side of body
Spinal nerves
* Correspond to spinal &
vertebral segments
* Dorsal roots send sensory
input up to CNS
* Ventral roots send motor
areas
phrenic
Vertebral column
* 7 cervicals-neck, most
unstable
* 12 thoracics- chest * 5 lumbars- support back-
again pain
* 5 sacrals * Coccyx * Cord is vulnerable so
intervertebral discs
Cervical Vertebrae
* Must allow head movt-
innately unstable
* Easily rotate, much risk for
injury
* Other issues in SCI are
* Upper motor neuron comes down from brain > travels in corticospinal/ corticobulbar tracts * Synapse with lower motor neurons * Job to suppress firing of lower motor neuorn * If no suppression, LMN will fire spontaneousl and lead to spasticity- so UMN controls primitive responses and reflex arcs * So if UMN is lost pt gets spastic paralysis coz of hyperactive response of reflex arcs to stim
* This reflex arc that control invol response * Damage then abolishes voluntary and reflex response to muscles/organs
* flaccid bowel with urinary retention, overflow incontinence and fecal retention and fecal impaction
* Here need straining of musculature
Pathophysiology
* Result of the injury to the
vertebrae
* Think of how the injury
happened
* Acceleration * Deceleration * Compression * Tearing
* shearing
Hyperextension
* Get this in elderly with degen vertebrae when hit windshield * Or in a diving injury * Cord is stretched against ligamentum flavae and get a dorsal column injury with a posterior dislocation * Or transect cord * Will lose all voluntary below and reflexes in the injured segment
* Here pt falls on feet or butt * Fx to vertebrae wh then compress cord * Fragments jammed into cordat lumbar/thoracic * Mostly incomplete injury with edema, bleed with some loss of sensation and function * Hard to know what will be permanent * Eventual death at 48hrs & neuron sheath destruction * Petechial hemorrhage with swelling and diffuse scars
Compression injury
* Two ways
Hyperflexion Injury
* How could this be
Lateral injury
* With a twist
Flexion-rotation dislocation
* turning
* Function depends on if lesion complete or not * Incomplete injury> some preservation of sensory, motor or both below level of lesion * Complete > total loss of motor, sensory or both below injury * Could be orthopedically at C5 but neurol intact to C6
Types of injury
* Complete cord transection
* Flaccid paraly c total loss of
some tracts intact with varying loss of motor and sensory function
Examples
* C spine injuries> quads
* C1-C4 =fatal s vent
* Loss of diaphragm innervation and no intercostals so no bellows effect * Trapezius, sternocleidomastoid, and platysma function * Sensory loss to occiput, ears and face but will need an attendant for ADLs * Electric wheelchair with hi back for head , vent or breath control or head and shoulder controls``
Injury at C4
a while
* Have better head control * Have some diaphragm- but
C5
* Where can live c independence * See intestinal paralysis and gastric dilatation * Upper extremities rotate out so shoulders are elevated
* May have exagg reflexes below the lesion * Some sensation in neck and upper arm * Can do some feeding, writing and transfer
C6
* Here still resp distress and intestinal paralysis * Lack inhibition of deltoid and biceps so arms must be positioned correctly with forearms in extension and arm in adduction * Person does have sensation
* There is more independence and can dress, feed and even drive a car with hand controls
C7
* Here can live independently
and transfer
* Perform own ADLs * Get a fusion
T2-L
* These are paraplegic levels
of injury
* Will do diaphragmic
Relook at levels
* see
hyperreflexic
neuron disorders
could have one of these presentations so the ER nurse needs to assess for this
Cord loss
bladder
* From damage to the
cervical tracts
* This is most common injury
* Pt retains light touch, proprioception and position sense as posterior columns are spared
cervical spine
* Lose position sense, light
Brown Sequard
Complete Transection
* Immediate loss of sensation and voluntary muscle below the transaction * All reflex activity is lost initially * The reflexes will come back and my be hyperactive because there is no inhibition from above
* Have loss brain influence of cord * So the spinal automatisms are left to own devices
Same as always
* Primary injury with initial
damage
* Secondary injury from cell
and vascular changes edema, lyte issues, release of catecholamines, toxic metabolites, hypoxia
* Get ABCs
* Look at neuro signs- alert, responsive * Check motor and sensory * ? Incontinence * Pain * Will immediately be hypotensive so will need immediate fluids * Will need a hard C-spine collar til C level injury is eliminated
Cord presents to ER
* Will need CT and
emptying of bowel/bladder
position in alignment
* Make sure have a rigid
DX test
* Xray is key test * C Spine and then thoracic,
process
* Mri ok for soft tissue
damage
* CT for extent of injury
* Incomplete injury if can feel finger or can contract rectal sphincter * This is a better prognosis
* IV fluids> pump, I&O as pt is in spinal shock and this will maintain perfusion
motor is present
* Think and document by
dermatomes
* Look for symmetry * What is spared and what is
retained
* Document locus, symmetry,
strength
* Look at spontaneous
In Any C injury
* Place in Halo or tongs-
immobilize spine
* Reduce fractures with
alignment
Tongs
* Tippy Wells
Gardner Wells
48 hrs
wbc in area, inhibs breakdown of phospholipids- > blood flow and blox inflamm cascades
More Initial Tx
* Will also need aggressive respiratory therapy- hi levels will be on vent * NG decompression of stomach during spinal shock phase * Bladder decompression in early phase * Start initial PROM on all joints then move to active ROM * SCDS
* Some centers using FESfunctional electrical stim to create contraction, relax with hope to walk * Gene therapy to allow axon growth
Experimental tx
* Growing myelin cells in lab
* Blood pools, vasodilate, bradycardia, from reflex vagal stimuli * This is immediate response to transection * Gives total loss of skeletal muscle function
* Loss of sexual function * Loss of autonomic function * Loss of venous return so hypotension * BRADYCARDIA
Spinal Shock
* Have lost hypothalamic control so you cant use vasoconstriction or increased metabolism * So client assumes temperature of surrounding air * Starts within 30 mins-Lasts week to a few months * Ends when reflexes return
* Had been flaccid> now are hyperreflexic * So bladder starts to empty reflexly * Flexors come back 1ts and respond to cutaneous stimulation * Notice the Babinski
Spinal Shock
* Orthostatic hypotension is
Early Surgery
* Controversial but common in university setting * Also do in any progressive neuro deficit * Also in any compound fx, and penetrating wounds with fragments * May have to do a decompression laminectomy
* Remove lamina of vertebrae to min pressure on cord
Early surgery
* Or in some settings will do
Neurosurgery
* Oft with cameras * Fine and delicate
Placing a Halo
* Other pts will be immobilized in halo device
* Fit to skull with pins to maintain alignment * Need wrench taped to front of jacket for immediate access * Never hold by rods when turning * Halo changes center of gravity so also danger of falls, balance * Pt will need to move as a unit * Check pins for tightness and report to doc
Halo 2
* Clean pin sites BID with prescribed solution
* Cork pin ends to protect & minimize sound magnification * Rolled towel behind neck * 1 finger breadth under vest to avoid breakdown * Check sheets for drainage * Encourage to sleep prone with pillows under hips with specific orders from doc * Keep buckles tight * Will have to have PT work with positioning
Halo 3
* Danger of resp distress and compromise from hyperextension of neck * Many think halo will cure any deficits and expect to walk after brace off so need teaching * Will also have vision obstruction * Continue to assess for ability of sensation * Expect post halo depression
injury
intercostals?
* Also at risk for code, bleed
Temperature Control
* There is disconnect from
body heat
* Cant shiver coz no
vasoconstriction
* Worse the higher the injury * Hypothermia/hypothermia * Try to keep temp at 97
Motion Beds
* Electrical stim to cause
muscles to contract
* Watch pooling and
hypotension
Beds- in cord
* Roto-Rest * Stryker
sores
start to breakdown
* Turn q 2 so make a turning
kinetic bed
Early Mobility
* PROM early to maintain and prevent contractures * mid hi sneakers, moon boots to prevent drop as well as splints * Get PT/OT involved * If OOB get straight back chair with reposition q 1hrs and check for breakdown
Early Meds
* IM & SC are not absorbed
Constipation
immediately
* Look for distention, check
bowel sounds
* Watch N,V and fecal
impaction
* May need enemas but only
Early Psych
* Hope * Denial * Family issues
Chronic Cord
* Begins as spinal shock dissipates * Pressure and temp is more normal * Less vasodilated * Now will look at how much function is present * What will rehab plan be * All need family involvement * All need a motivated client
SO REFLEXES RETURN
* This is not movement - it is
automaticity
Spasms
* This will present after a complete transection * Will expect painful intense spasms of lower extremities
* Could be from a twitch to wild horrid spasms * So may have to pad side rails to protect patient
* Spasms are triggered by cold, long sitting, emotion etc * This is not movement returning
* Still will be in denial of at least some aspects of situation- will I walk> how can I do it?
Psych
* Will also begin to see the
full impact here- severe depression, loss of motivation and any involvement
* Will talk of suicide * Will need to be mobilized
nurse
* Work on coping skills
Autonomic hyperreflexia
* The blood vessels below the injury vasoconstrict * This causes extreme hypertension 130/150 * A pounding headache, flushing, sweating above level of injury
So think about AD
* Any time the quad feels
out
Emergency interventions AD
* If you suspect AD raise HOB immediately to 90 degrees or assist to upright to drop BP * Remove TEDS, SCDS * Now check BP and continue q 2-3 mins * Stay c pt but get help to call doc
* Speed is essential but you stay calm * No Crede, remove kinks- if no cath may have to immed straight cath if bladder distended
* Check skin surfaces and may need topical anesthetic * Give ordered antihypertensives- nitrates, Nifedipine (procardia) apresoline
Constipation
* Obviously this can become serious problem * May need manual disimpactions,or enema but watch for AD
* If UMN issue will eventually have a reflex bladder so use reflex to help empty- warm drink, increase intraabdom pressure, Crede, insure enough fluid intake, suppositories, anesthetic jelly * If no risk for AD, can use digital stim and disimpaction
Airway issues
* Depends on level of injury * Goal of RR 12-20, lungs clear, no adventitious * Head neutral, suction available
* If in halo will need to frequently check breathing, incentive spirometry to encourage * Assisted coughing as you hold you hand on pt diaphragm and have them exhale as you press up on diaphragm to make forceful cough
Disuse Issues
* Will want complete ROM of all parts * Position change* Hand splints with spasticity issues
* Find out triggers of spasmscold, anxiety, fatigue, emotion, infection, distention, tight clothes, lack of position change * Position, ROM frequently, heat, vibration, touch is more firm and deep to prevent spasms
Promote Mobility
* Monitor for tendon contractures, joint ankylosis, muscle shortening * Supports to match the deficits so appropriate use of adaptive devices * Cushions to prevent ulcerations * Proper fitting wheelchairs
* Strengthen muscles and support with braces * Active and passive conditioning
to stroke
* Exercise to tolerance- what
can pt do
* Wt bear if any possibility- to
stimulate osteoblasts
* Tilt tables, stand and prone
Pain
* Almost all of these patients have pain- so pain clinic but danger of opiod dependency * Dysesthetic pain- distal to injury
* Like phantom pain- disabling * NSAIDs, elavil, neurontin, lyrica, tegretol,Tens * Follows the dermatome * Goal is to verbalize pain relief
Spasticity
* As recovery progresses- get stronger flexors begin to contract and extensor muscle spasms * Spasticity is increased muscle tone wh results in stiffness * Can initiate spastic behaviors even with emotion, touch, temp * Can optimize and recruit spasticity for trunk support, to hold position and to help urinate
Spasticity
with forced flexion or adduction of lower limbs can interfere with sitting or ambulating
* Nurses job is to decrease
noxious stimulation
* So need ROM- ongoing PT * Meds> Baclofen, Dantrium,
Klonopin ( danger)
Neurogenic Bladder
* In early phase were atonic- and cathed for months with danger or stone, UTI
* Cath was to prevent overdistention
* Now u still check for distention, I&O, asepsis * Keep urine acidic * Give enough fluids * Then now move into 2 types of bladder
* UMN * LMN
Heterotopic Ossification
* Form bone in abnormal loci
resorpt bone
syndromes
* Paralysis, immobilization,
spasticity
* Worry decubiti * Worry UTI * Prevent spasms-cold, anx,
vibration, massage,
SEX
* All think about it but may
are there
* Goal is a personally
satisfying relationship
* So need to verbalize needs * If they PICK YOU_ YOU
TALK
* And then get some help with
Sex
* Will need to examine own
Sex
* Psychogenic erection- from sexual thoughts- this is lesion above T11-L2- above this will not get idea thru damage * Reflexogenic erection- this is from penile stimulation - may get with a cath change or bath
* Length will vary as will presentation r/t level of injury * Cervical and thoracics get better erections * LS damage may destroy the reflex arc
* Spontaneous erection- oft happens when bladder is full and causes internal stimulationthis is a S2-4 level
lubrication, orgasm but generally will ovulate- can become pregnant, deliver vaginally- uterine contractions can cause AD
* Will need to think birth
control,
* Worry UTI, pressure sores,
anemia
terrible
Goals then
* Maintain optimal function
ADLs
* Work, computer * Normal psych and coping
* Prognosis depends on site and type * If get spinal cord compression will need immediate relief
* Steroids will remove swelling and then get to surgery to decompress
* Get edema, inflammation , nerve entrapment * Presents as back pain, motor weakness or decreased sensation * Can take months to develop
* Also burning, shooting * Motor weakness is heavy, stiff, paralysis, once motor have 75% blockage of cord * Sensory with paresthesia, decreased temp * So will need X-Ray, MRI, find those at risk
reduce edema
* Radiation therapy to
management
* Tricyclics, Dilantin,
neurontin, tegretol
* Prevent neuron firing,
potentiate analgesia
* Will also elevate mood
So think rehab
* And Health South