Assessment (PAROS) / Diagnostic Test

System Physical Assessment Diagnostic Test Results

nspection Auscultation Percussion Palpation
Head bigger than
normal
_ _ _ CT scan, MR,
Ultrasonography
Genitourinary _ dribbling of
urine
_ _
Musculoskeletal scoliosis,
hip
dislocation,
foot deformity,
kyphosis,
weakness in
leg,
flaccid
paralysis in
lower limbs
_

_
_
_
_


_







decreased
in sensation

no response
_

_
_
_
_


_


X-Ray, MR
Neurological hydrocephalus _ _ _ CT scan, MR,
Ultrasonography
ntegumentary tuft hair over
the spine,
lemon sign or
banana sign
_

_
_

_
_

_


Ultrasonogram


Anatomy and PhysioIogy

Anatomical Considerations:

There are 30 segments in the spinal cord:
O 8 cervical
O 12 thoracic
O 5 lumbar
O 5 sacral
n the early stage of development the spinal cord is approximately the same length as the vertebral
canal and the spinal nerves pass out horizontally through the intervertebral foramina.
During development in utero the vertebral column and the spinal cord grow at different rates and
eventually the cord finishes at the lower border of the L1 or the upper border of L2 vertebra.
As the spinal cord terminates opposite the first lumbar vertebra, there is a progressive discrepancy
between spinal cord segments and vertebral body levels.
All cervical nerve roots pass through the intervertebral foramen adjacent to the vertebra of
equivalent number.
Roots C1 to C7 inclusive leave above the appropriate vertebral body, whereas root C8 and the
remainder exit below the appropriate vertebral body.
The higher the root, more laterally it is situated within the spinal cord.
Although there is little difference between spinal cord segments and vertebral body levels in the
cervical area, the nerve roots below C8 travel increasing distance in the canal before exiting.
The 12 thoracic segments lie within the area covered by the upper 9 thoracic vertebrae; the lumbar
segments lie within that covered by vertebrae T10 and T11; and the 5 sacral segments lie within
T12 and L1 vertebrae.
Blood Supply of Spinal Cord:
O Anterior spinal artery supplies anterior two-thirds of spinal cord.
O Paired posterior spinal arteries supply posterior third of spinal cord.
Both are supplied via radicular arteries, the largest of which is the artery of Adamkiewicz, which
enters the spinal canal in the lower thoracic segments but sends branches as high as the T4 level.

Functions:
Receptors detect a change (the stimulus) and generate impulses.
Sensory neurons transmit impulses from receptors to the CNS.
Central Nervous System contains one or more synapses.
Motor neurons transmit impulses from the CNS to the effector.
Effector performs its characteristic action.

Ascending & Descending Tracts of Spinal Cord:




Spinal Reflexes:







O C5 Biceps reflex
O C6 Brachioradialis reflex
O C7 Triceps reflex
O T6 to T12 (abdominal) Superficial abdominal reflex
O L1 & L2 Cremasteric reflex
O L4 Patella reflex
O S1 Achilles reflex
O S3 & S4 Bulbocavernosus reflex
O S3 to S5 Anal wink

PathophysioIogy
Spina Bifida










Alteration of the fetal development / organogenesis
Failure of development of neural tube
Failure of the spinous process on the vertebrae to fuse
Leaving an opening in the neural tube
Spina Bifida Occulta Permits to herniated
Meningocele Myelomeningocele

Signs and Symptoms

Precipitating Factors
environment such as exposure to radiation
folic acid deficiency
teratogens (drugs especially carbamezapine and
valproic acid (anticonvulsants))
anti-epilectic medication during early intrauterine
life
poor nutrition
socio-economic status
alcohol and drug abuse
viral infection


Predisposing Factors
genetics/hereditary
has a previous sibling that has a neural tube
defect
family history
history of miscarriage

Musculoskeletal
Scoliosis
Foot deformity (foot
clubbing)
Hip dislocation
Difficulty in walking
Weakness in leg
(muscle weakness)
Flaccid paralysis of
the lower limbs
Kyphosis
Lumbosacral
scoliosis
Talipes or varus
(foot) contractures
ntegumentary
Protruding fluid
filled sac over
the spine
Abnormal tuft or
clump of hair or
a simple dimple
or birthmark at
the site
port wine
angiomatous
soft,
subcutaneous
lipomas

Neurological
Hydrocephalus
Absence of
sensation
Sensory
disturbance usually
parallel to motor
dysfunction
varying degrees of
sensory deficit

GU
Urinary
incontinence
Overflow
incontinence with
constant dribbling
of urine

G
Fecal
incontinence
Lack of bowel
control
Rectal
prolapsed
Bladder and
anal sphincter
paralysis

Prioritized NCP's

1. Risk for infection related to rupture or bacterial invasion of the neural tube sac
2. Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure
3. mpaired elimination related to neural tube disorder
4. mbalanced nutrition, less than body requirements, related to difficulty assuming normal feeding
position
5. neffective breathing pattern related to required prone position



Nursing Managements

Prevent drying and putting pressure on the exposed membrane.
Measure head circumference once daily or more frequently to detect increase in head size.
nstruct the parents about urinary catheterization technique (inserting a clean catheter through the
urethra into the bladder every 4 hours to drain urine from the bladder).
Help the parents to hold the infant in as normal a feeding position as possible. Make certain that a
supporting arm does not press against the lesion.
Children should be watched for signs of hydrocephalus, tethered spinal cord, seizure activity,
obesity, bowel and/or bladder control problems, frequent urinary tract infections, learning
disorders, emotional and psychosocial problems, and other complications of spina bifida.


SurgicaI Managements

Perform intracranial surgery.
Perform ureterosigmoidostomy or continent urinary reservoir is constructed to bypass the non-
functioning bladder.
Perform osteotomy or tendon transplant to prevent contractures and poor bone alignment.
mplanting a shunt for hydrocephalus patient. A shunt is a special tube surgically placed in the
head and under the skin down into the chest or abdomen. The shunt drains excess fluid from the
brain into the abdomen, where it can be eliminated without harm.
The first, which usually is done in the first 48 hours of the child's life, involves tucking the exposed
spinal cord and nerve roots back into the surrounding membrane, closing the defects in cord and
membrane, and covering the wound with muscle and skin flaps taken from either side of the back.
Subsequent surgeries involve correction of deformities. This might include cutting tendons or
ligaments to release contractures and/or rebalancing muscles around the involved joint. When
regular examinations indicate that the individual's functioning is declining while a physical
deformity gets worse, surgery should be considered.
Perform urologic surgery.



PharmacoIogicaI Management

Administer osmotic diuretics (mannitol, glycerol) to dehydrate the brain and reduce cerebral
edema.
Administer drugs such as oxybutynin chloride(Ditropan) may improve bladder capacity and allow
a child to need less frequent catheterization.

oxybutynin chloride (Ditropan) direct antispasmodic effect on smooth muscle and
inhibits the muscarinic action of acetylcholine on smooth
muscle. No blocking effect occur at skeletal
neuromuscular junctions or autonomic ganglia
(antinicotinic effect).
mannitol is an osmotic diuretic that is metabolically inert in humans and occurs
naturally, as a sugar or sugar alcohol, in fruits and vegetables. t also elevates
blood plasma osmolality, resulting in enhanced flow of water from tissues,
including brain and cerebrospinal fluid into interstitial fluid and plasma.
glycerol is an osmotic dehydrating agent that possesses hygroscopic and lubricating
properties. t causes plasma osmolality leading to the movement of water into
the plasma from extravascular spaces via osmosis.