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Spinal Cord Injury

Mohd Nidzammuddin Mohd Azhar


Bachelor of Nursing (Hons) Kulliyyah of Nursing, IIUM, Kuantan Campus

Objective
By the end of this lecture, students will be able to
Describe what is spinal cord and function of spinal cord Understand the definition, course, symptom, Dx test, Treatment, prognosis, expectation & complication of Spinal Cord Injury Nursing Care for patient will spinal injury

What is Spinal Cord


long, thin, tubular bundle of nervous tissue and support cells that extends from the brain (the medulla oblongata specifically). The brain and spinal cord together make up the central nervous system. The spinal cord begins at the Occipital bone and extends down to the space between the first and second lumbar vertebrae; it does not extend the entire length of the vertebral column.

Function of Spinal Cord


The spinal cord functions primarily in the transmission of neural signals between the brain and the rest of the body but also contains neural circuits that can independently control numerous reflexes and central pattern generators. The spinal cord has three major functions:
A. Serve as a conduit for motor information, which travels down the spinal cord. B. Serve as a conduit for sensory information, which travels up the spinal cord. C. Serve as a center for coordinating certain reflexes.

The spinal cord extends from the skull to the first lumbar vetebral It consist of gray matter located centrally and white matter- surrounding the grey matter The white matter of the spinal cord consist of ascending and descending fiber tract
Ascending tract transmitting sensory information (from receptors in the skin, skeletal muscle, tendon, joint & various visceral receptors) Descending tract transmitting motor information (to skeletal muscle. Smooth muscle, cardiac muscle & gland)

The spinal cord also responsible for spinal reflexes

Definition
Damage to the spinal cord that results in a loss of function such as mobility or feeling. Begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae. The damage begins at the moment of injury when displaced bone fragments, disc material, or ligaments bruise or tear into spinal cord tissue. Spinal cord trauma is damage to the spinal cord. It may result from direct injury to the cord itself or indirectly from damage to surrounding bones, tissues, or blood vessels.

Any number of injuries to the spine. They can result from motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial accidents, gunshot wounds, assault, and other causes. A minor injury can cause spinal cord trauma if the spine is weakened (such as from rheumatoid arthritis or osteoporosis) or if the spinal canal protecting the spinal cord has become too narrow (spinal stenosis) due to the normal aging process.

Causes

Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or the disks have been damaged. Fragments of bone (for example, from broken vertebrae, which are the spine bones) or fragments of metal (such as from a traffic accident) can cut or damage the spinal cord. Direct damage can also occur if the spinal cord is pulled, pressed sideways, or compressed. This may occur if the head, neck, or back are twisted abnormally during an accident or injury.

Bleeding, fluid accumulation, and swelling can occur inside the spinal cord or outside the spinal cord (but within the spinal canal). The accumulation of blood or fluid can compress the spinal cord and damage it. Most spinal cord trauma happens to young, healthy individuals. Men ages 15 - 35 are most commonly affected. The death rate tends to be higher in young children with spinal injuries.

Older people with weakened spines (from osteoporosis) may be more likely to have a spinal cord injury. Patients who have other medical problems that make them prone to falling from weakness or clumsiness (from stroke, for example) may also be more susceptible.

Symptom
Symptoms vary somewhat depending on the location of the injury. Spinal cord injury causes weakness and sensory loss at and below the point of the injury. The severity of symptoms depends on whether the entire cord is severely injured (complete) or only partially injured (incomplete).

CERVICAL (NEAR THE NECK) INJURIES


When spinal cord injuries occur near the neck, symptoms can affect both the arms and the legs:
Breathing difficulties (from paralysis of the breathing muscles) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness Paralysis

THORACIC (CHEST LEVEL) INJURIES


When spinal injuries occur at chest level, symptoms can affect the legs:
Breathing difficulties (from paralysis of the breathing muscles) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis Injuries to the cervical or high thoracic spinal cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining normal body temperature.

LUMBAR SACRAL (LOWER BACK) INJURIES


When spinal injuries occur at the lower back level, varying degrees of symptoms can affect the legs:
Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Pain Sensory changes Spasticity (increased muscle tone) Weakness and paralysis

Dx Test
Spinal cord injury is a medical emergency requiring immediate attention. The health care provider will perform a physical exam, including a neurological exam. This will help identify the exact location of the injury, if it is not already known. Some of the person's reflexes may be abnormal or absent. Once swelling goes down, some reflexes may slowly recover. The following tests may be ordered:
A CT scan or MRI of the spine may show the location and extent of the damage and reveal problems such as blood clots (hematomas). Myelogram (an x-ray of the spine after injection of dye) may be necessary in rare cases. Somatosensory evoked potential (SSEP) testing or magnetic stimulation may show if nerve signals can pass through the spinal cord. Spine x-rays may show fracture or damage to the bones of the spine.

A spinal cord trauma is a medical emergency requiring immediate treatment to reduce the long-term effects. The time between the injury and treatment is a critical factor affecting the eventual outcome. Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord compression is caused by a mass (such as a hematoma or bony fragment) that can be removed or reduced your spinal nerves are completely destroyed, paralysis may improve. Ideally, corticosteroids should begin as soon as possible after the injury.

Treatment

Surgery may be needed to:


Remove fluid or tissue that presses on the spinal cord (decompression laminectomy) Remove bone fragments, disk fragments, or foreign objects Fuse broken spinal bones or place spinal braces Bed rest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal. remove bone fragments, disk fragments, or foreign objects or to stabilize fractured vertebrae (by fusion of the bones or insertion of hardware).

Spinal traction may be recommended. This can help keep the spine from moving. The skull may be held in place with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body). The spine braces may need to be worn for a long time. The health care team will also provide information on muscle spasms, care of the skin, and bowel and bladder dysfunction. Extensive physical therapy, occupational therapy, and other rehabilitation therapies are often required after the acute injury has healed. Rehabilitation helps the person cope with disability that results from spinal cord injury. Muscle spasticity can be relieved with medications taken by mouth or injected into the spinal canal. Pain killers (analgesics), muscle relaxers, and physical therapy are used to help control pain.

Bed rest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal. Anatomic realignment is important.
Spinal traction may reduce dislocation and/or may be used to immobilize the spine. The skull may be immobilized with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body).

Treatment will address muscle spasms, care of the skin, and bowel and bladder dysfunction.

Improved emergency care for people with spinal cord injuries and aggressive treatment and rehabilitation can minimize damage to the nervous system and even restore limited abilities. Respiratory complications are often an indication of the severity of spinal cord injury About one-third of those with injury to the neck area will need help with breathing and require respiratory support. The steroid drug methylprednisolone appears to reduce the damage to nerve cells if it is given within the first 8 hours after injury. Rehabilitation programs combine physical therapies with skill-building activities and counseling to provide social and emotional support.

Extra Important

Prognosis
Spinal cord injuries are classified as either complete or incomplete. An incomplete injury = the ability of the spinal cord to convey messages to or from the brain is not completely lost. People with incomplete injuries retain some motor or sensory function below the injury. A complete injury = total lack of sensory and motor function below the level of injury. People who survive a spinal cord injury will most likely have medical complications such as chronic pain and bladder and bowel dysfunction, along with an increased susceptibility to respiratory and heart problems. Successful recovery depends upon how well these chronic conditions are handled day to day

Expectation
Paralysis and loss of sensation of part of the body are common. This includes total paralysis or numbness and varying degrees of movement or sensation loss. Death is possible, particularly if there is paralysis of the breathing muscles. How well a person does depends on the level of injury. Injuries near the top of the spine result in more extensive disability than do injuries low in the spine. Recovery of some movement or sensation within 1 week usually means the person has a good chance of recovering more function, although this may take 6 months or more. Losses that remain after 6 months are more likely to be permanent.

Routine bowel care frequently takes one hour or more on a daily basis. A majority of people with spinal cord injury must perform bladder catheterization from time to time. Modifications of the person's living environment are usually required. Most people with spinal cord injury are wheelchair- or bed-bound, or have impaired mobility requiring a variety of assistive devices.

Complications
The following are possible complications of a spinal cord injury: Blood pressure changes - can be extreme (autonomic hyperreflexia) Complications of immobility:
Deep vein thrombosis Pulmonary infections Skin breakdown Contractures

Increased risk of injury to numb areas of the body Increased risk of kidney damage Increased risk of urinary tract infections

Loss of bladder control Loss of bowel control Loss of sensation Loss of sexual functioning (male impotence) Muscle spasticity Pain Paralysis of breathing muscles Paralysis (paraplegia, quadriplegia) Shock

Trauma Care

1.Assess with care 2.Handling with care 3.Plan with care 4.Implement with care

Spinal shock
Loss of continuous tonic impulses from the brain
Transient suppression of reflex below the Spinal Cord Injury Flaccid(minor) paralysis Abscess of cutaneous sensation loss of autonomic function Cessation of all reflex activities below the site of injury

24 48 hr period paralysis, hypotonia(abnormally low muscle tone) & areflexia Return of reflex activities and development of spasticity below level of injury indicates end of spinal shock

Nursing Care

Assessment
Clinical manifestations depend on type and level of injury - Below level of injury there is total loss of sensory and motor paralysis, loss of bladder and bowel control, loss of sweating and vasomotor tone. - Complains of acute pain in back or neck which may radiate along involved nerve. - Respiratory problems (T1-T11 and diaphragm are used in breathing) intercostal muscles. - above C4 phrenic nerve paralysis of diaphragm. Respiratory status - observe respiratory pattern, - strength of cough - auscultate lungs.

Changes in motor or sensory function - Squeeze hand, spread fingers, move toes. - Pricking skin with dull item, start at shoulders. Signs of spinal shock - Complete loss of all reflexes, motor, sensory and autonomic below level of injury

Management of Spinal Cord Injuries High dose corticosteroids within 8 hrs of injury - Methylprednisolone, loading dose followed by infusion for 23 hrs. Oxygen, intubation if necessary Skeletal reduction and traction - Immediate immobilization - Reduction of dislocations (restore to normal position) - Stabilization of vertebral column. - Traction used in cervical fractures. Surgery.

Nursing Interventions Promote adequate breathing and airway clearance. - Monitor pulse oximetry, ABGs. - Clear bronchial and pharyngeal secretions - Use suctioning cautiously can stimulate vagus nerve causing bradycardia. - Chest Physiotherapy, breathing exercises. - Humidification. - Adequate hydration. - Assess for signs of respiratory infection. - Intubate and ventilate

Improve Mobility Maintain proper alignment at all times. Reposition frequently. Prevent foot drop wear shoes. Prevent external rotation of hip joints trochanter rolls. Prevent contractures range of motion exercises 4 times daily. If injury above midthoracic level, monitor BP when turning (loss of sympathetic control of peripheral vasoconstriction)

Maintain Urinary and Bowel Function Intermittent or indwelling catheter to avoid overdistention of bladder. - Urinary retention results from bladder becoming atonic. Intake and output. Insert NG tube to relieve distention and prevent aspiration. - Paralytic ileus(painful obstruction of the ileum or other part of the intestine) usually develops. - Bowel activity usually returns within 1 week. High fiber, high protein diet. Stool softener.

Managing Potential Complications Thrombophlebitis and pulmonary embolism - Assess for symptoms (chest pain, dyspnea, ABGs) - Measure circumference of thighs and calves daily - Anticoagulation low dose heparin - Pressure stockings. - Adequate hydration Orthostatic Hypotension - BP unstable and low for first 2 weeks. - Monitor closely when repositioning patient. - Reposition slowly, wear pressure stockings.

Reference
http://www.spinalinjury.net/html/_spinal_cord_1 01.html http://www.ninds.nih.gov/disorders/sci/sci.htm http://www.umm.edu/ency/article/001066.htm http://pennstatehershey.adam.com/content.aspx ?productId=117&pid=1&gid=001066 http://www.nursinglectures.com/2011/02/spinal-cord-injury-andnursing.html http://www.scribd.com/doc/14009149/Nursingcr ibcom-Nursing-Care-Plan-Spinal-Cord-Injury

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