Prepared by: Barrios, Kevin George B.

BSN 4-A

Introduction
The spinal cord contains the nerves that carry messages between your brain and your body. The cord passes through your neck and back. A spinal cord injury is very serious because it can cause paralysis below the site of the injury.

It can cause myelopathy or damage to white matter or myelinated fiber tracts that carry signals to and from the brain. It also damages gray matter in the central part of the brain, causing segmental losses of interneurons and motorneurons

 usually begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae.
damage begins at the moment of injury when displaced bone fragments, disc material, or ligaments bruise or tear into spinal cord tissue. Most injuries don't completely severe it, instead, an injury is more likely to cause fractures and compression of the vertebrae, which then crush and destroy the axon. An injury to the spinal cord can damage a few, many, or almost all of these axons. Some injuries will allow almost complete recovery. Others will result in complete paralysis.

Anatomy of the Spinal Cord

The SPINAL CORD is a thick length of nerve tissue that extends from the base of the brain, down the back, through the spinal column.

The SPINAL COLUMN is made up of bones called vertebrae that protect the spinal cord.

The spinal cord is made up of motor and sensory nerve cells called neurons.
The motor nerves are grouped together and transmit motor commands from the brain to the muscles and initiate movement. The sensory nerves are also grouped together. They carry information about sensations, such as pain and temperature, to the brain.

The spinal cord is divided into FOUR

AREAS:

cervical (neck), thoracic (chest), lumbar (lower back), and sacral (tailbone)
Each area is referred to by its first letter (C, T, L, or S) and the vertebrae within each area of the spine are numbered as follows: C1 to C8: Cervical vertebrae T1 to T12: Thoracic vertebrae L1 to L5: Lumbar vertebrae S1 to S5: Sacral vertebrae

* By adulthood, the 5 sacral vertebrae fuse to form one bone, and the 4 coccygeal vertebrae fuse to form one bone.)

Physiology of the Spinal Cord

Highways for nerve impulse propagation Receives and integrates incoming and outgoing information Maintainins gait and balance

Segmental Spinal Cord Level and Function Level Function C1-C6 Neck flexors Neck extensors

C1-T1

C3, C4, C5

Supply diaphragm (mostly C4)

C5, C6

Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates)

C6, C7 C7, T1 C7, T1

Extends elbow and wrist (triceps and wrist extensors); pronates wrist Flexes wrist Supply small muscles of the hand

T1 -T6

Intercostals and trunk above the waist

Abdominal muscles Thigh flexion Thigh adduction

T7-L1

L1, L2, L3, L4

L2, L3, L4

L4, L5, S1 L5, S1, S2

Thigh abduction Extension of leg at the hip (gluteus maximus) Extension of leg at the knee (quadriceps femoris) Flexion of leg at the knee (hamstrings) Dorsiflexion of foot (tibialis anterior) Extension of toes Plantar flexion of foot

L2, L3, L4

L4, L5, S1, S2

L4, L5, S1 L4, L5, S1 L5, S1, S2

L5, S1, S2

Flexion of toes

What is Spinal Cord Injury?

Spinal cord injury (SCI) is a traumatic injury to the spinal cord that may vary from a mild cord concussion with transient numbness to immediate and complete tetraplegia.
The most common sites are the cervical areas C5, C6, and C7, and the junction of the thoracic and lumbar vertebrae, T12 and L1.
Alternative Names Spinal cord injury; Compression of spinal cord; Spinal cord trauma

It is estimated that there are 40,000 people in the UK alone that are paralyzed through spinal cord injury.
The

life expectancy for an individual with SCI is lower (80% to 85%) than that of a person without SCI.

Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.

Tetraplegia or quadriplegia. This means your arms, trunk, legs and pelvic organs are all affected by your spinal cord injury.

Types of Spinal Cord Injury

Complete spinal cord injuries refer to the types of injuries that result in complete loss of function below the level of the injury which usually result in complete paraplegia or complete tetraplegia. Incomplete spinal cord injuries are those that result in some sensation and feeling below the point of injury.
The level and degree of function in incomplete injuries is highly individual, and is dependent upon the way in which the spinal cord has been damaged.

Risk Factors

Being a man. Spinal cord injuries affect

a disproportionate amount of men. In fact, women account for only about 20 percent of spinal cord injuries in the United States.

Being between the ages of 16 to 30. You're most

likely to suffer a spinal cord injury if you're between the ages 16 and 30. Motor vehicle crashes are the leading cause of spinal cord injuries for people under 65, while falls cause most injuries in older adults.

Being active in certain sports. While

being active is one of the best things you can do for your overall health, it may place you at greater risk of a spinal cord injury.

Having an underlying bone or joint disorder.

A relatively minor injury can cause a spinal cord injury if you have another disorder that affects your bones or joints, such as arthritis or scoliosis.

Common Causes of Spinal Cord Injury

Motor vehicle accidents- 38.5% Falls 21.8%

Diseases 4.0%

Sports and recreation injuries- 7.2%

Alcohol 4.0%

Acts of violence 24.5%

Clinical Manifestations
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.

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) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis

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

Note: The Clinical Manifestations depend on the following: The Location of the Injury The Severity of the Injury

Based on the Location of Injury

C3 vertebrae and above : Typically lose diaphragm function and require a ventilator to breathe.
C4 : May have some use of biceps and shoulders, but weaker C5 : May retain the use of shoulders and biceps, but not of the wrists or hands.

 C6 : Generally retain some wrist control, but no hand function.

C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the hand and fingers. C7 is generally the level for functional independence
T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury.

 T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good. Lumbar and Sacral injuries: The effect of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus. yield decreasing control of the hip flexors and legs.

PATHOPHYSIOLOGY OF THE SPINAL CORD INJURY

Predisposing Factors Age Gender Genetics Race Precipitating Factors oLifestyle oOccupational / environmental factors

Force or impact is applied to a certain body area

immediate mechanical damage to neural and other soft tissue, including endothelial cells of the vasculature

Microscopic bleeding occurs in the gray matter of the cord

Cell death or necrosis occurs (hemorrhage, edema)

Microcirculation of the cord is impaired

Vascular perfusion is reduced & ischemic areas develop

Oxygen tension in the tissues at the injury site is decreased

Cellular & subcellular alterations & tissue necrosis occurs

Chemical & metabolic changes in the spinal cord tissues include increase tissue lactate & increase norepinephrine concentration

Cord swelling

Infiltration of site by neutrophils & macrophages

Proliferation of microglia & changes in astrocytes

Red cells begin to disintegrate & resorption of hemorrhages begin

Degenerating axons are engulfed by the macrophages

American Spinal Injury Association (ASIA) Impairment Scale

ASIA A = Complete; absent sensory and motor function at S4-5.

ASIA B = Incomplete; intact sensory but absent motor function below the neurologic level of injury (LOI) and includes level S4-5.

 ASIA C = Incomplete; intact motor function distal to neurologic LOI, and more than half of key muscles distal to LOI have muscle grade less than 3.
ASIA D = Incomplete; intact motor function distal to neurologic LOI, and more than half of key muscles distal to LOI have muscle grade greater than or equal to 3. ASIA E = Normal; intact motor and sensory function.

POSSIBLE COMPLICATIONS
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

Diagnostic Evaluation
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.

Electrophysiologic monitoring - determine function of neural pathways.

 Urodynamic studies
- include urine flow to detect bladder outlet obstruction and/or impaired bladder contractility; cystometrogram to determine bladder sensation, compliance, and capacity; sphincter EMG and other studies. If DVT or pulmonary emboli are suspected, an ultrasound of the lower extremity or ventilation/perfusion scan is performed. Heterotopic ossification may be diagnosed in the inflammatory stages using ultrasound. Alkaline phosphatase and ESR are typically elevated.

 Nutritional status should be assessed using nutritional history, anthropometric measurements, prealbumin (half-life 12 to 36 hours) and transferrin (half-life 6 to 10 days). Total lymphocyte count and creatinine height index are also used to establish nutritional risk.

Spine Xrays may show fracture or damage to the bones of the spine.

Nursing Assessment
Assess cardiopulmonary status and vital signs to help determine degree of autonomic dysfunction, especially in patients with tetraplegia. Determine LOC and cognitive function indicating TBI or other pathology. Perform frequent motor and sensory assessment of trunk and extremities as the extent of deficits may increase due to edema and hemorrhage. Later, increasing neurologic deficits and pain may indicate development of syringomyelia.

 Note signs and symptoms of spinal shock, such as flaccid paralysis, urine retention, absent reflexes.
Assess bowel and bladder function. Assess quality, location, severity of pain. Perform psychosocial assessment to evaluate motivation, support network, financial or other problems. Assess for indicators of powerlessness, including verbal expression of no control over situation, depression, nonparticipation, dependence on others, passivity.

Nursing Diagnosis
Ineffective Breathing Pattern related to paralysis of respiratory muscles or diaphragm
Impaired Physical Mobility related to motor dysfunction Risk for Impaired Skin Integrity related to immobility and sensory deficit Urinary Retention related to neurogenic bladder

 Constipation or Bowel Incontinence related to neurogenic bowel

Risk for Injury: autonomic dysreflexia and orthostatic hypotension Powerlessness related to loss of function, long rehabilitation, depression Sexual Dysfunction related to erectile dysfunction and fertility changes Chronic Pain related to neurogenic changes

Nursing Interventions

Emergency Actions
1. Maintaining clients ability to breathe.
2. Keeping client from going into shock. 3. Immobilizing the neck to prevent further spinal cord damage.

Attaining an Adequate Breathing Pattern

1. For patients with high-level lesions, continuously monitor respirations and maintain a patent airway. Be prepared to intubate if respiratory fatigue or arrest occurs. 2. Frequently assess cough and vital capacity. Teach effective coughing, if patient is 3. Provide adequate fluids and humidification of inspired air to loosen secretions. 4. Suction as needed; observe vagal response (bradycardia should be temporary).

5. When appropriate, implement chest physiotherapy regimen to assist pulmonary drainage and prevent infection.
6. Monitor results of ABG values, chest X-ray, and sputum cultures. 7. Tape halo wrench to body jacket or halo traction in the event the jacket must be removed for basic or advanced life support or respiratory distress.

Promoting Mobility
1. Place patient on firm kinetic turning bed until spinal cord stabilization. After stabilization, turn every 2 hours on a pressure reduction surface, ensuring good alignment.

2. Logroll patient with unstable SCI.

3. Perform ROM exercises to prevent contractures and maintain rehabilitation potential.

4. Monitor BP with position change in the patient with lesions above midthoracic area to prevent orthostatic hypotension. 5. Encourage physical therapy and practicing of exercises as tolerated. Functional electrical stimulation may facilitate independent standing and ambulation. 6. Encourage weight-bearing activity to prevent osteoporosis and risk of kidney stones.

Protecting Skin Integrity

1. Pay special attention to pressure points when repositioning patient. Seating and mobility requirements must be determined.

2. Obtain pressure relief mattress and appropriate wheelchair and cushion. 3. Inspect for pressure ulcer development daily over bony prominences, including the back of head, ears, trunk, heels, and elbows. Observe under stabilization devices for pressure areas, particularly on the scapulae. Use a risk assessment tool to determine risk of developing pressure ulcer.

4. Keep skin clean, dry, and well-lubricated.

5. Turn a minimum of every 2 hours, and instruct patient to perform wheelchair weight shifts every 15 minutes. Place the patient in prone position at intervals, unless contraindicated.
6. Institute treatment for pressure ulcers immediately, and relieve pressure to promote healing.

Preventing Autonomic Dysfunction

1, Use tilt table as ordered to gradually increase the patient's ability to tolerate sitting after acute SCI. 2. Other conservative strategies consist of use of embolic hose, abdominal binder, and high-salt diet. 3. Administer a sympathomimetic, such as ephedrine or pseudoephedrine, as ordered, before patient is transferred to wheelchair.

REMINDERS:
Additional movement may cause further damage to the nerves in the cord and can sometimes mean the difference between life and death. DO NOT move the injured person even a little bit, unless it is absolutely necessary (like getting someone out of a burning car).

If in doubt about whether a person has a spinal injury, assume that he or she DOES have one.

Health Teachings
Teach patient and family about the physiology of nerve transmission and how the SCI has affected normal function, including mobility, sensation, bowel and bladder function.

Reinforce that rehabilitation is lengthy and involves compliance with therapy to increase function.
Explain that spasticity may develop 2 weeks to 3 months after injury and may interfere with routine care and ADLs.

 Teach patient to protect skin from pressure ulcer development by frequent repositioning while in bed, weight-shifting and liftoffs every 15 minutes while in a wheelchair, and avoiding shear forces and friction.
Teach inspection of skin daily for development of pressure ulcers, using a mirror if necessary. Teach importance of seat belts.

Medications.

Treatments and drugs

Methylprednisolone (Medrol) is a treatment option for an acute spinal cord injury. It appears to work by reducing damage to nerve cells and decreasing inflammation near the site of injury. However, this is not a cure for a spinal cord injury.

Surgery.
Often, surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity.

Immobilization.
You may need traction to stabilize your spine, to bring the spine into proper alignment or both.

New technologies:

Rehabilitation

Inventive medical devices can help people with a spinal cord injury become more independent and more mobile. Some devices may also restore function. These include:

Modern wheelchairs. Improved, lighter weight wheelchairs are

making people with a spinal cord injury more mobile and more comfortable. For some, an electric wheelchair may be needed

Computer adaptations. For someone that has limited hand

function, computers can be very powerful tools, but they're difficult to operate.

Electronic aids to daily living. Essentially any device that uses electricity can be controlled with an electronic aid to daily living (EADL Electrical stimulation devices. These sophisticated devices use
electrical stimulation to produce actions. They're often called functional electrical stimulation (FES) systems, and they use electrical stimulators to control arm and leg muscles to allow people with a spinal cord injury to stand, walk, reach and grip.

Prevention:
Maintain your gait and posture.

Drive safely.
Take precautions when playing sports.

Be safe with firearms.

Prevent falls
Have a healthy lifestyle.

say NO to alcohol.

Take Care.

Halong gd.

Ingatz!
-The end-