PathophysiologyNormal Spinal Cord

Spinal cord begins at the foramen magnum in the cranium

Cord ends at the L1-L2 vertebra level

Spinal nerves continue to the last sacral vertebra

The Human Spine

Spinal CordGray matter-

cell bodies of voluntary and autonomic motor neurons

White matter axons of ascending and descending motor fibers

Upper Motor NeuronsUMN Originate in cerebral cortexProject downwardResult in skeletal muscle movementInjury = SPASTIC paralysis

Lower Motor NeuronsLMNOriginate at each vertebral levelProject to specific parts of the bodyResult in movement /sensationInjury = FLACCID paralysis

Normal Spinal Cord

DermatonesSkin innervated by

sensory spinal nervesMyotome- muscle group

innervated by motor neurons

Nervous System and the Spinal CordANS can be

affected by SCISympathetic

chains on both sides of the spinal column (T1-L2)

Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)

Spinal Cord ProtectionBones- vertebral column7 Cervical12 Thoracic5- Lumbar5- Sacral

Discs- between vertebra

Spinal Cord Protection

Internal and external ligaments

DuraMeningesCSF in

subarachnoid space allow for movement within spinal canal

Etiology of Traumatic SCIMVA- most common causeOther: falls, violence, sport injuriesSCI typically occurs from indirect injury from

vertebral bones compressing cord SCI frequently occur with head injuriesCord injury may be caused by direct trauma

from knives, bullets, etc

Etiology of Traumatic SCI78% people with SCI are maleTypically young men – 16-30Number of older adults rising (>61 yr)Greater complications

Spinal Cord Injury- SCICompressionInterruption of blood supplyTractionPenetrating Trauma

Spinal Cord InjuryPrimary

Initial mechanism of injurySecondary

Ongoing progressive damageIschemiaHypoxiaMicrohemorrhageEdema

Spinal and Neurogenic ShockSpinal Shock

Decreased reflexes and loss of sensation below the level of injury

Motor loss- flaccid paralysis below level injury

Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury

Lasts days to months

Spinal and Neurogenic ShockNeurogenic shockDue to loss of vasomotor tone

peripheral pooling and decreased cardiac output

Hypotension and Bradycardia Orthostatic hypotension and poor

temperature control (poikilothermic)

How do you know spinal shock is over?

Clonus is one of the first signs

Hyperreflexia of footTest by flexing leg at

knee & quickly dorsiflex the foot

Rhythmic oscillations of foot against hand

clonus

Classifications of SCIMechanism of InjurySkeletal and Neurologic LevelCompleteness (degree) of Injury

Mechanism of InjuryFlexionHyperextension CompressionFlexion /Rotation

Classifications of SCIMechanism of Injury

Flexion (hyperflexion)Most common because

of natural protection position.

Generally cause neck to be unstable because stretching of ligaments

Classifications of SCIMechanism of Injury

HyperextentionCaused by chin hitting a

surface area, such as dashboard or bathtub

Usually causes central cord syndrome symptoms

Classifications of SCIMechanism of Injury

CompressionCaused by force from

above, as hit on headOr from below as

landing on buttUsually affects the

lumbar region

Classifications of SCIMechanism of Injury

Flexion/RoatationMost unstableResults in tearing of

ligamentous structures that normally stabilize the spine

Usually results in serious neurologic deficits

Skeletal levelVertebral level

where the most damage to the bones

Neurologic levelThe lowest segment

of the spinal cord with normal sensory and motor function on both sides of the body

Levels of Function in Spinal Cord Injury

Classification of SCI- Level of InjurySpinal cord level

When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level.

the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone

Classifications of SCICompleteness (Degree) of Injury

CompleteIncomplete

Central cord syndromeAnterior Cord syndromeBrown-Sequard SyndromePosterior Cord SyndromeCauda Equina and Conus Medullaris

Classification of SCI Completeness (degree) of InjuryComplete (transection)After spinal shock: Motor deficits-

spastic paralysis below level of injury

Sensory- loss of all sensation

perceptionAutonomic deficits-

vasomotor failure and spastic bladder

Classification of SCI Completeness (degree) of InjuryIncomplete

Central Cord Syndrome

Injury to the center of the cord by edema and hemorrhage

Motor weakness and sensory loss in all extremities

Upper extremities affected more

Classification of SCI Completeness (degree) of InjuryIncomplete

Brown-Séquard Syndrome

Hemisection of cordIpsilateral paralysisIpsilateral superficial

sensation, vibration and proprioception loss

Contralateral loss of pain and temperature perception

Classification of SCI Completeness (degree) of InjuryincompleteAnterior Cord Syndrome

Injury to anterior cord Loss of voluntary motor,

pain and temperature perception below injury

Retains posterior column function (sensations of touch, position, vibration, motion)

Classification of SCI Completeness (degree) of InjuryincompletePosterior Cord Syndrome

Least frequent syndromeInjury to the posterior

(dorsal) columns Loss of proprioceptionPain, temperature,

sensation and motor function below the level of the lesion remain intact

Classification of SCI Completeness (degree) of Injuryincomplete

Conus MedullarisInjury to the sacral

cord (conus) and lumbar nerve roots

Cauda EquinaInjury to the

lumbosacral nerve roots

Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs

Clinical Manifestations of SCISkin:

pressure ulcers

Neuro: pain sensory lossupper/lower motor

deficitsautonomic

dysreflexia

Cardio: dysrhythmiasspinal shockorthostatic

hypotension,

Respiratory-decrease chest

expansion, cough reflex & vital capacity

diaphragm function-phrenic nerve

GIstress ulcersparalytic ileusbowel- impaction &

incontinence

GUupper/lower motor

bladdersexual dysfunction

Musculoskeletaljoint contracturesbone

demineralizationosteoporosismuscle spasmsmuscle atrophypathologic fracturespara/tetraplegia

Common Manifestation/ComplicationsUpper and Lower Motor Deficits

Upper motor deficits result in spastic paralysis

Lower motor deficits result in flaccid paralysis and muscle atrophy

Common Manifestations/ComplicationsSpinal cord injuries are described by the level of the injury–

the cord segment or dermatome levelSuch as C6; L4 spinal cord injury

Terms used to describe motor deficitsPrefix:

para- meaning two extremities tetra- or quadra- all four extremities

Suffix : -paresis meaning weakness

-plegia meaning paralysis

Quadraparesis means what?

Immediate CareEmergency Care at Scene, ER & ICU

Transport with cervical collar

Assess ABC’s; O2; tracheotomy/vent

IV for life lineNG to suction

Diagnostic Studies for SCI

X-ray of spinal columnCT/MRIBlood gases

Therapeutic Interventions MedicationsIV methylprednisolone (Solu-Medrol)

within 8 hrs to decrease cord edema

Therapeutic InterventionsStabilization/Immobilization

Traction-Gardner-wells tongsHalo

CastsSplintsCollarsBraces

Therapeutic InterventionsSurgery for SCI

Manipulation to correct dislocation or to unlock vertebrae

Decompression laminectomy

Spinal fusionWiring or rods to

hold vertebrae together

Nursing Management AssessmentHEALTH HISTOYDescription of how and when injury

occurredOther illnesses or disease processesAbility to move, breathe, and associated

injury such as a head injury, fractures

Nursing Management AssessmentPHYSICAL EXAM

LOC and pupils- may have indirect SCI from head injury

Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds

Vital signsMotorSensoryBowel and bladder function

Nursing ManagementAssessmentMotor Assessment Upper Extremity

Movement, strength and symmetry

Hand grips

Flex and extend arm at elbow- with and without resistance

Nursing Management Assessment Motor Assessment Lower Extremity

Flex and extend leg at knee with and without resistance

Planter and dorsi flexion of foot

Assess for Clonus

Nursing Management AssessmentSensory assessment

With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify

Use the dermatome as reference to identify level

C6 thumb; T4 nipple; T10 naval

Nursing Problems/Interventions

1.Impaired mobility2.Impaired gas exchange3. Impaired skin integrity4. Constipation5. Impaired urinary elimination6. Risk for autonomic dysreflexia7. Ineffective coping

1. Impaired Physical Mobilityprovide assistance as needed to keep

alignment; teach patient Care traction, collars, splints, braces,

assistive devices for ADL’sFlaccid paralysis- use high top tennis shoes

or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)

1. Impaired Physical MobilitySpastic Paralysis

Prevent spasms by avoiding; sudden movements or jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue

Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications

Assess skin break down thrombophlebitis; remove TED hose(compression stockings) at least every shift

1. Impaired Physical MobilityPrevent/treat orthostatic hypotension

Abdominal binder, calf compressors, TED hose when individual gets up

Assess BP, especially when rising

Teach use of transfer boardAssist Physical Therapy with tilt table as

individual gradually gets use to being in an upright position

2. Impaired Gas ExchangePhrenic nerve (C3-5) controls the diaphragm

bilaterally. If nerve is nonfunctioning then individual is ventilator dependent.

Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing

2. Impaired Gas ExchangeRespiratory rate, rhythm,

depth, breath sounds, respiratory effort, ABG’s, O2 saturation

Need for ventilatory assistance tracheotomy, ventilator

Quad cough (assistive cough) as needed

3. Impaired Skin IntegrityChange position frequentlyProtection from extremes in temperatureInspect skin at least 2x/day especially over boney

prominences Avoid shearing and friction to soft tissue with

transfersRemoval of TED hose every 8 hoursNutritional status

4. Constipation

Bowels rely more on bulk than on nervesStimulate bowels at the same time each day.

Best after a meal when normal peristalsis occurs

Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation

Assess bowel sounds prior to giving food for the first time– paralytic ileus!

5. Impaired Urinary EliminationFlaccid bladder (lower motor neuron lesion)

No reflex from S2,3,4Automatic empting of bladder Urine fills the bladder and dribbles outNeed Foley or freq intermittent self catheterization

Spastic bladder (upper motor neuron lesion) Reflex arc but no connection to or from brain Bladder training- trigger points to stimulate empting;

self catheterization

5. Impaired Urinary EliminationUse bladder scan to see amount of urine

in bladder Goal- residual <100ml/20% bladder

capacitySome individuals may need suprapubic

catheterAssess effectiveness of medication

Urecholine to stimulate bladder contractionUrinary antiseptic

6. Risk for Autonomic Dysreflexia

Elevate head of bed- causes orthostatic hypotension

Identify cause/alleviate- if full bladder- cath; if skin- remove pressure, if full bowel- empty, etc

Remove support hose/abdominal binderMonitor blood pressure- can get > 300 SGive PRN medication to lower BPIf above not effective– call physician

7. Ineffective Coping/Grief and Depression

Assess thoughts on ‘quality of life’; body image; role changes

Physical and psychological supportMost common SCI is 15-30 yeas old and

generally a risk taker– this greatly affects their perception of life and rehabilitation

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