Spinal Cord

common causes of spinal cord injury

motor vehicle accidents, falls, sporting, and industrial accidents, gunshor or stab wounds

spinal cord edema

compromises capillary circulation and venous return, which could lead to necrosis of the spinal cord

complications of spinal cord injuries

respiratory failure, autonomic dysreflexia, spinal shock, neurogenic shock, further cord damage, and death

mechanisms of spinal cord injuries

hyperflexion, hyperextension, compression, rotating, penetrating

C4 injury

results in complete paralysis below the neck 

C6 injury

results in partial paralysis of hands and arms as well as lower body

T6 injury

paraplegia, results in paralysis below the chest

L1 injury

results in paralysis below the waist

complete transection of the cord

spinal cord is completely severed with total loss of sensation and movement below the injury. However, reflexes remain intact

partial transection of the cord

spinal cord is partially damaged or severed. some function and sensation below the level of the injury is preserved

anterior cord syndrome

damage to the anterior portion of the gray and white matter of the spinal cord

anterior cord syndrome s.s

motor function, pain, temperature sensation are lost below the level of injury; however, the sensations of touch, position and vibration remain intact

posterior cord injury

damage to the posterior portion of the gray and white matter of the spinal cord

posterior cord injury s.s

motor function remains intact but the client experiences a loss of vibratory sense, crude touch, and position sensation

central cord syndrome

occurs from a lesion the central portion of the spinal cord, most commonly found in cervical cord injuries

central cord syndrome s.s

loss of motor function is more pronounced in the upper extremities than the lower extremities, and varying degrees and patterns of sensation remain intact

brown sequard syndrome

results from penetrating injuries that cause hemisection of the spinal cord or injuries that affect half of the cord

brown sequard syndrome s/s

motor function, proprioception, vibration, and deep touch sensations are lost on the same side of the body as the lesion

s.s of brown sequard syndrome on the opposite of the body

the sensations of pain, temperature, and light are affected

secondary complications

hypoxia, lactate metabolites, vasoactive substances, vasospasm, hypoxia, necrosis

neurogenic shock

temporary loss of autonomic function below the level of injury

neurogenic shock causes

vasodilation

vasodilation causes

hypotension, bradycardia, hypothermia

neurogenic shock resolution

return of sympathetic tone (no more vasodilation

spinal shock

a sudden depression of reflex activity in the spinal cord below the level of injury

onset of spinal shock

can occur within minutes of the injury and can last days to months

what happens to the body during spinal shock

muscles become completely paralyzed and flaccid and reflexes are absent

when do you know when spinal shock is healed

when reflexes are regained

autonomic dysreflexia (hyperreflexia)

a neurological emergency and must be treated immediately to prevent a htn stroke

what causes autonomic dysreflexia

commonly caused by visceral distension from a distended bladder or impacted rectum

autonomic dysreflexia s.s

HTN, BRADYCARDIA, flushing of face and neck, severe throbbing headache, nasal stuffiness, piloerection (gooseflesh), sweating, nausea, restlessness, dilated pupils and blurred vision

interventions of autonomic dysreflexia

assess for potential cause and remove, monitor vs q15 min, raise the hob to high fowlers, administer vasodilators 

spinal cord injuries assessment considerations

total sensory loss and motor paralysis, loss of reflexes below level of injury, loss of bladder and bowel control, presence of sweat which does not occur on paralyzed areas

C2 to C3 injuries

FATAL

C4 injury

the major innervation to the diaphragm by the phrenic nerve

involvement above C4 causes

respiratory difficulty and paralysis of all four extremities.

C5 or below

may have movement in the shoulder

thoracic vertebrae injury

loss of movement of the chest, trunk, bowel, bladder and legs depending on the level of injury (paraplegia)

visceral distention from a distended bladder or impacted rectum may cause

sweating, bradycardia, htn, nasal stuffiness, and goose bumps

thoracic injury complication

autonomic dysreflexia with lesions above T6 and in cervical lesions

Lumbar and sacral injury

loss of movement and/ or sensation of the lower extremities

S2- S3 center on urination

bladder will contract but not empty (neurogenic bladder)

S2- S4 control reflex erection

involuntary response and not a result from a sexual thought

priapism

respiratory interventions and assessments

assess respiratory status, monitor ABG, encourage deep breathing, monitor s.s of respiratory infection 

cardiovascular assessments and interventions

monitor for dysrhythmias, monitor for blood loss, assess for signs of neurogenic shock, assess for DV, monitor for orthostatic hypotension

assess motor ability

squeeze hands, spread fingers, wiggle toes, turn feet

assess sensation

pinch skin or prick with a pin starting at shoulders and working down the extremities

neuromuscular assessment and interventions

monitor for s.s of autonomic dysreflexia and spinal shock, immobilize the client to promote healing and prevent further spinal injury, assess pain, monitor for complications of immobility, prepare for surgical interventions, pt/ot conults

surgical interventions for neuromuscular

decompression laminectomy, spinal fusion, or steel rods

GI assessment and interventions

assess abd for distention, monitor bowel sounds and assess for paralytic ileus, prevent bowel retention, maintain adequate nutrition and a high fober diet

renal assessment and intervention

prevent bladder retention, FR of 2000ml/ day, monitor for UTI and calculi from stasis

integumentary system assessment and interventions

assess skin integrity, q2 turn, institute measures to prevent skin breakdown

general interventions for spinal cord injury

immobilize the client on a spinal backboard, maintain a patent airway, always suspect spinal cord injury until it is ruled out

positioning

head in neutral position, maintain an extended position, maintain traction and alignment, logroll the client, cervical traction

cervical tongs

weighted tongs that are inserted into the outer aspect of the client’s skill

skull tongs interventions and assessment

ensure wgts are hanging freely, monitor neurological status of the client, maintain body alignment, turning bed, assess insertion site, provide sterile pin site care, DO NOT remove traction

Halo traction

static traction device consisting of a head piece with four pins attached to a vest/ jacket to allow for increased mobility 

halo traction interventions

monitor neurological status for changes in movement or decreased strength, NEVER move or turn the client by holding or pulling on a halo device, assess skin integrity

nursing care of halo traction

pin site care, keep key close in case of cardiac arrest, notify dr if halo vest or ring bolts loosen, notify of s.s of infection, get up by rolling to side and push on mattress with arms, adaptive clothing

bathing with a halo traction

sponge bath only (no showers), cover vest when washing hair, no haircare products(shampoo only)

halo traction assessment

fleece or foam inserts to relive pressure points, keep the vest lining dry, 1 finger width under vest/ jacket

anticoagulants

helps DVT, start withing 72 hour od injury

muscle relaxers

used for clients with upper motor neuron injuries, controls muscle spasticity

vasoconstrictors

used to maintain perfusion to spinal cord, goal is MAP >85 for first week post SCI

thoracic, lumbar, sacral fractures intervention

bed rest, immobilization with body cast, use of a tlso brace when a client is out of bed

surgical interventions

decompressive laminectomy, spinal fusion rod insertion

decompressive laminectomy

removal of one or more laminae, allows for cord expansion from edema, performed if conventional methods fail to prevent neurological deterioration

spinal fusion and rod insertion

used for thoracic spinal injuries, insertion of rods, plates, and/or screws to stabilize the thoracic spine

post op care

monitor motor function and sensation immediately postop, keep client flat while in bed and brace is off, log roll, rehab

mechanical ventilation for injury above C4

round the clock caregiver, respiratory hygiene, tracheostomy care

respiratory rehab

phrenic nerve stimulator, diaphragmatic pacemaker, mobile ventilators, pt teaching

neurogenic bladder

areflexic (flaccid), hyperreflexia (spastic), dyssynergia (dysfunctional)

neurogenic bladder common problems

urgency, frequency, incontinence, inability to void, high bladder pressure

what happens with a high bladder pressure

resulting in reflux of urine into kidneys

drug therapy for spasticity

anticholinergic drugs, alpha adrenergic blockers, antispasmodic drugs

drainage methods for neurogenic bladder

bladder reflex training, indwelling, intermittent, external catheterization, urinary diversion surgery

neurogenic bowel

voluntary control is lost of bowels

neurogenic bowel interventions

high fiber diet, adequate fluid intake, suppositories, small volume enemas, digital stimulation, stool softener, oral stimulant laxatives, valsalva maneuver with manual stimulation, use of gastrocolic reflex, timing to not interrupt therapy

spasticity treatment

rom exercises, antispasmodic drugs (baclofen)

neurogenic skin interventions

prevention essential, pt teaching, comprehensive daily exam, q2 turn or q15 minute if in chair, pressure relieving cushion, adequate nutrition, protect from thermal injury

acute pain

assess, evaluate, and treat routinely, analgesics, massage and repositioning

chronic pain

may be result of overuse of muscles, sleep may be disrupted, may refer to pain management specialist

neuropathic pain

pregabalin, gabapentin