spinal cord injury

function of the spine

• Structural support

  • The spine provides the body with structure and support. The spine supports about half of the body's weight.

• Protection

  • The spine protects the spinal cord, the column of nerves that connects the brain to the rest of the body. The spine also protects nerve roots and some internal organs. For example, the thoracic spine and rib cage work together to protect the heart and lungs.

• Spinal cord:

  • Sending and receiving information. The spinal cord sends motor commands from the brain to the body, and sensory information from the body to the brain.

  • Coordinating reflexes

  • Controlling voluntary muscle movements

  • Regulating autonomic functions. The spinal cord regulates digestion, urination, body temperature, heart rate, and blood pressure.

  • Monitoring sensation of touch, pressure, temperature, and pain.

what is a spinal cord injury

• Trauma or damage to spinal cord causing temporary or permanent dysfunction

• Spinal cord compression by

  • Bone displacement

  • Interruption of blood supply

  • Traction from pulling on cord

  • Penetrating trauma, causing tearing and transection

long term issues that occur due to a spinal cord injury

• Disruption in growth and development

• Altered family dynamics

• Economic loss

• High cost of rehabilitation and long-term care

primary and secondary injury

• Initial Injury/Primary injury results from direct physical trauma to the spinal cord due to blunt or penetrating trauma. Ie causing an immediate and direct loss or movement and sensation below the neck.

• Secondary Injury: next minutes to months following the initial injury

  • Ischemia, Hypoxia, Micro-hemorrhage

  • These causes cell death, disruption of the blood-brain barrier, and demyelination.

  • This can extend the level of deficit and worsen long-term outcomes. Incomplete damage can become complete cord damage from the infarction and necrosis

the progression of an injury weeks after

• The edema can cause compression of the spinal cord. Edema extends above and below the injury, increasing ischemic damage. Within 24 hours, permanent damage may occur from edema.

• Apoptosis (cell death)

• Glial scarring restricts cells in spinal cord from migration and regeneration causing irreversible nerve damage and permanent neurologic deficit

• The extent of the injury cannot be determined until the secondary cord injury is resolved

• spinal or neurogenic shock

spinal shock

• Occurs shortly after injury and lasts days to weeks

• Characterized by

  • Loss of deep tendon reflexes and sphincter reflexes

  • Loss of sensation

  • Flaccid paralysis below level of injury

• Resolution of spinal shock is manifested by spasticity, reflex return, and neurogenic bladder (Frequent urination, Urgency, Incontinence, Difficulty starting or stopping urination, and Incomplete bladder emptying)

neurogenic shock

• Occurs in cervical or high thoracic (at or above T6) injury; can last as long as 5 weeks after injury

• Loss of sympathetic vasoconstrictor tone resulting in massive vasodilation leading to pooling of blood in vessels, tissue hypoperfusion

• Characterized by

  • Hypotension (less than 90 mmHg)

  • Bradycardia

  • Temperature dysregulation

classifications of SCI

• Mechanism of injury

• Level of injury

level of injury

• Cervical (C1-C4):

  • Severely impact breathing, neck movement, and arm function, potentially requiring a ventilator. Tetraplegia. Incontinence BB

• C4: May be able to shrug shoulders and have some sensation in the upper chest.

• Thoracic (T1-T12):

  • Impacts trunk muscles and abdominal function, with potential for loss of sensation and movement in the lower body. Below T-2, paraplegia. Below T-12 Flaccid bladder, may have intact abdominal muscles

• Lumbar (L1-L5): Primarily affects leg movement and sensation, Paraplegia.

• Sacral (S1-S5):

  • Flaccid bowel and bladder function, as well as decreased sensation in the buttocks and genital area. Difficulty bending knees

Scales/measurements

• american spinal injury association impairment score

• dermatome: sensory and know where to test

spinal cord injury respiratory clinical manifestations

• Above C3

  • Total loss of respiratory muscle function; will arrest within minutes if not intubated

• C3 to C5

  • Respiratory insufficiency; loss of phrenic nerve innervation to diaphragm

  • Decreased strength in chest and abdominal wall

  • Complete SCI requires intubation

• Cervical & thoracic injuries can cause paralysis of abdominal & intercostal muscles produces ineffective cough which can lead to aspiration, atelectasis, and pneumonia 

  • Artificial airway provides direct access for pathogens

• Traumatic injury (e.g., lung contusion) causing compromised function like fluid overload causing pulmonary edema

  • Hypoxemia, Dyspnea, inability to manage secretion. TX: O2 at least 92%, possibly mech vent

spinal cord injury cardiovascular clinical manifestations

• Injury above T6 leads to dysfunction of sympathetic nervous system (SNS) which leads to neurogenic shock

• Bradycardia, Hypotension, Hypovolemia because of increased capacity of dilated veins = decreased CO

• Hemorrhagic shock may occur from other injuries which will further reduce BP

spinal cord injury urinary clinical manifestations

• Neurogenic bladder:

• Higher than T-12, Hyperactive contractions (spastic): feel the need to urinate frequently and urgently, incontinence

• Lower than T-12, Bladder flaccid (atonic-unable to contract), hypotonic (low muscle tone), difficulty emptying.

• Dyssynergia: pelvic floor muscles are unable to contract and relax properly in coordination with the abdominal muscles. Symptoms include abdominal pain, bloating, and a feeling of incomplete evacuation

• High risk for UTIs

spinal cord injury GI clinical manifestations

• Decreased GI motor activity leading to gastric distention and development of paralytic ileus…NPO, NGT suction

• Excessive release of HCl causing stress ulcers

• Dysphagia may be present

• Stool retention and constipation, impaction, possible megacolon

• Above the T12 level (Upper Motor Neuron/Reflexic/Spastic Bowel) Sacral nerves are intact, sphincter tight

• Lower than T-12 is considered a lower motor neuron injury, which results in a "flaccid bowel" with no reflex activity to stimulate bowel movements

• Intraabdominal bleeding Monitor BP, Hgb, and Hct, and abdominal girth

  • Bleeding = Rapidly decreasing BP and increasing pulse

spinal cord injury skin and thermoregulation clinical manifestations

• Potential for Skin Breakdown

  • Decreased or absent sensation, leading to pressure injuries over bony prominences

  • Risk of infection and sepsis

• Poikilothermia: inability to maintain a constant core temperature

  • Interruption of SNS prevents peripheral temperature sensations from reaching hypothalamus

  • Decreased ability to sweat or shiver below the level of injury

  • More common with high cervical injury

common complications of a spinal cord injury

• Venous thromboembolism (VTE)…due to hypercoagulability, venous stasis, and venous endothelial injury

• Pain…Located at or below level of injury. Hot, burning, tingling, pins and needles, cold and/or shooting. May be extremely sensitive to stimuli

• Increased metabolism and increased protein breakdown…leads to decreased lean body mass, muscle atrophy, and weight loss

diagnostic studies

• CT scan

• Cervical x-rays…Hard to see C7 and T1

• MRI…Soft tissue injury and neurologic conditions

collaborative care

• Immobilize and stabilize cervical spine first for possible spinal cord injury…cervical collar, back board, log roll only

• ABC--Patent airway and adequate respirations

• Administer O2; keep SaO2 higher than 90%

• Intubation to secure airway if in respiratory distress: Monitor ETCO2

• Cardiac monitor

• Vitals

• IV access; infuse NSS or LR

• Neurologic

  • ASIA tool

  • Test muscle groups bilaterally. Record strength, symmetry and spontaneous movement

  • Sensory assessment

  • Frequent Neuro checks, every 1-2 hrs

• Control bleeding: Guaiac stools, check for bruising or distention

• Determine degree of deficit/injury

• Assess for other injuries

• Obtain appropriate imaging

• Paralytic Ileus: NPO, NGT to suction, Parenteral Nutrition

• Pressure Injury prevention/Skin care

• Spine immobilization: Skeletal traction

• Sensory Stimulation

  • Conversation with patient

  • Music Therapy

  • Aroma Therapy

  • Reading/Television

  • Open visitation

• Psychological counseling…pt and family

  • Grieving and depression

  • Support group

what is a bladder program

• For an upper motor neuron bladder, above T-12, the bladder is spastic. Incontinence.

• With a lower motor neuron injury, below T12, the patient won't feel the urge to urinate. Bladder fills without emptying but can overflow. Abdomen may be distended.

• In hospital, use urinary (Purewick) or condom catheter. Then timed straight/intermittent catheterizations every 4 hrs at home/rehab.

• Crede maneuver (pressure to lower abdomen)

• Teach/prevent UTI symptoms

• Bladder scan, if needed

• Encourage 2 liters of fluid per day

what is a bowel program

• Suppositories/enemas with manual evacuation for SCI above the T12 level (Upper Motor Neuron/Reflexic Bowel) to trigger the reflex. Sacral nerves are intact, sphincter tight.

• Injuries below T12 (Lower Motor Neuron/Flaccid Bowel) often needs daily manual removal because the sphincter is loose. Suppositories/enemas are less effective.

• Regular schedule for bowel elimination. A good time is 30 min after the first meal of the day

• Measures to reduce constipation include adequate fluid intake (2 to 3 liters), a diet high in fiber and vegetables, moderate, not high intake of calcium, and increased activity and exercise as able

• Stool softener

medications for a spinal cord injury

• IV fluids and vasopressors (phenylephrine, norepinephrine) for BP

  • Treat systemic and neurogenic shock

  • Keep SBP above 90 mmHg

  • mean arterial pressure above 85 mmHg

• VTE prophylaxis

  • Low-molecular-weight heparin or low-dose heparin (unless contraindicated)

  • Compression boots, Ted stockings, ROM

• Stress ulcer prophylaxis

  • H2-receptor blockers

  • Proton pump inhibitors

• Pain management: Anti-inflammatory drugs, Opioids

• Spasms: Anti-spasmodics

• Constipation

  • Stool softener, suppositories

  • Minimize calcium intake

skeletal traction collaborative care

• Crutchfield or Gardner-Wells Tongs for cervical injury (short term)

• Pin Care: Cleanse with chlorhexidine twice a day

• Apply antibiotic ointment

• Halo Vest for spinal cord injury (long term)

• Sternal-occipital-mandibular immobilizer brace

autonomic dysreflexia

• Occurs in patients with injuries above T-6

• Massive uncompensated CV reaction caused by sympathetic nervous system and return of reflexes related to a trigger

• Can lead to stoke, MI, status epilepticus

• Visceral stimulation below level of the lesion causes vasoconstriction, HTN, and bradycardia.

• Triggers:

  • Bladder distention (check obstruction in foley catheter) or Bowel Impaction

  • Labor

  • Temperature change

  • Ingrown toenail

  • Pressure

autonomic dysreflexia clinical manifestations

• HTN

• Bradycardia  30-40 bpm

• Throbbing headache

• Flushing

• Sweating above level of lesion

• Blurred vision

• Anxiety

• Nausea

autonomic dysreflexia treatment

• Elevate HOB at least 45 degrees to decrease BP right away

• Quick search to reduce noxious stimuli: fecal impaction, urinary retention/catheter obstruction, pressure injury

• Anti-hypertensives after stimulus relieved

• Always check BP if SCI patient C/O H/A

• Maintain regular bowel & bladder function with B/B retraining

• Notify provider

• Teach pt & family S & S recognition

• Wear Medic Alert bracelet