Spinal Cord Injury

The Peripheral Nervous System

Composed of the spinal nerves, the cranial nerves, and the autonomic nervous system (SNS and PSNS).

The spinal cord is about 18 inches long. Nerves within the cord carry

messages from the brain to the spinal nerves (upper motor neurons) and back.

Spinal nerves called lower motor neurons

branch out from the spinal cord to specific areas of the body. Sensory/ascending tracts and Motor/descending tracts

Sensory/ascending tracts

messages from the body to the brain

Motor/descending tracts

messages from the cord to target muscles

Some pathways, during ascent or descent, decussate

(crossover) in the spinal column which results in the right side of the brain controlling the left side of the body< and vice versa.

The vertebral column is the skeletal structure that covers and protects the spinal cord. With spinal cord injury, the level of injury refers to

the vertebra closest to the site of cord injury.

SCI is

damage to the cord with resulting functional loss of mobility and/or sensation. The cord does NOT have to be severed for loss of function to occur.

Extent of injury associated with clinical presentation

complete vs incomplete

Complete SCI

loss of function permanent below the level of injury.

Incomplete SCI

Some function below the level of injury.

Etiologies for SCI

Most common is Motor vehicle accidents! Also, falls, violent acts (gunshot wounds, for example), sports accidents, other things like tumors, osteoporosis, reduced blood flow to the spinal cord . . .

Regardless of the etiology, Respiratory complications and cardiac events are

the most frequent cause of death with SCI!

SCI Initial Clinical Presentation

Pain at the fracture site, Brain and systemic injuries may limit pain reporting ability, About ½ involve the cervical cord, Quadriplegia , Quadriparesis

Quadriplegia

paralysis

Quadriparesis

weakness

On-site Care SCI Priorities

Airway and breathing support, Immobilization with C collar and backboard, Patient confused or obtunded—assume SCI

Level of injury associated with

clinical presentation. The higher the injury, the greater the degree of disability! (Table and Figure)

C1-C2

Most severe SCI, Brainstem impact, Full paralysis likely, Often fatal

“C 3-4-5

Keeps the Diaphragm Alive!”, phrenic never, breathing compromise, often requires ventilation (maybe for life)

T2-T8

intercostal muscle innervation!

SCI Initial Patient Care Measures

Ventilation support, Cardiac monitoring and vital signs, Fluid and electrolyte replacement, (Solumedrol) (not routine) Indwelling catheter, DVT prevention and Stress ulcer prophylaxis, Imaging (CT, MRI). HCP examination-level of injury.

SCI Initial Patient Care Measures Possible Methylprednisolone (Solumedrol)

Within 8 hrs. of injury, Bolus then IV infusion over 23 hrs.

SCI Spinal precautions Log roll.

Someone to hold c-spine. Others to roll patient.

SCI Spinal precautions

Cervical collar (C-collar). Caution with repositioning, No egg crate or other mattress topper, Reverse Trendelenburg to elevate HOB

C spine clearance?

on imaging, HCP assessment, patient saying what there feeling

Spinal Shock

Immediate response to injury. Complete, but TEMPORARY, loss of all functions (motor, sensory, reflex, autonomic). Lasts less than 48 hrs up to several weeks.

Spinal Shock Manifestations

Flaccid paralysis, Decreased sensation, Absence of DTRs, Impaired proprioception. Bulbocavernosus (Penile) reflex absent—”anal wink”, Urinary/fecal retention, ileus, Anhidrosis (no sweat!)

Neurogenic Shock

Distributive shock. Temporary loss of SNS signals to the blood vessels—loss of tone (vasodilation!). And, loss of SNS signals to the heart—decreased cardiac output and bradycardia! Body temperature instability. PSNS influence is unopposed/dominant.

Neurogenic Shock With injury at

T6 and above.

Neurogenic Shock SNS

T1-T12

Gut

About T6 and below

Neurogenic Shock Polytrauma

may be involved. hemorrhagic shock possibility.

Neurogenic Shock Manifestations

Hypotension. Bradycardia. Body temp instability, Signs of poor perfusion

Neurogenic Shock Hemodynamic alterations

Low SVR , Low CO, Low CVP, low PA diastolic/PCWP

Neurogenic Shock Possible lab alterations

Metabolic acidosis, Elevated serum lactate, Hyperkalemia, Increased BUN/Creatinine

Neurogenic Shock Management

Assessment, vital signs, cardiac monitoring, Fluids, Vasopressors, Atropine, pacing, epi or dopamine drips, Ace wraps/compression boots, Temp regulation

Non-surgical Spine Stabilization

Lumbar (brace or corset), Thoracic (bed rest, body cast)

Spine Stabilization Cervical

Halo Traction, Gardner Wells Tongs Maintain alignment, Neuro assessment. Infection risk, pin site care

Spine Stabilization Halo Traction

Monitor neuro status, Never move patient using the device, Monitor for pin-site loosening (pt will say it feels different C collar and call HCP) Pin-site care per protocol, monitor for infection, Swallowing difficulty (let technician know)

CPR with Halo Traction

Allens wrench, take off front plate

Surgical stabilization of the spine

(fixation, fusion, early decompression!)

Autonomic Dysreflexia (AD)

Syndrome of massive imbalanced reflex sympathetic discharge occurring in 80% of patients with SCI above the T5-T6 level. Most often occurs after the first year of injury but can occur at any time after spinal shock resolves.

Autonomic Dysreflexia Triggered by a strong sensory input. Possible Stimuli

Bladder distension, Bowel impaction, Pressure sores, Other noxious stimuli, Sexual activity, Complication of medical procedures (L & D e.g.)

Autonomic Dysreflexia patho

Sympathetic surge from intact thoracolumbar sympathetic nerves, Vasoconstriction leads to high BP, Baroreceptors detect high pressure and send a message to the brain, , Inhibitory impulses sent out—BLOCKED in the injured cord!, Parasympathetic response (vagus nerve) leads to low heart rate

Autonomic Dysreflexia Manifestations

Headache, face flushing and warmth, nasal congestion, Hypertension (possible hypertensive crisis!), Bradycardia, Anxiety/impending doom, Skin below the spinal cord lesion—cold with piloerection (goose bumps)

Autonomic Dysreflexia Hypertension

Baseline tends to be low, watch trends, Hypertensive crisis potential

Autonomic Dysreflexia Management (Table) FRIST

Sit the patient up, elevate the HOB*, Identify and remove the stimulus if possible! *, Monitor VS Q 2-5 minutes until resolution.,

Autonomic Dysreflexia If BP remains high,

drug therapy per protocol (Nitro, hydralazine IV)

Autonomic Dysreflexia Educate to prevent recurrence

Recognize/avoid triggers., Recognize S & S, Remove stimulus properly., Bowel and bladder regimen!

SCI Respiratory Issues

Diaphragm and respiratory muscle function compromise., Weak cough and reduced clearing of secretions., Speech abnormalities., Sleep apnea potential.

• SCI Respiratory Care

Ventilator support possibly. (long term vent with trach possible) Chest physiotherapy (CPT). CDB and position change, Respiratory muscle training, Diaphragm and /or phrenic nerve pacing., Quad cough, Abdominal binder, Vaccination (Flu, Pneumococcus)

SCI Cardiovascular Issues and Care

Increased CAD risk (reduced muscle mass, increased fat, inactivity).. Elevated lipids and impaired glucose tolerance (IGT).

SCI Cardiovascular Issues Injury above T6

Baseline BP, HR decreased., Orthostasis possible. Raise HOB slowly before OOB. TED hose, Abdominal binder

SCI DVT risk. Assessment and prevention?

Heparin or LMWH 3 months (after that the body has adjusted

SCI GI tract function Ileus development

Prevention mobility, mesd like Metamucil, docalasce maybe reglen,, signs like decreased bowel sounds,

SCI GI tract function Ileus development Treatment

NPO, increase hydration, Reglan, may need NGT to decompress

SCI GI tract function

Total parenteral nutrition (TPN), Oral intake or tube feeding, stress ulcer prevention.

SCI GI tract function Bowel Regimen

Maintain routine. Fiber and fluids, Reduced dairy and fat., Rectal stimulation with/without suppository, Manual dis-impaction (flaccid bowel)—(Risk of AD) Abdominal massage, Valsalva, forward lean.

SCI GI tract function Bowel Regimen Medications

Metamucli, etc

SCI Urinary Issues

Neurogenic bladder, Incontinence potential, Stasis and infection risk. Reflux with possible kidney damage.

SCI Renal stone risk

May NOT cause pain, unrecognized can lead to AKI

SCI Urinary Care

Indwelling cath initially, permanent for some (may need permanently—change Q month Bladder scan and straight cath PRN . Clean technique intermittent catheterization (CIC), Fluid intake, teach infection prevention and recognition.

SCI Bladder regimen

(BR/bedpan/urinal Q 2 hrs and after meal)

SCI Osteoporosis risk

give Bisphosphonates - Alendronate (Fosamax), Ibandronate (Boniva)—esophageal irritation

SCI Heterotopic ossification

Inflammation around joints, decreased ROM and pain, give NSAIDs & ROM (watch kidneys)

SCI Contracture prevention and management

Frequent repositioning, ROM, Splinting, Some contractures facilitate function!

SCI Spasticity (UMN damage)

Pain, decreased mobility, contractures, muscle spasms, can facilitate some functional activities, PT, stretching, braces

SCI Spasticity Baclofen (GABA Agonist),

Drowsiness, dizziness, H/A, fatigue

SCI Pressure ulcer prevention

Assessment daily, Emollients to reduce friction., Avoid excessive moisture., Nutrition and hydration, “Pressure releases” for patients with upper body strength, Pressure relieving wheelchairs, cushions, mattresses. Physical therapy and Occupational therapy!

SCI Pain Syndromes

Anti-seizure meds, Antidepressants, Medical marijuana, Botulinum toxin type A injections, Opiates (GI effects, tolerance, dependence, overdose potential)

SCI Psychiatric Concerns

Depression, Drug addiction., Divorce, Suicide

Reproductive Concerns Male

Impotence 75%, Meds (Viagra, Cialis, Levitra). High risk for infertility

Reproductive Concerns Female

Ovulation and fertility intact, Personal choice, High risk pregnancy (infection and AD risk increased)

SCI Will the patient be able to walk? What will they be able to do?

The higher the injury, the less likely that they will be independent.

C4

No independent function likely, possible vent dependency

C5

May be able to feed/dress self with adaptive device, possible vent

C6-C7

Wheelchair with knobs, car with special adaptions, possible vent

T1-T10

Independent self-care, manual wheel chair

T11-L5

Can walk a short distance with braces

S1-S5

Free roaming, may use braces for support