Spinal Cord Injury

SCI

• occurs when the axons of the spinal cord are damaged

  • tetraplegia: impairment or loss of motor and/or sensory fxn in trunk, legs, pelvic organs, and arm (at or above T-1)

  • paraplegia: impairment or loss of motor and/or sensory function in the trunk, legs, and pelvic organs (at or below T-2)

• most common: MVA (cars) → falls → violence → sports

complete vs. incomplete SCI

• most common is incomplete tetraplegia

• most common tetraplegic injury level → C5

• most common paraplegic levels → T12 and L1

leading cause of death in SCI patients

• complete SCI

  • originally thought to be renal failure

  • now known to be pneumonia, PE, septicemia

  • other related factors: heart dz, subsequent trauma, suicide (<25), alcohol-related

• incomplete paraplegia

  • related to cancer, suicide, then heart disease

nontraumatic causes of SCI

• tumor

• degenerative disease

• infection

• embolic event

• congenital abnormality

primary vs. secondary SCI

• primary: initial physical/mechanical disruption of axons from stretching, laceration, compression

• secondary: progressive injury occurring afterward d/t ischemia, hypoxia, micro-hemorrhage, edema

  • ↓ spinal cord blood flow → tissue hypoxia → more spinal cord damage

how common is complete neurologic recovery before hospital discharge?

less than 1%

complete SCI recovery emphasized in the slides?

• <5% chance of recovery with complete SCI

• persistent paralysis after 72 hours is associated with very poor recovery

factors affecting functional recovery

• Injury severity

• Injury level

• Complete vs incomplete

• Amount of direct/secondary damage

• Age

• Preexisting health

• Fitness

• Motivation

• Care setting/resources

• spasticity does NOT indicate return of function

major causes of death after SCI

• pneumonia

• pulmonary embolism

• septicemia/sepsis

• premature death in tetraplegia → d/t compromised respiratory function

spinal shock

• temporary loss of neurologic/reflex activity BELOW the level of injury

  • ↓/absent reflexes

  • flaccid paralysis

  • loss of sensation below injury

• spinal shock resolving → return of reflexes below the injury

• may last 8-12 weeks (days to months)

neurogenic shock

• loss of sympathetic/vasomotor tone following HIGH SCI

  • hypotension

  • vasodilation

  • bradycardia

  • impaired temp regulation/poikilothermia

• may last up to 6 weeks

• medications:

  • atropine → bradycardia

  • vasopressor → hypotension (Neo-Synephrine/phenylephrine)

SCI classification

1. mechanism

2. level

3. degree/completeness

SCI mechanisms of injury

• flexion (WORST): cervical spine bends forward → may rupture posterior ligaments

• hyperextension (most common): neck bends backward → may rupture anterior ligaments

• flexion-rotation: tearing of stabilizing ligament structures

• compression/axial loading: vertebrae are crushed → bone fragments can enter spinal canal

• penetration

complete vs incomplete SCI

• complete: total loss of spinal cord nerve pathway function below injury

• incomplete: some degree of motor, sensory, and/or autonomic function remains below the injury (recovery more variable)

ASIA impairment scale

• ASIA A: complete; no motor or sensory function preserved in S4-S5

• ASIA B: incomplete sensory; sensory but not motor fxn preserved below level, including S4-S5

• ASIA C: motor incomplete; motor preserved below level, but more than half key muscles < grade 3

• ASIA D: motor incomplete; at least half key muscles >= grade 3

• ASIA E: normal motor and sensory function

  • A = Absent

  • B = sensation Below

  • C = weak motor

  • D = stronger motor

  • E = Everything normal

upper motor neuron SCI

• higher cord injury → loss of cerebral control below injury

  • spastic paralysis

  • reflex/spastic bladder

  • reflex bowel program/digital stimulation

lower motor neuron SCI

• damage to reflex arc

  • flaccid paralysis

  • areflexic/flaccid bladder

  • manual bowel evacuation

levels of injury (KEY)

C1-C3 fxn

• No movement/sensation below neck

• Often ventilator-dependent

• Dependent ADLs

• Power chair may use sip-and-puff/voice control

C4 fxn

• Head/neck movement

• Some diaphragm function

• Dependent care

• Power wheelchair

• May breathe without ventilator but cough/respiratory reserve impaired

C5 fxn

• Shoulder movement

• Elbow flexion

• May self-feed/groom with adaptive equipment

• Usually dependent for many other ADLs

• Respiratory endurance decreased

C6 fxn

• C5 abilities +

• Wrist extension

• Can often assist with transfers

• Feed self with minimal help

• Upper-body dressing/bathing

• Manual wheelchair indoors

• May drive adapted vehicle

C7-C8 fxn

• Triceps/elbow extension

• Wrist/finger function improves

• Most self-care increasingly independent

• Transfers

• Manual wheelchair

• May drive with hand controls

T1-T5 fxn

• Full hand/finger control

• Upper extremities intact

• Lower-body paralysis

• Manual wheelchair

• Usually independent in many ADLs

T6-T10 fxn

• Improved abdominal/trunk control

• Better balance

• Independent wheelchair function

T11-L5 fxn

• Increasing hip/knee function

• May ambulate with braces/canes depending on injury

S1-S5 fxn

• Greater leg function

• Progressive bowel/bladder/sexual function

incomplete SCI syndromes

• central cord syndrome

• brown-sequard syndrome

• anterior cord syndrome

• conus medullaris

• cauda equina

central cord syndrome

• occurs d/t hyperextension cervical injury (older adults)

• deficit pattern: upper extremities affected MORE than lower extremities

  • Arms/hands worse

  • Legs relatively better

  • Walking may recover

  • Feeding, dressing, hygiene can be difficult

brown-sequard syndrome

• Damage to one side of spinal cord, often from penetrating injury or tumor.

  Same side as injury:

  • ↓ motor

  • ↓ proprioception

  • ↓ vibration

  Opposite side:

  • ↓ pain

  • ↓ temperature

anterior cord syndrome

• Injury to anterior cord/anterior spinal artery.

  Results in:

  • Paralysis

  • Loss of pain

  • Loss of temperature

  • Loss of touch listed in speaker notes

  • Position sense preserved

conus medullaris syndrome

• Injury around distal spinal cord, usually near L1.

  May cause:

  • Sudden bilateral symptoms

  • Distal leg weakness

  • Saddle anesthesia

  • Erectile dysfunction

  • Urinary retention

  • Fecal incontinence

  • Mixed UMN/LMN findings

cauda equina syndrome

• Injury/compression of nerve roots below the conus.

  Can cause:

  • Severe radicular pain

  • Asymmetric weakness

  • Areflexic paraplegia

  • Asymmetric paresthesia

  • Bowel/bladder dysfunction

  • Sexual dysfunction

  Often described as gradual and asymmetric

respiratory problems after SCI

• Apnea in very high cervical injury

• Respiratory insufficiency

• Weak cough

• Ineffective airway clearance

cardiovascular problems after SCI

• Hypotension

• Bradycardia

• Orthostatic hypotension: interruption of descending autonomic nervous system control

urinary complications after SCI

• Areflexic bladder

• Spastic/reflex bladder

• Urinary retention

• Reflex incontinence

• UTI risk

GI complications after SCI

• Neurogenic bowel

• Constipation

• Fecal impaction

• Stress ulcer risk

integumentary complications after SCI

• Pressure injuries
  → immobility + loss of sensation + impaired circulation.

Exam guide says:

• Assess skin

• Reposition q2h

thermoregulation problem after SCI

• Poikilothermia — impaired ability to regulate body temperature.

  May have:

  • ↓ sweating

  • ↓ shivering

types of SCI pain

• Musculoskeletal

• Neuropathic

Neuropathic examples:

• Allodynia

• Hyperalgesia

psychosocial problems after SCI

• Grief

• Depression

• Powerlessness

• Anxiety

• Altered body image

• Coping difficulties

• Caregiver strain

• Spiritual distress

autonomic dysreflexia (AD)

• Massive, uncontrolled sympathetic cardiovascular response to stimulation below the injury (T6 or higher) MEDICAL EMERGENCY

• SBP >20 mmHg above patient's normal baseline

  • SCI patients may normally have lower BPs, so compare to their baseline

signs ABOVE injury during AD

• Flushing

• Profuse sweating/diaphoresis

• Piloerection

• Headache

• Blurred vision

• vasodilation above the lesion

signs BELOW injury during AD

• Pale

• Cool

• Vasoconstricted

• Little/no sweating

classic AD sxs

• Severe hypertension

• Throbbing headache

• Flushing

• Sweating

• Blurred vision

• Piloerection

• Possible bradycardia

• Anxiety/nausea/nasal congestion

autonomic dysreflexia triggers

• Full bladder / UTI

• Fecal impaction

• Pressure areas

• Tight/restrictive clothing

first actions for AD

• Elevate HOB / sit patient upright

• Search for and remove trigger

• Check bladder/catheter

• Empty bladder if needed

• Loosen restrictive clothing

• Assess bowel/skin if bladder isn't cause

• Give prescribed antihypertensive if necessary

  • alpha blockers

  • nitroglycerin as ordered

prevention for AD & dangers of AD

prevention:

• Bladder care

• Bowel care

• Skin care

AD dangerous if untreated leads to:

• Stroke

• MI

• Seizures/status epilepticus

• Death

autonomic dysreflexia vs. neurogenic shock

	Neurogenic Shock	Autonomic Dysreflexia
BP	LOW	VERY HIGH
HR	Bradycardia	Often bradycardia
When	Acute SCI	Usually later, after spinal shock resolves
Cause	Loss sympathetic tone	Noxious stimulus below lesion
Skin	Warm/vasodilated can occur	Flushed/sweaty above; pale/cool below
Priority	Support perfusion	Sit up + remove trigger
Memory	Nothing squeezes vessels	Sympathetic system overreacts

acute SCI priorities

• Stabilize spine

• Maintain patent airway

• Monitor AD/neurogenic shock/bleeding

• Maintain skin integrity

• Mobility/rehab/PROM

• Manage constipation/fecal impaction

• Address sensory deficits

• log-roll SCI patient → maintain spinal alignment/prevent further cord damage during turning

devices used to stabilize SCI

• Hard cervical collar

• Halo brace: cervical (pin care)

• TLSO brace: thoracic-Lumbar-Sacral Orthosis, used to stabilize the thoracic/lumbar spine

• Skeletal traction

• Surgical fixation

main goals of acute tx

Stabilize:

• Respiratory system

• Cardiac system

• Musculoskeletal/spine

Then:

• Decompress spinal cord (laminectomy with fusion)

• Realign vertebrae (rods/pins/screws)

• Prevent additional injury

steroids & SCI

• high-dose methylprednisolone within 8hrs of injury (4-8 hrs)

• spinal shock → steroids for inflammation

• do not use long term

main nursing assessment areas

• Perfusion

• Homeostasis

• Tissue integrity

• Coping

• Patient education

• Mobility

• Pain

• predict → prevent → manage → promote

top 10 memorization

• SCI priority = spinal stabilization + airway

• C4 and above → respiratory failure risk

• Spinal shock = flaccid + absent reflexes

• Neurogenic shock = hypotension + bradycardia + vasodilation

• Autonomic dysreflexia = hypertension + headache + diaphoresis

• AD → sit upright → check bladder first

• UMN = spastic; LMN = flaccid

• Central cord = arms worse than legs

• Brown-Séquard = same-side motor, opposite pain/temp

• C5 elbow, C6 wrist, C7 triceps, C8 fingers