Alterations Spinal cord

anatomy

Gray matter comprises cell bodies of the sensory and motor neurons, interneurons, and neuropils.

White matter consists of myelinated sensory and motor axons

Central canal in middle of spinal cord and continues from ventricles + w/ CSF

pia mater

subarachnoid = CSF, major blood vessels, cisterns ( separation of arachnoid mater from pia mater)

the arachnoid mater

the dura mater

ascending deliver, descending receive

has reflex arc

31 pairs of spinal nerves = each pair has sensory/motor

sensory in posterior(dorsal) → pass through dorsal root ganglia

motor nerves → anterior (ventral)

plexus -= group of nerves that exit the spinal cord through the intervertebral foramina to innervate different motor and sensory structures throughout the body.

control diff parts of body = C1-8, T1-12, L1-5, S1-5, one coccygeal nerve

cauda equina = lower portion of the spinal cord that allows movement and the ability to feel sensations in the bladder and legs.

spinal injury

temporary or permanent change in body functioning, sensation, movement, and strength

level of injury is lowest point where there is absent motor and sensory

mechanism of injury =

• consistent compression of spinal cord by vertebral fractures, or dislocating injuries

• intermittent compression = hyperextension injuries

• 2 adjoining vertebrae pull apart causing spine to stretch and tear

• transection (complete severing) / laceration → projectile or bone fractures

classification =

level of injury = letter and number of vertebra

complete/ incomplete = severe loss of sensation/ partial

• A: no sensory/motor function

• B:incomplete sensory but no motor loss

• C: incomplete motor, but half of muscle groups lift against gravity w/ full ROM

• D: incomplete motor but more than half muscle groups lift against gravity w/ full ROM

• E: normal findings

secondary = impaired blood flow → inflammation, hematoma formation, blood loss, and hypovolemic shock = recovery 3-18 months

risk: trauma, over 65 = falls

comorbidities: sequelae = arise from previous injury, illness, or disease

HTN, arthritis, DM, HLD, obesity, depression, alcoholism

spasticity, UTI, chronic pain, SD, bowel/bladder dysfunction. sleep problems, contractures

prevention: seatbelt, airbags, proper seating for child, no influence when driving

Window latches and safety gate, Responsible gun ownership, Appropriate protective sports gear

Trampolines should be well-lit and at ground level to prevent falls.

C4 and above = loss of ROM in all extremities

C5: sip/puff

C6: wrist control

• C1 to C4: ventilator dependence

• C1 to C8: limited proprioception

• T1 to T8: affects trunk movement, lack of abdominal control

• T9 to T12: limited abdominal control

• L1 to S5: loss of bowel and bladder functioning, affects sexual function

C1-T1: tetraplegia

T2-S5= paraplegia

spinal shock = loss of muscle function below the injury, loss of anal sphincter tone, and the absence of bowel and bladder control. It is transient

lab: XR, CT, MRI,

plain radiographs = identify orthopedic injuries

CT angiogram = vascular injury suspected

GCS

complications

VTE: ~72hrs of injury → 8w

monitor for edema, pain, tender, red

avoid crossing arms/legs , wear SCD, LMWH

Atelectasis/ pneumonia → aspiration precautions

• Cough and deep breathe to keep respiratory passages clear. 

• Keep the mouth free of food particles after eating to avoid aspiration into the lungs. 

• Provide oral and trachael suction as needed.

• Administer antibiotics as prescribed.

• Breathe deeply, followed by complete exhalation multiple times throughout the day.

• Strengthen chest muscles with therapy exercises, such as shoulder rolls.

daily chest physiotherapy w/ percussion + deep suction

vaccine pneumococcus, FLU

resp assessment q4h

assisted cough technique:

Step 1: Place the client on their back, if possible. If the client is sitting, ensure the wheelchair is locked. Recline the wheelchair if possible.

Step 2: Place hands on the client below the rib cage with the thumbs together, forming a butterfly shape on top of the client’s abdomen. Avoid bony areas.

Step 3: Have the client take 3 to 5 deep breaths. On the last breath exhalation, assist the client to breathe out by pushing in and up with firm, steady pressure. Have the client cough deeply during this procedure.

heterotopic ossification: ~12w

abnormal bone growth in nonskeletal areas → decreases ROM

autonomic dysreflexia:!!!! above T6 = inc BP(150/ >40 in base) due to bladder distention or fecal impaction

pressure ulcers, fractures, urinary tract infections, sexual intercourse, constipation, and surgery.

Manifestations above the level of the injury include the following.

• Hypertension

• Pounding headache

• Fast or slow heart rate

• Anxiety

• Changes in vision

• Diaphoresis

• Tingling sensations or goosebumps

• Flushed skin

Manifestations below the level of injury include the following.

• Cool, pale, clammy skin

• Nausea

• Chills without fever

→ immediately place pt upright w/ legs dangling, determine if urinary retention or fecal impaction`

if not Nifedipine 10 mg q20-30mins w/ max 40mg dose

neurogenic shock: above T6 → reduction in sympathetic tone in the blood vessels

hypotension, bradycardia, and hypothermia

→ tx: vasopressor, dopamine, fluid resusitation (BP)/ low HR atropine sulfate

GU/GI → paralytic ileus → NG

urinary catheter

upper motor → leaking

lower motor → retention

tx: stool softner, daily rectal stim

bladder scan, should be taught how to intermittent self-catheterization (4-6 times /day)

→ Oxybutynin can also decrease spasm-induced incontinence.

chronic pain: neuro, muscular, visceral

changes in mobility, physical therapy

TENS / dorsal column stimulator→ nerve pain

risk of DM, weight management

inline cervical collar use log roll, backboards removed ASAP

halo fixation device:

halo is a ring that circles the forehead and is attached to the skull with pins and screws (two anterior, two posterior). The second section is a rigid vest that is to be worn under clothes

pin care qday, cleanse w/ hydrogen peroxide, betadine, or another antiseptic

never adjust pins

Resilience after spinal cord:

• Finding an effective coping strategy

• Having a “fighter's” attitude using every means necessary to overcome setbacks and challenges

• Looking at the injury as a challenge and find potential for personal growth to improve quality of life

• Accepting that the injury has occurred and choose to live with it

• Bouncing back during difficult times or life changes

• Seeking purpose and meaning in life

• Setting goals and striving to achieve them

• Staying connected with the support network, including family, friends, faith, and community

Rx

ibuprofen (NSAID)

gabapentin (anticonvulsant)

• no sudden discontinue

• avoid taking ~ 2hrs within antiacids

• inc suicide risk

dopamine (vasopressin/ inotropic)

• 0.5 to 3 mcg/kg/min → renal vasodilation by stimulation of dopaminergic receptors.

• 2 to 10 mcg/kg/min produces cardiac stimulation and renal vasodilation by stimulating dopaminergic and beta-adrenergic receptors

• 10 mcg/kg/min can cause vasoconstriction.   

  • C/I: pheochromocytoma, tachyarrhythmias

  • extravasation/ necrosis

Atropine (anticholinergic/ antimuscarinic)

• antiarrhytmic

• c/i glaucoma/ BPH

Enoxaparin

Baclofen (antispasticity, central skeletal muscle relaxant)

• improvement of bowel and bladder functioning

• no abrupt discontinuation if yes then over 1-2w

morphine

venlafaxine (SNRI) (also use for neuro pain)

docusate sodium: stool softener

polyethylene glycol: laxative

• can cause dependence and E/I

Tamsulosin: (peripherally acting antiadregenic)

• decrease s/s of BPH

sildenafil

MS

inflammation and demyelination → vision impaired, muscle weakness, paresthesia, cognitive/memory issues, coordination and balance

plaque formation → edema, demyelination, axonal injury

also noted in BBB, and synapses

relapse: the development of s/s must last a minimum of 24 hr and be separated from a previous relapse by at least 30 days, and not have another potential cause, such as an infection. Relapses can last for days up to months and are caused by inflammation in the CNS

lab/dx:

rule out other diseases, environmental exposures, hx of illness, family hx of MS

neuro test, CN test,

MRI, CSF analysis

McDonald criteria:

Clients must have evidence of nervous system damage that is disseminating in space and time.

• Dissemination in space: neurologic damage that appears in multiple areas of the client’s nervous system

• Dissemination in time: neurologic damage that occurs at different periods of time.

With relapsing MS, disease exacerbations and damage to distinct brain areas can assist in diagnosing MS.

Primary progressive MS may be diagnosed in clients who have a deteriorating disability for a minimum of one year and who display at least 2 of the following.

• Minimum of one MS-like lesion in the brain

• Minimum of two lesions in the spinal cord

• Confirmed test for oligoclonal bands in the CSF

Types:

remitting MS (RRMS): new ep or inc s/s during exacerbations w/ remissions (no progression of disease

primary progressive MS (PPMS): progressive worsening from onset of s/s

• no early remission

secondary progressive MS (SPMS):

• from onset, periods of active disease w/ progression and w/o progression

clinically isolated syndrome (CIS): 1st occurrence lasting at least 24hrs, not yet dx of MS

can develop = progressive multifocal leukoencephalopathy (PML): by John Cunningham virus

MS that are tx w/ natalizumab inc risk

s/s memory loss, vision difficulty, progressive weakness in the arms and legs, loss of coordination, clumsiness, and aphasia

risk

unknown antigen that causes an immune attack that results in inflammatory-mediated tissue damage

autoimmune, genetic, and environmental (vitamin D deficiencies in high latitude areas and infections, including the Epstein-Barr virus)

comorbidities: thyroid disease, diabetes, and inflammatory bowel disease, COPD, DM, hypercholesterol

emia, HTN

s/s

visual: optic neuritis: central vision loss and pain w/ eye movement, nystagmus, diplopia, diff adducting lateral gaze

immune: during disease process oligodendrocytes may be lost

cognition: brain atrophy

• difficult collecting sensory info

• difficult w/ memories

• difficult planning and prioritizing, word finding, and attention

pain: neuropathic pain

• trigeminal neuralgia

• Lhermitte’s sign: brief pain like electrical shock from back of head to spine

  • when pt bends neck forward (damage to cervical)

• MS hug: squeezing felling around trunk

• paroxysmal spasms: intermittern and painful spams

illness, fatugues, and overheating increases risk

dysesthesias (burning, electrical, ice-cold, or stabbing pain)and pruritis

muscle skeletal pain

→ tx: nonpharm or anti-seizure or antidepressant

gait training and muscle strengthening

mobility: ataxia, and sensory ataxia (can’t feel feet) → falls

vertigo

dysphagia, dysarthria

incontinence, urgency, retention, reflux, diarrhea, constipation

anxiety, depression, inc risk of SUD

Pseudobulbar affect: laugh suddenly over something they did not find funny or cry when they are not sad

pt education

physical wellness: Consuming a healthy diet, refraining from smoking, preventative care, exercise, and management of other medical conditions

immunization,

assistance animals, shoe type, ambulation tools

48 to 64 ounces of fluid per day, limit caffeine and alcohol, bladder meds (tamsulosin and oxybutynin) to reduce retention

tea/coffee may stim BS, q2-3days

• Pacing: Integrate short breaks into activities regularly to avoid overexertion and proceed with activities at a moderate pace.

• Prioritization: Complete important tasks before others that are less important and rest as needed.

• Planning: Determine which tasks need to be accomplished on which day and organize the tasks according to priority and effort.

• Positioning: Practice using good posture, body mechanics, and ergonomics, placing needed supplies within reach.

Spaced rehearsal involves having the client repeat and practice recalling information at increasing time intervals. Finally, repeating and verifying help clients remember information and increase memory.

building association

Rx

natalizumab: IV for relapsing MS

• liver injury

• thrombocytopenia

Glatiramer acetate (Copaxone): relapsing forms of MS in adults, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease

• liver injury,

• no pregnancy

• store in no more than 1 month

Interferon beta-1a: reduction of relapses MS

• teach how to autoinfect

• suicidal ideation

• pregnancy

Mitoxantrone: antineoplastic

to slow MS, and decrease disability

• can cause alopecia,

• pregnacy

Fingolimod: decrrease frequent relapses

• linver injury, PRES, no live vaccines'

• varicella titer, can cause basa cell carcinoma (so sunscreen)

Methylprednisolone: corticosteriod → supress inflammation

• no grapefruit

• no stoping abruptly

• HCP → tarry stools, abdominal pain, manifestations of hypercortisolism, adrenal suppression, or infection.

Degenerative spinal

spinal stenosis: spaces in the spine narrow and cause increased pressure on the nerve roots

by injury, age related

usually in cervical and lumbar area

neural foramen (opening of nerve roots) can be compressed by disk herniating, hypertrophy of the posterior longitudinal ligament or ligamentum flavum, or the facet joints

by spondylolisthesis( vertebra move out of correct position and forwards onto bone below) or disc herniation

s/s: difficulty walking, pain, numbness, or weakness in legs → inc fall

burning pain, inital w/ arm/ neck pain but depends on affected

cauda equina syndrome → loss of motor and sensory function → loss of bowel and bladder + SD

pt education: exercise and maintain spine flexibility, lifting techniques, healthy weight

degenerative disc disease:

→ when aging = disk lose their absorption = loss of height = dry and crack = bulging disks, disc herniations, osteophyte development, disc desiccation, and a loss of disc height.

can be no s/s but

s/s: Pain is worse when sitting, bending, lifting, or twisting,'; foot drop, numbness, chronic pain

poor sleep due to pain

paresthesia, radiating pain into their arms or lower extremities, and changes in gait, related to weakness.

can also experience caudina equina syndrome

pt education: whole grains, leafy green vegetables, fruit, healthy fats, and lean protein, exercising, hydrating

lab/dx:

1. MRI/CT eletrodynamic

2. lateral XR, MRI, CT, electromyography

tx: epidural steroid spine injections

Surgery to remove the pressure from the nerves within 48 hr improves sensory and motor deficits and bowel function.

Spinal cord stimulation: pulsed electrical energy to manage pain by placing leads within epidural space

Radiofrequency ablation: thermal energy to destroy the tissue around specific nerves responsible for transmitting pain

• radiofrequency ablation (PRF), water-cooled radiofrequency ablation (WCRF), and cryoneurolysis (CN).

anterior and posterior decompression

laminectomy, foraminotomy (remove part of intervertebral foramen), and discectomy and fusion. 

PT, massage to increase circulation, heat to reduce pain and muscle spasms or cryotherapy, muscle training, aerobic exercise, isometric, ROM, lumbar disc degeneration

lumbar disctomy w/ fusion and lumbar total disc replacement for lumbar degenerative disc disease