SCI

Spinal Cord Injuries







Becca Maddox

N2205

Spring 2002

SPINAL CORD INJURY (SCI)



FAST FACTS

 Occurs primarily in young males (> 75% of cases)

 Half of these injuries result from MVAs

 2/3 of patients are < 30 years old

 Other sources of SCI: Falls, sporting and industrial

accidents, gunshot wounds.

 Most common vertebrae involved are C5, C6, C7, T12,

and L1 because they have the greatest ROM

 The estimated cost of these injuries exceeds $2 billion

annually.

Type of Injury



 Transient concussion - is due to extreme vibration of

the cord and may cause temporary loss of function

lasting 24 to 48 hours. No neuropathologic changes

are present.

 Contusion - is a bruising that includes bleeding,

subsequent edema, and possible necrosis from the

edematous compression.

• The neurological involvement depends on the severity

of contusion and necrosis

 Laceration

 Compression of cord substance

 Complete transection of the cord

Pathophysiology



 Hemorrhage: Blood flows into the extradural,

subdural, or subarachnoid spaces of the spinal

cord

 Injury to spinal cord vasculature causes nerve

fibers to swell and disintegrate

 Blood circulation to the gray matter of the spinal

cord is impaired

 Secondary chain of events: Ischemia, hypoxia,

edema, and hemorrhagic lesions

 These secondary events result in destruction of

myelin and axons.

Pathophysiology Cont’d



 These secondary reactions, are believed to be the

principal causes of spinal cord degeneration .

 The damage may be reversible within the first 4 to

6 hours after the injury.

 The consequence of spinal cord injury depends

on

• The type of injury (concussion, contusion,

laceration, compression, transection)

• The neurologic level (lowest level at which

sensory and motor functions are normal)

Management of Spinal Cord Injuries





 Immediate management at the scene is critical.

 Improper handling can cause further damage and

loss of functioning

 Always assume there is a spinal cord injury until

it is ruled out

• Immobilize

• Prevent flexion, rotation or extension of neck

• Avoid twisting patient

 If conscious, patients will usually mention acute

pain in back or neck which may radiate along the

involved nerve

Management cont’d



 Management is aimed at preventing

further injury and observing for

progression of neuro deficits

 Consists of emergency treatment

following an A-B-C-D-E sequence.

Airway Management



 First priority.

 Open airway with jaw-thrust maneuver.

 Use bag-valve-mask devise initially for

airway compromise and if necessary to

prepare for intubation.

 High concentration of 02 will prevent

bradycardia or asystole for patients

exhibiting signs of neurogenic shock.

Breathing



 Lesions above C5 level will cause partial

to complete diaphragmatic paralysis

(recall the diaphragm is innervated at C3-5

levels).

 Any lesion above T12 may cause some

airway compromise.

 Lesions at C5 and below will allow full

diaphragmatic movement, but intercostal

muscles (innervated at T1) and abdominal

muscles (innervated at T12) are affected.

Circulation



 Cardiac output is affected by external or internal

hemorrhage and neurogenic shock.

 To determine external bleeding, turn the patient in

log-roll fashion and quickly note the site of injury.

 Two signs of internal bleeding from abdominal

trauma are abdominal pain and muscular rigidity.

However, these signs may be masked in a patient

with sensory and motor deficits.

 Other usual signs of shock from internal bleeding

are absence of urine and/or classic signs of

shock (decreased BP and increased HR)

Disability



 Neurological Examination

 Lateral C-Spine X-ray

 CT scan

 Telemetry - bradycardia and asystole are

common with acute cervical injury

 Search for other injuries - spinal trauma is

often accompanied by other injuries,

particularly of the head and chest

Exposure



 Patients with SCI become poikilothermic,

meaning that their body temperature will

increase and decrease with the

temperature of the environment.

 Because they lose the ability to regulate

core body temperature through

vasodilatation and vasoconstriction, they

can become dangerously hyperthermic or

hypothermic.

Medical Management



 High dose corticosteroids (Methylprednisolone) -

improves the prognosis and decreases disability

if initiated within 8 hours of injury. Patient

receives a loading dose and then a continuous

drip.

 High dose steroids, Mannitol, Dextran

 Naloxone - has shown promise in use on humans,

minimal side effects, may promote neurological

improvement

Neurogenic Shock



 Neurogenic shock may complicate the

assessment because it masks the typical signs

of hypovolemia - tachycardia, cold and clammy

skin.

 Vasomotor tone is lost, producing hypotension

from vasodilatation.

 Increased vagal tone causes bradycardia.

 The skin stays warm and dry because the

sympathetic nervous system cannot initiate the

usual compensatory mechanism for hypovolemic

shock (shunting blood from periphery to core).

Neurogenic vs. Spinal Shock



 Neurogenic Shock- loss of vasomotor tone and

impairment of autonomic function.

• Tx - close monitoring of HR, use of vasoactive drugs.

• Typically it lasts from 3 days to 3 weeks after injury.

 Spinal shock - loss of spinal reflexes resulting in

flaccid paralysis below the level of the injury.

• Tx - monitor patient for respiratory difficulty, bladder

and bowel management, abrupt onset of fever (as

patient loses ability to perspire in areas of paralysis).

• May last from weeks to months. When it ends, flaccid

muscles become spastic.

Neurological/Orthopedic

Management



 Neurological/orthopedic management

includes methods a surgeon may use to

treat unstable spinal cord injuries:

• Reduction

• Fixation

• Fusion

Reduction

 With reduction, the spine is realigned through the

application of a skeletal traction devise, such as

Gardner-Wells tongs or Halo traction.

 5 to 10 pounds of weight are usually added for each

involved vertebral interspace, beginning at C1.

 Be careful - too much weight can pull the spine apart,

causing a distraction injury.

 Check traction regularly for free-hanging weights and

correct amount of weight.

 Pins should fit tightly against the cranium. The patient

should not be able to shake his head.

 Assess pin sites for infection and clean according to

policy.

Fixation and Fusion





 Fixation involves  Fusion involves

stabilizing attaching injured

vertebral fractures vertebrae to

with wires, plates, uninjured

and other types of vertebrae with

hardware. bone grafts, and

steel rods to help

maintain structural

integrity.

Complications of SCI -

Pulmonary

 Pulmonary complications - Function compromise,

Airway compromise, infection, decreased vital

capacity, atelectasis, retention of secretions,

respiratory failure, pulmonary edema

 Acute respiratory failure is the leading cause of

death in high cervical injuries

 Management of pulmonary complications: Chest

physiotherapy & postural drainage, frequent

suctioning, quad cough technique, incentive

spirometry, assessing breath sounds, monitoring

ABG’s and chest x-rays.

Deep Vein Thrombosis (DVT)



 The incidence of DVT is extremely high in SCI

patients due to pressure on their calf muscles,

loss of the skeletal muscle pump, and the

hypercoagulability of their blood.

 Treatment consists of hospital’s choice of DVT

prophylaxis - pneumatic compression hose, low

dose Heparin or Lovenox, ROM exercises, and

vena cava filters.

 May require Coumadin long term.

 Measure thighs and calves daily.

Orthostatic Hypotension



 May develop in the acute or transitional phase.

 Caused by venous pooling in the legs and abdomen,

loss the skeletal muscle pump, and impaired

sympathetic nervous system control of BP.

 May occur with position changes and can result in

syncope, bradycardia, or asystole.

 Treatment consists of quickly returning the patient to

a supine position, administering oxygen, and if

necessary, atropine to increase heart rate.

 Preventive measures include TED stockings, elastic

bandages, and abdominal binders that promote

venous return from the extremities.

GI and GU dysfunction



 Assess for bowel distention, ileus or

gastrointestinal bleeding - may require an NGT

 Monitor patient’s bowel function and establish

bowel routine.

 During acute injury phase, the bladder is atonic

so the patient is unable to void voluntarily or

spontaneously - also increases risk of UTI

 Maintain strict Intake and Output

 Begin bladder training

Skin Integrity



 Below the level of SCI, the patient cannot sense

discomfort from pressure, skin irritants, or

temperature extremes.

 Patient will remain at high risk for pressure

ulcers, serious skin injury and infection.

 During acute phase, inspect skin for redness or

other signs of breakdown - pressure ulcers can

occur within 6 hours

 May use special bed as roto-rest or striker frame

to turn patient.

Autonomic Dysreflexia



 An acute emergency

 It is an exaggerated response to stimuli

 Classic signs are pounding headache, marked

hypertension, diaphoresis (particularly of the

forehead), bradycardia, flushing, piloerection,

nausea, and nasal congestion

 Occurs only after spinal shock has resolved

 The increase in ICP and blood pressure can lead

to cerebral hemorrhage

Autonomic Dysreflexia Pathophysiology



 Occurs with spinal cord lesions above the thoracic sympathetic

outflow (T6 or T7). The feedback system between the sympathetic

and parasympathetic branches of the ANS is disrupted.

 The parasympathetic response is partially disabled and the

sympathetic response is dominant.

 As a result, the sympathetic response produces profound

vasoconstriction thus producing a rapid rise in blood pressure.

 Normally, baroceptors in the cerebral vessels, carotid sinus, and

aorta detect the rising blood pressure and attempt to trigger visceral

and peripheral vasodilatation, but these impulse are blocked by a

damaged cord.

 The parasympathetic response is limited to vagal slowing of the

heart rate and vasodilatation, flushing, and diaphoresis above the

level of spinal cord injury.

Autonomic Dysreflexia cont’d



 Anything that can cause discomfort to a

neurologically intact person can trigger autonomic

dysreflexia in a patient with a spinal cord injury.

 The most common stimulus is a distended bladder or

rectum.

 Other causes include: Stimulation of the skin from

pressure, pain, heat or cold.

 The goal of treatment is to identify and remove the

cause of the dysreflexia and thus lower the BP.

 Sit patient with feet down to promote orthostatic

reduction of blood pressure. (If patient unable to sit,

elevate head of bed to 90 degrees).

Quadraplegics and Paraplegics



 Quadraplegics - results from a cervical

impairment

 Paraplegic - results from impairment at the

thoracic, lumbar, or sacral root area.

 Can result from accidents, spinal cord

lesions, tumors, vascular lesions, multiple

sclerosis, infections or abscesses of the

spinal cord or congenital defects

 You will see these patients in the hospital for

all of the other things you see patients for

Rehab and Long-Term Issues



 Mobility - initially may require a brace or halo.

Needs to bear weight as soon as possible

because it helps decrease disuse atrophy,

decrease the opportunity for osteoporosis,

decrease the possibility of renal calculi, and

enhances metabolic processes

 Exercise - to strengthen unaffected parts and

promote self-care

 Skin Integrity - needs to be taught the importance

of being responsible for own skin integrity

Rehab and Long-Term Issues cont’d





 Urinary and Bowel Programs - will have to

develop and maintain programs. Will need to

learn how/when to self-cath, check residual urine.

Will need to know how to stimulate a bowel

movement. Will need to be able to recognize an

impaction or ileus.

 Prevent and Manage Complications

 Spastic Muscles - maximum spastic activity is

usually 2 years out and then minimizes some.

May require long-term use of anti-spasmodic

drugs such as valium, baclofen or dantrium

Rehab and Long Term Issues cont’d





 Contractures - Needs to understand the

importance of exercise and maintaining function

 UTI’s and sepsis - needs to recognize signs and

symptoms of UTI and sepsis.

 Heterotropic ossification - overgrowth of bone in

hips, knees, shoulders elbows. This causes pain

and decreased ROM for pain, thus decreasing

mobility

 Self-Esteem - May need counseling to deal with

changes in self-identity, sexual function, social

and emotional roles. Needs to feel strong, lovable

and loved.

Psychosocial Behavior



 Denial, anger and depression are common

reactions to SCI.

 Manipulative behavior and emotional times are

managed by setting mutually reasonable

expectations of the patient and nursing staff.

 Ultimately the SCI patient will ask the question of

walking again. Often this question cannot be

answered in the immediate post-injury phase.

The goals are to provide honest and realistic

communication about the nature of the injury and

help the patient develop short-term goals.

Intraspinal Tumors



 Tumors within the spine are classified

according to their anatomic relation to the

spinal cord

 Intramedullary lesions (within the spinal

cord)

 Extramedullary- intradural lesions (within

the subarachnoid space)

 Extradural lesions (outside the dural

membrane)

Symptoms Associated with

Intraspinal Tumors

 Weakness

 Loss of reflexes above the tumor level

 Localized or shooting pains in the area that is

innervated by the spinal roots that originate

in the cord near the tumor site

 Progressive loss of motor function and

paralysis below the level of the lesion

 Diagnosis is made by neurological exam and

myelogram plus CT scanning and Magnetic

Reasoning Imaging (MRI)

Preoperative Management



 Assess patient for weakness, muscle wasting,

spasticity, and sensory or sphincter disorders.

 Important areas in patient’s history include:

pulmonary system(especially when a cervical

lesion is present), hx of coagulopathies, any

anticoagulants taken recently including aspirin or

anti-inflammatory drugs.

 Importance of pulmonary toilet (cough and deep

breathing exercises and use of incentive

spirometer) is taught prior to surgery.

Surgical Management of

Intraspinal Tumors

 Excision of the tumor while sparing the uninvolved

portions of the spinal cord is the most desirable form

of treatment/cure.

 Prognosis is related to degree of neurologic

impairment at the time of surgery, the speed with

which symptoms occurred, and the tumors origin.

 Other treatment modalities include partial removal of

the tumor, decompression of the spinal cord,

chemotherapy, and radiation therapy.

 Spinal cord compression from metastatic Ca is

treated with high dose dexamethasone and radiation

to help relieve pain

Postoperative Nursing Interventions



 Monitor patient for deterioration in neurological status

 Note: a sudden onset of neurological deficit is an

ominous sign and should be treated as an emergency.

 It may be due to vertebral collapse associated with

spinal cord infarction.

 Respiratory function: Assess for rate and quality of

breath sounds, manage artificial airway if present, and

encourage pulmonary toilet.

 Bladder: Palpate for urinary retention or urinary

incontinence. Monitor intake and output.

 Assist with pain management.

Postoperative Nursing Interventions cont’d





 Positioning - keep flat, log roll when turning. Patient

may be more comfortable on side. Avoid extreme knee

flexion.

 Monitor wound for CSF leakage - can lead to serious

infection and severe pain

Herniation of an Intervertebral Disc





 The intervertebral disc is a cartilaginous plate

that forms a cushion between vertebral bodies.

 This tough, fibrous material is incorporated in a

capsule.

 A ball-like cushion in the center of the disc is

called the nucleus pulposus.

 Herniation occurs when the nucleus of the disc

protrudes into the fibrous ring causing nerve

compression.

 Can occur related to degenerative changes or

trauma

Herniation of an IV Disc cont’d





 Manifestation depends on:

• location

• rate of development (acute vs. chronic)

• effect on surrounding structures

Herniation of a Cervical IV Disc



 The cervical spine is subjected to stresses that result

from disc degeneration (from aging, occupational

stresses), and spondylosis (degenerative changes

occurring in disc and adjacent vertebral bodies).

 Cervical disc herniation usually occurs at the C5-C6

and C6-C7 interspaces.

 Pain and stiffness may occur in the neck, the top of the

shoulders, the region of the scapulae, in the upper

extremities, head, and may be accompanied by

numbness of the upper extremities.

 Diagnosis of cervical disc herniation is confirmed on

MRI.

Management of Herniation

of a Cervical IV Disc

 The goals of treatment are (1) rest and

immobilization of cervical spine and (2) reduce

inflammation of supportive tissue and affected

nerve roots

 Management may include:

• Immobilization

• Traction

• Pain Relief - moist heat, analgesics, sedatives,

muscle relaxants, anti-inflammatories,

corticosteroids

• Surgical repair of injured spine

Herniation of a Lumbar Disc



 Most lumbar disc herniations occur at the L4-L5 or

L5-S1 interspaces.

 Typically produces low back pain accompanied by

various degrees of sensory and motor impairment.

 Patient presents with low back pain and muscle

spasms, followed by radiation of the pain into one hip

and traveling down the leg (sciatica).

 Pain is aggravated by actions that increase intraspinal

fluid pressure

 Pain is usually relieved by bed rest.

 Diagnosis by MRI - if symptoms and pathology don’t

match, then confirmation with CT or myelogram

Management of Herniation

of a Lumbar Disc

 The goals of treatment are (1) reduce pain, (2)

slow progression of the disease, and (3) increase

functional abilities.

 Management may include:

• Bed rest - firm mattress

• Position of comfort - usually semi-fowler’s with

modest hip and knee flexion

• Muscle relaxants, anti-inflammatories,

corticosteroids

• Moist heat

Disc Surgery



 Surgical excision of a herniated disc is performed

when there is evidence of a progressing

neurological deficit (muscle weakness and

atrophy, loss of sensory and motor function, loss

of sphincter control), and continuing pain and

sciatica that is not responsive to medical

management.

 The goal of surgical management is to lessen the

pressure on the nerve root to relieve pain and

reverse neurological deficits.

Disc Surgery cont’d



 Diskectomy - removal of herniated or extruded fragments of

intervertebral disc.

 Laminectomy - removal of the lamina to expose the neural

elements in the spinal canal; allows the surgeon to inspect

the spinal cord, identify and remove tissue for pathology,

and relieve compression of the cord and roots.

 Laminotomy - division of the lamina of a vertebra

 Diskectomy with fusion - a bone graft (from iliac crest or

bone bank) is used to fuse the vertebral spinous processes;

the object of spinal fusion is to bridge over the defective

disc to stabilize the spine and reduce the rate of recurrence.

Disc Surgery cont’d



 Preoperative Management includes

evaluation of movement in extremities

plus bowel and bladder function.

 Patient is taught useful techniques such

as log-rolling, pulmonary toilet, and

muscle-setting (isometric) exercises,

which will help to maintain muscle tone

postoperatively.

Disc Surgery cont’d



 Post-operative Management includes:

• Frequent neurological checks, along with

vascular supply checks to extremities.

• Sitting is discouraged

• Position patient using a pillow under the head,

and the knee rest is slightly elevated. When

patient lying on side, avoid excessive knee

flexion

• Encouraged to move from side to side by log

rolling

Complications of Disc Surgery



 Arachnoiditis - inflammation of the arachnoid

membrane. Causes diffuse frequent burning pain

in lower back radiating to buttocks

 Failed Disc Syndrome - recurrence of sciatica

after surgery

 Bleeding and hematoma formation

 Fixing one level may cause problems at other

levels

 Recurrence of herniation