SPINAL CORD INJURY (SCI)

Care of the Clients with Spinal Cord Injury

Presented by:LIBALIB, Rhenalynne A.

Definition:

Traumatic injury to the spinal cord that results in sensory and motor deficits.

Two(2) types of SCI

1. Paraplegia : paralysis of the legs.

2. Quadriplegia: (also termed as TETRAPLEGIA) paralysis of all four(4)

extremities.

Causes:• Car accidents• Falls• Gunshot wounds• Stab wounds• Diving into shallow

water• Infections• Tumors• Congenital anomalies

Mechanism of Injury• Physical manner and forces involved

in producing injuries or potential injuries

• Valuable tool in determining if a particular set of circumstances could have caused a spinal injury

• Mechanisms likely to produce spinal injuries occur in, falls, violence, and sports (including diving accidents)

Hyperflexion -

Excessive/abnormal bending forward of the chin toward the chest. This is one mechanism seen

when patients are ejected from moving

vehicles

Hyperextension -

Excessive/abnormal bending back of the head beyond

its normal range of motion

Hyperotation -Excessive/abnormal rotation. This

may produce injuries in any

area of the spine.

Axial Loading-Sudden/excessive compression of the spine. Examples

include falling and landing on your feet or ejection from a

vehicle and landing on your head

Axial Distraction- by

sudden/excessive elongation at the spine caused by

stretching or tearing anywhere along the spinal

column. Ex. hanging

Sudden/Extreme Lateral Bending

• Excessive/abnormal lateral movement of the spine

• Can affect any portion of the spine• Example: T-bone MVAs

Pathophysiology:INJURY

Complete transection of the Spinal Cord

Associated edema and hemorrhage from the injury

Ischemia

NECROSIS and SCAR TISSUE form in the area of the traumatized cord

May result inPARAPLEGIA

OrQUADRIPLEGIA

Assessment findings:• Paralysis below the level of the injury• Paresthesia below the level of the injury• Neck pain• Loss of bowel and bladder control• Respiratory distress• Numbness and tingling• Flaccid muscle• Absence of reflexes below the level of the injury• Loss of perspiration below level of the injury

SCI results to the following effects below

level of lesion:ParalysisLoss of reflexesLoss of sensory functionLoss of motor functionAutonomic dysfunction

Clinical manifestation of SCI:

1.) Cervical SCI- injury at C2 and C3 is usually fatal.- QUDRIPLEGIA (paralysis of all four extremities)- respiratory muscle paralysis- bowel and bladder retention

Clinical manifestation of SCI:

2.) Thoracic SCI- PARAPLEGIA (paralysis involving the lower extremities)-poor control of upper trunk- bowel/bladder retention- autonomic dysreflexia with lesion or

injury above T6 and in cervical lesions.

Clinical manifestation of SCI:3.) Lumbar SCI

- PARAPLEGIA (flaccid paralysis)- bowel and bladder retention

4.) Sacral SCI- injury above s2 in males allows erection but there is no

ejaculation.- injury between S2 to S4 prevents erection and

ejaculation.- PARAPLEGIA- bowel and bladder incontinence

The higher the level of lesion, the greater is the probability to perform sexually.

The lower the level of lesion, the lesser is the probability to perform sexually.

The PARAPLEGIC MALE may experience IMPOTENCE.

The PARAPLEGIC FEMALE is capable of PREGNANCY, but is unable to experience ORGASM.

ASIA Impairment Scale for classifying spinal cord injury[11][13]Grade Description

A Complete injury. No motor or sensory function is preserved in the sacral segments S4 or S5.

BSensory incomplete. Sensory but not motor function is preserved below the level of injury, including the sacral segments.

CMotor incomplete. Motor function is preserved below the level of injury, and more than half of muscles tested below the level of injury have a muscle grade less than 3 (see muscle strength scores table).

DMotor incomplete. Motor function is preserved below the level of injury and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.

E Normal. No motor or sensory deficits, but deficits existed in the past.

Actions of the spinal nervesLevel Motor Function

C1–C6 Neck flexorsC1–T1 Neck extensors

C3, C4, C5 Supply diaphragm (mostly C4)C5, C6 Move shoulder, raise arm(deltoid); flex elbow (biceps)

C6 externally rotate (supinate) the arm

C6, C7 Extend elbow and wrist (tricepsand wrist extensors); pronatewrist

C7, T1 Flex wrist; supply small muscles of the handT1–T6 Intercostals and trunk above the waistT7–L1 Abdominal musclesL1–L4 Flex thigh

L2, L3, L4 Adduct thigh; Extend leg at theknee (quadriceps femoris)

L4, L5, S1 abduct thigh; Flex leg at the knee (hamstrings); Dorsiflexfoot (tibialis anterior); Extendtoes

L5, S1, S2 Extend leg at the hip (gluteus maximus); Plantar flex foot and flex toes

Diagnostic test findings:

• Spinal X-rays : vertebral fracture

• CT Scan : spinal cord edema, vertebral fracture, spinal cord compression

• MRI : spinal cord edema, vertebral fracture, spinal cord compression

Medical management:

• Diet : low-calcium, high-protein• I.V therapy: saline lock• Oxygen therapy• Intubation and mechanical ventilation• GI decompression : NG tube• Position: flat, neck immobilized• Activity : bed rest, passive ROM exercises

• Monitoring : VS, I/O, ECG, ICP, and neurovital signs

• Laboratory studies: Na, K, and glucose levels and WBC count

• Indwelling urinary catheter• Antacids: Mg and Al hydroxide (Maalox), Al

hydroxide gel (AlternaGEL)• Anticonvulsant: phenytoin (Dilantin)

• Glucocorticoid : dexamethasone (Decadron), methylprednisolone sodium succinate (Solu-Medrol)

• Histamine antagonists: cimetidine (Tagamet), ranitidine (Zantac)

• Cervical collar• Maintenance of vertebral alingment: Stryker turning

frame, Crutchfield tongs, Halo brace• Laxative : bisacodyl (Dulcolax)• Antianxiety agent : diazepam (Valium)

• Antihypertensives: diazoxide ( Hyperstat), hydralazine (apresoline)

• Muscle relaxant : dantrolene (Dantrium)• Pulse oximetry• Specialized bed : rotation (Rotorest, Tilt and

Turn, Paragon)• Mucosal barrier fortifier : sucralfate (Carafate)

Nursing interventions:

• Maintain the patient’s diet• Encourage fluids• Administer I.V fluids• Administer oxygen• Provide suction and turning; encourage

coughing and deep breathing• Assess neurologic and respiratory status• Keep the patient flat

• Monitor and record VS, I/O, laboratory studies, and pulse oximetry

• Administer medications, as prescribed• Encourage the patient to express his/her feelings

about changes in his body image, changes in sexual expression and function, and altered mobility

• Turn the patient every 2 hrs. using the logrolling technique

• Maintain body alignment• Initiate bowel and bladder retraining• Provide sexual counseling• Provide passive ROM exercises• Check for autonomic dysreflexia• Assess for spinal shock• Provide skin care• Provide heel and elbow protectors and sheepskin

• Apply antiembolism stockings• Provide information about the National Spinal Cord

Injury Association• Individualize home care instructions:

- exercise regularly to strengthen muscles- recognize the S/Sx of autonomic dysreflexia, UTI, and upper respiratory tract infections- continue bowel and bladder program- maintain acidic urine with cranberry juice

- consume adequate fluids : 3L/day- use assistive devices for ADL’s- maintain skin integrity- stay mobile using a wheelchair- reinforce independence

Complications:• Spinal shock – loss of all neurological activity below

the level of injury. • Autonomic dysreflexia - is a potentially dangerous

clinical syndrome that develops in individuals with spinal cord injury, resulting in acute, uncontrolled hypertension.

• Respiratory distress• Osteomyelitis - inflammation of bone or bone

marrow, usually due to infection.• Pressure ulcers

Possible surgical interventions:

• Laminectomy - is surgery that creates space by removing the lamina — the back part of the vertebra that covers your spinal canal. Also known as decompression surgery, laminectomy enlarges your spinal canal to relieve pressure on the spinal cord or nerves.

Possible surgical interventions:

• Spinal fusion - is a surgical procedure used to correct problems with the small bones of the spine (vertebrae). It is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.

Whiplash InjuryIs caused by violent

hyperextension and flexion of the neck. It usually results from vehicular accident.

There is damage to muscles, disks, ligaments and nervous tissues of the cervical spine.

Clinical manifestations:• Pallor• Weakness• Gait disturbance• Dizziness• Nausea and

vomiting• Occipital headache• Nuchal rigidity

Collaborative management:

• Promote bed rest.• Apply cervical collar as needed.• Apply hot packs to the neck as indicated.• Administer analgesic and muscle relaxant as

prescribed.

References: - Medical-Surgical Nursing: Concepts and Clinical Application by: Josie Quiambao-UDAN RN, MAN - Straight A’s Medical-Surgical Nursing

Thank you…