Spinal Cord Injury - Medical Notes PDF

SPINAL CORD INJURY VERTEBRAL COLUMN Consists of 33 vertebrae 7 cervical (C1 through C7) 12 thoracic (T1 through T12) 5 lumbar (L1 through L5) 5 sacral (S1 through S5) 4 fused coccygeal DISKS Vertebrae separated by disks which serve as shock absorbers for the verte...

SPINAL CORD INJURY VERTEBRAL COLUMN Consists of 33 vertebrae 7 cervical (C1 through C7) 12 thoracic (T1 through T12) 5 lumbar (L1 through L5) 5 sacral (S1 through S5) 4 fused coccygeal DISKS Vertebrae separated by disks which serve as shock absorbers for the vertebral column Composed of anulus fibrosus and nucleus pulposus Anulus fibrosus: ring of tissue; encircles nucleus pulposus Nucleus pulposus: saclike structure with a gelatinous filling that has a high water content As we age, nucleus pulposus loses water and becomes less effective as a shock absorber SPINAL CORD Extends from the brainstem to the second lumbar vertebra (L2) in pelvic cavity Surrounded by three protective meningeal layers Dura mater Outermost layer Arachnoid Middle layer: contains CSF Pia mater Innermost layer: directly covers the spinal cord CSF circulates through the brain and spinal column, protecting the entire central nervous system DIAGNOSTIC TESTS AND PROCEDURES Imaging studies Radiography Detects vertebral compression, fractures, or problems with alignment Coned-down radiographs are views that can more clearly reveal fractures Computed tomography (CT)-better for imaging injuries from trauma Magnetic resonance imaging (MRI)-better for looking at soft tissues Myelogram Dye injected into the subarachnoid space Visualizes the spinal cord and vertebrae TYPES OF INJURIES Classified by Location Cervical, thoracic, or lumbar Open or closed Closed: trauma in which the skin and meningeal covering that surround the spinal cord remain intact Open: damage to the protective skin and meninges Extent of damage to the cord Complete injury: the cord has been completely severed Incomplete injury: results from partial cutting of the cord EFFECTS OF SPINAL CORD INJURY Extent of cut and level of injury determine the effect the injury will have on the patient Initial symptoms of spinal cord edema may mimic partial or complete transection making level of injury difficult to determine Incomplete spinal cord injuries: Some function remains below the level of the injury INCOMPLETE SPINAL CORD INJURYS Central cord syndrome: Hyperextension injury to the cord Results in: Motor and sensory loss in upper extremities Bown-Sequard syndrome: Rare neurologic condition characterized by lesions. Transverse hemisection of the cord Results in: Ipsilateral loss of motor function Same side of body Contralateral loss of pain and temperature perception Opposite side of body EFFECTS OF SPINAL CORD INJURY The higher the level of injury, the more severe the neurologic dysfunction Quadriplegia (tetraplegia) High cervical spine injuries; loss of motor and sensory function in all four extremities Paraplegia Injuries at or below T2 may cause paralysis of the lower part of the body RESPIRATORY IMPAIRMENT Injuries at or above C5 may result in instant death Nerves that control respiration are affected Injuries below C4 spare the diaphragm but can affect intercostal and abdominal muscles This patient may be able to breathe independently May have respiratory difficulty, weakened muscles and cough depending on involvement SPINAL SHOCK An immediate, temporary response to injury Reflex activity below the level of the injury temporarily ceases Can mask the true extent of the patient’s injury Permanent effects not known until spinal shock subsides Occurs 30-60 minutes after injury Lasts from days to months Causes flaccid paralysis: No muscle tone Eventually, affected neurons will gradually regain excitability Resolution: When pt’s extremities have spastic, involuntary movements BREAK 1 (15MIN) AUTONOMIC DYSREFLEXIA One of the most serious complications: medical emergency Exaggerated response of autonomic nervous system to painful stimuli With injury at or above T6 Risk increases when spinal shock subsides and reflexes return Sympathetic nervous system is stimulated Parasympathetic response cannot be elicited because the spinal cord injury separates the two divisions of the autonomic nervous system AUTONOMIC DYSREFLEXIA Triggered by various stimuli including Distended bladder Constipation Renal calculi Ejaculation Uterine contractions Pressure sores Skin rash Enemas Sudden position changes 6 B’S OF AUTONOMIC DYSREFLEXIA Bladder: Catheter blockage, distension, stones, infections, spasms. Bowel: Constipation, impaction. Back passage: Hemorrhoids, rectal issues, anal abscess, fissures. Boils: skin lesions, infected ulcers, pressure sores. Bones: fractures, dislocations. AUTONOMIC DYSREFLEXIA Symptoms Arterioles constrict Results in severe hypertension, seizures and stroke Body attempts to compensate by vasodilating Only able to dilate above the injury Causes sweating, congestion and headache HTN causes pt to develop bradycardia EFFECTS OF SPINAL CORD INJURY Spasticity Muscle spasms may be incapacitating Should gradually reduce over 1-2 years Impaired Sensory and Motor Function Results in immobility complications Impaired bladder function In Spinal Shock, pt has no bladder function Catheter is inserted Distended bladder can result in Autonomic Dysreflexia Once spinal shock resolves, reflex activity returns, bladder becomes spastic and may spontaneously empty EFFECTS OF SPINAL CORD INJURY Impaired bowel function Peristalsis usually returns by third day after injury Most patients are able to maintain bowel function because the bowel has its own neural center Impaired Temperature Regulation Pt may not be able to maintain temperature Take measures to regulate temp IMPAIRED SEXUAL FUNCTION Spinal levels S2, S3, and S4 control sexual function Injury at or above these levels results in sexual dysfunction IMPAIRED SKIN INTEGRITY Skin is very susceptible to breaking down due to immobility SAVING THE PATIENT’S LIFE: ESTABLISH AIRWAY Establishing an airway is first priority Conventional head tilt–chin lift: Inappropriate with spinal injury Increases risk of cord damage Risk of additional damage is especially high with cervical injury Neck flexion must be avoided (even from a pillow) Jaw-thrust method of opening the airway is preferred SAVING THE PATIENT’S LIFE: ESTABLISH AIRWAY Once airway is open, administer 100% oxygen by mask Endotracheal or tracheostomy tube is placed to allow direct access to the airway and facilitate optimal oxygenation Any injury that compromises ventilation must be treated immediately PREVENTING FURTHER CORD INJURY Traction Immobilization with skeletal traction manages cervical spinal cord injuries acutely Gardner-Wells tongs Secured just above the ears Don’t penetrate skull Crutchfield tongs Applied directly to the skull just behind the hairline PREVENTING FURTHER CORD INJURY Traction Halo vest: Immobilizes and aligns cervical vertebrae Placed as soon as surgery is done Internally stabilizes fractures and relieves the compression of nerve roots Vest allows the patient to be moved out of bed, ambulate and be more mobile Elevate patient’s HOB to allow for proper alignment and positioning while in bed PREVENTING FURTHER CORD INJURY Special beds and cushions Kinetic bed, such as the Roto-Rest bed, continually rotates the patient from side to side Overlay air mattresses: flotation devices placed on standard hospital beds Air-fluidized and flotation beds may be used after the spine has been stabilized Stryker wedge frame: canvas and metal frame bed that may be used to help turn the patient Types of cushions include those inflated with air, flotation devices, and gel pads PREVENTING FURTHER CORD INJURY Drug therapy Methylprednisolone Reduces the damage to the cellular membrane May limit the neurologic effects of the injury Administered within the first 8 hours of injury Completely paralyzed patients often regain about 20% of function Partially paralyzed have regained up to 75% of function PRESERVING CORD FUNCTION Early surgical intervention to repair cord damage Cord compression by bony fragments, compound vertebral fractures, and gunshot and stab wounds Surgery within the first 24 hours is most desirable Laminectomy Involves removing all or part of the posterior arch of the vertebra Spinal fusion If multiple vertebrae are involved Placing a piece of donor bone into area between the involved vertebrae LAMINECTOMY PATIENT Removal of part of the vertebra to reduce pressure on spinal nerves Preop Baseline vitals and neuro assessment Pt teaching LAMINECTOMY PATIENT Assessment Vital signs, neurologic status, and breath sounds Frequently assess movement, strength, range of motion, and ability to localize sensory stimulus Fluid intake and output Abdomen for bowel sounds Palpate bladder, urine output should return within 6 hours Inspect the surgical dressing for bleeding, clear CSF drainage, and foul drainage Assess pain in detail LAMINECTOMY PATIENT Interventions Monitor and prevent surgical complications Listen to lung sounds ever 2-4 hours Assess for DVT Soft neck collar for cervical laminectomy PHYSICAL EXAMINATION FOR SPINAL CORD INJURED PATIENTS Take vital signs Level of responsiveness, posture, and spontaneous movements Inspect the skin for lesions Evaluate tissue turgor Inspect head for lesions and palpate for masses and swelling PHYSICAL EXAMINATION Examine pupils for size, equality, reaction to light Respiratory effort and breath sounds Inspect abdomen; auscultate for bowel sounds Inspect extremities for open fractures or abnormal positions Range of motion Ability to perceive sharp and dull sensation Patients with a C8 injury may still have upper extremity mobility and ability to use hand knobs and devices Assess for depression evidenced by decreased concentration INTERVENTIONS Pt with C5 or above injury will need mechanical ventilation Monitor respiratory status Logroll patients in cervical traction Safety precautions for pt’s with uncontrolled spasms Spinal shock may occur resulting in swelling. Clouding the extent of injury. DVT prevention Administer injections above the level of paralysis Poor circulation below the level of paralysis Monitor for autonomic dysreflexia: it is an emergency Immediately elevate HOB 45 degrees to decrease pressure Checks for kinks in the catheter (urinary retention causes AD) INTERVENTIONS Prevent immobility complications ROM Turning and reposition every 2 hours Splint extremities to prevent contractures Keep skin clean and dry Pad all bony prominences and use pillows o keep heels off bed surface. Do not massage bony prominences Keep humidity above 40% Provide pin care to the pt in traction to prevent infection Keep room temp at 70 degrees Prevent hypothermia or hyperthermia REHABILITATION Goal is to achieve highest possible level of self-care and independence IDT team Physician, nurse, physical therapist, occupational therapist, speech therapist, dietitian, social worker, psychologist, and counselor Patient and family must be emotionally and physically prepared to make adjustments