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- 2. SUBMITTED BY : UPASNAKUMARI M.SC. 1ST YEAR STUDENT , COLLEGE OF NURSING , PGIMS, ROHTAK SPINAL CORD INJURIES
- 3. Objectives Spinal cord injuries •Incidence • Causes • Types of SCI • Clinical menifestations • Diagnosis & assesment • Emergency management • Medical , surgical & nursing management Spinal cord compression • Causes • Clinical menifestation • Diagnosis • Medical & nursing management
- 4. INCIDENCE • Spinal cordinjury is a major health disorder • Anually 15-40 new cases per million people or 12000-20000 new patients are estimated to occur in USA. • The predominant risk factor for SCI includes young age , male gender & alcohal & drug use.
- 5. • Life expectancycontinues to increase for people with SCI because of improved health care . • Major cause of death are pneumonia , pulmonary embolism & sepsis.
- 6. CAUSES OF SCI •Motor vehicle crashes or RTA • Falls • Violence • Sports • Electric shock • Bullet or stab wound • Extreme twisting of middle of body
- 7. TYPE OF SCI •Primaryinjuries •Secondary injuries
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- 9.
- 10. Incomplete SCI • CENTRALCORD SYNDROME • ANTERIOR CORD SYNDROME • LATERAL CORD SYNDROME ( brown sequard syndrome )
- 11. Contd... •POSTERIOR CORD SYNDROME •CONUSMEDULARIS SYNDROME •CAUDA EQUINUS SYNDROME
- 12. 1. Central cordsyndrome • Motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved. • Cause: Injury or edema of the central cord, usually of the cervical area.
- 15. 2. Anterior cordsyndrome • Characteristics: Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact. • Cause: The syndrome may be caused by acute disk herniation or hyperflexion injuries a/w fracture-dislocation of vertebra. It also may occur as a result of injury to the anterior Spinal artery, which supplies the anterior two thirds of the spinal cord.
- 16. 3. Lateral cordsyndrome • Characteristics: Ipsilateral paralysis or paresis is noted, together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature. • Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, Fracture dislocation of a unilateral articular process, or possibly an acute ruptured disk.
- 19. 4. Conus medullarissyndrome • It follows damage to the lumbar nerve roots & conus medularis in spinal cord . • Client experiences bowel & bladder areflexia & flaccid lower extremities.
- 21. 5. Cauda equinasyndrome • It occurs from injury to the lumbosacral nerve roots below the conus medullaris . • The client experiences areflexia of bowel , bladder & lower reflexes .
- 22.
- 23. Clinical menifestation • Itmainly depends on the type & level of injury . Breathing difficulty Sensory or motor paralysis Loss of bowel & bladder control Loss of sweating & vasomotor tone Reduction of BP from loss of peripheral vascular resistance Sexual dysfunction Pain may radiate along the involved nerve
- 24. Cervical injuries Breathing difficulty Lossof normal bowel & bladder control Numbness Sensory changes Spasticity
- 25. Thoracic injuries Loss ofbowel & bladder control Numbness Sensory changes Spasticity (increased muscle tone ) Weakness , paralysis
- 26. Lumbar & sacralinjuries • Loss of bowel & bladder control • Pain • Sensory changes • Weakness & paralysis
- 27. ASSESMENT & DIAGNOSTICFINDINGS • Neurological examination • X ray • CT scan • MRI scan • Myelogram if MRI is contraindicated • ECG Monitoring
- 28.
- 30. • Any patientwho is involved in RTA or any trauma to head & neck must be considered to have SCI until such injury is ruled out . • At the scene of injury , patient is immobilised on a spinal board , with head & neck maintained in neutral position , to prevent progression of injury. • Asses for respiratory pattern & maintain a patent airway. • Prevent head flexion , rotation & extension .
- 31. Contd.... • During immobilisation, maintain traction & alignment on the head by placing hands on both sides of head by the ears . • Maintain an extended position. • Logroll the patient .( alteast 4 people are required ) • No part of body should be twisted or turned & patient is not allowed to sit .
- 32. MEDICAL MANAGEMENT 1. PHARMACOLOGICTHERPY • High dose of IV corticosteroids in 1st 24-48 hrs ( if they are needed) 2. RESPIRATORY THERPY • Oxygen administration • Diaphragmatic pacing ( electrical stimulation of phrenic nerve )
- 33. 3. skeletal fracturereduction & traction
- 34. 4. Surgical management •It is indicated in following cases: a) Cord compression b) If injury involved a wound c) Bony fragments in the spinal canal d) Patient’s neurological status is deteriorating . • Laminectomy is done for selective patients .
- 35. Complications of SCI& their management 1. Spinal shock • A complete but temporary loss of motor , sensory , reflex , autonomic function that occurs immidiatly after injury as the cord’s response to injury • Usually lasts <48 hrs but can continue for several weeks . • flaccid paralysis , loss of reflex activity below the level of injury , Bradycardia ,hypotension , paralytic ileus may occur
- 36. 2. Neurogenic shock: • Occurs most commonly in clients with injuries above T6 and usually is experienced soon after the injury. • Massive vasodilation occurs, leading to pooling of the blood in blood vessels, tissue hypoperfusion, and impaired cellular metabolism. • Hypotension & bradycardia will occur in a patient with spinal shock .
- 37. Interventions for spinal& neurogenic shock a. Monitor for signs of shock following a spinal cord injury. b. Monitor for hypotension and bradycardia. c. Monitor for reflex activity. d. Assess bowel sounds. e. Monitor for bowel and urinary retention. f. Provide supportive measures as prescribed, based on the presence of symptoms. g. Monitor for the return of reflexes.
- 38. 3. Autonomic dysreflexia A.Also known as autonomic hyperreflexia b. It generally occurs after the period of spinal shock is resolved and occurs with lesions or injuries above T6 and in cervical lesions. c. It is commonly caused by visceral distention from a distended bladder or impacted rectum. d. It is a neurological emergency and must be treated immediately to prevent a hypertensive stroke. e. Sudden onset , severe throbbing headache , severe hypotension & bradycardia , flushing above the level of injury, nasal stuffiness , dilated pupils or blurred vision , piloerection etc. may occur .
- 39. Interventions for autonomic dysreflexia 1.Raisethe head of the bed and health care provider (HCP) be notified. 2. Loosen tight clothing on the client. 3. Check for bladder distention or other noxious stimulus. 4. Administer an antihypertensive medication. 5. Document the occurrence, treatment, and response.
- 40. 4. Venous thromboembolism •Potential complication of immobility . • Patients who develop VTE are also at risk of having DVT & PE . • Menifestations include : i. pleuritic chest pain ii. Anxiety iii. SOB iv. Abnormal blood gas values • Low dose anticoagulants, antiembolism stockings & pneumatic compression devices can be used to prevent DVT & PE.
- 41. NOTE : Thecalves & thighs of a patient who is immobile should never be massaged because of the danger of dislodging an undetected thromboemboli .
- 42. Nursing management ofpatient with acute SCI 1. Ineffective breathing pattern r/t weakness or paralysis of abdominal &intercoastal muscles & inability to clear secretions . • Clear bronchial & phayngeal secretions by using suctioning . • Proper humidification & hydration . • Assess for respiratory infections .
- 43. 2. impaired physicalmobility r/t motor & sensory impairements • Mainatin proper body alignments at all the times • Prevent footdrop • Prevent contractures • Promote passive range of motion exercises
- 44. 3. Risk ofinjury r/t motor & sensory impairement • Provide glasses to enable patient to see from the supine position • Encourage use of hearing aids • Provide emotional support • Provide education
- 45. 4. Risk ofimpaired skin integrity r/t immobility & sensory loss • Prevent pressure ulcers • Keep the skin clean • Pressure sensitive areas should be kept well lubricated & soft with oil & emollient lotion • Maintain urinary elimination by using indwelling catheterisation to avoid bladder distention & UTI
- 46. 5. Constipation r/tpresence of atonic bowel as a result of autonomic disruption . • As soon as bowel sounds returns ; patient is given high calorie ,high protein , high fibre diet with the amount of food gradually increased . • Provide stool softeners as per prescription .
- 47. 6. Provide comfortmeasures : the patient with halo’s traction • Inspect the skin under the traction • Observe the pins for loosening • Clean the areas around the pin site & assess for any drainage , redness or pain • Don’t use powder under the vest because it may lead to pressure sores .
- 48. 7. Recognise autonomicdysreflexia • It is characterised by a severe , pounding headache with paroxysmal HTN , profuse diaphoresis , nausea , nasal congestion & bradycardia . • Place the patient in sitting position to lower BP • Empty the bladder immidiately • The rectum is examined for rectal impaction or masses.
- 49. 8. Monitoring &managing potential complications • Record the circumference of thighs & calves daily • Provide anticoagulants as per prescription • Provide ROM exercises , antiembolism stockings & adequate hydration . • Pneumatic compression devices may also be used to reduce venous pooling & promote venous return. • Provide education .
- 50.
- 51. • compression ofthe cord and its nerve roots may result from tumor, lymphomas, or intervertebral collapse. • Potentially leading to permanent neurologic impairment and associated morbidity and mortality. • The prognosis depends on the severity and rapidity of onset. About 70% of compressions occur at the thoracic level, 20% in the lumbosacral level,and 10% in the cervical region.
- 52. • Metastatic cancers(breast, lung, kidney, prostate, myeloma, lymphoma) and related bone erosion are associated with spinal cord compression.
- 53. Clinical menifestation • Localinflammation, edema, venous stasis, and impaired blood supply to nervous tissues • Local or radicular pain along the dermatomal areas innervated by the affected nerve root (eg, thoracic radicular pain extends in a band around the chest or abdomen) • Pain exacerbated by movement, coughing, sneezing, or the Valsalva maneuver Neurologic dysfunction, and related motor and sensory deficits (numbness, tingling, feelings of coldness in the affected area, inability to detect vibration, loss of positional sense) • Motor loss ranging from subtle weakness to flaccid paralysis • Bladder and/or bowel dysfunction depending on level of compression (above S2, overflow incontinence; from S3 to S5, flaccid sphincter tone and bowel incontinence)
- 54. Diagnosis • Percussion tendernessat the level of compression • Abnormal reflexes • Sensory and motor abnormalities • MRI, myelogram, spinal cord x-rays, bone scans, and CT scan
- 55. Medical management • Radiationtherapy to reduce tumor size to halt progression and corticosteroid therapy to decrease inflammation and swelling at the compression site • Surgery only if symptoms progress despite radiation therapy or if vertebral fracture leads to additional nerve damage • Chemotherapy as adjuvant to radiation therapy for patients with lymphoma or small cell lung cancer
- 56. Nursing management • Performongoing assessment of neurologic function to identify existing and progressing dysfunction. • Control pain with pharmacologic and nonpharmacologic measures. • Prevent complications of immobility resulting from pain and decreased function (eg, skin breakdown, urinary stasis, thrombophlebitis, and decreased clearance of pulmonary secretions). • Maintain muscle tone by assisting with range-of motion exercises in collaboration with physical and occupational therapists.
- 57. • Institute intermittenturinary catheterization and bowel training programs for patients with bladder or bowel dysfunction. • Provide encouragement and support to patient and family coping with pain and altered functioning, lifestyle, roles, and independence.