Spinal Cord IssuesA. Leah Kelly, EdD, APNC

The Cord* Two views

The Cord* What’s in the cord?

* 33 vertebrae to protect and support

* 7 cervicals-neck, most unstable

* 12 thoracics- chest

* 5 lumbars- support back- again pain

* 5 sacrals

* Coccyx

* Vertebrae separated by discs- shock absorbers

* Inner core of disc is NP

* Cord has CSF & meninges

* Contains ascending sensory & descending motor tracts

Cord in sections* 4 basic divisions

* Cervical

* Thoracic

* Lumbar

* Sacrococcygeal

* Intervertebral discs wh absorb shock, resist compression, allow flexibility

Cord Problems* From progressive

neuropathy,Osteoporosis

* Cancer,Lower back pain with muscle strain- pain worse oft at rest

* So get locus, radiation, duration of pain, paresthesias, muscle weakness and report anything rapid or worsening

Damage Temp or Perm* Related to level and area of

injury

* Cervical issues =some degree quadriplegia

* T/LS injury= varying degrees of paraplegia

* Need to worry about this in falls, trauma, mets>> get baseline and then address change

* X-Ray tells fx; CT tells cord edema; MRI tells degree/locus of compression injury

Cord Psychosocial* Will always give change in

body image and perception

* What happens with mobility issues

* What about self concept & powerlessness

* Anxiety

* Can also alter family structure, home management, adls

Congenital Problems* Will also be addressed in

Pedi

* Spina Bifida, Meningocele, Meningomyelocele

* Congenital deficits of neural closure

* Normal bones and meninges but bony structures are abnormal

* Can be the whole cord or just a small area

Spina Bifida Occulta* Failed closure at arches but

no cord herniation

* Not visible except as a dent of pimple

* Few physical manifestations - occ gait, bowel or bladder problems

With bigger problems* Have both sensory and

motor problems

* If below L2 are flaccid, areflexic with lower extremity paralysis

* Oft overflow incontinence of bladder and bowel

* If below S3 will have no motor impairment but still have bladder issues

Meningocele* Sac is filled with spinal fluid-

looks like a cyst

* Mass will transilluminate

* May see this on prenatal ultrasound

* Will also see > AFP so now know ahead of time

Meningomyelocele* This is worse with protrusion of

meninges, fluid and cord

* Very disrupted

* Will have neurogenic bladder & oft ongoing UTIs

* May need intermittent cath programs

* Surgery later with artificial sphincters

* Probanthine, urecholine as pt ages

Care in these* Genetic c viral trigger-

* so counseling

* Most lumbar & oft assoc with hydrocephalus, scoliosis and congenital hip issues

* Goal > prevent infection, > safety, maintain tissue perfusion

* In parents- issues will be psych

Care in these* Keep sac sterile & moist

* Saline towels to cover-occ silver nitrate

* Q 2 hr checks -? leak, irritation & infection

* Keep Prone pre-op to prevent pressure on sac

* No diaper either but touch for bonding

Hydrocephalus* See c previous- if before suture

close, then skull can expand and will not herniate

* As usual worse danger is if CSF accumulates too rapidly- from blockage or defective reabsorption

* See with trauma, infection, genetics

* Will need to shunt this- place ventriculostomy

Hydrocephalus and shunt* This is before fontanelles

close

Lower back pain* Covered in ortho- everyone

gets it once

* 80% of adults c 1 + episodes- 5% of all doc visits> leading cause of job disability

* 90% resolve in 6 weeks c/s Tx

* 5-10% will need surgery

* Red flag> immed MRI

* Sudden weakness, anesth, bowel/bladder stuff get MRI

* Recent trauma with back injury- had films

* Ca or infection> get CBC, UA

Sciatica* Pain in lower back, radiating

down posterior, lateral thigh

* Only 45% will have herniation detectable on xray- pain can be severe, functionally limiting- usu worse in leg

* Straight leg test is most sensitive- supine or seated- pain at 30-70 degrees of hip flexion- then do crossed leg- lift opp leg & get pain in affected leg

locus* L3-4> ankle dorsiflexion,

sensory loss at medial malleolus

* L4-5> great toe dorsiflexion, middle metatarsal sensory loss

* L5-S1- ankle plantar flexion with sensory loss on side

Sciatica* Improves in 90% at 6

weeks

* Bed rest is out- mobility in

* No steroids, opiates initially but not chronically- !!!!!

* If not better in 6 weeks then get MRI

So do you have it yet* Remember- muscles,

nerves, bones

MRI cross sectionHerniated Disc

* Disk is shock absorber to provide a cushion & give flexibility, distributed load

* Gelatinous center surrounded by fibro cartilage ring

* Disk can get weak with age, excess movement

* A rupture will allow gelatinous center to pour out, exude & compress root

Anatomy* many processes protruding

from vertebral segments.

* The facet joints are held together with capsular ligaments.

* The spinous processes are held together by the interspinous ligaments.

Anatomy* The facet joints > held together -

capsular ligaments.

* The spinous processes > held together by inter-spinous ligaments.

* The transverse processes are secured by the intertransverse ligaments and membrane.

* anterior & posterior longitudinal ligaments running along the front and bock of the vertebral bodies, respectively, holding the bodies together.

* All held in place by the extensive muscular network of the low back, clearly seen above.

HNP happens* Could be at any level but in

general where the spine has most movt- at L4-5 or L5-S1

* Other issues are at C5-7

* In anyone with active life, falls

* Poor abdominal tone

* Risk factors

Disc herniateAssessment for disc

* Sx: low back pain radiating down thigh oft down 1 dermatome

* Pain is sharp, numbing, stabbing, burning oft with paresthesias

* Oft a while after injury

* See muscle spasm

* If herniate centrally may get issues with urination, incontinent or impotence

* Aggrav with strain, cough, straight leg raising,

diagnostics

* Can tell best with MRI- hi res, contrast or not but what will insurance company bear- super details of nerves

* SPECT- can distinguish benign from malignant lesions- technetium or gallium scan that gets uptake in hydroxyapatite crystals in new bone- tells tumors, fx, mets

Tests* XRAY-lateral x ray of lumbar

spine - excellent for determining alignment > tells Compression fractures, collapse of the disk spaces

* Myelogram>LP c dye if MRI inconclusive shows lateral or central herniation - also if cannot do MRI- contrast into subarachnoid space- can irritate

Discogram* A discogram = study of radio

opaque dye injected into the disk space.

* both anatomical study & functional study.

* looks at anatomy of disk space > can show when dye leaks through rents in the annulus fibrosis.

* Also functional test > patient reports, on a scale from 1 to 10, how much pain has been produced.

Disc neck pain* May see as numbness or

pain in arms, shoulder or occiput

* Can radiate to hands/fingers

* Neck movement restricted > mobility, spasms

* Weak biceps, triceps

Dermatomes* Levels of nerve distribution

* Damage follows the levels

Feet issues* Sensory loss

* Paresthesias

* Motor problems

Cord sensory loss* As it comes up to parietal

thru cord

IDET

* IDET =intradiscal electrothermoplasty. to reduce or eliminate back pain caused by disc degeneration.

* uses heat to seal cracks or fissures in the disc wall, thus reducing bulging of inner disc material & impingement on nerve diminishes

* done outpatient c local anesthesia

Other treatments

* http://www.spineandscoliosi s.com/animation.php?pn=artificialdisc

* http://www.spineandscoliosis.com/animation.php?pn=discmicro

Blue hand dilantin* Added it

Red Flags* Fecal incontinence, saddle

anesthesia and urinary retention> cauda equina sndrome

* Fxp from steroids, infection, osteoprorosis

The PE* Diminished reflexes

* Paresthesias in dermatomes

* Cannot straight leg raise without pain & cannot dorsiflex the foot

Or Lumbar Stenosis* Under pressure

Lumbar or spinal stenosis

* narrowing of space thru wh nerves go to legs

* Gets smaller if bone there grows

* Causes leg pain, mobility problems

* Arthritis, falls, wear cause it- get back pain,leg pain, weakness

* Pain worse with activity- tx exercise, PT, surgery to open up canal

Spinal stenosis* Affects 1.2 million- oft from

degeneration

* Pain described as problem when exercise- pain is burning, cramped, weak, a neural claudication- may feel better if get in fetal position- to open space

* Few studies but epidurals do not help- expect surgery in moderate pain or at least a neurogenic regional block

Spinal stenosis* Can treat with pain meds or

decompression surgery

* Local anesthetic block

* Seems best results after surgery

* New procedure- MILD- min invasive decompression- device to elim compression* http://www.mildprocedure.co

m/the-mild-procedure.html

Mild procedure* http://www.youtube.com/wa

tch?v=fE8BJMJmjM0

* http://www.youtube.com/wa tch?v=QMee68ZuRIo

Tx Disc

* Conservative Tx is best & first- no longer a long time of bed rest now up and moving

* Deep ultrasonic heat, exercise, progressive muscle work, energy, massage, ice to reduce spasm

* Bed avoid prone and pillows

* Williams position

* PT for back class and exercises

* Roll to move- log roll

Back Class* Stretch- proper body

mechanics

* The way to bend

* Review the mobility video

* Strengthen abdominal muscles- sit ups, crunchers, pelvic tilts, gluteal sets

* Sit with knees higher than hips

PostureMeds for low back pain* Analgesics> Tylenol, NSAIDS

for reduced inflammation

* Muscle relaxants>all reduce spasm, watch drowsiness, fatigue, dry mouth

* Steroids

* Facet joint injections

* Epidurals

* Trigger point injections

* Lidoderm patches

Back Surgery* For scoliosis, tumors, HNP,

fusions for instability

* Discectomy, laminectomy, * Percutaneous, laser varies

with site and doc

* Chymopapain injections now in Canada

* Again now need lots of approvals

Laminectomy* Remove posterior arch of

vertebrae

* Fusion = to ensure stability by inserting bone grafts into interspace and immobilize the area

* Will do this when conservative Tx ineffective

* Pre-Op> usu now is EMA so will need good teaching

* assessment is get baseline of pain, motor, sensory function

* Teach roll, turn cough deep breathe

Post Op Laminectomy* Vitals, movement, voiding, pain,

sensation

* Cervical

* Flat, worry for laryngeal nerve damage

* Hoarse, difficulty swallowing, signs of dependent bleeding

* Lumbar

* Oft flat in bed for period of time, log roll

* Check for bleeding, paresthesias

* Will log roll in 1st 2 hrs- flat minimizes CSF leakage

* Keep pillow between legs, arms across chest

Post op Laminectomy* Care is changing and oft varies

with surgeon- may stay 48 hrs or go home at 24

* Always get OOB on 1st day so need to pay close attention to body mechanics

* You need specific positioning orders

* Log roll with extra help

* Cervical fusion will need to watch swallow, increasing edema, stridor, distress

Specific Lami assessments* Watch for new or increasing

neuro deficits and report promptly

* If anterior cervical discectomy> assess ability to breathe and watch for resp paralysis

* Watch for CSF leakage, hemorrhage- the checks are for motor and sensation q 2-4 hrs

* Edema could worsen SX

* Can also get pain and spasm wh is depressing to pt as thought this would end with surgery

* Import of maintaining alignment

Teaching Laminectomy* Body mechanics

* Seat belts

* Wt loss

* Williams exercises- pelvic tilt, knee chest, nose to chest

* crunches

Disc surgeries* http://www.youtube.com/wa

tch?v=pAwod39nlFo&feature=related

* http://www.youtube.com/wa tch?v=EvQPZxXr3Rs

* http://www.youtube.com/watch?v=fL3V1Z7BehQ&feature=related

SCI Spinal cord injury

* Every year there are 14,000. Esp in age 16-30 group more in men, risky business

* 35% are MVA, 20% are falls, 30% violence

* 33% are thoracic/cervical

* Mostly young men in July

* Cervicals become quadriplegics or tetraplegics- these are most common

* Also related to knives, guns, osteoporosis, tumors, vasc disease with infarcts

Some at Health South* These come form mild flexion

-extension issues

* Whiplash to complete transections

* Any level but particularly C-spine C1-2, C4-6, T11-12 where spine is most mobile

* Trauma to tissue and then tissue death

* This then becomes a chronic illness or disability

Christopher Reeves* Got a lot of money from NIH

and his foundation so things are moving

* Private money, Medicaid or whatever it will bear

* Group homes - mobilize- can they live alone

* Care is complex, overwhelming, and demanding

* Cost for a quad in 1st year is over $500,000

At Risk* Those with feelings of

immortality, PSA

* Bikes, motorcycles

* Prevention is oft lost on those who need it but better with helmets, seat belts

* Secondary prevention-stabilize cord on scene- so may need to hold traction & avoid twisting

* Tertiary prevention-prevent respiratory, cardiac, urinary compromise, promote skin integrity

The spine* So any

* Or all

* What is innerv

* How impacted

Injury from* Transection

* Compression

* Infarction

* Look at motor and sensory loss

* C1-C4= Quadriplegia- loss of resp

* C4-C5= Quadriplegia- phrenic involved

* C5-6= gross arm movt, diaphragm breathing

* C7-8= Quad> triceps & biceps, no hand

* T1-2= Paraplegia- some intercostal & abd

ASIA classifications* A= complete lesion- no

motor or sensory preserved

* B=incomplete lesion-sensation below lesion but no function or motor behavior

* C= incomplete motor preserved below lesion but non functional

* D=preservation of some motor with reasonable motor function

Terms* Paraplegia- both lower

extremities

* Quadriplegia- involves all 4 extremities

* Complete lesion- above C6 with no potential for independence

* Use of dermatomes to describe the loss- sensory loss to the spinal nerve

* Could be a different level for sensory and for motor

* Damage can be primary or from edema & inflammation > idea of ischemic penumbra again

Cord made of white & gray

* Gray is in inner areas of cord and comprises anterior, lateral and posterior horns- sensory fx arises from dorsal gray matter- ventral gray matter is motor function

* Viscera and body get innervated from this- and activation of symp and paraasym autonomic ns occur in white and gray matter

SNS

* SNS makes catechols for adrenal release> work on rate, ventil, perfusion,

* SNS responses orig in gray matter of cord and go from thoracic to lumbar- damage to cord affects sns response

White matter in cord* Outer c paths for ascending

& descending tracts* Corticospinal tract> motor

activity transmission- orig in brain and crosses over in brainstem to innervate opp side of body

* Spinothalam tract orig in cord- crosses within 2 segments and up to thalamus c pain and temp

* Posterior column relays position, vibration and touch

Spinal nerves * Correspond to spinal &

vertebral segments

* Dorsal roots send sensory input up to CNS

* Ventral roots send motor from cord to body

* Also are plexes to innervate areas

* Cervical for neck’/shoulder, phrenic

Vertebral column* 7 cervicals-neck, most

unstable

* 12 thoracics- chest

* 5 lumbars- support back- again pain

* 5 sacrals

* Coccyx

* Cord is vulnerable so vertebrae supp by ant and post ligamens- to stabilize

* Also stability thru intervertebral discs

Cervical Vertebrae* Must allow head movt-

innately unstable

* Easily rotate, much risk for injury

* Other issues in SCI are related to motor neurons

Upper Motor Neurons

* Upper motor neuron comes down from brain > travels in corticospinal/ corticobulbar tracts

* Synapse with lower motor neurons

* Job to suppress firing of lower motor neuorn

* If no suppression, LMN will fire spontaneousl and lead to spasticity- so UMN controls primitive responses and reflex arcs

* So if UMN is lost – pt gets spastic paralysis coz of hyperactive response of reflex arcs to stim

UMN from motor strip dwn* Comes down from above with

motor output

Lower Motor Neuron* Anterior horn cells that originate

in spinal cord Transmit nerve impulses to nerve & muscle

* These are the motor paths from cord and are the spinal nerves wh supply peripheral nerves

* Impulses from stim outside cord come in thru reflex arc and synapse with these and then go back to muscle

* This reflex arc that control invol response

* Damage then abolishes voluntary and reflex response to muscles/organs

Lower motor neuronBowel & bladder issues* -UMN bowel is reflex

incontinence

* So us suppositories and digital stimulation to initiate defecation

* Stretch initiates peristalsis

* - LMN_ get non reflex flaccid bowel-

* flaccid bowel with urinary retention, overflow incontinence and fecal retention and fecal impaction

* Here need straining of musculature

Pathophysiology* Result of the injury to the

vertebrae

* Think of how the injury happened* Acceleration

* Deceleration

* Compression

* Tearing

* shearing

Hyperextension* Get this in elderly with degen

vertebrae when hit windshield

* Or in a diving injury

* Cord is stretched against ligamentum flavae and get a dorsal column injury with a posterior dislocation

* Or transect cord -

* Will lose all voluntary below and reflexes in the injured segment

Hyperextension InjuryCompression Injury

* Here pt falls on feet or butt

* Fx to vertebrae wh then compress cord

* Fragments jammed into cord- at lumbar/thoracic

* Mostly incomplete injury with edema, bleed with some loss of sensation and function

* Hard to know what will be permanent

* Eventual death at 48hrs & neuron sheath destruction

* Petechial hemorrhage with swelling and diffuse scars

Compression injury

* Two ways

Hyperflexion Injury* How could this be

Lateral injury* With a twist

Flexion-rotation dislocation * turning

Class by level of injury* Level of SCI injury determined

by most distal uninvolved segment of cord

* Function depends on if lesion complete or not

* Incomplete injury> some preservation of sensory, motor or both below level of lesion

* Complete > total loss of motor, sensory or both below injury

* Could be orthopedically at C5 but neurol intact to C6

Types of injury* Complete cord transection

* Flaccid paraly c total loss of motor and sensory below level of injury

* Incomplete injury

* Partial transection of cord- some tracts intact with varying loss of motor and sensory function

Examples* C spine injuries> quads

* C1-C4 =fatal s vent

* Loss of diaphragm innervation and no intercostals so no bellows effect

* Trapezius, sternocleidomastoid, and platysma function

* Sensory loss to occiput, ears and face but will need an attendant for ADLs

* Electric wheelchair with hi back for head , vent or breath control or head and shoulder controls``

Injury at C4

* Here can come off vent for a while

* Have better head control

* Have some diaphragm- but are dependent on others for ADLs,

* Will need electric wheelchair, breath, head and shoulder controls

C5* Where can live c independence

* See intestinal paralysis and gastric dilatation

* Upper extremities rotate out so shoulders are elevated

* May have exagg reflexes below the lesion

* Some sensation in neck and upper arm

* Can do some feeding, writing and transfer

C6* Here still resp distress and

intestinal paralysis

* Lack inhibition of deltoid and biceps so arms must be positioned correctly with forearms in extension and arm in adduction’

* Person does have sensation

* There is more independence and can dress, feed and even drive a car with hand controls

C7* Here can live independently

and transfer

* Perform own ADLs

* Get a fusion

T2-L* These are paraplegic levels

of injury

* Will do diaphragmic breathing with more inspiration depth

* Have postural hypotension

* Have sensory issues with loss of touch, pain and temp

Relook at levels* see

Injuries above T12* These are called upper

motor neuron syndromes

* Pts are spastic and hyperreflexic

Injuries below T12* These are the lower motor

neuron disorders

* These pts have flaccid paralysis and hypo or arreflexia

Spinal cord syndromes* These are incomplete

lesions that have recognizable patterns relative to the area damaged

* Any concussion or bruise could have one of these presentations so the ER nurse needs to assess for this

* Most injury today is partial and 1st hr is crucial

The typical syndromes* Central Cord Syndrome

* Anterior Cord Syndrome

* Posterior Cord Syndrome

* Brown Sequard

* Complete Transection

* Have a familiarity here

Cord loss

Central Cord Syndrome* Central damage in cord as

result of hyperextension & hyperflexion* Also hemorr, contusion,

edema

* Weak to paralyzed arms but oddly no leg or bladder deficits

* Hands weak, some bowel & bladder

* From damage to the cervical tracts

* This is most common injury

Central Cord problemsAnterior Cord Syndrome* Anterior part of cord so get

complete motor paralysis because this takes out the corticospinal tracts

* From Flexion with forward dislocation & damage to ant spinal artery

* Lose pain, temp, and touch as the spinothalamic tracts are knocked out

* Pt retains light touch, proprioception and position sense as posterior columns are spared

Anterior Cord Posterior Cord Syndrome* Hyperextension injury at

cervical spine

* Lose position sense, light touch and vibration sense below the injury

Brown Sequard

* This is lateral hemisection of the cord from a bullet or knife injury

* Get either increased or decrease sensation of pain, temp, touch on the same side as lesion

* Also some motor loss on same side below lesion

* Limb with best motor ability has less sensation

Complete Transection* Immediate loss of sensation

and voluntary muscle below the transaction

* All reflex activity is lost initially

* The reflexes will come back and my be hyperactive because there is no inhibition from above

* Have loss brain influence of cord

* So the spinal automatisms are left to own devices

Same as always* Primary injury with initial

damage

* Secondary injury from cell and vascular changes – edema, lyte issues, release of catecholamines, toxic metabolites, hypoxia

Given all those possibilities* Initial assessment of SCI is

important

* Get ABCs

* Look at neuro signs- alert, responsive

* Check motor and sensory

* ? Incontinence

* Pain

* Will immediately be hypotensive so will need immediate fluids

* Will need a hard C-spine collar til C level injury is eliminated

So Acute Injury Phase* Time is crucial

* Spare the damage

* Acute interventions

Cord presents to ER* Will need CT and

immediate C- spine X-ray

* Watch for hemodynamic and pulmonary instability

* Will do peritoneal lavage to r/o intraperitoneal injury- is it bloody?

* ? Flexor withdrawal, reflex emptying of bowel/bladder

Will need Immediate Immobilization

* Allow no flexion or rotation

* All needs to be in neutral position in alignment

* Make sure have a rigid cervical collar in place- tape head to board

* Then place on some sort of Stryker, Rotorest to ensure contd immobilization

DX test* Xray is key test

* C Spine and then thoracic, lumbar and sacral

* Protect pt during xray process

* Mri ok for soft tissue damage

* CT for extent of injury

So then- you the nurse* Get Hx - vitals, odors, do

thorough neuro exam

* Get chest injury films

* NG or Foley now but careful insertions

* Digital rectal exam to tell if complete injury

* Incomplete injury if can feel finger or can contract rectal sphincter

* This is a better prognosis

More immediate care* First hour counts- influences

the extent of injury and deficits

* Immobilize on firm surface

* ? Other injuries- DPL

* Turn with others using logroll

* Watch for any respiratory distress-C3 is level of phrenic nerve-

* IV fluids> pump, I&O as pt is in spinal shock and this will maintain perfusion

Early Neuro Exam* What sensation and what

motor is present

* Think and document by dermatomes

* Look for symmetry

* What is spared and what is retained* Document locus, symmetry,

strength

* Look at spontaneous movement, response to pinprick

In Any C injury* Place in Halo or tongs-

Gardner Wells, Crutchfield etc- tongs becoming obsolete

* Skeletal traction to immobilize spine

* Reduce fractures with some 10-20 lb wts

* Keep body in good alignment

Tongs

* Tippy Wells Gardner Wells

Drugs in early SCI* Osmotic Diuretics

* Antacids- PPI, H2

* Vasoactive blood pressure support-dopamine

* Steroids- oft with Solumedrol at 30mg/kg

* Prevents lipid peroxidation, prevents calcium buildup, glutamate antagonists

* Urinary anti-infectives

* Anticoagulants-

* Laxatives- stool softeners

* Antispasmodics- like Lioresal

High dose initial steroids* Methylprednisolone- IV 30

mg/Kg/ bolus followed by 5.4 mg/kg/hr for 23 hrs

* Improves neuro recovery if get within 8 hrs of injury- evidence based

* And can continue for up to 48 hrs

* Reduces edema, reduces wbc in area, inhibs breakdown of phospholipids- > blood flow and blox inflamm cascades

More Initial Tx* Will also need aggressive

respiratory therapy- hi levels will be on vent

* NG decompression of stomach during spinal shock phase

* Bladder decompression in early phase

* Start initial PROM on all joints then move to active ROM

* SCDS

* Some centers using FES- functional electrical stim to create contraction, relax with hope to walk

* Gene therapy to allow axon growth

Experimental tx* Growing myelin cells in lab

& then transplant into injured area works in animals

* Bone marrow stem cells into CSF migrate to injured area works in animals too

* Also new drug 4AP with signif improvt in sensory and motor function

Biggest initial problem- Spinal Shock* Normal function of cord

depends on contd tonic excitation of nerves that enter cord from higher centers- so no excitability

* Loss of sympathetic transmission leads to unopposed parasympathetic activity

* Blood pools, vasodilate, bradycardia, from reflex vagal stimuli

* This is immediate response to transection

* Gives total loss of skeletal muscle function

Spinal shock is Neurogenic Shock* Arterial BP falls to 40/D

because the SNS is blocked- HYPOTENSION

* Flaccid paralysis without reflexes

* Loss of bowel/bladder tone from sacral reflex blockade

* Loss of sexual function

* Loss of autonomic function

* Loss of venous return so hypotension

* BRADYCARDIA

Spinal Shock* Have lost hypothalamic control

so you can’t use vasoconstriction or increased metabolism

* So client assumes temperature of surrounding air

* Starts within 30 mins-Lasts week to a few months

* Ends when reflexes return

* Had been flaccid> now are hyperreflexic

* So bladder starts to empty reflexly

* Flexors come back 1ts and respond to cutaneous stimulation

* Notice the Babinski

Spinal Shock* Orthostatic hypotension is

big!!! And no ability to respond to compensate for position change

* Getting no vasoconstricting message from medulla

* Will need to treat this with atropine or some vasoconstrictor

Early Surgery* Controversial but common in

university setting

* Also do in any progressive neuro deficit

* Also in any compound fx, and penetrating wounds with fragments

* May have to do a decompression laminectomy

* Remove lamina of vertebrae to min pressure on cord

Early surgery* Or in some settings will do

immediate spinal fusion with plates/screws* Oft use anterior approach so

return with chest tubes

* Log roll, manage pain

Neurosurgery* Oft with cameras

* Fine and delicate

Placing a Halo* Other pts will be immobilized in

halo device

* Fit to skull with pins to maintain alignment

* Need wrench taped to front of jacket for immediate access

* Never hold by rods when turning

* Halo changes center of gravity so also danger of falls, balance

* Pt will need to move as a unit

* Check pins for tightness and report to doc

Halo 2* Clean pin sites BID with

prescribed solution

* Cork pin ends to protect & minimize sound magnification

* Rolled towel behind neck

* 1 finger breadth under vest to avoid breakdown

* Check sheets for drainage

* Encourage to sleep prone with pillows under hips with specific orders from doc

* Keep buckles tight

* Will have to have PT work with positioning

Halo 3

* Danger of resp distress and compromise from hyperextension of neck

* Many think halo will cure any deficits and expect to walk after brace off so need teaching

* Will also have vision obstruction

* Continue to assess for ability of sensation

* Expect post halo depression

Initial Cord Problems* Expect resp issues in hi C

injury

* Always anticipate resp failure- if on vent watch tidal volume, vital capacity, breath sounds

* How is diaphragm, intercostals?

* Also at risk for code, bleed with Lovenox, even quad assist cough like a Heimlich

Initial Cord Issues* Will also have paralytic

ileus and gastric distention which will increase respiratory embarrassment

* Danger of starvation so will have to worry about food

Respiratory Issues early cord* Can also get ascending edema

wh compromises cord so may be on vent for time

* SCI oft has paraly of inspir/exp muscle

* Intercostals are gone

* So are predisposed to atelectasis

* No cough- so hand under diaphragm > push in on exhalation

* Keep suction equip and pulse OX

* Pulmonary toileting, turn, cough, oob

* Who will feed patient

Temperature Control* There is disconnect from

thalamus so poor thermoregulation

* Can’t sweat to get rid of body heat

* Can’t shiver coz no vasoconstriction

* Worse the higher the injury

* Hypothermia/hypothermia

* Try to keep temp at 97

Worry DVT and Circ* Low molec wt heparin

* Teds or SCDs

* Roto-Rest or Passive Motion Beds

* Electrical stim to cause muscles to contract

* Watch pooling and hypotension

Beds- in cord* Roto-Rest

* Stryker

Alt Skin Integrity* Major danger of pressure

sores

* No more than 30 mins til start to breakdown

* Turn q 2 so make a turning sheet and adhere to it

* Get someone to order a kinetic bed

Early Mobility* PROM early to maintain and

prevent contractures

* mid hi sneakers, moon boots to prevent drop as well as splints

* Get PT/OT involved

* If OOB get straight back chair with reposition q 1hrs and check for breakdown

* Braden scale to monitor skin breakdown

Early Meds* IM & SC are not absorbed

well coz no muscle tone so must rotate sites

* Sensation is also limited

* Watch any narcotics so position change is very important

* Best IV site is subclavian- higher flow here & less chance for thrombosis

Constipation

* Start a bowel program immediately

* Look for distention, check bowel sounds

* Watch N,V and fecal impaction

* May need enemas but only small volume enema as atony can result in megacolon

Early Psych* Hope

* Denial

* Family issues

* Stages of grieving

* Don’t ignore it

Chronic Cord* Begins as spinal shock

dissipates

* Pressure and temp is more normal

* Less vasodilated

* Now will look at how much function is present

* What will rehab plan be

* All need family involvement

* All need a motivated client

* REHAB BEGINS AT ADMISSION

SO REFLEXES RETURN* This is not movement - it is

automaticity

The reflex arcs* Which we test

* Or see with stim

Spasms* This will present after a

complete transection

* Will expect painful intense spasms of lower extremities

* Could be from a twitch to wild horrid spasms

* So may have to pad side rails to protect patient

* Spasms are triggered by cold, long sitting, emotion etc

* This is not movement returning

Psych is even more key* Unique to each person

* Patient will go back and forth between stages

* Emotions predominate here

* Shock and disbelief give way to being overwhelmed

* Will I live?, how dependent will I be?

* Staff is overwhelmed too

* Still will be in denial of at least some aspects of situation- will I walk> how can I do it?

Psych* Will also begin to see the

full impact here- severe depression, loss of motivation and any involvement

* Will talk of suicide

* Will need to be mobilized and start to problem solve

* Might get possessive of nurse

* Work on coping skills

The other famous SCI problem* Autonomic Hyperreflexia or

Dysreflexia

* A cluster of clinical manifestations resulting from simultaneous discharge of multiple spinal cord autonomic responses> Massive SNS response

* With HTN, Tachycardia, headache

* See in SCI with injury above T7 for at least 6-15 yrs after injury

* Results from exaggerated sympathetic discharge response to noxious stimuli

* As from bowel/bladder distention. Ulcers, pain, pressure, cramps

* Also form phlebitis, menses, tight clothes, sexual impulses, temp changes

Autonomic hyperreflexia* The blood vessels below the

injury vasoconstrict

* This causes extreme hypertension 130/150

* A pounding headache, flushing, sweating above level of injury

* Nasal stuffiness, blurred vision, Goosebumps

* Nausea, dilated pupils s

So think about AD* Any time the quad feels

weird, upset, looks strange, says “I have a terrible headache”

* What to do is intervene immediately to prevent a CVA, seizures, brain damage

* Intervene and then check it out

* Need outcome of normal BP and no headache, odd feelings

* So remove noxious stimuli

Emergency interventions AD* If you suspect AD raise HOB

immediately to 90 degrees or assist to upright to drop BP

* Remove TEDS, SCDS

* Now check BP and continue q 2-3 mins

* Stay c pt but get help to call doc

* Speed is essential but you stay calm

* No Crede, remove kinks- if no cath may have to immed straight cath if bladder distended

Interventions Autonomic Dysreflexia* Remove noxious stimuli-

* Establish good bowel regime so this doesn’t happen

* Handle pressure areas/ulcers- turn off area

* Loosen clothing, bed sheets

* Check skin surfaces and may need topical anesthetic

* Give ordered antihypertensives- nitrates, Nifedipine (procardia) apresoline

Constipation* Obviously this can become

serious problem

* May need manual dis-impactions,or enema but watch for AD

* If UMN issue will eventually have a reflex bladder so use reflex to help empty- warm drink, increase intraabdom pressure, Crede, insure enough fluid intake, suppositories, anesthetic jelly

* If no risk for AD, can use digital stim and disimpaction

Airway issues* Depends on level of injury

* Goal of RR 12-20, lungs clear, no adventitious

* Head neutral, suction available

* If in halo will need to frequently check breathing, incentive spirometry to encourage

* Assisted coughing as you hold you hand on pt diaphragm and have them exhale as you press up on diaphragm to make forceful cough

Disuse Issues* Will want complete ROM of all

parts

* Position change-

* Hand splints with spasticity issues

* Find out triggers of spasms- cold, anxiety, fatigue, emotion, infection, distention, tight clothes, lack of position change

* Position, ROM frequently, heat, vibration, touch is more firm and deep to prevent spasms

Promote Mobility* Monitor for tendon

contractures, joint ankylosis, muscle shortening

* Supports to match the deficits so appropriate use of adaptive devices

* Cushions to prevent ulcerations

* Proper fitting wheelchairs

* Strengthen muscles and support with braces

* Active and passive conditioning

Muscle Weakness & fatigue* Continue to watch wrists

and foot drop

* Arm slings- a lot is similar to stroke

* Exercise to tolerance- what can pt do

* Wt bear if any possibility- to stimulate osteoblasts* Tilt tables, stand and prone

to prevent hip contractures

* Shoes that fit

Pain* Almost all of these patients

have pain- so pain clinic but danger of opiod dependency

* Dysesthetic pain- distal to injury

* Like phantom pain- disabling

* NSAIDs, elavil, neurontin, lyrica, tegretol,Tens

* Follows the dermatome

* Goal is to verbalize pain relief

Spasticity

* As recovery progresses- get stronger flexors begin to contract and extensor muscle spasms

* Spasticity is increased muscle tone wh results in stiffness

* Can initiate spastic behaviors even with emotion, touch, temp

* Can optimize and recruit spasticity for trunk support, to hold position and to help urinate

Spasticity

* But painful recurrent spasm with forced flexion or adduction of lower limbs can interfere with sitting or ambulating

* Nurses job is to decrease noxious stimulation

* So need ROM- ongoing PT

* Meds> Baclofen, Dantrium, Klonopin ( danger)

Neurogenic Bladder* In early phase were atonic- and

cathed for months with danger or stone, UTI

* Cath was to prevent overdistention

* Now u still check for distention, I&O, asepsis

* Keep urine acidic

* Give enough fluids

* Then now move into 2 types of bladder

* UMN

* LMN

UMN- spastic Bladder* This is spastic reflex bladder

* Will be incontinent, dribbling, oft wet

* Goal it a routine train bladder to void on time or on cue

* This bladder can be TRAINED so won’t need cath

* Tap suprapubic, bear down, lean on commode and anal stretch

* Baclofen helps here

* Valsalva to empty as well

Flaccid Bladder- LMN* This is like an old sac- S

injury from disrupted reflex arcs

* Increase intrabdominal pressure to overcome sphincter

* Crede method

* Or may need intermitt cath

Heterotopic Ossification* Form bone in abnormal loci

like hips and knees

* Note this on bone scan

* Give ROM

* May take med didronel to resorpt bone

What do you think are long term issues* Mainly are disuse

syndromes

* Paralysis, immobilization, spasticity

* Worry decubiti

* Worry UTI

* Prevent spasms-cold, anx, fatigue, infection, ulcers, tight clothes, staying in one space

* Cooling, icing, heat, vibration, massage,

SEX* All think about it but may

not verbalize it directly

* Nurse must address as you are there

* Goal is a personally satisfying relationship* So need to verbalize needs

* If they PICK YOU_ YOU TALK

* And then get some help with what you can’t do

Sex* Will need to examine own

values- elicit pt concerns, ask questions, listen

* Expect acting out- will need to set limits but understand from whence

Sex* Psychogenic erection- from

sexual thoughts- this is lesion above T11-L2- above this will not get idea thru damage

* Reflexogenic erection- this is from penile stimulation - may get with a cath change or bath

* Length will vary as will presentation r/t level of injury

* Cervical and thoracics get better erections

* LS damage may destroy the reflex arc

* Spontaneous erection- oft happens when bladder is full and causes internal stimulation- this is a S2-4 level

Sex and Women* May have trouble with

lubrication, orgasm but generally will ovulate- can become pregnant, deliver vaginally- uterine contractions can cause AD

* Will need to think birth control,

* Worry UTI, pressure sores, anemia

* Labor will be painless or terrible

Goals then* Maintain optimal function

with the most independence possible

* Mobility, transfer, feed, ADLs

* Work, computer

* Normal psych and coping

Spinal Cord Tumors* Or infarcts

* Can be intradural or extradural

* Primary or metastatic

* Prognosis depends on site and type

* If get spinal cord compression will need immediate relief

* Steroids will remove swelling and then get to surgery to decompress

* So how would you know, assess, chart

Spinal cord compression* This is a medical emergency

* Will need OR ASAP

* See in mets from breast, lung, prostate, kidney

* 85% will go to vertebral body

* Get edema, inflammation , nerve entrapment

* Presents as back pain, motor weakness or decreased sensation

* Can take months to develop

Late signs of compression* Motor, sensory, Proprioceptive,

vibration loss

* Dysfunction of bowel/bladder

* All have back pain, usu localized

* Constant pain wh worsen in supine position

* Also burning, shooting

* Motor weakness is heavy, stiff, paralysis, once motor have 75% blockage of cord

* Sensory with paresthesia, decreased temp

* So will need X-Ray, MRI, find those at risk

Tx of Spinal Cord Compression* Steroids immediately

reduce edema

* Radiation therapy to decompress over a 2-4 weeks above and below

* Or surgery

* Will also need pain management* Tricyclics, Dilantin,

neurontin, tegretol

* Prevent neuron firing, potentiate analgesia

* Will also elevate mood

So think rehab* And Health South