SPINAL CORD INJURY

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INTRODUCTION

Spinal cord injury is major health problem. The most common causes of spinal cord injury are road traffic accidents,,falls,violence related injuries, sports related injuries etc...The vertebrae most frequently involved are 5^th,6^th,7^th cervical vertebrae(neck)(C5-C7) and 12^th thoracic vertebrae(T12)and the first lumbar vertebrae(L1)These vertebrae are most commonly affected because there is a greater range of motion in the vertebral columns in these areas. The risk factors are age,gender,alcohol and drug use.

 

CLASSIFICATION OF SPINAL CORD INJURIES

• Primary injury-It is as a result of initial insult or trauma and is usually permanent.
• Secondary injury-It may be as a result of contusion or tear injury in which nerve fibres begins to swell and disintegrate. A secondary chain of events produces ischemia,hypoxia,edema and hemorrhagic lesions which results in destruction of myelin and axons. These secondary reactions are reversible during 4to 6 hours after the injury. Early treatment is needed to prevent partial damage from developing into total and permanent damage.

CLINICAL MANIFESTATIONS

• Manifestations depends on the type and level of injury. Incomplete spinal cord lesions are classified according to the area of spinal cord damage, the central,lateral,anterior or peripheral. Neurological level refers to the lowest level at which the sensory and motor functions are normal
• Below the neurological level there is total sensory and motor paralysis.
• Loss of bladder and bowel control(usually with urinary retention and bladder distension)
• Loss of sweating and vasomotor tone and mass loss of blood pressure from loss of peripheral vascular resistance.
• A complete spinal cord lesion can result in paraplegia(paralysis of the lower body)and tetraplegia and also quadriplegia(paralysis of all the four extremities).
• If the patient is conscious he may complaint about acute pain in the neck or back. Often patient speaks about the fear that his neck or back is broken.
• Respiratory dysfunction is related to the level of injury.The muscles contributing to the respiration are the abdominals and intercoastals(T1-T11) and the diaphragmatic(C4).

PATHOPHYSIOLOGY

Damage to the spinal cord ranges from transient concussion(from which the patient fully recovers)to contusion laceration or compression of the cord substance(either alone or in combination)to complete transaction(severing)of the cord which renders the patient paralyzed from the level of injury.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• Neurological examination.
• CT Scan and MRI.
• A Myelogram is used to visualize the spinal axis.
• Continuous ECG monitoring is needed because bradycardia(slow heart rate)and asystole(cardiac standstill)are common in patients with spinal cord injury.

EFFECTS OF SPINAL CORD INJURY

Central cord syndrome-It is characterized by motor deficits (in the upper extremities when compared to the lower extremities)bowel or bladder dysfunctionis variable or function may be completely preserved.
CAUSE-Injury or edema to the central cord usually of the cervical area.May be caused by hyperextension injuries.
Anterior cord syndrome-It is characterized by loss of pain,temperature and loss of function.loss of motor function is noted below the level of lesion.
CAUSE-It is caused by acute disc herniation or hyperflexion injuries associated with fracture dislocation of the vertebrae.It may be also as a result of the injury to the anterior spinal artery which supplies anterior two thirds of the spinal cord.
MEDICAL MANAGEMENT-The goal of medical management is to prevent further injury and to observe for symptoms of progressive neurological deficits.Patient is resuscitated if necessary and oxygenation and cardiovascular stability is maintained.
High doses of corticosteroids superficially,methylprednisolone,improves motor and sensory functions at 6 weeks,6 months and one year.
RESPIRATORY THERAPY-Oxygen is given to maintain a high partial pressureof oxygen because hypoxemia can worsen the condition.It endotracheal intubation is needed extreme care is given to prevent flexion or extension of the patients neck which can result in cervical injury.Diaphragmmatic pacing(electrical stimulation of the phrenic nerve)attempts to stimulate the patients diaphragm to help the patient brethe.
 
COMPLICATIONS-

• spinal or neurogenic shock,
• Deep vein thrombosis,
• Respiratory complications(respiratory failure,pneumonia),
• Autonomic dysreflexia(characterized by headache,
• profuse sweating,nasal congestion,piloerection(goose bumps),
• bradycardia and hypertension.
• Infection(Urinary,respiratory and local infection).

SKELETAL FRACTION REDUCTION AND TRACTION

• Management of skeletal fracture reuction and traction requires immobilizatioin and reduction of dislocations(restoration of normal position)and stabilization of the vertebral column.Cervical fractures are reduced and cervical spine is aligned with some form of skeletal traction such as skeletal tongs or callipers or with the use of halo device.

SURGICAL MANAGEMENT

Surgery is indicated when the compression to the spinal cord is evident.The injury results in fragmented or unstable vertebral body.The injury involves a wound that penetrates the cord.Bony fragments are usually seen in the spinal cord.Patients neurological status will be deteriorating.Surgery is performed to reduce the spinal fracture or dislocation or to decompress the cord.Laminectomy is indicated in the presence of progressive deficit,epidural hematoma,bony fragments or penetrating injury.

EMERGENCY MANAGEMENT

• Initial care must include a rapid assessment,immobilization or control of life threatening injuries and transportation to the nearest medical emergency.
• At the scene of injury the patient s neck should be immobilized on aspinal backboard.One member of the team must prevent the patient s head from flexion,rotation or extention.This can be done by placing hands on both sides of the patients head at the ear level to limit the movement and to maintain alignment.Any twisting movement irreversibly damages the spinal cord.
• The standard care is that the patient has to be transferred to a regional spinal injury center because multidisciplinary persons and support services are required to prevent damage that can occur within 24 hours.
• No part of the body is twisted or turned,the patient is not allowed to sit.
• Patient can be placed on a rotating bed,if rotating bed is not available a cervical collar can be given to the patient.

ASSESSMENT

• The breathing pattern is observed, the strength of coughing is noted and lungs are auscultated because paralysis of the abdominal and respiratory muscles diminishes the coughing and makes the clearing of the bronchi difficult.
• Motor for changes in the motor and sensory function.
• Assess for edema of the spinal cord.
• Motor ability is checked by asking the patient to spread the fingers and squeeze the examiner’s hand.
• Sensation is evaluated by gently pinching the skin or touching it lightly with an object such as tongue blade. Patient’s eyes are closed and asked where the sensation is felt.
• Any decrease in the neurological function should be reported.
• The lower abdomen is palpated for urinary retention and distension of the bladder.
• Temperature is noted because the patient may have hyperthermia as a result of alteration of temperature control.

NURSING DIAGNOSIS

• Ineffective breathing pattern related to weakness or paralysis of the abdominal and intercostals muscles and inability to clear the secretions.
• Ineffective airway clearance related to weakness of intercostals muscles.
• Acute pain and discomfort related to treatment and prolonged immobility.
• Impaired physical mobility related to motor and sensory impairments.
• Disturbed sensory perception related to motor and sensory impairment.
• Risk for impaired skin integrity related to immobility and sensory loss.
• Impaired urinary elimination related to inability to void spontaneously.
• Constipation related to atonic bowel as a result of autonomic distruption

COLLABORATIVE PROBLEMS AND POTENTIAL COMPLICATIONS

DVT,Orthostatic hypotension.

NURSING INTERVENTIONS

Promoting adequate breathing and airway clearances-

• Measure the vital capacity, monitor oxygen saturation through pulse oxymetry and monitor ABG values.
• Vigorous attention for clearing bronchial and pulmonary secretions
• Suctioning is indicated but it should be done cautiously because this may stimulate the vagus nerve and causes bradycardia.
• If the patient cannot cough chest physiotherapy is given.
• Proper humidification and hydration is essential to prevent secretions from becoming thick and difficult to remove.
• Patient is assessed for signs of infection(eg:cough)
• Smoking is discouraged because it increases bronchial and pulmonary secretions.

 
Improving mobility

• Proper body alignment is done all the time.
• The patient is repositioned frequently and assisted out of the bed as soon as possible once the spinal cord is stabilized.
• Feet is prone for foot drop so splints are used.
• Contractures(A joint that is immobilized for a long time becomes fixed due to contractures)can be prevented by range of motion exercises.

 
Promoting adaptation to sensory and perceptual alterations

• The intact senses above the level of injury is stimulated through touch,aromas,flavourful beverages, conversation and music.
• Provide prism glasses to enable the patient to see in supine position.
• Encouraging use of hearing aids if indicated to enable the patient hear conversations and environmental sounds.
• Provide emotional support to the patients.
• Teach the patient to compensate for the losses.

 
Maintaining skin integrity

• Pressure ulcers will develop within 6 hours where there is continuous pressure and where there is continuous pressure and where peripheral circulation is inadequate. The most common sites includes ischial tuberoisity,The greater trochanter,the sacrum, the occiput(back of the head).Patient who has cervical collar for prolonged periods of time develops breakdown from the pressure collars under chin, on shoulders and occiput.
• Patient is turned every 2 hours to prevent pressure ulcers and pooling of blood and edema in dependant areas.
• Careful inspection is made every time the patient is turned.
• Skin over the pressure points is assessed for redness or breaking, perineum is checked for soiling and the catheter is checked.
• Special attention is given to the areas which are in contact with the transfer board.
• Patients skin should be kept clean by washing with mild soap.
• Patients body alignment and posture should be assessed
• Pressure sensitive areas are lubricated and softened with hand crème or lotion.
• Educate patient about the importance of providing skin care.

 
Maintaining urinary elimaination

• Intermittent catheterization is done to prevent bladder distension.
• The family members are shown how to cjatheterize the patient.
• Record the fluid intake,voiding pattern,characteristics of urine,unusual sensation etc..

 
Improving the bowel function

• Bowel activity is maintained.It usually return back to the normal state within one week.As soon as the bowel sounds are heard provide high calorie,high protein and high fibre diet.Provide stool softeners.

Monitor for complications

• THROMBOPHLEBITIS-
• ORTHOSTATIC HYPOTENSION

EXPECTED OUTCOMES

• Demonstrates improvement in the gas exchange and clearance of secretions as evidenced by normal breath sounds or auscultation.
• Moves within the limits of dysfunction and demonstrates completion of exercises.
• Demonstrates adaptation to sensory and perceptual alteration.
• Demonstrates optimal skin integrity.
• Regains urinary bladder function.
• Regains bowel function.
• Reports absence of pain and discomfort
• Patient is free from from complications.
• Exibits no manifestations of pulmonary embolism(eg...chest pain and shortness of breath)
• Maintains BP within the normal limits.
• Reports no light headedness with position changes.

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