Spinal Cord Injury

 Definition: 

    Spinal cord injury is an insult to the spinal cord resulting on a change, either temporary or permanent, in its normal motor, sensory or autonomic functions.

  Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons.

Causes: 

Common causes are,

1. Motor vehicle accidents
2. Falls
3. Act of violence
4. Sports and recreation injuries
5. Alcohol
6. Diseases such as cancer, arthritis, osteoporosis and inflammation of the spinal cord

Signs and symptoms: Signs and symptoms of the spinal cord injuries depend on the type of injury.

Types of Spinal Cord Injuries:

    Spinal cord injuries are divided into complete and incomplete injuries.

Complete Spinal Cord Injury: Result in total loss of sensation and movements below the site of injury 

Incomplete Spinal Cord Injury: Do not result in complete loss of sensation and movements below the injury site .There ate many types of Incomplete Spinal Cord Injuries. They are

1. Anterior Cord Syndrome:

• Results from damage to the motor and sensory pathways in the anterior areas of the spinal cord.
• Motor function, pain and temperature sensations are lost below the level of injury but the sensations of position, vibration and touch remain intact.

2. Central Cord Syndrome:

• Results from injury to the central portion of the spinal cord.
• Loss of motor function is more pronounced in the upper extremities and some experience considerable recovery in the first 6 weeks following the injury.

3. Brown - Sequard Syndrome:

• Results from injury to the right or left side of the spinal cord
• Motor function, vibration, proprioception and deep touch sensation are lost on the same side of the body (ipsilateral)
• Pain, temperature and light touch sensation are lost on the opposite side of the body (contralateral) because these pathways cross in the spinal cord

4. Posterior Cord Syndrome:

• Results from injury to the posterior portion of the spinal cord
• There will be good motor function pain and temperature sensation, but loss of vibration, proprioception and deep touch sensation

5. Cauda Equina Syndrome:

• Results from injury to the lumbosacral nerve roots below the conus medullaris
• Patient experiences areflexia of the bowel , bladder and lower reflexes
• In some cases nerves regrow and function is recovered

Paralysis occuring as a result of spinal cord injury may be referred as,

• Tetraplegia or quadriplegia - means the arms, hands, trunk , legs and pelvic organs are all affected by the injury
• Paraplegia- means the paralysis affects all or part of the trunk, legs and pelvic organs

Spinal cord injury of any kind may result in, 

1. Loss of movement
2. Loss of sensation, including the ability to feel heat, cold and touch
3. Loss of bowel and bladder control
4. Changes in sexual function, sexual sensitivity and fertility
5. Pain or an intense stinging sensation caused by damage to the nerve fibres in the spinal cord
6. Difficulty in breathing, coughing or cleaning secretions from the lungs

Emergency signs and symptoms of spinal cord injuries after an accident may include,

• Extreme back pain or pressure in the neck, head or back
• Weakness, incoordination or paralysis in any part of the body
• Numbness, tingling or loss of sensation in the hands, finger, feet or toes
• Loss of bladder or bowel control
• Difficulty with balance and walking
• Impaired breathing after injury
• An oddly positioned or twisted neck or back

Note: If someone has a back or neck injury;-

1. Do not move the injured patient - Permanent paralysis and other serious complications may result
2. Keep the person still and place heavy towels on both side of the neck or hold the head and neck to prevent them from moving until emergency care arrives
3. Provide basic first aid such as measures to stop any bleeding and making the person comfortable, without moving the head or neck

Complications: Complications related to spinal cord injury include, 

• Respiratory failure
• Autonomic dysreflexia
• Spinal shock
• Further cord damage

Tests and Diagnosis:

1. Physical examination
2. CT and MRI scan
3. ABG measurement - evaluate adequacy of oxygenation and ventilation
4. Lactic acid levels- indicate the presence of shock
5. Complete blood count
6. Urine analysis- to detect any associated genitourinary injury

Management : 

  

   Spinal cord injury is a medical emergency and urgent medical attention is critical, to minimize the effect of any head or neck trauma.

   The treatment of spinal cord injury often begins at the scene of the accident

Prehospital Management:

1. Immobilize the head and neck with hard towels on the either side of the neck or using cervical collar if available
2. Transport the patient to the emergency room in a spine extended position

Emergency Room Management:

1. Assessment and management of airway breathing and circulation takes place.

  

   Airway and Breathing Management:

• Suction of oral secretion is essential to maintain airway patency. In some cases insertion of an oral airway is needed to maintain a patent airway
• Intubation and mechanical ventilation is needed in severe cases.

   Circulation:

  

1. Assess the pulse rate and blood pressure
2. Assess for any signs of shock such as hypotension, tachycardia and a weak and thready pulse
3. Administer IV fluids

2. Immobilize the neck of the patient to prevent further spinal cord damage

3. Patient may be sedated so that he /she does not move and sustain more damage whole undergoing diagnostic yests for spinal cord injury

4. If the patient has a spinal cord injury then the patient is admitted in intensive care unit

In Intensive Care Unit:

• Corticosteroids such as dexamethasone and methylprednisolone are given to reduce the swelling around the spinal cord
• Immobilization: Patient may need traction to stabilize the spine and to bring the spine to proper alignment or both
• Surgery- Often surgery is necessary to remove fragments of bones, and to stabilize the spine to prevent further pain and deformity
• Rehabilitation: Rehabilitation team will begin to work when the patient is in early stage of recovery

Nurse's Interventions:

1. Emergency management is critical because improper movement can cause further damage and loss of neurological function
2. Assess the respiratory pattern and maintain a patent airway
3. Monitor vital signs
4. Immobilize the patient on a spinal back board with the head in a neutral  position
5. Prevent head flexion, rotation or extension
6. Maintain an extended position by giving skeletal traction via skull tongs or halo traction
7. Patient should be in supine position
8. Monitor arterial blood gas levels and maintain mechanical ventilation if prescribed to prevent respiratory arrest especially with cervical injury
9. Assess for signs of shock such as hypotension, tachycardia and a weak thready pulse
10. Assess for any signs of hemorrhage or bleeding around the fracture site
11. Apply DVT stocking to the patient as prescribed
12. Assess the neurological status of the patient and assess the motor and sensory status to determine the level of injury
13. Monitor for signs of spinal shock and autonomic dysreflexia
14. Assess for pain and initiate measures to reduce pain
15. Prepare the patient for decompression laminectomy, spinal fusion or insertion of instrumentation or rods if prescribed 
16. Monitor for bowel sounds and assess for paralytic ileus
17. Maintain adequate fluid intake of 2000 ml /day and monitor for any urinary tract infection
18. Assess skin integrity and turn the patient every 2 hrs
19. Encourage the patient to express feeling of anger and depression
20. Instruct physiotherapy with the help of a physiotherapist when the patient starts recovering 

Autonomic Dysreflexia:

 

     This is a syndrome of massive imbalanced reflex sympathetic discharge occuring in patient with spinal cord injury above the T5 - T6 level.

     Usually caused by visceral distension from a distended bladder or impacted rectum

       The patient will have sudden rise in systolic and diastolic blood pressure, profuse sweating above the level of lesion, goose bumps above the level of lesion , flushing of the skin above the level of lesion, blurred vision and nasal congestion.

Management:

1. Assess the cause and remove the stimulus
2. Raise the head end of the bed to a high Fowler's position
3. Loosen tight clothing
4. Monitor blood pressure every 15 minutes
5. Assess fo bladder distension and prepare for urinary catheterization. If the urinary catheter is in-situ then check for kinks, in the tubing and for drainage 
6. Assess for any fecal impaction and dis-impact immediately
7. Administer antihypertensives as prescribed

Spinal cord:

    A sudden depression of reflex activity in the spinal cord occuring below the level of injury is called spinal shock.

    Occurs within first hours of spinal injury and can last up to 6 weeks.

  The muscles become completely paralyzed and flaccid and reflexes are absent.

  Spinal shock ends when the reflexes are regained.

Management:

1. Monitor for hypotension and bradycardia
2. Monitor for reflex activity
3. Assess bowel sounds
4. Monitor for bowel and urinary retention
5. Provide supportive measures as prescribed based on the presence of symptoms
6. Monitor for return of reflexes