SEMINAR

SPINAL CORD INJURIES

If you would seek health, look first
to the spine.

- Socrates
ANATOMY OF NERVOUS SYSTEM
CENTRAL NERVOUS SYSTEM

PERIPHERAL NERVOUS SYSTEM

ANATOMY OF SPINAL CORD
 TYPES OF NEURONS

1. Upper motor neuron (UMN)

a. Modulated by the cerebrum, cerebellum, basal ganglia, reticular neurons
b. Injury = paralysis, hypertonicity, hyperreflexia

2. Lower motor neuron (LMN)

a. Originated in CNS
b. Injury = flaccidity, hyporeflexia, fasciculations
SYMPATHETIC AND PARASYMPATHETIC SYSTEM
FUNCTIONS OF SPINAL CORD
DERMATOMES

1. This describes the area of skin

innervated by sensory axons within
a particular segmental nerve root.
2. Knowledge is essential in
determining
level of injury.
3. Useful in assessing improvement
or
deterioration.
SPINAL CORD INJURIES
DEFINITION
 Classification of spinal cord injury

According to
According to According to
ASIA [American
Cause the area of
Spinal Injury
Association] injury

Primary Secondary
Injury Injury Complete Incomplete Cervical Spine Thoracolumbar
Injuries Injuries

- Central
cord Hyperflexion injuries
Wedge or
- Paraplegia syndromes - Anterior Subluxation Compression
- Tetraplegia - Anterior cord - Teardrop fracture fracture
syndrome - Clay shoveler’s fracture Axial compression
- Brown-Sequard Hyperextension injuries fracture
syndrome - Fracture of the anterior or Flexion-distraction
Posterior Cord posterior arch of C1 mechanism
Syndrome -Laminar fracture Rotational
- Conus Medullaris Axial compression fracture-
- Cauda equina - Burst Fractures dislocation
syndrome mechanism
- Fracture of the pedicle of C2
Flexion Rotation Injuries
MECHANISMS OF INJURY
MECHANISMS OF INJURY
HYPER ROTATION INJURY
COMPRESSION INJURY
Etiology:
National Spinal Cord Injury Database

MVA 44.5%
Falls 18.1%
Violence 16.6%
Gunshot Injuries 11%
Blunt Assault 6%
Diving Accidents 5%
Stab Wounds 4%
Sports 12.7%
55% of cases occur in the 16–30yrs age
81.6% are male!
Etiology:
Other causes:

Vascular disorders
Tumors
Infectious conditions
Spondylosis
Iatrogenic
Vertebral fractures secondary to osteoporosis
Development disorders
Cord Syndromes

● Central Cord
○ Typically fall with hyperextension

○ Elderly

○ Presents with weak upper extremities, irregular bowel,

bladder dysfunction, and disproportionately functional
lower extremities.
Cord Syndromes
● Anterior Cord
○ Primarily a hyperflexion mechanism

○ Anterior segment of the spinal cord controls motor

function below the injury.
Cord Syndromes
● Brown-Sequard
○ Hemisection of the cord usually from penetrating
injury

○ Loss of motor on side of injury

○ Loss of sensation on the opposite side

 Cord Syndromes
● Conus Medullaris
○ S4-5 exit at L1; may have L1 fracture

○ Areflexic bowel and bladder, flaccid anal

sphincter

○ Variable lower extremity loss

● Cauda Equina
○ Lumbar sacral nerve roots, with or
without fracture

○ Variable loss; areflexia; radicular pain

Complete Cord Injury
● Quadriplegia (Tetraplegia)
○ Loss of function below the level of injury

○ Includes sacral roots (bowel and

bladder)

○ C1-T1
● Paraplegia
○ Loss of function below the level of injury

○ Below T1
Sensorimotor Assessment
Lateral corticospinal
tract
Lateral
spinothalamic tract

Dorsal column
Reflex Assessment
● Test for sensory/motor sparing
● Major deep tendon reflexes ++ ++
(DTR) assessed ++ ++

++ ++
○ Biceps (C5)

○ Brachioradialis (C5-6)

○ Triceps (C7-8)

○ Quadriceps (knee-jerk) (L3-4) ++ ++

++ ++
○ Achilles (S1-2)
● Scoring 0 to ++++
Superficial Reflex Assessment
Abdominal - umbilicus pulls toward
stimulus
Cremasteric - scrotum pulls up with
stoking inner thigh
Bulbocavernosus - anal sphincter contraction
with stimulus
Superficial anal – anal sphincter contraction
with stroking peri-anal area
Priapism – results with tugging on
catheter
Spinal Cord Injury
● ASIA Impairment scale
○ Complete (A) – lack of motor/sensory function in sacral roots (S4-5)

○ Incomplete (B) – sensory preservation, motor loss below injury

including S4-5

○ Incomplete (C) – motor preservation below the injury, more than ½

muscle groups motor strength <3

○ Incomplete (D) - motor preservation below the injury, at least 50%

muscle groups motor strength >3

○ Normal (E) – all motor/sensory functions present

Diagnostics
● Plain films

○ Lateral, A/P, odontoid; C-T-L spines

○ May be used for rapid identification of gross deformity

● CT Scan

○ Comprehensive, cervical through sacral

○ Demonstrates a degree of compression and cord canal

impingement
● MRI Scan

○ Demonstrates ligamentous, spinal cord injury

Fractures-Dislocations
● Atlanto-occipital dissociation

○ Complete injury; death

● Atlanto-axial dislocation

○ Complete injury; death

● Jumped, Jump-locked facets

○ Require reduction; may impinge on

cord; unstable due to ligamentous
injury
Atlanto-axial dislocation
Jumped, Jump-locked facets
Fractures-Dislocations

● Odontoid (dens) fractures

○ Rarely cord injury
SCIWORA

● Spinal Cord Injury without Radiographic

Abnormality
○ Most frequently children

○ Dislocation occurs with spontaneous relocation

○ Cord injury evident

○ Radiographs negative
Management
● Airway
○ C1-4 injuries require definitive airway

○ Injuries below C4 may also require airway due to

■ Work of breathing

■ Weak thoracic musculature

● Breathing
○ Adequacy of respirations

■ SpO2

■ Tidal volume

■ Effort

■ Pattern
Management
● Circulation
○ Neurogenic shock

■ Injuries above T6

■ Hypotension

■ Bradycardia –treat symptomatic only

■ Warm and dry

■ Poikilothermic – keep warm

○ Fluid resuscitation

○ Identify and control any source of bleeding

○ Supplement with vasopressors

Neurogenic Shock
Injury to T6 and above

Loss of sympathetic innervation Increase in venous capacitance

Bradycardia Decrease in venous return

Hypotension

Decreased cardiac output

Decreased tissue perfusion

Management
● Urine output
○ Urinary retention

■ Atonic bladder

○ Foley

■ Initially avoid intermittent catheterization

■ High urine output from resuscitation fluids

Management
● Deficit
○ Spinal shock

■ Flaccid paralysis

■ Absence of cutaneous and/or proprioceptive sensation

■ Loss of autonomic function

■ Cessation of all reflex activity below the site of injury

○ Identify the level of injury

Management
● Pain

○ Frequent physical and verbal contact

○ Explain all procedures to patient

○ Patient-family contact as soon as possible

○ Appropriate short-acting pain medication

and sedatives
● Foster trust
Management
● Communication
○ Blink board

○ Adapted call bell system

○ Avoid clicking, provide a better option

○ speech and occupational therapy

○ Prism glasses

○ Setting limits/boundaries for behavior

Management
● Special Treatment

○ Hypothermia
■ Recommends 33oC intravascular cooling

■ Rapid application, Monitor closely

■ Anecdotal papers

■ No peer reviewed/ class I clinical research studies to substantiate

○ High dose methylprednisolone

■ No longer considered standard of care
Management
● Pharmacologic agents
○ Lazaroids (21-aminosteroids)

○ Opiate antagonists (Naloxone)

○ EAA receptor antagonists

○ Calcium channel blocker

○ Antioxidants and free radical scavengers

○ Arachidonic acid inhibitors

Management
● Reduction
○ Cervical traction
■ Halo

■ Gardner-Wells tongs

○ Surgical
● Stabilization
○ Cervical collar – convert
to padded collar as soon
as possible

○ CTO or TLSO for low

Management
● Rotational bed therapy
○ Maintain alignment and traction

○ Prevent respiratory complications of immobility

Management
● Surgical
○ Determined by

■ Degree of deficit, location of injury, instability, cord

impingement

■ Anterior vs. posterior decompression/ both

○ Emergent

■ Reserved for neurologic deterioration when evidence of cord

compression is present

○ SSEP –during procedure to monitor changes

■ Limited to ascending sensory tracts esp.. dorsal columns

Complication Prevention
● Respiratory
○ Complications of immobility

■ Atelectasis, Pneumonia

■ Pulmonary embolism

○ Respiratory insufficiency/ failure

■ Level of injury affects the phrenic nerve, intercostals

■ Increased work of breathing, fatigue

■ Rate and pattern are altered (accessory muscle use)

■ Monitor breath sounds

Respiratory
● Pulmonary management

• Weaning parameters

• Monitor SpO2 and ABGs

• Routine CXR

• Aggressive pulmonary toilet

– Postural drainage (PD)

– Chest physiotherapy (CPT)

– Kinetic bed therapy

• Suctioning
Respiratory

● Non-ventilated patients

○ Pulmonary function tests

○ Incentive Spirometry
○ Non-invasive ventilation (CPAP, BiPAP)
○ Abdominal binder
○ Early mobilization
Complication Prevention
● Cardiovascular

○ Neurogenic shock
○ IV fluids –include vasopressors
○ Atropine or pacing ONLY when
bradycardia is symptomatic
Cardiovascular
● Orthostatic hypotension

○ Decreased BP, possibly increased heart rate, dizziness or

lightheadedness, blurred vision, loss of consciousness

○ Provide physical support with the abdominal binder. Slowly raise the
head of the bed for mobilization

○ Turn slowly

○ Prone to vasovagal response

Cardiovascular
● Poikilothermia
○ Inability to shiver/sweat and adjust body
temperature

○ Keep patient warm

○ Warm the environment

○ Monitor skin to prevent burns or frostbite from

exposure

■ Insensate skin
Complication Prevention
● Gastrointestinal
○ Ileus

○ Gastric/ intestinal ulcers

○ Pancreas dysfunction

○ Nutritional deficiencies

○ Constipation/ impaction

○ Cholecystitis
Gastrointestinal
● Abdominal distention
○ Nasogatric tube to decompress stomach

○ Monitor bowel sounds

○ Monitor N/G output for bleeding

○ Gastric prophylaxis-

■ Histamine blockers, proton-pump inhibitors, antacids

● Bowel routine
○ Stool softeners, suppositories; high fiber diet

○ Digital stimulation, fluids, mobilization

Complication Prevention
● Venous thromboembolism
○ Slightly higher risk the first 2-3 months post injury

○ Duplex ultrasonography evaluation

○ Prevention (x 3months)

■ LMWH

■ Apply sequential compression devices

■ Vena cava filter (in patients who cannot be anticoagulated or have

failed anti-coagulation)

○ Monitor for signs and symptoms

○ Early mobilization, hydration

Urinary Tract Infection
● Signs and symptoms

○ Fever, spontaneous voiding between

catheterizations, Autonomic Dysreflexia,
hematuria, cloudy- foul-smelling urine,
vague abdominal discomfort, pyuria
● Prevention

○ Remove indwelling catheter as soon as

clinically possible, intermittent cath,
hydration
Urinary
Renal calculi
○ Chronic bacteriuria and sediment, long-term indwelling catheters, urinary
stasis, chronic calcium loss

○ Signs and symptoms – persistent UTI, hematuria, unexplained Autonomic

Dysreflexia

○ KUB x-ray, IVP with cystogram, the passage of the stone.

○ Interventions - increased fluid intake, dietary modifications, lithotripsy.

Complication Prevention
Musculoskeletal
● Spasticity – flexor, extensor, alternating
○ Reduce venous pooling, stabilize thorax, aid in dressing and
stand-pivot transfer

○ Chronic pain, contractures, heterotrophic ossification, skin

breakdown

○ ROM, positioning, weight-bearing, splinting, pharmacologic

management, surgery- neural severing (permanent)
Autonomic Dysreflexia
Autonomic Dysreflexia

● Sit patient upright to produce orthostatic hypotension

● Monitor BP every 5 minutes
● Monitor neurologic status (GCS)
● Eliminate the offending stimulus
○ Empty bladder, and bowel; identify skin lesion
● Administer anti-hypertensives if the above fails
● Education –family, and patient
Psychologic
Pain/Depression
○ Nocioceptive – noxious stimuli to
normally innervated parts

○ Neurogenic – nerve tissue injury in

CNS or PNS

○ Evaluate for depression associated

with pain

○ Counseling, ROM, pharmacologic

treatment, TENS
Rehabilitation

● Mobility

○ Tendon transfer

○ Functional electrical stimulation

○ Lower level of injury, more functional

● Bowel and Bladder Management
● Prevention of complications
 NURSING
MANAGEMENT
Nursing Theory:
Roy adaptation
Model
Summary
● Spinal cord injury occurrence is decreased with safety
equipment use
● Prevent secondary injury to result in optimal neurologic
recovery
● Spinal column fractures can occur without long term
effects
● Spinal cord injury requires diligence in complication
prevention