SPINAL CORD INJURY

DEFINITION
A spinal cord injury (SCI) refers to any injury to the spinal cord that is caused by trauma instead of disease.
It may result from direct injury to the cord itself or indirectly from disease of the surrounding bones, tissues, or
blood vessels.
CAUSES
 Assault
 Falls
 Gunshot wounds
 Industrial accidents
 Motor vehicle accidents
 Sports injuries (particularly diving into shallow water)
 a violent attack (such as a stabbing or a gunshot)
 diving into water that is too shallow and hitting the bottom
 trauma during a car accident (specifically trauma to the face, head and neck region, back, or chest area)
 falling from a significant height
 head injuries during sporting events
 electrical accidents
 severe twisting of the middle portion of the torso

PATHOPHYSIOLOGY

Damage to the spinal cord ranges from transient concussion (from which the patient fully recovers) to
contusion, laceration, and compression of the cord, to complete transection of the cord (which renders the patient
paralyzed below the level of the injury).
SCIs can be separated into two categories:
1. primary injuries and
2. secondary injuries.
 Primary injuries are the result of the initial insult or trauma and are usually permanent.
 Secondary injuries are usually the result of a contusion or tear injury, in which the nerve fibers begin to
swell and disintegrate.
 A secondary injury produces ischemia, hypoxia, edema, and hemorrhagic lesions, which in turn result in
destruction of myelin and axons.
 Some method of early treatment is needed to prevent these secondary reactions, believed to be the principal
causes of spinal cord degeneration at the level of Injury.

CLINICAL MANIFESTATIONS

1. Central Cord Syndrome

 It is caused by Injury or edema of the central cord, usually of the cervical area.
 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.
2. Anterior Cord Syndrome

 It is caused by acute disk herniation or hyperflexion injuries associated with 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.
 Loss of pain, temperature, and motor function is noted below the level of the lesion; l
  Light touch, position, and vibration sensation remain intact.

3. Brown-Sequard Syndrome (Lateral Cord Syndrome)

 It 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.

 Ipsilateral paralysis or paresis is noted, together with ipsilateral loss of touch, pressure, and vibration
 contralateral loss of pain and temperature.

4. Others
 problems walking
 loss of control of the bladder or bowels
 inability to move the arms or legs
 feelings of spreading numbness or tingling in the extremities
 unconsciousness
 headache
 pain or stiffness in the neck area
 signs of shock
 unnatural positioning of the head
 A complete spinal cord lesion can result in paraplegia (paralysis of the lower body) or quadriplegia
paralysis of all four extremities).

EXAMS AND TESTS

Physical exam, including a brain and nervous system (neurological) exam. This will help identify the exact
location of the injury, if it is not already known.
 CT scan or MRI of the spine
 Myelogram (an x-ray of the spine after injecting dye)
 Somatosensory evoked potential (SSEP) testing or magnetic stimulation
 Spine x-rays (lateral cervical spine x-rays)
MANAGEMENT

1. Initial management
 Immobilization
 Rigid collar
 Sandbags and straps
 Spine board
 Prevent hypotension
 Pressors( drugs that increase BP) : Dopamine
 Fluids to replace losses; do not over hydrate
 Maintain oxygenation
 O2 per nasal canula
 If intubation is needed, do NOT move the neck
2. Ongoing management

• NGT to suction
•Prevents aspiration
•Decompresses the abdomen (paralytic ileus is common in the first days)
• Foley
•Urinary retention is common
 • Methylprednisolone
•Only if started if injury occurred within 8 hours of injury
•Exclusion criteria
• Cauda equina syndrome
• GSW gunshot wound
• Pregnancy
• Age <13 years
• Patient on maintenance steroids
• Cervical Traction
• Provides temporary stability of the cervical spine
• Cervical collar can be removed while patient is in traction
• Cervical fractures are reduced and the cervical spine is aligned with some form of skeletal traction

3. Surgical Management

• Surgery is indicated in any of the following instances:

• Compression of the cord is evident.
• The injury results in a fragmented or unstable vertebral body.
• The injury involves a wound that penetrates the cord.
• There are bony fragments in the spinal canal.
• The patient’s neurologic status is deteriorating.
• A laminectomy (excision of the posterior arches and spinous processes of a vertebra) may be indicated in
the presence of progressive neurologic deficit, suspected epidural hematoma, bony fragments, or
penetrating injuries that require surgical débridement, or to permit direct visualization and exploration of
the cord.
•
NURSING MANAGEMENT
1. Ineffective breathing patterns related to weakness or paralysis of abdominal and intercostal muscles
and inability to clear secretions

Interventions:
- Open airway with jaw Thrust or chin lift while maintaining cervical spine immobilization.
- suction airway.
- Obtain blood sample for ABGs as indicated.
- Assist with endotracheal intubation
2. Fluid volume deficit
Interventions
- Cannulate two veins with large- bore catheters and initiate
- infusion of lactated Ringer’s solution or normal saline; monitor rate carefully
- Consider vasopressors as needed
- Insert urinary catheter
- Monitor hemodynamics
3. Impaired skin integrity related to immobility and poor tissue perfusion

Interventions
- Remove patient from backboard as soon as possible
- Avoid allowing a paralyzed patient to lie on backboard for more than 2 hours
- Consider placement on special bed
- Inspect skin and areas around pins or tongs
- Turn at least q2h and use kinetic table or other specialty care devices.
 - Insure adequate nutritional intake
- INFORM family and client about risk of pressure ulcers

4. Impaired gas exchange Related to diaphragmatic fatigue or paralysis evidenced by

Interventions

- Maintain patent airway

- Assess respiratory status q 2 hours
- Monitor ABGs
- Provide aggressive pulmonary toilet; chest PT and quad-assist coughing
- Assess strength of cough
- Suction secretions
- Provide chest PT
- Assist with mechanical ventilation
- Provide emotional support

5. Decreased cardiac output Related to venous pooling of blood and immobility as evidenced by
Hypotension, Tachycardia, Restlessness , Oliguria Decreased pulmonary artery pressures

Interventions

- Monitor blood pressure, pulse and cardiac rhythm

- Administer vasopressors to maintain MAP at 800mm/Hg or above
- Apply pneumatic compression boots or stockings
- Perform ROM at least q8h to aid in muscle contraction and venous return