Spinal Cord injury (SCI)

By:
C. Agu (Miss)
 Objectives
At the end of the discussion, Students will be able to:
 Describe spinal Cord injury
 State the prevalence of spinal cord injury
 Describe the pathophysiology of spinal cord injury
 State the causes of spinal cord injury
 Discuss the types/grades of spinal cord injury
 State at least five clinical manifestation of SCI
 State the diagnostic test used in Sci
 Describe and manage Autonomic dysreflexia
 Discuss nursing and medical management of SCI
 Introduction

 An acute traumatic lesion of the neural elements in the

spinal canal, resulting in temporary or permanent
sensory deficit, motor deficit, or bowel/bladder
dysfunction
 Spinal cord injury’ refers to damage to the spinal cord
resulting from trauma or from disease or degenerative
conditions resulting in complete or incomplete loss of
the sensory and motor function
 WHO, 2020
 Introduction
 The Injury in the spinal cord may be
in the form of :
 bruise (also called a contusion)
a partial tear
 complete tear (called a transection).
 SCI is a common cause of permanent
disability and death in children and
adults
 Prevalence

 Over 50% of all SCI occurs in persons age 16-30

 More prevalent in male (80%).
 Males also represent nearly all (90%) of sports-related
SCIs.
 According to WHO,
 Males are most at risk in young adulthood (20-29 years)
and older age (70+).
 Females are most at risk in adolescence (15-19) and older
age (60+).
 Male-to-female ratios of at least 2:1 among adults or
higher
 (WHO, 2020)
 Pathophysiology

 The pathophysiology of spinal cord injury can be categorized as acute

impact or compression.
 Acute impact injury is a concussion of the spinal cord. This type of
injury initiates a cascade of events = hemorrhage leading to hypo
perfusion = ischaemia = Necrosis = loss of function
 Spinal cord compression occurs when a mass impinges on the spinal
cord causing increased parenchymal pressure. The tissue response is
gliosis, demyelination, and axonal loss.
 The compression will result in collapse of the venous side of the
microvasculature, resulting in vasogenic edema. Vasogenic edema
exacerbates parenchymal pressure, hypoperfussion= ischaemia= and
may lead to progression of dysfunction
 Causes of SCI
 Birth injuries, which typically affect the spinal cord in the neck area
 Some congenital deformities (Spina bifida)

 Falls from height

 Motor vehicle accidents (automobiles, motorcycles, and being struck as a pedestrian)

 Sports injuries

 Diving accidents

 Trampoline accidents

 Violence (gunshot or stab wounds)

 Infections that form an abscess on the spinal cord

Types of Spinal Cord Injury
Depends on the extent of damage to the spinal cord
COMPLETE SCI
 Total loss of all motor and sensory function below the level
of injury.
 Nearly 50% of all SCIs are complete.
 Both sides of the body are equally affected.

INCOMPLETE SCI
 some function remains below the primary level of the
injury.
 May be able to move one arm or leg more than the other M
 May have more functioning on one side of the body than the
other.
 Grades of SCI according to American Spinal Injury
Association (ASIA)

 ASIA A: injury is complete spinal cord injury with no sensory or motor

function preserved.
 ASIA B: a sensory incomplete injury with complete motor function loss.
 ASIA C: a motor incomplete injury, where there is some movement, but
less than half the muscle groups are anti-gravity (can lift up against the
force of gravity with a full range of motion).
 ASIA D: a motor incomplete injury with more than half of the muscle
groups are anti-gravity.
 ASIA E: normal.
 Clinical manifestations
 The degrees of symptoms is associated with the severity and location
of the SCI
 Initial manifestation is loss or decrease in feeling, muscle movement,
and reflexes.
 If c1 –c5 is involved: affects the respiratory muscles and the ability to
breathe.

 tetraplegia(Quadriplegia)
 If in lumbar vertebrae, may affect nerve and muscle control to the
bladder, bowel, and legs.
 Paraplegia
INJURY TO SPINAL CORD
 Clinical manifestations
 Muscle weakness
 Loss of voluntary muscle movement in the chest, arms, or
legs (flaccid paralysis)
 Sensory disturbances: analgesia and anesthesia
 Difficulty in breathing
 Loss of feeling in the chest, arms, or legs
 Loss of bowel control: paralytic ileus
 Loss of bladder function (retention, urgency,
incontinence)
 Male patients might develop priapism
 Hypotension and bradycardia
 Diagnosis

 Blood tests: CBC

 X-ray of the spine

 Computed tomography scan (a CT or CAT scan).

 Magnetic resonance imaging (MRI).

 Treatment of spinal cord injury

 Depends on
 age, overall health, and medical history

 Extent of the SCI

 Type of SCI

 Tolerance for specific medications, procedures, or therapies

 Prognosis of the course of the SCI

 Management of spinal cord injuries
 Emergency medical treatment starts at the scene of the
accident or injury
 ABCDE approach (airway, breathing, circulation, disability, and
exposure) in the field
 Stabilize spine /Immobilize the entire spine at the scene of the
accident
 Log-rolling of patient
 Backboard for transfer
 Rigid cervical collar
 Management of spinal cord injuries

 Acute management
 ABCDE approach (airway, breathing, circulation, disability, and
exposure) in the field
KEDRICK Extrication
Device (sitting
patient)
 Management of spinal cord injuries

 Acute management
 Intensive medical care (intubate, ventilator)
 Analgesia
 Insert urinary catheter
 VTE prophylaxis (e.g., heparin)
 IVcorticosteroids to reduce swelling and inflammation in the
spinal cord
IV Methylprednisolone has shown to improve outcome
if given within
8hours of injury
Dose: 30mg/kg body weight bolus
Then 5mg/kg body weight hourly for 24 hours
 Management of spinal cord injuries

Definitive Management
 Bracing (e.g., with gunshot wounds)
 surgical repair (e.g., decompression and stabilization of
spine fracture) Internal fixation (T10-S vertebrae)
 Traction

 C1–C4 tetraplegia: phrenic nerve pacemakers may be

indicated; a tracheostomy and/or ventilator may be needed
Braces for spinal injury
Different types of braces
Traction used for cervical spine
Traction with Blackburn calipers
Nursing care of patients with spinal cord Injury
 Autonomic dysreflexia

 Autonomic dysreflexia is a syndrome in which there is

a sudden onset of excessively high blood pressure.

 It is more common in people with spinal cord injuries

that involve the thoracic nerves of the spine or above

(T6 or above).
 Autonomic dysreflexia in spinal cord injury
A pounding headache.
A flushed face and/or red blotches on the skin above the
level of spinal injury.
 Sweating above the level of spinal injury.
 Goose bumps below the level of spinal injury
 Cold, clammy skin below the level of spinal injury
 Nasal stuffiness.
 Nausea.
A slow heart rate (bradycardia).
Causes of Autonomic Dysreflexia Prevention
•Overfull bladder, •Follow bladder management program.
•UTIs

•Overfull bowel or constipation •Follow bowel management program.

•Gastrointestinal problems such as gallstones, •Diet rich in fiber and increase fluid intake
stomach ulcers, or gastritis

• pressure injuries Check the skin daily.

•Ingrown nails •Make sure all clothing or devices fit
•Other skin problems correctly.

•Sexual activity •Be aware that sexual activity can cause the
condition. Discuss with doctor and advice
appropriately

•Broken bones or other injuries •Be aware that these can cause the condition.
•Tight clothing or devices •Make sure all clothing are suitable for the
•Extreme temperatures or quick temperature temperature
changes
 Management of AD
 Position in semi/high fowlers position. lower legs if possible

until blood pressure is back to normal.

 Loosen or take off any tight clothing or accessories. This

includes braces, catheter tape, socks or stockings, shoes, and

bandages.

 Empty bladder by draining your Foley catheter or using

catheter.
 Management of AD
 Use digital stimulation to empty your bowel.

 Check skin for red spots that mean a pressure injury.

 check blood pressure every 5 minutes (with monitor)

 Call your doctor, even if symptoms was alleviated and blood

pressure is decreasing.

 If the symptoms return, repeat the above steps and if at

home go to the emergency department

 Rehabilitation
 Walking aids
 physical therapy
 occupational therapy
 Psychotherapy
 some patients are admitted to a rehabilitation facility.
 Other patients can continue rehabilitation on an outpatient basis
and/or at home.
 Pressure ulcer prophylaxis
 Osteoporosis prophylaxis
 treatment of pneumonia and urinary tract infections
Rehabilitation
 Complications

 Pressure ulcers (most common)

 Deep vein thrombosis (DVT).

 Osteoporosis

 Pneumonia
 Supportive care

 By Family members

 Nurses

 specially trained aides all may provide supportive

care.

 Assist wit activities of daily living

 Prognosis

 Early mortality: 4–20%

< 5% chance of recovery

 In complete thoracic and lumbar injury, up to ∼ 8%

of patients can still walk with the assistance of
special devices.

 Leadingcauses of death are pneumonia, pulmonary

embolism, and suicide.
 Spinal Cord tumors
A spinal tumor is an abnormal mass of tissue within or
surrounding the spinal cord and/or spinal column.
 Spinal tumors can be benign (non-cancerous) or malignant
(cancerous).
 Primary tumors originate in the spine or spinal cord
 metastatic secondary tumors result from cancer spreading
from another site to the spine.
 Classification
 According to the area of spine affected: cervical, thoracic, lumbar and
sacrum.
 By their location within the spine.
 Intradural-extramedullary – The tumor is located inside the thin covering
of the spinal cord (the dura), but outside the actual spinal cord.
Frequency: 40% of spinal cord tumour.
 Intramedullary – These tumors grow inside the spinal cord. They typically
derive from glial or ependymal cells (a type of glial cell) that are found
throughout the interstitium of the spinal cord

Constitute 5% of spinal cord tumour

 Extradural – The tumor is located outside the dura, which is the thin
covering surrounding the spinal cord.

55% of spinal cord tumour

 Manifestations
 Pain
 Feeling worse with sneeze, or cough

 Severe pain when lying down

 Specific to the spine

 Not alleviated by analgesics

 Worse as condition progresses

 Pain that spreads to the arms, feet, legs, or hips

 Manifestation

 Bowels and/or bladder dysfunction

 Muscles weakness
 Fall easily or have trouble walking
 Muscle spasms
 An unusual feeling or sensation in the legs
 Feeling cold in the hands, fingers, or legs
 Paediatric Spinal tumour

Some common paediatric spinal tumour include

 Osteoid Osteoma
 Osteoblastoma

 Osteochondroma

 Osteosarcoma

 Ewing Sarcoma
 Diagnostic investigations

Physical examination with emphasis on back pain and neurological

deficits .

Other tests are required for an accurate diagnosis.

 X-ray

 Computed tomography scan (CT or CAT scan

 Magnetic resonance imaging (MRI)

 Bone Scan
 Treatment

 Nonsurgical treatment
 Palliative treatment
 Corticosteroid medications
 chemotherapy
 Radiation therapy.

 Surgical treatment
Surgical removal of all or part of the tumor
En bloc resection (EBR) remove a primary lesion, the contiguous
draining lymph nodes, and other tissues around in non-metastatic spinal
tumors
 References
Department of Neurology (2015). Acute Spinal Cord Injury. Columbia University Vagelos College of
Physicians and Surgeons(. Columbia University Medical Center. New York-Presbyterian Hospital . Retrieved
from https://www.columbianeurology.org/neurology/staywell/document.php?id= 33903
WHO (2020). Spinal Cord Injury. Retrieved from https://www.who.int/news-
room/fact-sheets/detail/spinal-cord-injury
Shenot PJ. (2017). Neurogenic Bladder. Retrieved from
http://www.msdmanuals.com/professional/genitourinary-disorders/voiding- disorders/neurogenic-bladder.
Hansebout RR, Kachur E. (2014). Acute traumatic spinal cord injury. Retrieved from
https://www.uptodate.com/contents/acute-traumatic-spinal-cord- injury.
Chin LS. Spinal Cord Injuries (2016).. In: Spinal Cord Injuries. New York, NY: WebMD. Retrieved from
http://emedicine.medscape.com/article/793582- overview#showall.
 References
Mazwi NL, Adeletti K, Hirschberg RE. (2015). Traumatic Spinal Cord Injury: Recovery, Rehabilitation, and
Prognosis. Curr Trauma Rep. 2015; 1(3): pp. 182–192. doi: 10.1007/s40719-015-0023-x.

Vaidyanathan S, Soni BM, Sett P, Watt JW, Oo T, Bingley J. (1998). Pathophysiology of autonomic dysreflexia:
long-term treatment with terazosin in adult and paediatric spinal cord injury patients manifesting recurrent
dysreflexic episodes. Spinal cord, 36(11): pp. 761–70. doi: 10.1038/sj.sc.3100680.

Eltorai I, Kim R, Vulpe M, Kasravi H, Ho W (1992). Fatal cerebral hemorrhage due to autonomic dysreflexia in a
tetraplegic patient: case report and review. Paraplegia, 30(5): pp. 355–360. doi: 10.1038/sc.1992.82.

Bycroft J. (2005).Autonomic dysreflexia: a medical emergency. Postgrad Med J. 81(954): pp. 232–235. doi:
10.1136/pgmj.2004.024463.