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Spinal Cord
Gray matter- cell
messages to and from the brain Ascending Tracts carry into higher levels
PyramidalVoluntary movements Posterior column (Dorsal)- touch, proprioception, and vibration sense Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord) voluntary movement
Upper Motor Neurons UMN Originate in cerebral cortex Project downward Result in skeletal muscle movement Injury = SPASTIC paralysis Lower Motor Neurons LMN Originate at each vertebral level Project to specific parts of the body Result in movement /sensation Injury = FLACCID paralysis
stimulus
Where sensory and motor
nerves arise from cord Sensory fibers enter posterior Synapse in the grey matter Motor fibers leave anterior Once outside cord join form spinal nerve
reflex movement
SCI Sympathetic chains on both sides of the spinal column (T1-L2) Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)
ligaments Dura Meninges CSF in subarachnoid space allow for movement within spinal canal
bones compressing cord SCI frequently occur with head injuries Cord injury may be caused by direct trauma from knives, bullets, etc
Secondary
Ongoing progressive damage
Initially SCI experience spinal shock depression of all cord & ANS function below injury. Lasts from few min to wks
Clonus is one of the first signs Hyperreflexia of foot Test by flexing leg at knee &
quickly dorsiflex the foot Rhythmic oscillations of foot against hand clonus
Classifications of SCI
Mechanism of Injury
Skeletal and Neurologic Level Completeness (degree) of Injury
natural protection position. Generally cause neck to be unstable because stretching of ligaments
surface area, such as dashboard or bathtub Usually causes central cord syndrome symptoms
as hit on head Or from below as landing on butt Usually affects the lumbar region
ligamentous structures that normally stabilize the spine Usually results in serious neurologic deficits
Skeletal level Vertebral level where the most damage to the bones Neurologic level The lowest segment of the spinal cord with normal sensory and motor function on both sides of the body Levels of Function in Spinal Cord Injury
cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level. sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone
level of injury Sensory loss of all sensation perception Autonomic deficitsvasomotor failure and spastic bladder
sensation, vibration and proprioception loss Contralateral loss of pain and temperature perception
pain and temperature perception below injury Retains posterior column function (sensations of touch, position, vibration, motion)
(dorsal) columns Loss of proprioception Pain, temperature, sensation and motor function below the level of the lesion remain intact
(conus) and lumbar nerve roots Cauda Equina Injury to the lumbosacral nerve roots Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs
Cardio: dysrhythmias spinal shock loss of SNS control over blood vessels orthostatic hypotension, poikilothermic
Respiratory decrease chest expansion, cough reflex & vital capacity diaphragm functionphrenic nerve GI stress ulcers paralytic ileus bowel- impaction & incontinence
GU upper/lower motor bladder Impotence sexual dysfunction Musculoskeletal joint contractures bone demineralization osteoporosis muscle spasms muscle atrophy pathologic fractures para/tetraplegia
Common Manifestation/Complications
Upper and Lower Motor Deficits
Upper motor deficits result in
spastic paralysis
Lower motor deficits result in
Common Manifestations/Complications
Spinal cord injuries are described by the level of the injury the cord
para- meaning two extremities tetra- or quadra- all four extremities Suffix : -paresis meaning weakness -plegia meaning paralysis
Common Manifestations/Complications
C1-3 usually fatal Loss of phrenic innervation
ventilator dependent No B/B control Spastic paralysis Electric w/c with chin/mouth control
Common Manifestations/Complications
C6- weak grasp Has shoulder/biceps to
independence
Common Manifestations/Complications
T1-6- full use of upper
extremity Transfer Drive car with hand controls and do ADLs No bowel/bladder control
Immediate Care
Emergency Care at Scene, ER & ICU
Transport with cervical collar Assess ABCs; O2;
Therapeutic Interventions
Medications
Therapeutic Interventions
Medications
To control or to prevent complications of SCI and immobility:
Vasopressors to maintain perfusion Histamine H2 blockers to prevent stress ulcers Anticoagulants Stool softeners Antispasmodics
Therapeutic Interventions
Stabilization/ Immobilization TractionGardner-wells tongs Halo Casts Splints Collars Braces
Therapeutic Interventions
Surgery for SCI
Manipulation to correct dislocation or to unlock vertebrae Decompression laminectomy Spinal fusion Wiring or rods to hold vertebrae together
Ability to move, breathe, and associated injury such as a head injury, fractures
symmetry
Hand grips
knee with and without resistance Planter and dorsi flexion of foot Assess for Clonus
naval
Nursing Problems/Interventions
1.Impaired mobility 2.Impaired gas exchange 3. Impaired skin integrity 4. Constipation 5. Impaired urinary elimination 6. Risk for autonomic dysreflexia 7. Ineffective coping
to keep alignment; teach patient Care traction, collars, splints, braces, assistive devices for ADLs Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)
jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications
Assess skin break down thrombophlebitis; remove TED hose at least every shift
bilaterally. If nerve is nonfunctioning then individual is ventilator dependent. Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing
SCI up cord to phrenic nerve level (C3-5) Need for ventilatory assistance tracheotomy, ventilator
Quad cough (assistive cough) as
needed
prominences Avoid shearing and friction to soft tissue with transfers Removal of TED hose every 8 hours Nutritional status
4. Constipation
Bowels rely more on bulk than on nerves Stimulate bowels at the same time each day. Best after
a meal when normal peristalsis occurs Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation Assess bowel sounds prior to giving food for the first time paralytic ileus!
No reflex from S2,3,4 Automatic empting of bladder Urine fills the bladder and dribbles out Need Foley or freq intermittent self catheterization
Spastic bladder (upper motor neuron lesion) Reflex arc but no connection to or from brain Reflex fires at will Bladder training- trigger points to stimulate empting; self catheterization
when sympathetic nervous system is stimulated Life threatening- if goes unchecked BP can result in cerebral hemorrhage
Vasodilatation symptoms above SCI
remove pressure, if full bowel- empty, etc Remove support hose/abdominal binder Monitor blood pressure- can get > 300 S Give PRN medication to lower BP If above not effective call physician
changes Physical and psychological support Most common SCI is 15-30 yeas old and generally a risk taker this greatly affects their perception of life and rehabilitation
7. Ineffective Coping/sexuality
Male
UMN lesion reflexogenic (S2,3,4) erections LMN lesion psychogenic erections (psychological stimulation)
Female
hormones more than nerves
regarding fertility. C-section because of chance for autonomic dysreflexia during labor. Lack of sensation/movement affects sexual performance
Ejaculation/fertility may be
affected
7. Ineffective Coping/sexuality
Assess readiness/knowledge/your ability
Use proper terminology Suggestions: empty bladder before sex withhold fluids and antispasmodics certain positions may increase spasms explore new erogenous zones penile implants Refer to specially trained counselor
Home Care
Assess psychological, physiological resources
need for rehabilitation (in-house or out patient) need for community resources Home assessment
Kevin Everett hypothermia treatment for SCI Standing Tall Travis Roy- 11 Seconds
Stem Cell treatment for SCI Lipitor for SCI
Case study- Jim Valdez 1. Why does Jim have flaccid paralysis on admission to
ICU? 2. What symptoms indicate that he is in spinal shock? What was done about these symptoms? 3. How will we know when he is out of spinal shock? 4. How does progressive mobilization assist with orthostatic hypotension? What else can be done? 5. What are realistic functional goals for Jim?
for mobility of the spine and act as shock absorber spinal cord anatomy
Pathophysiology/Etiology
Located between vertebral bodies Composed of nucleus pulposus a gelatinous
material surrounded by annulus fibrosis- a fibrous coil Spinal nerves come out between vertebra
Herniated Disc
Herniated nucleus pulposus, (HNP) slipped disc,
ruptured disc HNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it. Risk Factors Standing erect Aging changes Poor body mechanics Overweight Trauma
Common Manifestations/Complications
HNP compresses
Spinal nerve (sensory or
motor component) as it leaves the spinal cord Or the cord itself- the white tracts within the cord- rare
Common Manifestations/Complications
Sensory root or nerve usually affected
pain, parenthesis, or loss of sensation
Manifestations
depend on what nerve root, spinal nerve is being
Classic symptoms low back sciatica pain pain increases with increase in intrathoracic pressure
Foot drop
Paresthesias Numbness
Muscle spasms
Absent cord reflexes
Muscle spasms
and narrowing of disk space CT/MRI Mylogram p1336 Nerve conduction studies (EMG) detect electrical activity of skeletal muscles
Treatment- Conservative
Bed rest with firm mattress
log roll side lying position with knees bent and pillow between
legs to support legs Avoid flexion of the spine brace/corset, cervical collar to provide support Medications non-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers
Treatment- Conservative
Heat/cold therapy to decrease muscle spasms Break the pain-spasm-pain cycle Ultrasound, massage, relaxation techniques Progressive mobilization with approved exercise program includes abdominal/thigh strengthening Teaching good body mechanics Weight loss TENS unit
Treatment- Surgery
Laminectomy removal of a portion of the lamina to relieve
pressure and to get to the herniated nucleus pulposus that is protruding out herniated disc repair Foraminotomy
Enlargement of the bony overgrowth at the opening
Treatment- Surgery
Microdiskectomy
Use of electron microscope through a small incision to
the neck
anterior cervical fusion
Treatment- Surgery
Spinal fusion
removes most of the disc and replaces it with bone
usually from the patient iliac crest Fusion also with rods, pins, synthetic protein Flexibility is lost at the site- requires longer hospital stay
spinal fusion Artificial Disc Combination of metal and plastic Attached to vertebrae above and below
Prevention of HNP
Back school approach Causes of HNP Learn how to prevent Good body mechanics Exercises to strengthen leg and abdominal muscles
Trauma
Employment History of pain and other neuro changes
Sensation
sharp/dull of paperclip using dermatome as reference
Pre/Post-op assessment
prior to surgery
laryngeal nerve (speech- hoarseness) Assess respiration, neck size, swallowing and speech
If Post-Op Lumbar Assess bowels sounds, voiding. Minimize stress of post-op site- flat with pillow between
2. Chronic Pain
Surgery may not relieve pain
Nonpharmalogical methods
to control pain
Pain clinic
3. Constipation
As a result of bed rest and decreased mobility and fear of pain with straining of stool
Constipation prevention methods fluids, diet, etc
4. Home Care
When riding in a car, take frequent stops to move and stretch
Prevention Back school approach May have to deal with pain as a chronic condition May need to make life/job changes
Intramedullary- arise from neural tissues of the spinal cord Extramedullary- arise from tissues outside the spinal cord may be benign or malignant Intradural-from the nerve roots or meninges in subarachnoid space Extradural- from the epidural tissue or vertebra
Classification by origin
Primary- originating in the
other parts of the body Most spinal cord tumors are found in the thoracic region
Spinal cord tumors can
compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction
Common Manifestations/Complications
Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected
Pain that is not relieved by bed rest is the most common presenting symptom Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor
Common Manifestations/Complications
Manifestations of thoracic cord tumor
Paresis & spasticity of one leg then the other Pain back & chest, not relieved by bedrest
Sensory changes
Babinski reflex Bowel (ileus); bladder dysfunction (UMN in
type)
Therapeutic Interventions
Diagnostic tests include:
X-ray of the spinal column Myelogram
Therapeutic Interventions
Medications spinal tumors
Control pain- narcotic analgesics, epidural
Therapeutic Interventions
Surgery for spinal cord tumors
Laminectomy to remove or to decrease the size
(decompression laminectomy) of the spinal cord tumor Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable
Radiation to reduce size and control pain
Nursing Assessment
Health history Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex.
Physical exam Similar to physical assessment for HNP
Nursing Problems/Interventions
1. Anxiety
Metatastic tumor vs benign spinal cord tumor Education and support system
Nursing Problems/Interventions
3. Impaired physical mobility
From bed rest and motor involvement Basic nursing- ROM, etc
4. Acute pain
From compression or invasion of tumor Assess and treat
5. Sexual dysfunction
Male sacral reflex arc (S 2,3,4) interference Similar care as discussed with SCI
Nursing Problems/Interventions
6. Urinary retention
Reflex arc (S2,3,4) interference can cause neurogenic
7. Home care
Rehabilitation Home evaluation
Support groups
case study
with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?
Bladder distension
Neurological deficit Pulse ox readings
blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?
Autonomic dysreflexia
Hemorrhagic shock Neurogenic shock
Pulmonary embolism
and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
Place the client flat in bed Assess patency of the indwelling urinary catheter
herniated nucleus pulposus of L4-L5. Which scientific rationale explains the incidence of a ruptured disc in the elderly?
The client did not use good body mechanics when lifting an
object. There is an increased blood supply to the back as the body ages. Older clients develop atherosclerotic joint disease as a result of fat deposits. Clients develop intervertebral disc degeneration as they age.
level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?
Acetazolamide (Diamox)
Furosemide (Lasix) Methylprednisolone (Solu-Medrol) Sodium bicarbonate
appropriate bladder program for a client in rehabilitation for spinal cord injury?
Insert an indwelling urinary catheter to straight
drainage Schedule intermittent catherization every 2 to 4 hours Perform a straight catherization every 8 hours while awake Perform Credes maneuver to the lower abdomen before the client voids.
Which of the following conditions would the nurse anticipate during the acute phase?
Absent corneal reflex
Decerebate posturing Movement of only the right or left half of the body
client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Positive reflexes Hyperreflexia
and is in for palliative radiation. What is your main goal with this patient?
Teach patient self catheterization
Ensure patient receives pain medication as needed Encourage patient to discuss fears