SPINAL CORD INJURY

- Injury to the spinal cord which ranges in severity

from mild flexion-extension “whiplash” injuries to
complete transection of the cord w/ quadriplegia
 Etiology
• Trauma
- most common cause
- May be due to automobile or motorcycle
accidents, gunshot or knife wounds, falls, or
sporting mishaps

Risk factors:
• Adolescents and young adults
• Alcohol and drug users
Factors that affect vertebral injury
• Position of the person’s head, neck, and
trunk at the time of injury
• Magnitude, rate of application, and duration
of injuring force
• Point of application of the injuring force
 Classification of spinal cord injury
• According to the level of injury
1. QUADRIPLEGIA
- Paralysis (complete or incomplete) involves all four extremities
- Injury to the cervical spine and cord
2. PARAPLEGIA
- Paralysis of the lower extremities
- Injuries to the thoracic or lumbar spine

*QUADRIPARESIS and PARAPARESIS are used to denote

weakness rather than total paralysis
Classification of spinal cord injuries
• Complete vs. incomplete lesion
COMPLETE LESION
- total and permanent functional disruption of the spinal
cord

INCOMPLETE LESION
- Spinal cord is not totally disrupted at the level of injury
- Some ascending/ descending fibers/ both remain intact
and continue to function
 Spinal Cord Injury
• SCI most often occur as a result of injury to the
vertebrae
• C5,6,7, T12, L1- most common sites of injury
• Incomplete lesions:
- Central cord syndrome
- Anterior cord syndrome
- Brown-Sequard syndrome
 Pathophysiology
Damage to the cord

Contusion, laceration or compression of cord

Cord edema occurs

Ischemia then necrosis of cord due to compromised capillary circulation

and venous return

Destruction of myelin and axons

Total sensory and motor paralysis, loss of reflex activity below the level of
injury
 Mechanism of Injury
• FLEXION-ROTATION, DISLOCATION, OR
FRACTURE DISLOCATION
- Usually at the Cervical spine (C5 to C6)
- Thoracic-lumbar spine (T12 to L1)
- Ruptures supporting ligaments, fractures the
vertebrae, damages blood vessels, leads to ischemia
of SC
Wedge fracture
Flexion teardrop fracture
Unilateral facet dislocation
resulting from combined Bilateral facet dislocation
flexion and rotation
Common mechanism of
flexion-rotation
Flexion-distraction
injury of the lumbar
spine
Common mechanism of
shearing of the spine
shear
 Mechanism of Injury
• Hyperextension
- Seen in elderly clients, young men who have been in
automobile accidents in w/c they hit the windshield or
steering wheel, young people who sustained neck injuries
while diving
- Can lead to dorsal column contusion and posterior
dislocation
- Complete transection and complete lesions of the cord
can also occur
Common mechanism of
extension injury

Hyperextension injury
Hyperextension sprain
 Mechanism of Injury
• Compression
- Often caused by falls and jumps in w/c individual
lands on his feet or buttocks
- Disc and bone fragments may be propelled
backward into the SC on impact
- Edema and microscopic bleeding occurs
Common mechanism of
injury of burst fracture

Burst fracture
 Diagnostic assessment
• CT scans
• X-ray
• MRI
• Peritoneal lavage
(to rule out intra-abdominal hemorrhage)
 Assessment of SCI
• Depends on the level of the cord injury
• The level of SCI is the lowest spinal cord segment
with intact sensory and motor function
(neurological level)
• Motor and sensory changes below the injury
• Loss of reflexes below the level of injury
• Loss of bowel and bladder control
• Absence of sweat and vasomotor tone
• Decreased BP from loss of peripheral vascular
resistance
 Cervical Injuries
• C2-C3 injury is usually fatal
• C4 is the major innervation to the diaphragm
by the phrenic nerve
• Involvement above C4 causes respiratory
difficulty and paralysis of all 4 extremities
• May have movement in the shoulder if the
injury is at C5 or below
 Thoracic Level injuries
• Loss of movement of the chest, trunk and
bowel, bladder and legs depending on the
level of injury
• Autonomic dysreflexia with injuries to T6
common
 Lumbar and Sacral Injuries
• Loss of movement and sensation of the lower
extremities
• S2 and S3 center of micturation; therefore below
this level, bladder will contract but not empty
(neurogenic bladder)
• Injury above S2 in males allows them to have an
erection but unable to ejaculate because of
sympathetic nerve damage
• Injury between S2 and S4 damages the sympathetic
and parasympathetic response- no erection nor
ejaculation
 Complications
1) Spinal shock
- post-traumatic areflexia
- Complete loss of skeletal muscle function,
bowel and bladder tone, sexual function, and
autonomic reflexes
- Loss of venous return and hypotension
- Hypothalamus cannot control temperature by
vasoconstriction and increased metabolism
 Complications
1) Spinal shock
- May last for 7 days to 3 months
- Indications that spinal shock is resolving: return
of reflexes, development of hyperreflexia
rather than flaccidity, return of reflex emptying
of the bladder, babinski reflex
 Bulbospongiosus reflex
• The bulbocavernosus reflex (BCR) or "Osinski reflex" is
a polysynaptic reflex that is useful in testing for spinal shock
• Elicit by: The test involves monitoring anal
sphincter contraction in response to squeezing the glans
penis or clitoris, or tugging on an indwelling catheter
• The reflex is spinal mediated and involves S2-S4. The absence
of the reflex without sacral spinal cord trauma indicates spinal
shock.
• One of the first reflexes to return after spinal shock. Lack of
motor and sensory function after the reflex has returned
indicates complete SCI. Absence of this reflex in instances
where spinal shock is not suspected could indicate a lesion or
injury of the conus medullaris or sacral nerve roots.
 Complications
2) Autonomic dysreflexia
- Clusters of clinical manifestations that results when
multiple SC autonomic responses discharge
simultaneously
- In clients w/ injury above T7 and can occur for up to 6
years after injury
- Exaggerated response to a noxious stimuli (bladder &
bowel distention; pressure ulcers, spasms, pain, pressure
on the penis, uterine contractions)
 Autonomic Dysreflexia
• Stimulation of sensory receptors below the
lesion
• ANS senses the stimulation causing reflex
arteriolar vasoconstriction
• Baroreceptors senses the increased BP
stimulating the PNS which results to
bradycardia
 Autonomic dysreflexia
Signs and Symptoms:
- Pounding headache
- Profuse sweating
- Nasal congestion
- Piloerection (goosebumps)
- Bradycardia
- Hypertension
Autonomic
dysreflexia
 Complications
2) Autonomic dysreflexia
– Treatment:
 To prevent cerebral bleeding or seizures:
- HOB is elevated
- Tight clothing is loosened
- Noxious stimulus is found and removed
- Nitrates, nifedipine, hydralazine ganglionic blocking agents
 distended bladder
- Catheterization
 Impacted feces
- Removed by anesthetic ointments
 Complications
3) Spasticity
- Increased tone or contraction of muscles, producing stiff
movements
– Treatment:
 ROM exercises
 baclofen, dantrolene sodium, clonidine
 Complications
Neurogenic bladder
- Occurs w/ both upper and lower motor neuron disorders
*Upper motor neuron disorders = spastic or reflex bladder
*Lower motor neuron disorders = flaccid bladder
– Treatment:
 Credes method (for clients w/ arm function)
 intermittent catheterization
 Bethanechol (Urecholine)
 urine acidifying agents
 Complications
Neurogenic bowel
– Treatment
 Sufficient fluid and fiber intake
 stool softeners, bulk laxatives

Respiratory Dysfunction
– Treatment
 Incentive spirometry
 diaphragmatic breathing
 Complications
Sexual dysfunction
- Depends on the location of the lesion:
• Reflex Erection – upper motor neuron lesions
• Psychogenic erection – lower motor neuron lesions
• Ejaculation – lower motor neuron lesions; lesion is
more caudal
– Treatment:
 psychological counseling
 education
• Reflex erections are achieved by manual stimulation of the genital region.
Typically, erections will be sustained only as long as the stimulation is provided. In
contrast, psychogenic erections are the result of erotic stimuli that result in cortical
modulation of the sacral reflex arc.
• In general, erections are more likely with incomplete injuries (both upper and
lower motor neuron), than complete injuries. Men with spinal cord injury can only
maintain an erection while the penis is stimulated and the rigidity of the erection
is insufficient for sexual intercourse.
• In men with spinal cord injury, the ability to ejaculate is less common than the
ability to obtain an erection. The rate of ejaculation varies depending on the
nature and location of the neurological injury.

• In complete upper motor neuron lesions, the ejaculation rate is estimated at 2

percent. In incomplete upper motor neuron lesions, the ejaculation rate is higher
at 32%. Many men who are able to ejaculate experience retrograde ejaculation
into the bladder, some may experience dribbling of semen.
• The experience of orgasm in men with SCI is variable. Some individuals describe a
primarily emotional event. Others experience generalized muscle relaxation or a
pleasant sensation in the pelvis or at the sensory level. Other men report orgasm
to be non-existent following the injury.
 Emergency Management
• Jaw thrust
• Log-rolling
• Client is in supine position on a firm surface. Head is
supported in alignment w/ the body and is
immobilized by placing sandbags on either side of it
or taping it to the board. Cervical collar is applied.
• Clothing is cut off
• Always suspect SCI until injury is ruled out
• Prevent head flexion, extension or rotation
 Medical Management
• Immediate care in the hospital
 suction
 mechanically assisted respiration
 careful monitoring of hemodynamic parameters
- Hypotension initially treated w/ IVF
 neurologic examination
 assess motor function
 Medical management
• If patient has a severe cervical injury
 should be placed in skeletal traction
 various types of tongs may be used:
Crutchfield, Barton, Gardner-Wells
 Pharmacologic management
• Vasoactive agents
- To support blood pressure immediately after
injury
• Methylprednisolone
- In high doses started w/ in 8 hours of injury can
result into improved motor and sensory function
• Anti-infectives, anticoagulants, laxatives, and
antispasmodics
 Surgical management
• Decompressive laminectomy
- For complete SCI
- Lamina of the vertebrae are removed to minimize the
pressure on SC; allows for cord expansion from edema
• Surgical fusion (spinal fusion and rod insertion)
- Insertion of metal plates and screws and/or use of bone
grafts
 Disc Herniation
or
Herniated Nucleus Pulposus
(slipped disc)
 Definition
• A condition in which part or all of the soft,
gelatinous central portion of an
intervertebral disc (the nucleus pulposus) is
forced through a weakened part of the disk,
resulting in back pain and nerve root
irritation.
 Incidence
• 80% low back pain
– 10% HNP
• lumbosacral discs
– forces of gravity
– L4-L5, L5-S1
• middle aged and older men
– strenuous physical activity
 Risk Factors
• increased straining and other stresses on the disk.
• Heavy physical labor, strenuous exercise, weak
abdominal and back muscle
– Sitting-unsupported (without lumbar support)
– Driving-Truck drivers
• congenital conditions that affect the size of the
lumbar spinal canal
 Clinical Manifestation
• SYMPTOMS OF HERNIATED LUMBAR DISC:
– Severe Low Back Pain
– Pain Radiating to the Buttocks, Legs, and Feet
– Pain made worse with Straining
• coughing, defecation, bending, lifting, laughing,
straight leg raising
– Hyperparesthesia
• Tingling or Numbness in Legs or Feet
• SYMPTOMS OF HERNIATED CERVICAL DISC:
– Neck pain, especially in the back and sides
– Deep pain near or over the Shoulder Blades on
the affected side
– Pain radiating to the shoulder, upper arm,
forearm, and rarely the hand, fingers or chest
– Increased pain when bending the neck or turning
head to the side
 Assessment
– Thorough health history
– Physical exam
– Straight leg raise test
• (+) nerve root irritation
• Raise leg and flex foot at 90 degress
• Back pain or leg pain is produced
 Diagnostics
• spine X-ray
– rule out other causes of back or neck pain.
• spine MRI and/or spine CT
– show spinal canal compression by the herniated
disc
• myelogram
– define the size and location of disc herniation.
 Conservative therapy
• Restrictive Activity
– Limitation of extremes of spinal movement
• Brace, corset or belt
– Bedrest
• initial 1 or 2 days
• (X) - prone
- thick pillows under head
 HNP

• Medications
– Analgesics/ short term narcotic opiods
– NSAIDS
– Muscle relaxants
 HNP
• Local heat or ice
• physical therapy
• Ultrasound & massage
• Traction
– Pelvic girdle/head halter traction
– help muscle spasm but does not reduce the HNP
• transcutaneous electrical nerve stimulation
(TENS)
 Surgical therapy
• Laminectomy (w/ or w/o spinal fusion)
– Most common
– Surgical excision of post. arch of vertebra
• Diskectomy
– Removal of herniated fragments of intervertebral
disk
– decompress nerve root
END