SPINAL CORD INJURY

Spinal cord injury is the damage to the spinal cord

that causes loss of sensation and motor control. This
causes myelopathy or damage to nerve roots or
myelinated fiber tracts that carry signals to and from the
brain. Depending on its classification and severity, this
type of traumatic injury could also damage the gray
matter in the central part of the cord, causing segmental
losses of interneurons and motorneurons. Spinal cord
injury can occur from many causes, including Trauma,
Tumor, Ischemia , Developmental disorders,
Neurodegenerative diseases, Demyelinative diseases,
Transverse myelitis, or Vascular malformations.

Incidence Rate in the Philippines

About 250,000 people are affected with Spinal Cord Injury each year. Spinal cord
injuries can happen to anyone at any time of life. The typical patient, however, is a man
between the ages of 19 and 26, injured in a motor vehicle accident (about 50% of all
SCIs), a fall (20%), an act of violence (15%), or a sporting accident (14%). Alcohol or
other drug abuse plays an important role in a large percentage of all spinal cord injuries.
Six percent of people who receive injuries to the lower spine die within a year, and 40%
of people who receive the more frequent higher injuries die within a year.

Classifications of Spinal Cord Injury

Traumatic spinal cord injury is classified into five categories by the American Spinal
Injury Association and the International Spinal Cord Injury Classification System:

• A- indicates a "complete" spinal cord injury where no motor or sensory function is

preserved in the sacral segments S4-S5.
• B- indicates an "incomplete" spinal cord injury where sensory but not motor
function is preserved below the neurological level and includes the sacral
segments S4-S5. This is typically a transient phase and if the person recovers
any motor function below the neurological level, that person essentially becomes
a motor incomplete, i.e. ASIA C or D.
• C- indicates an "incomplete" spinal cord injury where motor function is preserved
below the neurological level and more than half of key muscles below the
neurological level have a muscle grade of less than 3, which indicates active
movement with full range of motion against gravity.
• D- indicates an "incomplete" spinal cord injury where motor function is preserved
below the neurological level and at least half of the key muscles below the
neurological level have a muscle grade of 3 or more.
• E- indicates "normal" where motor and sensory scores are normal. Note that it is
possible to have spinal cord injury and neurological deficits with completely
normal motor and sensory scores.

In addition, there are several clinical syndromes associated with incomplete spinal cord
injuries.

• The Central cord syndrome is associated with greater loss of upper limb
function compared to lower limbs.
• The Brown-Séquard syndrome results from injury to one side with the spinal
cord, causing weakness and loss of proprioception on the side of the injury and
loss of pain and thermal sensation of the other side.
 • The Anterior cord syndrome results from injury to the anterior part of the spinal
cord, causing weakness and loss of pain and thermal sensations below the injury
site but preservation of proprioception that is usually carried in the posterior part
of the spinal cord.
• Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually
from infection diseases such as syphilis, causing loss of touch and proprioceptive
sensation.
• Conus medullaris syndrome results from injury to the tip of the spinal cord,
located at L1 vertebra.
• Cauda equina syndrome is, strictly speaking, not really spinal cord injury but
injury to the spinal roots below the L1 vertebra.

Causes of Spinal Cord Injury

• Injury may be traumatic or non-traumatic:

A traumatic spinal cord injury may stem from a sudden, traumatic blow to
your spine that fractures, dislocates, crushes or compresses one or more of your
vertebrae. It may also result from a gunshot or knife wound that penetrates and
cuts your spinal cord. Additional damage usually occurs over days or weeks
because of bleeding, swelling, inflammation and fluid accumulation in and around
your spinal cord.
A non-traumatic spinal cord injury may be caused by arthritis, cancer,
inflammation or infections, or disk degeneration of the spine.

• Motor vehicle accidents.

Auto and motorcycle accidents are the leading cause of spinal cord
injuries, accounting for more than 40 percent of new spinal cord injuries each
year.

• Acts of violence.
As many as 15 percent of spinal cord injuries result from violent
encounters, often involving gunshot and knife wounds, according to the National
Institute of Neurological Disorders and Stroke.

• Falls.
Spinal cord injury after age 65 is most often caused by a fall. Overall, falls
cause about one-quarter of spinal cord injuries.

• Sports and recreation injuries.

Athletic activities, such as impact sports and diving in shallow water,
cause about 8 percent of spinal cord injuries.

• Alcohol.
Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
• Diseases.
Cancer, arthritis, osteoporosis and inflammation of the spinal cord also
can cause spinal cord injuries.

The Risk Factors of Spinal Cord Injury

Although a spinal cord injury is usually the result of an unexpected accident that can
happen to anyone, certain factors may predispose you to a higher risk of sustaining a
spinal cord injuring, including:
 • Being a man. Spinal cord injuries affect a disproportionate amount of men. In
fact, women account for only about 20 percent of spinal cord injuries.
• Being between the ages of 16 to 30. You're most likely to suffer a spinal cord
injury if you're between the ages 16 and 30. Motor vehicle crashes are the
leading cause of spinal cord injuries for people under 65, while falls cause most
injuries in older adults.
• Being active in certain sports. While being active is one of the best things you
can do for your overall health, it may place you at greater risk of a spinal cord
injury. Athletic activities that may increase your risk of a spinal cord injury include
football, rugby, wrestling, gymnastics, horseback riding, diving, surfing, roller-
skating, in-line skating, ice hockey, downhill skiing and snowboarding.
• Having an underlying bone or joint disorder. A relatively minor injury can
cause a spinal cord injury if you have another disorder that affects your bones or
joints, such as arthritis or osteoporosis.

PATHOPHYSIOLOGY OF SPINAL CORD INJURY

To understand the rationale of the recent advances, it is first necessary to review
the pathophysiology of spinal cord injury. There are four general types of spinal cord
injury: 1) cord maceration, in which the morphology of the cord is severely distorted; 2)
cord lacerations (gun shot or knife wounds); 3) contusion injury, which leads to a central
hematomyelia that may evolve to syringomyelia; and 4) solid cord injury, in which there
is no central focus of necrosis as in contusion injury. In the first two injuries, the surface
of the cord is lacerated and a prominent connective tissue response is invoked,
whereas in the latter two the spinal cord surface is not breached and the connective
tissue component is minimal. Of these four injury types, the contusion injury represents
from 25 to 40% of the cases and is a progressive injury that enlarges over time. The
most commonly used animal model in SCI research is patterned after the contusion
injury. Within these four injury types, degree of completeness must be considered,
as incomplete lesions will benefit more dramatically from experimental interventions than
complete lesions in terms of degree of recovery that can be obtained. It is important to
note that the clinical presentation of SCI is most often characterized as an
anatomically incomplete lesion, irrespective of initial neurological presentation.
There are three phases of SCI response that occur after injury: the acute, secondary,
and chronic injury processes. In the acute phase, which encompasses the moment of
injury and extends for the first few days, a variety of parallel
pathophysiological processes begins. Upon initial impact or injury, there is
immediate mechanical damage to neural and other soft tissue, including endothelial cells
of the vasculature. Thus necrosis, or cell death, results from these mechanical and
ischemic insults, is instantaneous, and, in a contusion injury, appears to be
more predominant in the grey matter of the spinal cord than in the white matter, resulting
in a ring of preserved white matter at the contusion site (Fig. 1). After the insult, over the
next few minutes, the injured nerve cells respond with an injury-induced barrage of
action potentials. Accompanying this are significant electrolytic shifts, principally
involving the monovalent and divalent cations Na+ (intracellular concentrations
increase), K+ (extracellular concentrations increase), and
2+
Ca (intracellular concentrations increase to toxic levels), that contribute to a failure in
normal neural function and spinal shock, which lasts for about 24 hours and represents
a generalized failureof circuitry in the spinal neural network. Hemorrhage occurs, with
localized edema, loss of microcirculation by thrombosis, vasospasm and mechanical
damage, and loss of vasculature autoregulation, all of which further exacerbate the
neural injury. Furthermore, compression of the spinal cord occurs as a result of
vertebral displacement followed by edema and later by fibrotic responses, contributing
further to the neural injury. Because in the best circumstances the time to admission
after spinal cord injury is about three hours, the immediate acute injury processes do not
offer a clinically useful target for therapeutic intervention unless the Emergency Medical
Service can adapt an easy-to-administer intervention, and/or the population adopts a
preventative stance, such as taking aspirin once a day to prevent cardiac death after an
episode of cardiac ischemia as recommended by the American Heart Association. In
contrast, the secondary and chronic injury processes, because these occur within
minutes to weeks after injury, are strategically better for therapeutic targets.
In the secondary phase (which occurs over the time course of minutes to weeks),
the ischemic cellular death, electrolytic shifts, and edema continue from the acute
phase. Within the first 15 minutes after injury, extracellular concentrations of glutamate
and other excitatory amino acids reach cytotoxic concentrations that are six- to eightfold
higher than normal as a result of cell lysis from mechanical injury and both synaptic and
nonsynaptic transport. In addition, lipid peroxidation and free-radical production also
occur as a result of glutamate receptor-activated and subsequently mediated pathways.
Apoptosis—asecondary, programmable cell death different from necrosis—occurs and
involves reactive gliosis that includes increased expression of glial fibrillary acidic
protein (GFAP) and astrocytic proliferation.Neutrophils (which secrete myeloperoxidase)
invade the spinal parenchyma from the circulatory system within 24 hours, followed by
lymphocytes (which secrete a variety of cytokines and growth factors) that invade and
reach peak numbers within 48 hours. The invading inflammatory cells increase the local
concentrations of cytokines (cyto = ‘cell’; kine = ‘small protein’) and chemokines
(chemotactic cytokine). In addition, inhibitory factors and/or barriers to regeneration are
expressed in the perilesion site. The lesion grows in size from the initial core of cell
death with cells at risk of dying in the perilesioned region, to a larger region of cell death.
Finally, in the chronic phase, which occurs over a time course of days to years,
apoptosis continues in both orthograde and retrograde directions including brain
regions; a variety of receptors and ion channels are altered in expression levels and
activation states, scarring and tethering of the cord occurs in the penetrating injuries
(about 25% of all SCI); demyelination results in conduction deficits; a cyst forms in a
subset of all SCI patients (20%), and continues to enlarge in a condition called
syringomyelia; cut and nearby uncut axons exhibit regenerative and sprouting responses
but go no farther than 1 mm; neural circuits are altered due to changes in inhibitory and
excitatory input; and in many cell types, permanent hyperexcitability develops, which
results in chronic pain syndromes in a majority of SCI patients.

Clinical Manifestations:

Your ability to control your limbs after spinal cord injury depends on two factors: the
neurological level of the injury and the completeness of injury. The lowest normally
functioning segment of your spinal cord is referred to as the neurological level of your
injury. The completeness of the injury is classified as either:

• Complete. If all sensory (feeling) and motor function (ability to control

movement) is lost below the neurological level, your injury is called complete.
• Incomplete. If you have some motor or sensory function below the affected area,
your injury is called incomplete.

Additionally, paralysis from a spinal cord injury may be referred to as:

• Tetraplegia or quadriplegia. This means your arms, trunk, legs and pelvic
organs are all affected by your spinal cord injury.
• Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.

Spinal cord injuries of any kind may result in one or more of the following signs and
symptoms:

• Loss of movement
 • Loss of sensation, including the ability to feel heat, cold and touch
• Loss of bowel or bladder control
• Exaggerated reflex activities or spasms
• Changes in sexual function, sexual sensitivity and fertility
• Pain or an intense stinging sensation caused by damage to the nerve fibers in
your spinal cord
• Difficulty breathing, coughing or clearing secretions from your lungs

Emergency Signs and Symptoms

Emergency signs and symptoms of spinal cord injury after an accident may include:

• Extreme back pain or pressure in your neck, head or back

• Weakness, incoordination or paralysis in any part of your body
• Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
• Loss of bladder or bowel control
• Difficulty with balance and walking
• Impaired breathing after injury
• An oddly positioned or twisted neck or back

Medical Management

Unfortunately, there's no way to reverse damage to the spinal cord. But,

researchers are continually working on new treatments, including innovative treatments,
prostheses and medications that may promote nerve cell regeneration or improve the
function of the nerves that remain after a spinal cord injury.In the meantime, spinal cord
injury treatment focuses on preventing further injury and empowering people with a
spinal cord injury to return to an active and productive life.

A. Emergency Actions

Urgent medical attention is critical to minimizing the effects of any head or neck trauma.
So treatment for a spinal cord injury often begins at the scene of the accident.
Emergency personnel typically immobilize the spine as gently and quickly as possible
using a rigid neck collar and a rigid carrying board, which they'll use to transport you to
the hospital.

B. Early (acute) stages of treatment:

In the emergency room, doctors focus on:

• Maintaining your ability to breathe

• Preventing shock
• Immobilizing your neck to prevent further spinal cord damage
• Avoiding possible complications, such as stool or urine retention, respiratory or
cardiovascular difficulty, and formation of deep vein blood clots in the extremities

You may be sedated so that you don't move and sustain more damage while
undergoing diagnostic tests for spinal cord injury. If you do have a spinal cord injury,
you'll usually be admitted to the intensive care unit for treatment. You may even be
transferred to a regional spine injury center that has a team of neurosurgeons,
orthopedic surgeons, spinal cord medicine specialists, psychologists, nurses, therapists
and social workers with expertise in spinal cord injury.

• Medications. Methylprednisolone (Medrol) is a treatment option for an acute

spinal cord injury. If methylprednisolone is given within eight hours of injury,
some people experience mild improvement from their spinal cord injury. It
appears to work by reducing damage to nerve cells and decreasing inflammation
near the site of injury. However, this is not a cure for a spinal cord injury.
 • Immobilization. You may need traction to stabilize your spine, to bring the spine
into proper alignment or both. Sometimes, traction is accomplished by securing
metal braces, attached to weights or a body harness, to your skull to keep your
head from moving. In some cases, a rigid neck collar also may work. A special
bed also may help immobilize your body.
• Surgery. Often, surgery is necessary to remove fragments of bones, foreign
objects, herniated disks or fractured vertebrae that appear to be compressing the
spine. Surgery may also be needed to stabilize the spine to prevent future pain or
deformity.
• Experimental treatments. Scientists are trying to figure out ways to stop cell
death, control inflammation and promote nerve regeneration. Ask your doctor
about the availability of such treatments.

C. Ongoing care
After the initial injury or disease stabilizes, doctors turn their attention to
preventing secondary problems that may arise, such as deconditioning, muscle
contractures, pressure ulcers, bowel and bladder issues, respiratory infections
and blood clots.

The length of your hospitalization depends on your individual condition and

what medical issues you're facing. Once you're well enough to participate in
therapies and treatment, you may transfer to a rehabilitation facility.

D. Rehabilitation. Rehabilitation team members may begin to work with you while
you're in the early stages of recovery. Your team may include a physical
therapist, occupational therapist, rehabilitation nurse, rehabilitation psychologist,
social worker, dietitian, recreation therapist and a doctor who specializes in
physical medicine (physiatrist) or spinal cord injuries.

During the initial stages of rehabilitation, therapists usually emphasize maintenance

and strengthening of existing muscle function, redeveloping fine motor skills and
learning adaptive techniques to accomplish day-to-day tasks. You'll be educated on the
effects of a spinal cord injury and how to prevent complications, as well as be given
advice on rebuilding your life and increasing your quality of life. You'll be taught many
new skills, and will use equipment and technology that can help you live on your own as
much as possible. You'll be encouraged to resume your favorite hobbies, participate in
social and fitness activities, and return to school or the workplace.

Medications. Medications may be used to manage some of the effects of spinal

cord injury. These include medications to control pain and muscle spasticity, as well as
medications that can improve bladder control, bowel control and sexual functioning.

New technologies. Inventive medical devices can help people with a spinal cord
injury become more independent and more mobile. Some devices may also restore
function. These include:

• Modern wheelchairs. Improved, lighter weight wheelchairs are making people

with a spinal cord injury more mobile and more comfortable. For some, an
electric wheelchair may be needed. Some wheelchairs can even climb stairs,
travel over rough terrain and elevate a seated passenger to eye level to reach
high places without help.
• Computer adaptations. For someone that has limited hand function, computers
can be very powerful tools, but they're difficult to operate. Some examples of
computer adaptations range from simple to complex, such as key guards or voice
recognition.
 • Electronic aids to daily living. Essentially any device that uses electricity can
be controlled with an electronic aid to daily living (EADL). Devices can be turned
on or off by switch or voice-controlled and computer-based remotes.
• Electrical stimulation devices. These sophisticated devices use electrical
stimulation to produce actions. They're often called functional electrical
stimulation (FES) systems, and they use electrical stimulators to control arm and
leg muscles to allow people with a spinal cord injury to stand, walk, reach and
grip.

The Prognosis and Recovery

It's often impossible for your doctor to make a precise prognosis right away.
Recovery, if it occurs, typically starts between a week and six months after an injury.
However, some people experience small improvements for up to one year or longer.

Nursing Care Plans

1. Acute pain r/t nerve root compression secondary to spinal injury

Interventions

• Provide comfort measures(position changes, ROM exercises, warm/cold packs)

• Encourage use of relaxation techniques(guided imagery, deep breathing
exercises)
• Provide diversional activities(television, radio)
• Administer medication as indicated
• Maintain patient airway: keep head in neutral position, elevate head of bed
slightly if tolerated, and use airway adjuncts as indicated.

2. Impaired physical mobility r/t muscle weakness and paralysis

Interventions

• Inspect skin daily. Observe for pressure areas and provide meticulous skin care
• Reposition periodically even when sitting in chair.
• Perform/assist with full ROM exercises on all extremities and joints using slow,
smooth movements
• Assist with/ encourage pulmonary hygiene(deep breathing, coughing, suctioning)
• Maintain bed rest and immobilization device(s), e.g., sandbags, traction, halo,
hard/soft cervical collars, brace

3. Risk for ineffective breathing pattern r/t the inadequate respiratory function due to
paralysis of the intercostal muscles or diaphragm

Interventions

• Maintain patent airway: keep head in neutral position, elevate head of bed slighty
if tolerated, use airway adjuncts as indicated
• Assist patient in taking control of respirations as indicated. Instruct in and
encourage deep breathing focusing attention on steps of breathing
• Auscultate breath sounds. Note areas of absent or decreased breath sounds or
development of adventitious sound
• Observe skin color for developing cyanosis, duskiness
• Reposition /turn periodically. Avoid / limit prone position when indicated
4. Disturbed sensory perception r/t destruction of the sensory tract with altered sensory
reception, transmission, integration

Interventions

• Protect from bodily harm(falls, burns, positioning)

• Assist patient to recognize and compensate for alterations in sensations
• Assess/document sensory dysfunction or deficit (by means of touch, pinprick,
hot/cold),progressing from area of deficit to neurologically intact area
• Provide uninterrupted sleep and rest periods

5. Impaired urinary elimination r/t decreased or absent tone of urinary sphincter

Interventions

• Assess voiding pattern (frequency and amount). Compare urine output with fluid
intake
• Cleanse perineal area and keep it dry. Provide catheter care as necessary
• Palpate for bladder distention and observe for overflow
• Observe for cloudy or bloody urine, foul odor
• Begin bladder retraining per protocol when appropriate, (fluids between certain
hours, digital stimulation of trigger area, contraction of abdominal muscles)