SPINAL CORD INJURIES

 PRESENTED TO:-
DR. S.K SHARMA
Vice Principal, CON
DMC&H, Ludhiana.  PRESENTED BY:-
GURINDER KAUR.
M.Sc. (N)- I yr.
Roll No. – 6.
 INTRODUCTION:-
Patients with Spinal Cord Injuries (SCI)
usually have permanent and often
devastating neurologic deficits and
disability.The injuries ranges from the
mild flexion - extention 'wiplash injury '
to complete transection of the cord with
permanent quadriplagia.
 Anatomy Review
 Bone Structure
of the Spine
 Cervical

 Lumbar

 Thoracic

 Sacral/Coccyx
 Anatomy Review
 Cervical Spine
7 vertebrae
 very flexible
 C1: also known as the
atlas
 C2: also known as the
axis
 Thoracic Spine
 12 vertebrae
 ribs connected to spine
 provides rigid framework
of thorax
 Anatomy Review
 Lumbar Spine
5 vertebrae
 largest vertebral bodies
 carries most of the body’s weight

 Sacrum
5 fused vertebrae
 common to spine and pelvis

 Coccyx
4 fused vertebrae
 “tailbone”
Anatomy Review
 Anatomy Review

•Blood supplied by
vertebral and spinal
arteries
•Gray matter: core
pattern resembling
butterfly
•White matter:
longitudinal bundles of
myelinated nerve fibers
 Anatomy Review
 Spinal Cord
 Thoracic and lumbar
levels supply
sympathetic nervous
system fibers
 Cervical and sacral
levels supply
parasympathetic
nervous system fibers
 Spinal Cord Pathways
 Ascending Nerve Tracts (sensory input)
 carryimpulses from body structures and
sensory information to the brain

 Posterior column (dorsal)

 conveys nerve impulses for proprioception,
discriminative touch, pressure, vibration, & two-
point discrimination
 cross over at the medulla ablongata from one side
to the other
 e.g. impulses from left side of body ascend to the right
side of the brain
 Spinal Cord Pathways
 Spinothalmic Tracts (anterolateral)
 Convey nerve impulse for sensing pain,
temperature & light touch
 Impulses cross over in the spinal cord not the
brain
 Lateral tracts
 conduct impulses of pain and temperature to the brain
 Anterior tracts
 carry impulses of light touch and pressure
 Spinal Cord Pathways
 Descending Motor Tracts (motor output)
 conveys motor impulses from brain to the
body
 Pyramidal tracts: Corticospinal &
Corticobulbar

 destined to cause precise voluntary movement and

skeletal muscle activity
 lateral tract crosses over at medulla
 Spinal Cord Pathways
 Descending Motor Tracts (motor output)
 Extrapyramidal tracts
 rubrospinal, pontine reticulospinal, medullary
reticulospinal, lateral vestibulospinal and
tectospinal
 Pontine reticular and lateral vestibular have powerful
excitatory effects on extensor muscles
 brain stem lesions above these two areas below
midbrain cause dramatic increase in extensor tone
 called decerebrate rigidity or posturing
 Reticulospinal: impulses to control muscle tone & sweat
gland activity
 Rubrospinal: impulses to control muscle coordination &
control of posture
 Spinal Nerves
 31 pairs originate from the spinal cord
 Carry both sensation and motor function
 Named according to level of spine from where
they arise
 Cervical 1-8
 Thoracic 1-12
 Lumbar 1-5
 Sacral 1-5
 Coccygeal 1
 Motor & Sensory
Dermatomes
 Dermatome
 Specific area in which the
spinal nerve travels or controls
 Useful in assessment of
specific level SCI
 Plexus
 peripheral nerves rejoin and
function as group
 Cervical Plexus
 diaphragm and neck
 Dermatomes
 C3,4  C7
 motor:shoulder  motor: elbow, wrist, finger
shrug(Trapezium) extension
 sensory: top of shoulder  sensory: middle finger
 C3, 4, 5  C8, T1
 motor: diaphragm,wrist  motor: finger abduction &
flexion & extention adduction
 sensory: top of shoulder  sensory: little finger, fist
 C5, 6 formation.
 motor:elbow flexion,deltoid  T4
abduction.  motor: level of nipple
 sensory: thumb  Sensory: intercoastal
muscles.
 T10
 motor: level of umbilicus
 Sensory: intercoastal
muscles.
 Dermatomes
 L1, 2  S1
 motor: hip flexion  motor: knee flexion
 sensory: inguinal crease  sensory: lateral foot
 L3,4  S1, 2
 motor: quadriceps, knee
extention  motor: foot plantar
 sensory: medial thigh, calf flexion
 L5  S2,3,4
 motor: great toe, foot  motor: anal sphincter
dorsiflexion
tone
 sensory: lateral calf
 sensory: perianal
 Definition of Spinal Cord I njuries
 Spinal cord injury (SCI) is
damage to the spinal cord
that results in a loss of
function such as mobility
or feeling. The spinal cord
does not have to be
severed in order for a loss
of function to occur. In
most SCI cases, the spinal
cord is intact, but the
damage to it results in
loss of function.
 INCIDENCE:-
 The incidence of spinal cord injury is
approximately 40 cases per million
population, or about 12,000 patients, per
year based on data in the National Spinal
Cord Injury database. However, this
estimate is based on older data from the
1970s as there has not been any new
overall incidence studies completed.
 Mortality/Morbidity
Life expectancies for patients with spinal
cord injury continues to increase but are
still below the general population.
 Based on 2003 US Life Tables, a healthy
20-year-old would have a life expectancy
of 78.4 years, whereas a quadriplegic who
was injured at age 20 would have a life
expectancy of only 60.
 Gender;
 The male-to-female ratio is approximately 4:1

 Age
 Since 2005, the average age at injury is 35-40
years, reflecting the rise in the median age of the
general population in the United States.

 About 50% of spinal cord injuries (SCIs) occurred

between the ages of 16 and 30.

 Of SCIs, 3.5% occur in children aged ≤ 15 years,

while there has been an increasing incidence of
spinal cord injury in persons older than 60 years
(11.5%).
 Etiology and risk
factors;
1.Traumatic SCI
 Road traffic accidents,

 Domestic and work-related accidents,

 Sports injuries,

 Self-harm,

 Assault

 Gunshot or knife wounds.

 Examples of Injury
 Accidents (45%)
 Car, van 16.5%
 Motorcycle 20%
 Bicycle 5.5%
 Pedestrian 1.5%
 Helicopter 1.5%
 Domestic / Industrial Accidents (34%)
 Sport Injury 15%
 Diving 5%
 Horse Riding 3%
 Other 7%
 Assault 6%
 Self Harm 5%
 Assaulted 1%
Risk Factors:- The risk factors for the spinal
cord injuries includes the following;

-Alcohol consumption while operating

motor vehicles,

-Recreational activities such as bicycling,

motorcycling, rollerblading, or horseback
riding especially without helmet.

-Occupation that require the use of ladders,

climbing or heights usually more than 5
feet above the ground.
 2.Non - Traumatic:-
 Infection of the spinal nerve cells (bacterial and viral),

 cysts or tumours pressing on the spinal cord,

 interruption of the blood supply to the spinal cord

(causing cord damage),

 congenital medical conditions (i.e. present since birth)

that affect the structure of the spinal column e.g., spina
bifida.

 Cervical Spondylosis with myelopathy ( spinal canal

arrowing with progressive injury to cord and roots).

 Osteopoesis causing vertebral compression fractures.

 Syrinomyelia ( centeral cavitation of the cord) .

 CLASSIFICATION OF SCI:
 Flexion injury

 Flexion - rotation injury

 vertical compression injury

 Extension injury

 Flexion-distraction injury

 Direct injury

 Indirect injury due to violent muscle

contraction.
 Flexion Injury:-
This is the commonest spinal injury.
Examples:
 Heavy blow across the shoulder by a heavy
object.
 Fall from height on the heels or buttocks.

Results: In the cervical supine, a flexion force

can result in;
 a sprain of the ligaments and the muscles of
the back of the neck.
 compression fracture of the vertebral body,
C5 - C7.
 Dislocation of the one vertebra over the
another ( commonest C5 over C6 ) .
Type SCI: Hyperflexion
injury
 Vertical compression injury:-
It is a common spinal injury.

Examples;
 a blow on the top of the head by some object falling on the
head;
 a fall from height in erect position.

RESULTS;
 In the cervical spine, this force result in a burst fracture i.e., the
vertebral body is crushed throughout its vertical dimentions.

 A piece of bone or disc may get displaced into the spinal canal
causing pressure on the cord.

 In the dorso-lumbar spine, this force results in a fracture similar

to that in the cervical spine, but due to a wide cannal at this
level, neurological deficit rarely occurs. It is an unstable injury.
Type SCI: Compression Injury
 Flexion - rotation injury ;
This is the worst type of the spinal cord injuries because it leaves the highly
unstable supine, and is associated with the high degree of the
neurological damage.

Examples;
 Heavy blow across the shoulder by a heavy object causing the trunk to
be in flexion and rotation to opposite side.
 a blow or the fall on postero-lateral aspect of the head.

RESULTS; On the cervical supine this force can result in :

 dislocation of the facet joint on one or both of the sides,

 fracture-dislocation of the cervical vertebra

 in the dorso-lumber spine, this force can result in the fracture –

dislocation of the joint. Here, one vertebra is twisted-off in front of the one
below it.While dislocating, the upper vertebra takes a slice of body of the
lower vertebra with it. There is extensive damage to the neural arch and
posterior ligament complex. It is highly unstable injury.
 Flexion-distraction Injury:
This is a rcently described spinal spinal injury, being
recognsed in Western countries where use of a seat belt
is compulsory while driving a car.

Examples;
With the sudden stopping of a car, the upper part of the
body is forced forward by inertia while the lower part is
tied to the seat by the seat belt. The flexion force thus
generated has a component of distraction with it.

Results;
 it commonly results in a horizontal fracture extended
into the posterior elements and involing a part of the
body.
 It is termed a 'chance fracture'. It is an unstable injury.
 Extension Injury:-
This injury is commonly seen in the
cervical spine.

Examples;
 motor vehical accident - the
forehead striking against the
windscreen forcing the neck into
hyperextension.

 shallow water diving - the head

hitting the ground, extending the
neck.

Results: This injury results in a chip

fracture of the anterior rim of a
vertebra. Sometimes, these injuries
may be unstable.
Type SCI: Hyperextension Injury
 Direct Injury:-
This is rare type of the spinal cord injury.

Examples;
 Bullet injury,
 a bloe hitting the spinous processes of the
cervical vertebrae.

Results;
 Any part of the vertebrae may be smashed by
a bullet, but , a lathi blow generally causes a
fracture of the spinous process only.
 Violent muscle contractions:-
This is the rare injury.

Examples;
 Sudden contraction of the
psoas.

Results;
 It results in the fractures
of the transeverse
processes of multiple
lumber vertebrae. It may
be associated with a huge
retroperitonial
haematoma.
 PATHOPHYSIOLOGY
Any of the mechanism of the spinal cord injury

leads to the rupturing of the blood capilleries

microhemorrhagic area appears in the central grey matter of spinal
cord

due to which there is;

1. decreased blood supply to the injured area,
inflammatory response takes place and leads to edema nad
2. putts pressure on the surrounding cells

effects highly specialised function of the CNS

replacement of the normal neuronal cells with the necrosed and

fibertic scar tissue

if pressure does not relieved or condition does not reverse then the
neuronal deficit becomes permanent
 According to extent of injuries:-
 Complete lesions

 Incomplete lesions

1. Centeral cord syndrome

2. Anterior cord syndrome
3. Brown sequard syndrome
4. Conus medullaris syndrome
5. Cauda Equina syndrome
 Complete lesions :-
 A complete lesion means that the
cord is completely transected. It is
characterised by total loss of motor,
sensory, and reflexes activity below
the level of the lesion.
 Incomplete Lesions:-
 In this there is preservation of a mixed
pattern of motor, sensory and reflex
functions.
 1. Central cord syndrome
 Most common incomplete cord syndrome.

 Frequently found in elderly with underlying

spondylosis or younger people with severe
extension injury (figure).

 Upper extremity deficit is greater than lower

extremity deficit, because the lower extremity
corticospinal tracts are located lateral in the
cord.

 weakness is caused by edema and hemorrage in

the central arc of the cord, which is
predominantly occupied by nerve tracts to
hands and arms.
 2. Anterior cord syndrome:-
 In this there is damage to the
anterior portion of the both white and
gray matter of the spinal cord.

 Seen in flexion injuries e.g. burst

fracture, flexion tear drop fracture .

 Presents with immediate paralysis,

because the corticospinal tracts are
located in the anterior aspect of the
spinal cord.

 Although motor function, pain, and

temperature sensations are lost
below the level of the injury, the
sensation of touch, position, and
viberation remains intact.
 3. Brown - squard syndrome:-
 It is caused by lateral hemisection of the
cord ( i.e. when a lesion cuts or affects half
the cord ) such as with a bullet wound or
knife wound.

 Brown-Sequard syndrome may result from

rotational injury such as fracture-
dislocation or from penetrating trauma
such as stab wound.

 This result in the ipsilateral motor

paralysis, loss of viberatory and position
sense, and contralateral loss of pain and
temperature sensation.
4. Conus medullaris syndrome:-
 It follows the damage to the
lumber nerve roots and the
conus medullaris in the spinal
cord.

 The client has bowel and

bladder areflexia and flaccid
lower extremities.
 5. Cauda equina syndrome:-
 Injury to the
lumbosacral
nerve roots
below the conus
medullaris is
called as the
cauda equina
syndrome.

 The client
experience
atexia of the
bowel, bladder
and lower
extremities.
 CLINICAL MANIFESTATIONS:-
 Longitudinal distraction with or without flexion and/or
extension of the vertebral column may result in primary spinal
cord injury without spinal fracture or dislocation.

 Longitudinal distraction of the spinal cord with or without

flexion and/or extension of the vertebral column may result in
SCIWORA.

 The term SCIWORA (spinal cord injury without

radiologic abnormality)

 SCIWORA should now be more correctly renamed as "spinal

cord injury without neuroimaging abnormality" and recognize
that its prognosis is actually better than patients with spinal
cord injury and radiologic evidence of traumatic injury.
 LEVEL OF INJURY;
 The initial clinical manifestations of acute SCI depends on
the level and extent of injury to the cord. Below the level of
injury or lesions, there is loss of;

 voluntary movements

 sensation of pain, temperature, pressure, and peoprioception

(ability to know where body is in space).

 Bowel and bladder function

 spinal and autonomic reflexes.

 Flaccid paralysis of all skeletal muscle below the level of

injury.
LEVEL OF INJURY CONTD…..

 Injury to cervical spine and cord produces

quadriplegia. Injuries above the C4 may
be fetal because of loss of innervation to
the diaphragm and intercostal muscles.

 Injury to thoracic or lumber spine produce

paraplegia.
 Cervical injuries
 Cervical (neck) injuries usually result in full or
partial QUADRIPLAGIA. However, depending on
the specific location and severity of trauma,
limited function may be retained.

 C3 vertebrae and above : Typically results in

loss of diaphragm function, necessitating the
use of a ventilator for breathing.

 C4 : Results in significant loss of function at

the biceps and shoulders.
 Contd…..
 C5 : Results in potential loss of function at the
shoulders and biceps, and complete loss of
function at the wrists and hands.

 C6 : Results in limited wrist control, and

complete loss of hand function.

 C7 and T1 : Results in lack of dexterity in the

hands and fingers, but allows for limited use of
arms. C7 is generally the threshold level for
retaining functional independence.
 Breathing
 Any injury of the spinal cord at or above the C3,
C4, and C5 segments, which supply the phrenic
nerves causing the diaphragm, could stop
breathing. People with these injuries need
immediate ventilatory support.

 If the injuries are at the C5 level and below, the

sufferers' diaphragm function is reserved, but
breathing is apt to be rapid and shallow and
people have trouble coughing and clearing
secretions from their lungs due to weak thoracic
muscles.
 Thoracic injuries
 Injuries at or below the thoracic spinal levels
result in paraplegia. Function of the hands,
arms, neck, and breathing is usually not
affected.

 T1 to T8 : Results in the inability to control the

abdominal muscles. Accordingly, trunk stability
is affected. The lower the level of injury, the
less severe the effects.

 T9 to T12 : Results in partial loss of trunk and

abdominal muscle control.
 Lumbar and Sacral injuries
 The effects of injuries to the lumbar or
sacral regions of the spinal cord are
decreased control of the legs and hips,
urinary system, and anus.
 Changes in Reflexes:-
 Reflexes which normally cross the spinal cord and return to
the stimulates limb, are absent in early SCI because of Spinal
Cord Edema.

 BP and temperature in denervated areas fall markedly and

respond poorly to reflex stimuli.

 After cord edema subsides, some body functions may return

by reflex (e.g. control of the urinary bladder), but they lack
integration with other visceral activities.

 Visceral activities may be initiated atypical stimuli. For e.g.

Scratching the skin may cause vasodilation , sweating and
urination.

 Defective urinary bladder function ( cord bladder ).

 Muscle Spasm
 Intense and painful muscular spasm of the lower
extremities occurs following a traumatic complete
transverse spinal cord lesion.

 Muscle spasm are often aggravated by cold

weather, prolonged period of sitting or emotionally
upsetting events. Reflexes spasms may be triggered
by extrinsic or visceral stimuli, such as distended
bladder

 Muscle spasms vary from mild muscular twitching to

vigorous mass reflexogenic states.
 AUTONOMIC DYSREFLEXIA
 Autonomic dysreflexia is a life-threatening reflex
action that primarily affects those with injuries to the
neck or upper back.
 It happens when there is an irritation, pain, or
stimulus to the nervous system below the level of
injury.
 The irritated area tries to send a signal to the brain,
but since the signal is not able to get through, a reflex
action occurs without the brain's regulation.
 Unlike spasms that affect muscles, autonomic
dysreflexia affects vascular and organ systems
controlled by the sympathetic nervous system.
 Pressure sores
 Pressure sores are areas of skin tissue
that have broken down because of
continuous pressure on the skin. People
with paraplegia and quadriplegia are
susceptible to pressure sores because they
can't move easily on their own.
 Pain
 People who are paralyzed often have what is
called neurogenic pain resulting from damage
to nerves in the spinal cord.
 For some survivors of spinal cord injury, pain
or an intense burning or stinging sensation is
unremitting due to hypersensitivity in some
parts of the body.
 Others are prone to normal musculoskeletal
pain as well, such as shoulder pain due to
overuse of the shoulder joint from pushing a
wheelchair and using the arms for transfers.
 Bladder and bowel problems
 Most spinal cord injuries affect bladder and bowel functions because the
nerves that control the involved organs originate in the segments near
the lower termination of the spinal cord and are cut off from brain input.

 Without coordination from the brain, the muscles of the bladder and
urethra can not work together effectively, and urination becomes
abnormal.

 The bladder can empty suddenly without warning, or become over-full

without releasing.

 In some cases the bladder releases, but urine backs up into the kidneys
because it is not able to get past the urethral sphincter.

 Most people with spinal cord injuries use either intermittent

catheterization or an indwelling catheter to empty their bladders.
 Reproductive and sexual
function
 Spinal cord injury has a greater impact on sexual and
reproductive function in men than it does in women.

 Most spinal cord injured women remain fertile and can conceive
and bear children.

 Even those with severe injury may well retain orgasmic

function, although many lose some if not all of their ability to
reach satisfaction.

 Depending on the level of injury, men may have problems with

erections and ejaculation, and most will have compromised
fertility due to decreased motility of their sperm.
 DIAGNOSTIC EVALUATION :-
 History Taking
 Physical Examination
 X- Rays
 C T Scan
 MRI
 Laboratory Investigations
 Laboratory Studies
 Arterial blood gas measurements may be
useful to evaluate adequacy of
oxygenation and ventilation.
 Lactate levels to monitor perfusion status
can be helpful in the presence of shock.
 Hemoglobin and/or hematocrit levels may
be measured initially and monitored
serially to detect or monitor sources of
blood loss.
 Perform urinalysis to detect associated
genitourinary injury.
 Imaging studies;
 X-Rays
According to the Mayo Clinic, it is fairly common to have an X-ray
conducted on injury. Any signs of damage, such as an injury to vertebrae or
bone fragments lodged within spinal cord tissue can be detected with an X-
ray.

 CT Scan
A computerized tomography can provide a clearer picture of any damage
caused by accident. For example, a CT scan is usually issued because an X-
ray could not provide a clear enough picture of injury. CT scans are
designed to make cross-sectional pictures of body. The CT uses a high
powered computer to show the results of scan. As a result, any abnormality
such as bone damage or disk damage can be detected by the CT scan.
 Imaging studies;
 MRI
According to Spine Universe, magnetic resonance imaging can examine spinal
cord directly, or even check for signs of blood clots, herniated discs, or any
other material that is possibly compressing spinal cord. An MRI is a machine
that uses magnetic forces and radio waves to develop images of organs and
tissues. Images taken of spine are created in 3-D on a computer screen.
 Myelography
 According to the Mayo Clinic, myelography is conducted when unable to
conduct an MRI, or when further information is needed to diagnosis the
severity of injury. In myelography, a dye is injected directly into spinal
canal. This dye provides better imaging of spinal nerves, especially when
used with an X-ray or CT scan.
 Further Diagnosis
After undergoing testing, and After patient have suffered from injury, will
immobilize spine. It is likely that within a few days of suffering injury, patient
will undergo a repeat testing of X-rays, MRIs, questioning, or other tests to
determine how severe injury is and what course of treatment will be.
MANAGEMENT
 Pre-hospital Care
 Most pre-hospital care providers recognize the need to
stabilize and immobilize the spine on the basis of mechanism
of injury, pain in the vertebral column, or neurologic
symptoms.

 Patients are usually transported to the Emergency

Department with a cervical hard collar on a hard backboard.

 The patient should be secured so that in the event of emesis, the

backboard may be rapidly rotated while the patient remains fully
immobilized in a neutral position. Spinal immobilization protocols
should be standard in all pre hospital care systems.
 Emergency Department Care contd…..
 Most patients with spinal cord injuries (SCIs)
have associated injuries. In this setting,
assessment and treatment starts with
maintenance of;

 Airway,

 Breathing,

 and Circulation .
 Emergency Department Care contd…..
 The cervical spine must be
maintained in neutral
alignment at all times.

 Clearing of oral secretions

and/or debris is essential to
maintain airway patency
and to prevent aspiration.

 The modified jaw thrust

and insertion of an oral
airway may be all that is
required to maintain an
airway in some cases.
However, intubation may
be required in others.
 Emergency Department Care contd…..
 Hypotension may be hemorrhagic and/or
neurogenic in acute spinal cord injury.
 The most common causes of occult
hemorrhage are chest, intra-abdominal, or
retroperitoneal injuries and pelvic or long bone
fractures.
 Appropriate investigations, including
radiography or CT scanning, are required and
ultrasonographic study may be required to
detect intra-abdominal hemorrhage.
 Emergency Department Care contd…..
 Once occult sources of hemorrhage have been excluded, initial treatment of
neurogenic shock focuses on fluid resuscitation. Judicious fluid replacement
with isotonic crystalloid solution to a maximum of 2 liters is the initial
treatment of choice.
 Neurogenic shock involves
1. Loss of motor function
2. Loss of sensory function
3. Loss of sympathetic autonomic function
 SOMATIC MOTOR COMPONENT
1. Paralysis
2. Flaccidity
3. Areflexia

 SENSORY AND AUTONOMIC

1. Sensory - Anaesthesia to all modalities
2. Autonomic – Hypotension: skin hyperaemia
3. and warmth (sympathetic) bradycardia
 Difference between spinal and
systemic shock
SPINAL SHOCK SYSTEMIC SHOCK
(Hypovolaemic)
 Hypotension  Hypotension

 Bradycardia  Tachicardia

 Warm extremities  Cold extremities

 Emergency Department Care contd…..
 The therapeutic goal for neurogenic shock is
adequate perfusion with the following
parameters:
 Systolicblood pressure (BP) should be 90-100 mm
Hg. Systolic BPs in this range are typical for patients
with complete cord lesions. The most important
treatment consideration is to maintain adequate
oxygenation and perfusion of the injured spinal
cord.
 Heart rate should be 60-100 beats per minute in
normal sinus rhythm.
Emergency Department Care contd…..
 Hemodynamically significant bradycardia may be
treated with atropine (0.5 mg to 1 mg ).

 Urine output should be more than 30 mL/h.

Placement of a Foley catheter to monitor urine
output is essential. Rarely, inotropic support with
dopamine is required. It should be reserved for
patients who have decreased urinary output despite
adequate fluid resuscitation. Usually, low doses of
dopamine in the 2- to 5-mcg/kg/min range are
sufficient.

 Prevent hypothermia.
 Emergency Department Care contd…..
 Associated head injury occurs in about 25% of
patients with spinal cord injury.

 A careful neurologic assessment for associated head

injury is compulsory.

 The presence of amnesia, external signs of head

injury or basilar skull fracture, focal neurologic
deficits, associated alcohol intoxication or drug
abuse, and a history of loss of consciousness
mandates a thorough evaluation for intracranial
injury, starting with noncontrast head CT scanning.
 Emergency Department Care contd…..
 Placement of a nasogastric tube is essential.

 Aspiration pneumonitis is a serious complication

in the patient with a spinal cord injury with
compromised respiratory function.

 Antiemetics (Diphenhydramine 10–50mg IV

max 400mg. ) should be used aggressively.
 The patient is best treated initially in the
supine position.
 Logrolling the patient to the supine
position is safe to facilitate diagnostic
evaluation and treatment.
 Use analgesics appropriately and
aggressively to maintain the patient's
comfort if he or she has been lying on a
hard backboard for an extended period.
 Prevent pressure sores.
 Denervated skin is particularly prone to
pressure necrosis.
 Turn the patient every 1-2 hours. Pad all
extensor surfaces.
 Undress the patient to remove belts and back
pocket keys or wallets.
 Remove the spine board as soon as possible.
 Use of steroids in spinal cord injury
 High-dose steroids are thought to reduce the
secondary effects of acute spinal cord injury
(SCI). Studies have shown limited but
significant improvement in the neurologic
outcome of patients treated within 8 h of
injury.

 Methylprednisolone 30 mg/kg bolus over 15

minutes and an infusion of methylprednisolone
at 5.4 mg/kg/h for 23 hours beginning 45
minutes after the bolus.
 OTHER MEDICATIONS:-
 Acetaminophen:It's proven to be a
good pain reliever.
 NSAIDs (non-steroidal anti-
inflammatory drugs):-COX-2
Inhibitor (cyclooxygenase-2), such as
Celebrex.
 Muscle Relaxants: Spinal fractures
can cause spinal muscles to work
harder as they try to support the
spine. Overworked muscles can have
spasms, and those can add to pain. A
muscle relaxant will help stop the
pain. Valium is a muscle relaxant.
 OTHER MEDICATIONS:-
 Neuropathic Agents: If the fracture is causing nerve
problems,it may need to take medication that specifically
targets the nerves. Neurontin (100mg-600 mg) .

 Opioids (Narcotics): These are very serious medications, and

they should be used only in the most extreme cases and under
the careful supervision of doctor.eg.-Fentanyl

 Prescription NSAIDs: Like the over-the-counter variety,

prescription NSAIDs work to reduce inflammation. The doctor
may recommend a COX-2 Inhibitor, such as Celebrex. It's a
newer development in the world of NSAIDs, and it doesn't
cause as many gastrointestinal side effects.
 ACUTE PHASE (1-24 Hrs)
 After the maintenance of pulmonary
and cardiovascular stability, the next
step is to maintain the Spinal Cord
Immobilization- use of skeletal tongs.
1. Crutchfield and Vinke tongs require
predrilled holes in the skull under local
anesthesia.

2. Weight added to traction gradually to

reduce the vertebral fracture; weight
maintained at the level to ensure
vertebral alignment.

3. Rigid kinetic turning bed to immobilize

the patients with thoracic and lumber
injuries.
 ACUTE PHASE (1-24 Hrs)
1. Surgical interventions are considered when the patient has
vertebral instability that may result in further neurological
damage; an injury that is incomplete at the onset may
become complete if instability exists.

 Decompression , typically using anterior approach n the

cervical instance, may be accomplished by removing the bony
structures and soft tissues ( eg. Fusion . Decompression
laminectomy). Reallignment of the soft tissues and vertebral
column is required.

 Stabilization , typically done using the posterior approach ,

involves the use of wires , bone grafts , plates , screws and
other fixation devices to prevent movement at the damaged
boney site ( eg. Fusion , Harrington rodes).
 SUBACUTE PHASE(1 WEEK)
1. Hallo traction is the primary treatment for cervical injuries.

 Some Halos are now can open posteriorly , which reduces the
incidence of cervical fracture displacement.

 The ring is attached to stainless steel pins ( two anteriorly and

two posteriorly) and attached to a vest by four connecting
rodes( MRI compateble and radiolucent)

 Pins and locking bolts are tightened approximately 24 to 48

hrs after placement and periodically thereafter.Pin site should
be cleaned daily with hydrogen peroxide.

 Average length of time in a Halo vest is 12 weeks , followed

by philabodelphia collar for four weeks.
 SUBACUTE PHASE( 1 WEEK)
 GM-1 Ganglioside sodium salt I.V , begun
within 72 hrs after injury , and continued for
18-32 days, is believed to enhance neuronal
regeneration.
 Heparin 5,000units, BD , to prevent
thromboembolism. Other measures includes
compression boots and inferior vena cava filters
are used.
 CHRONIC PHASE ( BEYOND 1 WEEK)
1. Harrington rods, used in conjunction with body jackets , are
used for patients with thoracolumber injuries .
2. To prevent thrombophlebitis in the chronic phase ,
compression boots should be used for 2 weeks.
3. Management of the complications may include;

 Treatment of infections with antibiotics ,

 Treatment of the respiratory complications phrenic nerve
pacing, mechanical ventilation, and other methods.
 Pressure ulcers
 Management of the spasticity with antispasmodic agents
 Management of the central neuropathic pain with
anticonvulsants ( Phenetoin), minor sedatives(lorazepam),
antidepressants(immiprazine and chlorpromazine) , nerve
block .
 CHRONIC PHASE CONTD…..

4. Spasticity should be managed by ;

 Maintain calm, stress-free environment .
 Allowing ample time for activities such as
positioning and transferring.
 Perform joint ROM exercises with slow,
smooth movements.
 Administering muscle relaxants such as
baclfen, diazepam as prescribed.
5. Rehabilitation includes medical and
psychological support, physical therapy,
occupational therapy.
 COMPLICATIONS
1. Spinal shock lasting few hours to few weeks noted by
loss of all reflex,motor , sensoray , and autonomic
activity below the level of lesion.

2. Respiratory arrest , pneumonia, atelectasis requiring

mechanical ventilation with cervical injury.

3. Cardiac arrest may results from the initial trauma.

4. Thromboembolitic complications- in 15% of patients.

5. Infections- respiratory urinary, pressure ulcers ,

sepsis.
6. Autonomic dysreflexia – exaggerated autonomic
response to stimuli below the level of the lesion in
patients with lesions at or above the T6 is medical
emergency and can result in dangerous elevation of the
BP.
7. Urologic – neurogenic bladder, and patients with the
indwelling catheters may have UTI.
8. Paralytic ileus – common in the acute and subacute
phase.
9. Syringomyelia – cyatic formation in spinal cord may
occur any time after SCI.
10. Spasticity may results in the contractures.
11. Amenorrhea occurs in the 60% of women with SCI ,
usually temporary.
NURSING MANAGEMENT
NURSING PRIORITIES

1. Maximize respiratory function.

2. Prevent further injury to spinal cord.
3. Promote mobility/independence.
4. Prevent or minimize complications.
5. Support psychological adjustment of patient/SO.
6. Provide information about injury, prognosis and expectations, treatment
needs, possible and preventable complications.

DISCHARGE GOALS

1. Ventilatory effort adequate for individual needs.

2. Spinal injury stabilized.
3. Complications prevented/controlled.
4. Self-care needs met by self/with assistance, depending on specific situation.
5. Beginning to cope with current situation and planning for future.
6. Condition/prognosis, therapeutic regimen, and possible complications
understood.
7. Plan in place to meet needs after discharge.
 The American Spinal Injury Association
recommends use of the following scale of
findings for the assessment of motor
strength in SCI:

0 - No contraction or movement
 1 - Minimal movement
 2 - Active movement, but not against gravity
 3 - Active movement against gravity
 4 - Active movement against resistance
 5 - Active movement against full resistance
 NURSING DIAGNOSIS:-Inability to clear secretions or obstructions from
the respiratory tract to maintain airway patency r/t Spinal Cord Injury.

 NURSING DIAGNOSIS:- Ineffective Breathing Pattern r/t altered level

of consciousness.

 Nursing Diagnosis: Impaired Gas Exchange , Ventilation or Perfusion

Imbalance r/t inadequate ventilation.

 Nursing Diagnosis:- Risk for Aspiration r/t regurgitation of gastric

content.

 Nursing Diagnosis: Risk for Impaired Skin Integrity r/t immobility.

 According to Arizona Spinal Cord Injury Association :-

 "Improving Orthostatic Tolerance after Spinal Cord Injury“.

 This study seeks to determine if people with spinal cord
injury (SCI) can benefit from an at-home exercise
program.
 In particular, are studying if exercise can help avoid or
reduce sudden drops in blood pressure that sometimes
occur after a change in posture, such as a move from lying
down to a seated position.
 Participation in this study involved completion of a 12-
week exercise program involving electrical stimulation of
legs muscles (five 45-minute sessions per week) in wheel
chair sitting position.
 Bibliography:
 Black M.Joyce.Medical Surgical Nursing(2008):Elsevier
publishers.vol-2,ed-8th. P-515 - 28
 Wilkins,Williams.Mannual of Nursing Practice(2009):Wolter
Kluner.ed-9.P-279-85.
 Keen Janet hicks,Swearingen Pulmelal.Critical Care Nursing
Consultant(1997):Mosby publishersvol-1st,ed-1st.P-
366,318,172,108.
 Perry potter.Spinal Cord Injuries,Foundation of Nursing.New
Delhi;Harcourt Private limited publishers.P 1194-1196
 William & Lippincott .Spinal Cord Injuries.Lippincott Manual of
Nursing Practice,9th edition,2010;New Delhi.P 802-803
References:- 
 http://www.mayoclinic.com/health/spinal-cord-injury/DS00460/DSECTION=
coping-and-support
 http://emedicine.medscape.com/article/793582-overview
 http://emedicine.medscape.com/article/793582-diagnosis 
 http://emedicine.medscape.com/article/793582-treatment
 http://www.google.co.in/#hl=en&biw=897&bih=335&q=DIAGRAM+OF+
+autonomic+dysreflexia&aq=f&aqi=&aql=&oq=&fp=68b2ac9bfcc08c02
ANY QUARY ?