Spinal cord injury

2. Spinal cord
syndromes???
Causes of
spinal cord
injury???
Spinal
plexus????
Immediate
management??

3. CASE
• A 42-year-old male was admitted to emergency department after a
motor vehicle accident. His complaint was back pain and was unable to
move both lower limbs. Upon physical examination, the patient was
not ambulatory. Sensory examination revealed the absence of
sensation below the T12 level. The strength of the bilateral lower limbs
was grade 0. The patient received a radiographic evaluation. The initial
diagnosis was T11 fracture with complete paraplegia of the lower
limbs. Sagittal MRI demonstrated an isointense lesion on T1-weighted
imaging and a high-signal spindle-like lesion on T2-weighted imaging of
the spinal cord adjacent to the T11 vertebra. The patient was ultimately
diagnosed with complete paraplegia with a T11 butterfly vertebra. He
underwent urgent posterior decompressive and fixation surgery from
T10 to T12. His postoperative recovery was uneventful.

4. Butterfly vertebra

18. DEFINITION
• Spinal cord injury (SCI) is caused
by trauma or damage to the
spinal cord. It can result in
either a temporary or
permanent alteration in the
function of the spinal cord.

19. INCIDENCE AND PREVALENCE
• In India, approximately 1.5 million people live with SCI.
Approximate 20,000 new cases of SCI are added every year and
60-70% of them are illiterate, poor villagers. Majority of them
are males in the age group of 16-30 years, signifying higher
incidence in young, active and productive population of the
society.

20. RISK FACTORS OF SPINAL CORD
INJURY
• Gender- Male > Female (80:20)
• Age – 16 to 30 years and older than 65 years
• Diving into too-shallow water or playing sports without
wearing the proper safety gear or taking proper precautions
• Motor vehicle accidents
• Having a bone or joint disorder

21. CAUSES OF SPINAL CORD INJURY
• Tumours
• Falls
• Infections
• Gunshot Injuries
• Blunt Assault
• Road traffic accidents
• Vertebral fractures
secondary to osteoporosis
• Stab Wounds
• Sport Injuries
• Vascular disorders
• Development disorders

23. The initial mechanical disruption
of axons as a result of stretch or
laceration is referred to as the
primary injury.

27. CLASSIFICATION OF SPINAL CORD
INJURY
SCIs are classified by the:
(1) Mechanism of injury
(2) Level of injury
(3) Degree of injury

31. JEFFERSON FRACTURE

33. CLINICAL MANIFESTATIONS
• The manifestations of SCI are generally the direct result of trauma that
causes cord compression, ischemia, edema, and possible cord
transection.
• Manifestations of SCI are related to the level and degree of injury. The
patient with an incomplete injury may demonstrate a mixture of
manifestations.
• The higher the injury, the more serious the sequelae because of the
proximity of the cervical cord to the medulla and brainstem

39. OTHER TYPES OF INJURY

41. RESPIRATORY SYSTEM-
Respiratory insufficiency, hypoventilation, decrease in vital capacity
and tidal volume, impairment of the intercostal muscles.
CARDIOVASCULAR SYSTEM-
Decreased cardiac output, resulting in hypotension.
IV fluids or vasopressor drugs may be required to support the BP.
URINARY SYSTEM-
The bladder is atonic and becomes over distended.

42. GASTROINTESTINAL SYSTEM-
Decreased or increase GI motor activity contributes to the
development of paralytic ileus and gastric distention.
INTEGUMENTARY SYSTEM-
Skin breakdown over bony prominences in areas of decreased or
absent sensation.
THERMOREGULATION-
Spinal cord disruption there is also decreased ability to sweat or
shiver below the level of injury, which also affects the ability to
regulate body temperature.

43. METABOLIC NEEDS-
The person with an SCI has greater nutritional needs than other
patients who are immobilized. A high-protein diet helps prevent skin
breakdown and infections and decreases the rate of muscle atrophy.
MUSCLE SPASM-
Emotion and cutaneous stimulation may initiate spastic movement.
AUTOGENIC DYSREFLEXIA-
It is a cluster of clinical manifestation that result in multiple spinal cord
autonomic response discharge simultaneously.

44. DIAGNOSTIC TEST
• History collection
• Physical examination
• Neurological examination
• CT and MRI
• Cervical X-ray
• CT angiogram

45. COLLABORATIVE CARE
• Immediate post injury goals include maintaining a patent
airway, adequate ventilation, and adequate circulating blood
volume and preventing extension of cord damage (secondary
injury).

46. Emergency management of the patient with an SCI-
Assessment Findings
• Pain, tenderness, deformities, or muscle spasms adjacent to
vertebral column
• Numbness, paraesthesia
• Alterations in sensation: temperature, light touch, deep
pressure
• Weakness or heaviness in limbs
• Weakness, paralysis, or flaccidity of muscles

47. • Spinal shock
• Cuts; bruises; open wounds over-head, face, neck, or back
• Neurogenic shock: hypotension, bradycardia, dry, flushed skin
• Bowel and bladder incontinence
• Urinary retention
• Difficulty breathing
• Diminished rectal sphincter tone

48. Interventions
• Ensure patent airway.
• Immobilize and stabilize cervical spine.
• Administer O2 via nasal cannula or non-rebreather mask.
• Establish IV access with two large-bore catheters to infuse
normal saline or lactated Ringer’s solution as appropriate.
• Assess for other injuries.
• Control external bleeding.
• Obtain CT scan or cervical spine x-rays.
• Ongoing Monitoring

49. • Monitor vital signs, level of consciousness, O2 saturation,
cardiac rhythm, urine output.
• Keep warm.
• Monitor for urinary retention, hypertension.
• Anticipate need for intubation if gag reflex absent.
• Systemic and neurogenic shock must be treated to maintain
BP. For injury at the cervical level, all body systems must be
maintained until the full extent of the damage can be
evaluated.

50. NON-OPERATIVE STABILIZATION
• Traction or realignment
• Stabilization methods eliminate
damaging motion at the injury site.
• These methods are intended to
prevent secondary spinal cord damage
caused by repeated contusion or
compression.

51. DRUG THERAPY
• Methylprednisolone
• Low-molecular-weight heparin (e.g., enoxaparin) is used to
prevent VTE unless contraindicated.
• Vasopressor agents such as dopamine (Inotropic) are used in the
acute phase as adjuvants to treatment.
• Analgesic (Tramadol) to reduce the pain.

52. SURGICAL THERAPY
Criteria used in the decision for early surgery include :
(1) Evidence of cord compression
(2) Progressive neurologic deficit
(3) Compound fracture of the vertebrae
(4) Bony fragments (may dislodge and penetrate the cord)
(5) Penetrating wounds of the spinal cord or surrounding structures

53. • A fusion procedure involves
attaching metal screws,
plates, or other devices to
the bones of the spine to
help keep them properly
aligned.

54. NURSING DIAGNOSIS
1) Ineffective breathing pattern related to respiratory muscle
fatigue, neuromuscular paralysis, and retained secretions as
evidence by altered respiratory rate.
2) Chronic pain related to spinal cord injury as evidence by
immobilization, facial expression and verbal explanation of client.
3) Impaired physical mobility related to spinal cord injury as
evidenced by inability to move upper or lower extremities,
secondary to paralysis.

55. 4) Impaired skin integrity related to immobility and poor
tissue perfusion as evidence by presence of bed sore.
5) Impaired urinary elimination related to spinal injury and/
or limited fluid intake as evidence by decreased urine
output.

56. COMPLICATIONS OF SPINAL CORD INJURY
• Urinary tract infection or urinary incontinence
• Bowel incontinence
• Pressure sore
• Lung infection
• Blood clot
• Muscle spasm
• Chronic pain and depression
• Breathing difficulty
• Impaired activities of daily living

57. Rehabilitation of spinal cord injury
• Initiate range of motion exercises of all joints within the first week
after injury and continue throughout the acute phase.
• Strengthening Exercises.
• Seating and Positioning.
• Mobilization, including bed mobility, transfer training, relevant
locomotion (gait or wheelchair).
• Splinting - Upper and Lower Extremity.
• Respiratory Interventions including percussion, vibration,
suctioning, postural drainage, mobilization, training of accessory
muscles, cough, and deep breathing exercises.

58. • Functional communication.
• Assessment of swallowing.
• Assessment of cognitive and/or language deficits from concomitant
traumatic brain injury.
• Nutritional Status including anthropometric measurements, dietary
intake and losses, nutrition- and hydration-related blood work,
ability to self-feed or dependence on others for eating and drinking
and other barriers to optimal food and fluid intake
• Educate patients and families about the rehabilitation process and
encourage their participation in discharge planning discussions.

60. Contextualizing the lived experience of quality of life
for persons with spinal cord injury: A mixed-methods
application of the response shift model
A mixed-method study, applying the Schwartz and Sprangers response
shift (RS) model was conducted to gain greater insight into individuals’
quality of life (QOL) definitions, appraisals, and adaptations following
spinal cord injury (SCI) in community dwelling participants. RS is a cognitive
process wherein, in response to a change in health status, individuals
change internal standards, values, or conceptualization of QOL. A
purposive sample of 40 participants with SCI completed semi-structured
interviews and accompanying quantitative measures. Four RS themes were
identified. The themes ranged from complete RS, indicating active
engagement in maintaining QOL, to awareness and comparisons redefining
QOL, to a relative lack of RS. The study concluded that the RS model
contextualizes differences in QOL definitions, appraisals, and adaptations
in a way standardized QOL measures alone do not.

61. A Cross Sectional Study of Spinal Cord Injury-Induced
Musculoskeletal Pain
A cross-sectional study was conducted by Mohammad Kamrujjaman in 2019 to
determine the spinal cord injury-induced musculoskeletal pain in Dhaka city on 90
spinal cord injury subjects. Numerical Pain Rating Scale was used to assess the
grade of musculoskeletal pain and American Spinal Injury Association scale was
used to find out the types of injury. The study concluded that more than two-third
of the person with spinal cord injury complained to musculoskeletal pain. Neck,
shoulder, and back were the more prevalent site of musculoskeletal pain. Road
traffic accident and fall from height were the common causes of injury. Cervical
and thoracic levels were the vulnerable site in person with spinal cord injury.
However, there was a highly significant relationship found between the level of
injury and musculoskeletal pain. The prevalence of musculoskeletal pain is
extremely high in person with spinal cord injury. Some factors like spinal levels
and causes of injury are significantly accountable for musculoskeletal pain.
Adequate physiotherapy might help to reduce the incidence and intensity of
spinal cord injury-induced musculoskeletal pain.

62. CONCLUSION
• Brain and spinal cord injury are most complex injuries the human
can endure. Nurses who have to look after neurologically impaired
patients must develop and maintain assessment skills to detect the
suitable signs of neurologic deterioration.
• The physical and psychological impairment vary with the degree of
damage as well as the client response to and ability to cope with
the body changes. It is imperative that nurse comprehend the
severity of the client dysfunction as it relates to quality of life as
well as its impact on family dynamics.