Includes Types Management

1. Spinal Cord Injury
Presented by: Anjali Arora
M.Sc. Nursing -1ST Year
College Of Nursing
Institute Of Liver and Biliary Sciences

2. The spinal cord is very sensitive to injury. Unlike other parts of
your body, the spinal cord does not have the ability to repair
itself if it is damaged.
A spinal cord injury occurs when there is damage to the spinal
cord either from trauma, loss of its normal blood supply, or
compression from tumour or infection.

3. Spinal cord injury is a
traffic jam in the body’s
highway system

4. Definition
A spinal cord injury — damage to any part of the spinal cord or
nerves at the end of the spinal canal (cauda equina) — often
causes permanent changes in strength, sensation and other
body functions below the site of the injury.

5. Prevalence
According to WHO,
 Every year, around the world, between 250 000 and 500 000
people suffer a spinal cord injury (SCI).
 There is no reliable estimate of global prevalence, but
estimated annual global incidence is 40 to 80 cases per
million population.
 Up to 90% of these cases are due to traumatic causes,
though the proportion of non-traumatic spinal cord injury
appears to be growing.

6. Prevalence
IN INDIA
Though there is no proper epidemiological study, it is
estimated from pilot studies that the incidence is 20 per
million population and the main mode of injury is fall from
height.
Road traffic accidents are the second or third most
common mode of injury and are on the increase.
India’s vehicular population is 1% of global shares
whereas share of road accidents is 6%. In addition, the
difference in population distribution (74% of the Indian
population lives in rural areas) and the fact that most
accidents takes place at home.

7. RISK FACTORS
Young adults and seniors
People who are active in sports
People with predisposing
conditions
Substance abuse (alcohol and
drugs)

8. CAUSES
TRAUMATIC CAUSES
 Bullet or stab wound
 Electric shock
 Extreme twisting of the middle of the body
 Landing on the head during a sports injury
 Fall from a great height
 Motor vehicle crashes.
 violence (primarily from gunshot wounds)
 Recreational sporting activities.

9. CAUSES
NON-TRAUMATIC CAUSES
 Communicable diseases − tuberculosis (TB) and human immunodeficiency
virus (HIV)
 Non-communicable conditions − cancer, degenerative diseases such as
osteoarthritis leading to spinal stenosis, Tubercular Spondylosis
 Nutritional deficiencies – neural tube defects, vitamin B12 deficiency
 Complications of medical care especially after spinal injections and
epidural catheter placement
 Developmental disorders (spinal stenosis)

10. Category of spinal cord injuries
Injury can be categorized as:
 Primary spinal cord injury (actual physical disruption of axons)
 Secondary spinal cord injury(ischemia, hypoxia, haemorrhage,
oedema)

11. Pathophysiology

12. Classification of spinal cord injury
Degree of injury
Complete Incomplete
Level of injury
Skeletal Neurological
Mechanism of injury
Flexion Hyperextension Flexion rotation
Extension
rotation
Compression

13. Mechanism of injury

14. Level of spinal cord injury

16. Degree of injury
 A complete spinal cord lesion (total loss of sensation and voluntary
muscle control below the lesion) can result in paraplegia or
tetraplegia.
 Complete Spinal cord injury involves complete loss of sensation and
muscle function in the body below the level of the injury and can
result in paraplegia (paralysis of the lower body) or tetraplegia
(formerly quadriplegia— paralysis of all four extremities.
 Total loss of function below the level of injury is complete spinal
cord injury. No functional recovery is expected. This has profound
prognostic value and helps in setting realistic rehabilitation goals.

18. Degree of injury
 In an incomplete spinal cord injury, there is some remaining
function below the level of the injury and lesions are classified
according to the area of spinal cord damage: central, lateral, anterior,
or peripheral.
 If the spinal cord is partially damaged some signals from the brain
can cross the injured area to reach muscles and skin. This is an
incomplete injury and further recovery may be expected with time.
 With incomplete injuries, the cord is only partially severed, allowing
the injured person to retain some function. In these cases, the
degree of function depends on the extent of the injuries.

24. ASIA Impairment scale

26. Clinical Manifestations
CERVICAL (NECK) INJURIES
 Breathing difficulties
 Loss of normal bowel and bladder control
 Numbness
 Sensory changes
 Spasticity (increased muscle tone)

27. THORACIC (CHEST LEVEL) INJURIES
 Loss of normal bowel and bladder control
 Numbness
 Sensory changes
 Spasticity (increased muscle tone)
 Weakness, paralysis
Clinical Manifestations

28. LUMBAR SACRAL (LOWER BACK) INJURIES
 Loss of normal bowel and bladder control (you
may have constipation, leakage, and bladder
spasms)
 Numbness
 Pain
 Sensory changes
 Weakness and paralysis
Clinical Manifestations

29. Diagnostic Studies
 Laboratory studies
 Arterial blood gas (ABG) measurements
 Lactate levels
 Haemoglobin and/or haematocrit levels
 Urinalysis
 Imaging studies
 Diagnostic x-rays
 Computed tomography (CT) scanning
 Magnetic resonance imaging (MRI)
 Continuous electrocardiographic monitoring

30. Emergency management
 Immediate patient management at the accident scene is crucial. Improper handling
can cause further damage and loss of neurologic function.
 Consider any victim of a motor vehicle crash, a diving or contact sports injury, a fall,
or any direct trauma to the head and neck as having an SCI until ruled out.
 Initial care includes rapid assessment, immobilization, extrication, stabilization or
control of life-threatening injuries, and transportation to an appropriate medical
facility.
 Maintain patient in an extended position (not sitting); no body part should be
twisted or turned.
 Airway management - The cervical spine must be maintained in neutral alignment
at all times; clearing of oral secretions and/or debris is essential to maintaining
airway patency and preventing aspiration
 The standard of care is referral to a regional spinal injury centre or trauma centre for
treatment in first 24 hours.

31. MEDICAL MANAGEMENT
 The goals of management are to prevent secondary injury to observe
for symptoms of progressive neurologic deficits, and to prevent
complications.
 The patient is resuscitated as necessary, and oxygenation and
cardiovascular stability are maintained. SCI is a devastating event; new
treatment methods and medications are continually being investigated
for the acute and chronic phases of care.
 Pharmacologic Therapy
 Respiratory Therapy
 Skeletal Fracture Reduction and Traction

32. Surgical Management
Surgery is indicated in any of the following
situations:
Compression of the cord is evident.
The injury results in a fragmented or unstable
vertebral body.
The injury involves a wound that penetrates the
cord
Bony fragments are in the spinal canal.
The patient's neurologic status is deteriorating.

33. Surgical Management
Intradiscal electrothermoplasty(IDET)
Radiofrequency discal nucleoplasty(coblation
nucleoplasty)
Interspinous process decompression system
Laminectomy
Diskectomy
Percutaneous diskectomy
Spinal fusion

34. Charite Disc

35. Complications of spinal cord injury
 The spinal shock reflects a sudden depression of reflex activity in
the spinal cord (areflexia) below the level of injury and are without
sensation, paralyzed, and flaccid, and the reflexes are absent. In
particular, the reflexes that initiate bladder and bowel function are
affected. Bowel distention and paralytic ileus can be caused by
depression of the reflexes and are treated with intestinal
decompression by insertion of a nasogastric tube.
 Neurogenic shock develops as a result of the loss of autonomic
nervous system function below the level of the lesion. The vital
organs are affected, causing decreases in blood pressure, heart rate,
and cardiac output, as well as venous pooling in the extremities and
peripheral vasodilation. In addition, the patient does not perspire in
the paralyzed portions of the body, because sympathetic activity is
blocked; therefore, close observation is required for early detection
of an abrupt onset of fever.

36. Complications of spinal cord injury
 Deep Vein Thrombosis
 Other Complications
In addition to respiratory complications (respiratory failure,
pneumonia) and autonomic dysreflexia (characterized by pounding
headache, profuse sweating, nasal congestion, piloerection ["goose
bumps’, bradycardia, and hypertension),
 other complications that may occur include pressure ulcers and
infection (urinary, respiratory, and local infection at the skeletal
traction pin site)

37. Nursing Management

38. Nursing process with Acute SCIs
Assessment (Subjective Data)
 Important Health Information
Health History: Motor vehicle collision sports injury, industrial incident, gunshot or
stabbing injury, falls
 Functional Health Patterns
Health Perception: Health Management-Use of alcohol or recreational drugs risk
taking behaviors
Activity- exercise: loss of Strength, movement and sensation below level of injury,
dyspnea, inability to breathe adequately (air hunger)
Cognitive-perceptual Tenderness, pain at or above level of injury, numbness, tingling
burning twitching of extremities
Coping-stress tolerance, Fear, denial, anger, depression

39. Nursing process with Acute SCIs
 Assessment(Objective data)
 General
Poikilothermic-unable to regulate body heat
 Integumentary
Warm dry skin below level of injury
 Respiratory
Injury at C1-3. Aprea inability to cough
Injury at C4 Poor cough, diaphragmatic breathing, hypoventilation
Injury at C5-16 Decreased respiratory reserve
 Cardiovascular
Injury above T5 Bradycardia, hypotension, postural hypotension, absence of
vasomotor tone

40. Nursing process with Acute SCIs
Gastrointestinal
Decreased or absent bowel sounds (paralytic ileus in injuries above
T5)-abdominal distension, constipation, fecal incontinence, fecal
impaction
Urinary
Retention (for injury at T1-L2) flaccid bladder (acute stages);
spasticity with reflex bladder emptying (later stages)
Reproductive
loss of sexual function
Neurologic
Complete: Flaccid paralysis and anesthesia below level of injury

41. Nursing process with Acute SCIs
Incomplete: Mixed loss of voluntary motor activity and sensation
 Musculoskeletal
Muscle atony (in flaccid state, contractures (in spastic state)
 Possible Diagnostic Findings
Location of level and type at bony involvement on spinal x-ray: injury, edema,
compression on CT scan and MRI.

42. Nursing Diagnosis
 Ineffective breathing patterns related to weakness or paralysis of
abdominal and intercostal muscles and inability to clear secretions
 Ineffective airway clearance related to weakness of intercostal
muscles
 Impaired physical mobility related to motor and sensory
impairment
 Disturbed sensory perception related to immobility and sensory
loss
 Risk for impaired skin integrity related to immobility or sensory
loss

43. Nursing Diagnosis
 Impaired urinary elimination related to inability to void
spontaneously
 Constipation related to presence of atonic bowel as a result of
autonomic disruption
 Acute pain and discomfort related to treatment and prolonged
immobility
 Risk for fall related to immobility and sensory loss
 Risk for injury related to immobility and sensory loss

44. Planning and goals
Major patient goals may include :
 To improve breathing pattern and airway clearance
 To improve mobility,
 To improve sensory and perceptual awareness
 To maintain skin integrity,
 To improve bowel function,
 To promote comfort and absence of complications

45. Nursing Interventions
 Promote Adequate Breathing and Airway Clearance
 Improve Mobility
 Maintain Skin Integrity
 Maintain Urinary Elimination
 Improve Bowel Function
 Provide Comfort Measures
 Monitor and Manage Potential Complications
 THROMBOPHLEBITIS.
 ORTHOSTATIC HYPOTENSION
 AUTONOMIC DYSREFLEXIA.

46. Halo- Vest

47. Evaluation
Expected patient outcomes may include the following:
 Demonstrate improvement in gas exchange and clearance of
secretions, as evidenced by normal breath sounds on auscultation
 Moves within limits of the dysfunction and demonstrates completion
of exercises within functional limitations
 Demonstrates adaptation to sensory and perceptual alterations
 Demonstrates optimal skin integrity
 Regains urinary bladder and bowel function
 Reports absence of pain and discomfort
 Is free of complications

48. Management of Long-term complications
 Genitourinary
 Review bladder management programmes regularly.
 Investigate further if there are changes in bladder function (e.g. urinary retention,
episodes of incontinence, UTIs, blood in urine).
 Test renal function.
 Carry out regular imaging of the urinary tract.
 Conduct prostate cancer screening for men.
 Bowel
 Review bowel management programmes regularly.
 Investigate further if there are changes in bowel function (e.g. constipation, diarrhoea).
 Perform a digital rectal exam routinely from middle age.
 Encourage a high-fibre diet and regular daily fluid (water) intake.
 Carry out regular monitoring of bowel function, including the frequency, colour and
consistency of stools

49. Management of Long-term complications
 Neurological/ musculoskeletal
 Review neuro-musculoskeletal function, particularly if there are changes in
sensation, muscle strength/tone, joint range of movement, or increased
pain.
 Provide education and training to prevent injuries due to overuse,
particularly in the upper limbs. Encourage regular exercise each week.
 Review assistive technology to ensure proper fit and function.
 Respiratory
 Provide education on strategies to prevent and manage infection.
 Perform regular respiratory tests (e.g. vital capacity, peak flow).
 Immunize against influenza and pneumococcal pneumonia.
 Provide support and encouragement for cessation of smoking.

50. Management of Long-term complications
 Cardiovascular System
 Check cholesterol, lipids and blood pressure regularly.
 Review risk factors (e.g. diet and smoking).
 Provide education and support for control of risk factors.
 Encourage regular aerobic exercise each week.
 Mental health and well-being
 Screen and monitor psychosocial functioning (e.g. depression).
 Review capacity of caregivers to provide and sustain support.
 Provide education and support on appropriate diet and exercise.
 Encourage community participation.

51. Management of Long-term complications
 Skin
 Provide education on how to perform daily skin checks.
 Provide advice on appropriate nutrition.
 Provide education on changing posture every two hours.
 Review assistive technology regularly to ensure proper fit and
function (e.g. wheelchair/seating systems).

52. Nursing Management (long term SCIs)
The goals for the patient may include
 Attainment in the form of mobility
 Maintenance of healthy, intact skin
 Achievement of bladder management without infection
 Achievement of bowel control
 Strengthening of coping mechanisms
 And absence of complications

53. Nursing Diagnosis
 Impaired bed and physical mobility related to loss of motor function
 Risk for disuse syndrome
 Risk for impaired skin integrity related to permanent sensory loss and
immobility
 Impaired urinary elimination related to level of injury
 Constipation related to effects of spinal cord disruption
 Sexual dysfunction related to neurologic dysfunction
 Ineffective coping related to impact of disability on daily living
 Deficient knowledge about requirements for long-term management

54. Nursing Management (long term SCIs)
 Collaborative Problems/Potential Complications
 Based on all the assessment data, potential complications of
tetraplegia or paraplegia that may develop include:
 Spasticity
 Infection and sepsis

55. Rehabilitation in patient with spinal cord injuries
This period begins with admission to hospital and stabilization of the
patient’s neurological state and is a 6-12 weeks bed period.

58. Tilt Table

59. Wheel chair, walkers crutches

60. Battery Assisted Wheelchair

61. Long and locked knee joint walking device

63. Para walker (Reciprocating gait Orthosis)

64. Hybrid walking Device

65. Robotic Assisted Gait Training

66. Home Modifications

67. Occupational Therapy

71. Research Article
The influence of neurological examination timing within hours after acute
traumatic spinal cord injuries: an observational study.
OBJECTIVES
It is widely accepted that the prediction of long-term neurologic outcome after traumatic spinal
cord injury (SCI) can be done more accurately with neurological examinations conducted days to
weeks post injury. However, modern clinical trials of neuroprotective interventions often require
patients be examined and enrolled within hours. Our objective was to determine whether
variability in timing of neurological examinations within 48 h after SCI is associated with
differences in observations of follow-up neurologic recovery.
METHODS
An observational analysis testing for differences in rates and changes in total motor scores by
neurological examination timing, controlling for potential confounders with multivariate stepwise
regression.

72. Research Article
RESULTS
We included 85 patients, whose mean times from injury to baseline and follow-up
examinations were 11.8 h (SD 9.8) and 208.2 days (SD 75.2), respectively. AIS
conversion by 1+ grade was significantly more likely in patients examined at ≤4 h in
comparison with later examination (78% versus 47%, RR = 1.66, p = 0.04), even after
controlling for timing of surgery, age, and sex (OR 5.0, 95% CI 1.1-10, p = 0.04). We
failed to identify any statistically significant associations for total motor score recovery in
unadjusted or adjusted analyses.
CONCLUSIONS
AIS grade conversion was significantly more likely in those examined ≤4 h of injury; the
effect of timing on motor scores remains uncertain. Variability in neurological
examination timing within hours after acute traumatic SCI may influence observations of
long-term neurological recovery, which could introduce bias or lead to errors in
interpretation of studies of therapeutic interventions.

74. Conclusion
Spinal cord injuries are a serious, widespread health issue
resulting in a large amount of dysfunction and as such have a
big socio-economic impact. Therapy is multidisciplinary and
focus should be on regaining of function, relevant to the
individual with a spinal cord injury, as tissue recovery is often
impossible.