SPINAL CORD INJURY-Spinal cord injury usually begins with a sudden traumatic blow to the spine that fractures or dislocates vertebrae.

 

 

SPINAL CORD INJURY

 

Spinal cord injury usually begins with a sudden traumatic blow to the spine that fractures or dislocates vertebrae. The damage begins at the movement of injury when displaced bone fragments , disc material ,or ligaments bruise or tear into spinal cord tissue. Spinal cord injury

Often causes permanent disability or loss of movement and sensation below the site of the injury.

 

ETIOLOGY

Spinal cord injury can occur from many causes, including:

·         Trauma   :  such as automobile crashes, falls, gunshots, diving accidents , war injuries, etc.

·         Tumor   :  such as meningiomas, ependmomas, astrocytomas ,and metastatic  cancer.

·         Ischemia : resulting from occlusion of spinal blood vessels, including  aortic aneurysms, emboli, arteriosclerosis.

·         Developmental disorders: such as spina bifida meningomyolcoele,and other.

·         Neurodegenerative diseases: such as friedreich’s  ataxia spinocerebellar ataxia, etc .

·         Demyelinative diseases: such as multiple sclerosis.

·         Transverse myelitis: resulting from stroke, inflammation ,or other causes.

·         Vascular malformations such as arteriovenous malformation (AVM), arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and aneurysm.

 

CLASSIFICATION

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.C

·         C indicates an “ incomplete” spinal cord injury where motor function s preserved  below the neurological level.

·         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. 

·         The consequences of a spinal cord injury may vary depending on the type , level, and severity of injury ,but can be classified into two general categories :

·         In a complete injury , function below the “neurological” level is lost . absence of motor and sensory function below a specific spinal level is considered a “ complete injury”.

·         In an incomplete injury, some sensation and /or movement below the level of the injury is retained . the      lowest spinal segment in humans is located at vertebral levels S4-S5,corresponding to the anal sphincter and peri-anal sensation . the ability to contract the anal sphincter voluntarily or to feel peri- anal pinprick or touch , the injury is considered to be “ incomplete”.

Cervical injuries

Cervical (neck) injury usually result in full or partial tetraplegia (quadriplegia) . how  ever, depending on the specific location and severity of trauma . limited function may be retained.

Ø  C3 vertebrae and above :  typically results in loss of diaphragm function , necessitating the use of a ventilator for breathing.  

Ø  C4:Results  in significant loss of function at the biceps and shoulders.

Ø  C5: Result in potential loss of function at the shoulders and biceps, and complete loss of function at wrists and hands.

Ø  C6: Results in limited wrist control, and complete loss of hand function.

 

Ø  C7 and T1: Results in lack of dexterity in the hands and fingers, but allows for limited

Ø  use of arms. C7 is generally the threshold level for retaining functional independence.

 

 

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.

Ø  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.

Ø  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, loss of bladder & bowel control, numbness, weakness & paralysis occur.

 

PARAPLEGIA

 

Paraplegia is impairment in motor and/or sensory function of the lower extremities. It is usually the result of spinal cord injury or a congenital condition such as spina bifida which affects the neural elements of the spinal canal. The area of the spinal canal which is affected in paraplegia is either the thoracic, lumbar, or sacral regions. If the arms are also affected by paralysis, quadriplegia is the proper terminology. If only one limb is affected the correct term is monloplegia.

 

Causes

 

The causes range from trauma (acute spinal cord injury: transsection or compression of the cord, usually by bone fragments from vertebral fractures) to tumors (chronic compression of the cord), myelitis transversa and multiple sclerosis. Inborn errors of metabolism may also lead to paraparesis in some cases

 

Central Nervous System (CNS): The most common cause of paraplegis (and all spinal cord injuries) is motor vehicle accidents. Other causes include violence, sports, cancer (tumors) involving the epidural or dural space, vertebral fractures and myelitis transversa. Gun shot wounds to the spine, although decreasing, are one of the major causes of paraplegic spinal cord injuries. Sometimes, paralysis of both legs can result from injury to the brain (bilateral

injury of the motor cortex controlling the legs, eg, due to a stroke or a brain tumor

      Peripheral nervous system: e.g. poly neuropathy.

 

Disability

       While some people with paraplegia can walk to a degree, many are dependent on wheel chairs or other supportive measures. Impotence and various degrees of urinary and fecal in continence are very common in those affected. Many use catheters and/or a bowel management program (often involving suppositories, enemas, or digital stimulation of the bowels) to address these problems. With successful bladder and bowel management, paraplegics can prevent virtually all accidental  urinary or bowel discharges.

 

HEMIPLEGIA

 

Hemiplegia is a condition in which half of a body is paralyzed. Hemiplegia is more severe

than hemiparesis, wherein one half of the body is weakened but not paralysed. Hemiplegia may be congenital or acquired from an illness or stroke.

 

CAUSES

 

        The most common cause of hemiplegia is a cerebrovascular accident, also known as a

stroke, traumatic brain injury, or other disease affecting the central nervous system. In cerebral palsy, damage to the hemisphere may limit function or cause spasticity without resulting

in total paralysis of one half of the body.

 

ETIOLOGICAL FACTORS

 

·         Vascular:  cerebral hemorrhage.  stroke, diabetic neuropathy

·         Infective: encephalitis, meningitis, brain abscess

·         Neoplastic: glioma-meningioma

·         Demyelination : disseminated sclerosis, lesions to the internal capsule

·         Traumatic : cerebral lacerations, subdural hematoma rare cause of hemiplegia is due to local    anaesthetic injections given intra-arterially rapidly, instead of given in a nerve branch.

·         Congenital: cerebral palsy

·         Disseminated: multiple sclerosis

·         Psychological: parasomnia (nocturnal hemiplegia)

 

QUADRIPLEGIA

 

Quadriplegia, also known as tetraplegia, is paralysis caused by illness or injury to a human that results in the partial or total loss of use of all of their limbs and torso; paraplegia is similar but does not affect the arms. The loss is usually sensory and motor, which means both sensation and control are lost.

 

CAUSES

 

It is caused by damage to the brain or the spinal cord at a high level C1-C8-in particular, spinal cord injuries secondary to an injury to the cervical spine. The injury, known as a lesion, causes victims to lose partial or total function of all four limbs, meaning the arms and the legs. Quadriplegia is defined in many ways; C1-C4 usually affects arm movement more so than a CS-C7 injury; however all quadriplegics have or have had some kind of finger dysfunction. So, it is not uncommon to have a quadriplegic with fully functional arms, only having their fingers not working

 

Typical causes of this damage are trauma (such as car crash, fall, or sports injury) or disease (such as transverse myelitis , polio, or spina bifida).

 

SYMPTOMS, SIGNS AND COMPLICATIONS

 

Although the most obvious symptom is impairment to the limbs, functioning is also impaired in the torso. This can mean a loss or impairment in controlling bowel and bladder, sexual function, digestion, breathing, and other autonomic functions. Furthermore, sensation

Although the most obvious symptom is impairment to the limbs, functioning is also impaired in the torso. This can mean a loss or impairment in controlling bowel and bladder, sexual function, digestion, breathing, and other autonomic functions. Furthermore, sensation is usually impaired in affected areas.  This can manifest as numbness, reduced sensation , or burning neuropathic pain.

          Secondarily ,because of their  depressed functioning and immobility , quadriplegics are often more vulnerable to pressure sores, osteoporosis dysreflexia deep vein thrombosis, and cardiovascular disease.

       Severity depends on both the level at which  the spinal cord is injury and the extent of the injury.

          An individual with an injury at C1(the highest cervical vertebra, at the base of the skull) will probably lose function from the neck down and be ventilator-dependent.an individual with

a C7 injury may lose function from the  chest down but still retain use of the arms and much of the hands .

          The extent of the injury is also important. A complete severing of the spinal cord will result in complete loss of function from that vertebra down .   A  partial severing or even bruising of the spinal cord results in varying degrees of mixed function and paralysis. A common misconception with quadriplegia is that the victim cannot move legs, arms or any of the major  function, this is often not the case. Some quadriplegic individuals can walk ,use their hands and live a life as if they did not have a spinal cord injury, while others may use wheelchairs, they can still have function of their arms and mild finger movement , again, varying on the spinal cord damage.

           It is common to have movement in limbs, such as the ability to move the arms but not the hands ,or to be able to use the fingers but not the same before injury . furthermore , the deficit   in the limbs may not be the same on both sides of the body; the left or right side may be more   affected, depending on the location of the lesion on the spinal cord .

 

   

MANAGEMENT

 

1.      Respiratory Management: Patient may need O2 therapy, tracheotomy and mechanical ventilation.

2.      Pharmacologic Treatment:

 

Treatment options for acute, traumatic non-penetrating spinal cord injuries include.

·         Th administration of a high dose of an anti-inflammatory agent, methylprednisolone, within 8 hours of injury.

·         The use of this anti-inflammatory drugs after spinal cord injuries.

·         Presently, administration of cold saline acutely after injury is gaining popularity.

·         Stem cell transplants and treatment with neuro degenerative substances.

 

3.      Immobilization: Spinal traction may be applied (crutch field OR Gardner wells tongs)

 

  Surgical management:

 

            Surgery is indicated in any of the following instances:

1.      Compression of the cord is evident.

2.      The injury is a compound fracture.

3.      The injury involves a wound that penetrates the cord.

4.      There are bony fragments in the spinal canal.

5.      The patient’s neurologic status is deteriorating.

Surgery is performed to reduced the spinal fracture or dislocation or to decompress the cord. A leminectomy which is excision of the posterior arches and spinous processes of a vertebra.

 

NURSING MANAGEMENT IN SPINAL CORD INJURY

 

NURSING DIAGNOSIS:

1.      Ineffective airway clearance related to weakness of intercostals muscles.

2.      Ineffective breathing patterns related to weakness or paralysis of abdominal and intercostals muscles and inability to clear sections.

3.      Impaired physical mobility related to motor and sensory impairment.

4.      Sensual / perceptual alteration related to motor and sensory impairment.

5.      Risk for impaired skin integrit related to immobility and sensory loss

6.      Urinary retention related to inability to void spontaneously

7.      Constipation related to presence of a tonic bowel as a result of autonomic disruption

8.      Pain and discomfort related to treatment and prolonged immobility.

 

NURSING INTERVENTIONS:

 

1)      Promoting adequate breathing and airway clearance:

·         By observing the patient, measuring vital capacity, monitoring O2 saturation through pulse oximetry.

·         Do effective suctioning procedure. Provide chest physiotherapy & breathing exercise.

·         Guard against aspiration and respiratory insufficiency

·         Monitor ABG (Atrial Blood Gass) to asses the adequacy of ventilation

·         Intubate & Ventilate.

 

2)      Improving mobility:

·         Asses the body alignment of patient

·         The patient is repositioned frequently and is out of bed as soon as spinal column is stabilized

·         In chance of foot drop, high – top sneakers can help prevent foot drop

·         Patient with lesions above the midthoracic level have loss of sympathetic control of peripheral vasoconstrictors activity lead to hypo tension, usually the patients is tuned every 2 hours.

·         Patients with a cervical fracture without neurologic deficit, reduction in traction followed by rigid immobilization.

 

3)      Promoting adaptation to sensory and perceptual alteration:

·         Asses the sensory and perceptual alterations

·         Providing prism glasses to enable the patient to see from the supine position

·         Encouraging use of hearing aids, if indicated to enable the patients to hear conversations and environmental sounds.

·         Providing emotional support

·         Teaching the patients strategies to compensate for cope with these deficits.

 

4)      Maintaining skin integrity:

·         Asses all body surface and documents skin integrity at least every 8 hours

·         Turn and reposition the patient every 2 to 4 hours

·         Provide skin care every 4 hours

·         Assist patient to get out of bed to a chair three times a day.

 

5)      Maintaining urinary elimination:

·          Assessing the bladder distension and urinary elimination

·         Intermittent catheterization is carried is out to avoid over distension of bladder

·         Record fluid intake, voiding pattern, amount of residual urine after catheterization

 

6)      Improving bowel function:

·         Assessing  the bowel function and elimination

·         A nasogastric tube is often required to relieve distension and prevent aspiration

·         The patient is given a high calorie, high protein, high fiber diet with the amount of blood gradually increased.

 

7)      Providing comfort measures:

·         Assess the condition of patient

·         Assess the patient’s skull for sign of infection, including drainage around the tongs

·         The back of head is checked periodically for signs of pressure and is massaged at intervals, with care taken not to move the neck.

·         Provide appropriate position as required and frequently change the position.