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SPINAL CORD TRAUMA Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT Most spinal trauma cases do not generally involve complete severance of the spinal cord. Spinal trauma usually includes fracture and compression of the vertebrae, such as crush injuries and nerve cell destruction. Some spinal cord trauma may eventually heal with complete recovery while others result in complete paralysis. New hope exists for spinal trauma cases with improved emergency care for individuals with spinal cord injuries, including aggressive treatment and rehabilitation that can minimize damage to the nervous system and even restore limited abilities. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacy content is 0.5 hours (30 minutes). Statement of Learning Need Individuals with spinal trauma and permanent damage may face challenges to healing and lifelong recovery. The effects of damage to the spinal cord also influence other body systems, which require health clinicians to engage in continuous learning to improve patient knowledge of their spine injury and treatment plan. Course Purpose This course will provide advanced learning for health clinicians interested in the management of the patient with spinal trauma during initial stabilization, early treatment and ongoing interventions that promote recovery and healing. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. The annual incidence of spinal cord injuries in the U.S., is approximately a. b. c. d. 22 35 40 65 cases cases cases cases per per per per million. million. million. million. 2. True or False: Spinal stenosis is a condition caused by the compression or narrowing of the spinal canal. a. True b. False 3. The thoracic vertebrae are located in what region of the body? a. b. c. d. Coccyx Upper and middle back Neck Lower back 4. Central cord syndrome involves hyperextension injuries as well as a. b. c. d. spinal cord ischemia, and cervical spinal stenosis. a cervical lesion always with lower extremity motor weakness. a burning sensation in the lower extremities only. All of the above 5. Spinal stabilization surgery involves a. removal of bone fragments. b. restoring vertebral alignment to reduce spinal cord compression. c. a 72-hour minimum delay in all cases. d. Answers a., and b., above nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction Spinal cord trauma affects a number of individuals each year, and the injuries can be life threatening. There are approximately 200,000 people living with spinal cord injuries in the United States. Additionally, there are approximately 12,000 to 20,000 new cases of spinal cord trauma annually.1 Spinal cord trauma is primarily caused by motor vehicle accidents, falls, industrial accidents, assault, sports related injuries, and gunshot wounds.2 Spinal cord injury (SCI) is an important contributing factor to morbidity and mortality in the United States. Most spinal injuries don't completely sever the spinal cord. Instead, a spinal injury is more likely to cause fractures and compression of the vertebrae, which then crush and destroy nerve cells that carry signals up and down the spinal cord between the brain and the rest of the body.3 Early Identification And Treatment A patient may experience an incomplete or complete spinal injury depending on the location and extent of damage. Each type of injury requires different treatment and will affect the patient differently. Some spinal cord injuries will allow almost complete recovery, and others will result in complete paralysis.4 Early identification and treatment is crucial for minimizing the initial damage and preventing secondary injuries, which are common with spinal cord trauma. In recent years, the diagnosis and management of spinal cord injuries has improved with advancements in technology and treatment options. There are a number of options available for the diagnosis of spinal cord injuries, including Computed Tomography (CT) scans, Magnetic Resonance Imaging (MRIs), X-Rays, and other advanced imaging nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 procedures. In addition, improved emergency care for people with spinal cord injuries and aggressive treatment and rehabilitation have made it easier to manage spinal cord injuries in the trauma patient. The availability of these advanced measures enable the treatment providers to minimize damage to the nervous system and even restore limited abilities. Definition of Spinal Cord Trauma Spinal cord trauma is defined as any injury that occurs in the spinal column. Spinal injuries are often the result of accidents that cause significant impact, and often occur in conjunction with other traumatic injuries such as head or abdominal injuries.5 Patients who experience spinal trauma will present with different injuries, depending on the location of the injury, the cause of the injury, and the severity of the injury. Since a spinal injury can occur in any region of the spinal column, the patient will experience a variety of symptoms.2 To fully understand the complexity of spinal cord trauma, the health clinician must be familiar with the anatomy of the spinal column. The spinal column is composed of thirty-one bones, which are called the vertebrae. The vertebrae are further categorized, based on the type and location of the bones.6 The following table highlights the different names and regions of the vertebrae.7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 Name Region Number of vertebrae Cervical Vertebrae Neck 7 Thoracic Vertebrae Upper and Middle Back 12 Lumbar Vertebrae Lower Back 5 Sacral Vertebrae Sacrum 5 Fused Coccygeal Vertebrae Coccyx (commonly known as the tailbone) 2 Each of the vertebrae is part of a distinct region and they each function as independent vertebral bodies. In fact, each vertebra is part of an independent vertebral body and vertebral arch.8 The vertebral arch and vertebral body come together to form a vertebral foramen, which is an enclosed opening. Each vertebra is stacked on top of another vertebra. The stacked vertebra form the vertebral foramen, which is the formation for the spinal column.9 The spinal column contains the spinal cord, which is responsible for communication between the brain and the rest of the body.10 The spinal cord is a bundle of nerves that extends from the brain and branches outward peripherally.11 The spinal cord is very fragile, and trauma to the spinal column may affect the spinal cord, thereby causing neurologic impairments. These impairments may be temporary or permanent and will range in severity.12 The central nervous system is comprised of the spinal cord and the brain, and both components work together to control the body’s functions. The spinal cord is responsible for coordinating movement and sensation.8 The nerves within the spinal cord serve as transmitters of signals to the brain. These signals initiate the functions controlled by the spinal cord. When the nerves in the spinal cord are damaged, nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 they are not able to regenerate.9 Therefore, the patient often experiences permanent damage as the result of spinal cord trauma.13 The spinal cord, while small, is very complex. It is comprised of neurons and axons that both transmit signals to the brain. The axons are responsible for sending signals downward from the brain using descending pathways. Axons also send signals upward to the brain using ascending pathways.11 A substance called myelin, which acts as a sheath over the nerve structure, protects the axons. The myelin is whitish, which is why the region they are contained in is referred to as “white matter.”10 The neurons contain branching structures called dendrites. These structures are responsible for receiving signals from other nerve cells. The dendrites have a greyish appearance, which is why the region that contains them is called “grey matter.”14 The grey matter is contained in a section of the spinal cord that is butterfly shaped. The entire spinal cord is enclosed within three membranes, known as the8 Pia Mater – inner layer Arachnoid – middle layer Dura Mater – outer layer The entire spinal cord is divided into segmented areas that fall along the length of the column. Each area is comprised of specific nerves that control distinct regions of the body. The following table lists each segment and the region it controls.15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 Segment Name C1 – C8 Cervical Region Responsibility Controls signals to the neck, arms, and hands T1 – T12 Thoracic Region (Upper Back Region) L1 – L5 Lumbar Region (Mid-Back Region) S1 – S5 Sacral Region Relays signals to the torso and parts of the arms Controls signals to the hips and legs Control signals to the groin, toes, and parts of the legs Damage to specific regions of the spinal cord will result in problems with functions in the areas of the body connected to those regions. Therefore, if a patient experiences trauma to the lumbar region, he or she will experience problems with hip and leg movement or feeling.16 The uninjured spinal cord coordinates all of the movement and sensation throughout the body. The higher segments are responsible for controlling these functions in the upper regions of the body, while the lower segments of the spinal cord control the functions of the lower regions of the body. Damage to any area of the spinal cord will most likely affect movement and sensation in one or more areas of the body.17 The exact injury and resulting disability caused by spinal cord trauma will vary depending on a number of factors, including the type of injury, the severity of the injury, the segment of the cord that is injured, and which nerves are damaged. In severe trauma, the damage to the spinal cord causes paralysis to the region controlled by the cord, as well as a complete loss of sensation in the associated area.18 If the trauma affects a significant portion of the spinal cord, the patient will experience full paralysis. Further complications may nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 develop after a patient experiences trauma to the spinal cord such as the result of damage to the body’s functions.12 A spinal cord injury typically occurs when a patient experiences a sudden blow to the spine. In many instances, this impact will cause fractures and dislocations within the vertebrae, which will result in damage to the patient’s spinal region.19 Initial damage occurs during impact, and often manifests as displaced bone fragments, ruptured discs, or bruises and/or tears in the ligaments and spinal cord tissue.15 This initial damage will often cause damage to the axons and neural cell membranes, which cannot be repaired. In some patients, the impact will cause the blood vessels to rupture, thereby resulting in bleeding in the spinal grey matter and other areas of the spinal cord.3 Many patients will experience swelling of the spinal cord, which will happen within a short period of time. The spinal cord will typically swell enough to fill the cavity of the spinal canal, thereby reducing or cutting off blood flow and oxygen to the spinal cord tissue.20 In addition, patients may experience a drop in blood pressure, which will interfere with the activity of the neurons and axons. Once a patient experiences the symptoms listed above, he or she is at risk of spinal shock, which can last for a number of days.21 Approximately fifty percent of spinal trauma patients will experience spinal shock.22 It is more common in patients who experience severe injury.19 When a patient experiences spinal shock, he or she will temporarily lose the function of most of the spinal cord, which will often result in lack of sensation and reflexes. Some patients may experience complete paralysis.16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 After the initial trauma phase, the spinal column will continue to experience damage. It is especially common for the patient’s axons and neurons to be destroyed, which will cause an inflammatory response in the patient’s immune system.23 This response will result in additional damage to other parts of the patient’s body and can occur in the days or weeks following an injury. In many instances, this additional damage will cause the patient’s long-term complications to become even more severe and long lasting.19 Therefore, it is important to begin treating the patient as soon as possible to minimize any further damage. The following table provides an overview of the changes that will occur in the days and weeks following the initial trauma.24 Changes in Blood The major reduction in blood flow to the site following the Flow Cause initial injury can last for as long as 24 hours and become Ongoing Damage progressively worse if there is continued compression of the cord due to swelling or bleeding. Because of the greater blood flow needs of gray matter, the impact is greater on the central cord than on the outlying white matter. Blood vessels in the gray matter also become leaky, sometimes as early as 5 minutes after injury, which initiates spinal cord swelling. Cells that line the still-intact blood vessels in the spinal cord also begin to swell, and this further reduces blood flow to the injured area. The combination of leaking, swelling, and sluggish blood flow prevents the normal delivery of oxygen and nutrients to neurons, causing many of them to die. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 Excessive Release of Neurotransmitters Kills Nerve Cells After the injury, an excessive release of neurotransmitters (chemicals that allow neurons to signal each other) can cause additional damage by over-stimulating nerve cells. The neurotransmitter glutamate is commonly used by axons in the spinal cord to stimulate activity in other neurons. But when spinal cells are injured, their axons flood the area with glutamate and trigger additional nerve cell damage. This process kills neurons near the injury site and the myelin-forming oligodendrocytes at and beyond the injured area. An Invasion of Immune System Cells Creates Under normal conditions, the blood-brain barrier keeps potentially destructive immune system cells from entering the brain or spinal cord. Inflammation This barrier is a naturally occurring result of closely spaced cells along the blood vessels that prevent many substances from leaving the blood and entering brain tissues. But when the blood-brain barrier breaks down, immune system cells — primarily white blood cells — can invade the spinal cord tissue and trigger an inflammatory response. This inflammatory response can cause additional damage to some neurons and may kill others. Free Radicals Attack Nerve Cells Another consequence of inflammation is the increased production of highly reactive forms of oxygen molecules called free radicals — chemicals that modify the chemical structure of other molecules in damaging ways, for example, damaging cell membranes. Free radicals are produced naturally as a by-product of normal oxygen metabolism in small enough amounts that they cause no harm. But injury to the spinal cord causes cells to overproduce free radicals, which destroy critical molecules of the cell. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 Nerve Cells Self-destruct For reasons that are still unclear, spinal cord injury sets off apoptosis, which is a normal process of cell death that helps the body get rid of old and unhealthy cells. Apoptosis kills oligodendrocytes in damaged areas of the spinal cord days to weeks after the injury. Apoptosis can strip myelin from intact axons in adjacent ascending and descending pathways, causing the axons to become dysfunctional and disrupting the spinal cord’s ability to communicate with the brain. Scarring Occurs Following a spinal cord injury, astrocytes (star-shaped glial cells that support the brain and spinal cord) wall off the injury site by forming a scar, which creates a physical and chemical barrier to any axons which could potentially regenerate and reconnect. Even if some intact myelinated axons remain, there may not be enough to convey any meaningful information to or from the brain. Epidemiology Spinal cord trauma affects a number of individuals each year, and the injuries can be life threatening. There are approximately 200,000 people living with spinal cord injuries in the United States. Additionally, there are approximately 12,000 to 20,000 new cases of spinal cord trauma annually.2 Spinal cord trauma is primarily caused by motor vehicle accidents, falls, industrial accidents, assault, sports related injuries, and gunshot wounds.1 Approximately twenty-five percent of all spinal cord traumas involve alcohol.25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 The following table, provided by the National Spinal Cord Injury Statistical Center, gives a full overview of the epidemiological breakdown of spinal cord injuries.26 Incidence It is estimated that the annual incidence of spinal cord injury (SCI), not including those who die at the scene of the accident, is approximately 40 cases per million population in the U.S., or approximately 12,000 new cases each year. Since there have not been any incidence studies of SCI in the U.S., since the 1990's it is not known if incidence has changed in recent years. Prevalence The number of people in the United States who are alive in 2012 who have SCI has been estimated to be approximately 270,000 persons, with a range of 236,000 to 327,000 persons. (Note: Incidence and prevalence statistics are estimates obtained from several studies. These statistics are not derived from the National SCI Database). Age at Injury SCI primarily affects young adults. From 1973 to 1979, the average age at injury was 28.7 years, and most injuries occurred between the ages of 16 and 30. However, as the median age of the general population of the United States has increased by approximately 9 years since the mid1970, the average age at injury has also steadily increased over time. Since 2005, the average age at injury is 41 years. Other possible reasons for the observed trend toward older age at injury might include changes in either referral patterns to model systems, the locations of model systems, survival rates of older persons at the scene of the accident, or age-specific incidence rates. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 Gender Overall, 80.6% of spinal cord injuries reported to the national database have occurred among males. Over the history of the database, there has been a slight trend toward a decreasing percentage of males. Prior to 1980, 81.8% of new spinal cord injuries occurred among males. Race/Ethnicity A significant trend over time has been observed in the racial/ethnic distribution of persons in the database. Among persons injured between 1973 and 1979, 76.8% were Caucasian, 14.2% were African American, 1.9% were Native American and 0.9% were Asian. However, among those injured since 2005, 66.0% are Caucasian, 26.2% are African American, 0.9% are Native American and 2.1% are Asian. Hispanic origin increased from 5.9% in 1970’s to 12.5% in 2000-2004 and 8.3% since 2005. This trend is due in part to trends in the United States general population and also possibly explained by the changing locations of model systems, referral patterns to model systems, or racespecific incidence rates. Etiology Since 2005, motor vehicle crashes account for 39.2% of reported SCI cases. The next most common cause of SCI is falls, followed by acts of violence (primarily gunshot wounds). The proportion of injuries that are due to sports has decreased over time while the proportion of injuries due to falls has increased. Violence caused 13.3% of spinal cord injuries prior to 1980, and peaked between 1990 and 1999 at 24.8% before declining to only 14.6% since 2005. Neurologic Persons with tetraplegia have sustained injuries to one of Level and the eight cervical segments of the spinal cord; those with Extent of paraplegia have lesions in the thoracic, lumbar, or sacral Lesion regions of the spinal cord. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 Since 2005, the most frequent neurologic category at discharge of persons reported to the database is incomplete tetraplegia (40.8%), followed by complete paraplegia (21.6%), incomplete paraplegia (21.4%) and complete tetraplegia (15.8%). Less than 1% of persons experienced complete neurologic recovery by hospital discharge. Over the last 15 years, the percentage of persons with incomplete tetraplegia has increased while complete paraplegia and complete tetraplegia have decreased. Occupational More than half (57.1%) of those persons with SCI admitted Status to a model system reported being employed at the time of their injury. At one year after injury, 11.7% of persons with SCI are employed. By 20 years post-injury, 35.2% are employed and a similar level of employment is observed through post-injury year 35. Residence Overall, 89.3% of all persons with SCI who are discharged alive from the system are sent to a private, noninstitutional residence (in most cases their homes before injury). Only 6.6% are discharged to nursing homes. The remaining are discharged to hospitals, group living situations or other destinations. Marital Status Considering the youthful age of most persons with SCI, it is not surprising that most (51.7%) are single when injured. Among those who were married at the time of injury, as well as those who marry after injury, the likelihood of their marriage remaining intact is slightly lower when compared to the general population. The likelihood of getting married after injury is also reduced. Length of Stay Overall, median days hospitalized in the acute care medical/surgical unit for those who enter a model system immediately following injury has declined from 24 days between 1973 and 1979 to 11 days since 2005. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 Substantial downward trends are noted for days in the rehab unit (from 98 to 37 days). Overall, median days hospitalized (during acute care and rehab) were greater for persons with neurologically complete injuries. Types Of Spinal Injuries Overview There are a number of different types of spinal cord injuries, which vary depending on the location and severity of the injury. At the most basic level, spinal injuries are divided into two distinct categories of 1) complete injury, and 2) incomplete injury. Complete Injury In a complete injury, the spinal cord is sufficiently damaged across the whole of its width such that there is no function (either sensation or muscle control) below the level of injury. Incomplete Injury In an incomplete injury, the injury does not spread across the whole of the spinal cord; some areas away from the injury remain intact or at least intact enough to retain some function. People with incomplete injuries have some sensation and/or movement control below the level of injury. Sometimes, one side of the body is more affected than the other.27 The two categories of spinal injury are used to distinguish spinal injuries. However, clinicians also use these categories during spinal nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 assessment to identify the type and severity of the injury. The American Spinal Injury Association further breaks down the categories into an assessment scale that can be used to determine the extent of spinal injury. The following are the categories that comprise the American Spinal Injury Association Impairment Scale.28 A = Complete: No sensory or motor function is preserved in the sacral segments S4-S5. B = Sensory Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 (light touch, pin prick at S4-S5: or deep anal pressure (DAP)), AND no motor function is preserved more than three levels below the motor level on either side of the body. C = Motor Incomplete: Motor function is preserved below the neurological level, and more than half of key muscle functions below the single neurological level of injury (NLI) have a muscle grade less than 3 (Grades 0-2). D = Motor Incomplete: Motor function is preserved below the neurological level, and at least half (half or more) of key muscle functions below the NLI have a muscle grade > 3. E = Normal: If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade. For an individual to receive a grade of C or D, i.e. motor incomplete status, they must have either (1) voluntary anal sphincter contraction or (2) sacral sensory sparing with sparing of motor function more than three levels below the motor level for that side of the body. The Standards at this time allows even non-key muscle function more than 3 levels below the motor level to be used in determining motor incomplete status (AIS B versus C). NOTE: When assessing the extent of motor sparing below the level for distinguishing between AIS B and C, the motor level on each side is used; whereas to differentiate between AIS C and D (based on proportion of key muscle functions with strength grade 3 or greater) the single neurological level is used. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 An incomplete spinal cord injury will cause different injury patterns depending on the type, location and severity of injury. Therefore, there are standard classifications that are used to identify incomplete injuries; and, these are shown below.29 Anterior Cord Syndrome Results from damage to the motor and sensory pathways in the anterior areas of the spinal cord. Effects include loss of movement and overall sensation, although some sensations that travel by way of the still intact pathways can be felt. Central Cord Syndrome Results from injury to the center of the cervical area of the spinal cord. The damage affects the corticospinal tract, which is responsible for carrying signals between the brain and spinal cord to control movement. Patients of central cord syndrome experience weakness or paralysis in the arms and some loss of sensory reception. The loss of strength and sensation is much less in the legs than in the arms. Many patients with central cord syndrome spontaneously recover motor function, and others experience considerable recovery in the first six weeks following the injury. Brown-Sequard Syndrome Results from injury to the right or left side of the spinal cord. On the side of the body where the injury occurred, movement and sensation are lost below the level of the injury. On the side opposite the injury, temperature and pain sensation are lost due to the crossing of these pathways in the spinal cord. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 Cauda Equina Cauda equina syndrome refers to a characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris (see the image below). These symptoms include low back pain, sciatica (unilateral or, usually, bilateral), saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss. Conus Medullaris The conus medullaris syndrome may involve disturbances of urination (usually from a denervated, autonomic bladder that manifests clinically with overflow incontinence) and sphincter impairment or sexual dysfunction. Sensory involvement may affect the sacral and coccygeal segments, resulting in saddle anesthesia. Pure lesions of the conus medullaris are rare. Injuries to Individual Nerve Cells Result in loss of sensory and motor function in the area of the body to which the injured nerve root corresponds. Thus, symptoms from these injuries vary depending on the location and function of the particular nerve root. Spinal Contusions The most common type of spinal cord injury. The spinal cord is bruised, not severed, but the consequence is inflammation and bleeding from blood vessels near the injury. A spinal contusion results in temporary (usually one to two days) incomplete or complete debilitation of the spinal cord. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 Cuts to the Spinal Cord In some trauma situations, a patient will experience direct cuts to the spinal cord. Cuts are especially common in instances when the bones or disks of the spinal region have been weakened.6 Cuts can be caused directly by the accident, especially in instances involving shrapnel, gunshots, or knives.30 In other instances, the cut to the spinal cord will occur as a secondary injury. Secondary cuts are often the result of fragments of bone that have broken off during impact.31 Spinal Compression Spinal compression can occur as the result of a number of different injuries and incidents and is considered a neurological emergency.20 Early identification and diagnosis is imperative as untreated spinal compression can cause long-term damage, such as permanent loss of function. Spinal cord compression will range in severity and distinguishing factors, depending on the type, location and severity of injury. The following is a list of the different patterns of injury that will occur when a patient experiences spinal compression.3 Complete Cord Injury Absence of any motor or sensory function below the level of the injury. Minimal chance of functional recovery. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 Anterior Cord Syndrome Caused by direct anterior cord compression, flexion injuries of cervical spine, or thrombosis of anterior spinal artery. Leads to variable paralysis below lesion level with loss of pain and temperature perception. Dorsal columns (proprioception and vibration sense) are mainly preserved. Poor prognosis. Brown-Séquard's Syndrome Caused by hemi-transection or unilateral compression of the cord. Ipsilateral spastic paresis and loss of proprioception and vibration sense. Contralateral loss of pain and temperature perception. Moderately good prognosis. Central Cord Syndrome Caused by hyperextension injuries, spinal cord ischemia and cervical spinal stenosis. Usually involves a cervical lesion, with greater motor weakness in the upper extremities than in the lower extremities. The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness. Sensory loss is variable, with pain and/or temperature sensation more likely to be affected than proprioception and/or vibration. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 Burning sensation, especially in the upper extremities, is common. There is usually sacral sensory sparing. Posterior Cord Syndrome Very rarely occurs in isolation. Caused by penetrating trauma to the back or hyperextension injury associated with vertebral arch fractures. Loss of proprioception and vibration sense. Motor and pain/temperature sensation preserved. Spinal Cord Concussion Rarely occurs. Temporary cessation of spinal cord neurological function, but spontaneous recovery occurs within 48 hours. Spinal Shock Spinal shock results from autonomic dysfunction and the interruption of sympathetic nervous system control in acute spinal cord injuries. Spinal shock is characterized by severe autonomic dysfunction, resulting in hypotension, relative bradycardia, peripheral vasodilation and hypothermia. It occurs with spinal cord injuries above T6 but does not usually occur with injuries below the level of T6 (hypotension and/or shock with acute spinal cord injury at or below T6 is usually caused by hemorrhage). Areflexia, which is loss of sensation and flaccid paralysis below nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 the level of the lesion, and flaccid bladder and loss of rectal tone, as well as bradycardia and hypotension. Spinal Cord Injury Without Radiological Abnormality (SCIWORA) SCIWORA can be diagnosed only after scans have shown no bony or ligamentous injury. This is more common in children (as their spine is more flexible and less likely to sustain vertebral fracture) and carries a poor prognosis. Displacement of the Spine In some instances, the spine will become displaced. This occurs as the result of direct impact to the spine during accidents. Spinal displacement can cause more significant problems in the patient as the displacement will often cause swelling and bruising in the spinal region.32 Some patients will experience displacement in areas of the spinal column that will affect mobility and other functions. In most instances, the displacement can be repaired. However, some patients will experience permanent damage from spinal displacement.33 Bleeding and Fluid Buildup In many instances, bleeding and fluid buildup will occur as the result of spinal trauma. The blood and fluid are often caused by the initial injury. However, they can also cause additional secondary injuries. In most instances, the accumulation of blood or excess fluid will cause pressure in the spinal region. This increase in pressure will often nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 damage the spinal cord, and can sometimes kill spinal cord neurons.34 Excess blood and fluid must be reduced immediately to avoid these complications.19 Swelling Many patients will experience swelling immediately following a spinal cord injury. Swelling is caused by the initial damage, but will expand to other regions of the spinal column within a short period of time.35 The spinal cord will typically swell enough to fill the cavity of the spinal canal. Thereby reducing or cutting off blood flow and oxygen to the spinal cord tissue.22 Common Causes Of Spine Trauma Motor Vehicle Accidents Motor Vehicle accidents account for the highest number of trauma cases in the United States.36 Of those, a number involve spinal cord trauma injuries. The U.S. Department of Transportation breaks motor vehicles into categories involving, among other things, the type of vehicle (i.e., passenger car, light truck, motorcycle, etc.), fatal versus non-fatal accidents, pedestrian, and statistics for accidents involving alcohol.37 When discussing spinal cord trauma caused by motor vehicle accidents, all of the types listed above are included. In 2009, approximately 2.3 million adults were admitted to emergency departments for treatment for injuries sustained during a motor vehicle accident.38 Most injuries sustained during a motor vehicle accident cause significant trauma to the patient as they impact a nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 number of areas on the body. In addition, motor vehicle accidents are one of the leading causes of death in the United States.39 Motor vehicle accidents that cause injuries are often severe and result in significant damage to the driver and passengers.38 Due to the blunt force caused by the accident, as well as the amount of flying debris caused by breaking glass, shards of metal and other random objects, injuries often occur both internally and externally. It is rare for a patient to sustain only spinal cord injuries during a motor vehicle accident. In most instances, the patient will present with a number of injuries, including but not limited to spinal cord injuries.40 Many injuries sustained during a motor vehicle accident cause permanent damage and often result in a significant lifelong disability.41 While motor vehicle accidents pose a significant risk of causing spinal cord trauma, the chances are increased by a number of factors. Increased Speed: Increased speed has a direct impact on the potential for a crash as well as the amount of damage and severity of injuries that result from the crash. Drinking and Driving: Drinking and driving often increases the severity and type of injuries caused. Intoxicated drivers and passengers are also at a higher risk of sustaining severe injuries due to their limited response time and relaxed physical state. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 Seat Belts and Child Restraints: Many drivers and passengers choose not to wear a seatbelt or a proper child restraint system. Not being properly secured in the vehicle can cause the individual to be propelled from the vehicle, most often through the windshield or other window, during an accident. If an individual is not propelled through the windshield, he or she will still be thrown around the vehicle during the accident, which can cause additional injuries. Helmet Use (Motorcycles): Motorists who fail to wear a helmet when riding on a motorcycle risk sustaining severe head, neck and spinal cord injuries during an accident. The motorist is not protected in any way during a motorcycle crash, and the blunt trauma that occurs to the head without the protection of a helmet is severe and significant. According to the World Health Organization (WHO), wearing a helmet during a motorcycle accident reduces the chance of a severe injury by approximately 70 percent. Distracted Driving: While distracted driving directly increases the chances of a motor vehicle accident, it is also responsible for increasing the chances that the motorist will sustain more severe injuries. Distracted driving can occur for a variety of reasons, including the use of mobile devices, not paying attention to the road, talking to other motorists, applying makeup, etc. However, the most common cause of distracted driving is the use of mobile devices. Drivers who use mobile devices when driving are at an increased risk of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 sustaining severe injuries as the driver is not properly engaged with the vehicle.36 Violent Assault Injuries Violent assault injuries comprise approximately fifteen percent of spinal cord trauma cases.2 Assault injuries can be caused by either blunt or penetrating trauma and will often result in extensive, severe damage.42 The type and severity of the injury will vary depending on the cause of the trauma, and will have to be treated accordingly. The majority of assault injuries are caused by physical attacks, the force of an individual being thrown to the ground, or by stabbing or gunshot trauma.6 Industrial and Occupational Accidents Industrial and occupational accidents include a variety of different events and have differing effects on the individual. Industrial accidents account for the majority of occupational related accidents.43 However, many different occupations pose a risk of accidents that can result in trauma. Due to the vast differences between occupations, it is difficult to categorize and define occupational trauma. Each occupation poses its own risk. Treatment will depend on the type of accident. In the case of industrial occupations, individuals typically sustain injuries from coming into contact with machines. In many cases, trauma is caused when an individual falls into or is pulled into a machine.44 This often results in extensive damage to the internal organs and bones. Other occupations also pose a risk of accidents that can cause spinal trauma. The construction trade is highly dangerous and is responsible for a number of occupational trauma cases. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 According to the Occupation Health and Safety Administration (OHSA), there are distinct causes of death and severe injury in the construction industry, and they are listed below.45 Falls: Construction workers are often situated well above the ground while they are working. Therefore, the highest incidence of workplace injuries occurs as the result of falls. Falls result in both internal and external trauma. Common fall related injuries include head trauma, broken bones, spinal trauma and internal organ damage. Flying or Falling Object: Objects often strike individuals as part of construction work. These objects may be small flying objects or they may be large falling objects. Each type of flying object will inflict different types of damage on the individual. Smaller objects will often pierce the skin and may also cause trauma to internal organs. Large objects have the potential to crush the individual and cause severe head and spinal trauma. Crushed Between Two Objects: Much like industrial accidents, construction accidents are often caused when an individual falls into a machine or when the individual is crushed between two objects. This will cause severe internal damage and may also result in spinal damage. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 Sports Injuries Many sports related accidents do not cause spinal trauma; however, some accidents have the potential to do so. These accidents typically involve a blunt force from physical contact or an injury caused by a fall.46 Physical contact sports such as football and hockey pose the risk of severe head, neck and spinal injury due to the impact caused from hitting into another player of from hitting objects such as the wall or the ground.47 Other sports also present the risk for spinal trauma. These sports include hiking, skiing, rafting, and snowboarding.48 Each sport presents a specific risk. For example, skiing and snowboarding accidents often involve significant falls and/or crashes involving trees or other objects. These accidents typically result in severe head and spinal trauma.2 Hiking accidents typically involve falls, which can result in spinal trauma. While they are not commonly considered sport related injuries, injuries caused by recreational vehicles are included in this category. This includes all terrain vehicles (ATV’s), snowmobiles and four wheelers. These vehicles are not included in the section on motor vehicle related accidents, as they are not considered motor vehicles. Therefore, they are included in this section as recreational vehicles, which are often considered sporting vehicles. Recreational vehicles are responsible for a significant number of the trauma cases each year. Regardless of the type of recreational vehicle, the driver and passenger travel at high speeds in unsafe conditions (snow, mud, trails), with minimal protective gear.49 Most recreational nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 vehicle accidents cause the driver and passenger to be thrown some distance from the vehicle and often involve impact with another object (tree, ground, vehicle, building). Therefore, the injuries sustained during recreational vehicle accidents are quite severe. It is common for individuals to sustain head, neck and spinal injuries as the result of a recreational vehicle accident.46 Ballistic Trauma Ballistic trauma, which is the trauma caused by firearms, is often severe, if not fatal. There are approximately 500,000 gunshot wounds per year in the United States, and these wounds typically cause severe damage.50 The amount and severity of injury caused by firearms depends on a number of factors, and these are listed below.51 • Type of weapon or bullet used • Distance from weapon • Location and trajectory/path of injury • Permanent versus temporary cavity All firearm injuries are not the same. Injury and trauma level depends on the type of firearm used. Typically, firearm injuries are categorized as either low velocity injuries or high velocity injuries, and they are classified based on the type of firearm used and the projectile impact that is caused.52 Low velocity injuries are primarily caused by firearms with a muzzle velocity of less than 600 meter per second (m/s). Most low velocity firearm injuries are caused by handguns and are more prevalent than other types of injuries.50 High velocity injuries are caused by firearms with a muzzle velocity of more than 600 meter per second. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 Military weapons or high-powered hunting rifles cause most high velocity injuries.52 Injury severity and pattern differs depending on whether it is a low velocity injury or a high velocity injury. Gunshots cause injuries upon impact and can affect all different parts of the body depending on the location of initial impact. Therefore, multiple traumas can occur externally and internally and may be located in one specific area of the body, such as the head, spine or the chest.53 However, when a bullet makes impact with the body, it can produce extensive damage as it moves throughout the body. Upon initial impact, the bullet crushes the tissue of the individual. From there, the bullet propels forward and creates a tunnel that expands throughout the path of projection to create a larger tunnel. The tunnel is temporary, but it causes damage to the tissue and ligaments in the surrounding areas. Damage is caused by compression, deformation and shear force. Once the bullet has passed through the temporary cavity, the cavity decreases in size and returns to normal. However, the bullet does leave behind a permanent cavity in the location of cavitation. The tissue in this area will be permanently damaged.54 Damage is often dependent on the type of bullet used. Bullets that are encased with hard shells produce deeper penetration and more significant cavitation. Bullets with soft or hollow points typically deform or fragment and often ricochet inside the body.52 This can produce damage to more areas. The actual injuries are influenced by a number of factors, including the point of entry and the distance that the victim is from the weapon.55 Some guns, such as shotguns, contain small pellets that spread apart when they are released from the barrel. This produces a blast that spreads over a larger area and will often cause nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 damage to numerous areas of the body rather than one specific point of entry. However, these produce less damage when fired from a greater distance.50 Gunshot wounds are not limited to the point of entry. Gunshots also have the potential to create exit wounds as the bullet may leave the body after tunneling through.51 In addition, gunshots can produce contact wounds, which occur when a gun is held directly against the skin. Exit wounds can be more severe than entrance wounds as the bullet often expands within the body.52 The impact of the bullet, the path it takes, and the injuries it causes are dependent upon a number of factors. If a bullet deforms or fragments once it enters the body, it can cause damage to numerous bones and organs.53 Contributing Factors And Complications While spinal trauma can be severe and damaging on its own, there are a number of contributing factors that will increase an individual’s susceptibility to spinal damage following a trauma situation. In addition, spinal trauma can further exacerbate spinal issues that are already present in the patient, as well as cause life long spinal complications. Rheumatoid Arthritis Rheumatoid arthritis can weaken the spinal column, thereby increasing the patient’s chances of experiencing a spinal injury.56 In patients with rheumatoid arthritis, the spine is already weak. When the patient experiences spinal trauma, the weakened area is more prone to nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 damage than it would be in a patient who does not have rheumatoid arthritis.57 Osteoporosis Osteoporosis is a frequent consequence of spinal cord injury and is present in almost every instance of spinal cord trauma.58 However, the osteoporosis experienced as the result of spinal cord trauma differs from that caused by other issues such as endocrine disorders.59 Trauma-related osteoporosis will produce a different bone loss pattern and will typically cause an increase in lower extremity fractures.60 The amount of bone loss caused by trauma related osteoporosis will vary depending on the type and severity of injury, the age and sex of the patient, and the patient’s muscle spasticity.61 Regardless of the extent of damage, trauma related osteoporosis will cause fragility to the bones and will increase the patient’s risk of fracture.58 Spinal Stenosis Spinal stenosis is a condition that is caused by compression of the spinal canal. This condition is often referred to as narrowing of the spinal canal. When the spinal canal is compressed, it causes the spinal cord and nerve roots to become pinched, which results in increased pain, cramping, weakness and numbness.62 Spinal stenosis is often caused by factors such as osteoarthritis. However, it can also occur as the result of spinal trauma. When spinal stenosis is caused by trauma, the location of the narrowing will depend on the type and location of the injury. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 The symptoms that a patient can experience will vary, which depends on the location of the injury and the subsequent narrowing. Depending on the location of narrowing, patients will typically experience symptoms in the lower back, legs, neck, shoulders, or arms.63 Patients may not experience the symptoms of spinal stenosis immediately following spinal trauma. In many patients, the symptoms will develop over time as the compression worsens.62 Most symptoms will begin slowly and worsen over time. Eventually, the symptoms will be severe enough that they will limit a patient’s ability to carry out daily functions such as walking short distances. In many instances, the patient will require frequent breaks and will need to lean forward onto a solid surface to ease the pain associated with spinal stenosis.64 Spinal Trauma Injury Levels Spinal trauma will vary depending on the region of the spinal column that is injured. Therefore, spinal cord injuries are classified based on the region they affect. The following table provides descriptions for each injury level.6 Cervical Spinal Cord Injury C1 – C8 Cervical level injuries cause paralysis or weakness in both arms and legs (quadriplegia). All regions of the body below the level of injury or top of the back may be affected. (Quadriplegia, also known as Tetraplegia) Sometimes this type of injury is accompanied by loss of physical sensation, respiratory issues, bowel, bladder, and sexual dysfunction. This area of the spinal cord controls signals to the back of the head, neck and shoulders, arms and hands, and diaphragm. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 Since the neck region is so flexible it is difficult to stabilize cervical spinal cord injuries. Patients with cervical level injuries may be placed in a brace or stabilizing device. Thoracic Spinal Thoracic level injuries are less common because of the Cord Injury protection given by the rib cage. Thoracic injuries can T1- T12 cause paralysis or weakness of the legs (paraplegia) along with loss of physical sensation, bowel, bladder, and sexual dysfunction. In most cases, arms and hands are not affected. This area of the spinal cord controls signals to some of the muscles of the back and part of the abdomen. With these types of injuries most patients initially wear a brace on the trunk to provide extra stability. Lumbar Spinal Cord Injury L1-L5 Lumbar level injuries result in paralysis or weakness of the legs (paraplegia). Loss of physical sensation, bowel, bladder, and sexual dysfunction can occur. The shoulders, arms, and hand function are usually unaffected. This area of the spinal cord controls signals to the lower parts of the abdomen and the back, the buttocks, some parts of the external genital organs, and parts of the leg. These injuries often require surgery and external stabilization. Sacral Spinal Cord Sacral level injuries primarily cause loss of bowel and Injury bladder function as well as sexual dysfunction. These types S1 – S5 of injuries can cause weakness or paralysis of the hips and legs. This area of the spinal cord controls signals to the thighs and lower parts of the legs, the feet, and genital organs. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 Symptoms for Spinal Injuries The symptoms for spinal injuries will differ depending on the type and location of the injury. When observing and analyzing symptoms, the spinal injuries are broken into the following regions: Cervical (near the neck) Thoracic (chest region) Lumbar Sacral (lower back) The following section provides an overview of the various symptoms that may be present during spinal cord trauma.34 Cervical (Near The Neck) Injuries When spinal cord injuries occur near the neck, symptoms can affect both the arms and the legs. These symptoms are outlined below as: Breathing difficulties (from paralysis of the breathing muscles) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis Thoracic (Chest-Level) Injuries When spinal injuries occur at chest level, symptoms can affect the legs and result in a variety of symptoms, such as: Breathing difficulties (from paralysis of the breathing muscles) nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis Injuries to the cervical or high-thoracic spinal cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining normal body temperature. Lumbar Sacral (Lower-Back) Injuries When spinal injuries occur at the lower-back level, varying degrees of symptoms can occur and affect the legs, such as: Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Pain Sensory changes Spasticity (increased muscle tone) Weakness and paralysis Symptoms vary depending on the level of spinal trauma, which is diagnosed through the use of an assessment scale and other diagnostic techniques. The performance of a physical exam, including neurological evaluation of reflexes, and other tests to ensure a prompt and accurate diagnosis is discussed further in the section below. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 Diagnosis Of Spinal Trauma It is imperative that spinal trauma be diagnosed immediately so that the patient can receive the appropriate treatment. Since spinal damage will worsen over time, immediate treatment is necessary to minimize the long term effects.65 The initial diagnosis utilizes diagnostic imaging techniques such as X-rays, MRIs, and CT Scans. In addition, the clinician will conduct a thorough neurologic examination. The purpose of the neurologic examination is to measure the patient’s limb and trunk reflexes, as well as sensation and muscle tone.7 Once the assessments are complete, the results will be compiled on an American Spinal Injury Association (ASIA) Classification of Spinal Injury Scale. This scale provides a means for categorizing the injury and identifying appropriate treatment. Computed Tomography Scan/Magnetic Resonance Imaging The two most common diagnostic assessments used in instances of spinal trauma are computed tomography (CT) scan and magnetic resonance imaging (MRI). Computed Tomography Scan Computed tomography scan is a diagnostic imaging procedure that produces horizontal, or axial, images of the body. These images are often called “slices”.66 The CT scan uses a combination of X Ray imaging and computer technology to obtain the images in a noninvasive format.67 A CT scan is an important diagnostic tool as it is able to provide detailed images of different parts of the body. It is nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 especially useful in obtaining images of the bones, muscles, fat and organs.68 Computed tomography scans are used more frequently than standard X-rays because the images are more detailed.69 Standard X-rays use a single beam of energy that is aimed at the specific body part being analyzed. The image is captured on a plate that is placed behind the body, once the beam of light passes through the various body parts (skin, bone, muscle, and tissue).70 An X-ray is limited in its ability to provide detailed imaging, as X-ray cannot capture images of internal organs and other structures of the body. Therefore, a CT scan is often the primary assessment used. A CT scan uses a moving X-ray beam to capture the images. The beam circles around the body, thereby capturing a number of different views of the same body part.71 The information is transmitted to a computer, which then interprets the data and creates a two-dimensional form. The form is displayed on a monitor, which is then reviewed by the radiologist.72 CT scans are conducted in two ways, as explained below. Contrast CT: During a contrast CT scan patients ingest a substance orally, or receive an injection intravenously. The contrast solution enables the radiologist to view the specific body part or region more clearly. Non-Contrast CT: The non-contrast CT scan is conducted without the use of any solution.73 CT scans are used frequently in instances of spinal trauma nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 as they provide thorough views of the brain and the spine. A CT scan is especially useful for detecting the following injuries in spinal trauma patients:74 Bone fractures Bleeding Spinal stenosis Computed tomography scans are less useful in detecting injuries to the spinal cord or any ligament injuries associated with an unstable spine.75 Magnetic Resonance Imaging Magnetic Resonance Imaging is a radiologic scan that produces images of various body structures using a combination of magnetism, radio waves and computer technology. The MRI is conducted using a large circular magnet that surrounds a scanner tube.76 Placing the patient on a movable surface and inserting him or her into the magnetic tube allows images to be obtained. Once the patient is in the tube, a strong magnetic field is created. This magnetic field aligns the protons of the hydrogen atoms. Once the hydrogen atoms are aligned, they are exposed to a beam of radio waves. The radio waves impact the protons within the body, causing them to spin, thereby producing a faint signal, which is easily detected by the MRI receiver. The information obtained by the scanner is sent to a computer, where it is processed to produce an image.74 An MRI utilizes high-resolution technology, which allows it to produce highly detailed images that will show changes in many of the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 structures in the body.77 In some instances, additional agents will be used to enhance the accuracy of the images. It is most common to use contrast agents such as gadolinium, while keeping in mind that routes of administration may have a negative effect on particular patients, such as those with renal failure.21 Due to the MRI’s high level of sensitivity, it is able to detect many injuries that are undetectable using other methods.78 While an MRI and CT scan both use the slicing technique for obtaining images, the process is different for each. The MRI uses a magnetic field while the CT scan uses X-rays.76 As a result, the MRI provides more detailed images than a CT scan and is able to detect damage that is as small as 1 – 2 mm. A CT scan cannot detect damage this small.71 Magnetic Resonance Imaging is used to assess both brain and spinal injuries as it provides detailed images of areas of the spine that other diagnostic imaging technology cannot obtain. An MRI can detect basic injuries, as well as any bleeding and inflammation that may be present. It is also useful in detecting injuries to the cervical spine ligaments.79 Myelogram A myelogram, or myelography, is a diagnostic imaging procedure that utilizes a combination of contrast substance with a standard X-ray or a CT scan. The myelogram is used when diagnosing and identifying abnormalities present in the spinal canal.80 It is especially useful for detecting abnormalities in the spinal cord, nerve roots and tissue. The contrast dye is injected into the region that is being assessed and it enables the radiologist to obtain a more detailed view of the area.70 In nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42 many instances, the myelogram will utilize a standard X-ray. However, in some instances, the radiologist will use a CT scan.81 Regardless of the mechanism, a myelogram will provide a more detailed image of the spinal canal, and is often used when another diagnostic imaging method is inconclusive.82 Somatosensory Evoked Potential (SSEP) A Somatosensory Evoked Potential (SSEP) detects and provides images of the electrical signals of sensation that travel from the body to the brain. This test is used to identify areas where there may be problems with the nerves that connect to the spinal cord.83 The images help the radiologist determine if the nerves are properly sending and receiving sensory information. An SSEP is used in conjunction with other diagnostic tools to identify and diagnose problems in the spinal column.84 It is often used to detect areas of the spine that may be pinched or damaged. It can also detect the presence of a bone spur, herniated disc, or area of the spine that is compressed or experiencing an increase in pressure.83 It is also used after surgery to ensure that all nerves are working properly. An SSEP does not show the cause of the problem, but it does show the damage that has been caused. Additional diagnostic tests are used to determine what is causing the nerve to be pinched or compressed.84 Cervical Spine X-ray A cervical spine X-ray is used to identify any complications associated with back and neck pain.95 A cervical X-ray is commonly used when a patient presents with neck pain following a trauma situation of if the patient is experiencing chronic neck pain in conjunction with upper nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43 limb weakness, numbness or tingling.68 A cervical spine X-ray is commonly used to identify cervical vertebrae fractures (bone breaks), vertebral misalignment, dislocation and degenerative spine disease.71 When a cervical spine X-ray is conducted as part of an emergency trauma situation, the images are interpreted immediately so that treatment can begin as soon as possible.7 Since the images are being interpreted in an emergency department, it is often an emergency physician who interprets them.70 Most often, it will be an emergency physician, orthopedic surgeon, or general surgeon who is already involved in the care and treatment of the patient. If a radiologist is available, he or she will often be asked to interpret the images.71 The following is a description of the process used to perform the cervical spine X-ray.86 Cervical Spine X-Ray (C-Spine X-Ray) is performed by a radiographer in an X-Ray room. The standard three views taken are the AP (anteroposterior view, which looks at the spine from the front); lateral (which looks at the spine from the side) and peg view (this looks at the upper part of the cervical spine and requires the patient to open the mouth wide). The 5-series also includes flexion and extension views. X-Rays are taken with the patient’s head in full flexion (leaning as far forward as possible). The patient will be asked to bend the head forward as far as possible, and to extend the neck backwards as far as possible. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44 Appropriateness Criteria For Use Of Diagnostic Imaging The evaluation of individuals with spine trauma involves a collaborative approach between medical specialties and radiology. Although there remains questions and controversy about which patient needs imaging and the type or amount of imaging necessary, there are some standard criteria to help guide patient care. The American College of Radiology provides the following appropriateness criteria for the use of diagnostic imaging in patients with suspected spinal trauma.87 These are categorized according to the level or severity of injury, and are age-specific. The appropriateness criteria is outlined in the tables below specific to a particular condition related to suspected spinal trauma, and lists each variant radiologic procedure and rating, along with the relative radiation exposure encountered. Major Recommendations ACR Appropriateness Criteria® Clinical Condition: Suspected Spine Trauma Variant 1: Cervical spine imaging not indicated by NEXUS or CCR clinical criteria (patient meets low-risk criteria). Radiologic Procedure Rating X-ray cervical spine 1 CT cervical spine without contrast 1 CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 Myelography and post myelography CT cervical spine 1 Comments RRL With sagittal and coronal reformat. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45 CTA head and neck with contrast 1 MRI cervical spine without contrast 1 O MRI cervical spine without and with contrast 1 O MRA neck without and with contrast 1 O MRA neck without contrast 1 O Arteriography cervicocerebral 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 2: Suspected acute cervical spine trauma Imaging indicated by clinical criteria (NEXUS or CCR). Not otherwise specified. Radiologic Procedure Rating Comments CT cervical spine without contrast 9 With sagittal and coronal reformat. X-ray cervical spine 6 Lateral view only. Useful if CT reconstructions are not optimal. CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 Myelography and post myelography CT cervical spine 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com RRL 46 CTA head and neck with contrast 1 See variant 6. MRI cervical spine without contrast 1 See variant 3. O MRI cervical spine without and with contrast 1 See variant 3. O MRA neck without and with contrast 1 See variant 6. O MRA neck without contrast 1 See variant 6. O Arteriography cervicocerebral 1 See variant 6. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 3: Suspected acute cervical spine trauma Imaging indicated by clinical criteria (NEXUS or CCR). Myelopathy. Radiologic Procedure CT cervical spine without contrast Rating 9 Comments With sagittal and coronal reformat. MRI and CT provide complementary information. It is appropriate to perform both exams. RRL MRI cervical spine without contrast 9 MRI and CT provide complementary information. It is appropriate to perform both examinations. O X-ray cervical spine 6 Lateral view only. Useful if CT reconstructions are not optimal. Myelography and post myelography CT cervical spine 5 If MRI is contraindicated or inconclusive. CT cervical spine with contrast 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47 CT cervical spine without and with contrast 1 MRI cervical spine without and with contrast 1 CTA head and neck with contrast 1 See variant 6. MRA neck without and with contrast 1 See variant 6. O MRA neck without contrast 1 See variant 6. O Arteriography cervicocerebral 1 See variant 6. O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 4: Acute cervical spine trauma Imaging indicated by clinical criteria (NEXUS or CCR). Treatment planning for mechanically unstable spine. Radiologic Procedure CT cervical spine without contrast Rating 9 Comments With sagittal and coronal reformat. RRL MRI cervical spine without contrast 8 Useful for thorough evaluation of ligamentous injury. O X-ray cervical spine 6 Either lateral views only, or AP, lateral, open mouth, and oblique views may be appropriate. Individualized in consultation with ordering physician for surgical planning. Myelography and post myelography CT cervical spine 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48 CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 MRI cervical spine without and with contrast 1 CTA head and neck with contrast 1 See variant 6. MRA neck without and with contrast 1 See variant 6. O MRA neck without contrast 1 See variant 6. O Arteriography cervicocerebral 1 See variant 6. O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 5: Suspected acute cervical spine trauma Imaging indicated by clinical criteria (NEXUS or CCR). Patient persistently clinically unevaluable for >48 hours. Radiologic Procedure CT cervical spine without contrast Rating Comments RRL MRI cervical spine without contrast 8 To look for ligamentous injury, cord pathology, and edema. May be complementary to MDCT (see narrative). O X-ray cervical spine 4 Limited use when there are motion artifacts on CT. 9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49 CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 MRI cervical spine without and with contrast 1 Myelography and post myelography CT cervical spine 1 CTA head and neck with contrast 1 MRA neck without and with contrast 1 O MRA neck without contrast 1 O Arteriography cervicocerebral 1 O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 6: Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or imaging findings suggest arterial injury. Radiologic Procedure CT cervical spine without contrast Rating Comments 9 With sagittal and coronal reformat. Another CT is not needed if already done on initial evaluation. CTA head and neck with contrast 9 Either CTA or MRA can be performed depending on institutional preference. nursece4less.com nursece4less.com nursece4less.com nursece4less.com RRL 50 MRA neck without and with contrast 9 Either CTA or MRA can be performed depending on institutional preference. See statement regarding contrast in text under "Anticipated Exceptions." O MRI cervical spine without contrast 8 If neurological deficit present. O Arteriography cervicocerebral 5 For treatment planning or problem solving. CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 MRA neck without contrast 1 O MRI cervical spine without and with contrast 1 O X-ray cervical spine 1 Myelography and post myelography CT cervical spine 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 7: Suspected acute cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Clinical or imaging findings suggest ligamentous injury. Radiologic Procedure CT cervical spine without contrast Rating 9 Comments Should be initial study. nursece4less.com nursece4less.com nursece4less.com nursece4less.com RRL 51 MRI cervical spine without contrast 9 Procedure of choice for ligament damage. X-ray cervical spine 4 Flexion/extension views are not helpful in acute stage because of spasm. CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 MRI cervical spine without and with contrast 1 Myelography and post myelography CT cervical spine 1 CTA head and neck with contrast 1 MRA neck without and with contrast 1 O MRA neck without contrast 1 O Arteriography cervicocerebral 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate O O Relative Radiation Level Variant 8: Suspected cervical spine trauma. Imaging indicated by clinical criteria (NEXUS or CCR). Follow-up imaging on patient with no unstable injury demonstrated initially, but kept in collar for neck pain. Returns for evaluation. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52 Radiologic Procedure X-ray cervical spine Rating 7 Comments AP, lateral, open-mouth, obliques, and flexion/extension views. Individualized based on clinical findings. CT cervical spine without contrast 1 With sagittal and coronal reformat. Not indicated unless follow-up suggest an abnormality. CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 Myelography/post myelography CT cervical spine 1 CTA head/neck with contrast 1 MRI cervical spine without contrast 1 MRI cervical spine; without/with contrast 1 O MRA neck without/with contrast 1 O MRA neck without contrast 1 Arteriography 1 cervicocerebral Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate O May be appropriate if radiographs suggest a further problem. Not indicated unless follow-up suggests an abnormality. nursece4less.com nursece4less.com nursece4less.com nursece4less.com RRL O Relative Radiation Level 53 Variant 9: Blunt trauma that meets criteria for thoracic or lumbar imaging (with or without localizing signs). Radiologic Procedure CT thoracic or lumbar spine without contrast Rating Comments 9 Dedicated images with sagittal and coronal reformat or derived from TAP scan. MRI thoracic or lumbar spine without contrast 5 Myelography and post myelography CT thoracic and lumbar spine 3 If MRI contraindicated. X-ray thoracic or lumbar spine 3 Useful for localizing signs. CT thoracic and lumbar spine with contrast 1 CT thoracic and lumbar spine without and with contrast 1 MRI thoracic and lumbar spine without and with contrast 1 RRL O Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate nursece4less.com nursece4less.com nursece4less.com nursece4less.com O Relative Radiation Level 54 Variant 10: Blunt trauma that meets the criteria for thoracic or lumbar imaging. Neurologic abnormalities. Radiologic Procedure CT thoracic and lumbar spine without contrast Rating Comments 9 Dedicated images with sagittal and coronal reformat or derived from TAP scan. CT and MRI are complementary examinations, and both should be performed. MRI thoracic or lumbar spine without contrast 9 For cord abnormalities. CT and MRI are complementary examinations, and both should be performed. Myelography and post myelography CT thoracic and lumbar spine 7 If MRI is not possible. X-ray thoracic and lumbar spine 4 For surgical planning purposes. CT thoracic and lumbar spine with contrast 1 CT thoracic and lumbar spine without and with contrast 1 MRI thoracic and lumbar spine without and with contrast 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate nursece4less.com nursece4less.com nursece4less.com nursece4less.com RRL O O Relative Radiation Level 55 Variant 11: Child, age <14 years, alert, no neck or back pain, neck supple, no distracting injury. Radiologic Procedure X-ray cervical spine Rating 1 Comments CT cervical spine without contrast 1 With sagittal and coronal reformat. CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 CT thoracic and lumbar spine without contrast 1 CT thoracic and lumbar spine with contrast 1 CT thoracic and lumbar spine without and with contrast 1 RRL Dedicated images with sagittal and coronal reformat or derived from TAP scan. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 12: Child age <14 years, alert, no neck or back pain, neck supple, fractured femur. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56 Radiologic Procedure X-ray cervical spine Rating 5 Comments AP, lateral, and open-mouth views. Distracting injury alone is not an indication for thoracolumbar imaging. CT cervical spine without contrast 3 With sagittal and coronal reformat. Should not be first-line evaluation. CT thoracic and lumbar spine without contrast 3 Dedicated images with sagittal and coronal reformat or derived from TAP scan. If TAP CT performed for other reasons, then look at the spine. CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 CT thoracic and lumbar spine with contrast 1 CT thoracic and lumbar spine without and with contrast 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate RRL Relative Radiation Level Variant 13: Child age <14 years, with known cervical fracture. Radiologic Procedure X-ray thoracic/lumbar spine CT thoracic/lumbar spine without contrast Rating 9 Comments Not needed if fracture is visualized on TAP scan. Preferred modality. 9 Dedicated images with sagittal and coronal reformat or derived from TAP scan. nursece4less.com nursece4less.com nursece4less.com nursece4less.com RRL 57 CT thoracic/lumbar spine with contrast 1 CT thoracic/lumbar spine without and with contrast 1 Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate Relative Radiation Level Variant 14: Child age <14 years, with known thoracic or lumbar fracture. Radiologic Procedure X-ray cervical spine Rating 9 CT cervical spine without contrast 7 CT cervical spine with contrast 1 CT cervical spine without and with contrast 1 Comments Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate RRL Relative Radiation Level Treatment Of The Patient With Spinal Trauma Spinal trauma treatment begins with initial stabilization of the patient and continues through long-term rehabilitation. Throughout the process, the focus is on eliminating and/or treating any initial damage, while preventing any further damage. The specific treatment nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58 administered will vary depending on the type, severity and location of the injury. Stabilization When an individual experiences an injury, the primary goal is stabilization. The patient’s airway, breathing and circulation will be assessed and any issues will be treated. Patients who experience spinal trauma will often have extensive spinal damage. Therefore, initial treatment will be administered to stabilize any potential damage. Until a spinal injury has been ruled out, the patient will be treated as if one is present.88 Therefore, the patient will often be placed on a stabilization board and will be required to maintain spinal stabilization until an injury is ruled out.7 The following fact sheet provides thorough information regarding the stabilization of patients with a suspected spinal injury.89 The spine should be protected at all times during the management of the patient. The ideal position is with the whole spine immobilized in a neutral position on a firm surface. This may be achieved manually or with a combination of semi-rigid cervical collar, side head supports and strapping. Strapping should be applied to the shoulders and pelvis as well as the head to prevent the neck becoming the center of rotation of the body. Pre-hospital Manual spinal protection should be instituted immediately. The application of definitive immobilization devices should not take precedence over life-saving procedures. If the neck is not in the neutral position, an attempt should be made to achieve alignment. If the patient is awake and co-operative, they should actively move nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59 their neck into line. If unconscious or unable to co-operate this is done passively. If there is any pain, neurological deterioration or resistance to movement the procedure should be abandoned and the neck splinted in the current position. Long spine (rescue) boards are valuable primarily for extrication from vehicles. Repeated transfers to and from the board may compromise spinal protection and induce a significant amount of spinal movement. Patients may also be transferred on a scoop stretcher and/or vacuum mattress. There is little place for the short spine board or spinal extrication devices in the prehospital environment. In-hospital The spine board should be removed as soon as possible once the patient is on a firm trolley. Prolonged use of spine boards can rapidly lead to pressure injuries. Full immobilization should be maintained. Manual protection should be reinstated if restraints have to be removed for examination or procedures (i.e., intubation). The log-roll is the standard maneuver to allow examination of the back and transfer on and off backboards. Four people are required, one holding the head and coordinating the roll, and three to roll the chest, pelvis and limbs. The number and degree of rolls should be kept to an absolute minimum. Rigid transfer slides (i.e., Patslide) are useful for transferring the patient from one surface to another (i.e., CT scanner, operating table). Patients who are agitated or restless due to shock, hypoxia, head injury or intoxication may be impossible to immobilize adequately. Forced restraints or manual fixation of the head may risk further injury to the spine. It may be necessary to remove immobilization devices and allow the patient to move unhindered. Anesthesia may be necessary to allow adequate diagnosis and therapy. Intubation of the trauma victim is best achieved via rapid sequence induction of anesthesia and orotracheal intubation, though the technique used should ultimately depend on the skills of the operator. The collar should be removed and manual, in-line protection re-instituted for the maneuver. The routine use of a gum elastic bougie is recommended, minimizing cervical movement by allowing intubation with minimal visualization of the larynx. Spinal immobilization is a priority in multiple trauma, spinal clearance is not. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60 Transfer to Secondary Units Patients may require transfer to other units for definitive care of other injuries such as head or pelvic trauma. There should be no unnecessary delays in the transport of these patients. Transfer should not wait for unnecessary diagnostic procedures that will not alter management. This includes radiological imaging of the spine. The spine should be immobilized and protected for the transfer. Split-scoop stretchers and vacuum mattresses are more appropriate for transfer than rigid spinal (rescue) boards, which should be reserved for primary extrication from vehicles, rather than as devices for transporting patients. Management of a Spinal Injury Once a patient is stabilized, treatment will focus on minimizing and repairing any damage to the spinal region. Various treatments will be used depending on the type, location and severity of damage. The goal with initial treatment is to reduce pain and swelling, repair initial damage, and prevent secondary damage. There has been much advancement in the field of spinal cord injury and treatment, which have improved the patient’s opportunity for recovery. In recent years, improvements in diagnostic imaging techniques have made the process of diagnosing spinal injuries more accurate, while advancements in drug and other therapies have improved the management of spinal injuries. Currently, the management of spinal injuries includes three components:18 Diagnosis and treatment of immediate damage to provide relief and minimize the risk of secondary injuries. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61 Stabilizing the vertebrae and repairing structural damage. Long-term care and rehabilitation to address and improve the physical and neurological effects of the injury. These treatment goals are accomplished using a variety of treatment options. The specific treatment protocol will depend on the type, location and severity of the injury as well as the patient’s individual needs. Corticosteroids For quite a while, methylprednisolone has been used to treat spinal cord injures. Methylprednisolone is a corticosteroid that has significant anti-inflammatory properties. It is a derivative of prednisolone and belongs to the glucocorticoid family of corticosteroids.90 In many instances, patients who receive methylprednisolone within eight hours of a spinal injury experience an improvement in sensory and motor functions.91 According to three trials conducted by the National Spinal Cord Injury Study (NASCIS), there is evidence that acute steroid therapy reduces the cellular damage that occurs as a result of secondary injury process, including but not limited to lipid peroxidation.92 However, there is some controversy surrounding these results due to the inconsistencies in improvement levels and the risk of the administration of high doses of steroids.93 While there is some controversy, the results of these trials have prompted the regular and consistent use of high dose steroids in the management of acute spinal injuries.94 Recently, the use of these steroids was challenged as a result of many patients experiencing significant negative results after nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62 receiving high doses of steroids. The following effects were reported frequently and caused significant problems for the patients:95 immunosuppression with increased susceptibility to infections (pneumonia, sepsis, etc.) increased risk of gastrointestinal disturbances (ulcers, bleeding, and ileus) adult respiratory distress syndrome hyperglycemia deep venous thrombosis (DVT) pulmonary embolism As a result of the negative consequences experienced by patients, experts are now recommending against the use of high dose steroids immediately following a spinal injury. Recently, the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) released an updated document on the management of acute cervical spine and spinal cord injuries. Within this document, both groups recommend against the use of high dose steroids immediately following cervical spine and spinal cord injuries.96 Surgical Intervention Once a patient has been stabilized and the initial damage has been treated, management of the injuries will shift to stabilizing the vertebrae and repairing structural damage. In many instances, this will include surgical intervention and repair. Patients will often be recommended for surgery for the following conditions:93 removal of bone fragments presence of foreign objects nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63 blood clots herniated disks fractured vertebrae anything that appears to be compressing the spine spinal stabilization Many patients will require spinal stabilization surgery following a spinal injury. Spinal stabilization surgery “removes bone fragments and restores the alignment of the vertebrae thus reducing compression on the spinal cord. Stabilization can occur within the first 72 hours or it may be delayed until after the body has been medically stabilized. There is no evidence to support an advantage for either early or delayed treatment.”6 Some patients may require spinal fusion surgery. This procedure is performed when a patient’s vertebrae in the spinal column are unstable. Spinal fusion surgery is used to stabilize the vertebrae. This procedure “may be done with metal plates, screws, wires and/or metal rods; sometimes small pieces of bone from other areas of the body (usually the hip or knee) or from a cadaver (bone bank) are used. Bone grafts help the patient's bones grow, thus serving to fuse the vertebrae. In cervical injuries the stabilization can be done through the throat (anterior) or through the neck (posterior) or both. Thoracic and lumbar injuries are usually approached through the back.”6 The specific type of surgery will depend on the type, location and severity of the patient’s injury. The surgeon will assess the patient and determine the specific approach based on information obtained from diagnostic imaging procedures, such as an X Ray, CT Scan or MRI. In nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64 some instances, the surgery will be performed posteriorly, which is from the back of the spine. While, in other instances, the surgery will be performed anteriorly, which is from the front of the spine. In rare instances, the surgeon may need to use both approaches, but these will be done as two separate surgeries.97 The following is a list of the different types of spinal surgery:98 Lumbar discectomy Surgical procedure used to remove all or part of a herniated or ruptured disc in the lower part of the spine. Cervical discectomy Surgery used to remove one or more discs from the neck. Microdisectomy Microdisectomy involves minimally invasive surgery on a ruptured disc in the neck or back. This procedure aims at removing a small part of the ruptured disc in order to alleviate pain while avoiding any possible instability in the spine. Spinal fusion Surgical procedure for fusing or joining two or more vertebrae. There are different types of this surgery for different areas of the spine, as highlighted here. Anterior Lumbar Interbody Fusion In this procedure, the spine is operated on from the front. The surgeon removes a disc from the lower part nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65 of the spine and replaces it with bone graft. The desired result is for the two surrounding vertebrae to grow or fuse together into one solid bone. Posterior Lumbar Interbody Fusion This procedure is virtually the same as the anterior fusion except that the surgeon approaches the spine from the back. Transforaminal Lumbar Interbody Fusion In this procedure, the spine is approached from the side. Laparoscopic Fusion This is a minimally invasive surgical alternative to open surgery that requires a much smaller incision in the back to gain access to the spine. Recuperation time and pain levels are significantly reduced compared to other types of spinal fusion surgery. Intradiscal Electrothermal Therapy Minimally invasive treatment for lower back pain utilizes fluoroscopic (X-ray) guidance and an electrothermal catheter to heat up the affected lumbar disc. The goal is to destroy pain receptors in the disc. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66 Surgical Decompression A small portion of the bone over the nerve root is removed to allow more space for the nerve root while helping it to heal. There are different types of surgical decompression: Foraminotomy The foramen, or opening where the nerve root comes out of the spinal column, is widened by shaving away a portion of the bone. Laminotomy Partial removal of the lamina, or bony arches in the canal of the spine Laminectomy Complete removal of the lamina, or bony arches in the canal of the spine Corpectomy The entire degenerated vertebrae is removed and replaced by bone graft. Laminoplasty The lamina, or bony arches in the spinal canal, is cut open on both sides to create an open flap to relieve pressure on the spinal cord. The bone flap is propped open with small wedges or pieces of bone. Kyphoplasty/Vertebroplasty Kyphoplasty and vertebroplasty are both minimally invasive procedures that treat pain and other symptoms caused by a spine fracture resulting from osteoporosis. Each procedure can also restore vertebral body height lost due to a compression fracture. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67 Anterior Cervical Discectomy and Fusion Surgical procedure used to treat neck problems resulting from fractures, herniated discs and spinal instability. Spinal Cord Stimulation This procedure uses an electrical current to treat chronic back pain by implanting a small pulse generator in the back. The pulse generator sends electrical pulses to the spine in order to block the nerve signals, which causes a sensation of pain. Patients who require surgery for their spinal injuries will typically need additional care and time to recover following the surgery. Therefore, many patients will remain in the Intensive Care Unit (ICU) for care and monitoring.7 Many patients will require ventilator assisted breathing or intravenous medications, especially for blood pressure maintenance.97 In some instances, patients will only require an overnight stay for observation purposes. Most patients will require a cervical collar or brace following surgery. This will prevent undue stress on the muscles and bones and will aid in recovery. Some patients will be required to wear a brace for a number of months.99 Bedrest Following Spinal Injury Many patients will require bed rest immediately following a spinal injury, and throughout the duration of initial treatment. Bed rest improves the outcome as it reduces the pressure and stress to the patient’s bones and muscles. Early treatment of a spinal cord injury requires that the spine be properly stabilized. When a patient is nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68 mobile, there is increased risk of further damage to the spine, as the area does not stay stable. Bed rest is used to ensure proper healing. When a patient requires bed rest, the spine is typically immobilized completely to ensure proper healing. Patients who undergo complete bed rest have an increased chance of full recovery.100 Traction for Spine Stabilization Many patients will require traction to help stabilize the spine or to bring it into alignment so that further damage does not occur. The specific type of traction used will depend on the patient’s individual needs as well as the type and severity of injury. In more severe cases, the patient will have metal braces, which are attached to weights, and secured to the skull. This will prevent the head from moving. In some instances, the patient will be immobilized with the use of a special bed. However, some patients may only require the use of a rigid neck collar.101 Physical Therapy Most spinal cord trauma patients will require physical therapy as part of the long-term management process. The specific types of physical therapy used will vary by patient, and will address issues with sensory and motor function.102 Physical therapists administer services based on the domains included in the International Classification of Functioning, Disability and Health (ICF), which are promoted by the World Health Organization (WHO). The following is a list of the domains included in the ICF and how they are applied to spinal cord injuries:103 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69 body function and structure - impairments in sensation or motor function, range of motion (ROM) limitations, musculoskeletal pain, etc. activity limitation - deficits in daily tasks such as rolling in bed or propelling a wheelchair participation - activities that contribute to social and leisure skill roles, such as homemaker, sports participant, or college student. Physical therapy can be administered over the duration of weeks, months or years. The specific amount of time required will depend on the patient’s needs, the limitations present, and the baseline level of functioning. Throughout the duration of physical therapy, the goal is to maximize patient independence, improve basic functioning, increase mobility, and develop adaptations.104 Medication Many patients will require medication to treat the various effects of spinal cord injury. In some instances, patients will be given medication to control symptoms directly caused by the injury itself, such as medications to reduce the pain associated with injury or to control muscle spasticity. In other instances, patients will be given medications to minimize or improve the secondary effects of spinal injury, such as bladder control or bowel control. The specific medications administered will differ depending on the needs of the patient.105 Other Therapies In addition to the treatment options listed above, there are other therapies that are used to treat spinal trauma. These other therapies nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70 are not used in every instance of spinal trauma, but they are options if the patient presents with an injury that will benefit from additional treatment. The following fact sheet provides descriptions of the different treatment options available during spinal trauma.6 Neuroprotection Therapeutic hypothermia (spinal cord cooling) is a medical treatment that lowers the body temperature in order to protect the cells in the body from damage after a traumatic brain or spinal cord injury, stroke or cardiac event. Body temperature can be lowered by invasive methods, using catheters filled with saline to cool a patient's blood as it leaves the heart, thus lowering the temperature of the whole body. Non-invasive techniques use special blankets that have cold water running through them. These blankets may be combined with ice packs or cold fans in order to achieve more rapid temperature decline. According to the American Association of Neurological Surgeons, there is currently no published data that shows that SCI patients who are treated with therapeutic hypothermia improve compared to others who are not treated using this method. The use of local therapeutic hypothermia at the time of surgery appears safe but no criteria for treatment guidelines have been established. Currently, there is not enough evidence available to recommend for or against therapeutic hypothermia with traumatic spinal cord injury. Respiratory The lungs themselves are not usually affected by paralysis but the muscles of the chest, abdomen, and diaphragm may be. If complete paralysis occurs at level C3 or above, the phrenic nerve is no longer stimulated and the diaphragm will not function. Some individuals with lower level injuries may also need ventilator assistance for short periods of time before they can breathe on their own (called being weaned nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71 off the ventilator). Successful weaning from a ventilator is impacted by many factors: age, level of injury and time spent on the ventilator. People injured at the mid-thoracic level or higher may have trouble taking deep breaths and exhaling forcefully. This can lead to lung congestion and respiratory infections. Ways of preventing respiratory complications include maintaining proper posture, coughing regularly (if necessary, with assistance), following a healthy diet, drinking plenty of fluids, eliminating smoking or being around smoke, exercising, and getting vaccinated for influenza and pneumonia. Spinal Injury Prognosis The level of severity and the type of injury that a patient experiences as the result of spinal trauma will vary. Therefore, the prognosis for each patient with a spinal injury will differ. However, there are some specific components that will be indicative of the potential outcome. The prognosis for a complete injury is much worse than it is for an incomplete injury. Incomplete injuries have a greater likelihood of recovery than complete injuries. Most recovery occurs within the early stages of the injury, with the majority of the recovery occurring in the first 9 – 12 months post injury.19 In most instances, patients will only recover partially. The specific amount and type of recovery will vary depending on the type of spinal cord injury. Lifestyle It is well established that cigarette smoking adversely affects healing after spine surgery. Smoking cessation after spine surgery promotes improved healing and a faster rate of recovery.107 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72 The following chart provides information regarding the specific level of Spinal Cord Injury and the resulting rehabilitation potential.106 Level of injury Possible impairment Rehabilitation potential C2 - C3 Usually fatal as a result of inability to breathe Totally dependent for all care C4 Quadriplegia and breathing difficulty Dependent for all cares; usually needs a ventilator C-5 Quadriplegia with some shoulder and elbow function May be able to feed self using assistive devices; usually can breathe without a ventilator, but may need other types of respiratory support C6 Quadriplegia with shoulder, elbow, and some wrist function May be able to propel a wheelchair inside on smooth surfaces; may be able to help feed, groom, and dress self; dependent on others for transfers C7 Quadriplegia with shoulder, elbow, wrist, and some hand function May be able to propel a wheelchair outside, transfer self, and drive a car with special adaptions; may be able to help with bowel and bladder programs C8 Quadriplegia with normal arm function; hand weakness May be able to propel a wheelchair outside, transfer self, and drive a car with special adaptions; may be able to help with bowel and bladder programs T1 - T6 Paraplegia with loss of function below mid-chest; full control of arms Independent with self-care and in wheelchair; able to be employed full time T6 - T12 Paraplegia with loss of function below the waist; good control of torso Good sitting balance; greater ability for operation of a wheelchair and athletic activities L1 - L5 Paraplegia with varying degrees of muscle involvement in the legs May be able to walk short distances with braces and assistive devices nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73 Summary Spinal cord trauma is a significant medical problem that affects a number of individuals each year. In many instances, the injuries can be life threatening. Spinal cord trauma is primarily caused by motor vehicle accidents, falls, industrial accidents, assault, sports related injuries, and gunshot wounds. Depending on the location and extent of damage, a patient will experience an incomplete or complete spinal injury. Each type of injury requires different treatment and will affect the patient differently. Most spinal injuries will not lead to complete severance of the spinal cord. Instead, a spinal injury is more likely to cause fractures and compression of the vertebrae, which then crush and destroy nerve cells that carry signals up and down the spinal cord between the brain and the rest of the body. Some spinal cord injuries will result in almost complete recovery while others will lead to complete paralysis. Early identification and treatment is crucial to minimize the initial damage and to prevent secondary injuries, which are common with spinal cord trauma. In recent years, the diagnosis and management of spinal cord injuries has improved with advancements in technology and treatment options. There are a number of options available for the diagnosis of spinal cord injuries, including CT scans, MRIs, X-rays, and other advanced imaging procedures. In addition, improved emergency care for people with spinal cord injuries and aggressive treatment and rehabilitation have made it easier to manage spinal cord injuries. The availability of these advanced measures enable health clinicians to minimize damage to the nervous system and to help restore limited abilities. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74 Once stabilization of the patient with a spinal injury is achieved, treatment should focus on minimizing and repairing any damage to the spinal region. Various treatments used will depend on the type, location and severity of damage to the spine. The goal of the initial treatment is to reduce pain and swelling, repair initial damage, and prevent secondary damage. This course has highlighted that there has been much advancement in the field of spinal cord injury and treatment, which have improved the patient’s opportunity for recovery and quality of life. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75 1. The annual incidence of spinal cord injuries in the U.S., is approximately a. b. c. d. 22 35 40 65 cases cases cases cases per per per per million. million. million. million. 2. True or False: Spinal stenosis is a condition caused by the compression or narrowing of the spinal canal. a. True b. False 3. The thoracic vertebrae are located in what region of the body? a. b. c. d. Coccyx Upper and middle back Neck Lower back 4. Central cord syndrome involves hyperextension injuries as well as a. b. c. d. spinal cord ischemia, and cervical spinal stenosis. a cervical lesion always with lower extremity motor weakness. a burning sensation in the lower extremities only. All of the above 5. Spinal stabilization surgery involves a. removal of bone fragments. b. restoring vertebral alignment to reduce spinal cord compression. c. a 72-hour minimum delay in all cases. d. Answers a., and b., above 6. True or False: Therapeutic hypothermia may be done to protect body cells from damage after spinal cord injury. a. True b. False nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76 7. Spinal injuries are broken into the following regions: a. b. c. d. Cervical, Cervical, Cervical, Cervical, Thoracic, Lumbar Sacral. Cardio-pulmonary, Abdominal. Thoraco-abdominal, Sacrococcygeal. Thoracic, Abdominal. 8. The cervical vertebrae are located in the a. b. c. d. tailbone. pelvic region. middle back. neck. 9. Variant 12 of the ACS appropriateness criteria for spinal injury involves: a. b. c. d. Adult Teen/Young adult ages 15 – 25 Child age >14 years Child age <14 years 10. CT with contrast allows the radiologist to view a specific body part or region more clearly. Typically, the patient will a. b. c. d. ingest a substance orally or receive an injection intravenously. ingest a substance orally. receive an injection intravenously. receive an injection intravenously or arterially. 11. In cervical injuries, surgery may be done to stabilize the area through a. b. c. d. the throat (anterior). the neck (posterior). both the throat and the neck. All of the above 12. The ____________ is also commonly known as the tailbone. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 77 a. b. c. d. sacrum coccyx posterior lower back 13. True or False: Thoracic injuries are usually approached through the front whereas lumbar injuries are usually approached through the back. a. True b. False 14. Methylprednisolone is a corticosteroid with significant antiinflammatory properties often used within __________ of a spinal injury for patients to experience an improvement in sensory and motor functions. a. b. c. d. 2 hours 4 hours 8 hours 1-2 days 15. Traction helps to stabilize the spine, bringing it into alignment so that further damage does not occur. In more severe cases, the patient may a. b. c. d. have metal braces attached to weights, secured to the skull. strict bedrest with no weights, such as for 1 to 2 months. require constant weights to all limbs. require positioning on his sides, with frequent turning. 16. According to the Occupation Health and Safety Administration, distinct causes of death and severe injury in the construction industry include a. b. c. d. falls, struck by object, and caught-in/between injuries. falls, dislocation, and crush injuries. blunt force, crush, and evisceration injuries. blunt force, laceration and crush injuries. 17. ______________________ comprise approximately fifteen percent of spinal cord trauma cases. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 78 a. b. c. d. Blast injuries Motor vehicle injuries Fall injuries Violent assault injuries 18. After a spinal injury, an excessive release of the neurotransmitter glutamate a. b. c. d. protects nerve cells from further damage. reduces swelling in the spinal cord. may trigger additional nerve cell damage. causes additional damage to the myelin. 19. True or False: Early identification and treatment is crucial to prevent secondary injuries (common with spinal cord trauma). a. True b. False 20. Intradiscal Electrothermal Therapy is a a. b. c. d. minimally invasive treatment for lower back pain. minimally invasive treatment for c-spine pain. minimally invasive treatment using (freezing) cryotherapy. major surgical procedure to treat pain in the thoracic spine. 21. Approximately ______ percent of spinal trauma patients will experience spinal shock. a. b. c. d. 25 35 50 62 22. True or False: MRI’s are able to detect many injuries undetectable with other methods. The MRI uses a magnetic field as compared to CT X-Ray. a. True b. False 23. Spinal stenosis is a condition where a. the spinal canal is compressed nursece4less.com nursece4less.com nursece4less.com nursece4less.com 79 b. nerve roots become pinched c. pain, cramping, weakness and numbness occur. d. All of the above. 24. A substance called myelin, which acts as a sheath over the nerve structure, protects the axons. The myelin is referred to as a. b. c. d. the spinal canal. white matter. grey matter. the anterior cord. 25. True or False: Long-term care is generally not considered part of the treatment planning for spinal injury cases, as it is not part of the acute phase to improve the physical and neurological effects of an injury. a. True b. False 26. A major reduction in blood flow to a trauma site following the initial injury has a greater impact on ______________ due to its greater blood flow needs. a. b. c. d. the myelin white matter grey matter lower spine 27. Following a spinal injury, the normal delivery of oxygen and nutrients to neurons may be hindered by leaks from ______________ in the gray matter, causing many of neurons to die. a. b. c. d. the the the the axons blood-brain barrier myelin sheath blood vessels 28. True or False: Spinal cord injury sets off apoptosis, a normal process of cell death that helps the body get rid of old and unhealthy cells, because these injuries interrupt oxygen and nutrients to the spinal cord. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 80 a. True b. False 29. Microdisectomy involves minimally invasive surgery on a ruptured disc in a. b. c. d. the the the the lumbar region. neck or back. sacrum. coccyx. 30. A patient with _________________ loses movement and sensation below the level of the injury on the side where the injury occurred, while opposite the side of the injury temperature and pain sensation are lost. a. b. c. d. conus medullaris central cord syndrome Brown-Sequard syndrome cauda equina CORRECT ANSWERS: 1. The annual incidence of spinal cord injuries in the U.S., is nursece4less.com nursece4less.com nursece4less.com nursece4less.com 81 approximately c. 40 cases per million. p. 14: “It is estimated that the annual incidence of spinal cord injury (SCI), not including those who die at the scene of the accident, is approximately 40 cases per million population in the U.S., or approximately 12,000 new cases each year.” 2. True or False: Spinal stenosis is a condition caused by the compression or narrowing of the spinal canal. a. True p. 34: “Spinal stenosis is a condition that is caused by compression of the spinal canal.” 3. The thoracic vertebrae are located in what region of the body? b. Upper and middle back p. 7: “Thoracic Vertebrae: Upper and Middle Back” 4. Central cord syndrome involves hyperextension injuries as well as a. spinal cord ischemia, and cervical spinal stenosis. p. 22: “Central cord syndrome: Caused by hyperextension injuries, spinal cord ischemia and cervical spinal stenosis.” 5. Spinal stabilization surgery involves a. removal of bone fragments. b. restoring vertebral alignment to reduce spinal cord nursece4less.com nursece4less.com nursece4less.com nursece4less.com 82 compression. c. a 72-hour minimum delay in all cases. d. Answers a., and b., above p. 64: “Spinal stabilization surgery ‘removes bone fragments and restores the alignment of the vertebrae thus reducing compression on the spinal cord. Stabilization can occur within the first 72 hours or it may be delayed until after the body has been medically stabilized. There is no evidence to support an advantage for either early or delayed treatment.’” 6. True or False: Therapeutic hypothermia may be done to protect body cells from damage after spinal cord injury. a. True p. 71: “Therapeutic hypothermia (spinal cord cooling) is a medical treatment that lowers the body temperature in order to protect the cells in the body from damage after a traumatic brain or spinal cord injury, stroke or cardiac event.” 7. Spinal injuries are broken into the following regions: a. Cervical, Thoracic, Lumbar Sacral. p. 37: “The symptoms for spinal injuries will differ depending on the type and location of the injury. When observing and analyzing symptoms, the spinal injuries are broken into the following regions: Cervical (near the neck); Thoracic (chest region); Lumbar Sacral (lower back).” 8. The cervical vertebrae are located in the d. neck. p. 7: “Cervical Vertebrae: neck” 9. Variant 12 of the ACS appropriateness criteria for spinal injury involves: d. Child age <14 years nursece4less.com nursece4less.com nursece4less.com nursece4less.com 83 p. 56: “Variant 12: Child age <14 years, alert, no neck or back pain, neck supple, fractured femur.” 10. CT with contrast allows the radiologist to view a specific body part or region more clearly. Typically, the patient will a. ingest a substance orally or receive an injection intravenously. p. 40: “CT scans are conducted in two ways, as explained below: … Patients ingest a substance orally, or receive an injection intravenously. The contrast solution enables the radiologist to view the specific body part or region more clearly.” 11. In cervical injuries, surgery may be done to stabilize the area through a. b. c. d. the throat (anterior). the neck (posterior). both the throat and the neck. All of the above p. 64: “In cervical injuries the stabilization can be done through the throat (anterior) or through the neck (posterior) or both. Thoracic and lumbar injuries are usually approached through the back.” 12. The ____________ is also commonly known as the tailbone. b. coccyx p. 7: “Coccyx (commonly known as the tailbone)” 13. True or False: Thoracic injuries are usually approached through the front whereas lumbar injuries are usually approached through the back. b. False nursece4less.com nursece4less.com nursece4less.com nursece4less.com 84 p. 64: “Thoracic and lumbar injuries are usually approached through the back.” 14. Methylprednisolone is a corticosteroid with significant antiinflammatory properties often used within __________ of a spinal injury for patients to experience an improvement in sensory and motor functions. c. 8 hours p. 62: “Methylprednisolone is a corticosteroid that has significant anti-inflammatory properties. It is a derivative of prednisolone and belongs to the glucocorticoid family of corticosteroids. In many instances, patients who receive methylprednisolone within eight hours of a spinal injury experience an improvement in sensory and motor functions.” 15. Traction helps to stabilize the spine, bringing it into alignment so that further damage does not occur. In more severe cases, the patient may a. have metal braces attached to weights, secured to the skull. p. 69: “The specific type of traction used will depend on the patient’s individual needs as well as the type and severity of injury. In more severe cases, the patient will have metal braces, which are attached to weights, and secured to the skull.” 16. According to the Occupation Health and Safety Administration, distinct causes of death and severe injury in the construction industry include a. falls, struck by object, and caught-in/between injuries. p. 29: “According to the Occupation Health and Safety Administration, there are distinct causes of death and severe injury in the construction industry, and they are listed below as: Falls, Struck by Object, and Caught-in/between Injuries.” 17. ______________________ comprise approximately fifteen percent of spinal cord trauma cases. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 85 d. Violent assault injuries p. 28: “Violent assault injuries comprise approximately fifteen percent of spinal cord trauma cases.” 18. After a spinal injury, an excessive release of the neurotransmitter glutamate c. may trigger additional nerve cell damage. p. 12: “The neurotransmitter glutamate is commonly used by axons in the spinal cord to stimulate activity in other neurons. But when spinal cells are injured, their axons flood the area with glutamate and trigger additional nerve cell damage.” 19. True or False: Early identification and treatment is crucial to prevent secondary injuries (common with spinal cord trauma). a. True p. 74: “Early identification and treatment is crucial for minimizing the initial damage and preventing secondary injuries, which are common with spinal cord trauma.” 20. Intradiscal Electrothermal Therapy is a a. minimally invasive treatment for lower back pain. p. 66: “Intradiscal Electrothermal Therapy: Minimally invasive treatment for lower back pain.” 21. Approximately ______ percent of spinal trauma patients will experience spinal shock. c. 50 p. 10: “Approximately fifty percent of spinal trauma patients will experience spinal shock.” nursece4less.com nursece4less.com nursece4less.com nursece4less.com 86 22. True or False: MRI’s are able to detect many injuries undetectable with other methods. The MRI uses a magnetic field as compared to CT X-Ray. a. True p. 42: “Due to the MRI’s high level of sensitivity, it is able to detect many injuries that are undetectable using other methods.” 23. Spinal stenosis is a condition where a. b. c. d. the spinal canal is compressed nerve roots become pinched pain, cramping, weakness and numbness occur. All of the above. p. 34: “Spinal stenosis is a condition that is caused by compression of the spinal canal. This condition is often referred to as narrowing of the spinal canal. When the spinal canal is compressed, it causes the spinal cord and nerve roots to become pinched, which results in increased pain, cramping, weakness and numbness. Spinal stenosis is often caused by factors such as osteoarthritis. However, it can also occur as the result of spinal trauma. When spinal stenosis is caused by trauma, the location of the narrowing will depend on the type and location of the injury.” 24. A substance called myelin, which acts as a sheath over the nerve structure, protects the axons. The myelin is referred to as b. white matter. p. 8: “A substance called myelin, which acts as a sheath over the nerve structure, protects the axons. The myelin is whitish, nursece4less.com nursece4less.com nursece4less.com nursece4less.com 87 which is why the region they are contained in is referred to as ‘white matter.’” 25. True or False: Long-term care is generally not considered part of the treatment planning for spinal injury cases, as it is not part of the acute phase to improve the physical and neurological effects of an injury. b. False p. 62: “Long-term care and rehabilitation to address and improve the physical and neurological effects of the injury.” 26. A major reduction in blood flow to a trauma site following the initial injury has a greater impact on ______________ due to its greater blood flow needs. c. grey matter p. 11: “Because of the greater blood flow needs of gray matter; the impact is greater on the central cord than on the outlying white matter.” 27. Following a spinal injury, the normal delivery of oxygen and nutrients to neurons may be hindered by leaks from ______________ in the gray matter, causing many of neurons to die. d. the blood vessels p. 11: “Blood vessels in the gray matter also become leaky, sometimes as early as 5 minutes after injury, which initiates spinal cord swelling. Cells that line the still-intact blood vessels in the spinal cord also begin to swell, and this further reduces blood flow to the injured area. The combination of leaking, swelling, and sluggish blood flow prevents the normal delivery of oxygen and nutrients to neurons, causing many of them to die.“ 28. True or False: Spinal cord injury sets off apoptosis, a normal process of cell death that helps the body get rid of old and unhealthy cells, because these injuries interrupt oxygen and nutrients to the spinal cord. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 88 b. False p. 13: “For reasons that are still unclear, spinal cord injury sets off apoptosis—a normal process of cell death that helps the body get rid of old and unhealthy cells. Apoptosis kills oligodendrocytes in damaged areas of the spinal cord days to weeks after the injury. Apoptosis can strip myelin from intact axons in adjacent ascending and descending pathways, causing the axons to become dysfunctional and disrupting the spinal cord’s ability to communicate with the brain.” 29. Microdisectomy involves minimally invasive surgery on a ruptured disc in b. the neck or back. p. 65: “Microdisectomy involves minimally invasive surgery on a ruptured disc in the neck or back. This procedure aims at removing a small part of the ruptured disc in order to alleviate pain while avoiding any possible instability in the spine.” 30. A patient with _________________ loses movement and sensation below the level of the injury on the side where the injury occurred, while opposite the side of the injury temperature and pain sensation are lost. c. Brown-Sequard syndrome p. 19: “Brown-Sequard syndrome: Results from injury to the right or left side of the spinal cord. On the side of the body where the injury occurred, movement and sensation are lost below the level of the injury. On the side opposite the injury, temperature and pain sensation are lost due to the crossing of these pathways in the spinal cord.” References Section The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. 1. Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy M, Sieber R, et al. Epidemiology and predictors of spinal injury in nursece4less.com nursece4less.com nursece4less.com nursece4less.com 89 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. adult major trauma patients: European cohort study. Eur. Spine J. [Internet]. 2011 Dec [cited 2013 Oct 19];20(12):2174–80. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3229 733&tool=pmcentrez&rendertype=abstract Devivo MJ. Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord [Internet]. International Spinal Cord Society; 2012 May [cited 2013 Sep 18];50(5):365– 72. Available from: http://dx.doi.org/10.1038/sc.2011.178 Spinal Cord Injury and Compression | Doctor | Patient.co.uk [Internet]. [cited 2013 Oct 6]. Available from: http://www.patient.co.uk/doctor/Spinal-Cord-Injury.htm Essentials of Spinal Cord Injury: Basic Research to Clinical Practice [Internet]. Thieme; 2012 [cited 2013 Oct 19]. p. 682. Available from: http://books.google.com/books?hl=en&lr=&id=aQCsQOCzhQC&pgis=1 Keel M, Trentz O. Pathophysiology of polytrauma. Injury [Internet]. 2005 Jun [cited 2013 Sep 18];36(6):691–709. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15910820 Spinal Cord Injury Types - Spinal Cord Injury - Paralysis Resource Center [Internet]. [cited 2013 Oct 6]. Available from: http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.45146 03/ O’Dowd JK. Basic principles of management for cervical spine trauma. Eur. Spine J. [Internet]. 2010 Mar [cited 2013 Oct 17];19 Suppl 1:S18–22. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2899 718&tool=pmcentrez&rendertype=abstract Cramer GD, Darby SA. Clinical Anatomy of the Spine, Spinal Cord, and ANS (Google eBook) [Internet]. Elsevier Health Sciences; 2013 [cited 2013 Oct 20]. p. 688. Available from: http://books.google.com/books?hl=en&lr=&id=9upfXATNzjgC&pg is=1 AANS - Anatomy of the Spine and Peripheral Nervous System [Internet]. Available from: http://www.aans.org/Patient Information/Conditions and Treatments/Anatomy of the Spine and Peripheral Nervous System.aspx Clinical Anatomy of the Lumbar Spine & Sacrum, (4th Ed.) BOGDUK Nikolai: Librairie Lavoisier [Internet]. Available from: http://www.lavoisier.fr/livre/notice.asp?ouvrage=1327316 Anatomy of the Spine | Southern California Orthopedic Institute (SCOI) [Internet]. Available from: http://www.scoi.com/spine.php nursece4less.com nursece4less.com nursece4less.com nursece4less.com 90 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. SCI, Spinal Cord Injury, Injuries of the Spine and Vertebra [Internet]. [cited 2013 Oct 5]. Available from: http://www.shepherd.org/patient-programs/spinal-cordinjury/about Van den Berg MEL, Castellote JM, de Pedro-Cuesta J, MahilloFernandez I. Survival after spinal cord injury: a systematic review. J. Neurotrauma [Internet]. Mary Ann Liebert, Inc. 140 Huguenot Street, 3rd Floor New Rochelle, NY 10801 USA; 2010 Aug 16 [cited 2013 Sep 20];27(8):1517–28. Available from: http://online.liebertpub.com/doi/abs/10.1089/neu.2009.1138 American Association of Neurological Surgeons - Anatomy of the Brain [Internet]. [cited 2013 Sep 30]. Available from: http://www.aans.org/Patient Information/Conditions and Treatments/Anatomy of the Brain.aspx Tewarie RDSN, Hurtado A, Bartels RHMA, Grotenhuis JA, Oudega M. A clinical perspective of spinal cord injury. NeuroRehabilitation. IOS Press; 2010;27(2):129–39. Looby S, Flanders A. Spine trauma. Radiol. Clin. North Am. Elsevier; 2011;49(1):129–63. Patel V V., Burger E, Brown CW, editors. Spine Trauma [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 2010 [cited 2013 Oct 17]. 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