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Acute Spinal Cord Injury: Caring for Victims of this Devastating Event Brenda Lynn Morgan RN BScN MSc CNCC(C) Clinical Nurse Specialist, Critical Care Trauma Centre Victoria Hospital, London Health Sciences Centre National Trauma Registry (CIHI) • ~1000 new traumatic spinal cord injuries per year in Canada • ~80% are male • 60% < 50 years of age • 36, 000 living with disease 1 Spinal Anatomy 101 Vertebral Column • • • • • • Verebral column Canal Spinous processes Disc Dorsal (back) sensory Ventral (front) motor 7 Cervical 12 Thoracic 5 Lumbar 5 sacral 3-5 coccygeal (fused to create tailbone) Brainstem extends to C2 (Odontoid) Hangman’s Fracture (C2) C1 2 Spinal Canal Contains spinal cord Filled with CSF Spinal Cord Spinal Cord 31 spinal cord segments, each with a pair of ventral (anterior) and dorsal (posterior) nerve roots for motor and sensory function. Cord is shorter than vertebral column Spinal cord stops growing in infancy, skeleton continues Extends from base of skull to lower margin of L1-L2 (T12-L3 range) Spinal tap done at L3 or L4 intervertebral Conus medullaris is bulbous end of cord Cauda equina (nerve roots from L1-5 and S1-5) located in spinal canal • Urinary/fecal sphincter, sexual function Vertebrae Spinal Cord Segments C1-C7 C1-C8 C1-C7 nerves emerge above respective vertebrae C8 emerges between C7-T1 T1-T8 T1 nerve root emerges below T1 vertebrae Contain segmentsT1-T12 Contain L1-L5 segments T9-T12 Contain segments S1-S5 T9-T11 T12-L1 3 Anterior Spinal Artery 4 How stuff works Motor Stip Motor Pathway (Corticospinal) Cross at Brainstem Synapse with LMN Activate muscle Sensory Strip Pain and Temperature Pathway (Spinothalamic) Pain/ Temperature Proprioception (posterior columns-medial lemniscus) Cross within 2 spinal segments Crosses at brainstem Vibration/ Position 5 Light touch (Posterior columns and spinothalamic) Spinal Reflex Light Touch Lower Motor Nerves Motor Score (0-5/5) 5. normal strength (muscle contraction against resistance) 4. mild weakness (weakly against resistance) 3. support limb against gravity but not against examiner’s resistance 2. able to move but not against gravity 1. flicker but no movement 0. no movement Upper (Brain/Cord) vs Lower (Peripheral) Nerve Lesions Upper: • Brain and cord • Associated with increased tone and reflex • Clonus – Sustained involuntary contractions induced by stretching (>5 pathological) Lower: • Lower motor nerve • Associated with decreased tone and reflex • Fasciculations may be present Deep Tendon Reflexes Rating 4+ Findings Hyper responsive 3+ Brisk 2+ 1+ 0.5+ 0 Normal Low normal, diminished Only elicited with reinforcement Absent 6 Bicep Reflex Tricep Reflex C5 C7 C6 C6 Biceps Brachii Tendon Wrist Reflex Triceps Tendon Patellar Reflex (knee jerk) C6 L4 C5 L3, L2 Brachioradialis Tendon Quadriceps Tendon Achilles Reflex (ankle jerk) Babinski (plantar reflex) S1 Achilles Tendon Abnormal: Upgoing toe 7 Clonus Hoffman’s Reflex Oscillations between flexion and extension. Key Motor Function Cervical Movement Level Function T5-12 Intercostals Level Function C3 Some head, swallow, speach T11-12 Abdominals C4 Neck, shoulder shrug, diaphragm (C3-5) L2 Hip flexion L3 Knee extension L4 Dorsiflexion C5 Elbow flexion C6 Wrist flexion C7 Elbow extension L5 Long toe extension C8 Finger flexion S1 Plantar flexion (point toes) T1 Baby finger abduction S4,5 Anal sphincter Key Sensory Levels Level Sensation C3 Neck C4 Shoulder C5 Bicep C6 Thumb C7 Middle finger T2 Axillary line T4 Nipples T10 Umbillicus L2 Thighs S4,5 Anus 8 American Spinal Injury Scale ASIA IMPAIRMENT SCALE A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5. http://www.asia-spinalinjury.org/publications/2006_Classif_worksheet.pdf ASIA IMPAIRMENT SCALE ASIA IMPAIRMENT SCALE B = Incomplete: C = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3. ASIA IMPAIRMENT SCALE ASIA IMPAIRMENT SCALE D = Incomplete: E = Normal Function: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more. Normal motor and sensory function. 9 Syndromes: Central Brown-Sequard Anterior Conus Medullaris Cauda equina Central SCI Upper extremity motor and light touch deficit > lower extremity deficit Bladder dysfunction Vibration and propriocepion often spared Variable sensory loss below injury level Anterior SCI Spinal artery flow disrupted during flexion injury Injury greatest to motor and pain/temperature pathways Loss of motor and pain below lesion Bladder dysfunction Posterior columns may be preserved (light touch, vibration, and position) Brown-Sequard Syndrome One side of cord affected • Loss of motor and proprioception • Maintains pain and temperature Side opposite injury • Maintains motor and proprioception • Loss of pain and temperature The side that feels can’t move; the side that moves can’t feel 10 Conus Medullaris Injury can involve both conus (spinal cord) and nerve roots (mixed upper and lower motor nerve findings) Knee jerks preserved, ankle jerks affected Symmetrical lower limb weakness, hyperreflexia Symmetrical lower limb sensory loss, frequently in peri-anal area Severe low back pain Impotence Bladder and anal sphincter dysfunction SCIWORA Spinal Cord Injury WithOut Radiographic Evidence ? More common in children Should definition include MRI? CT best at picking up or vertebral fractures (especially posterior) MRI is best for ligamentous, spinal cord and disc interspace CTA/MRA Neurogenic Shock Mirrors spinal shock Loss of sympathetic nervous system response Vasodilation and bradycardia Can mask other types of shock Labile HR and BP may occur with turning, suctioning or other activities Cauda Equina Injury can involve both conus (spinal cord) and nerve roots (mixed upper and lower motor nerve findings) Both ankle and knee jerks affected Asymmetrical lower limb weakness, hypoflexia Saddle numbness, often asymmetrical sensory dysfunction, loss of sexual sensation Mild low back pain Erectile dysfunction less frequent Urinary retention, late onset Spinal Shock Lasts for hours or weeks following injury Initial loss of motor and sensory function below lesion Flaccid paralysis with initial loss of reflexes Resolution of spinal shock recognized by spasticity, hyperreflexia, and reflex bowel and bladder emptying Rectal sphincter reflex often first to return Autonomic Dysreflexia Life-threatening emergency Most common above T6 Occurs after spinal shock period ends Noxious stimulus triggers catecholamine release (increasing BP) Homeostatic attempts to send inhibitory message below level of lesion are blocked by injury 11 Autonomic Dysreflexia Inhibition above lesion • • • • • • • Vasodilation of face Bounding headache Nasal congestion Bradycardia Anxiety Nausea Blurred vision • Hypertension, gooseflex Treatment: Autonomic Dysreflexia Remove cause • Bladder distention, bowel impaction, pressure sores, bone fractures, visceral disturbances Can complicate medical procedures (e.g., labour and delivery) Sit patient up if possible (orthostatic BP lowering) Remove tight clothing Treatment: Autonomic Dysreflexia If needed: nitrates (contraindicated with sildenafil), nifedipine, captopril or hydralazine. Labetolol with caution (HR) Optimizing outcomes following Acute Spinal Cord Injury (ASCI) Visualize C1 to C7-T1 junction Review before other views completed 12 Adequate view AP View Imaging Odontoid View CT best at picking up or vertebral fractures (especially posterior) MRI is best for ligamentous, spinal cord and disc interspace CTA/MRA if vascular injury suspected 13 Alignment Neck Stabilization CTL until proven otherwise All trauma victims with neck pain, multiple trauma or altered mentation 3 person minimum turn ABCs Continue trauma resuscitation priority Treat cord injury like head injury: prevent secondary injury Hypoxia, hypercarbia, acidosis and hypertension increases cord edema and injury Spinal shock may mask other types of shock Bradycardia may persist and require pacemaker (especially complete C spine injury) Steroids? 14 Cardiovascular Current guidelines support aiming for MAP 85-90 mmHg following ASCI with fluid and/or vasopressors (limited evidence) Following resolution of spinal shock, baseline BP and HR often remains low May contribute to reduced exercise tolerance and risk for hemodynamic instability Cardiovascular Mobilize slowly with gradual incline increase (to avoid orthostatic hypotension/bradycardia) Compression stockings and abdominal binders may reduce venous pooling Atropine on standby Position changes can precipitate cardiac arrest in first few months post ASCI If severe, alpha adrenergic agonists (e.g., midodrine) or fludrocortisone may be indicated Respiratory Respiratory Care 1/3 of cervical spine injured patients require intubation within 24 hours Oral with in-line traction current recommendation Rapid sequence intubation Ventilator dependence likely at C4 or higher Edema following surgical stabilization (monitor for cuff leak before extubation) T1-T11 intercostals T11-T12 abdominals Injuries above L1 associated with secretion retention due to impaired cough Lifetime risk for pneumonia; greatest in first year Respiratory Care Lung Recruitment Avoid neuromuscular blockers Assisted cough with suctioning and DB&C Increase PEEP while fully ventilated; lung recruitment if collapse Breath stacking: • Abdominal thrust (clear with spine surgeon) or lateral costal compressions following deep inspiration • Ensure neck stabilization Aggressive chest vibrations/percussion to manage atelectasis/prevent collapse Initiate immediately for non ventilated patients or as soon as trach cuff can be deflated Contraindicated with recent pneumothorax, emphysema/bullous disease, asthma, lung surgery or increased ICP Monitor for bradycardia/hypotension 15 Breath Stacking Thermoregulation Peform QID/BID and prn Can be performed on extubated patient using oral mouthpiece/resuscitation bag and nose clip Extubated patients can be taught glossopharyngeal breathing to expand lungs Have patient hold for 2-3 seconds; assisted cough during exhalation Inability to shiver/generate heat and vasodilation can lead to hypothemia Hyperthermia can develop in hot weather or during exercise Blunted fever with infection DVT Prophylaxis Nutrition/GI Prophylaxis DVT in 50-100 percetn of untreated patients (72 hrs to 14 days highest insidence) PE leading cause of death LMWH considered treatment of choice Low dose unfractionated heparin or elastic stockings/SCDs in isolation considered inadequate (combined use acceptable) Consider IVC filter if anticoagulation contraindicated Feed early by gut Small bowel feeding tube due to g Consider glutamine to feeds (antiinflammatory), may reduce pneumonia Swallowing assessment for high cervical injuries GI prophylaxis; increased risk for stress ulcers (especially C spine) Pain Control Neuropathic Pain Neck/back pain common; 2/3 will have chronic pain Balance narcotics with ventilator weaning May be spontaneous or stimulus provoked Described as burning, stabbing or electrical in quality At-level pain may be due to injury of nerve roots and dorsal gray matter Below-level pain may be due to injury in the spinothalamic tract 16 Neuropathic Pain Bowel Dysfunction Antiepileptic drugs: pregabalin only drug with evidence; gabapentin and valproate also used Antidepressants: trazodone and amitriptyline for pain syndromes may be tried, but no actual evidence Intrathecal morphine, clonadine and baclofen have been used. Non traditional therapies Ileus common for days to weeks after injury Spinal shock associated with fecal incontinence Injuries above conus medullaris associated with hyperflexic sphincter and loss of voluntary relaxation Bowel Dysfunction Injuries below conus associated with areflexic bowel with slow transit time, decreased tone and constipation with incontinence Start bowel routine early Bowel Routine Example: Regular time point Chemical suppository stimulant Digital stimulation 15-60 seconds q 5-10 minutes until stool is evacuated Diet important part of routine Abdominal massage, deep breathing, leanforward position and valsalva might help May include stool softeners initially, but should be weaned off to prevent long term side effects Constipation and fecal impaction, requiring regular evacuation routine Bowel Routine Example: Regular time point Chemical suppository stimulant Digital stimulation 15-60 seconds q 5-10 minutes until stool is evacuated GI Complications Cholecystitis, UGI bleeds, pancreatitis or appendicitis in 10% of patients Greatest risk in first few months Increased incidence of gallstones probably due to denervation of gallbladder Sensory deficits delay detection and increase mortality Vague abdominal symptoms should be investigated 17 Bladder Dysfunction Spinal shock associated with incontinence SCI impacts storage and emptying Sensation of bladder fullness impaired, leading to distension Loss of voluntary emptying worsens distension Reflexive bladder emptying is stimulated by stretch: emptying is incomplete and causes bladder spasm Bladder spasm against closed sphincter can cause vesicoureteral reflux Bladder Dysfunction Conus medullaris or cauda equina injuries associated with flaccid bladder, urinary retention and overflow incontinence and incomplete emptying Most need assistance with bladder function Goal is to preserve renal function, prevent infection and promote quality of life Risk for calculi, urosepsis including peylonephritis, renal failure (25% at 20 yrs) Bladder Routine Bladder Spasm Foley upon admission to monitor shock, manage incontinence due spinal shock and prevent bladder distension As soon as patient is stable, convert to intermittent catheterization Q4H with a goal of < 500 ml per catheterization Adjust fluid intake to achieve an output of ~2L per day Manage intermittent incontinence (condom, pads) Rule out infection and adjust catheterization frequency/fluid intake Anticholinergic meds (oxybutnin, tolterodine) may decrease bladder tone Alpha adrenergic medications (ephedrine, phenylpropanolamine) may increase bladder storage if sphincter relaxation a problem Botulinum injection for detrusor hyperactivity Spasticity Believed to be due to disruption of descending inhibitory messages Cause pain, decreased mobility, contractures and disrupt sleep and ADLs Can also facilitate function (standing, transfers), promote venous return, reduce DVT formation and prevent orthostatic hypotension 18 Spasticity Spasticity Goal is not necessarily abolishment Stretching and braces Baclofen (GABA) decreases spasticity; can cause dry mouth, dizziness and weakness Wean off; rapid discontinuation can cause withdrawal Intrathecal use has been tried with success Botulinum toxin, phenol and alcohol injections Tizanidine is only drug with any supporting evidence, causes sedation Diazepam may be used alone or with other agents Dantrolene acts peripherally to inhibit calcium release Other agents: clonidine, gabapentin, cannabinoids and cyprohepatidine Other Complications of SCI Rehabilitation Pressure sores; can develop in first few hours and be lifelong Impotence (75%), male infertility Osteoporosis Coronary artery disease Heterotopic ossification (bone deposition around soft tissues and joints) Repetitive use injuries Syringomyelia Psychosocial Support Communication Primary team of nurses, RRTs, physicans, physiotherapist Visits by other spinal cord victims Up in chair Trips outside Consider antidepressants early Psychiatry/psychology referrals Passy Muir Communication boards Start in ICU Stretching to prevent contractures Exercise of all funtioning muscle group Cardiovascular excercise (e.g., arm bicycle) Splinting to prevent contractures Include patient and family in rehabilitation and plan of care 19 20