Download Acute Spinal Cord Injury

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
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Spinal Anatomy 101
Vertebral Column
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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
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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
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Anterior Spinal Artery
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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
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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
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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
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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
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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.
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Syndromes:
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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
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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
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Autonomic Dysreflexia
 Inhibition above lesion
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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
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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
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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?
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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
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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
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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
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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
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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
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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
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