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Spinal Cord Injury and Back Pain
John Miller
Spinal Cord Injuries
 Etiologies and Risk Factors
o Flexion-rotation, dislocation injuries
o Hyperextension injuries
o Compression injuries
Pathophysiology
 Microscopic bleeding
 Cord edema, causing larger temporary dysfunction
 GI ulceration
 Spasticity
o Spastic bowel and bladder: reflex emptying of bowel, bladder (cervical and
above T12 levels)
o Flaccid bowel and bladder: no reflex emptying (T12, lumbar, sacral levels)
Assessment
 Level of injury
 Complete or partial injury
o Lowest segment of cord with bilateral intact sensory and motor function
o C1-3 may be fatal
o Cervical damage: tetraplegia (formerly quadriplegia)
o Thoracic or lumbar damage: paraplegia
o Most common levels of injury: C4, C5, C6, T12
Spinal Cord Injury: High Cervical Level, ShepherdCenter, http://youtu.be/RR8mdrh3bRE
Spinal Cord Injury: Low Cervical Level, ShepherdCenter, http://youtu.be/bqXSCSh6Lfg
How To - Transfer from Wheelchair to Floor, HealthyTomorrow, http://youtu.be/3KYGuYzxeDg
Assessment: Changes in Reflexes
 Absent in spinal shock phase
 Reflex bladder, empties with skin stimulation
 Muscle spasms
o Triggers
 Emotion
 Full bladder
 Cold
 Prolonged sitting
Standard Neurological Classification of Spinal Cord Injury,
http://emedicine.medscape.com/article/793582-clinical
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Assessment: Autonomic dysreflexia
 Most injuries above T6, but after spinal shock
 Stimuli
o Bowel, bladder
o Rectal stimulation
o Tight shoe laces
o Pain
o Cold
 Severe hypertension
 Headache
 Bradycardia
 Dilated pupils
 Blurred vision
 Diaphoresis
Autonomic Dysreflexia and Spinal Cord Injury https://youtu.be/uQMyHflQAkA
Cord Syndromes Causing Partial Paralysis
 Central cord syndrome
o More weakness in the upper extremities than lower
 Anterior cord syndrome
o Complete motor loss and decreased pain sensation
 Brown-Sequard syndrome (hemisection)
o Paralysis, vibration and position loss on one side; opposite side has loss of pain
and temperature
Spinal shock
 Common in cervical
 Loss of muscle function, bowel and bladder, autonomic reflexes
 Cool below injury level
 Lasts up to six weeks
 Resolving when reflexes return and hyperreflexic
Diagnostic Tests
 X-ray
o Initially for cervical injuries: Cross table C-spine, portable
 CT, MRI
Interventions: Initial Care
 Immobilize: hard collar, backboard and sandbags with tape, logroll with MD
 Skull tongs with skeletal traction to immobilize and reduce the fracture, lessening pressure
on the cord
 Treat head and other injuries.
 Respiratory distress or failure: Intubation, jaw thrust, suction, ventilation, oxygen
o Suction and ET can cause bradycardia from unopposed vagal stimulation.
o Abdominal binder
 NS IV to keep BP 90-100 systolic, up to 2 L (neurogenic shock)
 Steroid option: methylprednisolone
 Foley with urine output of at least 30 ml/hr
 NG, ileus is common and aspiration pneumonia potential
 Keep warm
 Remove board asap to reduce pressure
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Skeletal traction
 Constantly in place
o Do not interrupt, will cause bones to override again, requiring many hours or days
to undo.
 Maintain alignment
o Body should be in alignment to prevent stresses on fracture.
 Counter traction
o In cervical traction, body weight is the counter traction.
 Traction
o Weight amount is ordered. Weight should hang freely, not touching anything.
Make sure knots are tight. Rope should be in pulley groove.
Halo Traction Bed Set Up https://youtu.be/cHnHwIuM7H4
Halo Be Gone, elfenwick, http://youtu.be/RgQMxQ1AL8w
Interventions Later Care in the Acute Period
 Kinetic treatment bed to increase ventilation, decrease complications of mobility and
ulcer formation
 H2 receptor blockers
 Urinary antiseptics, anticoagulants, laxatives, antispasmodics
 Difficulty swallowing and eating
o Enteral or TPN if needed
Interventions after Acute Period
 Ventilator dependent if high cervical injury
o Diaphragm pacing, incentive spirometer, diaphragmatic and glossopharyngeal
breathing
o Quad assisted coughing
 Positioning and adaptive equipment
o Brace, sliding board, tilt table, orthostatic pressures, abdominal binder, thigh high
support hose, high top tennis shoes
o ROM, prone to prevent contractures, antispasmodic medications, slings, braces
o Wheelchairs, prevent pressure
 Chronic pain: phantom pain in clients with sensation
 Autonomic dysreflexia
o Elevate head of bed, medications to reduce BP
o Anesthetic lubricant for cath and rectal insertion
 Injections above level of injury to keep skin intact
 Anticoagulants for thrombophlebitis
Bowel and Bladder Interventions
 Bladder: intermittent catheterization (q4-6hr) (clean cath at home), stimulate reflex,
Crede’, condom or suprapubic catheters, medications
 Bowel: suppository or digital reflex stimulation, remove impaction
 Sexual and Psychological Interventions
 Sexual dysfunction: contraceptives, fertility low in male, penile implants or injections
 Promote psychological adjustment: peer group counseling, vocational rehabilitation
 Anticipatory grieving: help client regain some control
 Disabled family coping
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Complications
 Atelectasis, VQ mismatch, decreased compliance, pneumonia
 Shock
 Sepsis
 Pressure sores
 Respiratory distress
 Thrombophlebitis
Interventions: Surgical
 Indications
o Compound fracture
o Penetrating wounds of spine or canal
o Anterior cord syndrome
 Laminectomy
 Surgical fusion: bone graft from iliac crest
 Halo traction
o Pin care
 Internal fixation
o Rods, pins
 Body brace: wear postoperatively
Anterior Cervical Decompression and Fusion (ACDF) | Live Spine Surgery Video | Spine
Surgeon, neckandback, http://youtu.be/yfSkOF_DAfA
Halo Brace or Vest
 Pin care
o Sterile Q Tips, one for each pin
o Gauze for each pin
o Options, one or more below
 Hydrogen peroxide, may be diluted with NS
 NS only
 Chlorhexidine
 Shower with Hibiclens or regular soap
 Antibiotic ointment around pin
 Dressing
o Change top by sliding from legs up to chest
 Washing hair
o Sink
My SP Catheter Change **(Caution Graphic)** https://youtu.be/b-3gUeg_GGg
Madonna patients receive diaphragm pacer, may breathe free from vent, MadonnaRehab,
http://youtu.be/1mcveEJLjvw
Sexuality and Disability, SCI http://emedicine.medscape.com/article/319119-overview#a7
RESPIRATORY CARE: Quad cough, zobeckd, http://youtu.be/vy2sXjc2ni8
True Life: Living as a Quadriplegic (MR's Story), MindshiftMediaOnline, http://youtu.be/NYnfbMZQoE
5
What kind of adaptive equipment can make life with SCI easier, and how do we find it?
http://www.brainandspinalcord.org/kind-adaptive-equipment-can-make-life-sci-easier-find/
United Spinal Association, http://www.spinalcord.org/
NINDS Spinal Cord Injury Information Page, National Institute of Health,
http://www.ninds.nih.gov/disorders/sci/sci.htm
Chronic Back Pain
 Incidence
o Lumbar-Sacral or Cervical
o Nucleus pulposus center in disk
o Most L4-5 or L5-S1 levels
o Weakens or ruptures with age, activity, trauma
Assessment
 Pain
o Sharp
o Follows one dermatome
o Associated with stress on the back or increased pressure (sneezing, coughing,
driving, standing)
o Does not appear at time of injury
o Lordosis
o Relieved by walking, lying on back with legs elevated or lying on side with legs
flexed.
Tests
 MRI with contrast
 CT
 Electromyography
What to Expect During Nerve Conduction Study and EMG Test
https://youtu.be/GalU9SWiYic
Myotomes and Dermatomes http://www.apparelyzed.com/myo-dermatomes.html
Low Back Pain and Sciatica, Emedicine, http://emedicine.medscape.com/article/1144130overview#a1
Interventions
 Medical (conservative)
o Bedrest
o Avoid stress
o Back brace
o Firm mattress
o Hot and cold, hydrotherapy, diathermy
o TENS
o Exercise program
 Semi-sit-ups, pelvic tilt, gluteal setting, and others
Largo Back Therapy: Diathermy, chiropractor33778, http://youtu.be/Bm_o8xLZM34
Where To Place Tens Electrodes For Back Pain With Infrex Tens Unit On Tens & Interferential
Modes, medfaxx1, http://youtu.be/mwFhB1Kvazo
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Lower Back Pain Relief / Hip and Back Pain Exercises, whitetigerhawaii,
http://youtu.be/ftuYJKvBbw4
Medications
 Muscle relaxants:
o Carisoprodol
o Cyclobenzaprine
o Baclofen
o Dantrolene sodium
 Analgesics
o Acetaminophen
o Morphine, Codeine
 NSAIDs
o Naproxen
 Steroids
o Dexamethsone, including epidural route
 Tricyclic antidepressants
o Amitriptyline
Surgical Treatment
 Use if medical treatment does not work.
 Discectomy with or without laminectomy (remove bone)
 Fusion, with bone graft and/or metal hardware
 Microdiskectomy
 Minimally Invasive Endoscopic Surgery (with robotics)
Minimally Invasive Lumbar Fusion Surgery - MIS TLIF https://youtu.be/hO-sbVraM2I
Dr. Casden Performs Anterior Cervical Spine Surgery https://youtu.be/GQA8IRL5Gds
Back Surgery: Spinal Fusion https://youtu.be/6zOMOLEG9lg
Postoperative Laminectomy / Fusion
 Bed flat in operative area, knee should be gatched
 Log roll
 Teach patient to log roll.
 CDB q 2hrs, neuro checks of sensation and motor below the level.
 Should show improvement in preoperative symptoms, although edema may prevent
that initially.
 Monitor bowel and bladder function, especially urinary retention
o Dangling (sitting) at edge of bed after log rolling or using bedside commode
helps in voiding.
 Medicate for pain prior to activity.
 Watch for postural hypotension.
 Repeated surgeries are not uncommon
Spine Universe.com, http://www.spineuniverse.com/
Spine Health.com http://www.spine-health.com/