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1 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 2 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 3 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 4 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 6 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/