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Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors Chris Puglia, MSN, RN, CEN Based on the Lecture by Lisa Randall, RN, MSN, ACNS-BC Objectives • Consider the risk factors, signs & symptoms, diagnostic tests, complications, and treatments of: – Spinal cord injury – Herniated disc – Spinal cord tumors • Prioritize nursing diagnoses • Discuss legal and ethical issues • Case study/questions Spinal Cord Protection Bonesvertebral column 7 Cervical 12 Thoracic 5 Lumbar 5 Sacral Discsbetween vertebra Nervous System and the Spinal Cord • ANS can be affected by Spinal Cord Injury (SCI) • Sympathetic chains on both sides of the spinal column (T1-L2) • Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4) • Reflex Arc Etiology of Traumatic SCI • MVC: most common cause • Other: falls, violence, sport injuries • SCI typically occurs from indirect injury from vertebral bones compressing cord • SCI frequently occur with head injuries • Cord injury may be caused by direct trauma from knives, bullets, etc Spinal Cord Injury- SCI • • • • Compression Interruption of blood supply Traction Penetrating Trauma Spinal Cord Injury • Primary – Initial mechanism of injury • Secondary – Ongoing progressive damage • Ischemia • Hypoxia • Microhemorrhage • Edema • Hemorrhage and edema occur in the cord post injury, causing more damage to cord • Extension of the cord injury from cord edema can occur over the first few days – watch the phrenic nerve Spinal Shock – Decreased reflexes and loss of sensation below the level of injury – Motor loss: flaccid paralysis below level injury – Sensory loss: loss touch, pressure, temperature pain and proprioception perception below injury – Lasts days to months Neurogenic Shock Due to loss of vasomotor tone SNS loss results in parasympathetic dominance with vasomotor failure Loss of SNS innervation causes peripheral pooling and decreased cardiac output Hypotension and Bradycardia Orthostatic hypotension and poor temperature control (poikilothermic) Classifications of SCI • Mechanism of Injury (MOI) • Skeletal and Neurologic Level • Completeness (degree) of Injury Mechanism of Injury 1. Flexion 2. Hyperextension 3. Compression 4. Flexion /Rotation Classifications of SCI Mechanism of Injury Flexion (hyperflexion) • Most common because of natural protection position. • Generally cause neck to be unstable because stretching of ligaments Classifications of SCI Mechanism of Injury Hyperextention • Caused by chin hitting a surface area, such as dashboard or bathtub • Usually causes central cord syndrome symptoms Classifications of SCI Mechanism of Injury Compression • Caused by force from above – Such as hit on head – Or from below as landing on butt • Usually affects the lumbar region Classification of SCI Level of Injury Spinal cord level When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level The thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone Classifications of SCI Completeness (Degree) of Injury • Complete • Incomplete – Central cord syndrome – Anterior cord syndrome – Brown-Sequard syndrome – Posterior cord syndrome – Cauda Equina and Conus Medullaris Classification of SCI Completeness (degree) of Injury Complete (transection) • After spinal shock: • Motor deficits – Spastic paralysis below level of injury • Sensory – Loss of all sensation perception • Autonomic deficits – Vasomotor failure and spastic bladder Classification of SCI Completeness (degree) of Injury Incomplete Central Cord Syndrome • Injury to the center of the cord by edema and hemorrhage • Motor weakness and sensory loss in all extremities • Upper extremities affected more Classification of SCI Completeness (degree) of Injury Incomplete Brown-Séquard Syndrome • Hemisection of cord • Ipsilateral paralysis • Ipsilateral superficial sensation, vibration and proprioception loss • Contralateral loss of pain and temperature perception Classification of SCI Completeness (degree) of Injury Incomplete Anterior Cord Syndrome • Injury to anterior cord • Loss of voluntary motor, pain and temperature perception below injury • Retains posterior column function (sensations of touch, position, vibration, motion) Classification of SCI Completeness (degree) of Injury Incomplete Posterior Cord Syndrome • Least frequent syndrome • Injury to the posterior (dorsal) columns • Loss of proprioception • Pain, temperature, sensation and motor function below the level of the lesion remain intact Classification of SCI Completeness (degree) of Injury Incomplete Conus Medullaris Injury to the sacral cord (conus) and lumbar nerve roots Cauda Equina Injury to the lumbosacral nerve roots Result = areflexic (flaccid) bladder and bowel, flaccid lower limbs Clinical Manifestations of SCI • Skin: - pressure ulcers • Neuro: - pain - sensory loss - upper/lower motor deficits - autonomic dysreflexia • Cardio: - dysrhythmias - spinal shock - loss of SNS control over blood vessels - orthostatic hypotension, - poikilothermic Clinical Manifestations of SCI • Respiratory: – decrease chest expansion, cough reflex & vital capacity – diaphragm functionphrenic nerve • GI: – stress ulcers – paralytic ileus – bowel- impaction & incontinence • GU: – upper/lower motor bladder – impotence – sexual dysfunction • Musculoskeletal: – – – – – – – joint contractures bone demineralization osteoporosis muscle spasms muscle atrophy pathologic fractures para/tetraplegia Common Manifestation/Complications Upper and Lower Motor Deficits • Upper motor deficits result in spastic paralysis • Lower motor deficits result in flaccid paralysis and muscle atrophy Common Manifestations/Complications • Spinal cord injuries are described by the level of the injury – the cord segment or dermatome level – such as C6; L4 spinal cord injury • Terms used to describe motor deficits – Prefix: • para- meaning two extremities • tetra- or quadra- all four extremities – Suffix: • -paresis meaning weakness • -plegia meaning paralysis Quadraparesis means what? Common Manifestations/Complications • C1-3 = usually fatal • Loss of phrenic innervation = ventilator dependent • No B/B control • Spastic paralysis • Electric w/c with chin/mouth control Common Manifestations/Complications • C6 = weak grasp • Has shoulder/biceps to transfer & push w/c • No bowel/bladder control • Consider level of independence Common Manifestations/Complications • T1-6 = full use of upper extremity • Transfer self • Drive car with hand controls and do ADL’s • No bowel/bladder control Immediate Care Emergency Care at Scene, ED & ICU • MOI • Transport with cervical collar (LOG ROLL) • Assess ABC’s – Suction PRN/Airway – O2 – BVM/Intubate • IV x2 large bore • Foley • CMS Diagnostic Studies for SCI • X-ray of spinal column • CT with and/or without contrast (depends on MOI) • MRI • Lab work • Blood gases Therapeutic Interventions • Medications • IV methylprednisolone (Solu-Medrol) within 8 hrs to decrease cord edema • Controversial!! Therapeutic Interventions • Medications • To control or to prevent complications of SCI and immobility: – Vasopressors to maintain perfusion – Histamine H2 blockers to prevent stress ulcers – Anticoagulants – Stool softeners – Antispasmodics Therapeutic Interventions Stabilization/ Immobilization Traction Gardner-wells tongs Halo Casts Splints Collars Braces Therapeutic Interventions Surgery for SCI • Manipulation to correct dislocation or to unlock vertebrae • Decompression laminectomy • Spinal fusion • Wiring or rods to hold vertebrae together Nursing Management Assessment • • • • HEALTH HISTORY (SAMPLE) Description of how and when injury occurred (MOI) Other illnesses or disease processes Ability to move, breathe, and associated injury such as a head injury, fractures Nursing Management Assessment PHYSICAL EXAM • LOC and pupils – may have indirect SCI from head injury • Respiratory status – phrenic nerve (diaphragm) and intercostals; lung sounds • Vital signs • Motor • Sensory • Bowel and bladder function Nursing Management Assessment Motor Assessment Upper Extremity Movement, strength and symmetry Hand grips Flex and extend arm at elbow with and without resistance Nursing Management Assessment Motor Assessment Lower Extremity • Flex and extend leg at knee – with and without resistance • Planter and dorsi flexion of foot • Assess for Clonus Nursing Management Assessment Sensory assessment • With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify • Use the dermatome as reference to identify level • C6 thumb; T4 nipple; T10 naval Nursing Problems/Interventions • • • • • • • 1.Impaired mobility 2.Impaired gas exchange 3. Impaired skin integrity 4. Constipation 5. Impaired urinary elimination 6. Risk for autonomic dysreflexia 7. Ineffective coping 1. Impaired Physical Mobility • Log roll as a single unit; provide assistance as needed to keep alignment; teach patient • Care traction, collars, splints, braces, assistive devices for ADL’s • Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best) 1. Impaired Physical Mobility • Spastic Paralysis – Prevent spasms by avoiding: sudden movements or jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue) – Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications • Assess skin breakdown & thrombophlebitis; remove TED hose at least every shift 1. Impaired Physical Mobility • Prevent/treat orthostatic hypotension – Abdominal binder, calf compressors, TED hose when individual gets up – Assess BP, especially when rising – Teach use of transfer board – Assist Physical Therapy with tilt table as individual gradually gets use to being in an upright position 2. Impaired Gas Exchange • Phrenic nerve (C3-5) controls the diaphragm bilaterally. If nerve is nonfunctioning then individual is ventilator dependent. • Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing 2. Impaired Gas Exchange • Respiratory rate, rhythm, depth, breath sounds, respiratory effort, ABG’s, O2 saturation • Signs of impending extension of SCI up cord to phrenic nerve level (C3-5) • Need for ventilatory assistance (tracheotomy, ventilator ) • Quad cough (assistive cough) as needed 3. Impaired Skin Integrity • Change position frequently • Protection from extremes in temperature • Inspect skin at least 2x/day especially over boney prominences • Avoid shearing and friction to soft tissue with transfers • Removal of TED hose every 8 hours/SCDs • Nutritional status 4. Constipation • Bowels rely more on bulk than on nerves • Stimulate bowels at the same time each day. Best after a meal when normal peristalsis occurs • Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation • Assess bowel sounds prior to giving food for the first time– paralytic ileus! 5. Impaired Urinary Elimination Flaccid bladder (lower motor neuron lesion) - No reflex from S2,3,4 - Automatic empting of bladder - Urine fills the bladder and dribbles out - Need Foley or freq intermittent self catheterization Spastic bladder (upper motor neuron lesion) - Reflex arc but no connection to or from brain - Reflex fires at will - Bladder training- trigger points to stimulate empting; self catheterization 5. Impaired Urinary Elimination • • • • Use bladder scan to see amount of urine in bladder Goal = residual <100ml/20% bladder capacity Some individuals may need suprapubic catheter Assess effectiveness of medication – Urecholine to stimulate bladder contraction – Urinary antiseptic 6. Risk for Autonomic Dysreflexia • SCI above T6 • Results in loss of normal compensatory mechanisms when sympathetic nervous system is stimulated • Life threatening! • If goes unchecked BP can result in cerebral hemorrhage • Vasodilatation symptoms above SCI • Vasoconstriction symptoms below SCI 7. Ineffective Coping/Grief and Depression • Assess thoughts on ‘quality of life’; body image; role changes • Physical and psychological support • Most common SCI is 15-30 year old males and generally risk takers – This greatly affects their perception of life and rehabilitation 7. Ineffective Coping/Sexuality Male • UMN lesion – reflexogenic (S2,3,4) erections • LMN lesion – psychogenic erections (psychological stimulation) • Ejaculation/fertility may be affected Female • Hormones more than nerves regarding fertility • C-section because of chance for autonomic dysreflexia during labor • Lack of sensation/movement affects sexual performance 7. Ineffective Coping/Sexuality • Assess readiness/knowledge/your ability to teach • Use proper terminology • Suggestions: – – – – – empty bladder before sex withhold fluids and antispasmodics certain positions may increase spasms explore new erogenous zones penile implants • Refer to specially trained counselor Home Care • Assess psychological & physiological resources • Need for rehabilitation (in-house or out patient) • Need for community resources • Home assessment What’s new in SCI treatment? Superman breather Superman Breather • Kevin Everett Hypothermia for SCI Travis Roy 11 Seconds Travis Roy B.U. Stem Cell treatment for SCI Lipitor for SCI CASE STUDY • Patient Profile – Mr. Porter is a 19-year-old man with a spinal cord injury (paraplegic), status post gunshot wound to the lumbar spine. His accident was 4 months ago, and he is in the rehabilitation unit. • Subjective Data – States he is depressed and “is getting used to the idea of not walking again” • Objective Data • Physical Examination • Vital signs: supine blood pressure 120/68, sitting blood pressure 114/62, pulse 68, temperature 99º F, respirations 16 • Apical pulse: 69 • Slight edema bilateral lower extremities • Urine dark yellow in drainage bag • Last bowel movement yesterday • Coccyx with 2 cm red area • Right heel with 1 cm red area • Full passive range of motion in the bilateral lower extremities without crepitation • Full active range of motion in the bilateral upper extremities without crepitation • No sensation in bilateral lower extremities, normal sensation bilateral upper extremities • • • • Diagnostic Studies White blood cells: 9500/µl Hemoglobin: 16 g/dl Hematocrit: 45% Critical Thinking Questions – What is the primary nursing concern for this patient? – What nursing interventions are appropriate for impaired skin integrity? – Based on all of the assessment data, what are other nursing priorities? – What are appropriate nursing diagnoses for a patient with paraplegia? Herniated Discs Herniated Disc Herniated nucleus pulposus, (HNP) slipped disc, ruptured disc HNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it Risk Factors Standing erect Aging changes Poor body mechanics Overweight Trauma Common Manifestations/Complications • HNP compresses – Spinal nerve (sensory or motor component) as it leaves the spinal cord – Or the cord itself (the white tracts within the cord) • rare Common Manifestations/Complications Sensory root or nerve usually affected pain, parenthesis, or loss of sensation Motor root or nerve may be affected paresis or paralysis Manifestations depend on what nerve root, spinal nerve is being compressed– which dermatomes Radiculopathy pathology of the nerve root Common Manifestations/Complications Lumbar HNP Most common site for HNP L4-5 disc- the 5th lumbar nerve root posterior sensory nerve or root compressed Classic symptoms low back / sciatica pain pain increases with increase in intrathoracic pressure Herniated disc L4-L5 Other Symptoms Lumbar HNP • • • • • • • • Postural changes Urinary/male sexual function changes Paresis or paralysis Foot drop Paresthesias Numbness Muscle spasms Absent cord reflexes Common Manifestations/Complications Cervical HNP C5-C6 disc- affects the 6th cervical nerve root • Pain- neck, shoulder, anterior upper arm to thumb • Absent/diminished reflexes to the arm • Motor changes- paresis or paralysis • Sensory- paresthesias or pain • Muscle spasms Therapeutic Interventions Diagnostic Tests • X-ray – identify deformities and narrowing of disk space • • • • CT MRI Myelogram Nerve conduction studies (EMG) – detect electrical activity of skeletal muscles Treatment: Conservative Bed rest with firm mattress log roll side lying position with knees bent and pillow between legs to support legs Avoid flexion of the spine brace/corset, cervical collar to provide support Medications non-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers Treatment: Conservative Heat/cold therapy to decrease muscle spasms Break the pain-spasm-pain cycle Ultrasound, massage, relaxation techniques Progressive mobilization with approved exercise program –includes abdominal/thigh strengthening Teaching good body mechanics Weight loss TENS unit Treatment: Surgery • Laminectomy – removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out • Herniated disc repair • Foraminotomy – enlargement of the bony overgrowth at the opening which is compressing the nerve • Microdiskectomy – Use of electron microscope through a small incision to remove a portion of the HNP that is displaced • Anterior cervical fusion – If cervical HNP, usually use the anterior approach in the neck Treatment: Surgery • Spinal fusion • removes most of the disc and replaces it with bone usually from the patient iliac crest • fusion also with rods, pins, synthetic protein • flexibility is lost at the site- requires longer hospital stay • Artificial Disc • combination of metal and plastic • attached to vertebrae above and below Prevention of HNP • Back school approach – Causes of HNP – Learn how to prevent – Good body mechanics – Exercises to strengthen leg and abdominal muscles • Change in life-style or occupation Nursing Assessment Specific to HNP Health History • Assess for risk factors • The cumulative effect of standing erect and daily stress • Aging changes in disc/ligaments • Poor body mechanics • Overweight • Trauma • Employment • History of pain and other neuro changes Nursing Assessment Specific to HNP Physical Exam • Use similar methods to assess as utilized SCI • Muscle strength and coordination • Sensation – sharp/dull of paperclip using dermatome as reference • Pain evaluation- pain scale • Pre/Post-op assessment Post-Op Assessment for HNP • Sensory/motor assessment – be careful not to injure op site • Assess for CSF drainage or bleeding from op site • Encourage turn (log roll, cough, deep breath) • Assess for postural hypotension – especially if patient was on bed rest for several days/weeks prior to surgery Post-op Assessment for HNP • If Anterior Cervical – Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness) – Assess respiration, neck size, swallowing and speech • If Post-Op Lumbar – Assess bowels sounds, voiding – Minimize stress of post-op site- flat with pillow between knees, log roll, etc Nursing Problems/Interventions 1. Acute Pain Post surgery the individual may have similar pain as preop due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly Donor site (illiac crest) may cause more pain than laminectomy Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic 2. Chronic Pain • Surgery may not relieve pain • Consider nonpharmalogical methods to control pain • Pain clinic Spinal Cord Tumors Spinal Cord Tumors • CNS is made up of neural tissue and support tissue • These tissues undergo changes and result in spinal cord tumors • Blood vessels and bone also can be part of the tumor Classification by origin Primary originating in the spinal cord or meninges Secondary metastases from other parts of the body Most spinal cord tumors are found in the thoracic region Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction Common Manifestations/Complications • Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected • Pain that is not relieved by bed rest is the most common presenting symptom • Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor Common Manifestations/Complications • Manifestations of thoracic cord tumor – Paresis & spasticity of one leg then the other – Pain back & chest, not relieved by bed rest – Sensory changes – Babinski reflex – Bowel (ileus); bladder dysfunction (UMN in type) Therapeutic Interventions • Diagnostic tests include – X-ray of the spinal column – Myelogram – Lumbar puncture with CSF analysis Therapeutic Interventions • Medications for spinal tumors – Control pain • narcotic analgesics, epidural catheter, PCA, NSAID’s – Reduce cord edema and tumor size • steroids- high dose Dexamethasone Therapeutic Interventions • Surgery for spinal cord tumors – Laminectomy to remove or to decrease the size (decompression laminectomy) of the spinal cord tumor – Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable • Radiation to reduce size and control pain Nursing Assessment • Health history – Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex • Physical exam – Similar to physical assessment for HNP Nursing Problems/Interventions • 1. Anxiety – Metatastic tumor vs benign spinal cord tumor – Education and support system • 2. Risk for constipation – From spinal cord compression, narcotics, bed rest – Adjust fluid and diet Nursing Problems/Interventions 3. Impaired physical mobility – From bed rest and motor involvement – Basic nursing- ROM, etc 4. Acute pain – From compression or invasion of tumor – Assess and treat 5. Sexual dysfunction – Male sacral reflex arc (S 2,3,4) interference – Similar care as discussed with SCI Nursing Problems/Interventions • 6. Urinary retention – Reflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI • 7. Home care – Rehabilitation – Home evaluation – Support groups A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? 1. Bladder distension 2. Neurological deficit 3. Pulse ox readings 4. The patient’s feelings about the injury While in the ED, a patient with a C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism A 22-year-old patient with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? 1. Place the client flat in bed 2. Assess patency of the indwelling urinary catheter 3. Give one SL nitroglycerin tablet 4. Raise the head of the bed immediately to 45-90 degrees A patient with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? 1. To hasten wound healing 2. To immobilize the surgical spine 3. To prevent autonomic dysreflexia 4. To hold bony fragments of the skull together A patient has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1. Absent corneal reflex 2. Decerebrate posturing 3. Movement of only the right or left half of the body 4. The need for mechanical ventilation The nurse is evaluating neurological signs of the male patient in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1. Positive reflexes 2. Hyperreflexia 3. Inability to elicit a Babinski’s reflex 4. Reflex emptying of the bladder Your T1 spinal cord injured patient complains of a headache. You should 1. Give him prn Tylenol 2. Disimpact his bowels 3. Call the doctor 4. Take his blood pressure Your patient has a malignant metastatic lesion at T8 and is in for palliative radiation. What is your main goal with this patient? 1. Teach patient self catheterization 2. Ensure patient receives pain medication as needed 3. Encourage patient to discuss fears 4. Ambulate twice a shift