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the foramen
magnum in the
cranium
Cord ends at the L1L2 vertebra level
Spinal nerves
continue to the last
sacral vertebra
The Human Spine
Spinal
Cord
Gray matter-
cell bodies of
voluntary and
autonomic
motor neurons
White matter
axons of
ascending and
descending
motor fibers
messages to and
from the brain
Ascending Tractscarry into higher
levels of CNS
touch, deep
pressure,vibration,
position,
temperature
Descending Tracts
impulses for
voluntary muscle
movement
PyramidalVoluntary
movements
Posterior column
(Dorsal)- touch,
proprioception,
and vibration
sense
Lateral
spinothalamic
tract- pain and
temperature
sensation (only
tract that
crosses within
the cord)
voluntary
movement
stimulus
ANS
Nervous
can be affected
System
by SCI
Spinal
Cord
Sympathetic chains
on both sides of the
spinal column (T1L2)
Parasympathetic
nervous system is
the cranial-sacral
branch (brainstem,
S2-4)
and the
Spinal
Cord
Bones- vertebral
column
Protectio
7 Cervical
n
12 Thoracic
5- Lumbar
5- Sacral
Discsbetween
vertebra
external ligaments
Dura
Meninges
CSF in subarachnoid
space allow for
movement within
spinal canal
without injury
90% go home
Secondary
Ongoing progressive damage
Ischemia
Hypoxia
Microhemorrhage
Edema
signs
Hyperreflexia of foot
Test by flexing leg at
knee & quickly dorsiflex
the foot
Rhythmic oscillations of
foot against hand
clonus
Classifications of SCI
Mechanism of Injury
Skeletal and Neurologic Level
Completeness (degree) of Injury
Mechanism of Injury
Flexion
Hyperextension
Compression
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
Classifications of SCI
Mechanism of Injury
Compression
Caused by force from
Classifications of SCI
Mechanism of Injury
Flexion/Roatation
Most unstable
Results in tearing of
ligamentous structures
that normally stabilize
the spine
Usually results in serious
neurologic deficits
Skeletal level
Vertebral level where
the most damage to
the bones
Neurologic level
The lowest segment
Levels of Function in
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
Complete (transection)
Injury
After spinal shock:
Motor deficitsspastic paralysis
Classification of SCI
Completeness (degree) of
Incomplete
Injury
Central Cord Syndrome
Injury to the center of
Classification of SCI
Completeness (degree) of
Incomplete
Injury
Brown-Squard Syndrome
Hemisection of cord
Ipsilateral paralysis
Ipsilateral superficial
Classification of SCI
Completeness (degree) of
incomplete
Injury
Anterior Cord Syndrome
Injury to anterior cord
Loss of voluntary motor,
Classification of SCI
Completeness (degree) of
incomplete
Injury
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
incomplete
Injury
Conus Medullaris
Injury to the sacral
Clinical Manifestations of
SCI
Skin:
Cardio:
pressure ulcers
dysrhythmias
spinal shock
Neuro:
pain
sensory loss
upper/lower motor
deficits
autonomic
dysreflexia
Respiratorydecrease chest
expansion, cough
reflex & vital
capacity
diaphragm functionphrenic nerve
GI
GU
upper/lower motor
bladder
Impotence
sexual dysfunction
Musculoskeletal
joint contractures
bone demineralization
stress ulcers
osteoporosis
paralytic ileus
muscle spasms
muscle atrophy
incontinence
pathologic fractures
para/tetraplegia
Common
Manifestation/Complications
Upper and Lower Motor
Deficits
Common
Manifestations/Complications
Spinal cord injuries are described by the level of the injury the
Common
Manifestations/Complicati
C1-3 usually fatalons
Loss of phrenic
innervation ventilator
dependent
No B/B control
Spastic paralysis
Electric w/c with
chin/mouth control
Common
Manifestations/Complicati
C6- weak grasp
ons
Has shoulder/biceps to
transfer & push w/c
No bowel/bladder
control.
Considered level of
independence
Common
Manifestations/Complicati
T1-6- full use of upper
ons
extremity
Transfer
Drive car with hand
Immediate Care
Emergency Care at
Scene, ER & ICU
Transport with cervical
collar
Assess ABCs; O2;
tracheotomy/vent
IV for life line
NG to suction
Foley
Therapeutic Interventions
Medications
Therapeutic
Interventions
Medications
To control or to prevent complications of
Therapeutic
Interventions
Stabilization/
Immobilization
TractionGardner-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 HISTOY
Description of how and when injury
occurred
Other illnesses or disease processes
Ability to move, breathe, and associated
injury such as a head injury, fractures
Nursing Management
Assessment
PHYSICAL EXAM
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
Nursing Management
Assessment
Motor Assessment
Lower Extremity
Nursing Management
Assessment
Sensory assessment
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
needed to keep alignment; teach patient
Mobility
Care traction, collars, splints, braces,
1.
Impaired
Physical
Spastic Paralysis
Mobility
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
1.
Impaired
Physical
Prevent/treat orthostatic hypotension
Mobility
Abdominal binder, calf compressors, TED hose
when individual gets up
Assess BP, especially when rising
2.
Impaired
Gas
Exchange
2. Impaired Gas
Exchange
Respiratory rate, rhythm,
as needed
prominences
Avoid shearing and friction to soft tissue with
transfers
Removal of TED hose every 8 hours
Nutritional status
4. Constipation
Bowels rely more on bulk than on nerves
Stimulate bowels at the same time each day.
5. Impaired Urinary
Elimination
Flaccid bladder (lower motor neuron lesion)
5. Impaired Urinary
Elimination
bladder
Goal- residual <100ml/20% bladder
capacity
Some individuals may need suprapubic
catheter
Assess effectiveness of medication
Urecholine to stimulate bladder contraction
Urinary antiseptic
SCI above T6
Results in loss of normal compensatory
hypotension
Identify cause/alleviate- if full bladder- cath; if
skin- remove pressure, if full bowel- empty, etc
Remove support hose/abdominal binder
Monitor blood pressure- can get > 300 S
Give PRN medication to lower BP
If above not effective call physician
7. Ineffective Coping/
Grief and Depression
Assess thoughts on quality of life; body
7. Ineffective
Coping/sexuality
Male
Female
UMN lesion
reflexogenic (S2,3,4)
erections
LMN lesion
psychogenic erections
(psychological
stimulation)
Ejaculation/fertility may
be affected
7. Ineffective
Coping/sexuality
Assess readiness/knowledge/your ability
Use proper terminology
Suggestions:
empty bladder before sex
withhold fluids and antispasmodics
certain positions may increase spasms
explore new erogenous zones
penile implants
Home Care
Assess psychological, physiological resources
need for rehabilitation (in-house or out
patient)
need for community resources
Home assessment
Kevin Everett
hypothermia treatment for SCI
Standing Tall
Travis Roy- 11 Seconds
Stem Cell treatment for SCI
Lipitor for SCI
admission to ICU?
2. What symptoms indicate that he is in spinal
shock? What was done about these symptoms?
3. How will we know when he is out of spinal
shock?
4. How does progressive mobilization assist with
orthostatic hypotension? What else can be
done?
5. What are realistic functional goals for Jim?
Pathophysiology/Etiology
Located between
vertebral bodies
Composed of
nucleus pulposus a
gelatinous material
surrounded by
annulus fibrosis- a
fibrous coil
Spinal nerves come
out between
vertebra
Herniated Disc
Herniated nucleus pulposus, (HNP) slipped
Common
Manifestations/Complications
HNP compresses
Spinal nerve
(sensory or motor
component) as it
leaves the spinal
cord
Or the cord itselfthe white tracts
within the cord- rare
Common
Manifestations/Complications
Sensory root or nerve usually affected
Manifestations
depend on what nerve root, spinal nerve is
Common Manifestations/Complications
Lumbar HNP
Most common site for HNP
L4-5 disc- the 5th lumbar nerve root
pressure
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
Treatment- Conservative
Bed rest with firm mattress
log roll
side lying position with knees bent and pillow
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
Laminectomyremoval of a portion of the lamina to
Treatment- Surgery
Microdiskectomy
Use of electron microscope through a small
Treatment- Surgery
Spinal fusion
removes most of the disc and replaces it with
spinal fusion
Artificial Disc
Combination of metal and plastic
Attached to vertebrae above and below
Prevention of HNP
Back school approachCauses of HNP
Learn how to prevent
Good body mechanics
Exercises to strengthen leg and abdominal
muscles
SCI
Muscle strength and coordination
Sensation
sharp/dull of paperclip using dermatome as
reference
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 client was on bed rest for several
Nursing Problems/Interventions
1. Acute Pain
Post surgery the individual may have similar
2. Chronic Pain
Surgery may not relieve pain
Nonpharmalogical methods
to control pain
Pain clinic
3. Constipation
As a result of bed rest and decreased
diet, etc
4. Home Care
When riding in a car, take frequent stops
Intramedullary- arise
from neural tissues of
the spinal cord
Extramedullary- arise
from tissues outside the
spinal cord may be
benign or malignant
Intradural-from
the nerve roots or
meninges in
subarachnoid space
Extradural- from
the epidural tissue
or vertebra
Classification by origin
Primary- originating in the
Secondary- metastases
Common
Manifestations/Complications
Symptoms depend on the anatomical level of
Common
Manifestations/Complications
Manifestations of thoracic cord tumor
Paresis & spasticity of one leg then the
other
Pain back & chest, not relieved by
bedrest
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 spinal tumors
Control pain- narcotic analgesics,
Therapeutic Interventions
Surgery for spinal cord tumors
Laminectomy to remove or to decrease
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
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
7. Home care
Rehabilitation
Home evaluation
Support groups
case study
degrees
lifting an object.
There is an increased blood supply to the back as the
body ages.
Older clients develop atherosclerotic joint disease as a
result of fat deposits.
Clients develop intervertebral disc degeneration as
they age.
drainage
Schedule intermittent catherization every 2 to 4
hours
Perform a straight catherization every 8 hours
while awake
Perform Credes maneuver to the lower abdomen
before the client voids.
body
The need for mechanical ventilation
needed
Encourage patient to discuss fears
Ambulate twice a shift