Spinal cord injuries: cause myelopathy or damage to nerve roots or myelinated fiber tracts that carry signals to and from the brain. Depending on its classification and severity, this type of traumatic injury could also damage the gray matter in the central part of the cord, causing segmental losses of interneurons and motorneurons. Occurs from many causes:
MVA, falls, sport injuries, industrial injuries, war injuries, diving accidents, gunshot .. etc.
• Primary prevention important.
– Drive slow, use seat belts & helmets, water safety, protective devices for athletes, prevent falls.
• An international classification based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, i.e. shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), elbow extension (C7), hip flexion (L2). Traumatic spinal cord injury is classified into five categories by the American Spinal Injury Association and the International Spinal Cord Injury Classification System:
• A indicates a “complete” spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5.
• B indicates an “incomplete” spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
• C indicates an “incomplete” spinal cord injury where motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3, which indicates active movement with full range of motion against gravity.
• D indicates an “incomplete” spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
• E indicates “normal” where motor and sensory scores are normal
• Clinical manifestations depend on type and level of injury
– Below level of injury there is total loss of sensory and motor paralysis, loss of bladder and bowel control, loss of sweating and vasomotor tone.
– Complains of acute pain in back or neck which may radiate along involved nerve.
– Respiratory problems (T1-T11 and diaphragm are used in breathing) – intercostal muscles.
– above C4 – phrenic nerve – paralysis of diaphragm.
• Respiratory status
– observe respiratory pattern, strength of cough, auscultate lungs.
• Changes in motor or sensory function
– Squeeze hand, spread fingers, move toes.
– Pricking skin with dull item, start at shoulders.
• Signs of spinal shock
– Complete loss of all reflexes, motor, sensory and autonomic below level of injury.
Management of Spinal Cord Injuries
• High dose corticosteroids within 8 hrs of injury
– Methylprednisolone, loading dose followed by infusion for 23 hrs.
• Oxygen, intubation if necessary
• Skeletal reduction and traction
– Immediate immobilization
– Reduction of dislocations (restore to normal position)
– Stabilization of vertebral column.
– Traction used in cervical fractures.
• Promote adequate breathing and airway clearance.
– Monitor pulse oximetry, ABGs.
– Clear bronchial and pharyngeal secretions
– Use suctioning cautiously – can stimulate vagus nerve causing bradycardia.
– Chest Physiotherapy, breathing exercises.
– Adequate hydration.
– Assess for signs of respiratory infection.
– Intubate and ventilate.
• Maintain proper alignment at all times.
• Reposition frequently.
• Prevent foot drop – wear shoes.
• Prevent external rotation of hip joints – trochanter rolls.
• Prevent contractures – range of motion exercises 4 times daily.
• If injury above midthoracic level, monitor BP when turning (loss of sympathetic control of peripheral vasoconstriction).
Maintain Urinary and Bowel Function
• Intermittent or indwelling catheter to avoid overdistention of bladder.
– Urinary retention results from bladder becoming atonic.
• Intake and output.
• Insert NG tube to relieve distention and prevent aspiration.
– Paralytic ileus usually develops.
– Bowel activity usually returns within 1 week.
• High fibre, high protein diet.
• Stool softener.
Managing Potential Complications
• Thrombophlebitis and pulmonary embolism
– Assess for symptoms (chest pain, dyspnea, ABGs)
– Measure circumference of thighs and calves daily
– Anticoagulation – low dose heparin
– Pressure stockings.
– Adequate hydration
• Orthostatic Hypotension
– BP unstable and low for first 2 weeks.
– Monitor closely when repositioning patient.
– Reposition slowly, wear pressure stockings.
• Exaggerated autonomic response.
– Severe headache, hypertension, profuse diaphoresis, nausea, nasal congestion, bradycardia.
– Can be triggered by distended bladder, distended bowel, stimulation of skin.
• Immediate action required –
– Place in sitting position, alleviate cause (empty bladder, check rectum, examine skin for areas of pressure, irritation)
– Apresoline (ganglionic blocking agent)