SPINALCORD INJURY SPINALCORD INJURY

Prabhuswamy A. C.

Anatomy of Spinal Cord

Anatomy of Spinal Cord

Anatomy of Spinal Cord

Anatomy of Spinal Cord

Anatomy of Spinal Cord

Anatomy of Spinal Cord

What is Spinal Cord Injury?

A spinal cord injury usually begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae.
The damage begins at the moment of injury when displaced bone fragments, disc material, or ligaments bruise or tear into spinal cord tissue.
an injury is more likely to cause fractures and compression of the vertebrae

Etiology & Risk Factors

Traumatic causes:
Auto mobile or Accidents Gun Shot Injuries Knife Wounds Falls Sport Injuries Motor cycle

Contd..

Etiology & Risk Factors

Non Traumatic causes: Cervical Spondylosis with myelpathy
spinal canal narrowing with progressive injury to the cord & roots)
(

Myelitis (infective or non infective) Osteoporosis (causing vertebral

fractures)

compression

Syringomyelia (central cavitation of the cord) Tumours (both infiltrative & Compressive) Vascular diseases (usually infarction
Hemmorrhage)

&

Contd..

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Risk Factors
The feeling of immortality
adolescents & young)
(in

Young people think they can engage in dangerous behavior without being injured Use of Alcohol & Illicit drugs while Operating moving vehicle Diving
Contd..
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Risk Factors
Recreational activities proper safety measures
bicycling, Motorcycling Rollerblading Horse Back riding

without

Occupations that need to use Ladders Climbing Heights 5ft. or more above the ground
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Causes:
i) ii) Direct trauma Compression by bone fragments / haematoma / disc material iii) Ischemia from damage / impingement on the spinal arteries

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Pathophysiology of Spinal Injury

Mechanisms of Spinal Injury
Extremes of Motion
Hyperextension Hyperflexion: Kiss the Chest Excessive Rotation Lateral bending

Axial Stress
Axial Loading Compression common between T-12 and L-2 Distraction :Distraction is the pulling apart of the spine Combination Distraction/Rotation or Compression/Flexion

Other Mechanisms of injury

Direct, Blunt, or Penetrating trauma Electrocution

Types of SCI
Unique Cervical Injuries

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Mechanisms causing spinal injury

Pathophysiology of Spinal Injury

Column Injury
Movement of vertebrae from normal position Subluxation or Dislocation Fractures
Spinous process and Transverse process Pedicle and Laminae Vertebral body

Ruptured intervertebral disks Common sites of injury

C-1/C-2: Delicate vertebrae C-7: Transition from flexible cervical spine to thorax T-12/L-1: Different flexibility between thoracic and lumbar regions

Pathophysiology of Spinal Injury

Cord Injury
Concussion
Similar to cerebral concussion Temporary and transient disruption of cord function

Contusion
Bruising of the cord Tissue damage, vascular leakage and swelling

Compression
Secondary to:
displacement of the vertebrae herniation of intervertebral disk displacement of vertebral bone fragment swelling from adjacent tissue

Pathophysiology of Spinal Injury

Cord Injury
Laceration
Causes
Bony fragments driven into the vertebral foramen Cord may be stretched to the point of tearing

Hemorrhage into cord tissue, swelling and disruption of impulses

Hemorrhage
Associated with contusion, laceration, or stretching

Injury that partiallyifor person is able to contractspinal cord completely severs the the So, a
INCOMPLETE COMPLETE Intense &pinprick or touch, the painful muscular feel peri-anal spasms injury is said to be "incomplete" Cord Syndrome Central Recent evidence suggest over Recent evidence suggest that that Below T-1 95% of people with "incomplete" spinal less than 5% of people with Anterior Cord Syndrome cord injury recover somecord injury "complete" spinal locomotory Quadriplegia recoverParaplegia ability locomotion
Brown-Sequards Syndrome Incontinence incontinence

injury retains some sensation the or no function below movement below the level of Transection Cord Injury the "neurological" level, defined injury. as the lowest level that has

Pathophysiology of A person with Injury an incomplete Spinal injury, there is In a complete

intact sphincter voluntarily or is able to neurological function. anal

Cervical Spine

Respiratory paralysis

Pathophysiology of Spinal Injury

Incomplete Transection Cord Injury
i. Anterior Cord Syndrome
Anterior vascular disruption Loss of motor function and sensation of pain, light touch, & temperature below injury site Retain motor, positional and vibration sensation

Pathophysiology of Spinal Injury

Incomplete Transection Cord Injury
ii. Central Cord Syndrome
Hyperextension of cervical spine Motor weakness affecting upper extremities Bladder dysfunction

Pathophysiology of Spinal Injury

Incomplete Transection Cord Injury
iii. Brown-Sequards Syndrome
Penetrating injury that affects one side of the cord Ipsilateral sensory and motor loss Contralateral pain and temperature sensation loss

Pathophysiology of Spinal Injury

General Signs & Symptoms
Extremity paralysis Pain with & without movement Tenderness along spine Impaired breathing Spinal deformity Priapism - Priapism is a potentially painful medical
condition, in which the erect penis or clitoris does not return to its flaccid state

Posturing Loss of bowel or bladder control Nerve impairment to extremities

Clinical Manifestations
Loss of voluntary movement Loss of Sensation of pain, temperature, and proprioception (-is the
sense of the relative position of neighbouring parts of the body)

Loss of Bowel & Bladder function Loss of Spinal & Autonomic reflexes

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Clinical Manifestations
SPINAL SHOCK Immediate response to cord transection is called spinal or post-traumatic a-reflexia

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Clinical Manifestations
SPINAL SHOCK Loss of skeletal muscle function bowel & bladder tone sexual function autonomic reflexes venous return & hypotension temperature control
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Clinical Manifestations
SPINAL SHOCK may last for 7 days to 3 months. return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder the earliest reflexes recovered are the flexor reflexes evoked by the noxious cutaneous stimulation.
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Clinical Manifestations
SPINAL SHOCK return of the bulbo-spongiosis reflex in male patients is also early indicator of recovery from spinal shock Babinskis reflex (dorsiflexion of the great toe with fanning of the other toes when the sole is foot is stroked) is an early-returning reflex
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Muscle Strength Grading:

5 Normal strength 4 Full range of motion, but less than normal strength against resistance 3 Full range of motion against gravity 2 Movement with gravity eliminated 1 Flicker of movement 0 Total paralysis

Diagnostic Assessment
Spinal x-rays CT scans MRI to locate level of the lesion Myelography (Myelography is an x-ray
examination of the spinal canal. A contrast agent is injected through a needle into the space around the spinal cord to display the spinal cord, spinal canal, and nerve roots on an x ray)
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Emergency Management
Before moving the patient immobilize the spine with adequate number of people to accomplish the task Neck should be stabilized in neutral position without flexion/extension Use spinal board to immobilize the spine Secure the spine with hard collar around the neck (white transparent cervical
collar is now days very useful as through that we can visualize carotid arteries and trachea)
Cont.
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Emergency Management
Care should be given for the any other injuries present along with SCI As for as possible turning should be avoided, if necessary logrolling maneuver is used Clothing can be cut off instead of removing Care should be taken to maintain patent airway suctioning is performed as necessary (neck should not be hyper extended while intubation) In case of respiratory impairment mechanical assistance is provided Cervical traction can be used with x-ray guidance
Cont.

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Emergency Management
Skeletal Traction is applied for a patient who is having severe cervical injury to immobilize & to reduce the fracture & dislocation Crutchfield tongs Gardner-wells tongs Weights should be 10 20 lbs (4.5 9.1 kgs) and gradually increased to accomplish the reduction; proper alignment is obtained & verified with x-ray Neurological examination is made to assess the extent of injury and establish a baseline of function & involvement for later comparison
Cont.

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Emergency Management
Common emergent interventions Insertion of IV line Infusion of normal saline Insertion of indwelling Catheter Administration of potent steroids Administration of vaso-active medications to maintain systolic BP Insertion of Naso-gastric tube Provision of oxygen Once patient is stabilized can be shifted to ICU
Cont. 35

Medical Management

Cont.

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Medical Management
A complete neurologic assessment Assess for any associate injury to other systems of the body and treat the same. Monitored for spinal shock & effects of hypotension, bradycardia & decreased cardiac output Respiratory compromise may occur if the client develops diaphragmatic fatigue; mechanical ventilation may be required Monitoring of arterial Blood Gases Monitor integumentary system and measures to be taken to prevent pressure sores
Cont. 37

Medical Management
Vasoactive agents
Methylprednisolone 30mg/kg within 8hrs after injury

Dexamethasone for older injuries

Neuropeptides and thyrotropin-releasing hormone histamine (H2) receptor blocker - gastric & intestinal bleeding Urinary antiseptics anticoagulants, Laxative Antispasmodics
Cont.
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Surgical Management
Cont.

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Nutrition Management
Disturbed GIT Patients with tracheostomy may require time to adjust swallowing with the tube in place and must be carefully monitored to prevent aspiration Patient with traction also has the risk of aspiration Clients who have halo jackets ofen experience difficulty eating because their head is immobilethey should be encouraged to take small bites, eat slowly and concentrate on swallowing Patient may have depression & it may inhibit the appetite

Cont.

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Nutrition Management
Choosing when and what to eat may be one of the few areas of control left to the person with and SCI Any of these conditions can severely limit a spinal cord injured patients oral intake at a time when a high calorie, high protein diet is needed, enternal feeding or total parenteral hyper-alimentation is often prescribed until oral intake is sufficient to meet body needs.
Cont.
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Complications
Atelectasis Pneumonia Bradycardia hypotension, Deep vein thrombosis Gastrointestinal bleeding Pressure ulcers Joint contractures Denial & depression
Cont.
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Complications
Autonomic Dysreflexia: characterized by
pounding headache profuse sweating nasal congestion piloerection [goose bumps] bradycardia hypertension Bladder & bowel distention Spasms Pressure on penis Excessive rectal stimulation Bladder stones Ingrown toenails Abdominal abnormalities Uterine contractions
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