Traumatic Spinal Cord Injury Introduction Spinal cord injury has become epidemic in modern society.

Despite advances made in the understanding of the pathogenesis and improvements in early recognition and treatment, it remains a devastating event, often producing severe and permanent disability. With a peak incidence in young adults, traumatic spinal cord injury remains a costly problem for society. Spinal cord injury refers to any injury to the spinal cord that is caused by trauma instead of disease. Depending on where the spinal cord and nerve roots are damaged, the symptoms can vary widely, from pain to paralysis to incontinence. Spinal cord injuries are described at various levels of "incomplete", which can vary from having no effect on the patient to a "complete" injury which means a total loss of function. Treatment of spinal cord injuries starts with restraining the spine and controlling inflammation to prevent further damage. The actual treatment can vary widely depending on the location and extent of the injury. In many cases, spinal cord injuries require substantial physical therapy and rehabilitation, especially if the patient's injury interferes with activities of daily life. Injuries affecting the spinal cord commonly results from trauma, gunshot wounds and motor vehicle accidents. Many cases of SCI are caused by falls, sports-related injury and minor trauma. The principal risk factors for SCI include age, gender, and alcohol and drug use. Males are affected four times more often than females. Over half of the victims are 16 to 30 years of age. The most common vertebrae involved in SCI are the 5th, 6th and 7th cervical, the 12th thoracic, and the 1st lumbar. These vertebrae are the most vulnerable because there is a greater range of mobility in the vertebral column in these areas. Damage to the spinal cord ranges from transient concussion, to contusion, laceration and compression of the cord substance, to complete transection of the cord. Injury can be categorized as primary which is usually permanent or secondary wherein nerve fibers swell and disintegrate as a result of ischemia, hypoxia, edema, and hemorrhagic lesions. The type of injury on the other hand, refers to the extent of injury to the spinal cord itself. Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central, lateral, anterior, or peripheral. A complete spinal cord injury can result in paraplegia, which is paralysis of the lower body or quadriplegia which is the paralysis of all four extremities. This topic reviews acute traumatic spinal cord injury. The anatomy and clinical localization of spinal cord disease, other diseases affecting the spinal cord, and the chronic complications of spinal cord injury are discussed separately.

Diagnosis Diagnosis of SCI is based on physical examination, radiologic examination, CT scan, MRI and myelography. Diagnostic x-rays such as lateral cervical spine x-rays and CT scanning are usually performed initially. An MRI scan may be ordered as a further work up if a ligamentous injury is suspected, since significant spinal cord damage may exist even in the ansence of bony injury. Continuous electrocardiographic monitoring may be indicated if a cord injury is suspected since bradycardia and asystole are common in acute spinal injuries

Signs and symptoms Signs observed by a physician and symptoms experienced by a patient will vary depending on where the spine is injured and the extent of the injury. These are all determined by the area of the body that the injured area of the spine innervates. A section of skin innervated through a specific part of the spine is called a dermatome, and spinal injury can cause pain, numbness, or a loss of sensation in the relevant areas. A group of muscles innervated through a specific part of the spine is called a myotome, and injury to the spine can cause problems with voluntary motor control. The muscles may contract uncontrollably, become weak, or be completely unresponsive. The loss of muscle function can have additional effects if the muscle is not used, including atrophy of the muscle and bone degeneration. A severe injury may also cause problems in parts of the spine below the injured area. In a "complete" spinal injury, all function below the injured area is lost. In an "incomplete" injury, some or all of the functions below the injured area may be unaffected. If the patient has the ability to contract the anal sphincter voluntarily or to feel a pinprick or touch around the anus, the injury is considered to be incomplete. The nerves in this area are connected to the very lowest region of the spine, the sacral region, and retaining sensation and function in these parts of the body indicates that the spinal cord is only partially damaged. A complete injury frequently means that the patient has little hope of functional recovery. The relative incidence of incomplete injuries compared to complete spinal cord injury has improved over the past half century, due mainly to the emphasis on better initial care and stabilization of spinal cord injury patients. Most patients with incomplete injuries recover at least some function. In addition to sensation and muscle control, the loss of connection between the brain and the rest of the body can have specific effects depending on the location of the injury. Determining the exact "level" of injury is critical in making accurate predictions about the specific parts of the body that may be affected by paralysis and loss of function. The level is assigned according to the location of the injury by the vertebra of the spinal column. While the prognosis of complete injuries is generally predictable since recovery is rare, the symptoms of incomplete injuries can vary and it is difficult to make an accurate prediction of the outcome. Symptoms vary somewhat depending on the location of the injury. Spinal cord injury causes weakness and sensory loss at and below the point of the injury. The severity of symptoms depends on whether the entire cord is severely injured (complete) or only partially injured (incomplete). The spinal cord doesn't go below the 1st lumbar vertebra, so injuries at and below this level do not cause spinal cord injury. However, they may cause "cauda equina syndrome" -- injury to the nerve roots in this area. CERVICAL (NECK) INJURIES When spinal cord injuries occur in the neck area, symptoms can affect the arms, legs, and middle of the body. The symptoms may occur on one or both sides of the body. Symptoms can include:

Breathing difficulties (from paralysis of the breathing muscles, if the injury is high up in the neck) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes

Spasticity (increased muscle tone) Pain Weakness, paralysis

THORACIC (CHEST LEVEL) INJURIES When spinal injuries occur at chest level, symptoms can affect the legs:

Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis

Injuries to the cervical or high thoracic spinal cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining normal body temperature. LUMBAR SACRAL (LOWER BACK) INJURIES When spinal injuries occur at the lower back level, varying degrees of symptoms can affect one or both legs, as well as the muscles that control your bowels and bladder:

Loss of normal bowel and bladder control (you may have constipation, leakage, and bladder spasms) Numbness Pain Sensory changes Spasticity (increased muscle tone) Weakness and paralysis

Pathophysiology The pathophysiology of spinal cord injury can be categorized as acute impact or compression. Acute impact injury is a concussion of the spinal cord. This type of injury initiates a cascade of events focused in the gray matter, and results in hemorrhagic necrosis. The initiating event is a hypoperfusion of the gray matter. Increases in intracellular calcium and reperfusion injury play key roles in cellular injury, and occur early after injury. The extent of necrosis is contingent on the amount of initial force of trauma, but also involves concomitant compression, perfusion pressures and blood flow, and administration of pharmacological agents. Preventing or quelling this cascade of events must involve mechanisms occurring in the initial stages. Spinal cord compression occurs when a mass impinges on the spinal cord causing increased parenchymal pressure. The tissue response is gliosis, demyelination, and axonal loss. This occurs in the white matter, whereas gray matter structures are preserved. Rapid or a critical degree of compression will result in collapse of the venous side of the microvasculature, resulting in vasogenic edema.

Vasogenic edema exacerbates parenchymal pressure, and may lead to rapid progression of disfunction. Treatment of compression should focus on removal of the offending mass. Factors and Causes of the Disease Spinal cord injuries are most often traumatic, caused by lateral bending, dislocation, rotation, axial loading, and hyperflexion or hyperextension of the cord or cauda equina. Motor vehicle accidents are the most common cause of SCIs, while other causes include falls, work-related accidents, sports injuries, and penetrations such as stab or gunshot wounds. SCIs can also be of a non-traumatic origin, as in the case of cancer, infection, intervertebral disc disease, vertebral injury and spinal cord vascular disease. Exams and Testing Procedures Spinal cord injury is a medical emergency requiring immediate attention. The health care provider will perform a physical exam, including a neurological exam. This will help identify the exact location of the injury, if it is not already known. Some of the person's reflexes may be abnormal or absent. Once swelling goes down, some reflexes may slowly recover. The following tests may be ordered:

A CT scan or MRI of the spine may show the location and extent of the damage and reveal problems such as blood clots (hematomas). Myelogram (an x-ray of the spine after injection of dye) may be necessary in rare cases. Somatosensory evoked potential (SSEP) testing or magnetic stimulation may show if nerve signals can pass through the spinal cord. Spine x-rays may show fracture or damage to the bones of the spine.

Management of the Disease A spinal cord trauma is a medical emergency requiring immediate treatment to reduce the longterm effects. The time between the injury and treatment is a critical factor affecting the eventual outcome. Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord compression is caused by a mass (such as a hematoma or bony fragment) that can be removed or reduced before your spinal nerves are completely destroyed, paralysis may improve. Ideally, corticosteroids should begin as soon as possible after the injury. Surgery may be needed to:

Remove fluid or tissue that presses on the spinal cord (decompression laminectomy) Remove bone fragments, disk fragments, or foreign objects Fuse broken spinal bones or place spinal braces

Bedrest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal. Spinal traction may be recommended. This can help keep the spine from moving. The skull may be held in place with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body). The spine braces may need to be worn for a long time. The health care team will also provide information on muscle spasms, care of the skin, and bowel and bladder dysfunction. Extensive physical therapy, occupational therapy, and other rehabilitation therapies are often required after the acute injury has healed. Rehabilitation helps the person cope with disability that results from spinal cord injury. Muscle spasticity can be relieved with medications taken by mouth or injected into the spinal canal. Botox injections into the muscles may also be helpful. Pain killers (analgesics), muscle relaxers, and physical therapy are used to help control pain. Collaboration for Rehabilitation The rehabilitation process following a spinal cord injury typically begins in the acute care setting. Physical therapists, occupational therapists, social workers, psychologists and other health care professionals typically work as a team to decide on goals with the patient and develop a plan of discharge that is appropriate for the patients condition Prognosis In general, patients with complete injuries recover very little lost function and patients with incomplete injuries have more hope of recovery. Some patients that are initially assessed as having complete injuries are later changed to incomplete injuries. Recovery is typically quickest during the first six months, with very few patients experiencing any substantial recovery more than nine months after the injury. Possible Complications The following are possible complications of a spinal cord injury:

Blood pressure changes - can be extreme (autonomic hyperreflexia) Chronic kidney disease Complications of immobility: o Deep vein thrombosis o Pulmonary infections o Skin breakdown o Contractures Increased risk of injury to numb areas of the body Increased risk of urinary tract infections Loss of bladder control Loss of bowel control Loss of sensation

Loss of sexual functioning (male impotence) Muscle spasticity Pain Paralysis of breathing muscles Paralysis (paraplegia, quadriplegia) Pressure sores Shock

People living at home with spinal cord injury should do the following to prevent complications:

Daily pulmonary care, for those who need it. Follow all instructions regarding bladder care to avoid infections and damage to the kidneys. Follow all instructions regarding routine wound care to avoid pressure sores. Keep immunizations up to date. Maintain routine health visits with their doctor.

Nursing Interventions Promoting Adequate Breathing Detect potential respiratory failure by observing patient, measuring vital capacity, and monitoring oxygen saturation through pulse oximetry and arterial blood gas values. Prevent retention of secretions and resultant atelectasis with early and vigorous attention to clearing bronchial and pharyngeal secretions. Suction with caution, because this procedure can stimulate the vagus nerve, producing bradycardia and cardiac arrest. Initiate chest physical therapy and assisted coughing to mobilize secretions. Supervise breathing exercises to increase strength and endurance of inspiratory muscles, particularly the diaphragm. Ensure proper humidification and hydration to maintain thin secretions. Assess for signs of respiratory infection: cough, fever, and dyspnea. Discourage smoking. Monitor respiratory status frequently. Improving Mobility Maintain proper body alignment; place patient in dorsal or supine position. Turn patient every 2 hours; monitor for hypotension in patients with lesions above the midthoracic level. Assist patient out of bed as soon as spinal column is stabilized. Do not turn patient who is not on a turning frame unless physician indicates that it is safe to do so. Apply splints to prevent footdrop ans trochanter rolls to prevent external rotation of the hip joint; reapply every 2 hours. Perform passive range-of-motion exercises within 48 to 72 hours after injury to avoid complications such as contractures and atrophy. Provide a full range of motion at least every four or five times daily to toes, metatarsals, ankles, knees & hips. Maintaining Skin Integrity

Change patients position every 2 hours and inspect the skin, particularly under cervical collar. Assess for redness or breaks in skin over pressure points; check perineum for soilage; observe catheter for adequate drainage; assess general body alignment and comfort. Wash skin every few hours with a mild soap, rinse well, and blot dry. Keep pressure sensitive areas well lubricated and soft with bland cream or lotion; gently perform massage using a circular motion. Teach patient about pressure ulcers and encourage participation in preventive measures. Promoting Urinary Elimination Perform intermittent catheterization to avoid overstreatching the bladder and infection. If this is not feasible, insert an indwelling catheter. Show family members how to catheterize, and encourage them to participate in this facet of care. Teach patient to record fluid intake, voiding pattern, amounts of residual urine after catheterization, quality of urine, and any unusual feelings. Promoting Adaptation to Disturbed Sensory Perception Stimulate the area above the level of the injury through touch, aromas, flavorful food, conversation, and music. Provide prism glasses to enable patient to see from supine position. Encourage use of hearing aids, if applicable. Provide emotional support; teach patient strategies to compensate for or cope with sensory deficits. Improving Bowel Function Monitor reactions to gastric intubation. Provide a high-calorie, high-protein, and high-fiber diet. Food amount may be gradually increased after bowel sound resume. Administer prescribed stool softener to counteract effects of immobility and pain medications, and institue a bowel program as early as possible. Providing Comfort Reassure patient in halo traction that he/she will adapt to steel frame. Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening; keep a torque screwdriver readily available. Assess skull for signs of infection, including drainage around halo-vest tongs. Check back of head periodically for signs of pressure. Massage at intervals, taking care not to move the neck. Shave hair around tongs to facilitate inspection. Avoid probing under encrusted areas. Inspect skin under halo vest for excessive perspiration, redness, and skin blistering, especially on bony prominences. Open vest at the sides to allow torso to be washed. Do not allow vest to become wet; do not use powder inside vest.