# Spinal Cord Injury --- A **spinal cord injury** is an injury to the [[spinal cord]], usually due to some form of trauma, such as a motor vehicle accident or swimming accident. It has a wide variety of ramifications depending on the severity of the accident as well as the location along the spinal cord the injury occurs. ## Signs & Symptoms The signs and symptoms of spinal cord injury vary greatly depending on the location of the injury. Broadly speaking the systems affected are below the site of the injury, because this is how signals travel along the spinal cord. - acute pain in the back or neck, radiating along the involved nerve - absence of pain does not rule out this injury, in fact it's quite a bad sign that signals are not reaching the CNS Something that is important to remember is that the neurons of the [[sympathetic nervous system]] connect to the thoracic region of the spinal cord, so depending on location of the injury different sympathetic responses will be affected. - **Paraplegia** is paralysis of the lower body (i.e. the legs) - **Tetraplegia** (previously called quadriplegia, but people got cranky that that was mixing Latin and Greek) is a paralysis of all four extremities. - Injuries can be **complete** or **incomplete**. It's the difference between total lack of sensation or motor control and having regions of some sensation and some motor control. ![[spinal cord injuries.png]] The order of occurrence of paralysis from spinal cord injuries is: - incomplete tetraplegia - complete paraplegia - complete tetraplegia - incomplete paraplegia Respiratory dysfunction may also occur, depending on the level of injury and how it impacts [[pulmonary ventilation]]. (Note: we're going against convention and going toe-to-head to illustrate the least severe conditions first...remember all injuries *above* the previously affected region are also affected.) - Injuries in the **T6-T12** region affect the **abdominal muscles**, which are innervated along the [[phrenic nerve]]. This impacts breathing because these are accessory muscles that can assist the action of breathing. - Injuries in the **T1-T6** region affect the **intercostal muscles**, which even more strongly affect the act of breathing. These are also the muscles we use to cough. - Injuries to the **C4** region and up control the [[diaphragm]], and that individual is no longer able to breath on their own. Artificial ventilation is needed. ## Complications - **Secondary injury** result from edema and hemorrhage - especially dangerous when blood supply is cut off from the nerve, like [[compartment syndrome]]. - early treatment is essential to prevent partial damage from becoming permanent - can last days to weeks after the initial injury - **Spinal shock** is a condition where the spinal cord is essentially "stunned" and function is limited. It is temporary but very disruptive. - occurs shortly after the initial injury - usually only last days to weeks, but can last longer (up to years) - we see s/s depending on where the injury occurred, and functions below that level are impaired: - loss of motor/sensory/reflex function below the level of the injury - bowel distention and [[paralytic ileus]] - we don't want to feed people with this - **Neurogenic shock** is a type of [[shock|distributive shock]] that is caused by a loss of autonomic [[sympathetic nervous system]] function, which causes an over-vasodilation. It is a [[medical emergency]] It can be caused by other injuries to the nervous system as well, fainting or insulin reaction. - found in injuries above T6, usually shows up pretty soon - we see s/s such as: - hypotension - bradycardia - temperature dysregulation (warm, dry skin) - this is due to inappropriate peripheral vasodilation - risk for venous [[embolus|thromboembolism]] due to blood pooling - [[Autonomic dysreflexia]] is a later complication that can happen to anyone with a history of a spinal cord injury (usually T6 and above) even long after the other signs/symptoms of it have dissipated. - an exaggerated sympathetic response—this is an *emergency* - the massive sympathetic response causes a skyrocketing BP, but that also increases a parasympathetic system (via the vagal stimulation which is from baroreceptors triggered by the BP) - triggered by "noxious stimuli" to the lower extremities, but hydralazine can be given if the problem is not corrected quickly enough - AD can go away if the stimulus is removed - respiratory failure - especially with higher SCIs that effect breathing - C4 is where the [[diaphragm]] is innervated. Injuries here and above require mechanical ventilation. - T1-T6 is where the intercostals are innervated, which are accessories to breathing. - T6-T12 is where the abdominal muscles are innervated, which are accessories to breathing. - risk for pneumonia ## Diagnostic *Tests* - focused [[neurological assessment]] - x-ray/CT/MRI - MRI is the most sensitive to assess the soft tissue - myelogram ## Treatment Treatment for spinal cord injury consists of preventing secondary injuries and complications. - In the emergency phase treatment involves immobilization and stabilization of the injured area. - In the acute phase we're assessing for complications, secondary injury and the extent of the injury - Surgery can be successful if done early, usually for the thoracic and lumbar regions, if the following indications are present: - compression of the cord - unstable or fragmented vertebral body - wound penetrating the cord - bony fragments in the spinal canal - neurological status is deteriorating - Meds can be given, such as: - muscle relaxants like Baclophen - anti-inflammatories like methylprednisolone ## Nursing Considerations This is a system wide problem, we're looking at a lot of places. Increased risk of infection. Oral care is really important if a patient has trouble breathing. Normal flora from the mouth can spread and lead to pneumonia...and the patient already likely has problems clearing their lungs due to breathing difficulties. ___