CEDERA MEDULLA CEDERA MEDULLA SPINALISSPINALIS

YULIATIYULIATI

FIKES / KEPERAWATANFIKES / KEPERAWATAN

CEDERA MEDULLA SPINALISCEDERA MEDULLA SPINALIS

75 % TERJADI PADA PRIA75 % TERJADI PADA PRIA

Review anatomy :Review anatomy :

Kerusakan medulla spinalis Kerusakan medulla spinalis berkisar dari komusio, berkisar dari komusio, sampai kontusio.sampai kontusio.Pasien mengalami paralisisPasien mengalami paralisisDianggap reversibel pada 4 Dianggap reversibel pada 4 – 6 jam pertama– 6 jam pertama

Spinal cord trauma is Spinal cord trauma is damage to the spinal cord. damage to the spinal cord. It may result from direct It may result from direct injury to the cord itself or injury to the cord itself or indirectly from damage to indirectly from damage to surrounding bones, soft surrounding bones, soft tissues, and blood vessels.tissues, and blood vessels.

CausesCauses        Spinal cord trauma can be Spinal cord trauma can be caused by any number of caused by any number of injuries to the spine. They can injuries to the spine. They can result from motor vehicle result from motor vehicle accidents, falls, sports injuries accidents, falls, sports injuries (particularly diving into (particularly diving into shallow water), industrial shallow water), industrial accidents, gunshot wounds, accidents, gunshot wounds, assault, and others.assault, and others.

A minor injury can cause spinal A minor injury can cause spinal cord trauma if the spine is cord trauma if the spine is weakened (such as from weakened (such as from rheumatoid arthritis or or osteoporosis) or if the spinal ) or if the spinal canal protecting the spinal cord canal protecting the spinal cord has become too narrow (spinal has become too narrow (spinal stenosis) due to the normal stenosis) due to the normal aging process.aging process.

Direct injury, such as cuts, can Direct injury, such as cuts, can occur to the spinal cord, occur to the spinal cord, particularly if the bones or the particularly if the bones or the disks have been damaged. disks have been damaged. Fragments of bone (from Fragments of bone (from fractured vertebrae, for fractured vertebrae, for example) or fragments of metal example) or fragments of metal (such as from a traffic accident) (such as from a traffic accident) can cut or damage the spinal can cut or damage the spinal cord.cord.

Direct damage can also Direct damage can also occur if the spinal cord is occur if the spinal cord is pulled, pressed sideways, or pulled, pressed sideways, or compressed. This may occur compressed. This may occur if the head, neck, or back if the head, neck, or back are twisted abnormally are twisted abnormally during an accident or injury.during an accident or injury.

Bleeding, fluid Bleeding, fluid accumulation, and swelling accumulation, and swelling can occur inside the spinal can occur inside the spinal cord or outside the spinal cord or outside the spinal cord (but within the spinal cord (but within the spinal canal). The accumulation of canal). The accumulation of blood or fluid can compress blood or fluid can compress the spinal cord and damage the spinal cord and damage it.it.

Most spinal cord trauma Most spinal cord trauma occurs to young, healthy occurs to young, healthy individuals. Males between individuals. Males between ages 15 and 35 are most ages 15 and 35 are most commonly affected. The commonly affected. The death rate tends to be death rate tends to be higher in young children higher in young children with spinal injuries.with spinal injuries.

Risk factors include Risk factors include participating in risky participating in risky physical activities, not physical activities, not wearing protective gear wearing protective gear during work or play, or during work or play, or diving into shallow water.diving into shallow water.

Older people with weakened Older people with weakened spines (from osteoporosis) may spines (from osteoporosis) may be more likely to have a spinal be more likely to have a spinal cord injury. Patients who have cord injury. Patients who have other medical problems that other medical problems that make them prone to falling make them prone to falling from weakness or clumsiness from weakness or clumsiness (from stroke, for example) may (from stroke, for example) may also be more susceptible.also be more susceptible.

SymptomsSymptoms        Symptoms vary somewhat Symptoms vary somewhat depending on the location of depending on the location of the injury. Spinal cord injury the injury. Spinal cord injury results in varying degrees of results in varying degrees of weakness and sensory loss at weakness and sensory loss at and below the injury. The and below the injury. The pattern depends on whether pattern depends on whether the entire cord is injured the entire cord is injured (complete) or only partially (complete) or only partially (incomplete).(incomplete).

The spinal cord doesn't go The spinal cord doesn't go below the 1st lumbar below the 1st lumbar vertebra, so injuries at and vertebra, so injuries at and below this level do not below this level do not cause spinal cord injury. cause spinal cord injury. However, they may cause However, they may cause "cauda equina syndrome" -- "cauda equina syndrome" -- injury to the nerve roots in injury to the nerve roots in this area.this area.

CERVICAL (NEAR THE NECK) INJURIESCERVICAL (NEAR THE NECK) INJURIESWhen spinal cord injuries occur near the When spinal cord injuries occur near the neck, varying degrees of symptoms can neck, varying degrees of symptoms can affect both the arms and the legs:affect both the arms and the legs:Weakness, paralysis Weakness, paralysis Breathing difficulties (from paralysis of Breathing difficulties (from paralysis of the breathing muscles) the breathing muscles) Spasticity (increased muscle tone) Spasticity (increased muscle tone) Sensory changes Sensory changes Numbness Numbness Pain Pain Loss of normal bowel and bladder Loss of normal bowel and bladder control (such as constipation, control (such as constipation, incontinence, bladder spasms) incontinence, bladder spasms)

THORACIC (CHEST-LEVEL) THORACIC (CHEST-LEVEL) INJURIESINJURIESWhen spinal injuries occur at chest level, When spinal injuries occur at chest level, varying degrees of symptoms can affect the varying degrees of symptoms can affect the legs:legs:Weakness, paralysis Weakness, paralysis Breathing difficulties (from paralysis of Breathing difficulties (from paralysis of the breathing muscles) the breathing muscles) Spasticity (increased muscle tone) Spasticity (increased muscle tone) Sensory changes Sensory changes Numbness Numbness Pain Pain Loss of normal bowel and bladder Loss of normal bowel and bladder control (such as constipation, control (such as constipation, incontinence, bladder spasms) incontinence, bladder spasms)

Injuries to the cervical or Injuries to the cervical or high thoracic cord may also high thoracic cord may also result in blood pressure result in blood pressure problems, abnormal problems, abnormal sweating, and trouble sweating, and trouble maintaining regular body maintaining regular body temperature.temperature.

    Spinal cord injury is a medical Spinal cord injury is a medical emergency requiring emergency requiring immediate attention. immediate attention. The health care provider will The health care provider will perform a physical exam, perform a physical exam, including a neurological exam. including a neurological exam. This will help identify the exact This will help identify the exact location of the injury, if it is not location of the injury, if it is not already known. Some of the already known. Some of the person's reflexes may be person's reflexes may be abnormal or absent.abnormal or absent.

Once swelling goes down, Once swelling goes down, some reflexes may slowly some reflexes may slowly recover.recover.The following tests may be The following tests may be ordered:ordered:Spine x-rays may show may show fracture or damage to fracture or damage to the bones of the spine. the bones of the spine.

A A CT scan or scan or MRI of the spine may show the location and may show the location and extent of the damage and extent of the damage and reveal problems such as reveal problems such as blood clots (hematomas). blood clots (hematomas). Myelogram (an x-ray of the (an x-ray of the spine after injection of dye) spine after injection of dye) may be necessary in rare may be necessary in rare cases. cases.

Somatosensory evoked Somatosensory evoked potential (SSEP) testing potential (SSEP) testing or magnetic stimulation or magnetic stimulation may show if nerve may show if nerve signals can pass through signals can pass through the spinal cord. the spinal cord.

TreatmentTreatment        A spinal cord trauma is a A spinal cord trauma is a medical emergency medical emergency requiring immediate requiring immediate treatment to reduce the treatment to reduce the long-term effects. The time long-term effects. The time between the injury and between the injury and treatment is a critical factor treatment is a critical factor affecting the eventual affecting the eventual outcome.outcome.

Corticosteroids, such as Corticosteroids, such as dexamethasone or methylprednisolone, dexamethasone or methylprednisolone, are used to reduce swelling that may are used to reduce swelling that may damage the spinal cord. If spinal cord damage the spinal cord. If spinal cord compression is caused by a mass (such compression is caused by a mass (such as a hematoma or bony fragment) that as a hematoma or bony fragment) that can be removed or brought down can be removed or brought down before there is total destruction of the before there is total destruction of the nerves of the spine, nerves of the spine, paralysis may in may in some cases be reduced or relieved. some cases be reduced or relieved. Ideally, corticosteroids should begin as Ideally, corticosteroids should begin as soon as possible after the injury.soon as possible after the injury.

Surgery may be necessary. Surgery may be necessary. This may include surgery to This may include surgery to remove fluid or tissue that remove fluid or tissue that presses on the spinal cord presses on the spinal cord (decompression laminectomy). (decompression laminectomy). Surgery may be needed to Surgery may be needed to remove bone fragments, disk remove bone fragments, disk fragments, or foreign objects or fragments, or foreign objects or to stabilize fractured vertebrae to stabilize fractured vertebrae (by fusion of the bones or (by fusion of the bones or insertion of hardware).insertion of hardware).

Bedrest may be needed to Bedrest may be needed to allow the bones of the allow the bones of the spine, which bears most of spine, which bears most of the weight of the body, to the weight of the body, to heal.heal.

Anatomic realignment is Anatomic realignment is important. Spinal important. Spinal traction may may reduce dislocation and/or may reduce dislocation and/or may be used to immobilize the be used to immobilize the spine. The skull may be spine. The skull may be immobilized with tongs (metal immobilized with tongs (metal braces placed in the skull and braces placed in the skull and attached to traction weights or attached to traction weights or to a harness on the body).to a harness on the body).

Treatment will address Treatment will address muscle spasms, care of the , care of the skin, and bowel and skin, and bowel and bladder dysfunction.bladder dysfunction.

Extensive physical therapy, Extensive physical therapy, occupational therapy, and occupational therapy, and other rehabilitation other rehabilitation interventions are often interventions are often required after the required after the acute injury injury has healed. Rehabilitation has healed. Rehabilitation assists the person in coping assists the person in coping with disability that results from with disability that results from spinal cord trauma.spinal cord trauma.

Spasticity can be reduced by Spasticity can be reduced by many oral medications, many oral medications, medications that are injected medications that are injected into the spinal canal, or into the spinal canal, or injections of botulinum toxins injections of botulinum toxins into the muscles. It is important into the muscles. It is important to treat pain with analgesics, to treat pain with analgesics, muscle relaxants, or physical muscle relaxants, or physical therapy modalities.therapy modalities.

Support GroupsSupport Groups    For     For organizations that provide organizations that provide support and additional support and additional information, see information, see spinal injury resources..

Outlook (Prognosis)Outlook (Prognosis)        Paralysis and Paralysis and loss of sensation of part of the body are of part of the body are common. This includes total common. This includes total paralysis or numbness and paralysis or numbness and varying degrees of movement varying degrees of movement or sensation loss. Death is or sensation loss. Death is possible, particularly if there is possible, particularly if there is paralysis of the breathing paralysis of the breathing muscles.muscles.

How well a person does How well a person does depend on the level of depend on the level of injury. Injuries near the top injury. Injuries near the top of the spine result in more of the spine result in more extensive disability than extensive disability than injuries low in the spine.injuries low in the spine.

Recovery of some movement Recovery of some movement or sensation within 1 week or sensation within 1 week usually means the person will usually means the person will eventually recover most eventually recover most function, although this may function, although this may take 6 months or more. Losses take 6 months or more. Losses that remain after 6 months are that remain after 6 months are more likely to be permanent.more likely to be permanent.

Possible ComplicationsPossible Complications    Paralysis Paralysis (paraplegia, quadriplegia) (paraplegia, quadriplegia) Loss of sensation Loss of sensation Loss of bladder control Increased risk of Increased risk of urinary tract infections Increased risk of Increased risk of chronic bilateral bilateral obstructive nephropathy Loss of bowel control Loss of sexual functioning (Loss of sexual functioning (male impotence) ) Paralysis of breathing muscles Paralysis of breathing muscles Increased risk of injury to numb areas of Increased risk of injury to numb areas of the body the body Pain Pain

Complications of Complications of immobility: immobility: Deep vein thrombosis Pulmonary infections Pulmonary infections Skin breakdown Skin breakdown Contractures Contractures Shock Blood pressure changes - Blood pressure changes - can be extreme can be extreme Muscle spasticity Muscle spasticity When to Contact a Medical When to Contact a Medical

Call your health care provider if Call your health care provider if injury to the back or neck injury to the back or neck occurs. Call 911 if there is any occurs. Call 911 if there is any loss of movement or sensation. loss of movement or sensation. This is a medical emergency!This is a medical emergency!

Penatalaksanaan tidak tepat Penatalaksanaan tidak tepat dapat menyebabkan kerusakan dapat menyebabkan kerusakan dan kehilangan fungsidan kehilangan fungsi

Management of spinal cord Management of spinal cord injury begins at the site of injury begins at the site of an accident with paramedics an accident with paramedics trained in immobilizing the trained in immobilizing the injured spine to prevent injured spine to prevent further damage to the further damage to the nervous system. nervous system.

Someone suspected of Someone suspected of having a spinal cord injury having a spinal cord injury should NOT be moved should NOT be moved without immobilization without immobilization unless there is an unless there is an immediate threat.immediate threat.

PreventionPrevention        Safety practices during work Safety practices during work and recreation can prevent and recreation can prevent many spinal cord injuries. many spinal cord injuries. Use proper protective Use proper protective equipment if an injury is equipment if an injury is possible.possible.

Diving into shallow water is Diving into shallow water is a major cause of spinal cord a major cause of spinal cord trauma. Check the depth of trauma. Check the depth of water before diving, and water before diving, and look for rocks or other look for rocks or other possible obstructions.possible obstructions.

Football and sledding Football and sledding injuries often involve sharp injuries often involve sharp blows or abnormal twisting blows or abnormal twisting and bending of the back or and bending of the back or neck and can result in spinal neck and can result in spinal cord trauma. Use caution cord trauma. Use caution when sledding and inspect when sledding and inspect the area for obstacles. the area for obstacles.

Use appropriate techniques Use appropriate techniques and equipment when playing and equipment when playing football or other contact football or other contact sports.sports.Falls while climbing at work Falls while climbing at work or during recreation can or during recreation can result in spinal cord injuries. result in spinal cord injuries.

Defensive driving and Defensive driving and wearing seat belts greatly wearing seat belts greatly reduces the risk of serious reduces the risk of serious injury if there is an injury if there is an automobile accident.automobile accident.

Tindakan yang harus Tindakan yang harus dilakukandilakukan1.1. Imobilisasikan korban pada spinal Imobilisasikan korban pada spinal

board,inline posisionboard,inline posision

2.2. satu orang petugas menjaga kepala satu orang petugas menjaga kepala tetap inline.tetap inline.

3.3. Gunakan traksi leher atau collar neckGunakan traksi leher atau collar neck

4.4. Hati-hati saat mengangkat dan Hati-hati saat mengangkat dan memindahkan ke rs minimal 4 orangmemindahkan ke rs minimal 4 orang

PenatalaksanaanPenatalaksanaan

1.1. Farmakoterapi; pemberian Farmakoterapi; pemberian metilprednisolon dosis metilprednisolon dosis tinggi,mannitol dan dextran.tinggi,mannitol dan dextran.

2.2. Hipotermia, untuk mengatasi Hipotermia, untuk mengatasi autodestruktif.autodestruktif.

3.3. Bantuan pernafasanBantuan pernafasan

4.4. Traksi dan reduksi skelet.Traksi dan reduksi skelet.

5.Prosedur pembedahan5.Prosedur pembedahan

Intervensi perawatan Intervensi perawatan lanjutanlanjutan

1.1. Tingkatkan pernafasan adekuatTingkatkan pernafasan adekuat

2.2. Perbaiki mobilitas fisikPerbaiki mobilitas fisik

3.3. Pertahankan integritas kulitPertahankan integritas kulit

4.4. Pertahankan eliminasi urinePertahankan eliminasi urine

5.5. Perbaiki fungsi defekasiPerbaiki fungsi defekasi

6.6. Tingkatkan kenyamanan pasien dan Tingkatkan kenyamanan pasien dan minimalisasi stressorminimalisasi stressor