Peripheral and Spinal Cord Problems

Zoya Minasyan RN, MSN-Edu

Etiology and Pathophysiology

• Causes– 42% Motor vehicle crashes– 27% Falls– 15% Violence

• In large urban areas, gunshot wounds may surpass falls.

– 7% Sports injuries– 8% Other miscellaneous

Crashes Falls Violence Sports Injuries Other

Crashes Falls Violence Sports Injuries Other

Mechanisms of Injury

• Major mechanisms of injury are– Flexion– Hyperextension– Flexion-rotation– Extension-rotation– Compression

Fig. 61-5. A, Flexion injury of the cervical spine ruptures the posterior ligaments. B, Hyperextension injury of the cervical spine ruptures the anterior ligaments. C, Compression fractures crush the vertebrae and force bony fragments into the spinal canal. D, Flexion-rotation injury of the cervical spine often results in tearing of ligamentous structures that normally stabilize the spine.

Level of Injury

• Level of injury may be Cervical Thoracic Lumbar

• Paralysis of all four extremities occurs (tetraplegia [quadriplegia]) if cervical cord is involved.

• Paraplegia results if thoracic or lumbar cord is damaged.

Level of Injury

Degree of Injury

• Result from damage to very lowest portion of spinal cord and lumbar and sacral nerve root produces flaccid paralysis of lower limbs and areflexic (flaccid) bladder and bowel.

ASIA Impairment Scale

Clinical Manifestations

• Generally direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection

• Related to level and degree of injury• Immediate post injury problems include

– Maintaining a patent airway– Adequate ventilation – Adequate circulating blood volume – Preventing extension of cord damage (secondary

damage)

Clinical Manifestations Respiratory System• Respiratory complications closely correspond to level of injury.• Cervical injury

– Above level of C4 • total loss of respiratory muscle function• Mechanical ventilation is required to keep patient alive.

Below level of C4 • Diaphragmatic breathing if phrenic nerve is functioning• Spinal cord edema and hemorrhage can cause respiratory insufficiency. • Hypoventilation almost always occurs with diaphragmatic breathing.

• Cervical and thoracic injuries cause paralysis of – Abdominal muscles– Intercostal muscles

• Patient cannot cough effectively. • Leads to atelectasis at or above C3

– Patient is exhausted.– Labored breathing– Endotracheal intubation/tracheostomy– Mechanical ventilation

• Artificial airway provides direct access for pathogens.– Important to ↓ infections

• Pulmonary edema may occur in response to fluid overload.

Clinical ManifestationsCardiovascular System

• Any cord injury above level T6 greatly ↓ the influence of the sympathetic nervous system – Bradycardia occurs.– Peripheral vasodilation results in hypotension.– Relative hypovolemia exists because of ↑ in venous insuficency

• Cardiac monitoring is necessary.• Peripheral vasodilation

↓ venous return of blood to heart ↓ cardiac output

• IV fluids or vasopressor drugs may be required to support BP.

Clinical ManifestationsGastrointestinal System

• If cord injury is above T5, primary GI problems related to hypomotility

• Decreased GI motor activity contributes to development of – Paralytic ileus – Gastric distention

• Nasogastric tube may relieve gastric distention.

Clinical ManifestationsPeripheral Vascular Problems

• Deep vein thrombosis (DVT) problem • Pulmonary embolism a leading cause of death• DVT assessments

– Doppler examination– Measurement of legs and thigh girth

Diagnostic Studies

• CT scan may be used to assess stability of injury, location, and degree of bone injury.

• MRI is used where there is unexplained neurologic deficit.

• Neurologic examination

Immobilization

• Proper immobilization involves maintenance of a neutral position.

• Stabilize neck to prevent lateral rotation of cervical spine.– A blanket or towel– Hard cervical collar– Backboard

• Body should always be correctly aligned.• Turn patient so that he or she is moved as a unit

to prevent movement of spine.

Immobilization • After cervical fusion, a hard cervical collar or a sternal–

occipital– mandibular immobilizer brace can be worn.

Halo Vest

Halo vest. The halo traction brace immobilizes the cervical spine, which allows the patient to ambulate and participate in self-care.

Fluid and Nutritional Maintenance

• High-protein, high-calorie diet• Evaluate swallowing before starting oral

feedings.• If patient is not eating, cause should be

thoroughly assessed.

Bladder and Bowel Management• Constipation– Problem during spinal shock– No voluntary or involuntary evacuation of bowels occurs.– Rectal stimulant (suppository or

mini-enema) inserted daily • Urine retention– Loss of autonomic and reflex control of bladder and

sphincter– Bladder over distention can result in reflux into kidney

with eventual renal failure.– Intermittent catheterization program – Urinary tract infections

Cranial nerve disorders• Trigeminal Neuralgia/tic douloureux-CN V

Unilateral, severe, stabbing, knife-like pain in the distribution of the trigeminal nerve (ophtalmic, maxillary and mandibular,)

• Bell’s Palsy Facial paralysis-CN VII, pain around the ear, paralysis of motor fx of facial nerve-hearing deficit, fever, unilateral loss of taste, inability to smile, frown.

• Guillain-Barre Syndrome-polyneuropathy-Loss of myelin, edema and inflammation of affected nerve. Weakness of lower extremities, dysfx of sympathetic and parasympathetic NS, pain and muscle ache. Resp. failure.