Care of Patients with Problems of the Central Nervous System: The Spinal Cord

1. Chapter 45 Care of Patients with Problems of the Central Nervous System: The Spinal Cord

2. Spinal Cord

3. Lumbosacral Back Pain (Low Back Pain) • Herniated nucleus pulposus

4. Health Promotion and Maintenance • Good posture • Proper lifting • Exercise • Ergonomics

5. Patient-Centered Collaborative Care • Assessment • Diagnostic assessment

6. Nonsurgical Management • Positioning • Drug therapy • Heat therapy • Physical therapy • Weight control • Complementary and alternative therapies

7. Surgical Management • Minimally invasive surgery: • Percutaneous lumbar diskectomy • Thermodiskectomy • Laser-assisted laparoscopic lumbar diskectomy • Conventional open surgical procedures: • Diskectomy • Laminectomy • Spinal fusion

8. Postoperative Care • Prevention and assessment of complications • Neurologic assessment; vital signs • Patient’s ability to void • Pain control • Wound care • CSF check • Patient positioning and mobility

9. Community-Based Care • Home care management • Health teaching • Health care resources

10. Cervical Neck Pain • Conservative treatment is the same as described for back pain except that the exercises focus on shoulder and neck. • If these treatments do not work, soft collar may be used at night for a period of no longer than 10 days. • If conservative treatment is ineffective, surgery such as an anterior cervical diskectomy and fusion is commonly performed.

11. Spinal Cord Injuries • Hyperflexion injury • Hyperextension injury • Axial loading injury or vertical compression such as those that occur in jumping • Excessive rotation of the head beyond its range • Penetration injury, such as those wounds caused by a bullet or a knife

12. Spinal Cord Injuries (Cont’d)

13. Spinal Cord Injuries (Cont’d)

14. Common Spinal Cord Syndromes • Complete lesion • Anterior cord syndrome • Posterior cord lesion • Brown-Séquard syndrome • Central cord syndrome

15. Common Spinal Cord Syndromes (Cont’d)

16. Anterior Cord Syndrome • Damage to the anterior portion of both gray and white matter of the spinal cord • Usually a result of decreased blood supply • Motor function and pain and temperature lost below the level of the injury • Sensations of touch, position, and vibration remain intact

17. Posterior Cord Lesion • Damage to the posterior gray and white matter of the spinal cord • Motor function remains intact • Patient experiences loss of vibratory sense, touch, and position sensation

18. Brown-Séquard Syndrome • Results from penetrating injuries that cause hemisection of the spinal cord, or injuries that affect half of the spinal cord. • Motor function, proprioception, vibration, deep touch sensations are lost on the same side (ipsilateral) of the body as the lesion. • Opposite side (contralateral) of the body sensations of pain, temperature, light touch are affected.

19. Central Cord Syndrome • Lesions of the central portion of the spinal cord. • Loss of motor function is more pronounced in the upper extremities than in the lower extremities. • Varying degrees and patterns of sensation remain intact.

20. SCI: Etiology • Trauma is the leading cause • Incidence/prevalence

21. Patient with SCI: Initial Assessment • First priority is assessment of the patient’s airway, breathing pattern, and circulation status • Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites • Assessment of level of consciousness using Glasgow Coma Scale

22. Initial Assessment (Cont’d) • Establishment of level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, and paraparesis

23. Spinal Shock/Spinal Shock Syndrome • This condition occurs immediately as a concussion response to the injury. The patient has: • Flaccid paralysis • Loss of reflex activity below the level of the lesion • Usually resolves within 24 hours • Muscle spasticity begins in patients with cervical or high thoracic injuries

24. Assessment of Sensory and Motor Ability • Hypoesthesia • Hyperesthesia

25. Cardiovascular and Respiratory Assessment • Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra. • Cardiac dysrhythmias may result. • Systolic BP below 90 requires treatment because lack of perfusion to the spinal cord could worsen the patient’s condition. • Hypothermia.

26. Cardiovascular and Respiratory Assessment (Cont’d) • Patients with cervical SCI are at risk for respiratory problems resulting from immobility or from an interruption of spinal innervations to the respiratory muscles. • Continued respiratory assessment including vital capacity and minute volume.

27. Gastrointestinal and Genitourinary Assessment • Assess abdomen for indications of hemorrhage, distention, or paralytic ileus. • Assess for reflex or hypotonic bowel. • Assess for areflexic bladder, which later leads to urinary retention. • Assess for neurogenic bladder.

28. Other Assessments • Lower motor neuron assessment • Upper motor neuron assessment • Skin assessment • Heterotrophic ossification assessment • Psychosocial assessment • Laboratory assessment • Imaging assessment

29. Nonsurgical Management • Constant assessment • Assess for neurogenic shock. Neurogenic shock is spinal shock with: • Bradycardia • Decreased or absent bowel sounds • Warm, dry skin • Hypothermia • Hypotension

30. Immobilization for Cervical Injuries • Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury • Halo fixation and cervical tongs • Stryker frame, rotational bed, kinetic treatment table • Pin site care and monitoring of traction ropes

31. Immobilization of Thoracic and Lumbosacral Injuries • For patients with thoracic injuries—bedrest and possible immobilization with a fiberglass or plastic body cast • For patients with lumbar and sacral injuries—immobilization of the spine with a brace or corset worn when the patient is out of bed; custom-fit thoracic lumbar sacral orthoses preferred

32. Drug Therapy • Methylprednisolone (controversial) • Dextran • Atropine sulfate • Dopamine hydrochloride • Tizanidine • Intrathecal baclofen

33. Surgical Management • Emergency surgery necessary for spinal cord decompression • Decompressive laminectomy • Spinal fusion • Harrington rods to stabilize thoracic spinal injuries

34. Ineffective Airway Clearance and Breathing Pattern • Interventions for the patient with spinal cord injury: • Airway management is the priority. • Patients with injuries at or above the 6th thoracic vertebra are especially at risk for respiratory complications. • Provide measures to maintain airway.

35. Ineffective Airway Clearance and Breathing Pattern(Cont’d) • Assisted coughing, quad cough, cough assist • Use of incentive Spiro meter

36. Impaired Physical Mobility; Self-Care Deficit • Interventions include: • In patients with spinal cord injury, monitor for risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli. • Proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings.

37. Impaired Physical Mobility; Self-Care Deficit (Cont’d) • Prevent orthostatic hypotension. • Promote self-care.

38. Impaired Urinary Elimination; Constipation • Interventions include: • A bladder retraining program • Spastic bladder—manipulating external area • Flaccid bladder—Valsalva maneuver • Encouraging consumption of 2000 to 2500 mL of fluid daily to prevent urinary tract infection

39. Impaired Urinary Elimination; Constipation (Cont’d) • Long-term renal complication • Signs and symptoms of urinary tract infection not perceived by the patient

40. Autonomic Dysreflexia • Commonly seen in patients with upper spinal cord injury • Severe hypertension • Bradycardia • Severe headache • Nasal stuffiness • Flushing • Treatment

41. Establishing a Bowel Retraining Program • Consistent time for bowel elimination • High fluid intake • High-fiber diet • Rectal stimulation (with or without suppositories) • Stool softener medications, as needed

42. Impaired Adjustment • Interventions include: • Invite patients to ask questions about significant life changes; reply openly and honestly. • Encourage patients to discuss their perceptions of their situation and coping strategies that can be used. • Begin a patient education program to clarify misconceptions.

43. Community-Based Care • Home care management • Health teaching • Health care resources

44. Spinal Cord Tumors • Primary spinal cord tumors • Intramedullary tumors • Extramedullary tumors

45. Patient-Centered Collaborative Management • Assessment • Diagnostic assessment • Surgical management—need for emergency surgery • Nonsurgical management—radiation, chemotherapy

46. Community-Based Care • Home care management • Health teaching • Health care resources

47. Multiple Sclerosis • Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS • Characterized by periods of remission and exacerbation • Inflammatory response resulting in random or patchy areas of plaque in the white matter of the CNS

48. Multiple Sclerosis (Cont’d) • Etiology • Genetic risk • Incidence • Prevalence

49. Major Types of Multiple Sclerosis • Relapsing-remitting • Primary progressive • Secondary progressive • Progressive-relapsing

50. Patient-Centered Collaborative Care • Patient history • Physical assessment/clinical manifestations • Fatigue