spinal cord injury
DESCRIPTION
TRANSCRIPT
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Spinal Cord Injury: What Now?Expected Outcomes. Maura Nee RNP Elizabeth Tammaro RN, CRRN
VA Boston Healthcare System
SCI Out Patient Clinic
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Objectives: Discuss Anatomy and Physiology of the
Spinal Cord Understand the Impact of Neurologic
Level of Injury (LOI) and ASIA Classification
Discuss Expected Functional Outcomes Specific to LOI
Understand Role of the Nurse in Achieving Functional Outcomes
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SCI Statistics (2002)
250,000 in USA Paraplegic: 52% Quadriplegia: 47% New SCI/yr: 11,000 Male: 82% 16yr-30yr: 56%
Causes– MVA: 37%– Violence: 28%– Falls: 21%– Sports: 6%– Other: 8%
89%: D/C’d home
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Anatomy of the Spine Vertebrae
– Body• Front section, shaped like drum• Supports weight
– Lamina• Towards the back• Boney arch surrounds spinal canal
– Spinous process• Boney process from arch• Points of attachment for muscles and ligaments
Discs• Cushions between vertebrae
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Anatomy of the Spine Vertebrae:
– 7 Cervical• Flexion, extension, bending and turning of head
– 12 Thoracic• Chest region, allows mostly for rotation
– 5 Lumbar• Larger boney structures to support added wgt
– 5 Sacral• Fused together
– Coccyx
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Anatomy of the Cord
Cervical Cord– C1-C2: – C3-4: Phrenic nucleus– C4: Deltoids– C4-5: Biceps– C6: Wrist extensors– C7: Triceps– C8: Wrist extensors– C8-T1: Hand muscles
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Anatomy of the Cord
Thoracic Cord• Intercostal muscles and associated dermatones
Lumbarsacral• Starts at T9 and continues to L2• Innervates hips, legs, buttocks and anal region
Cauda Equina (horses tail)• Spinal cord ends at L2• Tip called conus, below conus a spray of spinal
roots
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Dermatomes/Sensory Level
Dermatome: – patch of skin innervated by a given spinal
cord level
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C2 to C4. The C2 dermatome
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Myotomes/Motor Level
Myotome: – Spinal nerve roots which innervates
muscles groups– Most muscles are innervated by more than
one root
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ASIA Impairment Scale– ASIA A: Complete: no motor or sensory function
is preserved in the sacral segments S4-S5– ASIA B: Incomplete: sensory but NOT motor
function is preserved below the neurological level and includes the sacral segments
– ASIA C: Incomplete: motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade <3
– ASIA D: Incomplete: motor function is preserved w/ muscle grade > 3
– ASIA E: Normal
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Definition of Disability
Tetraplegia (preferred to quadriplegia)– Refers to impairment or loss of
motor/sensory function in cervical segments of the spinal cord
– Impairment of function in arms, trunk, legs and pelvic organs
– ASIA Scale vs quadriparesis
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Definition of Disability Paraplegia
– Refers to impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
– Arm function spared– Possible impairment of function in trunk,
legs and pelvic organs– ASIA Scale vs paraparesis
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Clinical Syndromes– Central Cord Syndrome:
• lesion occurring almost exclusively in the cervical region
• Sacral sensory sparing• Weakness > UE vs LE
– Brown-Sequard Syndrome:• Lesion that produces ipsilateral,
proprioceptive and motor loss and contralateral loss of sensitivity to pain and temp
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Clinical Syndromes
– Anterior Cord Syndrome:• Lesion that produces variable loss of motor
function and of sensitivity while preserving proprioception
– Cauda Equina Syndrome:• Injury to the lumbosacral nerve roots w/ in
the neurocanal resulting in areflexive bladder, bowel and lower limbs
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Achievement of Functional Goals
Age Body type Comorbidities Prior athletic sense Fatigue level
Type of stabilization HX HO/POA Spasticity Psychosocial factors Nutrition
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Functional Outcomes
Motor/sensory recovery Ability to perform or direct ADLs Social reintegration Quality of life
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Functional Outcomes
LEVEL C1-C3– Limited head/neck movement– Rotate/flex neck (sternocleidomastoid)– Extend neck (cervical paraspinals)– Speech and swallowing (neck accessories)– Total paralysis of trunk,UE and LE
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LEVEL: C1-3– 24 hr care needs– Able to direct care needs
ADLs– Ventilator dependent– Impaired communication– Dependent for all care needs
Mobility– Power wheelchair– Hoyer lift
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LEVEL: C1-C3
Equipment Needs– Adapted computer– Bedside/portable ventilator– Suction machine– Specialty bed– Hoyer– Reclining shower chair
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Functional Outcomes
LEVEL: C4– Head and neck control (cerv paraspinals)– Shoulder shrug (upper traps)– Inspiration(diaphragm)– Lack of shoulder control (deltoids)– Paralysis of trunk, UE and LE– Inability to cough, low respiratory reserve
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LEVEL: C4– 24 hr care needs– Able to direct care needs
ADLs– May or may not be vent dependent– Improved communication– Assisted cough– Dependent for all care needs
Mobility– Power wheelchair– Hoyer lift
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LEVEL: C4
Equipment Needs– Adapted computer– Bedside/portable ventilator as needed– Suction machine– Specialty bed– Hoyer– Reclining shower chair
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Functional Outcomes LEVEL: C5
– Shoulder control (deltoids)– Elbow flexion (biceps/elbow flexors)– Supinate hands (brachialis and
brachioradialis)– Lack elbow extension and hand pronation – Paralysis of trunk and LE
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LEVEL: C5– 10hrs personal care need– 6 hrs homemaking assistance
ADLs– Set-up/equipment: eating, drinking, face
wash and teeth– Assisted cough– Dependent for bowel, bladder and lower
body hygiene – Dependent for bed mobility and transfers
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LEVEL: C5 Mobility
– Hoyer or stand pivot– Power wheelchair w/ hand controls– Manual wheelchair– Drive motor vehicle w/ hand controls
Equipment Needs– Power and manual wheelchairs– Adaptive splints/braces– Page turners/computer adaptations
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Functional Outcomes
LEVEL: C6– Wrist extension (extensor carpi ulnaris and
extensor carpi radialis longus/brevis)– Arm across chest (clavicular pectrocialis)– Lack elbow extension (triceps)– Lack wrist flexion – Lack hand control– Paralysis of trunk and LE
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LEVEL: C6– 6 hrs personal care needs– 4hrs homemaking assistance
ADLs– Assisted cough– Set-up for feeding, bathing and dressing– Independent pressure relief, turns and skin
assessment– May be independent for bowel/bladder
care
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LEVEL: C6
Mobility– Independent slide board transfer– Manual wheelchair– Drive with adaptive equipment
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Functional Outcomes
LEVEL: C7– Elbow flexion and extension
(biceps/triceps)– Arm toward body (sternal pectoralis)– Lack finger function– Lack trunk stability
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LEVEL: C7
– 6hrs personal care needs– 2hrs homemaking assistance
ADLs– More effective cough– Fewer adaptive aids– Independent w/ all ADLs– May need adaptive aids for bowel care
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LEVEL: C7
Mobility– Manual wheelchair– Transfers without adaptive equipment
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Functional Outcomes
LEVEL: C8-T1– Increased finger and hand strength
• Finger flexion (flexor digitorum)• Finger extension (extensor communis)• Thumb movement (policus longis brevis)• Separate fingers (introssi separates)
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LEVEL: C8-T1
– 4hrs personal care needs– 2hrs homemaking assistance
ADLs– Independent w/ or w/o assistive devices– Assist w/ complex meal prep and home
management Mobility
– Manual wheelchair
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Functional Outcomes
LEVEL: T2-T6– Normal motor function of head, neck,
shoulders, arms, hands and fingers– Increased use of intercostals– Increase trunk control (erector spinae)
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LEVEL: T2-T6– 3hrs personal care needs/homemaking
ADLs– Independent in personal care
Mobility– Manual wheelchair– May have limited walking with extensive
bracing– Drive with hand controls
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Functional Outcomes
LEVEL: T7-T12– Added motor function– Increased abdominal control– Increased trunk stability
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LEVEL: T7-T12– 2 hrs personal care needs/homemaking
ADLs– Independent– Improved cough– Improved balance control
Mobility– Manual wheelchair– May have limited walking with bracing– Driving with hand controls
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Functional Outcomes
LEVEL: L2-L5– Added motor function in hips and knees
• L2 Hip flexors (iliopsas)• L3 Knee extensors (quadriceps)• L4 Ankle dorsiflexors (tibialis anterior)• L 5 Long toe extensors (ext hallucis longus)
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LEVEL: L2-L5
– May need 1hr personal care/homemaking ADLs
– Independent Mobility
– Manual wheelchair– May walk short distance with braces and
assistive devices– Driving with hand controls
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Functional Outcomes
LEVEL: S1-S5– Ankle plantar flexors (gastrocnemius)– Various degrees of bowel, bladder and
sexual function– Lower level equals greater function
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LEVEL: S1-S5
– No personal or homemaker needs ADLs
– Independent Mobility
– Increased ability to walk with less adaptive/supportive devices
– Manual w/c for distance
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Functional Outcomes
Achieving maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life
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Functional Outcomes
Power Point presentation can be found:
www1.va.gov/spinalcordboston/