Spinal Cord Injury: What Now?

Expected Outcomes.
 Maura Nee RNP
 Elizabeth Tammaro RN, CRRN
VA Boston Healthcare System
SCI Out Patient Clinic
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
SCI Statistics (2002)
 250,000 in USA  Causes
 Paraplegic: 52% – MVA: 37%
– Violence: 28%
 Quadriplegia: 47%
– Falls: 21%
 New SCI/yr: 11,000
– Sports: 6%
 Male: 82% – Other: 8%
 16yr-30yr: 56%  89%: D/C’d home
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
 
                                                               
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
                                                         
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
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
                                                          
Dermatomes/Sensory Level

 Dermatome:
– patch of skin innervated by a given spinal
cord level
                                                                                    C2 to C4. The C2 dermatome
Myotomes/Motor Level

 Myotome:
– Spinal nerve roots which innervates
muscles groups
– Most muscles are innervated by more than
one root
 
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
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
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
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
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
Achievement of Functional Goals
 Age  Type of stabilization
 Body type  HX HO/POA
 Comorbidities  Spasticity
 Prior athletic sense  Psychosocial factors
 Fatigue level  Nutrition
Functional Outcomes

 Motor/sensory recovery
 Ability to perform or direct ADLs
 Social reintegration
 Quality of life
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
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
LEVEL: C1-C3

 Equipment Needs
– Adapted computer
– Bedside/portable ventilator
– Suction machine
– Specialty bed
– Hoyer
– Reclining shower chair
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
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
LEVEL: C4

 Equipment Needs
– Adapted computer
– Bedside/portable ventilator as needed
– Suction machine
– Specialty bed
– Hoyer
– Reclining shower chair
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
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
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
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
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
LEVEL: C6

Mobility
– Independent slide board transfer
– Manual wheelchair
– Drive with adaptive equipment
Functional Outcomes

 LEVEL: C7
– Elbow flexion and extension
(biceps/triceps)
– Arm toward body (sternal pectoralis)
– Lack finger function
– Lack trunk stability
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
LEVEL: C7

 Mobility
– Manual wheelchair
– Transfers without adaptive equipment
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)
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
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)
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
Functional Outcomes

 LEVEL: T7-T12
– Added motor function
– Increased abdominal control
– Increased trunk stability
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
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)
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
Functional Outcomes

 LEVEL: S1-S5
– Ankle plantar flexors (gastrocnemius)
– Various degrees of bowel, bladder and
sexual function
– Lower level equals greater function
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
Functional Outcomes

 Achieving maximum functional

outcomes provides the opportunity to
reach the highest level of independence
and quality of life
Functional Outcomes

 Power Point presentation can be found:

www1.va.gov/spinalcordboston/