Spinal Cord Injury: Clinical Features, Diagnosis Assessment, Medical Management & Home Based Care

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Spinal Cord Injury (SCIs) are a major health problem. Most SCIs result from road traffic accident, violence (gunshots, fights), fall injury or from the athletic activity which is most likely to be worse by the mishandling of patient with a spinal injury. Half of the victims are between the age group of 16 to 30 years of age; most are males. Another risk factor is substance abuse (Alcohol and drugs). There is a high frequency of associated injuries and medical complications. The vertebrae most frequently involved in SCIs are the 5th, 6th and 7th cervical vertebrae (C5-C7), the 12th thoracic vertebra (T12), and the first lumbar vertebra (l1). These vertebrae are the most susceptible because there is a greater range of mobility in the vertebral column in these areas. Damage to the spinal cord ranges from a transient concussion (full recover) to contusion, laceration and compression of the cord substance (either alone or in combination) to complete the transaction of the cord Paralysis below the level of injury). Injury can be classified as primary (usually permanent) or secondary (nerve fibers swell and disintegrate as a result of ischaemia, hypoxemia, oedema and haemorrhagic lesions). Whereas a primary injury is permanent, a secondary injury may be reversible if treated within 4 to 6 hours of the initial injury. The type of injury refers to the extent of injury to the spinal cord itself.

Incomplete spinal cord lesions are classified according to the area of spinal cord damage: Central, lateral, anterior or peripheral. A complete SCI can result in paraplegia (paralysis of lower body) or tetraplegia (formerly quadriplegia – paralysis of all four extremities).

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Clinical features of Spinal cord injury

The consequences of SCI depend on the type and level of injury of the cord.

Neurologic level

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  • Total sensory and motor paralysis below the neurologic level.
  • Loss of bladder and bowel control ( usually with urinary retention and bladder distension).
  • Loss of sweating and vasomotor tone.
  • Marked reduction of BP from loss of peripheral vascular resistance.
  • If conscious, patient reports acute pain in back or neck; a patient may complain that the neck or back is broken.

Respiratory problems

  • Related to compromised respiratory function; severity depends on the level of injury.
  • Acute respiratory failure is the leading cause of death in high cervical cord injury.

Diagnostic assessment

  • Detailed neurologic examination
  • X-ray examination  (lateral cervical spine X-rays)
  • computed tomography  (CT)
  • magnetic resonance imaging (MRI)
  • ECG ( bradycardia and asystole are common in the acute spinal injuries) are common diagnostic methods.
  • Vital signs and other laboratory tests

Complications

A serious complication from SCI is spinal shock, Areflexia ( depression of reflex activity in the spinal cord) below the level of injury, the muscles innervated by the part of the cord segment situated below the level of the lesion become completely paralyzed and flaccid, and the reflexes are absent. Changes in blood pressure, respiration, and heart rate as vital organs are affected.

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Emergency management or primary care

  • Improper patient management or handling can cause further damage and loss of neurologic function.
  • Immediate patient management at the accident scene is crucial.
  • Consider any victim of road traffic accident, fall, sports injury or direct trauma to the head and neck as having spinal cord injury until ruled out.
  • Initial care includes rapid assessment, immobilization, stabilization or control of life-threatening injuries, and transportation to an appropriate medical facility.
  • Maintain victim in an extended position (not sitting), body part should not be moved, twisted or turned especially the neck.
  • The standard of care is a referral to a regional spinal injury center or trauma center for specialized treatment in first 24 hours.

Medical management

The goal of management is to prevent further SCI and to observe for symptoms of progressive neurologic deficits.

  • The patient is resuscitated as necessary, and oxygenation and Cardiovascular stability are maintained.
  • High dose corticosteroids  (methylprednisolone) may be administered to counteract spinal cord oedema.
  • Oxygen is administered to maintain high arterial Pa02.
  • Intensive care is provided to avoid flexing or extending the neck if endotracheal intubation is necessary.
  • SCI requires immobilization, reduction of dislocations, and stabilization of the vertebral column. A cervical collar may be used for immobilization.
  • The cervical fracture is reduced and the cervical spine aligned with a form of skeletal traction with weights freely hung as not to interfere the traction.

Early surgery reduces the need for traction. The goals of surgical treatment are to preserve neurologic function by removing pressure from the spinal cord and to provide stability. The surgical procedures for spinal cord injuries are implanted fixation to fix the dislocation or fracture, laminectomy, decompression, anterior or posterior cervical fixation may be done as per the need and preferences of the patient.

Management of complications

  • The loss of sympathetic innervation causes a variety of other clinical manifestation, including neurologic shock characterized by decreased cardiac output, venous pooling in the extremities and peripheral vasodilation.
  • Intestinal decompression is used to treat bowel distension and paralytic ileus caused by depression of reflexes.
  • A patient who does not perspire  (sweat) on a paralyzed portion of the body requires close observation for early detection of an abrupt onset of fever.
  • Body defenses are maintained and supported until the spinal shock abates and the system has recovered from the traumatic insult (up to 4 months).
  • Special care is given to the respiratory system  (may not be enough intrathoracic pressure to cough effectively). Problems include decreased vital capacity, decreased oxygen levels, pneumonia, respiratory failure and pulmonary oedema.
  • Chest physiotherapy and suctioning are implemented to help clear pulmonary secretions.
  • A patient is observed for deep vein thrombosis (DVT), a complication of immobility (for instance pulmonary embolism). Symptoms include pleuritic chest pain, anxiety, shortness of breath, and abnormal blood gas values.
  • Low-dose anticoagulation therapy is initiated to prevent DVT and pulmonary embolism, along with the use of anti-embolism stockings or pneumatic compression devices.
  • A patient is monitored for autonomic hyperreflexia (characterized by pounding headache, profuse sweating, nasal congestion, bradycardia, and hypertension).
  • Constant surveillance is maintained for signs and symptoms of pressure ulcers or bed sores and infection  (urinary, respiratory, local infection at pin sides).

HOME BASED CARE

  • Focus patient teaching on the injury and its effects on mobility, dressing, and bowel, bladder, and sexual function. As the patient and family acknowledge the consequences of the injury and the resulting disability, broaden the focus of teaching to address issues necessary for carrying out the tasks of daily living and taking charge of their lives.
  • Support and assist patient and family in assuming responsibility for increasing care and provide assistance in dealing with the psychological impact of SCI and its consequences.
  • A coordinate management team, and serve as liaison with rehabilitation centers and home care agencies.
  • Reassurance to the female patients with SCI that pregnancy is not contraindicated and fertility is relatively unaffected, but that pregnant women with acute or chronic SCI pose unique management challenges.
  • Refer to home care nursing support as indicated for preference.
  • The patient of spinal cord injury Refers to mental health care facility if needed.

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