Acute Spinal Cord Injury Definition Acute spinal cord injury (SCI) is a sudden traumatic injury that results

in a bruise (also called a contusion), a partial tear, or a complete tear (called a transection) in the spinal cord.

Other name Causes/Etiology > Motor vehicle accidents > Falls > Violence (gunshots or stab wounds) > Sports injuries > Diving accidents > Trampoline accidents Signs and Symptoms > muscle weakness > loss of voluntary muscle movement in the chest, arms or legs > breathing problems > loss of feeling in the chest, arms or legs > loss of bowel and bladder function > Quadriplegia (tetraplegia)involves loss of movement and sensation in all four limbs (arms and legs). Quadriplegia also affects the chest muscles and may require a mechanical breathing machine for the patient > Paraplegiainvolves loss of movement and sensation in the lower half of the body (right and left legs) Medical Management > Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) prevention therapy Lack of mobility can decrease the blood flow through the veins and cause blood clots to form. When a blood clot forms in a vein deep within the muscle it is called deep vein thrombosis (DVT). These clots can break loose and travel through the bloodstream to the lung and cause a sudden blockage called a pulmonary embolism (PE). Steps taken to deter such an event include: y Pneumatic compression devices to help blood circulation y Anticoagulation medications such as: warfarin, heparin and enoxaparin y Range-of-motion exercises to maintain flexibility and promote circulation y Weekly blood flow studies for early detection and diagnosis of blood clots y Surgical placement of an inferior vena cava filter (IVC) is placed in a major vein in the abdomen to block large clots from traveling to the lungs > Gastrointestinal / stress ulcer prevention therapy Preventative therapy against gastrointestinal/stress ulceration begins early in the critical care phase and may include the use of antacids, histamine-2-receptor antagonists and proton pump inhibitors to neutralize or reduce the production of gastric acid.

> Respiratory Management Spinal cord injury patients often need help to breathe and may require ventilatory assistance such as intubation. Sometimes a long-term artificial airway called a tracheostomy may be necessary if patients do not have the ability to breathe on their own. Pneumonia and other respiratory infections are common in patients with spinal cord injuries. To minimize and prevent respiratory complications, an aggressive bronchial hygiene program is implemented by the care team. Individualized care programs may include: y Turning schedule to change the position of each patient to assist with mobilization of lung secretions y Assisted exercise designed to promote coughing and deep breathing y Specialized beds designed to facilitate respiratory management therapy like continuous rotation or chest percussion > Pressure Ulcer Prevention Prevention begins the moment patients arrive at the hospital. The most common places on the body to develop pressure ulcers are: y Sacrum (lower back) y Buttocks y Hips y Heels y Shoulder blades y Ankles To prevent this complication, care providers frequently assess the patient, use specialized lift equipment, implement an aggressive turning schedule and educate the family about the cause and prevention of pressure sores. > Orthotics Different kinds of support braces called cervical orthoses are used to keep the spine immobilized while healing. Orthoses are usually used after an injury or after surgery to prevent secondary injuries to the spine. Cervical Orthoses: Cervical collars (C-collars)These collars are popular for treating different conditions of the cervical spine. The C-collars come in two forms: y Soft C-collars generally do not restrict motion but provide comfort and warmth and serve as a reminder to patients to limit their motion. y Rigid C-collars are made of plastic that consists of two pieces, a front and a back that are attached on the sides with Velcro and provide support in the front under the chin and in the back at the base of the head. These orthoses (the Philadelphia, Aspen and Miami J) restrict cervical motion, particularly side-to-side and front-to-back flexion and extension of the head. Poster TypeThese types of orthoses are usually made of a combination of aluminum and plastic, and they consist of three parts (head, chin and chest) that support the spine and restrict movement of the (cervical) spine. Examples of poster type orthoses include: y SOMI (sternoooccipital-mandibular immobilizer) y Four-poster cervical orthosis

Guilford two-poster orthosis

Cervical Thoracic Orthoses (CTO)These types of orthoses extend from the chest to the chin and provide multilevel cervical immobilization that prevents motion between the cervical spine and thorax (chest). Halo OrthosesThese are for patients who require the most cervical stability. The halo consists of a metal ring that is secured to the skull with pins and then fastened to two metal rods that attach to a thoracic vest. The patient's skull is held in position relative to their trunk, preventing all movement of the head and neck. Non-Cervical Orthoses: Thoracolumbosacral Orthosis (TLSO)This type of orthosis is a rigid brace made from plastic and is often custom-made in one piece with a single opening or two pieces with openings on sides located under the arms. It spans from the thorax (chest) to the sacrum (tail bone) and supports the spinal column from the middle to lower backfrom the sixth thoracic vertebrae (T6) to the sacrum. The TLSO will keep the middle to lower back immobile by limiting forward and backward movement and twisting from side-to-side. Surgical Management > Emergent Decompression of spinal cord- for progressive neurologic deterioration, facet dislocation, or bilateral locked facets. > Spinal Fixation Surgery Commonly used drugs > Corticosteroids (dexamethasone or methylprednisolone) are used to reduce swelling around the injured area of the spinal cord which reduces or relieves paralysis. Swelling may lead to further damage to the spinal cord if left untreated. > Pain medications (Narcotics) will initially be used to control pain after the injury. If pain continues, other options to control it may include: y Non-steroidal anti-inflammatories (Toradol, Motrin, Advil) y Antispasmodics (Baclophen, Flexeril) y Benzodiazepines (Valium) y Neuropathic pain agents (Neurontin, Elavil) > Nutrition supplements are used after the initial injury, such as multivitamins, zinc, calcium, or vitamin C, to help promote skin and bone healing and general health. > Insulin may be given if high blood sugar levels develop. High blood sugar is sometimes a side effect of corticosteroids. > Bowel medication is given to help patients have regular bowel movements. When the spinal cord is injured, the stomach and bowels do not work well for a period of time, and bowel medications help combat that.

> Antispasmodic medications like Baclofen, Flexeril and Valium are given to relieve or prevent muscle spasticity. Spasticity is an abnormal increase in muscle tone causing muscles to continually contract. Continual contraction of the muscles causes tightness or stiffness of the muscles that may interfere with movement. Spasticity can occur when the muscles are stretched or irritated below the level of the spinal cord injury. Pathophysiology Acute impact injury is a concussion of the spinal cord. This type of injury initiates a cascade of events focused in the gray matter, and results in hemorrhagic necrosis. The initiating event is a hypoperfusion of the gray matter. Increases in intracellular calcium and reperfusion injury play key roles in cellular injury, and occur early after injury. The extent of necrosis is contingent on the amount of initial force of trauma, but also involves concomitant compression, perfusion pressures and blood flow, and administration of pharmacological agents. Preventing or quelling this cascade of events must involve mechanisms occurring in the initial stages. Spinal cord compression occurs when a mass impinges on the spinal cord causing increased parenchymal pressure. The tissue response is gliosis, demyelination, and axonal loss. This occurs in the white matter, whereas gray matter structures are preserved. Rapid or a critical degree of compression will result in collapse of the venous side of the microvasculature, resulting in vasogenic edema. Vasogenic edema exacerbates parenchymal pressure, and may lead to rapid progression of disfunction. Laboratory and Diagnostic Findings > X-rays. Medical personnel typically order these tests on people who are suspected of having a spinal cord injury after trauma. X-rays can reveal vertebral (spinal column) problems, tumors, fractures or degenerative changes in the spine. > Computerized tomography (CT) scan. A CT scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other problems. > Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is very helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may be compressing the spinal cord. > Blood tests