SPINAL CORD INJURY

Spinal cord injury includes injuries to the bone and joint with associated trauma to the spinal
cord, which causes changes in its functions either temporary or permanent. These changes
translate into loss of muscles functions, sensation or autonomic functions in parts of the body
served by the affected spinal cord below the level of injury or lesion.

Common terms frequently used in the study of spinal cord injuries:

- Monoplegia: Paralysis of one limb.

- Hemiplegia: Paralysis of the arm and leg on one side of the body only.
- Paraplegia: Paralysis of both legs, however, lower half of the body is frequently
involved.
- Quadriplegia/Tetraplegia: Paralysis of the four limbs (extremities).
- Paralysis: Complete loss of movement.
- Paresis: Certain degree of movement is still possible in a group of muscle.

Types of Paralysis

There are basically two types of paralysis, which are:

- Spastic Paralysis: When the paralysed limb is found to be rigid and difficult to bend at
the joints during examination. Usually occurs in disorders of the upper motor neurone
and pyramidal tract.
- Flaccid Paralysis: Paralysed limb appear limp and seems lifeless. There is usually
absence of tendon reflexes. It occurs in disorders of the lower motor neurone, motor cells
in the horn of the spinal cord and the peripheral nerves.

Causes

- Stab wound of the Spinal column

- Gunshot
- Fracture of the vertebral from a fall
- Inflammation of the spinal cord (myelitis)
- Degeneration of the spinal cord e.g. Multiple sclerosis, Cervical myelopathy
 - Tumor of the spinal cord
- Thrombosis of the spinal artery
- Physical trauma from hyperflexion (forward movement of the head), hyperextension
(backward movement of the head), lateral stress (sideways movement), rotation (twisting
of the head), compression, distraction (pulling apart of the vertebrae)
- Motor vehicle accidents
- Iatrogenic injury caused by an improperly done medical procedure such as an injection
into the spinal column.

Classifications

Spinal cord injury can be traumatic and non-traumatic that is it can result from injury or other
causes such as infection or thrombosis as earlier mentioned.

Based on the cause: mechanical forces, toxic and ischemic

Primary and secondary injury: injuries can be cervical (C1-C8), thoracic (T1-T12), lumbar (L1-
L5), sacral (S1-S5). A person’s level of injury is the lowest level of full sensation and function.

Paraplegia occur when thoracic, lumbar or sacral injuries occur. Tetraplegia occur when the
cervical nerves are affected.

Based on the degree of impairment:

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is
widely use to document sensory and motor impairments following SCI. it is based on:

- Neurological Responses: i.e. touch, pinprick sensation. It is in scale of 0-2, 0- no

sensation, 1- altered sensation and 2- full sensation.
- Strength of the muscles that control key motions on both sides of the body which is
scored on the scale of 0-5.

Muscle strength

Grade Muscle Function

0 No muscle Contraction
1 Muscle Flickers
 2 Full range of motion, gravity eliminated
3 Full range of motion against gravity
4 Full range of motion against resistance
5 Normal strength.

Based on American Spinal Injury Association Impairment scale for classifying SCI

Grade Description

A Complete injury - No motor or sensory function is preserved in the sacral segments

S4-S5

B Sensory Incomplete - Sensory function is preserved below the level of injury

including

the Sacral segment.

C Motor Incomplete - Motor function is preserved below the level of injury, more than

half of muscles tested below the level of injury nave a muscle

grade less than 3.

D Motor Incomplete - Motor function is preserved below the level of injury and at
least

half of the key muscles below the neurological level have a

muscle grade of 3 or more.

E Normal - No motor or sensory deficits, but deficits existed in the past.

Complete and Incomplete Injuries

Levels Complete Incomplete

Tetraplegia 18.3% 34.1%

Paraplegia 23.0% 18.5%

Complete Injury – All functions below the injured area are lost, whether or not the spinal cord
is

Severed.

Incomplete Injury – preservation of motor or sensory functions below the level of injury in the

Spinal cord i.e. areas innervated by S4-S5, e.g. voluntary external and

Sphincter contractions.

Central Cord Syndrome (Top)- always almost resulting from damage to cervical spinal cord,
it’s

characterized by weakness in the arms with relative sparing of

the legs, and spare sensation in region served by the sacral

segments.

There is loss of sensation of pain, temperature, light touch, and pre-

ssure below the level of injury.

Anterior Cord Syndrome (Middle) – due to damage to the front portion of the spinal cord or
red-

uction in the blood supply from the anterior spinal artery

motor function, pain sensation and temperature sensation

are

lost below the level of injury, while sense of touch and pro-

pioception remains intact.

Brown Sequard Syndrome (Bottom) – this occurs when injury on one side is much more than

the other. On the ipsilateral side of the injury, the body

may
 loses motor function, proprioception, and senses of vibr

-ation and touch. On the contralateral of the injury, there

is

loss of pain and temperature sensations.

Posterior Cord Syndrome - dorsal columns of the spinal column are affected. There is loss

of proprioception and vibration below the level of injury, while

motor function and sensory sensation of pain, temperature and

touch remain intact.

Conus Medullaris - injury to the end of the spinal cord, located at about the T12 -
L2

vertebrae in adults. This region contains the S4 – S5 spinal seg-

ments responsible for bowel, bladder and some sexual

functions.

Caudal Equina Syndrome – this results from a lesion below the level at which the spinal
cord

splits into the cauda equine at levels L2 –S5 below the conus

medullaris. Can cause low back pain, weakness or paralysis in

the

lower limbs, loss of sensation, bowel and bladder dysfunction

and

loss of reflexes, symptoms often occur on only one side of the

body.

Clinical Manifestations

Injury to Dermatome: pain, numbness in the related areas, tingling or burning sensation and
lowered level of consciousness.
Injury to Myotome: spasticity, muscle weakness, complete paralysis, spinal shock and loss of
neural activity.

Lumbosacral: decreased control of legs and hips, genitourinary system and anus, sexual
dysfunction, bowel and bladder dysfunction, fecal and urinary incontinence.

Thoracic: injuries at the level of T1 to T8 – inability to control abdominal muscles and trunk
instability.

T9 to T12 – partial loss of trunk and abdominal muscles’ control and paraplegia.

T6 – Autonomic dysreflexia – blood pressure increases to dangerous level, high enough to cause
potentially deadly stroke, results from pain stimulus below the level of injury. Sign and
symptoms include: anxiety, headache, ringing in the ears, blurred vision, flushed skin, nasal
congestion and neurogenic shock.

Cervical: Full or partial tetraplegia and respiratory failure.

C1 to C4 – Full paralysis of limbs, respiratory failure

C5 – Paralysis of the wrists, hands and triceps, difficulty coughing

C6 – Paralysis of the wrist flexors, triceps and hands

C7 to C8 – Hand muscle weakness, difficulty grasping and releasing

Additional signs and symptoms – low heart rate, low BP, problems regulating body
temperature and breathing dysfunction.

Diagnosis

- A radiographic evaluation using an X-ray, CT Scan, or MRI to determine damage and

location.
- Neurological evaluation to help determine the degree of impairment. The ASIA
Impairment scale is used to determine the level and severity of injury.

Management

Pre- Hospital Management

The first stage management of SCI is geared towards basic life support and preventing further
injury, maintaining airway, breathing and circulation and immobilizing the spine.

Emergency Management:

- To prevent an incomplete injury from becoming complete, patient must be immobilized

on a spinal board with head and neck in a neutral position.
- For a transfer to the hospital, at least four people should slide the patient carefully onto a
board. Patient is maintained in an extended position.
- No part of the body should be twisted or turned nor the patient should be allowed to sit
up.
- Patient may be placed on a rotating bed in a cervical collar, once the extent of the injury
has been determined.
- If SCI and bone instability is ruled out, the patient may be moved to conventional bed or
the collar may be removed without harm.

Medical Management

Aims: To ensure adequate airway, breathing, cardiovascular function and spinal immobilization.

Pharmacologic Therapy

- Administration of high dose of corticosteroids, specifically methylprednisolone – to

improve motor and sensory outcomes at 6wks, 6mths and 1yr. if given within 6-8hrs after
injury to prevent secondary infections.

Respiratory therapy

- Administration of oxygen to maintain a high partial pressure of oxygen (Pa02).

- In a high cervical spine injury, spinal cord innervation to the phrenic nerve which
stimulates the diaphragm is lost, to help the patient breath, Diaphragmatic Pacing
(electrical stimulation of phrenic nerve) is attempted.

Reduction and Traction

SCI requires immobilization and reduction of dislocations and stabilization of vertebra column.
 - Cervical fractures are reduced, and the spine is aligned with some form of skeletal
traction e.g. skeletal tongs such as Gardner – wells – tongs, or Calipers, or with the use of
Halo devices.
- Traction is applied to the skeletal traction device by weights, the amount depends on the
size of the patient and the degree of fracture displacement. The traction force is exerted
along the longitudinal axis of the vertebral bodies with the patient’s neck in a neutral
position, the traction is then gradually increased by adding more weights. As the amount
of traction is increased, the spaces between the inter-vertebral disc widens and the
vertebra are given a chance to slip back into position. Reduction usually takes place after
correct alignment has been restored. Once reduction is achieved as verifies by cervical
spine X-rays and neurologic examination, weights are gradually removed until the
amount of weight needed to maintain the alignment is identified.

Surgical Management

Surgery may be necessary in any of the following instances to:

- Relieve excess pressure on the cord

- Stabilize the spine or to put vertebra back into their proper place.
- Remove bone fragments, blood, material from ligaments or inter-vertebral discs
- The injury involves a wound that penetrates the cord
- When patient’s neurologic status is deteriorating.

Although, the ideal timing is still debated, studies have found that earlier surgical intervention
(within 24 hours of injury) is associated with better outcomes.

Surgery is performed to permit direct visualization and exploration of the cord

LAMINECTOMY (excision of the posterior arches and spinous processes of a vertebra) and
surgical debridement is done. Stem cell implantation, engineered materials for tissue support and
wearable robotic exo -skeletons e.g. ankle – foot orthoses (AFOs) and knee. AFOs can be used to
stabilized week joints.

Nursing Management
Patient should be nursed on either a conventional hospital bed with a firm mattress, a wedge
turning frame (Stryker frame) or one of the mechanical turning beds e.g. an Egerton Stoke
Mandeville bed.

Observation: – Patient with SCI need repeated neurological assessment to detect early any
complications. If the systolic BP falls below 90mmHg, blood supply to the spinal cord may be
reduced resulting in further damage, thus it is important to maintain BP using venous catheter,
I/V fluid and vasopressin and to treat cases of shock.

Mean arterial pressure should be kept at 85 – 90mmHg for 7 days after injury.

TPR also are to be taken frequently to detect early progress or deterioration in patient’s
condition,

Respiration: - Patient should be encouraged to breathe deeply and cough up respiratory

secretions, so as to aid easy breathing and prevent hypostatic pneumonia.

Diet: - nutrition and fluid intake of the patient must be maintained. High protein diet controls
decubitus ulcer, helps tissue to look healthy and also aid healing. High fluid intake lessen the
possibility of Urinary Tract Infection and Calculi.

Pain Control: - patient may complain of burning pain in the affected area, which may be
associated with irritation around the nerve roots. Mild analgesics e.g. ASA can be administered.

Medication: - Treatment of infection with an appropriate antibiotic is essential.

Exercise: - Possible exercise and changes in position help to decrease spasm. It also maintains
body in a good condition. Foot board can be used to prevent foot drop. Physiotherapist should
also be invited. Active exercise of the unaffected part is encouraged to prevent atrophy.

Skin Care: - Patient should be assisted to maintain personal hygiene. Bed-bath and oral hygiene,
use of pressure relieving aids such as 2hourly turns, care of pressure areas, regular inspection of
the main weight bearing points. Spine must be kept straight to encourage healing in good
alignment.

Elimination: - Catheterization should be done to relief urinary retention, catheter care should be
done, avoid urethral sore. Urinary output should be 150 – 200ml/hour.
Bowel incontinence is a major problem for patient with SCI, affecting psychological and
physiological status of the patient. Use of stool softeners, adequate fluid intake, balance diet with
sufficient bulk to stimulate peristalsis, avoidance of constipation drugs can help the patient.
Enema of 500ml tap water can be given in faecal impaction.

Psychological supports: - The nurse must assess the family’s ability to:

- Express distress at the patient’s condition

- Cope with the patient’s illness and deficit
- Obtain support.

Complications

- Spinal shock
- Bowel incontinence and paralytic ileus
- Low BP and heart rate
- Decreased cardiac output
- Venous pooling
- Peripheral vasodilatation
- Respiratory failure
- Pulmonary oedema
- Deep vein thrombosis
- Pleuritic chest pain
- Shortness of breath
- Abnormal gas volume (increased Paco2 and decreased Pao2)
- Low grade fever

Nursing diagnosis

- Ineffective breathing pattern related to weakness or paralysis of abdominal and

intercostal muscles and inability to clear secretions evidenced by dyspnea.
- Ineffective airway clearance related to weakness of intercostal muscles evidenced by
labored breathing.
- Impaired physical mobility related to motor and sensory impairments evidenced by
patient’s inability to move his body.
 - Pain related to irritation around the nerve roots evidenced by patient’s verbalization.
- Activities intolerance related to spinal injury evidenced by inability to carry out activities
of daily living.

MYASTHENIA GRAVIS

Introduction

Myasthenia Gravis (MG) is a long term neuromuscular disease that leads to varying degrees of
skeletal muscle weakness. The most commonly affected muscle are those of the eyes, face and
swallowing.

Definition

Myasthenia Gravis is a chronic auto-immune disorder affecting the neuromuscular junction

(Myoneural) and it is characterized by varying degrees of muscle (voluntary) weakness and
fatigability i.e. during exercise.
Incidence

Women are affected more frequently than men, and they tend to develop the disease at an earlier
age 20-40 years, in males 60-70 years.

Aetiology

Myasthenia Gravis is associated with disorders of auto-immune with an increase incidence of

other auto-immune diseases including systemic lupus erythematosus, rheumatoid arthritis,
polymyositis and thyrotoxicosis.

Pathophysiology

Normally, a chemical impulse precipitates the release of acetylcholine from vesicles on the nerve
terminal at the neuromuscular (myoneural) junction. The acetylcholine attaches to the receptor
sites on the motor plate and stimulate muscle contraction. Continuous binding of acetylcholine to
the receptor site is required for muscular contraction to be sustained.

In myasthenia gravis, there is a defect in nerve impulse transmission at the neuromuscular

junction. The post synaptic acetylcholine receptors on the muscles cell’s plasma membrane are
no longer recognized as “self” and elicit the generation of autoantibodies. IgG antibody is
produced against acetylcholine receptors and fixes onto the receptor sites, blocking the binding
of acetylcholine. receptor sites are eventually destroyed by the antibody action. This causes
diminished transmission of the nerve impulse across the neuromuscular junction and lack of
muscle depolarization.

Clinical Manifestations

Myasthenia gravis has an insidious onset, usually involves the ocular muscles.

- Diplopia
- Ptosis
- Weakness of the muscle of the face and throat
- Generalized weakness
- Dysphonia
- Bland facial expression
 - Decreasing vital capacity and respiratory failure due to weakness of all the extremities
and the intercostal muscles.
- Dietary changes and weight loss.

Assessment and Diagnostic Findings

- An acetylcholinesterase inhibitors test

- Presence of acetylcholine receptor antibodies in the serum
- MRI- to identify an enlarged thymus gland.

Medical and Nursing Management

Medical Management

- The first line of therapy: Pyridostigmine bromide (mestinon) 60mg tds, an

anticholinesterase medication, it provides symptomatic relief by inhibiting the breakdown
of acetylcholine and increase the relative concentration of available acetylcholine at the
neuromuscular junction.
- Immunomodulating drugs such as corticosteroids e.g. prednisolone 60-100mg are used to
decrease the amount of antibody production, if pyridostigmine does not improve muscle
strength and control fatigue.
- Cytotoxic medications are used if there is an inadequate response to steroids.
Azathioprine (Imuran) inhibits T-lymphocytes and reduces acetylcholine receptor
antibody levels.

Plasmapheresis

Plasmapheresis is a technique used to treat exacerbations. The patient’s plasma and plasma
components are removed through a centrally placed large – bore double-lumen catheter. The
blood cells and antibody containing plasma are separated after which the cells and a plasma
substitute are reinfused. To sustain improvement, cholinesterase inhibitors, corticosteroids,
immune-suppressive drugs are used.
Surgical Management

Thymectomy: produce antigen-specific immune-suppression and result in clinical improvement.

The procedure results in either partial or complete remission. For optimal clinical outcomes the
entire gland must be removed.

Patient may take up to 3 years to benefit from the procedure, because of the long life of
circulating T-Cells.

Nursing Management

Most patient can manage their disorders at home quite adequately, however, if a deterioration or
a complication occurs, then they need to be admitted to hospital.

- Admission: Patient should be admitted and nursed in a quiet and relaxed environment
preferably in a side room.
- Observation: Ongoing assessment of the patient’s respiratory and general status is
required to detect any deviation from normal.
- Endotracheal intubation and mechanical ventilation may be needed in case patient lapse
into respiratory failure.
- Patient should be taught strategies to conserve energy, so, the nurse must help the patient
identify the optimal time for rest throughout the day.
- Meals times should coincide with the peak effect of anticholinesterase medication in
order to minimize risk of aspiration.
- Patient who wear eye glasses can have “crutches” attached to help lift the eyelids.
Patching of one eye can help with double vision.

Education: Patient should be reminded of the importance of maintaining health promotion

practices and of following health care screening recommendations.

- Factors that exacerbate symptoms and potentially caused crisis should be noted and
avoided such as emotional stress, infections, vigorous physical activities, some
medications and high environmental temperature.

While nursing ventilated patients, the following should be considered:

- Frequent vital signs and neurological observations

 - Frequent check to ascertain safe working of ventilator
- Two hourly positional changes
- Light support for the patient’s head and neck
- Four hourly eye and oral hygiene
- Four hourly urinary catheter care
- Supervision of i/v fluids including cannula site and infusion rate
- Administration of sedation as required.

Myasthenia Crisis

Respiratory distress and varying degree of dysphagia, dysarthria, eyelid ptosis, diplopia
and prominent muscle weakness are principal symptoms of myasthenia crisis.

Management

- The patient should be nursed in intensive care unit for constant monitoring.
- Provide ventilator assistance.
- Ongoing assessment for respiratory failure; assess respiratory rate, depth and breadth
sounds.
- Endotracheal intubation may be needed
- Chest physical therapy e.g. postural drainage to mobilize secretions and suctioning to
remove secretions may be performed frequently.

Assessment strategies and supporting measures include the following:

- Arterial Blood Gas, Serum electrolytes, input and output and daily weight monitoring.
- NGT feedings if the patient cannot swallow
- Avoid sedatives and tranquilizers because they aggravate hypoxia and hypercapnia and
can cause respiratory and cardiac depression.