module 8: Spinal cord injuries, Autonomic Dysreflexia, Back pain, Osteomyelitis, & Fractures

An injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma

• Ranges from transient concussion (which is fully recoverable) to contusion, laceration, and compression of the spinal cord tissue to complete severing of the spinal cord

  • Renders patient paralyzed below the level of injury

• Vertebra C5-C7, T12, and L1 are the most susceptible to injury due to a greater range of motion

• Primary injuries = result of initial insult or trauma; permanent damage

• Secondary injuries = result from hypoxemia, edema, or hemorrhage which damages the tissue

• Younger age

• Male gender

• Alcohol and illicit drug use

• Complete spinal cord lesion = loss of sensory and voluntary motor communication; paraplegia or tetraplegia

  • Incomplete spinal cord lesion = sensory and motor communication is preserved below the lesion

• Total or partial paralysis

• Loss of bowel and bladder control

• Loss of sweating

• Reduction in BP with loss of peripheral vascular resistance

• Acute back or neck pain

• Respiratory dysfunction (depending on level of injury)

• Immobilization in the extended position until proper assessment and treatment is performed

  • Incomplete injury may become complete if pt continues to move after trauma event

• Neurological assessment

• X-ray

• CT scan

• MRI scan for  further workup

• Monitor respirations/pattern

• Vitals

• Respiratory therapy

• Pacing

• High dose IV corticosteroids

  • Methylprednisolone

• Immobilization

  • Stabilization of vertebral column

• Reduction of dislocations

• Skeletal traction (cervical injuries)

• Surgical intervention (thoracic and lumbar injuries)

• Spinal shock

• Neurogenic shock

• VTE

  • DVT

  • PE

• Pressure injuries

• Monitor respirations and breathing pattern

• Lung sounds and cough

• Monitor for changes in motor or sensory function; report immediately

• Assess for spinal shock

• Monitor for bladder retention or distention, gastric dilation, and ileus

• Temperature; potential hyperthermia

• Motor deficits

  • In the upper extremities compared to the lower extremities

  • Sensory loss more pronounced in upper extremities

• bowel/bladder dysfunction

• Injury

• Edema

• Hyperextension injuries

• Loss of pain (below the level of lesion)

• Loss of temperature function (below the level of lesion)

• Loss of motor function (below the level of lesion)

• Light touch, position, and vibration sensation remain intact

• Acute disc herniation

• Hyperflexion injuries associated with fracture or dislocation of vertebra

• Injury to anterior spinal artery

• Ipsilateral paralysis or paresis is noted

• Ipsilateral loss of touch, pressure, and vibration

• Contralateral loss of pain and temperature

• Lesion is caused by a vertical transection

• Result of knife or missile injury, fracture/dislocation, or acute ruptured disk

• Used to reduce cervical fractures and align the cervical spine

• Traction is applied to via weights

• As the traction increases, the spaces between the intervertebral disks widen, allowing the disks to slip back into place

• Reduction in traction occurs after proper alignment is restored

Sudden depression of reflex activity below the level of injury caused by muscles being paralyzed and flaccid

• Decreased BP

• Bradycardia

• Bowel distention

• Paralytic ileus

• Maintain MAP of at least 85 mm Hg

• NG tube

• Result of the loss of autonomic NS function below level of injury

• Vital organs are affected

• Decrease BP, HR, and cardiac output

• Venous pooling

• Respiratory complications

  • Decreases vital capacity

  • Retention of secretions

  • Increased PaCO2

  • Decreased O2

  • Pulmonary edema

Acute life threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli after spinal shock has been resolved

• Exaggerated autonomic responses to stimuli

• Triggers:

  • Distended bladder

  • Distention or contraction of visceral organs

    • Bowel

  • Stimulation of the skin

• SCI

• Spinal shock

• Paroxysmal HTN

• Profuse diaphoresis above injury

• bradycardia

• Severe pounding headache

• Nausea

• Nasal congestion

• Remove the triggering stimulus

• Immediately place in sitting position to lower BP

• Empty bladder

• Examine for fecal mass and remove

• Skin assessment for pressure or broken skin

• Antihypertensives

  • Slow IV

• Caused by musculoskeletal problems such as

  • Acute lumbosacral strain

  • Insatiable lumbosacral ligaments

  • Weak muscles

  • Unequal leg length

  • Intervetebral disc problems

• The spinal column has rigid units = vertebrae and flexible units = intervetebral discs, held together by joints, ligaments, and muscles

• Spinal curves absorb vertical shocks from movement

• Abdominal and thoracic muscles are important in lifting and minimize stress on the spinal units

• Intervertebral discs change with age

  • Fibrocartilage becomes dense and irregularly shaped with time; disc degeneration

• Low lumbar discs, L4 and L5-S1, are subject tot he greatest mechanical stress and degeneration

compression of a bundle of spinal nerves from the lower spinal cord

• Results from the compression of the cauda equina, a bundle of spinal nerves from the lower portion of the spinal cord

• Requires immediate attention before nerve damage occurs

• Depression

• Smoking

• Alcohol abuse

• Obesity

• Stress

• Acute back pain (lasting <3 months)

• Chronic back pain (lasting 3< without improvement)

• Fatigue

• Pain radiating down the leg

  • Radiculopathy = pain from a diseased spinal nerve root

  • Sciatica = pain from inflamed sciatic nerve

• Affected gait, spinal mobility, reflexes, leg length, motor strength, and sensory perception

• Cauda equina

• Focused history and physical exam

  • Gait evaluation

  • Neurologic testing

• X-ray, CT scan, MRI, etc.

• Assess posture, position changes, and gait

• Analgesics, rest, and avoidance of strain

• Activity modification

• NSAIDs and short term muscle relaxants

• Opioids (1-2 weeks)

• Thermal applications

• Spinal manipulation (chiropractor)

• Cognitive behavioral therapy

• Exercise regiments

• Spinal manipulation

• PT

• Acupuncture

• Massage

• Avoid stress to back

• Positioning

• Location, severity, duration, characteristics, radiation (radiculopathy), leg weakness

• How the pain occurred and has been managed by the patient

• Work and recreational activities

• Spinal curvature, back and limb symmetry

• Palpate paraspinal muscles

• Movement ability and effects on ADLs

• DTRs, sensation, and muscle strength

• Sever or progressive neurologic deficit

• Recent bowel or bladder dysfunction

• Saddle anesthesia

  • Paresthesias in the but and inner thighs

• An infection of the bone that results in inflammation, necrosis, and formation of new bone

• Can be

  • Hematogenous (bloodborne spread)

  • Contagious-focus (contamination from surgery, fracture, or trauma)

  • With vascular insufficiency

• Infections caused by staph aureus, MRSA, streptococci, enterococci, or pseudomonas

• Initial response is inflammation, increased vascularity, and edema; after 2-3 days, thrombosis of local blood vessel occurs causing ischemia with bone necrosis

• Infection spreads to tissues and joints, and may cause a bone abscess

  • Abscess contains dead bone tissue and cannot heal, but instead new bone growth forms around the dead bone tissue

  • Chronic infection of the bone tissue = chronic osteomyelitis

• Old age

• Poor nourishment

• Obesity

• Impaired immune function

• Chronic illness

• Long term corticosteroid therapy

• Sudden onset of sepsis manifestations

  • Chills

  • High fever

  • Rapid pulse

  • General malaise

• Infected area becomes painful, swollen, and extremely tender

• Constant, pulsating pain that intensifies with movement

• Pus

• Early x-ray

• MRI

• Blood studies

• Bone biopsies

• Ability to adhere to prescribed therapeutic regimen— antibiotic therapy

• Signs and symptoms of infection, localized pain, edema, erythema, fever, drainage

• IV antibiotics

• Prophylactic antibiotics

• Surgical debridement

  • All dead, infected bone, tissue, and cartilage must be removed for permenant healing

• Disposable medical tools (to minimize possibility of infection)

• Encourage adequate hydration, vitamins, and protein

• Relieving pain

  • Immobilization

  • Elevation

  • Handle with great care and gentleness

  • Administer prescribed analgesics

• Improving physical mobility

  • Activity is restricted

  • Gentle ROM to joints above and below the affected part

  • Participation in ADLs within limitations

• soft tissue injury produced by blunt force

  • Pain, swelling, and discoloration: ecchymosis

• Pulled muscle injury to the musculotendinous unit

  • Pain, edema, muscle spasm, ecchymosis, and loss of function are on a continuum graded first, second, and third degree

• injury to ligaments and supporting muscle fiber around a joint

  • Pain (may increase with motion), edema, tenderness; severity graded according to ligament damage and joint stability

• articular surfaces of the joint are not in contact

  • A traumatic dislocation is an emergency with pain change in contour, axis, and length of the limb and loss of mobility

• partial or incomplete dislocation

  • Does not cause as much deformity as a complete dislocation

• Rest

• Ice

• Compression

• Elevation

• A complete or incomplete disruption in the continuity of bone structure and is defined according to its type and extent

• Occur when a bone is subjected to stress greater than it can absorb

May be caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions

• Adjacent structures may have soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels

• Continuous pain that increases in severity

  • Numbness immediately after

• Loss of function

• Displacement, angulation, or rotation

• Shortening

• Crepitus

• Localized edema and echymosis

• Immobilization of body part

• X-ray

• Adequate splinting

  • Bandaging affected to unaffected extremity or chest

  • Sling

• Assessment of perfusion and nerve function

• Cover wound with sterile dressing (open fracture)

• Reduction = restoration of bone fragments to anatomic realignment and positioning with realignment

  • Closed uses manipulation and manual traction

  • Open uses surgery and internal fixation devices

• Immobilization until union occurs

• IV antibiotics and debridement (open)

• Maintaining and restoring function

  • Position changes

  • Pain relief

  • Isometric exercise

  • Reassurment

• Age >40 years

• Avascular necrosis

• Bone loss

• Cigarette smoking

• Comorbidities (e.g., diabetes, rheumatoid arthritis)

• Corticosteroids, nonsteroidal anti-inflammatory drugs

• Extensive local trauma

• Inadequate immobilization

• Infection

• Local malignancy

• Malalignment of the fracture fragments

• Space or tissue between bone fragments

• Weight bearing prior to approval

• Shock

• Fat embolism

• Acute compartment syndrome

• DVT; PE

• Infection

• Union

• Malunion

• Nonunion

• AVN of bone

• Closed

• Open

  • Type I

  • Type II

  • Type III

• Intra-articular

• Simple fracture

• Fracture that does not break the skin

• Compound or complex fracture

• Fracture that breaks the skin or mucous membranes around it

• Type I = clean wound less than 1cm ina simple fracture pattern

• Type II = larger wound with minimal soft tissue damage; no flaps or avulsions

• Type III = most severe, highly contaminated, and has extensive soft tissue damage

  • Vascular injury or traumatic amputation

Extends into the joint surface of a bone

• Ridgid external immobilizing device that is molded to the contours of the body; must fir the shap of the injured limb to provide the best support

• Before application

  • General health assessment

  • Emotional status

  • Presenting signs and symptoms and condition of the area (prior to doing immobilzation)

• Monitoring of neurovascular status and for potential complications

• Treat lacerations and abrasions before cast, brace, splint

• Provide information about the purpose of treatment

• Prepare patient for application by explaining procedure

  • prepare them for what they might feel while being splinted or casted.

  • With the cast- It may feel weird because it is warm as you put it on and gets warmer as it dried. Then it gets hard, this may make them feel claustrophobic

• Assessing for neurovascular changes using “5 Ps”

  • Pain

  • Pallor

  • Pulselessness

  • Paresthesia

  • Paralysis

• Monitoring and treating pain