Spinal injuries
Spinal injuries: Excerpt from Handbook of Diseases
Aside from spinal cord damage, spinal injuries include fractures, contusions, and compressions of the vertebral column. These injuries usually are the result of trauma to the head or neck. The real danger lies in possible spinal cord damage. Spinal fractures most commonly occur in the 5th, 6th, and 7th cervical, 12th thoracic, and 1st lumbar vertebrae.
UNDER STUDY: The expression of some genes changes significantly in the early stages following spinal cord injury, indicating the complexity of secondary spinal cord injury. In studies, 45 genes changed significantly in the early stages following spinal cord injury — 22 genes up-regulated and 23 genes down-regulated in expression.
Causes
Most serious spinal injuries result from motor vehicle accidents, falls, diving into shallow water, and gunshot and stab wounds; less serious injuries, from lifting heavy objects, contact sports such as football, and minor falls. Spinal dysfunction may also result from hyperparathyroidism and neoplastic lesions.
Signs and symptoms
The most obvious symptom of spinal injury is muscle spasm and back pain that worsens with movement. In cervical fractures, pain may produce point tenderness; in dorsal and lumbar fractures, it may radiate to other body areas such as the legs.
If the injury damages the spinal cord, clinical effects range from mild paresthesia to quadriplegia and shock. After milder injuries, such symptoms may be delayed for several days or weeks. During this time, the patient may unknowingly aggravate the condition
CLINICAL TIP: Because the diaphragm is innervated by cervical levels 1 to 4, damage to this level will result in respiratory compromise. Also, be aware of edema at levels C5 to C7, which may expand up into these areas, resulting in problems.
Complications
The following are complications of spinal injuries: autonomic dysreflexia, spinal shock, and neurogenic shock.
Also known as autonomic hyperreflexia, autonomic dysreflexia is a serious medical condition that occurs after resolution of spinal shock. Emergency recognition and management is a must. Suspect autonomic dysreflexia in the patient with a history of spinal cord trauma at level T6 and above who exhibits cold or goose-fleshed skin below the lesion level, bradycardia, and hypertension. The hypertension is generally accompanied by severe, pounding headache.
Some dysreflexia is caused by noxious stimuli, most commonly a distended bladder or skin lesion. Treatment focuses on eliminating the stimulus; rapid identification and removal may avoid the need for pharmacologic control of the headache and hypertension.
Spinal shock is the loss of autonomic, reflex, motor, and sensory activity below the level of the cord lesion. It occurs secondary to damage of the spinal cord. Signs of spinal shock include flaccid paralysis, loss of deep tendon and perianal reflexes, and loss of motor and sensory function.
Until spinal shock has resolved (usually 1 to 6 weeks after injury), the extent of actual cord damage can’t be assessed. The earliest indicator of spinal shock resolution is the return of reflex activity.
This temporary loss of autonomic function below the level of injury produces cardiovascular changes. Signs of neurogenic shock include orthostatic hypotension, bradycardia, and loss of the ability to sweat below the level of the lesion. This abnormal vasomotor response occurs secondary to disruption of sympathetic impulses from the brain stem to the thoracolumbar area and is seen most commonly in cervical cord injury.
Diagnosis
Typically, a diagnosis is based on the patient history, the physical examination, X-rays and, possibly, lumbar puncture, computed tomography (CT) scan, and magnetic resonance imaging (MRI).
❑ Patient history may reveal trauma, a metastatic lesion, an infection that could produce a spinal abscess, or an endocrine disorder.
❑ Physical examination (including a neurologic evaluation) locates the level of injury and detects cord damage.
❑ Spinal X-rays, the most important diagnostic measure, locate the fracture.
❑ Lumbar puncture may show increased cerebrospinal fluid pressure from a lesion or trauma in spinal compression.
❑ CT scan or MRI can locate the spinal mass.
Treatment
The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage; other treatment is supportive. Cervical injuries require immobilization, using sandbags on both sides of the patient’s head, a hard cervical collar, or skeletal traction with skull tongs or a halo device. When patients show clinical evidence of cord injury, high doses of methylprednisone are started.
Supportive treatment
Treatment of stable lumbar and dorsal fractures consists of bed rest on firm support (such as a bed board), analgesics, and muscle relaxants until the fracture stabilizes (usually 10 to 12 weeks). Later treatment includes exercises to strengthen the back muscles and a back brace or corset to provide support while walking.
An unstable dorsal or lumbar fracture requires a plaster cast, a turning frame and, in severe fracture, laminectomy and spinal fusion.
Other treatment
When the damage results in compression of the spinal column, neurosurgery may relieve the pressure. If the cause of compression is a metastatic lesion, chemotherapy and radiation may relieve it. Surface wounds accompanying the spinal injury require tetanus prophylaxis unless the patient has had recent immunization.
Special considerations
❑ In all spinal injuries, suspect cord damage until proven otherwise.
❑ During the initial assessment and X-rays, immobilize the patient on a firm surface, with sandbags on both sides of his head. Tell him not to move; avoid moving him, because hyperflexion can damage the cord.
❑ If you must move the patient, get at least one other member of the staff to help you logroll him to avoid disturbing body alignment.
❑ Throughout the assessment, offer comfort and reassurance. Remember, the fear of possible paralysis will be overwhelming. Allow a family member who isn’t too distraught to accompany the patient and talk to him quietly and calmly.
❑ If the injury requires surgery, administer prophylactic antibiotics. Catheterize the patient to avoid urine retention, and monitor defecation patterns to avoid impaction.
❑ Explain traction methods to the patient and his family, and reassure them that traction devices don’t penetrate the brain. If the patient has a halo or skull-tong traction device, clean pin sites daily, trim hair short, and provide analgesics for persistent headaches.
❑ During traction, turn the patient often to prevent pneumonia, embolism, and skin breakdown; perform passive range-of-motion exercises to maintain muscle tone. If available, use an automatic rotational bed to facilitate turning, to avoid further spinal cord injury, and to promote adequate lung expansion.
❑ Turn the patient on his side during feedings to prevent aspiration. Create a relaxed atmosphere at mealtimes.
❑ Suggest appropriate diversionary activities to fill your patient’s hours of immobility.
❑ Watch closely for neurologic changes. Changes in skin sensation and loss of muscle strength could point to pressure on the spinal cord, possibly as a result of edema or shifting bone fragments.
❑ If damage occurred to the spinal cord, involve a rehabilitation specialist as soon as possible to assist with a detailed and personal care plan.
❑ Before discharge, instruct the patient about continuing analgesics or other medication, and stress the importance of regular follow-up examinations.
❑ To help prevent a spinal injury from becoming a spinal cord injury, educate fire fighters, police officers, paramedics, and the general public about the proper way to handle such injuries.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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