# Presentation: 427970

## Spinal Cord Injury: What Now?Expected Outcomes.

- Maura Nee RNP
- Elizabeth Tammaro RN, CRRN
- VA Boston Healthcare System
- SCI Out Patient Clinic

## Objectives:

- Discuss Anatomy and Physiology of the Spinal Cord
- Understand the Impact of Neurologic Level of Injury (LOI) and ASIA Classification
- Discuss Expected Functional Outcomes Specific to LOI
- Understand Role of the Nurse in Achieving Functional Outcomes

## SCI Statistics (2002)

- 250,000 in USA
- Paraplegic: 52%
- Quadriplegia: 47%
- New SCI/yr: 11,000
- Male: 82%
- 16yr-30yr: 56%

- Causes
- MVA: 37%
- Violence: 28%
- Falls: 21%
- Sports: 6%
- Other: 8%
- 89%: D/C’d home

## Anatomy of the Spine

- Vertebrae
- Body
- Front section, shaped like drum
- Supports weight
- Lamina
- Towards the back
- Boney arch surrounds spinal canal
- Spinous process
- Boney process from arch
- Points of attachment for muscles and ligaments
- Discs
- Cushions between vertebrae

## Anatomy of  the Spine

-  Vertebrae:
- 7 Cervical
- Flexion, extension, bending and turning of head
- 12 Thoracic
- Chest region, allows mostly for rotation
- 5 Lumbar
- Larger boney structures to support added wgt
-  5 Sacral
- Fused together
- Coccyx

## Anatomy of the Cord

- Cervical Cord
- C1-C2:
- C3-4: Phrenic nucleus
- C4: Deltoids
- C4-5: Biceps
- C6: Wrist extensors
- C7: Triceps
- C8: Wrist extensors
- C8-T1: Hand muscles

## Anatomy of the Cord

- Thoracic Cord
- Intercostal muscles and associated dermatones
- Lumbarsacral
- Starts at T9 and continues to L2
- Innervates hips, legs, buttocks and anal region
- Cauda Equina (horses tail)
- Spinal cord ends at L2
- Tip called conus, below conus a spray of spinal roots

## Dermatomes/Sensory Level

- Dermatome:
- patch of skin innervated by a given spinal cord level

##                                                                                      C2 to C4. The C2 dermatome 

## Myotomes/Motor Level

- Myotome:
- Spinal nerve roots which innervates muscles groups
- Most muscles are innervated by more than one root

## Slide 15

## ASIA Impairment Scale

**ASIA A: Complete:** no motor or sensory function is preserved in the sacral segments S4-S5
**ASIA B: Incomplete:** sensory but NOT motor function is preserved below the neurological level and includes the sacral segments
**ASIA C: Incomplete:** motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade <3
**ASIA D: Incomplete:** motor function is preserved w/ muscle grade > 3
**ASIA E: Normal**

## Definition of Disability

**Tetraplegia** (preferred to quadriplegia)
- Refers to impairment or loss of motor/sensory function in cervical segments of the spinal cord
- Impairment of function in arms, trunk, legs and pelvic organs
- ASIA Scale vs quadriparesis

## Definition of Disability

**Paraplegia**
- Refers to impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
- Arm function spared
- Possible impairment of function in trunk, legs and pelvic organs
- ASIA Scale vs paraparesis

## Clinical Syndromes

**Central Cord Syndrome: **
**lesion occurring almost exclusively in the cervical region**
**Sacral sensory sparing**
**Weakness > UE vs LE**
**Brown-Sequard Syndrome:**
**Lesion that produces ipsilateral, proprioceptive and motor loss and contralateral loss of sensitivity to pain and temp**

## Clinical Syndromes

**Anterior Cord Syndrome:**
**Lesion that produces variable loss of motor function and of sensitivity while preserving proprioception**
**Cauda Equina Syndrome:**
**Injury to the lumbosacral nerve roots w/ in the neurocanal resulting in areflexive bladder, bowel and lower limbs**

## Achievement of Functional Goals

- Age
- Body type
- Comorbidities
- Prior athletic sense
- Fatigue level

- Type of stabilization
- HX HO/POA
- Spasticity
- Psychosocial factors
- Nutrition

## Functional Outcomes

- Motor/sensory recovery
- Ability to perform or direct ADLs
- Social reintegration
- Quality of life

## Functional Outcomes

- LEVEL C1-C3
- Limited head/neck movement
- Rotate/flex neck (sternocleidomastoid)
- Extend neck (cervical paraspinals)
- Speech and swallowing (neck accessories)
- Total paralysis of trunk,UE and LE

## LEVEL: C1-3

- 24 hr care needs
- Able to direct care needs
- ADLs
- Ventilator dependent
- Impaired communication
- Dependent for all care needs
- Mobility
- Power wheelchair
- Hoyer lift

## LEVEL: C1-C3

- Equipment Needs
- Adapted computer
- Bedside/portable ventilator
- Suction machine
- Specialty bed
- Hoyer
- Reclining shower chair

## <footer>

- <date/time>

## Functional Outcomes

- LEVEL: C4
- Head and neck control (cerv paraspinals)
- Shoulder shrug (upper traps)
- Inspiration(diaphragm)
- Lack of shoulder control (deltoids)
- Paralysis of trunk, UE and LE
- Inability to cough, low respiratory reserve

## LEVEL: C4

- 24 hr care needs
- Able to direct care needs
- ADLs
- May or may not be vent dependent
- Improved communication
- Assisted cough
- Dependent for all care needs
- Mobility
- Power wheelchair
- Hoyer lift

## LEVEL: C4

- Equipment Needs
- Adapted computer
- Bedside/portable ventilator as needed
- Suction machine
- Specialty bed
- Hoyer
- Reclining shower chair

## <footer>

- <date/time>

## <footer>

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## Functional Outcomes

- LEVEL: C5
- Shoulder control (deltoids)
- Elbow flexion (biceps/elbow flexors)
- Supinate hands (brachialis and brachioradialis)
- Lack elbow extension and hand pronation
- Paralysis of trunk and LE

## LEVEL: C5

- 10hrs personal care need
- 6 hrs homemaking assistance
- ADLs
- Set-up/equipment: eating, drinking, face wash and teeth
- Assisted cough
- Dependent for bowel, bladder and lower body hygiene
- Dependent for bed mobility and transfers

## LEVEL: C5

- Mobility
- Hoyer or stand pivot
- Power wheelchair w/ hand controls
- Manual wheelchair
- Drive motor vehicle w/ hand controls
- Equipment Needs
- Power and manual wheelchairs
- Adaptive splints/braces
- Page turners/computer adaptations

## <footer>

- <date/time>

## Functional Outcomes

- LEVEL: C6
- Wrist extension (extensor carpi ulnaris and extensor carpi radialis longus/brevis)
- Arm across chest (clavicular pectrocialis)
- Lack elbow extension (triceps)
- Lack wrist flexion
- Lack hand control
- Paralysis of trunk and LE

## LEVEL: C6

- 6 hrs personal care needs
- 4hrs homemaking assistance
- ADLs
- Assisted cough
- Set-up for feeding, bathing and dressing
- Independent pressure relief, turns and skin assessment
- May be independent for bowel/bladder care

## LEVEL: C6	

- Mobility
- Independent slide board transfer
- Manual wheelchair
- Drive with adaptive equipment

## <footer>

- <date/time>

## Functional Outcomes		

- LEVEL: C7
- Elbow flexion and extension (biceps/triceps)
- Arm toward body (sternal pectoralis)
- Lack finger function
- Lack trunk stability

## LEVEL: C7	

- 6hrs personal care needs
- 2hrs homemaking assistance
- ADLs
- More effective cough
- Fewer adaptive aids
- Independent w/ all ADLs
- May need adaptive aids for bowel care

## LEVEL: C7

- Mobility
- Manual wheelchair
- Transfers without adaptive equipment

## <footer>

- <date/time>

## Functional Outcomes

- LEVEL: C8-T1
- Increased finger and hand strength
**Finger flexion (flexor digitorum)**
**Finger extension (extensor communis)**
**Thumb movement (policus longis brevis)**
**Separate fingers (introssi separates)**

## LEVEL: C8-T1

- 4hrs personal care needs
- 2hrs homemaking assistance
- ADLs
- Independent w/ or w/o assistive devices
- Assist w/ complex meal prep and home management
- Mobility
- Manual wheelchair

## <footer>

- <date/time>

## Functional Outcomes

- LEVEL: T2-T6
- Normal motor function of head, neck, shoulders, arms, hands and fingers
- Increased use of intercostals
- Increase trunk control (erector spinae)

## LEVEL: T2-T6

- 3hrs personal care needs/homemaking
- ADLs
- Independent in personal care
- Mobility
- Manual wheelchair
- May have limited walking with extensive bracing
- Drive with hand controls

## <footer>

- <date/time>

## Functional Outcomes

- LEVEL: T7-T12
- Added motor function
- Increased abdominal control
- Increased trunk stability

## LEVEL: T7-T12

- 2 hrs personal care needs/homemaking
- ADLs
- Independent
- Improved cough
- Improved balance control
- Mobility
- Manual wheelchair
- May have limited walking with bracing
- Driving with hand controls

## <footer>

- <date/time>

## Functional Outcomes

- LEVEL: L2-L5
- Added motor function in hips and knees
**L2 Hip flexors (iliopsas)**
**L3 Knee extensors (quadriceps)**
**L4 Ankle dorsiflexors (tibialis anterior)**
**L 5 Long toe extensors (ext hallucis longus)**

## LEVEL: L2-L5

- May need 1hr personal care/homemaking
- ADLs
- Independent
- Mobility
- Manual wheelchair
- May walk short distance with braces and assistive devices
- Driving with hand controls

## <footer>

- <date/time>

## Functional Outcomes

- LEVEL: S1-S5
- Ankle plantar flexors (gastrocnemius)
- Various degrees of bowel, bladder and sexual function
- Lower level equals greater function

## LEVEL: S1-S5

- No personal or homemaker needs
- ADLs
- Independent
- Mobility
- Increased ability to walk with less adaptive/supportive devices
- Manual w/c for distance

## <footer>

- <date/time>

## Functional Outcomes

- Achieving maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life

## Functional Outcomes

- Power Point presentation can be found:
-       www1.va.gov/spinalcordboston/