1. By
Dr Imran Javed.
Associate Professor Surgery.
Fiji National University.

6.  Vertebrae
 7 cervical (flexion, extension, lateral flexion,
rotation)
 1st-atlas
 2nd-axis
 12 thoracic (little movement)
 5 lumbar (less flexion than extension, some
rotation
 5 sacral (fused)
 3-4 coccyx (fused)

18.  Each vertebrae has a nerve that exits either
below or above it
 31 pairs of spinal nerves
 8 cervical nerves
 12 thoracic nerves
 5 lumbar
 5 sacral
 1 coccygeal

19.  Part of the CNS along with brain
 Contained within vertebral canal
 Extends from cranium to 1st-2nd
lumbar vertebrae
 Lumbar roots & sacral nerves for a
―horse-like tail‖ called cauda equina
 2 plexuses
 Brachial, lumbosacral

25.  L1,2,3-iliopsoas—hip
flexion
 L2,3,4-Quads—knee
extension
 L4-tibialis anterior—
dorsiflexion/inversion at
ankle
 L5-Extensor hallicus
longus, extensor digitorum
longus/brevis,
extension/inversion at
ankle
 S1-peroneus
longus/brevis-eversion
 S1,2-gastroc/soleus—
plantar flexion
 C5-deltoid—shoulder
abduction
 C5-6-biceps—elbow
Flexion
 C6-wrist extensors—
extension
 C7-triceps & wrist/finger
flexors—elbow extension,
wrist/finger flexion
 C8-finger flexors—finger
flexion
 T1-finger Abductors--
abduction

35.  Who’s at risk?
 ADULT MEN BETWEEN 15 AND 30 YEARS
 Anyone in a risk-taking occupation or lifestyle
 SCI in older clients increasing largely due to
MVAs
 Causes (in order of frequency)
 MVA
 Gunshot wounds/acts of violence
 Falls
 Sports injuries

36.  Airway & Cervical Spine.
 Breathing.
 Circulation.
 Disability.
 Environment & Exposure.
 Fluids.

37.  Below site of injury:
 Total lack of function
 Decreased or absent reflexes and flaccid
paralysis
 Lasts from a week to several months after
onset.
 End of spinal shock signaled by muscular
spasticity, reflex bladder emptying,
hyperreflexia.

38.  Flexion (bending
forward)
 Hyperextension
(backward)
 Rotation (either
flexion- or
extension-
rotation)
 Compression
(downward
motion)

39.  Complete transection
 Total paralysis and loss of sensory and motor
function although arms or rarely completely
paralyzed
 Incomplete (partial transection)
 Mixed loss of voluntary motor activity and
sensation
 Four patterns or syndromes

41.  Central cord syndrome More common
in older clients
 Frequently from hyperextension of
spine
 Weakness in upper and lower ext, but
greater in upper.
 Anterior cord syndrome
 Posterior cord syndrome
 Brown-Sequard syndrome

43.  Compression of the ant. Cord, usually
a flexion injury
 Sudden, complete motor paralysis at
lesion and below; decreased sensation
(including pain) and loss of
temperature sensation below site.
 Touch, position, vibration and motion
remain intact.

44.  Assoc with cervical
hyperextension injuries
 Dorsal area of cord is damaged
resulting in loss of proprioception
 Pain, temperature sensation and
motor function remain intact.

45.  Damage to one half of the cord on either side.
 Caused by penetrating trauma or ruptured disk.
ischemia (obstruction of a blood vessel), or
infectious or inflammatory diseases such as
tuberculosis, or multiple sclerosis. BSS may be
caused by a spinal cord tumor, trauma (such as a
puncture wound to the neck or back),.
 a rare SCI syndrome which results in
 weakness or paralysis (hemiparaplegia) on one
side of the body and
 a loss of sensation (hemianesthesia) on the
opposite side.

46.  Depend on the LEVEL and DEGREE of the injury!
 Quadriplegia occurs with C-1 through
 C-8 injuries.
 Paraplegia occurs with T-1 thru L-4.
 Respiratory
 C1 – C3: Absence of ability to breathe independently.
 C4 – poor cough, diaphragmatic breathing,
hypoventilation
 C5 – T6: decreased respiratory reserve
 T6 or T7 – L4: functional respiratory system with
adequate reserve.
 Cardiovascular:
 C1 – T5 shows decreased or absent SNS influence.
 BRADYCARDIA AND HYPOTENSION (due to vasodilation)

47.  The phrenic nerve stimulates the diaphragm to contract.
 Two phrenic nerves (right and left) - injury to one or the other
paralyzes contraction of only one half of the diaphragm but
even hemi- (half) paralysis can significantly interfere with
breathing for patients with lung disease.
 The nerve arises from branches of the C3,4, and 5 nerve roots.
 The phrenic nerve can be damaged by procedures exploring
the neck & upper back
 Loss of the phrenic nerve on either side results in paralysis of
the diaphragm on that side.
 Paralysis of the diaphragm on one side results in less inflation
of the lung on that side.
 Whether this is physiologically significant (producing
respiratory distress, hypoventilation/hypercapnia) depends on
other aspects of a patient's pulmonary physiology (namely
underlying chronic obstructive pulmonary disease
[emphysema, bronchitis], pneumonia, etc.).

48.  The longest of the cranial nerves-
exits out of the medulla and ends in
the abdomen
 It supplies sensory and motor function
to the pharynx
 Supplies motor function to the
muscles of the abdominal organs
 Provides parasympathetic activity to
the heart, lungs, and most of the
digestive system

49.  Atonic bladder with RETENTION in
spinal shock.
 Post acute phase – irritability causing
dribbling or frequent urination.
 Urinary infection and calculi from
retention and distention.
 INTERMITTENT CATHETERIZATION!

50.  Decreased motility
 Paralytic ileus
 Gastric distention – intermittent NG
suctioning
 Increased H2 – administer H2 inhibitors such
as Zantac or Pepcid in initial stages
 Carafate and antacids later as prophylaxis
 Intra-abdominal bleeding! Remember, no
pain or tenderness to warn you.
 Watch for impactions.

51.  Pressure ulcers!
 Muscle atrophy in flaccid paralysis
 Contractures in spastic paralysis
 Poikilothermism – the adjustment
of body temp to room
temperature
 Decreased ability to sweat below
lesion

52.  DVT common but not detected
easily
 Pulmonary embolism a significant
cause of death.
 Doppler studies, measurement of
extremity girth, impedance
plethysmography (what the heck
is this?)

53.  Goals are to
 Sustain life
 Prevent further cord damage
 Assessment of muscle groups; motor status
 Against gravity
 Against resistance
 Both sides of the body
 Ask to move legs, hands, fingers, wrists, then shrug
shoulders Thorough motor examination including
position sense and vibration.
 Sensory examination
 Pinprick starting at toes and working upward
 ALWAYS HAVE CLIENT CLOSE EYES OR LOOK AWAY! If
he can see what you’re doing, he will answer
accordingly.
 Assess for head injury and ICP
 X-ray, CT scan, EMG

54.  MRI provides Better Evaluation of Spinal cord.
 CT Scan is good for Bony Injury but radiation
exposure is involved.
 X-Ray is still good for initial evaluation &
Screening purposes with multiple views.
 Myelogram is outdated but still may be used
where MRI is not available.
 Tomograms may be of little value.
 Continuous Imaging (Fluoroscopy) may be
used during surgery & Manipulation of Spine.

55.  Surgical Therapy:
 Reduces injury and stabilizes the SC
 Done for Compression, Bony fragments in the cord,
Compound fracture, Penetrating trauma
 Vasopressors: to keep mean arterial pressure greater
than 80mm to 900mm/Hg so that PERFUSION TO
CORD is improved.
 MethylPrednisolone: Increases the recovery of
function. IV bolus then continuous IV over a 23 hour
period. Improves blood flow and reduces edema in
the SC.
 GI problems - zantac, tagamet, pepcid
 Bradycardia - atropine
 bladder spasticity - anticholinergics
 autonomic dysreflexia – blood pressure reduction