Section 6. Brain, Spinal Cord, and Nerve Disorders

Chapter 93. Spinal Cord Disorders

Topics: Introduction | Accident-Related Injuries | Spinal Cord Compression | Cervical Spondylosis | Spinal Hematoma | Syrinx | Hereditary Spastic Paraparesis | Acute Transverse Myelitis | Blockage of the Blood Supply | Subacute Combined Degeneration of the Spinal Cord

Accident-Related Injuries

When the spinal cord is injured in an accident, it may be severed, jarred (by a blunt injury), or compressed (by broken bones, swelling, or bleeding).

Because of the way the cord is organized, injury to the spinal cord always results in loss of function below the site of the injury. For example, if the spinal cord is severely damaged in the middle of the back, the arms function normally but the legs may be paralyzed. Sensation in the affected area as well as muscle control is usually lost.

Reflex movements that are not controlled by the brain remain intact or may even be exaggerated below the site of the injury. An example is the knee jerk reflex, in which a tap with a small hammer just below the knee normally causes the lower leg to jerk upward. When the spinal cord is injured, a spastic type of paralysis with leg spasms may result: The muscles controlled by the knee jerk reflex tighten, feel hard, and twitch from time to time, causing the legs to jerk.

Paralysis and loss of sensation may be partial or total, temporary or permanent. An injury that severs the cord or destroys nerve pathways in the spinal cord causes permanent loss, but a blunt injury that jars the cord may cause temporary loss, which can last days, weeks, or months. Recovery is more likely if paralysis is incomplete and movement or sensation returns during the first week after the injury. If function is not regained within 6 months, loss is likely to be permanent.

People who are weak or paralyzed because of a spinal cord injury are at risk of developing bedsores, urinary tract infections, and pneumonia.

Treatment

The first goal is to prevent further damage. Emergency personnel take great care when moving a person with a possible spinal cord injury. Usually, the person is strapped to a firm board and carefully padded to prevent movement. When the spinal cord is damaged, even slight shifting of the spine increases the possibility of permanent paralysis.

Usually, doctors immediately give corticosteroids (such as methylprednisolone) by injection to help prevent swelling around the injury. The drugs must be started within 8 hours of the injury to be effective and should be continued for about 24 hours. Muscle relaxants (such as cyclobenzaprine) and analgesics (such as ibuprofen) may be given to treat spasms. If the spine has been fractured or otherwise injured, a surgeon may implant steel rods to stabilize it because further movement may cause additional injury. A neurosurgeon removes any blood and bone fragments that have accumulated around the spinal cord.

While the spinal cord or spine is healing, skilled nursing care is needed to prevent complications. To help prevent bedsores (pressure sores (see Section 18, Chapter 205)), nurses can inspect the person's skin daily, keep the skin dry and clean, and turn the person frequently. When necessary, a special bed called a Stryker frame is used. It can be turned to shift pressure on the body from front to back and from side to side. A urinary catheter may be needed if the person is immobile and cannot use a toilet. To help reduce the risk of a urinary tract infection, nurses can use sterile techniques when the catheter is inserted and apply antimicrobial ointments or solutions daily. To help reduce the risk of pneumonia, therapists and nurses can teach the person deep breathing exercises and use techniques such as placing the person at an angle to help drain secretions that accumulate in the lungs (postural drainage).

Extensive loss of body functions can be devastating, causing depression and loss of self-esteem. Learning exactly what has happened and what to expect in the near and distant future helps people cope with the loss. Physical and occupational therapy (see Section 1, Chapter 7) helps preserve muscle function. Therapists teach people special techniques to help them overcome lost functions. For most people, compassionate and skilled nursing care, psychologic counseling, and emotional support from family members and close friends help. Family members may also benefit from counseling.