membranes, as well as cord swelling, in the area of impact initiate a cascade of events that result in disruption of au-toregulation of blood flow and axonal propagation leading, eventually, to spinal shock. Toxins that are released through broken cell membranes in the spinal grey matter, as well as electrolyte shifts in the area of injury, spark a process of secondary injury that eventually spreads to white matter, killing viable neural cells and further disrupting axon flow at, and below, the level of impact. The processes involved in non-traumatic spinal cord injury may bear some similarity to this cascade of events, but are, in their de-tails, largely specific to the disease that is responsible for the injury. Acute assessment of an SCI includes use of functional grading scales and im-aging – mostly MRI – to determine the level and extent of injury, whether the in-jury is complete (i.e., no sensation and/ or function below the level of injury) or partial (i.e., some preservation of neural function below the level of injury), and presence of comorbidities (including brain injuries, as these are a common combination). Electrophysiology may be employed to help characterize the injury if the patient is not responsive. Treatment, at this phase, is largely aimed at neuroprotection and sheer preservation of life. Neuroprotective strategies mostly involve focusing on the effects of secondary injury. Pharmaco-logical agents are employed to assist with inflammation, electrolyte imbalance and removal of toxic agents – being expelled in large quantities from disrupted cells in the area of injury. Surgery may be indi-cated, either to remove fragments threat-ening the spinal canal and/or to stabilize the spine. External stabilization/traction devices have also been employed. The post-injury course experienced by an SCI patient varies, in its many el-ements, from patient to patient, and re-quires the combined efforts of a team of practitioners and therapists in medical and rehabilitative disciplines. Acute and long-term course and care By Angela Sarro The early stages Some SCI individuals will require manage-ment in the intensive care unit with venti-www.canadianchiropractor.ca latory support un-til their respiratory function improves. If ventilation is prolonged, then a tracheostomy may be required. Inva-sive monitoring, which includes in-Angela Sarro travenous therapy, arterial lines, central venous catheters and cardiac monitoring, is not uncommon. Some individuals may be placed in halo traction to try to realign the spinal column prior to any surgical intervention. Astute nursing care during the acute phase is of utmost importance to provide the neces-sary day-to-day care, along with emotional support, to help the individual cope with his/her injury. Some individuals may require the placement of a nasogastric or gastrosto-my tube for enteral feeding. These mea-sures are usually temporary. The assis-tance of a speech language pathologist will be crucial to monitor swallowing mechanisms for safety of oral feeding. Once oral intake of nutrients is deemed safe, the diet is advanced from liquids to solid foods as tolerated. Because sensory impairment and motor function are often affected, the SCI individ-ual is prone to skin breakdown. The use of a special pressure-reducing mattress, and a regular turning schedule, often every two hours to relieve pressure areas, is an impor-tant aid in preventing skin breakdown. Bowel and bladder management are important aspects both in the early stages and long term. Initially, while in hospital, individuals will have a Foley catheter in place. Once the individual is medically stable, the catheter is removed and the bladder is monitored for any spontane-ous activity. If unable to void, an inter-mittent catheterization protocol is set up. An effective bladder management program is important to prevent urinary infections and allow the bladder to be emptied at a convenient time. Prevention of infection is very im-portant in SCI. Three common infec-tions include urinary tract infection, pneumonia and skin breakdown. These three in combination could result in death due to the impact on the indi-vidual’s overall ability to combat them. Physiotherapy and occupational therapy in the acute care phase focus on early mobilization of the individual. This will become more of a focus in re-habilitation, at which point methods for learning to become as independent as possible will be important. Considerations in the short and long term A spinal cord injury is a devastating event for any individual. It impacts both physical and psychological as-pects of one’s day-to-day activities. An individual who was completely inde-pendent in all facets of life is now de-pendent on someone else to do even the simplest things. This dependency varies based on the extent of injury. An individual with an incomplete SCI may be able to regain some of the initial loss of function to varying degrees, whereas, a complete spinal cord injury will require the indi-vidual to have daily support and care for most activities for the remainder of their lives. Most patients require day-to-day care for bathing, turning, eating and toi-leting. The simplest things, such as eat-ing, or getting in and out of bed, may require the assistance of one or more people. Psychosocial issues faced by the SCI individual, both in the short and long term, include anxiety, body image dis-turbance, grieving, ineffective coping, feelings of powerlessness and depres-sion. Quite often during the acute peri -od, individuals display feelings of anger, resentment and denial. Depending on previous coping mechanisms or situ-ations they may have been faced with, this period varies. Essential at this time is ongoing support and reassurance by the family and health-care staff, spiri-tual care and outside support groups to help with coping mechanisms. Living with an SCI can be very stress-ful. Stress-related symptoms can delay recovery and make other problems, such as pain and spasticity, worse. Ad-dressing this stress with a specialist, such as a rehab psychologist, can help with the development of skills and strat-egies for managing stress. In the short term, survival from the injury itself is the main focus. If the trauma resulted in other injuries, the transition from acute care to rehabilita-tion may be prolonged. Often the big-gest hurdle for the individual, following CANAdiAN CHiROpRACTOR | MAY 2011 • 9
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