Definition

Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either
temporary or permanent, in its normal motor, sensory, or autonomic function. The
International Standards for Neurological and Functional Classification of Spinal Cord
Injury is a widely accepted system describing the level and extent of injury based on
a systematic motor and sensory examination of neurologic function. The following
terminologies have developed around the classification of SCI:

• Tetraplegia (replaces the term quadriplegia) - Injury to the spinal cord in the
cervical region, with associated loss of muscle strength in all 4 extremities
• Paraplegia - Injury in the spinal cord in the thoracic, lumbar, or sacral
segments, including the cauda equina and conus medullaris

SCI can be sustained through different mechanisms, with the following 3 common
abnormalities leading to tissue damage:

• Destruction from direct trauma

• Compression by bone fragments, hematoma, or disk material
• Ischemia from damage or impingement on the spinal arteries

Edema could ensue subsequent to any of these types of damage. The different
clinical presentations of the above causes of tissue damage are explained further
below.

Spinal shock

Spinal shock is a state of transient physiologic (rather than anatomic) reflex

depression of cord function below the level of injury, with associated loss of all
sensorimotor functions. An initial increase in blood pressure due to the release of
catecholamines, followed by hypotension, is noted. Flaccid paralysis, including of
the bowel and bladder, is observed, and sometimes sustained priapism develops.
These symptoms tend to last several hours to days until the reflex arcs below the
level of the injury begin to function again (eg, bulbocavernosus reflex, muscle
stretch reflex [MSR]).

Neurogenic shock

Neurogenic shock is manifested by the triad of hypotension, bradycardia, and

hypothermia. Shock tends to occur more commonly in injuries above T6, secondary
to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal
tone, leading to a decrease in vascular resistance, with associated vascular
dilatation. Neurogenic shock needs to be differentiated from spinal and hypovolemic
shock. Hypovolemic shock tends to be associated with tachycardia.

Motor strengths and sensory testing

The extent of injury is defined by the ASIA Impairment Scale (modified from the
Frankel classification), using the following categories :
 • A - Complete: No sensory or motor function is preserved in sacral segments
S4-S5.4
• B - Incomplete: Sensory, but not motor, function is preserved below the
neurologic level and extends through sacral segments S4-S5.
• C - Incomplete: Motor function is preserved below the neurologic level, and
most key muscles below the neurologic level have muscle grade less than 3.
• D - Incomplete: Motor function is preserved below the neurologic level, and
most key muscles below the neurologic level have muscle grade greater than
or equal to 3.
• E - Normal: Sensory and motor functions are normal.

Perform a rectal examination to check motor function or sensation at the anal

mucocutaneous junction. The presence of either is considered sacral-sparing.

Definitions of complete and incomplete SCI are based on the above ASIA definition
with sacral-sparing.

• Complete - Absence of sensory and motor functions in the lowest sacral

segments
• Incomplete - Preservation of sensory or motor function below the level of
injury, including the lowest sacral segments

Other classifications of SCI include the following:

• Central cord syndrome often is associated with a cervical region injury and
leads to greater weakness in the upper limbs than in the lower limbs, with
sacral sensory sparing.
• Brown-Séquard syndrome, which often is associated with a hemisection
lesion of the cord, causes a relatively greater ipsilateral proprioceptive and
motor loss, with contralateral loss of sensitivity to pain and temperature.
• Anterior cord syndrome often is associated with a lesion causing variable loss
of motor function and sensitivity to pain and temperature; proprioception is
preserved.
• Conus medullaris syndrome is associated with injury to the sacral cord and
lumbar nerve roots leading to areflexic bladder, bowel, and lower limbs, while
the sacral segments occasionally may show preserved reflexes (eg,
bulbocavernosus and micturition reflexes).
• Cauda equina syndrome is due to injury to the lumbosacral nerve roots in the
spinal canal, leading to areflexic bladder, bowel, and lower limbs.

Causes

Spinal cord trauma can be caused by any number of injuries to the spine. They can
result from motor vehicle accidents, falls, sports injuries (particularly diving into
shallow water), industrial accidents, gunshot wounds, assault, and other causes.

A minor injury can cause spinal cord trauma if the spine is weakened (such as from
rheumatoid arthritis or osteoporosis) or if the spinal canal protecting the spinal cord
has become too narrow (spinal stenosis) due to the normal aging process.
Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or
the disks have been damaged. Fragments of bone (for example, from broken
vertebrae, which are the spine bones) or fragments of metal (such as from a traffic
accident) can cut or damage the spinal cord.

Direct damage can also occur if the spinal cord is pulled, pressed sideways, or
compressed. This may occur if the head, neck, or back are twisted abnormally
during an accident or injury.

Bleeding, fluid accumulation, and swelling can occur inside the spinal cord or
outside the spinal cord (but within the spinal canal). The accumulation of blood or
fluid can compress the spinal cord and damage it.

Most spinal cord trauma happens to young, healthy individuals. Men ages 15-35 are
most commonly affected. The death rate tends to be higher in young children with
spinal injuries.

Risk factors include participating in risky physical activities, not wearing protective
gear during work or play, or diving into shallow water.

Older people with weakened spines (from osteoporosis) may be more likely to have
a spinal cord injury. Patients who have other medical problems that make them
prone to falling from weakness or clumsiness (from stroke, for example) may also
be more susceptible.

Symptoms

Symptoms vary somewhat depending on the location of the injury. Spinal cord
injury causes weakness and sensory loss at and below the point of the injury. The
severity of symptoms depends on whether the entire cord is severely injured
(complete) or only partially injured (incomplete).

The spinal cord doesn't go below the 1st lumbar vertebra, so injuries at and below
this level do not cause spinal cord injury. However, they may cause "cauda equina
syndrome" -- injury to the nerve roots in this area.

CERVICAL (NEAR THE NECK) INJURIES

When spinal cord injuries occur near the neck, symptoms can affect both the arms
and the legs:

• Breathing difficulties (from paralysis of the breathing muscles)

• Loss of normal bowel and bladder control (may include constipation,
incontinence, bladder spasms)
• Numbness
• Sensory changes
• Spasticity (increased muscle tone)
• Pain
• Weakness, paralysis
THORACIC (CHEST-LEVEL) INJURIES

When spinal injuries occur at chest level, symptoms can affect the legs:

• Breathing difficulties (from paralysis of the breathing muscles)

• Loss of normal bowel and bladder control (may include constipation,
incontinence, bladder spasms)
• Numbness
• Sensory changes
• Spasticity (increased muscle tone)
• Pain
• Weakness, paralysis

Injuries to the cervical or high-thoracic spinal cord may also result in blood pressure
problems, abnormal sweating, and trouble maintaining normal body temperature.

LUMBAR SACRAL (LOWER-BACK) INJURIES

When spinal injuries occur at the lower-back level, varying dgrees of symptoms can
affect the legs:

• Loss of normal bowel and bladder control (may include constipation,

incontinence, bladder spasms)
• Numbness
• Pain
• Sensory changes
• Spasticity (increased muscle tone)
• Weakness and paralysis

Treatment

A. Medical

B. Surgical

C. Nursing

Medical management

A spinal cord trauma is a medical emergency requiring immediate treatment to

reduce the long-term effects. The time between the injury and treatment is a critical
factor affecting the eventual outcome.

Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce

swelling that may damage the spinal cord. If spinal cord compression is caused by a
mass (such as a hematoma or bony fragment) that can be removed or brought
down before there is total destruction of the nerves of the spine, paralysis may in
some cases be reduced or relieved. Ideally, corticosteroids should begin as soon as
possible after the injury.
Extensive physical therapy, occupational therapy, and other rehabilitation
interventions are often required after the acute injury has healed. Rehabilitation
assists the person in coping with disability that result from spinal cord trauma.

Spasticity can be reduced by many oral medications, medications that are injected
into the spinal canal, or injections of botulinum toxins into the muscles. It is
important to treat pain with analgesics, muscle relaxants, or physical therapy
modalities.

Anatomic realignment is important. Spinal traction may reduce dislocation and/or

may be used to immobilize the spine. The skull may be immobilized with tongs
(metal braces placed in the skull and attached to traction weights or to a harness on
the body).

Surgical management

Surgery may be necessary. This may include surgery to remove fluid or tissue that
presses on the spinal cord (decompression laminectomy). Surgery may be needed
to remove bone fragments, disk fragments, or foreign objects or to stabilize
fractured vertebrae (by fusion of the bones or insertion of hardware).

Nursing management

1. Assessment
History
-General: MIVT (Mechanism, Injury, Vital Signs, Treatment)
-Specific: 1-neck or back pain?
2-Spontaneous movement in extremities or altered sensation?
(Hematoma, edema)

2. Physical Assessment
Assessment of airway, breathing, circulation, and disability.
- Inspection:
Assess breathing effectiveness and rate of respirations.
• C3 - C5 interferes with diaphragmatic function.
• C6 spares the diaphragm, edema formation and hemorrhage may affect
respiratory effort.
• T2-T8 may spare the diaphragm but result in loss of intercostal muscle
function.
- Palpation
Palpate pulse rate and quality.
• Palpate skin temperature.
• Assess all four extremities for muscle strength.
-Assess sensory function
 • The use of a touch stimulus to determine levels of sensory function should
begin at the area of no feeling and proceed toward the area of feeling. This
will aid in localizing the level of injury.
• Gently palpate the vertebral column for pain, tenderness, or step deformities
between vertebrae.
• Palpate the anal sphincter for presence or absence of tone.
• Assess for sacral sparing.

Priorities of Nursing Care:

1. Maximize respiratory function.
2. Prevent further injury to spinal cord.
3. Promote mobility/independence.
4. Prevent or minimize complications.
5. Support psychological adjustment of patient/SO.
6. Provide information about injury, prognosis and expectations, treatment needs,
possible and preventable complications.

Nursing Diagnoses for patient with Spinal Cord Injury:

a. Ineffective airway clearance

Interventions:
- Open airway with jaw Thrust or chin lift while maintaining cervical spine
immobilization.
- Suction airway.
-Obtain blood sample for ABGs as indicated.
-Assist with endotracheal intubation
b. Impaired gas exchange
Interventions
- Administer oxygen via a nonrebreather mask.
-Ventilate with 100% oxygen via a bag-valve-mask device
-Monitor oxygen saturation with continuous pulse oximetry
-Assist with intubation
c. Risk for aspiration
Interventions
-Maintain spinal immobilization and stabilization
-Position patient
-Open and clear airway
 -Insert oro- or nasopharyngeal airway
-Consider and assist with endotracheal intubation, as indicated
-Insert gastric tube and evacuate stomach contents.
d. fluid volume deficit
Interventions
- Cannulate two veins with large- bore catheters and initiate infusion of
lactated Ringer’s solution or normal saline; monitor rate carefully

- Consider vasopressors as needed

- insert urinary catheter
- Monitor hemodynamics
e. altered tissue perfusion
Interventions
-control bleeding
- Infusion of IV fluids
-Blood transfusion as ordered
f. Ineffective coping
Interventions
-Provide support to the patient and family
-Provide information and answer questions
-Make appropriate referrals for support
g. Impaired skin integrity.
Interventions
- Remove patient from backboard as soon as possible
-Avoid allowing a paralyzed patient to lie on backboard for more than 2 hours
-Consider placement on special bed

Evaluation and Ongoing Assessment

- Continuously observe patient's breathing pattern.
o Patients with injuries at high levels are at risk for respiratory failure.
o Observe strength of cough effort.
- Continuously observe patient for motor and sensory changes due to cord
edema or hemorrhage, which may further compromise cord function.
o Test patient's motor ability by asking him/her to spread fingers, grip
your hands, shrug shoulders, etc.
 o Test sensory level by gently pinching the skin at shoulders and
progressing down sides; ascertain level at which patient can no longer
feel pinch.
o Note presence/absence of sweating.
o Carefully record findings in patient's clinical record; report changes in
patient's motor/sensory level immediately to professional nurse.
-Monitor temperature to avoid hypothermia.

• Be alert for signs of spinal shock and report immediately.

o Spinal shock represents a sudden loss of continuity between the spinal
cord and higher nerve centers.
o It is characterized by a complete loss of motor, sensory, reflex, and
autonomic activity below the level of the injury.
o Though temporary, spinal shock may last for several weeks.
• If turning is allowed and patient is not on a turning frame or turning bed, the
patient must be carefully log-rolled with the spine maintained in alignment.
• Patient will require passive range of motion exercises.
• Assist with active rehabilitation procedures when patient is stable.
o Program is designed according to neurological deficit.
o Usually involves 6 weeks of gradual mobilization with brace or cast,
depending upon level of injury.
• Provide constant encouragement and psychological support to the patient
with a spinal cord injury.