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Traumatic Spinal Cord Injury
Marnie Quick, RN, MSN, CNRN
A. Pathophysiology/etiology
Normal spinal cord as it relates to SCI
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Spinal cord begins at
the foramen magnum
in the cranium
Cord ends at the L1L2 vertebra level
Spinal nerves
continue to the last
sacral vertebra
Normal protection of spinal cord from
injury:
Bones- vertebral column
Protection of spinal cord from injury
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Disc between
vertebra
Internal and external
ligaments
Protection of Spinal Cord from Injury
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Meninges
CSF in subarachnoid
space allow for
movement within spinal
canal
Normal spinal cord as relates SCI:
Autonomic Nervous System & Cord
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ANS can be affected
by SCI
Sympathetic chains
on both sides of the
spinal column
Parasympathic
nervous system is the
cranial-sacral branch
Normal spinal cord: White tracks send
messages to and from the brain
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Pyramidal- Voluntary
movements
Posterior column
(Dorsal)- touch,
proprioception, and
vibration sense
Lateral spinothalamic
tract- pain and
temperature sensation
(only tract that crosses
within the cord)
Normal spinal cord: Reflex ark in center
of the spinal cord
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Where sensory and
motor nerves arise
from cord
Sensory fibers enter
posterior
Motor fibers leave
from anterior
Once outside cord
join form spinal nerve
Normal spinal cord:
Dermatones
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Skin innervated by
sensory spinal nerves
Normal spinal cord:
Spinal cord level
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When referring to spinal
cord level, it the reflex
arc level not the vertebral
or bone level.
Note that the thoracic,
lumbar & sacral reflex
arcs are higher than were
the spinal nerves actually
leave through the
opening of there
respective vertebral bone
Etiology of traumatic spinal cord injury
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MVA- most common cause
Other: falls, violence, sport injuries
SCI typically occurs from indirect injury
from vertebral bones compressing cord
SCI frequently occur with head injuries
Cord injury may be caused by direct
trauma from knives, bullets, etc
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Hemorrhage and edema occur in the cord
post injury, causing more damage to cord
Extension of the cord injury from cord
edema can occur over the first few dayswatch the phrenic nerve!
Initially SCI experience spinal shockdepression of all cord & ANS function
below injury. Lasts from few min to wks
Patho: Forces resulting in SCI
Flexion (hyperflexion)
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Most common
because of natural
protection position.
Generally cause neck
to be unstable
because stretching of
ligaments
Patho/forces:
Hyperextention
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Caused by chin
hitting a surface area,
such as dashboard or
bathtub
Usually causes
central cord
syndrome symptoms
Patho/forces:
Compression
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Caused by force from
above, as hit on head
Or from below as
landing on butt
Usually affects the
lumbar region
Classification of spinal cord injury:
1. Complete (transection) spinal cord inj
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After spinal shock:
Motor deficitsspastic paralysis
below level of injury
Sensory- loss of all
sensation perception
Autonomic deficitsvasomotor failure and
spastic bladder
2. Incomplete spinal cord injury- what white
tracks are working after spinal shock is over?
Incomplete spinal cord injury:
Central cord Syndrome
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Injury to the center of
the cord by edema
and hemorrhage
Weakness in both
upper extremitieslegs are spared
Varied loss of
sensation
Incomplete spinal cord injury:
Anterior Cord Syndrome
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Injury to anterior cord
Loss of voluntary
motor (Pyramidal
track) below
Loss of pain and
temperature
perception
Retains posterior
column function
Incomplete spinal cord injury:
Brown-Sequard Syndrome
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Hemisection of cord
Ipsilateral paralysis
Ipsilateral superficial
sensation, vibration
and proprioception
loss
Contralateral loss of
pain and temperature
perception
Incomplete cord injury:
Horner’s Syndrome
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Injury to the cervical
sympathetic nerves
Ipsilateral ptosis of
the eyelid
Constriction of the
pupil (miosis)
Facial anhidrosis
Horner’s Syndrome
Classification of spinal cord injury3. by level of spinal cord injury
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In addition to complete or
incompleteSpinal cord injuries are
also described by the
level of the injury– the
cord segment or
dermatome level
Such as C6; L4 spinal
cord injury
B. Common Manifestations and
Complications by body systems
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Skin: pressure ulcers
Neuro: pain; sensory loss; upper/lower
motor deficits; autonomic dysreflexia
Cardio: dysrhythmias; spinal shock; loss of
sympathetic nervous system control over
blood vessels (vasomotor control)- dec
venous return, orthostatic hypotension,
poikilothermic (takes on temp of room)
Body system cont.
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Resp: decrease chest expansion; cough reflex &
vital capacicty; diaphragm function-phrenic nerve
GI: stress ulcers; paralytic ileus; bowelimpaction & incontinence
GU: upper/lower motor bladder; impotence;
sexual dysfunction
Musculoskeletal: joint contractures; bone
demineralization; osteoporosis; muscle spasms;
muscle atrophy; pathologic fractures;
para/tetraplegia
Common manifestations/complications:
Spinal shock- depression of cord & ANS
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Motor loss- flaccid paralysis below level injury
Sensory loss- loss touch, pressure, temperature
pain and proprioception perception below injury
Sympathetic NS loss results in parasympathic
dominance with vasomotor failure
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Neurogenic shock, bradycardia, orthostatic
hypotension and poor temperature control
(poikilothermic- takes on temp of environment)
Parasympathetic NS loss of the S 2,3,4 reflex arks
results in flaccid bladder
Lasts from few minutes to weeks
How do you know spinal shock is over?
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Clonus is one of the
first signs
Hyperreflexia of foot
Test by flexing leg at
knee & quickly
dorsiflex the foot
Rhythmic oscillations
of foot against hand
Common manifestation/complications:
Upper and Lower Motor Deficits
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Upper motor deficits
results in spastic
paralysis
Lower motor deficits
are flaccid paralysis
and muscle atrophy
Common manifestation/complications:
Terms used to describe motor deficits
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Prefix: para- meaning two extremities;
tetra- or quadra- all four extremities
Suffix –paresis meaning weakness; -plegia
meaning paralysis
Quadraparesis means what?
Common manifestations/complications:
Functional Goals for Spinal Cord Injury
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C1-3 usually fatal- loss phrenic innervation;
ventilator dependent; no B/B control; spastic
paralysis; electric w/c with chin/mouth control
C6- weak grasp; has shoulder/biceps to transfer &
push w/c; no bowel/bladder control. Considered
level of independence
T1-6- full use of upper extremity; transfer; drive
car with hand controls and do ADL’s; no
bowel/bladder control
C. Therapeutic Interventions for SCI:
Diagnostic tests
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X-ray of spinal
column
CT/MRI
Blood gases
Therapeutic interventions:
Emergency care at scene, ER & ICU
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Transport with
cervical collar
Assess ABC’s; O2;
tracheotomy/vent
IV for life line
NG to suction
Foley
Therapeutic interventions:
Medications
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IV metylprednisone (Solu-Medrol) within 8 hrs to
decrease cord edema
Medications to control or to prevent
complications SCI and immobility:
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Vasopressors treat bradycardia or hypotension
Histamine H2 blockers to prevent stress ulcers
Anticoagulants
Stool softeners
Antispastomotics
Therapeutic interventions:
Stabilization/immobilization
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Traction with
Gardner-Wells tongs
Traction
External traction
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Halo device
For patients who do
not have motor
deficits
Experience less
immobility
complications
Therapeutic interventions:
Casts; splints; collars; braces
Therapeutic interventions:
Special Beds for SCI
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To decrease
immobility
complications
Rotorest is a common
one used- rotates 23
hrs a day
Therapeutic interventions:
Surgery for SCI
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Manipulation to
correct dislocation or
to unlock vertebrae
Decompression
laminectomy
Spinal fusion
Wiring or rods to hold
vertebrae together
D. Nursing Assessment specific to SCI
Health History
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Description of how and when injury occurred
Other illnesses or disease processes
Ability to move, breath, and associated injury
such as a head injury, fractures
Nursing Assessment specific SCI
Physical exam
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LOC and pupils- may have indirect SCI
from head injury
Respiratory status- phrenic nerve
(diaphragm) and intercostals; lung sounds
Vital signs
Motor
Sensory
Bowel and bladder function
Nursing assessment:
Motor assessment
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Movement, strength
and symmetry
Hand grips
Flex and extend arm
at elbow- with and
without resistance
Nursing assessment:
Motor assessment lower extremity
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Flex and extend leg at
knee with and without
resistance
Planter and dorsi
flexion of foot
Nursing assessment:
Motor assessment- Clonus
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Clonus- hyperreflexia
Flex knee and quickly
dorsiflex the foot with
your hand
If has return of reflex
function the foot will
have repetitive
movements against you
hand
Spinal shock is over
Nursing assessment:
Sensory assessment
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With the sharp and
dull ends of a
paperclip have the
individual, with their
eyes closed identify
Use the dermatome as
reference to identify
level
C6 thumb; T4 nipple;
T10 naval
E. Pertinent nursing problems/interventions
1. Impaired physical mobility
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Log roll as a single unit; provide assistance as
needed to keep alignment; teach patient
Care traction, collars, splints, braces, assistive
devices for ADL’s
Flaccid paralysis- use high top tennis shoes or
splints to prevent contractures. Remove at least
every 2 hrs for ROM (active ROM best)
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Spastic paralysis- assess for clonus
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Prevent spasms by avoiding; sudden movements or
jarring of the bed; internal stimulus (full bladder/skin
breakdown; use of footboard; staying in one position
too long; fatigue
Treat spasms by decreasing causes; hot or cold packs;
passive stretching; antispasmotic medications
Assess skin break down thrombophlebitis;
remove TED hose at least every shift
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Prevent/treat orthostatic hypotension
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Abdominal binder, calf compressors, TED hose when
individual gets up
Assess BP, especially when rising
Assist Physical Therapy with tilt table as individual
gradually gets use to being in an upright position
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Use of transfer board
2. Impaired gas exchange
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Phrenic nerve (C3-5) controls the diaphragm
bilaterally. If nerve is nonfunctioning then
individual is ventilator dependent.
Thoracic nerves control the intercostals muscles
for breathing and abdominal muscles aide in
breathing and coughing
Phrenic nerve
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Monitor vital capacity,
respiratory effort, ABG’s,
O2 saturation
Assess for signs of
impending extension of
SCI up cord to phrenic
nerve level (C3-5)
Quad cough (assistive
cough) as needed
3. Ineffective breathing patterns
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Assess respiratory rate, rhythm, depth, and breath
sounds
Assess need for ventilatory assistance,
tracheotomy, ventilator
4. Autonomic Dysreflexia
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SCI above T6
Results in loss of normal
compensatory
mechanisms when
sympathetic nervous
system is stimulated
Life threatening- if goes
unchecked BP can result
in cerebral hemorrhage
Autonomic Dysreflexia- assess
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Vasodilatation
symptoms above SCI
Vasoconstriction
symptoms below SCI
The cause of SNS
stimulation
Autonomic Dysreflexia- treatment
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Elevate head of bed- causes orthostatic
hypotension
Identify cause/alleviate- if full bladder- cath; if
skin- remove pressure, if full bowel- empty, etc
Remove support hose/abdominal binder
Monitor blood pressure- can get > 300 S
Give PRN medication to lower BP
If above not effective– call physician
5. Altered urinary elimination/constipation
Bladder
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Bladder reflex ark- sacral 2,3,4
Flaccid bladder (lower motor neuron lesion) has
no reflex from S2,3,4. Have automatic empting of
bladder. Urine fills the bladder and dribbles out.
Need foley or freq intermittent self catherization
Spastic bladder (upper motor neuron lesion) has
reflex ark, but no connection to or from brain.
Reflex fires at will. Bladder training- trigger
points to stimulate empting; self catherization
Upper/lower motor bladder
Bladder functioning:
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http://www.rnceus.com/course_frame.asp?e
xam_id=56&directory=uro
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Use bladder scan to see amount of urine in
bladder
Goal- residual <100ml/20% bladder capacity
Some individuals may need suprapubic catheter
Assess effectiveness of medication
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Urecholine to stimulate the parasympathic S 2,3,4
reflex to fire and cause bladder contraction
Urinary antiseptic
Bowel
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Bowel rely more on bulk than on nerves
Stimulate bowels at the same time each day. Best
after a meal when normal peristalsis occurs
Individual may progress from ducolax
suppository to glycerin then to gloved finger for
digital stimulation
Assess bowel sounds prior to giving food for the
first time– paralytic illus!
6. Sexual dysfunction
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Assess readiness/knowledge/your ability
Male sexual function- reflexogenic (S2,3,4)
erections; psychogenic erections (psychological
stimulation) Ejaculation/fertility may be affected
Female- hormones more than nerves regarding
fertility. C-section because of chance for
autonomic dysreflexia during labor. Lack of
sensation/movement affects sexual performance
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Suggestions: empty bladder before sex; withhold
fluids and antispasmodics; certain positions may
increase spasms; explore new erogenous zones;
penile implants
7. Low self-esteem
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Assess thoughts on ‘quality of life’; body image;
role changes
Physical and psychological support
Most common SCI is 15-30 yeas old and
generally a risk taker– this greatly affects their
perception of life and rehabilitation progress
8. Home care
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Assess psychological, physical resources, need
for rehabilitation (in-house or outpatient); need
for community resources
Home evaluation
Case Study PDS– Spinal Cord Injury
http://www.softwarefornurses.com/access/ind
ex.asp
LeMoneBlackboard Case Study & Media links
http://wps.prenhall.com/chet_lemone_medical
surg_3/0,7859,757263-,00.html
http://www.apacure.com/
http://spinalcord.org/
Nursing Care Plan: A Client with a SCI
LeMone p. 1334
http://wps.prenhall.com/wps/media/objects/
737/755395/sci.pdf
Additional Critical thinking questions
LeMone p 1334:
Nursing Care Plan: A Client with a SCI
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1. Why does Jim have flaccid paralysis on
admission to ICU?
2. What symptoms indicate that he is in spinal
shock? What was done about these symptoms?
3. How will we know when he is out of spinal
shock?
4. How does progressive mobilization assist with
orthostatic hypotension? What else can be done?
5. What are realistic functional goals for Jim?
Case Study SCI
http://www.pitt.edu/~rhe001/ugcs96.htm