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Chapter 29
Spinal Cord Injury
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Learning Objectives
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Explain the impact of spinal cord injury.
Describe the diagnostic tests used to evaluate spinal
cord injuries and related nursing responsibilities.
Explain the physical effects of spinal cord injury.
Describe the medical and surgical treatment during the
acute phase of spinal cord injury.
List the data to be included in the nursing assessment of
the patient with a spinal cord injury.
Identify nursing diagnoses, goals, interventions, and outcome
criteria for the patient with a spinal cord injury.
Describe the nursing care for the patient undergoing a
laminectomy.
State the goals of rehabilitation for the patient with spinal
cord injury.
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Anatomy and Physiology of the
Spinal Cord
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Vertebral Column
• Consists of 33 vertebrae
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7 cervical (C1 through C7)
12 thoracic (T1 through T12)
5 lumbar (L1 through L5)
5 sacral (S1 through S5)
4 fused coccygeal
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Figure 29-1
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Vertebral Column
• Each vertebra consists of a body and an arch
• The spinal cord passes through an opening in
the center of each arch
• Each arch has articulating surfaces against
which adjacent vertebrae smoothly glide with
movement
• The bony column is supported by muscles and
ligaments, which permit mobility and flexibility
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Disks
• Vertebrae separated by disks which serve as
shock absorbers for the vertebral column
• Composed of anulus fibrosus and nucleus
pulposus
• anulus fibrosus: ring of tissue; encircles nucleus
pulposus
• Nucleus pulposus: saclike structure with a
gelatinous filling that has a high water content
• As we age, nucleus pulposus loses much of its
water; less effective as a shock absorber
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Figure 29-2
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Spinal Cord
• Extends from the brainstem to L2 in pelvic cavity
• Surrounded by three protective meningeal layers
• Dura mater
• Outermost layer
• Arachnoid
• Middle layer: spaces containing cerebrospinal fluid (CSF)
• Pia mater
• Innermost layer: directly covers the spinal cord
• CSF circulates through the brain and spinal column, bathing and
protecting the entire central nervous system
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Figure 29-3
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Spinal Cord
• Gray matter
• Consists of the bodies of nerve cells that control
motor and sensory activities
• White matter
• Myelinated (surrounded by a sheath); consists of
bundles of fibers
• Convey information between the brain and the
spinal cord
• Tracts may be ascending or descending
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Figure 29-4
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Spinal Cord
• Blood supply
• Major arterial supply to the spinal cord; consists of
the vertebral arteries posteriorly and the anterior
spinal artery
• Reflexive activity
• The sensory stimulus is received, and a response is
initiated at the level of the spinal cord
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Spinal Cord
• Relay activity
• Stimulus enters spinal cord; travels up ascending
tracts to relay sensory signals to the brain
• Information processed in the brain; responses
initiated by impulses transmitted to the body by way
of descending tracts
• Information conveyed to brain and spinal cord
via peripheral nervous system
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Diagnostic Tests and Procedures
• Neurologic examination
• Initial evaluation of the spinal cord: injured patient
provides the nurse with a baseline assessment of
function and problems
• Ongoing assessment necessary to monitor the
effects of neurologic injury, detect related
complications, and determine patient’s need for
assistance in activities of daily living
• Focuses on the motor and sensory systems
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Diagnostic Tests and Procedures
• Imaging studies
• Radiography
• Detects vertebral compression, fractures, or problems with
alignment
• Computed tomography (CT)
• Noninvasive examination of the specific levels of the spinal
cord to be visualized, bony vertebrae, and the spinal
nerves
• Magnetic resonance imaging (MRI)
• Produces precise, clear images of internal structures
• Myelogram
• Visualizes the spinal cord and vertebrae
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Pathophysiology of
Spinal Cord Injury
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Types of Injuries
• Location
• Cervical, thoracic, or lumbar
• Open or closed
• Closed: trauma in which the skin and meningeal
covering that surround the spinal cord remain intact
• Open: damage to the protective skin and meninges
• Extent of damage to the cord
• Complete spinal cord injury occurs when the cord
has been completely severed, whereas an
incomplete injury results from partial cutting of the
cord
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Effects of Spinal Cord Injury
• Factors include extent of cut and level of injury
• Sometimes cannot be fully determined
because the symptoms of spinal cord edema
may mimic partial or complete transection
• With incomplete spinal cord injuries some
function remains below the level of the injury
• Specific tracts may be involved, causing particular
patterns of neurologic dysfunction
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Figure 29-6
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Effects of Spinal Cord Injury
• The higher the level of injury, the more
encompassing the neurologic dysfunction
• Quadriplegia
• High cervical spine injuries; loss of motor and
sensory function in all four extremities
• Paraplegia
• Injuries at or below T2 may cause paralysis of the
lower part of the body
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Respiratory Impairment
• Injuries at or above the level of C5 may result
in instant death because the nerves that
control respiration are interrupted
• Cervical injuries below the level of C4 spare
the diaphragm but can involve impairment of
intercostal and abdominal muscles
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Spinal Shock
• An immediate, transient response to injury in
which reflex activity below the level of the injury
temporarily ceases
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Autonomic Dysreflexia
• Exaggerated response of autonomic nervous
system to noxious (painful) stimuli
• With injury at or above the level of T6
• The sympathetic nervous system is stimulated,
but an appropriate parasympathetic modulation
response cannot be elicited because of the
spinal cord injury that separates the two
divisions of the autonomic nervous system
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Autonomic Dysreflexia
• Triggered by various stimuli including a
distended bladder, constipation, renal calculi,
ejaculation, or uterine contractions, but also
may be caused by pressure sores, skin rash,
enemas, or even sudden position changes
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Spasticity
• Muscle spasms may be incapacitating for
these patients, hampering efforts at
rehabilitation
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Impaired Sensory and Motor Function
• Impaired motor function can affect the patient’s
mobility and self-care and thus result in
complications from immobility
• Loss of sensation puts patient at risk for skin
breakdown and other injuries because
pressure and pain are not perceived
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Impaired Bladder Function
• During spinal shock, all bladder and bowel
function ceases
• Once spinal shock resolves, reflex activity
returns
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Impaired Bowel Function
• Most spinal cord–injured patients can maintain
bowel function because the large bowel
musculature has its own neural center that
responds to distention by the fecal mass
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Impaired Temperature Regulations
• May lose these regulatory mechanisms and be
unable to adapt to temperature extremes
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Impaired Sexual Function
• Spinal levels S2, S3, and S4 control sexual
function, so injury at or above these levels
results in sexual dysfunction
• Ability to achieve erection and ejaculation is
variable
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Impaired Skin Integrity
• Because immobile patient can’t change
positions, skin in sacral area and across bony
prominences may break down
• Loss of tone results in vasodilation and pooling
of blood in the periphery; impedes perfusion of
the skin; and encourages the development of
pressure sores
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Altered Self-Concept and Body Image
• French and Phillips (1991) describe the effects
of spinal cord injury on body image as
occurring in four phases: impact, retreat,
acknowledgment, and reconstruction
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Medical Treatment in the Acute
Phase
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Saving the Patient’s Life:
Establish Airway
• Conventional head-tilt–chin-lift: inappropriate
with spinal injury; increases risk of cord
damage
• Risk of additional damage is especially high
with cervical injury
• Neck flexion, even that caused by a pillow or
other support, must be avoided
• Jaw-thrust method of opening the airway is
preferred for these patients
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Saving the Patient’s Life:
Establish Airway
• Once airway is open, administer 100% oxygen
by mask and manual resuscitator
• Endotracheal or tracheostomy tube is placed to
allow direct access to the airway and facilitate
optimal oxygenation
• Any injury that compromises ventilation must
be treated immediately
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Preventing Further Cord Injury
• Traction
• Immobilization with skeletal traction manages
cervical spinal cord injuries acutely
• Gardner-Wells tongs
• Secured just above the ears; doesn’t actually penetrate skull
• Crutchfield tongs
• Applied directly to the skull just behind the hairline
• Halo vest: immobilizes and aligns cervical
vertebrae; placed when surgery is done to internally
stabilize fractures and relieve the compression of
nerve roots
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Figure 29-7
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Figure 29-8
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Preventing Further Cord Injury
• Special beds and cushions
• Kinetic bed, such as the Roto-Rest bed, continually
rotates the patient from side to side
• Overlay air mattresses: flotation devices placed on
standard hospital beds
• Air-fluidized and flotation beds may be used after the spine
has been stabilized
• Wedge-Stryker frame: canvas and metal frame bed
that may be used to help turn the patient
• Types of cushions include those inflated with air,
flotation devices, and gel pads
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Figure 29-9
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Preventing Further Cord Injury
• Drug therapy
• Methylprednisolone
• Reduces the damage to the cellular membrane
• Administered within the first 8 hours of injury
• Completely paralyzed patients often regain about 20% of
function
• Partially paralyzed have regained up to 75% of function
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Preserving Cord Function
• Early surgical intervention to repair cord
damage
• Cord compression by bony fragments, compound
vertebral fractures, and gunshot and stab wounds
• Surgery within the first 24 hours is most desirable
• Laminectomy
• Involves removing all or part of the posterior arch of
the vertebra
• Spinal fusion
• If multiple vertebrae are involved
• Placing a piece of donor bone into area between the
involved vertebrae
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Assessment
• Monitor the patient’s level of consciousness,
vital signs, respiratory status, motor and
sensory function, and intake and output
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Health History
• Present illness
• Event that brought the patient to the hospital
• Specific injuries incurred in the incident
• Describe pain and other symptoms in detail
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Past Medical History
• Other accidents or injuries and chronic
illnesses such as diabetes, hypertension, heart
disease, cancer, or seizure disorder
• Previous hospitalizations and operations
• Obstetric history from female patient
• Identify and record current medications and
allergies
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Family History
• Routine family history taken but not considered
specifically relevant to a diagnosis of spinal
cord injury resulting from trauma
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Review of Systems
• Skin condition, headache or dizziness, vision
disturbances, hearing impairment or tinnitus,
nasal or ear drainage, dyspnea, nausea and
vomiting, constipation or diarrhea, fecal
incontinence, bladder dysfunction, sexual
dysfunction, and impaired motor and sensory
function
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Functional Assessment
• Patient’s self-care abilities
• Patient’s roles and responsibilities as a family
member
• Occupation, hobbies, usual activity pattern,
habits, and diet
• Emotional response to the spinal injury
• Usual coping strategies
• Spiritual beliefs; other sources of support
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Physical Examination
• Record the patient’s reported height and
weight
• Take vital signs
• Take the temperature
• Level of responsiveness, posture, and
spontaneous movements
• Inspect the skin for lesions
• Evaluate tissue turgor
• Inspect head for lesions and palpate for
masses and swelling
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Physical Examination
• Examine pupils for size, equality, reaction to
light
• Respiratory effort and breath sounds
• Inspect abdomen; auscultate for bowel sounds
• Inspect extremities for open fractures or
abnormal positions
• Range of motion
• Ability to perceive sharp and dull sensation;
use a dermatome chart
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Figure 29-10
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Interventions
• Ineffective Breathing Pattern
• Risk for Injury and Disturbed Sensory
Perception
• Risk for Autonomic Dysreflexia
• Risk for Disuse Syndrome
• Bowel Incontinence
• Impaired Urinary Elimination
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Interventions
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Risk for Infection
Ineffective Thermoregulation
Feeding/Dressing/Grooming Self-Care Deficit
Sexual Dysfunction
Ineffective Coping
Ineffective Therapeutic Regimen Management
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Rehabilitation
• Activities that assist individual to achieve
highest possible level of self-care and
independence
• Well-organized interdisciplinary team that can
address all aspects of function
• Physician, nurse, physical therapist, occupational
therapist, speech therapist, dietitian, social worker,
psychologist, and counselor
• Patient and family must be emotionally and
physically prepared to make adjustments
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Rehabilitation
• Team helps the patient accomplish activities of
daily living and self-care and addresses
successful adjustment to social integration and
gainful employment in the workplace
• Although this phase of treatment may take
more than a year, patient, family, and
rehabilitation team can take pride in the
realization that a life can once again be
productive and happy
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Nursing Care of the
Laminectomy Patient
• Preoperatively
• Assess patient’s vital signs and neurologic status to
establish baselines
• Patient’s understanding of surgical routines
• Tell patient what to expect in the immediate
postoperative period
• Ongoing assessment of neurologic status and on
promoting healing at the operative site
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Nursing Care of the
Laminectomy Patient
• Assessment
• Vital signs, neurologic status, and breath sounds
• Frequently assess movement, strength, range of
motion, and ability to localize sensory stimulus
• Fluid intake and output
• Abdomen for bowel sounds; palpate bladder
• Inspect the surgical dressing for bleeding, clear
cerebrospinal fluid drainage, and foul drainage
• If the patient has pain, obtain a complete description
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Nursing Care of the
Laminectomy Patient
• Interventions
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Risk for Injury
Ineffective Tissue Perfusion
Acute Pain
Impaired Urinary Elimination
Constipation
Impaired Physical Mobility
Deficient Knowledge
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