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Module 7: Neurosensory Disorders: Traumatic Spinal Cord Injury
Marnie Quick, RN,MSN, CNRN
Etiology/Pathophysiology of Spinal Cord Injury
1. Normal spinal cord physiology as it relates to spinal cord injury
a. Cord begins at foramen magnum; ends L1-L2 vertebra level.
b. Spinal cord is protected by vertebral bones with discs in-between
vertebral bodies for flexibility, internal/external ligaments that hold
the vertebra in place, meninges, and cerebral spinal fluid flowing in
the subarachnoid space.
c. Autonomic nervous system- Sympathetic chains on both sides of the
spinal column; parasympathetic cranial-sacral branches.
d. Cord is composed of white tracts that send sensory and motor
messages to and from the brain. (p. 1295, Fig. 40-6)
1)
Pyramidal tract- voluntary movement
2)
Posterior columns (Dorsal)- touch, proprioception, vibration
3)
Lateral spinothalamic tract- pain and temperature (only
tract that crosses within the cord)
e. Gray matter in the center (‘H’ shape) is composed of cell bodies for
the reflex arks that leave the spinal cord to the rest of the body
(sensory-posterior and motor- anteriorly) through the opening in
vertebra (p. 1295-7 (Fig 40-6; Fig 40-5 & Fig 40-9)
f. Dermatomes- Skin innervated by the spinal nerve. (p. 1296 Fig 40-7)
also helpful in understanding motor innervations.
g. When referring to spinal cord level, it is the reflex ark level not the
vertebral or bone level. Note that the lower (thoracic/ lumbar) reflex
arks are higher that where the spinal nerves actually leave through
the opening in their respective vertebral
2. Etiology of traumatic spinal cord injury
a. Most SCI caused by MVA. Also falls, violence, sport injuries.
b. Risk factors- male 16-30 yr age, risk taker. Seeing more females as
they become involved in sports.
c. Cervical and lumbar regions usually areas injured.
d. C1, C2, C4-C6 most common spinal cord level of injury.
e. SCI typically occurs from indirect injury from vertebral bones
compressing cord and SCI frequently occurs with head injuries.
f. Cord injury may be caused by direct trauma from knives, bullets, etc
g. Hemorrhage and edema occurs in the cord post injury, causing
secondary damage to the cord.
h. Extension of the cord injury from edema can occur over the first few
days- watch for phrenic nerve involvement!
i.
Initially SCI experience spinal shock- depression of all cord &
autonomic nervous system function below level of spinal cord injury.
Lasts from few minutes to weeks.
3. Patho: Forces resulting in spinal cord injury (p. 1324, Fig 41-5)
a. Flexion (hyperflexion)- most common (normal protective mechanism
is flexing the body/head). Generally causes unstable fractures
because stretches the ligaments.
b. Hyperextension- caused by the chin hitting a surface area, such as a
dashboard or bathtub.
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c.
d.
e.
4. Patho:
a.
b.
c.
Compression- caused by force from above (hit on top of head) or
below (landing on butt, or feet from a tall building) usually lumbar
region.
Injury typically occurs from indirect injury from the vertebral bones
compressing the spinal cord resulting in cord edema and
inflammation. Spinal cord injuries may occur with head injuries.
Direct injury to the cord may occur with knives, bullets, etc.
Classification of spinal cord injury
Complete spinal cord injury- totally damaged cord horizontally and
post spinal shock the individual will have:
1)
Motor deficits- hyperreflexia/spastic paralysis below the
level of injury.
2)
Sensory deficits- loss of touch pressure, temperature, pain,
vibration and proprioception from below the level of injury.
3)
Autonomic deficits- vasomotor failure resulting in
orthostatic hypotension, poikilothermic (take on the
temperature of the environment); and parasympathetic
spastic bladder
Incomplete spinal cord injury- various white tracks damaged at the
level of spinal cord injury.
1)
Central Cord Syndrome- injury to the center of the cord by
edema and hemorrhage; usually cord is compressed
between vertebra; weakness in both upper extremities- legs
are spared; varied loss of sensation.
2)
Anterior Cord Syndrome- injury to the anterior part of the
cord; loss of motor (Pyramidal track) below the level of
injury; loss of pain and temperature below the level of
injury; retains the posterior column function.
3)
Brown-Sequard Syndrome- hemisection of the cord (injury
to ½ cord); ipsilateral paralysis (pyramidal tract) on the
same side as spinal cord injury; ipsilateral superficial
sensation, proprioception, and vibration loss; contralateral
loss of ability to get information regarding pain and
temperature to the brain from below the level of cord
injury. The lateral spinothalamic white track is only major
white track that crosses within the cord segments, rather
than in the medulla.
4)
Horner’s Syndrome- injury of the cervical sympathetic
nerves; ipsilateral ptosis of the eyelid; constricted pupil
(myosis) and facial anhidrosis
Level of spinal cord injury. This is another way to describe spinal cord
injuries. The cord segment or dermatome level- such as C6; L4; etc.
(p. 1296 Fig 40-7)
Common Manifestations/Complications of Spinal Cord Injury
1. By body systems (p. 1325 Box)
a. Skin: pressure ulcers
b. Neuro: pain; sensory loss; upper/lower motor deficits; autonomic
dysreflexia
c. Cardio: dysrhythmias; spinal shock; loss of sympathetic nervous
system control over blood vessels (vasomotor control) decrease
venous return, orthostatic hypotension, poikilothermic (take on
temperature of the environment)
158  RNSG 2432
2.
3.
4.
5.
d. Resp: decrease chest expansion; cough reflex and vital capacity;
diaphragm function- phrenic nerve
e. GI: stress ulcers; paralytic ileus; bowel- impaction & incontinence
f. GU: upper/lower motor bladder; impotence; sexual dysfunction
g. Musculoskeletal: joint contractures; bone demineralization;
osteoporosis; muscle spasms; muscle atrophy; pathologic fractures;
para/tetraplegia
Spinal shock
a. Is the result of inflammatory process in the cord after injury and
causes depression of spinal cord and autonomic nervous system
function below the level of spinal cord injury. It lasts from a few
minutes to weeks and results in:
1)
Motor loss results in flaccid paralysis below the level of
spinal cord injury.
2)
Sensory loss results in loss of touch, pressure, temperature,
pain and proprioception below the level of spinal cord
injury.
3)
Sympathetic nervous system loss results in
parasympathetic domination with vasomotor failure. This
causes neurogenic shock, bradycardia, orthostatic
hypotension, and poor temperature control. There is no
vasomotor response to environmental temperature changes
including loss of ability to perspire below injury and the
individual becomes poikilothermic- (individual takes on the
temperature of the environment).
4)
Parasympathetic nervous system loss at the S 3,4,5 reflex
arks results in flaccid bladder.
b. After spinal shock is over then the individual may recover or be left
with either complete or incomplete cord injury. Reflexes begin to
return such as spontaneous empting of the bladder and clonus
(hyperreflexia). Clonus is the first sign that spinal shock is over. (See
assessment)
Upper and lower motor neuron deficits
a. Upper motor neurons describe the motor neurons located in the brain
and descend down the white tracts into the spinal cord to just before
the anterior horn cell in the reflex ark. Damage or interruption to
upper motor neurons result in spastic paralysis and hyperreflexia.
b. Lower motor neurons are the motor neurons located in the anterior
horn cell of the reflex ark of the spinal cord, motor nuclei of the
brainstem and the axons that end in the motor end plate of the
skeletal muscles. Damage or interruption of lower motor neurons
result in flaccid paralysis, muscle atrophy and hyporeflexia.
Terms used:
a. Prefix: para- two extremities affected; tetra- or quadra- all four
extremities affected.
b. Suffix: -paresis meaning weakness; -plegia meaning paralysis.
c. Therefore quadriplegia means all four extremities paralyzed.
Functional goals expected of complete lesion by cord segments:
a. C1-C3 spinal cord injury- usually fatal because loss of the phrenic
nerve inervation (C3,4,5) and breathing stops; can use electric wheel
chair with chin/mouth control; uses portable ventilator; no vasomotor
control below lesion- loss of ability to control temperature and
RNSG 2432  159
orthostatic hypotension; no bowel or bladder control. Bladder usually
spastic UMN type.
b. C6 spinal cord injury- has weak grasp, but have use of shoulder/biceps
to transfer & push wheel chair; can use assistive devices; has a
decrease respiratory reserve (intercostals); loss of vasomotor control;
no bowel or bladder (spastic) control. This is the level that is
considered the ‘level of independence’ for a spinal cord injured
individual.
c. T1-T6 spinal cord injury- has full use of upper extremity to transfer,
drive car with hand controls and do ADL’s; no bowel or bladder
control.
6. Autonomic Dysreflexia (autonomic hyperrflexia)
a. Occurs in spinal cord injury above T6 after spinal shock is over.
b. Results in loss of normal compensatory mechanisms when sympathetic
nervous system is stimulated.
c. Stimuli include: full bladder (most common), fecal impaction (next
most common), pressure ulcers, labor contractions, etc.
d. When recognize symptoms early may be helpful in bladder training,
because it tells the individual that the bladder needs emptying. (full
bladder is the most common cause of autonomic dysreflexia; second,
full bowel)
e. However, it is considered life threatening- if autonomic dysreflexia
goes unchecked the blood pressure rises and can result in cerebral
hemorrhage- death. (BP may go as high as 300/160)
f. Symptoms:
1) Vasodilatation symptoms above the level of spinal cord
injury- sweating flushed face, nasal congestion, headache,
etc.
2) Vasoconstriction symptoms below the level of spinal cord
injury- cool, pale skin goose pumps, etc.
g. Treatment- refer to nursing diagnosis/intervention sectionAutonomic dysreflexia
Therapeutic Interventions for Spinal Cord Injury
1. Diagnostic tests- X-ray of the spinal column; CT/MRI; blood gases
2. Emergency care at the scene, emergency room, ICU
a. Transport with cervical collar, preserve cord function
b. Assessment of ABC’s, NVS, O2, possible tracheotomy/ventilator
c. IV for life line- to give drugs
d. NG tube to suction- may have paralytic ileus
e. Foley for flaccid bladder from spinal shock
3. Treatment- medications:
a. IV metylprednisone (Solu-Medrol) within 8 hrs of spinal cord injury to
decrease cord edema/inflammation.
b. Medications to control or to prevent complications from lack of nerve
innervations and immobility; such as vasopressors to treat bradycardia
or hypotension; histamine H2 blockers to prevent stress ulcers;
anticoagulants- immobility; stool softeners decreased bowel
function/immobility; antispasmodics for spasms- hyperreflexia (box on
p. 1328), etc
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4. Treatments- devices/surgery:
a. Stabilization/immobilization- traction (Gardner-Wells tongs)/external
traction (Halo)/casts/splints/collars or brace (p. 1328-9 Fig 41-6; 417)
b. Special beds- Rotorest bed; air; etc- to decrease immobility
complications
c. Surgery
1) Manipulation to correct dislocation or to unlock vertebrae
(facet part of bone the gets subluxed)
2) Decompression laminectomy (Refer to Module 8 HNP)
3) Spinal fusion (refer to Module 8)
4) Wiring or rods to hold vertebrae together
Nursing Assessment Specific to Spinal Cord Injury
1. Health history
a. Description of how and when injury occurred.
b. Other illnesses or disease processes.
c. Ability to move, breath, any associated injury such as a head injury.
2. Physical exam
a. LOC and pupils- may have indirect SCI from head injury
b. Respiratory status- phrenic nerve (diaphragm) and
intercostals(thoracic and abdominal muscles); lungs sounds
c. Vital signs
d. Motor- movement, strength and symmetry. Hand grips; with and
without resistance have individual flex and extend arm at elbow; flex
and extend leg at knee; dosi and planter flex feet. Check for clonus
(shows return of reflex ark- spinal shock over) by flexing the
patient’s leg at knee, quickly dorsiflex the foot with your hand.
Clonus causes the foot to have repetitive movements against your
hand.
e. Sensory- With the sharp and dull ends of a paperclip have the
individual, with their eyes closed identify. Use the dermatomes as
reference (LeMone p.1296) to identify level. C6= thumb; T4=
nippleline; T10= naval
f. Bowel and bladder function
Pertinent Nursing Problems and Interventions for Spinal Cord Injury
1. Impaired physical mobility
a. Log roll- roll as a single unit; provide assistance as needed; teach
patient.
b. Care of an individual with traction (box on p. 1329), collars, splints,
braces, assistive devices for ADL’s.
c. Flaccid paralysis- High top tennis shoes or splints to prevent
contractures. Remove frequently to perform ROM (active when
possible or passive)
d. Spastic paralysis- (assess for clonus)
1) Prevent spasms by avoiding: sudden movements or jarring
of the bed; internal stimulus (full bladder/skin infections);
use of footboard; staying in one position too long; fatigue
2) Treat spasms by decreasing causes; using a hard hand roll
or hand splints; hot or cold packs; passive stretching;
antispasmodic medications such as Dantrium or PRN Valium
RNSG 2432  161
2.
3.
4.
5.
e. Assess for skin breakdown and thrombophlebitis; remove TED hose at
least every shift.
f. Prevent/treat orthostatic hypotension by the use of abdominal binder,
calf compressors, and/or TED hose. Assess BP, especially when rising.
Assist Physical Therapy with tilt table. A table (similar to a stretcher
with a foot board) that allows for PT to raise the head by degrees and
assesses the patients blood pressure. The SCI patient’s blood pressure
gradually gets used to being in an upright position before getting into
a chair.
Impaired gas exchange
a. Phrenic nerve (C3-5) controls the diaphragm bilaterally (if
nonfunctioning individual is ventilator dependent); thoracic nerves
control the intercostals muscles for breathing; abdominal muscles aide
in coughing.
b. Monitor vital capacity, respiratory effort, and arterial blood gases.
c. Assess signs of impending extension of spinal cord injury up the cord
to the phrenic nerve level (C3-5)
d. Quad cough (assistive cough)- as individual attempts to cough, push
with your hand in and up from the area between the individuals
umbilicus and the xiyphoid process. (similar to Heimlich maneuver.
Ineffective breathing patterns
a. Assess respiratory rate, rhythm, depth and breath sounds
b. Assess need for ventilatory assistance, tracheotomy
Autonomic Dysreflexia
a. Assess for signs and symptoms- vasodilatation above; vasoconstriction
below. (see complication section above)
b. Treat:
1) Elevate head of bed (causes orthostatic hypotension)
2) Assess for cause and alleviate- if full bladder- cath; skinremove pressure, assess bowels- empty, etc.
3) Remove support hose/abdominal binder
4) Monitor blood pressure
5) Give PRN medication to lower blood pressure- Diazoxide
(Hyperstat); PRN ganglionic blocking agents- nifedipine
(Procardia) or hydralazine (Apresoline).
c. Notify MD, if above not effective.
Altered urinary elimination and constipation
a. Bladder
1) Reflex ark for both bladder function and male errection is
Sacral 2, 3, 4.
2) Flaccid bladder (lower motor neuron lesion) has no reflex
from S2,3,4; therefore no automatic empting of bladder.
Urine fills the bladder and dribbles out (incontinence) Use
foley, external catheter or intermittent self
catherization(p.1331, Procedure 41-1)
3) Spastic bladder (upper motor neuron lesion) has reflex ark,
but no connection to or from the brain. Reflex fires at will.
Bladder training for this individual is directed toward ability
to empty bladder at a socially accepted time and place. Use
the trigger points (stroking down inner aspect of thigh,
across lower abdomen, pulling pubic hair) to stimulate
parasymathic reflex ark S 2,3,4.
162  RNSG 2432
4)
5)
6)
Use a bladder scan to see amount of urine in bladder
(residual or otherwise).
Some individuals may need suprapubic catheter.
Assess effectiveness of medication (such as Urecholine) to
stimulate parasympathic S 2,3,4, and effectiveness of
urinary antiseptic.
b. Bowel
1)
2)
Bowels rely more on bulk than on nerves.
Stimulate bowels at the same time each day. Best after a
meal when normal peristalsis occurs.
3) Individual may progress from ducolax suppository; to
glycerin suppository; then to gloved finger for digital
stimulation
4) Assess bowels sounds prior to giving food for the first time,
may have a paralytic illus.
6. Sexual dysfunction
a. Assess readiness/knowledge
b. Male sexual function- reflexogenic (reflex ark- S2,3,4) erections;
psychogenic erections (psychological stimulation- think sexual
thoughts). Ejaculation and fertility may be a problem.
c. Suggestions: empty bladder before sex; withhold fluids and
antispasmotics (although spasms may help some individuals); certain
positions may increase spasms; explore new erogenous zones; penile
implants may be utilized.
d. Female- hormones more than nerves regarding fertility. May have Csection, because of chance for autonomic dysreflexia during labor.
Lack sensation and movement can affect sexual performance.
7. Low self-esteem
a. Assess thoughts on ‘quality of life’; body image; role changes.
b. Physical and psychological support
c. Most common SCI is 15-30 years old and generally a risk taker. This
greatly affects their perception of life and rehabilitation progress.
8. Home care
a. Assess psychological, physical resources, need for rehabilitation (inhouse or outpatient), need for community resources.
b. Home evaluation
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