Spinal Cord Injury

Spinal cord injury (SCI), trauma to the spinal cord, results in a temporary or permanent change in motor, sensory, or autonomic functioning. It affects approximately 18,000 Americans every year; approximately 300,000 people in the United States live with spinal cord injuries. Half of the injuries produce paraplegia and half tetraplegia, formerly known as quadriplegia. According to the International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISNCSCI), paraplegia is injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris. T12 and L1 are the most common levels of injury in paraplegia. Tetraplegia, which most often occurs in C5, is injury to the spinal cord in the cervical region, with associated loss of muscle strength in all four extremities. The ISNCSCI classifies impairment from Class A through Class E. Class A is loss of motor functions and sensation. Class B is sensory impairment. Class C is some sensory and motor function preserved. Class D indicates useful motor function is retained. Class E is normal function.

SCI is a dynamic process that triggers a physiological cascade of events and leads to neuronal damage and neurological deficits. The injury to the spinal cord occurs initially from direct trauma, followed by cord compression from bone fragments, hematoma, or material from the disks. Finally, ischemia occurs because of lack of perfusion from the spinal arteries. The initial injury causes a release of glutamate, which causes cellular damage and petechial hemorrhages at the injury site. Calcium influx into the neuron is caused by thrombus formation. This alteration in calcium triggers the arachidonic acid cascade to be initiated, leading to free radical formation, lactic acidosis, and lipid peroxidation. This final series of events hastens ischemia of the white matter and microvasculature destruction, with resultant neuronal damage and permanent neurological deficit. With aggressive medical interventions and nursing management, approximately 90% of patients with acute SCI survive, but many have permanent disability.

Several complications may occur after SCI. Neurogenic shock occurs with hypotension, bradycardia, and peripheral vasodilation, often accompanied by hypothermia. It occurs because of severe autonomic nervous system dysfunction and loss of sympathetic nervous system control. Spinal shock after SCI is defined as a temporary (hours to several days) but complete loss of sensorimotor function below the level of injury. Other complications include cardiac dysrhythmias, hypotension, hypertension, ileus, loss of bowel and bladder function, sexual dysfunction, spastic or flaccid paralysis, depression, and skin pressure injuries.

SCI can be classified by a variety of methods: complete and incomplete cord injury, mechanism of injury, and the level of injury. In a complete SCI, the patient loses all function below the neurological injury level (the lowest neurological segment with intact motor and sensory function). In an incomplete SCI, some motor or sensory function below the neurological injury level remains intact (Table 1).

Table 1 Types of Incomplete Spinal Cord Injury

INJURY	MECHANISM	DESCRIPTION	FUNCTIONS PRESERVED	FUNCTIONS IMPAIRED
Brown-Séquard syndrome	Penetrating trauma	One side of the cord is affected	Opposite-side pain and temperature sensation; same-side movement, proprioception, light touch	Opposite-side movement, proprioception, light touch; same-side pain and temperature sensation
Posterior cord syndrome	Extension	Loss of posterior column sensory function; motor paralysis	Pain sensation; temperature sensation	Vibratory sensation; proprioception
Anterior cord syndrome	Flexion	Hypalgesia; hypesthesia, motor paralysis, posterior column sensory function preserved	Light touch, proprioception, vibratory sensation	Pain sensation, motor function, temperature sensation, touch
Central cord syndrome	Flexion or extension	Injury to central gray matter	Motor functions of lower extremities but possible loss of sensation below the site of injury	Motor functions of upper extremities

Causes ⬆ ⬇

Leading causes of SCI include motor vehicle crashes (MVCs; 56%), falls (14%), acts of violence/firearm injuries (9%), and sporting injuries (7%). SCIs caused by violence have increased dramatically in the last decade. The mechanism of injury influences the type of SCI and the degree of neurological deficit. Associated factors are risk taking (e.g., speeding), ignoring seat belts in vehicles, violent or aggressive behaviors, bone and joint disorders, alcohol misuse and abuse, and substance abuse.

Genetic Considerations ⬆ ⬇

No clear genetic contributions to susceptibility have been defined.

Sex and Life Span Considerations ⬆ ⬇

Acute SCIs occur in both children and adults, although the majority occur between the ages of 16 and 30 years. The vast majority, approximately 80%, involve males. The financial impact of acute SCIs is tremendous for the patient and society, and it is related to the age of most patients and the degree of disability. Older adults have greater functional and mental status decline after an SCI as compared to their younger counterparts.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Ethnicity, race, and sexual/gender minority status have no known effect on the risk of SCI. However, Black, Hispanic, and Native American persons as well as sexual and gender minority persons and persons with low incomes are known to experience discrimination, stigma, and insensitivity to their unique needs when interacting with the healthcare system. In the setting of SCI, these issues may interfere with referral, rehabilitation, and recovery and lead to significant health disparities.

Global Health Considerations ⬆ ⬇

The World Health Organization estimates that each year, there are approximately 250,000 to 500,000 traumatic SCIs from injuries and violence. Road traffic injuries are decreasing in developed regions but increasing in developing regions due to the growing number of vehicles on the road, poor infrastructure, and difficulty enforcing laws. Males between the ages of 20 to 30 years are most at risk, but traumatic SCIs from falls among older adults is increasing in developed and developing regions; falls are common from trees, roofs, and balconies and at construction sites.

Assessment ⬆ ⬇

ASSESSMENT

History

The initial triage is done according to ABCDE principles of the primary survey: airway maintenance with stabilization of the cervical spine, breathing and ventilation, circulation with control of hemorrhage, disability assessment and neurological examination, and exposure along with environmental control. The secondary survey is a complete head-to-toe assessment that occurs later as part of the physical assessment. Sometime during the first 48 hours, a tertiary survey is performed to discover any subtle injuries that may have been missed during the initial assessment.

Determine the mechanism of injury in addition to taking a detailed report from the first responders about the patient with an acute SCI. Question the first responders, significant others, or witnesses about the situation surrounding the injury. If the patient was involved in a traffic injury, determine the speed and type of the vehicle, whether the patient was restrained, the patient's position in the vehicle, whether the patient was thrown from the vehicle on impact, or if the patient was a pedestrian. If the patient fell, the distance of the fall is important to know during the initial assessment and evaluation phase. If it was a sports-related injury, determine the sport and the patient's activities at the time of the injury. Determine if the patient has ingested alcohol or other drugs of abuse. A key component of the history in the patient with a suspected acute SCI is information about the patient's motor and sensory function at the scene as well as the severity of the injury. Determine if the patient also experienced a loss of consciousness. Determine any other organ dysfunction such as chronic heart, lung, or kidney conditions.

Physical Examination

Common symptoms include pain, changes in strength and motion of the extremities, changes in sensation, and changes in bowel and bladder function. Changes may be an autonomic response (urinary retention, constipation, paralytic ileus, hypotension, hypothermia, and bradycardia), a motor response (hemiplegia or hemiparesis, paraplegia or paraparesis, tetraplegia or tetraparesis), or sensory changes at a particular cord level. Assess the patient as soon as possible after the primary injury and again each hour during the acute period. Neurological assessments usually include the Glasgow Coma Scale and pupil reflexes. Assess the patient's injury level. Test the patient's ability to distinguish a pinprick from dull pain at each level of the dermatomes. Rectal examination helps determine if the sphincter tone is normal and if the SCI is complete or incomplete. Normal sphincter tone and anal winking indicate an incomplete SCI. Evaluate the patient's motor strength to help determine the injury level. Test the patient's motor movement. Patients may demonstrate agitation, anxiety, and restlessness. All patients with SCI should also be assessed for head injury.

Examine the patient for signs of neurogenic shock, which usually occurs within 30 to 60 minutes after the SCI when sympathetic nerves have lost their normal connections to the central nervous system (CNS). Signs to look for include decreased heart rate and pronounced hypotension (systolic pressure below 90 mm Hg). Assess the patient's respiratory status, paying particular attention to the rate and depth of respirations, chest wall expansion, and breath sounds.

Psychosocial

Acute SCI is catastrophic and alters not only the lives of patients but also the lives of their families, partners, friends, and the community they live in. Single people are more likely to have an SCI than married people, and the marriage rate after SCI is 60% lower than their noninjured counterparts. Divorce rates for married people with SCI are 2.5 times that of the general population after an SCI. Physiological alterations are significant in patients with acute SCIs, as are the psychosocial adjustments. The likelihood of employment after injury is higher for people with formal education and people who were employed at the time of injury. Ongoing assessment of patients' and families' coping skills is critical in planning meaningful support and interventions to assist patients in reaching their functional potential.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Spine x-rays	Normal body structures	May show spine fractures or injury such as dislocation or subluxation	Determines the integrity of bony structures of spine
Computed tomography scan	Normal body structures	Determines degree and extent of injury; may show spine fractures or injury such as dislocation or subluxation	Determines the integrity of bony structures of spine; highly sensitive to detect spinal fractures
Magnetic resonance imaging	Normal body structures	Determines degree and extent of injury; may show spine fractures or injury such as dislocation or subluxation	Determines the integrity of bony structures of spine; identifies cord lesions, ligamentous injuries, and soft tissue injuries

Other Tests: Electromyography, somatosensory-evoked potentials, motor-evoked potentials, complete blood count, urinalysis, arterial blood gases, serum lactate levels

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisIneffective airway clearance related to hypoventilation or airway obstruction as evidenced by cough, stridor, wheezing, decreased chest excursion, dyspnea, air hunger, anxiety, and/or restlessness

Outcomes

OutcomesRespiratory status: Airway patency; Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom severity; Symptom control; Neurological status

Interventions

InterventionsAirway insertion; Airway management; Airway suctioning; Oxygen therapy; Respiratory monitoring; Mechanical ventilation: Invasive; Oral health promotion; Neurologic monitoring

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Maintenance of ABCs is the highest priority in patients with SCI. The patient with a cervical or high thoracic injury is at risk for developing pulmonary insufficiency, problems with airway clearance, and ineffective breathing patterns. They may have a pneumothorax or hemothorax due to the traumatic impact. The patient may require endotracheal intubation or tracheostomy with mechanical ventilation. Assess tidal volume and vital capacity every 2 hours in the patient who is not endotracheally intubated. The patient likely needs a nasogastric tube to manage an ileus and to prevent aspiration of stomach contents. Hydration may be provided by IV crystalloid fluids or by dextran, a plasma expander that may be used to increase capillary blood flow. The systolic blood pressure should be maintained above 90 to 100 mm Hg. Neurogenic shock needs to be differentiated from hypovolemic shock by assessment of vital signs, laboratory testing, and hemodynamic monitoring, if necessary. The most common sources of a hidden hemorrhage after SCI are injuries to the chest, abdomen, retroperitoneum, and bone fractures. Hypothermia often accompanies both neurogenic shock and fluid resuscitation. The patient's temperature needs continuous monitoring, and interventions must be initiated to warm the patient if needed.

The benefits of early spinal stabilization are decreased morbidity and decreased length of hospital stay, but the neurological benefits are controversial. Although this is a temporary intervention, external stabilization may be accomplished by Gardner-Wells tongs, which can be applied until surgical stabilization can be performed. A halo apparatus can be applied either as a primary intervention or to protect a surgical repair. This device immobilizes the cervical spine but allows the patient increased mobility. Patients with stable thoracolumbar spine fractures require only support with a rigid external brace for several months. Timing for surgical (internal) stabilization of cervical spine injuries is controversial. Some suggest that early surgical stabilization enhances neurological recovery and decreases morbidity, but others believe that early stabilization may increase biochemical alterations and vascular instability.

Patients with unstable thoracolumbar spine fractures are managed with metal rods and surgical decompression. Neurological outcome may be improved by postponing surgery until spinal cord edema is decreased.

Postoperative patients may require a rigid cervical collar or rigid external brace to protect the surgical repair. Patients with acute SCI from penetrating trauma may require surgical intervention for débridement and closure of the dura if cerebrospinal fluid leakage persists. If x-ray films demonstrate that a bullet or other foreign body is within the spinal cord, surgical removal may be recommended to decrease the likelihood of chronic radicular pain.

Current thinking about corticosteroid administration after complete or incomplete spinal cord injuries is that it is associated with significant improvement in motor and sensory function if initiated within 8 hours after injury.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Methylprednisolone	30 mg/kg IV as a loading dose, followed by a 48-hr IV infusion of 5.4 mg/kg per hr	Corticosteroid; dexamethasone may also be used	Reduces inflammation and improves motor and sensory function
Inotropic agents	Varies by drug	Dopamine, norepinephrine	Improve systemic vascular resistance and blood pressure
Atropine	1 mg IV as needed	Anticholinergic	Manages symptomatic bradycardia

Other Drugs: Prophylactic anticoagulants may prevent the formation of deep vein thrombosis when the patient is no longer at risk for hemorrhage. Histamine-receptor antagonists decrease gastric acid secretion by inhibiting the receptor sites in the parietal cells and reducing the risk of stress ulcers. Pregabalin may be administered for neuropathic pain. Antacids may be administered to neutralize gastric acid.

Independent

The most critical nursing intervention for the patient with an acute SCI is to maintain airway, breathing, and circulation. Maintain cervical alignment and immobilization. An abdominal binder may be beneficial in patients with SCIs to provide additional support of the abdominal musculature, a major contributor to respiratory excursion. A potentially life-threatening complication associated with acute SCI is autonomic dysreflexia. This dysfunction may occur after the acute phase and is characterized by a hypersympathetic response to some noxious stimuli; this response is commonly found in patients with SCIs above the T8 level (Box 1). Deep vein thrombosis may also occur. Apply sequential compression devices or foot pumps as prescribed.

Box 1 Autonomic Dysreflexia

Precipitating Factors

Bladder distension or urinary tract infection
Bowel distention
Pressure ulcers
Thrombophlebitis
Gastric ulcers, gastritis
Pulmonary emboli
Menstruation
Constrictive clothing
Pain
Sexual activity; ejaculation
Manipulation of bowel or bladder
Spasticity
Exposure to hot or cold stimuli

Clinical Manifestations

Paroxysmal hypertension
Pounding headache
Blurred vision
Bradycardia
Diaphoresis above the level of injury
Piloerection
Nasal congestion
Nausea
Pupillary dilation

Check bony prominences and areas under the brace or jacket for skin breakdown. Aggressive physical and occupational therapy early in the acute phase may be beneficial to the patient's overall rehabilitation. Joint range-of-motion exercises prevent contractures and severe muscle wasting. Some patients may require splints for the upper and lower extremities to prevent flexion contractures and footdrop.

Prevent urinary tract infections by instituting an intermittent catheterization protocol early. Protocols vary, but most begin with catheterizing every 4 hours. Monitor the residual urine volume; when it is less than 400 mL, catheterization can be done every 6 hours. Record the amount of urine voided and the postvoid residuals. As the amount of residual volume decreases, increase the time intervals between catheterizations. Before catheterization, assist the patient in emptying the bladder by Crede method or by gently tapping or percussing the bladder. Establish bowel continence early in the acute phase.

When the patient is eating by mouth or is being tube fed, administer stool softeners as ordered. If the patient has not had a bowel movement, administer bisacodyl (Dulcolax) suppository. If the patient is NPO (nothing by mouth), administer bisacodyl every other night. Digital stimulation is used in conjunction with the bowel program. Adequate fluid volume status is important for a successful bowel and bladder program.

Provide diversionary activities to help pass the time. Arrange for the patient or family to consult with a clinical nurse specialist, chaplain, or social worker to assist in coping with anxiety and stress if it is deemed necessary. The disruption in the patient's life is extraordinary, and supporting the patient's psychological health is critical. If the patient has little hope for recovery, consider speaking with the family about donating the patient's organs if appropriate.

If the patient is scheduled for discharge, teach the patient and family about the recommended activity level and rehabilitative exercises. Explain how to recognize the signs and symptoms of infection or a deteriorating level of consciousness. Instruct the patient and family in the name, dosage, action, and potential adverse effects of all prescribed medications. Show them the proper care for wounds and lacerations. Make sure the patient and family are aware of the schedule for follow-up medical care.

Evidence-Based Practice and Health Policy

Burkhart, L., Skemp, L., Siddiqui, S., & Bates-Jensen, B. (2021). Developing a decision support tool to prevent community-acquired pressure injuries in spinal cord injury in ambulatory care: A nurse-led protocol for mix methods research. Nursing Outlook, 69, 127–135.

The authors described a plan to create and test a decision support tool to prevent community-acquired pressure injuries (CAPrIs) in people with SCI. They identified mental models of CAPrI prevention from the perspectives of Veterans and Veterans Health Administration SCI providers through a mix of photovoice, guided tours, and interviews.
They used triangulation to compare the two mental models that led to the development of a decision support tool and used Delphi approaches for validation strategies. Their research protocol provides a systematic map to explore, address, and translate research on SCI into evidence-based practice.

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DRG Information ⬇

Introduction ⬆ ⬇