Spinal Cord Injury

Spinal cord injury (SCI)—an injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral disks caused by trauma—is a major health disorder. In the United States in 2014, approximately 276,000 persons were living with a disability from SCI. An estimated 17,000 new cases occur annually; common causes are motor vehicle crashes, falls, violence (predominantly gunshot wounds), and sports-related injuries. Males account for 80% of patients with SCI. The average age of injury has increased from 29 years of age in the 1970s to 42 years in 2010. The predominant risk factors for SCI include younger age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI serves to emphasize the importance of primary prevention. The vertebrae most frequently involved in SCIs are the fifth, sixth, and seventh cervical vertebrae (C5-C7), the 12th thoracic vertebra (T12), and the first lumbar vertebra (L1). These vertebrae are the most susceptible because there is a greater range of mobility in the vertebral column in these areas. Damage to the spinal cord ranges from: (1) transient concussion (patient recovers fully), to (2) contusion, laceration, and compression of the cord substance (either alone or in combination), to (3) complete transection of the cord (paralysis below the level of injury). Injury can be categorized as primary (usually permanent) or secondary (nerve fibers swell and disintegrate as a result of ischemia, hypoxia, edema, and hemorrhagic lesions). Whereas a primary injury is permanent, a secondary injury may be reversible if treated within 4 to 6 hours of the initial injury. The type of injury refers to the extent of injury to the spinal cord itself.

Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central, lateral, anterior, or peripheral. A complete SCI can result in paraplegia (paralysis of the lower body) or tetraplegia (formerly quadriplegia—paralysis of all four extremities).

Complications

Spinal shock, a serious complication of SCI, is a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. The muscles innervated by the cord segment situated below the level of the lesion become completely paralyzed and flaccid, and the reflexes are absent. BP and heart rate fall as vital organs are affected. Parts of the body below the level of the cord lesion are paralyzed and left without sensation.

Emergency Management

Immediate patient management at the accident scene is crucial. Improper handling can cause further damage and loss of neurologic function.
Consider that any victim of a motor vehicle crash, a diving or contact sports injury, a fall, or any direct trauma to the head and neck has an SCI until it is ruled out.
Initial care includes rapid assessment, immobilization, extrication, stabilization or control of life-threatening injuries, and transportation to an appropriate medical facility.
Maintain patient in an extended position (not sitting); no body part should be twisted or turned.
The standard of care is referral to a regional spinal injury center or trauma center for treatment in first 24 hours.

Management of Complications

Spinal and Neurogenic Shock

Intestinal decompression is used to treat bowel distention and paralytic ileus caused by depression of reflexes. This loss of sympathetic innervation causes a variety of other clinical manifestations, including neurogenic shock signaled by decreased cardiac output, venous pooling in the extremities, and peripheral vasodilation.
Patient who does not perspire on paralyzed portion of body requires close observation for early detection of an abrupt onset of fever.
Special attention is paid to the respiratory system (may not be enough intrathoracic pressure to cough effectively). Special problems include decreased vital capacity, decreased oxygen levels, and pulmonary edema.
Chest physiotherapy and suctioning are implemented to help clear pulmonary secretions. Patient is monitored for respiratory complications (respiratory failure, pneumonia).

Quality and Safety Nursing Alert

The patient's vital organ functions and body defenses must be supported and maintained until spinal and neurogenic shock abates and the neurologic system has recovered from the traumatic insult; this can take up to 4 months.

Deep Vein Thrombosis and Other Complications

Patient is observed for deep vein thrombosis (DVT), a complication of immobility (e.g., pulmonary embolism [PE]). Symptoms include pleuritic chest pain, anxiety, shortness of breath, and abnormal blood gas values.
Low-dose anticoagulation therapy is initiated to prevent DVT and PE, along with the use of antiembolism stockings or pneumatic compression devices. A permanent indwelling filter may be placed in the vena cava to prevent dislodged clots (emboli) from migrating to the lungs and causing PE.
Patient is monitored for autonomic hyperreflexia (characterized by pounding headache, profuse sweating, nasal congestion, piloerection [gooseflesh], bradycardia, and hypertension).
Constant surveillance is maintained for signs and symptoms of pressure ulcers and infection (urinary, respiratory, local infection at pin sites).

Quality and Safety Nursing Alert

The calves or thighs should never be massaged because of the danger of dislodging an undetected thromboembolus.

Outline

Complications
Emergency Management
Management of Complications

The consequences of SCI depend on the type and level of injury of the cord. The American Spinal Injury Association (ASIA) provides classification of SCI according to the degree of sensory and motor function present after injury.

Neurologic Level

The neurologic level refers to the lowest level at which sensory and motor functions are normal. Signs and symptoms include the following:

Total sensory and motor paralysis below the neurologic level
Loss of bladder and bowel control (usually with urinary retention and bladder distention)
Loss of sweating and vasomotor tone
Marked reduction of BP from loss of peripheral vascular resistance
Acute pain in back or neck (if patient is conscious and can report); possible fear that the neck or back is broken

Respiratory Problems

Related to compromised respiratory function; severity depends on level of injury
Acute respiratory failure: leading cause of death in high cervical cord injury

Outline

Neurologic Level
Respiratory Problems

Detailed neurologic examination, x-ray examinations (lateral cervical spine x-rays), CT, and MRI are common assessment and diagnostic tools. ECG is also commonly used, as bradycardia and asystole are frequent findings in acute spinal injuries.

Acute Phase

Goals of management are to prevent further SCI and to observe for symptoms of progressive neurologic deficits. The patient is resuscitated as necessary, and oxygenation and cardiovascular stability are maintained. High-dose corticosteroid drugs (methylprednisolone) may be given to counteract spinal cord edema, though this is no longer the standard of care because studies suggest it offers only slight benefit.

Oxygen is given to maintain a high arterial PaO₂. Extreme care is taken to avoid flexing or extending the neck if endotracheal intubation is necessary. Diaphragm pacing (electrical stimulation of the phrenic nerve) may be considered for patients with high cervical spine injuries. Surgically implanted, intramuscular diaphragm pacing techniques may be used.

SCI requires immobilization, reduction of dislocations, and stabilization of the vertebral column. The cervical fracture is reduced and the cervical spine aligned with a form of skeletal traction (using skeletal tongs, calipers, or the halo-vest technique). Weights are hung freely so as not to interfere with the traction.

Early surgery reduces the need for traction. The goals of surgical treatment are to preserve neurologic function by removing pressure from the spinal cord and to provide stability.

The Patient With Acute SCI

Assessment

Observe breathing pattern; assess strength of cough; auscultate lungs.
Monitor patient closely for any changes in motor or sensory function and for symptoms of progressive neurologic damage.
Test motor ability by asking patient to spread fingers, squeeze examiner's hand, and move toes or turn the feet.
Evaluate sensation by pinching the skin or touching it lightly with a tongue blade, starting at shoulder and working down both sides; patient's eyes should be closed. Ask patient where sensation is felt.
Assess for spinal shock.
Palpate lower abdomen for signs of urinary retention and overdistention of the bladder.
Assess for gastric dilation and paralytic ileus due to atonic bowel.
Monitor temperature; hyperthermia may result owing to autonomic disruption.

Diagnosis

Nursing Diagnoses

Ineffective breathing patterns and airway clearance related to weakness (or paralysis) of abdominal and intercostal muscles, and inability to clear secretions
Impaired physical mobility related to motor and sensory impairment
Disturbed sensory perception related to immobility and sensory loss
Risk for impaired skin integrity related to immobility or sensory loss
Impaired urinary elimination related to patient's inability to void spontaneously
Constipation related to presence of atonic bowel as a result of autonomic disruption
Acute pain and discomfort related to treatment and prolonged immobility
Autonomic dysreflexia related to uninhibited sympathetic response of the nervous system following SCI

Collaborative Problems/Potential Complications

Venous thromboembolism (DVT, PE)
Orthostatic hypotension
Autonomic hyperreflexia

Planning and Goals

Major patient goals may include improved breathing pattern and airway clearance; improved mobility; improved sensory and perceptual awareness; maintenance of skin integrity; relief of urinary retention; improved bowel function; promotion of comfort; and absence of complications.

Nursing Interventions

Promoting Adequate Breathing and Airway Clearance

Detect potential respiratory failure by observing patient, measuring vital capacity, and monitoring oxygen saturation through pulse oximetry and arterial blood gas values.
Prevent retention of secretions and resultant atelectasis with early and vigorous attention to clearing bronchial and pharyngeal secretions.
Suction with caution, because this procedure can stimulate the vagus nerve, producing bradycardia and cardiac arrest.
Initiate chest physical therapy and assisted coughing to mobilize secretions if the patient cannot cough effectively.
Supervise breathing exercises to increase strength and endurance of inspiratory muscles, particularly the diaphragm.
Ensure proper humidification and hydration to maintain thin secretions.
Assess for signs of respiratory infection: cough, fever, and dyspnea.
Monitor respiratory status frequently.

Improving Mobility

Maintain proper body alignment at all times.
Reposition the patient frequently and assist patient out of bed as soon as the spinal column is stabilized.
Apply splints (various types) to prevent footdrop, and apply trochanter rolls to prevent external rotation of the hip joints; reapply every 2 hours.
Patients with lesions above the midthoracic level may tolerate changes in position poorly; monitor BP when position is changed.
Do not turn a patient who is not on a rotating specialty bed, unless physician indicates that it is safe to do so.
Perform passive range-of-motion exercises as soon as possible after injury to avoid complications such as contractures and atrophy.
Provide a full range of motion at least four or five times daily to toes, metatarsals, ankles, knees, and hips.
For patients who have a cervical fracture without neurologic deficit, reduction in traction followed by rigid immobilization for 6 to 8 weeks restores skeletal integrity. These patients are allowed to move gradually to an erect position. Apply a neck brace or molded collar when the patient is mobilized after traction is removed.

Promoting Adaptation to Disturbed Sensory Perception

Stimulate the area above the level of the injury through touch, aromas, flavorful food and beverages, conversation, and music.
Provide prism glasses to enable patient to see from supine position.
Encourage use of hearing aids, if applicable.
Provide emotional support; teach patient strategies to compensate for, or cope with, sensory deficits.

Maintaining Skin Integrity

Change patient's position every 2 hours and inspect the skin, particularly under cervical collar.
Assess for redness or breaks in skin over pressure points; check perineum for soilage; observe catheter for adequate drainage; assess general body alignment and comfort.
Wash skin every few hours with a mild soap, rinse well, and blot dry. Keep pressure-sensitive areas well lubricated and soft with oil or lotion.
Educate patient about pressure ulcers and encourage participation in preventive measures.

Maintaining Urinary Elimination

Perform intermittent catheterization to avoid overstretching the bladder and infection. If this is not feasible, insert an indwelling catheter.
Show family members how to catheterize and encourage them to participate in this facet of care.
Educate patient in recording fluid intake, voiding pattern, amounts of residual urine after catheterization, characteristics of urine, and any unusual feelings.

Improving Bowel Function

Monitor reactions to gastric intubation.
Provide a high-calorie, high-protein, high-fiber diet. Food amount may be gradually increased after bowel sounds resume.
Administer prescribed stool softener to counteract effects of immobility and analgesic agents, and institute a bowel program as early as possible.

Providing Comfort Measures

Reassure patient in halo traction that he or she will adapt to steel frame (i.e., feeling caged in and hearing noises).
Cleanse pin sites daily and observe for redness, drainage, and pain; observe for loosening. If one of the pins becomes detached, stabilize the patient's head in a neutral position and have someone notify the neurosurgeon; keep a torque screwdriver readily available.
Inspect the skin under the halo vest for excessive perspiration, redness, and skin blistering, especially on the bony prominences. Open vest at the sides to allow torso to be washed. Do not allow vest to become wet; do not use powder inside vest.

Monitoring and Managing Potential Complications

Thrombophlebitis

Refer to “Medical Management” under Vein Disorders in Section V.

Orthostatic Hypotension

Reduce frequency of hypotensive episodes by administering prescribed vasopressor medications. Provide antiembolism stockings and abdominal binders; allow time for slow position changes and use tilt tables as appropriate. Close monitoring of vital signs before and during position changes is essential.

Autonomic Hyperreflexia

Perform a rapid assessment to identify and alleviate the cause of autonomic hyperreflexia and remove the stimulating trigger.
Place patient immediately in sitting position to lower BP.
Catheterize the patient to empty bladder immediately.
Examine rectum for fecal mass. Apply topical anesthetic for 10 to 15 minutes before removing fecal mass.
Examine skin for areas of pressure, irritation, or breaks.
As prescribed, administer a ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) if the foregoing measures do not relieve hypertension and excruciating headache.
Label chart clearly and visibly, noting the risk for autonomic hyperreflexia.
Educate patient in prevention and management measures. Inform patient with lesion above T6 that hyperreflexic episode can occur years after initial injury.

Promoting Home, Community-Based, and Transitional Care

Educating Patients About Self-Care

Shift emphasis from ensuring that patient is stable and free of complications to specific assessment and planning for independence and the skills necessary for activities of daily living.
Initially, focus patient education on the injury and its effects on mobility, dressing, and bowel, bladder, and sexual function. As the patient and family acknowledge the consequences of the injury and the resulting disability, broaden the focus of education to address issues necessary for the patient to carry out the tasks of daily living and take charge of their life.

Continuing and Transitional Care

Support and assist patient and family in assuming responsibility for increasing care; provide assistance in dealing with psychological impact of SCI and its consequences.
Coordinate management team and serve as liaison with rehabilitation centers and home care agencies.
Reassure female patients with SCI that pregnancy is not contraindicated and fertility is relatively unaffected but that pregnant women with acute or chronic SCI pose unique management challenges.
Refer for home care nursing support as indicated or desired.
Refer patient to mental health care professional as indicated.

Evaluation

Expected Patient Outcomes

Demonstrates improvement in gas exchange and clearance of secretions
Moves within limits of dysfunction and demonstrates completion of exercises within functional limitations
Demonstrates adaptation to sensory and perceptual alterations
Demonstrates optimal skin integrity
Regains urinary bladder function
Regains bowel function
Reports absence of pain and discomfort
Is free of complications

For more information, see Chapter 68 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Outline

Assessment
Diagnosis
Planning and Goals
Nursing Interventions
Evaluation

section name header

Introduction ⬇

Clinical Manifestations ⬆ ⬇

Assessment and Diagnostic Findings ⬆ ⬇

Medical Management ⬆ ⬇

Nursing Process ⬆