Republic of the Philippines

MARIANO MARCOS STATE UNIVERSITY

COLLEGE OF HEALTH AND SCIENCES
Department of Nursing

ORTHOPEDIC NURSING

SPINAL CORD INJURY

Submitted by:

Bianca Montes
John Lester M. Fernandez
Noreeka Nia J. Tamayo
Laurice Faye A. Ranjo
BSN III-B
Cluster 5

June 2017
 Spinal Cord Injury

It is the damage of the spinal cord that causes changes in its function, either temporary or
permanent. These changes translate into loss of muscle function, sensation, or autonomic function
in parts of the body served by the spinal cord below the level of the lesion. Spinal injuries include
fractures, contusions, and compressions of the vertebral column. These injuries usually result from
trauma to the head or neck. The real danger lies in complications such as spinal cord damage
arising from a spinal injury. Spinal fractures most commonly occur at C5, C6, and C7, T12 and
L1.

Classification of Spinal Cord Injury

1. Complete Spinal Cord Injury
Usually the loss of sensation and motor ability associated with a complete spinal
cord injury caused by caused by bruising, loss of blood to the spinal cord or
pressure on the spinal cord, cut the severed spinal cord are rare. Generally,
complete spinal cord injuries results on total loss of the sensation and movement
below the site of the injury.

2. Incomplete Spinal Cord Injury

Incomplete spinal cord injury does not result in complete loss of movement and
sensation below the injury site. S variety of patterns exist to classify such injuries:

a. Anterior cord Syndrome result from damage to the motor and sensory
pathways in the anterior areas of the spinal cord. Effects include loss of
movement and overall sensation although some sensations that travel by way
of the still intact pathways can be felt.

b. Central Cord Syndrome results from injury to the center of the cervical
area of the spinal cord. The damage affects the corticospinal tract, which is
responsible for carrying signals between the brain and spinal cord to control
movement. Patients of central cord syndrome experience weakness or
 paralysis in the arms and some loss of sensory reception. The loss of strength
and sensation is much less in the legs than in the arms. Many patients with
central cord syndrome spontaneously recover motor function and others
experience considerable recovery in the first six weeks following the injury.

c. Brown-Squad Syndrome result from injury to the right or left side of the
spinal cord. On the side of the body where the injury occurred movement and
sensation are lost below the level of injury. On the side opposite the injury,
temperature and pain sensation are lost6 due to the crossing of these pathways
in the spinal cord.

d. Injuries to individual nerve cells result in loss of sensory and motor

function in the area of the body to which the injured nerve root corresponds.

e. Spinal Contusions the most common type of spinal cord injury. The spinal
cord is bruised, not severed, but the consequences in inflammation and
bleeding from blood vessels near the injury. A spinal contusion result in
temporary (usually 1 to 2 days) incomplete or complete debilitation of the
spinal cord.
3. Paraplegia
Paralysis of the lower body
The result of a person suffering a spinal cord injury at the thoracic level or below.

4. Tetraplegia (formerly called quadriplegia)

This can result in a partial or total sensory and motor loss of the four limbs
and torso or the paralysis of all four extremities.
The injuries that occur above level C4 often result in respiratory deficiency
Risk factors
1. Age. People aged 1835 are more likely to sustain spinal cord injuries from car or
motorcycle accidents, and the elderly aged 65 and above are more likely to become injured
in falls.
2. Gender. Males are more at risk of developing SCI due to having more strenuous activities
than females.
3. Alcohol and drug use. Alcohol can damage nerve function when it accumulates inside
the body. Heavy alcohol intake for extended periods of time can lead to alcoholic
neuropathy, a serious form of nerve damage.
4. Athletes. Gymnasts, skiers, hockey players, divers, and surfers are at increased risk. Diving
into too-shallow water or playing sports without wearing the proper safety gear or taking
proper precautions can lead to spinal cord injuries.
5. Having a bone or joint disorder. Patients with diseases that affect the bones and joints
are also more susceptible to spinal cord injuries.

Triggering Factors
1. Arachnoiditis
- It is a pain disorder caused by the inflammation of the arachnoid, one of the membranes
that surrounds and protects the nerves of the spinal cord.
2. Infections (Potts disease, TB, epiduritis)
-
3. Parasite (Schistosomiasis/ Bilharziosis)
4. Tumor-related disease (Hodgkins disease and myeloma)
5. Surgical accidents (lesions resulting from the lack of O2 supply to the spinal cord; anoxia
during anesthesia)

Etiology
Traumatic
Most frequent cause of adult SCI
Result from:
Motor vehicle accidents,
 Falls
Gunshot wounds

Non-traumatic
Approx 30% of all SCI
Result from diseases or pathological influence such as Cancer, arthritis,
osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.
Vertebral subluxations due to Rheumatoid Arthritis or Degenerative Joint Disease
Infections
Multiple Sclerosis (MS)
Spinal cord plaques (patches of myelin loss) due to MS in the neck (cervical) region
can cause cape like sensation loss in both shoulders and in the upper arms.
Quadriplegia is the great danger in cervical region MS. Anesthesia in a band like
distribution around the trunk can be experienced in MS patients with mid spinal cord
inflammation. Such patients may become paraplegic.
Amyotrophic Lateral Sclerosis (ALS)
It is a rare group of neurological diseases that mainly involve the nerve cells
(neurons) responsible for controlling voluntary muscle movement. Voluntary muscles
produce movements like chewing, walking, breathing and talking. The disease is
progressive, meaning the symptoms get worse over time. Currently, there is no cure
for ALS and no effective treatment to halt, or reverse, the progression of the disease.
ALS belongs to a wider group of disorders known as motor neuron diseases, which
are caused by gradual deterioration (degeneration) and death of motor neurons. Motor
neurons are nerve cells that extend from the brain to the spinal cord and to muscles
throughout the body. These motor neurons initiate and provide vital communication
links between the brain and the voluntary muscles.
Messages from motor neurons in the brain (called upper motor neurons) are
transmitted to motor neurons in the spinal cord and to motor nuclei of brain (called
lower motor neurons) and from the spinal cord and motor nuclei of brain to a particular
muscle or muscles.
Signs and Symptoms
Symptoms vary somewhat depending on the location of the injury. Spinal cord injury
causes weakness and sensory loss at and below the point of the injury. The severity of symptoms
depends on the whether the entire cord is severely injured (complete) or only partially injured
(incomplete).
Cervical (Neck) Injuries
When SCI occur in the neck area, symptoms can affect the arms, legs and middle of the body.
The symptoms may occur on one or both sides of the body. Symptoms can include:
breathing difficulties (from paralysis of the breathing muscles, if the injury is higher up in
the neck)
loss of normal bowel and bladder control (may include constipation, incontinence, bladder
spasms)
numbness
sensory changes
spasticity (increased muscle tone)
pain

Thoracic (Chest level) Injuries

loss of normal bowel and bladder control (may include constipation, incontinence, bladder
spasms)
numbness
sensory changes
spasticity (increased muscle tone)
pain
weakness, paralysis

Lumbosacral (Lower Back) Injuries

When spinal injuries occur at the lower back level, varying degrees of symptoms can affect
one or both legs as well as the muscles that control the bowel and bladder:
numbness
sensory changes
 spasticity (increased muscle tone)
pain
weakness, paralysis

Complications
1. Autonomic Dysreflexia
It is a condition that occurs when a stimulus (e.g., blocked catheter, skin irritation)
below the injury site triggers a message to the brain that cannot be received. This causes a
reflex that constricts blood vessels and results in a reduced heart rate and high blood
pressure. Autonomic dysreflexia increases the risk for stroke and rarely, seizures.
Sometimes this condition can be resolved if the patient changes position or the stimulus is
removed.
It is a very dangerous complication occurring in patients with lesions above T6. Also
known as autonomic hyperreflexia, autonomic dysreflexia is a serious medical condition
that occur after resolution of spinal shock. Emergency recognition and management is a
must. Suspect autonomic dysreflexia in the patient with a history of spinal cord trauma at
level T6 and above who exhibits cold or goose-fleshed skin below the lesion level,
bradycardia, and hypertension. The hypertension is generally accompanied by severe,
pounding headache.
Some dysreflexia is caused by noxius stimuli , most commonly a distended bladder or
skin lesion below the level of the lesion triggers the autonomic nervous system causing a
sudden increase in blood pressure, which if untreated can lead to convulsions, hemorrhage,
and death. Treatment focuses on eliminating the stimulus; rapid identification and removal
may avoid the need for pharmacologic control of the headache and hypertension.
Symptoms: high BP, severe HA, blurred vision, stuffy nose, profuse sweating, goose
bumps below & vasodilation (flushing) above the level of the injury
Common Causes: distended or full bladder, kink or blockage in the catheter, bladder
infection, pressure ulcer, extreme temperature change, tight clothing, in grown toenail
2. Orthostatic Hypotension
Orthostatic Hypotension is a particular common problem for patient with lesions above
T7. In some patients with tetraplegia, even slight elevations of the head can result in
dramatic decreases in blood pressure. Close monitor of vital signs before and during
position changes. Activity should be planned in advance, and adequate time should be
allowed for a slow progressive of position changes from recumbent to sitting and upright.

3. Spinal Shock
Spinal shock is the loss of autonomic, reflex, motor and sensory activity below the level
of the cord lesion. It occurs secondary to damage of the spinal cord. Signs of spinal shock
include flaccid paralysis, loss of deep tendon and perianal reflexes, and kiss of motor and
sensory function.
Until spinal shock has resolved (usually 1 to 6 weeks after injury), the extent of the
actual cord damage can't be assessed. The earliest indicator of spinal shock resolution is
the return of reflex activity.
4. Neurogenic Shock
Neurogenic shock is a temporary loss of autonomic function below the level of injury
that produces cardiovascular changes. Signs include orthostatic hypotension, bradycardia
and loss of ability to sweat below the level of the lesion. This abnormal vasomotor response
occurs secondary to disruption of sympathetic impulses from the brain stem to the
thoracolumbar area and is seen most commonly in cervical cord injury.
5. Pneumonia and Asthma
Pneumonia and asthma are common long-term complications because muscles
associated with breathing usually are weakened. Breathing assistance may be necessary if
the nerves to the diaphragm are damaged. Medications may be used to regulate breathing
issues and patients are encouraged to get an annual flu shot.
The heart rate can slow down considerably, or increase to an alarming level following
spinal cord injury. This may cause heart problems and low blood pressure that may require
intravenous blood infusions.
6. Blood clots
These are of particular concern for spinal cord injury patients, as immobility reduces
blood flow through the veins. Patients often are prescribed medications to prevent clotting.
7. Pressure Sores
When a patient has been sitting or lying in the same position for a long time, pressure on
the skin can cause the tissue to deteriorate resulting in pressure sores (also
called bedsores). If feeling has been lost in certain parts of the body, the patient may not
even be aware of these sores. Patients who develop pressure sores should change positions
frequently, should take measures to maintain healthy skin, and should follow a balanced
diet. Patients or caregivers also should inspect all areas of the skin carefully for cuts and
sores.
8. Neurogenic pain (i.e. pain that originates from nervous tissue) and burning and stinging
sensations are common and may even occur in limbs that no longer have movement or
feeling. Using other parts of the body to compensate for paralyzed limbs (e.g., using the
arms to move a wheelchair) can also cause pain. Treatment includes medications,
acupuncture, surgery, and spinal or brain electrical stimulation.
9. Spasms are reflexes that cause uncontrolled limb movement. Spasticity is a term used to
describe spasms of increased tone. These conditions occur when nerves in the spinal cord
are affected by the injury and the brain and nerves can no longer communicate and control
the movements. Medical treatments are available to help reduce spasticity. In some cases,
spasms are actually beneficial, as they can improve muscle tone in the affected areas and
allow some patients a little stability of the limb, which can improve mobility.
10. Urinary problems (e.g., urinary tract infection [UTI], kidney infection) and bowel
difficulties occur when the nerves controlling these functions are damaged. The brain and
body can no longer coordinate and the bladder and bowel may eliminate uncontrollably.
Drinking plenty of water and incorporating more fiber into the diet can sometimes help
both of these problems. In some cases, catheters and medications also are used.
11. Spinal cord injuries often result in sexual dysfunction and fertility problems. Typically,
these problems affect men more often than women. Doctors can prescribe medication and
other treatments to increase fertility. In many cases, spinal cord injury does not affect a
woman's fertility; however, pregnancy is considered high risk and should be considered
 only under the care of a qualified health care provider. For both men and women, specialists
can provide advice for intimacy.
12. Weight loss or gain can also occur, since spinal cord injuries affect diet as well as the
patient's ability to exercise. Physical therapists and nutritionists can help patients maintain
healthy habits through exercise and diet.
13. Depression is common in patients who have sustained a spinal cord injury. During
recovery, patients often feel sadness, grief, anxiety, and stress, and a caring network of
qualified health care providers, family, and friends is very important. Therapists can also
help patients through this difficult time.
ASIA (American Spinal Injury Association) Impairment Scale (AIS)
The ASIA (American Spinal Injury Association) Impairment Scale (AIS), based on the Frankel
scale, is a clinician-administered scale used to classify the severity (completeness) of injury in
individuals with SCI. It identifies sensory and motor levels indicative of the highest spinal level
demonstrating unimpaired function. Preservation of function in the sacral segments (S4-S5) is a
key for determining the AIS grade.

5 point ordinal scale, based on the Frankel scale, classifies individuals from A (complete
SCI) to E (normal sensory and motor function):

A: Complete. No sensory or motor function is preserved in the sacral segments S4-S5.

B: Sensory incomplete. Sensory but not motor function is preserved below the neurological
level and includes the sacral segments S4-S5 (light touch, pin prick at S4-S5 or deep anal
pressure), AND no motor function is preserved more than three levels below the motor level
on either side of the body.
C: Motor incomplete. Motor function is preserved below the neurological level and more
than half of key muscle functions below the single neurological level of injury (NLI) have a
muscle grade less than 3.
D: Motor incomplete. Motor function is preserved below the neurological level and at least
half of key muscle functions below the NLI have a muscle grade of 3 or greater.
E: Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal
in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without
 an initial SCI does not receive an AIS grade.

AIS scores are considered essential when classifying persons with SCI as to their
neurological status. AIS scores are routinely collected in administrative databases such the
Model Systems and CIHI National Rehabilitation Reporting System.

Diagnostic Tests
Spinal X-rays, the most imprtant dianostic measure, locate the fracture.
Lumbar puncture may show increased cerebrospinal fluid pressure from a lesion or trauma
in spinal compression.
Computed tomography scan or magnetic resonance imaging can locate the spinal mass.
Somatosensory Evoked Potential (SSEP) testing or magnetic stimulation may show if
nerve signals can pass through the spinal cord.

Treatment
The primary treatment after spinal injury is immediate immobilization to stabilize the spine
and prevent and prevent spinal cord damage; other treatment is supportive.
Cervical inquiries require immobilization, using sandbags on both sides of the patient's head, a
hard cervical collar, or skeletal traction with skull tongs or a halo device.
When patients show signs of spinal cord injury, high doses of methylprednisolone are
given.
Treatment of stable lumbar and dorsal fractures consists of bed rest on firm support (such
as a bed board), analgesics, and muscle relaxants until the fracture stabilizes (usually 10 to
12 weeks). Later treatment includes exercises to strengthen the back muscles and a back
brace or corset to provide support while walking.
An unstable dorsal or lumbar fracture requires a plaster cast, a turning frame and, in severe
fracture, laminectomy and spinal fusion.
When the damage results in compression of the spinal column, neurosurgery may relieve
the pressure.
If the cause of compression is a neoplastic lesion, chemotherapy and radiation may relieve
it.
 Surface wounds accompanying the spinal injury requires tetanus prophylaxis unless the
patient has had recent immunization.
Emergency Management
The immediate management at the scene of the injury is critical, because improper handling
of the patient can cause any further damage and loss of neurological function. Any patient who is
involved in a motor vehicle crash, a driving or contract sports injury, fall, or any direct trauma to
the head and neck must be considered have spinal cord injury until such an injury is ruled out.
Initial care include rapid assessment, immobilization, extrication, and stabilization or control of
life-threatening injuries, and transportation to the most appropriate medical facility. Immediate
transportation to the trauma center with the capacity to manage major neurologic trauma is the
necessary.

Medical Management
Goals of management:
1. To prevent secondary injury
2. To observe for symptoms of progressive neurologic deficits
3. To prevent complication

Pharmacologic Therapy
Administration of high dose IV corticosteroids (methylprednisolone sodium
succinate [Solu-Medrol])
Given in the first 24 to 48 hours
It is used to reduce the secondary effect of acute cord injury
Reducing damage to nerve cells and decreasing inflammation near the
site of injury.
Respiratory Therapy
Oxygen administration to maintain a high partial pressure of arterial
oxygen (PaO2), because hypoxemia can create or worsen a neurologic
deficit of spinal cord.
 Skeletal Fracture Reduction a Traction
Management of spinal cord injury requires immobilization and reduction of
dislocations (restoration of pre-injury position) and stabilization of the vertebral column.
Cervical fracture are reduced, and the cervical spine is aligned with some form of
skeletal traction, or with the use of halo devices.
Traction is applied to the skeletal traction device by weights, the amount depending
on the size of the patient and the degree of fracture displacement. The traction forced is
exerted along the longitudinal axis of the vertebral bodies, with the patients neck in a
neutral position. The traction is then gradually increased by adding more weights. As the
amount of traction is increased, the spaces between the intervertebral disk widen and the
vertebrae are given a chance to slip back into position. Reduction usually occurs after
correct alignment has been restored. Nce reduction is achieved, as verified by cervical spine
x-rays and neurologic examination, the weights are gradually removed until the amount of
weight needed to maintain the alignment is identified.
The weights should hang freely so as not to interfere with the traction
Traction sometimes supplemented with manual manipulation of the neck to
help achieved realignment of the vertebral bodies
Cervical traction is used less frequently with the advent of earlier and better
surgical stabilization

A halo device may be used initially with traction or may be applied after removal
of the tongs. It consist of a stainless steel halo ring that is fixed to the skull by four pins.
The ring is attached to a removal halo vest, a device that suspends the weight of the unit
circumferentially around the chest. A metal frame connects the ring to the chest, halo
devices provide immobilization of the cervical spine while allowing early ambulation.
Thoracic and lumbar injuries are usually treated with surgical interventions followed by
immobilization with a fitted brace.
Traction is not indicated either before or after surgery, due to the relative
stability of the spine in these regions.
 Surgical Management
Indication:
Compression of the cord is evident
The injury results in a fragmented or unstable vertebral body
The injury involves a wound that penetrate the cord
Bony fragments are in the spinal canal
The patients neurologic status is deteriorating
1. Spinal Decompressing (laminectomy)
To relieve pressure on the spinal cord or on one or more compressed nerve
roots passing through or exiting the spinal column.
To remove the bony roof covering the spinal cord and nerves to create more
space for them to move freely.
Spinal decompression can be performed anywhere along the spine from the neck
(cervical) to the lower back (lumbar). The procedure is performed through a surgical
incision in the back (posterior). The lamina is the bone that forms the backside of the
spinal canal and makes a roof over the spinal cord. Removing the lamina and other soft
tissues gives more room for the nerves and allows for removal of bone spurs.
Depending on the extent of stenosis, one vertebra (single-level) or more (multi-level)
may be involved.
2. Stabilizing the spine
There has been much progress in minimally invasive spine surgery. Spine surgeons
may use posterior fixation, such as percutaneous pedicle screws, facet screws, and
spinous process plates, to stabilize the spine and facilitate fusion after
decompression. Posterior means from the back side, so posterior fixation means
inserting instruments on the back side of the spine in order to stabilize it.

Nursing Management

1. Promote adequate breathing and airway clearance of the patient

Early and vigorous attention to clearing bronchial and pharyngeal secretion can
prevent retention of secretions and atelectasis.
 Suction cautiously
Teach patient about breathing exercise
Adequate hydration
2. Improve mobility
Maintain proper alignment at all times
Reposition the patient frequently and is assisted out of the bed as soon as the spinal
column is stabilize
Range-of-motion exercise should be implemented to help preserve joint motion and
stimulate circulation.
Prevent foot drop by using a foot board
Apply trochanter rolls from the crest of the ilium to the midthigh of both legs to
help prevent external rotation of the hip joints.
Maintaining stable blood pressure (BP), establishing a baseline helps caregivers
promptly detect improvement or deterioration.

3. Administer prescribed medications which may include high dose of corticosteroids.

4. Provide bladder care to prevent urine stasis
Schedule frequent times for voiding
Maintain an adequate fluids before bedtime
Identify and use triggering mechanism that can stimulate voiding
Prevent intermittent bladder catheterization appropriately
5. Maintaining skin integrity
Patients skin should be kept clean by washing with a mild soap, rinsing well, and
blotting dry.
Provide comfort measures by cleaning every day the halo device and observed for
redness, drainage, and pain.
Make sure that the halo vest is not wet to because dampness causes skin excoriation.
Do not used powder inside the vest because it may contribute to the development
of pressure ulcers.
6. Positive reinforcement helps recovery by improving self-esteem and promoting
independence of the patient.
7. Provide emotional support to the patient.
8. Change the patient position every 2 hours to prevent pressure ulcers as one of the
complication of spinal cord injury; also prevents pooling of blood and edema in the
dependent areas.
9. Give the patient a high-calorie, high-protein, high-fiber diet to counteract the effects
of immobility and analgesic agents.