Prepared by

:
Barrios, Kevin George B.
BSN 4-A
ntroduction
The spinal cord contains the
nerves that carry messages
between your brain and your
body. The cord passes through
your neck and back. A spinal
cord injury is very serious
because it can cause paralysis
below the site of the injury.
t can cause myelopathy or
damage to white matter or
myelinated fiber tracts that
carry signals to and from the
brain. t also damages gray
matter in the central part of the
brain, causing segmental
losses of interneurons and
motorneurons
W usually begins with a sudden, traumatic blow to the spine
that fractures or dislocates vertebrae.
W damage begins at the moment of injury when displaced
bone fragments, disc material, or ligaments bruise or tear
into spinal cord tissue.
W ost injuries don't completely severe it, instead, an injury
is more likely to cause fractures and compression of the
vertebrae, which then crush and destroy the axon.
W An injury to the spinal cord can damage a few,
many, or almost all of these axons. Some
injuries will allow almost complete recovery.
Others will result in complete paralysis.
Anatomy of the SpinaI Cord
The SPINAL CORD is a thick length of nerve tissue that extends
from the base of the brain, down the back, through the spinal column.
The SPINAL COLUMNis made up of bones called
vertebrae that protect the spinal cord.
The spinal cord is made up of motor and sensory
nerve cells called neurons.
The motor nerves are grouped together and transmit
motor commands from the brain to the muscles and
initiate movement.
The sensory nerves are also grouped together. They
carry information about sensations, such as pain and
temperature, to the brain.
The spinal cord is divided into OUR AREAS:
W cervicaI neck),
W thoracic chest),
W Iumbar lower back), and
W sacraI tailbone)
Lach area ls referred Lo bv lLs flrsL leLLer
(Cţ 1ţ Lţ or S) and Lhe verLebrae wlLhln each
area of Lhe splne are numbered as followsť
-C1 Lo C8ť Cervlcal verLebrae
-11 Lo 112ť 1horaclc verLebrae
-L1 Lo L3ť Lumbar verLebrae
-S1 Lo S3ť Sacral verLebrae
* 8v adulLhoodţ Lhe 3 sacral verLebrae fuse Lo form one boneţ and Lhe 4 coccvaeal
verLebrae fuse Lo form one boneŦ)
Physiology of the Spinal Cord
W ighways for nerve impulse
propagation
W #eceives and integrates incoming
and outgoing information
W aintainins gait and balance
Segmental Spinal Cord Level
and Function
Level Function
C1-C6 Neck flexors
C1-T1
Neck extensors
C3, C4, C5
Supply diaphragm mostly C4)
C5, C6
Shoulder movement, raise arm
deltoid); flexion of elbow
biceps); C6 externally rotates
the arm supinates)
C6, C7
Extends elbow and wrist triceps
and wrist extensors); pronates
wrist
C7, T1 Flexes wrist
C7, T1 Supply small muscles of the hand
T1 -T6
ntercostals and trunk above the
waist
T7-L1
Abdominal muscles
L1, L2, L3, L4
Thigh flexion
L2, L3, L4
Thigh adduction
L4ţ L3ţ S1 1hlah abducLlon
L3ţ S1ţ S2
LxLenslon of lea aL Lhe hlp (aluLeus
maxlmus)
L2ţ L3ţ L4
LxLenslon of lea aL Lhe knee
(quadrlceps femorls)
L4ţ L3ţ S1ţ S2
llexlon of lea aL Lhe knee
(hamsLrlnas)
L4ţ L3ţ S1 uorslflexlon of fooL (Llblalls anLerlor)
L4ţ L3ţ S1 LxLenslon of Loes
L3ţ S1ţ S2 ÞlanLar flexlon of fooL
L3ţ S1ţ S2 llexlon of Loes
W SpinaI cord injury (SCI) is a
traumatic injury to the spinal cord
that may vary from a mild cord
concussion with transient
numbness to immediate and
complete tetraplegia.
W The most common sites are the
cervical areas C
5
, C
6
, and C
7
, and the
junction of the thoracic and lumbar
vertebrae, T
12
and L
1
.
What is SpinaI Cord Injury?
A|ternat|ve Names
Splnal cord ln[urvŤ Compresslon of splnal cordŤ Splnal cord Lrauma
P t is estimated that there are 40,000 people in the UK
alone that are paralyzed through spinal cord injury.
P 1he llfe expecLancv for an
lndlvldual wlLh SCl ls lower
(80Ʒ Lo 83Ʒ) Lhan LhaL of a
person wlLhouL SClŦ
ParapIegia. This paralysis affects all or
part of the trunk, legs and pelvic organs.
1etrap|eg|a or quadr|p|eg|aŦ 1hls means
vour armsţ Lrunkţ leas and pelvlc oraans are
all affecLed bv vour splnal cord ln[urvŦ
%ypes of SpinaI Cord Injury
CompIete spinaI cord injuries refer to the types
of injuries that result in complete loss of function
below the level of the injury which usually result in
complete paraplegia or complete tetraplegia.
IncompIete spinaI cord injuries are
those that result in some sensation and
feeling below the point of injury.
1he level and dearee of funcLlon ln lncompleLe ln[urles ls
hlahlv lndlvldualţ and ls dependenL upon Lhe wav ln whlch Lhe
splnal cord has been damaaedŦ
Risk
actors
-8e|ng a manŦ Splnal cord ln[urles affecL
a dlsproporLlonaLe amounL of menŦ ln facLţ
women accounL for onlv abouL 20 percenL of
splnal cord ln[urles ln Lhe unlLed SLaLesŦ
-8e|ng between the ages of 16 to 30Ŧ ?ouƌre mosL
llkelv Lo suffer a splnal cord ln[urv lf vouƌre beLween Lhe aaes 16
and 30Ŧ MoLor vehlcle crashes are Lhe leadlna cause of splnal cord
ln[urles for people under 63ţ whlle falls cause mosL ln[urles ln
older adulLsŦ
8e|ng act|ve |n certa|n sportsŦ Whlle
belna acLlve ls one of Lhe besL Lhlnas vou can
do for vour overall healLhţ lL mav place vou aL
areaLer rlsk of a splnal cord ln[urvŦ
-nav|ng an under|y|ng bone or [o|nt d|sorderŦ
A relaLlvelv mlnor ln[urv can cause a splnal cord ln[urv lf vou have
anoLher dlsorder LhaL affecLs vour bones or [olnLsţ such as arLhrlLls or
scolloslsŦ
Common Causes of
SpinaI Cord Injury
Sports and recreation
injuries- 7.2%
AIcohoI
4.0%
Motor vehicIe
accidents- 38.5%
Acts of vioIence
24.5%
aIIs
21.8%
Diseases
4.0%
CIinicaI Manifestations
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.
CLkVICAL (NLAk 1nL NLCk) INIUkIL5
When splnal cord ln[urles occur near Lhe neckţ svmpLoms can affecL boLh Lhe arms and Lhe leasť
8reaLhlna dlfflculLles (from paralvsls of Lhe breaLhlna muscles)
Loss of normal bowel and bladder conLrol (mav lnclude consLlpaLlonţ
lnconLlnenceţ bladder spasms)
numbness
Sensorv chanaes
SpasLlclLv (lncreased muscle Lone)
Þaln
Weaknessţ paralvsls
1nCkACIC (CnL51 LLVLL) INIUkIL5
When splnal ln[urles occur aL chesL levelţ svmpLoms can affecL Lhe leasť
-8reaLhlna dlfflculLles (from paralvsls of Lhe breaLhlna)
-Loss of normal bowel and bladder conLrol (mav lnclude
consLlpaLlonţ lnconLlnenceţ bladder spasms)
-numbness
-Sensorv chanaes
-SpasLlclLv (lncreased muscle Lone)
-Þaln
-Weaknessţ paralvsls
LUM8Ak/ 5ACkAL (LCWLk 8ACk) INIUkIL5
When splnal ln[urles occur aL Lhe lower back levelţ varvlna dearees of svmpLoms can affecL Lhe leasť
-Loss of normal bowel and bladder conLrol (mav
lnclude consLlpaLlonţ lnconLlnenceţ bladder spasms)
-numbness
-Þaln
-Sensorv chanaes
-SpasLlclLv (lncreased
muscle Lone)
-Weakness and paralvsls
W Note: The Clinical
anifestations depend on
the following:
The Location of the njury
The Severity of the njury
ased on the Location of Injury
W C3 vertebrae and above : Typically lose
diaphragm function and require a ventilator
to breathe.
W C4 : ay have some use of biceps and
shoulders, but weaker
W : ay retain the use of shoulders and
biceps, but not of the wrists or hands.
W C6 : Generally retain some wrist control,
but no hand function.
W C7 and T1 : Can usually straighten their
arms but still may have dexterity problems
with the hand and fingers. C7 is generally
the level for functional independence
W T1 to T8 : ost often have control of the
hands, but lack control of the abdominal
muscles so control of the trunk is difficult
or impossible. Effects are less severe the
lower the injury.
W T9 to T12 : Allows good trunk and
abdominal muscle control, and sitting
balance is very good.
W Lumbar and Sacral injuries: The effect of
injuries to the lumbar or sacral region of
the spinal canal are decreased control of
the legs and hips, urinary system, and
anus. yield decreasing control of the hip
flexors and legs.
9A1nC9n¥5ICLCG¥ CI 1nL 59INAL CCkD INIUk¥
9red|spos|ng Iactors
-Age
-Gender
-Genet|cs
-kace
9rec|p|tat|ng Iactors
4L|festy|e
4Cccupat|ona| /
env|ronmenta|
factors
lorce or lmpacL ls applled Lo a
cerLaln bodv area
lmmedlaLe mechanlcal damaae Lo neural and oLher sofL
Llssueţ lncludlna endoLhellal cells of Lhe vasculaLure
Mlcroscoplc bleedlna occurs ln Lhe arav maLLer of Lhe cord
Cell deaLh or necrosls occurs (hemorrhaaeţ edema)
icrocirculation of the cord is impaired
Vascular perfusion is reduced & ischemic
areas develop
Cxvaen Lenslon ln Lhe Llssues aL Lhe ln[urv slLe ls decreased
Cellular Ǝ subcellular alLeraLlons Ǝ Llssue necrosls occurs
Chemlcal Ǝ meLabollc chanaes ln Lhe splnal cord Llssues lnclude lncrease Llssue
lacLaLe Ǝ lncrease noreplnephrlne concenLraLlon
Cord swelling
lnfllLraLlon of slLe bv neuLrophlls Ǝ macrophaaes
ÞrollferaLlon of mlcroalla Ǝ chanaes ln asLrocvLes
8ed cells bealn Lo dlslnLearaLe Ǝ resorpLlon of hemorrhaaes bealn
ueaeneraLlna axons are enaulfed bv Lhe macrophaaes
American SpinaI Injury Association
(ASIA) Impairment ScaIe
W ASIA A Complete; absent
sensory and motor function at
S
4-5
.
W ASIA ncomplete; intact
sensory but absent motor
function below the neurologic
level of injury LO) and
includes level S
4-5
.
W ASIA C ncomplete; intact motor
function distal to neurologic LO, and
more than half of key muscles distal to
LO have muscle grade less than 3.
W ASIA D ncomplete; intact motor
function distal to neurologic LO, and
more than half of key muscles distal to
LO have muscle grade greater than or
equal to 3.
W ASIA E Normal; intact motor and
sensory function.
POSSILE COMPLICA%IONS
W Blood pressure changes - can
be extreme autonomic
hyperreflexia)
W Complications of immobility:
W eep vein thrombosis
W Pulmonary infections
W Skin breakdown
W Contractures
W ncreased risk of injury to
numb areas of the body
W ncreased risk of kidney
damage
W ncreased risk of urinary tract
infections
W Loss of bladder control
W Loss of bowel control
W Loss of sensation
W Loss of sexual functioning
male impotence)
W uscle spasticity
W Pain
W Paralysis of breathing
muscles
W Paralysis paraplegia,
quadriplegia)
W Shock
Diagnostic EvaIuation
W A CT scan or # of the spine
- may show the location and extent of the
damage and reveal problems such as blood clots
hematomas).
W yelogram
- an x-ray of the spine after injection of dye) may
be necessary in rare cases.
W Somatosensory evoked potential SSEP) testing or
magnetic stimulation
- may show if nerve signals can pass through the
spinal cord.
W Electrophysiologic monitoring
- determine function of neural pathways.
W Urodynamic studies
- include urine flow to detect bladder outlet
obstruction and/or impaired bladder contractility;
cystometrogram to determine bladder sensation,
compliance, and capacity; sphincter EG and
other studies.
W f VT or pulmonary emboli are suspected, an
ultrasound of the lower extremity or
ventilation/perfusion scan is performed.
W eterotopic ossification may be diagnosed in the
inflammatory stages using ultrasound. Alkaline
phosphatase and ES# are typically elevated.
W Nutritional status should be assessed
using nutritional history, anthropometric
measurements, prealbumin half-life 12 to
36 hours) and transferrin half-life 6 to 10
days).
W Total lymphocyte count and creatinine
height index are also used to establish
nutritional risk.
W Spine Xrays may show fracture or damage
to the bones of the spine.
Nursing Assessment
W Assess cardiopulmonary status and vital signs
to help determine degree of autonomic
dysfunction, especially in patients with
tetraplegia.
W etermine LOC and cognitive function
indicating TB or other pathology.
W Perform frequent motor and sensory
assessment of trunk and¨ extremities as the
extent of deficits may increase due to edema
and hemorrhage. Later, increasing neurologic
deficits and pain may indicate development of
syringomyelia.
W Note signs and symptoms of spinal shock,
such as flaccid paralysis, urine retention,
absent reflexes.
W Assess bowel and bladder function.
W Assess quality, location, severity of pain.
W Perform psychosocial assessment to evaluate
motivation, support network, financial or other
problems.
W Assess for indicators of powerlessness,
including verbal expression of no control over
situation, depression, nonparticipation,
dependence on others, passivity.
Nursing Diagnosis
W neffective Breathing Pattern related to
paralysis of respiratory muscles or
diaphragm
W mpaired Physical obility related to motor
dysfunction
W #isk for mpaired Skin ntegrity related to
immobility and sensory deficit
W Urinary #etention related to neurogenic
bladder
W Constipation or Bowel ncontinence
related to neurogenic bowel
W #isk for njury: autonomic dysreflexia and
orthostatic hypotension
W Powerlessness related to loss of function,
long rehabilitation, depression
W Sexual ysfunction related to erectile
dysfunction and fertility changes
W Chronic Pain related to neurogenic
changes
Nursing
Interventions
Emergency Actions Emergency Actions
1. aintaining client's ability to
breathe.
2. Keeping client from going into
shock.
3. mmobilizing the neck to
prevent further spinal cord
damage.
Attaining an Adequate reathing Pattern
1. For patients with high-level lesions,
continuously monitor respirations and maintain
a patent airway. Be prepared to intubate if
respiratory fatigue or arrest occurs.
2. Frequently assess cough and vital capacity.
Teach effective coughing, if patient is
3. Provide adequate fluids and humidification of
inspired air to loosen secretions.
4. Suction as needed; observe vagal response
bradycardia should be temporary).
5. When appropriate, implement chest
physiotherapy regimen to assist
pulmonary drainage and prevent
infection.
6. onitor results of ABG values,
chest X-ray, and sputum cultures.
7. Tape halo wrench to body jacket or
halo traction in the event the jacket
must be removed for basic or
advanced life support or respiratory
distress.
Promoting MobiIity
1. Place patient on firm kinetic turning bed
until spinal cord stabilization. After
stabilization, turn every 2 hours on a
pressure reduction surface, ensuring
good alignment.
2. Logroll patient with unstable SC.
3. Perform #O exercises to prevent
contractures
and maintain rehabilitation potential.
4. onitor BP with position change in the
patient with lesions above midthoracic
area to prevent orthostatic hypotension.
5. Encourage physical therapy and
practicing of exercises as tolerated.
Functional electrical stimulation may
facilitate independent standing and
ambulation.
6. Encourage weight-bearing activity to
prevent osteoporosis and risk of kidney
stones.
Protecting Skin Integrity
1. Pay special attention to pressure points when
repositioning patient. Seating and mobility
requirements must be determined.
2. Obtain pressure relief mattress and
appropriate wheelchair and cushion.
3. nspect for pressure ulcer development daily
over bony prominences, including the back of
head, ears, trunk, heels, and elbows. Observe
under stabilization devices for pressure areas,
particularly on the scapulae. Use a risk
assessment tool to determine risk of
developing pressure ulcer.
4. Keep skin clean, dry, and well-
lubricated.
5. Turn a minimum of every 2 hours, and
instruct patient to perform wheelchair
weight shifts every 15 minutes. Place
the patient in prone position at
intervals, unless contraindicated.
6. nstitute treatment for pressure ulcers
immediately, and relieve pressure to
promote healing.
Preventing Autonomic
Dysfunction
1, Use tilt table as ordered to gradually
increase the patient's ability to tolerate
sitting after acute SC.
2. Other conservative strategies consist of
use of embolic hose, abdominal binder,
and high-salt diet.
3. Administer a sympathomimetic, such as
ephedrine or pseudoephedrine, as
ordered, before patient is transferred to
wheelchair.
REMINDERS:
W Additional movement may cause further damage
to the nerves in the cord and can sometimes
mean the difference between life and death.
W O NOT move the injured person even a little bit,
unless it is absolutely necessary like getting
someone out of a burning car).
W f in doubt about whether a person has a spinal
injury, assume that he or she OES have one.
eaIth %eachings
W Teach patient and family about the physiology
of nerve transmission and how the SC has
affected normal function, including mobility,
sensation, bowel and bladder function.
W #einforce that rehabilitation is lengthy and
involves compliance with therapy to increase
function.
W Explain that spasticity may develop 2 weeks to
3 months after injury and may interfere with
routine care and ALs.
W Teach patient to protect skin from
pressure ulcer development by
frequent repositioning while in bed,
weight-shifting and liftoffs every 15
minutes while in a wheelchair, and
avoiding shear forces and friction.
W Teach inspection of skin daily for
development of pressure ulcers,
using a mirror if necessary.
W Teach importance of seat belts.
1reatments and drugs
Medications.
MeLhvlprednlsolone (Medrol) ls a LreaLmenL opLlon for
an acuLe splnal cord ln[urvŦ lL appears Lo work bv reduclna
damaae Lo nerve cells and decreaslna lnflammaLlon near Lhe slLe
of ln[urvŦ Poweverţ Lhls ls noL a cure for a splnal cord ln[urvŦ
ImmobiIization.
ou may need traction to stabilize your
spine, to bring the spine into proper alignment or
both.
5urgeryŦ
CfLenţ suraerv ls necessarv Lo remove
fraamenLs of bonesţ forelan ob[ecLsţ hernlaLed dlsks
or fracLured verLebrae LhaL appear Lo be compresslna
Lhe splneŦ Suraerv mav also be needed Lo sLablllze
Lhe splne Lo prevenL fuLure paln or deformlLvŦ
New techno|og|esť
lnvenLlve medlcal devlces can help people wlLh a splnal cord ln[urv become more lndependenL and more
moblleŦ Some devlces mav also resLore funcLlonŦ 1hese lncludeť
-Modern whee|cha|rsŦ lmprovedţ llahLer welahL wheelchalrs are
maklna people wlLh a splnal cord ln[urv more moblle and more
comforLableŦ lor someţ an elecLrlc wheelchalr mav be needed
-Computer adaptat|onsŦ lor someone LhaL has llmlLed hand
funcLlonţ compuLers can be verv powerful Loolsţ buL Lhevƌre dlfflculL Lo
operaLeŦ
-L|ectron|c a|ds to da||y ||v|ngŦ LssenLlallv anv devlce LhaL uses
elecLrlclLv can be conLrolled wlLh an elecLronlc ald Lo dallv llvlna (LAuL
-L|ectr|ca| st|mu|at|on dev|cesŦ 1hese sophlsLlcaLed devlces use
elecLrlcal sLlmulaLlon Lo produce acLlonsŦ 1hevƌre ofLen called funcLlonal
elecLrlcal sLlmulaLlon (lLS) svsLemsţ and Lhev use elecLrlcal sLlmulaLors Lo
conLrol arm and lea muscles Lo allow people wlLh a splnal cord ln[urv Lo
sLandţ walkţ reach and arlpŦ
kehab|||tat|on
9revent|onť
Drive safeIy.
e safe with firearms.
Prevent faIIs.
%ake precautions when pIaying sports.
ave a heaIthy IifestyIe.
say NO to aIcohoI.
Maintain your gait and posture.
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