SPINAL CORD

INJURY
Presented by:
Feliciano, Jenard R.
Flores, Arliah Q.
Gaspar, Danica V.
 INTRODUCTION

The spinal cord is an elongated and cylinder-shaped collection of nerves

that arise from the end of the brain and extends into the neck and back region.
It forms a primary communication channel between the brain and the body.
Injury to the delicate spinal cord or its surroundings is known as a spinal cord
injury.
Trauma involving the central nervous system can be life threatening. Even if
not life threatening, brain and spinal cord injury (SCI) may result in major
physical and psychological dysfunction and can alter the patient’s life
completely. Neurologic trauma affects the patient, the family, the health care
system, and society as a whole because of its major sequelae and the costs of
acute and long-term care of patients with trauma to the brain and spinal cord. 2
GENERAL
OBJECTIVES
This report aims to identify and determine the general health condition and
needs of a patient with spinal cord injury. This report also intends to help
promote health and medical understanding of such disease through the
application of nursing skills.
SPECIFIC
OBJECTIVES
At the end of this lecture, the students should be able to:
- Understand the definition of Spinal Cord Injury
- Determine what are the clinical features of the disease during assessment
- Understand the pathophysiology of the disease in able to trace the disease progression
and its origin and be able to formulate a plan
- Determine what are the diagnostic and laboratory procedure done in patient with
Spinal Cord Injury
- Learn the different managements in terms of nursing, medical and surgical in taking
care in patient with Spinal Cord Injury
 DEFINITION
Spinal Cord Injury (SCI) is a major health problem. Almost 200,000 people
in the United States live each day with a disability from SCI, and an estimated
12,000 to 14,000 new injuries occur each year (Mendel, Hentschel&Guiot,
2005). Spinal Cord Injury occurs often in males (82%) than in females (18%)
(Bader &Littlejohns, 2004). Young people between the ages of 16 and 30 years
account for more than half of the new SCIs each year. African Americans are at
higher risk than Caucasian Americans, with the incidence rising in recent years.
The most common cause of SCI is motor vehicle crashes, which account for 35%
as many SCIs (24%), with falls causing 22% and sports related injuries causing
8%. The frequency of associated injuries and medical complications is high.
5
 DEFINITION
The vertebrae most frequently involved in SCI are the 5th, 6th and 7th
cervical (neck) vertebrae (C5-C7), the 12th thoracic vertebra (t12), and the 1st
lumbar vertebra (L1). These vertebrae are most susceptible because there is a
greater range of mobility in the vertebral column in these areas (Porth, 2005).
 Causes of most SCIs are trauma (such as motor vehicle accidents), diving
accidents, and gunshot wounds.
 Hyperflexion injuries are caused by acceleration injuries that cause sharp
forward flexion of the spine (head-on collision, fall, or diving).
Hyperextension injuries are caused by a backward snap of the spine (rear-
end collision or a downward fall onto the chin).
6
RISK FACTORS

High-risk activities
Participation in Acts of violence
Male clients age (extreme sports or
impact sports (gunshot and
16 to 30 high-speed
(football or diving) knife wounds)
driving)

Disease
Alcohol or drug (metastatic Falls, especially in
use cancer or arthritis older adults
of the spine)

7
 SEVERAL TERMS RELATED TO SPINAL CORD INJURY

• Tetraplegia - refers to a lesion involving one of the cervical segments of the

spinal cord that results in dysfunction of both arms, both legs, bowel, and
bladder.
• Paraplegia - refers to a lesion involving the thoracic lumbar or sacral regions
of the spinal cord that results in dysfunction of the lower extremities, bowel, or
bladder.
• A complete lesion ( complete tetraplegia or complete tetraplegia) implies
total loss of sensation and voluntary muscle control below the injury.
• An incomplete lesion implies preservation of the sensory or motor fibers, or
both, below the lesion. Incomplete lesions are classified according to the area
of damage: central, lateral, anterior, or peripheral.
8
 CLINICAL MANIFESTATIONS
Manifestations of SCI depend on the type and level of injury. The type of injury refers to
the extent of injury to the spinal cord itself.

• A complete spinal cord lesion signifies loss of both sensory and voluntary
motor communication from the brain to the periphery, resulting in paraplegia
or tetraplegia (Bader et al., 2016).
• Incomplete spinal cord lesion denotes that the ability of the spinal cord to
relay messages to and from the brain is not completely absent.
• Sensory and/or motor fibers are preserved below the lesion.

9
 The American Spinal Injury Association (ASIA, 2019) provides classification of
SCI according to the degree of sensory and motor function present after injury:

Neurologic level refers to the lowest level at which sensory and motor functions are intact.
= Total or partial, sensory and/or motor paralysis (dependent upon affected tracts),
= loss of bladder and bowel control (usually with urinary retention and bladder distention),
= loss of sweating and vasomotor tone,
= marked reduction of blood pressure from loss of peripheral vascular resistance.
If conscious;
= complains of acute pain in the back or neck, which may radiate along the involved nerve.
= absence of pain does not rule out spinal injury- careful assessment of the spine should be
conducted
= significant force and mechanism of injury (i.e., concomitant head injury).
Respiratory dysfunction is related to the level of injury.
= Muscles contributing to respiration are the diaphragm (C4), intercostals (T1–T6), and
abdominals (T6–T12).
= Injuries at C4 or above (causing paralysis of the diaphragm) often will require ventilator
support, since acute respiratory\failure is a leading cause of death (Hickey, 2014).
10
 INJURIES OF CERVICAL SPINE

Injuries of the cervical spine are dangerous; and if associated with

neurological damage, the results can be devastating. Though diagnostic and
treatment methods have vastly improved over years, still injuries of the cervical
spine pose the greatest challenge to the skill and acumen of orthopedic and
neurosurgeons.
Jefferson pointed out two areas commonly involved in cervical spine injuries,
C1-2 and C5-7. According to Meyer, C2 and C5 are commonly involved.
Neurological damage is seen in 40 percent of cases. In 10 percent of cases,
radiographs are normal.
11
CAUSES

• Fall from height • Diving Injuries

It is the most common cause in developing Diving into water with insufficient depth or in an
countries. inebriated condition.

12
CAUSES

• Road traffic accidents (RTAs) • Gunshot injuries

Common cause in developed countries, e.g. These injure the cervical spine and the cord
whiplash injury directly.

13
MECHANISM OF INJURY

 Pure flexion force: For example, compression

fracture of vertebral body, e.g. fall from height.
 Flexion rotation force: For example, fall on
one side of the shoulder, disruption of facet
capsule is seen.
 Axial compression: For example, fall of an
object on the head results in load
compression, e.g. explosive comminuted
fracture of C5 body.
 Extension force: For example, avulsion
fracture of superior margin of vertebral body,
e.g. whiplash injury.
 Lateral flexion: For example, fracture pedicle,
fracture transverse process and facet joints,
etc.
 Direct injuries: For example, fracture spinous
Common mechanism of cervical spine injuries: (A) 14
process and body. Due to assault, gunshot Hyperextension injury, (B) Flexion extension injury, (C) Flexion
injury, etc. rotation injury, (D) Hyperflexion injury
WHIPLASH INJURY

(SYN: Acceleration injury, cervical sprain

syndrome, soft tissue neck injury)
Definition
It is an unconventional and inconsequential
ligament injury of the cervical spine allegedly
due to an extension injury following a rear-end
collision
Incidence
• It is seen in about 25 percent of rear-end
collision of RTAs.
• Seventy percent of those affected are women.
• It is common in the 3rd or 4th decades.
15
WHIPLASH INJURY

Clinical Features
Symptoms
• Upper neck pain that becomes worse with
movement.
• Occipital headache.
• Neck stiffness.
• Rarely vertigo, auditory or visual disturbances,
etc.
Signs
• Decreased range of neck movements.
• Neck muscle spasm is seen.

16
ALLEN’S CLASSIFICATION OF CERVICAL
SPINE FRATURES

 Compressive flexion (5 stages): Ranges from blunting of anterosuperior vertebral margin to

posterior displacement into the spinal canal. It is usually a stable fracture but may become
unstable if compression is more than 50 percent.
 Vertical compression (3 stages): Ranges from fracture of superior or inferior endplate with
centrum fracture of the vertebral body. Stable fracture if compression is less than 50 percent of
the vertebral body.
 Distractive flexion (4 stages): Ranges from failure of posterior ligamentous complex to full-
width vertebral body displacement. This is an unstable fracture.
 Compression extension (5 stages): Ranges from unilateral vertebral arch fracture to bilateral
vertebral arch fracture with full-vertebral body displacement anteriorly. It is unstable.
 Distractive extension: Ranges from failure of anterior ligament complex to posterior ligament
complex. This is also an unstable fracture.
 Lateral flexion: Ranges from asymmetric compression and ipsilateral vertebral arch 17to
fracture without displacement and with displacement. May become unstable.
ALLEN’S CLASSIFICATION OF CERVICAL
SPINE FRATURES

Cervical spine injuries: (A) Distraction injury,(B) Compression injury,

18
(C)Hyperextension injury,(D) Compression and distraction injury
ALLEN’S CLASSIFICATION OF CERVICAL
SPINE FRACTURES

Clinical Features
The patient usually gives history of
trauma following which there will be
pain, swelling and inability to move
the neck. There will be tenderness
over the involved spinous process and
there could be a palpable gap. There
may be signs of neurological
involvement. Determine the level of
cord injury by examining the affected
spine.
Dermatomal levels: 19

(A) Anterior, and (B) Posterior

The injuries to the spinal cord at the cervical region can manifest in the following ways:
 Concussion
This is a state of spinal shock and there will be sensory loss, flaccid paralysis, visceral
paralysis, reflexes are in abeyance and anal reflex is absent. By 8 hours, concussion is
known to regress; and by8-10 days, there is complete recovery.
 Nerve Root Involvement
Individual nerve roots could be affected at their respective intervertebral foramen. All
the features of peripheral nerve injury with LMN type of lesion are seen. The myotome
and the dermatome should be assessed to know the root involvement
 Cord involvement could be:
Complete: This leads to quadriplegia or quadriparesis.
Incomplete: Here the central cord, lateral cord, anterior or posterior cord could be
20
involved
 INDIVIDUAL CERVICAL FRACTURE OF INTEREST
• Burst Fracture of C1
This is popularly known as Jefferson’s fracture. It is due to axial loading over the top of the head.
• Odontoid Process Fracture
It is also called Dens fracture
Anderson and D’olonzo‘s Classification
Type I: Oblique fracture of the upper part of the odontoid process. It is uncommon and is treated by
cervical cast.
Type II: Junction of odontoid process and body. Common with a nonunion rate of 36 percent.
Requires surgical wiring and fusion.
Type III: Fracture is through the upper part body of the body of vertebra. Cancellous area hence
fracture unites well with a halo cast.

21

Odontoid process fracture: (A) Type I,

(A) Type II, and (C) Type III
 INDIVIDUAL CERVICAL FRACTURE OF INTEREST
Hangman’s Fracture
It is a fracture through pedicle at pars-interarticular is of C2 and is due to distraction
extension force. There is no neurological deficit and the patient needs rigid cervical
support usually through a Philadelphia collar immobilization.

22
 THORACIC AND LUMBOSACRAL INJURIES

Thoracolumbar spine is generally regarded as extending from 10th

thoracic vertebrae to 2nd lumbar vertebrae and is the transitional area
between the kyphotic upper thoracic spines to the lordotic lumbar spine.
The general anatomy of the vertebral column is more or less the same as in
other areas of spine. The three-column concept has already been described.
Anterior column is the load bearing structure and the posterior column
functions as motion limiters as well as load bearing structures. Mercifully,
the thoracolumbar injuries spare the upper limbs and vital functions.
Though a lesser challenge than cervical injury, nevertheless it poses
problems, no less risky than the former.
23
 THORACIC AND LUMBOSACRAL INJURIES

Mechanism of Injury
• Fall from a height.
• RTA: Seat belt injury (chance fracture).
• Other causes like gunshot injuries, assault, etc.

24
MC AFEE’S CLASSIFICATION

 Wedge Compression  Stable Burst Fractures

Isolated failure of anterior column due to Anterior and middle columns fail. No loss of
forward flexion. No neurological deficit. integrity of posterior elements.

25
MC AFEE’S CLASSIFICATION
 Unstable Burst Fractures
Anterior and middle column fail in compression.
Posterior column fail in compression, lateral flexion
or rotation. Post-traumatic kyphosis and neural
symptoms are present.
 Chance Fracture (Seatbelt injury)
It is seen in people who wear a lap belt without a shoulder
harness. Horizontal avulsion fracture of vertebral bodies
caused by flexion about an axis anterior to the anterior
longitudinal ligament. A strong tensile force pulls entire
vertebrae apart.
26
MC AFEE’S CLASSIFICATION
 Flexion Distraction Injury
Flexion axis is posterior to the anterior longitudinal
ligament. Anterior column fails in compression. Middle and
posterior columns fail in tension. It is unstable because
supraspinous, interspinous and ligamentum flavum fail.
 Translational Injuries
Malalignment of neural canal, which has been
totally disrupted. All three columns fail in shear. At
the affected level, one part of sacral canal has been
displaced in the transverse plane.
27
MODIFIED MAGERL CLASSIFICATION

Type A: Compression varieties:

• Wedge.
• Split.
• Burst.
Type B: Distraction:
• Through posterior soft tissues (subluxation).
• Through the posterior arch (chance fracture).
• Through the anterior disk.
Type C: Multidirectional with translation:
• Anteroposterior dislocation.
• Lateral (lateral shear fracture).
• Rotational (rotational burst). 28
MODIFIED MAGERL CLASSIFICATION

Clinical Features
The patient gives history of trauma due to RTA or fall from a height and
complains of pain; posterior swelling, tenderness, palpable interspinous gap or
a step may be felt. Neurological involvement may vary from paraplegia to
individual nerve root involvement. Spinal shock is present for 24 hours during
which all the reflexes are lost. Cauda equina paralysis is present if the lesion is
below L1. Exaggerated lumbar lordosis may be seen in old cases.

29
30
EFFECTS OF SPINAL CORD INJURY

1.CENTRAL CORD SYNDROME:

• Characteristics: Motor deficits (in the upper
extremities compared to the lower extremities;
Sensory loss varies but is more pronounced in the
upper extremities); Bowel/bladder dysfunction is
variable, or function may be completely preserved.
• Cause: Injury or edema of the central cord, usually
of the cervical area. - May be caused by
hyperextension injuries.
• Result: Edema in the central cord exerts pressure
on the anterior horn cells. - cervical fibers of the
corticospinal tract are located in a more central
position in the cord than the sacral fibers, which
are located in the periphery. - motor deficits are
ADD A FOOTER less severe in the lower extremities than in the31
upper extremities.
EFFECTS OF SPINAL CORD INJURY

2. ANTERIOR CORD SYNDROME:

• Characteristics: Loss of pain, temperature, and motor
function is noted below the level of the lesion; light
touch, position, and vibration sensation remain intact.
• Cause: Acute disc herniation or hyperflexion injuries
associated with fracture/dislocation of vertebra. -
Occur as a result of injury to the anterior spinal artery,
which supplies the anterior two thirds of the spinal
cord.
• Result: Injury to the anterior part of the spinal cord,
which includes the spinothalamic tracts (pain),
corticospinal tracts (temperature),and anterior gray
horn motor neurons.

ADD A FOOTER 32
EFFECTS OF SPINAL CORD INJURY

3. LATERAL CORD SYNDROME (Brown–Séquard

Syndrome)
• Characteristics: Ipsilateral paralysis or paresis is
noted, together with ipsilateral loss of touch,
pressure, and vibration and contralateral loss of
pain and temperature.
• Cause: Lesion is transversed hemisection of the
cord (half of the cord is transected from north to
south), usually as a result of a knife or missile
injury, fracture/dislocation of a unilateral
articular process, or possibly an acute ruptured
disc.

33
EFFECTS OF SPINAL CORD INJURY

3. LATERAL CORD SYNDROME (Brown–Séquard

Syndrome)
 Result: With right-sided cord transection, the following
would occur: - Paralysis of all voluntary muscles below
the level of injury on the right side of the body (lateral
corticospinal tract); - Loss of perception of touch,
vibration, and position on the right side of the body
below the level of injury (posterior columns, which
include the fasciculus gracilis and fasciculus cuneatus); -
Loss of pain and temperature perception on the left side
of the body below the injury (lateral spinothalamic
tracts). - Fibers that carry pain and temperature cross to
the opposite side of the cord immediately after entering
the cord and then ascend. - Other tracts mentioned 34
do
not cross until they reach the brainstem.
EFFECTS OF SPINAL CORD INJURY

4. CONUS MEDULLARIS SYNDROME

 Presentation: A lumbar enlargement of the spinal
cord corresponds to the innervation for the lower
extremities and extends from L-3 to S-2.
Conus medullaris is the cone-shaped lower end of
the spinal cord.
 Causes: Falls, vertebral trauma such as
subluxation or dislocation, intervertebral disc
herniation, and spinal epidural metastatic lesions.
 Result: Compression of the conus medullaris will
result in the signs and symptoms outlined above.

35
EFFECTS OF SPINAL CORD INJURY

5. CAUDA EQUINA SYNDROME:

 Presentation: The spinal cord terminates at T-12 or L-1,
and the cauda equina begins at lumbar disc space L-1 or
L-2.
- Nerve roots from the lumbar, sacral, and coccygeal that
extend distally from the conus medullaris are collectively
called the Cauda equina.
- Cauda equina is not a true spinal cord injury because it
is outside the spinal cord,
 Causes: Large herniated disc.
- Epidural bony collapse, epidural tumor, epidural
hematoma, trauma, and metastatic lesions.
 Result: Compression of the spinal nerves results in loss
of neurological function that can be permanent if not
relieved.
36
- Radiologic evaluation helps to determine treatment
options.
ASIA IMPAIREMENT SCALE

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

B= Incomplete: Sensory but not motor function is preserved below the neurologic level,
and includes the sacral segments S4-S5.
C= Incomplete: Motor function is preserved below the neurologic level, and more than half
of key muscles below the neurologic level have a muscle grade less than 3.
D= Incomplete: Motor function is preserved below the neurologic level, and more than half
of key muscles below the neurologic level have a muscle grade of 3 or greater.
E= Normal: Motor and sensory function are normal.

37
 PATHOPHYSIOLOGY

Non-Modifiable risk factor Modifiable risk factor

Age Alcohol and Drug use
Gender Moderate vigorous physical
History of bone disease activities
Occupation related

Primary Trauma Secondary Injury

Evolves after primary injury (ischemia,
Compression, contusion, or shear
hypoxia, inflammation, edema,
apoptosis)

Damaged neural tissue of the

spinal cord

Complete Incomplete

Motor and sensory function loss

with intact Bulbocavernosus
reflex

Permanent

38
 Partial sparing of motor
or sensory function

Anterior Cord Central Cord Syndrome Posterior Cord Brown-Sequard Conus Medullaris
Syndrome Syndrome Syndrome Syndrome

Cord compression,
Anterior spinal artery often with pre-existing Posterior spinal artery Complete hemicord Trauma, disc herniation
injury, often from spondylosis injury lesion or tumour causing injury
vascular event to conus medullaris

Commonly Primarily penetrating

S/S Mixed upper and lower
hyperextension injuries
Complete loss of motor motor neuron
function below injury deficiencies
S/S S/S
level. Loss of pain, and S/S
Upper extremity Loss of vibration,
temperature at and Ipsilateral loss of motor S/S
weakness ang proprioception, and
below level of injury function, vibration, and Sphincter dysfunction,
hyperpathia. Sensory light touch below level
proprioception below loss of bladder and
loss below level of of injury. Preserved
level of injury. rectal reflex, saddle
injury, Bladder motor function
Often mimics complete Contralateral loss of anesthesia, leg
retention
pain and temperature weakness and
below level of injury paresthesia.

Primarily upper 39
extremity dysfunction
(pain, spasticity and
clumsiness in hands)
DIAGNOSTIC PROCEDURE

C5 innervates the deltoid and

biceps and gives sensation to
the dermatome over the deltoid.

40
DIAGNOSTIC PROCEDURE

C6 innervates the dermatome over the

lateral forearm and hand and
innervates the wrist extensors.

41
DIAGNOSTIC PROCEDURE

C7 innervates the small dermatome

over the middle finger plus the
triceps, wrist flexors and finger
extensors.

42
DIAGNOSTIC PROCEDURE

C8 supplies the dermatome of the

medial hand and forearm plus the
finger flexor.

43
DIAGNOSTIC PROCEDURE

T1 supplies the intrinsic muscles of

the hand, the interossei, and the
dermatome on the medial upper arm

44
EXAMINERS
DONE TO THE
PATIENT
Vital Steps
• The lowermost functioning muscle is documented and a functional level
is established.
• Next the sacrally innervated skin is examined. Perianal, anal, scrotal,
labia, and plantar surface of the toes are examined.
• Perianal sensation may be the only sign to indicate an incomplete lesion.
Other Examinations
Rectal sensation: Loss of sensation around the anus.
Rectal motor: Sphincter contracts, over a gloved
finger.
Bulbocavernosus reflex: Involves S1, S2 and S3 nerve roots. Squeeze the
glans penis, anal sphincter contracts around the gloved finger. Initially,
following the injury, the above reflexes are absent, indicating spinal shock.
Usually, it returns within 24 hours. If not a presumptive diagnosis and
45
determination of a root or cord lesion is made. A diagnosis of a complete
or incomplete syndrome is documented.
DIAGNOSTIC PROCEDURE

X-RAY Medical personnel typically order

these tests on people who are suspected of
having a spinal cord injury after trauma. X-
rays can reveal vertebral (spinal column)
problems, tumors, fractures or degenerative
changes in the spine.

46
DIAGNOSTIC PROCEDURE
Nursing Responsibilities
Before
 Instruct the patient to remove any clothing, jewelry, or other articles that
may interfere with the study.
 Patients will be provided by an X-ray gown to wear.
 Instruct patient to cooperate during the procedure.
During
 Instruct patient to relax during the procedure.
After
 Provide comfort to the patient.
 

47
DIAGNOSTIC PROCEDURE

•COMPUTERIZED TOMOGRAPHY (CT)

SCAN -A CT scan may provide a better look at
abnormalities seen on an X-ray. This scan uses
computers to form a series of cross-sectional
images that can define bone, disk and other
problems

48
DIAGNOSTIC PROCEDURE
Nursing Responsibilities
Before
• Obtain an informed consent properly signed.
• Assess for any history of allergies to iodinated dye or shellfish if contrast media is to be
used.
• Ask the patient about any recent illnesses or other medical conditions and current
medications being taken. The specific type of CT scan determines the need for an oral or I.V.
contrast medium
• Instruct the patient to not to eat or drink for a period amount of time especially if a contrast
material will be used.
• Instruct the patient to wear comfortable, loose-fitting clothing during the exam.
• Provide information about the contrast medium. Tell the patient that a mild transient pain
from the needle puncture and a flushed sensation from an I.V. contrast medium will be
experienced.

49
DIAGNOSTIC PROCEDURE
Nursing Responsibilities
During
• Instruct the patient to remain still.  tell the patient to remain still
• Instruct patient to report immediately symptoms of itching, difficulty breathing or
swallowing, nausea, vomiting, dizziness, and headache.
• Inform the patient that the procedure takes from five (5) minutes to one (1) hour
depending on the type of CT scan and his ability to relax and remain still.
After
• Instruct the patient to resume the usual diet and activities unless otherwise ordered.
• Encourage the patient to increase fluid intake (if a contrast is given). This is so to promote
excretion of the dye.
 

50
DIAGNOSTIC PROCEDURE

•MAGNETIC RESONANCE IMAGING (MRI)

uses a strong magnetic field and radio waves
to produce computer-generated images. This
test is very helpful for looking at the spinal
cord and identifying herniated disks, blood
clots or other masses that may be
compressing the spinal cord.

51
DIAGNOSTIC PROCEDURE
Nursing Responsibilities
Before
• Provide patient with comfort measures as needed.
After
• Tell the patient to resume his normal diet and activities unless otherwise indicated.
• Monitor vital signs.
• Monitor the patient for orthostatic hypotension.

52
MEDICAL MANAGEMENT

Pharmacologic therapy (high dose of corticosteroids specifically methylprednisolone) -

Controlling the symptoms like pain, spasticity and inflammation can help limit further
complications such as autonomic dysreflexia, initiate tissue repair, and help patients and
physical therapists preserve or restore function.
Respiratory therapy/Oxygen therapy - Oxygen is administered to maintain a high partial
pressure of oxygen, because hypoxemia can create or worsen a neurologic deficit of the spinal
cord. If endotracheal intubation
Skeletal fracture reduction and traction(skeletal tongs or calipers or with use of halo
device)-Spinal traction stretches the spine to take pressure off compressed discs. This
straightens the spine and improves the body’s ability to heal itself.

53
MEDICAL MANAGEMENT

Skull Tongs are inserted into the outer aspect of the client’s skull, and traction is applied.
Nursing responsibility
1. Weights are attached to the tongs, and the client is used as a countertraction. the nurse should not
add or remove weights.
2. Determine the amount of weight prescribed to be added to the traction
3. Ensure that weights hang securely and freely at all times.
4. Ensure that the ropes for the traction remain within the pulley.
5. Maintain body alignment and maintain care of the client on a special bed (such as to rest bed or
Stryker or foster frame) as prescribed.
6. Turn the client every 2 hours.
7. Assess the insertion site of the tongs for infection.
8. Provide sterile pin site care as prescribed.
54
MEDICAL MANAGEMENT

Halo traction is a static traction device that consists of a headpiece with 4 pns,2 anterior and 2 posterior,
inserted into the client’s skull.
Nursing responsibility
1. The metal halo ring may be attached to a vest(jacket) or cast when the spine is stable, allowing
increased client mobility.
2. Monitor the client’s neurological status for changes in movement or decreased strength.
3. Never move or turn the client by holding or pulling on the halo traction device.
4. Assess for the tightness of the jacket by ensuring that 1 finger can be placed under the jacket.
5. Assess the skin integrity to ensure that the jacket or cast is not causing pressure.
6. Provide sterile pin site care as prescribed.
7. Initiate interventions in support of the client’s self-image.
8. Teach the client and family pin care, care of the vest, and sign and symptoms of infection to report to
her or his Primary health care provider. 55
SURGICAL MANAGEMENT

Open reduction and internal

fixation (ORIF) surgery - Open
reduction and internal fixation (ORIF)
is a type of surgery used to stabilize
and heal a broken bone

56
SURGICAL MANAGEMENT

Spinal decompression surgery - The

goal of decompression surgery is to
relieve the pressure on the spinal
cord and/or spinal nerves. This can be
accomplished by removing damaged
structures (eg, herniated disc, bone
fracture) or soft tissues pressing on
the cord and nerves—thereby
creating space around these neural
elements
57
SURGICAL MANAGEMENT

Corpectomy or vertebrectomy -
A corpectomy is a procedure that
removes damaged vertebrae and
intervertebral discs that are
compressing the spinal cord and
spinal nerves

58
SURGICAL MANAGEMENT

Laminectomy - This helps ease

pressure on the spinal cord or
the nerve roots that may be caused
by injury, herniated disk, narrowing of
the canal (spinal stenosis), or tumors.

59
SURGICAL MANAGEMENT

Lateral mass screw fixation - Lateral

mass screw fixation provides rigid
internal fixation in previous
laminectomies or when the spinous
processes are damaged.

60
SURGICAL MANAGEMENT

Postoperative interventions
1. Monitor for respiratory impairment.
2. Monitor vital signs, motor function, sensation, and circulatory status in the lower extremities.
3. Encourage breathing exercises.
4. Assess for signs of fluid and electrolyte imbalances.
5. Observe for complications of immobility.
6. Keep the client in a flat position as prescribed.
7. Provide cast care if the client is in a full body cast.
8. Turn and reposition frequently by logrolling side, using turning sheets and pillows between the legs
to maintain alignment.
9. Administer pain medication as prescribed.
10. Maintain NPO status until the client is passing flatus
11. Monitor bowel sounds.
12. Provide the use of a fracture bedpan. 61
13. Monitor intake and output.
14. Maintain nutritional status
EMERGENCY MANAGEMENT

Immediate management at the scene of the injury is critical, because improper handling of the
patient can cause further damage and loss of neurologic function. - motor vehicle crash, a
diving or contact sports injury, a fall, or any direct trauma to the head and neck
 Initial care - rapid assessment, immobilization, extrication, and stabilization or control of
life-threatening injuries, and transportation to the most appropriate medical facility.
 Immediate transportation to a trauma center with the capacity to manage major
neurologic trauma is then necessary (Hickey, 2014).
 At the scene of the injury - immobilized on a spinal (back) board, with the head and neck
maintained in a neutral position, to prevent an incomplete injury from becoming complete.

62
EMERGENCY MANAGEMENT

 One member of the team must assume control of the patient’s head to prevent
flexion, rotation, or extension;
 Done by placing the hands on both sides of the patient’s head at about ear level to limit
movement and maintain alignment while a spinal board and/or cervical immobilizing
device is applied.
 If possible, at least four people should slide the patient carefully onto a board for transfer
to the hospital.
 Head blocks should also be considered, as they will further limit any neck movement.
 Any twisting movement may irreversibly damage the spinal cord by causing bony fragment
or disc movement or exacerbating ligamentous injury, causing further instability (Bader et
al., 2016).

63
NURSING DIAGNOSIS

1. Ineffective breathing pattern related to weakness or paralysis of

abdominal and intercostal muscles and inability to clear secretions
GOAL: Improved breathing pattern and airway clearance
 Possible impending respiratory failure is detected by observing the patient, measuring vital
capacity, monitoring oxygen saturation through pulse oximetry, and monitoring arterial blood gas
values.
 Early and vigorous attention to clearing bronchial and pharyngeal secretions canprevent retention
of secretions and atelectasis.
 Suctioning - used with caution to avoid stimulating the vagus nerve and producing bradycardia and
cardiac arrest.
 If the patient cannot cough effectively because of decreased inspiratory volume and inability to
generate sufficient expiratory pressure, chest physical therapy and assisted coughing may be
indicated.
 Specific breathing exercises are supervised by the nurse to increase the strength and endurance of
inspiratory muscles, particularly the diaphragm. 64
NURSING DIAGNOSIS

1. Ineffective breathing pattern related to weakness or paralysis of

abdominal and intercostal muscles and inability to clear secretions
• Assisted coughing promotes clearing of secretions from the upper respiratory tract and is
similar to the use of abdominal thrusts to clear an airway.
• Ensuring proper humidification and hydration is important to prevent secretions from
becoming thick and difficult to remove even with coughing.
• The patient is assessed for signs of respiratory infection (cough, fever, dyspnea)
• Smoking is discouraged, because it increases bronchial and pulmonary secretions and
impairs ciliary action.
• Ascending edema of the spinal cord in the acute phase may cause respiratory difficulty
that requires immediate intervention. Therefore, the patient’s respiratory status must be
monitored frequently
65
NURSING DIAGNOSIS

2. Impaired physical mobility related to motor and sensory impairments

GOAL: Improved mobility
 Proper body alignment is maintained at all times.
 The patient is repositioned frequently and is assisted out of bed as soon as the spinal column is
stabilized.
 The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop.
When used, the splints are removed and reapplied every 2 hours.
 Trochanter rolls, applied from the crest of ilium to the midthigh of both legs, help prevent rotation
of the hip joints.
 Patients with lesions above the midthoracic level have loss of sympathetic control of peripheral
vasoconstrictor activity, leading to hypotension. These patients may tolerate changes in position
poorly and require monitoring of blood pressure when positions are changed.
66
NURSING DIAGNOSIS

2. Impaired physical mobility related to motor and sensory

impairments
• If not on rotating bed, the patient should not be turned unless the spine is stable and the
physician has indicated that is safe to do so.
• Contractures develop rapidly with immobility and muscle paralysis. Contractures and other
complications may be prevented by range-of-motion exercises that help preserve joint motion
and stimulate circulation.
• Passive range-of-motion exercises should be implemented as soon as possible after injury. Toes,
metatarsal, ankles, knees and hips should be put through a full range of motion at least four, and
ideally five, times daily.
• For most patients who have 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. A four-poster neck brace or molded collar is
applied when the patient is mobilized after traction is removed. 67
NURSING DIAGNOSIS

3. Risk for impaired skin integrity related to immobility

GOAL: Maintenance of skin integrity
 The patient’s position is changed at least every 2 hours. Turning not only
assists in the prevention of pressure ulcers but also prevents pooling of
blood and edema in the dependent areas.
 Careful infection of the skin is made each time the patient is turned. The
skin over the pressure points is assessed for redness or breaks; the
perineum is checked for soilage, and the catheter is observed for adequate
drainage.
 The patient’s general body alignment and comfort are assessed. Special
attention should be given to pressure areas in contact with the transfer 68
board.
NURSING DIAGNOSIS

3. Risk for impaired skin integrity related to immobility

• The patient’s skin should be kept clean by washing with mild
soap, rinsing well, and blotting dry.
• Pressure sensitive areas should be kept well lubricated and soft
with hand cream or lotion.
• To increase understanding of the reasons for preventive
measures, the patient is educated about the danger of pressure
ulcers and is encouraged to take control and make decisions
about appropriate skin care (Kinder, 2005). 69
NURSING DIAGNOSIS

4. Impaired Urinary Elimination related to inability to

void spontaneously
GOAL: Relief of urinary retention
 Immediately after SCI, the urinary bladder becomes atonic and cannot
contract by reflex activity. Urinary retention is the immediate result.
 Intermittent catheterization is carried out to avoid overdistention of the
bladder and high risk for UTI due to retention of urine.
 At an early stage, family members are shown how to carry out intermittent
catheterization and are encouraged to participate in this facet of care,
because they will be involved in long-term follow-up and must be able to
recognize complications so that treatment can be instituted. 70
NURSING DIAGNOSIS

4. Impaired Urinary Elimination related to inability to void

spontaneously
• The patient is taught to record fluid intake, voiding pattern, and amounts of
residual urine after catheterization, characteristics of urine, and any
unusual sensations that may occur.

71
NURSING DIAGNOSIS

5. Constipation related to presence of atonic bowel as a

result of autonomic disruption
GOAL: Improved bowel function
 Paralytic ileus - develops as a result of neurogenic paralysis of the bowel - a
nasogastric tube is required to relieve distention and to prevent vomiting
and aspiration (Rodriguez, 2016).
 As soon as bowel sounds are heard on auscultation, the patient is given a
high-calorie, high-protein, high-fiber diet, with the amount of food gradually
increased.
 The nurse administers prescribed stool softeners to counteract the effects of
immobility and analgesics agents. 72
NURSING DIAGNOSIS

6. Disturbed Sensory Perception related to motor and

sensory impairment
GOAL: Improved sensory and perceptual awareness
 The intact senses above the level of the injury are stimulated through touch,
aromas, flavorful food and beverages, conversation and music
 Providing prism glasses to enable the patient to see from the supine position
 Encouraging use of hearing aids, if indicated, to enable the patient to hear
conversations and environment sounds
 Providing emotional support to the patient
 Teaching the patient strategies to compensate for or cope with these deficits
73
COMPLICATIONS

 ORTHOSTATIC HYPOTENSION
Occurs when clients change position due to the interruption in functioning of the automatic
nervous system and pooling of blood in lower extremities when in an upright position.
Nursing Actions
● Close monitoring of vital signs before and during position changes is essential.
● Vasopressor medication can be used to treat the profound vasodilation.
● Thigh-high elastic compression stockings should be applied to improve venous returns from
the lower extremities.
● Abdominal binders may also be used to encourage venous return and provide diaphragmatic
support when the patient is upright.
● Activity should be planned in advance, and adequate time should be allowed for a slow
progression of position changes from recumbent to sitting and upright.
● Tilt tables frequently are helpful in assisting patients to make this transition. 74
COMPLICATIONS

 SPINAL SHOCK
Spinal shock is the spinal cord’s response to the inflammation caused by the injury.
● Manifestations include flaccid paralysis, loss of reflex activity below level of injury, and
paralytic ileus due to the loss of autonomic function
 NEUROGENIC SHOCK
Neurogenic shock is a common response of the spinal cord following an injury.
● Manifestations of bradycardia, hypotension, dependent edema, and loss of temperature
regulation are caused by a sudden loss of communication within the sympathetic nervous
system that maintains the normal muscle tone in blood vessel walls.
Nursing Actions
● Monitor vital signs for hypotension and bradycardia.
● Treat symptoms with appropriate medications (vasopressors or atropine) and IV fluids.
ADD A FOOTER 75
COMPLICATIONS

 DEEP VEIN THROMBOSIS

DVT is a potential complication of immobility and is common in patients with SCI (Bader &
Littejohns, 2004). Patients who developed DVT are at risk for pulmonary embolism, a life-
threatening complication.
• The patient should be assessed for low-grade fever, which may be the first sign of a DVT,
and thigh and calf measurements are made daily.
• Low-dose anticoagulation therapy usually is initiated to prevent DVT and PE, along with the
use of thigh-high elastic compression stockings or pneumatic compression devices.

ADD A FOOTER 76
COMPLICATIONS

 AUTONOMIC DYSREFLEXIA
Occurs secondary to the stimulation of the sympathetic nervous system and inadequate compensatory
response by the parasympathetic nervous system. Clients who have lesions below T6 do not experience
dysreflexia because the parasympathetic nervous system is able to neutralize the sympathetic response.
Nursing Actions
● The patient is placed immediately in a sitting position to lower blood pressure.
● Rapid assessment is performed to identify and alleviate the cause.
● The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is
irrigated or replaced with another catheter.
● The rectum is examined for a fecal mass. If one is present, a topical anesthetic is inserted 10 to 15 minutes
before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia.
● The skin is examined for any areas of pressure, irritation, or broken skin.
● The medical record or chart is labeled with a clearly visible note about the risk for autonomic dysreflexia.

77
REFERENCES

Book Based
Brunner &Suddarth. (2018). Textbook of Medical-Surgical Nursing, 14th edition, Vol. 1 and 2; Lippincott Williams &
Wilkins
Brunner &Suddarth’s. (2016). Textbook in Medical- Surgical Nursing 10th edition Vol. 1&2; Lippincott Williams & Wilkins
Ebnezar, J. (2010). Textbook of Orthopedics 4 th Edition; Jaypee Brothers Medical Publishers (P) Ltd
Silvestri, L. & Silvestri, A. (2019). Saunders Comprehensive review for the NCLEX-RN Examination, 8 th edition; Elsevier
3251 Riverport Lane St. Louis, Missouri 63043
Internet Based
Shepherd Center. (2020). Spinal Cord Injury Information. Retrieved from
https://www.shepherd.org/patient-programs/spinal-cord-injury/about#:~:text=A%20spinal%20cord%20injur
y%20(SCI,Friedreich's%20ataxia%2C%20etc.)
, Accessed on June 20,2021
Physiopedia. (2021). Cervical Examination. Retrieved from https://www.physio-pedia.com/Cervical_Examination,
Accessed on June 22,2021 78
 Click icon to add picture

THANK YOU!

Feliciano, Jenard R.
Flores, Arliah Q.
Gaspar, Danica V.