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Spinal Cord Injury

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Overview

Damage to the main cord of nerves running from the brain, down the spinal column, which branches out to innervate the body.

Nursing Points

General

  1. Complete Cord Injury
    1. Cut clean through
    2. Irreversible nerve damage
  2. Incomplete Cord Injuries
    1. Central Cord Syndrome
      1. Loss of pain, temperature, light touch/pressure below level of injury
      2. Motor Intact
    2. Anterior Cord Syndrome
      1. Only the anterior portion of the cord is  affected
      2. Loss of motor, pain, temperature sensation below level of injury
      3. Touch/Proprioception intact
    3. Brown-Sequard Syndrome
      1. Only half of cord is affected
      2. Ipsilateral loss of motor, proprioception, touch
      3. Contralateral loss of pain, temperature sensation
  3. Complications
    1. Autonomic dysreflexia
      1. Loss of autonomic regulation
      2. Causes – full bowel, bladder, pain, skin stimulus
    2. Breathing problems
      1. Diaphragm innervated by C3-C5
      2. Intercostals innervated by thoracic nerves
    3. Circulation
      1. Immobility → Clots
      2. Neurogenic Shock in first 24-72 hours
    4. Discomfort – neurogenic pain
    5. Elimination
      1. May lose control of bowels and bladder

Assessment

  1. Dermatomes
    1. Section of skin supplied by a specific level of spinal nerve
    2. i.e. T5 = approximately nipple level
  2. Loss of motor and sensory functions BELOW level of spinal cord injury
    1. Use sharp, dull test to move upward until sensation intact
  3. Autonomic Dysreflexia
    1. Severe HTN
    2. Bradycardia
    3. Elevated Temp
    4. Flushed skin
    5. Blurry vision
    6. Seizures → Death
    7. Look for source!
  4. Airway – for high level injuries, ensure ability to breathe effectively
    1. SpO2
    2. ABG

Therapeutic Management

  1. Initial Insult
    1. Therapeutic Hypothermia may be neuroprotective
    2. Frequent monitoring for neurogenic shock
  2. Autonomic Dysreflexia
    1. Nitroglycerin
    2. Calcium Channel Blockers
    3. Reverse cause
  3. Immobilization/Traction
    1. Halo Brace
    2. Prevents further damage
    3. Allows time to heal
      1. May have swelling UP cord
      2. Regain sensation as swelling decreases
  4. Pain
    1. Analgesics
    2. Muscle Relaxants (i.e. gabapentin, cyclobenzaprine)

Nursing Concepts

  1. Functional Ability
    1. Halo Brace
      1. Pin care twice daily
      2. Report s/s infection
    2. Encourage PT/OT
    3. Maintain Spinal Precautions as long as ordered
      1. Cervical Collar
      2. Log Roll
  2. Perfusion
    1. Monitor for s/s DVT
    2. Monitor for s/s Autonomic Dysreflexia
      1. Prevention is Key
    3. Monitor hemodynamics
  3. Comfort
    1. Pad bony prominences
    2. Administer analgesics & muscle relaxants

Patient Education

  1. Purpose for PT / OT / Rehab
  2. Restrictions for mobility, especially at first
  3. Purpose for Halo Brace or traction

Reference Links

Study Tools

Video Transcript

Okay let’s talk about spinal cord injuries and what you need to know as the nurse to care for these patients.

First, know that not all spinal cord injuries are the same – they can be complete or incomplete. In complete cord injuries, the entire cord is affected – meaning the patient will lose all sensory and motor abilities BELOW the level of the injury. It’s like a powerline going down – everything past that loses power. So this is a cross section of our spinal cord. This is Anterior and this is Posterior. Anterior is where we find the nerve roots for motor function and Posterior is where we find nerve roots for sensory function. You can remember A-M-P-S, amps (as in amps of electricity). What happens in a partial or incomplete spinal cord injury is that only part of the cord is affected. So based on where the injury is will determine what sort of loss we have. For example, in anterior cord syndrome, we lose all motor function below the level of injury, but much of their sensory function is still intact.

When we have a patient with a spinal cord injury, we use dermatomes to assess their level of injury or spinal cord damage. Sometimes the cord may swell above the actual physical injury, so using dermatomes can help us determine if the swelling is going down. We’ll use sharp or dull or just light touch to test from the bottom up until the patient is able to feel us touching them. So it might be that they can’t feel anything below their nipple line – so that would be about the level of T5. Note that if they have a T5 injury, they will still have sensorimotor function of their arms. The MOST important thing you need to recognize here is that the higher the injury, the more chance of the patient having difficulty breathing. The intercostal muscles are innervated by the thoracic nerves and the diaphragm is innervated by C3-C5. If we have an injury at that level, we will find that the patient will struggle to breathe on their own and will need to be on a ventilator.

Now, aside from the loss of function, there are a few other complication we need to keep in mind. First is neurogenic shock, which usually occurs within the first few days after the injury. We discuss this in detail in the Shock module in the Cardiac course. Essentially, the patient loses their sympathetic tone which causes massive vasodilation and severe hypotension. As the swelling around the cord decreases, we should see these things improve. The other complication, called Autonomic Dysreflexia, is something that can occur at any time and is often a regular complication for these patients even years after their injury. Essentially, when the body experiences some sort of noxious stimulus or pain sensation – it tries to send that to the brain. This could be something as simple as a full bladder or a wrinkle in the bedsheets. Because of the disconnect in the nerves, the brain overreacts and interprets this as a massive crisis and causes an extreme fight or flight response. Their blood pressure will skyrocket and most of the time they’ll experience reflexive bradycardia. Their temperature will increase, they’ll get flushed and sweaty. Many will complain of blurry vision because their pupils dilate and they’ll complain of dizziness. This is a very urgent situation. Most patients and their families are taught how to manage this at home, but if it’s not addressed, it can quickly progress and cause a stroke or heart attack.

To manage autonomic dysreflexia, we will give vasodilators like nitroglycerin, calcium channel blockers like nifedipine, and alpha blockers like prazosin. But, once we’ve given them these meds – usually in a fast acting chewable or sublingual form, we need to determine the cause and address it. If we don’t remove the cause, that overactive sympathetic response will continue. This may mean inserting a catheter to drain their bladder, giving an enema to relieve constipation, or turning and repositioning them to make sure the sheets are straight. Even the slightest wrinkle in sheets can cause this overreaction. Now, for patients who have a new spinal cord injury, we want to focus on immobilization and stabilization, especially with spinal fractures – this can prevent further irritation and damage to the spinal cord. Sometimes we will also see therapeutic hypothermia used. The cold has been shown to be extremely neuroprotective and may help protect the nerves from the swelling that occurs. I see this a lot with professional athletes – you’ll see the athletic trainers packing them in ice before they cart them off the field. Believe it or not, this has shown to preserve a lot of function.

When it comes to spinal cord injuries, we want to optimize functional ability – that is, keep it from getting worse and helping them with physical therapy to learn how to adapt to their new ability level. We also want to promote comfort, especially in later stages where autonomic dysreflexia is a risk. And, as always, we want to keep these patients safe from injury since we know the kinds of problems immobility can cause. Make sure you check out the care plan and case study attached to this lesson to see more detailed nursing interventions and rationales.

So remember that our sensorimotor effects will be determined by the severity and level of injury. We can use the dermatomes to determine the level of injury, because we see loss of sensorimotor function below that level. This includes possible loss of the ability to breathe, so keep that in mind. The 3 most common instigators for autonomic dysreflexia are bowels, bladder, and skin irritation, so make sure you monitor these closely. And remember to do everything you can to preserve the patient’s optimal functional level.

So those are the important points for spinal cord injuries. Let us know if you have any questions. Now, go out and be your best selves today. And, as always, happy nursing!

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