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SPINAL CORD INJURIES (SCIs) involve damage to the neurons of the spinal cord. They're often devastating because they're associated with life-threatening complications and loss of functional independence. SCIs may be permanent or temporary, depending on the injury.1
About 53% of SCI cases involve adolescents or young adults age 16 to 30; most injuries are caused by motor vehicle crashes, falls, violence (such as gunshot wounds), and sports.2 In this article, you'll find the latest information on types of SCIs, how they're treated, and what you can do to protect your patients from further injury and maximize recovery.
Most SCIs are associated with injuries to the vertebral column, including fractures, dislocations, and subluxations.
Fractures involve the pedicle, lamina, vertebral body, or transverse/spinal processes. A fracture can exist alone or be associated with dislocation or any degree of spinal cord or spinal nerve root injury.
Dislocations or subluxations (partial dislocations) cause the vertebrae to become displaced, preventing correct alignment. A dislocation occurs when one vertebra overrides another with unilateral or bilateral facet dislocation. A disruption in alignment is visible radiographically. The supporting ligaments may also be injured, and the spinal cord may or may not be involved. Any movement of the spine can cause compression or stretching of neural tissue, which may lead to or exacerbate SCI.2
An SCI can be classified by the type of injury:
* Concussion is the severe shaking of the spinal cord that may result in a temporary loss of function that can last hours to weeks.
* Compression occurs at the moment of injury and distorts the spine's normal curvature.
* Contusion is bruising of the spinal cord that can lead to bleeding into the cord and edema. Necrosis may be caused by compression from the edema or direct damage to the tissue. Fractures, dislocations, and direct trauma to the cord can cause a contusion.
* Laceration is a tear in the spinal cord that results in permanent injury; contusion, edema, and cord compression accompany a laceration.
* Transection is a severing of the cord, either complete or incomplete. High cervical cord transections (above C4) result in loss of respiratory control and death if not promptly recognized and treated appropriately.
* Hemorrhage can occur in or around the spinal cord after an injury, becoming an irritant to the tissue and causing pressure on the spinal cord and nerve roots.
* Injury to the blood vessels that supply the spinal cord, the anterior spinal artery, or the two posterior spinal arteries results in ischemia and possible necrosis; prolonged ischemia and necrosis can result in permanent deficits.
An SCI can be complete or incomplete. A complete SCI results in the absence of sensory and voluntary motor function below the level of injury including the lowest sacral segments of S4 and S5.1 (See A look at the spine.) With a complete SCI, losses below the level of injury include:
* flaccid paralysis of all voluntary muscles
* loss of all spinal reflexes
* loss of pain perception, light touch, proprioception, temperature, and pressure
* absence of somatic and visceral sensations
* loss of the ability to perspire (autonomic function)
* bowel and bladder dysfunction.1
The patient may experience pain at the site of injury because of a zone of heightened sensitivity called hyperesthesia immediately above the level of the lesion. There's usually no chance of recovery when an SCI results in total loss of neurologic function and no recovery is demonstrated within the first 24 hours after the injury.1
Spinal shock is the response of the cord itself to injury. Spinal shock is characterized by a complete but temporary loss of sensory, motor, reflex, and autonomic function below the level of injury. Examples include flaccid paralysis, loss of cutaneous and deep tendon reflexes, urinary bladder tone, peristalsis, perspiration and piloerection, and vasomotor tone. Return of function is heralded by bladder tone, hyperreflexia, and sacral reflexes. Flaccid paralysis is followed by spasticity-hypertonicity.3
Neurogenic shock is present in cord injuries above T6. Signs are evident below the level of injury due to interruption of the sympathetic nervous system leaving the parasympathetic system unopposed. Autonomic dysfunction is characterized by systemic hypotension (vasodilation with decreased venous return), warm and dry skin, and bradycardia.
The patient's body temperature will be lower than normal because of the break in the connection between the hypothalamus and the sympathetic nervous system. The body temperature responds to ambient room temperature (poikilothermia).
An incomplete SCI indicates that the patient has some remaining motor or sensory function below the level of injury. Incomplete SCIs have the potential to improve or resolve. For a list of incomplete SCI syndromes and their clinical presentations, see Determining syndromes. If no motor or sensory function returns after spinal shock resolves, the SCI is considered complete. The American Spinal Injury Association (ASIA) Impairment Scale is often used to determine the extent of SCI. (See Complete or incomplete?)
Rapid assessment and critical thinking are essential to identify the primary injury (occurring at the time of impact) as well as protect the spine from secondary injury (occurring after primary injury due to hypoxia and/or ischemia). As in any emergency, the basics come first, followed by special care needed to stabilize the patient and enable optimal recovery.
How well the patient is managed in the field and during initial resuscitation can determine the eventual level of neurologic recovery. Until proven otherwise, all trauma patients should be treated as if they have a spine injury or SCI.
At the injury site, the patient should undergo rapid assessment to identify issues with airway, breathing, circulation, and a brief neurologic exam; immobilization and stabilization of the entire spine; removal of the patient from the vehicle or injury site; and triage to the appropriate trauma center.
When a patient with a suspected SCI arrives in the ED on a backboard with a cervical collar, rapidly obtain a report of the prehospital management and history of the injury event. You'll need to determine:
* the circumstances of the injury
* the patient's neurologic status immediately after the injury
* treatment at the injury site.
Begin with rapid assessment and management of airway, breathing, and circulation. Provide an airway and ventilatory support in patients with high tetraplegia (quadriplegia) or those with any evidence of airway or respiratory compromise as soon as possible. If a definitive airway isn't immediately available, provide rescue breathing with the jaw thrust maneuver to maintain the immobilization of the spine. If endotracheal intubation is needed, a fiberoptic laryngoscopic insertion technique may be performed if time allows, by a specially trained physician, usually the ED physician or anesthesiologist. Fiberoptic intubation prevents hyperextension of the neck through direct visualization of the cords. It's important to note that maintaining the airway is essential and time constraints may require conventional intubation. Maintaining alignment of the neck before, during, and after intubation is necessary. Be sure to replace the front of the cervical collar immediately after intubation.
To prevent hypoxemia and secondary SCI, maintain the patient's oxygen saturation within the normal range (94% to 100%) by administering supplemental oxygen. Monitor patients for signs of ascending injury, which may rapidly compromise respirations and require intubation. Shallow respirations, respiratory distress/failure, and weakness are signs of ascending injury or exhaustion from loss of muscle/diaphragm control.
Focus on rapid patient assessment and stabilization. The primary survey and patient stabilization include logrolling the patient as a unit when repositioning, during back exam, and during transfers.
Prevent and treat hypotension as with every trauma patient through the use of fluids and blood products. Any source of bleeding should be identified. Once bleeding is ruled out, vasopressors are effective in managing hypotension in the SCI patient. Determine the initial base deficit or lactate level (arterial or venous) via blood work to assess the effectiveness of resuscitation. Monitor and treat symptomatic bradycardia and regulate the patient's temperature.4 Temperature regulation can be assisted with warm blankets or a warming device, a warm room (ambient temperature), and warm fluids.
The final component of the primary survey and the beginning of the secondary survey is an assessment of neurologic status. Assessing motor function includes the patient's ability to move or respond to stimuli at different levels of the spinal cord. Motor strength is evaluated on a 6-point scale:
* 0 = total paralysis (no response)
* 1 = palpable or visible contraction, muscle flicker but without movement
* 2 = active movement, but not against gravity
* 3 = active movement, against gravity
* 4 = active movement, against some resistance
* 5 = active movement, against full resistance.
Ask the patient to move actively against your resistance or to resist your movement. If muscles are too weak to overcome resistance, test them against gravity alone or with gravity eliminated. If the patient can't move the body part, watch or feel for weak muscular contraction.5
Always compare the right and left side of the body and compare motor function of the upper extremities to lower extremity function. Normal motor responses are determined by the nerve root attached. (See Sensory and motor assessment: Know your nerves.) Assess the patient's rectal tone as well. Sacral sparing (when patient maintains some sensation around the anus), along with rectal tone and sensation, may indicate an incomplete SCI.
Some patients with incomplete SCIs have motor deficits and intact sensation, or vice versa. To assess for sensory deficits, carefully provide a light touch and a gentle pinprick to areas of the body innervated by the sensory root of each spinal nerve (dermatome) to determine the lowest level of intact sensation. (See Mapping dermatomes.) Pay special attention to the dermatomes on the anterior chest. Cervical roots map to the nipple line, not the thoracic roots. Lack of sensation down to the nipple line indicates cervical injuries. Have patients close their eyes during the exam because they may "wish" to be able to feel and confirm sensation where there is none if they observe the area being tested.
During the initial treatment, a computed tomography (CT) scan may be used to rule out spine injury. A CT scan is superior to magnetic resonance imaging (MRI) for detailed information about bony structures and fractures; an MRI provides better detail on soft tissues, including the spinal cord, ligaments, and discs.
Admission to the ICU is usually the next step after the patient with an SCI is stabilized. The primary goal is to preserve or improve neurologic function.1
Treatment is focused on prevention of secondary injury, spinal realignment and stabilization, and prevention of complications.
Prevention of secondary injury is accomplished by the same means initiated in the ED. Maintain airway and ventilation as well as BP.
Alignment and stabilization to provide neural decompression of the spinal cord or spinal nerves is a high priority to control or eliminate ischemia and necrosis in the spinal cord. Early stabilization also allows for early mobilization and prevention of complications of immobility. Depending on the patient's condition, options include skeletal traction, application of a halo and vest, or immediate surgery (decompression laminectomy, reduction, stabilization with instrumentation, and/or bone graft). Surgery may be by anterior and/or posterior approach. Not all patients will require surgery. Some may be managed with a halo device or rigid cervical collar (cervical fracture), cervicothoracic orthotic device (high thoracic fracture), or thoracolumbrosacral device (lower thoracic or lumbar fractures). Skin care under these devices is essential to prevent breakdown. If the vertebral facets are locked, the patient may need skeletal traction to reduce the facets and/or surgical reduction to align the vertebrae. Jump-locked facets are an unstable spine situation that is often associated with cord impingement and ligamentous injury. Reduction is required.
Postoperative management includes continued prevention of secondary injury as well as customary postoperative wound care. The patient will usually continue to have external support of the spine through a cervical collar, halo device, or other orthotic depending on the site of injury and repair. If an anterior approach to the cervical spine is used, assessment and monitoring of swallow is necessary to prevent aspiration. Thoracic anterior stabilization includes placement of a chest tube due to the opening of the thoracic cavity. Anterior lumbar spine stabilization will have a laparotomy incision and will require monitoring for return of bowel function.
Prevention of complications is a lifetime commitment for patients with SCI. Early mobilization is key to decrease the potential for pressure ulcers, pneumonia, atelectasis, deep vein thrombosis (DVT)/pulmonary embolism, and ileus. Institute coughing and deep breathing, including the manually assisted cough. Initiate DVT prophylaxis as soon as possible after arrival, including sequential compression devices and low-molecular-weight heparin (if bleeding is ruled out). Some patients may require an inferior vena cava filter.
Frequent turning with spinal alignment and early out-of-bed activity after stabilization prevent pressure ulcers. Pressure ulcers are a common source of readmission and a potential source of infection. Pneumonia, sepsis, and pulmonary embolism are common causes of death in patients with SCI.3 Determine the need for bowel and bladder management regimens and incorporate them into the plan of care. Patients with fractures of the lower spine can also develop an ileus with immobilization. Early mobilization after stabilization is essential.
Orthostatic hypotension can develop when patients are first mobilized upright from a supine position. Frequent BP monitoring, the use of compression stockings and an abdominal binder, and even a tilt table (with a physical therapist consult) to assist in moving a SCI patient to an upright position can help prevent and/or manage this complication.
Autonomic dysreflexia can occur in patients with cord injury above T6. Evidence of this syndrome may not occur until months after the original injury; however, both nurses and families should be skilled in identifying this life-threatening syndrome. Signs and symptoms include severe headache, hypertension, bradycardia, nasal congestion, blurred vision, anxiety/distress, nausea, flushing of the head/neck, and diaphoresis above the lesion. Causes include everyday events such as onychocryptosis (an ingrown toenail), bladder distension, constipation, pressure ulcers, tight clothing, and urinary tract infection. The syndrome can usually be treated by identifying and removing the precipitating cause.
Caring for a patient with an SCI involves complex medical and nursing care. Anticipation of the need for rehabilitation and early transfer will prevent complications and start your patient on the road to the best level of recovery possible.
To determine the extent of SCI, use the ASIA Impairment Scale:
Complete A: no motor or sensory function is preserved in sacral segments S4-S5
Incomplete B: sensory but no motor function preserved below neurologic level, includes sacral segments S4-S5
Incomplete C: motor function preserved below neurologic level, at least half of key muscles below neurologic levels have muscle grade less than 3
Incomplete D: motor function preserved below neurologic level, at least half of key muscles below neurologic level have muscle grade of 3 or more
Normal E: motor and sensory function normal
1. Hickey JV. The Clinical Practice of Neurological and Neurosurgical Nursing. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. [Context Link]
2. Porth CM. Essentials of Pathophysiology. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. [Context Link]
3. Nayduch DA. Nurse to Nurse: Trauma Care Expert Interventions. New York, NY: McGraw-Hill; 2009. [Context Link]
4. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury. J Spinal Cord Med. 2008;31(4):403-479. [Context Link]
5. Bickley LS. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. [Context Link]
6. Young W. Spinal cord injury levels and classification. http://www.sci-info-pages.com/levels.html. [Context Link]
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