Spinal Cord Injuries

  1. General information
    1. Occurs most commonly in young adult males between ages 15 and 25
    2. Common traumatic causes: motor vehicle accidents, diving in shallow water, falls, industrial accidents, sports injuries, gunshot or stab wounds
    3. Nontraumatic causes: tumors, hematomas, aneurysms, congenital defects (spina bifida)
    4. Classified by extent, level, and mechanism of injury
      1. Extent of injury
        1. may affect the vertebral column: fracture, fracture/dislocation
        2. may affect anterior or posterior ligaments, causing compression of spinal cord
        3. may be to the spinal cord and its roots: concussion, contusion, compression or laceration by fracture/dislocation or penetrating missiles
      2. Level of injury: cervical, thoracic, lumbar
      3. Mechanisms of injury
        1. hyperflexion
        2. hyperextension
        3. axial loading (force exerted straight up or down spinal column as in a diving accident)
        4. penetrating wounds
    5. Pathophysiology: hemorrhage and edema cause ischemia, leading to necrosis and destruction of the cord
  2. Medical management: immobilization and maintenance of normal spinal alignment to promote fracture healing
    1. Horizontal turning frames (Stryker frame)
    2. Skeletal traction: to immobilize the fracture and maintain alignment of the cervical spine
      1. Cervical tongs (Crutchfield, Gardner- Wells, Vinke): inserted through burr holes; traction is provided by a rope extended from the center of tongs over a pulley with weights attached at the end.
      2. Halo traction
        1. stainless steel halo ring fits around the head and is attached to the skull with four pins; halo is attached to plastic body cast or plastic vest
        2. permits early mobilization, decreased period of hospitalization and reduces complications of immobility
    3. Surgery: decompression laminectomy, spinal fusion
      1. Depends on type of injury and the preference of the surgeon
      2. Indications: unstable fracture, cord compression, progression of neurologic deficits
  3. Assessment findings
    1. Spinal shock
      1. Occurs immediately after the injury as a result of the insult to the CNS
      2. Temporary condition lasting from several days to three months
      3. Characterized by absence of reflexes below the level of the lesion, flaccid paralysis, lack of temperature control in affected parts, hypotension with bradycardia, retention of urine and feces
    2. Symptoms depend on the level and the extent of the injury.
      1. Level of injury
        1. quadriplegia: cervical injuries (C1-C8) cause paralysis of all four extremities; respiratory paralysis occurs in lesions above C6 due to lack of innervation to the diaphragm; (phrenic nerves at the C4-C5 level).
        2. paraplegia: thoraco/lumbar injuries (T1-L4) cause paralysis of the lower half of the body involving both legs
      2. Extent of injury
        1. complete cord transection
          1. loss of all voluntary movement and sensation below the level of the injury; reflex activity below the level of the lesion may return after spinal shock resolves.
          2. lesions in the conus medullaris or cauda equina result in permanent flaccid paralysis and areflexia.
        2. incomplete lesions: varying degrees of motor or sensory loss below the level of the lesion depending on which neurologic tracts are damaged and which are spared.
    3. Diagnostic test: spinal x-rays may reveal fracture.
  4. Nursing interventions: emergency care
    1. Assess airway, breathing, circulation
      1. Do not move the client during assessment.
      2. If airway obstruction or inadequate ventilation exists: do not hyperextend neck to open airway, use jaw thrust instead.
    2. Perform a quick head-to-toe assessment: check for LOC, signs of trauma to the head or neck, leakage of clear fluid from ears or nose, signs of motor or sensory impairment.
    3. Immobilize the client in the position found until help arrives.
    4. Once emergency help arrives, assist in immobilizing the head and neck with a cervical collar and place the client on a spinal board; avoid any movement during transfer, especially flexion of the spinal column.
    5. Have suction available to clear the airway and prevent aspiration if the client vomits; client may be turned slightly to the side if secured to a board.
    6. Evaluate respiration and observe for weak or labored respirations.
  5. Nursing interventions: acute care
    1. Maintain optimum respiratory function.
      1. Observe for weak or labored respirations; monitor arterial blood gases.
      2. Prevent pneumonia and atelectasis: turn every 2 hours; cough and deep breathe every hour; use incentive spirometry every 2 hours.
      3. Tracheostomy and mechanical ventilation may be necessary if respiratory insufficiency occurs.
    2. Maintain optimal cardiovascular function.
      1. Monitor vital signs; observe for bradycarida, arrhythmias, hypotension.
      2. Apply thigh-high elastic stockings or Ace bandages.
      3. Change position slowly and gradually elevate the head of the bed to prevent postural hypotension.
      4. Observe for signs of deep-vein thrombosis.
    3. Maintain fluid and electrolyte balance and nutrition.
      1. Nasogastric tube may be inserted until bowel sounds return.
      2. Maintain IV therapy as ordered; avoid overhydration (can aggravate cord edema).
      3. Check bowel sounds before feeding client (paralytic ileus is common).
      4. Progress slowly from clear liquid to regular diet.
      5. Provide diet high in protein, carbohydrates, calories.
    4. Maintain immobilization and spinal alignment always.
      1. Turn every hour on turning frame.
      2. Maintain cervical traction at all times if indicated.
    5. Prevent complications of immobility; use footboard/high-topped sneakers to prevent foot drop; provide splint for quadriplegic client to prevent wrist drop.
    6. Maintain urinary elimination.
      1. Provide intermittent catheterization or maintain indwelling catheter as ordered.
      2. Increase fluids to 3000 ml/day.
      3. Provide acid-ash foods/fluids to acidify urine and prevent infection (see Bladder Surgery).
    7. Maintain bowel elimination: administer stool softeners and suppositories to prevent impaction as ordered.
    8. Monitor temperature control.
      1. Check temperature every 4 hours.
      2. Regulate environment closely.
      3. Avoid excessive covering or exposure.
    9. Observe for and prevent infection.
      1. Observe tongs or pin site for redness, drainage.
      2. Provide tong- or pin-site care. Cleanse with antiseptic solution according to agency policy.
      3. Observe for signs of respiratory or urinary infection.
    10. Observe for and prevent stress ulcers.
      1. Assess for epigastic or shoulder pain.
      2. If corticosteroids are ordered, give with food or antacids; administer cimetadine (Tagamet) as ordered.
      3. Check nasogastric tube contents and stools for blood.
  6. Nursing interventions: chronic care
    1. Neurogenic bladder
      1. Reflex or upper motor neuron bladder; reflex activity of the bladder may occur after spinal shock resolves; the bladder is unable to store urine very long and empties involuntarily
      2. Nonreflexive or lower motor neuron bladder: reflex arc is disrupted and no reflex activity of the bladder occurs, resulting in urine retention with overflow
      3. Management of reflex bladder
        1. intermittent catheterization every 4 hours and gradually progress to every 6 hours.
        2. regulate fluid intake to 1800-2000 ml/day.
        3. bladder taps or stimulating trigger points to cause reflex emptying of the bladder.
      4. Management of nonreflexive bladder
        1. intermittent catheterization every 6 hours.
        2. Credé maneuver or rectal stretch.
        3. regulate intake to 1800-2000 ml/day to prevent overdistention of bladder.
      5. Management depends on life-style, age, sex, home care, and availability of care giver.
    2. Spasticity
      1. Return of reflex activity may occur after spinal shock resolves; severe spasticity may be detrimental
      2. Drug therapy: baclofen (Lioresal), dantrolene (Dantrium), diazepam (Valium)
      3. Physical therapy: stretching exercises, warm tub baths, whirlpool
      4. Surgery: chordotomy
    3. Autonomic dysreflexia
      1. Rise in blood pressure, sometimes to fatal levels
      2. Occurs in clients with cord lesions above T6 and most commonly in clients with cervical injuries
      3. Reflex response to stimulation of the sympathetic nervous system
      4. Stimulus may be overdistended bladder or bowel, decubitus ulcer, chilling, pressure from bedclothes
      5. Symptoms: severe headache, hypertension, bradycardia, sweating, goose bumps, nasal congestion, blurred vision, convulsions
      6. Interventions
        1. raise client to sitting position to decrease BP.
        2. check for source of stimulus (bladder, bowel, skin).
        3. remove offending stimulus (e.g., catheterize client, digitally remove impacted feces, reposition client).
        4. monitor blood pressure.
        5. administer antihypertensives (e.g., hydralazine HCl [Apresoline]) as ordered.
  7. Nursing interventions: general rehabilitative care
    1. Provide psychologic support to client/significant others.
      1. Support during grieving process.
      2. Assist client to adjust to effects of injury.
      3. Encourage independence.
      4. Involve the client in decision making.
    2. Provide sexual counseling.
      1. Work with the client and partner.
      2. Explore alternative methods of sexual gratification.
    3. Initiate rehabilitation program.
      1. Physical therapy.
      2. Vocational rehabilitation
      3. Psychologic counseling
      4. Use of braces, electronic wheelchair, and other assistance devices to maximize independence.