Definition / Description:

Classes/ types
Review of anatomy and physiology
Diagnostic tests / lab procedures
Risk factors / Etiology
Medical / surgical management
Nursing management

Spinal cord injury (SCI)

Definition / Description:
Spinal cord injury (SCI) is a medically complex and life-disrupting condition. SCI refers to damage
to the spinal cord arising from trauma – such as car crash – or from non-traumatic disease or
degeneration – such as tuberculosis (TB). SCI encompasses the baby born with spina bifida and the
construction worker who falls from scaffolding. It includes the victim of conflict or gun violence, and the
older person who develops SCI as a result of osteoporosis or a tumour. (WHO, 2013)

https://apps.who.int/iris/bitstream/handle/10665/94192/WHO_NMH_VIP_13.03_eng.pdf;jsessionid=AE
789289D55EDDE8468B6DC16C1A0A01?sequence=1

Spinal cord injury occurs when there is any damage to the spinal cord that blocks communication
between the brain and the body. After a spinal cord injury, a person’s sensory, motor and reflex
messages are affected and may not be able to get past the damage in the spinal cord. In general, the
higher on the spinal cord the injury occurs, the more dysfunction the person will experience. Injuries are
referred to as complete or incomplete, based on whether any movement and sensation occurs at or
below the level of injury.

https://www.spinalinjury101.org/files/understanding-spinal-cord-injury.pdf

Spinal Cord Injury Types

Spinal cord injuries can be divided into two types of injury – complete spinal
cord injury vs. incomplete:

 A COMPLETE SPINAL CORD INJURY the most serious and occur when the
spinal cord is injured, eliminating the brain’s ability to send signals below the injury site. It
 causes permanent damage to the area of the spinal cord that is affected.
Paraplegia or tetraplegia are results of complete spinal cord injuries.

 An INCOMPLETE SPINAL CORD INJURY refers to partial damage to

the spinal cord. The ability to move and the amount of feeling depends on the
area of the spine injured and the severity of the injury. Outcomes are based
on a patient’s health and medical history.

Some of the most common types of incomplete or partial spinal cord injuries include:

 Anterior cord syndrome: This type of injury, to the front of the spinal cord,
damages the motor and sensory pathways in the spinal cord. You may retain
some sensation, but struggle with movement.
 Central cord syndrome: This injury is an injury to the center of the cord, and
damages nerves that carry signals from the brain to the spinal cord. Loss of fine
motor skills, paralysis of the arms, and partial impairment—usually less
pronounced—in the legs are common. Some survivors also suffer a loss of bowel
or bladder control, or lose the ability to sexually function.
 Brown-Sequard syndrome: This variety of injury is the product of damage to
one side of the spinal cord. The injury may be more pronounced on one side of
the body; for instance, movement may be impossible on the right side, but may
be fully retained on the left. The degree to which Brown-Sequard patients are
injured greatly varies from patient to patient.

 The most common types of spinal cord injuries include:

 Tetraplegia: These injuries, which are the result of damage to the cervical spinal cord,
are typically the most severe, producing varying degrees of paralysis of all limbs.
Sometimes known as quadriplegia, tetraplegia eliminates your ability to move below the
site of the injury, and may produce difficulties with bladder and bowel control, respiration,
and other routine functions. The higher up on the cervical spinal cord the injury is, the
more severe symptoms will likely be.
 Paraplegia: This occurs when sensation and movement are removed from the lower half
of the body, including the legs. These injuries are the product of damage to the thoracic
spinal cord. As with cervical spinal cord injuries, injuries are typically more severe when
they are closer to the top vertebra.
 Triplegia: Triplegia causes a loss of sensation and movement in one arm and both legs,
and is typically the product of an incomplete spinal cord injury.

https://www.spinalcord.com/types-of-spinal-cord-injuries

Anatomy
The human spine consists of 33 bony vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5
sacral (fused), and 4 coccygeal (usually fused).

The vertebral column provides the body's basic structural support and protects the
spinal cord, which extends from the midbrain caudally to the level of the second lumbar
vertebra and then continues as the cauda equina (Figure 1).

o The 3rd-6th cervical vertebrae have a "typical" structure. The 1st, 2nd, and 7th cervical
vertebrae are "atypical." Typical vertebrae demonstrate rectangular bodies with articular
uncinate processes on their lateral aspects, triangular vertebral foramina, bifid spinous
processes, and transverse foramina.
o The occipital condyles articulate with the superior articular surfaces (facets) of the atlas
(vertebra C1).
o The atlas, on which the cranium rests, has neither a spinous process nor a body. It consists of
two lateral masses connected by anterior and posterior arches.
 o The tooth-like dens characterize the axis (vertebra C2) and provides a pivot around which the
atlas turns and carries the cranium. It articulates anteriorly with the anterior arch of the atlas
("Facet for dens") and posteriorly with the transverse ligament of the atlas.
https://ceufast.com/course/traumatic-spinal-cord-injuries

Incidence
Given the current population size of 314 million people in the U.S., the recent estimate showed that the
annual incidence of spinal cord injury (SCI) is approximately 54 cases per million population in the U.S. or
approximately 17,000 new SCI cases each year.
https://www.nscisc.uab.edu/Public/Facts%202016.pdf

Prevalence
- The number of people in the U.S. who are alive in 2016 who have SCI has been estimated
to be approximately 282,000 persons, with a range from 243,000 to 347,000 persons.
- Gender: Males account for approximately 80% of new SCI cases
- Race/Ethnicity: About 22% of injuries have occurred among non-Hispanic blacks since
2010, which is higher than the proportion of non-Hispanic blacks in the general
population (12%).
- Age: The majority of people who sustain a spinal cord injury are young adults between
the ages of 16 and 30 because of riskier behaviors.

https://www.nscisc.uab.edu/Public/Facts%202016.pdf

Etiology
Traumatic injuries: Vehicle crashes are currently the leading cause of injury, followed by falls, acts
of violence (primarily gunshot wounds), and sports/recreation activities such as Gymnastics,
Football, Diving into shallow water

Non-traumatic injuries/illnesses: Cancer, Osteoporosis, Multiple sclerosis, Inflammation of the

spinal cord, Arthritis

Motor vehicle accidents (MVA) - Auto and motorcycle accidents the leading cause of spinal cord
injuriesActs of Violence – mostly gunshot woundsFalls – SPI after age 65 is often caused by a
fallSports and recreation injuries - Impact sports and diving in shallow water * ATV *Diseases -
Cancer, infections, arthritis and inflammation
  EFFECTS The effects of spinal cord injury may include the following: Loss of movement, Loss of
sensation, Loss of bowel and/or bladder control, exaggerated reflex actions or spasms, Changes
in sexual function, sexual sensitivity and fertility, Pain or intense stinging sensation

https://www.spinalinjury101.org/files/understanding-spinal-cord-injury.pdf
https://www.nscisc.uab.edu/Public/Facts%202016.pdf

Risk factors
 Gender - Spinal cord injury affects a disproportionate amount of men
 Age – (Young adults and seniors)
- Between ages 16 and 35 / MVA leading cause
- Another peak in people older than 60 / falls leading cause
 People active in sports – High risk athletic activities include football, rugby, wrestling,
gymnastics, diving, surfing, ice hockey and downhill skiing
 Predisposing conditions - A relatively minor injury can cause spinal cord injury in people
with conditions that affect their bones or joints, such as arthritis or osteoporosis

Diagnostic test Lab procedures:

The following laboratory studies can be helpful in the evaluation of spinal cord injury:
 Arterial blood gas (ABG) measurements - May be useful to evaluate adequacy
of oxygenation and ventilation
 Lactate levels - To monitor perfusion status; can be helpful in the presence of
shock
 Hemoglobin and/or hematocrit levels - May be measured initially and
monitored serially to detect or monitor sources of blood loss
 Urinalysis - Can be performed to detect any associated genitourinary injury

Imaging studies
Imaging techniques in spinal cord injury include the following:
 Plain radiography - Radiographs are only as good as the first and last vertebrae
seen, therefore, radiographs must adequately depict all vertebrae
 CT Scan (Computerized Tomography) – Provides doctors with more detailed
information about spinal cord or brain damage than X-rays can show. This reserved for
delineating bony abnormalities or fracture; can be used when plain radiography is
inadequate or fails to visualize segments of the axial skeleton
 Magnetic resonance imaging (MRI) - Used for suspected spinal cord lesions,
ligamentous injuries, and other soft-tissue injuries or pathology. It uses a strong
magnetic field and radio waves to produce computer-generated images. It can help identify
blood clots, swelling or skull fractures that may be compressing the brain and/or the spinal
cord.
  ASIA/ISCoS Exam and Grade
This is a system of tests used to define and describe the extent and severity of a
patient’s spinal cord injury and help determine future rehabilitation and recovery needs. It is
ideally completed within 72 hours after the initial injury. The patient’s grade is based on how
much sensation he or she can feel at multiple points on the body, as well as tests of motor
function.

 Motor Index Score (MIS) – A portion of ASIA/ISCoS exam that determines muscle strength of 10
different muscles on both sides of the body
 Sensory Index Score (SIS) – Part of ASIA/ISCoS exam that measures patient’s response to light
touch and a pinprick in 28 points on each side of the body to determine what the patient can
feel. Together, the SIS and MIS determine the patient’s level and severity of injury.
 Myelography – A test using injected dye to help the doctor visualize your loved one’s spinal
nerves more clearly. After the dye is injected into the spinal canal, X-rays and CT scans of the
vertebrae can reveal herniated disks or other problems.

https://www.spinalinjury101.org/files/understanding-spinal-cord-injury.pdf

Pathophysiology
The initial primary trauma causes mechanical injury to the spinal cord, a combination of
compression, laceration, distraction or shearing. After the resulting damage to the microvasculature,
progressive edema develops, ongoing ischemia worsens and a pro-apoptotic signaling is initiated. There
is disruption of the blood-spinal cord barrier, influx of inflammatory cells, vasoactive peptides, and
release of coagulation factors. These events promote thrombosis and spasm of the microvessels, leading
to further hypoxia. An energetic crisis is installed, there is production of oxygen free radicals, and
excitotoxicity and cytotoxic edema develop. With loss of the parenchymal volume, cystic cavities
coalesce, generating a physical barrier to cell migration. Because of the distortion of the structural
framework, regenerative attempts do not succeed. Proliferation of astrocytes and deposition of
fibroblasts worsen the picture. The Rho-ROCK (rho-associated protein kinase) is activated and inhibits
neurite outgrowth. Together, all those mechanisms contribute to the restriction of regeneration1,2. The
final extent of spinal cord damage results from primary and secondary mechanisms that start at the
moment of the injury and go on for days and even weeks. Neuroprotective agents attempt to avert
specific secondary injuries and prevent neural damage, while neuroregenerative therapies act to
promote axonal regrowth after the damage has occured1 .

https://www.scielo.br/j/anp/a/D5MZLCn7xRcMg67mxFgbGmr/?
format=pdf&lang=en

Medical / surgical management

Acute Phase
Goals of management are to prevent further SCI and to observe for symptoms of
progressive neurologic deficits.
 The patient is resuscitated as necessary, and
 oxygenation and cardiovascular stability are maintained.
 High-dose corticosteroids (methylprednisolone) may be administered to
counteract spinal cord edema
 Oxygen is administered to maintain a high arterial PaO2.
 Extreme care is taken to avoid flexing or extending the neck if endotracheal
intubation is necessary.
 Diaphragm pacing (electrical stimulation of the phrenic nerve) may be considered
for patients with high cervical spine injuries.
 SCI requires immobilization, reduction of dislocations, and stabilization of the
vertebral column. The cervical fracture is reduced and the cervical spine aligned
with a form of skeletal traction (using skeletal tongs or calipers or the halo-vest
technique). Weights are hung freely so as not to interfere with the traction.

Pharmacologic Therapy

Administration of high-dose IV corticosteroids or methylprednisolone sodium succinate in the

first 24 or 48 hours is controversial.

Respiratory Therapy
 Oxygen is administered to maintain a high partial pressure of oxygen (PaO2), because
hypoxemia can create or worsen a neurologic deficit of the spinal cord.
  If endotracheal intubation is necessary, extreme care is taken to avoid flexing or
extending the patient’s neck, which can result in extension of a cervical injury
 Diaphragmatic pacing (electrical stimulation of the phrenic nerve) attempts to stimulate
the diaphragm to help the patient breathe

Skeletal Fracture Reduction and Traction

 Management of SCI requires immobilization and reduction of dislocations (restoration of
normal position) and stabilization of the vertebral column.
 Cervical fractures are reduced, and the cervical spine is aligned with some form of
skeletal traction, such as skeletal tongs or calipers, or with use of the halo device (Sole, et
al., 2009).
 Traction is applied to the skeletal traction device by weights, the amount depending on
the size of the patient and the degree of fracture displacement. The traction force is
exerted along the longitudinal axis of the vertebral bodies, with the patient’s neck in a
neutral position. The traction is then gradually increased by adding more weights. As the
amount of traction is increased, the spaces between the intervertebral disks widen and the
vertebrae are given a chance to slip back into position.
 Reduction usually occurs after correct alignment has been restored.

Management of Complications
Spinal and Neurogenic Shock
 Intestinal decompression is used to treat bowel distention and paralytic ileus caused by
depression of reflexes. This loss of sympathetic innervation causes a variety of other
clinical manifestations, including neurogenic shock signaled by decreased cardiac output,
venous pooling in the extremities, and peripheral vasodilation.

 Patient who does not perspire on paralyzed portion of body requires close observation for
early detection of an abrupt onset of fever.

 Body defenses are maintained and supported until the spinal shock abates and the system
has recovered from the traumatic insult (up to 4 months).

 Special attention is paid to the respiratory system (may not be enough intrathoracic
pressure to cough effectively). Special problems include decreased vital capacity,
decreased oxygen levels, and pulmonary edema.

 Chest physiotherapy and suctioning are implemented to help clear pulmonary secretions.
Patient is monitored for respiratory complications (respiratory failure, pneumonia).

Deep Vein Thrombosis

Deep vein thrombosis (DVT) is a potential complication of immobility and is common in
patients with SCI.
 .In some cases, permanent indwelling filters may be placed prophylactically in the vena
cava to prevent emboli (dislodged clots) from migrating to the lungs and causing a PE
(Hickey, 2009).
Surgical Management
Surgery is indicated in any of the following situations:
• Compression of the cord is evident.
• The injury results in a fragmented or unstable vertebral body.
• The injury involves a wound that penetrates the cord.
• Bony fragments are in the spinal canal.
• The patient’s neurologic status is deteriorating.

The goals of surgical treatment are to preserve neurologic function by removing pressure from
the spinal cord and to provide stability (Sherwood, et al., 2007)

Emergency department care

 Airway management - The cervical spine must be maintained in neutral
alignment at all times; clearing of oral secretions and/or debris is essential to
maintaining airway patency and preventing aspiration
 Hypotension - Hypotension may be hemorrhagic and/or neurogenic in acute
spinal cord injury; a diligent search for occult sources of hemorrhage must be
made
 Neurogenic shock - Judicious fluid replacement with isotonic crystalloid solution
to a maximum of 2 L is the initial treatment of choice; maintain adequate
oxygenation and perfusion of the injured spinal cord; supplemental oxygenation
and/or mechanical ventilation may be required  [4, 5]
 Head injuries - Amnesia, external signs of head injury or basilar skull fracture,
focal neurologic deficits, associated alcohol intoxication or drug abuse, or a history
of loss of consciousness mandates a thorough evaluation for intracranial injury,
starting with non-contrast head CT scanning
 Ileus - Placement of a nasogastric (NG) tube is essential; antiemetics should be
used aggressively
 Pressure sores - To prevent pressure sores, turn the patient every 1-2 hours,
pad all extensor surfaces, undress the patient to remove belts and back pocket
keys or wallets, and remove the spine board as soon as possible

Pulmonary management
Treatment of pulmonary complications and/or injury in patients with spinal cord injury
includes supplementary oxygen for all patients and chest tube thoracostomy for those
with pneumothorax and/or hemothorax.

Surgical decompression
Emergent decompression of the spinal cord is suggested in the setting of acute spinal
cord injury with progressive neurologic deterioration, facet dislocation, or bilateral locked
facets. The procedure is also suggested in the setting of spinal nerve impingement with
progressive radiculopathy, in patients with extradural lesions such as epidural
hematomas or abscesses, and in the setting of the cauda equina syndrome.

https://emedicine.medscape.com/article/793582-overview

Nursing management
Assessment:

 Observe breathing pattern; assess strength of cough; auscultate lungs.

 Monitor patient closely for any changes in motor or sensory function and for symptoms of
progressive neurologic damage.
 Test motor ability by asking patient to spread fingers, squeeze examiner’s hand, and move toes
or turn the feet.
 Evaluate sensation by pinching the skin or touching it lightly with a tongue blade, starting at
shoulder and working down both sides; patient’s eyes should be closed. Ask patient where
sensation is felt.
 Assess for spinal shock.
 Palpate lower abdomen for signs of urinary retention and overdistention of the bladder.
 Assess for gastric dilation and paralytic ileus due to atonic bowel.
 Monitor temperature (hyperthermia may result due to autonomic disruption).

Nursing Diagnoses

 Ineffective breathing patterns related to weakness or paralysis of abdominal and intercostal

muscles and inability to clear secretions
 Ineffective airway clearance related to weakness of intercostal muscles
 Impaired bed and physical mobility related to motor and sensory impairment
 Disturbed sensory perception related to immobility and sensory loss
 Risk for impaired skin integrity related to immobility or sensory loss
 Impaired urinary elimination related to inability to void spontaneously
 Constipation related to presence of atonic bowel as a result of autonomic disruption
 Acute pain and discomfort related to treatment and prolonged immobility

Nursing Interventions

Promoting Adequate Breathing and Airway Clearance

 Detect potential respiratory failure by observing patient, measuring vital capacity, and
monitoring oxygen saturation through pulse oximetry and arterial blood gas values.
  Prevent retention of secretions and resultant atelectasis with early and vigorous attention to
clearing bronchial and pharyngeal secretions.
 Suction with caution, because this procedure can stimulate the vagus nerve, producing
bradycardia and cardiac arrest.
 Initiate chest physical therapy and assisted coughing to mobilize secretions if the patient cannot
cough effectively.
 Supervise breathing exercises to increase strength and endurance of inspiratory muscles,
particularly the diaphragm.
 Ensure proper humidification and hydration to maintain thin secretions.
 Assess for signs of respiratory infection: cough, fever, and dyspnea.
 Monitor respiratory status frequently

Improving Mobility

 Maintain proper body alignment at all times.

 Reposition the patient frequently and assist patient out of bed as soon as the spinal column is
stabilized.
 Apply splints (various types) to prevent footdrop and trochanter rolls to prevent external
rotation of the hip joints; reapply every 2 hours.
 Patients with lesions above the midthoracic level may tolerate changes in position poorly;
monitor BP when positions are changed.
 Do not turn patient who is not on a rotating specialty bed unless physician indicates that it is
safe to do so.
 Perform passive range-of-motion exercises as soon as possible after injury to avoid
complications such as contractures and atrophy.
 Provide a full range of motion at least four or five times daily to toes, metatarsals, ankles, knees,
and hips.
 For patients who have a 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. Apply a neck brace or molded collar when the
patient is mobilized after traction is removed.

Promoting Adaptation to Disturbed Sensory Perception

 Stimulate the area above the level of the injury through touch, aromas, flavorful food and
beverages, conversation, and music.
 Provide prism glasses to enable patient to see from supine position.
 Encourage use of hearing aids, if applicable.
 Provide emotional support; teach patient strategies to compensate for or cope with sensory
deficits. Maintaining Skin Integrity
 Change patient’s position every 2 hours, and inspect the skin, particularly under cervical collar.
  Assess for redness or breaks in skin over pressure points; check perineum for soilage; observe
catheter for adequate drainage; assess general body alignment and comfort.
 Wash skin every few hours with a mild soap, rinse well, and blot dry. Keep pressure-sensitive
areas well lubricated and soft with bland cream or lotion.
 Teach patient about pressure ulcers and encourage participation in preventive measures.

Maintaining Skin Integrity

Pressure ulcers are a significant complication of SCI.

 It is important to move the patient from the backboard as soon as possible and inspect the skin.
 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 inspection 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 board.
 The patient’s skin should be kept clean by washing with a mild soap, rinsing well, and blotting
dry.
 Pressure-sensitive areas should be kept well lubricated and soft with hand cream or lotion.
 The patient is educated about the danger of pressure ulcers and is encouraged to take control
and make decisions about appropriate skin care (King, et al., 2008).

Maintaining Urinary Elimination

 Perform intermittent catheterization to avoid overstretching the bladder and infection. If this is
not feasible, insert an indwelling catheter.
 Show family members how to catheterize, and encourage them to participate in this facet of
care.
 Teach patient to record fluid intake, voiding pattern, amounts of residual urine after
catheterization, characteristics of urine, and any unusual feelings.

Improving Bowel Function

 Monitor reactions to gastric intubation.
 Provide a high-calorie, high-protein, and high-fiber diet. Food amount may be gradually
increased after bowel sounds resume. • Administer prescribed stool softener to counteract
effects of immobility and analgesic agents, and institute a bowel program as early as possible.

Providing Comfort Measures

  Reassure patient in halo traction that he or she will adapt to steel frame (ie, feeling caged in and
hearing noises).
 Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening. If
one of the pins becomes detached, stabilize the patient’s head in a neutral position and have
someone notify the neurosurgeon; keep a torque screwdriver readily available.
 Inspect the skin under the halo vest for excessive perspiration, redness, and skin blistering,
especially on the bony prominences. Open vest at the sides to allow torso to be washed. Do not
allow vest to become wet; do not use powder inside vest.

Monitoring and Managing Potential Complications

 THROMBOPHLEBITIS. Thrombophlebitis is a relatively common complication in patients after

SCI. The patient must be assessed for symptoms of thrombophlebitis and PE. Chest pain,
shortness of breath, and changes in arterial blood gas values must be reported promptly to the
physician. The circumferences of the thighs and calves are measured and recorded daily; further
diagnostic studies are performed if a significant increase is noted. Patients remain at high risk
for thrombophlebitis for several months after the initial injury

 ORTHOSTATIC HYPOTENSION - Reduce frequency of hypotensive episodes by administering

prescribed vasopressor medications. Provide antiembolism stockings and abdominal binders;
allow time for slow position changes, and use tilt tables as appropriate. Close monitoring of vital
signs before and during position changes is essential.

 AUTONOMIC HYPERREFLEXIA

- Perform a rapid assessment to identify and alleviate the cause of autonomic

hyperreflexia and remove the trigger.
- Place patient immediately in sitting position to lower BP.
- Catheterize the patient to empty bladder immediately.
- Examine rectum for fecal mass. Apply topical anesthetic for 10 to 15 minutes before
removing fecal mass.
- Examine skin for areas of pressure, irritation, or broken skin.
- As prescribed, administer a ganglionic blocking agent such as hydralazine hydrochloride
(Apresoline) if the above measures do not relieve hypertension and excruciating
headache.
- Label chart clearly and visibly, noting the risk for autonomic hyperreflexia
- Instruct patient in prevention and management measures. Inform patient with lesion
above T6 that hyperreflexic episode can occur years after initial injury.

Promoting Home- and Community-Based Care

TEACHING PATIENTS SELF-CARE

 Shift emphasis from ensuring that patient is stable and free of complications to specific
assessment and planning for independence and the skills necessary for activities of daily living.
 Initially, focus patient teaching on the injury and its effects on mobility, dressing, and bowel,
bladder, and sexual function. As the patient and family acknowledge the consequences of the
injury and the resulting disability, broaden the focus of teaching to address issues necessary for
carrying out the tasks of daily living and taking charge of their lives.

CONTINUING CARE

 Support and assist patient and family in assuming responsibility for increasing care and provide
assistance in dealing with psychological impact of SCI and its consequences.
 Coordinate management team, and serve as liaison with rehabilitation centers and home care
agencies.
 Reassure female patients with SCI that pregnancy is not contraindicated and fertility is relatively
unaffected, but that pregnant women with acute or chronic SCI pose unique management
challenges.
 Refer for home care nursing support as indicated or desired.
 Refer patient to mental health care professional as indicated

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https://www.slideshare.net/SachinDwivedi15/spi
nal-cord-injury-sci-166109243