SPINAL CORD INJURY

Submitted by:
Christine H. Ababao
Raymond Kaye E. Martillano
BSN III-A/Group 3

Submitted to:
Dr. Elmer A. Santos
Clinical Instructor

July 20, 2021

 I. DESCRIPTION/DEFINITION

Injury to the Spinal Cord can range in severity from mild flexion-extension “whiplash”
injuries to complete transection of the cord with permanent quadriplegia. Trauma to the cord
can occur at any level but most commonly occur in the cervical and lower thoracic-upper
lumbar vertebrae. This finding is due in part to the support given by the ribs to the thoracic
spine and the flexibility of the cervical and lumbar spinal segments.
Spinal cord injury (SCI) is a debilitating neurological condition with tremendous
socioeconomic impact on affected individuals and the health care system.
Spinal cord injury is defined as traumatic damage to the spinal cord or nerves at the end
of the spinal canal. This affects the conduction of sensory and motor signals across the site of
the lesion.
There are two types: incomplete and complete injury.

● Incomplete Lesion: not all the nerves are severed or the nerves are only slightly
damaged. Recovery is possible, but never to the pre-injury level.
● Complete lesion: the nerves are severed and there is no motor or sensory
function preserved at this point.

II. RISK FACTORS/ETIOLOGY

A. Risk Factors
Although a spinal cord injury is usually the result of an accident and can happen to
anyone, certain factors may predispose you to a higher risk of sustaining a spinal cord injury,
including (Mayo Clinic, 2019):

Being male. Spinal cord injuries affect a disproportionate number of men. In fact, females
account for only about 20% of traumatic spinal cord injuries in the United States.

Being between the ages of 16 and 30. You're most likely to suffer a traumatic spinal cord injury
if you're between the ages of 16 and 30. The average age at time of injury is 43 years.

Being older than 65. Falls cause most injuries in older adults.
Engaging in risky behavior. Diving into too-shallow water or playing sports without wearing the
proper safety gear or taking proper precautions can lead to spinal cord injuries. Motor vehicle
crashes are the leading cause of spinal cord injuries for people under 65.

Having a bone or joint disorder. A relatively minor injury can cause a spinal cord injury if you
have another disorder that affects your bones or joints, such as arthritis or osteoporosis.

B. Causes
Spinal cord injury occurs when something interferes with the function or structure of
the cord. This can include consequences of a medical illness or trauma resulting in over
stretching the nerves, a bump, the bone of the vertebra pressing against the cord, a shock
wave, electrocution, tumors, infection, poison, lack of oxygen (ischemia), cutting or tearing of
the nerves. Spinal cord injury can occur as a fetus develops, from trauma or medical conditions.
The main causes of SCI across most geographical locations were falls and road traffic accidents,
suggesting that interventions targeting fall prevention and improved road safety should be key
public health priorities. Some possible causes of spinal cord injuries (from most to least
common) include:

● Motor vehicle accidents. (e.g. trauma during a car accident, specifically trauma
to the face, head, and neck region, back, or chest area). Road traffic accidents
(RTAs) are the most common cause of spinal fractures in developing countries.
RTAs have a tendency to affect the younger age population (21–40 years old)
and are associated with a higher degree of injury severity score, associated
injuries and mortality than other causes of spinal injuries (Fakharian, et al.,
2017). A car accident can result in a sudden blow to the spinal cord or the
surrounding tissues, including ligaments, discs, and vertebrae. This trauma can
cause vertebrae to break or the sensitive tissues to become crushed or
dislocated. Some spinal cord injuries also bleed. If the injury spreads down the
spinal cord after hitting the head while driving, it can result in damage to the
nervous system that interferes with motor function. Any damage to the spinal
 cord can result in difficulty functioning even if the spinal cord has not been
severed. The impact of these injuries depends on the intensity of the trauma, the
location of the injury, as well as the general health of the person injured (Viles &
Beckman, 2021).
● Falls. Fall-induced SCI is particularly common among the elderly, about 75% of
SCI cases occurring among persons 76 years of age and older are due to falls.
According to the recent report of International Spinal Cord Society, falls from low
heights or level ground are common in developed countries and are typically
associated with tetraplegic injury among the elderly, while falls from greater
heights are usually work-related, resulting in paraplegic injury, are
predominantly among younger individuals in developing countries. Falls from
unprotected rooftops and terraces, falls out of trees while cutting leaves to feed
livestock, and falls while carrying a heavy load on one's head are also common
regional features in developing countries. The World Health Organization's
(WHO's) International Perspectives on SCI report recognizes 4 patterns of falls as
resulting in SCI: (1) falls on the same level, (2) falls from heights of less than one
meter, (3) falls from heights of one meter or more, and (4) being struck by a
falling object (Chen, et al., 2016).
● Gunshot wounds. Violent acts are the third leading cause of spinal injury
according to Mayo Clinic, and violence causes around 15 percent of all new SCIs.
Gun shots, knife wounds, and assaults of all types could result in damage to the
spine (Auger & Auger, 2020).
● Sports injuries. (e.g.diving into water that’s too shallow and hitting the
bottom). According to Chan, et al., and Spinal Cord Research Evidence team
(2016), the sports causing the greatest number of SCIs in the most countries
were diving, skiing, and rugby. In 5 of the 9 countries (USA, Canada, Japan, China
and Denmark), diving had the highest contribution to sport-related SCIs out of all
the other sports included.
 ● Specific types of infections. Spinal infections can be classified by the anatomical
location involved: the vertebral column, intervertebral disc space, the spinal
canal and adjacent soft tissues. Infection may be caused by bacteria or fungal
organisms and can occur after surgery. Most postoperative infections occur
between three days and three months after surgery (American Association of
Neurological Surgeons, n.d.). According to John Hopkins Medicine. Org. (n.d.),
spinal cord injury results from the abscess formed by the infection.

Spinal cord injuries may result from damage to the vertebrae, ligaments or disks of the
spinal column or to the spinal cord itself.

A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine
that fractures, dislocates, crushes or compresses one or more of your vertebrae. It may also
result from a gunshot or knife wound that penetrates and cuts your spinal cord.

Additional damage usually occurs over days or weeks because of bleeding, swelling,
inflammation and fluid accumulation in and around your spinal cord.

A nontraumatic spinal cord injury may be caused by arthritis, cancer, inflammation,

infections or disk degeneration of the spine.

Results of a spinal cord injury can appear differently depending on the type and location
of the injury. The most common is loss of motor, sensory and slowing of some of the body’s
internal organs (autonomic nerve function) below the level of the injury. In general, the higher
in the spinal cord an injury occurs, the more function, sensation and internal body functions will
be affected.

III. CLASS/TYPES/STAGES

Types of Spinal Cord Injury (Cleveland Clinic, 2020)

Spinal cord injuries can be complete or incomplete (partial):

 Complete: A complete injury causes total paralysis (loss of function) below the level of
the injury. It affects both sides of the body. A complete injury may cause paralysis of all four
limbs (quadriplegia) or the lower half of the body (paraplegia).

Incomplete: After an incomplete injury, some function remains on one or both sides of
the body. The body and brain can still communicate along certain pathways.

Types of Spinal Cord Injury (Berry, J. 2020)

Cervical spinal injury. The top portion of the spine, which includes the vertebrae in the
neck, is the cervical spine. As cervical spine injuries are closest to the brain and may affect the
largest portion of the body, they tend to be the most severe type. An injury to the cervical spine
often causes tetraplegia, also known as quadriplegia, which is full or partial paralysis of the four
limbs and the torso.

Thoracic spinal injury. The thoracic spine includes the upper and middle part of the
back. A thoracic spine injury often affects the muscles in the abdomen, legs, and lower back.
People with a thoracic spine injury may have paraplegia, which means that they have paralysis
in parts of the trunk and legs. A person with paraplegia can still use their arms and hands.
 Lumbar spinal injury. The lumbar spine is the lowest major portion of the spine. The
vertebrae in this section are larger because they support more weight than those in other areas
of the spine. A person with a lumbar spine injury may lose some function in the hips and legs,
but they usually retain control of their upper body. Some people with a lumbar spine injury may
be able to walk with braces or use a wheelchair.

Sacral spinal injury. The sacral spine is the area just above the tailbone. The nerves
arising from this part of the spinal cord control the area of the hips, groin, and backs of the
thighs. An injury to the sacral spine can cause some loss of function in the hips and legs. It may
also affect bladder and bowel control. However, people with a sacral spine injury can often still
walk.

Other Types of Spinal Cord Injury (Christopher & Dana Reeve Foundation (n.d.)

There are other less common types of spinal cord injury that affect specific areas of the
spinal cord.

Anterior Cord Syndrome (sometimes called Ventral Cord Syndrome) is caused by lack of
blood flow or lack of oxygen (infarction) to the front two thirds but not the back of the spinal
cord and in a part of the brain called the medulla oblongata. The result is loss of motor, pain
and temperature sensations but where your body is in space (proprioception) and vibration
sensations remain from the level of injury down. Individuals with Anterior Cord Syndrome will
note their body position by visually observing their environment as opposed to sensing where
their body is positioned.

Central Cord Syndrome is usually caused most often by a fall with over stretching
(hyperextension) of the neck. Loss of function occurs from the neck to the nipple line which
includes the arms and hands. The torso has variable function and sensation. The lower body has
unaffected function but variable to total lack of sensation. Individuals with this type of injury
usually retain the ability to walk but might have poor balance. Central Cord Syndrome occurs
most often in elderly individuals due to decreased flexibility with age.
 Posterior Cord Syndrome results in loss of light touch, vibration and position sense
starting at the level of injury. Motor function remains. It is caused from trauma, compression of
any length of the back side of the spinal cord, tumors and Multiple Sclerosis.

Brown-Séquard Syndrome is noted by one side of the body with motor function loss
and the other side of the body with sensation loss. Depending on the location of the injury, the
result can be presented as tetraplegia or paraplegia. Brown Sequard Syndrome can be caused
from a tumor, injury, ischemia (loss of oxygen), puncture, infection or Multiple Sclerosis (MS).

Cauda Equina is an injury to the nerve roots below L2 which results in leg weakness,
bowel incontinence, urinary retention and sexual dysfunction.

Conus Medullaris can be caused from an injury or disease affecting the core of nerves
inside the nerve root. Injury to this area results in an incomplete spinal cord injury affecting leg
function, bowel, bladder and sexual function. Pain is typically present.

Cord Concussion results from a bump to the spinal cord. Much like a concussion to the
brain, the spinal cord can be bruised or have message disruption for about 48 hours with
possible return of function thereafter. As with brain concussion, long term dysfunction of
various types can occur. Cord concussion is sometimes referred to as a ‘stinger’ especially in the
sporting world.

Tethered Cord is an attachment of the spinal cord to the tissues in the tract where the
spinal cord is housed in the body. This typically is an anatomical anomaly formed as a fetus and
not detected until birth or later in early childhood. Sometime, tethered cord is not detected
until adulthood. Surgery can release the cord if necessary. Tethered cord can appear after
spinal cord injury due to complications of the injury.

Spina Bifida and other neural tube diseases occur in fetal development. The spinal cord
does not form in the enclosed space of the vertebrae. In utero surgery (surgery before birth)
can possibly correct spinal placement before a baby is born. Surgery after birth can correct the
placement but with mixed results. Taking folic acid (vitamin B9) during pregnancy can reduce
the risk of spina bifida. A vitamin like molecule, Inositol, is being tested to assess if prevention
of neural tube defects is possible.

III. ANATOMY AND PHYSIOLOGY

A. Anatomy
Spinal Cord. The vertebrae of the spine contains and protects. The vertebrae are the
bones stacked on top of each other that make up the spine. The spine contains many nerves,
and extends from the brain’s base down the back, ending close to the buttocks that sends
messages from the brain to other parts of the body. It is vital to a person’s ability to feel and
control various body parts, such as the arms, legs, and bladder (O’ Connel, 2018 & Berry, 2020).
The length of the spinal cord varies from person to person. According to some
estimates, females have a spinal cord of about 43 centimeters (cm), while males have a spinal
cord of about 45 cm.
The spinal cord comprises three parts: the cervical (neck), thoracic (chest), and lumbar
(lower back) regions.
Three layers of tissue protect the spinal cord: the dura mater, arachnoid mater, and pia mater.
Doctors call these layers “meninges.” The layers are as follows:
● Dura mater: This is the outermost layer of the spinal cord’s meninges. It is a tough,
protective coating.
● Epidural space: Between the dura and arachnoid space is the epidural space. This is
where doctors may insert local anesthetic to reduce pain during childbirth and some
surgical procedures, such as those to operate on a lung or abdominal aneurysm.
● Arachnoid mater: The arachnoid mater is the middle layer of spinal cord covering.
● Subarachnoid space: This is located between the arachnoid mater and pia mater.
Cerebrospinal fluid (CSF) is located in this space. Sometimes, a doctor has to sample CSF
to test for the presence of infection, such as meningitis. They can also inject local
anesthetic into this space for some surgical procedures, such as a cesarean delivery or a
knee replacement.
● Pia mater: The pia mater is the layer that directly covers the spinal cord.

Cross-section of the Spinal Cord

Key areas of a cross-section of the spinal cord include:

● Gray matter: The gray matter is the dark, butterfly shaped region of the spinal cord
made up of nerve cell bodies.
● White matter: The white matter surrounds the gray matter in the spinal cord and
contains cells coated in myelin, which makes nerve transmission occur more quickly.
Nerve cells in the gray matter are not as heavily coated with myelin.
● Posterior root: The posterior root is the part of the nerve that branches off the back of
the spinal column. Looking at the spinal cord cross-section, the top wings of the gray
matter “butterfly” reach toward the spinal bones. The bottom wings are toward the
 front of the body and its internal organs.
● Anterior root: The anterior root is the part of the nerve that branches off the front of
the spinal column.
● Spinal ganglion: The spinal ganglion is a cluster of nerve bodies that contain sensory
neurons.
● Spinal nerve: The posterior and anterior roots come together to create a spinal nerve.
There are 31 pairs of spinal nerves. These control sensation in the body, as well as
movement.

The spinal cord does not extend for the entire length of the spine. It usually stops in the
top parts of the lumbar spine.
For adults, this is usually the first or second lumbar vertebrae. Children’s spinal cords
may stop slightly lower, at the second or third lumbar vertebrae.
Covering the spinal cord and its protective layers is the vertebral column, or the spinal
bones. These bones start at the base of the skull and extend down to the sacrum, a bone that
fits into the pelvis.
The spinal cord is a continuation of the medulla oblongata and extends to the lower
back or about two-thirds down the vertebral column, which protects it. The vertebral column is
made up of 33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 4 coccygeal, although
the sacral and coccygeal vertebrae are fused). There are 31 pairs of spinal nerves (their names
relating to where they enter or exit the vertebrae), which transmit impulses to and from various
parts of the body (Brade, et al. (Ed), 2014).

B. Functions

The spinal cord plays a vital role in various aspects of the body’s functioning. Examples
of these key functions include:

● Carrying signals from the brain: The spinal cord receives signals from the brain that
control movement and autonomic functions.
● Carrying information to the brain: The spinal cord nerves also transmit messages to the
brain from the body, such as sensations of touch, pressure, and pain.
● Reflex responses: The spinal cord may also act independently of the brain in conducting
motor reflexes. One example is the patellar reflex, which causes a person’s knee to
involuntarily jerk when tapped in a certain spot.

These functions of the spinal cord transmit the nerve impulses for movement, sensation,
pressure, temperature, pain, and more.

Each group of spinal nerves is involved with movements in certain parts of your body, including
your hands, fingers, arms, upper back, hips, and abdominal muscles. Some spinal nerves are
even responsible for ensuring you can walk and run properly.

Cervical Spine Nerves (Ammerman, J., 2021)

The cervical spinal nerves, sometimes called nerve rootlets, exit the spinal canal through
the neuroforamen in pairs—1 nerve exits on the left side and 1 on the right. These nerve
structures are sometimes numbered to correlate with the level in the cervical spine: C1 through
C8.
Each cervical nerve innervates or provides sensation (feeling) and motor function
(movement) to both sides of a corresponding part of the upper body. In general, the cervical
spinal nerves perform these functions including:
● C1, C2 and C3 provide motor function to the head and neck, as well as sensation from
the top of your scalp to the sides of your face
● C4 enables you to shrug your shoulders and automatically causes the diaphragm to
contract when you are breathing. The 4th cervical spinal nerve also provides sensation
to your neck, shoulders and parts of your upper arms
● C5 enables various upper body movements like lifting your shoulders and flexing your
biceps, and enables feeling toward the tip of the shoulder
● C6 allows you to move your wrists and flex your biceps and also provides sensation to
the inner (thumb) side of your forearms and hand
● C7 powers the triceps muscle on the back of your upper arms and transmits sensation
along the back of the arms, and down to the middle finger
● C8 allows you to open and close your hands (hand grip) and gives you the ability to feel
the outer (pinky) side of your hands and forearms

Thoracic Nerves (Ammerman, J., 2021)

● T1 and T2 (top two thoracic nerves) feed into nerves that go into the top of the chest as
well as into the arm and hand.
● T3, T4, and T5 feed into the chest wall and aid in breathing.
● T6, T7, and T8 can feed into the chest and/or down into the abdomen.
● T9, T10, T11, and T12 can feed into the abdomen and/or lower in the back.

Lumbar Nerves (Beasley, K., 2020)

● L1 spinal nerve provides sensation to the groin and genital regions and may contribute
to the movement of the hip muscles.
● L2, L3, and L4 spinal nerves provide sensation to the front part of the thigh and inner
side of the lower leg. These nerves also control movements of the hip and knee muscles.
● L5 spinal nerve provides sensation to the outer side of the lower leg, the upper part of
the foot, and the web-space between the first and second toe. The L5 spinal nerve
controls hip, knee, foot, and toe movements.
Sacral Nerves

● S1 serves the hips and groin.

● S2 affects the back of the thigh area.
● S3 serves medial buttock.
● S4 and S5 both impact on the perineal.
● The sacral nerves have both afferent and efferent fibers, thus they are responsible for
part of the sensory perception and the movements of the lower extremities of the
human body. From the S2, S3 and S4 arise the pudendal nerve and parasympathetic
fibers whose electrical potential supply the descending colon and rectum, urinary
bladder and genital organs. These pathways have both afferent and efferent fibers and,
this way, they are responsible for conduction of sensory information from these pelvic
organs to the central nervous system (CNS) and motor impulses from the CNS to the
pelvis that control the movements of these pelvic organs.

Coccygeal Nerves

● S1 serves the hips and groin.

● S2 affects the back of the thigh area.
● S3 serves medial buttock.
● S4 and S5 both impact on the perineal.
● The sacral nerves have both afferent and efferent fibers, thus they are responsible for
part of the sensory perception and the movements of the lower extremities of the
human body. From the S2, S3 and S4 arise the pudendal nerve and parasympathetic
fibers whose electrical potential supply the descending colon and rectum, urinary
bladder and genital organs. These pathways have both afferent and efferent fibers and,
this way, they are responsible for conduction of sensory information from these pelvic
organs to the central nervous system (CNS) and motor impulses from the CNS to the
pelvis that control the movements of these pelvic organs.

Autonomic Nervous System (Lumen, n.d.)

The autonomic nervous system regulates involuntary actions such as internal-organ
function and blood-vessel movement. It supplies nerves to (“innervates”) cardiac and smooth
muscle tissue. The autonomic nervous system is made of two components, which work in
opposition to one another: the sympathetic nervous system, responsible for the body’s “fight-
or-flight” response to danger, and the parasympathetic nervous system, which calms the body
back down

Sympathetic Autonomic System

Sympathetic Autonomic Nervous System - part of the autonomic nervous system it is
located near the thoracic and lumbar regions in the spinal cord. Its primary function is to
stimulate the body’s fight or flight response. It does this by regulating the heart rate, rate of
respiration, pupillary response and more

Parasympathetic Autonomic System

Parasympathetic Autonomic Nervous System - It is located in between the spinal cord
and the medulla. It primarily stimulates the body’s “rest and digest” and “feed and breed”
response. In other words it inhibits the body from overworking and restores the body to a calm
and composed state. (BYJU’S, 2021)

Somatic Nervous System (Lumen, n.d.)

The somatic nervous system controls voluntary movements such as those in the skin,
bones, joints, and skeletal muscles.
Both of these systems within the PNS work together with the CNS to regulate bodily
function and provide reactions to external stimuli.

IV. PATHOPHYSIOLOGY
V. DIAGNOSTIC PROCEDURES

Medical history: The first step in diagnosing a spinal cord injury is a medical history and physical
examination. The patient's physician will obtain a medical history asking questions about the
details surrounding the time of the injury. The amount of time since the injury is important
because spinal cord injury is a medical emergency. The quicker the patient obtains treatment,
the better the chances for recovery. Other details of the medical history could include details of
any prior neck or back injuries or surgeries, the presence of pain in the neck or back, any
weakness in the arms or legs, loss of bowel or bladder control, loss of sensation in the arms or
legs, and other previous medical conditions(Eck, J. 2019). According to the National Institute of
Health (NIH) (2016), SCIs are not always immediately recognizable. The following injuries should
be assessed for possible damage to the spinal cord:
● Head injuries, particularly those with trauma to the face
● Pelvic fractures
● Penetrating injuries in the area of the spine
● Injuries from falling from heights
If any of these injuries occur together with any of the symptoms mentioned above (acute head,
neck, or back pain; decline of feeling in the extremities; loss of control over part of the body;
urinary or bowel problems; walking difficulty; pain or pressure bands in the chest area; difficulty
breathing; head or spine lumps), then SCI may be implicated.

Physical examination: The physical examination will include testing to see if sensation to touch
is intact in the arms and legs as well as testing muscle strength and reflexes in the arms and
legs. The patient may be kept in a cervical collar or on a backboard to immobilize them until the
physician determines whether or not the patient has a spinal cord injury (Eck, J. 2019).

X-rays: The next step is often x-rays of the neck or back. These can help identify a fracture or
dislocation of the vertebrae. These may or may not be present with a spinal cord injury. It is
possible to have a spinal cord injury without an injury to the vertebrae. X-rays can also help
identify a tumor or infection or severe arthritis that could cause spinal cord injury (Eck, J. 2019).

CT scan: According to Fehlings, M. (2019), another common first-line diagnostic tool is the CT
scan, which is extremely accurate in identifying spinal fractures and bone problems. In fact,
many doctors prefer to use CT scan over x-ray to get a clearer, more comprehensive picture of
the spinal damage. Computerized tomography (CT) provides rapid, clear two-dimensional
images of organs, bones, and tissues (National Institute of Neurological Disorders and Stroke,
2021) . A computed tomography (CT) scan is a more advanced imaging test that can give the
physician a better view of the vertebrae. CT can identify some injuries to the vertebrae not seen
on the plain x-rays (Eck, J. 2019).

MRI scan: Magnetic resonance imaging (MRI) produces detailed three-dimensional images of
body structures, including tissues, organs, bones, and nerves (National Institute of Neurological
Disorders and Stroke, 2021). A magnetic resonance imaging (MRI) scan is another more
advanced imaging study that can identify a spinal cord injury. The MRI is better at evaluating
the soft tissues including the ligaments, intervertebral discs, nerves and spinal cord. The MRI
scan also can show evidence of injury within the spinal cord (Eck, J. 2019). According to
Fehlings, M. (2019), In some cases, MRI has clear benefits for patients with SCI. For example,
using MRI in patients who have a cervical spinal cord injury before they undergo traction
treatment allows doctors to see a possible disc bulge or herniation. Identifying a disc disorder
before traction may help prevent new or additional nerve-related problems down the line.

VI. MEDICAL/SURGICAL MANAGEMENT

Medical Management
Pharmacological Management

● Glucocorticoids (Methylprednisolone), which suppress many of the ‘secondary’ events of

spinal cord injury. These are inflammation, lipid peroxidation, and excitotoxicity.
Randomized clinical trials are contradictory in their results and so are the opinions of
experts.
● Thyrotropin-releasing Hormone (TRH) shows antagonistic effects against the secondary
injury mediators.
● Polyunsaturated Fatty Acids (PUFA) such as Docosahexaenoic Acid (DHA) have recently
been explored for spinal cord injury management. It is said to improve neurological
recovery through increased neuronal and oligodendrocyte survival and decreased
microglia/macrophage responses, which reduces the axonal accumulation of B-Amyloid
Precursor Protein (b-APP) and increases synaptic connectivity. Similarly
Eicosapentaenoic Acid (EPA) increases synaptic connectivity, to restore neuro-plasticity.
Immobilization.

● You may need traction to stabilize your spine, to bring the spine into proper alignment
or both. In some cases, a rigid neck collar may work. A special bed also may help
immobilize your body.

Surgical ManagementBasically, spine surgery to treat SCI involves:

● Decompressing the spine (ie, spinal cord)

● Stabilizing the spine
Decompression Surgery

Decompression of the spinal cord involves removing fragments of vertebrae or any

foreign objects that are pressing down on the spinal cord.

Commonly performed spinal cord decompression surgeries include:

● Laminotomy: removing a section from the back of the vertebra (the lamina)
● Laminectomy: removing the entire lamina
● Discectomy: removing a portion of a vertebral disc
● Foraminotomy: removing a large amount of bone to expand the nerve root
openings

Decompression surgery will help minimize swelling, cell death, and other secondary
complications that can restrict the spinal cord’s blood supply.

Non-Surgical Treatments

● Standard ICU care, including maintaining a stable blood pressure, monitoring

cardiovascular function, ensuring adequate ventilation and lung function and preventing
and promptly treating infection and other complications, is essential so that SCI patients
can achieve the best possible outcome.
VII. NURSING MANAGEMENT

NCP #1
Nursing Diagnosis
Autonomic Dysreflexia related to bladder/bowel distention as manifested by sweating,
headache, HR of 58 bpm, and a BP of 140/100 mmHg.
Nursing Goal
 After 30 minutes to 1 hour of rendering appropriate nursing interventions, the patient
will be able to demonstrate corrective or preventive techniques as manifested by absence of
sweating, headache, HR of 70 bpm, and a BP of 130/80 mmHg.
Nursing Inference
Autonomic dysreflexia occurs when something happens to the body below the level of
spinal cord injury. This can be a pain or irritant (such as tight clothing or something pinching
your skin) or a normal function that the body may not notice (such as having a full bladder and
needing to urinate). These situations trigger an automatic reaction that causes blood pressure
to go up. As blood pressure goes up, heartbeat slows and may become irregular. Body cannot
restore the blood pressure to normal because of the spinal cord damage.
Nursing Interventions

Rationale

Monitor vital signs routinely, noting elevation To identify trends and intervene immediately.
in blood pressure, heart rate, and
temperature especially during times of
physical stress.

Elevate the head of the bed as high as Lowers BP to prevent intracranial

tolerated or place the client in a sitting hemorrhage, seizures, or even death. Note:
position with legs dangling. Placing tetraplegic in sitting position
automatically lowers BP.

Administer medications as required. To block excessive autonomic nerve

transmission, normalize heart rate and
reduce hypertension.

Place a urinary catheter as often as To prevent overfilling.

necessary.

Eliminate causative stimulus as able such as Removing noxious stimulus usually

bladder, bowel, skin pressure (including
loosening tight leg bands or clothing,
removing abdominal binder or elastic
stockings); temperature extremes.
terminates episode and may prevent more
serious autonomic dysreflexia (in the
presence of sunburn, topical anesthetic
should be applied). Removal of constrictive
clothing and vascular support also promotes
venous pooling to help lower BP. Note:
Removal of bowel impaction must be delayed
until cardiovascular condition is stabilized.
Administer medications as indicated (IV,
parenteral, oral, or transdermal), and
monitor response:

● Diazoxide (Hyperstat), Reduces BP if severe and sustained

hydralazine (Apresoline hypertension occurs.

● Nifedipine (Procardia), 2% Sublingual administration usually effective, in

nitroglycerin ointment absence of IV access for diazoxide
(Nitrostat) (Hyperstat), but may require repeat dose in
30 to 60 min. May be used in conjunction
with topical nitroglycerin.

● Atropine sulfate Increases heart rate if bradycardia occurs.

● Morphine sulfate Relaxes smooth muscle to aid in lowering

blood pressure and muscle tension.

● Adrenergic blockers like May be used prophylactically if the problem

methysergide maleate persists and recurs frequently.
(Sansert)

● Antihypertensives like prazosin Long-term use may relax bladder neck and
(Minipress), enhance bladder emptying, alleviating the
phenoxybenzamine most common cause of chronic autonomic
(Dibenzyline) dysreflexia.

Obtain urinary culture as indicated. Presence of infection may trigger autonomic

dysreflexia episode.

Apply local anesthetic ointment to rectum; Ointment blocks further autonomic

remove impaction if indicated after stimulation and eases later removal of
symptoms subside. impaction without aggravating symptoms.

Prepare patient for pelvic or pudendal nerve Procedures may be considered if autonomic
block or posterior rhizotomy if indicated. dysreflexia does not respond to other
therapies.

Nursing Evaluation
After 30 minutes of rendering appropriate nursing interventions, the patient was able to
demonstrate corrective or preventive techniques as manifested by absence of sweating,
headache, HR of 70 bpm, and a BP of 130/80 mmHg.

NCP # 2
Nursing Diagnosis
Acute pain related to Physical Injury as evidenced by a self-report of pain with a scale of
8/10, burning pain below level of injury (paraplegia), and positioning to ease pain with the
verbalization of “nagsakit unay tuy likod ken barukong ko”

Nursing Goal
After 30 minutes to 1 hour of rendering appropriate nursing interventions, the patient
will report control of discomfort and pain is relieved with a pain scale of 4/10, follow prescribed
pharmacological regimen, and identify ways to manage pain and demonstrate use of relaxation
skills and with the verbalization of “haan unay a nasakit t barukong ken likod kon”.

Nursing Inference
Acute Pain or an intense stinging sensation is caused by damage to the nerve fibers in
your spinal cord from the SCI or musculoskeletal problems that arise in dealing with an SCI

Nursing Interventions

Rationale

Assess for presence of pain. Help patient Patient usually reports pain above the level of
identify and quantify pain (location, type of injury such as the chest and back or headache
pain, intensity on scale of 0–10). possibly from stabilizer apparatus. After
spinal shock phase, patient may also report
muscle spasms and radicular pain, described
as a burning or stabbing pain (associated
with injury to peripheral nerves and radiating
in a dermatomal pattern). Onset of this pain
is within days to weeks after SCI and may
become chronic.

Evaluate increased irritability, muscle Nonverbal cues indicative of pain and

tension, restlessness, and unexplained vital discomfort requiring intervention
sign (VS) changes.

Assist patient in identifying precipitating Burning pain and muscle spasms can be
factors. precipitated and aggravated by multiple
factors (anxiety, tension, external
temperature extremes, sitting for long
periods, bladder distension).

Provide comfort measures (position changes, Alternative measures for pain control are
massage, ROM exercises, warm or cold packs, desirable for emotional benefit, in addition to
as indicated). reducing pain medication need and
undesirable effects on respiratory function.

Encourage use of relaxation techniques Refocuses attention, promotes sense of

(guided imagery, visualization, deep- control, and may enhance coping abilities.
breathing exercises). Provide diversional
activities (television, radio, telephone,
unlimited visitors) as appropriate.

Note when pain occur To meditate prophylactically, as appropriate

Administer medications as indicated: muscle May be desired to relieve muscle spasm and
relaxants: dantrolene (Dantrium), baclofen pain associated with spasticity or to alleviate
(Lioresal); analgesics; antianxiety agents: anxiety and promote rest.
diazepam (Valium).

Nursing Evaluation
After 45 minutes of rendering appropriate nursing interventions, the patient were able
to report control of discomfort with a pain scale of 3/10, follow prescribed pharmacological
regimen, identify ways to manage pain, demonstrate use of relaxation skills and verbalizes
“haan unay a nasakit t barukong ken likod kon”.

NCP#3

Nursing Diagnosis

Impaired physical mobility related to neuromuscular impairment secondary to spinal cord

injury as manifested by

Nursing Inference

Neuromuscular impairment like spinal cord injury affects a person’s physical mobility since
the communication between the brain and spinal cord fails in which their function of sending
signals to the different parts of the body is impaired. Thus, resulting to impaired physical
mobility.

Nursing Goal

After 8-10 hours of rendering appropriate nursing interventions, the patient will be able to
demonstrate techniques or behavior that enable resumption of activities as evidenced by

Nursing Interventions
 Nursing Interventions Rationale

Continually assess motor function by Evaluates status of individual situation

requesting client to perform certain (motor-sensory impairment may be mixed
actions (e.g, shrug shoulders, spread and or not clear) for a specific level of
fingers, release/squeeze examiner’s hands) injury, affecting type and choice of
interventions.

Provide means to summon help (special Enables patient to have a sense of control,
sensitive call light). and reduces fear of being left alone.

Perform/assist with full ROM exercises on Enhances circulation, restores/maintains

all extremities and joints, using slow muscle tone and joint mobility and
smooth movements. Hyperextend hips prevents disuse contractures and muscle
periodically. atrophy.

Position arms at 90 degree at regular Prevents frozen shoulder contractures.

intervals.

Maintain ankles at 90 degree with Prevents foot drop and external rotation of
footboard. Place trochanter rolls along hips.
thighs when in bed.

Elevate lower extremities at intervals when To assess and promote blood circulation
in chair, or raise foot of bed when
permitted in individual situation. Assess for
edema of feet and ankles.
Assess skin daily. Observe for pressure Altered circulation, loss of sensation, and
areas and provide meticulous skin care. paralysis potentiate pressure sore
formation.

Assess for redness, swelling/muscle To determine if there is thrombi

tension of calf tissues. Record calf and development due to altered peripheral
thigh measurements as indicated. circulation

Investigate sudden onset of dyspnea, Development of pulmonary emboli may be

cyanosis, and other signs of resp. distress. silent because pain is altered and DVT is
not easily recognized.

Administer muscle relaxants and

antispasticity agents as indicated:
May be useful in limiting or reducing pain

· Diazepam (Valium), baclofen associated with spasticity. Note: Baclofen

(Lioresal), dantrolene (Dantrium) may be delivered via implanted intrathecal
pump on a long-term basis as appropriate.

Nursing Evaluation

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