SCI

1. S P I N A L
CO R D
I N J U R I E S
L I N D A H W A R R E N
E D D R N M S N C C R N
N U R 3 3 5

2. OBJECTIVES
• Identify common Mechanisms of Injury associated with SCI.
• Describe pathophysiological changes as a basis for S&S.
• Discuss nursing assessment of spinal cord injured patients.
• Identify appropriate nursing diagnosis and expected outcomes
associated with SCI.
• Plan appropriate interventions for patients with SCI.
• Evaluate effectiveness of nursing interventions.

3. SPINAL ANATOMY
Vertebral Column:
• 33 Vertebrae:
– 7 Cervical Vertebrae (7 C)
– 12 Thoracic Vertebrae (12 T)
– 5 Lumbar Vertebrae (5 L)
– 5 Sacral Vertebrae (fused into one)
– 4 Coccygeal Vertebrae (fused into one)

4. • Ligaments:
– Provide support & stability
– Prevent excessive flexion and extension.
– Anterior & Posterior Longitudinal Ligaments
– Spinous and Transverse Processes:
serve as attachment points for muscles and
other ligaments.
• Intervertebral Discs:
– Fibrocartilaginous discs located btwn.
vertebral bodies.
– Shock Absorbers
– As we age, intervertebral discs harden / are
not good shock absorbers  herniation,
compression injury, etc.

5. LUMBAR VERTEBRAE
(1) Vertebral Body
(2) Spinous Process
(3) Articular Process
(4) Transverse Process
(5) Foramen: where spinal
cord passes through
(6) Pedicle: where nerve fibers
attach

6. SPINAL CORD
• Elongated mass of Nerve Tissue
• Occupies the vertebral foramen of the vertebral
column.
• Superior border of C1 to superior border of L2.
• Conus Medullaris
• Cauda Equina
• Corticospinal (Pyramidal) Tracts
– Descending pathways: motor
• Spinothalamic and Posterior Tracts
– Ascending pathways: sensory

7.  Spinal cord passing through vertebral foramen

8. MOTOR NEURONS:
DESCENDING TRACTS: nerve impulses move from brain  body
Upper Motor Neurons:
– Voluntary motor movement originate in cells in the frontal
lobe of the cerebral cortex.
– Cross-over in the Medulla of the brain stem.
• Opposite sides: L brain controls R side, R brain, controls L side.
– Descend in the corticospinal (pyramidal) tract.
Lower Motor Neurons:
– Innervate skeletal muscle.
– Cervical Nerve Fibers: innervate upper extremities
– Sacral Nerve Fibers: innervate lower extremities

11. SENSORY:
**Integrated into spinal reflexes or relayed to brain for interpretation.
Classifications of Sensation: Ascending Tracts (TRAVELS UPWARDS TOWARDS BRAIN)
• Superficial (spinothalamic)
Touch
Pain
Temperature
• Deep (Posterior tracts – Dorsal)
Proprioception (position sense)
Vibration Sensation
Deep Muscle Pain

12. SPINAL NERVES
• 31 Pairs of Spinal Nerves
• Each pair of spinal nerves exits
the spinal cord bilaterally.
Posterior (dorsal) root = Sensory Impulses
• Ascending pathways.
Anterior (ventral) root = Motor Impulses
• Descending pathways.

15. AUTONOMIC NERVOUS
SYSTEM (ANS)
• Nerve fibers innervate…
– smooth muscle
– cardiac muscle
– Glands
• Controls INVOLUNTARY vital functions.
– BP, HR
– Fight-or-flight response
– Rest & digest
Two Subdivisions:
– Parasympathetic (PSNS)
– Sympathetic (SNS)

16. SPINAL CORD INJURY
• Mechanical force that disrupts neurological
tissues & vascular supply (neurons & vessels)
• Loss of motor and/or sensory function.
PRIMARY:
• Neuro. damage occurs at time of impact.
SECONDARY:
• Biochemical process effects cellular function
occurs within minutes of injury.
• May last days to weeks.
• Spinal Cord Ischemia: major cause of loss of
neurological FX.

18. SPINAL CORD INJURY
SCI = inflammatory response  spinal cord edema 
compresses tissue & blood vessels  ascending /
descending cord edema  microscopic hemorrhages 
worsening edema & further hypoperfusion  ischemia
If ischemia is not reversed…
• Axonal degeneration & conduction
failure of neurons occurs.
• Eventually cell death occurs 
permanent loss of function.

19. SPINAL CORD INJURY
• QUADRIPLEGIA / TETRAPLEGIA: (4)
– Spinal cord injury in the cervical region.
– Associated with motor loss in ALL FOUR
extremities.
• PARAPLEGIA:
– Injury in thoracic, lumbar or sacral segments
including cauda equina and conus medullaris.
– Loss of motor function BELOW level of
injury.
– Lower extremity loss of FX.

22. EPIDEMIOLOGY
• Approx. 12,000 new SCI each year.
• 4,800 die before reaching the hospital
– Especially if it’s a high cervical injury  affects respiratory drive
• 75% Male
• Majority 16-30 years of age
COMMON CAUSES:
o Motor Vehicle Crashes (45%)
o Falls (20%)
o Sports Injuries (15%)
o Violence (15%)
o Others (5%)

23. PREVENTION:
• Alter high risk behaviors
• Legislation
– Seatbelt laws
– Child safety seats
– Helmets
• Provide automatic
protections

25. MECHANISMS OF INJURY:
• Hyper-Reflexion: head is forced forward.
– Head-on crash
• Hyperextension: head is forced back.
– Car is hit from behind
• Vertical Compression (axial loading): severe
blow to the top of the head.
– Jumping off a bridge, land on their feet.
– Diving into a swimming pool
• Excessive Rotation
• Penetrating:
– Gunshot wounds
– Stab wounds

28. CONCURRENT INJURIES:
• Closed head injuries
• Long bone fractures
• Thoracic injuries
• Abdominal injuries
• Pelvic fractures
• Calcaneus fracture
Need to assess pt for other injuries,
Bc they are more likely than not to be present.
SCI are multiple-injury events.

29. PATHOPHYSIOLOGY (SCI):
Neurological Deficits: neurons & vessels are both involved.
• Microscopic hemorrhages  worsening spinal cord
edema and hypoperfusion  more pressure on
nerves.
• Cellular damage
• Structural changes
• Biochemical response to injury cytokines, WBCs,
inflammation.
• Rarely completely severed or transected.
• Usually bruised / compressed  hemorrhage,
edema  S&S of SCI
• The quicker we can relieve edema & pressure on
spinal cord, the better our outcomes.

30. PATHOPHYSIOLOGY OF INJURY:
C1–C4: Loss of all motor function from the
neck down
– TOTAL CARE, ventilated, straight cath.
C5: Loss of function below shoulders & biceps.
– Have gross motor mvmt, no fine motor skills
C6: Loss of function below the shoulders &
upper arms.
– Lacks elbow, forearm, & hand control.
C7: Loss of motor control to portions of the
arms/ hands:
– Can straighten arms.
– Dexterity of hands & fingers
Depends on location & severity
of damage to nerve fibers.

32. T1-T8: Paraplegia, loss of function below mid-chest.
T9-T12: No trunk / abdominal muscle control.
L1-L3: Loss of most control of legs and pelvis.
L3-L4: Loss of control of portions of lower legs, ankles, feet.
L4-L5: Degree of paraplegia varies
Sacral Injuries: Decrease control of hip flexors/ legs.
PATHOPHYSIOLOGY OF INJURY:

33. SPINAL CORD
INJURY LEVEL &
GENERAL EFFECTS:

34. SECONDARY DAMAGE:
• Hypovolemic shock from
hypoperfusion (Cushings triad)
• Neurogenic shock
• Injury r/t inadequate spinal
immobilization.
– Straight alignment (nose = toes)
• Endogenous biochemical
responses  edema & cellular
necrosis.
• Hypoxia

35. SPINAL CORD PATHOLOGIES
Concussion: result of mechanical force (short duration) 
temporary failure of impulse conduction.
• Lasting effects are not common (24-48hrs)
• Neuro. deficits are mild & reversible.
Contusions: result of coup & contrecoup injuries  bruising /
bleeding into brain tissue
• Edema  cord compression  necrosis
• Neuro deficits are dependent on neuron cell death.
• Transection: complete (rare), incomplete (can lead to
permanent deficits)
• Disruption of vascular supply  ischemia neuron cell death

36. SPINAL SHOCK
Occurs shortly after sudden injury or damage.
Onset: usually immediate.
Duration: varies with level of the lesion.
• Temporary loss of motor,
sensory, and reflex functions
BELOW level of lesion.
• Flaccid Paralysis, no muscle
control.
• Areflexia to deep tendon &
cutaneous stimuli.
• Bowel & bladder dysfunction

37. NEUROGENIC SHOCK:
Form of Distributive Shock:
– Vasodilation  Maldistribution of
blood volume
– Relative hypovolemia
– Cardiac deceleration
• Caused by injuries at T6 OR ABOVE.
• Impairs descending sympathetic pathways.
• Loss of vasomotor tone & sympathetic
cardiac innervation.
• Loss of temperature control.
• Inability to sweat below the level of injury.

40. VERTEBRAL COLUMN FRACTURES
• Simple:
– Due to acceleration / Deceleration Forces
– Dislocation / malalignment of vertebra
• Compression (Wedge):
– Vertebral body compression
– Anterior or lateral flexion
– Hyperflexion
• Burst:
– Axial Loading
• Teardrop:
– Due to hyperflexion
– Small fracture, fragment can cause cord compression

41. C1 DISLOCATIONS & FRACTURES:
Atlanto-occipital Dislocation:
• Hyperextension / extreme force
Atlas Fracture (Jefferson Fracture):
•Axial loading forces transmitted from occiput to C1

42. C2 FRACTURES:
Hangman’s Fracture:
• Axial Loading
• Lateral Bending Forces
Odontoid Fracture:
•Hyperextension
•Hyperflexion

43. SPINAL CORD LESIONS:
COMPLETE:
– Loss of ALL motor & sensory
function BELOW level of injury.
– Flaccid paralysis
– Hips will be rotated outwards b/l
– Spinal & Neurogenic Shock
INCOMPLETE:
– Preservation of SOME motor &
sensory function BELOW level of
injury.
– Sacral sparing

44. COMPLETE SCI: S&S
• Loss of motor FX  flaccid paralysis
• Loss of sensory FX
• Bilateral external rotation of legs at the hips.
• Spinal shock
• Neurogenic Shock
– Hypotension
– Bradycardia
– Poikilothermia: pt will take on the temp. of
their environment bc they can’t regulate
their own temp.
• Spinal shock
• Priapism
• Loss of voluntary bowel and bladder FX.

45. INCOMPLETE SPINAL
CORD LESIONS:

47. CENTRAL CORD SYNDROME:
• Due to hyperextension injuries.
• Swelling in the center of the cord.
• No bony abnormality.
• Loss of motor & sensory FX
below level of lesion.
– Greater loss in arms than in legs.
– Varying degrees of bladder dysFX.

49. ANTERIOR CORD SYNDROME:
• Spinothalamic / Corticospinal (Pyramidal) Tract
• Acute Anterior Cord Compression
• Disruption of blood flow in frontal part of cord.
• Loss of motor FX
• Loss of pain and temperature sensations
• Intact Proprioception:
– Fine touch
– Fine pressure
– Vibration

51. POSTERIOR CORD SYNDROME:
• Posterior / Dorsal Tract
• Acute Posterior Cord Compression
• Loss of Proprioception:
– Vibration
– Fine Touch / Pressure
• Intact Motor Function:
– Pain
– Temperature
– Crude Touch /Pressure

53. BROWN-SEQUARD SYNDROME:
• Posterior Tract / Dorsal: same side
• Spinothalamic: opposite side
• Corticospinal / Pyramidal: same side
• Caused by a Transverse Hemisection of Cord
• Penetrating Injury
• LOSS: Motor FX, proprioception, and
vibration on same side of injury.
• LOSS: Pain & Temperature opposite side of
injury.

55. AMERICAN SPINAL INJURY ASSOCIATION
(ASIA) IMPAIRMENT SCALE
A = COMPLETE: No motor or sensory FX
preserved in sacral segments S4 and S5.
B = INCOMPLETE: No motor, only sensory FX.
C = INCOMPLETE: Motor FX preserved below
neurological level…50% of muscles < grade 3.
D = INCOMPLETE: Motor FX preserved below
neurological level 50% of muscles > grade 3.
E = NORMAL: Motor and Sensory FX intact.

56. EMERGENCY CARE:
Cervical Spine Precautions:
Put pt. in supine position on a hard surface.
Immobilize the neck.
Support the head.
Avoid:
• Flexion
• Extension…Jaw thrust NOT head-tilt-chin lift
• Rotation

61. NEUROLOGICAL ASSESSMENT
AIRWAY
BREATHING
CIRCULATION
DISABILITY

62. HEALTH HISTORY
• Details of the Injury
• Loss of Consciousness
• Patient’s understanding of injury
• Co-morbidities
• Smoking History
• Substance Abuse
• Family / Social resources
• Pre-Injury Weight
• Diet History
• Last Urination / Defecation (neurogenic bladder  rupture)

63. PHYSICAL EXAMINATION
• Alignment of head, neck, and spine
• Level of Consciousness
• Baseline Respiratory Status
• Vital Signs
• Motor Evaluation: assess both sides.
– GCS
– Level of Injury
– Motor Strength and Movement
– Spinal Reflexes
– Anal Sphincter Tone
– Assess pts ability to follow commands (give me a thumbs up,
push against my hands, etc)

64. PHYSICAL EXAMINATION
• Sensory Evaluation:
- Dermatome Assessment: Pain, Touch,
Temperature, Pressure, and
Proprioception
- Presence of Paresthesia
- Assess bilaterally, arms & legs.
• Skin Assessment:
- Redness
- Pressure
- Breakdown

65. • Bowel Assessment:
- Presence of stool in rectum
- Sphincter Tone
- Guaic
• Bladder Assessment:
Bladder Distention: bladder scan
• Presence / Absence
• Pain / Severity
• Neurogenic bladder can lead to a bladder rupture.
PHYSICAL EXAMINATION

66. DIAGNOSTIC TESTS:
•Radiographs
•CT Scan
•MRI

67. PHARMACOLOGICAL MANAGEMENT:
• Corticosteroids
• Vasopressors
• Antispasmodics
• Analgesics
• Histamine H2 Antagonists
• Anticoagulants
• Superior Vena Cava (SVC) Filter
• Bowel Regimen

69. PHARMACOLOGY:
High-Dose Methylprednisolone:
• Primary Benefit: Limits cord edema, ischemia, and
prevention of cell death
Dosage:
• 30 mg/kg IV loading dose over 15 minutes
• Wait 45 minutes
• Initiate 5.4 mg/kg/hr IV infusion over 23 hours
• Maximum effect: Initial dose within first 8 hours of injury.
• Initial dose within 3 hours, maintain treatment 24 hours
• Maintain steroid therapy 48 hours

71. STABILIZATION AND
IMMOBILIZATION

72. CERVICAL TRACTION:
Gardner–Wells / Crutchfield Tongs:
• Immobilize cervical spine
• Maintain C-Spine Alignment
• Decreases cord compression.
• Prevent further SCI
• Indications:
- Cervical Vertebral Fracture
- Vertebral Dislocation / Fracture
- Injury to soft tissue ligaments that support
cervical vertebral column
Stryker Frame:
• Provides cervical traction.
• Helps to safely turn pts with SCI.

73. ADVERSE OUTCOMES (CRUTCHFIELD TONGS)
• Scalp Infection
• Misalignment of vertebral column.
• Damage to bone at pin sites.
• Nerve damage due to excessive traction.

74. HALO DEVICE
• Provide Immobility to Cervical Spine
• Prevent Advancement of C-Spine Injury
• Maintain Alignment of Cervical Vertebrae
• Enhance Early Mobility
• Indications
– Cervical Fracture / Dislocation
– Cervical SCI
– Degenerative Process of the Cervical Vertebrae or Spinal Surgery (elderly pts)
Used more often than crutchfield tongs / stryker bed

75. HALO VEST DEVICE
• Allows pt to get out of bed.
• Does not allow flexion,
extension, or rotation of neck.

76. ADVERSE OUTCOMES (HALO)
• Infection at pin sites
• Interruption of continuous traction
• Penetration of the skull
• Nerve damage due to excessive traction
• Extension or deterioration of neurological deficits
• Osteomyelitis
• Skin irritation around vest or injury
• Respiratory compromise or arrest
• Injury from falls while ambulating with vest
– Limited motion of head/neck, can’t see surroundings too well.
– Cant look down, may trip
– Balance issues

77. COMPLICATIONS OF SCI
• Limited chest expansion
• Decreased cough reflex
• Paroxysmal HTN
• Orthostatic hypotension
• Hypercalcemia (r/t breakdown of bone)
• Pain
• Spasticity
• Stress ulcers
• Autonomic Dysreflexia
• Stool Impaction/incontinence
• Urinary Retention/Incontinence
• Joint contractures
• Muscle atrophy
• Inability to ejaculate
• Decreased vaginal lubrication

78. Causes: bladder distention, constipation
-Need bowel & bladder regimens
-Bladder scan
-May need to straight cath.

79. NURSING DIAGNOSIS
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Risk of Aspiration
• Impaired Gas Exchange
• Fluid Volume Deficit
• Altered Tissue Perfusion
• Impaired Physical Mobility
• Impaired Skin Integrity
• Risk for Injury
• Altered urinary Elimination / Constipation
• Risk for Impaired Skin Integrity

80. IMPROVED OUTCOMES
• Emergency Interventions on scene by skilled providers
• Decreased transport time
• Implement Evidence Based SCI Guidelines