Spinal Cord Injury (SCI)

Definition:
Refers to an injury to the spinal cord. It can cause myelopathy or damage to nerve roots or myelinated fiber tracts that carry signals to and from the
brain. Depending on its classification and severity, this type of traumatic injury could also damage the grey matter in the central part of the cord, causing
segmental losses of interneurons and motor neurons. can be caused by trauma to the spinal column ,(stretching, bruising, applying pressure, severing,
laceration, etc.). The vertebral bones or intervertebral disks can shatter, causing the spinal cord to be punctured by a sharp fragment of bone. Usually,
victims of spinal cord injuries will suffer loss of feeling in certain parts of their body. In milder cases, a victim might only suffer loss
of hand or foot function.
Classifications and Types:
The American Spinal Injury Association (ASIA) defined an international classification based on neurological responses, touch and pinprick sensations
tested in each dermatome, and strength of ten key muscles on each side of the body, e.g. shoulder shrug (C4), elbow flexion (C5), wrist extension (C6),
elbow extension (C7), hip flexion (L2). Traumatic spinal cord injury is classified into five categories by the American

Spinal Injury Association and the International Spinal Cord Injury Classification System:
 A indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5.
 B indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the
sacral segments S4-S5. This is typically a transient phase and if the person recovers any motor function below the neurological level, that
person essentially becomes a motor incomplete, i.e. ASIA C or D.
 C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and more than half of key
muscles below the neurological level have a muscle grade of less than 3, which indicates active movement with full range of motion against
gravity.
 D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key
muscles below the neurological level have a muscle grade of 3 or more.
 E indicates "normal" where motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficits
with completely normal motor and sensory scores.

Incomplete Syndrome:
 The Central cord syndrome is associated with greater loss of upper limb function compared to lower limbs.
 The Brown-Séquard syndrome results from injury to one side with the spinal cord, causing weakness and loss of proprioception on the side of
the injury and loss of pain and thermal sensation of the other side.
 The Anterior cord syndrome results from injury to the anterior part of the spinal cord, causing weakness and loss of pain and thermal
sensations below the injury site but preservation of proprioception that is usually carried in the posterior part of the spinal cord.
 Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from infection diseases such as syphilis, causing loss of touch
and proprioceptive sensation.
 Conus medullaris syndrome results from injury to the tip of the spinal cord, located at L1 vertebra.
 Cauda equina syndrome is, strictly speaking, not really spinal cord injury but injury to the spinal roots below the L1 vertebra.

Risk Factors:
While spinal cord injuries can happen to anyone, certain populations may be more prone to them. According to the Mayo Clinic, 80% of spinal
cord injuries in the United States occur in men. Age is another risk factor. People aged 18–35 are more likely to sustain spinal cord injuries from car or
motorcycle accidents, and the elderly are more likely to become injured in falls.
Athletes, particularly gymnasts, skiers, hockey players, divers, and surfers are at increased risk. Patients with diseases that affect the
bones and joints are also more susceptible to spinal cord injuries.
The Mayo Clinic notes that approximately 50% of spinal cord injuries are caused bymotor vehicle accidents and approximately 24% result
from falls. Acts of violence(primarily gunshot wounds) account for approximately 11% of cases and sports and other recreational activities cause
about 9% of spinal cord injuries. Diseases such as cancer, arthritis, and osteoporosis are another common cause.

Manifestations:
The effects of a spinal cord injury may vary depending on the type, level, and severity of injury, but can be classified into two general categories:
In a complete injury, function below the "neurological" level is lost. Absence of motor and sensory function below a specific spinal level is considered a
"complete injury". Recent evidence suggests that less than 5% of people with "complete" spinal cord injuries recover locomotion.[citation needed]
In an incomplete injury, some sensation and/or movement below the level of the injury is retained. The lowest spinal segment in humans is located at
vertebral levels S4-5, corresponding to the anal sphincter and peri-anal sensation. The ability to contract the anal sphincter voluntarily or to feel peri-
anal pinprick or touch, the injury is considered to be "incomplete". Recent evidence suggests that over 95% of people with "incomplete" spinal cord
injuries recover some locomotor function.[citation needed]
In addition to loss of sensation and motor function below the level of injury, individuals with spinal cord injuries will also often experience other
complications:
• Bowel and bladder function is regulated by the sacral region of the spine. In that regard, it is very common to experience dysfunction of the
bowel and bladder, including infections of the bladder and anal incontinence, after traumatic injury.
• Sexual function is also associated with the sacral spinal segments, and is often affected after injury. During a psychogenic sexual experience,
signals from the brain are sent to spinal levels T10-L2 and in case of men, are then relayed to the penis where they trigger an erection. A reflex
erection, on the other hand, occurs as a result of direct physical contact to the penis or other erotic areas such as the ears, nipples or neck. A
reflex erection is involuntary and can occur without sexually stimulating thoughts. The nerves that control a man’s ability to have a reflex
erection are located in the sacral nerves (S2-S4) of the spinal cord and could be affected after a spinal cord injury.[3]
• Injuries at the C-1/C-2 levels will often result in loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing.
• Inability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature.
• Spasticity (increased reflexes and stiffness of the limbs).
• Neuropathic pain.
 • Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances.
• Atrophy of muscle.
• Superior Mesenteric Artery Syndrome.
• Osteoporosis (loss of calcium) and bone degeneration.
• Gallbladder and renal stones.

Anatomy and Physiology:

The spinal cord has two functions:
Transmission of nerve impulses. Neurons in the white matter of the spinal cord transmit
sensory signals from peripheral regions to the brain and motor signals from the brain to peripheral
regions.

Spinal reflexes. Neurons in the gray matter of the spinal cord integrate incoming sensory
information and respond with motor impulses that control muscles (skeletal, smooth, or cardiac)
or glands.

The spinal cord is an extension of the brain stem that begins at the foramen magnum and
continues down through the vertebral canal to the first lumbar vertebra (L1). Here, the spinal cord
comes to a tapering point, the conus medullaris. The spinal cord is held in position at its inferior
end by the filum terminale, an extension of the pia mater that attaches to the coccyx. Along its
length, the spinal cord is held within the vertebral canal by denticulate ligaments, lateral extensions
of the pia mater that attach to the dural sheath.
The following external features on the spinal cord

• Spinal nerves emerge in pairs, one from each side of the spinal cord along its length.
• The cervical enlargement is a widening in the upper part of the spinal cord (C4 to T1). Nerves that extend into the upper limbs originate or
terminate here.
• The lumbar enlargement is a widening in the lower part of the spinal cord (T 9 to T12). Nerves that extend into the lower limbs originate or
terminate here.
• The anterior median fissure and the posterior median sulcus are two grooves that run the length of the spinal cord on its anterior and
posterior surfaces, respectively.
• The cauda equina are nerves that attach to the end of the spinal cord and continue to run downward before turning laterally to other parts of
the body.
• A ventral root (anterior or motor root) is the branch of the nerve that enters the ventral side of the spinal cord. Ventral roots contain motor
nerve axons, transmitting nerve impulses from the spinal cord to skeletal muscles.
• A dorsal root (posterior or sensory root) is the branch of a nerve that enters the dorsal
side of the spinal cord. Dorsal roots contain sensory nerve fibers, transmitting
nerve impulses from peripheral regions to the spinal cord.
• A dorsal root ganglion is a cluster of cell bodies of a sensory nerve. It is located on
the dorsal root.
*Gray matter appears in the center of the spinal cord in the form of the letter H (or a pair of
butterfly wings) when viewed in cross section.
• The gray commissure is the cross-bra of the H.
• The anterior (ventral) horns are gray matter areas at the front of each side of the H. Cell
bodies of motor neurons that stimulate skeletal muscles are located here.
• The posterior (dorsal) horns are gray matter areas at the rear of each side of the H. These
horns contain mostly interneurons that synapse with sensory neurons.
• The lateral horns are small projections of gray matter at the sides of H. These horns
are present only in the thoracic and lumbar regions of the spinal cord. They contain cell
bodies of motor neurons in the sympathetic branch of the autonomic nervous
system.
• The central canal is a small hole in the center of the H cross-bar. It contains CSF and runs
the length of the spinal cord and connects with the fourth ventricle of the brain.
*White columns (funiculi) refer to six areas of the white matter, three on each side of the H. They
are the anterior (ventral) columns, the posterior (dorsal) columns, and the lateral columns.
*Fasciculi are bundles of nerve tracts within white columns containing neurons with common
functions or destinations.
• Ascending (sensory) tracts transmit sensory information from various parts of the body to the brain.
• Descending (motor) tracts transmit nerve impulses from the brain to muscles and glands.
Pathophysiology:
Acceleration, deceleration or deformation forces
(usually applied forces)
↓
Compress the tissues, pull or exert tension on the tissues, or shear tissues
(slide tissues into one another)
↓
Bones, ligaments, joints of the vertebral column are damaged through fracture & compression of one or more elements, dislocation of elements, or both
fracture & dislocation
↓
Simple Fracture │ Compressed/Wedged Vert.Fracture │ Comminuted Burst Fracture │ Dislocation
↓
Microscopic hemorrhages appear in the gray matter * pia-arachnoid
(increases in size until the gray matter is hemorrhagic & necrotic)
↓
Reduced vascular perfusion and development of ischemic areas
(oxygen tension in the tissue at the injury site is decreased)
↓
Cellular & subcellular alterations & tissue necrosis occurs
↓
Increases degree of dysfunction
(permanent/temporary)

Laboratory Test
Laboratory screening tests of blood, urine, or other substances are used to help diagnose disease, better understand the disease process, and monitor
levels of therapeutic drugs. Certain tests, ordered by the physician as part of a regular check-up, provide general information, while others are used to
identify specific health concerns. For example, blood and blood product tests can detect brain and/or spinal cord infection, bone marrow disease,
hemorrhage, blood vessel damage, toxins that affect the nervous system, and the presence of antibodies that signal the presence of an autoimmune
disease. Blood tests are also used to monitor levels of therapeutic drugs used to treat epilepsy and other neurological disorders. Genetic testing of DNA
extracted from white cells in the blood can help diagnose Huntington’s disease and other congenital diseases. Analysis of the fluid that surrounds the
brain and spinal cord can detect meningitis, acute and chronic inflammation, rare infections, and some cases of multiple sclerosis. Chemical and
metabolic testing of the blood can indicate protein disorders, some forms of muscular dystrophy and other muscle disorders, and diabetes. Urinalysis
can reveal abnormal substances in the urine or the presence or absence of certain proteins that cause diseases including the mucopolysaccharidoses.

Diagnostic Test
Diagnosis of SCI is based on physical examination, radiologic examination, CT scan, MRI and myelography.
Diagnostic x-rays such as lateral cervical spine x-rays and CT scanning are usually performed initially. An MRI scan may be ordered as a further work up
if a ligamentous injury is suspected, since significant spinal cord damage may exist even in the ansence of bony injury. Continuous electrocardiographic
monitoring may be indicated if a cord injury is suspected since bradycardia and asystole are common in acute spinal injuries.

Medical Management
A spinal cord trauma is a medical emergency requiring immediate treatment to reduce the long-term effects. The time between the injury and treatment
is a critical factor affecting the eventual outcome.
Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord compression
is caused by a mass (such as a hematoma or bony fragment) that can be removed or reduced your spinal nerves are completely destroyed, paralysis may
improve. Ideally, corticosteroids should begin as soon as possible after the injury.
Surgery may be needed to:
• Remove fluid or tissue that presses on the spinal cord (decompression laminectomy)
• Remove bone fragments, disk fragments, or foreign objects
• Fuse broken spinal bones or place spinal braces
Bedrest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal.
Spinal traction may be recommended. This can help keep the spine from moving. The skull may be held in place with tongs (metal braces placed in the
skull and attached to traction weights or to a harness on the body). The spine braces may need to be worn for a long time.
The health care team will also provide information on muscle spasms, care of the skin, and bowel and bladder dysfunction.
Extensive physical therapy, occupational therapy, and other rehabilitation therapies are often required after theacute injury has healed. Rehabilitation
helps the person cope with disability that results from spinal cord injury.
Muscle spasticity can be relieved with medications taken by mouth or injected into the spinal canal. Botox injections into the muscles may also be
helpful. Pain killers (analgesics), muscle relaxers, and physical therapy are used to help control pain.

Nursing Management
Promoting Adequate Breathing
• 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.
• 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.
• Discourage smoking.
• Monitor respiratory status frequently.

Improving Mobility
• Maintain proper body alignment; place patient in dorsal or supine position.
• Turn patient every 2 hours; monitor for hypotension in patients with lesions above the midthoracic level. Assist patient out of bed as soon as spinal
column is stabilized.
• Do not turn patient who is not on a turning frame unless physician indicates that it is safe to do so.
• Apply splints to prevent footdrop ans trochanter rolls to prevent external rotation of the hip joint; reapply every 2 hours.
• Perform passive range-of-motion exercises within 48 to 72 hours after injury to avoid complications such as contractures and atrophy.
• Provide a full range of motion at least every four or five times daily to toes, metatarsals, ankles, knees & hips.
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;
gently perform massage using a circular motion.
• Teach patient about pressure ulcers and encourage participation in preventive measures.
Promoting Urinary Elimination
• Perform intermittent catheterization to avoid overstreatching 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, quality of urine, and any unusual feelings.
Promoting Adaptation to Disturbed Sensory Perception
• Stimulate the area above the level of the injury through touch, aromas, flavorful food, 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.
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 sound resume.
• Administer prescribed stool softener to counteract effects of immobility and pain medications, and institue a bowel program as early as possible.
Providing Comfort
• Reassure patient in halo traction that he/she will adapt to steel frame.
• Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening; keep a torque screwdriver readily available.
• Assess skull for signs of infection, including drainage around halo-vest tongs.
• Check back of head periodically for signs of pressure. Massage at intervals, taking care not to move the neck.
• Shave hair around tongs to facilitate inspection. Avoid probing under encrusted areas.
• Inspect skin under halo vest for excessive perspiration, redness, and skin blistering, especially on 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.

Possible Complications
The following are possible complications of a spinal cord injury:
• Blood pressure changes - can be extreme (autonomic hyperreflexia)
• Chronic kidney disease
• Complications of immobility:
o Deep vein thrombosis
o Pulmonary infections
o Skin breakdown
o Contractures
• Increased risk of injury to numb areas of the body
• Increased risk of urinary tract infections
• Loss of bladder control
• Loss of bowel control
• Loss of sensation
• Loss of sexual functioning (male impotence)
• Muscle spasticity
• Pain
• Paralysis of breathing muscles
• Paralysis (paraplegia, quadriplegia)
• Pressure sores
 • Shock
People living at home with spinal cord injury should do the following to prevent complications:
• Daily pulmonary care, for those who need it.
• Follow all instructions regarding bladder care to avoid infections and damage to the kidneys.
• Follow all instructions regarding routine wound care to avoid pressure sores.
• Keep immunizations up to date.
• Maintain routine health visits with their doctor.