INTRODUCTION

Spinal Cord Injuries are a major health problem. Most spinal cord injuries result from motor vehicle
crashes. Other causes include falls, sporting and industrial accidents, gunshot wounds.

 Over half of the victims are 16 to 30 years of age.

 Males are affected four times more often than females.
 Vertebrae most frequently involved in spinal cord injuries are the 5th, 6th, and 7th cervical, the
12th thoracic, and the 1st lumbar.
 Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central,
lateral, anterior, or peripheral.
 A complete spinal cord injury can result in paraplegia (paralysis of the lower body) or
quadriplegia (paralysis of all four extremities)

INCIDENCE (WORLDWIDE)
 Approx 12,000 new cases per year
 Average age 40.7 years
 80.7% male
 Increased incidence among African Americans (27%) and Asians (2%)
 Most common causes - MVC (41%), Falls, Violence
SIGNS AND SYMPTOMS
Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:

 Loss of movement
 Loss or altered sensation, including the ability to feel heat, cold and touch
 Loss of bowel or bladder control
 Exaggerated reflex activities or spasms
 Changes in sexual function, sexual sensitivity and fertility
 Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
 Difficulty breathing, coughing or clearing secretions from your lungs

Anatomy and Physiology

 Spinal column consists of 33 vertebrae with spongy discs in between to provide flexibility, absorb
energy and cushion the bones during everyday activities; both the sacrum and coccyx are part of
the pelvis
 7 cervical
 12 thoracic
 5 lumbar
 5 sacral (fused)
 4 coccyx (fused)
 Ligaments support the spine both anteriorly and posteriorly; most instability relates to the
degree of ligamentous damage; injury to the ligaments allows movement of the vertebrae that
may impinge on the spinal canal
 Spinal cord itself is housed within the vertebrae with nerve roots exiting the bones at each level;
the cord ends at L1-L2 forming the cauda equina – the nerves roots feeding the lower
extremities and perineum; note there are 8 cervical roots for the 7 cervical vertebrae
 Anterior and posterior spinal arteries feed the cord; an injury to these vessels or to the main
vessels feeding these will result in ischemia to the cord and resultant loss of function

Vertebral Column

 Note that there is natural curvature to

the spine
 Loss of the normal lordosis indicates
ligamentous injury
Thoracic Vertebra

 Note the shape of the majority of the vertebrae; the central area is for the spinal cord
 The transverse processes are longer in the thoracic spine to allow for the attachment of the ribs
 The vertebral body gets larger for the lower vertebrae providing support
 The facets are like thumbprints onto which the cephalad vertebra articulates

Cervical Vertebrae
 C1 (atlas) is a ring which articulates with the occipital condyles (atlas)
 C2 (axis) is shaped as all the other vertebrae except for the odontoid (dens) which is a finger-like
structure around which C1 sits allowing the head to rotate
 Note the increase in length of the spinous processes down to C7

Spinal Cord

Spinal Cord

Nerve Roots

 Spinal cord and 31 pair of nerve roots are protected by the bony structure and each root exits
between each vertebra at the intervertebral foramen
 The spinal cord is an extension of the medulla oblongata
 The termination point is called the conus medullaris
 Divided into central gray and surrounding white matter
 The dorsal component is the sensory fiber (afferent) and the ventral root is the motor fiber
(efferent)
 This distribution becomes important in understanding the sensorimotor findings in injury
 Covered by meninges
 dura, arachnoid and pia mater
 Spinal nerves exit at each vertebral level in “pairs”
 Gray matter = cell bodies, axons, dendrites; 3 horns
 Anterior – motor (final common pathway)
 Intermediolateral- preganglionic sympathetic fibers T1-L2; parasympathetic L3-4
 Posterior – peripheral sensory neurons
 White matter = large fiber bundles are columns with ascending sensory and descending motor
tracts ( 3 horns)
 Anterior- motor function, light touch, pressure
 Lateral – 8 tracts
 Spinocerebellar (position sense, movement for coordination)
 Spinothalamic (information to the thalamus)
 Posterior- position sense (proprioception), vibration, 2 point discrimination, touch, deep
pressure

 Remember the arrangement- motor anterior and sensory posterior

 Descending carry information from the brain to the body
 Ascending brings information to the brain
 Major descending – corticospinal, reticulospinal, vestibulospinal
 Lateral corticospinal (pyramidal tracts) largest and clinically most important
 These tracts originate in the motor cortex and decussate or cross over at the level of the
medulla and continue along the column. They are arranged so that the fibers innervating
the legs are most peripheral and those innervating the arms are medial/central. This
arrangement becomes significant during injury.
 Upper motor neuron – remains within the central nervous system
 Lower motor neuron- motor neurons (final common pathway)

 Upper motor neuron- within the spinal cord and results in profound injury
 Lower motor neuron – terminates in the muscle fibers; anterior horn cells and their motor
neuron
 These tracts are in the gray matter, the anterior horn
 All Lower Motor Neurons are influenced by Upper Motor Neurons
 Disruption to the LMN produces the opposite affect of the UMN disruption

Spinal Arteries
 Terminal branches of the vertebral artery unite to form the spinal artery
 Critical to spinal cord blood flow is that the major arterial supply arises from the anterior spinal
artery which feeds the anterior two thirds of the spinal cord
 Disruption to the spinal artery will produce significant ischemia of the spinal cord substance
where the motor tracts are arranged
  Autonomic nervous system – regulates
function of involuntary muscles and glands; controlled by hypothalamus
 Sympathetic – fight or flight
 Parasympathetic – homeostasis/balance
 Majority exit C1

NURSING CONSIDERATIONS

Promoting Adequate Breathing and Airway Clerance. Possible impending respiratory failure is
detected by observing the patient, mearsuring vital capacity, monitoring oxygen saturation through
pulse oximetry, and monitoring arterial blood gases. Early and vigorous attention to clearing brochial
and pharengeal secretions can prevent retention of secretions and arelectasis. Suctioning may be
indicated, but it should be used with caution to avoid stimulating the vagus nerve and producing
bradycardia and caridiac arrest. Specific breathing exercise are supervised by the nurse to increase
the strenght and endurance of the inspiratory muscles, particularly the diaphragm. Asissted coughing
promotes clearing of secretions from the upper respiratory tract and is similar to the use of
abdominal thrusts to clear an airway.

Improving Mobility. Proper body alignment is maintained at all times. The patient is repositioned
frequently and is assisted out of bed as soon as the spinal column is stablized. The feet are prone to
footfrop; therefore, various types of splints are used to prevent footdrop. When used , the splints are
removed and applied every two hours. Trochanter rolls, applied from the crest of the ilium to the
midhigh of both legs, help prevent external rotation of the hip joints. Contractures can fdevelop
rapidly with immobility and muscle paralysis. Contractures and other complications may be prevented
by range of motion exercises that help preserve joint motion and stimulate circulation. Passive range
of motion should be implemented as soon as possible after injury. Toes, matatarsals, ankles, knees,
and hips should be put through a full range of motion at least four, and ideally five, times daily.

Promoting Adaptation to Sensory and Perception Alterations. The nurse assists the patient to
compensate sensory and perceptual alternations that occur with SCI. the intact senses above the level
of the injury are stimulated through touch, aromas, flavorful and foos and beverages, conversation,
and music.
Maintaning Skin Integrity. Pressure ulcers are significant complications of SCI. Pressure ulcers may
begin within hours of an acute SCI where pressure is continous and where the peripheral circulation is
inadequate as aresult of spinal shock and recumbent positoin. It is important to move the patient
from the back board as soon as possible and inspect the skin. The patient’s position is changed at leart
2 hours. Turning not only assists in the prevention of pressue ulcers but also prevents pooling of blood
and edema in the dependent areas. The skin over the pressure is assessed of redness or breaks, the
perinuem is checked for solaige, and the catheter is observed fpr adequate drainage. The patient’s
skin should be kept clean by washing with a mild soap, rinsing well, and blotting dry. Pressre sensitive
areas should be kept well lubricated and soft with hand cream or lotion.

Maintaining Urinary Elimination. Immediately after SCI, the urinary bladder becomes atonic and
connot contract by reflex activity. Urinary retention is the immediate result. Because the patient has
no sensation of baldder distention, overstretching of the bladder and destrumor may occur, delaying
the return of bladder function. The patient or S.O is taught to to record fluid intake, voiding pattern,
amounts of urine, and may unusual sensatioins that may occur.