1. Spinal cord Injury
This unit aims at helping learners understand the physical, physiological and
psychological sequel of spinal cord injuries. Unit will also focus on preventive
and curative care of patients with intervertebral disc herniations.

2. OBJECTIVES:
By the end of this unit the learners will be able to:
1. Review basic anatomy and physiology of spinal cord and its protective
structures.
2. Describe various mechanisms of injury that may be involved in spinal cord
injury.
3. Relate pathophysiological changes that take place after a partial or complete
cord transaction.
4. Identify life threatening complications that may result from spinal cord injury.
5. Appreciate the need for prompt interventions incase of a patient with spinal
shock and autonomic dysreflexia.
6. Describe the nursing care of a patient with spinal cord injury in an emergency
and acute care setting.
7. Explain briefly the rehabilitative needs of patients with Spinal cord injury.
8. Identify the causes and mechanism of injury involved in intervertebral disc
herniaition.
9. Describe the role of nurses in surgical and non surgical management of a
patient with intervertebral disc herniation.
10. Discuss the importance of maintaining proper body mechanics in preventing
Intervertebral disc herniation.

3. Introduction
• Continuation of medulla oblongata
• 31 segments each with pair of spinal nerves
• Protected by meninges
- dura mater,
- arachnoid,
- pia mater

5. Functions of spinal cord
• Conveys sensory impulses to the brain
• Integrates reflexes
• Spinal nerves connects at roots
- Dorsal root: sensory
- Ventral root: motor
• All 31 pairs arise from union of dorsal and ventral
roots
• Mixed nerves consisting of motor and sensory
fibers
• Most exit vertebral column between vertebrae

6. • Named and numbered according to region
and level of spinal cord
• Cervical: 8 pairs
• Thoracic: 12 pairs
• Lumbar: 5 pairs
• Sacral: 5 pairs
• Coccygeal: 1 pair

7. Physiology and function
• Dorsal root- sensory fibres
• Ventral root- motor fibres
• Dorsal and ventral roots join at intervertebral
foramen to form the spinal nerve

8. CROSS SECTION OF CERVICAL SPINAL
CORD

9. TRACTS
1- Posterior column:
• Fine touch
• Light pressure
• Proprioception
2- Lateral corticospinal tract:
• skilled voluntary work
3- Lateral spinothalamic tract:
• Pain and temperature sensation

10. • Posterior column and lateral corticospinal
tract crosses over at medulla oblongata
• Spinothalamic tract crosses in the spinal and
ascends on the opposite side

11. MECHANISM OF INJURY
Mechanisms:
1. Direct trauma
2. Compression by bone
fragments/hematoma/disc material
3. Ischemia from damage/ impingement on the
spinal arteries

12. Other causes:
• Vascular disorder
• Tumors
• Infectious conditions
• Spondylosis
• Latrogenic
• Vertebral fractures secondary to osteoporosis
• Developmental disorders

13. MECHANISM OF SCI:
• Hyper flexion: injuries in which the head strikes
against steering wheel and flexion results in
forward dislocation of the vertebrae
• Hyperextension: injuries in which head is thrown
back and hyperextension of sc leads to
transection of the cord
• Compression: injuries caused by falls or jumpsthe force of impact fractures the vertebra

14. PATHOPHYSIOLOGY OF SCI
• The spinal cord is injured by compression, pull or tear of
tissues. Microscopic bleeding occurs in grey matter. Edema
develops within the first hours and peaks within 2 to 3 days
and subsides within the first 7 days after injury.
Fragmentation of axonal covering loss of myelin, tissue
necrosis are the later changes.
• Also leads to bleeding, hematoma and compression of the
nerve roots. The cord server either partially or completely.
The client experiences motor and sensory dysfunction
below the site of injury. Physiologic response extends
beyond SC
• decreased GI perfusion, respiratory arrest spasticity of
muscles.

15. Myotomes
•
•
•
•
•
•
•
•
Segmental nerve root innervating a muscle
Again important in developing level of injury
Upper limbs:
C5- deltoid
C6- wrist extensors
C7- elbow extensor
C8- long finger flexors
T1- small hand muscles

16. • Lower limbs:
L2- hip flexors
L3,4- knee extensors
L4,5- S1- knee flexion
L5- ankle dorsiflexion
S1- Ankle plantar flexion

17. Muscle strength grading:
• 5-normal strength
• 4- full range of motion, but less than normal
strength against resistance
• 3- full range of motion against gravity
• 2- movement with gravity eliminated
• 1- flicker of movement
• 0- total paralysis

18. CONSEQUENCES OF SCI
• C1-C3- paralysis below neck and no sensation below
neck c4c5- ventilation support is required; no sensation
below clavicle c6-8- possible diaphragmatic breathing;
some elbow to wrist movements possible. Sensation in
chest is impaired T 1-6 – paralysis below waist; no
sensation below mid chest
• T7- 12- varying degrees of trunk and abdominal
control; varying sensation below waist L 1-2- hip
adduction impaired; no sensation below lower
abdomen L3-5- knee and ankle movement impaired;
no sensation below upper thighs S1-5- varying degrees
of bowel and bladder control and sexual dysfunction;
no sensation in perineum

19. Spinal cord Injury classification
• Quadriplegia: injury in cervical region, all
extremities affected
• Paraplegia: injury in thoracic, lumbar or sacral
segments 2 extremities affected.
Injury either:
1) complete
2) incomplete

20. Complete:
• loss of voluntary movement of parts
innervated by segment, this is irreversible
• Loss of sensation
• spinal shock

21. Incomplete:
1. Some function is present below site of injury
2. More favorable prognosis overall
3. Are recognizable patterns of injury, although
they are rarely pure and variations occur

22. Common cause of SCI

23. SCI Type
Incomplete/partial SCI:
•
Spinal cord is able to convey some messages to or from the brain. Therefore, retain
some sensation and possibly some motor function below the affected area
Complete injury:
•
•
•
•
•
Complete loss of motor function and sensation below the area of injury
Even in a complete injury, the spinal cord is almost never completely cut in half.
Doctors use the term complete to decrease to describe a large amount of damage
to the spinal cord
It’s a key distinction because many people with partial spinal cord injured are able
to experience signification recovery, while those with complete injuries are not.
Most trauma to the spinal cord causes permanent disability or loss of movement
(paralysis) and sensation below the site of the injury
Paralysis can involve all four extremities, a condition called quadriplegia or
tetraplegia or only the lower body, a condition called paraplegia

26. SCI Casual categories
• Traumatic spinal cord injury may stem from: sudden,
traumatic blow that fractures, dislocates, crushes or
compresses one or more of vertebrae
• Gunshot or knife: wound that penetrates and cuts your
spinal cord
• Additional (secondary) damage usually occur over days
or weeks because of bleeding, swelling, inflammation
and fluid accumulation in and around spinal cord
• Non-traumatic spinal cord injury may be cause by
arthritis, cancer, blood vessel problems or bleeding,
inflammation or infection or disk degeneration of the
spine

27. Risk factors:
• Gender- spinal cord injury affects a disproportionate
amount of men
• Age- (young adults and seniors)
- Between ages 16 and 35 / MVA(motor vehicle accident)
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

28. Priorities:
• Maintaining ability to breathe
• Preventing shock
• immobilization to prevent further spinal cord
damage(backboard & c-collar)

29. Complications:
• The following list of complications that can follow a spinal cord injury is not exhaustive. The very
nature of spinal cord lesion usually means some of the secondary complications below may follow
the initial injury. Every injury is unique and these complications will not affect everyone
• Skin breakdown
Pneumonia
Osteoporosis and fracture
Spasticity
Urinary tract infections
Autonomic dysreflexia deep vein thrombosis
Pulmonary embolism
Orthostatic hypotension
Cardiovascular disease
Neuropathic/spinal cord pain
Medication problems
Hyperthermia/hypothermia

30. Life threatening complication
• Spinal shock
• Autonomic dysreflexia

31. Autonomic dysreflexia
• Is a life threatening syndrome in which a cluster
of clinical manifestation results, when multiple
spinal cord autonomic reponses discharge
simultaneously. The manifestations results from
an exaggerated sympathetic response to stimuli
like bladder/ bowel distention cause the blood
vessels below the injury to constrict.
• S/S:
• Hypertension,headache,diaphoresis,piloerection,
restlessness,nausea,blurrerd vision and
bradycardia

32. Spinal shock
• It is the immediate response to cord
transection(damage to cord due to trauma).
S/S
• Complete loss of skeletal muscle function,
bowel and bladder tone, sexual function and
autonomic reflexes. Body assumes
environmental temperature. It is most severe
in clients with high levels of SCI and it lasts for
1-6 wks.

33. Immediate management
• Move only with adequate personnel. Stabilize
head and neck before transferring. Perform
logrolling maneuver. Cut off clothing provide
oxygen support. open a IV port, insert a
indwelling catheter, vasoactive drugs,
insertion of NG tube

34. SURGICAL MANAGEMENT:
• Depending on the extent of injury –removal of
bone fragments – repair of dislocated
vertebrae –stabilization of spine – external
immobilization with a brace and cast

35. MEDICAL MANAGEMENT:
• Immobilize head & neck in neutral. Stabilize
vital functions and manage shock.
Corticosteroids to reduce SC edema-short
term high dose methyl-prednisolone within 8
hrs. other therapies-neuro peptides,
thyrotropin releasing hormones and H2
receptor antagonists; urinary antiseptic,
laxatives, anticoagulants and antispasmodics

36. HERNIATION OF AN INTERVERTEBRAL
DISC
• The intervertebral disc is a cartilaginous plate that forms a
cushion between vertebral bodies.
• This tough, fibrous material is incorporated in a capsule
• The ball-like cushion in the center of the disc is called the
nucleus pulposus.
• Herniation occurs when the nucleus of the disc protrudes
into the fibrous ring causing nerve compression.
• Can occur related to degenerative changes or trauma
Manifestation depends on :
• Location
• Rate of development(acute vs. chronic)
• Effect on surrounding structures

37. Herniation of a Cervical IV Disc
• The cervical spine is subjected to stresses that result
from disc degeneration(from aging, occupational
stresses), and spondylosis(degenerative changes
occurring in disc and adjacent vertebral bodies)
• Cervical disc herniation usually occurs at the C5-C6 and
C6-C7 interspaces.
• Pain and stiffness may occurs in the neck , the top of
the shoulders, the region of the scapulae, in the upper
extremities, head, and may be accompanied by
numbness of the upper extremities.
• Diagnosis of cervical disc herniation is confirmed on
MRI

38. Management of herniation of a
cervical IV disc
• The goals of treatment are (1) rest and immobilization
of cervical spine and (2) reduce inflammation of
supportive tissues and affected never roots
Management may include:
• immobilization
• Traction
• Pain relief-moist heat, analgesics, sedatives, muscle
relaxants, anti- inflammatory, corticosteroids
• Surgical repair of injured spine

39. Disc surgery
• Surgical excision of a herniated disc is performed
when there is evidence of a progressing
neurological deficit (muscle weakness and atropy,
loss of sensory and motor function, loss of
sphincter control) and continuing pain and
sciatica that is not responsive to medical
management
• The goal of surgical management is to lessen the
pressure on the nerve root to relive pain and
reverse neurological deficits

40. Surgical management
• The surgery usually includes removing the part of
the disc that has squeezed outside its proper
place called a discectomy.
• The surgeon also may want to remove the back
part of the vertebrae called the lamina, in a
laminectomy or laminectomy- removal of the
lamina to expose the neutral elements in the
spinal canal; allows the surgeon to inspect the
spinal cord, identify and remove tissue for
pathology, relieve compression of the cord and
roots

41. • Diskectomy- removal of herniated or extruded
fragments of intervertebral disc.
• Laminotomy- division of the lamina of a
vertebrae
• Diskectomy with fusion- a bone graft(from a iliac
crest or bone bank) is used to fuse the vertebral
spinous processes; the object of spinal fusion is
to bridge over the defective disc to stabilize the
spine and reduce the rate of recurrence

42. Preoperative management
• Preoperative management includes evaluation
of movement in extremities plus bowel and
bladder function
• Patient is taught useful techniques such as
log-rolling, pulmonary toilet, and musclesetting(isometric) exercises, which will help to
maintain muscle tone postoperatively

43. Postoperative management
Postoperative management includes:
• Frequent neurological checks, along with vascular
supply checks to extremities.
• sitting is discouraged
• Position using a pillow under the head, and the
knee rest is slightly elevated. When patient lying
on side, avoid excessive knee flexion
• Encouraged to move from side to side by log
rolling

44. Complications of disc surgery
• Arachnoiditis- inflammation of the arachnoid
membrane. Cause diffuse frequent burning
pain in lower back radiating to buttocks
• Failed disc syndrome- recurrence of sciatica
after surgery
• Bleeding and hematoma fromation
• Fixing one level may cause problems at other
levels
• Recurrence of herniation.

45. Baseline assessment of scene & upon
arrival to ER
• ABCs/ATLS assessment includes vital signs &
Glasgow coma scale
• Neck/ spine stabilization
• Maintaining BP
• Multisystem support
• May be sedated

46. Be vigilant!
• Spinal cord injury isn’t always obvious
• Numbness or paralysis may result immediately after a
spinal cord injury or gradually as bleeding or swelling
occurs in or around the spinal cord
• In either case, time between injury and treatment is a
critical factor that can determine the extent of
complications and the level of recovery
• It’s safest to assume that trauma victims have a spinal
cord injury until proved other wise
• If you suspect that someone has a back or neck injury
Spinal immobilization STAT!

47. History of injury
• Loss of consciousness
• Other victims seriously hurt?
• Mechanism of injury?
- Driver/passenger/seat belt?
- Fall height/what caused fall?
- Hit where and with what?
- Gunshot/impaled object?

48. NURSING PROCESS ASSESSMENT: Obtain information about the injury.
Perform neurological assessment. Assess vital signs with a focus to
respiratory function. Ongoing monitoring-neurologic, motor,
sensory abilities, bowel and bladder pattern and signs of respiratory
distress and spinal shock
NURSING SDIAGNOSIS:
• Ineffective breathing pattern
• ineffective airway clearance
• risk for impaired gas exchange
• pain-neuropathic
• impaired physical mobility
• risk for impaired skin integrity
• altered elimination
• imbalanced nutrition

49. • Respiratory support: mechanical ventilation, chest
physical therapy, suctioning, kinetic bed, tracheotomy,
abdominal binder to facilitate abdominal breathing,
incentive spirometry
• THERMOREGULATION: rectal or core temperature
monitoring. Environment control. prevention of cool
draughts top linen to protect hypothermia blanket
• Physical mobility: position to avoid contractures and
foot drop. Maintain skin integrity by 2 hrly position
change, massaging bony prominences, keep skin clean
and dry and use pressure relieving devices. Assist to
perform isometric, active and passive exercise

50. • SPINAL REHABILITATION: rehabilitation begins on
admission. During acute stage care should focus on
prevention of infection , pressure sore and
contractures facilitates rehabilitation and reduce the
sufferings, disability and expense . Establish functional
goals and motivate client and family and involve them
in all phases of rehabilitation.
• GOALS OF REHABILITATION: Promote mobility, Reduce
spasticity. Improve bladder and bowel Control. Prevent
pressure ulcers. Reduce respiratory dysfunction.
Promote expression of sexuality. Control pain
nutritional management and weight gain control.
Effective health maintenances