Spinal Cord Injury (SCI)

AJ Sturdivant

Background 

  • SCIs are graded according to the American Spinal Injury Association (ASIA) grading scale which describes the severity of injury. The scale is graded with letters:
  • ASIA A: complete SCI with no sensory or motor function preserved (at least no sensory or motor function preserved in sacral segments S4-S5). ASIA A patients also have no voluntary anal contraction or deep anal pressure.
  • ASIA B: a sensory incomplete injury with complete motor function loss
  • ASIA C: a motor incomplete injury where there is some movement, but less than half of the muscle groups below the neurologic level of injury are anti-gravity (can lift against the force of gravity with full ROM)
  • ASIA D: a motor incomplete injury with more than half of the muscle groups anti-gravity
  • ASIA E: neurologically intact
  • 17,000 SCIs occur annually. Most are traumatic (MVC and falls are the most common causes), but some are “acquired,” such as from tumors, spinal stroke, and/or abscesses which are also considered non-traumatic SCI’s.

Assessment and Classification 

  • Mechanism of injury
  • Other injuries; greater than 50% of cases have concurrent TBI
  • Surgical vs non-surgical intervention
  • International Standards for Neurological Classification of SCI (ISNCSCI) Exam
  • Full neurological assessment including manual muscle testing bilaterally for upper and lower extremities, sensory exam to light touch AND pinprick at each dermatome, sacral sensation and rectal exam for deep anal pressure and voluntary anal contraction
  • Determine sensory level, motor level, neurological level of injury (NLI), and completeness of injury for prognostication
  • Note in regions where there is no myotome to test (thoracic region), the motor level is presumed to be the same as sensory level
  • NLI: most caudal segment of the cord with intact sensation and anti-gravity (3 or more) muscle function strength, if there is normal (intact) sensory and motor function
  • Classification uses ASIA ISCNSCI exam including bilateral sensory level, bilateral motor level, NLI, injury completeness (complete vs incomplete), and AIS Impairment Score

Management 

  • Neurogenic bowel: depending on the level, can lead to constipation or fecal incontinence
    • Bowel regimen (stool softeners and laxatives) with bowel program (up out of the bed to shower chair for an enema every day to every other day)
    • Goal: 1 BM every day during bowel program without incontinence inbetween
  • Neurogenic bladder: main concerns include urinary retention and incontinence
    • Managed acutely with foley or straight catheter. Note, even if the pt has urine output, it does not mean that they are not retaining. It may represent overflow incontinence.
  • Autonomic dysreflexia: an abnormal state of sympathetic overdrive from a noxious stimulus
    • Unique complication in T6 level or above injuries
    • Symptoms: flushing, sweating, headache, relative hypertension, tachycardia, lightheadedness, nausea, anxiety
    • Immediate treatment: sit the pt upright and remove all tight clothing
    • Next step: determine source/noxious stimuli
    • Most common causes: urinary retention and constipation followed by tight clothing, pressure wound, infection
    • HTN treatment: nitro-paste on the forehead (does not work on the chest if pt had an injury above the chest, which includes all cervical injuries and most upper thoracic injuries)
  • Pressure injuries
    • q2H turns and instruction on pressure relief. Engage wound care and nursing as needed.
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