Spinal Cord Injury Nursing Guide

Spinal Anatomy Quick Reference

Region	Segments	Key Structures / Function
Cervical	C1–C8	Neck, diaphragm (C3-C5), upper limbs; injury here = tetraplegia
Thoracic	T1–T12	Chest wall, intercostals, abdominal muscles; injury = paraplegia
Lumbar	L1–L5	Lower limb motor/sensory; hip flexors, knee extensors
Sacral	S1–S5	Bladder, bowel, sexual function; S4-S5 = sacral sparing assessment

Neurological Level of Injury (NLI): The most caudal spinal segment with normal motor AND sensory function bilaterally. Determines classification and prognosis.

ASIA Impairment Scale (AIS)

Grade	Name	Definition	Implication
A	Complete	No motor or sensory function preserved below the NLI, including S4–S5	No sacral sparing; full loss
B	Sensory Incomplete	Sensory but no motor function below NLI; S4–S5 sensation present	Sacral sensation preserved
C	Motor Incomplete	Motor function below NLI, but >50% key muscles grade <3/5	Weak but present motor
D	Motor Incomplete	Motor function below NLI, ≥50% key muscles grade ≥3/5	Functional motor, good rehab prognosis
E	Normal	Normal motor and sensory function in all segments	Full neurological recovery

Sacral Sparing — The Key to "Incomplete"

Any perianal sensation, voluntary anal sphincter contraction, or great toe flexor activity = sacral sparing = AIS B, C, or D — NOT complete (AIS A). Always test S4–S5 before classifying.

Injury Patterns & Syndromes

Extent of Injury

Tetraplegia (Quadriplegia)

C1–C8 injuries

All 4 limbs + trunk affected; may include respiratory muscles

Paraplegia

T1–S5 injuries

Lower limbs ± trunk affected; full upper limb function

Clinical Syndromes

Central Cord Syndrome: Most common incomplete syndrome. Hyperextension injury in elderly. Arms weaker than legs. Often incomplete bladder emptying.
Brown-Séquard (Hemisection): Ipsilateral motor loss + proprioception loss; contralateral pain/temperature loss. Best prognosis of cord syndromes.
Anterior Cord Syndrome: Loss of motor + pain/temperature below injury. Preserved proprioception and vibration (posterior columns intact). Poor prognosis for motor recovery.
Posterior Cord Syndrome: Rare. Loss of proprioception/vibration; motor and pain/temp preserved.

GCC-Specific SCI Causes

Road Traffic Accidents

Major cause in GCC

High-speed collisions; often young males; cervical SCI common

Camel / Horse Riding

Cultural activity injury

Falls from height; cervical and thoracic injuries

Diving — Shallow Water

Cervical hyperflexion

C5-C6 most common level; often young males at beaches/pools

Construction Falls

Scaffolding / height falls

Large migrant worker population; thoracic/lumbar fractures common

Spinal Precautions & Initial Management

C-spine collar: Apply hard collar until imaging clears cervical spine; maintain neutral alignment at all times
Log roll technique: Minimum 3 nurses for log roll (1 at head maintaining traction, 2 on body); entire spine kept in alignment
Spinal board: Use for extrication/transport only — do NOT leave patient on spinal board; transfer to mattress promptly to prevent pressure injury
Imaging: CT spine (gold standard) and MRI for soft tissue/cord assessment
IV access + monitoring: ECG, SpO2, BP, neuro obs; UO via IDC

Neurogenic Shock vs Spinal Shock — Do NOT Confuse

Feature	Neurogenic Shock	Spinal Shock	Hypovolaemic Shock
Definition	Haemodynamic instability from loss of sympathetic tone	Complete loss of all reflexes below injury	Shock from blood/fluid loss
Heart Rate	Bradycardia	Variable	Tachycardia
Blood Pressure	Hypotension	Not applicable (neurological)	Hypotension
Skin	Warm, flushed	N/A	Cold, clammy
Level	Cervical / high thoracic (T6 and above)	Any level	Any
Duration	Days to weeks	Days to weeks → resolves with return of reflexes	Until resuscitated

Neurogenic Shock Management

IV fluid resuscitation (cautious in cardiac patients)
Atropine for symptomatic bradycardia
Vasopressors: Noradrenaline is first choice
MAP target: 85–90 mmHg for first 7 days to maintain spinal cord perfusion pressure

Spinal Shock — Key Points

Complete flaccid paralysis + areflexia below injury level
Lasts days to weeks
End of spinal shock = return of bulbocavernosus reflex
Cannot accurately classify AIS during spinal shock phase

Respiratory Management — High Cervical SCI

Phrenic Nerve (C3-C4-C5) — "C3, 4, 5 keeps the diaphragm alive"

Injury at or above C5 risks diaphragm paralysis. C3-C4 injury = almost certain ventilator dependence. C5 injury = partial diaphragm function, usually requires ventilator support.

Mechanical ventilation: Early intubation for C3-C5 injuries; weaning is prolonged and difficult
Tracheostomy: Early tracheostomy recommended in high cervical SCI for long-term ventilation; facilitates speech valve use later
Phrenic nerve pacing: Considered for select patients as alternative to continuous mechanical ventilation
Cough assistance: Manual assisted cough (quad cough), breath stacking, mechanical insufflation-exsufflation (MI-E / CoughAssist)
Monitoring: Serial spirometry (FVC), ABGs, continuous SpO2, secretion management

Autonomic Dysreflexia (AD) — EMERGENCY

EMERGENCY — Injuries T6 and Above. Can cause hypertensive crisis, stroke, death.

Uncontrolled sympathetic discharge triggered by a stimulus below the level of injury.

Common Triggers

Bladder distension (most common!) — blocked catheter, overfull bladder
Bowel distension / constipation / fecal impaction
Pressure injuries, skin irritation, ingrown toenail
Sexual activity, ejaculation
Tight clothing, leg bag straps
Fractures or painful stimuli below lesion

Clinical Features

Sudden severe throbbing headache
Systolic BP can exceed 200 mmHg
Flushing and sweating above the lesion
Pallor, piloerection below the lesion
Reflex bradycardia (vagal response to high BP)
Anxiety, nasal congestion, blurred vision

Emergency Management Steps

SIT PATIENT UP immediately — upright position reduces blood pressure via postural effects. If supine, elevate head to 90°.
Monitor BP every 2–5 minutes throughout episode
Check bladder first — catheterise if bladder full; if IDC in situ, check for kinks, blockage, bypass. Use lignocaine gel if needed.
Check bowel — if bowel impaction suspected, apply rectal anaesthetic gel (lidocaine 2%) before digital removal to prevent worsening stimulus
Check skin & clothing — remove any tight items, check for pressure areas, ingrown nails
If systolic BP remains >150 mmHg after trigger removed: GTN spray sublingually or Nifedipine 10 mg chewed (sublingual nifedipine now less recommended in some guidelines — follow local protocol)
Call medical team — document BP, triggers found, treatment given; ensure ongoing monitoring

Respiratory Complications by Injury Level

Injury Level	Respiratory Status	Nursing Priorities
C1–C2	No diaphragm or intercostal function; full ventilator dependence	Ventilator management, trach care, suction; backup ventilation plan essential
C3–C4	Partial/absent diaphragm; ventilator dependent	As above + weaning assessment, phrenic nerve pacing evaluation
C5–C8	Diaphragm intact but no intercostals; reduced cough, reduced VC	Assisted cough, MI-E, incentive spirometry, chest physio
T1–T6	Intercostals partially affected; independent breathing possible	Assisted cough techniques, monitor for fatigue
T7 and below	Full respiratory independence	Standard monitoring; pneumonia prevention

Skin Integrity — Pressure Injury Prevention

SCI patients are the highest-risk group for pressure injuries

Loss of sensation = cannot feel pain warning; loss of mobility = cannot self-reposition; autonomic dysfunction = impaired vasodilation and healing.

Prevention Strategies

Turn / reposition every 2 hours in bed
Pressure-relieving foam or alternating air mattress
Wheelchair pressure relief every 15–30 minutes (weight shifts)
Specialist wheelchair cushion (ROHO, Jay)
Full visual skin inspection at each turn
Adequate nutrition and hydration

High-Risk Anatomical Sites

Sacrum — supine position
Heels — elevate off mattress
Ischial tuberosities — sitting position
Occiput — supine, especially with collar
Greater trochanters — lateral position
Medial knees & malleoli — lateral position

Bladder Management

Phase	Management	Goals
Acute / Spinal Shock	Indwelling urinary catheter (IDC)	Accurate UO monitoring, prevent overdistension, reduce AD risk
Recovery / Rehabilitation	Intermittent Self-Catheterisation (ISC)	4–6× per day; catheterise before bladder volume >400 mL; fluid restriction to ~1500–2000 mL/day
Spastic bladder (upper motor neuron)	Anticholinergics (oxybutynin, solifenacin) + ISC	Reduce uninhibited contractions, maintain low pressure
Acontractile bladder (lower motor neuron)	ISC or suprapubic catheter	Empty fully to prevent UTI and upper tract damage

UTI Prevention — Critical

UTI is the most common cause of rehospitalisation in SCI. Maintain ISC schedule, adequate fluid intake, sterile/clean technique, avoid unnecessary IDC, monitor for symptoms (cloudy urine, fever, worsening spasticity, new AD episodes — classic UTI presentation in SCI as pain may be absent).

Neurogenic Bowel Management

Establish a regular bowel routine — same time each day, ideally after a meal (gastrocolic reflex)
Upper motor neuron bowel (injury above conus T12-L1): spastic sphincter, reflex defecation — digital rectal stimulation, glycerine or bisacodyl suppositories
Lower motor neuron bowel (conus/cauda equina): flaccid sphincter, risk of incontinence — manual evacuation, careful scheduling
High-fibre diet + adequate fluid intake
Avoid constipation — major AD trigger
Document frequency, consistency (Bristol Stool Chart), any incontinence

DVT & Venous Thromboembolism Prevention

SCI patients are at very high risk of DVT

Loss of muscle pump action + venous pooling + immobility + hypercoagulable state post-injury.

LMWH (e.g., enoxaparin): commence within 72 hours if no contraindication (haemorrhagic injury)
Graduated compression stockings (TED stockings) below injury level
Pneumatic sequential compression devices (SCDs) on lower limbs
IVC filter: considered if anticoagulation contraindicated
Early mobilisation and passive range-of-motion exercises

Orthostatic Hypotension

Common in cervical and thoracic SCI — loss of sympathetic vasoconstriction on positional change
Gradual head-up tilt table progression (start at 15–20°, increase slowly over days)
Abdominal binder and compression stockings before upright positioning
Pharmacological: Fludrocortisone (mineralocorticoid) or Midodrine (alpha-1 agonist)
Ensure adequate hydration and salt intake
Monitor BP before and during position changes; recline immediately if symptoms or BP drop >20 mmHg systolic

Functional Goals by Level of Injury

Level	Expected Function	Mobility	Independence
C1–C4	No limb or trunk movement; C3-C4 ventilator dependent	Power wheelchair (head/chin/breath control)	Full-time carer required for all ADLs
C5	Elbow flexion, some shoulder movement; wrist/hand weak	Electric wheelchair independently	Self-feeding with adapted equipment; dependent for dressing, personal care
C6	Wrist extension, tenodesis grip; good shoulder & elbow	Manual wheelchair on flat; may drive with adaptations	Many ADLs with adaptations; may do own ISC; partial independence
C7–C8	Triceps, hand function improving; near-full upper limb	Manual wheelchair independently	Nearly fully independent in wheelchair; can transfer independently
T1–T12	Full upper limb function; varying trunk control	Manual wheelchair independently	Fully independent in wheelchair; vocational return likely
L1–L5	Hip flexors, some knee function preserved	Ambulation with KAFOs or AFOs + walking aids	Functional ambulation possible; may not need wheelchair

Assessment Tools

Modified Barthel Index (MBI)

0–100 points

Measures independence in 10 ADLs: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, mobility, stairs. Used widely in GCC rehabilitation units.

SCIM III — Spinal Cord Independence Measure

0–100 points, SCI-specific

SCI-specific tool covering self-care (20 pts), respiration & sphincter management (40 pts), mobility (40 pts). More sensitive to change in SCI population than Barthel.

Spasticity Management

Daily passive range-of-motion (ROM) exercises — prevents contractures, reduces spasticity
Correct positioning — anti-spasticity positioning in bed and wheelchair
Oral baclofen — first-line pharmacological agent; titrate slowly; monitor for sedation
Intrathecal baclofen pump — for severe spasticity refractory to oral medications; requires specialised monitoring for pump function and overdose/withdrawal risk
Botulinum toxin (Botox) injections — focal spasticity, e.g., spastic hip adductors, wrist/finger flexors
Treat precipitating causes: UTI, pressure injury, constipation, pain — all worsen spasticity

Pain Management

Neuropathic Pain (very common in SCI)

Burning, shooting, electric-shock quality pain at or below lesion
Gabapentin or Pregabalin — first line
Amitriptyline (TCAs) — also addresses depression
Duloxetine, tramadol as adjuncts
Assess pain using NRS; document location, quality, triggers

Musculoskeletal Pain

Shoulder pain — very common in wheelchair users (rotator cuff overuse)
Physiotherapy, activity modification
NSAIDs with caution (GI risk)
Ensure correct wheelchair setup and transfer technique

Psychological Support

Mental Health in SCI

Depression affects >30% of SCI patients. Anxiety, grief, post-traumatic stress, and adjustment disorders are common. Psychological support must be integrated into the rehabilitation team from day one.

Peer support programmes — connect patients with established SCI community members
Sexual health counselling — address sexual function, relationships, fertility early
Vocational counselling — return to work, education, purposeful activity
Spiritual support — chaplaincy / Islamic scholar support as appropriate in GCC context

GCC Rehabilitation Centres

UAE

Sheikh Khalifa Specialist Hospital, Ras Al Khaimah

Qatar

Hamad General Hospital Rehabilitation

Saudi Arabia

King Fahad Medical City (KFMC), Riyadh