Musculoskeletal / Orthopedics

Cervical Spine injuries: Preserving function, improving outcomes

Every year, about 11,000 people suffer a cervical spine injury, causing complete or incomplete loss of motor, sensory, autonomic, or reflex functions. Most are young adults.
For those who sustain a complete or partial loss, the physical, emotional, and financial costs can be staggering. But expert early care can help minimize complications and thus improve outcomes. Before discussing acute nursing care, let’s review some important information about the spinal cord and spinal cord injuries.

Spinal cord refresher
The spinal cord, a continuation of the medulla, is protected by the vertebral column, intervertebral disks, soft tissue, ligaments, and tendons. Eight spinal nerves exit the cervical area of the cord to innervate the autonomic nervous system, diaphragm, and arms. The C1 through C7 nerves exit the cord above their corresponding vertebrae, and the C8 nerve exits below the C7 vertebra.
Each spinal nerve contains a ventral and dorsal root. The ventral (motor) root carries messages from the brain to the limbs, and the dorsal (sensory) root carries messages from the limbs to the brain. Messages enter and exit nerve roots via descending and ascending tracts in the spinal cord.

Types of spinal cord injuries
Central cord syndrome, damage to the center of the cord only, often results from an interruption in blood flow or a fall. The patient loses motor movement in the arms, but not the legs.
A contusion, or bruising, of the cord may result from trauma to the cord or vertebral column.
A complete or incomplete transection occurs when an object, such as a knife or piece of disc, tears the cord. A complete transection is rare because of the protective structures around the cord. However, an incomplete transection with significant edema or loss of blood flow to the cord may cause a complete loss of function.
Clinicians grade injuries as complete or incomplete, using a scale such as the American Spine Injury Association (ASIA) scale. In this A-to-E scale, A represents a complete injury with no motor or sensory function preserved in the sacral segments S4 to S5, and E represents normal motor and sen­-sory function. The ASIA scale is a good prognostic tool. Patients with an A injury have less than a 5% chance of walking again.

Types of spinal column injuries
Spinal column injury is defined as damage to the supporting structures around the cord, such as vertebrae, discs, and ligaments. The seven cervical vertebrae are the smallest and most flexible in the vertebral column, which places them at high risk for injury. These cervical vertebrae support the head and allow the head and neck to flex, extend, and rotate. Because of the flexibility of the head and neck, cervical vertebrae are the most prone to injury from outside forces, particularly for patients who have anatomic abnormalities or cervical spine disorders. The most common forces are acceleration and deceleration that cause hyperflexion, hyperextension, compression, and rotational injuries.
Hyperflexion injuries usually result from acceleration-deceleration in which the head and neck are hyperflexed. Common causes include diving accidents and head-on motor vehicle accidents. Often occurring at C5 to C6, disruption to the ligaments and discs may cause vertebral bodies to fracture or become compressed, resulting in a stable or unstable injury to the cord. Stable fractures or injuries, those in which structural support is maintained, may be left to heal on their own or with an external orthotic device. Unstable fractures or injuries have a likelihood of progressing and may result in neurologic deterioration.
Hyperextension injuries occur when the head and neck are hyper­extended, which stretches the spinal cord. Common causes include rear-end motor vehicle accidents and falls. Injuries are most common in C4 and C5 and can be substantial because of the large degree of extension that may occur.
Compression injuries result from downward pressure on the spinal column, which can follow falls and other injuries that put vertical pressure on the column. As the spinal column is compressed, vertebrae may fracture, placing the spinal cord at risk for injury.
Rotational injuries occur when the head and neck are twisted, damaging supporting ligaments and causing instability to the spinal cord.
The degree of patient disability correlates with the level of cord invasion. The spine depends on support from ligaments, soft tissue, the bony vertebral column, and adequate blood flow. An injury affecting one or more of these supporting elements may result in a spinal cord injury.

Goals of care
The main goals of treatment for cervical spine injury are to stabilize the spine and prevent or minimize complications. Stabilization, whether surgical or nonsurgical, aims to maintain the injured patient’s neurologic function.

Stabilizing the spine
The nonsurgical approach to stabilization includes using orthotic devices, such as rigid or soft cervical collars, cervical traction, and halo vests. These devices decrease neck mobility, allowing the injury to heal through normal processes.
Orthotic devices such as cervical collars are used in the field and the emergency department to quickly immobilize the spine. Such devices should not be removed until you have written orders stating that based on radiologic and clinical examinations, the spine is clear of unstable injury.
If a patient has some spinal instability, but surgical intervention won’t be performed, he may need to wear a collar for several months. Cervical collars may also be used after surgery if the patient has a high risk of not healing—because he smokes or is unlikely to comply with activity restrictions, for example.
When spinal instability puts a patient at risk for progressive, secondary loss of motor and sensory function, he may need surgery. Research suggests that early surgical intervention increases the overall clinical benefits. The goals of surgery are to remove pressure from the spinal cord from bone or disk fragments and to provide internal stabilization, typically by placing hardware, such as plates, screws, rods, and cages.
Nursing care after surgery includes frequent neurologic and respiratory assessments and pain management. After the spine is stabilized by surgical or nonsurgical means, nursing care includes minimizing complications.


Minimizing complications
One serious complication is ascending spinal cord damage. The spinal cord rests in a narrow canal and has little room to swell laterally at the point of injury, so edema may ascend or descend the cord, placing the patient at risk for progressive neurologic dysfunction. Aggressive treatment consists of giving high-dose corticosteroid therapy within
8 hours of an acute, nonpenetrating injury, based on institutional protocols. Nursing care during cortico­-steroid administration includes assessing the patient for adequate oxygenation and monitoring the I.V. site for continuous administration. Patients receiving corticosteroids are at risk for developing diabetes and stress ulcers, so monitor blood glucose levels regularly and make sure the patient receives medication to prevent gastrointestinal distress. One of your highest priorities is thorough, frequent neurologic assessment. Perform full motor and sensory examinations regularly, paying particular attention to function affected by the spinal cord two to three levels above and below the injury. For patients with a cervical injury, assess the strength and equality of shoulder movements, flexion and extension of the elbows, flexion and extension of the wrist and fingers, and abduction and adduction of the fingers.
Patients in the acute phase of injury, especially those with injuries at C5 or above, are at risk for respiratory insufficiency. Patients with injuries above C5 may be intubated, and those at high risk for ascending edema may be placed on a ventilator. Patients with injuries above C7, especially those over age 45, may need a tracheotomy. On admission, aggressive pulmonary toileting measures should begin. Encourage patients who can use incentive spirometry to do so every hour. If a patient is receiving mechanical ventilation, collaborate with respiratory care personnel to implement an aggressive regimen. After orders have been received stating the patient’s injury is stable enough for patient turning, turn him every 2 hours. Remember, early mobilization helps prevent long-term respiratory complications. And early mobilization and intermittent pneumatic compression devices help prevent venous thromboembolism.
Patients with spinal cord injury, especially those with injuries between C1 and C5, are at risk for neurogenic shock in the acute phase of injury. Neurogenic shock occurs when autonomic function is lost, resulting in bradycardia and severe hypotension that place patients at risk for cardiac complications and may lead to cardiac arrhythmias. Nursing care includes placing the patient on a cardiac monitor and assessing vital signs frequently. Acute nursing interventions also include administering fluids and vasopressors, if the patient’s condition warrants. Orthostatic hypotension can result from spinal cord injury and may be treated by using an abdominal binder and support stockings and raising the patient slowly from a lying to sitting position.
An acute loss of spinal cord innervation can also result in an atonic bladder, making an indwelling catheter necessary. To minimize the risk of urinary tract infections, you should begin bladder training and remove the indwelling catheter as soon as possible. A patient may still need intermittent catheterization, but your goal is to limit the number of catheterizations needed daily. After spinal shock resolves, use and teach the patient to use bladder and bowel programs to prevent and treat autonomic dysreflexia, a potentially fatal complication for patients with cervical spine injury.
Providing emotional support
Besides providing nursing assessment and care to prevent serious complications, you’ll need to provide emotional support to patients and families during the acute phase. Such support begins with your patient teaching about the injury and the healthcare team’s plan of action. Then, as the patient’s condition stabilizes, you, along with social workers, therapists, and others providers, will help the patient and family begin to understand—and deal with—the long-term implications of cervical spine injury.

Selected references
American Association of Neuroscience Nurses. Cervical spine surgery: a guide to preoperative and postoperative patient care. Chicago: Author; 2007.
Cook N. Respiratory care in spinal cord injury with associated traumatic brain injury. Intensive Crit Care Nurs. 2003;19(3):143-153.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: The 7th ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(suppl 3):338S-400S.
Hickey J. Vertebral and spinal cord injuries. In: Hickey J, ed: The Clinical Practice of Neurological and Neurosurgical Nursing. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003.
Powe CB. Cervical spine clearance in the blunt trauma patient: a review of current management strategies. J Trauma Nurs. 2006;13(2):80-84.
For a complete list of selected references, visit www.AmericanNurseToday.com.

Paula R. Sherwood, PhD, RN, CNRN, is an Assistant Professor at the School of Nursing and the Department of Neurological Surgery in the School of Medicine at the University of Pittsburgh in Pittsburgh, Pennsylvania. Elizabeth A. Crago, MSN, RN, is a Research Associate at the School of Nursing at the University of Pittsburgh. Richard M. Spiro, MD, is an Assistant Professor in the Department of Neurological Surgery in the School of Medicine at the University of Pittsburgh. David Okonkwo, MD, PhD, is an Assistant Professor in the Department of Neurological Surgery in the School of Medicine at the University of Pittsburgh.

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