Nurses’ role in both prevention and treatment of cervical and lumbar injuries
A spinal cord injury is devastating for a patient, their family and their caregivers. Every 44 minutes a person sustains a spinal cord injury (SCI) in the United States resulting in approximately 12,000 SCIs each year.1 There are more than 265,000 persons currently living with this type of injury in the United States, and one out of every 50 persons lives with paralysis. 1 So as nurses, what can we do to reduce the risk of spinal cord injury in hopes of positively affecting these statistics?
Spinal Cord Injury Prevention
Motor Vehicle Accidents
Although there are seatbelt laws and texting while driving bans, motor vehicle accidents remain the number one cause of spinal cord injuries. In 2015, motor vehicle accidents were predicted to be the leading cause of premature death and disability in children ages five and older.1 Using a cell phone while driving, handheld or hands free, increases the risk of injury and damages four times.1
The average age for a driver or passenger at the time of a motor vehicle injury has increased to 40.7 years; while in the 1980s, the average age ranged from 15-29 years.1 Males are more likely to become injured, at 80%. Alcohol is a factor in approximately a quarter of all SCIs.1
General Automobile Accident Prevention Tips:
- Wear a seatbelt
- Properly restrain children ages 12 and under in the backseat
- Children who have outgrown child safety seats should use booster seats until they are at least the age of eight or 4’9” in height1
- Follow the speed limit
- Avoid distractions while driving, including the use of a cell phone
- Do not drink and drive
Acts of Violence
Approximately 25 percent of spinal cord injuries are related to acts of violence, resulting in more spinal cord injuries in the United States than in Western Europe or Australia. Gun owners should utilize gun safety, and precautions should be taken to make sure that guns are unloaded and ammunition is in a safe place.1,2
Falls account for approximately 22% of spinal cord injuries and are the leading cause of spinal cord injuries in persons 45 years and older.1
Fall Prevention Tips:
- Install proper lighting
- Use handrails
- Free floors of clutter and clean up any spills
- Utilize grab bars in bathrooms
- Remove throw rugs and repair flooring or carpet if damaged
- Proceed with extra caution when walking on uneven surfaces or being outdoors
- Avoid electrical cords in walkways3
Sports-related injuries are also a large contributor of SCIs, with football and wrestling having the highest incidence of injuries. Diving injuries among amateurs occur more than 1,000 times per year, with 90% resulting in paralysis and in less than six feet of water. Skateboarding, in teenagers 16 years-of-age and under, and skiing are also causes of injury. Bicycles are common causes of head injuries, but using properly fitting helmets can also prevent spinal cord injuries.2
Sports Injury Prevention Tips:
- Wear proper equipment and safety gear when playing sports
- Avoid helmet-to-helmet contact
- Always know the depth of water before diving in – only dive if water is at least nine feet deep – and if is there any slope to the pool1
- Avoid diving if water is not clear, such as for a lake or ocean1
- Walk into any water the first time to learn surroundings
- Inspect skateboard or skates before each use
- Wear properly fitted clothing
Lifetime Effects of a Spinal Cord Injury
Life expectancy has increased for persons with a spinal cord injury but still remains lower than the expectations in the general population. The lifetime costs of individuals who live with a spinal cord injury can be significant and fluctuate on the severity of the injury and side effects.1
Approximate lifetime costs living with a spinal cord injury (injured at age 25)1:
- High tetraplegia (C1-C4) = $2,712,000
- Low tetraplegia (C5-C8) = $1,848,000
- Paraplegia = $1,109,000
Treating Spinal Cord Injuries
Reducing risks for spinal cord injuries is important, but let us also think of our role in reducing complications once a spinal cord injury has happened. Depending on the level of injury, a patient may or may not be at a greater risk for complications. With injury to C1-T1, a patient is considered to have tetraplegia. Injury to C1-T12 is an Upper Motor Neuron (UMN) injury. For injury to T2 and below, a patient is considered to have paraplegia. Lower Motor Neuron (LMN) is injury below T12. With UMN, the patient will be spastic, and LMN patients will be flaccid. Knowing the level of injury and what a patient will be able to do at each level prepares nurses to better care for patients.
When completing a plan of care, we must think of the level of spinal cord injury and how this will affect the patient’s respiratory system, GI/GU, skin and temperature regulation, as the patient can overheat easily and/or be chilled the next minute. A patient will be at risk for pneumonia, venous thromboembolisms (VTEs), bowel and bladder issues/incontinence, infections, autonomic dysreflexia (T6 or above injuries) and wounds. Patients who are at risk for venous thromboembolism (VTE) will usually develop a deep vein thrombosis and then a pulmonary embolism.
Patients with injuries in the cervical region will have a higher incidence of respiratory complications and pneumonia, which, along with septicemia, are the leading causes of death in spinal cord patients. Using incentive spirometry, nurses encourage patients to deep breathe while monitoring lung sounds and vital signs.
Whether a patient is an UMN or LMN will impact their bowel and bladder function. Working with a patient’s bowel history and caregiver’s availability, the patient’s bowel program should be individualized, with the end goal of continence. Teaching signs and symptoms of infection is a must, monitoring for fevers and change in urine odor, color, and sediment.
Autonomic dysreflexia can be life threatening to spinal cord patients. A patient will usually complain of a headache or not feeling well. They can be flushed, with goose bumps and nasal congestion; diaphoretic above the level of injury; and below the level of injury, pale, cool and dry.
First, sit the patient up either in their bed or wheelchair, and drop their legs down if possible. If a Foley catheter is in place, look to see if it is kinked or obstructed. Even if the patient was catheterized two hours ago, they will need to be catheterized again. 85% of autonomic dysreflexia is caused from bladder issues. Next, check for bowel issues. Does the patient have an impaction?
Another cause of automatic dysreflexia are skin issues. Monitoring the patient’s skin daily is something the patient, family and/or caregivers should be trained to do. Any bony prominences and also heels, skin folds and coccyx, should be monitored. Are there wrinkles under the patient? Is there a wound or worsening wound? Once the cause has been found, the patient will return to their previous state within a couple of hours. Continue to monitor vital signs until back to baseline.
As nurses, we face a lot of challenges with both preventing spinal cord injuries, and reducing risks of complications after diagnosis. Providing education to the patient, family and caregivers is extremely important. It’s important to educate them on their injury and also how to properly care and monitor their body to remain as healthy as possible.
1. American Spinal Cord Injury Association. Prevention Committee Resources – Facts on SCI Prevention. http://www.asia-spinalinjury.org/committees/prevention_facts.php. Accessed March 21, 2016.
2.American Association of Neurological Surgeons – ©AANS June 2008. Spinal Cord Injury Prevention Tips. Accessed March 21, 2016.
3. Evidences Based Practice in Primary Prevention of Spinal Cord Injury: Top Spinal Cord Inj Rehabil 2013;19(1):25-30 ©2013 Thomas Land Publishers, Inc, www.thomasland.com: doi:10.1310/sci1 901-25
5. HealthSouth Spinal Cord Course – Bolyard served as a team member in the development of this course.