(ACUTE REHABILITATIVE PHASE)
I. Pathophysiology—injury or insult to spinal cord
a. Primary mechanism of injury (Hausman, 2006)
i. Hyperflexion (sudden acceleration forward) or hyperextension
(sudden acceleration forward, followed by
sudden deceleration) of neck
ii. Compression of spine: as with fall from height landing
on feet or buttocks, or blow to top of head as in a diving
iii. Rotation injury: Head is rotated beyond normal range.
iv. Penetrating injuries
1. Low-velocity, such as knife causing direct and local
injury to site
2. High-velocity, such as bullet or shrapnel causing both
direct and indirect damage
b. Secondary mechanism of injury (National Institute for
Neurological Disorders and Stroke [NINDS], 2003)
i. Hemorrhage and vascular insult
ii. Highly reactive chemicals called oxidants or “free
radicals” attack the body’s natural defenses and critical
iii. Release of excess neurotransmitters, leading to
secondary damage from overexcited nerve cells
iv. Neurogenic shock with hypoxemia and ischemia
v. Fluid and electrolyte imbalances
vi. Damage to axons—Nerve fibers that signal to other cells
vii. Nerve cells in the spinal cord below the lesion may die,
disrupting spinal cord circuits that help control movement
and interpret sensory information
c. Neurological involvement dependent on level of injury,
degree of spinal shock, phase, and degree of recovery
i. C1 to C3: Tetraplegia with total loss of muscular and
ii. C4 to C5: Tetraplegia with poor pulmonary capacity,
complete dependency for activities of daily living
iii. C6 to C7: Tetraplegia with some arm and hand movement
allowing some independence in upper body ADLs
iv. C7 to T1: Tetraplegia with limited use of fingers and
thumbs, increasing independence
v. T2 to L1: Paraplegia with intact arm function, varying
function of intercostal and abdominal muscles, and loss
of function below level of injury
vi. L1 to L2 or below: Mixed motor-sensory loss and bowel
and bladder dysfunction
a. Complete: total loss of sensation and voluntary motor
b. Incomplete: mixed loss of sensation and voluntary motor
III. Etiology (National Spinal Cord Injury Statistical Center
a. Trauma: Leading cause of spinal cord injury (SCI); motor vehicle
crashes account for 42% of reported SCI cases since 2005
b. Falls: second most common cause
c. Acts of violence: primarily gunshot wounds
IV. Statistics (NSCISC, 2008)
a. Morbidity: Approximately 12,000 new cases annually and
227,080 to 300,938 individuals living with SCI in 2007; primarily
affects young adults (aged 16 to 30); however, since
2005, average age of injury has increased to 39.5 years
(may reflect injury to a higher number of persons over 60
and war-related injury statistics); 77.8% are males.
b. Mortality: Rates significantly higher during first year after
injury due to pneumonia, pulmonary emboli, sepsis;
subsequently, death often related to treatable health problems,
such as with cardiovascular and respiratory diseases
or diabetes mellitus.
c. Cost: Approching $4 billion annually; in 2005, average
first-year expenses for a SCI (all groups) was $198,000 and
for quadriplegics with age of injury at age 25, $3 million
average lifetime cost.
Client is treated in inpatient medical-surgical, subacute, and
Psychosocial aspects of care
Thrombophlebitis: deep vein thrombosis
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Ventilatory assistance (mechanical)
1. Maximize respiratory function.
2. Prevent further injury to spinal cord.
3. Promote mobility and independence.
4. Prevent or minimize complications.
5. Support psychological adjustment of client and significant
6. Provide information about injury, prognosis and expectations,
treatment needs, and possible and preventable
1. Ventilatory effort adequate for individual needs.
2. Spinal injury stabilized.
3. Complications prevented or controlled.
4. Self-care needs met by self and with assistance, depending
on specific situation.
5. Beginning to cope with current situation and planning for
6. Condition, prognosis, therapeutic regimen, and possible
7. Plan in place to meet needs after discharge.