3.2 Spinal Cord Injury

Spinal cord injury (SCI) scenarios are heavily weighted within the neuro-rehabilitation domain because outcomes are tightly tied to injury level and completeness, and because one SCI complication - autonomic dysreflexia - is a true emergency the rehabilitation nurse must recognize instantly.

SCI Levels and Terminology

The neurologic level of injury is the lowest spinal segment with normal motor and sensory function on both sides. Level determines function.

• Tetraplegia (quadriplegia) - cervical injury affecting all four limbs and trunk.
• Paraplegia - thoracic, lumbar, or sacral injury affecting the trunk and lower limbs, with arms spared.

ASIA Impairment Scale

The American Spinal Injury Association (ASIA) Impairment Scale (AIS) classifies completeness. The defining concept is sacral sparing - preserved motor or sensory function in the lowest sacral segments (S4-S5), assessed by deep anal pressure, voluntary anal contraction, and perianal sensation.

Complete injury means no sacral sparing (AIS A). Incomplete injury means some function - including sacral sparing - is preserved below the level (AIS B-D), which generally carries a better functional prognosis.

Common Incomplete Syndromes

• Central cord syndrome - greater weakness in the arms than legs; often after hyperextension in older adults.
• Brown-Sequard syndrome - hemisection: ipsilateral motor loss with contralateral pain and temperature loss.
• Anterior cord syndrome - loss of motor and pain/temperature with preserved proprioception; poor prognosis.

Autonomic Dysreflexia: A Medical Emergency

Autonomic dysreflexia (AD) is a sudden, exaggerated sympathetic response to a noxious stimulus below the injury level, occurring in injuries at or above T6. Untreated, it can cause stroke, seizure, or death.

Recognize it: sudden severe pounding headache, sharply elevated blood pressure (often 20-40 mmHg above baseline), bradycardia, flushing and sweating above the level, and pallor, cool skin, or piloerection below the level.

Manage it - in order:

1. Sit the patient upright and lower the legs to use orthostatic drop to reduce blood pressure.
2. Loosen constrictive clothing or devices (binders, leg bags, stockings).
3. Find and remove the noxious stimulus. Check the bladder first - a kinked catheter or distended bladder is the most common trigger; then assess for bowel impaction and skin sources (pressure injury, tight shoe, ingrown nail).
4. Monitor blood pressure every 2-5 minutes and notify the provider; antihypertensives may be ordered if the trigger cannot be found and pressure remains dangerously high.

Do not leave the patient flat or delay finding the trigger to give medication first when a removable cause is present.

Neurogenic Bladder and Bowel

SCI disrupts bladder and bowel control, creating a neurogenic bladder and neurogenic bowel. A distended bladder or bowel impaction is also a leading AD trigger, so these programs are both functional and safety priorities.

• Bladder: scheduled intermittent catheterization is generally preferred over indwelling catheters to reduce infection and AD risk; fluid timing and volume are managed deliberately.
• Bowel: a consistent bowel program at the same time daily, using timing, diet/fiber, fluids, activity, and stimulation (digital stimulation or suppository as ordered) prevents impaction and incontinence.

Respiratory Considerations by Level

The diaphragm is innervated by C3-C5 (phrenic nerve), so cervical level drives respiratory risk.

Assisted cough (quad cough), pulmonary hygiene, and vigilance for respiratory infection are core nursing actions in cervical and high-thoracic SCI.

Functional Outcomes by Level

These outcomes assume a complete injury; incomplete injuries can exceed them. The rehabilitation nurse uses level-based expectations to set realistic goals, prevent immobility complications, and reinforce the interdisciplinary plan.

Spinal Shock vs. Autonomic Dysreflexia

Do not confuse two opposite phenomena. Spinal shock occurs in the acute period after injury: a transient loss of all reflexes, flaccid paralysis, and absent sensation below the level, often with neurogenic shock (hypotension and bradycardia from loss of sympathetic tone in injuries above T6). It resolves over days to weeks as reflexes return. Autonomic dysreflexia, by contrast, is a chronic-phase emergency of excessive sympathetic response with severe hypertension.

The exam may pair them to test whether you can tell acute low blood pressure (neurogenic/spinal shock) from chronic dangerously high blood pressure (autonomic dysreflexia).

Thermoregulation, DVT, and Skin

Above roughly T6, patients become poikilothermic — they cannot regulate body temperature well below the lesion and tend to assume the ambient temperature, so the nurse manages the environment and avoids overheating or chilling. SCI patients are at very high risk for deep vein thrombosis (prophylaxis and surveillance are routine), orthostatic hypotension (gradual upright progression, abdominal binder, compression), and pressure injury over insensate bony prominences (rigorous repositioning, pressure-relief weight shifts every 15–30 minutes in a wheelchair, daily skin inspection).

Teaching the patient to direct their own skin checks and weight shifts is a core independence goal.