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Pre‐procedural considerations

Equipment

Cervical collar or spinal brace

Where there is a risk of spinal instability due to vertebral injury or collapse, patients may require external spinal support. This may be in the form of a spinal brace or collar. A properly fitted hard collar must be used when there is suspicion of spinal instability in the cervical spine (MASCIP [69]). If there is suspected spinal instability in the thoracolumbar region then a spinal brace may be prescribed (GAIN [38]). Depending on local policy, these are available from surgical appliances or orthotics suppliers, or some physiotherapy departments. The manufacturer's product details and care instructions will be provided with the equipment. Staff should be guided by medical advice and local policy on the application of a collar or brace. It is essential that correct fitting and application of the collar or brace is adhered to, so as to ensure spinal stability and prevention of damage to pressure areas.

Moving and handling aids

Patients with stable injuries may be able to assist with transfers using transfer boards, standing aids, mobility aids, frames, crutches or sticks. If they are unable to assist, there is a variety of moving and handling aids, for example lateral patient transfer boards, hoists and standing hoists, which maintain the safety of both the patient and the carer.

Assessment and recording tools

The focus of an initial neurological assessment is to establish the level of cord injury and act as a baseline against which future improvements or declines may be compared (Harrison [42]). Standard assessments, including pain, motor and sensory, should be used as a baseline and updated with any change in a patient's presentation. It is vital that anal tone and sensation are assessed in all patients to establish the extent of damage to the spinal cord and whether bowel management strategies are required.
Assessments will depend on local policy and may include:
  • the American Spinal Injury Association's International Standards for Neurological Classification of Spinal Cord Injury (ASIA [7])
  • a pain assessment tool, for example a visual analogue scale (Dijkers [32])
  • a bladder and bowel management assessment (MASCIP [68])
  • a pressure ulcer assessment (see Chapter c18: Wound management).

Pain management: pharmacological and non‐pharmacological

As already discussed, spinal and radicular pain can be an indicator of SCI in the first instance but, in relation to moving and handling, it can also be suggestive of changes in neurology. Implementation of a pain assessment chart can enable continuity of care, allowing accurate assessment and evaluation of all pharmacological interventions (i.e. non‐steroidal anti‐inflammatory drugs, opiates, bisphosphonates and epidural) and non‐pharmacological interventions (i.e. relaxation and therapeutic management). Chapter c10: Pain assessment and management provides more specific information.
Table 7.10  Prevention and resolution (Procedures guidelines 7.13, 7.14 and 7.15)
ProblemCausePreventionAction
Autonomic dysreflexia: a mass reflex due to excessive activity of the sympathetic nervous system by noxious stimuli below the level of the lesion. It is a potential complication for all patients with complete lesions above T6. Symptoms:
  • bradycardia
  • hypertension
  • pounding headache
  • flushing, sweating or blotchy appearance of skin above the level of the lesion.
  • Overstretching of bladder or rectum (urinary obstruction being the most common cause)
  • Ingrowing toenail or other painful stimulus
  • Fracture below level of lesion
  • Pressure sore, burn, scald or sunburn
  • Urinary tract infection or bladder spasm
  • Visceral pain or trauma
  • Closely monitor urinary drainage
  • Bowel management regime
  • Early recognition that an individual with SCI above T6 often has a normal systolic blood pressure in the 90–110 mmHg range; blood pressure of 20 to 40 mmHg above baseline may be a sign of autonomic dysreflexia
  • This is a medical emergency as it could induce a myocardial infarct or a cerebrovascular accident
  • Sit the patient up
  • Loosen or remove tight clothing
  • Monitor blood pressure every 2–5 minutes
  • The patient's bladder and bowel should be checked as these are the most common causes
  • If the blood pressure is >150 mmHg, start pharmacological management (10 mg nifedipine sublingual or GTN spray: 1–2 sprays); repeat every 20–30 minutes if needed (RNOH [110])
Orthostatic hypotension: low blood pressure when moving from lying to upright position.
  • Loss of sympathetic vasoconstriction
  • Loss of muscle‐pumping action for blood return
  • Antiembolic stockings
  • Careful assessment and monitoring during early mobilization and upright position changes
  • Medical review: use of medication prior to mobilization
  • Trial of abdominal binder (Lundy‐Ekman [67])
Pain: increased pain on movement to the extent that it is perceived by the patient as severe or does not reverse with rest.
  • Potential extension of spinal cord compression
  • Ensure patients with unstable spine are moved correctly
  • Nurse patient flat
  • Reassess spinal stability prior to further movement (GAIN [38])
Impaired respiratory function: reduced respiratory function in a patient with lesions of T12 and above, especially T6 and above (GAIN [38]).Respiratory function following SCI is determined by the level and extent of injury. Alterations of respiratory function following SCI include:
  • reduction in lung capacity
  • impaired ability to cough
  • altered breathing pattern
  • imbalance in ANS following SCI above the level of T6, with relative bronchoconstriction (airway narrowing) and increased secretion production
  • chronic secondary changes including reduction in lung and chest wall compliance.
  • Routine assessment of respiratory function (e.g. vital capacity) (GAIN [38])
  • Consideration of prophylactic management including manual cough assistance and use of a cough assist machine (contact physiotherapist)
  • Education to promote long‐term self‐management (RNOH [110])
  • If patient's respiratory function decreases, contact medical team urgently
Reduced skin integrity: risk to skin integrity and the development of pressure sores.
  • Reduced mobility
  • Poor circulation
  • Altered sensation
  • Friction and shearing damage (GAIN [38])
  • Use of correct manual handling equipment
  • Regular positional changes
  • Regular assessment of the skin and pressure areas
  • Consider nutritional status
  • Contact local tissue viability service
ANS, autonomic nervous system; GTN, glyceryl trinitrate; SCI, spinal cord injury.
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