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Neurologic cheat sheet

Spinal Cord Injury Cheat Sheet

Injury levels and deficits, emergency immobilization, autonomic dysreflexia, neurogenic vs spinal shock, and spinal surgeries — high-yield for the NCLEX-RN.

What's in this cheat sheet

Trauma to the spinal cord disrupts motor, sensory and autonomic signaling below the level of injury. This cheat sheet covers how injury level predicts deficit, the airway-first emergency sequence and spinal immobilization, the acute-care priorities including the medical emergency of autonomic dysreflexia, and the nursing care for common spinal surgeries.

1

Pathophysiology & Assessment

Complete vs incomplete injury, the secondary injury cascade, and how injury level maps to clinical deficit and risk.

2

Emergency Management

Airway and breathing first, immediate spinal immobilization, IV access and neurogenic vs hemorrhagic shock.

3

Acute Care

Maintaining alignment and halo care, neuro monitoring, autonomic dysreflexia and preventing immobility complications.

4

Spinal Surgeries

Discectomy, laminectomy and fusion with post-op alignment, neuro checks and recognizing a CSF leak.

Key Takeaways

High-yield facts most likely to appear on the NCLEX-RN.

Cervical injuries at C3–C5 paralyze the diaphragm — continuously monitor respiratory status and be ready to assist with intubation.

Treat ALL trauma as a potential SCI until proven otherwise: apply a cervical collar immediately and use the logroll technique.

Halo traction: monitor pin sites and skin under the vest, and keep a wrench at the bedside for emergency vest removal during CPR.

Autonomic dysreflexia (injuries T6 and above): severe HTN, bradycardia, pounding headache, flushing — sit the patient up and remove the trigger.

Neurogenic shock = hypotension + bradycardia + warm dry skin; hemorrhagic shock = hypotension + tachycardia + cold clammy skin.

After spinal surgery, maintain alignment and monitor extremity motor/sensory function — any acute change needs urgent review.

1. Pathophysiology & Assessment

Complete SCI

Total loss of motor and sensory function below the injury level.

Incomplete SCI

Some function preserved — prognosis is better.

Secondary injury cascade: Cord edema develops rapidly → reduces perfusion → ischemia → secondary neuronal death. This is the key reason for urgent treatment.

Injury level vs clinical deficit

LevelDeficitKey risk
Cervical (C1–C8)Tetraplegia (all 4 limbs)Respiratory failure
Thoracic (T1–T12)Paraplegia (trunk + legs)Trunk instability
Lumbar / SacralParaplegia (legs only)Bowel/bladder dysfunction

Key assessment findings

  • Loss of sensation and voluntary movement below the injury level
  • Absent or decreased deep tendon reflexes
  • Bladder/bowel dysfunction (retention or incontinence)
  • Loss of temperature regulation below the injury

2. Emergency Management

Treat every trauma patient as a potential SCI until imaging rules it out.

Critical sequence

  • 1. Airway & breathing — cervical SCI may paralyze the diaphragm (C3–C5); monitor SpO2, prepare to intubate
  • 2. Cervical collar — apply a rigid C-collar (the #1 immobilization action)
  • 3. Backboard immobilization — logroll with a minimum of 4 people for repositioning
  • 4. Rapid transport, maintaining neutral spinal alignment

IV access & hemodynamic support

  • Establish 2 large-bore IV lines; give fluids cautiously to avoid overload
  • Target MAP ≥ 85–90 mmHg to perfuse the cord
  • Use vasopressors (norepinephrine) for neurogenic shock

Neurogenic vs hemorrhagic shock

FeatureNeurogenicHemorrhagic
HRBradycardiaTachycardia
SkinWarm, dryCold, clammy
BPLowLow

3. Acute Care Management

Alignment & halo traction

  • Logroll when repositioning (minimum 4 staff); never remove the C-collar without an order
  • Clean halo pin sites with sterile water or chlorhexidine daily; pad pressure points
  • Keep a wrench at bedside — required to remove the vest for CPR
  • Teach: move the whole body together, no twisting or bending

Neurogenic shock

Hypotension + bradycardia + vasodilation. Treat with IV fluids and vasopressors.

Spinal shock

Temporary flaccid paralysis below injury; resolves in days–weeks but masks true neuro status.

Autonomic dysreflexia (AD) — medical emergency

SignsTriggersInterventions
Severe HTN, pounding headacheBladder distension (most common)1. Raise HOB immediately (lowers BP)
BradycardiaFecal impaction / constipation2. Find & remove the stimulus: catheterize, disimpact
Sweating/flushing above injuryPressure injury, tight clothing, UTI3. Loosen tight clothing; give antihypertensive (nifedipine) if unresolved; notify HCP
AD occurs at T6 and above: An exaggerated sympathetic response to a noxious stimulus below the injury. Untreated it can cause stroke, MI or seizures — act immediately.

Preventing complications of immobility

  • DVT: sequential compression devices + LMWH
  • Pressure injuries: turn every 1–2 hours, specialty mattress, daily skin checks
  • Bowel/bladder program: intermittent catheterization, stool softeners
  • Respiratory: incentive spirometry, chest physiotherapy, assisted coughing

4. Spinal Surgeries

Procedures

ProcedurePurpose
DiscectomyRemoves herniated disc material pressing on a nerve
LaminectomyRemoves part of the vertebral arch to decompress cord/nerves
Spinal fusionFuses two or more vertebrae to stabilize the spine

Post-op nursing priorities

  • Maintain strict spinal alignment — logroll, no twisting or bending; brace as prescribed
  • Assess motor and sensory function in all four extremities every 1–4 hours
  • Acute neuro deterioration → suspect cord compression or epidural hematoma → notify HCP STAT
  • Multimodal pain control; SCDs/LMWH; incentive spirometry; monitor for infection
CSF leak — recognize & act fast: Clear/colorless drainage on the dressing with a severe positional headache. Lay the patient flat immediately, notify the HCP, and do NOT reposition until ordered. The fluid tests glucose-positive.

Spinal Cord Injury Self-Test

6 quick questions — answers reveal after you submit.

Q1. A client with a C4 spinal cord injury is admitted. Which assessment is the highest nursing priority?

Q2. A client with a T4 spinal cord injury suddenly develops a pounding headache, BP of 200/110, and flushing above the injury. What is the nurse's first action?

Q3. Which finding distinguishes neurogenic shock from hemorrhagic shock?

Q4. A client is in halo traction. Which item must remain at the bedside at all times?

Q5. After a laminectomy, the nurse notes clear drainage on the dressing and the client reports a severe headache that worsens when sitting up. What should the nurse do first?

Q6. When repositioning a client with an acute spinal cord injury, which technique must the nurse use?

Answered 0 / 6 — unanswered count as incorrect.

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