← Chapter 13
Medical-Surgical Nursing II · Chapter 13

Predict the Function: Cord Level, Shock and Syndromes

The neurological level of injury — the most caudal segment with normal sensation and at least antigravity strength — predicts nearly everything. Set a level and watch nine functions resolve into yes, no and almost. Then separate neurogenic shock from haemorrhage at the bedside, and name the incomplete syndrome from the pattern of what was lost.
Set the neurological level of injury
The definition matters. The neurological level is the most caudal segment with normal sensation and motor strength of at least 3 out of 5 (antigravity), provided the segment above is normal. Function is predicted by what is preserved at and above that level. Tetraplegia means all four limbs and the trunk, from a cervical lesion; paraplegia means the trunk and legs, from a thoracic, lumbar or sacral lesion.
A trauma bay, thirty minutes inBlood pressure 78/44. Set the two findings you can get in ten seconds — the pulse and the skin — and say whether there is a confirmed cord injury.
Heart rate
Skin below the level of injury
Imaging and examination
Spinal shock is not this. Spinal shock is a neurological event — flaccid, areflexic paralysis below the lesion with an atonic bladder and no bulbocavernosus reflex. It is not a circulatory state and the blood pressure can be entirely normal. Neurogenic shock is the circulatory event.
Read the pattern of loss
Name it

C7–C8

A spinal column diagram with the selected level of injury marked and everything below it shaded, alongside guide lines at the diaphragm, the tenodesis level, the independence level and the autonomic dysreflexia threshold LEVEL OF INJURY C3–C5 KEEP THE DIAPHRAGM ALIVE C6 TENODESIS C7 INDEPENDENCE LEVEL T6 — AT AND ABOVE: DYSREFLEXIA RISK Shaded region = below the lesion
What can this person do?

Read the pulse and the skin

The distinguishing question is skin and pulseHypotension plus bradycardia plus warm, dry skin equals neurogenic shock. Hypotension plus tachycardia plus cold, clammy skin equals haemorrhage until proven otherwise. In a multi-trauma patient, look for the second one first — you can treat a vasodilated cord patient with pressors, but you cannot treat a torn spleen with them.

What the pattern says

Six patterns, one questionAsk what was lost and on which side. Motor with pain and temperature but not position sense is a vascular territory. Motor and position sense on one side with pain and temperature on the other is a hemisection. Arms worse than legs is a central lesion. Choose a vignette, then name it.
Everything turns on sacral sparingThe ASIA Impairment Scale runs A complete — no motor or sensory function in the lowest sacral segments S4–S5 — through B sensory incomplete, C motor incomplete with more than half the key muscles below the level weaker than grade 3, D motor incomplete with at least half at grade 3 or better (most of these patients walk), to E normal. That is why the examination always ends with light touch and pinprick at the anal mucocutaneous junction, deep anal pressure and voluntary anal contraction. Never document “complete” without that part of the exam, and never classify at all until spinal shock has resolved — a completely transected cord and a badly bruised one look identical during it.