Analgesia
Analgesia — the absence of sensitivity to pain — can help to identify the type of nervous system lesion and determine its location. For example, thermanesthesia (loss of temperature sensation) without other sensory changes can occur because although all sensory nerve impulses follow the same route, only a few may be blocked when there is an incomplete spinal cord lesion. When all sensory impulses are blocked, the origin of the injury could be in the brain, spinal cord, or peripheral nerves. Examples of other sensory deficits include paresthesia (loss of proprioception and vibratory sense) and tactile anesthesia.
Below the level of the lesion, analgesia can be classified as partial or total and unilateral or bilateral. The onset may be slow and progressive, as seen with a tumor, or abrupt, as seen with trauma. Analgesia may be transient and resolve spontaneously.
Act Now: If the patient exhibits unilateral or bilateral analgesia over a large body surface, suspect a spinal cord injury and maintain proper body alignment until the spinal cord is stabilized. A cervical collar and a long backboard are the standards of care. If a collar is unavailable, maintain the patient’s head position with sandbags placed around the head and neck. Be prepared for an emergency response if respiratory failure occurs.
Assessment
History
After assuring spinal cord stabilization, proceed with assessing the patient. Establish the onset of analgesia (sudden or gradual). Did the patient suffer recent trauma, such as a fall, sports injury, or automobile accident? Obtain a complete medical history, noting incidence of cancer in the patient or his family.
Physical examination
Assess the patient’s vital signs, including the pattern of respirations. Determine his level of consciousness. Assist to test pupillary, corneal, cough, and gag reflexes to rule out brain stem and cranial nerve involvement. If the patient is conscious, evaluate his ability to swallow.
Assist to perform a full neurologic assessment, including orientation to person, place, and time. Assess the patient’s ability to speak clearly, pupil size and reaction to light, ability to follow commands, ability to wiggle extremities, and awareness of touch. Test for other sensory deficits over all dermatomes (individual skin segments innervated by a specific spinal nerve) by applying light tactile stimulation with a tongue depressor or cotton swab. Perform a more thorough assessment of pain sensitivity, if necessary, using a pin. (See Testing for analgesia, pages 18 and 19.) Assess the patient’s temperature sensation over all dermatomes, using two test tubes — one filled with warm water, the other with cold water. In each arm and leg, test vibration sense (using a tuning fork), proprioception, and superficial and deep tendon reflexes (DTRs). Check for increased muscle tone by extending and flexing the patient’s elbows and knees as he tries to relax.
After a spinal cord injury is ruled out, observe the patient’s gait and posture and assess his balance and coordination. Evaluate muscle tone and strength in all extremities.
Pediatric pointers
Because a child may have difficulty describing analgesia, observe him carefully during the assessment for nonverbal clues to pain, such as facial expressions, crying, and retraction from stimuli. Remember that pain thresholds are high in infants, so your assessment findings may not be reliable. Also, remember to test the temperature of bath water carefully for a child who’s too young to test it himself.
Geriatric pointers
Pre-existing sensory deficits in elderly patients may make an immediate diagnosis more difficult. Because elderly patients may have some degree of impairment to skin integrity, make sure that the water temperature used for sensory assessment won’t burn the skin.
Medical causes
Anterior cord syndrome
Analgesia and thermanesthesia occur bilaterally below the level of the lesion, along with flaccid paralysis and hypoactive DTRs.
Central cord syndrome
Analgesia and thermanesthesia occur bilaterally in several dermatomes, in many cases extending in a capelike fashion over the arms, back, and shoulders. Early weakness in the hands is evident and progresses to weakness and muscle spasms in the arms and shoulder girdle. Hyperactive DTRs and spastic weakness of the legs may develop. (If hypoactive, DTRs and flaccid weakness persist in the legs, a lesion in the lumbar spine may be suspected.)
With brain stem involvement, additional findings include facial analgesia and thermanesthesia, vertigo, nystagmus, atrophy of the tongue, dysarthria, dysphagia, urine retention, anhidrosis, decreased intestinal motility, and hyperkeratosis.
Spinal cord hemisection
Contralateral analgesia and thermanesthesia occur below the level of the lesion. In addition, loss of proprioception, spastic paralysis, and hyperactive DTRs develop ipsilaterally. Urine retention with overflow incontinence may be present.
Other causes
Drugs
Analgesia may occur with the use of a topical or local anesthetic, although numbness and tingling are more common.
Nursing considerations
Maintain spinal alignment during transport for laboratory or radiologic procedures. Monitor the patient’s vital signs and neurologic assessment closely. Provide continuous emotional support to the patient and his family.
Prevent pressure ulcer formation by such measures as meticulous skin care, massage, and frequent repositioning, especially when significant motor deficits hamper the patient’s movement. Guard against scalding by testing the water temperature before the patient bathes.
Patient teaching
Explain all tests and procedures. Advise the patient to test the water at home using a thermometer or a body part with intact sensation before showering or bathing.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Spine symptoms
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