Spinal cord injury 

Overview

A spinal cord injury is damage to the spinal cord. It’s an extremely serious type of physical trauma that’s likely to have a lasting and significant impact on most aspects of daily life.

The spinal cord is a bundle of nerves and other tissue that the vertebrae of the spine contains and protects. The vertebrae are the bones stacked on top of each other that make up the spine. The spine contains many nerves, and extends from the brain’s base down the back, ending close to the buttocks.

The spinal cord is responsible for sending messages from the brain to all parts of the body. It also sends messages from the body to the brain. We’re able to perceive pain and move our limbs because of messages sent through the spinal cord.

If the spinal cord sustains an injury, some or all of these impulses may not be able to “get through.” The result is a complete or total loss of sensation and mobility below the injury. A spinal cord injury closer to the neck will typically cause paralysis throughout a larger part of the body than one in the lower back area.

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 Spinal cord injury symptoms

A complete SCI produces total loss of all motor and sensory function below the level of injury. Nearly 50% of all SCIs are complete. Both sides of the body are equally affected. Even with a complete SCI, the spinal cord is rarely cut or transected. More commonly, loss of function is caused by a contusion or bruise to the spinal cord or by compromise of blood flow to the injured part of the spinal cord.

In an incomplete SCI, some function remains below the primary level of the injury. A person with an incomplete injury may be able to move one arm or leg more than the other or may have more functioning on one side of the body than the other.

SCIs are graded according to the American Spinal Injury Association (ASIA) grading scale, which describes the severity of the injury. The scale is graded with letters:

• ASIA A: injury is complete spinal cord injury with no sensory or motor function preserved.
• ASIA B: a sensory incomplete injury with complete motor function loss.
• ASIA C: a motor incomplete injury, where there is some movement, but less than half the muscle groups are anti-gravity (can lift up against the force of gravity with a full range of motion).
• ASIA D: a motor incomplete injury with more than half of the muscle groups are anti-gravity.
• ASIA E: normal.

The more severe the injury, the less likely a recovery will occur.

Spinal concussions can also occur. These can be complete or incomplete, but spinal cord dysfunction is transient, generally resolving within one or two days. Football players are especially susceptible to spinal concussions and spinal cord contusions. The latter may produce neurological symptoms, including numbness, tingling, electric shock-like sensations and burning in the extremities.

Open or penetrating injuries to the spine and spinal cord, especially those caused by firearms, may present somewhat different challenges. Most gunshot wounds to the spine are stable; i.e., they do not carry as much risk of excessive and potentially dangerous motion of the injured parts of the spine. Depending upon the anatomy of the injury, the patient may need to be immobilized with a collar or brace for several weeks or months so that the parts of the spine fractured by the bullet heals. In most cases, surgery to remove the bullet does not yield much benefit and may create additional risks, including infection, cerebrospinal fluid leak and bleeding. However, occasional cases of gunshot wounds to the spine may require surgical decompression and/or fusion in an attempt to optimize outcome.

Emergency signs and symptoms of a spinal cord injury after an accident may include:

• Extreme back pain or pressure in your neck, head or back
• Weakness, incoordination or paralysis in any part of your body
• Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
• Loss of bladder or bowel control
• Difficulty with balance and walking
• Impaired breathing after injury
• An oddly positioned or twisted neck or back

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When to see a doctor

Anyone who experiences significant trauma to his or her head or neck needs immediate medical evaluation for the possibility of a spinal injury. In fact, it's safest to assume that trauma victims have a spinal injury until proved otherwise because:

• A serious spinal injury isn't always immediately obvious. If it isn't recognized, a more severe injury may occur.
• Numbness or paralysis may occur immediately or come on gradually as bleeding or swelling occurs in or around the spinal cord.
• The time between injury and treatment can be critical in determining the extent and severity of complications and the possible extent of expected recovery.

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 Spinal cord injury causes

Spinal cord injuries are most often caused by physical trauma. Forces involved can be hyperflexion (forward movement of the head); hyperextension (backward movement); lateral stress (sideways movement); rotation (twisting of the head); compression (force along the axis of the spine downward from the head or upward from the pelvis); or distraction (pulling apart of the vertebrae). Traumatic SCI can result in contusion, compression, or stretch injury. It is a major risk of many types of vertebral fracture. Pre-existing asymptomatic congenital anomalies can cause major neurological deficits, such as hemiparesis, to result from otherwise minor trauma.

In the US, Motor vehicle accidents are the most common cause of SCIs; second are falls, then violence such as gunshot wounds, then sports injuries. In some countries falls are more common, even surpassing vehicle crashes as the leading cause of SCI. The rates of violence-related SCI depend heavily on place and time. Of all sports-related SCIs, shallow water dives are the most common cause; winter sports and water sports have been increasing as causes while association football and trampoline injuries have been declining. Hanging can cause injury to the cervical spine, as may occur in attempted suicide. Military conflicts are another cause, and when they occur they are associated with increased rates of SCI. Another potential cause of SCI is iatrogenic injury, caused by an improperly done medical procedure such as an injection into the spinal column.

SCI can also be of a nontraumatic origin. Nontraumatic lesions cause anywhere from 30 to 80% of all SCI; the percentage varies by locale, influenced by efforts to prevent trauma. Developed countries have higher percentages of SCI due to degenerative conditions and tumors than developing countries. In developed countries, the most common cause of nontraumatic SCI is degenerative diseases, followed by tumors; in many developing countries the leading cause is infection such as HIV and tuberculosis. SCI may occur in intervertebral disc disease, and spinal cord vascular disease. Spontaneous bleeding can occur within or outside of the protective membranes that line the cord, and intervertebral disks can herniate.  Damage can result from dysfunction of the blood vessels, as in arteriovenous malformation, or when a blood clot becomes lodged in a blood vessel and cuts off blood supply to the cord. When systemic blood pressure drops, blood flow to the spinal cord may be reduced, potentially causing a loss of sensation and voluntary movement in the areas supplied by the affected level of the spinal cord. Congenital conditions and tumors that compress the cord can also cause SCI, as can vertebral spondylosis and ischemia. Multiple sclerosis is a disease that can damage the spinal cord, as can infectious or inflammatory conditions such as tuberculosis, herpes zoster or herpes simplex, meningitis, myelitis, and syphilis.

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 Spinal cord injury prevention

Because spinal cord injuries are often due to unpredictable events, the best you can do is reduce your risk. Some risk-reducing measures include:

• always wearing a seatbelt while in a car
• wearing proper protective gear while playing sports
• never diving into water unless you’ve examined it first to make sure it’s deep enough and free of rocks

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 Spinal cord injury risk factors

Although a spinal cord injury is usually the result of an accident and can happen to anyone, certain factors may predispose you to a higher risk of sustaining a spinal cord injury, including:

• Being male. Spinal cord injuries affect a disproportionate number of men. In fact, females account for only about 20% of traumatic spinal cord injuries in the United States.
• Being between the ages of 16 and 30. You're most likely to suffer a traumatic spinal cord injury if you're between the ages of 16 and 30. The average age at time of injury is 43 years.
• Being older than 65. Falls cause most injuries in older adults.
• Engaging in risky behavior. Diving into too-shallow water or playing sports without wearing the proper safety gear or taking proper precautions can lead to spinal cord injuries. Motor vehicle crashes are the leading cause of spinal cord injuries for people under 65.
• Having a bone or joint disorder. A relatively minor injury can cause a spinal cord injury if you have another disorder that affects your bones or joints, such as arthritis or osteoporosis.

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 Spinal cord injury complications

At first, changes in the way your body functions may be overwhelming. However, your rehabilitation team will help you develop the tools you need to address the changes caused by the spinal cord injury, in addition to recommending equipment and resources to promote quality of life and independence. Areas often affected include:

• Bladder control. Your bladder will continue to store urine from your kidneys. However, your brain may not be able to control your bladder as well because the message carrier (the spinal cord) has been injured.

The changes in bladder control increase your risk of urinary tract infections. The changes may also cause kidney infections and kidney or bladder stones. During rehabilitation, you'll learn new techniques to help empty your bladder.

• Bowel control. Although your stomach and intestines work much like they did before your injury, control of your bowel movements is often altered. A high-fiber diet may help regulate your bowels, and you'll learn techniques to optimize your bowel function during rehabilitation.
• Skin sensation. Below the neurological level of your injury, you may have lost part of or all skin sensations. Therefore, your skin can't send a message to your brain when it's injured by certain things such as prolonged pressure, heat or cold.

This can make you more susceptible to pressure sores, but changing positions frequently — with help, if needed — can help prevent these sores. You'll learn proper skin care during rehabilitation, which can help you avoid these problems.

• Circulatory control. A spinal cord injury may cause circulatory problems ranging from low blood pressure when you rise (orthostatic hypotension) to swelling of your extremities. These circulation changes may also increase your risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus.

Another problem with circulatory control is a potentially life-threatening rise in blood pressure (autonomic hyperreflexia). Your rehabilitation team will teach you how to address these problems if they affect you.

• Respiratory system. Your injury may make it more difficult to breathe and cough if your abdominal and chest muscles are affected. These include the diaphragm and the muscles in your chest wall and abdomen.

Your neurological level of injury will determine what kind of breathing problems you may have. If you have a cervical and thoracic spinal cord injury, you may have an increased risk of pneumonia or other lung problems. Medications and therapy can help prevent and treat these problems.

• Muscle tone. Some people with spinal cord injuries experience one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
• Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility may lead to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes.

A dietitian can help you eat a nutritious diet to sustain an adequate weight. Physical and occupational therapists can help you develop a fitness and exercise program.

• Sexual health. Sexuality, fertility and sexual function may be affected by a spinal cord injury. Men may notice changes in erection and ejaculation; women may notice changes in lubrication. Physicians specializing in urology or fertility can offer options for sexual functioning and fertility.
• Pain. Some people experience pain, such as muscle or joint pain, from overuse of particular muscle groups. Nerve pain can occur after a spinal cord injury, especially in someone with an incomplete injury.
• Depression. Coping with all the changes a spinal cord injury brings and living with pain causes some people to experience depression.

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 Spinal cord injury diagnosis

In the emergency room, a doctor may be able to rule out a spinal cord injury by careful inspection and examination, testing for sensory function and movement, and by asking some questions about the accident.

But if the injured person complains of neck pain, isn't fully awake, or has obvious signs of weakness or neurological injury, emergency diagnostic tests may be needed.

These tests may include:

• X-rays. Medical personnel typically order these tests on people who are suspected of having a spinal cord injury after trauma. X-rays can reveal vertebral (spinal column) problems, tumors, fractures or degenerative changes in the spine.
• Computerized tomography (CT) scan. A CT scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other problems.
• Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is very helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may be compressing the spinal cord.

A few days after injury, when some of the swelling may have subsided, your doctor will conduct a more comprehensive neurological exam to determine the level and completeness of your injury. This involves testing your muscle strength and your ability to sense light touch and pinprick sensations.

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Spinal cord injury treatment

Treatment of SCI begins before the patient is admitted to the hospital. Paramedics or other emergency medical services personnel carefully immobilize the entire spine at the scene of the accident. In the emergency department, this immobilization is continued while more immediate life-threatening problems are identified and addressed. If the patient must undergo emergency surgery because of trauma to the abdomen, chest or another area, immobilization and alignment of the spine are maintained during the operation.

Non-Surgical Treatments

If a patient has a SCI, he or she will usually be admitted to an intensive care unit (ICU). For many injuries of the cervical spine, traction may be indicated to help bring the spine into proper alignment. Standard ICU care, including maintaining a stable blood pressure, monitoring cardiovascular function, ensuring adequate ventilation and lung function and preventing and promptly treating infection and other complications, is essential so that SCI patients can achieve the best possible outcome.

Surgery

Occasionally, a surgeon may wish to take a patient to the operating room immediately if the spinal cord appears to be compressed by a herniated disc, blood clot or other lesion. This is most commonly done for patients with an incomplete SCI or with progressive neurological deterioration. Even if surgery cannot reverse damage to the spinal cord, surgery may be needed to stabilize the spine to prevent future pain or deformity. The surgeon will decide which procedure will provide the greatest benefit to the patient.

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 Spinal cord injury recovery

The sections below will discuss the stages of recovery in more detail.

First stage

The first stage of recovery occurs immediately following a spinal cord injury. This will involve spending time in the hospital, usually in a critical care department. Sometimes, a person will also need to undergo surgery.

A doctor will first check that the person’s airways are clear and that their heart is beating normally. They will then test their movement and whether or not there is any sensation in the arms and legs.

The doctor may use a brace called a cervical collar to keep the spine stable. To examine the damage further, they may also use medical imaging, such as an MRI or CT scan.

Over the next few days, the doctor will focus on limiting the damage and reducing the risk of complications.

After initial treatment in the hospital, the doctor will organize long-term care on a case-by-case basis. They will only release someone with a spinal injury from care once they are stable.

Second stage

The second stage of recovery takes place outside of the hospital and focuses on rehabilitation. This may include undergoing physical or occupational therapy, and it sometimes involves counseling.

In most cases, a person will likely need to live in a subacute rehabilitation facility, where they will receive up to 3 hours of rehabilitation per day.

Some people will need regular checkups with their doctor during the first year. Rehabilitation and care will often continue for many years.

People with spinal cord injuries and their caregivers will also need to monitor for complications during this stage.

In some cases, a person may recover some bodily function up to 18 months after the injury. In a small number of cases, a person can even regain function years after the injury.

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