Spinal cord injury

Overview

A spinal cord injury involves damage to any part of the spinal cord. It also can include damage to nerves at the end of the spinal cord, known as the cauda equina. The spinal cord sends and receives signals between the brain and the rest of the body. A spinal cord injury often causes permanent changes in strength, feeling and other body functions below the site of the injury.

People who have had a spinal cord injury also may experience mental, emotional and social side effects.

Many scientists are optimistic that advances in research will someday make repair of spinal cord injuries possible. Research studies are ongoing around the world. In the meantime, treatments and rehabilitation allow many people with spinal cord injuries to lead productive, independent lives.

Symptoms

The ability to control your arms or legs after a spinal cord injury depends on two factors. One factor is where the injury occurred on the spinal cord. The other factor is how bad the injury is.

The lowest part of the spinal cord not damaged after an injury is known as the neurological level of the injury. "The completeness" of the injury refers to how much feeling, known as sensation, is lost. Completeness is classified as:

• Complete. If all feeling and all ability to control movement are lost below the spinal cord injury, the injury is called complete.
• Incomplete. If some feeling and control of movement remain below the affected area, the injury is called incomplete. There are varying degrees of incomplete injury.

Loss of feeling and control of movement is known as paralysis. Paralysis from a spinal cord injury can be referred to as:

• Tetraplegia, also known as quadriplegia. This means that your arms, hands, trunk, legs and pelvic organs are all affected by your spinal cord injury.
• Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs but not the arms.

Your healthcare team performs a series of tests to determine the neurological level and completeness of your injury.

Spinal cord injuries can cause the following symptoms:

• Loss of movement.
• Loss of or a change in sensation. This includes a change in the ability to feel heat, cold and touch.
• Loss of bowel or bladder control.
• Exaggerated reflex activities or spasms.
• Changes in sexual function, sexual sensitivity and fertility.
• Pain or an intense stinging sensation caused by damage to the nerve fibers in the spinal cord.
• Trouble breathing, coughing or clearing secretions from the lungs.

Emergency symptoms

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

• Extreme back pain or pressure in the neck, head or back.
• Weakness, incoordination or loss of control in any part of the body.
• Numbness, tingling or loss of feeling in the hands, fingers, feet or toes.
• Loss of bladder or bowel control.
• Trouble with balance and walking.
• Trouble breathing after injury.
• A twisted neck or back.

When to see a doctor

Anyone who has an injury to the head or neck needs an immediate medical evaluation. It is safest to assume that the person has a spinal injury until proved otherwise. This is important because:

• A serious spinal injury is not always immediately obvious. If a spinal injury occurs but it is not known, worse injury may occur.
• Numbness or paralysis can happen quickly or come on gradually.
• The time between injury and treatment can be critical. Learning the level of the injury can help determine the possible recovery.

If you suspect that someone has a back or neck injury:

• Do not move the injured person. Permanent paralysis and other serious complications can result.
• Call 911 or local emergency medical help.
• Keep the person still.
• Place heavy towels on both sides of the neck. Or hold the head and neck to prevent them from moving until emergency medical help arrives.
• Provide basic first aid, such as stopping bleeding and making the person comfortable, without moving the head or neck.

Causes

Spinal cord injuries can result from damage to the spinal cord itself or to the bones that surround the spinal cord, known as the vertebrae. Injuries also may happen as a result of damage to the ligaments or disks of the spinal column.

A sudden, traumatic blow to the spine can fracture, dislocate, crush or compress one or more of the vertebrae. A gunshot or knife wound that penetrates and cuts the spinal cord also can cause a spinal cord injury.

Additional damage usually occurs over days or weeks. This is because of bleeding, swelling and fluid accumulation in and around the spinal cord after an injury.

Other causes of a spinal cord injury don't include trauma. Arthritis, cancer, inflammation, infections or disk degeneration of the spine can be possible causes.

Your brain and central nervous system

The central nervous system includes the brain and spinal cord. The spinal cord is made of soft tissue and is surrounded by bones called vertebrae. It extends down from the base of the brain and contains nerve cells and groups of nerves called tracts. The tracts go to different parts of your body.

The lower end of your spinal cord stops a little above your waist in the region called the conus medullaris. Below this region is a group of nerve roots called the cauda equina.

Tracts in your spinal cord carry messages between your brain and the rest of your body. Motor tracts carry signals from your brain to control muscle movement. Sensory tracts carry signals from body parts to your brain relating to heat, cold, pressure, pain, and the position of your arms and legs.

Damage to nerve fibers

Whether the cause is traumatic or nontraumatic, spinal cord damage affects the nerve fibers passing through the injured area. This can impair part of or all the muscles and nerves below the injury site.

An injury to the chest or lower back can affect the trunk, legs, bowel, bladder and sexual function. A neck injury affects the same areas plus movements of the arms and possibly the ability to breathe.

Common causes of spinal cord injuries

The most common causes of spinal cord injuries in the United States are:

• Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries. They account for almost half of new spinal cord injuries each year.
• Falls. A spinal cord injury after age 65 is most often caused by a fall.
• Acts of violence. About 12% of spinal cord injuries result from violent encounters, usually from gunshot wounds. Knife wounds also are common.
• Sports and recreation injuries. Athletic activities, such as impact sports and diving in shallow water, cause about 10% of spinal cord injuries.
• Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Risk factors

A spinal cord injury usually results from an accident and can happen to anyone. But certain factors can increase the risk of having a spinal cord injury, including:

• Being male. Spinal cord injuries largely affect men. In fact, women account for only about 20% of traumatic spinal cord injuries in the United States.
• Being between the ages of 16 and 30. More than half of spinal cord injuries occur in people in this age range.
• Being 65 and older. Another spike in spinal cord injuries occurs at age 65. Falls cause most injuries in older adults.
• Alcohol use. Alcohol use is involved in about 25% of traumatic spinal cord injuries.
• Engaging in risky behavior. Motor vehicle crashes are the leading cause of spinal cord injuries for people under 65. Other risky behaviors include diving into shallow water and playing sports without wearing safety gear or taking proper precautions.
• Having certain diseases. A minor injury can cause spinal cord damage if you have a condition that affects your joints or bones, such as osteoporosis.

Complications

A spinal cord injury can lead to many complications. Your rehabilitation team helps you develop tools to address these complications. The team also recommends equipment and resources to promote your quality of life and independence. Areas often affected include:

• Bladder control. The bladder continues to store urine from the kidneys after a spinal cord injury. But the injury may interfere with the brain receiving the messages it needs to control the bladder.

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

• Bowel control. The stomach and intestines work much like they did before the injury, but control of bowel movements is often altered. A high-fiber diet might help regulate the bowels. You also can learn ways to help control your bowel.

• Pressure injuries. Below the neurological level of your injury, you might have lost some 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.

  This can increase the risk of getting pressure sores. Changing positions often — with help, if needed — can help prevent the sores. Proper skin care also can help prevent pressure sores.

• Circulatory control. People with a spinal cord injury may have low blood pressure when they rise, known as orthostatic hypotension. They also may have swelling in the arms and legs. This can increase the risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus.

  Another issue with circulatory control is a potentially life-threatening rise in blood pressure, known as autonomic dysreflexia. Your rehabilitation team can teach you how to address these issues if they affect you.

• Respiratory system. If the injury affects the stomach and chest muscles, it may be hard to breathe and cough.

  The neurological level of injury determines what kind of breathing problems you may have. If the injury affects your neck and chest, you might have an increased risk of pneumonia or other lung conditions. Medicines and therapy can be helpful for treatment and prevention.

• Bone density. A spinal cord injury increases the risk of osteoporosis and fractures below the level of injury.
• Muscle tone. Some people with spinal cord injuries have a tightening or motion in the muscles, known as spasticity. Other people may have soft and limp muscles lacking muscle tone, known as flaccidity.

• Fitness and wellness. Weight loss and muscle thinning are common soon after a spinal cord injury. Because limited mobility can lead to a more sedentary lifestyle, there is a risk of weight gain, cardiovascular disease and diabetes.

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

• Sexual health. A spinal cord injury may lead to changes in erection and ejaculation, or in changes in lubrication. Healthcare professionals specializing in urology or fertility can offer options for sexual functioning and fertility.
• Pain. Some people have 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. Pain and the changes a spinal cord injury brings can cause depression in some people.

Prevention

Following this advice might reduce your risk of a spinal cord injury:

• Drive safely. Car crashes are one of the most common causes of spinal cord injuries. Wear a seat belt every time you are in a moving vehicle.

  Make sure that your children wear a seat belt or use an age- and weight-appropriate child safety seat. To protect them from air bag injuries, children under age 12 should always ride in the back seat.

• Check water depth before diving. Don't dive into a pool unless it's at least 9 feet (about 2.74 meters) deep and clearly marked safe for diving. Competition diving requires a deeper depth. And don't dive into an aboveground pool or into water if you don't know how deep it is.
• Prevent falls. Use a step stool with a grab bar to reach high-up objects. Add handrails along stairways. Put nonslip mats on tile floors and in the tub or shower. For young children, use safety gates to block stairs and consider installing window guards.
• Take precautions when playing sports. Always wear recommended safety gear. Avoid leading with your head in sports. For example, don't slide headfirst in baseball. In American football, don't tackle using the top of your helmet. Use a spotter for new moves in gymnastics.
• Don't drink and drive. Don't drive after drinking alcohol or while under the influence of drugs. Don't ride with a driver who has been drinking.

Diagnosis

Healthcare professionals in the emergency room do an exam, test for sensory function and movement, and ask questions about the accident. They may be able to rule out a spinal cord injury based on this evaluation.

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

These tests can include:

• X-rays. X-rays can reveal damage to the bone surrounding the spinal cord, known as the vertebrae. They also can find tumors, fractures or changes in the spine.
• CT scan. A CT scan can provide a clearer image compared with an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other changes.
• MRI. MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is helpful for looking at the spinal cord to find herniated disks, blood clots or other masses that might compress the spinal cord.

A few days after the injury, when some of the swelling might have gone down, a more comprehensive neurological exam may be done. The exam looks at the level and completeness of the injury. This involves testing muscle strength and your ability to sense light touch and pinprick sensations.

Treatment

There's no way to reverse damage to the spinal cord. But researchers are continually working on new treatments. They include prostheses and medicines that might promote nerve cell regeneration or improve the function of the nerves that remain after a spinal cord injury.

In the meantime, spinal cord injury treatment focuses on preventing further injury and empowering people to return to an active and productive life.

Emergency actions

Urgent medical attention is critical to minimize the effects of a head or neck injury. Therefore, treatment for a spinal cord injury often begins at the accident scene.

Emergency personnel typically immobilize the spine as gently and quickly as possible. This is done using a rigid neck collar and a rigid carrying board during transport to the hospital.

Early stages of treatment

In the emergency room, medical care focuses on:

• Maintaining your ability to breathe.
• Preventing shock.
• Immobilizing your neck to prevent further spinal cord damage.
• Avoiding possible complications. Potential complications include stool or urine retention, respiratory or cardiovascular conditions, and the formation of deep vein blood clots.

People with a spinal cord injury often are admitted to the intensive care unit for treatment. Or they may be transferred to a regional spine injury center. Spine injury centers have a team of specialists trained in spinal cord injuries. The team may include neurosurgeons, orthopedic surgeons, neurologists, physician medicine and rehabilitation specialists, psychologists, nurses, therapists, and social workers.

• Medicines. Methylprednisolone (Solu-Medrol), given through a vein in the arm, has been used as a treatment option after a spinal cord injury in the past. But recent research has shown that it has potential side effects such as blood clots and pneumonia that outweigh the benefits. Because of this, methylprednisolone is no longer recommended for routine use after a spinal cord injury.
• Immobilization. You might need traction to stabilize or align your spine. Traction involves gently pulling your head to create the proper alignment of your spine. Traction may be done using a soft neck collar or a brace.
• Surgery. Often surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that may compress the spine. Surgery also can stabilize the spine and prevent future pain or complications.
• Experimental treatments. Scientists are trying to figure out ways to stop cell death, control inflammation and promote nerve regeneration. For example, lowering body temperature significantly — a condition known as hypothermia — for 24 to 48 hours might help prevent damaging inflammation. More study is needed.

Ongoing care

As the condition stabilizes, medical care focuses on preventing other medical conditions that may arise. A spinal cord injury can lead to a decline in physical functioning, known as deconditioning. Or it can lead to stiff muscles due to lack of use, known as muscle contractures. People with a spinal cord injury also may experience pressure ulcers, bowel and bladder issues, respiratory infections, and blood clots.

The length of your hospital stay depends on your condition and medical issues. Once you're well enough to participate in therapies and treatment, you might transfer to a rehabilitation facility.

Rehabilitation

Rehabilitation team members begin to work with you while you're in the early stages of recovery. Your team might include a physical therapist, an occupational therapist, a rehabilitation nurse, a rehabilitation psychologist and a social worker. The team also may include a doctor who specializes in physical medicine and rehabilitation, known as a physiatrist, or a doctor who specializes in spinal cord injuries. And you may work with a dietitian and a recreation therapist.

During the early stages of rehabilitation, therapists work on maintaining and strengthening muscle function and redeveloping fine motor skills. They also help you learn ways to adapt to do day-to-day tasks.

You may learn about the effects of a spinal cord injury and how to prevent complications. The team also works to build your quality of life and independence.

You're taught many new skills, often using equipment and technologies that can help you live on your own as much as possible. You can learn how to enjoy your favorite hobbies, participate in social and fitness activities, and return to school or the workplace.

Medications

Medicines can manage some of the side effects of spinal cord injury. These include medicines to control pain and muscle spasticity. Medicines also can help improve bladder control, bowel control and sexual functioning.

New technologies

Inventive medical devices can help people with a spinal cord injury become more independent and more mobile. These include:

• Modern wheelchairs. Improved, lighter weight wheelchairs are making people with spinal cord injuries more mobile and more comfortable. Some people need an electric wheelchair. Some wheelchairs can even climb stairs, travel over rough ground and elevate a user to reach high places without help.
• Computer adaptations. Computers can be hard to use if you have limited hand function. Computer adaptations range from simple to complex, such as key guards and voice recognition.
• Electronic aids to daily living. Any device that uses electricity can be controlled with an electronic aid to daily living. Devices can be turned on or off by switch or voice-controlled and computer-based remotes.
• Electrical stimulation devices. Often called functional electrical stimulation systems, these devices use electrical stimulators. The stimulators help control arm and leg muscles to allow people with spinal cord injuries to stand, walk, reach and grip.

Prognosis and recovery

Your healthcare professional might not have an expected outlook of your recovery right away. Recovery, if it occurs, usually relates to the level of the injury. The fastest rate of recovery usually happens during the first six months. But some people make small improvements for up to 1 to 2 years.

Coping and support

An accident that results in paralysis is a life-changing event, and adapting is no easy task. You may wonder how your spinal cord injury will affect you in the long term.

Recovery takes time, but many people who are paralyzed lead productive and fulfilling lives. It's essential to stay motivated and get the support you need.

Grieving

If your spinal cord injury is recent, you and your family may experience a period of mourning. The grieving process is a healthy part of your recovery. It's natural — and important — to grieve. But it's also necessary to set new goals and find ways to go forward.

You may have concerns about how the injury may affect your lifestyle, finances and relationships. Grieving and having emotional stress are common.

If your grief is affecting your care or causing you to isolate or misuse alcohol or drugs, talk to someone. You might reach out to a social worker, psychologist or psychiatrist. Or you might find it helpful to join a support group of people with spinal cord injuries.

Talking with others who understand what you're going through can be encouraging. You also might find good advice on adapting areas of your home or workspace to better meet your needs. Ask your healthcare professional or rehabilitation specialist if there are support groups in your area.

Taking control

One of the best ways to regain control of your life is to educate yourself about your injury and your options for gaining more independence. A range of driving equipment and vehicle modifications is available today.

The same is true of home modification products. Ramps, wider doors, special sinks, grab bars and easy-to-turn doorknobs make it possible for you to live more autonomously.

You might have access to economic assistance or support services from the state or federal government or from charitable organizations. Your rehabilitation team can help you identify resources in your area.

Talking about your disability

Some friends and family members may not be sure how to help. Being educated about your spinal cord injury and willing to educate others can benefit all of you.

Explain the side effects of your injury and what others can do to help. But don't hesitate to tell friends and loved ones when they're helping too much. Talking about your injury can strengthen your relationships with family and friends.

Dealing with intimacy, sexuality and sexual activity

Your spinal cord injury might affect your body's sexual responsiveness. However, you're a sexual being with sexual desires. A fulfilling emotional and physical relationship is possible but requires communication, experimentation and patience.

A professional counselor can help you and your partner communicate your needs and feelings. Your healthcare professional can provide the medical information you need regarding sexual health. You can have a satisfying future complete with intimacy and sexual pleasure.

Looking ahead

As you learn more about your injury and treatment options, you might be surprised by all you can do. Thanks to new technologies, treatments and devices, people with spinal cord injuries play basketball and participate in track meets. They paint and take photographs. They get married, have and raise children, and have rewarding jobs.

Advances in stem cell research and nerve cell regeneration give hope for greater recovery for people with spinal cord injuries. And new treatments are being investigated for people with long-standing spinal cord injuries.

No one knows when new treatments will be available, but you can remain hopeful about the future of spinal cord research while living your life to the fullest today.

Preparing for an appointment

Traumatic spinal cord injuries are emergencies. People who are injured might not be able to participate in their care at first.

A number of specialists are involved in stabilizing your condition. They may include a doctor who specializes in nervous system disorders, known as a neurologist. They also may include a surgeon who specializes in spinal cord injuries and other nervous system conditions, known as a neurosurgeon.

Your rehabilitation team is led by a doctor who specializes in spinal cord injuries and includes a variety of specialists.

Here's what you can do if you or someone you're with may have a spinal cord injury.

What you can do

• Be prepared to provide information about the event that caused the injury, including anything that may seem unrelated.
• Have another family member or friend join you when you speak with healthcare professionals, if possible. Someone who accompanies you can help you remember the information you're given.
• Write down questions to ask the healthcare team.

For a spinal cord injury, some basic questions to ask your healthcare professional include:

• What is the outlook of my condition?
• What will happen in the short term? What will happen over the long term? What treatments are available, and which do you recommend?
• Could surgery help?
• What type of rehabilitation might help?
• What research is being done to help this condition?
• Do you have brochures or other printed material? What websites do you recommend?

Don't hesitate to ask other questions you have.

What to expect from the doctor

You'll likely be asked questions that may include:

• What led to your injury?
• When did it occur?
• What do you do for work and leisure?
• With whom do you live?
• Do you live in a house or apartment? How many stairs does your home have?
• Do you or anyone in your family have a history of blood clots?
• Do you have any other medical conditions?