Introduction
Causes of spinal cord disorders include injuries, infections, a blocked blood supply, and
compression by a fractured bone or a tumor.
Typically, muscles are weak or paralyzed, sensation is abnormal or lost, and controlling
bladder and bowel function may be difficult.
Doctors base the diagnosis on symptoms and results of a physical examination and
imaging tests, such as magnetic resonance imaging (MRI).
The condition causing the spinal cord disorder is corrected if possible.
Often, rehabilitation is needed to recover
as much function as possible.
The spinal cord is the main pathway of
communication between the brain and the rest of
the body. It is a long, fragile, tubelike structure
that extends downward from the base of the
brain. The cord is protected by the back bones
(vertebrae) of the spine (spinal column). The
vertebrae are separated and cushioned by disks
made of cartilage.
1 Spinal Nerve 5 Central Canal
Dorsal Root
2 6 Grey Matter
Ganglion
Dorsal Root
3 7 White Matter
Spinal Cord Anatomy (Sensory)
Ventral Root
4
The Spinal Cord is connected to the brain and is (Motor)
about the diameter of a human finger. From the
brain the spinal cord descends down the middle
of the back and is surrounded and protected by
the bony vertebral column. The spinal cord is
surrounded by a clear fluid called Cerebral
Spinal Fluid (CSF), that acts as a cushion to
protect the delicate nerve tissues against damage
from banging against the inside of the vertebrae.
The anatomy of the spinal cord itself, consists of
millions of nerve fibres which transmit electrical
information to and from the limbs, trunk and
organs of the body, back to and from the brain.
The brain and spinal cord are referred to as the Central Nervous System, whilst the nerves
connecting the spinal cord to the body are referred to as the Peripheral Nervous System.
Ascending and Descending Spinal Tracts
The nerves within the spinal cord are grouped together in different bundles called Ascending and
Descending tracts.
Ascending tracts within the spinal cord carry information from the body, upwards to the brain,
such as touch, skin temperature, pain and joint position.
Descending tracts within the spinal cord carry information from the brain downwards to initiate
movement and control body functions.
Spinal Nerves
Nerves called the spinal nerves or nerve roots come off the spinal cord and pass out through a
hole in each of the vertebrae called the Foramen to carry the information from the spinal cord to
the rest of the body, and from the body back up to the brain
There are four main groups of spinal nerves which exit different levels of the spinal cord.
These are in descending order down the vertebral column:
Cervical Nerves "C" : (nerves in the neck) supply movement and feeling to the arms, neck and
upper trunk.
Thoracic Nerves "T" : (nerves in the upper back) supply the trunk and abdomen.
Lumbar Nerves "L" and Sacral Nerves "S" : (nerves in the lower back) supply the legs, the
bladder, bowel and sexual organs.
Spinal Cord Level Numbering System
The spinal nerves carry information to and from different levels (segments) in the spinal cord.
Both the nerves and the segments in the spinal cord are numbered in a similar way to the
vertebrae. The point at which the spinal cord ends is called the conus medullaris, and is the
terminal end of the spinal cord. It occurs near lumbar nerves L1 and L2. After the spinal cord
terminates, the spinal nerves continue as a bundle of nerves called the cauda equina. The upper
end of the conus medullaris is usually not well defined.
There are 31 pairs of spinal nerves which branch off from the spinal cord. In the cervical region
of the spinal cord, the spinal nerves exit above the vertebrae. A change occurs with the C7
vertebra however, where the C8 spinal nerve exits the vertebra below the C7 vertebra. Therefore,
there is an 8th cervical spinal nerve even though there is no 8th cervical vertebra. From the 1st
thoracic vertebra downwards, all spinal nerves exit below their equivalent numbered vertebrae.
The spinal nerves which leave the spinal cord are numbered according to the vertebra at which
they exit the spinal column. So, the spinal nerve T4, exits the spinal column through the foramen
in the 4th thoracic vertebra. The spinal nerve L5 leaves the spinal cord from the conus
medullaris, and travels along the cauda equina until it exits the 5th lumbar vertebra.
The level of the spinal cord segments do not relate exactly to the level of the vertebral bodies i.e.
damage to the bone at a particular level e.g. L5 vertebrae does not necessarily mean damage to
the spinal cord at the same spinal nerve level.
Diagram Showing The Relationship Between Spinal Nerve Roots and Vertebrae
Physiotherapy management
Spinal cord injury (SCI) is an uncommon but very serious condition usually from a high velocity
incident but can also be caused by tumours, infections and loss of blood supply to the spinal
cord. It occurs predominantly in younger persons who undertake more risky activities but can
present at any age, with motor vehicle accidents the most common cause. SCI needs intensive
and skilled management from a multidisciplinary team to achieve the best outcome of
independence for the patient. The resulting injuries from this condition are known as paraplegia
or quadriplegia.
The initial medical evaluation is performed to establish the respiratory status of the patient and
deal with any other of the likely multiple injuries. Once the patient is stabilised the doctors try
and work out the level in the spine where the damage has occurred, an important fact as it relates
closely to medical and therapy management. A low lumbar fracture will have no effect on the
arms or the ability to breathe so the patient will have good trunk and arm power and the aerobic
ability to develop independence. Cervical and upper thoracic injuries impair the respiratory
ability of the patient and limit arm function, making rehabilitation much harder.
Assessment of the patient's respiratory status is the initial concern of the physiotherapist, often in
the intensive care unit. The physiotherapist will attempt to encourage the patient to expand their
lungs, deep breathe and cough any secretions up to clear their chest. Paralysis of the lower trunk
can reduce propulsive force and thereby the effectiveness of coughing, a process which the
physiotherapist helps by stabilising the lower abdomen during attempted coughing. Suction may
be needed in severe cases and coughing can be promoted by using a cough assist machine.
Respiratory physiotherapy consists of assessing the patient's respiratory ability, teaching the
patient to deep breathe and expand the lungs fully, and cough to expectorate. If the lower
abdomen is paralysed the patient may need to stabilise the area with their arms to allow a
propulsive cough. In more disabled patients the physiotherapist may stabilise, helping the air to
exit suddenly in coughing. A cough assist machine can be used to provoke a cough, and initial
management in intensive care may also involve respiratory suction.
The correct positioning of the spinal cord patient is vital if they are to manage pressure care and
prepare themselves for the functional positions they will need to adopt to be independent.
Placing the patient in various positions makes the joints adapt to new postures, an example being
the frog position where the hips are bent up and outwards so the soles of the feet meet. Patients
need this position for independent living as they need to sit up and lean forward with balance that
they can self-catheterise their bladder, take care of their feet and lean forward to move their legs.
After lying flat for some time during the early period the patient needs to be progressed by the
physiotherapist to sitting upright in a wheelchair. This is a gradual process as moving the patient
into the upright position too quickly can cause a severe blood pressure drop. A wheelchair with
elevating leg rests and a sloping back is used initially until the patient is able to tolerate an
upright chair. Regular practice of sitting balance is vital under the close supervision of the
physiotherapist as trunk control is needed for independent living. Once sitting is mastered
transfers into a wheelchair and strengthening can be worked on.
By this time the patient will have learned trunk control in sitting, wheelchair transfers and
strengthening work, so at this stage they should be routinely transferred to a unit specialising in
spinal injuries. Experienced advice from the multidisciplinary team about the large number of
skills they need to learn is available there to foster the highest level of independence. Many
factors impact on whether the patient can lead a fully independent life including their age, other
medical difficulties, family support, motivation and attitude and the spinal level affected. Some
people with higher lesions may need routine care from a pool of carers throughout the day.
Spinal cord injury (SCI) is an uncommon but very serious condition usually from a high velocity incident
but can also be caused by tumours, infections and loss of blood supply to the spinal cord. It occurs
predominantly in younger persons who undertake more risky activities but can present at any age, with
motor vehicle accidents the most common cause. SCI needs intensive and skilled management from a
multidisciplinary team to achieve the best outcome of independence for the patient. The resulting
injuries from this condition are known as paraplegia or quadriplegia.
The initial medical evaluation is performed to establish the respiratory status of the patient and deal
with any other of the likely multiple injuries. Once the patient is stabilised the doctors try and work out
the level in the spine where the damage has occurred, an important fact as it relates closely to medical
and therapy management. A low lumbar fracture will have no effect on the arms or the ability to
breathe so the patient will have good trunk and arm power and the aerobic ability to develop
independence. Cervical and upper thoracic injuries impair the respiratory ability of the patient and limit
arm function, making rehabilitation much harder.
Assessment of the patient’s respiratory status is the initial concern of the physiotherapist, often in the
intensive care unit. The physiotherapist will attempt to encourage the patient to expand their lungs,
deep breathe and cough any secretions up to clear their chest. Paralysis of the lower trunk can reduce
propulsive force and thereby the effectiveness of coughing, a process which the physiotherapist helps by
stabilising the lower abdomen during attempted coughing. Suction may be needed in severe cases and
coughing can be promoted by using a cough assist machine.
Once the emergency treatment has been provided and the medical condition of the patient is stable
they can be transferred to a ward. Spinal surgery may be performed, using internal fixation and bone
grafting, to stabilise the fractured spinal segments. Once the segments are stable the patient can begin
early rehabilitation without waiting for fracture healing which for the spine can take up to 12 weeks.
Physiotherapists review the patient’s respiratory coping, teach range of movement and strengthening
exercises for unaffected parts and put the paralysed areas through full passive range of movement
several times every day to maintain the joint ranges.
The physiotherapist will ensure good positioning of the patient to protect the site of the fracture, ensure
good skin pressure care and prepare the patient to be able to adopt and maintain the postures they will
need to be independent. The physiotherapist will place the patient in the frog position, with the hips
abducted and flexed and the soles of the feet together. This position is very important for the patient to
be able to sit upright with good balance, manage the care of their feet, lean forward and move their legs
and manage their bladder care by catheterising themselves.
Positioning the spinal cord injured patient is very important for safety of the fracture site, for pressure
care of the skin and for preparing the patients body for the positions they will need to live as
independently as possible. The frog position is one of the postures the physiotherapist will place the
patient in, with the hips bent up and the knees placed out to the side so the soles of the feet are
touching. The patient will need this position to manage their sitting balance to lean forward to move the
legs, to self-catheterise and to get to their feet to put on socks and manage foot care.
By this time the patient will have learned trunk control in sitting, wheelchair transfers and strengthening
work, so at this stage they should be routinely transferred to a unit specialising in spinal injuries.
Experienced advice from the multidisciplinary team about the large number of skills they need to learn is
available there to foster the highest level of independence. Many factors impact on whether the patient
can lead a fully independent life including their age, other medical difficulties, family support, motivation
and attitude and the spinal level affected. Some people with higher lesions may need routine care from
a pool of carers throughout the day.
