Spinal Cord Injury

OVERVIEW:
What is a spinal cord injury?

A spinal cord injury (SCI) is damage to the spinal cord—the bundle of nerves and nerve fibers
that sends and receives signals from the brain. The spinal cord extends from the lower part of
the brain down through the lower back.

Direct injury to the spinal cord itself or damage to the tissue and bones (vertebrae) that
surround the spinal cord can cause an SCI. This damage can cause temporary or permanent
changes in feeling, movement, strength, and body functions below the point where the injury
happens.

Spinal cord injury symptoms:

The symptoms of spinal cord injuries depend on the part of the spinal cord that is damaged and
how much damage there is. SCIs to upper parts of the spinal cord affect more of the body than
injuries lower down. An injury to the upper part of the spinal cord can cause paralysis in most of
the body and affect all limbs (tetraplegia or quadriplegia).

An injury that happens lower down the spinal cord may only affect a person’s lower body and
legs (paraplegia). Paralysis can happen immediately upon injury (primary damage) or develop
over time from bleeding and swelling in the spinal cord and cell death (secondary damage).

An SCI can damage a few, many, or almost all of the nerve fibers that cross the site of injury. If
the injury causes little or no nerve cell death, a person can make an almost complete recovery.

An SCI can cause one or more symptoms, including:

 Numbness, tingling, or a loss of (or changes in) sensation in hands and feet

 Paralysis (loss of movement)

 Pain or pressure in the head, neck, or back

  Weakness in any part of the body

 Unnatural or uncomfortable positions of the spine or head

 Loss of bladder and bowel control

 Problems with walking

 Difficulty breathing

 Changes in sexual function

Types of spinal cord injury:

An SCI can be either complete or incomplete:

An incomplete injury means the spinal cord is still able to send some messages to or from the
brain. People still have some feeling, function, and muscle control below the site of their injury.

A complete injury means that there is no nerve communication below the injury site. People
lose muscle control, feeling, or function below the injury.

Anatomy of the spinal cord:

The spinal cord is a soft, cylindrical column of tightly bundled cells (nerve cells and glia), nerve
fibers that transmit nerve signals (called axons), and blood vessels. It sends and receives
information between the brain and the rest of the body. Millions of nerve cells in the spinal
cord coordinate complex patterns of movements, such as rhythmic breathing and walking.

The spinal cord extends from the brain to the lower back through a canal in the center of the
vertebrae. Like the brain, the spinal cord has three layers of tissue for protection—and
cerebrospinal fluid (CSF) surrounds it to act as a cushion against shock or injury.

Other types of nerve cells sit just outside the spinal cord and send information to and from the
brain. Doctors refer to these nerve cells based on their location:

Cervical spinal nerves (known as C1 to C7) in the neck control signals to the back of the head,
the neck and shoulders, the arms and hands, and the diaphragm.

Thoracic spinal nerves (known as T1 to T12) in the upper mid-back control signals to the chest
muscles, some muscles of the back, and many organ systems.
Lumbar spinal nerves (known as L1 to L5) in the lower mid-back control signals to the lower
parts of the abdomen and the back, the buttocks, some parts of the external genital organs, and
parts of the legs.

Sacral spinal nerves (known as S1 to S5) in the lower back control signals to the thighs and
lower parts of the legs, the feet, most of the external genital organs, and the area around the
anus.

Who is more likely to get a spinal cord injury?

Motor vehicle accidents and serious falls are the most common causes of SCI in the U.S. Other
causes include:

 Acts of violence (mostly gunshot wounds and assaults)

 Sports injuries

 Medical or surgical injuries

 Industrial or workplace accidents

 Diseases

Conditions that can damage the spinal cord:

Risk factors for an SCI include age (either being between ages 16 and 30, or after age 65 for
dangerous falls), alcohol use, or not wearing proper gear—such as a seat belt or protective
sports equipment.

 Breathing problems: About one-third of people with an SCI will need temporary or
permanent help with breathing and may require a breathing tube. Any injury to the
spinal cord between the C1-C4 segments can stop breathing as the nerves in this region
cause the diaphragm to move and the lungs to expand. People with an SCI may need
special training with breathing and swallowing. Their caregivers may need training as
well.

 Pneumonia: Breathing complications are the leading cause of death in people with an
SCI, commonly as a result of pneumonia. People using a ventilator to help with
breathing, are at increased risk of developing pneumonia. The person will need careful
monitoring and antibiotic treatment if symptoms of pneumonia appear. Ways to
 prevent pneumonia include clearing the throat and taking precautions to avoid food and
liquids being sucked into the lungs (aspiration).

 Circulatory (blood flow) problems: Changes in circulation can lead to unstable blood
pressure, abnormal heart rhythms (arrhythmias), and blood clots that may appear days
after injury. The injured person will need careful monitoring for each of these common
issues after an SCI. People with spinal cord injuries are at increased risk for blood clots
because blood flow can slow or stop in the large veins in the legs. Anticoagulant drugs
and compression stockings to increase blood flow in the lower legs and feet can reduce
the risk for blood clots.

 Stiffness and changes in muscle tone: Reflexes may become exaggerated over time,
causing muscle stiffness and an increase in muscle tone (spasticity) that may require
special treatment. Muscles below the injury site may weaken when people don’t use
them.

 Autonomic dysreflexia: Autonomic dysreflexia is a life-threatening reflex action that

primarily affects those with injuries to the neck or upper back. Symptoms may include
flushing or sweating, a pounding headache, anxiety, sudden increase in blood pressure,
vision changes, or goose bumps on the arms and legs. If possible, the person needs to
stay in a sitting position to keep blood flowing to the legs and feet, which helps reduce
blood pressure.

 Pressure sores (also known as pressure ulcers): Pressure sores are areas of skin that
have broken down because of continuous pressure on the skin and reduced blood flow
to the area. People with paraplegia and tetraplegia are at risk for pressure sores. To
prevent pressure sores, they change their position regularly, either on their own or with
the help of assistive devices or a caregiver.

 Pain: Some people with an SCI develop neurogenic pain—an intense burning or stinging
sensation. This pain may be constant or may come and go. Many things can trigger it—
and some people may even feel pain in parts of the body that have otherwise lost
sensation. Treatments for chronic pain include medicines, spinal or brain electrical
stimulation, and surgery. But none of these treatments are completely effective at
relieving neurogenic pain long term.

 Bladder and bowel problems: People may need to use a catheter to empty their
bladder and learn new ways to empty their bowels. The person may need to change
their diet.
  Sexual function: Depending on the severity and location of the injury, and the person’s
recovery after the injury, their sexual function and fertility may be affected. A urologist
and other specialists can suggest different options to support sexual functioning and
health.

 Depression: Many people living with an SCI may develop depression due to lifestyle
changes after the injury. Therapy and medicine can help treat depression and other
mental health conditions.

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.
Spinal cord injury rehabilitation:
Rehabilitation programs for people with an SCI combine physical therapies with skill-building
activities. They also have counseling designed to provide social and emotional support and
increase the person’s independence and quality of life.

A doctor specializing in physical medicine and rehabilitation usually leads the rehabilitation
team. The team may include social workers, physical and occupational therapists, recreational
therapists, rehabilitation nurses, rehabilitation psychologists, vocational counselors,
nutritionists, a case worker, and other specialists.

The first phase of rehabilitation after injury usually focuses on regaining communication skills
and leg and arm strength. Adaptive or assistive devices may help people with an SCI to regain
independence and improve mobility and quality of life. They can also help with communication
skills, such as writing, typing, and using the telephone.

Depending on how serious the injury is, the person may need:

 Braces

 A wheelchair

 Electronic stimulators

 Assisted training with walking

 Neural prosthetics (assistive devices that may stimulate the nerves to restore lost
functions)

 Computer adaptations and other computer-assisted technology

Rehabilitation for an SCI can include:

Physical therapy, which are exercise programs that strengthen muscles.

Occupational therapy, which helps redevelop fine motor skills. People with an SCI may need
help regaining skills to perform activities for daily living—such as getting in and out of a bed,
personal hygiene, eating, and using the toilet. The person may learn how to cope with
spasticity, autonomic dysreflexia, and neurogenic pain as part of their occupational therapy.
Vocational rehabilitation, which is identifying basic work skills and physical and cognitive
capabilities that can support paid work. Through this process, the person and their team can
identify potential, accessible workplaces and any assistive equipment they will need..

Educational training, which can help the person develop skills for a new line of work that may
be less dependent upon a person’s physical abilities. People with an SCI are encouraged to
participate in activities that provide a sense of satisfaction and self-esteem, such as educational
classes, hobbies, special interest groups, and family and community events.

Recreation therapy, which encourages people with an SCI to participate in sports, arts, or other
leisure activities that they can do with their new level of mobility. This can help people achieve
a balanced lifestyle that provides opportunities for socialization and self-expression.

What are the latest updates on spinal cord injury?

Current research on spinal cord injuries focuses on advancing our understanding of the four key
principles of spinal cord repair:

Neuroprotection. Preventing cell death and protecting surviving nerve cells from further
damage improves functional outcome. This includes using medicines to reduce nerve cell death
and lower the body's core temperature.

Repair and regeneration. Encouraging the spinal cord to self-repair and stimulating the
regrowth of nerve fibers can help people regain function. These efforts include exploring cell
transplants, growth-promoting substances, and bioengineered growth scaffolds.

Cell-based therapies. Replacing damaged nerve or support cells with other cell types, including
stem cells, jumpstarts nerve cell growth and creates new cell connections.

Neuroplasticity. Retraining central nervous system circuits to restore body functions and form
new nerve connections and pathways may help with voluntary muscle movement and
coordination. These techniques happen after injury or cell death. They include rehabilitation,
electrical stimulation, robot-assisted training, and brain-computer interface technology..

Further research includes basic spinal cord function studies on how the spinal cord develops,
processes sensory information, controls movement, and generates rhythmic patterns like
walking and breathing. Studies using cells and animal models provide an essential foundation
for developing interventions for an SCI.
Research on injury mechanisms focuses on what causes immediate harm and on the cascade of
reactions the body deploys that protect from (or contribute to) secondary damage in the hours
and days following an SCI. This includes testing neuroprotective interventions in animal models.

The Brain Research Through Advancing Innovative Technologies® (BRAIN) Initiative brings
multiple federal agencies and private organizations together to develop and apply new
technologies to understand how complex circuits of nerve cells enable thinking, movement
control, and perception. BRAIN’s SCI research includes:

Exploring brain circuits to better understand the sensory and motor basis of behavior

Next-generation neural prosthetics, devices that connect to the nervous system and restore
functions lost due to disease or injury

Improved brain and spinal cord imaging

New brain-computer interface devices

Self-care:
Appropriate self-management is indispensable to manage SCI related impairments, restore
optimal levels of functioning and prevent secondary conditions. Self-management requires
competencies to apply effective self-care strategies as independently as possible and
implement a healthy lifestyle.

However, people with more severe SCI often require ongoing care and support provided largely
by informal carers. Challenges for carers include stress, role strain, financial burden, social
isolation, lack of community services and bereavement in the event of loss of loved ones. Caring
for a person with SCI may affect the carer’s own health, well-being and social relationships.
Effective carer support and self-care interventions for health can significantly alleviate carer
strain and enhance quality of care and participation of people with SCI.

Self-care interventions provided by health workers aim to empower people with SCI and their
families to care for their health, prevent secondary conditions, maintain optimal levels of
functioning, and foster coping strategies.