Spinal Cord Injury

OVERVIEW

According to the National Spinal Cord Injury Association, as many as 450,000 people in the United States are living with a spinal cord injury (SCI). Other organizations conservatively estimate this figure to be about 250,000.

Every year, an estimated 17,000 new SCIs occur in the U.S. Most of these are caused by trauma to the vertebral column, thereby affecting the spinal cord’s ability to send and receive messages from the brain to the body’s systems that control sensory, motor and autonomic function below the level of injury.

According to the Centers for Diseases Control and Prevention (CDC), SCI costs the nation an estimated $9.7 billion each year.

Causes

Motor vehicle accidents are the leading cause of SCI in the U. S. in younger individuals, while falls are the leading cause for SCI for people over 65. Acts of violence and sports/recreation activities are other common causes for these injuries.Just over half of all SCI occurs in persons age 16-30, most of whom are male (80%). Males also represent nearly all (90%) of sports-related SCIs.

SYMPTOMS + TYPES

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.

When & How to Seek Medical Care

Following trauma, seek immediate medical attention if you experience any of the following:

• Extreme pain or pressure in the neck, head or back
• Tingling or loss of sensation in the hand, fingers, feet or toes
• Partial or complete loss of control over any part of the body
• Urinary or bowel urgency, incontinence or retention
• Abnormal band-like sensations in the thorax (pain, pressure)
• Impaired breathing after injury
• Unusual lumps on the head or spine

Testing & Diagnosis

In the trauma situation, the doctor will check first to make sure the patient has a working airway, is breathing and has a pulse. The next step in the evaluation is to assess an individual’s neurologic function. The doctor will do this by testing the patient’s strength and sensation in his/her arms and legs. If there is obvious weakness or the patient is not fully awake, the patient is kept in a rigid cervical collar and on a spine board until a full imaging assessment can be complete.

Radiological Evaluation

Historically, the radiological diagnosis of SCI started with x-rays. However, with the technological advancements and availability at most hospitals, the entire spine may be imaged with computerized tomography (CT or CAT scan) as an initial screen to identify fractures and other bony abnormalities. For patients with known or suspected injuries, MRI is helpful for looking at the actual spinal cord itself as well as for detecting any blood clots, herniated discs or other masses that may be compressing the spinal cord.

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.

Follow-up

Persons with neurologically complete tetraplegia are at high risk for secondary medical complications, including pneumonia, pressure ulcers and deep vein thrombosis. Pressure ulcers are the most frequently observed complications, beginning at 15% during the first year post-injury and steadily increasing thereafter.

Recovery of function depends upon the severity of the initial injury. Unfortunately, those who sustain a complete SCI are unlikely to regain function below the level of injury. However, if there is some degree of improvement, it usually evidences itself within the first few days after the accident.

Incomplete injuries usually show some degree of improvement over time, but this varies with the type of injury. Although full recovery may be unlikely in most cases, some patients may be able to improve at least enough to ambulate and to control bowel and bladder function.

Once a patient is stabilized, care and treatment focuses on supportive care and rehabilitation. Family members, nurses or specially trained aides all may provide supportive care. This care might include helping the patient bathe, dress, change positions to prevent bedsores and other assistance.

Rehabilitation often includes physical therapy, occupational therapy and counseling for emotional support. The services may initially be provided while the patient is hospitalized. Following hospitalization, some patients are admitted to a rehabilitation facility. Other patients can continue rehab on an outpatient basis and/or at home.

Latest Research

• Nature.com. (2019). Spinal Cord Injury
• NIH. (2018). Spinal Cord Injury: Hope Through Research
• Masterson, K. (2018). A New Spinal Cord Injury Treatment is Getting Patients Back on Their Feet. Retrieved from

Resources for More Information

Spinal Cord Injury Facts and Figures:

• American Spinal Injury Association
• National Spinal Cord Injury Statistical Center. (2018). Spinal Cord Injury Facts and Figures at a Glance.
• World Health Organization

Other resources:

Christopher Reeve Paralysis Foundation
Foundation for SCI Prevention, Care & Cure
The National SCI Association (NSCIA)
The Travis Roy Foundation