Spinal cord injury

Definition of the Disease (Mayo Clinic, 2015)

A spinal cord injury damage to any part of the spinal cord or nerves at the end of the spinal
canal often causes permanent changes in strength, sensation and other body functions
below the site of the injury.
The lowest part of your spinal cord that functions normally after injury is referred to
as the neurological level of your injury. The severity of the injury is often called "the
completeness" and is classified as either of the following:

Complete. If almost all feeling (sensory) and all ability to control movement
(motor function) are lost below the spinal cord injury, your injury is called
complete.

Incomplete. If you have some motor or sensory function below the affected
area, your injury is called incomplete. There are varying degrees of
incomplete injury.

Additionally, paralysis from a spinal cord injury may be referred to as:

Tetraplegia. Also known as quadriplegia, this means 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.

Risk Factor
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, accounting for more than 35 percent of new
spinal cord injuries each year.

Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall,
falls cause more than one-quarter of spinal cord injuries.

Acts of violence. Around 15 percent of spinal cord injuries result from

violent encounters, often involving gunshot and knife wounds, according to
the National Spinal Cord Injury Statistical Center.

Sports and recreation injuries. Athletic activities, such as impact sports

and diving in shallow water, cause about 9 percent of spinal cord injuries.

Alcohol. Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.

Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord

also can cause spinal cord injuries.

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 amount of men.

In fact, females account for only about 20 percent 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.
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.

Symptoms
Your ability to control your limbs after spinal cord injury depends on two factors: the
place of the injury along your spinal cord and the severity of injury to the spinal
cord.
Your health care team will perform a series of tests to determine the neurological
level and completeness of your injury.
Spinal cord injuries of any kind may result in one or more of the following signs and
symptoms:

Loss of movement

Loss of sensation, including 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

your spinal cord

Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms

Emergency signs and symptoms of 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

Physiology Involved
The central nervous system comprises the brain and spinal cord. The spinal
cord, made of soft tissue and surrounded by bones (vertebrae), extends downward
from the base of your brain and is made up of nerve cells and groups of nerves
called tracts, which go to different parts of your body (Mayo Clinic)
A spinal nerve has two nerve roots. The only exception is the first spinal
nerve, which has no sensory root. The root in the front (the motor or anterior root)
contains nerve fibers that carry impulses (signals) from the spinal cord to muscles
to stimulate muscle movement (contraction). The root in the back (the sensory or
posterior root) contains nerve fibers that carry sensory information about touch,
position, pain, and temperature from the body to the spinal cord. (Merck Manual)
The spinal cord ends in the lower back (around L1 or L2), but the lower spinal
nerve roots continue, forming a bundle that resembles a horses tail (called the
cauda equinasee What Is the Cauda Equina Syndrome?).
The spinal cord is highly organized (see Figure: How the Spine Is Organized).
The center of the cord consists of gray matter shaped like a butterfly. The front
"wings" (anterior or motor horns) contain nerve cells that carry signals from the
brain or spinal cord through the motor root to muscles. The back (posterior or
sensory) horns contain nerve cells that receive signals about pain, temperature, and
other sensory information through the sensory root from nerve cells outside the
spinal cord.
The outer part of the spinal cord consists of white matter that contains
pathways of nerve fibers (called tracts or columns). Each tract carries a specific
type of nerve signal either going to the brain (ascending tracts) or from the brain
(descending tracts).

Pathophysiology
Whether the cause is traumatic or nontraumatic, the damage affects the
nerve fibers passing through the injured area and may impair part or all of your
corresponding muscles and nerves below the injury site.
A chest (thoracic) or lower back (lumbar) injury can affect your torso, legs, bowel
and bladder control, and sexual function. In addition, a neck (cervical) injury affects
movements of your arms and, possibly, your ability to breathe.

Diagnosis (Merck
Manual)

Physical examination

Often, doctors can recognize a spinal cord disorder based on its characteristic
pattern of symptoms. Doctors always do a physical examination, which
provides clues to the diagnosis and, if the spinal cord is damaged, helps
doctors determine where the damage is. An imaging test is done to confirm
the diagnosis and determine the cause.
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.
Magnetic resonance imaging or myelography with computed tomography
Magnetic resonance imaging (MRI) is the most accurate imaging test for
spinal cord disorders. MRI shows the spinal cord, as well as abnormalities in
the soft tissues around the cord (such as abscesses, hematomas, tumors, and
ruptured disks) and in bone (such as tumors, fractures, and cervical
spondylosis).

Myelography
In myelography, x-rays of the spinal cord are taken after a radiopaque dye is
injected into the subarachnoid space via a spinal tap. Myelography has been
largely replaced by MRI, which produces more detailed images and is simpler
and safer to do.

Myelography with CT
Myelography with computed tomography (CT) is used when doctors need
more detail of the spinal cord and surrounding bone than MRI can provide.
Myelography with CT is also used when MRI is not available or cannot be
done safely (for example, when a person has a heart pacemaker).
Dermatomes
Along the length of the spinal cord, 31 pairs of spinal nerves emerge
through spaces between the vertebrae. Each spinal nerve runs from a specific
vertebra in the spinal cord to a specific area of the body. Based on this fact,
the skins surface has been divided into areas called dermatomes. A
dermatome is an area of skin whose sensory nerves all come from a single
spinal nerve root. Loss of sensation in a particular dermatome enables
doctors to locate where the spinal cord is damaged

Management
Unfortunately, there's no way to reverse damage to the spinal cord. But
researchers are continually working on new treatments, including prostheses
and medications that may promote nerve cell regeneration or improve the
function of the nerves that remain after a spinal cord injury. (Mayo clinic)

Pharmacologic

Intravenous (IV) methylprednisolone (A-Methapred, Solu-Medrol) is a

treatment option for an acute spinal cord injury. If methylprednisolone is
given within eight hours of injury, some people experience mild
improvement.

Antibiotics, which can cross the protective blood-brain barrier, have been
shown to improve motor function, restoration, decrease lesion size, and
reduce cell death in animal models of SCI. (NINDS NIH)
Therapeutic hypothermia (controlled lowering of the bodys core
temperature) can protect cells from damage following cardiac arrest, stroke,
and traumatic brain injury. Therapeutic hypothermia has been shown to
reduce the swelling and inflammation that presses on the spinal cord
following injury in animal models and in small, limited human studies. It also
can reduce damage to susceptible neurons following the primary injury,
reduce damage to spinal cord microvasculature, and improve functional
outcome. Researchers are studying the safety and effectiveness of different
durations of hypothermia following spinal cord injury. (NINDS NIH)
The drug riluzole, which slows the progression of the disease amyotrophic
lateral sclerosis, has shown in animal models to improve motor function and
reduce cell death loss caused by decreased blood flow following spinal cord
injury.

Non Pharmacologic
Cell Replacement
Controversy exists over potential benefits and possible harmful consequences of
cell replacement and cell transplants. The potential of several cell types,
including stem cells and glial cells, to treat spinal cord injury is being investigated
eagerly, but there are many things about stem cells that researchers still need to
understand. For example, researchers know there are many different kinds of
chemical signals that tell a stem cell what to do

It appears to work by reducing damage to nerve cells and decreasing inflammation

near the site of injury. However, it's not a cure for a spinal cord injury.

Treatment of the cause when possible (Merck Manual)

Prevention of complications

Physical and occupational therapy

If symptoms of spinal cord dysfunction (such as paralysis or loss of sensation)

suddenly occur, people should immediately go to the emergency department.
Sometimes doing so can prevent permanent nerve damage or paralysis. If possible,
the cause is treated or corrected. However, such treatment is often impossible or
unsuccessful.
People who are paralyzed or confined to bed because of a spinal cord disorder
require skilled nursing care to prevent complications, which include the following:

Pressure sores: Nurses inspect the person's skin daily, keep the skin dry
and clean, and turn the person frequently (see Pressure Sores). When
necessary, a special bed called a Stryker frame is used. It can be turned to
shift pressure on the body from front to back and from side to side.

Urinary problems: If a person is immobile and cannot use a toilet, a urinary

catheter may be needed. To help reduce the risk of a urinary tract infection,
nurses use sterile techniques when the catheter is inserted and apply
antimicrobial ointments or solutions daily.

Pneumonia: To reduce the risk of pneumonia, therapists and nurses may

teach the person deep breathing exercises. They may also place the person
at an angle to help drain secretions that accumulate in the lungs (postural
drainage), or they may suction secretions out.

Blood clots: Anticoagulant drugs, such as heparin or low molecular

weight heparin, may be given by injection. If a person cannot take
anticoagulants (for example, because of a bleeding disorder or stomach
ulcers), a filter, sometimes called an umbrella (see Figure: ), is inserted into
the inferior vena cava (the large vein that carries blood from the abdomen to
the heart). The filter traps blood clots that have broken loose from leg veins
before they reach the heart.

Extensive loss of body functions can be devastating, causing depression and loss of
self-esteem. Formal counseling can be very helpful. Learning exactly what has
happened and what to expect in the near and distant future helps people cope with
the loss and prepare them for rehabilitation.
Rehabilitation: Rehabilitation helps people recover as much function as possible.
The best care is provided by a team that includes nurses, physical and occupational
therapists (see Physical Therapy (PT)), a social worker, a nutritionist, a psychologist,
and a counselor, as well as the person and family members. A nurse may teach the
person ways to manage bladder and bowel dysfunction, such as how to insert a
catheter, when to use laxatives, or how to stimulate bowel movements using a
finger.
Physical therapy involves exercises for muscle strengthening and stretching.
People may learn how to use assistive devices such as braces, a walker, or a
wheelchair and how to manage muscle spasms.
Occupational therapy helps people relearn how to do their daily tasks and helps
them improve dexterity and coordination. They learn special techniques to help
compensate for lost functions. Therapists or counselors help some people make the
adjustments needed to return to work and to hobbies and activities. People are
taught ways to deal with sexual dysfunction. Sex is still possible for many people,
even though sensation is usually lost.
Emotional support from family members and close friends is important.