Spinal Cord Injuries

The spinal cord is a long bundle of nerve fibers and nerve cells that extend from the base of the skull to below the waist. It is protected by the bones of your spine. The spinal cord nerves carry messages between the brain and the rest of the body. For that reason, injuries to the spinal cord are very serious. They may cause loss of feeling below the injured area (numbness) or loss of the ability to move (paralysis). Emergency treatment may help prevent permanent damage or may reduce the severity of the damage.

The spinal cord is a bundle of nerves that carries signals between the brain and the rest of the body. Acute spinal cord injury (SCI) is due to a traumatic injury. The injury may cause a bruise (contusion), a partial tear, or a complete tear (transection) in the spinal cord. SCI is more common in men and young adults.

SCI results in a decrease or loss of movement, feeling, and organ function below the level of the injury. The most common sites of injury are the cervical and thoracic areas. SCI is a common cause of permanent disability and death in children and adults.

The spine has 33 bones (vertebrae). These bones are grouped into five sections:

• Cervical (C): Neck - 7 cervical vertebrae.
• Thoracic (T): Upper back - 12 thoracic vertebrae.
• Lumbar (L): Lower back - 5 lumbar vertebrae (sometimes 6).
• Sacral (S): Pelvis - 4 fused vertebrae.

The spinal cord runs through the center of the vertebrae from the base of the brain to the lower back. It contains many nerves that control movement and feeling in the body. The nerves exit and enter the spinal cord through spaces between the bones of the spine. There are:

• 8 cervical nerves: C1 through C8.
• 12 thoracic nerves: T1 through T12.
• 5 lumbar nerves: L1 through L5.
• 5 sacral nerves: S1 through S5.
• 1 coccygeal nerve.

An SCI is named with a letter for the section of the spine and a number for the nerve that was injured. The level of injury determines which parts of the body are affected. The spinal cord ends generally at the level of the L1 or L2 vertebrae. Individual spinal nerves continue below this level to exit at lower vertebral levels.

SCI can be divided into two main types of injury:

• Complete injury. There is no function below the level of the injury. This means no feeling or movement. Both sides of the body are equally affected. Complete injuries can happen at any level of the spinal cord.
• Incomplete injury. There is some function below the level of the injury. This could be movement in one limb more than the other, feeling in parts of the body, or more function on one side of the body than the other. Incomplete injuries can happen at any level of the spinal cord.

There are many causes of SCI. The more common injuries happen when the area of the spine or neck is bent or compressed. This can be caused by:

• Birth injuries, which often affect the spinal cord in the neck area.
• Falls.
• Car accidents, either when a person is a passenger in a car or is hit by a car.
• Sports injuries.
• Diving accidents.
• Trampoline accidents.
• Violence, such as injuries that pierce the spinal cord, including gunshots and stab wounds.

Age is the main risk factor linked to spinal cord injuries. Young adult males (between the ages of 15 and 35) and older adults are at the highest risk. 

SCI risk peaks during young adulthood. Young adults tend to have increased risk due to violence, motor vehicle accidents, and sports injuries. The rate of violence-related SCIs in young adults has gone down since the 1990s.

In older adults, falls are the leading cause of SCIs. These numbers have gone up since the 1990s.

Symptoms vary depending on the severity and location of the SCI. At first, the person may have spinal shock. This causes loss of feeling, muscle movement, and reflexes below the level of injury. Spinal shock often lasts from several hours to several weeks. As the shock lessens, other symptoms appear. This depends on the location of the injury.

For SCI, the higher up on the spinal cord, the more severe the symptoms. For example:

• Injury at C2 or C3. These are the second and third vertebrae in the spinal column. This affects the respiratory muscles and the ability to breathe. 
• Injury in the lumbar vertebrae. This may affect nerve and muscle control to the bladder, bowel, and legs.

SCI is classified according to a person's type of loss of motor and sensory function. These are the main types:

• Quadriplegia (quad means 4). This is loss of movement and feeling in all four limbs (arms and legs). It often happens as a result of injury at T1 or above. Quadriplegia also affects the chest muscles. Injuries at C4 or above require a mechanical breathing machine (ventilator).
• Paraplegia (para here means side by side). This is loss of movement and feeling in the lower half of the body (right and left legs). It often happens as a result of injuries at T1 or below.
• Triplegia (tri means 3). This is loss of movement and feeling in one arm and both legs. It often results from incomplete SCI.

The most common symptoms of acute spinal cord injury may include:

• Muscle weakness or paralysis in the trunk, arms, or legs.
• Loss of feeling in the trunk, arms, or legs.
• Muscle spasticity.
• Breathing problems.
• Problems with heart rate and blood pressure.
• Digestive problems.
• Loss of bowel and bladder function.
• Sexual problems.

The symptoms of SCI may look like other health conditions or problems. Always talk with your healthcare provider for a diagnosis.

SCIs are not always easy to recognize. These situations should be considered as a possible spinal cord injury:

• Head injury, especially with trauma to the face.
• Pelvic fractures.
• Penetrating injuries to the spinal area.
• Injuries from falling from heights.
• Complaints of spinal pain.
• Weakness or a loss of feeling in the hands or feet (extremities).
• Loss of urine or bowel control.

If the symptoms or accidents occur at home or in the community, 911 should be called. The person should not be moved until paramedics arrive. To prevent more spinal cord injury, the paramedics will use extreme care and allow as little movement of the spine as possible. The injured person will be taken to an emergency room or trauma center.

The first medical care focuses on reducing any life-threatening problems such as bleeding or breathing problems. Movement and feeling tests are done to see if a spinal cord injury occurred. If a spinal cord injury is suspected, tests are done. These include lab tests, X-rays, CT scans, and MRIs. These tests are used to find the location and severity of the injury. To protect the spine, the neck and body is kept immobile. 

A person with a traumatic spinal cord injury goes to an intensive care unit (ICU). There they are watched for things such as breathing problems and heart problems. A full neurologic exam is done as soon as possible. This is done to diagnose the exact level and severity of the injury. These factors determine both the treatment and the expected level of recovery.

An SCI can be complete. This means there is total loss of movement and feeling below the level of injury. Or an SCI can be incomplete. This means there is some loss of movement, feeling, or both below the level of injury. To assess the severity of your injury, your doctor may use the ASIA scale. (See the box below for a link to this resource.) With this scale, a grade (ranging from A to E) is given to explain the completeness of an injury. The grade is based on the results of various sensory and motor function tests. Your doctor can tell you more about the grade of your injury and how often you’ll be tested.

The first treatment for SCIs depends on the location and severity of the injury. Some people may be treated with medicines called steroids. These help reduce the swelling in the spinal column. If the back bones (vertebrae) were moved out of position, surgery may be used to fix them. Rehabilitation (rehab) begins during the early treatment phase. As the person’s condition improves, a more detailed rehab program is often begun.

The success of rehab depends on many things, including:

• Level and severity of the SCI.
• Type and degree of resulting impairments and disabilities.
• The person’s overall health.
• Family support.

The goal of SCI rehab is to help the person return to the highest level of function and independence possible, while improving the overall quality of life physically, emotionally, and socially. A variety of SCI treatment specialists will develop rehab treatment plans that focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement and emotional support are used throughout rehab to improve self-esteem and promote independence.

SCIs impact all parts of a person's life. SCI management involves knowledge of both the skills needed for daily living and an awareness of common long-term problems that happen in people with paraplegia and quadriplegia.

Depending on the level of your injury, daily management skills include such things as how to:

• Cope with emotions such as fear, sadness, or anger.
• Use a wheelchair.
• Manage your bladder and bowel (if you have no control over your bladder or bowel).
• Exercise, to help you regain as much movement in your arms or legs as possible.

Common long-term management problems in people with SCIs include:

• Emotional and financial issues linked to the disability.
• Pain.
• Urinary tract infections and kidney problems.
• Damage to the skin and tissue under the skin caused by pressure.
• Lung infections and breathing problems.
• Weakening of bones.
• Muscle and joint stiffness.

There are many spinal cord injury treatment and rehab programs to help you deal with both short and long-term SCI management. These include:

• Acute rehabilitation programs.
• Subacute rehabilitation programs.
• Long-term rehabilitation programs.
• Transitional living programs.
• Day-treatment programs.
• Vocational rehabilitation programs.

Talk with your family and your rehab team about short-term and long-term goals. Your rehab team can help you find treatment and rehab programs and local resources to help you and your family.

The goal is to prevent injuries. The following behaviors can help prevent SCI.

Car crash injuries

• Always wear seat belts
• Use the correct safety seats and restraints for children. In addition, the American Academy of Pediatrics states that children should ride in the back seat until they are over the age of 12.
• Don’t use cell phones while driving. Enforce hands-free driving laws.
• Enforce laws and educate others about impaired driving linked to alcohol and substance abuse, including prescription medicines.

Falls

• Use handrails while climbing stairs and keep floors clear of debris and hazards such as rugs and electrical cords.
• Have grab bars in bathrooms and showers to prevent slipping.
• For children, use window latches and safety gates to block dangerous areas

Firearm injuries

• Always assume a gun is loaded and handle it as such.
• Secure all guns in a locked location away from children.
• Store bullets separately from the guns.
• Educate children and teens about the dangers of guns and teach them how to solve arguments without violence.

Team sport injuries

• Ensure that players with the same skill levels, size, and maturity level play one another.
• Always use correct and adequate protective gear. Damaged gear should never be used.
• Use only fields and playgrounds that are well maintained and well lit.

Water-related injuries

• Don’t drink alcohol when swimming.
• Never dive into shallow water, whether it is a swimming pool, river, or lake.
• Use clearly marked depths in swimming pools and have designated diving and no-diving areas.
• Never push or shove another person into a swimming pool or body of water.
• Make sure there is a lifeguard or someone trained in water safety in the swimming area.
• Secure the pool with fencing and a gate when it is not being used.

Recreational sports injuries

• Use a correct helmet that is secured with a chin strap while bicycling, skateboarding, roller-skating, and during any other high-risk activities such as four-wheeling or motorcycle riding.
• Only use a helmet with a sticker stating that it meets the standards set by the U.S. Consumer Product Safety Commission (CPSC). Have the CPSC sticker displayed inside the helmet, and in a location obvious to consumers.

Trampoline injuries

• Trampoline injuries affect young kids. About 66% of injuries occur in children between ages 6 and 14. And 15% of injuries are reported in children younger than 6 years old. For children using trampolines.
• Competent supervision is the key primary prevention tip for trampoline usage.
• Netting constructed around the trampoline can reduce the number of falls. But it is not a substitute for supervision.
• The trampoline should be placed on ground level to prevent falls off the side and the area should be well lit.
• Acrobatic moves should be done only under the supervision of a trained professional or with specialized equipment, such as a harness.
• Trampolines should not be overcrowded.

Depending on the level and severity of the injury, a person with an SCI will have varying degrees of feeling and movement in his or her body. Other body functions, such as breathing and bowel and bladder control, may be affected as well. Some people with SCI may be able to do most personal care and daily activities on their own. Others may need more help. This can include help with certain tasks, such as dressing, eating, driving, and moving around.

Note that outcomes are different from person to person, even with the same level of injury. Many factors are involved. The grade and severity of your injury may change over time. Your abilities and function may change, too. After a period of adjustment, many people with all levels of SCI report a high quality of life. Work with your doctor and healthcare team to learn what outcomes you might expect with your injury, additional treatments and therapies from which you might benefit, and what goals to work toward.