Spinal cord injury

Diseases and Conditions

Spinal cord injury

Overview

A spinal cord injury — damage to any part of the spinal cord or nerves at the end of the spinal canal (cauda equina) — often causes permanent changes in strength, sensation and other body functions below the site of the injury.

If you've recently injured your spinal cord, it might seem like every aspect of your life has been affected. You might feel the effects of your injury mentally, emotionally and socially.

Many scientists are optimistic that advances in research will someday make repair of spinal cord injuries possible. Research studies are ongoing around the world. In the meantime, treatments and rehabilitation allow many people with spinal cord injuries to lead productive, independent lives.

Symptoms

Your ability to control your limbs after a spinal cord injury depends on two factors: where the injury occurred on your spinal cord and the severity of injury.

The lowest part of your spinal cord that remains undamaged after an 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 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 can be referred to as:

Tetraplegia. Also known as quadriplegia, this means that 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.

Your health care team will perform a series of tests to determine the neurological level and completeness of your injury.

Spinal cord injuries can cause one or more of the following signs and symptoms:

Loss of movement
Loss of or altered 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 a spinal cord injury after an accident 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

When to see a doctor

Anyone who has significant trauma to the head or neck needs immediate medical evaluation for a spinal injury. In fact, it's safest to assume that trauma victims have a spinal injury until proved otherwise because:

A serious spinal injury isn't always immediately obvious. If it isn't known, a more severe injury may occur.
Numbness or paralysis can be immediate or come on gradually.
The time between injury and treatment can be critical in determining the extent and severity of complications and the possible extent of expected recovery.

If you suspect that someone has a back or neck injury:

Don't move the injured person — permanent paralysis and other serious complications can result
Call 911 or your local emergency medical assistance number
Keep the person still
Place heavy towels on both sides of the neck or hold the head and neck to prevent them from moving until emergency care arrives
Provide basic first aid, such as stopping bleeding and making the person comfortable, without moving the head or neck

Causes

Spinal cord injuries can result from damage to the vertebrae, ligaments or disks of the spinal column or to the spinal cord itself.

A traumatic spinal cord injury can stem from a sudden, traumatic blow to your spine that fractures, dislocates, crushes or compresses one or more of your vertebrae. It can also result from a gunshot or knife wound that penetrates and cuts your spinal cord.

Additional damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around your spinal cord.

A nontraumatic spinal cord injury can be caused by arthritis, cancer, inflammation, infections or disk degeneration of the spine.

Your brain and central nervous system

The central nervous system comprises the brain and spinal cord. The spinal cord is made of soft tissue and surrounded by bones (vertebrae). It extends down from the base of your brain and contains nerve cells and groups of nerves called tracts, which go to different parts of your body.

The lower end of your spinal cord stops a little above your waist in the region called the conus medullaris. Below this region is a group of nerve roots called the cauda equina.

Tracts in your spinal cord carry messages between your brain and the rest of your body. Motor tracts carry signals from your brain to control muscle movement. Sensory tracts carry signals from body parts to your brain relating to heat, cold, pressure, pain and the position of your limbs.

Damage to nerve fibers

Whether the cause is traumatic or nontraumatic, the damage affects the nerve fibers passing through the injured area and can impair part of or all the 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. A neck (cervical) injury affects the same areas in addition to affecting movements of your arms and, possibly, your ability to breathe.

Common causes of spinal cord injuries

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 almost half of new spinal cord injuries each year.
Falls. A spinal cord injury after age 65 is most often caused by a fall.
Acts of violence. About 12% of spinal cord injuries result from violent encounters, usually from gunshot wounds. Knife wounds also are common.
Sports and recreation injuries. Athletic activities, such as impact sports and diving in shallow water, cause about 10% of spinal cord injuries.
Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Risk factors

Although a spinal cord injury is usually the result of an accident and can happen to anyone, certain factors can predispose you to being at higher risk of having a spinal cord injury, including:

Being male. Spinal cord injuries affect a disproportionate number of men. In fact, females account for only about 20% of traumatic spinal cord injuries in the United States.
Being between the ages of 16 and 30. More than half of spinal cord injuries occur in people in this age range.
Being 65 and older. Another spike in spinal cord injuries occurs at age 65. Falls cause most injuries in older adults.
Alcohol use. Alcohol use is involved in about 25 % of traumatic spinal cord injuries.
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 certain diseases. A relatively minor injury can cause a spinal cord injury if you have another disorder that affects your joints or bones, such as osteoporosis.

Complications

At first, changes in the way your body functions can be overwhelming. However, your rehabilitation team will help you develop tools to address the changes caused by the spinal cord injury, in addition to recommending equipment and resources to promote quality of life and independence. Areas often affected include:

Bladder control. Your bladder will continue to store urine from your kidneys. However, your brain might not control your bladder as well because the message carrier (the spinal cord) has been injured.

The changes in bladder control increase your risk of urinary tract infections. The changes may also cause kidney infections and kidney or bladder stones. During rehabilitation, you'll learn ways to help empty your bladder.
Bowel control. Although your stomach and intestines work much like they did before your injury, control of your bowel movements is often altered. A high-fiber diet might help regulate your bowels, and you'll learn ways to help control your bowel during rehabilitation.
Pressure injuries. Below the neurological level of your injury, you might have lost some or all skin sensations. Therefore, your skin can't send a message to your brain when it's injured by certain things such as prolonged pressure.

This can make you more susceptible to pressure sores, but changing positions frequently — with help, if needed — can help prevent these sores. You'll learn proper skin care during rehabilitation, which can help you avoid these problems.
Circulatory control. A spinal cord injury can cause circulatory problems ranging from low blood pressure when you rise (orthostatic hypotension) to swelling of your extremities. These circulation changes can also increase your risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus.

Another problem with circulatory control is a potentially life-threatening rise in blood pressure (autonomic dysreflexia). Your rehabilitation team will teach you how to address these problems if they affect you.
Respiratory system. Your injury might make it more difficult to breathe and cough if your abdominal and chest muscles are affected.

Your neurological level of injury will determine what kind of breathing problems you have. If you have a cervical and thoracic spinal cord injury, you might have an increased risk of pneumonia or other lung problems. Medications and therapy can help prevent and treat these problems.
Bone density. After spinal cord injury, there's an increased risk of osteoporosis and fractures below the level of injury.
Muscle tone. Some people with spinal cord injuries have one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility can lead to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes.

A dietitian can help you eat a nutritious diet to sustain an adequate weight. Physical and occupational therapists can help you develop a fitness and exercise program.
Sexual health. Men might notice changes in erection and ejaculation; women might notice changes in lubrication after a spinal cord injury. Physicians specializing in urology or fertility can offer options for sexual functioning and fertility.
Pain. Some people have pain, such as muscle or joint pain, from overuse of particular muscle groups. Nerve pain can occur after a spinal cord injury, especially in someone with an incomplete injury.
Depression. Coping with the changes a spinal cord injury brings and living with pain causes depression in some people.

Prevention

Following this advice might reduce your risk of a spinal cord injury:

Drive safely. Car crashes are one of the most common causes of spinal cord injuries. Wear a seat belt every time you're in a moving vehicle.

Make sure that your children wear a seat belt or use an age- and weight-appropriate child safety seat. To protect them from air bag injuries, children under age 12 should always ride in the back seat.
Check water depth before diving. Don't dive into a pool unless it's 12 feet (about 3.7 meters) or deeper, don't dive into an aboveground pool and don't dive into water if you don't know how deep it is.
Prevent falls. Use a step stool with a grab bar to reach high-up objects. Add handrails along stairways. Put nonslip mats on tile floors and in the tub or shower. For young children, use safety gates to block stairs and consider installing window guards.
Take precautions when playing sports. Always wear recommended safety gear. Avoid leading with your head in sports. For example, don't slide headfirst in baseball, and don't tackle using the top of your helmet in football. Use a spotter for new moves in gymnastics.
Don't drink and drive. Don't drive while intoxicated or under the influence of drugs. Don't ride with a driver who's been drinking.

Diagnosis

In the emergency room, a doctor may be able to rule out a spinal cord injury by examination, testing for sensory function and movement, and by asking some questions about the accident.

But if the injured person complains of neck pain, isn't fully awake, or has obvious signs of weakness or neurological injury, emergency diagnostic tests may be needed.

These tests can include:

X-rays. X-rays can reveal vertebral (spinal column) problems, tumors, fractures or degenerative changes in the spine.
CT scan. A CT scan can provide a clearer image of abnormalities seen on X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other problems.
MRI. MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that might compress the spinal cord.

A few days after injury, when some of the swelling might have subsided, your doctor will conduct a more comprehensive neurological exam to determine the level and completeness of your injury. This involves testing your muscle strength and your ability to sense light touch and pinprick sensations.

Treatment

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 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 with a spinal cord injury to return to an active and productive life.

Emergency actions

Urgent medical attention is critical to minimize the effects of head or neck trauma. 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 using a rigid neck collar and a rigid carrying board, which they use during transport to the hospital.

Early (acute) stages of treatment

In the emergency room, doctors focus on:

Maintaining your ability to breathe
Preventing shock
Immobilizing your neck to prevent further spinal cord damage
Avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular difficulty, and formation of deep vein blood clots in the extremities

If you have a spinal cord injury, you'll usually be admitted to the intensive care unit for treatment. You might be transferred to a regional spine injury center that has a team of neurosurgeons, orthopedic surgeons, spinal cord medicine specialists, psychologists, nurses, therapists and social workers with expertise in spinal cord injury.

Medications. Methylprednisolone (Solu-Medrol) given through a vein in the arm (IV) has been used as a treatment option for an acute spinal cord injury in the past. But recent research has shown that the potential side effects, such as blood clots and pneumonia, from using this medication 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. Options include soft neck collars and various braces.
Surgery. Often surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery might also be needed to stabilize the spine to prevent future pain or deformity.
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

After the initial injury or condition stabilizes, doctors turn their attention to preventing secondary problems that may arise, such as deconditioning, muscle contractures, pressure ulcers, bowel and bladder issues, respiratory infections, and blood clots.

The length of your hospital stay will depend on your condition and the medical issues you face. Once you're well enough to participate in therapies and treatment, you might transfer to a rehabilitation facility.

Rehabilitation

Rehabilitation team members will begin to work with you while you're in the early stages of recovery. Your team might include a physical therapist, an occupational therapist, a rehabilitation nurse, a rehabilitation psychologist, a social worker, a dietitian, a recreation therapist, and a doctor who specializes in physical medicine (physiatrist) or spinal cord injuries.

During the initial stages of rehabilitation, therapists usually emphasize maintaining and strengthening muscle function, redeveloping fine motor skills, and learning ways to adapt to do day-to-day tasks.

You'll be educated on the effects of a spinal cord injury and how to prevent complications, and you'll be given advice on rebuilding your life and increasing your quality of life and independence.

You'll be taught many new skills, and you'll use equipment and technologies that can help you live on your own as much as possible. You'll be encouraged to resume your favorite hobbies, participate in social and fitness activities, and return to school or the workplace.

Medications

Medications might be used to manage some of the effects of spinal cord injury. These include medications to control pain and muscle spasticity, as well as medications that can improve bladder control, bowel control and sexual functioning.

New technologies

Inventive medical devices can help people with a spinal cord injury become more independent and more mobile. These include:

Modern wheelchairs. Improved, lighter weight wheelchairs are making people with spinal cord injuries more mobile and more comfortable. Some people need an electric wheelchair. Some wheelchairs can even climb stairs, travel over rough ground and elevate a user to reach high places without help.
Computer adaptations. For someone who has limited hand function, computers can be difficult to operate. Computer adaptations range from simple to complex, such as key guards and voice recognition.
Electronic aids to daily living. Essentially any device that uses electricity can be controlled with an electronic aid to daily living. Devices can be turned on or off by switch or voice-controlled and computer-based remotes.
Electrical stimulation devices. Often called functional electrical stimulation systems, these sophisticated devices use electrical stimulators to control arm and leg muscles to allow people with spinal cord injuries to stand, walk, reach and grip.

Prognosis and recovery

Your doctor might not be able to give you a prognosis right away. Recovery, if it occurs, usually relates to the severity and level of the injury. The fastest rate of recovery is often seen in the first six months, but some people make small improvements for up to 1 to 2 years.

Coping and support

An accident that results in paralysis is a life-changing event. Suddenly having a disability can be frightening and confusing, and adapting is no easy task. You'll likely wonder how your spinal cord injury will affect your everyday activities, job, relationships and long-term happiness.

Recovery takes time, but many people who are paralyzed progress to lead productive and fulfilling lives. It's essential to stay motivated and get the support you need.

Grieving

If you're newly injured, you and your family will likely experience a period of mourning. The grieving process, which is a normal, healthy part of your recovery, is different for everyone.

It's natural — and important — to grieve the loss of the way you were. But it's also necessary to set new goals and find ways to go forward.

You'll probably have concerns about how your injury will affect your lifestyle, your financial situation and your relationships. Grieving and emotional stress are normal and common.

However, if your grief is affecting your care, causing you to isolate yourself or prompting you to abuse alcohol or other drugs, you might want to talk to a social worker, psychologist or psychiatrist. Or you might find it helpful to join a support group of people with spinal cord injuries.

Talking with others who understand what you're going through can be encouraging, and you might find good advice on adapting areas of your home or work space to better meet your needs. Ask your doctor or rehabilitation specialist if there are support groups in your area.

Taking control

One of the best ways to regain control of your life is to educate yourself about your injury and your options for gaining more independence. A range of driving equipment and vehicle modifications is available today.

The same is true of home modification products. Ramps, wider doors, special sinks, grab bars and easy-to-turn doorknobs make it possible for you to live more autonomously.

The costs of a spinal cord injury can be overwhelming, but you might be eligible for economic assistance or support services from the state or federal government or from charitable organizations. Your rehabilitation team can help you identify resources in your area.

Talking about your disability

Some friends and family members might be unsure about how to act around you. Being educated about your spinal cord injury and willing to educate others can benefit all of you.

Explain the effects of your injury and what others can do to help. But don't hesitate to tell friends and loved ones when they're helping too much. Although it may be uncomfortable at first, talking about your injury can strengthen your relationships with family and friends.

Dealing with intimacy, sexuality and sexual activity

Your spinal cord injury might affect your body's sexual responsiveness. However, you're a sexual being with sexual desires. A fulfilling emotional and physical relationship is possible but requires communication, experimentation and patience.

A professional counselor can help you and your partner communicate your needs and feelings. Your doctor can provide the medical information you need regarding sexual health. You can have a satisfying future complete with intimacy and sexual pleasure.

Looking ahead

As you learn more about your injury and treatment options, you might be surprised by all you can do. Thanks to new technologies, treatments and devices, people with spinal cord injuries play basketball and participate in track meets. They paint and take photographs. They get married, have and raise children, and have rewarding jobs.

Advances in stem cell research and nerve cell regeneration give hope for greater recovery for people with spinal cord injuries. And new treatments are being investigated for people with long-standing spinal cord injuries.

No one knows when new treatments will be available, but you can remain hopeful about the future of spinal cord research while living your life to the fullest today.

Preparing for an appointment

Traumatic spinal cord injuries are emergencies, and people who are injured might not be able to participate in their care at first.

A number of specialists will be involved in stabilizing the condition, including a doctor who specializes in nervous system disorders (neurologist) and a surgeon who specializes in spinal cord injuries and other nervous system problems (neurosurgeon), among others.

A doctor who specializes in spinal cord injuries will lead your rehabilitation team, which will include a variety of specialists.

If you have a possible spinal cord injury or you accompany someone who's had a spinal cord injury and can't provide the necessary information, here are some things you can do.

What you can do

Be prepared to provide information about the circumstances of the event that caused the injury, including any that may seem unrelated.
Have another family member or friend join you when you speak with the doctors, if possible. Someone who accompanies you can help you remember the information you're given and communicate them to the person with the injury when appropriate.
Write down questions to ask the doctors.

For a spinal cord injury, some basic questions to ask the doctor include:

What's the prognosis?
What will happen in the short term? What will happen over the long term? What treatments are available, and which do you recommend?
Could surgery help?
What type of rehabilitation might help?
What research is being done to help this condition?
Do you have brochures or other printed material? What websites do you recommend?

Don't hesitate to ask other questions you have.