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Understanding Spinal Cord Injury

Understanding
Spinal Cord Injury

Understanding Spinal Cord Injury

What is a Spinal Cord Injury?

Spinal Cord Injury Definition

A spinal cord injury (SCI) usually begins with a sudden traumatic blow to the spine. The blow fractures, compresses or dislocates some of the vertebrae, the rings of bone which protect the nerves inside the spinal cord. Damage to the nerves causes a disruption in the pathway that carries messages up and down the spinal cord between the brain and the rest of the body. A spinal cord injury can affect feeling and movement below the level of the injury temporarily or permanently.

Dr. David Chen defines spinal cord injuries

The Spinal Cord Pathway

Your spinal cord is a bundle of nerves about 18-inches long that runs down the middle of your back. It extends from the base of the brain down to somewhere near your waist. The nerves within the spinal cord constitute a pathway that carries messages back and forth from your brain to all parts of your body. This vital pathway is protected by a column of bony rings called vertebrae that surround the spinal cord. When an injury causes the vertebrae to break and press up against the spinal cord, the nerves within can be damaged, and the pathway broken or interrupted.

The break or interruption means that the messages that flow between the brain and the spinal cord can no longer get through. The paralysis that results depends on the location and extent of the break.

It’s a common misconception that the spinal cord is severed in people with a spinal cord injury. In fact, in most people with SCI, the spinal cord is intact; it is the cellular damage to the nerves that causes paralysis. This damage can occur even without damage to the vertebrae.

Complete Spinal Cord Injuries

A spinal cord injury is called “complete” if all feeling and ability to control movement is lost below the level of the injury, which suggests that no messages are getting through the spinal cord. With a complete spinal cord injury, you have no feeling or movement below the level of the injury. The damage to the nerves prevents any message from going back and forth between your body and your brain.

Incomplete Spinal Cord Injuries

With an incomplete spinal cord injury, the ability of the spinal cord to convey messages to and from the brain is not completely lost. Some signals still get through despite the damage. This means you have some feeling and movement below the level of the injury. With advances in the acute treatment of spinal cord injuries, incomplete injuries are becoming more common.

Paraplegia

Paraplegia involves loss of movement and feeling in the lower half of the body. It means that paralysis affects all or part of the trunk and both legs, but not the arms-. It usually happens as a result of injuries at T1 or below.

Quadriplegia (also called Tetraplegia)

Quadriplegia involves the loss of movement and feeling in all four limbs–both arms and legs. It usually happens as a result of an injury at T1 or above.

Effects on the Body

People with SCI often have medical complications resulting in bladder, bowel and sexual dysfunction. They may also develop chronic pain, respiratory complications, spasticity, unstable blood pressure and heart problems. Autonomic Dysreflexia, a condition in which the involuntary nervous system causes a dangerous spike in blood pressure that can lead to stroke, may affect people with spinal cord injuries at or above the T6 level.

Asia scale

ASIA Impairment Scale

The ASIA Impairment Scale is another helpful guide to understanding an injury. It was developed by doctors at the American Spinal Injury Association (ASIA) to categorize the extent of an injury in terms of the degree of damage to the spinal cord.

If the injury is “complete,” (ASIA A) it means that no messages can travel across the location of the injury to the brain. However, “incomplete” injuries, which mean that some messages can still get through, are classified as ASIA B, ASIA C or ASIA D, depending on amount of movement and feeling that remain below the level of the injury. Here are the classifications:

ASIA A: Complete, no motor or sensory function is preserved below the level of the injury, including the sacral segments S4 – S5
ASIA B: Incomplete Sensory, but not motor function is preserved below the neurological level of injury, and includes the sacral segments S4 – S5
ASIA C: Incomplete, motor function is preserved below the neurological level of injury, but more than half of the key muscles below the level have a muscle grade less than 3 (i.e. unable to move against gravity)
ASIA D: Incomplete, motor function is preserved below the neurological level of injury, and at least half the key muscles below the injury level have a muscle grade of 3 or more (i.e. joints can be moved against gravity
ASIA E: Normal, motor and sensory functions are normal

 

VIDEO— Anatomy of the Spinal Cord and How it Works

 

This video “Anatomy of the Spinal Cord and How it Works” is an easy-to-understand guide to the spinal pathway, the vital communication system that connects the brain and the body. It shows you where the cervical, thoracic, lumbar and sacral vertebrae are located on the spinal column and how the nerves branch from them to send messages to the brain about feeling and movement. It tells you the meaning of spinal injury classifications like C5, T4 and L1, and what they actually signify in terms of loss of feeling, control and the ability to move.

A listing of the spinal cord injury levels and how they affect movement and sensation are right below the video on this page. You can also check the Animated Chart.


Spinal Cord Injury Levels

Loss of movement and feeling depend on what part of the spine is damaged.

Cervical Vertebrae Levels: C1 – C8

Cervical injuries above the C4 level may require a ventilator for the person to breathe. C6 injuries often result in shoulder and biceps control, but no control at the wrist or hand. C6 injuries generally yield wrist control, but no hand function. Individuals with C7 and T1 injuries can straighten their arms but still may have problems with their hands.

Thoracic Vertebrae Levels: T1 – T12

The first thoracic vertebrae, T1, is located at approximately the same level as the top rib. Injuries in the thoracic region usually affect the chest and legs, and result in paraplegia. For T1 to T8 injuries, there is most often control of the hands, but lack of abdominal muscle control. Lower T-injuries (T9 – T12) allow good trunk control and good abdominal muscle control.

Lumbar Vertebrae Levels: L1 – L5

Injuries to nerves in the area of L1 – L5 generally result in some loss of functioning of the hips and legs. Bowel, bladder and sexual function may also be impacted.

Sacrum Levels:  S1 – S5

The Sacral Vertebrae run from the pelvis to the end of the spinal column. Injuries to S1 – S5 generally result in some loss of functioning in the hips, legs, ankles and feet. Loss of control of bowel, bladder and sexual functions is also common.

Causes of Spinal Cord Injuries

Vehicle crashes are the most common causes of spinal cord injuries in the U.S. They account for about 40 per cent of the estimated 17,000 new cases each year. Another 30 per cent are caused by falls; acts of violence involving gunshot and knife wounds account for about 13 per cent. Athletic activities cause about 9 per cent. Use of alcohol is a factor in about 1 out of every 4 spinal cord injuries. More than 80 percent of all spinal cord injuries occur to young males, mostly between the ages of 16 and 30.

Frequent Types of Spinal Cord Injuries

Dr. Lawrence Vogel defines incomplete and complete spinal cord injury

The most common type of spinal cord injury is incomplete quadriplegia, which accounts for almost half of all SCIs. Incomplete paraplegia accounts for about 20 per cent of all injuries. Complete paraplegia accounts for another 20 per cent; complete quadriplegia (tetraplegia) about 13 per cent. Less than 1 per cent of people with spinal cord injuries make a complete neurological recovery by the time of hospital discharge.

Length of Hospitalization and Rehabilitation Care

Lengths of stay in the acute care units of hospitals have dropped from an average of 24 days in the 1970’s to 11 days today. Rehabilitation stays have also dropped from 98 days to 25 days currently.

About 30 per cent of people with SCI are re-hospitalized within any given year after an injury. Urinary tract infections and skin breakdown (pressure ulcers) are the leading causes. The average length of hospital stay is about 22 days.

For more statistical details, download Facts and Figures at a Glance from NSCISC.

Emergency Care

Improved emergency care for people with spinal cord injuries and aggressive treatment can minimize damage to the nervous system. Treatment typically begins at the scene of the accident when emergency personnel immobilize the spine as gently and quickly as possible, using a neck collar and rigid carrying board to prevent additional damage to the spinal cord. The steroid drug methylprednisolone appears to reduce the damage to nerve cells if it is given within the first eight hour after injury. However, it is not a cure for spinal cord injury.

Surgery After Spinal Cord Injury

Surgery to relieve compression of the spinal tissue by surrounding bones that have been broken or dislocated by the injury is often necessary. Surgery may also be necessary to stabilize the spine to prevent pain or a deformity in the future.

These institutions are the national leaders in medical research and patient care, and provide the highest level of comprehensive services for spinal cord injury. The group has been identified by National Institute on Disability Rehabilitation and Research (NIDRR).

For a detailed listing: Model System Rehab Hospitals

Treatment Outlook

At this time, there is no way to reverse damage to the spinal cord. But researchers are continually working on new treatments, including stem-cell therapies, innovative electrical stimulation, bionic exoskeletons and new medications. They are aimed at promoting nerve cell regenerations or improving the function of the nerves that remain.

Spinal cord injury treatment and rehabilitation focuses on empowering people with spinal cord injuries to live active, productive lives.

Dr. Guy W. Fried looks at the future of spinal cord injury treatment

Research on Spinal Cord Injury

Scientists continually look for new ways to better understand and treat spinal cord injuries. Much of the research is supported by the National Institute of Neurological Disorders and Stroke (NINDS), which conducts research at the National Institutes of Health (NIH) and also sponsors research through grants to major research institutes. To read more, visit NIH’s Hope Through Research page.

Basic research on injured spinal cords has begun to show some promising results. Research projects that focus on ways to protect surviving nerve cells from more damage, stimulate the regrowth of nerve cells, replace damaged nerve cells and retrain the central nervous system to form new nerve pathways are showing some promising results.

Rehabilitation research projects investigate the types of therapy that work best to restore function and promote patient mobility. They include active rehabilitation and exercise, epidural stimulation (electrical stimulation of the spine) functional electrical stimulation (using a computer and electrodes to deliver small bursts of electricity to paralyzed muscles) and such things robotic assisted therapy, including Lokomats and exoskeletons. Brain-computer interfaces that bypass the spinal cord and use implanted electrodes to translate thoughts into physical movement are showing some results.

Clinical Trials

The National Institute of Neurological Disorders and Stroke (NINDS) maintains a current list of ongoing clinical trials. View them here.

Who Needs Rehabilitation?

Paralysis causes major changes to your body. Movement and feeling have been lost to some degree. Medical needs must be handled. There is weakness and fatigue in the muscles that can still move. Most people cannot handle the tasks of everyday life in the same way they did before.

That’s why everybody who has a spinal cord injury needs rehabilitation in order to maximize physical improvements and to help adjust to a new life. The goal of all SCI rehabilitation is to help you reach your full potential after injury.

Everybody is an individual; not all injuries are the same, which is why rehabilitation programs are designed to fit each individual’s needs. A team of people put together a plan to help you live an active, healthy life.

The SCI Rehabilitation Team

Kristine Cichowski, MS, on finding a good rehabilitation facility

Physiatrists are the rehab doctors who lead the team and manage your medical care. They are specially trained in Physical Medicine and Rehabilitation, and their job is to help you maximize what you can do, and to help you adapt to what you can’t.

Psychologists help you find strategies and develop methods for adjusting to life after a spinal cord injury; they help you create a “new normal.”

Nurses often provide the early in-hospital education in how to manage bowel and bladder issues.

Physical Therapists help you regain strength, flexibility and stamina and teach you important techniques for wheelchair and bed mobility and transferring from in and out of a wheelchair

Occupational Therapists focus on helping you find ways to take care of yourself and to carry out your daily living activities, such as bathing, eating and getting dressed. Their emphasis is on making you as independent as possible.

Social Workers help with the transition from hospital to home. They come up with a discharge plan for your continuing care and rehabilitation after you leave the hospital. They help with plans for home modifications that make for an accessible home environment.

Recreational Therapists help you get out into the world and back into recreational and leisure activities you can do and enjoy.

Physical Therapy

Physical therapy programs are individual, designed to help you regain as much ability to move in the world as is possible for you.

Typically, therapists develop a series of goals for mobility, strength, and independent movement. They focus on stretching and strengthening to increase your range of motion, on key mobility functions, such as sitting up and rolling around in bed, transferring from bed to wheelchair and back again and on developing wheelchair mobility skills.

It’s important to find a physical center that knows how to deal with people with spinal cord injuries. Since spinal cord injuries are relatively rare, many facilities have had little or no experience in working with SCI patients. To maximize your rehabilitation, you need be treated at a facility that has lots of experience in dealing with injuries like yours.

Occupational Therapy

It’s often said that the goal of occupational therapy is to help people “live life to the fullest.” The term “occupation” therapy doesn’t apply to doing a job, but to everything people do throughout the day. In addition to helping you learn to take care of yourself (bathe, dress, eat) your occupational therapist is primarily interested in helping you find a way to get back to doing the things you want to do.

Recreational Therapy

As you might guess, recreational therapy focuses on helping you to find ways to get out in the world and enjoy the activities you used to enjoy before you were injured. They help you find adaptive sports, and adaptive sports equipment and find ways to do outdoor activities like boating, sailing, camping and fishing. Adaptive recreation plays an important role in recovery.

About 20 per cent of all SCIs occur to children and adolescents, mostly as the result of motor-vehicle accidents. Diagnosis may be difficult because a child’s immature musculoskeletal system can mean an injury doesn’t show up on an X-ray or MRI.

Children require specialized care and treatment, which continually changes as they grow older. For example, children injured prior to puberty, before they have gone through their adolescent growth spurt, are at higher risk of developing scoliosis, ( a sideways curvature of the spine). Treatment at the right time can prevent scoliosis or slow its progress.

Sara Klaas, MSW, tells parents how to find the right rehabilitation facility

Parents need to find specialized rehabilitation programs that have experience in dealing with the unique growth and development issues of children with SCI. Pediatric physical therapy, occupational therapy and speech therapy (when needed) require equipment and techniques that foster individual progress. Assistive devices to help with mobility and accomplishing daily tasks need to be changed as the child grows. Play is the work of a child, and is the foundation of all growth, so their rehab should focus on activities that are interesting and fun.

Studies show children with SCIs experience depression and anxiety at about the same rate as their able-bodied peers. Pediatric patients have very different characteristics from their adult counterparts. Neurological recovery seems to be better than in adults. Adults injured as children grow up to marry and raise families, to attend college and find jobs.

What is a Spinal Cord Injury?
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