A spinal cord injury (SCI) is damage to the
spinal cord
The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spi ...
that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function,
sensation
Sensation (psychology) refers to the processing of the senses by the sensory system.
Sensation or sensations may also refer to:
In arts and entertainment In literature
* Sensation (fiction), a fiction writing mode
* Sensation novel, a Britis ...
, or
autonomic function in the parts of the body served by the spinal cord below the level of the injury. Injury can occur at any level of the spinal cord and can be ''complete'', with a total loss of sensation and muscle function at lower sacral segments, or ''incomplete'', meaning some nervous signals are able to travel past the injured area of the cord up to the Sacral S4-5 spinal cord segments. Depending on the location and severity of damage, the symptoms vary, from
numbness
Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli. In everyday speech this is generally referred to as num ...
to
paralysis
Paralysis (also known as plegia) is a loss of motor function in one or more muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage. In the United States, roughly 1 in 50 ...
, including bowel or bladder
incontinence
Incontinence or Incontinent may refer to:
*Fecal incontinence, the involuntary excretion of bowel contents
*Urinary incontinence, the involuntary excretion of urine
* Lack of moderation or self-control, especially related to sexual desire - see I ...
. Long term outcomes also range widely, from full recovery to permanent
tetraplegia
Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or t ...
(also called quadriplegia) or
paraplegia
Paraplegia, or paraparesis, is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek ()
"half-stricken". It is usually caused by spinal cord injury or a congenital condition that affects the neural ...
. Complications can include
muscle atrophy
Muscle atrophy is the loss of skeletal muscle mass. It can be caused by immobility, aging, malnutrition, medications, or a wide range of injuries or diseases that impact the musculoskeletal or nervous system. Muscle atrophy leads to muscle weakness ...
, loss of voluntary motor control,
spasticity
Spasticity () is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.
...
,
pressure sore
Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...
s,
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
s, and
breathing problems.
In the majority of cases the damage results from
physical trauma
An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, ...
such as
car accidents,
gunshot wound
A gunshot wound (GSW) is a penetrating injury caused by a projectile (e.g. a bullet) from a gun (typically firearm or air gun). Damages may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of th ...
s,
fall
Autumn, also known as fall in American English and Canadian English, is one of the four temperate seasons on Earth. Outside the tropics, autumn marks the transition from summer to winter, in September (Northern Hemisphere) or March ( Southe ...
s, or
sports injuries
Sports injuries are injuries that occur during sport, athletic activities, or exercising. In the United States, there are approximately 30 million teenagers and children who participate in some form of organized sport. Of those, about three mi ...
, but it can also result from nontraumatic causes such as
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
,
insufficient blood flow, and
tumor
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s. Just over half of injuries affect the
cervical spine
In tetrapods, cervical vertebrae (singular: vertebra) are the vertebrae of the neck, immediately below the skull. Truncal vertebrae (divided into thoracic and lumbar vertebrae in mammals) lie caudal (toward the tail) of cervical vertebrae. In sau ...
, while 15% occur in each of the
thoracic spine
In vertebrates, thoracic vertebrae compose the middle segment of the vertebral column, between the cervical vertebrae and the lumbar vertebrae. In humans, there are twelve thoracic vertebrae and they are intermediate in size between the cervical ...
, border between the thoracic and
lumbar spine
The lumbar vertebrae are, in human anatomy, the five vertebrae between the rib cage and the pelvis. They are the largest segments of the vertebral column and are characterized by the absence of the foramen transversarium within the transverse p ...
, and lumbar spine alone.
Diagnosis is typically based on symptoms and
medical imaging
Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
.
[
Efforts to prevent SCI include individual measures such as using safety equipment, societal measures such as safety regulations in sports and traffic, and improvements to equipment. Treatment starts with restricting further motion of the spine and maintaining adequate ]blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
.[ ]Corticosteroids
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involve ...
have not been found to be useful.[ Other interventions vary depending on the location and extent of the injury, from bed rest to surgery. In many cases, spinal cord injuries require long-term ]physical
Physical may refer to:
*Physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally co ...
and occupational therapy
Occupational therapy (OT) is a global healthcare profession. It involves the use of assessment and intervention to develop, recover, or maintain the meaningful activities, or ''occupations'', of individuals, groups, or communities. The field of ...
, especially if it interferes with activities of daily living
Activity may refer to:
* Action (philosophy), in general
* Human activity: human behavior, in sociology behavior may refer to all basic human actions, economics may study human economic activities and along with cybernetics and psychology may st ...
.
In the United States, about 12,000 people a year survive a spinal cord injury.[ The most commonly affected group are ]young adult
A young adult is generally a person in the years following adolescence. Definitions and opinions on what qualifies as a young adult vary, with works such as Erik Erikson's stages of human development significantly influencing the definition of ...
males.[ SCI has seen great improvements in its care since the middle of the 20th century. Research into potential treatments includes ]stem cell
In multicellular organisms, stem cells are undifferentiated or partially differentiated cells that can differentiate into various types of cells and proliferate indefinitely to produce more of the same stem cell. They are the earliest type o ...
implantation, hypothermia, engineered materials for tissue support, epidural
Epidural administration (from Ancient Greek ἐπί, , upon" + ''dura mater'') is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians an ...
spinal stimulation
Neurostimulation is the purposeful modulation of the nervous system's activity using invasive (e.g. microelectrodes) or non-invasive means (e.g. transcranial magnetic stimulation or transcranial electric stimulation, tES, such as tDCS or transcr ...
, and wearable robotic exoskeletons.
Classification
Spinal cord injury can be traumatic or nontraumatic, and can be classified into three types based on cause: mechanical forces, toxic, and ischemic
Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems w ...
(from lack of blood flow). The damage can also be divided into primary and secondary injury: the cell death that occurs immediately in the original injury, and biochemical cascade
A biochemical cascade, also known as a signaling cascade or signaling pathway, is a series of chemical reactions that occur within a biological cell when initiated by a stimulus. This stimulus, known as a first messenger, acts on a receptor that ...
s that are initiated by the original insult and cause further tissue damage. These secondary injury pathways include the ischemic cascade
The ischemic (ischaemic) cascade is a series of biochemical reactions that are initiated in the brain and other aerobic tissues after seconds to minutes of ischemia (inadequate blood supply). This is typically secondary to stroke, injury, or cardi ...
, inflammation
Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
, swelling, cell suicide, and neurotransmitter
A neurotransmitter is a signaling molecule secreted by a neuron to affect another cell across a synapse. The cell receiving the signal, any main body part or target cell, may be another neuron, but could also be a gland or muscle cell.
Neuro ...
imbalances. They can take place for minutes or weeks following the injury.
At each level of the spinal column, spinal nerve
A spinal nerve is a mixed nerve, which carries motor, sensory, and autonomic signals between the spinal cord and the body. In the human body there are 31 pairs of spinal nerves, one on each side of the vertebral column. These are grouped into th ...
s branch off from either side of the spinal cord and exit between a pair of vertebra
The spinal column, a defining synapomorphy shared by nearly all vertebrates,Hagfish are believed to have secondarily lost their spinal column is a moderately flexible series of vertebrae (singular vertebra), each constituting a characteristic ...
e, to innervate a specific part of the body. The area of skin innervated by a specific spinal nerve is called a dermatome Dermatome may refer to:
* Dermatome (anatomy), an area of skin that is supplied by a single pair of dorsal roots
* Dermatome (embryology), the portion of the embryonic paraxial mesoderm, the somite, which gives rise to dermis
* Dermatome (instrument ...
, and the group of muscles innervated by a single spinal nerve is called a myotome
A myotome is the group of muscles that a single spinal nerve innervates. Similarly a dermatome is an area of skin that a single nerve innervates with sensory fibers. Myotomes are separated by myosepta (singular: myoseptum). In vertebrate embryoni ...
. The part of the spinal cord that was damaged corresponds to the spinal nerves at that level and below. Injuries can be cervical 1–8 (C1–C8), thoracic 1–12 (T1–T12), lumbar 1–5 (L1–L5), or sacral (S1–S5). A person's level of injury is defined as the lowest level of full sensation and function. Paraplegia occurs when the legs are affected by the spinal cord damage (in thoracic, lumbar, or sacral injuries), and tetraplegia occurs when all four limbs are affected (cervical damage).
SCI is also classified by the degree of impairment. The ''International Standards for Neurological Classification of Spinal Cord Injury'' (ISNCSCI), published by the American Spinal Injury Association
The American Spinal Injury Association (ASIA), formed in 1973, publishes the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), which is a neurological exam widely used to document sensory and motor impairment ...
(ASIA), is widely used to document sensory and motor impairments following SCI.[ It is based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of the muscles that control key motions on both sides of the body.] Muscle strength is scored on a scale of 0–5 according to the table on the right, and sensation is graded on a scale of 0–2: 0 is no sensation, 1 is altered or decreased sensation, and 2 is full sensation. Each side of the body is graded independently.
Complete and incomplete injuries
In a "complete" spinal injury, all functions below the injured area are lost, whether or not the spinal cord is severed. An "incomplete" spinal cord injury involves preservation of motor or sensory function below the level of injury in the spinal cord. To be classed as incomplete, there must be some preservation of sensation or motion in the areas innervated by S4 to S5, e.g. voluntary external anal sphincter
The external anal sphincter (or sphincter ani externus ) is a flat plane of skeletal muscle fibers, elliptical in shape and intimately adherent to the skin surrounding the margin of the anus.
Anatomy
The external anal sphincter measures about 8 ...
contraction. The nerves in this area are connected to the very lowest region of the spinal cord, and retaining sensation and function in these parts of the body indicates that the spinal cord is only partially damaged. Incomplete injury by definition includes a phenomenon known as sacral sparing: some degree of sensation is preserved in the sacral dermatomes, even though sensation may be more impaired in other, higher dermatomes below the level of the lesion. Sacral sparing has been attributed to the fact that the sacral spinal pathways are not as likely as the other spinal pathways to become compressed after injury due to the lamination of fibers within the spinal cord.
Spinal cord injury without radiographic abnormality
Spinal cord injury without radiographic abnormality exists when SCI is present but there is no evidence of spinal column injury on radiograph
Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
s. Spinal column injury is trauma that causes fracture
Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displa ...
of the bone or instability of the ligaments
A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the:
* Peritoneal li ...
in the spine; this can coexist with or cause injury to the spinal cord, but each injury can occur without the other. Abnormalities might show up on magnetic resonance imaging
Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...
(MRI), but the term was coined before MRI was in common use.
Central cord syndrome
Central cord syndrome
Central cord syndrome (CCS) is the most common form of cervical spinal cord injury. It is characterized by loss of power and sensation in arms and hands. It usually results from trauma which causes damage to the neck, leading to major injury to ...
, almost always resulting from damage to the cervical spinal cord, is characterized by weakness in the arms with relative sparing of the legs, and spared sensation in regions served by the sacral segments. There is loss of sensation of pain, temperature, light touch, and pressure below the level of injury. The spinal tracts that serve the arms are more affected due to their central location in the spinal cord, while the corticospinal fibers destined for the legs are spared due to their more external location. The most common of the incomplete SCI syndromes, central cord syndrome usually results from neck hyperextension
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
in older people with spinal stenosis
Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in on ...
. In younger people, it most commonly results from neck flexion. The most common causes are falls and vehicle accidents; however other possible causes include spinal stenosis and impingement on the spinal cord by a tumor or intervertebral disc
An intervertebral disc (or intervertebral fibrocartilage) lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the vertebrae, to act as a ligament to hold t ...
.
Anterior spinal artery syndrome
Anterior spinal artery syndrome
Anterior spinal artery syndrome (also known as "anterior spinal cord syndrome") is syndrome caused by ischemia of the anterior spinal artery, resulting in loss of function of the anterior two-thirds of the spinal cord. The region affected inclu ...
also known as ''anterior spinal cord syndrome'', due to damage to the front portion of the spinal cord or reduction in the blood supply from the anterior spinal artery
In human anatomy, the anterior spinal artery is the artery that supplies the anterior portion of the spinal cord. It arises from branches of the vertebral arteries and courses along the anterior aspect of the spinal cord. It is reinforced by sever ...
, can be caused by fractures or dislocations of vertebrae or herniated disks. Below the level of injury, motor function, pain sensation, and temperature sensation are lost, while sense of touch and proprioception
Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense".
Proprioception is mediated by proprioceptors, mechanosensory neurons ...
(sense of position in space) remain intact. These differences are due to the relative locations of the spinal tracts responsible for each type of function.
Brown-Séquard syndrome
Brown-Séquard syndrome
Brown-Séquard syndrome (also known as Brown-Séquard's hemiplegia, Brown-Séquard's paralysis, hemiparaplegic syndrome, hemiplegia et hemiparaplegia spinalis, or spinal hemiparaplegia) is caused by damage to one half of the spinal cord, i.e. hem ...
occurs when the spinal cord is injured on one side much more than the other. It is rare for the spinal cord to be truly hemisected (severed on one side), but partial lesions due to penetrating wounds (such as gunshot or knife wounds) or fractured vertebrae or tumors are common. On the ipsilateral side of the injury (same side), the body loses motor function, proprioception
Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense".
Proprioception is mediated by proprioceptors, mechanosensory neurons ...
, and senses of vibration and touch. On the contralateral (opposite side) of the injury, there is a loss of pain and temperature sensations.Spinothalamic tracts are in charge for pain and temperature sensation and because these tracts cross to the opposite side and above the spinal cord there is loss on the contralateral side.
Posterior spinal artery syndrome
Posterior spinal artery syndrome (PSAS), in which just the dorsal column
Dorsal (from Latin ''dorsum'' ‘back’) may refer to:
* Dorsal (anatomy), an anatomical term of location referring to the back or upper side of an organism or parts of an organism
* Dorsal, positioned on top of an aircraft's fuselage
* Dorsal c ...
s of the spinal cord are affected, is usually seen in cases of chronic myelopathy
Myelopathy describes any neurologic deficit related to the spinal cord. The most common form of myelopathy in humans, ''Spinal cord compression, cervical spondylotic myelopathy (CSM)'', also called ''degenerative cervical myelopathy'', results fro ...
but can also occur with infarction of the posterior spinal artery
The posterior spinal artery (dorsal spinal arteries) arises from the vertebral artery in 25% of humans or the posterior inferior cerebellar artery in 75% of humans, adjacent to the medulla oblongata. It supplies the grey and white posterior column ...
. This rare syndrome causes the loss of proprioception and sense of vibration below the level of injury while motor function and sensation of pain, temperature, and touch remain intact. Usually posterior cord injuries result from insults like disease or vitamin deficiency rather than trauma. Tabes dorsalis
Tabes dorsalis is a late consequence of neurosyphilis, characterized by the slow degeneration (specifically, demyelination) of the neural tracts primarily in the dorsal root ganglia of the spinal cord (nerve root). These patients have lancinating n ...
, due to injury to the posterior part of the spinal cord caused by syphilis, results in loss of touch and proprioceptive sensation.
Conus medullaris and cauda equina syndromes
Conus medullaris syndrome
''Conus'' is a genus of predatory sea snails, or cone snails, marine gastropod mollusks in the family Conidae.Bouchet, P.; Gofas, S. (2015). Conus Linnaeus, 1758. In: MolluscaBase (2015). Accessed through: World Register of Marine Species ...
is an injury to the end of the spinal cord the conus medullaris
''Conus'' is a genus of predatory sea snails, or cone snails, marine gastropod mollusks in the family Conidae.Bouchet, P.; Gofas, S. (2015). Conus Linnaeus, 1758. In: MolluscaBase (2015). Accessed through: World Register of Marine Species at ...
, located at about the T12–L2 vertebrae in adults. This region contains the S4–S5 spinal segments, responsible for bowel, bladder, and some sexual function Sexual function is how the body reacts in different stages of the sexual response cycle, or as a result of sexual dysfunction. Relevant aspects of sexual function are defined on the basis of a modified version of Masters and Johnson's work. The aspe ...
s, so these can be disrupted in this type of injury. In addition, sensation and the Achilles reflex
The ankle jerk reflex, also known as the Achilles reflex, occurs when the Achilles tendon is tapped while the foot is dorsiflexed.
It is a type of stretch reflex that tests the function of the gastrocnemius muscle and the nerve that supplies it.
...
can be disrupted. Causes include tumors
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
, physical trauma, and ischemia
Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems wi ...
. Cauda equina syndrome may also be caused by central disc prolapse or slipped disc, infections such as epidural abscess, spinal haemorrhages, secondary to medical procedures and birth abnormalities.
Cauda equina syndrome
Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around th ...
(CES) results from a lesion below the level at which the spinal cord ends. Descending nerve roots continue as the cauda equina
The cauda equina () is a bundle of spinal nerves and spinal nerve rootlets, consisting of the second through fifth lumbar nerve pairs, the first through fifth sacral nerve pairs, and the coccygeal nerve, all of which arise from the lumbar enlargeme ...
at levels L2–S5 below the conus medullaris before exiting through intervertebral foraminae. Thus it is not a true spinal cord syndrome since it is nerve roots that are damaged and not the cord itself; however, it is common for several of these nerves to be damaged at the same time due to their proximity. CES can occur by itself or alongside conus medullaris syndrome. It can cause low back pain, weakness or paralysis in the lower limbs, loss of sensation, bowel and bladder dysfunction, and loss of reflexes. There may be bilateral sciatica with central disc prolapse and altered gait. Unlike conus medullaris syndrome, symptoms often occur only on one side of the body. The cause is often compression, e.g. by a ruptured intervertebral disk or tumor. Since the nerves damaged in CES are actually peripheral nerve
A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system.
A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
s because they have already branched off from the spinal cord, the injury has better prognosis for recovery of function: the peripheral nervous system
The peripheral nervous system (PNS) is one of two components that make up the nervous system of bilateral animals, with the other part being the central nervous system (CNS). The PNS consists of nerves and ganglia, which lie outside the brain ...
has a greater capacity for healing than the central nervous system
The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain and spinal cord. The CNS is so named because the brain integrates the received information and coordinates and influences the activity of all par ...
.
Signs and symptoms
Signs (observed by a clinician) and symptom
Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...
s (experienced by a patient) vary depending on where the spine is injured and the extent of the injury.
A section of skin innervated
A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system.
A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
through a specific part of the spine is called a dermatome Dermatome may refer to:
* Dermatome (anatomy), an area of skin that is supplied by a single pair of dorsal roots
* Dermatome (embryology), the portion of the embryonic paraxial mesoderm, the somite, which gives rise to dermis
* Dermatome (instrument ...
, and injury to that part of the spine can cause pain, numbness, or a loss of sensation in the related areas. Paraesthesia
Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Paresthesia may be transient or chronic, and may have any of dozens of possible underlying causes. Paresthesias ar ...
, a tingling or burning sensation in affected areas of the skin, is another symptom. A person with a lowered level of consciousness
An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment.
A mildly depressed level of consciousne ...
may show a response to a painful stimulus above a certain point but not below it.
A group of muscles innervated through a specific part of the spine is called a myotome
A myotome is the group of muscles that a single spinal nerve innervates. Similarly a dermatome is an area of skin that a single nerve innervates with sensory fibers. Myotomes are separated by myosepta (singular: myoseptum). In vertebrate embryoni ...
, and injury to that part of the spinal cord can cause problems with movements that involve those muscles. The muscles may contract uncontrollably (spasticity
Spasticity () is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.
...
), become weak, or be completely paralysed
Paralysis (also known as plegia) is a loss of motor function in one or more muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage. In the United States, roughly 1 in 50 ...
. Spinal shock Spinal shock was first explored by Whytt in 1750 as a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) – most often a complete transection. Reflexes in the sp ...
, loss of neural activity including reflexes below the level of injury, occurs shortly after the injury and usually goes away within a day. Priapism
Priapism is a condition in which a penis remains erect for hours in the absence of stimulation or after stimulation has ended. There are three types: ischemic (low-flow), nonischemic (high-flow), and recurrent ischemic (intermittent). Most cases ...
, an erection
An erection (clinically: penile erection or penile tumescence) is a physiological phenomenon in which the penis becomes firm, engorged, and enlarged. Penile erection is the result of a complex interaction of psychological, neural, vascular, ...
of the penis may be a sign of acute spinal cord injury.
The specific parts of the body affected by loss of function are determined by the level of injury. Some signs, such as bowel and bladder dysfunction can occur at any level. Neurogenic bladder Neurogenic bladder dysfunction, or neurogenic bladder, refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. There are multiple types of neurogenic bladde ...
involves a compromised ability to empty the bladder and is a common symptom of spinal cord injury. This can lead to high pressures in the bladder that can damage the kidneys.
Lumbosacral
The effects of injuries at or above the lumbar
In tetrapod anatomy, lumbar is an adjective that means ''of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum.''
The lumbar region is sometimes referred to as the lower spine, or as an area of the back i ...
or sacral
Sacral may refer to:
*Sacred
Sacred describes something that is dedicated or set apart for the service or worship of a deity; is considered worthy of spiritual respect or devotion; or inspires awe or reverence among believers. The property ...
regions of the spinal cord (lower back and pelvis) include decreased control of the legs
A leg is a weight-bearing and locomotive anatomical structure, usually having a columnar shape. During locomotion, legs function as "extensible struts". The combination of movements at all joints can be modeled as a single, linear element ...
and hip
In vertebrate anatomy, hip (or "coxa"Latin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) in medical terminology) refers to either an anatomical region or a joint.
The hip region is ...
s, genitourinary system
The genitourinary system, or urogenital system, are the organs of the reproductive system and the urinary system. These are grouped together because of their proximity to each other, their common embryological origin and the use of common pathwa ...
, and anus. People injured below level L2 may still have use of their hip flexor and knee extensor muscles. Bowel
The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organs of the digestive system, in humans and ...
and bladder
The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine enters ...
function are regulated by the sacral
Sacral may refer to:
*Sacred
Sacred describes something that is dedicated or set apart for the service or worship of a deity; is considered worthy of spiritual respect or devotion; or inspires awe or reverence among believers. The property ...
region. It is common to experience sexual dysfunction after injury, as well as dysfunction of the bowel and bladder, including fecal
Feces ( or faeces), known colloquially and in slang as poo and poop, are the solid or semi-solid remains of food that was not digested in the small intestine, and has been broken down by bacteria in the large intestine. Feces contain a relati ...
and urinary incontinence
Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geria ...
.
Thoracic
In addition to the problems found in lower-level injuries, thoracic (chest height) spinal lesions can affect the muscles in the trunk. Injuries at the level of T1 to T8 result in inability to control the abdominal muscles. Trunk stability may be affected; even more so in higher level injuries. The lower the level of injury, the less extensive its effects. Injuries from T9 to T12 result in partial loss of trunk and abdominal muscle control. Thoracic spinal injuries result in paraplegia
Paraplegia, or paraparesis, is an impairment in motor or sensory function of the lower extremities. The word comes from Ionic Greek ()
"half-stricken". It is usually caused by spinal cord injury or a congenital condition that affects the neural ...
, but function of the hands, arms, and neck are not affected.
One condition that occurs typically in lesions above the T6 level is autonomic dysreflexia (AD), in which the blood pressure increases to dangerous levels, high enough to cause potentially deadly stroke
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
. It results from an overreaction of the system to a stimulus such as pain below the level of injury, because inhibitory signals from the brain cannot pass the lesion to dampen the excitatory sympathetic nervous system
The sympathetic nervous system (SNS) is one of the three divisions of the autonomic nervous system, the others being the parasympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of th ...
response. Signs and symptoms of AD include anxiety, headache
Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches.
Headaches can occur as a result ...
, nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
, ringing in the ears
Tinnitus is the perception of sound when no corresponding external sound is present. Nearly everyone experiences a faint "normal tinnitus" in a completely quiet room; but it is of concern only if it is bothersome, interferes with normal hearin ...
, blurred vision, flushed skin, and nasal congestion
Nasal congestion is the blockage of nasal breathing usually due to membranes lining the nose becoming swollen from inflamed blood vessels.
Background
In about 85% of cases, nasal congestion leads to mouth breathing rather than nasal breathing. ...
. It can occur shortly after the injury or not until years later.
Other autonomic functions may also be disrupted. For example, problems with body temperature regulation mostly occur in injuries at T8 and above.
Another serious complication that can result from lesions above T6 is neurogenic shock
Neurogenic shock is a distributive type of shock resulting in hypotension (low blood pressure), often with bradycardia (slowed heart rate), caused by disruption of autonomic nervous system pathways. It can occur after damage to the central nerv ...
, which results from an interruption in output from the sympathetic nervous system
The sympathetic nervous system (SNS) is one of the three divisions of the autonomic nervous system, the others being the parasympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of th ...
responsible for maintaining muscle tone
In physiology, medicine, and anatomy, muscle tone (residual muscle tension or tonus) is the continuous and passive partial muscle contraction, contraction of the muscles, or the muscle's resistance to passive stretch during resting state.O’Sull ...
in the blood vessels. Without the sympathetic input, the vessels relax and dilate. Neurogenic shock presents with dangerously low blood pressure, low heart rate, and blood pooling in the limbs—which results in insufficient blood flow to the spinal cord and potentially further damage to it.
Cervical
Spinal cord injuries at the cervical (neck) level result in full or partial tetraplegia
Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or t ...
(also called quadriplegia). Depending on the specific location and severity of trauma, limited function may be retained. Additional symptoms of cervical injuries include low heart rate
Heart rate (or pulse rate) is the frequency of the heartbeat measured by the number of contractions (beats) of the heart per minute (bpm). The heart rate can vary according to the body's physical needs, including the need to absorb oxygen and excr ...
, low blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
, problems regulating body temperature
Thermoregulation is the ability of an organism to keep its body temperature within certain boundaries, even when the surrounding temperature is very different. A thermoconforming organism, by contrast, simply adopts the surrounding temperature ...
, and breathing dysfunction. If the injury is high enough in the neck to impair the muscles involved in breathing, the person may not be able to breathe without the help of an endotracheal tube
A tracheal tube is a catheter that is inserted into the Vertebrate trachea, trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate Gas exchange, exchange of oxygen and carbon dioxide.
Many diffe ...
and mechanical ventilator.
Complications
Complications of spinal cord injuries include pulmonary edema
Pulmonary edema, also known as pulmonary congestion, is excessive edema, liquid accumulation in the parenchyma, tissue and pulmonary alveolus, air spaces (usually alveoli) of the lungs. It leads to impaired gas exchange and may cause hypoxemia an ...
, respiratory failure
Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...
, neurogenic shock
Neurogenic shock is a distributive type of shock resulting in hypotension (low blood pressure), often with bradycardia (slowed heart rate), caused by disruption of autonomic nervous system pathways. It can occur after damage to the central nerv ...
, and paralysis
Paralysis (also known as plegia) is a loss of motor function in one or more muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage. In the United States, roughly 1 in 50 ...
below the injury site.
In the long term, the loss of muscle function can have additional effects from disuse, including atrophy
Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations (which can destroy the gene to build up the organ), poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply t ...
of the muscle. Immobility can lead to pressure sore
Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...
s, particularly in bony areas, requiring precautions such as extra cushioning and turning in bed every two hours (in the acute setting) to relieve pressure. In the long term, people in wheelchairs must shift periodically to relieve pressure. Another complication is pain, including nociceptive pain
Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
(indication of potential or actual tissue damage) and neuropathic pain
Neuropathic pain is pain caused by damage or disease affecting the somatosensory system. Neuropathic pain may be associated with abnormal sensations called dysesthesia or pain from normally non-painful stimuli (allodynia). It may have continuous ...
, when nerves affected by damage convey erroneous pain signals in the absence of noxious stimuli. Spasticity
Spasticity () is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.
...
, the uncontrollable tensing of muscles below the level of injury, occurs in 65–78% of chronic SCI. It results from lack of input from the brain that quells muscle responses to stretch reflexes. It can be treated with drugs and physical therapy. Spasticity increases the risk of contracture
In pathology, a contracture is a permanent shortening of a muscle or joint. It is usually in response to prolonged hypertonic spasticity in a concentrated muscle area, such as is seen in the tightest muscles of people with conditions like spasti ...
s ( shortening of muscles, tendons, or ligaments that result from lack of use of a limb); this problem can be prevented by moving the limb through its full range of motion
Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...
multiple times a day. Another problem lack of mobility can cause is loss of bone density and changes in bone structure. Loss of bone density (bone demineralization
Biomineralization, also written biomineralisation, is the process by which living organisms produce minerals, often to harden or stiffen existing tissues. Such tissues are called mineralized tissues. It is an extremely widespread phenomenon; ...
), thought to be due to lack of input from weakened or paralysed muscles, can increase the risk of fractures. Conversely, a poorly understood phenomenon is the overgrowth of bone tissue in soft tissue areas, called heterotopic ossification
Heterotopic ossification (HO) is the process by which bone tissue forms outside of the skeleton in muscles and soft tissue.
Symptoms
In traumatic heterotopic ossification (traumatic myositis ossificans), the patient may complain of a warm, tend ...
. It occurs below the level of injury, possibly as a result of inflammation, and happens to a clinically significant extent in 27% of people.
People with SCI are at especially high risk for respiratory and cardiovascular problems, so hospital staff must be watchful to avoid them. Respiratory problems (especially pneumonia) are the leading cause of death in people with SCI, followed by infections, usually of pressure sores, urinary tract infection
A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney ...
s and respiratory infection
Respiratory tract infections (RTIs) are infectious diseases involving the respiratory tract. An infection of this type usually is further classified as an upper respiratory tract infection (URI or URTI) or a lower respiratory tract infection (LRI ...
s. Pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...
can be accompanied by shortness of breath
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...
, fever, and anxiety.
Another potentially deadly threat to respiration is deep venous thrombosis
Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...
(DVT), in which blood forms a clot in immobile limbs; the clot can break off and form a pulmonary embolism
Pulmonary embolism (PE) is a blockage of an pulmonary artery, artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include dyspnea, shortness of breath, chest pain p ...
, lodging in the lung and cutting off blood supply to it. DVT is an especially high risk in SCI, particularly within 10 days of injury, occurring in over 13% in the acute care setting. Preventative measures include anticoagulant
Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where the ...
s, pressure hose
Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and e ...
, and moving the patient's limbs. The usual signs and symptoms of DVT and pulmonary embolism may be masked in SCI cases due to effects such as alterations in pain perception and nervous system functioning.
Urinary tract infection (UTI) is another risk that may not display the usual symptoms (pain, urgency, and frequency); it may instead be associated with worsened spasticity. The risk of UTI, likely the most common complication in the long term, is heightened by use of indwelling urinary catheter
In urinary catheterization a latex, polyurethane, or silicone tube known as a urinary catheter is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection. It may also be used to inject liquids used ...
s. Catheterization may be necessary because SCI interferes with the bladder's ability to empty when it gets too full, which could trigger autonomic dysreflexia or damage the bladder permanently. The use of intermittent catheterization
Intermittent catheterization is a medical technique used in conditions where patients need either short-term catheter-based management of the urinary bladder or as a daily habit for life. Intermittent catheterization is considered the "gold standa ...
to empty the bladder at regular intervals throughout the day has decreased the mortality due to kidney failure from UTI in the first world, but it is still a serious problem in developing countries.
An estimated 24–45% of people with SCI have disorders of depression, and the suicide rate is as much as six times that of the rest of the population. The risk of suicide is worst in the first five years after injury. In young people with SCI, suicide is the leading cause of death. Depression is associated with an increased risk of other complications such as UTI and pressure ulcers that occur more when self-care is neglected.
Causes
Spinal cord injuries are most often caused by physical trauma
An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, ...
. Forces involved can be hyperflexion
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
(forward movement of the head); hyperextension
Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...
(backward movement); lateral stress (sideways movement); rotation
Rotation, or spin, is the circular movement of an object around a '' central axis''. A two-dimensional rotating object has only one possible central axis and can rotate in either a clockwise or counterclockwise direction. A three-dimensional ...
(twisting of the head); compression (force along the axis of the spine downward from the head or upward from the pelvis); or distraction
Distraction is the process of diverting the attention of an individual or group from a desired area of focus and thereby blocking or diminishing the reception of desired information. Distraction is caused by: the lack of ability to pay attentio ...
(pulling apart of the vertebrae). Traumatic SCI can result in contusion
A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...
, compression
Compression may refer to:
Physical science
*Compression (physics), size reduction due to forces
*Compression member, a structural element such as a column
*Compressibility, susceptibility to compression
* Gas compression
*Compression ratio, of a ...
, or stretch injury. It is a major risk of many types of vertebral fracture
A spinal fracture, also called a vertebral fracture or a broken back, is a fracture affecting the vertebrae of the spinal column. Most types of spinal fracture confer a significant risk of spinal cord injury. After the immediate trauma, there i ...
. Pre-existing asymptomatic congenital anomalies can cause major neurological deficits, such as hemiparesis
Hemiparesis, or unilateral paresis, is weakness of one entire side of the body (''wikt:hemi-#Prefix, hemi-'' means "half"). Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused ...
, to result from otherwise minor trauma.
In the US, Motor vehicle accidents are the most common cause of SCIs; second are falls, then violence such as gunshot wounds, then sports injuries
Sports injuries are injuries that occur during sport, athletic activities, or exercising. In the United States, there are approximately 30 million teenagers and children who participate in some form of organized sport. Of those, about three mi ...
. Another study from Asia, found that the most common cause of the SCI is fall (31.70%) from various sites such as fall from roof-tops (9.75%), electric pole (7.31%), fall from tree (7.31%) etc. Whereas road traffic accidents count for 19.51%, firearm injuries (12.19%), slipped foot (7.31%) and sports injuries (4.87%). As a result of injury, 26.82% In some countries falls are more common, even surpassing vehicle crashes as the leading cause of SCI. The rates of violence-related SCI depend heavily on place and time. Of all sports-related SCIs, shallow water dives are the most common cause; winter sport
Winter sports or winter activities are competitive sports or non-competitive recreational activities which are played on snow or ice. Most are variations of skiing, ice skating and sledding. Traditionally, such games were only played in cold are ...
s and water sport
Water sports or aquatic sports are sport activities conducted on waterbodies, and can be categorized according to the degree of immersion by the participants.
On the water
* Boat racing, the use of powerboats to participate in races
* Boatin ...
s have been increasing as causes while association football
Association football, more commonly known as football or soccer, is a team sport played between two teams of 11 players who primarily use their feet to propel the ball around a rectangular field called a pitch. The objective of the game is ...
and trampoline
A trampoline is a device consisting of a piece of taut, strong fabric stretched between a steel frame using many coiled spring (device), springs. Not all trampolines have springs, as the Springfree Trampoline uses glass-reinforced plastic rods. ...
injuries have been declining. Hanging
Hanging is the suspension of a person by a noose or ligature around the neck.Oxford English Dictionary, 2nd ed. Hanging as method of execution is unknown, as method of suicide from 1325. The ''Oxford English Dictionary'' states that hanging i ...
can cause injury to the cervical spine, as may occur in attempted suicide
Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and s ...
. Military conflicts are another cause, and when they occur they are associated with increased rates of SCI. Another potential cause of SCI is iatrogenic
Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 2 ...
injury, caused by an improperly done medical procedure such as an injection into the spinal column.
SCI can also be of a nontraumatic origin. Nontraumatic lesions cause anywhere from 30 to 80% of all SCI; the percentage varies by locale, influenced by efforts to prevent trauma. Developed countries have higher percentages of SCI due to degenerative conditions and tumors than developing countries. In developed countries, the most common cause of nontraumatic SCI is degenerative diseases, followed by tumors; in many developing countries the leading cause is infection such as HIV
The human immunodeficiency viruses (HIV) are two species of ''Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune ...
and tuberculosis. SCI may occur in intervertebral disc disease, and spinal cord vascular disease. Spontaneous bleeding can occur within or outside of the protective membranes that line the cord, and intervertebral disk
An intervertebral disc (or intervertebral fibrocartilage) lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the vertebrae, to act as a ligament to hold t ...
s can herniate. Damage can result from dysfunction of the blood vessels, as in arteriovenous malformation
Arteriovenous malformation is an abnormal connection between arteries and veins, bypassing the capillary system. This vascular anomaly is widely known because of its occurrence in the central nervous system (usually cerebral AVM), but can appea ...
, or when a blood clot becomes lodged in a blood vessel and cuts off blood supply to the cord. When systemic blood pressure drops, blood flow to the spinal cord may be reduced, potentially causing a loss of sensation and voluntary movement in the areas supplied by the affected level of the spinal cord. Congenital conditions and tumor
A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s that compress the cord can also cause SCI, as can vertebral spondylosis
Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related wear and tear of the spinal column, which is the most common cause of spondylosis. The degenera ...
and ischemia
Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems wi ...
. Multiple sclerosis
Multiple (cerebral) sclerosis (MS), also known as encephalomyelitis disseminata or disseminated sclerosis, is the most common demyelinating disease, in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This d ...
is a disease that can damage the spinal cord, as can infectious or inflammatory conditions such as tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, in ...
, herpes zoster
Shingles, also known as zoster or herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. ...
or herpes simplex
Herpes simplex is a viral infection caused by the herpes simplex virus. Infections are categorized based on the part of the body infected.
Oral herpes involves the face or mouth. It may result in small blisters in groups often called cold ...
, meningitis
Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion or ...
, myelitis
Myelitis is inflammation of the spinal cord which can disrupt the normal responses from the brain to the rest of the body, and from the rest of the body to the brain. Inflammation in the spinal cord, can cause the myelin and axon to be damaged re ...
, and syphilis
Syphilis () is a sexually transmitted infection caused by the bacterium ''Treponema pallidum'' subspecies ''pallidum''. The signs and symptoms of syphilis vary depending in which of the four stages it presents (primary, secondary, latent, an ...
.
Prevention
Vehicle-related SCI is prevented with measures including societal and individual efforts to reduce driving under the influence
Driving under the influence (DUI)—also called driving while impaired, impaired driving, driving while intoxicated (DWI), drunk driving, operating while intoxicated (OWI), operating under the influence (OUI), operating vehicle under the infl ...
of drugs or alcohol, distracted driving
Distracted driving is the act of driving while engaging in other activities which distract the driver's attention away from the road. Distractions are shown to compromise the safety of the driver, passengers, pedestrians, and people in other vehic ...
, and drowsy driving. Other efforts include increasing road safety
Road traffic safety refers to the methods and measures used to prevent road users from being killed or seriously injured. Typical road users include pedestrians, cyclists, motorists, vehicle passengers, horse riders, and passengers of on-road ...
(such as marking hazards and adding lighting) and vehicle safety, both to prevent accidents (such as routine maintenance and antilock brakes
An anti-lock braking system (ABS) is a safety anti-skid braking system used on aircraft and on land vehicles, such as cars, motorcycles, trucks, and buses. ABS operates by preventing the wheels from locking up during braking, thereby maintainin ...
) and to mitigate the damage of crashes (such as head restraints, air bags, seat belts, and child safety seats). Falls can be prevented by making changes to the environment, such as nonslip materials and grab bars in bathtubs and showers, railings for stairs, child and safety gates for windows. Gun-related injuries can be prevented with conflict resolution
Conflict resolution is conceptualized as the methods and processes involved in facilitating the peaceful ending of conflict and retribution. Committed group members attempt to resolve group conflicts by actively communicating information abou ...
training, gun safety
Gun safety is the study and practice of using, transporting, storing and disposing of firearms and ammunition, including the training of gun users, the design of weapons, and formal and informal regulation of gun production, distribution, and ...
education campaigns, and changes to the technology of guns (such as trigger lock
Gun safety is the study and practice of using, transporting, storing and disposing of firearms and ammunition, including the training of gun users, the design of weapons, and formal and informal regulation of gun production, distribution, and u ...
s) to improve their safety. Sports injuries can be prevented with changes to sports rules and equipment to increase safety, and education campaigns to reduce risky practices such as diving into water of unknown depth or head-first tackling in association football.
Diagnosis
A person's presentation in context of trauma or non-traumatic background determines suspicion for a spinal cord injury. The features are namely paralysis, sensory loss, or both at any level. Other symptoms may include incontinence.
A radiographic evaluation using an X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
, CT scan, or MRI
Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
can determine if there is damage to the spinal column and where it is located. X-rays are commonly available and can detect instability or misalignment of the spinal column, but do not give very detailed images and can miss injuries to the spinal cord or displacement of ligaments
A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the:
* Peritoneal li ...
or disks that do not have accompanying spinal column damage. Thus when X-ray findings are normal but SCI is still suspected due to pain or SCI symptoms, CT or MRI scans are used. CT gives greater detail than X-rays, but exposes the patient to more radiation
In physics, radiation is the emission or transmission of energy in the form of waves or particles through space or through a material medium. This includes:
* ''electromagnetic radiation'', such as radio waves, microwaves, infrared, visi ...
, and it still does not give images of the spinal cord or ligaments; MRI shows body structures in the greatest detail. Thus it is the standard for anyone who has neurological deficits found in SCI or is thought to have an unstable spinal column injury.
Neurological evaluations to help determine the degree of impairment are performed initially and repeatedly in the early stages of treatment; this determines the rate of improvement or deterioration and informs treatment and prognosis. The ASIA Impairment Scale outlined above is used to determine the level and severity of injury.
Management
Prehospital treatment
The first stage in the management of a suspected spinal cord injury is geared toward basic life support
Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians). It can be pr ...
and preventing further injury: maintaining airway, breathing, and circulation and restricting further motion of the spine.
In the emergency setting, most people who has been subjected to forces strong enough to cause SCI are treated as though they have instability in the spinal column and have spinal motion restricted to prevent damage to the spinal cord. Injuries or fractures in the head, neck, or pelvis as well as penetrating trauma near the spine and falls from heights are assumed to be associated with an unstable spinal column until it is ruled out in the hospital. High-speed vehicle crashes, sports injuries involving the head or neck, and diving injuries are other mechanisms that indicate a high SCI risk. Since head and spinal trauma frequently coexist, anyone who is unconscious or has a lowered level of consciousness
An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment.
A mildly depressed level of consciousne ...
as a result of a head injury is spinal motion restricted.
A rigid cervical collar
A cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck. It is also applied by emergency personnel to those who have had traumatic head or neck injuries, and can be used to treat chronic m ...
is applied to the neck, and the head is held with blocks on either side and the person is strapped to a backboard. Extrication devices are used to move people without excessively moving the spine if they are still inside a vehicle or other confined space. The use of a cervical collar has been shown to increase mortality in people with penetrating trauma and is thus not routinely recommended in this group.
Modern trauma care includes a step called clearing the cervical spine
Clearing the cervical spine is the process by which medical professionals determine whether cervical spine injuries exist, mainly regarding cervical fracture. It is generally performed in cases of major trauma. This process can take place in the e ...
, ruling out spinal cord injury if the patient is fully conscious and not under the influence of drugs or alcohol, displays no neurological deficits, has no pain in the middle of the neck and no other painful injuries that could distract from neck pain. If these are all absent, no spinal motion restriction is necessary.
If an unstable spinal column injury is moved, damage may occur to the spinal cord. Between 3 and 25% of SCIs occur not at the time of the initial trauma but later during treatment or transport. While some of this is due to the nature of the injury itself, particularly in the case of multiple or massive trauma, some of it reflects the failure to adequately restrict motion of the spine. SCI can impair the body's ability to keep warm, so warming blankets may be needed.
Early hospital treatment
Initial care in the hospital, as in the prehospital setting, aims to ensure adequate airway, breathing, cardiovascular function, and spinal motion restriction. Imaging of the spine to determine the presence of a SCI may need to wait if emergency surgery is needed to stabilize other life-threatening injuries. Acute
Acute may refer to:
Science and technology
* Acute angle
** Acute triangle
** Acute, a leaf shape in the glossary of leaf morphology
* Acute (medicine), a disease that it is of short duration and of recent onset.
** Acute toxicity, the adverse eff ...
SCI merits treatment in an intensive care unit
220px, Intensive care unit
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
, especially injuries to the cervical spinal cord. People with SCI need repeated neurological assessments and treatment by neurosurgeons. People should be removed from the spine board as rapidly as possible to prevent complications from its use.[
If the ]systolic
Systole ( ) is the part of the cardiac cycle during which some chambers of the heart contract after refilling with blood. The term originates, via New Latin, from Ancient Greek (''sustolē''), from (''sustéllein'' 'to contract'; from ''sun ...
blood pressure falls below 90 mmHg
A millimetre of mercury is a manometric unit of pressure, formerly defined as the extra pressure generated by a column of mercury one millimetre high, and currently defined as exactly pascals. It is denoted mmHg or mm Hg.
Although not an SI ...
within days of the injury, blood supply to the spinal cord may be reduced, resulting in further damage. Thus it is important to maintain the blood pressure which may be done using intravenous fluids
Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
and vasopressors. Vasopressors used include phenylephrine
Phenylephrine is a medication primarily used as a decongestant, to dilate the pupil, to increase blood pressure, and to relieve hemorrhoids. In the United States, it was previously used orally as an over-the-counter decongestant to relieve nas ...
, dopamine
Dopamine (DA, a contraction of 3,4-dihydroxyphenethylamine) is a neuromodulatory molecule that plays several important roles in cells. It is an organic compound, organic chemical of the catecholamine and phenethylamine families. Dopamine const ...
, or norepinephrine
Norepinephrine (NE), also called noradrenaline (NA) or noradrenalin, is an organic chemical in the catecholamine family that functions in the brain and body as both a hormone and neurotransmitter. The name "noradrenaline" (from Latin '' ad'', ...
.[ Mean ]arterial blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
is measured and kept at 85 to 90 mmHg for seven days after injury.
The CAMPER Trial led by Dr Kwon and subsequent studies by the UCSF TRACK-SCI group (Dhall) have shown that spinal cord perfusion pressure (SCPP) goals are more closely associated with better neurologic recovery than MAP goals. Some institutions have adopted these SCPP goals and lumbar CSF drain placement as a standard of care. The treatment for shock from blood loss is different from that for neurogenic shock
Neurogenic shock is a distributive type of shock resulting in hypotension (low blood pressure), often with bradycardia (slowed heart rate), caused by disruption of autonomic nervous system pathways. It can occur after damage to the central nerv ...
, and could harm people with the latter type, so it is necessary to determine why someone is in shock. However it is also possible for both causes to exist at the same time.[ Another important aspect of care is prevention of insufficient oxygen in the bloodstream, which could deprive the spinal cord of oxygen. People with cervical or high thoracic injuries may experience a dangerously slowed heart rate; treatment to speed it may include ]atropine
Atropine is a tropane alkaloid and anticholinergic medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate, and to decrease saliva production during surgery. It is typically given i ...
.[
The ]corticosteroid
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
medication methylprednisolone
Methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol) is a synthetic glucocorticoid, primarily prescribed for its anti-inflammatory and immunosuppressive effects. It is either used at low doses for chronic illnesses or used concomitantly at hig ...
has been studied for use in SCI with the hope of limiting swelling and secondary injury. As there does not appear to be long term benefits and the medication is associated with risks such as gastrointestinal bleeding
Gastrointestinal bleeding (GI bleed), also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may incl ...
and infection its use is not recommended as of 2018.[ Its use in ]traumatic brain injury
A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity (ranging from mild traumatic brain injury TBI/concussionto severe traumatic b ...
is also not recommended.
Surgery may be necessary, e.g. to relieve excess pressure on the cord, to stabilize the spine, or to put vertebrae back in their proper place. In cases involving instability or compression, failing to operate can lead to worsening of the condition. Surgery is also necessary when something is pressing on the cord, such as bone fragments, blood, material from ligaments or intervertebral disc
An intervertebral disc (or intervertebral fibrocartilage) lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the vertebrae, to act as a ligament to hold t ...
s, or a lodged object from a penetrating injury. Although the ideal timing of surgery is still debated, studies have found that earlier surgical intervention (within 12 hours of injury) is associated with better outcomes. This type of surgery is often referred to as "Ultra-Early", coined by Burke et al. at UCSF. Sometimes a patient has too many other injuries to be a surgical candidate this early. Surgery is controversial because it has potential complications (such as infection), so in cases where it is not clearly needed (e.g. the cord is being compressed), doctors must decide whether to perform surgery based on aspects of the patient's condition and their own beliefs about its risks and benefits. Recent large-scale studies have shown that patients who do undergo earlier surgery (within 12–24 hours) experience significantly lower rates of life-threatening complications and spend less time in hospital and critical care.
However, in cases where a more conservative approach is chosen, bed rest
Bed rest, also referred to as the rest-cure, is a medical treatment in which a person lies in bed for most of the time to try to cure an illness. Bed rest refers to voluntarily lying in bed as a treatment and not being confined to bed because of ...
, cervical collars, motion restriction devices, and optionally traction are used. Surgeons may opt to put traction on the spine to remove pressure from the spinal cord by putting dislocated vertebrae back into alignment, but herniation of intervertebral disks may prevent this technique from relieving pressure. ''Gardner-Wells tongs'' are one tool used to exert spinal traction to reduce a fracture or dislocation
In materials science, a dislocation or Taylor's dislocation is a linear crystallographic defect or irregularity within a crystal structure that contains an abrupt change in the arrangement of atoms. The movement of dislocations allow atoms to sl ...
and to reduce motion to the affected areas.
Rehabilitation
SCI patients often require extended treatment in specialized spinal unit or an intensive care unit
220px, Intensive care unit
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
.[ The rehabilitation process typically begins in the acute care setting. Usually, the inpatient phase lasts 8–12 weeks and then the outpatient rehabilitation phase lasts 3–12 months after that, followed by yearly medical and functional evaluation. ]Physical therapist
Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
s, occupational therapist
Occupational therapists (OTs) are health care professionals specializing in occupational therapy and occupational science. OTs and occupational therapy assistants (OTAs) use scientific bases and a holistic perspective to promote a person's abilit ...
s, recreational therapist
Recreational therapy or therapeutic recreation (TR) is a systematic process that utilizes recreation (leisure) and other activities as interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, as a mea ...
s, nurses, social workers, psychologist
A psychologist is a professional who practices psychology and studies mental states, perceptual, cognitive, emotional, and social processes and behavior. Their work often involves the experimentation, observation, and interpretation of how indi ...
s, and other health care professionals work as a team under the coordination of a physiatrist to decide on goals with the patient and develop a plan of discharge that is appropriate for the person's condition.
In the acute phase physical therapists focus on the patient's respiratory status, prevention of indirect complications (such as pressure ulcer
Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...
s), maintaining range of motion
Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...
, and keeping available musculature active.
For people whose injuries are high enough to interfere with breathing, there is great emphasis on airway clearance during this stage of recovery.[ Weakness of respiratory muscles impairs the ability to cough effectively, allowing secretions to accumulate within the lungs.][ As SCI patients have reduced ]total lung capacity
Lung volumes and lung capacities refer to the volume of air in the lungs at different phases of the respiratory cycle.
The average total lung capacity of an adult human male is about 6 litres of air.
Tidal breathing is normal, resting breathi ...
and tidal volume
Tidal volume (symbol VT or TV) is the volume of air moved into or out of the lungs during a normal breath. In a healthy, young human adult, tidal volume is approximately 500 ml per inspiration or 7 ml/kg of body mass.
Mechanical vent ...
, physical therapists teach them accessory breathing techniques (e.g. apical breathing, glossopharyngeal breathing) that typically are not taught to healthy individuals. Physical therapy treatment for airway clearance may include manual percussions and vibrations, postural drainage
Postural drainage (PD) is the drainage of lung secretions using gravity. It is used to treat a variety of conditions that cause the build-up of secretions in the lungs.
Uses
Postural drainage is used to treat any condition that causes the build- ...
, respiratory muscle training, and assisted cough techniques. Patients are taught to increase their intra-abdominal pressure by leaning forward to induce cough and clear mild secretions. The quad cough technique is done lying on the back with the therapist applying pressure on the abdomen in the rhythm of the cough to maximize expiratory flow and mobilize secretions. Manual abdominal compression is another technique used to increase expiratory flow which later improves coughing. Other techniques used to manage respiratory dysfunction include respiratory muscle pacing, use of a constricting abdominal binder, ventilator-assisted speech, and mechanical ventilation
Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
.
The amount of functional recovery and independence achieved in terms of activities of daily living, recreational activities, and employment is affected by the level and severity of injury. The Functional Independence Measure
The Functional Independence Measure (FIM) is an assessment tool that aims to evaluate the functional status of patients throughout the rehabilitation process following a stroke, traumatic brain injury, spinal cord injury or cancer. Its area of use ...
(FIM) is an assessment tool that aims to evaluate the function of patients throughout the rehabilitation process following a spinal cord injury or other serious illness or injury.[ It can track a patient's progress and degree of independence during rehabilitation.][ People with SCI may need to use specialized devices and to make modifications to their environment in order to handle ]activities of daily living
Activity may refer to:
* Action (philosophy), in general
* Human activity: human behavior, in sociology behavior may refer to all basic human actions, economics may study human economic activities and along with cybernetics and psychology may st ...
and to function independently. Weak joints can be stabilized with devices such as ankle-foot orthoses (AFOs) or knee-ankle-foot orthoses (KAFOs), but walking may still require a lot of effort. Increasing activity will increase chances of recovery.
For treatment of paralysis levels in the lower thoracic spine or lower, starting therapy with an orthosis
Orthotics ( el, Ορθός, translit=ortho, lit=to straighten, to align) is a medical specialty that focuses on the design and application of orthoses, or braces. An is "an externally applied device used to influence the structural and functio ...
is promising from the intermediate phase (2–26 weeks after the incident). In patients with complete paraplegia (ASIA A), this applies to lesion heights between T12 and S5. In patients with incomplete paraplegia (ASIA B-D), orthoses are even suitable for lesion heights above T12. In both cases, however, a detailed muscle function test must be carried out to precisely plan the construction with an orthosis.
Prognosis
Spinal cord injuries generally result in at least some incurable
A cure is a substance or procedure that ends a medical condition, such as a medication, a surgical operation, a change in lifestyle or even a philosophical mindset that helps end a person's sufferings; or the state of being healed, or cured. The ...
impairment even with the best possible treatment. The best predictor of prognosis is the level and completeness of injury, as measured by the ASIA impairment scale. The neurological score at the initial evaluation done 72 hours after injury is the best predictor of how much function will return. Most people with ASIA scores of A (complete injuries) do not have functional motor recovery, but improvement can occur. Most patients with incomplete injuries recover at least some function. Chances of recovering the ability to walk improve with each AIS grade found at the initial examination; e.g. an ASIA D score confers a better chance of walking than a score of C. The symptoms of incomplete injuries can vary and it is difficult to make an accurate prediction of the outcome. A person with a mild, incomplete injury at the T5 vertebra will have a much better chance of using his or her legs than a person with a severe, complete injury at exactly the same place. Of the incomplete SCI syndromes, Brown-Séquard and central cord syndromes have the best prognosis for recovery and anterior cord syndrome has the worst.
People with nontraumatic causes of SCI have been found to be less likely to develop complete injuries and some complications such as pressure sores and deep vein thrombosis, and to have shorter hospital stays. Their scores on functional tests were better than those of people with traumatic SCI upon hospital admission, but when they were tested upon discharge, those with traumatic SCI had improved such that both groups' results were the same. In addition to the completeness and level of the injury, age and concurrent health problems affect the extent to which a person with SCI will be able to live independently and to walk. However, in general people with injuries to L3 or below will likely be able to walk functionally, T10 and below to walk around the house with bracing, and C7 and below to live independently. New therapies are beginning to provide hope for better outcomes in patients with SCI, but most are in the experimental/translational stage.
One important predictor of motor recovery in an area is presence of sensation there, particularly pain perception. Most motor recovery occurs in the first year post-injury, but modest improvements can continue for years; sensory recovery is more limited. Recovery is typically quickest during the first six months. Spinal shock Spinal shock was first explored by Whytt in 1750 as a loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) – most often a complete transection. Reflexes in the sp ...
, in which reflexes are suppressed, occurs immediately after the injury and resolves largely within three months but continues resolving gradually for another 15.
Sexual dysfunction after spinal injury is common. Problems that can occur include erectile dysfunction
Erectile dysfunction (ED), also called impotence, is the type of sexual dysfunction in which the penis fails to become or stay erect during sexual activity. It is the most common sexual problem in men.Cunningham GR, Rosen RC. Overview of male ...
, loss of ability to ejaculate, insufficient lubrication of the vagina, and reduced sensation and impaired ability to orgasm
Orgasm (from Greek , ; "excitement, swelling") or sexual climax is the sudden discharge of accumulated sexual excitement during the sexual response cycle, resulting in rhythmic, involuntary muscular contractions in the pelvic region charac ...
. Despite this, many people learn ways to adapt their sexual practices so they can lead satisfying sex lives.
Although life expectancy has improved with better care options, it is still not as good as the uninjured population. The higher the level of injury, and the more complete the injury, the greater the reduction in life expectancy. Mortality is very elevated within a year of injury.
Epidemiology
Worldwide, the number of new cases since 1995 of SCI ranges from 10.4 to 83 people per million per year. This wide range of numbers is probably partly due to differences among regions in whether and how injuries are reported. In North America, about 39 people per every million incur SCI traumatically each year, and in Western Europe, the incidence is 16 per million.[ In the United States, the incidence of spinal cord injury has been estimated to be about 40 cases per 1 million people per year or around 12,000 cases per year.][ In China, the incidence is approximately 60,000 per year.]
The estimated number of people living with SCI in the world ranges from 236 to 4187 per million. Estimates vary widely due to differences in how data are collected and what techniques are used to extrapolate the figures. Little information is available from Asia, and even less from Africa and South America. In Western Europe the estimated prevalence is 300 per million people and in North America it is 853 per million.[ It is estimated at 440 per million in Iran, 526 per million in Iceland, and 681 per million in Australia.] In the United States there are between 225,000 and 296,000 individuals living with spinal cord injuries, and different studies have estimated prevalences from 525 to 906 per million.
SCI is present in about 2% of all cases of blunt force trauma. Anyone who has undergone force sufficient to cause a thoracic spinal injury is at high risk for other injuries also. In 44% of SCI cases, other serious injuries are sustained at the same time; 14% of SCI patients also have head trauma
A head injury is any injury that results in trauma to the skull or brain. The terms ''traumatic brain injury'' and ''head injury'' are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of inju ...
or facial trauma
Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures ...
. Other commonly associated injuries include chest trauma
A chest injury, also known as chest trauma, is any form of physical injury to the chest including the ribs, heart and lungs. Chest injuries account for 25% of all deaths from traumatic injury. Typically chest injuries are caused by blunt mechanism ...
, abdominal trauma, pelvic fracture
A pelvic fracture is a break of the bony structure of the pelvis. This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bl ...
s, and long bone fracture
A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a '' ...
s.
Males account for four out of five traumatic spinal cord injuries. Most of these injuries occur in men under 30 years of age. The average age at the time of injury has slowly increased from about 29 years in the 1970s to 41. In Pakistan, spinal cord injury is more common in males (92.68%) as compared to females in the 20-30 years of age group with a median age of 40 years, although people from 12-70 years of age suffered from spinal cord injury Rates of injury are at their lowest in children, at their highest in the late teens to early twenties, then get progressively lower in older age groups; however rates may rise in the elderly. In Sweden between 50 and 70% of all cases of SCI occur in people under 30, and 25% occur in those over 50. While SCI rates are highest among people age 15–20, fewer than 3% of SCIs occur in people under 15. Neonatal SCI occurs in one in 60,000 births, e.g. from breech births or injuries by forceps. The difference in rates between the sexes diminishes in injuries at age 3 and younger; the same number of girls are injured as boys, or possibly more. Another cause of pediatric injury is child abuse
Child abuse (also called child endangerment or child maltreatment) is physical, sexual, and/or psychological maltreatment or neglect of a child or children, especially by a parent or a caregiver. Child abuse may include any act or failure to a ...
such as shaken baby syndrome
Shaken baby syndrome (SBS), also known as abusive head trauma (AHT), is the leading cause of fatal head injuries in children younger than two years. Diagnosing the syndrome has proved both challenging and contentious for medical professionals, ...
. For children, the most common cause of SCI (56%) is vehicle crashes. High numbers of adolescent injuries are attributable in a large part to traffic accidents and sports injuries. For people over 65, falls are the most common cause of traumatic SCI. The elderly and people with severe arthritis
Arthritis is a term often used to mean any disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, swelling, and decreased range of motion of the affected joints. In som ...
are at high risk for SCI because of defects in the spinal column. In nontraumatic SCI, the gender difference is smaller, the average age of occurrence is greater, and incomplete lesions are more common.
History
SCI has been known to be devastating for millennia; the ancient Egyptian Edwin Smith Papyrus
The Edwin Smith Papyrus is an ancient Egyptian medical text, named after Edwin Smith who bought it in 1862, and the oldest known surgical treatise on trauma. From a cited quotation in another text, it may have been known to ancient surgeons as t ...
from 2500 BC, the first known description of the injury, says it is "not to be treated". Hindu texts dating back to 1800 BC also mention SCI and describe traction techniques to straighten the spine. The Greek physician Hippocrates
Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history of ...
, born in the fifth century BC, described SCI in his Hippocratic Corpus
The Hippocratic Corpus (Latin: ''Corpus Hippocraticum''), or Hippocratic Collection, is a collection of around 60 early Ancient Greek medical works strongly associated with the physician Hippocrates and his teachings. The Hippocratic Corpus cove ...
and invented traction devices to straighten dislocated vertebrae. But it was not until Aulus Cornelius Celsus
Aulus Cornelius Celsus ( 25 BC 50 AD) was a Roman encyclopaedist, known for his extant medical work, ''De Medicina'', which is believed to be the only surviving section of a much larger encyclopedia. The ''De Medicina'' is a primary source on d ...
, born 30 BC, noted that a cervical injury resulted in rapid death that the spinal cord itself was implicated in the condition. In the second century AD the Greek physician Galen experimented on monkeys and reported that a horizontal cut through the spinal cord caused them to lose all sensation and motion below the level of the cut. The seventh-century Greek physician Paul of Aegina
Paul of Aegina or Paulus Aegineta ( el, Παῦλος Αἰγινήτης; Aegina, ) was a 7th-century Byzantine Greek physician best known for writing the medical encyclopedia ''Medical Compendium in Seven Books.'' He is considered the “Father ...
described surgical techniques for treatment of broken vertebrae by removing bone fragments, as well as surgery to relieve pressure on the spine. Little medical progress was made during the Middle Ages in Europe; it was not until the Renaissance
The Renaissance ( , ) , from , with the same meanings. is a period in European history marking the transition from the Middle Ages to modernity and covering the 15th and 16th centuries, characterized by an effort to revive and surpass ideas ...
that the spine and nerves were accurately depicted in human anatomy drawings by Leonardo da Vinci
Leonardo di ser Piero da Vinci (15 April 14522 May 1519) was an Italian polymath of the High Renaissance who was active as a painter, Drawing, draughtsman, engineer, scientist, theorist, sculptor, and architect. While his fame initially res ...
and Andreas Vesalius
Andreas Vesalius (Latinized from Andries van Wezel) () was a 16th-century anatomist, physician, and author of one of the most influential books on human anatomy, ''De Humani Corporis Fabrica Libri Septem'' (''On the fabric of the human body'' '' ...
.
In 1762 a surgeon named Andre Louis removed a bullet from the lumbar spine of a patient, who regained motion in the legs. In 1829 the surgeon Gilpin Smith performed a successful laminectomy
A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending ...
that improved the patient's sensation. However, the idea that SCI was untreatable remained predominant until the early 20th century. In 1934, the mortality rate
Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time. Mortality rate is typically expressed in units of de ...
in the first two years after injury was over 80%, mostly due to infections of the urinary tract and pressure sores, the latter of which were believed to be intrinsic to SCI rather than a result of continuous bedrest. It was not until the second half of the century that breakthroughs in imaging, surgery, medical care, and rehabilitation medicine contributed to a substantial improvement in SCI care. The relative incidence of incomplete compared to complete injuries has improved since the mid-20th century, due mainly to the emphasis on faster and better initial care and stabilization of spinal cord injury patients. The creation of emergency medical services
Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. ...
to professionally transport people to the hospital is given partial credit for an improvement in outcomes since the 1970s. Improvements in care have been accompanied by increased life expectancy of people with SCI; survival times have improved by about 2000% since 1940. In 2015/2016 23% of people in nine spinal injury centres in England had their discharge delayed because of disputes about who should pay for the equipment they needed.
Research directions
Scientists are investigating various avenues for treatment of spinal cord injury. Therapeutic research is focused on two main areas: neuroprotection
Neuroprotection refers to the relative preservation of neuronal structure and/or function. In the case of an ongoing insult (a neurodegenerative insult) the relative preservation of neuronal integrity implies a reduction in the rate of neuronal lo ...
and neuroregeneration
Neuroregeneration refers to the regrowth or repair of nervous tissues, cells or cell products. Such mechanisms may include generation of new neurons, glia, axons, myelin, or synapses. Neuroregeneration differs between the peripheral nervous system ...
. The former seeks to prevent the harm that occurs from secondary injury in the minutes to weeks following the insult, and the latter aims to reconnect the broken circuits in the spinal cord to allow function to return. Neuroprotective drugs target secondary injury effects including inflammation, damage by free radical
A daughter category of ''Ageing'', this category deals only with the biological aspects of ageing.
Ageing
Ailments of unknown cause
Biogerontology
Biological processes
Causes of death
Cellular processes
Gerontology
Life extension
Metabo ...
s, excitotoxicity
In excitotoxicity, nerve cells suffer damage or death when the levels of otherwise necessary and safe neurotransmitters such as glutamate become pathologically high, resulting in excessive stimulation of receptors. For example, when glutamate re ...
(neuronal damage by excessive glutamate
Glutamic acid (symbol Glu or E; the ionic form is known as glutamate) is an α-amino acid that is used by almost all living beings in the biosynthesis of proteins. It is a non-essential nutrient for humans, meaning that the human body can syn ...
signaling), and apoptosis
Apoptosis (from grc, ἀπόπτωσις, apóptōsis, 'falling off') is a form of programmed cell death that occurs in multicellular organisms. Biochemical events lead to characteristic cell changes (morphology) and death. These changes incl ...
(cell suicide). Several potentially neuroprotective agents that target pathways like these are under investigation in human clinical trial
Clinical trials are prospective biomedical or behavioral research studies on human participants designed to answer specific questions about biomedical or behavioral interventions, including new treatments (such as novel vaccines, drugs, dietar ...
s.
Stem cell transplantation is an important avenue for SCI research: the goal is to replace lost spinal cord cells, allow reconnection in broken neural circuits by regrowing axons, and to create an environment in the tissues that is favorable to growth. A key avenue of SCI research is research on stem cells
In multicellular organisms, stem cells are undifferentiated or partially differentiated cells that can differentiate into various types of cells and proliferate indefinitely to produce more of the same stem cell. They are the earliest type o ...
, which can differentiate into other types of cells—including those lost after SCI. Types of cells being researched for use in SCI include embryonic stem cell
Embryonic stem cells (ESCs) are pluripotent stem cells derived from the inner cell mass of a blastocyst, an early-stage pre- implantation embryo. Human embryos reach the blastocyst stage 4–5 days post fertilization, at which time they consi ...
s, neural stem cell
Neural stem cells (NSCs) are self-renewing, multipotent cells that firstly generate the radial glial progenitor cells that generate the neurons and glia of the nervous system of all animals during embryonic development. Some neural progenitor ste ...
s, mesenchymal stem cell
Mesenchymal stem cells (MSCs) also known as mesenchymal stromal cells or medicinal signaling cells are multipotent stromal cells that can differentiate into a variety of cell types, including osteoblasts (bone cells), chondrocytes (cartilage c ...
s, olfactory ensheathing cell
Olfactory ensheathing cells (OECs), also known as olfactory ensheathing glia or olfactory ensheathing glial cells, are a type of macroglia (radial glia) found in the nervous system. They are also known as olfactory Schwann cells, because they e ...
s, Schwann cell
Schwann cells or neurolemmocytes (named after German physiologist Theodor Schwann) are the principal glia of the peripheral nervous system (PNS). Glial cells function to support neurons and in the PNS, also include satellite cells, olfactory ensh ...
s, activated macrophage
Macrophages (abbreviated as M φ, MΦ or MP) ( el, large eaters, from Greek ''μακρός'' (') = large, ''φαγεῖν'' (') = to eat) are a type of white blood cell of the immune system that engulfs and digests pathogens, such as cancer cel ...
s, and induced pluripotent stem cell
Induced pluripotent stem cells (also known as iPS cells or iPSCs) are a type of pluripotent stem cell that can be generated directly from a somatic cell. The iPSC technology was pioneered by Shinya Yamanaka's lab in Kyoto, Japan, who showed in ...
s. Hundreds of stem cell studies have been done in humans, with promising but inconclusive results. An ongoing Phase 2
Michael Lawrence Marrow (August 2, 1955 – December 12, 2019), known as PHASE 2 and Lonny Wood, was an American aerosol paint artist based in New York City. Mostly active in the 1970s, Phase 2 is generally credited with originating the "bubble l ...
trial in 2016 presented data showing that after 90 days, 2 out of 4 subjects had already improved two motor levels and had thus already achieved its endpoint
An endpoint, end-point or end point may refer to:
* Endpoint (band), a hardcore punk band from Louisville, Kentucky
* Endpoint (chemistry), the conclusion of a chemical reaction, particularly for titration
* Outcome measure, a measure used as an e ...
of 2/5 patients improving two levels within 6–12 months. Six-month data is expected in January 2017.
Another type of approach is tissue engineering, using biomaterial
A biomaterial is a substance that has been engineered to interact with biological systems for a medical purpose, either a therapeutic (treat, augment, repair, or replace a tissue function of the body) or a diagnostic one. As a science, biomateria ...
s to help scaffold and rebuild damaged tissues. Biomaterials
A biomaterial is a substance that has been engineered to interact with biological systems for a medical purpose, either a therapeutic (treat, augment, repair, or replace a tissue function of the body) or a diagnostic one. As a science, biomateria ...
being investigated include natural substances such as collagen
Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
or agarose
Agarose is a heteropolysaccharide, generally extracted from certain red seaweed. It is a linear polymer made up of the repeating unit of agarobiose, which is a disaccharide made up of D-galactose and 3,6-anhydro-L-galactopyranose. Agarose is o ...
and synthetic ones like polymer
A polymer (; Greek '' poly-'', "many" + ''-mer'', "part")
is a substance or material consisting of very large molecules called macromolecules, composed of many repeating subunits. Due to their broad spectrum of properties, both synthetic a ...
s and nitrocellulose
Nitrocellulose (also known as cellulose nitrate, flash paper, flash cotton, guncotton, pyroxylin and flash string, depending on form) is a highly flammable compound formed by nitrating cellulose through exposure to a mixture of nitric acid and ...
. They fall into two categories: hydrogel
A hydrogel is a crosslinked hydrophilic polymer that does not dissolve in water. They are highly absorbent yet maintain well defined structures. These properties underpin several applications, especially in the biomedical area. Many hydrogels ar ...
s and nanofiber
Nanofibers are fibers with diameters in the nanometer range (typically, between 1 nm and 1 μm). Nanofibers can be generated from different polymers and hence have different physical properties and application potentials. Examples of natural polyme ...
s. These materials can also be used as a vehicle for delivering gene therapy to tissues.
One avenue being explored to allow paralyzed people to walk and to aid in rehabilitation of those with some walking ability is the use of wearable powered robotic exoskeletons. The devices, which have motorized joints, are put on over the legs and supply a source of power to move and walk. Several such devices are already available for sale, but investigation is still underway as to how they can be made more useful.
Preliminary studies of epidural spinal cord stimulators for motor complete injuries have demonstrated some improvement and in some cases to enable walking to some degree bypassing the injury
In 2014 Darek Fidyka
Dariusz "Darek" Fidyka (born ) is a Polish firefighter and recovering paraplegic who became the first person in history to verifiably recover sensory and motor function after the complete severing of his spinal cord.
Having been paralysed fro ...
underwent pioneering spinal surgery that used nerve grafts, from his ankle, to 'bridge the gap' in his severed spinal cord and olfactory ensheathing cells
Olfactory ensheathing cells (OECs), also known as olfactory ensheathing glia or olfactory ensheathing glial cells, are a type of macroglia ( radial glia) found in the nervous system. They are also known as olfactory Schwann cells, because they en ...
(OECs) to stimulate the spinal cord cells. The surgery was performed in Poland in collaboration with Prof. Geoff Raisman, chair of neural regeneration at University College London's Institute of Neurology, and his research team. The OECs were taken from the patient's olfactory bulbs in his brain and then grown in the lab, these cells were then injected above and below the impaired spinal tissue.
See also
*Paralyzed Veterans of America
The Paralyzed Veterans of America is a veterans' service organization in the United States of America, founded in 1946. The organization holds 33 chapters and 70 National Service Offices in the United States and Puerto Rico. It is based in Washin ...
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External links
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{{DEFAULTSORT:Spinal-Cord Injury
Medical emergencies
Neurotrauma
Spinal cord
Injuries