Spinal Cord Injury
Definition
Spinal cord injury is damage to the spinal cord that causes loss of sensation and motor control.
Description
Approximately 10,000 new spinal cord injuries (SCIs) occur each year in the United States. About 250,000 people are currently affected. Spinal cord injuries can happen to anyone at any time of life. The typical patient, however, is aman between the ages of 19 and 26, injured in a motor vehicle accident (about 50% of all SCIs), a fall (20%), an act of violence (15%), or a sporting accident (14%). Alcohol or other drug abuse plays an important role in a largepercentage of all spinal cord injuries. Six percent of people who receive injuries to the lower spine die within a year, and 40% of people who receive the more frequent higher injuries die within a year.
Short-term costs for hospitalization, equipment, and home modifications are approximately $140,000 for an SCI patient capable of independent living. Lifetime costs may exceed one million dollars. Costs may be three to four timeshigher for the SCI patient who needs long-term institutional care. Overall costs to the American economy in direct payments and lost productivity are more than $10 billion per year.
Causes and symptoms
Causes
The spinal cord is about as big around as the index finger. It descends from the brain down the back through hollow channels of the backbone. The spinal cord is made of nerve cells (neurons). The nerve cells carry sensory datafrom the areas outside the spinal cord (periphery) to the brain, and they carry motor commands from brain to periphery. Peripheral neurons are bundled together to make up the 31 pairs of peripheral nerve roots. The peripheral nerveroots enter and exit the spinal cord by passing through the spaces between the stacked vertebrae. Each pair of nerves is named for the vertebra from which it exits. These are known as:
- C1-8. These nerves enter from the eight cervical or neck vertebrae.
- T1-12. These nerves enter from the thoracic or chest vertebrae.
- L1-5. These nerves enter from the lumbar vertebrae of the lower back.
- S1-5. These nerves enter through the sacral or pelvic vertebrae.
- Coccygeal. These nerves enter through the coccyx or tailbone.
Peripheral nerves carry motor commands to the muscles and internal organs, and they carry sensations from these areas and from the body's surface. (Sensory data from the head, including sight, sound, smell, and taste, do notpass through the spinal cord and are not affected by most SCIs.) Damage to the spinal cord interrupts these signals. The interruption damages motor functions that allow the muscles to move, sensory functions such as feeling heatand cold, and autonomic functions such as urination, sexual function, sweating, and blood pressure.
Spinal cord injuries most often occur where the spine is most flexible, in the regions of C5-C7 of the neck, and T10-L2 at the base of the rib cage. Several physically distinct types of damage are recognized. Sudden and violent joltsto nearby tissues can jar the cord. This jarring causes a temporary spinal concussion. Concussion symptoms usually disappear completely within several hours. A spinal contusion or bruise is bleeding within the spinal column. Thepressure from the excess fluid may kill spinal cord neurons. Spinal compression is caused by some object, such as a tumor, pressing on the cord. Lacerations or tears cause direct damage to cord neurons. Lacerations can becaused by bone fragments or missiles such as bullets. Spinal transection describes the complete severing of the cord. Most spinal cord injuries involve two or more of these types of damage.
Symptoms
PARALYSIS AND LOSS OF SENSATION. The extent to which movement and sensation are damaged depends on the level of the spinal cord injury. Nerves leaving the spinal cord at different levels control sensation and movementin different parts of the body. The distribution is roughly as follows:
- C1-C4: head and neck.
- C3-C5: diaphragm (chest and breathing).
- C5-T1: shoulders, arms and hands.
- T2-T12: chest and abdomen (excluding internal organs).
- L1-L4: abdomen (excluding internal organs), buttocks, genitals, and upper legs.
- L4-S1: legs.
- S2-S4: genitals and muscles of the perineum.
Damage below T1, which lies at the base of the rib cage, causes paralysis and loss of sensation in the legs and trunk below the injury. Injury at this level usually does no damage to the arms and hands. Paralysis of the legs iscalled paraplegia. Damage above T1 involves the arms as well as the legs. Paralysis of all four limbs is called quadriplegia or tetraplegia. Cervical or neck injuries not only cause quadriplegia but also may cause difficulty inbreathing. Damage in the lower part of the neck may leave enough diaphragm control to allow unassisted breathing. Patients with damage at C3 or above, just below the base of the skull, require mechanical assistance to breathe.
Symptoms also depend on the extent of spinal cord injury. A completely severed cord causes paralysis and loss of sensation below the wound. If the cord is only partially severed, some function will remain below the injury. Damagelimited to the front portion of the cord causes paralysis and loss of sensations of pain and temperature. Other sensation may be preserved. Damage to the center of the cord may spare the legs but paralyze the arms. Damage to theright or left half causes loss of position sense, paralysis on the side of the injury, and loss of pain and temperature sensation on the opposite side.
DEEP VENOUS THROMBOSIS. Blood does not flow normally to a paralyzed limb that is inactive for long periods. The blood pools in the deep veins and forms clots, a condition known as deep vein thrombosis. A clot or thrombuscan break free and lodge in smaller arteries in the brain, causing a stroke, or in the lungs, causing pulmonary embolism.
PRESSURE ULCERS. Inability to move also leads to pressure ulcers or bed sores. Pressure ulcers form where skin remains in contact with a bed or chair for a long time. The most common sites of pressure ulcers are thebuttocks, hips, and heels.
SPASTICITY AND CONTRACTURE. A paralyzed limb is incapable of active movement, but the muscle still has tone, a constant low level of contraction. Normal muscle tone requires communication between the muscle and thebrain. Spinal cord injury prevents the brain from telling the muscle to relax. The result is prolonged muscle contraction or spasticity. Because the muscles that extend and those that bend a joint are not usually equal in strength, theinvolved joint is bent, often severely. This constant pressure causes deformity. As the muscle remains in the shortened position over several weeks or months, the tendons remodel and cause permanent muscle shortening orcontracture. When muscles have permanently shortened, the inner surfaces of joints, such as armpits or palms, cannot be cleaned and the skin breaks down in that area.
HETEROTOPIC OSSIFICATION. Heterotopic ossification is an abnormal deposit of bone in muscles and tendons that may occur after injury. It is most common in the hips and knees. Initially heterotopic ossification causeslocalized swelling, warmth, redness, and stiffness of the muscle. It usually begins one to four months after the injury and is rare after one year.
AUTONOMIC DYSREFLEXIA. Body organs that regulate themselves, such as the heart, gastrointestinal tract, and glands, are controlled by groups of nerves called autonomic nerves. Autonomic nerves emerge from three differentplaces: above the spinal column, in the lower back from vertebrae T1-L4, and from the lowest regions of the sacrum at the base of the spine. In general, these three groups of autonomic nerves operate in balance. Spinal cord injurycan disrupt this balance, a condition called autonomic dysreflexia or autonomic hyperreflexia. Patients with injuries at T6 or above are at greatest risk.
In autonomic dysreflexia, irritation of the skin, bowel, or bladder causes a highly exaggerated response from autonomic nerves. This response is caused by the uncontrolled release of norepinephrine, a hormone similar to adrenaline. Uncontrolled release of norepinephrine causes a rapid rise in blood pressure and a slowing of the heart rate. These symptoms are accompanied by throbbing headache, nausea, anxiety, sweating, and goose bumps below the level of the injury. The elevated blood pressure can rapidly cause loss of consciousness, seizures, cerebral hemorrhage, and death. Autonomic dysreflexia is most often caused by an over-full bladder or bladder infection, impaction or hard impassable fecal mass in the bowel, or skin irritation from tight clothing, sunburn, or other irritant. Inability to sense these irritants before the autonomic reaction begins is a major cause of dysreflexia.
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LOSS OF BLADDER AND BOWEL CONTROL. Bladder and bowel control require both motor nerves and the autonomic nervous system. Both of these systems may be damaged by SCI. When the autonomic nervous systemtriggers an urge to urinate or defecate, continence is maintained by contracting the anal or urethral sphincters. A sphincter is a ring of muscle that contracts to close off a passage or opening in the body. When the neuralconnections to these muscles are severed, conscious control is lost. In addition, loss of feeling may prevent sensations of fullness from reaching the brain. To compensate, the patient may help empty the bowel or bladder by usingphysical maneuvers that stimulate autonomic contractions before they would otherwise begin. However, the patient may not be able to relax the sphincters. If the sphincters cannot be relaxed, the patient will retain urine or feces.
Retention of urine may cause muscular changes in the bladder and urethral sphincter that make the problem worse. Urinary tract infection is common. Retention of feces can cause impaction. Symptoms of impaction include loss ofappetite and nausea. Untreated impaction may cause perforation of the large intestine and rapid overwhelming infection.
SEXUAL DYSFUNCTION. Men who have sustained SCI may be unable to achieve an erection or ejaculate. Sperm formation may be abnormal too, reducing fertility. Fertility and the ability to achieve orgasm are less impaired forwomen. Women may still be able to become pregnant and deliver vaginally with proper medical care.
[h=3]Diagnosis[/h]The location and extent of spinal cord injury is determined with computed tomography scans (CT scans), magnetic resonance imaging (MRI) scans, and x rays. X rays may be enhanced with an injected contrast dye.
[h=3]Treatment[/h]A person who may have a spinal cord injury should not be moved. Treatment of SCI begins with immobilization. This strategy prevents partial injuries of the cord from severing it completely. Use of splints to completely immobilizesuspected SCI at the scene of the injury has helped reduce the severity of spinal cord injuries in the last two decades. Intravenous methylprednisone, a steroidal anti-inflammatory drug, is given during the first 24 hours to reduceinflammation and tissue destruction.
Rehabilitation after spinal cord injury seeks to prevent complications, promote recovery, and make the most of remaining function. Rehabilitation is a complex and long-term process. It requires a team of professionals, including aneurologist, physiatrist or rehabilitation specialist, physical therapist, and occupational therapist. Other specialists who may be needed include a respiratory therapist, vocational rehabilitation counselor, social worker, speech-language pathologist, nutritionist, special education teacher, recreation therapist, and clinical psychologist. Support groups provide a critical source of information, advice, and support for SCI patients.
[h=4]Paralysis and loss of sensation[/h]Some limited mobility and sensation may be recovered, but the extent and speed of this recovery cannot be predicted. Experimental electrical stimulation has been shown to allow some control of muscle contraction in paraplegia.This experimental technique offers the possibility of unaided walking. Further development of current control systems will be needed before useful movement is possible outside the laboratory.
The physical therapist focuses on mobility, to maintain range of motion of affected limbs and reduce contracture and deformity. Physical therapy helps compensate for lost skills by using those muscles that are still functional. Italso helps to increase any residual strength and control in affected muscles. A physical therapist suggests adaptive equipment such as braces, canes, or wheelchairs.
An occupational therapist works to restore ability to perform the activities of daily living, such as eating and grooming, with tools and new techniques. The occupational therapist also designs modifications of the home and workplaceto match the individual impairment.
A pulmonologist or respiratory therapist promotes airway hygiene through instruction in assisted coughing techniques and postural drainage. The respiratory professional also prescribes and provides instruction in the use ofventilators, facial or nasal masks, and tracheostomy equipment where necessary.
[h=4]Pressure ulcers[/h]Pressure ulcers are prevented by turning in bed at least every two hours. The patient should be turned more frequently when redness begins to develop in sensitive areas. Special mattresses and chair cushions can distribute weightmore evenly to reduce pressure. Electrical stimulation is sometimes used to promote muscle movement to prevent pressure ulcers.
[h=4]Spasticity and contracture[/h]Range of motion (ROM) exercises help to prevent contracture. Chemicals can be used to prevent contractures from becoming fixed when ROM exercise is inadequate. Phenol or alcohol can be injected onto the nerve or botulinumtoxin directly into the muscle. Botulinum toxin is associated with fewer complications, but it is more expensive than phenol and alcohol. Contractures can be released by cutting the shortened tendon or transferring it surgically to adifferent site on the bone where its pull will not cause as much deformity. Such tendon transfers may also be used to increase strength in partially functional extremities.
[h=4]Heterotopic ossification[/h]Etidronate disodium (Didronel), a drug that regulates the body's use of calcium, is used to prevent heterotopic ossification. Treatment begins three weeks after the injury and continues for 12 weeks. Surgical removal of ossifiedtissue is possible.
[h=4]Autonomic dysreflexia[/h]Autonomic dysreflexia is prevented by bowel and bladder care and attention to potential irritants. It is treated by prompt removal of the irritant. Drugs to lower blood pressure are used when necessary. People with SCI shouldeducate friends and family members about the symptoms and treatment of dysreflexia, because immediate attention is necessary.
[h=4]Loss of bladder and bowel control[/h]Normal bowel function is promoted through adequate fluid intake and a diet rich in fiber. Evacuation is stimulated by deliberately increasing the abdominal pressure, either voluntarily or by using an abdominal binder.
Bladder care involves continual or intermittent catheterization. The full bladder may be detected by feeling its bulge against the abdominal wall. Urinary tract infection is a significant complication of catheterization and requiresfrequent monitoring.
[h=4]Sexual dysfunction[/h]Counseling can help in adjusting to changes in sexual function after spinal cord injury. Erection may be enhanced through the same means used to treat erectile dysfunction in the general population.
[h=3]Prognosis[/h]The prognosis of SCI depends on the location and extent of injury. Injuries of the neck above C4 with significant involvement of the diaphragm hold the gravest prognosis. Respiratory infection is one of the leading causes of death inlong-term SCI. Overall, 85% of SCI patients who survive the first 24 hours are alive 10 years after their injuries. Recovery of function is impossible to predict. Partial recovery is more likely after an incomplete wound than after thespinal cord has been completely severed.
[h=3]Prevention[/h]Risk of spinal cord injury can be reduced through prevention of the accidents that lead to it. Chances of injury from automobile accidents, the major cause of SCIs, can be significantly reduced by driving at safe speeds, avoidingalcohol while driving, and using seat belts.
[h=3]Resources[/h][h=4]Organizations[/h]National Spinal Cord Injury Association. 8300 Colesville Road, Silver Spring, Maryland 20910. (301) 588-6959. http://www.erols.com/nscia.
[h=3]Key terms[/h]Autonomic nervous system — The part of the nervous system that controls involuntary functions such as sweating and blood pressure.
Botulinum toxin — Any of a group of potent bacterial toxins or poisons produced by different strains of the bacterium Clostridium botulinum.
Computed tomography (CT) — An imaging technique in which cross-sectional x rays of the body are compiled to create a three-dimensional image of the body's internal structures.
Magnetic resonance imaging (MRI) — An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures.
Motor — Of or pertaining to motion, the body apparatus involved in movement, or the brain functions that direct purposeful activity.
Motor nerve — Motor or efferent nerve cells carry impulses from the brain to muscle or organ tissue.
Peripheral nervous system — The part of the nervous system that is outside the brain and spinal cord. Sensory, motor, and autonomic nerves are included.
Postural drainage — The use of positioning to drain secretions from the bronchial tubes and lungs into the trachea or windpipe.
Range of motion (ROM) — The range of motion of a joint from full extension to full flexion (bending) measured in degrees like a circle.
Sensory nerves — Sensory or afferent nerves carry impulses of sensation from the periphery or outward parts of the body to the brain. Sensations include feelings, impressions, and awareness of the state of the body.
Voluntary — An action or thought undertaken or controlled by a person's free will or choice.
