Spinal Cord Injury – Causes, Symptoms, Diagnosis, Treatment

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Spinal Cord Injury/The spinal cord is a tubular structure composed of nervous tissue that extends from the brainstem and continuing distally before tapering at the lower thoracic/upper lumbar region as the conus medullaris.  The spinal cord is anchored distally by the filum terminal, a fibrous extension of the pia mater anchoring the spinal cord to the coccyx. Protecting the spinal cord is the surrounding cerebrospinal fluid (CSF), supportive soft tissue membranes and meninges, and the osseous vertebral column.

Traumatic spinal cord injury (TSCI) is sudden forceful damage to the spinal nerves resulting in temporary or permanent paralysis, bladder and bowel dysfunction, and autonomic imbalance among other consequences [rx,rx]. A person with spinal cord injury is at immediate risk of respiratory and cardiac failure which may lead to death in the acute phase [rx]. Those who survive the acute phase faces a lifelong risk of secondary complications such as pressure ulcers, urinary tract infections, deep venous thrombosis, contractures, chronic pain, and spasms [rx,rx].

Trauma to the spinal cord may result from a road traffic accident (RTA), fall, assault and recreational or occupational accident [rx,rx]. The World Health Organization informs that up to 90% of all spinal cord lesions are due to trauma and that the leading cause globally is RTA [rx].

Spinal Cord Injury

Anatomy of Spinal Cord

The major tracts and their most defining features are as follows

Ascending Tracts

  • Dorsal column – contains the gracile fasciculus and cuneate fasciculus, which together are the dorsal funiculus. The dorsal column is responsible for pressure and vibration sensation as well as two-point discrimination, movement sense, and conscious proprioception. The dorsal column decussates at the superior portion of the medulla oblongata and forms medial lemniscus.
  • Lateral spinothalamic – carries pain and temperature information. The lateral spinothalamic tract decussates at the anterior commissure two segments above the entry to the spinal cord.
  • Anterior spinothalamic – carries crude touch and pressure information. It decussates similar to the lateral spinothalamic tract.
  • Dorsal and ventral spinocerebellar – transmit unconscious proprioception sensory information to the cerebellum. The ventral spinocerebellar tract does not decussate, while the dorsal spinocerebellar tract decussates twice, making them both ipsilateral.

 Descending Tracts

  • Lateral and anterior corticospinal – involved in conscious control of the skeletal muscle. The majority of lateral corticospinal tract fibers decussate at the inferior portion of the medulla oblongata while anterior corticospinal descends ipsilaterally in the spinal cord and decussates at the segmental level. Lateral corticospinal tract, also called pyramidal tract, innervates primarily contralateral muscles of the limbs, while anterior innervates proximal muscles of the trunk.
  • Vestibulospinal – carries information from the inner ear to control head positioning and is involved in modifying muscle tone to maintain posture and balance. The vestibulospinal tract does not decussate.
  • Rubrospinal – is involved in the movement of the flexor and extensor muscles. The rubrospinal tract originates from the red nuclei in the midbrain and decussates at the start of its pathway.
  • Reticulospinal – originates from the reticular formation housed in the brainstem and it facilitates, influences, and supplements the corticospinal tract. The reticulospinal tract does not decussate.

There is a laminar distribution of neurons in the gray matter, characterized by density and topography

  • Lamina I – is located at the tip of the dorsal horn and is composed of loosely packed neuropil along with neurons of low neuronal density. The most abundant neuron in lamina I is the Waldeyer cell: large, fusiform, and with a disk-shaped dendritic domain.
  • Lamina II – is composed mostly of islet cells with rostrocaudal axes, which contain GABA and are thought to be inhibitory, and stalked cells with dorsoventral dendritic trees.
  • Lamina III – has cells of intermediate size, including antenna-like and radial neurons, many of which contain GABA or glycine and are also considered inhibitory.
  • Lamina IV – contains antenna-like cells and transverse cells, with dendrites that mostly go to Laminas II and III, and whose axons are mainly thought to enter the spinothalamic tract. Lateral from lamina IV is the lateral spinal nucleus, which sends signals to lamina IV from the midbrain and brainstem.
  • Lamina V and VI – are composed of medium-sized multipolar neurons, that can be fusiform or triangular. These neurons communicate with the reticular formation of the brainstem.
  • Lamina VII – is composed of homogenous medium-sized multipolar neurons, and contains, in individual segments, well-defined nuclei, including the intermediolateral nucleus (T1-L1), which has autonomic functions, and the dorsal nucleus of Clarke (T1-L2), which make up the dorsal spinocerebellar tract.
  • Lamina VIII – consists of neurons with dorsoventrally polarized dendritic trees.
  • Lamina IX – has the cell bodies of motor neurons, with dendrites extending dorsally into laminas as far as VI. Lamina IX – also has Renshaw cells, inhibitory interneurons, placed at the medial border of motor nuclei.
  • Lamina X –  is the substantia grisea centralis or the gray matter that surrounds the central canal. In the distal portion, lamina X consists of bipolar cells with fan-shaped dendritic trees, and in the ventral portion, lamina X consists of bipolar cells with poorly ramified longitudinal dendrites.

Spinal Cord Injury

Meninges and Spaces

  • Epidural space – fatty space between the bony framework of the spinal vertebral column and the thick dura mater surrounding the spinal cord. It contains adipose tissue and blood vessels.
  • Dura mater – Thick outermost covering (meninges) of the spinal cord, extending down to the level of the S2 vertebra
  • Arachnoid mater – The middle covering of the spinal cord
  • Subarachnoid space – Space between the arachnoid mater and the innermost covering of the spinal cord. It contains Cerebrospinal fluid.
  • Pia mater – The innermost covering of the spinal cord, intimately adhering to its surface, it stabilizes the spinal cord through lateral extensions of the pia called the denticulate ligaments, extending between the ventral and dorsal roots unto the dura mater.

Spinal cord

  • The length is about 45 cm in men and 43 cm in women
  • Anatomic course originates in the brainstem before coursing through the foramen magnum.  The spinal cord continues distally through the cervical and thoracic regions of the spinal column before terminating as a tapered structure known as the conus medullaris
  • The spinal cord proper terminates at the L1-L2 vertebral level and is anchored distally via the filum terminale, representing an extension of the pia mater with fibrous attachments to the coccyx
  • The spinal cord comprises 5 segments, cervical, thoracic, lumbar, sacral and coccygeal
  • Long, cylindrical structure with varying levels of thickness/width depending on the corresponding vertebral levels

31 total nerve root segments

    • 8 cervical
    • 12 thoracic
    • 5 lumbar
    • 5 sacral
    • 1 coccygeal

Cord width ranges – from 0.64-0.83 cm in the thoracic region to 1.27-1.33 cm in the cervical and lumbar regions

  • A 2016 systematic review of the literature demonstrated that, on average, the largest transverse diameter corresponded to the C5 neuronal segment (1.33 +/- 0.22 cm) and the smallest transverse diameter, on average, corresponded to the T8 segment (0.83 +/- 0.21 cm)
  • Enlarged regions of gray matter correspond to nerve root distribution to the upper and lower extremities

A cross-sectional

  • Its view of the spinal cord shows its organization into the gray and white matter. The anterior aspect of the cord is identifiable with the presence of anterior median fissure. The gray matter is organized into an H- shaped body of cell bodies. The anterior horn comprises motor nuclei while the posterior horn comprises sensory nuclei.
  • The surrounding white matter is organized into anterior, posterior, and lateral columns (funiculi), from neuronal axons organized into tracts that convey neural messages back and forth the CNS (the ascending and descending tracts).
  • The anterolateral columns carry temperature and pain information, while the dorsal column communicates the sense of touch, proprioception, vibration. The cervical and thoracic spinal segments present an intermedio lateral gray horn which gives off preganglionic sympathetic fibers onto the sympathetic trunk on both sides of the spinal cord.

The spinal cord’s central canal

  • It is an extension of the 4th ventricle. It contains CSF, surrounding it is the gray commissure and the anterior white commissure. Decussation of the tracts of the white columns occurs at the anterior white commissure.

Spinal Cord Injury

Types of Spinal Cord Injury

Incomplete Spinal Cord Injury

Tetraplegia

  • Cervical spine injury resulting in the impaired arm, trunk leg, pelvic organ function. These injuries, which are the result of damage to the cervical spinal cord, are typically the most severe, producing varying degrees of paralysis of all limbs. Sometimes known as quadriplegia, tetraplegia eliminates your ability to move below the site of the injury and may produce difficulties with bladder and bowel control, respiration, and other routine functions. The higher up on the cervical spinal cord the injury is, the more severe symptoms will likely be.

Paraplegia

  • This occurs when sensation and movement are removed from the lower half of the body, including the legs. These injuries are the product of damage to the thoracic spinal cord. As with cervical spinal cord injuries, injuries are typically more severe when they are closer to the top vertebra.
  • Thoracic/lumbar/sacral spinal injury leading to impaired trunk/leg/pelvic organ function
  • Preserved arm function.

Triplegia

Triplegia causes a loss of sensation and movement in one arm and both legs and is typically the product of an incomplete spinal cord injury.

Complete Injuries

  • By definition – complete SCI yields no sparing of the motor or sensory function below the injured level
    • The patient must have already recovered from the acute phase of spinal shock (usually 48 hours from presentation)
    • Spinal shock: by definition, the temporary (typically 48 hours) loss of all spinal cord function (including reflex activity) below the level of injury
      • Absent bulbocavernosus reflex
      • Flaccid paralysis
      • Bradycardia/hypotension
  • Spina bifida – Neural tube defect in which the neural tube does not completely close leaving a dorsal defect. Folate deficiency in early pregnancy is a risk factor. The severity of symptoms depends on the extent of the defect; myelomeningocele is the most severe variant with the spinal cord, meninges both exposed. Other variants include meningocele, which exposes only the meninges, and spina bifida occulta which is the mildest. Symptoms include loss of lower limb sensations, lower limb weakness, urinary incontinence, bowel incontinence
  • Spinal shock – is the temporary loss of spinal reflex activity with motor and sensory losses. This loss results from loss of sympathetic vascular tone resulting in paradoxical bradycardia with hypotension. During spinal shock, patients appear physiologically completely paralyzed but may show significant recovery after the initial phases of spinal shock have resolved.

Partial Complete spinal cord injuries (SCIs)

Central cord syndrome

This injury is an injury to the center of the cord, and damages nerves that carry signals from the brain to the spinal cord. Loss of fine motor skills, paralysis of the arms, and partial impairment—usually less pronounced—in the legs are common. Some survivors also suffer a loss of bowel or bladder control or lose the ability to sexually function.
  • Most common incomplete SCI
  • Pathophysiology: central gray matter injury
  • Mechanism(s): hyperextension (i.e., from a fall) in a patient with underlying cervical spinal canal stenosis
  • Clinical presentation:
    • Upper extremity loss of motor function (lower extremity motor function no affected/minimally affected)
    • Sensory sparing variable
  • Prognosis: Good

Anterior cord syndrome

This type of injury, to the front of the spinal cord, damages the motor and sensory pathways in the spinal cord. You may retain some sensation but struggle with movement.
  • Second most common incomplete SCI
  • Pathophysiology: injuries occur secondary to direct compression to the anterior spinal cord (e.g., hyperflexion injuries, anterior spinal artery occlusion, or disc prolapse)
  • Mechanism(s): hyperflexion injuries, anterior spinal artery occlusion, disc prolapse
  • Clinical presentation:
    • Loss of motor, pain, and temperature reception below the level of injury
    • Preserved dorsal column function (i.e., proprioception, vibration sensation, and deep pressure sensation)
  • Prognosis: Poor (for motor recovery specifically)

Posterior cord syndrome

  • Very rare/least common incomplete SCI pattern of injury
  • Pathophysiology: injury to the dorsal column
  •  Mechanism(s):
    • subacute combined degeneration
    • tabes dorsalis (i.e., secondary to syphilis)
    • multiple sclerosis
    • vascular malformations (arterio-venous malformation – AVM)
    • malignancy (e.g., compressive extramedullary tumors)
    • degenerative conditions (e.g., spondylosis)
  • Clinical presentation:
    • Loss of proprioception, vibration, and deep pressure sensation below the level of injury
    • Preserved ambulatory function
      • patients will complain of difficulty balancing in the dark or with his/her eyes closed
    • Classic exam consistent with a positive Romberg sign
  • Prognosis: Preserved ambulatory function; dorsal column recovery unpredictable

Brown-Sequard syndrome Spinal cord hemisection/hemicord

  • Brown-Square syndrome – This variety of injury is the product of damage to one side of the spinal cord. The injury may be more pronounced on one side of the body; for instance, movement may be impossible on the right side but maybe fully retained on the left. The degree to which Brown-Sequard patients are injured greatly varies from patient to patient.
  • Rare (2% to 4% of SCIs)
  • Pathophysiology: trauma to one side of the spinal cord (in cross-sectional reference)
  • Mechanism(s):
    • Penetrating trauma (knife, gunshot wound)
  • Clinical presentation:
    • Ipsilateral loss of motor and proprioception (directly below the level of injury)
    • Contralateral loss of pain/temperatures classically the contralateral pain/temperature loss occurs one to two levels below the level of injury)
  • Prognosis: 90% recover ambulatory function.
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Cauda equina syndrome

  • Pathophysiology: Injury to (only) the nerve roots of the cauda equina itself (i.e., spares the spinal cord itself)
  •  Mechanism(s):
    • disc herniations
    • burst fractures (e.g., associated hematoma from trauma)
  • Clinical presentation:
    • bilateral buttock/lower extremity pain
    • bowel/bladder dysfunction (urinary retention)
    • saddle anesthesia
    • loss of lower extremity motor/sensory function
      • differentiated from conus medullaris syndrome in that findings are asymmetrical, as opposed to symmetrical (i.e. conus medullaris motor symptoms are symmetrical on presentation)
  • Prognosis: surgical decompression within the first 48 hours appears to yield improved overall outcomes (although the overall prognosis remains guarded)

Conus medullaris syndrome

  • Often confused with cauda equina syndrome, although this must be recognized as a separate clinical entity
  • Pathophysiology: injury to the spinal cord at L1-L2 level.
  •  Mechanism(s):
    • Direct spinal trauma to the thoracolumbar junction
  • Clinical presentation:
    • Saddle anesthesia
    • bowel/bladder dysfunction (often presents with dysfunction more acutely compared to cauda equina which can evolve over a variable period time prior to the patient’s presentation)
    • classically presents with mild, symmetrical motor symptoms (often mixed upper and lower motor neuron syndromes)
      • can present with both spasticity and flaccid paresis
      • hyperreflexia and/or hyporeflexia
    • Prognosis: guarded.

Causes of Spinal Cord Injuries

Most spinal cord injuries are preventable, and knowing the causes of these injuries can help you avoid becoming a victim. And if you or someone you love already deal with the frustration and pain of a spinal cord injury, knowing the most common sources of these injuries can help you feel a bit less alone.

  • Auto Accidents –  Nationwide, car accidents claim more than lives annually. Unsurprisingly, then, car accidents are the leading cause of spinal cord injuries, accounting for (29.3%) male injuries and (48.3%) female injuries. Find out what to do after a car accident.
  • Falls – Falls were the second-leading cause of SCI accounting for (22%) of male injuries and 1,262 (21.5%) of female injuries.
  • Gunshot Wounds – Gun-related injuries accounted for (16.9%) of male SCIs and (9.1%) of female injuries.
  • Diving Injuries – Propelling headfirst into the water is an inherently dangerous activity. (7%) men suffered spinal cord injuries due to diving accidents with (2.1%) female divers experiencing an SCI.
  • Motorcycle Accidents – The lack of external protection means that even minor motorcycle collisions can be deadly. In (6.9%) men suffered spinal cord injuries while on motorcycles, with a mere (2.5%) women experiencing such injuries.
  • Falling Objects – Those in industries where falling objects are common are especially vulnerable. Men (3.3%) and 37 women (.6%) experienced spinal cord injuries due to falling objects.
  • Medical and Surgical Complications – Choosing the right doctor, and carefully monitoring any unusual symptoms can help you avoid a medically induced SCI. (2.2%) men suffered spinal cord injuries due to medical complications.
  • Pedestrian Injuries – Ample research suggests that pedestrians are often distracted by phones and other devices, and many such pedestrians are in denial about the extent of their distraction.  (1.5%) men suffered pedestrian-related spinal cord injuries, with women (2.2%) meeting a similar fate.
  • Bicycle Accidents – Helmets save lives. Over time, fatal bicycle accidents have generally declined, suggesting that helmet laws are working to keep cyclists safe. Nevertheless, men (1.7%) and women (.8%) suffered bicycling-related spinal cord injuries.

Traumatic – (ground-level falls in the elderly, high-energy motor vehicle accidents in any age group)

  • The incidence and prevalence of traumatic SCI in the United States is higher compared to rates reported in the literature for other countries worldwide
  • The average age at clinical presentation continues to increase, corresponding to the aging of the general population
  • Heightened clinical suspicion should be given to vertebral compression fractures which can occur spontaneously (i.e., in the absence of trauma)
    • Infection
    • Tumors/malignancy (including metastatic disease)
    • Disc herniations
    • Spinal stenosis/degenerative conditions/facet arthropathy
    • Syringomyelia

Other SCI Injury Causes

Spinal cord disorders – injuries (SCIs), or syndromes may include (but are not limited to)

  • Unclassified, which includes injuries that don’t fit neatly into a single category, or for which adequate data is not available.
  • Penetrating wounds, such as an object entering the brain or spinal cord.
  • All-terrain vehicle (ATV) accidents.
  • Accidents in other vehicles, such as jet skis and boats.
  • Snow skiing.
  • Football.
  • Winter sports such as snowboarding.
  • Horseback riding.
  • Surfing, including body surfing.
  • Other sports-related injuries.
  • Birth injuries, which typically affect the spinal cord in the neck area
  • Falls
  • Sports injuries
  • Diving accidents
  • Trampoline accidents
  • Violence (gunshot or stab wounds)
  • Infections that form an abscess on the spinal cord

Symptoms of Spinal Cord Injury

A spinal cord injury is not the sort of thing you have to wonder about having. If you’ve suffered a spinal cord injury, your life is in danger, and you’ll know you’re injured. You can’t use symptoms to diagnose the sort of spinal cord injury you have, and every patient’s prognosis is different. Some make a miraculous recovery within months; others need years of physical therapy and still make little to no progress.

The outcome depends on the nature of the injury, the quality of medical care you receive, the degree to which you work at your own recovery by adopting a healthy lifestyle, your psychological health, luck, and innumerable other factors.

A partial list of common spinal cord injury symptoms includes:

  • Varying degrees of paralysis, including tetraplegia/quadriplegia, and paraplegia
  • Difficulty breathing; the need to be on a respirator
  • Problems with bladder and bowel function
  • Frequent infections; the likelihood of this increases if you are on a feeding or breathing tube
  • Extreme pain or pressure in the neck, head or back
  • Tingling or loss of sensation in the hand, fingers, feet or toes
  • Partial or complete loss of control over any part of the body
  • Urinary or bowel urgency, incontinence or retention
  • Abnormal band-like sensations in the thorax (pain, pressure)
  • Bedsores
  • Chronic pain
  • Headaches
  • Muscle weakness
  • Loss of voluntary muscle movement in the chest, arms, or legs
  • Breathing problems
  • Loss of feeling in the chest, arms, or legs
  • Loss of bowel and bladder function
  • Changes in mood or personality
  • Loss of libido or sexual function
  • Loss of fertility
  • Nerve pain
  • Chronic muscle pain
  • Pneumonia (more than half of cervical spinal cord injury survivors struggle with bouts of pneumonia)
  • Unusual lumps on the head or spine

Diagnosis of Spinal Cord Injury

Physical Exam

Patients with SCI will present with varying clinical pictures, depending on the level of the injury. The clinician should note the specific injury type and classification. Descriptive categories include:,

Paraplegia

  • SCI causing dysfunction from the trunk/pelvic regions to the lower extremities
  • Patients have spared upper extremity function which preserves varying levels of independent mobility

Tetraplegia

  • SCI injuries at the level of the cervical spine, leading to dysfunction of the upper extremities, trunk/pelvic regions, and lower extremities
  • Patients are particularly susceptible to progressive losses in BMD as well as spontaneous VCFs without an apparent mechanism
Complete SCI
  • Patient is diagnosed with a complete SCI in the acute setting after the resolution of the spinal shock state (i.e., after the return of the patient’s bulbocavernosus reflex)
  • Patients have no spared motor or sensory function below the defined level of injury (i.e., American Spinal Injury Association [ASIA] A injuries)
Incomplete SCI
  • Injuries are subdivided into syndromes of clinical manifestation based on the anatomic area of injury to the spinal cord
  • All of these syndromes demonstrate some preserved motor or sensory function below the defined level of injury
  • Syndromes include the following:
    • Anterior cord
    • Posterior cord
    • Central cord
    • Cauda equina
    • Conus medullaris
    • Brown-Sequard

In addition to documenting a comprehensive motor and sensory exam, careful palpation and heightened clinical suspicion for spontaneous/occult fractures are critical. The most common location for spontaneous fractures is in the sub lesson regions, especially the lower extremity long bones. The clinician should note any focal or diffuse areas of swelling, including deformity and overall limb alignment.

Muscle strength[rx] ASIA Impairment Scale for classifying spinal cord injury[rx][rx]
Grade Muscle function Grade Description
No muscle contraction A Complete injury. No motor or sensory function is preserved in the sacral segments S4 or S5.
1 Muscle flickers B Sensory incomplete. Sensory but not motor function is preserved below the level of injury, including the sacral segments.
2 Full range of motion, gravity eliminated C Motor incomplete. Motor function is preserved below the level of injury, and more than half of muscles tested below the level of injury have a muscle grade less than 3 (see muscle strength scores, left).
3 Full range of motion, against gravity D Motor incomplete. Motor function is preserved below the level of injury and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
4 Full range of motion against resistance E Normal. No motor or sensory deficits, but deficits existed in the past.
5 Normal strength
Function after complete cervical spinal cord injury[rx]
Level Motor Function Respiratory function
C1–C4 Full paralysis of the limbs Cannot breathe without mechanical ventilation
C5 Paralysis of the wrists, hands, and triceps Difficulty coughing, may need help clearing secretions
C6 Paralysis of the wrist flexors, triceps, and hands
C7–C8 Some hand muscle weakness, difficulty grasping and releasing

 

Electrophysiological testing

  • Evoked potentials (EPs) measure electrical signals going to the brain and can determine whether there is motor or somatosensory impairment. The signal gets detected by electroencephalography (EEG) or electromyography (EMG).
  • Evoked potentials can be used to assess for spinal cord damage in the setting of spinal cord injury and tumors, as well as to measure the functional impairment and predict disease progression in multiple sclerosis. Somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) are frequently used intra-operatively for monitoring and can be used post-operatively as surrogate endpoints to check muscle strength and sensory status.

Lumbar puncture

  • A lumbar puncture, or spinal tap, samples the cerebrospinal fluid from the subarachnoid space. The needle to obtain the sample should be inserted between lumbar spinal canal levels L3 and L4 to avoid contact with the spinal cord.
  • The cerebrospinal fluid is then sent to a laboratory to establish whether any insult can be determined. For instance, a lumbar puncture can confirm or exclude bacterial meningitis, which will produce a cloudy fluid suggestive of a high leukocyte count. It is also important to know when not to use a lumbar puncture. Contraindications to lumbar puncture include signs of cerebral herniation, focal neurological signs, uncorrected coagulopathies, or cardiorespiratory compromise.

Deep tendon testing

Part of the neurological exam is a test of the deep tendon reflexes, which are involuntary motor responses to various stimuli that function via reflex arcs within the spinal cord. They can be used to test the function of the motor and sensory nerves at specific spinal cord levels. Reflex grading is on a scale of 0 (absent reflex) to 5+ (sustained clonus). Some commonly tested reflexes are as follows:

  • Biceps reflex: C5/C6
  • Brachioradialis reflex: C6
  • Triceps reflex: C7
  • Patellar reflex: L2/L3/L4
  • Achilles reflex: S1

Additionally, the Babinski reflex, or the extensor plantar reflex, can be seen in newborns but is an abnormal response after between six to twelve months of age, and indicative of an abnormality in the corticospinal system.

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These have no real role in traumatic cord injury in patients with significant trauma as they have limited sensitivity for detecting spinal cord trauma and bony injuries associated with it.

  • This is best for assessing the associated bony injuries which may need concomitant treatment consideration but does not assess the cord itself.

Apart from routine axial and sagittal T1 and T2 imaging additional sequences should be considered depending on the clinical concern. T2 sequences (e.g. gradient echo, SWI) are more sensitive to hemorrhage, while STIR sequences are more sensitive to associated ligamentous injury.

  • Spinal cord swelling
    • focal cord enlargement at the level of trauma without signal change 5 best seen on sagittal T1
  • Spinal cord edema
    • as per swelling but with additional increased T2 signal
  • Spinal cord contusion
    • thick high T2 signal rim around small central low T1 signal above or below the level of trauma.
    • blooming on T2 sequences
  • Intramedullary hemorrhage
    • thin high T2 signal rim around large central low T1 signal 5
    • blooming on T2* sequences
    • see aging blood on MRI for other timescales
  • Spinal cord transection
    • discontinuity of cord best seen on sagittal sequences
  • Clinical evaluation – Your doctor will make a detailed list of all of your symptoms and may conduct blood tests, ask you to move your limbs, follow movement in your eyes, and conduct other tests to narrow down your symptoms.
  • Imaging tests – Your doctor may order MRI imaging or other forms of radiological imaging to view your spinal column, spinal cord, and brain.


Treatment of Spinal Cord Injury

Spinal injury: First aid

If you suspect a back or neck (spinal) injury, do not move the affected person. Permanent paralysis and other serious complications can result. Assume a person has a spinal injury if:

  • There’s evidence of a head injury with an ongoing change in the person’s level of consciousness
  • The person complains of severe pain in his or her neck or back
  • An injury has exerted substantial force on the back or head
  • The person complains of weakness, numbness, or paralysis or lacks control of his or her limbs, bladder or bowels
  • The neck or body is twisted or positioned oddly
  • Keep the person still – Place heavy towels or rolled sheets on both sides of the neck or hold the head and neck to prevent movement.
  • Avoid moving the head or neck – Provide as much first aid as possible without moving the person’s head or neck. If the person shows no signs of circulation (breathing, coughing or movement), begin CPR, but do not tilt the head back to open the airway. Use your fingers to gently grasp the jaw and lift it forward. If the person has no pulse, begin chest compressions.
  • Keep the helmet on – If the person is wearing a helmet, don’t remove it. A football helmet facemask should be removed if you need to access the airway.
  • Don’t roll alone – If you must roll the person because he or she is vomiting, choking on blood or because you have to make sure the person is still breathing, you need at least one other person. With one of you at the head and another along the side of the injured person, work together to keep the person’s head, neck and back aligned while rolling the person onto one side.
  • Unlike many other injuries, the most important component of spinal cord injury treatment begins before you even get to the doctor. Remaining still, avoiding moving your spinal column, and prompt emergency care, can all increase the odds that you survive while minimizing the long-term effects of your injury.
  • From there, doctors will focus on stabilizing you, since the first hours after a spinal cord injury are critical to a patient’s survival. Assistance with breathing, a collar to keep your neck still, blood transfusions, and other procedures to address your immediate symptoms may be necessary.

Eat Nutritiously During Your Recovery

  • All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal broken bones of all types. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
  • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.

Physical Therapy

  • Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.  It is common to lose some leg strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle hip, knee exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-Up Care

  • You will need to see your doctor regularly until your fracture heals. During these visits, he or they will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Medication

Your doctor will work with you and your family to construct a detailed plan for your SCI rehabilitation. Every injury is different, but common treatments for a spinal cord injury may involve:

  • Care to address, but not treat, your immediate symptoms. For instance, a ventilator can help you breathe and a feeding tube can help you eat if you are unable to do so.
  • Palliative care to help you be more comfortable. If you struggle with insomnia or chronic pain, your doctor might prescribe medication to help.
  • Lifestyle changes, such as a healthier diet or giving up smoking.
  • Physical therapy to help retrain your brain and body; many spinal cord injury survivors are able to regain significant mobility with physical therapy.
  • Family and individual counseling to help you cope with the pain and stress of life with a spinal cord injury.
  • Surgery as needed to correct injury-related health problems.

Spinal cord injury research is always looking for breakthroughs in treatments, such as stem cell therapy for SCI. Stem cell therapies have long been marketed as a holy grail for a range of diseases, including spinal cord injuries. Recent data suggests that further research could point toward a cure for spinal cord injuries.

Vibration Therapy

  • Low magnitude mechanical signals (LMMS) as a therapeutic modality has demonstrated bone formation capabilities in both human and rodent models. However, beyond limited case reports there is little evidence available to advocate its definitive therapeutic potential.  Similarly, low-intensity vibration treatment protocols have shown some promising results in a small case series of SCI-induced osteoporotic patients. ,

Calcium and Vitamin D

  • Without question, all patients should be taking calcium and vitamin D supplementation. Patients should be educated on the recommended daily intake for calcium and vitamin D. The National Osteoporosis Foundation (NOF) recommends 1200 to 1500 mg of calcium per day and 800 to 1000 IUs of daily vitamin D for adults over the age of 50. In the setting of SCI-induced osteoporosis, all patients should begin supplementation regardless of age at presentation. 

Anti-Osteoporotic Pharmacotherapy Options

  • Pharmacotherapy agents work through either anti-resorptive or anabolic means. In general, bisphosphonates are the most commonly prescribed medication class for osteoporosis treatment. These drugs are divided into non-nitrogen and nitrogen-containing compounds. The latter are considered first-line therapy for osteoporosis.
  • However, a major concern with SCI-induced osteoporosis coupled with the bisphosphonate anti-resorptive mechanism on bone is the inability to actually demonstrate measurable increases in BMD levels.
  • In one study, alendronate was able to prevent further bone loss in 55 patients with chronic SCI-induced osteoporosis at the 2-year follow-up.  However, this is a stark contrast to alendronate’s proven track record and documented capabilities to increase BMD values measured in an ambulatory (i.e., not SCI-induced), post-menopausal women with osteoporosis.

While alendronate, risedronate, and intravenous zoledronic acid have all demonstrated reduced fragility fracture rates in the general osteoporosis population, the clinical evidence has yet to be demonstrated in the SCI-induced osteoporosis population. Clinicians are encouraged to recognize the subtle differences in efficacy and evidence-based approaches for the pharmacologic management of these vulnerable patients.

Denosumab

  • Denosumab, a monoclonal antibody against receptor activator of nuclear factor-kappa-? ligand (RANKL), has recently been studied specifically in patients afflicted with SCI-induced osteoporosis. In 2016, one study demonstrated increases in lumbar and femoral BMD values as measured by DXA scans after 1 year of treatment compared to baseline BMD values. Denosumab was administered in a 60 mg every 6 months protocol during the study period.

Anabolic Agents and Emerging Pharmacotherapy Agents

  • Teriparatide is a recombinant form of PTH that stimulates osteoblasts to produce more bone. Teriparatide is now FDA approved for osteoporosis treatment in males and females, but more studies are needed in order to improve our understanding of its effects on BMD levels and clinical outcomes in SCI-induced osteoporotic patients. ,

Exercises for after a Spinal Cord Injury

Particularly in the early days after a spinal cord injury, you might be tempted to languish in bed. Moving around certainly seems counter-intuitive when you’ve suffered a catastrophic injury to your body. But the benefits of exercise don’t disappear just because you’ve been injured. Quite the contrary, in fact. Exercises after a spinal cord injury can expedite your SCI rehabilitation in addition to offering a myriad of health benefits.

Exercises

  • Yoga – ideal for spinal cord injury survivors because the gentle stretching encourages healthy breathing patterns, and can reduce the pain of spending all or most of your day in a wheelchair.
  • Water Aerobics – The water reduces pain and joint trauma, and can help support your weight even if you’ve lost a significant portion of your mobility or sensation.
  • Weightlifting – Lifting weights can help you regain significant muscle control. It will also enable you to maintain strength in regions unaffected by your spinal cord injury.
  • Seated Aerobics – You can still get an incredible aerobic workout from your wheelchair. Talk to your doctor about seated aerobic classes specifically targeted to spinal cord injury survivors
  • Rowing – Rowing is an ideal aerobic activity because it only requires movement in your upper body, but uses your lower body to stabilize your movements, making it an ideal choice for injury survivors with incomplete spinal cord injuries.
  • Walking – If your spinal cord injury is incomplete or you have only sustained nerve damage, you may still be able to walk. Maximize your muscle function by walking as frequently as is comfortable, maintaining a steady gait, and an upright posture.
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Exercise benefits:

  • Improving mental health by reducing depression and anxiety
  • Reducing the risk of cancer
  • Improving symptoms of chronic pain
  • Helping you avoid chronic illnesses such as diabetes and osteoporosis
  • Reducing your risk of falls
  • Improving your chances of living a longer life.

New technologies

Inventive medical devices can help people with spinal cord injury become more independent and more mobile. Some devices may also restore function. These include:

  • Modern wheelchair – Improved, lighter weight wheelchairs are making people with spinal cord injuries more mobile and more comfortable. For some, an electric wheelchair may be needed. Some wheelchairs can even climb stairs, travel over rough terrain, and elevate a seated passenger to eye level to reach high places without help.
  • Computer adaptations – For someone who has limited hand function, computers can be very powerful tools, but they’re difficult to operate. Computer adaptations range from simple to complex, such as key guards or voice recognition.
  • Electronic aids to daily living – Essentially any device that uses electricity can be controlled with an electronic aid to daily living. Devices can be turned on or off by a switch or voice-controlled and computer-based remotes.
  • Electrical stimulation devices – These sophisticated devices use electrical stimulation to produce actions. They’re often called functional electrical stimulation systems, and they use electrical stimulators to control arm and leg muscles to allow people with spinal cord injuries to stand, walk, reach and grip.
  • Robotic gait training – This emerging technology is used for retraining walking ability after a spinal cord injury.

Spinal Cord Injury Recovery

  • Your SCI rehabilitation journey can be long and often unpredictable. Some spinal cord injury sufferers spontaneously walk years after their injury. Others are never able to move again. While medical science can do a lot to predict what might happen to you, there are no guarantees when it comes to spinal cord injuries. What we do know is that a healthy lifestyle, sound psychological health, family support, and receiving treatment at a model system of care can all improve outcomes.

Physical Recovery

There is no single definition of physical recovery. Though many spinal cord injury survivors do regain some degree of function, some don’t. Thus, focusing solely on physical recovery can leave you feeling hopeless and overwhelmed.

Some common milestones for physical recovery include:

  • The reduction of swelling at the site of the injury.
  • Recovering from surgery.
  • Regaining some sensation below the site of the injury.
  • Regaining some movement below the site of the injury.
  • Learning to use assistive devices such as wheelchairs and prostheses.
  • Finding new ways to complete old tasks; for instance, you might change your approach to sex or making food.
  • Strengthening your body so you can work around your injuries. You might learn how to type with a part of your body other than your hands, for instance.

Psychological Recovery

  • Spinal cord injury guides, as well as doctors, lawyers, and loved ones, often focus on physical recovery. But this dogged fixation can actually undermine your psychological recovery. Poor psychological health can worsen your physical health, and believing that physical recovery is the only way to be happy can likewise undermine your psychological well-being. It is possible to be happy even in the face of a painful injury. Indeed, one study found that 86% of quadriplegics rated their lives as better than average.
  • This attitude can take some time to cultivate, but once you’ve mastered it, you may realize an important truth about life: happiness comes from within, and the way you think about things affects the way you perceive them. Spinal cord injuries are challenging, and there is no shame in seeking psychological help. Many survivors struggle with depression, anxiety, and other mental health issues, but with family support and lots of help, you can find new ways to live a life you love.

Complications

  • Cardiac and circulatory issues
  • Respiratory difficulties or loss of function
  • Numbness or loss of feeling below the injury site
  • Paralysis
  • Bladder and bowel function loss
  • Urinary tract infections (UTIs)
  • Thermoregulatory impairment (inability to regulate body temperature)
  • Bladder control – Your bladder will continue to store urine from your kidneys. However, your brain may not be able to control your bladder as well because the message carrier (the spinal cord) has been injured. The changes in bladder control increase your risk of urinary tract infections. The changes may also cause kidney infections and kidney or bladder stones. During rehabilitation, you’ll learn new techniques to help empty your bladder.
  • Bowel control – Although your stomach and intestines work much as they did before your injury, control of your bowel movements is often altered. A high-fiber diet may help regulate your bowels, and you’ll learn techniques to optimize your bowel function during rehabilitation.
  • Skin sensation – Below the neurological level of your injury, you may have lost part of or all skin sensations. Therefore, your skin can’t send a message to your brain when it’s injured by certain things such as prolonged pressure, heat, or cold.
  • Circulatory control – A spinal cord injury may cause circulatory problems ranging from low blood pressure when you rise (orthostatic hypotension) to swelling of your extremities. These circulation changes may also increase your risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus.
  • Respiratory system – Your injury may make it more difficult to breathe and cough if your abdominal and chest muscles are affected. These include the diaphragm and the muscles in your chest wall and abdomen.
  • Muscle tone – Some people with spinal cord injuries experience one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
  • Fitness and wellness – Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility may lead to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease, and diabetes.
  • Sexual health – Sexuality, fertility, and sexual function may be affected by a spinal cord injury. Men may notice changes in erection and ejaculation; women may notice changes in lubrication. Physicians specializing in urology or fertility can offer options for sexual functioning and fertility.
  • Pain – Some people experience pain, such as muscle or joint pain, from overuse of particular muscle groups. Nerve pain can occur after a spinal cord injury, especially in someone with an incomplete injury.
  • Depression – Coping with all the changes a spinal cord injury brings and living with pain causes some people to experience depression.

Prevention

The leading causes of spinal cord injury are road traffic crashes, falls, and violence (including attempted suicide). A significant proportion of traumatic spinal cord injury is due to work or sports-related injuries. Effective interventions are available to prevent several of the main causes of spinal cord injury, including improvements in roads, vehicles and people’s behavior on the roads to avoid road traffic crashes, window guards to prevent falls, and policies to thwart the harmful use of alcohol and access to firearms to reduce violence.

  • Drive safely – Car crashes are one of the most common causes of spinal cord injuries. Wear a seat belt every time you drive or ride in a car. Make sure that your children wear a seat belt or use an age- and weight-appropriate child safety seat. To protect them from airbag injuries, children under age 12 should always ride in the back seat.
  • Check water depth before diving – To make sure you don’t dive into shallow water, don’t dive into a pool unless it’s 12 feet (about 3.7 meters) or deeper, don’t dive into an aboveground pool, and don’t dive into any water of which you don’t know the depth.
  • Prevent falls – Use a step stool with a grab bar to reach objects in high places. Add handrails along stairways. Put nonslip mats on tile floors and in the tub or shower. For young children, use safety gates to block stairs and consider installing window guards.
  • Take precautions when playing sports – Always wear recommended safety gear. Avoid leading with your head in sports. For example, don’t slide headfirst in baseball, and don’t tackle using the top of your helmet in football. Use a spotter for new moves in gymnastics.
  • Don’t drink and drive. Don’t drive while intoxicated or under the influence of drugs. Don’t ride with a driver who’s been drinking.

Improving care and overcoming barriers

Many of the consequences associated with spinal cord injury do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social and policy environments. Implementation of the UN Convention on the Rights of Persons with Disabilities (CRPD) requires action to address these gaps and barriers. Essential measures for improving the survival, health, and participation of people with spinal cord injury include the following.

  • Timely, appropriate pre-hospital management: quick recognition of suspected spinal cord injury, rapid evaluation, and initiation of injury management, including immobilization of the spine.
  • Acute care (including surgical intervention) appropriate to the type and severity of the injury, degree of instability, presence of neural compression, and in accordance with the wishes of the patient and their family.
  • Access to ongoing health care, health education, and products (e.g. catheters) to reduce the risk of secondary conditions and improve the quality of life.
  • Access to skilled rehabilitation and mental health services to maximize functioning, independence, overall wellbeing, and community integration. Management of bladder and bowel function is of primary importance.
  • Access to appropriate assistive devices that can enable people to perform everyday activities they would not otherwise be able to undertake, reducing functional limitations and dependency. Only 5-15% of people in low- and middle-income countries have access to the assistive devices they need.
  • Specialized knowledge and skills among providers of medical care and rehabilitation services.

Essential measures to secure the right to education and economic participation include legislation, policy, and programs that promote the following:

  • physically accessible homes, schools, workplaces, hospitals, and transportation;
  • inclusive education;
  • elimination of discrimination in employment and educational settings;
  • Vocational rehabilitation to optimize the chance of employment;
  • micro-finance and other forms of self-employment benefits to support alternative forms of economic self-sufficiency;
  • access to social support payments that do not act as a disincentive to return to work; and
  • correct understanding of spinal cord injury and positive attitudes towards people living with it.

WHO response

WHO works across the spectrum from primary prevention of traumatic and non-traumatic causes of spinal cord injury, improvements in trauma care, strengthening health and rehabilitation services, and support for the inclusion of people with spinal cord injuries. WHO:

  • works in a multisectoral manner, in partnership with national stakeholders from a variety of sectors (e.g. health, police, transport, education) to improve prevention of spinal cord injury including of road traffic injuries, falls, violence and neural tube defects;
  • guides and supports the Member States to increase awareness of disability issues, and promotes the inclusion of disability as a component in national health policies and programs;
  • facilitates data collection and dissemination of disability-related data and information;
  • develops normative tools, including guidelines and good practice examples to strengthen primary prevention (road traffic crashes, falls and violence), trauma care, health care, rehabilitation and support and assistance;
  • builds capacity among health policy-makers and service providers;
  • promotes scaling up of community-based rehabilitation; and
  • promotes strategies to ensure that people with disabilities are knowledgeable about their own health conditions, and that health-care personnel support and protect the rights and dignity of persons with disabilities.

Following strategies should be undertaken for better recovery

  • Close routine follow-up with the neurologist/internist.
  • Educate patients for clean intermittent catheterization (CIC) to avoid urinary tract infections and secondary complications.
  • Educate patients to avoid immobility, and regularly change position after 2-4 hours.
  • Close follow-up with a physical therapist for muscle and core strengthening exercises to avoid muscle atrophy.
  • Blood pressure monitoring at home.
  • Close follow-up with the psychiatrist to look for any signs of depression and suicidal ideation.


References

Spinal Cord Injury


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