Spinal Cord Injury: Treatments and Rehabilitation

Paramedics stabilize a patient's spinal cord injury to prevent further damage.

• The most common cause of spinal cord injury is trauma.
• Spinal cord injury is most common in young, white men.
• Spinal cord injury can be either complete or incomplete. In complete injuries, there is no function below the level of injury. In incomplete injuries, there is some function remaining below the level of injury.
• Early immobilization and treatment are the most important factors in achieving recovery from spinal cord injury.
• Aggressive rehabilitation and assistive devices allow even people with severe spinal cord injuries to interact in society and remain productive.

The spinal cord is a collection of nerves that travels from the bottom of the brain down your back. There are 31 pairs of nerves that leave the spinal cord and go to your arms, legs, chest, and abdomen. These nerves allow your brain to give commands to your muscles and cause movements of your arms and legs. The nerves that control your arms exit from the upper portion of the spinal cord, while the nerves to your legs exit from the lower portion of the spinal cord. The nerves also control the function of your organs including your heart, lungs, bowels, and bladder. For example, signals from the spinal cord control how fast your heart beats and your rate of breathing.

Other nerves travel from your arms and legs back to the spinal cord. These nerves bring back information from your body to your brain including the senses of touch, pain, temperature, and position. The spinal cord runs through the spinal canal. This canal is surrounded by the bones in your neck and back called vertebrae which make up your backbone. The vertebrae are divided into 7 necks (cervical) vertebrae, 12 chest (thoracic) vertebrae, and 5 lower back (lumbar) vertebrae. The vertebrae help protect the spinal cord from injury.

Spinal Cord Injury

The spinal cord is very sensitive to injury. Unlike other parts of your body, the spinal cord does not have the ability to repair itself if it is damaged. A spinal cord injury occurs when there is damage to the spinal cord either from trauma, loss of its normal blood supply, or compression from a tumor or infection. There are approximately 12,000 new cases of spinal cord injury each year in the United States. They are most common in white males.

Spinal cord injuries are described as either complete or incomplete. In a complete spinal cord injury, there is a complete loss of sensation and muscle function in the body below the level of the injury. In an incomplete spinal cord injury, there is some remaining function below the level of the injury. In most cases, both sides of the body are affected equally.

An injury to the upper portion of the spinal cord in the neck can cause quadriplegia-paralysis of both arms and legs. If the injury to the spinal cord occurs lower in the back it can cause paraplegia-paralysis of both legs only.

The most common cause of spinal cord injury is trauma. Nearly half of the injuries are caused by motor vehicle accidents. Other types of trauma include:

• falls from heights,
• violence (stabbing or gunshot wounds to the spine), and
• sporting injuries (diving, football, rugby, equestrian, etc.).

Spinal cord injury can also be caused by compression of the cord by a tumor, infection, or inflammation. Some patients have a smaller than normal spinal canal (called spinal stenosis) and are at a higher risk of injury to the spinal cord.

All tissues in your body including the spinal cord require a good blood supply to deliver oxygen and other nutrients. Failure of this blood supply to the spinal cord can cause spinal cord injury. This can be caused by an aneurysm (ballooning of a blood vessel), compression of a blood vessel, or a prolonged drop in blood pressure.

The symptoms of spinal cord injury depend on where the spinal cord is injured and whether or not the injury is complete or incomplete. In incomplete injuries, patients have some remaining functions of their bodies below the level of injury, while in complete injuries they have no function below the level of injury.

Injuries to the spinal cord can cause weakness or complete loss of muscle function and loss of sensation in the body below the level of injury, loss of control of the bowels and bladder, and loss of normal sexual function. Spinal cord injuries in the upper neck can cause difficulty breathing and may require the use of a breathing machine, or ventilator.

The first step in diagnosing a spinal cord injury is a medical history and physical examination. The patient's physician will obtain a medical history asking questions about the details surrounding the time of the injury. The amount of time since the injury is important because spinal cord injury is a medical emergency. The quicker the patient obtains treatment, the better the chances for recovery. Other details of the medical history could include details of any prior neck or back injuries or surgeries, the presence of pain in the neck or back, any weakness in the arms or legs, loss of bowel or bladder control, loss of sensation in the arms or legs, and other previous medical conditions.

The physical examination will include testing to see if the sensation to touch is intact in the arms and legs as well as testing muscle strength and reflexes in the arms and legs. The patient may be kept in a cervical collar or on a backboard to immobilize them until the physician determines whether or not the patient has a spinal cord injury.

The next step is often x-rays of the neck or back. These can help identify a fracture or dislocation of the vertebrae. These may or may not be present with a spinal cord injury. It is possible to have a spinal cord injury without an injury to the vertebrae. X-rays can also help identify a tumor or infection or severe arthritis that could cause spinal cord injury.

A computed tomography (CT) scan is a more advanced imaging test that can give the physician a better view of the vertebrae. CT can identify some injuries to the vertebrae not seen on the plain x-rays. A magnetic resonance imaging (MRI) scan is another more advanced imaging study that can identify a spinal cord injury. The MRI is better at evaluating the soft tissues including the ligaments, intervertebral discs, nerves, and spinal cord. The MRI scan also can show evidence of injury within the spinal cord.

The first step in the treatment of a suspected spinal cord injury is to verify the patient is breathing and the heart is beating. A spinal cord injury in the upper neck can cause a loss of control of normal breathing. This may require the placement of a breathing tube and the use of a ventilator.

The next step in the treatment of a spinal cord injury is immobilization. This often occurs at the time of injury prior to being transported to the hospital. Emergency medical technicians may place the patient in a cervical collar or on a backboard to help prevent the spine from moving. If the patient has a spinal cord injury, further movement of the spine could lead to further damage.

After a spinal cord injury is diagnosed, the patient might be started on a high dose of steroids. This could help decrease the amount of damage to the spinal cord by reducing inflammation and swelling. There are risks associated with using steroids for spinal cord injury. The patient's doctor can help decide if steroids are appropriate. The use of steroids is only beneficial if they are started within eight hours of the time of injury.

Next, the patient may be placed in traction or a halo device around the head to try to stabilize the spine and prevent further damage. Many cases of spinal cord injury are treated with surgery. There are two major goals of the surgery.

• The first goal is to relieve any pressure on the spinal cord. This could involve removing portions of the vertebrae that have broken and are compressing the spinal cord. If the spinal cord is being compressed by a tumor, infection, or severe arthritis, surgery can be performed to reduce the amount of compression.
• The second major goal of surgery for spinal cord injury is to stabilize the spine. If the vertebrae are weakened from fracture, tumor, or infection, they may not be capable of supporting the normal weight of the body and protecting the spinal cord. A combination of metal screws, rods, and plates may be necessary to help hold the vertebrae together and stabilize them until the bones heal.

There are many potential complications related to spinal cord injury that may require specific treatment. These complications include:

• urinary tract infections or urinary incontinence (inability to control the flow of urine),
• bowel incontinence (inability to control bowel movements),
• pressure sores,
• infections in the lungs (pneumonia),
• blood clots,
• muscle spasms,
• chronic pain, and
• depression.

After the initial treatment and stabilization of patients with a spinal cord injury, much of the treatment is geared toward rehabilitation. This includes methods to help the patient maximize their function through physical and occupational therapy and the use of assistive devices.

No two people will experience the same emotions after surviving a spinal cord injury, but almost everyone will feel frightened, anxious, or confused about what has happened. It's common for people to have very mixed feelings: relief that they are still alive, but disbelief at the nature of their disabilities.

Rehabilitation programs combine physical therapies with skill-building activities and counseling to provide social and emotional support. The education and active involvement of the newly injured person and his or her family and friends are crucial.

A rehabilitation team is usually led by a doctor specializing in physical medicine and rehabilitation (called a physiatrist), and often includes social workers, physical and occupational therapists, recreational therapists, rehabilitation nurses, rehabilitation psychologists, vocational counselors, nutritionists, and other specialists. A caseworker or program manager coordinates care.

In the initial phase of rehabilitation, therapists emphasize regaining leg and arm strength since mobility and communication are the two most important areas of function. For some, mobility will only be possible with the assistance of devices such as a walker, leg braces, or a wheelchair. Communication skills, such as writing, typing, and using the telephone, may also require adaptive devices.

Physical therapy includes exercise programs geared toward muscle strengthening. Occupational therapy helps redevelop fine motor skills. Bladder and bowel management programs teach basic toileting routines, and patients also learn techniques for self-grooming. People acquire coping strategies for recurring episodes of spasticity, autonomic dysreflexia, and neurogenic pain.

Vocational rehabilitation begins with an assessment of basic work skills, current dexterity, and physical and cognitive capabilities to determine the likelihood of employment. A vocational rehabilitation specialist then identifies potential workplaces, determines the type of assistive equipment that will be needed, and helps arrange for a user-friendly workplace. For those whose disabilities prevent them from returning to the workplace, therapists focus on encouraging productivity through participation in activities that provide a sense of satisfaction and self-esteem. This could include educational classes, hobbies, memberships in special interest groups, and participation in family and community events.

Recreation therapy encourages patients to build on their abilities so that they can participate in recreational or athletic activities at their level of mobility. Engaging in recreational outlets and athletics helps those with spinal cord injuries achieve a more balanced and normal lifestyle and also provides opportunities for socialization and self-expression.

The best chance for recovery of function following spinal cord injury is through prompt treatment. Early surgical decompression and stabilization leads to better recovery. Aggressive physical therapy and rehabilitation after surgery also maximizes recovery. The majority of recovery occurs within the first six months after injury. Any remaining loss of function present after 12 months is much more likely to become permanent.

Maintaining a positive outlook is extremely important for patients with spinal cord injury. The use of assistive devices allows most people with even severe spinal cord injuries to integrate into society and stay productive. Unfortunately, the rate of depression, divorce, and substance abuse are significantly higher in people with spinal cord injury. There are many support groups and treatments available for people with spinal cord injury as listed below.

There is no cure for spinal cord injury at this time. Many physicians and scientists devote their professional lives to this goal. There have been many promising advancements in research into spinal cord injury recently. It is hoped that these advancements will lead to a cure.

Christopher Reeve Foundation & Resource Center
636 Morris Turnpike Suite 3A
Short Hills, NJ 07078
[email protected]
http://www.christopherreeve.org
Tel: 973-379-2690 800-225-0292
Fax: 973-912-9433

National Rehabilitation Information Center (NARIC)
4200 Forbes Boulevard Suite 202
Lanham, MD 20706-4829
[email protected]
http://www.naric.com
Tel: 301-459-5900/301-459-5984
(TTY) 800-346-2742
Fax: 301-562-2401

Miami Project to Cure Paralysis/ Buoniconti Fund
P.O. Box 016960 R-48
Miami, FL 33101-6960
[email protected]
http://www.themiamiproject.org
Tel: 305-243-6001 800-STANDUP (782-6387)
Fax: 305-243-6017

National Spinal Cord Injury Association
6701 Democracy Blvd. #300-9
Bethesda, MD 20817
[email protected]
http://www.spinalcord.org
Tel: 800-962-9629
Fax: 301-963-1265

Paralyzed Veterans of America (PVA)
801 18th Street, NW
Washington, DC 20006-3517
[email protected]
http://www.pva.org
Tel: 202-USA-1300 (872-1300)
800-424-8200
Fax: 202-785-4452

Spinal Cord Society
19051 County Highway 1
Fergus Falls, MN 56537
Tel: 218-739-5252 or 218-739-5261
Fax: 218-739-5262

Clearinghouse on Disability Information Special Education & Rehabilitative Services Communications & Customer Service Team
550 12th Street, SW, Rm. 5133
Washington, DC 20202-2550
http://www.ed.gov/about/offices/list/osers
Tel: 202-245-7307 202-205-5637 (TTD)
Fax: 292024507636

National Institute on Disability and Rehabilitation Research (NIDRR) U.S. Department of Education Office of Special Education and Rehabilitative Services
400 Maryland Ave., S.W.
Washington, DC 20202-7100
http://www.ed.gov/about/offices/list/osers/nidrr
Tel: 202-245-7460 202-245-7316 (TTY)