Spinal Cord Injury
According to the National Spinal Cord Injury Association, as many
as 450,000 people in the United States are living with a spinal cord
injury (SCI). Other organizations conservatively estimate this figure to
be about 250,000. Every year, an estimated 11,000 SCIs occur in the
United States. Most of these are caused by trauma to the vertebral
column, thereby affecting the spinal cord's ability to send and receive
messages from the brain to the body's systems that control sensory,
motor and autonomic function below the level of injury.
According to the Centers for Diseases Control and Prevention
(CDC), SCI costs the nation an estimated $9.7 billion each year.
Pressure sores alone, a common secondary condition among people with
SCI, cost an estimated $1.2 billion.
incidence of SCI is highest among persons age 16-30, in whom 53.1
percent of injuries occur; more injuries occur in this age group than in
all other age groups combined.
- Males represent 81.2 percent of
all reported SCIs and 89.8 percent of all sports-related SCIs.
both genders, auto accidents, falls and gunshots are the three leading
causes of SCI, in that order. Among males, diving accidents ranked
fourth, followed by motorcycle accidents. Among females,
medical/surgical complications ranked fourth, followed by diving
- Auto accidents are the leading cause of SCI in the
United States for people age 65 and younger, while falls are the leading
cause of SCI for people 65 and older.
- Sports and
recreation-related SCI injuries primarily affect people under age 29.
The spinal cord is about 18 inches long,
extending from the base of the brain to near the waist. Many of the
bundles of nerve fibers that make up the spinal cord itself contain
upper motor neurons (UMNs). Spinal nerves that branch off the spinal
cord at regular intervals in the neck and back contain lower motor
neurons (LMNs). The spine itself is divided into four sections, not
including the tailbone:
vertebrae (1-7), located in the neck
- Thoracic vertebrae
(1-12), in the upper back (attached to the ribcage)
vertebrae (1-5), in the lower back
- Sacral vertebrae (1-5), in
and Levels of SCI
The severity of an injury depends on the
part of the spinal cord that is affected. The higher the SCI on the
vertebral column, or the closer it is to the brain, the more effect it
has on how the body moves and what one can feel. More movement, feeling
and voluntary control are generally present with injuries at lower
(a.k.a. quadriplegia) results from injuries to the spinal cord in the
cervical (neck) region, with associated loss of muscle strength in all
- Paraplegia results from injuries to the
spinal cord in the thoracic or lumbar areas, resulting in paralysis of
the legs and lower part of the body.
A complete SCI produces total loss of all motor and sensory
function below the level of injury. Nearly 50 percent of all SCIs are
complete. Both sides of the body are equally affected. Even with a
complete SCI, the spinal cord is rarely cut or transected. More
commonly, loss of function is caused by a contusion or bruise to the
spinal cord or by compromise of blood flow to the injured part of the
In an incomplete SCI,
some function remains below the primary level of the injury. A person
with an incomplete injury may be able to move one arm or leg more than
the other, or may have more functioning on one side of the body than the
other. An incomplete SCI often falls into one of several patterns.
cord syndrome results from injury to the motor and sensory pathways
in the anterior parts of the spinal cord. These patients can feel some
types of crude sensation via the intact pathways in the posterior part
of the spinal cord, but movement and more detailed sensation are lost.
cord syndrome usually results from trauma and is associated with
damage to the large nerve fibers that carry information directly from
the cerebral cortex to the spinal cord. Symptoms may include paralysis
and/or loss of fine control of movements in the arms and hands, with far
less impairment of leg movements. Sensory loss below the site of the
SCI and loss of bladder control may also occur, with the overall amount
and type of functional loss related to the severity of damage to the
nerves of the spinal cord.
Brown-Sequard syndrome is a rare
spinal disorder that results from an injury to one side of the spinal
cord. It is usually caused by an injury to the spine in the region of
the neck or back. In many cases, some type of puncture wound in the neck
or in the back that damages the spine may be the cause. Movement and
some types of sensation are lost below the level of injury on the
injured side. Pain and temperature sensation are lost on the side of the
body opposite the injury because these pathways cross to the opposite
side shortly after they enter the spinal cord.
Injuries to a
specific nerve root may occur either by themselves or together with a
SCI. Because each nerve root supplies motor and sensory function to a
different part of the body, the symptoms produced by this injury depend
upon the pattern of distribution of the specific nerve root involved.
concussions" can also occur. These can be complete or incomplete, but
spinal cord dysfunction is transient, generally resolving within one or
two days. Football players are especially susceptible to spinal
concussions and spinal cord contusions. The latter may produce
neurological symptoms including numbness, tingling, electric shock-like
sensations, and burning in the extremities. Fracture-dislocations with
ligamentous tears may be present in this syndrome.
"Open" or penetrating injuries to the spine and spinal
cord, especially those caused by firearms, may present somewhat
different challenges. Most gunshot wounds to the spine are stable, i.e.,
they do not carry as much risk of excessive and potentially dangerous
motion of the injured parts of the spine. Depending upon the anatomy of
the injury, the patient may need to be immobilized with a collar or
brace for several weeks or months so that the parts of the spine that
were fractured by the bullet may heal. In most cases, surgery to remove
the bullet does not yield much benefit and may create additional risks,
including infection, cerebrospinal fluid leak, and bleeding. However,
occasional cases of gunshot wounds to the spine may require surgical
decompression and/or fusion in an attempt to optimize patient outcome.
SCI is suspected, immediate medical attention is required. SCI is
usually first diagnosed when the patient presents with loss of function
below the level of injury.
Signs and Symptoms of Possible SCI
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
- Difficulty with
balance and walking
- Abnormal band-like sensations in the thorax
- pain, pressure
- Impaired breathing after injury
lumps on the head or spine
physician may decide that significant SCI does not exist simply by
examining a patient who does not have any of the above symptoms, as long
as the patient meets the following criteria: unaltered mental status,
no neurological deficits, no intoxication from alcohol or other drugs or
medications, and no other painful injuries that may divert his or her
attention away from a SCI.
In other cases, such as when patients
complain of neck pain, when they are not fully awake, or when they have
obvious weakness or other signs of neurological injury, the cervical
spine is kept in a rigid collar until appropriate radiological studies
radiological diagnosis of SCI has traditionally begun with x-rays. In
many cases, the entire spine may be x-rayed. Patients with a SCI may
also receive both computerized tomography (CT or CAT scan) and magnetic
resonance imaging (MRI) of the spine. In some patients, centers may
proceed directly to CT scanning as the initial radiological test. For
patients with known or suspected injuries, MRI is helpful for looking at
the actual spinal cord itself, as well as for detecting any blood
clots, herniated discs, or other masses that may be compressing the
spinal cord. CT scans may be helpful in visualizing the bony anatomy,
including any fractures.
Even after all radiological tests have
been performed, it may be advisable for a patient to wear a collar for a
variable period of time. If patients are awake and alert but still
complaining of neck pain, a physician may send them home in a collar,
with plans to repeat x-rays in the near future, such as in one to two
weeks. The concern in these cases is that muscle spasm caused by pain
might be masking an abnormal alignment of the bones in the spinal
column. Once this period of spasm passes, repeat x-rays may reveal
abnormal alignment or excessive motion that was not visible immediately
after the injury. In patients who are comatose, confused, or not fully
cooperative for some other reason, adequate radiographic visualization
of parts of the spine may be difficult. This is especially true of the
bones at the very top of the cervical spine. In such cases, the
physician may keep the patient in a collar until the patient is more
cooperative. Alternatively, the physician may obtain other imaging
studies to look for radiologically evident injury.
of SCI begins before the patient is admitted to the hospital.
Paramedics or other emergency medical services personnel carefully
immobilize the entire spine at the scene of the accident. In the
emergency department, this immobilization is continued while more
immediate life-threatening problems are identified and addressed. If the
patient must undergo emergency surgery because of trauma to the
abdomen, chest, or another area, immobilization and alignment of the
spine are maintained during the operation.
Intensive Care Unit
If a patient has a SCI, he or she will usually be
admitted to an intensive care unit (ICU). For many injuries of the
cervical spine, traction may be indicated to help bring the spine into
proper alignment. Standard ICU care, including maintaining a stable
blood pressure, monitoring cardiovascular function, ensuring adequate
ventilation and lung function, and preventing and promptly treating
infection and other complications, is essential so that SCI patients can
achieve the best possible outcome.
a steroid drug, became available as a treatment for acute SCI in 1990
when a multicenter clinical trial showed better neurological change
scores in patients who were given the drug within the first eight hours
of injury. These studies have been criticized in part because this
increase in scores has never been shown to translate into better
functional outcomes for patients. This area remains controversial.
Perhaps clinicians should consider methylprednisolone infusion if its
potential benefits are felt to outweigh the risks of potential
surgeon may wish to take a patient to the operating room immediately if
the spinal cord appears to be compressed by a herniated disc, blood
clot, or other lesion. This is most commonly done for patients with an
incomplete SCI or with progressive neurological deterioration.
if surgery cannot reverse damage to the spinal cord, surgery may be
needed to stabilize the spine to prevent future pain or deformity. The
surgeon will decide which procedure will provide the greatest benefit to
Persons with neurologically
complete tetraplegia are at high risk for secondary medical
complications. The percentages of complications for individuals with
neurologically complete tetraplegia have been reported as follows:
percent developed pneumonia
- 52.8 percent developed pressure
- 16.4 percent developed deep vein thrombosis
percent developed a pulmonary embolism
- 2.2 percent developed a
postoperative wound infection
Pressure ulcers are the most
frequently observed complications, beginning at 15 percent during the
first year postinjury and steadily increasing thereafter. The most
common pressure ulcer location is the sacrum, the site of one third of
all reported ulcers.
Source: National Spinal Cord Injury
Statistical Center, University of Alabama at Birmingham, Annual
Statistical Report, June 2004
of function depends upon the severity of the initial injury.
Unfortunately, those who sustain a complete SCI are unlikely to regain
function below the level of injury. However, if there is some degree of
improvement, it usually evidences itself within the first few days after
Incomplete injuries usually show some degree of
improvement over time, but this varies with the type of injury. Although
full recovery may be unlikely in most cases, some patients may be able
to improve at least enough to ambulate and to control bowel and bladder
function. Patients with anterior cord syndrome tend to do poorly, but
many of those with Brown-Sequard syndrome can expect to reach these
goals. Patients with central cord syndrome often recover to the point of
being ambulatory and controlling bowel and bladder function, but they
often are not able to perform detailed or intricate work with their
Once a patient is stabilized, care and treatment focuses on
supportive care and rehabilitation. Family members, nurses, or
specially trained aides all may provide supportive care. This care might
include helping the patient bathe, dress, change positions to prevent
bedsores, and other assistance.
Rehabilitation often includes
physical therapy, occupational therapy, and counseling for emotional
support. The services may initially be provided while the patient is
hospitalized. Following hospitalization, some patients are admitted to a
rehabilitation facility. Other patients can continue rehab on an
outpatient basis and/or at home.
associated with SCI is influenced by several factors. Perhaps the most
important of these is the severity of associated injuries. Because of
the force that is required to fracture the spine, it is not uncommon for
a SCI patient to suffer significant damage to the chest and/or abdomen.
Many of these associated injuries can be fatal. In general, younger
patients and those with incomplete injuries have a better prognosis than
older patients and those with complete injuries.
diseases are the leading cause of death in people with SCI, pneumonia
accounting for 71.2 percent of these deaths. The second and third
leading causes of death, respectively, are heart disease and infections.
cumulative 20-year survival rate for SCI patients is 70.65 percent, but
due to underreporting and cases that are lost in follow-up, the
mortality rates may be higher.
Source: National Spinal Cord
Injury Statistical Center, University of Alabama at Birmingham, Annual
Statistical Report, June 2004
recent advances in emergency care and rehabilitation allow many SCI
patients to survive, methods for reducing the extent of injury and for
restoring function are still limited. Currently, there is no cure for
SCI. However, ongoing research to test surgical and drug therapies
continues to make progress. Drug treatments, decompression surgery,
nerve cell transplantation, nerve regeneration, stem cells, and complex
drug therapies are all being examined in clinical trials as ways to
overcome the effects of SCI. However, SCI prevention is crucial to
decreasing the impact of these injuries on individual patients and on
Motor Vehicle Safety Tips
- Always wear a
safety belt and make sure all passengers are wearing safety belts.
that infants, toddlers and young children are properly restrained in an
approved child safety seat that is installed correctly in the back
- Ensure that all children 12 and younger ride in the back
seat, properly restrained.
- Ensure that all children that have
outgrown child safety seats are properly restrained in booster seats
until they are age 8, or over 4'9" tall.
- Obey speed limits and
follow rules of the road at all times.
- Never drive under the
influence of drugs or alcohol or ride as a passenger in a vehicle with a
driver who is under the influence.
Tips to Prevent
Falls in the Home
- Keep the floor clear and free of
debris. Reduce clutter and move telephone and electrical cords out of
- Keep the floor clean, but do not apply floor wax.
Clean up grease, water and other liquids immediately.
non-skid throw rugs to reduce your chance of slipping on linoleum.
handrails in stairways and grab bars in the bathroom (by toilets and in
- Make sure living areas are well lit because it is
easy to trip in the dark.
- Be aware that climbing and reaching
high places will increase your chance of a fall. Use a sturdy step stool
with hand rails when these tasks are necessary.
medication dosages closely. Using medication incorrectly may lead to
dizziness, weakness and other side effects. These can all contribute to
Water and Sports Safety Tips
not dive in water less than 12 feet deep or in above-ground pools.
all rules at water parks and swimming pools.
- Do not
participate in sports when you are ill or very tired.
proper safety gear approved for the specific sport.
uneven or unpaved surfaces when cycling or skateboarding.
players should receive adequate preconditioning and strengthening of
the head and neck muscles.
- Proper football blocking and
tackling techniques must be taught and followed.
- Check sports
fields, playgrounds and equipment regularly for safety.
and replace sporting equipment or protective gear that is damaged.
- Always point the muzzle in a safe direction;
never point a firearm at anyone or anything you don't want to shoot.
your finger off the trigger and outside the trigger guard until you are
ready to shoot.
- Keep the action open and the gun unloaded
until you are ready to use it.
- Keep guns unloaded in a secure
location so that children cannot access them.
- Store bullets in a
separate, secure location so that children cannot access them.
to children that guns are dangerous and that they should never touch
them, either at home or in any other environment, such as at friends’
- Talk with your teenager about ways to solve arguments
without violence or guns.
Apparelyzed: Spinal Cord Injury Peer
Christopher Reeve Paralysis Foundation
Foundation for SCI Prevention, Care
International Center for Spinal Cord
The National SCI Association (NSCIA)
The Travis Roy Foundation