Spinal cord injury

If you've recently experienced a spinal
cord injury, it might seem like every aspect of your life will be
affected by this injury. A spinal cord injury often causes permanent
disability or loss of movement (paralysis) and sensation below the site
of the injury.

Many scientists are optimistic that advances in research will someday
make the repair of spinal cord injuries an attainable goal. In the
meantime, treatments and rehabilitation allow many people with a spinal
cord injury to lead productive, independent lives.


Symptoms

Your ability to control your limbs after spinal cord injury depends on
two factors: the neurological level of the injury and the completeness
of injury. The lowest normally functioning segment of your spinal cord
is referred to as the neurological level of your injury. The
completeness of the injury is classified as either:

* Complete. If all sensory (feeling) and motor function (ability to
control movement) is lost below the neurological level, your injury is
called complete.
* Incomplete. If you have some motor or sensory function below the affected area, your injury is called incomplete.

Additionally, paralysis from a spinal cord injury may be referred to as:

* Tetraplegia or quadriplegia. This means your arms, trunk, legs and
pelvic organs are all affected by your spinal cord injury.
* Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.

Your health care team will perform a series of tests to determine the neurological level and completeness of your injury.

Spinal cord injuries of any kind may result in one or more of the following signs and symptoms:

* Loss of movement
* Loss of sensation, including the ability to feel heat, cold and touch
* Loss of bowel or bladder control
* Exaggerated reflex activities or spasms
* Changes in sexual function, sexual sensitivity and fertility
* Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
* Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms
Emergency signs and symptoms of spinal cord injury after an accident may include:

* Extreme back pain or pressure in your neck, head or back
* Weakness, incoordination or paralysis in any part of your body
* Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
* Loss of bladder or bowel control
* Difficulty with balance and walking
* Impaired breathing after injury
* An oddly positioned or twisted neck or back

When to see a doctor
A spinal cord injury isn't always obvious. Numbness or paralysis may
result immediately after a spinal cord injury or gradually as bleeding
or swelling occurs in or around the spinal cord. In either case, the
time between injury and treatment can be a critical factor that can
determine the extent of complications and the amount of recovery.

Anyone who has experienced significant trauma to the head or neck needs
immediate medical evaluation for the possibility of a spinal cord
injury. In fact, it's safest to assume that trauma victims have a spinal
cord injury until proved otherwise.

If you suspect that someone has a back or neck injury, don't move the
injured person. Permanent paralysis and other serious complications may
result. Instead, take these steps:

* Call 911 or your local emergency medical assistance number.
* Keep the person still.
* Place heavy towels on both sides of the neck or hold the head and
neck to prevent them from moving, until emergency care arrives.
* Provide basic first aid, such as stopping any bleeding and making the person comfortable, without moving the head or neck.


Causes

Your brain and central nervous system
The central nervous system consists of the brain and spinal cord. The
spinal cord extends downward from the base of your brain and is made up
of nerve cells and groups of nerves called tracts, which go to different
parts of your body. The lower end of your spinal cord stops a little
above your waist in the region called the conus medullaris. Below this
region is a group of nerve roots called the cauda equina. Tracts in your
spinal cord carry messages between the brain and the rest of the body.
Motor tracts carry signals from the brain to control muscle movement.
Sensory tracts carry signals from body parts to the brain relating to
heat, cold, pressure, pain and the position of your limbs.

Injury may be traumatic or nontraumatic
A traumatic spinal cord injury may stem from a sudden, traumatic blow to
your spine that fractures, dislocates, crushes or compresses one or
more of your vertebrae. It may also result from a gunshot or knife wound
that penetrates and cuts your spinal cord. Additional damage usually
occurs over days or weeks because of bleeding, swelling, inflammation
and fluid accumulation in and around your spinal cord.

A nontraumatic spinal cord injury may be caused by arthritis, cancer,
inflammation or infections, or disk degeneration of the spine.

Damage to nerve fibers
Whether the cause is traumatic or nontraumatic, the damage affects the
nerve fibers passing through the injured area and may impair part or all
of your corresponding muscles and nerves below the injury site. A chest
(thoracic) or lower back (lumbar) injury can affect your chest,
abdomen, legs, bowel and bladder control, and sexual function. In
addition, a neck (cervical) injury affects movements of your arms and,
possibly, your ability to breathe.

Common causes of spinal cord injury
The most common causes of spinal cord injuries in the United States are:

* Motor vehicle accidents. Auto and motorcycle accidents are the
leading cause of spinal cord injuries, accounting for more than 40
percent of new spinal cord injuries each year.
* Acts of violence. As many as 15 percent of spinal cord injuries
result from violent encounters, often involving gunshot and knife
wounds, according to the National Institute of Neurological Disorders
and Stroke.
* Falls. Spinal cord injury after age 65 is most often caused by a
fall. Overall, falls cause about one-quarter of spinal cord injuries.
* Sports and recreation injuries. Athletic activities, such as
impact sports and diving in shallow water, cause about 8 percent of
spinal cord injuries.
* Alcohol. Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
* Diseases. Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Risk factors

Although a spinal cord injury is usually the result of an unexpected
accident that can happen to anyone, certain factors may predispose you
to a higher risk of sustaining a spinal cord injuring, including:

* Being a man. Spinal cord injuries affect a disproportionate amount
of men. In fact, women account for only about 20 percent of spinal cord
injuries in the United States.
* Being between the ages of 16 to 30. You're most likely to suffer a
spinal cord injury if you're between the ages 16 and 30. Motor vehicle
crashes are the leading cause of spinal cord injuries for people under
65, while falls cause most injuries in older adults.
* Being active in certain sports. While being active is one of the
best things you can do for your overall health, it may place you at
greater risk of a spinal cord injury. Athletic activities that may
increase your risk of a spinal cord injury include football, rugby,
wrestling, gymnastics, horseback riding, diving, surfing,
roller-skating, in-line skating, ice hockey, downhill skiing and
snowboarding.
* Having an underlying bone or joint disorder. A relatively minor
injury can cause a spinal cord injury if you have another disorder that
affects your bones or joints, such as arthritis or osteoporosis.


Complications

At first, changes in the way your body functions may be overwhelming.
However, you can learn new skills and ways to adapt old skills to deal
with the physical effects of a spinal cord injury. Possible difficulties
you may encounter include:

* Bladder control. Your bladder will continue to store urine from
your kidneys. However, your brain may no longer be able to control
bladder emptying, as the message carrier (the spinal cord) has been
injured. The loss of bladder control increases your risk of urinary
tract infections. It may also cause kidney infection and kidney or
bladder stones. Drinking plenty of clear fluids may help. And during
rehabilitation, you'll learn new techniques to empty your bladder.
* Bowel control. Although your stomach and intestines work much like
they did before your injury, your brain may no longer be able to
control the muscles that open and close your anus. This may cause fecal
incontinence. A high-fiber diet may help regulate your bowels, and
you'll learn techniques to better control your bowels during
rehabilitation.
* Impaired skin sensation. Below the neurological level of your
injury, you may have lost part or all skin sensations. Therefore, your
skin can't send a message to your brain when it's injured by things such
as prolonged pressure, heat or cold. This can make you more susceptible
to pressure sores, but changing positions frequently — with help, if
needed — can help prevent these sores. And, you'll learn proper skin
care during rehabilitation, which can help you avoid these problems.
* Circulatory control. A spinal cord injury may cause circulatory
problems ranging from spinal shock immediately following your spinal
cord injury to low blood pressure when you rise (orthostatic
hypotension) to swelling of your extremities throughout your lifetime.
These circulation changes may increase your risk of developing blood
clots, such as deep vein thrombosis or a pulmonary embolus. Another
problem with circulatory control is a potentially life-threatening rise
in blood pressure (autonomic hyperreflexia). Your rehabilitation team
will teach you how to prevent autonomic hyperreflexia.
* 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. Your neurological level of injury will determine what kind of
breathing problems you may have. If you have cervical and thoracic
spinal cord injury you may have an increased risk of pneumonia or other
lung problems. Medications and therapy can treat these problems.
* Muscle tone. Some people with spinal cord injuries may experience
one of two types of muscle tone problems: spastic muscles or flaccid
muscles. Spasticity can cause uncontrolled tightening or motion in the
muscles. Flaccid muscles are soft and limp, lacking muscle tone.
* Fitness and wellness. Weight loss and muscle atrophy are common
soon after a spinal cord injury. However, limited mobility after spinal
cord injury may lead to a more sedentary lifestyle, placing you at risk
of obesity, cardiovascular disease and diabetes. A dietitian can assist
you in attaining a nutritious diet to sustain an adequate weight.
Physical and occupational therapists can help you develop a fitness and
exercise program.
*

Sexual health. Sexuality, fertility and sexual function may be
affected by spinal cord injury. Men may notice changes in erection and
ejaculation; women may notice changes in lubrication. A spinal cord
injury may cause decreased or absent sensation and movement below the
level of injury, but a person may notice a heightened sensitivity in
areas above the level of injury. Doctors, urologists and fertility
specialists who specialize in spinal cord injury can offer options for
sexual functioning and fertility.

There's usually no physical change in women with a spinal cord
injury that inhibits sexual intercourse or pregnancy. Most women with a
spinal cord injury can experience labor, have a normal delivery and
breast-feed.
* Pain. Some people may experience pain, such as muscle or joint
pain from overuse of particular muscle groups. Nerve pain, also known as
neuropathic or central pain, can occur after a spinal cord injury,
especially in someone with an incomplete injury.


Preparing for your appointment

Traumatic spinal cord injuries are emergencies. After your condition is
stabilized, you'll be seeing numerous specialists, such as a doctor who
specializes in nervous system disorders (neurologist), a surgeon who
specializes in spinal cord injuries and other nervous system problems
(neurosurgeon), and a surgeon who specializes in bone procedures
(orthopaedic surgeon). Soon after, you'll also be introduced to your
rehabilitation team, led by a doctor who specializes in spinal cord
injury.

Here's some information that may help prepare you to speak with some of those doctors.

What you can do

* Keep track of any symptoms you're experiencing, including any that
may seem unrelated. If you're unable to write them down yourself, ask a
family member or friend to do this for you.
* Ask a family member or friend to join you when you're speaking
with your doctors, if possible. Sometimes it can be difficult to
remember all of the information provided to you. Someone who accompanies
you may remember something that you missed or forgot.
* Write down questions to ask your doctor, or have someone write them down for you.

For a spinal cord injury, some basic questions to ask your doctor include:

* What kinds of tests do I need? What information will these tests provide?
* What's my prognosis?
* What can I expect to happen short term? What can I expect in the long term regarding my condition?
* What treatments are available, and which do you recommend?
* What types of side effects can I expect from treatment?
* Could surgery help me?
* What type of rehabilitation might help me?
* Are there any alternatives to the primary approach that you're suggesting?
* Will I be able to work again?
* Can I still have sex?
* Will I be able to have children?
* Can I lead a productive life?
* What research is being done to help my condition?
* Are there any brochures or other printed material you can give me to read? Are there any Web sites that you recommend?

In addition to the questions that you've prepared to ask your doctor,
don't hesitate to ask questions during your time with your doctors if
you don't understand something.

Tests and diagnosis

In the emergency room, a doctor may be able to rule out a spinal cord
injury by careful inspection, testing for sensory function and movement,
and asking some questions about the accident. But if the injured person
complains of neck pain, isn't fully awake, or has obvious signs of
weakness or neurological injury, emergency diagnostic tests may be
needed.

These tests may include:

* X-rays. Medical personnel typically order these tests on all
people who are suspected of having a spinal cord injury after trauma.
X-rays can reveal vertebral (spinal column) problems, tumors, fractures
or degenerative changes in the spine.
* Computerized tomography (CT) scan. A CT scan may provide a better
look at abnormalities seen on an X-ray. This scan uses computers to form
a series of cross-sectional images that can define bone, disk and other
problems.
* Magnetic resonance imaging (MRI). MRI uses a strong magnetic field
and radio waves to produce computer-generated images. This test is
extremely helpful for looking at the spinal cord and identifying
herniated disks, blood clots or other masses that may be compressing the
spinal cord.
* Myelography. Myelography allows your doctor to visualize your
spinal nerves more clearly. After a special dye is injected into your
spinal canal, X-rays or CT scans of your vertebrae can suggest a
herniated disk or other lesions. This test is used when MRI isn't
possible or when it may yield important additional information that
isn't provided by other tests.

If your doctor suspects a spinal cord injury, he or she may prescribe traction to immobilize your spine.

A few days after injury, when some of the swelling may have subsided,
your doctor will conduct a neurological exam to determine the level and
completeness of your injury. This involves testing your muscle strength
and your ability to sense light touch and a pinprick.

Treatments and drugs

Unfortunately, there's no way to reverse damage to the spinal cord. But,
researchers are continually working on new treatments, including
innovative treatments, prostheses and medications that may promote nerve
cell regeneration or improve the function of the nerves that remain
after a spinal cord injury.

In the meantime, spinal cord injury treatment focuses on preventing
further injury and empowering people with a spinal cord injury to return
to an active and productive life.

Emergency actions
Urgent medical attention is critical to minimizing the effects of any
head or neck trauma. So treatment for a spinal cord injury often begins
at the scene of the accident.

Emergency personnel typically immobilize the spine as gently and quickly
as possible using a rigid neck collar and a rigid carrying board, which
they'll use to transport you to the hospital.

Early (acute) stages of treatment
In the emergency room, doctors focus on:

* Maintaining your ability to breathe
* Preventing shock
* Immobilizing your neck to prevent further spinal cord damage
* Avoiding possible complications, such as stool or urine retention,
respiratory or cardiovascular difficulty, and formation of deep vein
blood clots in the extremities

You may be sedated so that you don't move and sustain more damage while undergoing diagnostic tests for spinal cord injury.

If you do have a spinal cord injury, you'll usually be admitted to the
intensive care unit for treatment. You may even be transferred to a
regional spine injury center that has a team of neurosurgeons,
orthopedic surgeons, spinal cord medicine specialists, psychologists,
nurses, therapists and social workers with expertise in spinal cord
injury.

* Medications. Methylprednisolone (Medrol) is a treatment option for
an acute spinal cord injury. If methylprednisolone is given within
eight hours of injury, some people experience mild improvement from
their spinal cord injury. It appears to work by reducing damage to nerve
cells and decreasing inflammation near the site of injury. However,
this is not a cure for a spinal cord injury.
* Immobilization. You may need traction to stabilize your spine, to
bring the spine into proper alignment or both. Sometimes, traction is
accomplished by securing metal braces, attached to weights or a body
harness, to your skull to keep your head from moving. In some cases, a
rigid neck collar also may work. A special bed also may help immobilize
your body.
* Surgery. Often, surgery is necessary to remove fragments of bones,
foreign objects, herniated disks or fractured vertebrae that appear to
be compressing the spine. Surgery may also be needed to stabilize the
spine to prevent future pain or deformity.
* Experimental treatments. Scientists are trying to figure out ways
to stop cell death, control inflammation and promote nerve regeneration.
Ask your doctor about the availability of such treatments.

Ongoing care
After the initial injury or disease stabilizes, doctors turn their
attention to preventing secondary problems that may arise, such as
deconditioning, muscle contractures, pressure ulcers, bowel and bladder
issues, respiratory infections and blood clots.

The length of your hospitalization depends on your individual condition
and what medical issues you're facing. Once you're well enough to
participate in therapies and treatment, you may transfer to a
rehabilitation facility.

Rehabilitation. Rehabilitation team members may begin to work with you
while you're in the early stages of recovery. Your team may include a
physical therapist, occupational therapist, rehabilitation nurse,
rehabilitation psychologist, social worker, dietitian, recreation
therapist and a doctor who specializes in physical medicine
(physiatrist) or spinal cord injuries.

During the initial stages of rehabilitation, therapists usually
emphasize maintenance and strengthening of existing muscle function,
redeveloping fine motor skills and learning adaptive techniques to
accomplish day-to-day tasks. You'll be educated on the effects of a
spinal cord injury and how to prevent complications, as well as be given
advice on rebuilding your life and increasing your quality of life.
You'll be taught many new skills, and will use equipment and technology
that can help you live on your own as much as possible. You'll be
encouraged to resume your favorite hobbies, participate in social and
fitness activities, and return to school or the workplace.

Medications. Medications may be used to manage some of the effects of
spinal cord injury. These include medications to control pain and muscle
spasticity, as well as medications that can improve bladder control,
bowel control and sexual functioning.

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

* Modern wheelchairs. Improved, lighter weight wheelchairs are
making people with a spinal cord injury 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 that has limited hand function,
computers can be very powerful tools, but they're difficult to operate.
Some examples of 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
(EADL). Devices can be turned on or off by 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 (FES) systems, and they use electrical
stimulators to control arm and leg muscles to allow people with a
spinal cord injury to stand, walk, reach and grip.

Prognosis and recovery
It's often impossible for your doctor to make a precise prognosis right
away. Recovery, if it occurs, typically starts between a week and six
months after an injury. However, some people experience small
improvements for up to one year or longer.


Coping and support

An accident that results in paralysis is a life-changing event. The
sudden presence of disability can be frightening and confusing. After
all, adapting to life with a disability — often in a wheelchair — is no
easy task. You may wonder how your spinal cord injury will affect your
everyday activities, job, relationships and long-term happiness.

Recovery from such an event takes time, but many people who are
paralyzed move on to lead productive and fulfilling lives. It's
essential to stay motivated and get the support you need.

Grieving
If you're newly injured, you and your family will likely experience a
period of mourning and grief. Although the grieving process is different
for everyone, it's common to experience denial or disbelief, followed
by sadness, anger, bargaining and, finally, acceptance.

The grieving process is a common, healthy part of your recovery. It's
natural — and important — to grieve the loss of the way you were. But
it's also necessary to set new goals and find a way to move forward with
your life.

You'll likely experience many thoughts and emotions. And you'll probably
have concerns about how your injury will affect your lifestyle, your
financial situation and your personal relationships. Grieving and
emotional stress are normal and common. However, if your grief and
sadness are affecting your personal care, causing you to isolate
yourself from others, or prompting you to abuse alcohol or other drugs,
you may want to consider talking to a social worker, psychologist or
psychiatrist. Or, you might find a support group made up of people with
spinal cord injuries to be helpful. Talking with others who truly
understand what you're going through can be very encouraging, and
members of the group may also have good advice on adapting areas of your
home or workspace to better accommodate your current needs. Ask your
doctor or rehabilitation specialist if there are any support groups in
your area.

Taking control
One of the best ways to regain control of your life is to educate
yourself about your injury and your options for reclaiming an
independent life. A wide range of driving equipment and vehicle
modifications is available today. The same is true of home modification
products. Ramps, wider doors, special sinks, grab bars and easy-to-turn
doorknobs make it possible for you to live more autonomously.

Because the costs of a spinal cord injury can be overwhelming, you may
want to find out if you're eligible for economic assistance or support
services from the state or federal government or from charitable
organizations. Your rehabilitation team can help you identify resources
in your area.

Talking about your disability
Your friends and family may respond to your disability in different
ways. Some may be unfazed by your injury. Others may be uncomfortable
and unsure if they're saying or doing the right thing.

Being educated about your spinal cord injury and willing to educate
others is helpful. Children are naturally curious and sometimes adjust
rather quickly if their questions are answered in a clear,
straightforward way. Adults can also benefit from learning the facts.
Explain the effects of your injury and what your family and friends can
do to help. At the same time, don't hesitate to tell friends and loved
ones when they're helping too much. Although it may be uncomfortable at
first, talking about your injury often strengthens your relationships
with family and friends.

Dealing with intimacy, sexuality and sexual activity
Your spinal cord injury may affect your body's response to sexual
stimuli. However, you're a sexual being with sexual desires. A
fulfilling emotional and physical relationship is possible, but requires
communication, experimentation and patience. A professional counselor
can help you and your partner communicate your needs and feelings. Your
health care provider can provide the medical information you need
regarding sexual health. You can have a very satisfying future complete
with intimacy and sexual pleasure.

Looking ahead
By nature, a spinal cord injury has a sudden impact on your life and the
lives of those closest to you. When you first hear your diagnosis, you
may start making a mental list of all of the things you can't do
anymore. However, as you learn more about your injury and your treatment
options, you may be surprised at all of the things you can do.

Thanks to new technologies, treatments and devices, people with a spinal
cord injury play basketball and participate in track meets. They paint
and take photographs. They get married, have and raise children, and
have rewarding jobs.

Today, advances in stem cell research and nerve cell regeneration give
hope for a greater recovery for people with spinal cord injuries. At the
same time, new medications are being investigated for people with
long-standing spinal cord injuries. No one knows exactly when new
treatments will become available, but you can remain hopeful about the
future of spinal cord research, while living your life to the fullest
today.


Prevention

Following this advice may reduce your risk of a spinal cord injury:

* 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 air bag
injuries, children under age 12 should always ride in the back seat.
Don't drive while intoxicated or under the influence of drugs.
* Be safe with firearms. Lock up firearms and ammunition in a safe
place to prevent accidental discharge of weapons. Store guns and
ammunition separately.
* Prevent falls. Use a stool or stepladder 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. Check water depth before diving to make sure you don't dive
into shallow water. 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.