Spinal cord trauma

Causes

Spinal cord trauma can be caused by a number of injuries to the spine, including:

• Assault
• Falls
• Gunshot wounds
• Industrial accidents
• Motor vehicle accidents
• Sports injuries (particularly diving into shallow water)

A minor injury can cause spinal cord injury if the spine is weakened (such as from rheumatoid arthritis or osteoporosis) or if the spinal canal protecting the spinal cord has become too narrow (spinal stenosis) due to the normal aging process.

Direct injury, such as cuts, can occur to the spinal cord, especially if the bones or the disks have been weakened. Fragments of bone (for example, from broken vertebrae, which are the spine bones) or fragments of metal (such as from a traffic accident or gunshot) can cut or damage the spinal cord.

Direct damage can also occur if the spinal cord is pulled, pressed sideways, or compressed. This may occur if the head, neck, or back are twisted abnormally during an accident or intense chiropractic manipulation.

Bleeding, fluid buildup, and swelling can occur inside or outside the spinal cord (but within the spinal canal). The buildup of blood or fluid can press on the spinal cord and damage it.

Most spinal cord trauma happens to young, healthy individuals. Men ages 15 - 35 are most commonly affected. The death rate tends to be higher in young children with spinal injuries.

Risk factors include:

• Participating in risky physical activities
• Not wearing protective gear during work or play
• Diving into shallow water

Older people with weakened spines (from osteoporosis) may be more likely to have a spinal cord injury. Patients who have other medical problems (stroke or prostate cancer, for example) that make them more likely to fall may also be more susceptible.

Symptoms

Exams and Tests

Spinal cord injury is a medical emergency that needs immediate medical attention.

The health care provider will perform a physical exam, including a brain and nervous system (neurological) exam. This will help identify the exact location of the injury, if it is not already known.

Some of the reflexes may be abnormal or missing. Once swelling goes down, some reflexes may slowly recover.

The following tests may be ordered:

• CT scan or MRI of the spine
• Myelogram (an x-ray of the spine after injecting dye)
• Somatosensory evoked potential (SSEP) testing or magnetic stimulation
• Spine x-rays

Treatment

A spinal cord injury is a medical emergency that needs to be treated right away. The time between the injury and treatment can affect the outcome.

Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord pressure is caused by a growth that can be removed or reduced before your spinal nerves are completely destroyed, paralysis may improve. Ideally, corticosteroids should begin as soon as possible after the injury.

Surgery may be needed to:

• Remove fluid or tissue that presses on the spinal cord (decompression laminectomy)
• Remove bone fragments, disk fragments, or foreign objects
• Fuse broken spinal bones or place spinal braces

Bedrest may be needed to allow the bones of the spine to heal.

Spinal traction may be recommended. This can help keep the spine from moving. The skull may be held in place with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body). You may need to wear the spine braces for a long time.

The health care team will also provide information on muscle spasms, care of the skin, and bowel and bladder dysfunction. Your skin will be protected against pressure sores.

You will probably need physical therapy, occupational therapy, and other rehabilitation therapies after the injury has healed. Rehabilitation will help you cope with the disability from your spinal cord injury.

Muscle spasticity can be relieved with medications taken by mouth or injected into the spinal canal. Botox injections into the muscles may also be helpful. Painkillers (analgesics), muscle relaxers, and physical therapy are used to help control pain.

See also:

• Autonomic hyperreflexia
• Bowel retraining
• Neurogenic bladder 
• Pressure ulcer
• Urinary catheter

Support Groups

For organizations that provide support and additional information, see spinal injury resources.

Outlook (Prognosis)

How well a person does depends on the level of injury. Injuries near the top of the spine lead to more disability than injuries low in the spine.

Paralysis and loss of sensation of part of the body are common. This includes total paralysis or numbness, and loss of movement and feeling. Death is possible, especially if there is paralysis of the breathing muscles.

A person who recovers some movement or feeling within 1 week usually has a good chance of recovering more function, although this may take 6 months or more. Losses that remain after 6 months are more likely to be permanent.

Routine bowel care often takes one hour or more each day. Most people with spinal cord injury must perform bladder catheterization regularly.

The home will usually need to be modified.

Most people with a spinal cord injury are in a wheelchair, or need assistive devices to get around.

Possible Complications

The following are possible complications of a spinal cord injury:

• Blood pressure changes - can be extreme (autonomic hyperreflexia)
• Chronic kidney disease
• Complications of immobility:
  • Deep vein thrombosis
  • Lung infections
  • Skin breakdown
  • Muscle contractures
• Increased risk of injury to numb areas of the body
• Increased risk of urinary tract infections
• Loss of bladder control
• Loss of bowel control
• Loss of feeling
• Loss of sexual function (male impotence)
• Muscle spasticity
• Pain
• Paralysis of breathing muscles
• Paralysis (paraplegia, quadriplegia)
• Pressure sores
• Shock

People living at home with spinal cord injury should do the following to prevent complications:

• Get lung (pulmonary) care each day (if they need it).
• Follow all instructions for bladder care to avoid infections and damage to the kidneys.
• Follow all instructions for routine wound care to avoid pressure sores.
• Keep immunizations up to date.
• Maintain routine health visits with their doctor.

When to Contact a Medical Professional

Call your health care provider if you have a back or neck injury. Call 911 if you lose movement or feeling. This is a medical emergency!

Managing a spinal cord injury begins at the site of an accident. Trained paramedics immobilize the injured spine to prevent further nervous system damage.

Someone who may have a spinal cord injury should NOT be moved unless he or she is in immediate danger.

Prevention

Proper safety practices during work and recreation can prevent many spinal cord injuries. Use proper protective equipment for any activity in which an injury is possible.

• Diving into shallow water is a major cause of spinal cord trauma. Check the depth of water before diving, and look for rocks or other possible objects in the way.
• Football and sledding can often involve sharp blows or abnormal twisting and bending of the back or neck, which can cause spinal cord injury. Use caution when sledding and inspect the area for obstacles. Use appropriate techniques and equipment when playing football or other contact sports.
• Falls while climbing at work or during recreation can cause spinal cord injuries. Defensive driving and wearing seat belts greatly reduces the risk of serious injury if there is an automobile accident.

Alternative Names

Spinal cord injury; Compression of spinal cord; SCI; Cord compression

References

Gupta MC, Benson DR, Keenen TL. Initial evaluation and emergency treatment of the spine-injured patient. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 25.

Ling GSF. Traumatic brain injury and spinal cord injury. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 406.

Shih P, Fessler RG. Trauma of the nervous system: spinal cord trauma. In: Daroff RB, Fenichel GM, Jankovic I, Mazziotta JC, eds. Bradley's Neurology in Clinical Practice. 6th ed. Philadelphia, Pa: Saunders Elsevier; 2012:chap 50C.

Edgerton VR, Roy RR. A new age for rehabilitation. Eur J Phys Rehabil Med. 2012;48(1):99-109.

Update Date: 5/14/2012

Updated by: Shabir Bhimji, MD, PhD, Specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.