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Spinal Cord Injury


The spinal cord is a bundle of nerves that carries messages between the brain and the rest of the body.

Acute spinal cord injury (SCI) is due to a traumatic injury that can either result in a bruise (also called a contusion), a partial tear, or a complete tear (called a transection) in the spinal cord.

SCI results in a decreased or absence of movement, sensation, and body organ function below the level of the injury. The most common sites of injury are the cervical and thoracic areas. SCI is a common cause of permanent disability and death in children and adults.

Anatomy of the spine:

The spine consists of 33 vertebrae, including the following:
  • 7 cervical (neck)
  • 12 thoracic (upper back)
  • 5 lumbar (lower back)
  • 5 sacral* (sacrum - located within the pelvis)
  • 4 coccygeal* (coccyx - located within the pelvis)

* By adulthood, the five sacral vertebrae fuse to form one bone, and the four coccygeal vertebrae fuse to form one bone.)

These vertebrae function to stabilize the spine and protect the spinal cord. In general, the higher in the spinal column the injury occurs, the more dysfunction a person will have.

Injury to the vertebrae does not always mean the spinal cord has been damaged. Likewise, damage to the spinal cord itself can occur without fractures or dislocations of the vertebrae.

What are the types of SCI?



SCI can be divided into two main types of injury:
  • Complete injury
    Complete injury means that there is no function below the level of the injury ? either sensation and movement ? and both sides of the body are equally affected. Complete injuries can occur at any level of the spinal cord.
  • Incomplete injury
    Incomplete injury means that there is some function below the level of the injury ? movement in one limb more than the other, feeling in parts of the body, or more function on one side of the body than the other. Incomplete injuries can occur at any level of the spinal cord.

Statistics

  • SCI occurs mainly in young adults, ages 16 to 30.
  • Eighty-two percent of SCI patients are male.
  • There are about 8,000 new cases of SCI per year in the US.
  • Current estimates indicate between 250,000 and 400,000 people in the US are living with a spinal cord injury or spinal dysfunction.

Causes



Causes of SCI include:
  • Motor vehicle accidents - 44 percent
  • Violence - 24 percent
  • Falls - 22 percent
  • Sports - eight percent (the majority of which occurs during diving accidents)
  • Other - two percent

Nearly 10 percent of new SCI in the US occur in children ages one to 15.

Source: National Spinal Cord Injury Association

Symptoms

Symptoms vary depending on the severity and location of the SCI. At first, the patient may experience spinal shock, which causes loss of feeling, muscle movement, and reflexes below the level of injury. Spinal shock usually lasts from several hours to several weeks. As the period of shock subsides, other symptoms appear, depending on the location of the injury.

Generally, the higher up the level of the injury to the spinal cord, the more severe the symptoms. For example, an injury at C2 or C3 (the second and third vertebrae in the spinal column), affects the respiratory muscles and the ability to breathe. A lower injury, in the lumbar vertebrae, may affect nerve and muscle control to the bladder, bowel, and legs.

SCI is classified according to the person's type of loss of motor and sensory function. The following are the main types of classifications:
  • Quadriplegia (quad means four) ? involves loss of movement and sensation in all four limbs (arms and legs). It usually occurs as a result of injury at T1 or above. Quadriplegia also affects the chest muscles and injuries at C4 or above require a mechanical breathing machine (ventilator).
  • Paraplegia (para means two like parts) ? involves loss of movement and sensation in the lower half of the body (right and left legs). It usually occurs as a result of injuries at T1 or below.
  • Triplegia (tri means three) ? involves the loss of movement and sensation in one arm and both legs and usually results from incomplete SCI.

The following are the most common symptoms of acute spinal cord injuries. However, each individual may experience symptoms differently. Symptoms may include:
  • Muscle weakness or paralysis in the trunk, arms or legs
  • Loss of feeling in the trunk, arms, or legs
  • Muscle spasticity
  • Breathing problems
  • Problems with heart rate and blood pressure
  • Digestive problems
  • Loss of bowel and bladder function
  • Sexual dysfunction

The symptoms of SCI may resemble other medical conditions or problems. Always consult your physician for a diagnosis.

Diagnosis

The full extent of the SCI may not be completely understood immediately after the injury, but may be revealed with a comprehensive medical evaluation and diagnostic testing. The diagnosis of SCI is made with a physical examination and diagnostic tests. During the examination, the physician obtains a complete medical history and inquires as to how the injury occurred. Trauma to the spinal cord can cause neurological problems and requires further medical follow-up.

Diagnostic tests may include:
  • Blood tests
  • X-ray ? a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
  • Computed tomography scan (also called a CT or CAT scan) ? a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
  • Magnetic resonance imaging (MRI) ? a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

Treatment


Specific treatment for an acute spinal cord injury will be determined by your physician based on:
  • Your age, overall health, and medical history
  • Extent of the SCI
  • Type of SCI
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the SCI
  • Your opinion or preference

SCI requires emergency medical attention on the scene of the accident or injury. This is accomplished by immobilizing the head and neck areas to prevent the patient from moving. This may be very difficult since the victim and/or bystanders may be very frightened after the traumatic incident.

There is currently no way to repair a damaged or bruised spinal cord, though researchers are actively seeking means of stimulating spinal cord regeneration. The severity of the SCI and the location determines if the SCI is mild, severe, or fatal.

Surgery is sometimes necessary to evaluate the injured cord, stabilize fractured back bones, decompress (or release) the pressure from the injured area, and to manage any other injuries that may have been a result of the accident. Treatment is individualized, depending on the extent of the condition and the presence of other injuries.

Treatments may include:
  • Observation and medical management in the intensive care unit (ICU)
  • Medications, such as corticosteroids (to help decrease the swelling in the spinal cord)
  • Mechanical ventilator, a breathing machine (to help the patient breathe)
  • Foley catheter ? a tube that is placed into the bladder that helps to drain the urine into a collection bag.
  • Feeding tube (placed through the nostril to the stomach, or directly through the abdomen into the stomach, to provide extra nutrition and calories)

Recovery from a SCI requires long-term hospitalization and rehabilitation. An interdisciplinary team of physicians, nurses, therapists (physical, occupational, or speech), and other specialists work to medically manage the patient to control pain, to monitor the
  • Heart function
  • Blood pressure
  • Body temperature
  • Nutritional status
  • Bladder and bowel function and
  • Spasticity (attempt to control involuntary muscle shaking)

Rehabilitation focuses on preventing muscle wasting and contractures, and works to retrain the patient to use other muscles to aid in mobility and movement.

Life-long considerations for a person with a SCI


A traumatic event that results in a SCI is devastating to the person and the family. The healthcare team educates the family after hospitalization and rehabilitation on how to best care for the person at home and outlines specific clinical problems that require immediate medical attention by the patient's physician.

The disabled person requires a focus on maximizing his/her capabilities at home and in the community. Positive reinforcement will encourage him/her to strengthen his/her self-esteem and promote independence.

A person with a SCI requires frequent medical evaluations and diagnostic testing following hospitalization and rehabilitation to monitor his/her progress.

Rehabilitation potential with SCI


The following chart is a comparison of the specific level of SCI and the resulting rehabilitation potential. This chart is a guide, with general information only; impairments and rehabilitation potential can vary depending on the type and severity of SCI. Always consult your physician for more specific information based on your individual medical condition and injury.

Level of injury Possible impairment Rehabilitation potential
C2 - C3 Usually fatal as a result of inability to breathe Totally dependent for all cares
C4 Quadriplegia and breathing difficulty Dependent for all cares; usually needs a ventilator
C-5 Quadriplegia with some shoulder and elbow function May be able to feed self using assistive devices; usually can breathe without a ventilator, but may need other types of respiratory support
C6 Quadriplegia with shoulder, elbow, and some wrist function May be able to propel a wheelchair inside on smooth surfaces; may be able to help feed, groom, and dress self; dependent on others for transfers
C7 Quadriplegia with shoulder, elbow, wrist, and some hand function May be able to propel a wheelchair outside, transfer self, and drive a car with special adaptions; may be able to help with bowel and bladder programs
C8 Quadriplegia with normal arm function; hand weakness May be able to propel a wheelchair outside, transfer self, and drive a car with special adaptions; may be able to help with bowel and bladder programs
T1 - T6 Paraplegia with loss of function below mid-chest; full control of arms Independent with self care and in wheelchair; able to be employed full time
T6 - T12 Paraplegia with loss of function below the waist; good control of torso Good sitting balance; greater ability for operation of a wheelchair and athletic activities
L1 - L5 Paraplegia with varying degrees of muscle involvement in the legs May be able to walk short distances with braces and assistive devices


Spinal cord injury rehabilitation

Rehabilitation of the patient with a SCI begins during the acute treatment phase. As the patient's condition improves, a more extensive rehabilitation program is often begun.

The success of rehabilitation depends on many variables, including the following:
  • Level and severity of the SCI
  • Type and degree of resulting impairments and disabilities
  • Overall health of the patient
  • Family support

It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence.

The goal of SCI rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially.

Areas covered in spinal cord injury rehabilitation programs may include:
Patient need: Example:
Self-care skills, including activities of daily living (ADLs) Feeding, grooming, bathing, dressing, toileting, and sexual functioning
Physical care Support of heart and lung function, nutritional needs, and skin care
Mobility skills Walking, transfers, and self-propelling a wheelchair
Respiratory care Ventilator care, if needed; breathing treatments and exercises to promote lung function
Communication skills Speech, writing, and alternative methods of communication
Socialization skills Interacting with others at home and within the community
Vocational training Work-related skills
Pain and muscle spasticity (increased muscle tone) management Medications and alternative methods of managing pain and spasticity
Psychological counseling Identifying problems and solutions for thinking, behavioral, and emotional issues
Family support Assistance with adapting to lifestyle changes, financial concerns, and discharge planning
Education Patient and family education and training about SCI, home care needs, and adaptive techniques


The spinal cord injury rehabilitation team:


The spinal cord injury rehabilitation team revolves around the patient and family and helps set short-and long-term treatment goals for recovery. Many skilled professionals are part of the spinal cord injury rehabilitation team, including any/all of the following:
  • Neurologist/neurosurgeon
  • Orthopedist/orthopedic surgeon
  • Physiatrist
  • Internists
  • Rehabilitation nurse
  • Social worker
  • Physical therapist
  • Occupational therapist
  • Speech/language pathologist
  • Psychologist/psychiatrist
  • Recreation therapist
  • Dietitian
  • Vocational counselor
  • Orthotist
  • Case manager
  • Respiratory therapist
  • Chaplain

Types of spinal cord injury rehabilitation programs:


There are a variety of spinal cord injury treatment programs, including the following:
  • Acute rehabilitation programs
  • Subacute rehabilitation programs
  • Long-term rehabilitation programs
  • Transitional living programs
  • Day-treatment programs
  • Vocational rehabilitation programs


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