Spinal Cord Injury
Thoracolumbar Spinal Injuries
Presentation
Symptomatology involved in spinal cord injury greatly depends on the level of injury. Usually there is a loss of sensation and weakness below the level of the injury. Severity of symptoms may also depend on the completeness or incompleteness of the spinal cord injury. In general, spinal cord injuries occurring at any level may presents with symptoms of spasticity, incontinence, sensory changes, pain and paralysis.
Injuries at the level of the neck may affect the arms, the legs and the middle body. Symptoms may present unilaterally or bilaterally. Injuries at the chest level can affect the legs. The co-involvement of the upper thoracic vertebrae and cervical vertebrae can cause erratic blood pressure problems, abnormal sweating, and trouble maintaining normal body temperature. Injuries sustained at the lower back or lumbar level will affect both legs and the muscles that control the bowel and the bladder.
Entire Body System
Impaired Balance
- A spinal cord injury (SCI) frequently results in impaired balance, endurance, and strength with subsequent limitations in functional mobility and community participation.[ncbi.nlm.nih.gov]
Increased Energy
- Other benefits may include increasing energy expenditure and improving the profile of body composition.[ncbi.nlm.nih.gov]
Gastrointestinal
Fecal Incontinence
- The lack of function results in fecal incontinence, chronic constipation, or both. Bowel training (during rehab) can help regulate bowel movements but often a care provider is needed to complete the bowel maintenance process.[unitedspinal.org]
- The most important factors are the spasm, decubitus nature, insufficient motivation, deformity, urinary and fecal incontinence.[boneandspine.com]
Cardiovascular
Hypertension
- OBJECTIVES: To quantify diurnal blood pressure (BP) patterns and nocturnal hypertension and to measure diurnal urine production in people with chronic spinal cord injury (SCI), compared with controls without SCI.[ncbi.nlm.nih.gov]
- These discoveries are now being translated into the clinical realm and have led to targeted upfront medical management with a focus on tissue oxygenation and perfusion and include avoidance of hypotension, induction of hypertension, early transfer to[ncbi.nlm.nih.gov]
- Given the intervention carries risk, induced hypertension requires careful consideration on a case-by-case basis. Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved.[ncbi.nlm.nih.gov]
- Headache may be due to intracranial arterial dilatation, which occurs as part of the effort by the parasympathetic system to adjust for the hypertension.[emedicine.com]
Musculoskeletal
Proximal Muscle Weakness
- The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness.[emedicine.medscape.com]
Muscle Spasticity
- Some people with spinal cord injuries experience one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity). Fitness and wellness.[mayoclinic.org]
- The most common symptoms of acute spinal cord injury 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[massgeneral.org]
- Reflexes may become exaggerated over time, causing muscle spasticity. Muscles may waste away or diminish due to underuse. If spasms become severe enough, they may require medical treatment.[web.archive.org]
Joint Dislocation
- Causes of spinal cord compression Trauma (including car accidents, falls and sports injuries): There is usually either vertebral fracture (most common in cervical vertebrae) or facet joint dislocation.[patient.info]
Skeletal Dysplasia
- Spinal cord injury is a rare complication after lower extremity surgery in children with skeletal dysplasia and thoracic kyphosis.[ncbi.nlm.nih.gov]
Neurologic
Quadriplegia
- MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO were searched from inception to May 2009 for population keywords (spinal cord injury, paraplegia, tetraplegia, quadriplegia) paired with secretion removal-related interventions and outcomes.[ncbi.nlm.nih.gov]
- Data Sources and Study Selection: MEDLINE/PubMed, CINAHL, EMBASE, and PsyclNFO were searched from inception to May 2009 for population keywords (spinal cord injury, paraplegia, tetraplegia, quadriplegia) paired with secretion removal-related interventions[doi.org]
- Two forms of injury are: Quadriplegia – This is the loss of function in both arms and legs. Quadriplegia typically results from cervical spinal cord injury. High tetraplegia involves injury to the C1-C4 region.[jebailylaw.com]
- There is tetraplegia (called quadriplegia or quadraplegia in USA), paraplegia and there are complete or incomplete lesions too.[spinal-injury.net]
- Cervical spinal cord injuries usually cause loss of function in the arms and legs, resulting in quadriplegia. The 12 vertebra in the chest are called the thoracic vertebra.[shepherd.org]
Myelopathy
- We reported a patient with C5 [S(C5/C6)] ASIA Impairment Scale C SCI due to cervical myelopathy who presented CO2 retention when taking a therapeutic dosage of pregabalin.[ncbi.nlm.nih.gov]
- To date, no traumatic myelopathy has ever been described in patients with HCU. This case report describes a 30-year-old male patient with HCU who was not aware that he was at high risk of sustaining debilitating bone fractures.[ncbi.nlm.nih.gov]
- Subacute posttraumatic ascending myelopathy (SPAM) is a rare event that occurs after spinal cord trauma or ischemia.[ncbi.nlm.nih.gov]
- […] for the Management of Degenerative Cervical Myelopathy and Traumatic Spinal Cord Injury .[spineuniverse.com]
- […] for the Management of Degenerative Cervical Myelopathy and Traumatic Spinal Cord Injury.[spineuniverse.com]
Hyperreflexia
- Spasticity is characterized as hyperreflexia and hypertonicity as a result of damage to the supraspinal tracts in the aftermath of SCI. Intrathecal baclofen (ITB) is the mainstay therapy for spasticity unresponsive to oral baclofen.[ncbi.nlm.nih.gov]
- BACKGROUND: Tibialis Anterior (TA) cutaneous reflex (CR) activity evoked following cutaneous stimulation of the plantar (Pl) surface (Pl-TA CR) has demonstrated hyperreflexia and damage of inhibitory mechanisms in subjects with spinal cord injury (SCI[ncbi.nlm.nih.gov]
- Autonomic hyperreflexia Autonomic hyperreflexia (AH), or autonomic dysreflexia, is an acute, potentially lethal complication particular to patients with spinal injuries above T7.[emedicine.com]
- Complications The following medical disorders are common complications seen in spinal cord injury patients: Blood pressure fluctuation due to autonomic hyperreflexia Decubitus ulcers due to long standing immobility Deep venous thrombosis Pneumonia due[symptoma.com]
- These complications can become life-threatening: Pressure injuries (bedsores) Deep vein thrombosis Hyperreflexia caused by an irritant to nerves below the level of injury Lung conditions such as pneumonia, pulmonary blood clots, collapsing of your lung[drugs.com]
Radiculopathy
- The procedure is also suggested in the setting of spinal nerve impingement with progressive radiculopathy, in patients with extradural lesions such as epidural hematomas or abscesses, and in the setting of the cauda equina syndrome.[emedicine.medscape.com]
Unable to Walk
- Spinal pain is often present for three months and neurological symptoms for two months before paraplegia, but almost 50% of patients are unable to walk by the time of diagnosis. Of these, almost 70% remain immobile.[patient.info]
- Besides leading to physical complications such as skin breakdown, muscle atrophy, reduced cardiorespiratory capacity, and pain [ 1 ], being unable to walk also affects psychological well-being and can increase the risk of depression and reduce quality[doi.org]
- The study was carried out on acute SCI patients who were unable to walk without any physical assistance and both groups had the same amount of training.[doi.org]
Urogenital
Urinary Retention
- The latter can lead to neurogenic shock, paralytic ileus, aspiration, urinary retention, priapism and loss of thermoregulation. Clinical features depend upon the extent and rate of development of cord compression.[patient.info]
- Problems can include urinary retention or high intravesical voiding pressure due to detrusor-sphincter dyssynergy.[emedicine.com]
Urinary Incontinence
- Effect of sacral nerve stimulation in patients with fecal and urinary incontinence. Dis. Colon Rectum 44(6): 779 – 789 ; 2001. Google Scholar Medline ISI 154. Linder, S. H. Functional electrical stimulation to enhance cough in quadriplegia.[doi.org]
Workup
When patients suspected with spinal cord injury is brought to the emergency room, the health care provider conducts a complete clinical examination and neurologic examination do determine the exact location of the injury. Spinal reflexes may initially diminish and may return after the swelling has subdued in time.
The following tests may be used in patients suspected of spinal cord injury:
- Computed tomography (CT Scan)
- Magnetic resonance imaging (MRI)
- Myelogram
- Somatosensory evoked potential (SSEP)
- X-ray of the spine
Treatment
All spinal cord injury are considered as a medical emergency that needs to be worked on immediately. Corticosteroids are usually given intravenously to control the swelling of the spinal cord. A subdural probe may be inserted to monitor intraspinal pressure during the acute phases of traumatic spinal cord injury [7].
Surgical intervention is indicated in the following conditions: removal of masses that impinge on the spinal cord, decompress intraspinal pressure by dissecting the lamina (laminectomy), removal of foreign objects or fragments, and fuse spinal bones.
Early surgical decompression within the first 8 hours of injury is associated with a good outlook in terms of neurologic recovery [8]. Advances in stem cell research have implicated in recent studies that the use of umbilical cord mesenchymal stem cells in the functional restoration of spinal cord injury has proven to be very promising [9].
Rehabilitation, physical and occupational therapies may be needed for patients to cope up with the disability associated with the spinal cord injury [10].
Prognosis
Prognosis of patients with spinal cord injury may depend on the level of injury. Injuries sustained in the higher levels will have more neurologic symptoms compared to injuries in the lower levels of the spine. Mortality is possible if muscles of respiration are paralyzed.
Patients sustaining spinal cord injury with improvements of function within one week have a good chance of recovering some somatic and neurologic functions within the next 6 months. However, neurologic deficits that persists beyond 6 months are more likely to stay permanent. Pain control is major predictor of patient’s outlook as to the quality of living beyond 2 years of survival [6]. Majority of spinal cord injury patients may need medical devices like wheelchairs in order to move around.
Complications
The following medical disorders are common complications seen in spinal cord injury patients:
- Blood pressure fluctuation due to autonomic hyperreflexia
- Decubitus ulcers due to long standing immobility
- Deep venous thrombosis
- Pneumonia due to incompetent respiratory toilet
- Muscular contractures
- Urinary tract infections due to chronic catheter use
- Chronic renal diseases
- Bladder and bowel incontinence
- Male impotence
- Muscle spasms
- Pain
- Paralysis
- Shock
Etiology
As of 2005 in the United States, the most common cause of spinal cord injury is vehicular accidents accounting for more than 40% of cases. This is followed by falls which occurs commonly among 45 year old at a rate of more than 27% of the cases. Females with ongoing osteoporosis are at risk of vertebral fractures. Armed violence especially gunshot wounds also tops the chart at 15% of cases representing the most common cause of spinal cord injury in the urban setting.
Patients sustaining penetrating injuries with a projectile carries a poorer outcome [1]. Diving sports and other sport injury follows this trend at 8% of cases of spinal cord injury [2]. There are other significant causes of spinal cord injuries like tumors [3], vasculopathies, infectious processes, vertebral fracture, and spondylitis. Spinal cord injuries is an important medical condition because it can virtually affect patients psychologically, financially, and physically [4].
Epidemiology
The National Spinal Cord Injury database in the United States, confers approximately 40 cases of spinal cord injuries per million population, or an approximated 12,000 cases per annum. As of 2010, the number of people living with spinal cord injury reaches more than a quarter of a million in the country. Spinal cord injuries have an increasing frequency in the months of July during day time hours.
The white race sustaining spinal cord injuries represents as much as 65% of all the cases recorded worldwide. Males are more predisposed in up to four folds incidence compared to females. The median age for spinal cord injury as of 2005 is slated at 40.7 years old worldwide. In pediatric cases, spinal cord injuries are more dominant in the black races scoring up to 1.53 cases per 100,000 children population [5].
Pathophysiology
Spinal cord injury has an evolving pathophysiology representing a dynamic process. The full effect of the injury is not apparent at first but may later evolve in the succeeding days rising 1 to 2 levels each time. Spinal cord injury can be sustained by the destruction of the spinal tissue matter caused by direct trauma, compression injury by bone fragments and hematoma, and ischemia from blocked spinal arteries.
Prevention
Proper safety precaution in the work place and recreation by wearing safety gears may prevent this types of injury. A thorough inspection of the dive site before plunging may be a prudent move to prevent spinal trauma, for recreational diving is still the leading cause of sports related spinal cord injury.
Precaution by using the appropriate protective gear in contact sports like football and high risk recreational sports like rock climbing may prevent such accidents. Defensive driving with seat belts intact may prevent whiplash injury that can cause spinal cord trauma of the cervical area.
Summary
Spinal cord injury is a clinical disorder caused by any damage in the spinal cord and its nerves. This injury is brought about by direct trauma to the spinal cord or indirectly by diseases of the bones and soft tissue proximal to the spinal cord mater.
Spinal cord injury often causes permanent changes in strength, sensation and other bodily function below the level of the lesion. Most spinal cord injuries are irreversible but physical therapy may somehow restore some of the patient’s daily function and independence.
Patient Information
Definition
Spinal cord injury refers to any injury in the spinal cord and its spinal root nerves.
Cause
Vehicular accidents, falls, diving, armed conflict, and tumors are common causes.
Symptoms
Paralysis, spasticity, incontinence, weakness, paralysis, unstable blood pressure, and difficulty in breathing may occur.
Diagnosis
X-ray, CT scan, MRI and myelography may be used to daignose a spinal cord injury.
Treatment and follow-up
Corticosteroids, laminectomy, and surgical removal of foreign bodies are the most common treatment options.
References
Article
- Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. Nov 2006; 61(5):1166-70.
- National Spinal Cord Injury Statistical Center (NSCIS). Spinal cord injury facts and figures at a glance. February 2011; Accessed August 30, 2011.
- Avery JD, Avery JA. Malignant spinal cord compression: a hospice emergency. Home Healthc Nurse. Sep 2008; 26(8):457-61; quiz 462-3.
- Krause JS, Sternberg M, Lottes S, Maides J. Mortality after spinal cord injury: an 11-year prospective study.Arch Phys Med Rehabil. Aug 1997; 78(8):815-21.
- Vitale MG, Goss JM, Matsumoto H, Roye DP Jr. Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000. J Pediatr Orthop. Nov-Dec 2006; 26(6):745-9
- Budh CN, Osteråker AL. Life satisfaction in individuals with a spinal cord injury and pain. Clin Rehabil. Jan 2007; 21(1):89-96.
- Werndle MC, Saadoun S, Phang I, Czosnyka M, Varsos GV, Czosnyka ZH. Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study. Crit Care Med. 2014; 42(3):646-55 (ISSN: 1530-0293)
- Gaebler C, Maier R, Kutscha-Lissberg F, Mrkonjic L, Vecsei V. Results of spinal cord decompression and thoracolumbar pedicle stabilisation in relation to the time of operation. Spinal Cord. Jan 1999; 37(1):33-9.
- Hu SL, Luo HS, Li JT, Xia YZ. Functional recovery in acute traumatic spinal cord injury after transplantation of human umbilical cord mesenchymal stem cells. Crit Care Med. 2010; 38(11):2181-9 (ISSN: 1530-0293)
- Van Middendorp JJ, Hosman AJ, Donders AR, Pouw MH, Ditunno JF Jr, Curt A, et al. A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study. Lancet. Mar 19 2011; 377(9770):1004-10.