Spinal Cord Injury

A spinal cord injury can change almost every aspect of a person’s life in an instant, affecting movement, sensation, and bodily functions. While these injuries present profound challenges, advances in research and rehabilitation are opening new possibilities for recovery and independence.

Table of contents

• What is a Spinal Cord Injury?
• The Spinal Cord and How It Works
• Types of Spinal Cord Injuries
• Signs and Symptoms
• Common Causes
• How It Is Diagnosed
• Who Is Affected
• Treatment Approaches
• Rehabilitation and Recovery
• Common Complications
• Living with Spinal Cord Injury
• What to Expect

What is a Spinal Cord Injury?

A spinal cord injury (SCI) happens when there is damage to the spinal cord, a thick bundle of nerve fibers that allows your brain to communicate with nerves throughout your body^[1]. The spinal cord is a soft bundle of nerves that extends from the base of the brain down through the lower back^[2].

The spinal cord sends and receives signals between the brain and the rest of the body. When injury occurs, it can disrupt this communication, causing permanent or temporary changes in strength, feeling, and other body functions below the site of the injury^[1]. These changes can range from minor and manageable to severe and permanent^[3].

The injury can result from direct damage to the spinal cord itself or from damage to the tissue and bones that surround it. This damage stops the flow of messages below the site of the injury^[2]. The spinal cord is protected by the bony spine, which helps shield it from harm, but when that protection fails, serious injury can occur^[14].

• Spinal cord
• Cervical spine (neck)
• Thoracic spine (upper and mid back)
• Lumbar spine (lower back)
• Sacral spine (lower back and tailbone area)
• Vertebrae (spinal bones)
• Cauda equina nerves

The Spinal Cord and How It Works

The spinal cord is a soft, cylindrical column made of tightly bundled nerve cells and nerve fibers that transmit signals. It extends from the lower part of the brain down through the lower back^[2]. It runs through the spinal canal, a protective tunnel formed by holes in the bones of the spine^[14].

Your nervous system works like a multilane expressway to and from your brain. It has lanes for traffic leaving your brain and other lanes for traffic heading to your brain. Your spinal cord connects to your spinal nerves, which branch out everywhere else in your body^[3].

Millions of nerve cells in the spinal cord coordinate complex patterns of movements, such as rhythmic breathing and walking^[2]. The spinal cord carries messages that allow you to move and to feel touch, among other things^[14].

The spinal cord has 31 segments that line up with 31 pairs of spinal nerves. Different sections control different parts of the body. The cervical section in your neck controls your arms and hands. The thoracic section in your upper back supports trunk stability. The lumbar section in your lower back controls your legs and hips. The sacral section contains nerve roots that affect bowel and bladder function^[3].

Types of Spinal Cord Injuries

Spinal cord injuries are organized in two main ways: by the location where the injury happens and by how severe the damage is. An injury can interrupt nerve signals going to and coming from anywhere below where it happens^[3].

Complete injuries mean that there is no nerve communication below the injury site. People lose muscle control, feeling, and function below the injury. A complete injury affects all the lanes of the nerve highway. No traffic gets through, which usually means permanent loss of all abilities below the injury, including paralysis^[2][3].

Incomplete injuries mean the spinal cord is still able to send some messages to or from the brain. People still have some feeling, function, and muscle control below the site of their injury. An incomplete injury is like a closure that only affects some lanes while others remain open, so some abilities below the injury remain intact^[2][3].

Injuries to the upper part of the spinal cord affect more of the body than injuries lower down^[2]. An injury to the upper part of the spinal cord can cause paralysis in most of the body and affect all limbs. This condition is called tetraplegia or quadriplegia. An injury that happens lower down the spinal cord may only affect a person’s lower body and legs, which is called paraplegia^[2][14].

Spinal cord injuries commonly involve multiple phases. The first phase is the initial injury. But in the following hours and days, a secondary injury can also develop, causing swelling and further damage to your spinal cord^[3]. Paralysis can happen immediately upon injury or develop over time from bleeding and swelling in the spinal cord and cell death^[2].

Signs and Symptoms

The symptoms of spinal cord injuries depend on the part of the spinal cord that is damaged and how much damage there is. The ability to control your arms or legs after a spinal cord injury depends on where the injury occurred on the spinal cord and how bad the injury is^[1].

An injury can damage a few, many, or almost all of the nerve fibers that cross the site of injury. If the injury causes little or no nerve cell death, a person can make an almost complete recovery^[2].

People with a spinal cord injury may experience one or more of these symptoms^[2][3]:

• Numbness, tingling, or a loss of (or changes in) sensation in hands and feet
• Paralysis (loss of movement)
• Pain or pressure in the head, neck, or back
• Weakness in any part of the body
• Unnatural or uncomfortable positions of the spine or head
• Loss of bladder and bowel control
• Problems with walking
• Difficulty breathing
• Changes in sexual function
• Pain or severe stinging feeling due to nerve damage
• Increase in muscle reflexes or spasms

In addition to physical consequences, spinal cord injuries can also have a significant impact on an individual’s mental and social well-being^[1][13].

Common Causes

A spinal cord injury usually happens because of a sudden, severe blow to the spine. Broken or dislocated bones of the spine may damage the spinal cord^[14]. Most cases are due to trauma, including falls, road traffic injuries, or violence, and are thus preventable^[4].

The leading causes of spinal cord injury include^[7]:

• Motor vehicle accidents (38.3%)
• Falls (31.6%)
• Acts of violence (13.8%)
• Sports (8.2%), with two-thirds of sports injuries from diving
• Medical or surgical complications (4.3%)
• Other causes (1.3%)

According to injury statistics, falls overtake motor vehicles as the leading cause of injury after age 45. Acts of violence and sports cause fewer injuries as age increases^[7].

Spinal cord injuries can be caused by incidents that result in excessive flexing, compression, or trauma to the spinal column. Other causes include high-impact falls from significant heights, vehicular collisions involving cars, motorcycles, or pedestrians, and sports where intense physical contact or high-risk maneuvers are involved^[13].

Sometimes the spinal cord is damaged by non-traumatic causes like infection, tumors, degenerative and vascular conditions, toxins, birth defects such as spina bifida, or spinal stenosis^[4][14].

How It Is Diagnosed

Healthcare professionals in the emergency room do an exam, test for sensory function and movement, and ask questions about the accident^[8]. They may be able to rule out a spinal cord injury based on this evaluation, but emergency diagnostic tests may be needed if the injured person has neck pain, isn’t fully awake, or has obvious weakness or neurological injury^[8].

Several imaging tests can help diagnose spinal cord injury^[8][14]:

• X-rays can reveal damage to the bones surrounding the spinal cord and can find tumors, fractures, or changes in the spine
• CT scan (computed tomography scan) can provide a clearer image compared with an X-ray and uses computers to form a series of cross-sectional images that can define bone, disk, and other changes
• MRI (magnetic resonance imaging) uses a strong magnetic field and radio waves to produce computer-generated images that are helpful for looking at the spinal cord to find herniated disks, blood clots, or other masses that might compress the spinal cord

You will be tested to see how you respond to pinpricks and light touch all over your body. The doctor will ask you to move different parts of your body and test the strength of your muscles. These tests help the doctor know how severe the injury is and determine how likely it is that you could get back some feeling and movement^[14].

A few days after the injury, when some of the swelling might have gone down, a more comprehensive neurological exam may be done. The exam looks at the level and completeness of the injury, testing muscle strength and your ability to sense light touch and pinprick sensations^[8].

Who Is Affected

Spinal cord injuries are uncommon. Between 250,000 and 500,000 happen every year worldwide^[3]. Globally, over 15 million people are living with spinal cord injury^[4].

In the United States, there are about 18,000 new traumatic cases each year. Over 305,000 people in the United States are living with traumatic spinal cord injuries^[5]. Current estimates suggest that between 250,000 and 400,000 individuals are living with spinal cord injury or spinal dysfunction in the United States^[7].

Males are more commonly affected than females, with consistently higher rates. About 78% to 80% of people with a new spinal cord injury are male^[3][4][7].

The average age at the time of injury is 43^[3]. The highest per capita rate of injury occurs between ages 16 and 30, with the median age at injury being 26 and the most frequent age being 19^[7].

Treatment Approaches

A spinal cord injury is a medical emergency requiring immediate treatment to reduce the long-term effects. The time between injury and treatment is a critical factor affecting your eventual outcome^[12].

Management of a spinal cord injury begins at the site of an accident with paramedics trained in immobilizing the injured spine to prevent further damage to your nervous system. If a spinal cord injury is suspected, you should not be moved without immobilization, unless there is an immediate threat to your safety^[12].

At the hospital, treatment starts right away to prevent more damage to the spine and spinal cord. Steps are taken to get your blood pressure stable and help you breathe^[17]. You may get a steroid medicine to reduce swelling of the spinal cord. Ideally, administration of medications such as dexamethasone or methylprednisolone should begin as soon as possible after your injury^[12].

Surgery may be necessary for various reasons^[12]:

• Remove fluid or tissue that presses on your spinal cord
• Remove bone fragments
• Remove disk fragments
• Remove foreign objects
• Stabilize fractured vertebrae by fusion of the bones or insertion of hardware

If spinal cord compression is caused by a mass, such as a collection of blood that can be dissolved or a bony fragment that can be removed before the nerves of your spine are permanently damaged, paralysis may in some cases be reduced or relieved^[12].

Bedrest may be needed to allow the bones of your spine to heal, since they bear most of the weight of your body. Proper realignment of your spine is important. Traction may be used to reduce dislocation or immobilize your spine. Your skull may be immobilized with metal braces placed in the skull and attached to traction weights or to a harness on your body^[12].

There is no way to reverse damage to the spinal cord. However, researchers are continually working on new treatments, including prostheses and medicines that might promote nerve cell regeneration^[8]. Many scientists are optimistic that advances in research will someday make repair of spinal cord injuries possible, with research studies ongoing around the world^[1].

Rehabilitation and Recovery

Treatments and rehabilitation allow many people with spinal cord injuries to lead productive, independent lives^[1]. You may require extensive physical therapy, occupational therapy, and other rehabilitation interventions after the injury has healed. Rehabilitation assists you in coping with disability resulting from your spinal cord trauma^[12].

Your care team will work with you to address muscle spasms, skin care, and bowel and bladder dysfunction. Muscle stiffness (spasticity) can be reduced by oral medications, medications that are injected into your spinal canal, or injections of botulinum toxins into your muscles. It is important to treat pain with pain relief medications, muscle relaxants, or physical therapy methods^[12].

Recovery of some movement or sensation within one week usually means you have a good chance of recovering more function, although this may take six months or more. Losses that remain after six months are more likely to be permanent^[12].

New treatments show promise for helping people with spinal cord injury. One innovative treatment is transcutaneous spinal stimulation, where electrical stimulation is applied through the skin to the spinal cord. For people with spinal cord injury, this treatment has been transformative. Studies show that with this noninvasive treatment, people with paralysis from spinal cord injury can regain their abilities for months and even years afterward^[11].

The most exciting part of the transcutaneous stimulation studies is that participants have maintained their gains in function and hand dexterity for months or even years after the study ended^[11].

Common Complications

People with spinal cord injury are at risk of developing debilitating and even life-threatening secondary conditions, which can cause premature death^[4]. Life expectancy in people with spinal cord injury strongly correlates with neurological impairment and preventable secondary conditions^[4].

Common complications from spinal cord injury include^[7]:

• Urinary dysfunction
• Respiratory infection
• Bedsores (pressure injuries)

Some of these complications require re-hospitalization. About 30% of persons with spinal cord injury are re-hospitalized one or more times during any given year following injury. Among those re-hospitalized, the length of the hospital stay averages 22 days^[7].

Inappropriate management of spinal cord injury-related impairments and secondary conditions often causes premature death. Spinal cord injury can diminish the capacity to perform daily activities, including walking, using one’s hands, physiological emptying of bowel and bladder, or washing and dressing oneself^[4].

Spinal cord injury is a major cause of long-term disability, accounting for over 4.5 million years of life lived with disability in 2021^[4].

Living with Spinal Cord Injury

Experiencing a spinal cord injury is life-changing in nearly every aspect of a person’s well-being: physically, emotionally, and socially. The initial shock of the injury often comes with fear, uncertainty, and grief as the individual now faces the loss of mobility and independence^[18].

Similar to losing a loved one, there is a sense of deep and profound loss. Patients are learning to live life in a whole new way. Daily tasks that were once second nature can now be immensely challenging and require assistance^[18].

Most people with a spinal cord injury are wheelchair- or bed-bound, or have impaired mobility requiring a variety of assistive devices. Modifications of your living environment are usually required. They might need specialized equipment, such as vans or ramps, and modifications of their living environments^[12][18].

Many restrictions in performing activities and participating in meaningful life areas do not result from the condition itself, but from insufficient or inadequate medical care, rehabilitation and assistive technologies access, a high economic burden, and from barriers in the physical, social, and policy environments. For example, globally, only 5 to 35% have wheelchair access^[4].

Spinal cord injury is associated with lower school enrollment and economic participation rates, carrying substantial individual and societal costs^[4]. The average first-year expenses for a spinal cord injury with paraplegia is $537,271 and up to $1,102,403 for quadriplegia. Each subsequent year, the average yearly expenses are $71,172 for paraplegia and up to $191,436 for quadriplegia^[7].

Ways to support someone with a spinal cord injury include^[18]:

• Encourage independence by helping with daily tasks while promoting self-sufficiency as much as possible
• Provide emotional support by offering patience, reassurance, and a listening ear to help them cope with emotional challenges
• Receive training to learn how to help with mobility, transfers, and personal care while prioritizing comfort and dignity
• Help reconnect socially to stay connected with friends, engage in hobbies, and explore adaptive activities

It’s a very important part of the healing process to allow somebody to feel their feelings. Active listening goes a long way. As a caregiver, one of the best things you can do is simply listen. Allow your loved one to have bad days and to grieve what they have lost^[18].

Many people find encouragement through peer-to-peer programs. Seeing someone who has been through a similar situation living their life two or three years out from injury can be inspiring^[18].

What to Expect

How well you do depends on the level of your injury. Injuries near the top of your spine result in more extensive disability than do injuries lower on the spine^[12].

Paralysis and loss of sensation are common, ranging from varying degrees of movement or sensation loss to total paralysis. Paralysis of the breathing muscles can be fatal^[12].

The closer the injury is to the brain, the more of the body that is affected. Injury to the middle of the back usually affects the legs. Injury to the neck can affect the arms, chest, and legs^[14].

Effective prevention, treatment, rehabilitation, and ongoing health care are essential to alleviate the global burden of spinal cord injury^[4]. In the meantime, treatments and rehabilitation allow many people with spinal cord injuries to lead productive, independent lives^[1].