Spinal Cord Injury Cervical

Cervical spinal cord injuries affect the uppermost section of the spine in the neck and are the most severe of all spinal cord injuries, often leading to significant disability or even paralysis.

Table of contents

• What is a Cervical Spinal Cord Injury?
• The Cervical Spine
• Causes of Cervical Spinal Cord Injuries
• Symptoms
• Types of Cervical Spine Injuries
• Diagnosis
• Treatment
• Long-Term Effects and Recovery
• Coping with a Cervical Spinal Cord Injury

What is a Cervical Spinal Cord Injury?

A cervical spinal cord injury is damage to the uppermost section of the spine, which controls breathing, arm and hand movement, and many vital body functions^[2]. The spinal cord is a thick bundle of nerve fibers that allows your brain to communicate with nerves throughout your body^[1]. When this bundle is damaged in the neck region, it can interrupt the signals traveling between your brain and the rest of your body.

Cervical spinal cord injuries are the most severe of all spinal cord injuries and may affect one or both sides of the body^[2]. The higher up in the spine that the injury occurs, the more severe the potential outcome. These injuries can range from minor and manageable to severe and permanent, with some cervical spinal cord injuries being severe enough to result in death^[2].

Between 250,000 and 500,000 spinal cord injuries happen every year worldwide^[1]. In the United States, there are about 18,000 new traumatic spinal cord injury cases each year, with cervical spine injuries accounting for a significant proportion of these injuries^[1][12]. About 78% of people with a new spinal cord injury are male, and the average age at the time of injury is 43^[1].

The Cervical Spine

The cervical spine is located at the very top of the spinal column and consists of seven specialized vertebrae (bones) between the skull and the thoracic vertebrae^[2][3]. These seven vertebrae are classified as C1 through C7 from the top down, forming the human neck^[2]. There is also an additional cervical-level injury known as a C8 injury, which relates to damage to the spinal cord root that exits the spinal column between vertebrae C7 and T1^[2].

The cervical spine supports the head and its movements, protects the spinal cord, and is a conduit for the vascular supply to the brain^[12]. Due to the inherent bony instability of the cervical spine, there is an over-reliance on ligamentous structures for stability, making this segment of the vertebral column most prone to injuries^[3][12].

This region includes eight spinal nerves (C1 through C8) that control breathing, arm and hand movement, and sensation in the upper body^[9]. The C1 vertebra, also known as Atlas, along with the C2 vertebra, also known as Axis, are the first two segments in the cervical spine^[2]. These levels are especially important, as they support the head, with the Atlas vertebra pivoting on the Axis vertebra to allow the head to rotate^[2].

Causes of Cervical Spinal Cord Injuries

Cervical spinal cord injuries can result from both traumatic and non-traumatic events^[9]. These injuries often result from high-energy mechanisms such as motor vehicle collisions, sports trauma, or falls^[3].

Traumatic causes are the most common and include^[9]:

• Falls
• Motor vehicle accidents
• Sports or recreational injuries, such as diving accidents or contact sports
• Acts of violence, like gunshot wounds or stabbings to the neck

The frequently occurring mechanisms of injury include axial compression (pressure along the spine), hyperflexion (extreme forward bending), hyperextension (extreme backward bending), and rotational type injuries^[12].

Non-traumatic causes may develop due to^[9]:

• Infections, including ones affecting the spine or brain
• Medical or surgical complications
• Tumors that compress the spinal cord

Symptoms

Symptoms of a cervical spinal cord injury vary depending on where in the neck (level) the spinal cord is damaged^[9]. Injuries higher in the neck often affect more of the body and may interfere with breathing, while lower injuries may preserve some arm or hand movement^[9]. An injury can interrupt nerve signal traffic going to and coming from anywhere below where it happens^[1].

Common symptoms include^[9]:

• Difficulty breathing due to lack of diaphragm control
• Loss of bladder or bowel control
• Loss of sensation in the arms or legs
• Muscle stiffness (spasticity)
• Sharp, burning or aching pain
• Tingling or numbness in the hands, arms or legs
• Weakness or paralysis in the arms, legs or entire body

Additional symptoms can include^[4]:

• Numbness, tingling, or a loss of sensation in hands and feet
• Pain or pressure in the head, neck, or back
• Unnatural or uncomfortable positions of the spine or head
• Problems with walking
• Changes in sexual function

Some symptoms may appear right away. Others develop over time as swelling or damage progresses^[9]. Spinal cord injuries commonly involve multiple phases, with the first phase being the initial injury. In the following hours and days, a secondary injury can also develop, causing swelling and further damage to the spinal cord^[1].

Types of Cervical Spine Injuries

There are two main ways that experts organize the types of spinal cord injuries: by severity and by location^[1].

By severity:

An injury can be either complete or incomplete^[6]:

• Incomplete injury: 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^[6].
• Complete injury: There is no nerve communication below the injury site. People lose muscle control, feeling, or function below the injury. A complete spinal cord injury affects all nerve signals and usually means permanent loss of all abilities below the injury, including paralysis^[1][6].

Specific types of cervical spine injuries include^[8]:

• Cervical fractures: A break or crack in the bones of the vertebrae structure in the neck. Patients usually have significant pain and stiffness in the neck and may experience pain in other areas due to neurologic compression or irritation.
• Cervical dislocations: Misalignment of two or more adjoining bones of the vertebrae structure caused by trauma to the neck. The structure can become abnormally separated and cause misalignment, which typically causes instability and damage to neurological function.
• Nerve root damage: Occurs when an injury pinches, compresses, or severs the nerves in the cervical spine. Muscle weakness, sensitivity, or numbness is common.
• Intervertebral disc damage: A tear, rupture, or lesion on the disc tissue resulting from trauma to the vertebrae structure. Impaired motion or bodily function might result.
• Cervical stenosis: Narrowing of passages in the neurological system caused by trauma. Numbness, pain, tingling, and lack of sensation are common results.
• Cervical sprains and strains: Overstretching of neck muscles or tendons during the initial trauma, causing conditions like whiplash. Most patients recover after a few weeks of rest and limited mobility.

Injuries to the spinal cord at the C1 and C2 vertebral levels are considered to be the most severe of all spinal cord injuries as they can lead to full paralysis but are most often fatal^[2]. Most injuries to the cervical spinal column occur near the C4/C5 levels^[2].

Diagnosis

The objective of the initial evaluation of a patient with a suspected cervical spine injury is to identify the presence of injuries through thorough clinical and radiologic assessments, as missed injuries are potentially catastrophic^[12]. Good pre-hospital care and a thorough assessment in the emergency department of patients suspected to have a cervical spine injury leads to improved clinical outcomes^[12].

Healthcare professionals in the emergency room do an exam, test for sensory function and movement, and ask questions about the accident^[10]. 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^[10].

These tests can include^[10]:

• X-rays: Can reveal damage to the bone surrounding the spinal cord, known as the vertebrae. They also can find tumors, fractures or changes in the spine.
• CT scan: A CT scan can provide a clearer image compared with an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other changes.
• MRI: MRI uses a strong magnetic field and radio waves to produce computer-generated images. This test is helpful for looking at the spinal cord to find herniated disks, blood clots or other masses that might compress the spinal cord.

A few days after the injury, when some of the swelling might have gone down, a more comprehensive neurological exam may be done^[10]. The exam looks at the level and completeness of the injury. This involves testing muscle strength and your ability to sense light touch and pinprick sensations^[10].

Treatment

A spinal cord injury is a medical emergency requiring immediate treatment to reduce the long-term effects^[15]. The time between injury and treatment is a critical factor affecting your eventual outcome^[15]. 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^[15]. If a spinal cord injury is suspected, you should not be moved without immobilization, unless there is an immediate threat to your safety^[15].

Immediate treatment:

Immediately following an injury, the goals are to protect the spine and prevent further damage^[9]. This often starts at the scene with a neck brace and breathing support if needed^[9]. Corticosteroids such as dexamethasone or methylprednisolone are used to reduce swelling that may damage your spinal cord^[15]. Ideally, administration of corticosteroids should begin as soon as possible after your injury^[15].

Surgical treatment:

In the hospital, doctors use scans to see how severe the injury is and may do surgery to relieve pressure or stabilize the spine^[9]. Surgery may be necessary for a variety of reasons^[15]:

• Remove fluid or tissue that presses on your spinal cord (decompression laminectomy)
• 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 hematoma 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^[15].

Ongoing care:

Care continues in the ICU, with 24/7 monitoring and medications that reduce swelling and support vital functions^[9]. Bedrest may be needed to allow the bones of your spine to heal, since they bear most of the weight of your body^[15]. Proper realignment of your spine is important. Traction may be used to reduce dislocation or immobilize your spine^[15].

Your care team will work with you to address muscle spasms, skin care, and bowel and bladder dysfunction^[15]. Spasticity can be reduced by oral medications, medications that are injected into your spinal canal or injections of botulinum toxins into your muscles^[15]. It is important to treat pain with analgesics, muscle relaxants or physical therapy modalities^[15].

Long-Term Effects and Recovery

The long-term effects of a cervical spinal cord injury vary depending on the area of the neck affected^[9]:

• Higher-level injuries (C1–C4) are more likely to impact breathing and full-body movement
• Lower-level injuries (C5–C8) may allow for some arm or hand function

The ability to control your arms or legs after a spinal cord injury depends on two factors: where the injury occurred on the spinal cord and how bad the injury is^[4]. An injury to the upper part of the spinal cord can cause paralysis in most of the body and affect all limbs, a condition called tetraplegia or quadriplegia^[6]. An injury that happens lower down the spinal cord may only affect a person’s lower body and legs, called paraplegia^[6].

Recovery is often unpredictable^[9]. Some people regain function over time, while others adapt to lasting changes in their abilities. 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^[15]. Losses that remain after six months are more likely to be permanent^[15].

Paralysis and loss of sensation are common, ranging from varying degrees of movement or sensation loss to total paralysis^[15]. Paralysis of the breathing muscles can be fatal^[15]. Early and ongoing cervical spinal cord injury rehabilitation can help you achieve the highest level of independence^[9].

You may require extensive physical therapy, occupational therapy and other rehabilitation interventions after the spinal cord injury has healed^[15]. Rehabilitation assists you in coping with disability resulting from your spinal cord trauma^[15]. Modifications of your living environment are usually required^[15].

Coping with a Cervical Spinal Cord Injury

Coping with life after a spinal cord injury can be incredibly difficult, but you don’t have to go through this adjustment alone^[17]. Understanding the stages of grief—denial, sadness, anger, bargaining, and acceptance—can help you move through them so you can get on with your life^[17].

Important tips for coping include^[17]:

• Give your injury time: Recovering from and adjusting to a spinal cord injury takes time. You don’t need to rush things.
• Know that not all injuries are the same: Don’t feel that you have to compare your injury to others—even those who have the same kind of injury.
• Have patience: You’re not going to be able to do everything you could before right away. It’s important to be patient and give yourself the time you need to adjust.
• Realize that you’ll need help: Accepting help after being partially or completely paralyzed isn’t a sign of weakness.
• Get into a routine: Settling into a routine for catheterizing, taking medications, planning restroom breaks, and more helps to make things a bit easier to manage.
• Stay positive: The more you can stay positive and motivated, the more likely it is that things will eventually go your way.
• Take control: By being positive, taking control, then setting and following through on personal goals, you can do a lot to lead a fuller, more productive life.

People who have had a spinal cord injury also may experience mental, emotional and social side effects^[4]. Many scientists are optimistic that advances in research will someday make repair of spinal cord injuries possible, and research studies are ongoing around the world^[4]. In the meantime, treatments and rehabilitation allow many people with spinal cord injuries to lead productive, independent lives^[4].