Spinal cord trauma

Alternative names
Spinal cord compression or injury; Compression of spinal cord

Definition
Spinal cord trauma is damage to the spinal cord that results from direct injury to the cord itself, or from indirect injury from damage to the bones, soft tissues, and blood vessels surrounding the spinal cord.

Causes, incidence, and risk factors

Spinal cord trauma can be caused by any number of injuries to the spine. They can result from motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial accidents, gunshot wounds, assault, and others.

A seemingly minor injury can cause spinal cord trauma 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, particularly if the bones or the discs have been damaged. Fragments of bone (from fractured vertebrae, for example) or fragments of metal (such as from a traffic accident) 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 injury.

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

Spinal cord injuries occur in approximately 12,000-15,000 people per year in the U.S. About 10,000 of these people are permanently paralyzed, and many of the rest die as a result of their injuries. Most spinal cord trauma occurs to young, healthy individuals. Males between ages 15 and 35 are most commonly affected.

Only about 5% of spinal cord injuries occur in children. The fatality rate is higher with pediatric spine injuries.

Risk factors include participating in risky physical activities, not wearing protective gear during work or play, or 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 that make them prone to falling from weakness or clumsiness (from stroke, for example) may also be more susceptible.

Symptoms

Symptoms vary somewhat depending on the location of the injury. Spinal cord injury results in varying degress of weakness and sensory loss at and below the injury. The pattern depends on whether the entire cord is injured (complete) or only partially (incomplete).

The spinal cord doesn’t go below the 1st lumbar vertebra, so injuries at and below this level do not cause spinal cord injury. However, they may cause “cauda equina syndrome” - injury to the nerve roots in this area.

CERVICAL (NEAR THE NECK) INJURIES

When spinal cord injuries occur near the neck, varying degrees of symptoms can affect both the arms and the legs:

     
  • weakness, paralysis  
  • breathing difficulties (from paralysis of the breathing muscles)  
  • spasticity (increased muscle tone)  
  • sensory changes  
  • numbness  
  • pain  
  • loss of normal bowel and bladder control (constipation, incontinence, bladder spasms)

THORACIC (CHEST-LEVEL) INJURIES

When spinal injuries occur at chest level, varying degrees of symptoms can affect the legs:

     
  • weakness, paralysis  
  • breathing difficulties (from paralysis of the breathing muscles)  
  • spasticity (increased muscle tone)  
  • sensory changes  
  • numbness  
  • pain  
  • loss of normal bowel and bladder control       o constipation       o incontinence       o bladder spasms

Injuries to the cervical or high thoracic cord may also result in:

     
  • abnormal blood pressure       o blood pressure fluctuates quickly and through a wide range       o can be worsened with pain or bladder spasms  
  • abnormal sweating; trouble maintaining proper temperature

Signs and tests
Symptoms may develop immediately after injury or may occur gradually because of fluid accumulation around the spinal cord or swelling within the spinal cord itself. Spinal cord injury is a medical emergency requiring immediate attention to minimize the long-term effects.

A neurologic examination indicates the location of the injury, if it is not immediately evident. The reflexes may be abnormal or may be absent in affected areas of the body. There may be some recovery of reflexes after swelling has subsided. Muscle spasticity is common as a late effect of spinal cord injury.

     
  • Spine X-rays may show fracture or damage to the bones of the spine.  
  • A CT scan or MRI of the spine may pinpoint the location and extent of spinal cord trauma and demonstrate any compressive lesions like blood clots (hematomas).  
  • Rarely a myelogram (an X-ray of the spine after injection of dye) may be necessary.  
  • Somatosensory evoked potential (SSEP) testing or magnetic stimulation may determine if signals can get through the spinal cord.

Treatment

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

Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord compression is caused by a mass (such as a hematoma or bony fragment) that can be removed or brought down before there is total destruction of the nerves of the spine, paralysis may in some cases be reduced or relieved. Ideally, corticosteroids should begin as soon as possible after the injury.

Surgery may be necessary. This may include surgery to remove fluid or tissue that presses on the spinal cord (decompression laminectomy). Surgery may be needed to remove bone fragments, disc fragments, or foreign objects or to stabilize fractured vertebrae (by fusion of the bones or insertion of hardware).

Bedrest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal.

Anatomic realignment is important. Spinal traction may reduce dislocation and/or may be used to immobilize the spine. The skull may be immobilized with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body).

Treatment will address muscle spasms, care of the skin, and bowel and bladder dysfunction.

Extensive physical therapy, occupational therapy, and other rehabilitation interventions are often required after the acute injury has healed. Rehabilitation assists the person in coping with disability that results from spinal cord trauma.

Spasticity can be reduced by many oral medications, medications that are injected into the spinal canal, or injections of botulinum toxins into the muscles. It is important to treat pain with analgesics, muscle relaxants, or physical therapy modalities.

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

Expectations (prognosis)

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

The level of injury affects the outcome. Injuries near the top of the spine result in more extensive disability (numbness and paralysis, breathing difficulty) than injuries low in the spine.

Recovery of some movement or sensation within one week usually indicates eventual recovery of most function, although this may take 6 months or more. Losses that emain after 6 months are more likely to be permanent.

Complications

     
  • paralysis (paraplegia, quadriplegia)  
  • loss of sensation  
  • loss of bladder control  
  • increased risk of urinary tract infections  
  • increased risk of chronic bilateral obstructive nephropathy  
  • loss of bowel control  
  • loss of sexual functioning (male impotence)  
  • paralysis of breathing muscles  
  • increased risk of injury to numb areas of the body  
  • pain  
  • complications of immobility:       o deep vein thrombosis       o pulmonary infections       o skin breakdown       o contractures  
  • shock  
  • extreme blood pressure fluctuations  
  • spasticity (late complication)

Calling your health care provider

Call your health care provider if injury to the back or neck occurs. Call 911 if there is any loss of movement or sensation. This is a medical emergency!

Management of spinal cord injury begins at the site of an accident with paramedics trained in immobilizing the injured spine to prevent further damage to the nervous system. Someone suspected of having a spinal cord injury should NOT be moved without immobilization unless there is an immediate threat.

Prevention

Safety practices during work and recreation can prevent many spinal cord injuries. Use proper protective equipment if 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 obstructions.

Football and sledding injuries often involve sharp blows or abnormal twisting and bending of the back or neck and can result in spinal cord trauma. 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 result in spinal cord injuries. Defensive driving and wearing seat belts greatly reduces the risk of serious injury if there is an automobile accident.

Johns Hopkins patient information

Last revised: December 5, 2012
by David A. Scott, M.D.

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All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.