Spinal cord trauma is damage to the spinal cord. It may result from direct injury to the cord itself or indirectly from damage to surrounding bones, tissues, or blood vessels.

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 other causes.

A 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 disks have been damaged. Fragments of bone (for example, from broken vertebrae, which are the spine bones) 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.

Most spinal cord trauma happens to young, healthy individuals. Men ages 15-35 are most commonly affected. The death rate tends to be higher in young children with spinal 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 vary somewhat depending on the location of the injury. Spinal cord injury causes weakness and sensory loss at and below the point of the injury. The severity of symptoms depends on whether the entire cord is severely injured (complete) or only partially injured (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, symptoms can affect both the arms and the legs:

• Breathing difficulties (from paralysis of the breathing muscles)
• Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms)
• Numbness
• Sensory changes
• Spasticity (increased muscle tone)
• Pain
• Weakness, paralysis

THORACIC (CHEST-LEVEL) INJURIES

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

• Breathing difficulties (from paralysis of the breathing muscles)
• Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms)
• Numbness
• Sensory changes
• Spasticity (increased muscle tone)
• Pain
• Weakness, paralysis

Injuries to the cervical or high-thoracic spinal cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining normal body temperature.

LUMBAR SACRAL (LOWER-BACK) INJURIES

When spinal injuries occur at the lower-back level, varying dgrees of symptoms can affect the legs:

• Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms)
• Numbness
• Pain
• Sensory changes
• Spasticity (increased muscle tone)
• Weakness and paralysis

Spinal cord injury is a medical emergency requiring immediate attention.

The health care provider will perform a physical exam, including a neurological exam. This will help identify the exact location of the injury, if it is not already known. Some of the person's reflexes may be abnormal or absent. Once swelling goes down, some reflexes may slowly recover.

The following tests may be ordered:

• A CT scan or MRI of the spine may show the location and extent of the damage and reveal problems such as blood clots (hematomas).
• Myelogram (an x-ray of the spine after injection of dye) may be necessary in rare cases.
• Somatosensory evoked potential (SSEP) testing or magnetic stimulation may show if nerve signals can pass through the spinal cord.
• Spine x-rays may show fracture or damage to the bones of the spine.

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, disk 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.

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

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.

How well a person does depends on the level of injury. Injuries near the top of the spine result in more extensive disability than do injuries low in the spine.

Recovery of some movement or sensation within 1 week usually means the person has a good chance of recovering more function, although this may take 6 months or more. Losses that remain after 6 months are more likely to be permanent.

Routine bowel care frequently takes one hour or more on a daily basis.

A majority of people with spinal cord injury must perform bladder catheterization from time to time.

Modifications of the person's living environment are usually required.

Most people with spinal cord injury are wheelchair- or bed-bound, or have impaired mobility requiring a variety of assistive devices.

The following are possible complications of a spinal cord injury:

• Blood pressure changes - can be extreme (autonomic hyperreflexia)
• Complications of immobility:
  • Deep vein thrombosis
  • Pulmonary infections
  • Skin breakdown
  • Contractures
• Increased risk of injury to numb areas of the body
• Increased risk of kidney damage
• Increased risk of urinary tract infections
• Loss of bladder control
• Loss of bowel control
• Loss of sensation
• Loss of sexual functioning (male impotence)
• Muscle spasticity
• Pain
• Paralysis of breathing muscles
• Paralysis (paraplegia, quadriplegia)
• Shock

People living at home with spinal cord injury should do the following to prevent complications:

• Daily pulmonary care, for those who need it.
• Follow all instructions regarding bladder care to avoid infections and damage to the kidneys.
• Follow all instructions regarding routine wound care to avoid pressure sores.
• Keep immunizations up to date.
• Maintain routine health visits with their doctor.

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.

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.

Evans RW, Wilberger JE, Bhatia S. Traumatic disorders. In: Goetz, CG, ed. Textbook of Clinical Neurology. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2007: chap 51.

Ling GSF. Traumatic brain injury and spinal cord injury. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, PA: Saunders Elsevier; 2007: chap 422.