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Overview of spinal cord

injuries
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Contents
1 What is a Spinal Cord Injury
2 Clinically Relevant Anatomy
3 Etiology and Epidemiology
4 Clinical Presentation
4.1 Types
4.1.1 Complete (AIS A)
4.1.2 Incomplete (AIS B, C, D and E)
5 Differential Diagnosis
6 Diagnostic Procedures
7 Medical Management
7.1 Conservative Management
7.2 Surgical Management
7.3 Pharmacological Management
7.4 Cellular Therapy Interventions
8 Physiotherapy Management
9 Clinical Bottom Line
10 References

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more testimonials Introduction Spinal Cord Injury refers to any •

What is a Spinal Cord Injury

Spinal Cord Injury (SCI) is a sudden onset disruption to the neuronal tissue within
the spinal canal resulting in spinal cord damage, which occurs as a result of trauma,
disease or degeneration.[1][2] Any damage to the spinal cord is a very complex injury.
Each injury is different and can affect the body in many different ways. It can present
as either an upper motor neuron lesion or lower motor neuron lesion with varying
loss of motor, sensory and autonomic function, either temporary or permanent
depending on the level and type of injury to the Spinal Cord or Cauda Equina. [2][3]
Effective management of spinal cord injury is reliant upon accurate clinical
examination and classification of the neurological injury combined with detailed
radiological assessment of the vertebral column injury. [4]

Clinically Relevant Anatomy

The spinal column is comprised of 33 Vertebra; 7 Cervical Vertebrae
(/Cervical_Vertebrae), 12 Thoracic Vertebrae (/Thoracic_Vertebrae), 5 Lumbar
Vertebrae (/Lumbar_Vertebrae), 5 Fused Sacral Vertebrae and 4 Fused Coccygeal
Vertebrae, which provide support and protection for the spinal cord
(/Spinal_cord_anatomy). The spinal cord is the major conduit between the peripheral
nerves and the brain (/Brain_Anatomy) and transmits motor information from the
brain to the muscles, tissues and organs, and sensory information from these areas
back to the brain. [5][6]

The nervous system is divided into the central nervous system (brain and spinal
cord) and the peripheral nervous system (nerves that enter and exit the spinal cord).
Information to and from the muscles, glands, organs and sensory receptors are
carried through the peripheral nervous system, which is divided into the autonomic
nervous system carrying information to and from the organs, and the somatic
nervous system carrying information to and from the muscles and the external
environment. [5]

The autonomic nervous system consists of the parasympathetic nervous system

that governs resting function and the sympathetic nervous system that governs
excitatory functions. The spinal cord and peripheral nerves provide all impulses to
control muscle contraction, cardiac rhythm, pain and other bodily functions so
therefore any lesion to the spinal cord prevents or reduces transmission of this
information to and from the brain to the peripheries, affecting movement, sensation
and visceral function. [6]

Read more about Spinal Cord Anatomy (/Spinal_cord_anatomy)

(/File:42282-O3EL6G.jpg)
 (/File:Spinal_Cord_Sectional_Anatomy.png)

Etiology and Epidemiology

Spinal Cord Injury can occur as a result of:

Non-traumatic causes (16%) secondary to disease, infection and congenital

defect
Trauma (84%), with the most the common occurring as a result of motor vehicle
and motor-bike accidents, followed by falls. Sport, in particular, water-based
activities and work-related injuries are also common, while violence-related
injuries from a gun, stab or war-related injuries are high in some countries.
Global Prevalence of spinal cord injury varies from 236 to 1298 per million of
population, with a recent trend in increasing prevalence over the last decade. A
recent systematic review found the prevalence of spinal cord injury to be dependent
on the region the studies were conducted in, ranging from the highest prevalence of
906 per million in the USA and the lowest prevalence of 250 per million in Rhone-
Alpes, France. [9] While further studies found similar results with prevalence ranging
from 1298 per million to 50 per million. [10]

Global incidence also shows a huge variance from 8 to 246 cases per million of the
population in one study while further research found similar results with 246 per
million to 3.3 per million. [9][10] Annual incidence rates also varied significantly
between region, ranging from 246 per million in Taiwan, 49.1 per million in New
Zealand to just 10.0 per million in Fiji. [9] Similarly studies available also show a high
male-to-female ratio of 5:1 with the peak incidence of spinal cord injury occurring at
42 years old, increased from 29 years old in 1970.

These results indicate that the incidence and prevalence of Spinal Cord Injury can
differ significantly between countries and regions, and identifies the need for the
development of preventative and management strategies that are tailored towards
regional trends. There is limited available research that examines the reasons for this
variation suggesting the need for further comparative studies, and for international
standards and guidelines for reporting on spinal cord injury. [9]

Read more about Epidemiology of Spinal Cord Injury

(/Epidemiology_of_Spinal_Cord_Injury)

Clinical Presentation
Injuries to the spinal cord are complex, and each individuals injury is unique in terms
of the functions affected and therefore the clinical presentation. Most spinal cord
injuries do not involve full transection or severing of the spinal cord. Rather, the
spinal cord remains intact and the neurological damage is due to secondary
vascular and pathogenic events, including oedema, inflammation and changes to
the blood-spinal cord barrier. [11] Signs and symptoms vary depending on where the
spine is injured and the extent of the injury but can include loss of power, sensation,
respiration, temperature regulation, bladder, bowel and sexual function.

Paraplegia (/Paraplegia) refers to impairment or loss of motor, sensory or autonomic

function in areas of the body served by the thoracic, lumbar or sacral segments of
the spinal cord. Depending on the level of the injury trunk, pelvic organs and lower
limbs may be involved with upper limb function preserved. [1]
Tetraplegia (/Tetraplegia), sometimes referred to as quadriplegia in some countries,
refers to impairment or loss of motor, sensory or autonomic function in areas of the
body served by the cervical segments of the spinal cord. This results in impairment
in upper and lower limbs, trunk and pelvic organs with respiratory function impaired
in those with high cervical injuries. [1]

Classification of the spinal cord injury is conducted by means of a neurologic

assessment including motor, sensory and autonomic evaluation to determine the
degree of sparing of motor, sensory and autonomic function below the level of the
Injury using the American Spinal Injury Association (ASIA) Impairment Scale. [4][11]

Types
Spinal cord injury can result in complete or incomplete injury to the spinal cord,
which can prevent the transmission of all or just some neural messages across the
site of the lesion, resulting in highly varied presentations of injury. Some individuals
will have extensive preservation of motor and sensory pathways with a more
favourable outcome, while in others there is limited preservation. Partial preservation
of the spinal cord tends to be more common in cervical, lumbar and sacral level
injuries.

The American Spinal Injury Association (ASIA) classification system, based on a

standardized motor and sensory assessment, is used to classify spinal cord
injuries.It is used to define two motor, two sensory and one neurological level. It is
also used to classify injuries as either complete (AIS A) or incomplete (AIS B, C, D or
E), with a distinction between different ASIA impairments made on the basis of:

Motor Function in S4 - S5, reflected by the ability to voluntarily contract the anal
sphincter.
Sensory Function in S4 - S5, reflected by the appreciation of deep anal pressure
or preservation of either light touch or pinprick sensation in the perianal area.
Strength in muscles below the motor and neurological level.
The S4 - S5 segments is linked to prognosis, with preservation a strong predictor of
neurological recovery. Similarly, preservation of pinprick sensation anywhere on the
body helps predict motor recovery.

Complete (AIS A)
A complete spinal cord injury has no motor or sensory function in S4 - S5 area of the
spinal cord. Complete ASIA A lesions can also have zones of partial
preservation reflecting some preservation of motor or sensory function below the
neurological level, however, if there is motor or sensory function in S4 - S5 the lesion
is no longer complete but rather incomplete.

Incomplete (AIS B, C, D and E)

An incomplete spinal cord injury has some preservation of sensory and/or motor
function in the S4 - S5 area of the spinal cord. There are a number of recognised
patterns of incomplete cord injury. More commonly these tend to present clinically
as combinations of syndromes rather than in isolation with signs and symptoms
related to the anatomical areas of the spinal cord affected.

Central Cord Lesion: The most common of the incomplete spinal cord injury
syndromes, central cord syndrome is typically seen in older patients with cervical
spondylosis secondary to degenerative changes in the spinal column, with
osteophytes and possible disc bulges, combined with spondylitic joint changes in
the anterior part of the vertebral column with thickening of the ligamentum flavum
posteriorly. Predominantly occurs as a result of a hyperextension injury, which
compresses the central cord in the narrowed canal and leads to interference of the
blood supply causing hypoxia and haemorrhage of the central cord grey matter,
which is often already compromised in an older person and so has less potential for
recovery. This presents with upper limbs more profoundly affected than lower limbs,
often flaccid weakness of the arms, due to lower motor neuron lesions, and spastic
patterning in the arms and legs due to upper motor neuron lesions as the central
cervical tracts are predominantly affected with some partial dysfunction of bowel
and bladder common. Prognosis varies and is often age dependent with ambulation
seen in 97% of younger patients under 50 years compared with only 41% in those
over 50 years. [12]

Brown Sequard Syndrome: Occurs when just one side of the spinal cord is
damaged. Presents as sagittal hemicord damage with dorsal column interruption
resulting in ipsilateral paralysis and loss of proprioception with contralateral loss of
temperature and pain sensation. As a result of the spinothalamic tract crossing over
to the opposite side of the cord, relatively normal pain and temperature sensation
remain on the ipsilateral side. While it is rare for the spinal cord to be truly
hemisected, this syndrome was originally described by Galen and most commonly
occurs as a result of a penetrating injury to the spinal column eg. gunshot or knife,
accounting for between 2 - 4% of all spinal cord injuries. It is thought that axons in
the contralateral cord may facilitate recovery leading to a good prognosis, with
almost all patients ambulating successfully. [13][14]
Anterior Cord Syndrome: Presents as complete motor loss caudal to the lesion
secondary to anterior cord damage affecting the spinothalamic and corticospinal
tracts, with and loss of pain and temperature sensation as these sensory tracts are
located anterolaterally in the spinal cord. Vibration and proprioception remain intact
on the ipsilateral side due to preservation of the posterior columns. This occurs as a
result of a flexion injury that damages the anterior two-thirds of the spinal cord, most
commonly caused by a vascular insult to the anterior vertebral artery, leaving the
two posterior vertebral arteries intact. Motor recovery is less common in these
patients compared with other incomplete lesions. [12][15]
Posterior Cord Lesion: Presents with preservation of motor function, pain and
temperature pathways but with loss of light touch, proprioception and vibration
secondary to damage to the posterior column. This presentation is very rare and
individuals will display profound ataxia due to loss of proprioception.

Conus Medullaris Lesion: An injury located around T12 - L2, Conus Medullaris can
present as either an upper motor neuron lesion, lower motor neuron lesion or mixed
pattern, with or without the sacral reflexes (anal/bulbocavernosus), displaying
variable symmetrical lower-limb deficits with bladder and bowel dysfunctions,
depending on the level of injury. Can also cause disruption to bowel, bladder, and
some sexual function. Commonly occurs as a result of avulsion of the lumbar or
sacral roots from the terminal part of the cord from trauma or tumour. [16]

Cauda Equina Syndrome (/Cauda_Equina_Syndrome): An injury located below the

level at which the spinal cord splits into the Cauda Equine, around Levels L2 - S5
below the Conus Medullaris, most commonly caused by compression. While not a
true spinal cord injury as it impacts on the nerve roots rather than the spinal cord, it
presents as a lower motor neuron lesion with flaccid paralysis secondary to
peripheral nerve damage at this level of the spine, usually affecting several levels
with variable sacral root interruption and loss of spinal cord mediated reflexes. It can
cause low back pain, weakness or paralysis in the lower limbs, loss of sensation,
bowel and bladder dysfunction, and loss of reflexes, and more commonly occur on
one side of the body. This type of injury has a better prognosis for recovery of
function if managed early as the peripheral nervous system has a greater capacity
for healing than the central nervous system. [16][17]

Differential Diagnosis
Aortic Artery Dissection
Epidural and Subdural Infections
 Spinal Cord Infections
Spinal Abscess
Syphilis (Tertiary)
Vertebral Fracture (/Thoracic_Spine_Fracture)
Transverse Myelitis (http://www.physio-pedia.com/Transverse_Myelitis)
Acute Intervertebral Disk Herniation (http://www.physio-
pedia.com/Disc_Herniation)

Diagnostic Procedures
Imaging technology is an important part of the diagnostic process of acute or
chronic spinal cord injuries. Spinal cord injuries can be detected using different
types of imaging, which depends on the type of underlying pathology. Antero-
posterior, lateral, and special-view Radiographs (/X-Rays) (odontoid, neural foramina
views) can define integrity and alignment of bony structures. However, radiographs
can miss fractures, especially facet fractures therefore absence of fracture on
radiographs does not ensure spinal-column stability. Additional information can be
provided with dynamic views eg, in flexion-extension movement of the spine, but
these views are contraindicated in acute neurological dysfunction. [18]

Spinal fractures and bony lesions are well characterized by Computed Tomography
(/CT_Scans) (CT), which can also detect soft-tissue changes with cord oedema,
infarction, demyelination, cysts, or abscesses producing reduced signal density,
while haemorrhages and calcifications increase signal density. Combination of
computed tomography and myelography better defines abnormalities in the spinal
canal than computed tomography alone, with combination especially useful when
spinal hardware in situ makes MRI difficult. Canal compromise and extradural
lesions (tumour, arteriovenous malformations) are especially well defined in
computed tomography myelograms. [18]

Magnetic Resonance Imaging (/MRI_Scans) (MRI) has become the golden standard
for imaging neurological tissues such as the spinal cord, ligaments, discs and other
soft tissues and can provide better definition of bony structures than radiography,
especially when radiographs suggest injury or include poorly visualised areas. Only
MRI sequences of sagittal T2 were found to be useful for prognosticative
purposes. [19]

Medical Management
An holistic approach, in which all team members
(/Interdisciplinary_Management_in_Spinal_Cord_Injury) work towards common
goals, are necessary throughout the acute and rehabilitation phase of spinal cord
injury management. All medical intervention at the time of injury is directed at
minimising further spinal cord damage while managing other injuries, associated
impairments and optimising neurological recovery. Traumatic spinal cord injuries can
be associated with structural damage and instability or the vertebral column, with
spinal fractures classified as stable, unstable or quasi-stable (i.e. currently stable but
the possibility for instability in the course of everyday activity), based on the three-
column principles.

Individuals are generally mobilized within a few days of injury provided they are
medically stable, if there is no vertebral instability or damage, as often can occur
following ischaemic injuries. However, when there is instability of the vertebral
column, the management is quite different, and depending on severity and type of
injury can include conservative or surgical management. [1][2]

Conservative Management
Individuals managed conservatively are generally confined to bed rest with the spine
immobilized for a period of 6 - 12 weeks. Depending on the degree of instability,
they may have to be maintained in spinal alignment by skull traction (cervical
lesions), or some type of pillow wedge (for thoracic, lumbar and sacral lesions) with
tight restrictions placed on therapies, which may cause movement at the injury site,
and patients are turned and moved only under strict medical supervision. Post this
period of immobilization the individual is mobilized in a wheelchair, often with a
spinal orthosis, that is worn for a further few months. In some cases, this
immobilization may be done with extensive bracing e.g. halo-thoracic brace that
may allow for earlier mobilization in a wheelchair. [1][2]

Surgical Management
The more common approach in the management of vertebral damage and instability
is surgical, which aims to minimize neurological deterioration, restore alignment and
stabilization, facilitate early mobilization, reduce pain, minimize hospital stay and
prevent secondary complications. [13] Currently, there are no defined standards
existing regarding the timing of decompression and stabilization in spinal cord injury.
Decompression of the spinal cord is suggested in the setting of acute spinal cord
injury with progressive neurologic deterioration, facet dislocation, or bilateral locked
facets or in spinal nerve impingement with progressive radiculopathy and in those
select patients with extradural lesions such as epidural hematomas or abscesses or
cauda equina (/Cauda_Equina_Syndrome) syndrome. There are many different
surgical approaches but typically vertebrae are realigned and surgical stabilization is
achieved by anterior or posterior fixation, or a combination of the two, with or
without spinal decompression. [1][2][20]

Patients managed surgically are often permitted to mobilize much more rapidly than
those managed conservatively, sometimes within 7 - 10 days post-surgery. They
may or may not require some type of bracing once mobilized. The main implication
of this approach for physiotherapy management is that patients are confined to bed
for a shorter period, and so experience fewer complications associated with
immobilization and often result in a shorter inpatient stay. On the other hand,
anaesthesia depresses respiratory function, increasing the risk of respiratory
compromise in the days after surgery. [1][2]

Pharmacological Management
There is still no commonly accepted pharmacological agent. [21] The most important
candidates currently in use include:

Glucocorticoids (/Corticosteroid_Medication) (Methylprednisolone), which

suppress many of the ‘secondary’ events of spinal cord injury. These are
inflammation, lipid peroxidation and excitotoxity. Randomised clinical trials are
contradictory in their results and so are the opinions of experts.[22]
Thyrotropin-releasing Hormone (TRH) shows antagonistic effects against the
secondary injury mediators. [21]
For more information, see article
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303789/pdf/WJO-6-42.pdf).
Polyunsaturated Fatty Acids (PUFA) such as Docosahexanoic Acid (DHA) has
recently been explored for spinal cord injury management. It is said to improve
neurological recovery through increased neuronal and oligodendrocyte survival
and decreased microglia/macrophage responses, which reduces axonal
accumulation of B-Amyloid Precursor Protein (b-APP) and increase synaptic
connectivity.
Eicosapentaenoic Acid (EPA) is also thought to increase synaptic connectivity, to
restore neuro-plasticity. [23]
Read more about Pharmacological Management of Spinal Cord Injuries
(/Pharmacological_Management_of_Spinal_Cord_Injuries)
Cellular Therapy Interventions
Cellular therapies have been quite controversial in the management of spinal cord
injury with the aim of cellular therapies to provide functional recovery of the deficit
through axonal regeneration and restoration. Much of these cellular therapy
interventions are still only in use in clinical trials and research but may in the future
play a larger role in the management of spinal cord injury. [21]

Schwann Cell is one of the most widely used cell types for the repair of the
spinal cord.
Olfactory Ensheating Cells are capable of promoting axonal regeneration and
remyelination after injury.
Bone Marrow derived Mononuclear Cells (BM-MNC’s) transplantation is feasible,
safe and have a good degree of outcome improvement.
Stimulated Macrophages invade the impaired tissue. [21]

Physiotherapy Management
The rehabilitation of patients who had a spinal cord injury depends on the level of
the spine injured, and whether it is a complete or an incomplete spinal cord injury. In
case of an incomplete spinal cord injury, approximately 25% will not become
independent ambulators. The therapies differ according to where the lesion
happened, cervical, thoracic or lumbar. The management of an individual with spinal
cord injury is complex and lifelong requiring a multidisciplinary approach. A
functional, goal-oriented, interdisciplinary, rehabilitation programme should enable
the individual with a spinal cord injury to live as full and independent a life as
possible. [1][2][24][25]

In the early post-injury phase, physical management will mainly involve prevention
and management of respiratory and circulatory complications, care of pressure
areas and minimize the impact of immobilization such as contractures (Chartered
Society of Physiotherapy Standards, 1997).

Treatment objectives in the acute phase include:

to institute a prophylactic respiratory regimen and treat any complications

to achieve independent respiratory status where possible
to maintain full ROM of all joints within the limitations determined by fracture
stability
to monitor and manage neurological status as appropriate
 to maintain/strengthen all innervated muscle groups and facilitate functional
patterns of activity
to support/educate the patient, carers, family and staff.
While the aims and objectives of the rehabilitation phase include:

to establish an interdisciplinary process which is patient-focused,

comprehensive and co-ordinated 

physical motor functional activities with early intervention and prophylaxis to
prevent further 
complications 

to learn new information to equip the individual 
with knowledge to achieve
independence 

to achieve functional independence, whether physical or verbal, and equipment
provision in order to 
facilitate this independence 

to achieve and maintain successful reintegration 
into the community.

Clinical Bottom Line

Spinal cord injuries are a serious, widespread health issue resulting in a large
amount of disfunction and as such have a big socio-economic impact. Therapy is
multidisciplinary and focus should be on regaining of function, relevant to the
individual with a spinal cord injury, as tissue recovery is often impossible. Read more
about the management of an individual with a spinal cord injury
(/Physiotherapy_Management_of_Individuals_with_Spinal_Cord_Injury).

Related articles

Spinal Cord Injury - Physiopedia

Introduction Spinal cord injury (SCI) is a debilitating neurological condition with tremendous
socioeconomic impact on affected individuals and the health care system. Today, the estimated
lifetime cost of a SCI patient is $2.35 million per patient. According to the National Spinal Cord
Injury Statistical Center, there are 12,500 new cases of SCI each year in North America. More
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discontinuation of Cord
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the drug[2].
norms 2011; 34: therapy
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users should
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Guidelines
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for local
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to ensure
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interprofessional
treatment and agreements".
interventions. [5]Back
To describe
to
6. Francisco
appropriate care based
Pharmacological de Assis
Management Aquino
on the bestof SpinalGondim
available Injuries evidence and broad consensus; ToAnatomy
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reduce of inappropriate
the Spinal Cord, variation Medshape,
in practice;2015 To provide a more rational basis for referral; To
7. Designed
provide a focus for bycontinuing
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