Traumatic Brain Injury
- Cerebral concussion/contusion
- Head injury
- Skull fracture
- Subarachnoid hemorrhage (traumatic)
The Spinal Cord
The spinal cord is about 18 inches long, extending from the base of the brain to near the waist. Many of the bundles of nerve fibers that make up the spinal cord itself contain upper motor neurons (UMNs). Spinal nerves that branch off the spinal cord at regular intervals in the neck and back contain lower motor neurons (LMNs). The spine itself is divided into four sections, not including the tailbone:
- Cervical vertebrae (1-7), located in the neck
- Thoracic vertebrae (1-12), in the upper back (attached to the ribcage)
- Lumbar vertebrae (1-5), in the lower back
- Sacral vertebrae (1-5), in the pelvis
Types and Levels of Spinal Cord Injury
The severity of an injury depends on the part of the spinal cord that is affected. The higher the SCI on the vertebral column, or the closer it is to the brain, the more effect it has on how the body moves and what one can feel. More movement, feeling and voluntary control are generally present with injuries at lower levels.
- Tetraplegia (a.k.a. quadriplegia) results from injuries to the spinal cord in the cervical (neck) region, with associated loss of muscle strength in all four extremities.
- Paraplegia results from injuries to the spinal cord in the thoracic or lumbar areas, resulting in paralysis of the legs and lower part of the body.
Complete Spinal Cord Injury
A complete SCI produces total loss of all motor and sensory function below the level of injury. Nearly 50 percent of all SCIs are complete. Both sides of the body are equally affected. Even with a complete SCI, the spinal cord is rarely cut or transected. More commonly, loss of function is caused by a contusion or bruise to the spinal cord or by compromise of blood flow to the injured part of the spinal cord.
Incomplete Spinal Cord Injury
In an incomplete SCI, some function remains below the primary level of the injury. A person with an incomplete injury may be able to move one arm or leg more than the other, or may have more functioning on one side of the body than the other. An incomplete SCI often falls into one of several patterns.
Anterior cord syndrome results from injury to the motor and sensory pathways in the anterior parts of the spinal cord. These patients can feel some types of crude sensation via the intact pathways in the posterior part of the spinal cord, but movement and more detailed sensation are lost.
Central cord syndrome usually results from trauma and is associated with damage to the large nerve fibers that carry information directly from the cerebral cortex to the spinal cord. Symptoms may include paralysis and/or loss of fine control of movements in the arms and hands, with far less impairment of leg movements. Sensory loss below the site of the SCI and loss of bladder control may also occur, with the overall amount and type of functional loss related to the severity of damage to the nerves of the spinal cord.
Brown-Sequard syndrome is a rare spinal disorder that results from an injury to one side of the spinal cord. It is usually caused by an injury to the spine in the region of the neck or back. In many cases, some type of puncture wound in the neck or in the back that damages the spine may be the cause. Movement and some types of sensation are lost below the level of injury on the injured side. Pain and temperature sensation are lost on the side of the body opposite the injury because these pathways cross to the opposite side shortly after they enter the spinal cord.
Injuries to a specific nerve root may occur either by themselves or together with a SCI. Because each nerve root supplies motor and sensory function to a different part of the body, the symptoms produced by this injury depend upon the pattern of distribution of the specific nerve root involved.
“Spinal concussions” can also occur. These can be complete or incomplete, but spinal cord dysfunction is transient, generally resolving within one or two days. Football players are especially susceptible to spinal concussions and spinal cord contusions. The latter may produce neurological symptoms including numbness, tingling, electric shock-like sensations, and burning in the extremities. Fracture-dislocations with ligamentous tears may be present in this syndrome.
“Open” or penetrating injuries to the spine and spinal cord, especially those caused by firearms, may present somewhat different challenges. Most gunshot wounds to the spine are stable, i.e., they do not carry as much risk of excessive and potentially dangerous motion of the injured parts of the spine. Depending upon the anatomy of the injury, the patient may need to be immobilized with a collar or brace for several weeks or months so that the parts of the spine that were fractured by the bullet may heal. In most cases, surgery to remove the bullet does not yield much benefit and may create additional risks, including infection, cerebrospinal fluid leak, and bleeding. However, occasional cases of gunshot wounds to the spine may require surgical decompression and/or fusion in an attempt to optimize patient outcome.
Spinal Cord Diagnosis
When SCI is suspected, immediate medical attention is required. SCI is usually first diagnosed when the patient presents with loss of function below the level of injury.
Signs and Symptoms of Possible SCI
- Extreme pain or pressure in the neck, head or back
- Tingling or loss of sensation in the hand, fingers, feet, or toes
- Partial or complete loss of control over any part of the body
- Urinary or bowel urgency, incontinence, or retention
- Difficulty with balance and walking
- Abnormal band-like sensations in the thorax – pain, pressure
- Impaired breathing after injury
- Unusual lumps on the head or spine
A physician may decide that significant SCI does not exist by examining a patient who does not have any of the above symptoms, as long as the patient meets the following criteria: unaltered mental status, no neurological deficits, no intoxication from alcohol or other drugs or medications, and no other painful injuries that may divert his or her attention away from a SCI.
In other cases, such as when patients complain of neck pain, when they are not fully awake, or when they have obvious weakness or other signs of neurological injury, the cervical spine is kept in a rigid collar until appropriate radiological studies are completed.
The radiological diagnosis of SCI has traditionally begun with x-rays. In many cases, the entire spine may be x-rayed. Patients with a SCI may also receive both computerized tomography (CT or CAT scan) and magnetic resonance imaging (MRI) of the spine. In some patients, centers may proceed directly to CT scanning as the initial radiological test. For patients with known or suspected injuries, MRI is helpful for looking at the actual spinal cord itself, as well as for detecting any blood clots, herniated discs, or other masses that may be compressing the spinal cord. CT scans may be helpful in visualizing the bony anatomy, including any fractures.
Spinal Cord Treatment
Treatment of SCI begins before the patient is admitted to the hospital. Paramedics or other emergency medical services personnel carefully immobilize the entire spine at the scene of the accident. In the emergency department, this immobilization is continued while more immediate life-threatening problems are identified and addressed. If the patient must undergo emergency surgery because of trauma to the abdomen, chest, or another area, immobilization and alignment of the spine are maintained during the operation.
Intensive Care Unit Treatment
If a patient has a SCI, he or she will usually be admitted to an intensive care unit (ICU). Traction may be indicated to help bring the spine into proper alignment. Standard ICU care, including maintaining a stable blood pressure, monitoring cardiovascular function, ensuring adequate ventilation and lung function, and preventing and promptly treating infection and other complications, is essential so that SCI patients can achieve the best possible outcome.
Methylprednisolone, a steroid drug, became available as a treatment for acute SCI in 1990 when a multicenter clinical trial showed better neurological scores in patients who were given the drug within the first eight hours of injury. Clinicians may consider methylprednisolone infusion if its potential benefits are felt to outweigh the risks of potential associated complications.
A surgeon may wish to take a patient to the operating room immediately if the spinal cord appears to be compressed by a herniated disc, blood clot, or other lesion. Even if surgery cannot reverse damage to the spinal cord, surgery may be needed to stabilize the spine to prevent future pain or deformity.
Neurological Improvement and Rehabilitation
Recovery of function depends upon the severity of the initial injury. Those who sustain a complete SCI are unlikely to regain function below the level of injury. However, if there is some degree of improvement, it usually evidences itself within the first few days after the accident. Incomplete injuries usually show some degree of improvement over time, but this varies with the type of injury. Although full recovery may be unlikely in many cases, some patients may be able to improve enough to ambulate and to control bowel and bladder function.
Rehabilitation often includes physical therapy, occupational therapy, and counseling for emotional support. The services may initially be provided while the patient is hospitalized. Following hospitalization, some patients are admitted to a rehabilitation facility. Other patients can continue rehab on an outpatient basis and/or at home.
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