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Spinal Cord Injury

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Spinal Cord Injury (SCI) is trauma to the spinal cord, resulting directly or indirectly from damage to the cord or surrounding tissues. There are numerous causes, ranging from fluid accumulation and swelling in the spinal canal to compression of the spine, leading to fracture. Symptoms vary based on the level of injury. There is a range of severity of injury, with incomplete spinal cord injury meaning some function at the injury level is still retained while complete injury indicates a total loss of function at and below the level of injury.

Contents

Incidence and Prevalence

It is estimated that there are 12,000 new cases of SCI per year. The average age at injury has been 40.2 years since 2005, and 80.9% of all injuries were male. Additionally, 66.1% of the injured individuals were Caucasian, 27.1% were African American, and 2.0% were Asian. Finally, incomplete tetraplegia accounted for 30.1% of the injuries, complete paraplegia was 25.6% of the injuries, complete tetraplegia was 20.4% of the injuries, and incomplete paraplegia was 18.5% of the injuries. [1]

Causes

There are many causes of SCI, including trauma, tumor, ischemia, developmental disorders, neurodegenerative disorders, demyelinative disorders, transverse myelitis, and vascular malformations. [2][3][4] Minor injuries leading to SCI occur if the spine is weakened, as in the case of osteoporosis, or if spinal stenosis is present. SCI can be due to the spine being damaged and fragments of bone or metal cutting the spinal cord. Additionally, any incident where the spinal cord is pulled, pressed sideways, or compressed leads to direct damage of the spinal cord. Finally, any fluid accumulation within the spinal canal, such as blood or swelling, can compress the cord, thereby causing damage. [5] Injuries due to trauma account for a very large portion of SCI. Of these, motor vehicle accidents, falls, acts of violence and sports accidents leading to SCI are the most common. [6]

Breakdown of traumatic causes of SCI
Breakdown of traumatic causes of SCI [7]

Signs and Symptoms

The following list includes signs and symptoms of SCI:

  • Loss of movement
  • Loss of sensation, including ability to feel heat, cold, or touch
  • Loss of bowel or bladder control
  • Exaggerated reflex activities or spasms
  • Changes in sexual function, sexual sensitivity and fertility
  • Pain or an intense stinging sensation caused by damage to the nerve fibers in the spinal cord
  • Difficulty breathing, coughing, or clearing secretions from your lungs
  • Extreme back pain or pressure in your neck, head, or back
  • Weakness, incoordination or paralysis in any part of the body
  • Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
  • Difficulty with balance and walking
  • Oddly positioned or twisted neck or back [8]

Diagnosis of SCI

The following medical tests can be performed to determine whether or not a spinal cord injury has occurred:

  • X- ray: reveals vertebral problems, tumors, fractures or degenerative changes in the spine
  • CT Scan: better look at abnormalities seen on x-ray. Can define bone, disk, and other problems
  • MRI: can look at the spinal cord and identify herniated disks, blood clots, or other masses that may compress the spinal cord
  • Myelography: allows visualization of the spinal nerves more clearly[9]

ASIA Impairment Scale

The American Spinal Injury Association (ASIA) impairment scale is used to describe a person’s functional impairment as a result of their spinal cord injury. The ASIA scale is used to document both sensory and motor impairments as a result of SCI. Based on neurologic responses, sensation testing, and strength of key muscle groups, this scale describes the individual’s function level.

  • A: complete; no sensory or motor function preserved in S4-S5
  • B: incomplete; sensory but not motor function preserved below neurological level and extending through S4-S5
  • C: incomplete; motor function preserved below neurological level. Most key muscles have < grade 3 power
  • D: incomplete; motor function preserved below neurological level. Most key muscles have > grade 3 power
  • E: normal motor and sensory function[10]

Dermatomes

Dermatomes describe spinal levels corresponding to sensory areas on the body
Dermatomes describe spinal levels corresponding to sensory areas on the body [11]

Dermatomes describe the levels of the spinal cord corresponding to ability to feel sensation at various parts of the body. Spinal cord injuries typically affect the levels at and below the level of injury. It is important to note, however, that incomplete spinal cord injuries can have virtually any presentation, so not all injuries at the same level will result in the same sensational and functional limitations.

The principle dermatomes are listed below.

  • C5: clavicles
  • C5, 6, 7: lateral side of upper limbs
  • C8, T1: medial side of upper limbs
  • C6: thumb
  • C6, 7, 8: hand
  • C8: ring and little fingers
  • T4: level of nipples
  • T10: level of umbilicus
  • T12: inguinal or groin regions
  • L1, 2, 3, 4: anterior and inner surfaces of lower limbs
  • L4, 5, S1: foot
  • L4: medial side of great toe
  • S1, 2, L5: posterior and outer surfaces of lower limbs
  • S1: lateral margin of the foot and little toe
  • S2, 3, 4: perineum

Functional Motor Levels

Functional motor levels can be determined based on the level of injury along with a physical examination of the patient. It is important to note that, although a patient may have an injury at one level, the functional level may present differently due to an incomplete injury. In general, a higher level injury indicates a higher loss in sensation and motor function. Function of muscles at and below the level of injury is generally affected.

Innervation levels corrseponding to spinal nerve roots
Innervation levels corrseponding to spinal nerve roots [12]

The following list shows how the level of injury affects function.

  • C1-C6: Neck flexors
  • C1-T1: neck extensors
  • C3, 4, 5: diaphragm (mostly C4)
  • C5, 6: shoulder movement, arm raise, elbow flexion, supination of arm
  • C6, 7: elbow extension, wrist extension, wrist pronation
  • C7, T1: wrist flexion, intrinsic hand muscles
  • T1-6: Intercostal muscles and trunk above waist
  • T7-L1: Abdominals
  • L1-4: Thigh flexion
  • L2-3: thigh adduction
  • L4-S1: thigh abduction
  • L5-S2: extension of hip
  • L2-4: knee extension
  • L4-S2: knee flexion
  • L4-S1: dorsiflexion of foot
  • L4-S1: toe extension
  • L5-S2: plantar flexion of foot
  • L5-S2: toe flexion

Medical Management

Early treatment and management is necessary to prevent further damage to the spinal cord. Immediately post-injury, there should be a focus on maintaining the ability to breathe, preventing shock, and immobilizing the neck to prevent further damage. Early administration of corticosteroids may improve the spinal cord injury by reducing damage to nerve cells and decreasing inflammation near the site of the injury. Additionally, surgery should be performed early if fragments of bones, foreign objects, herniated disks, or fracture vertebrae that could compress the spine are present; if the spine is unstable, surgery may also be required in order to reduce the risk of further injury. [13]

Early rehabilitation is key to the maintenance of strength and existing function, redevelopment of fine motor skills, and adaptive techniques to accomplish day-to-day tasks. Long-term treatment and rehabilitation maintains a focus on the prevention of secondary problems. These problems often include deconditioning, muscle contractures, pressure ulcers, bowel and bladder issues, respiratory infections, and blood clots. A very comprehensive rehabilitation team typically includes individuals from many fields, including but not limited to physical therapists, occupational therapists, rehabilitation nurses, rehabilitation psychologists, social workers, dieticians, recreation therapists, and physiatrists. [14]

References

  1. Foundation for Spinal Cord Injury Prevention, Care & Cure. (2009). “Spinal Cord Injury Facts.” National Spinal Cord Injury Statistical Center (NSCISC). Retrieved October 8, 2011, from http://www.fscip.org/facts.htm.
  2. (2010). "Spinal Cord Injury Rehabilitation." Patient Care. Retrieved October 8, 2011, from http://www.shepherd.org/patient-care/spinal-cord-injury.
  3. (2010). "Spinal Cord Injury." Retrieved Sept 15, 2010, from http://www.spinalcord.org/index.php.
  4. (2010). "NINDS Spinal Cord Injury Information Page." Retrieved October 10, 2011, from http://www.ninds.nih.gov/disorders/sci/sci.htm.
  5. A.D.A.M. Medical Encyclopedia. (2010). “Spinal cord trauma.” U.S. National Library of Medicine. Retrieced October 10, 2011, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002061/.
  6. Foundation for Spinal Cord Injury Prevention, Care & Cure. (2009). “Spinal Cord Injury Facts.” National Spinal Cord Injury Statistical Center (NSCISC). Retrieved October 8, 2011, from http://www.fscip.org/facts.htm.
  7. http://www.fscip.org/facts.htm
  8. Mayo Clinic Staff. (2010). “Spinal Cord Injury.” Mayo Foundation for Medical Research. Retrieved October 10, 2011, from http://www.mayoclinic.com/health/spinal-cord-injury/.
  9. Mayo Clinic Staff. (2010). “Spinal Cord Injury.” Mayo Foundation for Medical Research. Retrieved October 10, 2011, from http://www.mayoclinic.com/health/spinal-cord-injury/.
  10. http://www.aic.cuhk.edu.hk/web8/spinal_injury.htm
  11. (2010). “Disks, Spurs, Stenosis: Slippage, and Osteoporosis.” Retrieved October 6, 2011, from http://www.backpain-guide.com/Chapter_Fig_folders/Ch06_Path_Folder/4Radiculopathy.html.
  12. http://www.sci-info-pages.com/levels.html
  13. Mayo Clinic Staff. (2010). “Spinal Cord Injury.” Mayo Foundation for Medical Research. Retrieved October 10, 2011, from http://www.mayoclinic.com/health/spinal-cord-injury/.
  14. Mayo Clinic Staff. (2010). “Spinal Cord Injury.” Mayo Foundation for Medical Research. Retrieved October 10, 2011, from http://www.mayoclinic.com/health/spinal-cord-injury/.