Injury to the Spinal Cord (Spinal Cord Injury)

First aid for a suspected spinal injury

1. Call 911 or your local emergency number.
2. Do not move the person unless they are in danger, such as from fire or traffic.
3. Keep the head and neck still. Kneel behind the person and hold their head in line with the body, or place rolled towels on both sides.
4. Do not remove a helmet unless it blocks the airway.
5. Check breathing. If the person is not breathing, start CPR, moving the head as little as possible, using a jaw thrust if trained.
6. If the person must be rolled because of vomiting, roll them as a unit ("log roll") with helpers keeping the head, neck and body aligned.
7. Keep them warm and reassure them.

How the spinal cord works

The spinal cord runs from the base of the brain down the spinal canal, protected by the vertebrae. Nerves branching off at each level supply specific areas of the body. Injury damages nerve fibers at and below the injury site, so the higher the injury, the more of the body is affected.

Levels and types of injury

Complete vs incomplete injury

• complete: no movement or sensation below the injury, including the lowest sacral segments
• incomplete: some function remains below the injury. Incomplete injuries now make up most new cases and have better recovery potential

Doctors use the ASIA Impairment Scale (A to E) to describe severity.

Incomplete cord syndromes

• central cord syndrome: arms weaker than legs, common in older adults after falls with neck arthritis
• anterior cord syndrome: loss of movement and pain sensation, with preserved position sense
• Brown-Séquard syndrome: weakness on one side and loss of pain and temperature sensation on the other
• cauda equina and conus injuries: low back injuries affecting legs, bladder, bowel and sexual function

Causes

• motor vehicle crashes, the leading cause
• falls, especially in adults over 65
• acts of violence, mainly gunshot wounds
• sports and recreation, including diving into shallow water
• non-traumatic causes: tumors, infections, disc herniations, spinal cord compression, loss of blood supply

Symptoms

• weakness or paralysis
• loss of sensation, numbness or tingling
• loss of bladder or bowel control
• difficulty breathing or coughing
• neck or back pain or pressure
• changes in sexual function
• spasms and exaggerated reflexes, later
• nerve pain

Diagnosis

• trauma assessment and neurological examination using ASIA standards
• CT scan of the spine to identify fractures
• MRI to show cord damage, bleeding, swelling, disc herniation or ligament injury
• X-rays in some cases

Head injuries often coexist, so a traumatic brain injury assessment is also done.

Acute treatment

• spinal immobilization and careful transfer
• airway and breathing support, sometimes a ventilator
• blood pressure support, since neurogenic shock can cause low blood pressure and slow heart rate
• surgery to decompress the spinal cord and stabilize the spine, often within 24 hours
• prevention of complications: blood clot prevention, pressure injury prevention, bladder catheterization

High-dose steroids are no longer routinely recommended.

Complications and long-term care

• neurogenic bladder: managed with intermittent catheterization and other methods
• neurogenic bowel: managed with a bowel program
• pressure ulcers: prevented by regular position changes and skin checks
• spasticity: stiffness and spasms, treated with stretching, medicines or botulinum toxin
• autonomic dysreflexia: a dangerous blood pressure spike in injuries at T6 or above, triggered by a full bladder, constipation or skin problems. It needs immediate action: sit up, loosen clothing and find the trigger
• deep vein thrombosis
• breathing problems and pneumonia
• chronic pain, often nerve pain
• osteoporosis and fractures
• depression and anxiety

Rehabilitation and outlook

Rehabilitation begins early in specialized centers. Physical and occupational therapy, wheelchairs and assistive technology, home and vehicle adaptations, vocational rehabilitation and peer support help people regain independence. Most recovery occurs in the first 6 to 12 months, with smaller gains possible for years, particularly in incomplete injuries. Research into stimulation, cell therapies and nerve repair continues.

Life expectancy depends on age, injury level and completeness, but many people with SCI live long and active lives.

Prevention

• wear seat belts and use appropriate child car seats
• never dive headfirst into shallow or unknown water
• prevent falls in older adults
• use proper technique and protective gear in sports
• store firearms safely

Frequently asked questions

What are the signs of a spinal cord injury?

Signs include neck or back pain after an injury, weakness or paralysis, numbness or tingling in the arms or legs, loss of bladder or bowel control, and difficulty breathing. Anyone with these after a fall, crash or diving accident should be kept still and assessed urgently.

What is the difference between complete and incomplete spinal cord injury?

In a complete injury, there is no movement or sensation below the level of injury. In an incomplete injury, some movement or feeling remains. Incomplete injuries are more common today and generally have better potential for recovery.

What is the difference between paraplegia and quadriplegia?

Paraplegia is paralysis of the legs and lower body, usually from injuries in the chest or lower back. Quadriplegia, also called tetraplegia, affects the arms, legs and trunk, usually from neck injuries.

Can you recover from a spinal cord injury?

Some recovery is possible, especially with incomplete injuries. Most improvement happens in the first 6 to 12 months, although gains can continue for years. Rehabilitation, assistive devices and adaptations help people achieve independence even when paralysis remains.

What is autonomic dysreflexia?

Autonomic dysreflexia is a sudden, dangerous rise in blood pressure in people with spinal cord injuries at or above the mid-chest level. It causes a pounding headache, flushing and sweating above the injury. It is usually triggered by a full bladder or bowel and needs immediate treatment.