Spinal Cord Injury can result in paralysis. It may be present in two or four limbs. Paraplegia is the paralysis of the lower extremities. Quadriplegia is the paralysis of all extremities. An estimated 30,000 Canadians live with a spinal cord injury. Each year, about 1,000 Canadians sustain damage to their spinal cord.
- Approximately 80% are male;
- About 50% are paraplegic; 50% are quadriplegic;
- The majority are ages 18 to 24
Paralysis may be complete or incomplete. The extent of paralysis depends on the level of injury in the spinal cord and the extent of damage. Spinal cord injury can result in:
- Loss of control of trunk muscles
- Loss of control of breathing
- Loss of sensation
- Loss of bladder and bowel control
- Alteration of sexual functioning
- Pain and muscle spasms
Spinal Cord Injury:
- Is usually permanent and non-progressive
- Is presently incurable
- Does not cause intellectual disability
- Does not prevent a person from working, playing, having a family and living a full life
Causes of Spinal Cord Injury
The causes of spinal column and/or cord injury may be classified as follows:
- raumatic: motor vehicle accidents • falls • industrial accidents • diving injuries • gunshot wounds • stab wounds • sports related injuries • surgical complications
- Developmental: Spina bifida • Familial paralysis
- Infective: Viral • Bacterial • Tuberculosis
- Degenerative “wear and tear arthritis”: Disc herniation • Rheumatoid spine • Ankylosing spondylitis
- Tumours: Non-cancerous • Cancerous
- Vascular spinal artery thrombosis: Bleeding into the cord due to hemphelia • Artio-venous malformations • Angioma • Arteritis, as in systemic lupus erythematosus
- Metabolic: Vitamin B12 Deficiency
- Diopathis: Multiple sclerosis • Syringomyelia
- Iatrogenic: Radiation • Surgical complications
- Psychological: conversion reaction
A high percentage of spinal cord injuries are young adult males, the sports enthusiasts and the daredevils. A major consideration becomes the psychological impact of a sudden change from full physical capacity and independence to a paralyzed accident victim who may require partial to complete assistance to continue living.
Many times, the timesaving procedures at the time of injury contribute as much or more to spinal cord injury than the actual accident, when handling of the injured is attempted by someone who is untrained.
Spinal Injuries and their symptoms, residual outcomes and outcome of rehabilitation can vary from individual to individual.
Spinal Cord Injuries
Immediately following injury of any type, the spinal cord goes into a state of shock called spinal shock. During this period, the cord below the level of lesion stops functioning completely. This loss of movement, sensation, reflexes, bowel and bladder control can last from 6 hours to 6 weeks. When the spinal shock has subsided, it can be determined whether the injury is a complete or incomplete lesion.
Types of Injuries and Lesions
- Upper Motor Neuron: In this type of injury, the spinal cord and the nerves below the level of the injury are capable of reflex functioning, but no longer receive messages from the brain. The paralysis in these cases is associated with increased tone in the muscles and brisk reflexes.
- Lower Motor Neuron: This type of damage may be to the cord itself, with the nerve cells in the cord destroyed so that the cord cannot function, even independent of the central control. This type of injury may occur when the damage is to the cauda equina. It usually occurs in association with injuries to the lumbar vertebrae. Lower motor neuron type of paralysis is associated with absent reflexes and decreased or absent tone in the muscles leading to an eventual wasting of the muscles.
- Fixed type of Injury: A combination of upper and lower motor neuron type of injury can occur if there is damage at the level of T12 or L1 vertebrae. This results in damage to the last part of the spinal cord itself, as well as to the nerve roots which form the cauda equina.
- Complete Lesion: With this type of lesion, there is total paralysis and loss of sensation below the level of the lesion, associated with loss of normal bladder, bowel and sexual function.
- Incomplete Lesion: With this type of lesion, there is some sparing of movement and/or sensation below the level of the lesion. Depending upon the pattern of sparing, incomplete lesions can be classified as follows:
- Anterior Cord Syndrome: This type of damage is to the anterior part of the cord. There is complete paralysis below the level of the lesion, as well as a loss of pain, temperature and touch sensations. There is sparing of pressure and joint sensations. A small number of these patients go on to recover motor power.
- Central Cord Syndrome: The damage here is to the centre of the cord with a lot of swelling within the cord. In these patients, there is some sparing of motor power and sensations to pinprick and temperature which gradually improve with time. Recovery usually starts in the muscles of the lower legs and progresses upwards, with the hands being the last to recover. This recovery may occur over a period of 12 months.
- Brown-Sequard Syndrome: The damage here is mainly to one side of the spinal cord. On the side of the damage, below the lesion, there is loss of motor power and sensations to pressure and joint position. On the opposite side, below the lesion, there is loss of pain and temperature sensations. Chances of complete recovery in this type of lesion are quite good.
- Cauda Equina Lesion: With this type of lesion, there is a patchy loss of motor power and sensory loss, depending on the extent of the injury to the nerve roots. If not completely crushed, nerve roots regrow and there is functional recovery, which can occur over a period of 12 to 18 months.
Injury to the spinal cord may consist of transection (complete crushing or severance), or a nick (partial destruction), or a bruise, with resultant paralysis from total to varying degrees of recovery. Functional expectations, or the ability to manage various tasks, will vary according to the level of spinal cord involvement. Below is a brief description of expectations based on numerous observations.
- C4 Quadriplegia: Quadriplegia at this level means that a person has movement at the shoulders and neck. While assistance will be required for personal care, some independence can be maintained by using a motorized wheelchair with head controls to enable the person to use an intercom, a telephone, a door lock, a computer, etc. Functional activities such as turning the pages of a book and typing may be achieved through the use of a mouth stick.
- C5 Quadriplegia: A person with quadriplegia at this level will have good shoulder movement and some elbow movement. He/she will be able to raise the hand to the face. There will be no wrist or finger movements, so objects will need to be held by using various straps or attachments. With these aids, the person will be able to do some feeding, grooming (brushing teeth and hair), as well as activities such as writing, typing and dialing a phone. Assistance will be required for personal care such as bathing, dressing, bowel and bladder care and transferring. While some people may be able to push a manual wheelchair for short distances, a power chair with hand controls will provide independent mobility to travel long distances, such as shopping or going to work. Electronic aids, while not a necessity, will certainly increase the person’s control over the environment. Such controls could include a remote TV control, electronic door lock, remote control light switches, speaker phone, etc.
- C6 Quadriplegia: A person with spinal cord injury at this level, in addition to shoulder movements, has wrist extension. Wrist extension enables the person to grip light objects between the thumb and the index finger by taking advantage of the tenodesis action of the hand. Tenodesis is the automatic tightening of the finger tendons resulting in some grasp when the wrist is extended. It is very important not to push down on the open hand as this will stretch these tendons and weaken the available grasp. A tenodesis splint strengthens this grasp and allows for extended periods of hand activity. The person with this level of spinal cord injury will require minimal assistance with feeding, dressing, grooming, pushing a manual wheelchair and transferring. Aids may be used to increase independence in some areas of personal care. Bowel and bladder care is usually carried out with assistance. Driving a car is possible using hand controls for gas and brake pedals. Depending upon the person’s transfer skill, a car or van will be used.
- C7 Quadriplegia: The person with quadriplegia at the C7 level has active wrist flexion and elbow extension as well as wrist extension, elbow flexion and shoulder movement. The triceps muscle produces elbow extension and allows a person to straighten the elbow and obtain a good lift. A C7 quadriplegic has the potential to be independent in feeding, grooming, dressing, bowel and bladder care and transferring. One is able to push a manual wheelchair and has generally more endurance than a C6 quadriplegic. While a tenodesis splint may still be used to advantage, more activities can be performed without aids. Driving is possible with hand controls. A car may be used, as the person will probably be able to transfer independently and pull the wheelchair into the car.
- C8 to T1 Quadriplegia: A person with quadriplegia at C8 or T1 has good strength in the arms and some degree of hand function. The long flexors and extensors to the fingers allow grasp. The small intrinsic muscles in the hand provide strength to the grasp and the ability to do fine manipulative activities. At this level of spinal cord injury, the person is able to be completely independent in all self-care and has good endurance.
- Paraplegia: A person with paraplegia is able to be independent in a wheelchair and live completely independently once the architectural barriers such as stairs are resolved. Besides the wheelchair, the only aids which may be needed are cushions on hard surfaces to protect the skin and hand controls for the car. When the injury is at a low level around the hip joint, walking with bracing may be possible.
Complications Associated with SCI
Listed below are a few of the more commonly seen complications that may develop following a spinal cord injury. The descriptions are brief. For more information, please contact your local Spinal Cord Injury Association or Paraplegia Foundation.
- Bradyarrhythmias: An abnormally slow heart rate
- Paralytic Ileus: The small bowel loses its normal peristalsis (wave-live contractions).
- Gastric Ulceration: Stomach ulcers caused by an increase in the production of acid by the cells or the lining, due to the increased stress level.
- Phantom Sensation: Perception of pain or various types of sensations in the areas that have no sensation.
- Neurogenic Pain: Pain, tingling, or burning sensations felt at the level of the injury, caused by nerve cells of the spinal cord that have been damaged but not completely destroyed.
- Myofascial Pain: Loss of movement causes the muscles to become tight, resulting in pain.
- Autonomic Hyperreflexia: “Flu like” symptoms can occur when there is an undetected problem (injury, infection) below the level of lesion. Due to lack of sensation, it is difficult to detect such a problem, but the body responds with certain symptoms.
- Heterotropic Ossification: New bone is laid down in the muscles around the joints.
- Syringomyelia: (Syrinx – caviey; myelia – spinal cord) Formation of cysts in the spinal cord causing a progressive loss of sensation and muscle power above the level of the original injury.
- Osteoporosis: The bones become less dense and are at a greater risk of fractures.
- Postural Hypotension: A sudden drop in the blood pressure caused by the slow return of blood from the legs and feet following a rapid change in position from lying to sitting.
- Respiratory Changes: Normal breathing or respiratory function cannot be attained because the muscles involved have been affected by the spinal cord injury.
- Altered Temperature Regulation: Unable to control one’s body temperature when the air is hot or cold.
- Deep Vein Thrombosis: Lack of movement and inability to move causes the blood to flow more slowly, which may result in the development of a clot or thrombosis in the vein.
- Pulmonary Embolus: When a piece of blood clot in the leg breaks off and goes to the lung, impeding the normal flow of blood to the lungs.
- Swollen Feet: Gravity and reduced activity can cause some of the fluid to leak out of the blood and remain in the feet.
- Pressure Sores: Decubutis ulcers are a constant threat to the SCI patient who lacks sensation. A continuous program of exercise, shifting of position and a daily inspection of the involved areas is necessary in order to prevent tissue breakdown.
- Fractures and Burns: A lack of sensation and the flaccid condition of limbs requires careful movement of paralysed parts to avoid twisting or crushing with a resultant fracture and burns resulting from contact with hot surfaces.
- Pain: Pain of varying intensities is a common complaint of the paraplegic and may be of four types:
- Localized or somatic root pain
- Visceral (internal organs of the body)
- Diffuse pain in areas with sensory loss (phantom limb pain)
- Chronic pain resultant from improper positioning or continual muscle strain
- Psychic factors such as a hostile attitude, a sexual problem or a feeling of frustration can be the cause of recurrent pain or may increase one of the above three types.
- Emotional Problems: Spinal cord injury can result in a healthy individual becoming totally or partially dependent on others. Spells of depression and negativism may result. There may be refusal to co-operate, or at least to co-operate fully. There may be considerable concern over future vocational ability.
- Outlook: The site of the injury, the extent of the lesion, the mental attitude of the patient and his physical condition, are all factors in the determination of restoration of function. In the final analysis, only the SCI patient can indicate what progress is possible. Changes in environment and societal attitudes have made success in re-entry to vocations, recreation and normal involvement very probable.
Source: Canadian Paraplegic Association.