Spinal cord injuries

Spinal cord injury

ICD-10	G959, T093
ICD-9
OMIM	[1]
DiseasesDB	12327 29466
MedlinePlus	[2]
eMedicine	emerg/553 neuro/711 pmr/182 pmr/183 orthoped/425
MeSH	{{{MeshNumber}}}

Spinal cord injury causes myelopathy or damage to white matter or myelinated fiber tracts that carry sensation and motor signals to and from the brain. It also damages gray matter in the central part of the spine, causing segmental losses of interneurons and motorneurons. Spinal cord injury can occur from many causes, including:

• Trauma such as Car crashe whiplash, falls, gunshots, diving accidents, war injuries, etc.
• Tumor such as meningiomas, ependymomas, astrocytomas, and metastatic cancer.
• Ischemia resulting from occlusion of spinal blood vessels, including dissecting aortic aneurysms, emboli, arteriosclerosis.
• Developmental disorders, such as spina bifida,etc
• Neurodegenerative diseases, such as Friedreich's ataxia, spinocerebellar ataxia, etc.
• Demyelinative diseases, such as Multiple Sclerosis.
• Transverse myelitis, resulting from spinal cord stroke, inflammation, or other causes.
• Vascular malformations, such as arteriovenous malformation (AVM), dural arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and aneurysm.

Classification

The American Spinal Injury Association (ASIA) first published an international classification of spinal cord injury in 1982, called the International Standards for Neurological and Functional Classification of Spinal Cord Injury(ISNCSCI) and now, in its sixth edition, is still widely used to document sensory and motor impairments following SCI. It is based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, including hip flexion (L2), shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), and elbow extension (C7). Traumatic spinal cord injury is classified into five categories on the ASIA Impairment Scale:

• A indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5.
• B indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. This is typically a transient phase and if the person recovers any motor function below the neurological level, that person essentially becomes a motor incomplete, i.e. ASIA C or D.
• C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3, which indicates active movement with full range of motion against gravity.
• D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
• E indicates "normal" where motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores.

Dimitrijevic proposed a further class, the so-called discomplete lesion, which is clinically complete but is accompanied by neurophysiological evidence of residual brain influence on spinal cord function below the lesion.

In addition, there are several clinical syndromes associated with incomplete spinal cord injuries.

• The Central cord syndrome is associated with greater loss of upper limb function compared to lower limbs.
• The Brown-Séquard syndrome results from injury to one side with the spinal cord, causing weakness and loss of proprioception on the side of the injury and loss of pain and thermal sensation of the other side.
• The Anterior cord syndrome results from injury to the anterior part of the spinal cord, causing weakness and loss of pain and thermal sensations below the injury site but preservation of proprioception that is usually carried in the posterior part of the spinal cord.
• Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from infection diseases such as syphilis, causing loss of touch and proprioceptive sensation.
• Conus medullaris syndrome results from injury to the tip of the spinal cord, located at L1 vertebra.
• Cauda equina syndrome is, strictly speaking, not really spinal cord injury but injury to the spinal roots below the L1 vertebra.

One can have spine injury without spinal cord injury. Many people suffer transient loss of function ("stingers") in sports accidents or pain in "whiplash" of the neck without neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant hospitalization. In the United States, the incidence of spinal cord injury has been estimated to be about 35 cases per million per year, or approximately 10,500 per year (35 * 300). In China, the incidence of spinal cord injury was recently estimated to be as high as 65 cases per million per year in urban areas. If so, assuming a population of 1.3 billion, this would suggest an incidence of 84,500 per year (65 * 1300).

The prevalence of spinal cord injury is not well known in many large countries. In some countries, such as Sweden and Iceland, registries are available. About 450,000 people in the United States live with spinal cord injury (one in 670), and there are about 11,000 new spinal cord injuries every year (one in 30,000). The majority of them (78%) involve males between the ages of 16-30 and result from motor vehicle accidents (42%), violence (24%), or falls (27%). This is likely due to increased risk-taking behavior in men.

The Effects of Spinal Cord Injury

Divisions of Spinal Segments

File:Gray 111 - Vertebral column-coloured.png
Segmental Spinal Cord Level and Function
Level	Function
Cl-C6	Neck flexors
Cl-Tl	Neck extensors
C3, C4, C5	Supply diaphragm (mostly C4)
C5, C6	Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates)
C6, C7	Extends elbow and wrist (triceps and wrist extensors); pronates wrist
C7, T1	Flexes wrist
C7, T1	Supply small muscles of the hand
T1 -T6	Intercostals and trunk above the waist
T7-L1	Abdominal muscles
L1, L2, L3, L4	Thigh flexion
L2, L3, L4	Thigh adduction
L4, L5, S1	Thigh abduction
L5, S1, S2	Extension of leg at the hip (gluteus maximus)
L2, L3, L4	Extension of leg at the knee (quadriceps femoris)
L4, L5, S1, S2	Flexion of leg at the knee (hamstrings)
L4, L5, S1	Dorsiflexion of foot (tibialis anterior)
L4, L5, S1	Extension of toes
L5, S1, S2	Plantar flexion of foot
L5, S1, S2	Flexion of toes

The exact effects of a spinal cord injury vary according to the type and level injury, and can be organized into two types:

• In a complete injury, there is no function below the "neurological" level, defined as the lowest level that has intact neurological function. If a person has some level below which there is no motor and sensory function, the injury is said to be "complete". Recent evidence suggest that less than 5% of people with "complete" spinal cord injury recover locomotion.
• A person with an incomplete injury retains some sensation or movement below the level of the injury. The lowest spinal cord level is S4-5, representing the anal sphincter and peri-anal sensation. So, if a person is able to contract the anal sphincter voluntarily or is able to feel peri-anal pinprick or touch, the injury is said to be "incomplete". Recent evidence suggest that over 95% of people with "incomplete" spinal cord injury recover some locomotory ability.

In addition to a loss of sensation and motor function below the point of injury, individuals with spinal cord injuries will often experience other complications of spinal cord injury:

• Bowel and bladder function is regulated by the sacral region of the spine, so it is very common to experience dysfunction of the bowel and bladder, including infections of the bladder, and anal incontinence.
• Sexual function is also associated with the sacral region, and is often affected.
• Injuries of the C-1, C-2 will often result in a loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing.
• Inability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature.
• Spasticity (increased reflexes and stiffness of the limbs).
• Neuropathic pain.
• Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances.
• Atrophy of muscle.
• Superior Mesenteric Artery Syndrome
• Osteoporosis (loss of calcium) and bone degeneration.
• Gallbladder and renal stones.

The Location of the Injury

Knowing the exact level of the injury on the spinal cord is important when predicting what parts of the body might be affected by paralysis and loss of function.

Below is a list of typical effects of spinal cord injury by location (refer to the spinal cord map to the right). Please keep in mind that while the prognosis of complete injuries are predictable, incomplete injuries are very variable and may differ from the descriptions below.

Cervical injuries

Cervical (neck) injuries usually result in full or partial tetraplegia (Quadraplegia). Depending on the exact location of the injury, one with a spinal cord injury at the cervical level may retain some amount of function as detailed below, but are otherwise completely paralyzed.

• C3 vertebrae and above : Typically lose diaphragm function and require a ventilator to breathe.
• C4 : May have some use of biceps and shoulders, but weaker
• C5 : May retain the use of shoulders and biceps, but not of the wrists or hands.
• C6 : Generally retain some wrist control, but no hand function.
• C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the hand and fingers. C7 is generally the level for functional independence.

Patients with complete injuries above C7 typically cannot handle activities of daily living and cannot function independently.^{[citation needed]}

Additional signs and symptoms of cervical injuries include:

• Inability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature.
• Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances.

Thoracic injuries

Injuries at the thoracic level and below result in paraplegia. The hands, arms, head, and breathing are usually not affected.

• T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury.
• T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good.

Lumbar and Sacral injuries

The effect of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus.

Central Cord and Other Syndromes

uncomplete cord syndromes

Central cord syndrome (picture 1) is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs. This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly.

Most often the damage is to the cervical or upper thoracic regions of the spinal cord, and characterized by weakness in the arms with relative sparing of the legs with variable sensory loss.

This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord (the large nerve fibers that carry information directly from the cerebral cortex). Corticospinal fibers destined for the legs are spared due to their more external location in the spinal cord.

This clinical pattern may emerge during recovery from spinal shock due to prolonged swelling around or near the vertebrae, causing pressures on the cord. The symptoms may be transient or permanent.

Anterior cord syndrome (picture 2) is also an incomplete spinal cord injury. Below the injury, motor function, pain sensation, and temperature sensation is lost; touch, proprioception (sense of position in space), and vibration sense remain intact. Posterior cord syndrome (not pictured) can also occur, but is very rare.

Brown-Séquard syndrome (picture 3) usually occurs when the spinal cord is hemisectioned or injured on the lateral side. On the ipsilateral side of the injury (same side), there is a loss of motor function, proprioception, vibration, and light touch. Contralaterally (opposite side of injury), there is a loss of pain, temperature, and deep touch sensations.

Treatment

Treatment for acute traumatic spinal cord injuries have consisted of giving a high dose methylprednisolone if the injury occurred within 8 hours. The recommendation is primarily based on the National Acute Spinal Cord Injury Studies (NASCIS) II and III. Some of the claims of the studies have been challenged as being from faulty interpretation of the data.

Scientists are investigating many promising avenues of treatment for spinal cord injury. Thousands of articles in the medical literature describe work, mostly in animal models, aimed at reducing the paralyzing effect of injury to the spinal cord and promoting regrowth of functional nerve fibers. Despite the devastating effects of the condition, commercial funding for spinal cord cure research is limited, owing primarily to the small size of the population of potential beneficiaries. Despite this, a number of experimental treatments have reached controlled human trials. In addition, nerve protection and regeneration strategies are being studied in more common conditions like Alzheimer's Disease, Parkinson's Disease, Amyotrophic Lateral Sclerosis and Multiple sclerosis. There are many similarities between these neurodegenerative diseases and spinal cord injury, and this research adds considerable new information relevant to spinal cord injury treatment.

Advances in the science of spinal cord injury treatment are newsworthy, and considerable media attention is drawn towards new developments. Aside from the use of methylprednisolone, none of these developments have reached even limited use in the clinical care of human spinal cord injury. Around the world, proprietary centers offering stem cell transplants and treatment with neuroregenerative substances are fueled by glowing testimonial reports of neurological improvement. Independent validation of the results of these treatments is lacking.

See also

• Central nervous system disorders
• Hemiplegia
• Neuromuscular disorders
• Paralysis
• Paraplegia
• Quadriplegia
• Spinal column

External links

• Miami Project to Cure Paralysis Noted for experimental cooling protocol used on Kevin Everett
• United Spinal Association A membership organization dedicated to improving the quality of life of individuals with spinal cord injuries and related disorders.
• Rehabilitation Research and Training Center (RRTC) on Spinal Cord Injury: Promoting Health and Preventing Complications through Exercise
• CareCure Forums- Dr. Wise Young's SCI Forum
• SCI Images - Images of Spinal Cord Injury
• [3]- Spinal Cord Injury Levels and Classification
• Spinal Cord Injury Peer Support Patient, Carer and Spouse Support
• [4] The Spinal Cord Injury Project, W.M. Keck Center for Collaborative Neuroscience at Rutgers University
• EMSCI Network European Multicenter Study about Spinal Cord Injury
• Brigham and Women's Hospital Translational Pain Research Clinical trials for pain following SCI
• Pediatric and Adolescent Spinal Cord Injury
• Rehabilitation Engineering Research Center on Wheeled Mobility
• Spinal Cord Injury Forums SCI Support Forums
• International Institute for Research in Paraplegia Research funding foundation, based in Zurich
• Spinal Cord Injuries Emergency Medicine for Spinal Cord Injuries
• Trefethen, Tre. User's Manual for the Paralyzed Penis: Love after spinal cord injury American Sexuality Magazine. Accessed 3-22-07.
• About Spinal Cord Injury Spinal Cord Injury FAQ for those with SCI, and their families, by Canadian Paraplegic Assocation - Ontario.