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Quadriplegia / Spinal Cord Injury

Definition:
In 1995, actor Christopher Reeve fell off a horse and severely damaged his spinal cord, leaving him paralyzed from the neck down. From then until his death in 2004, the silver screen Superman became the most famous face of spinal cord injury. But he was not alone. Every year, about 11,000 Americans experience a traumatic spinal cord injury. Many other people develop nontraumatic spinal cord injuries, due to infection or chronic conditions.

A diagnosis of spinal cord injury can be devastating. The sudden presence of disability can be frightening, frustrating and confusing to those affected and their families and friends. They naturally wonder how spinal cord injury will affect their everyday activities, their jobs, their relationships, their dreams and their long-term happiness.

Most trauma to the spinal cord causes permanent disability or loss of movement (paralysis) and sensation below the site of the injury. Paralysis can involve all four extremities, a condition called quadriplegia or tetraplegia, or only the lower body, a condition called paraplegia.

But there is good news. Christopher Reeve's celebrity and advocacy raised national interest, awareness and research funding for spinal cord injury. Many scientists are optimistic that important advances will restore some function in people with a spinal cord injury within the next 10 to 25 years. In the meantime, medications, rehabilitation and counseling allow many people with spinal cord injury to lead happy, active, independent lives.

Causes:
Together, your spinal cord and your brain make up your central nervous system, which controls most of the functions of your body. Your spinal cord runs approximately 15 to 17 inches from the base of your brain to your waist and is composed of long nerve fibers that carry messages to and from your brain. These nerve fibers feed into nerve roots that emerge between your vertebrae — the 33 bones that surround your spinal cord and make up your backbone. There, the nerve fibers organize into peripheral nerves that extend to the rest of your body.

Injury may be traumatic or nontraumatic
A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine that fractures, dislocates, crushes or compresses one or more of your vertebrae. It may also result from a gunshot or knife wound that penetrates and cuts your spinal cord. Additional damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around your spinal cord. Nontraumatic spinal cord injury may be caused by arthritis, cancer, blood vessel problems or bleeding, inflammation or infections, or disk degeneration of the spine.

Whether the cause is traumatic or nontraumatic, the damage affects the nerve fibers passing through the injured area and may impair part or all of your corresponding muscles and nerves below the injury site. Spinal injuries occur most frequently in the neck (cervical) and lower back (thoracic and lumbar) areas. A thoracic or lumbar injury can affect leg, bowel and bladder control, and sexual function. A cervical injury may affect breathing as well as movements of your upper and lower limbs.

The spinal cord ends at the lower border of the first vertebra in your lower back — known as a lumbar vertebra. So injuries below this vertebra actually don't involve the spinal cord. However, an injury to this part of your back or pelvis may damage nerve roots in the area and may cause some loss of function in the legs, as well as difficulty with bowel and bladder control and sexual function.

Common causes of spinal cord injury
The most common causes of spinal cord injury in the United States are :

  • Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for approximately 50 percent of new spinal cord injuries each year.
  • Acts of violence. Since 2000, 11 percent of spinal cord injuries have resulted from violent encounters, primarily involving gunshot wounds.
  • Falls. Spinal cord injury after age 65 is often caused by a fall. Overall, falls make up approximately 24 percent of spinal cord injuries.
  • Sports and recreation injuries. Athletic activities such as impact sports and diving in shallow water cause about 9 percent of spinal cord injuries.
  • Diseases. Cancer, infections, arthritis and inflammation of the spinal cord also cause spinal cord injuries each year. The exact number isn't known, but some estimates suggest that the number could equal or exceed the number of people with traumatic spinal cord injuries each year.
Risk Factors:
Although a spinal cord injury is usually the result of an unexpected accident that can happen to anyone, some groups of people have a higher risk of sustaining a spinal cord injury. These include :
  • Men. Spinal cord injury affects a disproportionate amount of men. In fact, women account for only about 20 percent of spinal cord injuries in the United States.
  • Young adults and seniors. People are most often injured between ages 16 and 35. But there is another peak in people older than 60. Motor vehicle crashes are the leading cause of spinal cord injury for young people, while falls cause most injuries in older adults. However, in some cities, acts of violence — such as gunshot wounds, stabbings and assaults — are a major cause of spinal cord injury.
  • People who are active in sports. Sports and recreational activities cause up to 9 percent of the 11,000 spinal cord injuries in the United States each year. High-risk athletic activities include football, rugby, wrestling, gymnastics, diving, surfing, ice hockey and downhill skiing.
  • People with predisposing conditions. A relatively minor injury can cause spinal cord injury in people with conditions that affect their bones or joints, such as arthritis or osteoporosis.

When to seek medical advice :
Spinal cord injury isn't always obvious. Numbness or paralysis may result immediately after a spinal cord injury or gradually as bleeding or swelling occurs in or around the spinal cord. In either case, the time between injury and treatment is a critical factor that can determine the extent of complications and the level of recovery.

Anyone who has experienced significant trauma to the head or neck needs immediate medical evaluation for the possibility of spinal cord injury. In fact, it's safest to assume that trauma victims have a spinal cord injury until proved otherwise.

If you suspect that someone has a back or neck injury, don't move the injured person. Permanent paralysis and other serious complications may result. Instead, take these steps :

  • Dial 911 or call for emergency medical assistance.
  • Keep the person still.
  • Place heavy towels on both sides of the neck to prevent it from moving, until emergency care arrives.
  • Provide basic first aid, such as stopping any bleeding and making the person comfortable, without moving the head or neck.

Symptoms :

The signs and symptoms of a spinal cord injury depend on two factors :

  • The location of the injury. In general, injuries that are higher in the spinal cord produce more paralysis. For example, a spinal cord injury at the neck level may cause paralysis in both arms and legs and make it impossible to breathe without a respirator, while a lower injury may affect only the legs and lower parts of the body.
  • The severity of the injury. Spinal cord injuries are classified as partial or complete, depending on how much of the cord width is damaged. In a partial spinal cord injury, which may also be called an incomplete injury, the spinal cord is able to convey some messages to or from the brain. So people with partial spinal cord injury retain some sensation and possibly some motor function below the affected area. A complete injury is defined by complete loss of motor function and sensation below the area of injury. However, even in a complete injury, the spinal cord is almost never completely cut in half. Doctors use the term "complete" to describe a large amount of damage to the spinal cord. It's a key distinction because many people with partial spinal cord injuries are able to experience significant recovery, while those with complete injuries are not.

Spinal cord injuries of any kind may result in one or more of the following signs and Symptoms:

  • Pain or an intense stinging sensation caused by damage to the nerve fibers in the spinal cord
  • Loss of movement
  • Loss of sensation, including the ability to feel heat, cold and touch
  • Loss of bowel or bladder control
  • Exaggerated reflex activities or spasms
  • Changes in sexual function, sexual sensitivity and fertility
  • Difficulty breathing, coughing or clearing secretions from the lungs

Emergency signs and symptoms
Emergency signs and symptoms of spinal cord injury after a head injury or accident may include:

  • Fading in and out of consciousness
  • Extreme back pain or pressure in the neck, head or back
  • Weakness, incoordination or paralysis in any part of the body
  • Numbness, tingling or loss of sensation in the hands, fingers, feet or toes
  • Loss of bladder or bowel control
  • Difficulty with balance and walking
  • Impaired breathing after injury
  • An oddly positioned or twisted neck or back

Diagnosis:
Paramedics and emergency workers are trained to treat people who have suffered a traumatic head or neck injury as if they have a spinal cord injury or an unstable spinal column, until a thorough screening and diagnosis can be completed. A key step in the initial treatment is immobilizing the spine.

Immobilizing the spine can prevent injury to the spine or prevent worsening of any injury that is already present. For this reason, emergency personnel receive training in handling an injured person without moving the neck and back. They use rigid collars around the injured person's neck and place the injured person on a rigid board, until a complete evaluation can take place.

In the emergency room, a doctor may be able to rule out spinal cord injury by carefully inspecting an injured person, testing for sensory function and movement, and asking some questions about the accident. But if the injured person complains of neck pain, isn't fully awake, or has obvious signs of weakness or neurological injury, emergency diagnostic tests may be needed.

These tests may include :

  • X-rays. Medical personnel typically order these tests on all trauma victims suspected of having a spinal cord injury. X-rays can reveal vertebral problems, tumors, fractures or degenerative changes in your spine.
  • Computerized tomography (CT) scan. A CT scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional images that can define bone, disk and other problems.
  • Magnetic resonance imaging (MRI). MRI uses a strong magnetic force and radio waves to produce computer-generated images. This test is extremely helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may be compressing the spinal cord. But MRI can't be used on people with pacemakers or on trauma victims who need certain life-support machines or cervical traction devices.
  • Myelography. Myelography allows your doctor to visualize your spinal nerves more clearly. After a special dye is injected into your spinal canal, X-rays or CT scans of your vertebrae can suggest a herniated disk or other lesions. This test is used when MRI isn't possible or when it may yield important additional information that isn't provided by other tests.

If your doctor suspects a spinal cord injury, he or she may prescribe traction to immobilize your spine, as well as high doses of the corticosteroid drug methylprednisolone (Medrol). There is some controversy about the use of this medication due to the small benefits noted in research studies and the possible risks. However, there are no other medications available at this time. So, methylprednisolone is generally given as soon as possible, and it must be given within eight hours of injury.

Diagnosis doesn't stop there, though. A few days after injury, your doctor will conduct a neurological exam to determine the severity of the injury and to predict the likely extent of recovery. This may involve more X-rays, MRIs or more advanced imaging techniques.

It's often impossible for your doctor to make a precise prognosis right away. Recovery typically starts between a week and six months after injury, if it occurs, with the majority of recovery taking place within one year. Doctors generally regard any impairment remaining after 12 to 24 months as likely to be permanent.

However, some people experience small improvements for up to two years or longer. At one point, Christopher Reeve made national headlines when he regained the ability to move his fingers and wrists and feel sensations more than five years after he was paralyzed in a horse accident. But many not-so-famous folks with a spinal cord injury have made similar strides away from the media spotlight. And doctors are researching ways to improve late recovery.

Complications :
If you recently experienced a spinal cord injury, it might seem like every aspect of life just became a lot more complicated. After all, adapting to life with a disability — often in a wheelchair — is no easy task.

You'll likely experience many thoughts and emotions after the injury. And you'll likely have concerns about how your injury will affect your lifestyle, your financial situation and your personal relationships. Grieving and emotional stress are normal and common. However, if your grief and sadness are affecting your personal care, causing you to isolate yourself from others, or prompting you to abuse alcohol or other drugs, it's time to seek help. Depression and alcohol abuse can be common.

Other complications of a spinal cord injury may include :

  • Urinary tract problems. A spinal cord injury that affects nerves that run to the bladder can cause urinary incontinence — the inability to control the release of urine from your bladder. Loss of bladder control increases your risk of urinary tract infections. It may also cause kidney infection and kidney or bladder stones. Drinking plenty of clear fluids and using a catheter — a thin, soft tube that you insert into your urethra and bladder to drain your urine — several times a day may help.
  • Bowel management difficulties. After a spinal cord injury, voluntary control of the bowels may be lost or impaired. This can make it difficult for stool to move through your intestines, or it can result in fecal incontinence — the inability to control your bowel movements. Eating a high-fiber diet can help regulate your bowels. Medications and other products are also available to manage waste elimination.
  • Pressure sores. Sitting or lying in the same position for a long period of time can cause pressure sores, which are also called decubitus ulcers or bedsores. People with a spinal cord injury are particularly susceptible to pressure sores because the injury reduces or eliminates sensations, making it difficult to know when a sore is developing. Changing positions frequently — with help, if needed — is the best way to prevent these sores.
  • Deep vein thrombosis and pulmonary embolism. Sitting for long periods of time can also decrease blood flow through the veins and cause blood clots to form. These blood clots can develop in a vein deep within a muscle (deep vein thrombosis), and they can lead to a blocked pulmonary artery in the lungs (pulmonary embolism). Large clots that block blood flow can be fatal, so people with spinal cord injury may need devices or medications to try to prevent clotting.
  • Lung and breathing problems. It's more difficult to breathe and cough with weakened abdominal and chest muscles, so people with cervical and thoracic spinal cord injury may develop pneumonia, asthma or other lung problems. Medications and therapy can treat these problems. In some instances, people with spinal cord injury may also need a yearly flu shot or other immunizations.
  • Autonomic dysreflexia. Spinal cord injury above the middle of the chest may cause a condition called autonomic dysreflexia. This dangerous condition occurs when an irritation or pain below the level of the injury sends a signal that fails to reach the brain, producing a reflex action that can constrict blood vessels. The result is a rise in blood pressure and a drop in heart rate that can result in stroke or seizure. Changing positions or eliminating the cause of the irritation — which can be something as simple as a full bladder or tight clothes — can help.
  • Spasticity. Some people with spinal cord injury develop muscle spasms and jumping of their arms and legs. Unfortunately, this doesn't mean that they're recovering. These exaggerated reflexes occur because some of the nerves in the lower spinal cord become more sensitive after injury and cause muscle contractions. However, because of the spinal cord injury, the brain can no longer send signals to the lower nerves to regulate the contractions. Medical treatments may be needed if spasms become severe.
  • Weight control issues. After a spinal cord injury, weight loss and muscle atrophy are common. But the change in lifestyle and activities may eventually cause weight gain, which can make it difficult for you to lift yourself — or be lifted — from place to place and put you at risk of heart disease and other problems. It's a good idea to develop an exercise and diet plan with assistance from a dietitian and rehabilitation therapist.
  • Sexual dysfunction. Many men with a spinal cord injury still have erections, even men with little sensation in the genital area. But the erections may not be firm enough or last long enough for sexual activity. Fertility also can be affected. Ninety percent of men with a spinal cord injury aren't able to ejaculate during intercourse. However, this doesn't mean that men with a spinal cord injury can't be sexually active or father a child. Doctors, urologists and fertility specialists who specialize in spinal cord injury can offer options for better sexual functioning and fertility. Women with a spinal cord injury also may benefit from seeing a doctor about changes in their sexuality and fertility. There's usually no physical change in women with a spinal cord injury that inhibits sexual intercourse or pregnancy. But women may lose the ability to produce vaginal lubrication or control the vaginal muscles, and many experience changes in body image that affect sexuality. In addition, any pregnancy will likely be considered high risk. It's important to talk with a doctor before becoming pregnant.
  • Pain. You may experience pain as a result of damage to your spinal cord or other parts of your body during your accident. It's possible to feel pain in areas of your body where there's little or no sensation. You may also experience pain from overusing muscles in one part of the body. For example, many people develop shoulder tendinitis from manually operating a wheelchair for a long period of time. Any kind of pain can have a negative impact on daily living. Medications and modified activities can help manage pain.
  • New injuries. People with a spinal cord injury are susceptible to injury of any part of the body that has impaired sensation. Someone with a spinal cord injury may even receive a burn or cut without realizing it. Take steps to prevent new injuries and to inspect your body for any cuts or sores that need medical attention.

Q fever in pregnancy
In pregnancy, both acute and chronic Q fever can result in spontaneous abortion, premature birth and low birth weight.

Treatment:
Fifty years ago, a spinal cord injury was usually fatal. At that time, most injuries were severe, complete injuries and little treatment was available.

Today, there's still no way to reverse damage to the spinal cord. But modern injuries are usually less severe, partial spinal cord injuries. And advances in recent years have improved the recovery of patients with a spinal cord injury and halved the amount of time survivors must spend in the hospital. Researchers are working on new treatments, including innovative treatments, prostheses and medications that may promote nerve cell regeneration or improve the function of the nerves that remain after a spinal cord injury.

In the meantime, treatment focuses on preventing further injury and enabling people with a spinal cord injury to return to an active and productive life within the limits of their disability. This requires urgent emergency attention and ongoing care.

Emergency actions
Urgent medical attention is critical to minimizing the long-term effects of any head or neck trauma. So treatment for a spinal cord injury often begins at the scene of the accident.

If you suffer a head or neck injury, you'll likely be treated by paramedics and emergency workers who will attend to three immediate concerns — maintaining your ability to breathe, keeping you from going into shock and immobilizing your neck to prevent further spinal cord damage. Emergency personnel typically immobilize the spine as gently and quickly as possible using a rigid neck collar and a rigid carrying board, which they'll use to transport you to the hospital.

In the emergency room, doctors focus on maintaining your blood pressure, breathing and neck stabilization and avoiding possible complications, such as stool or urine retention, respiratory or cardiovascular difficulty, and formation of deep vein blood clots in the extremities. You may be sedated so that you don't move and cause more damage while undergoing diagnostic tests for spinal cord injury.

If you do have a spinal cord injury, you'll usually be admitted to the intensive care unit for treatment. You may even be transferred to a regional spine injury center that has a team of neurosurgeons, orthopedic surgeons, spinal cord medicine specialists, psychologists, nurses, therapists and social workers with expertise in spinal cord injury.

In the early stages of paraplegia or quadriplegia, your doctor will treat the injury or disease that caused the loss of function. Immediate treatment may include :

  • Medications. Methylprednisolone (Medrol) is a treatment option for acute spinal cord injury. This corticosteroid seems to cause some recovery in people with a spinal cord injury if given within eight hours of injury. Methylprednisolone works by reducing damage to nerve cells and decreasing inflammation near the site of injury.
  • Immobilization. You may need traction to stabilize your spine and bring the spine into proper alignment during healing. Sometimes, traction is accomplished by placing metal braces, attached to weights or a body harness, into your skull to hold it in place. In some cases, a rigid neck collar also may work.
  • Surgery. Occasionally, emergency surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity. However, some surgeons believe it's safer to wait for several days before attempting any surgery.

Ongoing care
After the initial injury or disease stabilizes, doctors turn their attention to problems that may arise from immobilization, such as deconditioning, muscle contractures, bedsores, urinary infection and blood clots. Early care will likely include range-of-motion exercises for paralyzed limbs, help with your bladder and bowel functions, applications of skin lotion, and use of soft bed coverings or flotation mattresses, as well as frequently changing your position. Hospitalization can last from several days to several weeks, depending on the cause and extent of the paralysis and the progress of your therapy. But treatment doesn't stop when you check out of the hospital. Here are some of the ongoing treatments you can expect.

Rehabilitation. During your hospital stay, a rehabilitation team will work with you to improve your remaining muscle strength and to give you the greatest possible mobility and independence. Your team may include a physical therapist, occupational therapist, rehabilitation nurse, rehabilitation psychologist, social worker, dietitian recreation therapist and a doctor who specializes in physical medicine (physiatrist) or spinal cord injury.

During the initial stages of rehabilitation, therapists usually emphasize regaining leg and arm strength, redeveloping fine-motor skills and learning adaptive techniques to accomplish day-to-day tasks. A program typically includes exercise, as well as training on the medical devices you'll need to assist you, such as a wheelchair or equipment that can make it easier to fasten buttons or dial a telephone.

Therapy often begins in the hospital and continues for several weeks in a rehabilitation facility. As therapy continues, you and your family members will receive counseling and assistance on a wide range of topics, from dealing with urinary tract infections and skin care to modifying your home and car to accommodate your disability. Therapists will encourage you to resume your favorite hobbies, participate in athletic activities and return to the workplace, if possible. They'll even help determine what type of assistive equipment you'll need for these vocational and recreational activities and teach you how to use it.

Medications. You may benefit from medications that manage the signs, symptoms and complications of spinal cord injury. These include medications to control pain and muscle spasticity, as well as medications that can improve bladder control, bowel control and sexual functioning. You may also need short-term medications from time to time, such as antibiotics for urinary tract infections.

New technologies. Inventive medical devices can help people with a spinal cord injury become more independent and more mobile. Some apparatuses may also restore function. These include :

  • Modern wheelchairs. Improved, lighter weight wheelchairs are making people with spinal cord injury more mobile and more comfortable. The Food and Drug Administration has even approved a wheelchair that can climb stairs and elevate a seated passenger to eye level to reach high places without help.
  • Computer devices. Computer-driven tools and gadgets can help with daily routines. You can use voice-activated computer technologies to answer and dial a phone, or to use a computer and pay bills. Computer-controlled technologies can also help with bathing, dressing, grooming, cleaning and reading.
  • Electrical stimulation devices and neural prostheses. These sophisticated devices use electrical stimulation to produce actions. Some are implanted under the skin and connect with the nervous system to supplement or replace lost motor and sensory functions. Others are outside the body. They are often called functional electrical stimulation (FES) systems, and they use electrical stimulators to control arm and leg muscles to allow people with a spinal cord injury to stand, walk, reach and grip. These systems are composed of computer-controlled electrodes that are taped to the skin or implanted under the skin by a needle and controlled by the user. One of the systems allows someone with a spinal cord injury to trigger hand and arm movements. These devices require more research, but they've gained a great deal of attention, in part because the actor Christopher Reeve was able to rely primarily on an FES bicycle that used computer-controlled electrodes to stimulate his legs to cycle. He also had a system implanted to stimulate his breathing.
Prevention:
Following this advice may reduce your risk of a spinal cord injury :
  • Drive safely. Motor vehicle accidents are the leading cause of spinal cord injuries. Wear a seat belt every time you drive. Make sure that your children wear a seat belt or, if they're very young, use a child safety seat. Don't drive while intoxicated.
  • Be safe with firearms. Lock up firearms and ammunition in a safe place to prevent accidental discharge of weapons. Store guns and ammunition separately.
  • Prevent falls. Use a stool or stepladder to reach objects in high places. Add handrails along stairways. Place nonslip mats on your bathroom and shower floor. For young children, use safety gates to block stairs and consider installing window guards.
  • Take precautions when playing sports. Always wear recommended safety gear. Avoid headfirst moves, such as diving into shallow water, spear tackling in football, sliding headfirst in baseball and skating headfirst into the boards in ice hockey. Use a spotter in gymnastics.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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