Spinal Cord Injury – Diganosis, Symptoms, Treatment and …

Posted: March 12, 2019 at 2:45 am

This post was added by Alex Diaz-Granados

How does the spinal cord work ?

To understand what can happen as the result of a spinal cord injury, it is important to understand the anatomy of the spinal cord and its normal functions.

The spinal cord is a tight bundle of neural cells (neurons and glia) and nerve pathways (axons) that extend from the base of the brain to the lower back. It is the primary information highway that receives sensory information from the skin, joints, internal organs, and muscles of the trunk, arms, and legs, which is then relayed upward to the brain. It also carries messages downward from the brain to other body systems. Millions of nerve cells situated in the spinal cord itself also coordinate complex patterns of movements such as rhythmic breathing and walking. Together, the spinal cord and brain make up the central nervous system (CNS), which controls most functions of the body.

Figure 1. Spinal cord anatomy

The spinal cord is made up of neurons, glia, and blood vessels. The neurons and their dendrites (branching projections that receive input from axons of other neurons) reside in an H-shaped or butterfly-shaped region called gray matter. The gray matter of the cord contains lower motor neurons, which branch out from the cord to muscles, internal organs, and tissue in other parts of the body and transmit information commands to start and stop muscle movement that is under voluntary control. Upper motor neurons are located in the brain and send their long processes (axons) to the spinal cord neurons. Other types of nerve cells found in dense clumps of cells that sit just outside the spinal cord (called sensory ganglia) relay information such as temperature, touch, pain, vibration, and joint position back to the brain.

The axons carry signals up and down the spinal cord and to the rest of the body. Thousands of axons are bundled into pairs of spinal nerves that link the spinal cord to the muscles and the rest of the body. The function of these nerves reflects their location along the spinal cord.

Figure 2. Spinal cord segments

The outcome of any injury to the spinal cord depends upon the level at which the injury occurs in the neck or back and how many and which axons and cells are damaged; the more axons and cells that survive in the injured region, the greater the amount of function recovery. Loss of neurologic function occurs below the level of the injury, so the higher the spinal injury, the greater the loss of function.

Each spinal nerve except C1 receives sensory input from a specific area of skin called a dermatome. A dermatome map is a diagram of the cutaneous regions innervated by each spinal nerve (see Figure 3). Such a map is oversimplified, however, because the dermatomes overlap at their edges by as much as 50%. Therefore, severance of one sensory nerve root does not entirely deaden sensation from a dermatome. It is necessary to sever or anesthetize three sequential spinal nerves to produce a total loss of sensation from one dermatome. Spinal nerve damage is assessed by testing the dermatomes with pinpricks and noting areas in which the patient has no sensation.

Figure 3. Dermatome (spinal nerves sensory innvervation)

The spinal cord, like the brain, consists of two kinds of nervous tissue called gray and white matter. Gray matter has a relatively dull color because it contains little myelin. It contains the somas, dendrites, and proximal parts of the axons of neurons. It is the site of synaptic contact between neurons, and therefore the site of all neural integration in the spinal cord. White matter, by contrast, is whitish containing a mixture of proteins and fat-like substances called myelin covering the axons and allows electrical signals to flow quickly and freely. Myelin is much like the insulation around electrical wires. The white matter is composed of bundles of axons, called tracts, that carry signals from one level of the central nervous system (CNS) to another. It is formed by axon-insulating cells called oligodendrocytes. Because of its whitish color, the outer section of the spinal cordwhich is formed by bundles of myelinated axonsis called white matter. Both gray and white matter also have an abundance of glial cells.

Figure 4. Spinal cord cross section

Knowledge of the locations and functions of the spinal tracts is essential in diagnosing and managing spinal cord injuries.

Ascending tracts carry sensory information up the cord, and descending tracts conduct motor impulses down. All nerve fibers in a given tract have a similar origin, destination, and function. Many of these fibers have their origin or destination in a region called the brainstem. Described more fully in the human brain article.

Several of these tracts undergo decussation as they pass up or down the brainstem and spinal cordmeaning that they cross over from the left side of the body to the right, or vice versa. As a result, the left side of the brain receives sensory information from the right side of the body and sends motor commands to that side, while the right side of the brain senses and controls the left side of the body. Therefore, a stroke that damages motor centers of the right side of the brain can cause paralysis of the left limbs and vice versa.

When the origin and destination of a tract are on opposite sides of the body, anatomists say they are contralateral to each other. When a tract does not decussate, its origin and destination are on the same side of the body and anatomists say they are ipsilateral. Bear in mind that each tract is repeated on the right and left sides of the spinal cord.

Figure 5. Spinal cord tracts

Figure 6. Processing of sensory input and motor output by the spinal cord

Note: Sensory input is conveyed from sensory receptors to the posterior gray horns of the spinal cord, and motor output is conveyed from the anterior and lateral gray horns of the spinal cord to effectors (muscles and glands).

Ascending tracts carry sensory signals up the spinal cord. Sensory signals typically travel across three neurons from their origin in the receptors to their destination in the brain: a first-order neuron that detects a stimulus and transmits a signal to the spinal cord or brainstem; a second-order neuron that continues as far as a gateway called the thalamus at the upper end of the brainstem; and a third-order neuron that carries the signal the rest of the way to the cerebral cortex. The axons of these neurons are called the first- through third-order nerve fibers.

Figure 7. Spinal cord ascending tracts to the brain

Descending tracts carry motor signals down the brainstem and spinal cord. A descending motor pathway typically involves two neurons called the upper and lower motor neurons. The upper motor neuron begins with a soma in the cerebral cortex or brainstem and has an axon that terminates on a lower motorneuron in the brainstem or spinal cord. The axon of the lower motor neuron then leads the rest of the way to the muscle or other target organ. The names of most descending tracts consist of a word root denoting the point of origin in the brain, followed by the suffix -spinal.

Figure 8. Spinal cord descending tracts from the brain

The nervous tissue of the central nervous system (CNS) is very delicate and does not respond well to injury or damage. Accordingly, nervous tissue requires considerable protection. The first layer of protection for the central nervous system is the hard bony skull and vertebral column. The skull encases the brain and the vertebral column surrounds the spinal cord, providing strong protective defenses against damaging blows or bumps.The spinal cord is located within the vertebral canal of the vertebral column. The surrounding vertebrae provide a sturdy shelter for the enclosed spinal cord. The vertebral ligaments, meninges, and cerebrospinal fluid provide additional protection. The second protective layer is the meninges, three membranes that lie between the bony encasement and the nervous tissue in both the brain and spinal cord. Finally, a space between two of the meningeal membranes contains cerebrospinal fluid, a buoyant liquid that suspends the central nervous tissue in a weightless environment while surrounding it with a shock-absorbing, hydraulic cushion.

Figure 9. Vertebral column

Figure 10. Spinal cord anatomy

The spinal cord, like the brain, is enclosed in three membrane layers called meninges: the dura mater (the tougher, most protective, outermost layer); the arachnoid (middle layer); and the pia mater (innermost and very delicate). The soft, gel-like spinal cord is protected by 33 rings of bone called vertebrae, which form the spinal column. Each vertebra has a circular hole, so when the rung-like bones are stacked one on top of the other there is a long hollow channel, with the spinal cord inside that channel. The vertebrae are named and numbered from top to bottom according to their location along the backbone: seven cervical vertebrae (C1-C7) are in the neck; twelve thoracic vertebrae (T1-T12) attach to the ribs; five lumbar vertebrae (L1-L5) are in the lower back; and, below them, five sacral vertebrae (S1-S5) that connect to the pelvis. The adult spinal cord is shorter than the spinal column and generally ends at the L1-L2 vertebral body level. A thick set of nerves from the lumbar and sacral cord form the cauda equina in the spinal canal below the cord.

The spinal column is not all bone. Between the vertebrae are discs of semi-rigid cartilage and narrow spaces called foramen that act as passages through which the spinal nerves travel to and from the rest of the body. These are places where the spinal cord is particularly vulnerable to direct injury.

Figure 11. Spinal nerve

Figure 12. Spinal nerve fiber anatomy

The arterial supply to the spinal cord comes from two sources. It consists of:

The longitudinal vessels consist of:

The anterior and posterior spinal arteries are reinforced along their length by eight to ten segmental medullary arteries. The largest of these is the arteria radicularis magna or the artery of Adamkiewicz. This vessel arises in the lower thoracic or upper lumbar region, usually on the left side, and reinforces the arterial supply to the lower portion of the spinal cord, including the lumbar enlargement.

Segmental spinal arteries

Segmental spinal arteries arise predominantly from the vertebral and deep cervical arteries in the neck, the posterior intercostal arteries in the thorax, and the lumbar arteries in the abdomen.

After entering an intervertebral foramen, the segmental spinal arteries give rise to anterior and posterior radicular arteries. This occurs at every vertebral level. The radicular arteries follow, and supply, the anterior and posterior roots. At various vertebral levels, the segmental spinal arteries also give off segmental medullary arteries. These vessels pass directly to the longitudinally oriented vessels, reinforcing these.

Figure 13. Spinal cord blood supply

As mentioned earlier, the vertebrae normally protect the soft tissues of the spinal cord, but they can be broken or dislocated in a variety of ways that puts harmful pressure on the spinal cord. Injuries can occur at any level of the spinal cord. The segment of the cord that is injured, and the severity of the damage to the nervous tissue, will determine which body functions are compromised or lost. An injury to a part of the spinal cord causes physiological consequences to parts of the body controlled by nerves at and below the level of the injury.

Spinal cord injuries are classified as either complete or incomplete. An incomplete injury means that the ability of the spinal cord to convey messages to or from the brain is not completely lost. People with incomplete injuries retain some motor or sensory function below the injury. A complete injury is indicated by a total lack of sensory and motor function below the level of injury. People who survive a spinal cord injury will most likely have medical complications such as chronic pain and bladder and bowel dysfunction, along with an increased susceptibility to respiratory and heart problems. Successful recovery depends upon how well these chronic conditions are handled day to day.

Your ability to control your limbs after spinal cord injury depends on two factors:

The lowest part of your spinal cord that functions normally after injury is referred to as the neurological level of your injury. The severity of the injury is often called the completeness and is classified as either of the following:

Additionally, paralysis from a spinal cord injury may be referred to as:

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

Emergency signs and symptoms of spinal cord injury after an accident may include 1):

Motor vehicle accidents and catastrophic falls are the most common causes of physical trauma that breaks, crushes, or presses on the vertebrae and can cause irreversible damage at the corresponding level of the spinal cord and below. Severe trauma to the cervical cord results in paralysis of most of the body, including the arms and legs, and is called tetraplegia 2). Trauma to the thoracic nerves in the upper, middle, or lower back results in paralysis of the trunk and lower extremities, called paraplegia.

Penetrating injuries, such as gunshot or knife wounds, damage the spinal cord; however, most traumatic injuries do not completely sever the spinal cord. Instead, an injury is more likely to cause fractures and compression of the vertebrae, which then crush and destroy the axons that carry signals up and down the spinal cord 3). A spinal cord injury can damage a few, many, or almost all of the axons that cross the site of injury. A variety of cells located in and around the injury site may also die. Some injuries in which there is little or no nerve cell death but only pressure-induced blockage of nerve signaling or only demyelination without axonal damage will allow almost complete recovery. Others in which there is complete cell death across even a thin horizontal level of the spinal cord will result in complete paralysis.

Surgery to relieve compression of the spinal tissue by surrounding bones broken or dislocated by the injury is often necessary, through timing of such surgery may vary widely. A recent prospective multicenter trial called STASCIS is exploring whether performing decompression surgery early (less than 24 hours following injury) can improve outcomes for patients with bone fragments or other tissues pressing on the spinal cord.

Today, improved emergency care for people with spinal cord injuries, antibiotics to treat infections, and aggressive rehabilitation can minimize damage to the nervous system and restore function to varying degrees 4). Advances in research are giving doctors and people living with spinal cord injury hope that spinal cord injuries will eventually be repairable. With new surgical techniques and developments in spinal nerve regeneration, cell replacement, neuroprotection, and neurorehabilitation, the future for spinal cord injury survivors looks brighter than ever.

When to see a doctor ?

Anyone who experiences significant trauma to his or her head or neck needs immediate medical evaluation for the possibility of a spinal injury. In fact, its safest to assume that trauma victims have a spinal injury until proven otherwise because:

If you suspect that someone has a back or neck injury:

Spinal cord injuries result from damage to the vertebrae, ligaments or disks of the spinal column or to the spinal cord itself.

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 also may 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.

A nontraumatic spinal cord injury may be caused by arthritis, cancer, inflammation, infections or disk degeneration of the spine.

Facts and Figures about Spinal Cord Injury 5):

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

Although a spinal cord injury is usually the result of an accident and can happen to anyone, certain factors may predispose you to a higher risk of sustaining a spinal cord injury, including:

Following this advice may reduce your risk of a spinal cord injury:

Traumatic spinal cord injury usually begins with a sudden, mechanical blow or rupture to the spine that fractures or dislocates vertebrae. The damage begins at the moment of primary injury, when the cord is stretched or displaced by bone fragments or disc material. Nerve signaling stops immediately but may not return rapidly even if there is no structural damage to the cord. In severe injury, axons are cut or damaged beyond repair, and neural cell membranes are broken. Blood vessels may rupture and cause bleeding into the spinal cords central tissue, or bleeding can occur outside the cord, causing pressure by the blood clot on the cord.

Within minutes, the spinal cord near the site of severe injury swells within the spinal canal. This may increase pressure on the cord and cut blood flow to spinal cord tissue. Blood pressure can drop, sometimes dramatically, as the body loses its ability to self-regulate. All these changes can cause a condition known as spinal shock that can last from several hours to several days 6).

There is some controversy among neurologists about the extent and impact of spinal shock, and even its definition in terms of physiological characteristics 7). It appears to occur in approximately half of the cases of spinal cord injury and is usually directly related to the size and severity of the injury. During spinal shock, the entire spinal cord below the lesion becomes temporarily disabled, causing complete paralysis, loss of all reflexes, and loss of sensation below the affected cord level.

The primary injury initiates processes that continue for days or weeks. It sets off a cascade of biochemical and cellular events that kills neurons, strips axons of their protective myelin covering, and triggers an inflammatory immune system response. This is the beginning of the secondary injury process 8). Days, or sometimes even weeks later, after this second wave of damage has passed, the area of destruction has increasedsometimes to several segments above and below the original injury.

Changes in blood flow cause ongoing damage. The major reduction in blood flow to the site following the initial injury can last for as long as 24 hours and become progressively worse if there is continued compression of the cord due to swelling or bleeding. Because of the greater blood flow needs of gray matter, the impact is greater on the central cord than on the outlying white matter. Blood vessels in the gray matter also become leaky, sometimes as early as 5 minutes after injury, which initiates spinal cord swelling. Cells that line the still-intact blood vessels in the spinal cord also begin to swell, and this further reduces blood flow to the injured area. The combination of leaking, swelling, and sluggish blood flow prevents the normal delivery of oxygen and nutrients to neurons, causing many of them to die 9).

Excessive release of neurotransmitters kills nerve cells 10). After the injury, an excessive release of neurotransmitters (chemicals that allow neurons to signal each other) can cause additional damage by over-stimulating nerve cells. The neurotransmitter glutamate is commonly used by axons in the spinal cord to stimulate activity in other neurons. But when spinal cells are injured, their axons flood the area with glutamate and trigger additional nerve cell damage. This process kills neurons near the injury site and the myelin-forming oligodendrocytes at and beyond the injured area.

An invasion of immune system cells creates inflammation. Under normal conditions, the blood-brain barrier keeps potentially destructive immune system cells from entering the brain or spinal cord. This barrier is a naturally-occurring result of closely spaced cells along the blood vessels that prevent many substances from leaving the blood and entering brain tissues. But when the blood-brain barrier breaks down, immune system cellsprimarily white blood cellscan invade the spinal cord tissue and trigger an inflammatory response. This inflammatory response can cause additional damage to some neurons and may kill others.

Free radicals attack nerve cells. Another consequence of inflammation is the increased production of highly reactive forms of oxygen molecules called free radicalschemicals that modify the chemical structure of other molecules in damaging ways, for example, damaging cell membranes. Free radicals are produced naturally as a by-product of normal oxygen metabolism in small enough amounts that they cause no harm. But injury to the spinal cord causes cells to overproduce free radicals, which destroy critical molecules of the cell.

Nerve cells self-destruct. For reasons that are still unclear, spinal cord injury sets off apoptosisa normal process of cell death that helps the body get rid of old and unhealthy cells. Apoptosis kills oligodendrocytes in damaged areas of the spinal cord days to weeks after the injury. Apoptosis can strip myelin from intact axons in adjacent ascending and descending pathways, causing the axons to become dysfunctional and disrupting the spinal cords ability to communicate with the brain.

Scarring occurs. Following a spinal cord injury, astrocytes (star-shaped glial cells that support the brain and spinal cord) wall off the injury site by forming a scar, which creates a physical and chemical barrier to any axons which could potentially regenerate and reconnect. Even if some intact myelinated axons remain, there may not be enough to convey any meaningful information to or from the brain.

Researchers are especially interested in studying the mechanisms of this wave of secondary damage because finding ways to stop it could save spinal cord tissue and thereby enable greater functional recovery.

The emergency room physician will test the individual to see if there is any movement or sensation at or below the level of injury. Methods to assess autonomic function also have been established (American Spinal Injury Association).

Figure 14. International Standards for Neurological Classification of Spinal Cord Injury

Emergency medical tests for a spinal cord injury include:

Magnetic resonance imaging (MRI), which uses computer-generated radio waves and a powerful magnetic field to produce detailed three-dimensional images of body structures, including tissues, organs, bones, and nerves. It can document brain and spinal trauma from injury, as well as aid in diagnosing brain and spinal cord tumors, herniated disks, vascular (blood vessel) irregularities, bleeding and inflammation that might compress the spine and spinal cord, and injury to the ligaments that support the cervical spine.

Computerized tomography (CT) provides rapid, clear two-dimensional x-ray images of organs, bones, and tissues. Neurological CT scans are used to view the brain and spine. CT is excellent in detecting bone fractures, bleeding, and spinal stenosis (narrowing of the spinal canal), but CT has less ability to image the spinal cord or identify ligament injury associated with an unstable spine than MRI.

Plane x-rays (which demonstrate the planes of bone on bone) of the persons chest and skull are often taken as part of a neurological work-up. X-rays can be used to view most parts of the body, such as a joint or major organ system. In a conventional x-ray, a concentrated burst of low-dose ionized radiation is passed through the body and onto a photographic plate. Since calcium in bones absorbs x-rays more easily than soft tissue or muscle, the bony structure appears white on the film. Vertebral misalignment or fracture can be seen within minutes. X-rays taken in different neck positions (i.e., flexion and extension views) detect instability of the cervical spine. Tissue masses such as injured ligaments or a bulging disc are not visible on conventional x-rays.

Once the swelling from within and around the spinal cord has eased a bitusually within a week to 10 daysphysicians will conduct a complete neurological exam to classify the injury as complete or incomplete. An incomplete injury means that the ability of the spinal cord to convey messages to or from the brain is not completely lost. People with incomplete injuries retain some sensory function and may have voluntary motor activity below the injury site. A complete injury prevents nerve communications from the brain and spinal cord to parts of the body below the injury site. There is a total lack of sensory and motor function below the level of injury, even if the spinal cord was not completely severed. Studies have shown that people with incomplete injuries have a greater chance of recovering some function in the affected limbs than those with a complete injury.

Physicians use the International Standards of Neurologic Classification of Spinal Cord Injury to measure the extent of neurologic injury following a spinal cord injury. The American Spinal Injury Association Impairment Scale (AIS) is used to categorize the degrees of injury into different groups.

Table 1. American Spinal Injury Association Impairment Scale







People who survive a spinal cord injury often have medical complications resulting in bladder, bowel, and sexual dysfunction. They may also develop chronic pain, autonomic dysfunction, and spasticity (increased tone in and contractions of muscles of the arms and legs) , but this is highly variable and poorly understood. Higher levels of injury may have an increased susceptibility to respiratory and heart problems.

Breathing. A spinal cord injury high in the neck can affect the nerves and muscles in the neck and chest that are involved with breathing. Respiratory complications are often an indication of the severity of spinal cord injury. About one-third of those with injury to the neck area will need help with breathing and require respiratory support via intubation, which involves inserting a tube connected to a machine that pushes oxygen into the lungs and removes carbon dioxide) through the nose or throat and into the airway. This may be temporary or permanent depending upon the severity and location of injury. Any injury to the spinal cord between the C1-C4 segments, which supply the phrenic nerves leading to the diaphragm, can stop breathing.

The phrenic nerves originate from C3, C4, and C5 and supply the diaphragm and cause the diaphragm to move and the lungs to expand. Complete severing of the spinal cord above the origin of the phrenic nerves (C3, C4,and C5) causes respiratory arrest. In injuries to the phrenic nerves, breathing stops because the phrenic nerves no longer send nerve impulses to the diaphragm. People with these injuries need immediate ventilatory support. People with high cervical cord injury may have trouble coughing and clearing secretions from their lungs. Special training regarding breathing and swallowing may be needed.

Figure 15. Nerves from the cervical spines (Cervical Plexus) including the phrenic nerve

Pneumonia. Respiratory complications are the leading cause of death in people with spinal cord injury, commonly as a result of pneumonia. Intubation increases the risk of developing ventilator-associated pneumonia; individuals with spinal cord injury who are intubated have to be carefully monitored and treated with antibiotics if symptoms of pneumonia appear. Attention to clearing secretions and preventing aspiration of mouth contents into the lungs can prevent pneumonia.

Circulatory problems. Spinal cord injuries can cause a variety of changes in circulation, including blood pressure instability, abnormal heart rhythms (arrhythmias) that may appear days after the injury, and blood clots. Because the brains control of the cardiac nerves is cut off, the heart can beat at a dangerously slow pace, or it can pound rapidly and irregularly. Arrhythmias are more common and severe in the most serious injuries. Low blood pressure also often occurs due to changes in nervous system control of blood vessels, which then widen, causing blood to pool in the small arteries far away from the heart. Blood pressure needs to be closely monitored to keep blood and oxygen flowing through the spinal cord tissue, with the understanding that baseline blood pressure can be significantly lower than usual in people living with spinal cord injuries. Since muscle movement contributes to moving blood back to the heart, people with spinal cord injuries are at triple the usual risk for blood clots due to stagnation of blood flow in the large veins in the legs. Treatment includes anticoagulant drugs and compression stockings to increase blood flow in the lower legs and feet.

Spasticity and muscle tone. When the spinal cord is damaged, information from the brain can no longer regulate reflex activity. Reflexes may become exaggerated over time, causing muscle spasticity. Muscles may waste away or diminish due to underuse. If spasms become severe enough, they may require medical treatment. For some, spasms can be as much of a help as they are a hindrance, since spasms can tone muscles that would otherwise waste away. Some people can even learn to use the increased tone in their legs to help them turn over in bed, propel them into and out of a wheelchair, or stand.

Autonomic dysreflexia. The autonomic nervous system controls involuntary actions such as blood pressure, heartbeat, and bladder and bowel function. Autonomic dysreflexia is a life-threatening reflex action that primarily affects those with injuries to the neck or upper back. It happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. The irritated area tries to send a sensory signal to the brain, but the signal may be misdirected, causing a runaway reflex action in the spinal cord that has been disconnected from the brains regulation. Unlike spasms that affect muscles, autonomic dysreflexia affects blood vessels and organ systems controlled by the sympathetic nervous system. Anything that causes pain or irritation can set off autonomic dysreflexia, including a full bladder, constipation, cuts, burns, bruises, sunburn, pressure of any kind on the body, or tight clothing. Symptoms of its onset may include flushing or sweating, a pounding headache, anxiety, sudden increase in blood pressure, vision changes, or goose bumps on the arms and legs. Emptying the bladder or bowels and removing or loosening tight clothing are just a few of the possibilities that should be tried to relieve whatever is causing the irritation. If possible, the person should be kept in a sitting position, rather than lying flat, to keep blood flowing to the lower extremities and help reduce blood pressure.

Pressure sores (or pressure ulcers). Pressure sores are areas of skin tissue that have broken down because of continuous pressure on the skin and reduced blood flow to the area. People with paraplegia and tetraplegia are susceptible to pressure sores because they may lose all or part of skin sensations and cannot shift their weight. As a result, individuals must be shifted periodically by a caregiver if they cannot shift positions themselves. Good nutrition and hygiene can also help prevent pressure sores by encouraging healthy skin. Special motorized rotating beds may be used to prevent and treat sores.

Pain. Some people who have spinal cord nerve are paralyzed often develop neurogenic painpain or an intense burning or stinging sensation may be unremitting due to hypersensitivity in some parts of the body. It can either be spontaneous or triggered by a variety of factors and can occur even in parts of the body that have lost normal sensation. Almost all people with spinal cord injury are prone to normal musculoskeletal pain as well, such as shoulder pain due to overuse of the shoulder joint from using a wheelchair. Treatments for chronic pain include medications, acupuncture, spinal or brain electrical stimulation, and surgery. However, none of these treatments are completely effective at relieving neurogenic pain.

Bladder and bowel problems. Most spinal cord injuries affect bladder and bowel functions because the nerves that control the involved organs originate in the segments near the lower end of the spinal cord and lose normal brain input. Although the kidneys continue to produce urine, bladder control may be lost and the risk of bladder and urinary tract infections increases. Some people may need to use a catheter to empty their bladders. The digestive system may be unaffected, but people recovering from a spinal cord injury may need to learn ways to empty their bowels. A change in diet may be needed to help with control.

Sexual function. Depending on the level of injury and recovery from the trauma, sexual function and fertility may be affected. A urologist and other specialists can suggest different options for sexual functioning and health.

Depression. Many people living with a spinal cord injury may develop depression as a result of lifestyle changes. Therapy and medicines may help treat depression.

Once someone has survived the injury and begins to cope psychologically and emotionally, the next concern is how to live with disabilities. Doctors are now able to predict with reasonable accuracy the likely long-term outcome of spinal cord injuries. This helps people experiencing SCI set achievable goals for themselves, and gives families and loved ones a realistic set of expectations for the future.

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