Spinal cord injuries can be devastating leading to partial or complete paralysis. Spinal cord injuries were once frequently fatal, but over the past fifty years many new treatments have been developed to help people with spinal cord injuries survive and possibly recover a great deal of function. Within the past twenty years, even more promising treatments have been developed for spinal cord injury.
Treatment of spinal cord injury may involve medication, and surgery, and always requires physical therapy. Spinal cord injury may be due to either traumatic or non-traumatic causes. Non-traumatic causes of spinal cord injury occur over time and include arthritis, cancer, infection, blood vessels problems, bleeding, and inflammation.
In the case of traumatic spinal cord injury due to an accident, immediate, comprehensive trauma care is crucial for both survival and long-term outcome. A competent trauma team can do much to minimize the spread of damage from a spinal cord injury. The long-term prognosis for a spinal cord injury depends on the nature and location of the injury, as well as the quality of care received.
If emergency medical personnel suspect you have sustained a spinal injury, they will do everything possible to prevent further injury. While medics work to stabilize your heart rate, breathing, and blood pressure, your head and neck will be put into a special brace to prevent movement and additional injury. You will be put on stiff back board to prevent injury while you are being loaded in the ambulance and taken to the hospital.
Once at the trauma center, doctors will continue to work to make sure that you are stabilized and that no further injury will occur. You will continue to be immobilized while undergoing tests such as CAT scans and MRI’s; these imaging tests will help the doctors determine the extent of your injury.
In cases of severe injury to the neck area of the spinal cord, respiratory problems may occur. Doctors may need to help you breathe by giving you oxygen through a tube inserted down your throat; this process is called intubation.
Spinal cord injuries have a tendency to worsen after the initial injury. Blood pressure and blood flow may drop dramatically immediately after the injury or may remain fairly normal in the first few hours only to drop dramatically within a day or so. As blood pressure drops and blow flow decreases, inflammation sets in and nerve cells at a distance from the injury begin to die. Researchers still do not understand all of the reasons why the injury spreads in this way, but a corticosteroid drug first used for spinal cord injuries in the early 1990s may help reduce the extent of the spread.
Doctors may give you this powerful corticosteroid, methylprednisolone (Medrol). When given within eight hours of the initial injury, methylprednisolone has been known to prevent further damage and to promote recovery in some people. Methylprednisolone reduces nerve damage and decreases inflammation around the injury. The use of methylprednisolone is controversial. It can cause serious side effects and some doctors believe it provides little benefit; however, other doctors are convinced that the drug is worth the risks and should be used to in most spinal cord injuries.
During the first few hours and days after a traumatic spinal cord injury, doctors may need to operate remove foreign objects, bone fragments, fractured vertebrae or herniated disks that are compressing the spine (decompressive surgery). Sometimes surgery is necessary to stabilize the spine; however, the precise time to perform emergency surgery is controversial. Some doctors believe that the sooner such an operation is performed, the greater chance a patient has of full recovery. Other doctors are convinced that surgery should be postponed for several days, so that the patient’s condition will be more stable.
The debate over when to perform surgery is yet to be settled, but in 2008 a comprehensive study seemed to indicate that earlier invention is better. According to the Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS) 24% of people who underwent decompressive surgery within a day of their initial injury showed significant improvement when measured by the American Spinal Injury Association (ASIA) scale. The condition of these patients improved by two grades or better on this scale. While doctors are encouraged by the study’s results, it is still too early for a definitive decision on these results. More research must be done.
In the meanwhile, patients and their families desiring early intervention should understand that such a procedure is not advisable for all spinal cord injuries. If you have had a severe spinal cord injury, but experienced no problems with your heart, blood pressure, breathing, and other vital functions, you may be eligible for early intervention. Unfortunately, many people who sustain a spinal cord injury have complications which delay surgery; they frequently have other injuries beside the spinal cord injury.
There are also other surgical procedures which may help you later in your road to recovering as much function as possible. Tendon transfer surgery can sometimes help people with a spinal cord injury gain more control of their arms and hands. A nonessential muscle which still has nerve function can be transferred to a place in the shoulders or arms to assist in motor function. Naturally, tendon transfer surgery is utilized only for people in relatively good health; it requires a period of being immobile for a length of time prior to the surgery, which can cause you to temporarily lose muscle gains you have made. Tendon transfer surgery will not be considered until at least a year after the initial injury.
Adjusting to a spinal cord injury is difficult because all physical aspects of your body are affected. You may lose control of your bladder and/or your bowels and you may experience urinary tract infections. You may experience pressure sores from being in one position for long time. You are at greatly increased risk of blood clots in your limbs and lungs (deep vein thrombosis and pulmonary embolism). Lung and breathing problems are common. You may experience spastic muscles. You are also at risk for a dangerous condition called autonomic dysreflexia and at risk of experiencing a new injury because you lack sensation in your limbs. Although these conditions are very disheartening, they are not insurmountable; your rehabilitation team will help you learn to manage each problem.
Managing bladder control
The extent of bladder control problems depends on the extent of your injury. In the hospital your bladder function will likely be managed with a catheter which stays in place. A catheter is a thin tube inserted into the bladder; the tube empties into a bag. Later you may benefit from intermittent catherization. You or a caregiver will insert a catheter at regular intervals, so that your bladder may empty completely; intermittent catheterization is less likely to lead to an infection, than leaving the catheter in around the clock. Emptying your bladder on schedule and careful monitoring can help you avoid urinary tract infections; if you do develop an infection, early intervention with antibiotics can help clear it.
A spinal cord injury can cause either a lack of bowel control or constipation. A high fiber diet and medications can help manage bowel function. Your rehabilitation team will help you device a schedule to help regulate bowel elimination.
Pressure sores are a real problem for people with spinal cord injury; they can become seriously infected if left untreated. Because you must sit or lay in the same position for a long period of time, your skin can break down; since you may have little or no sensation in the affected area, you may not realize that there is a problem. Pressure sores can be prevented by regularly changing position. Once you are stable, in the hospital and rehabilitation center, you will be routinely turned through the night, generally at intervals of two hours; this not only helps eliminate pressure sores, it also prevents fluid from accumulating in one area of your body and it helps protect the lungs from pneumonia. You will be turned or repositioned in the day time as well while you are immobile. Once at you will be reminded to change positions frequently, either on your own or with the help of a caregiver.
Staying immobile for long periods of time also slows blood circulation and can cause clots to form. Clots may develop deep within the vein of a muscle (deep vein thrombosis) and these can cause an artery in the lungs to be blocked (pulmonary embolism). Both conditions are extremely risk and can cause death.
You may be given medications to thin your blood and improve your circulation. Some people benefit from inflatable pumps which are placed on the legs to increase circulation and prevent fluid build. Special support stockings can help as well.
Spinal cord injuries can weaken the abdominal and chest muscles; sometimes movement of these muscles is completely impaired. If your diaphragm muscles (chest muscles used to breath with) are completely paralyzed you will be intubated and you may have to stay on a ventilator for a period of time; some people can learn to consciously breath and can thus stay off the ventilator for periods of time.
Even if your breathing is not directly impaired, you are still at greater risk of pneumonia. You will be given respiratory exercises and medications to help prevent lung infections and improve your lung function.
You may experience muscles spasms and your arms and legs may jump. This is relatively rare and unfortunately it is not an indication that you are regaining sensation or movement in these areas. These involuntary movements occur because some of your nerves have become more sensitive, yet your damaged spinal cord will not allow the brain to interpret and regulate their signals.
If your spinal cord was injured above the middle of the chest, you can be subject to autonomic dysreflexia, a dangerous, sometimes fatal problem. Pain or irritation below your injury may send a signal which cannot reach the brain. The interrupted signal causes a reflex which constricts your blood vessels; the blood pressure may rise while the heart rate drops, leading to a stroke or a seizure. Even a simple problem such as a full bladder or irritating clothes may trigger such a signal; eliminating the source of irritation can help relieve the problem. Sometimes a change of position will help.
Because you may not be able to feel pain or other stimuli on some areas of your body it is possible to injure yourself without realizing it. People with spinal cord injuries may experience severe burns or cuts without realizing it. Extra vigilance on your part and on your caregiver’s part can help eliminate this danger. Be on the lookout for cuts or sores that may require medical treatment.
When you have a spinal cord injury you are sometimes able to feel pain within areas of your body that cannot feel exterior sensations. Pain can come as a result of your initial injury. Your doctor can prescribe medication to help with this pain.
If you are able to regain some mobility, such as using your arms to work a wheelchair or using a walker, you may experience muscle pain from overuse or strain. You may experience less pain as you gains strength and stamina. Your physical therapist may also be able to show you new techniques that will reduce your muscle strain.
Once your condition has been stabilized, rehabilitation can begin. It is important that rehabilitation begin as soon as possible so that your muscles do not atrophy. Today, new technology can assist physical therapists in providing you with the best chance of recovery. A number of specialists may assist your recovery, including a physical therapist, an occupational therapist, a recreation therapist, a rehabilitation nurse, a rehabilitation psychologist, a social worker, and a physician specializing in physical medicine (physiatrist).
Physical therapy will begin in the hospital. At first you will be usually helped to regain strength in your arms and legs. An occupational therapist will help you with fine motor skills and you will be taught new ways of accomplishing every day tasks. You will learn to use adaptive equipment such as a wheelchair and equipment that can make self-care and every day tasks easier (such as an adaptor to help fasten your clothes and specially designed phone to facilitate dialing).
Later, according to your needs and your personal preferences, you may be transferred to a rehabilitation facility or allowed to go home and receive daily physical therapy at home. Severe injuries generally require a period of recuperation in a rehabilitation facility so that all of your medical needs can be attended to and you can receive more intensive therapy than you might at home.
At the rehabilitation center you will receive more and advanced therapy as your condition improves. You and your family will be taught techniques for managing skin care and dealing with possible urinary tract infections. You will also receive help with adapting your home to your new situation.
Newer technology can greatly assist your adjustment to your new limitations. Modern wheelchairs are lighter weight and easier to maneuver than past models. Electronic wheelchairs with adaptive controls can assist people with limited or no use of their arms. Some wheelchairs can elevate to allow you to reach objects above your head and to converse at high level with someone. Other wheelchairs allow the owner to negotiate curbs and climb stairs without assistance.
Computer driven devices can assist you with a wide-range of activities. Voice-activated computers can assist you with online bill paying and other computer work; they can also allow you to dial and answer a phone without using your hands. New computer devices also can help with personal hygiene and with reading.
In recent years an exciting technology called functional neuromuscular stimulation (FNS) has helped many people with a spinal cord injury increase their muscle strength and sometimes regain function. FNS works by stimulating intact peripheral nerves to cause muscle contractions in paralyzed muscles. Electrodes for this stimulation can be placed on the skin surface or can be implanted.
An implantable system can allow people with a certain type of spinal injury to grasp objects with their hands. The device is controlled by the shoulder’s position. FNS is commonly used with tendon transfer surgery.
The legs may also benefit from FNS. When electrodes are places on the skin of the legs, people with certain forms of spinal cord injury can ride a stationary bicycle. This strengthens the muscles, the bones, and the cardiovascular system. It also provides a psychological boost.
FNS can also stimulate gait for some patients. This can allow you to walk short distances with the aid of a walker. Soon FNS technology may allow people with spinal cord injuries a near return to their former level of function.
Treatment for Sexual Dysfunction
In addition to physical changes that can be dangerous, people with spinal cord injury also experience physical changes that directly affect them emotionally. Sexual dysfunction is a common problem for males with a spinal cord injury.
Although men with a spinal cord injury may still experience erections, they may have trouble maintaining an erection. The majority of men with a spinal cord injury have difficulty ejaculating. If you are a man with a spinal cord injury and concerns about your sexual function, consult a urologist or a fertility specialist.
Women with spinal cord injury are generally still able to experience intercourse and become pregnant, but sexual intimacy may not be as pleasurable. Pregnancy for a woman with a spinal cord injury is considered high risk. If you are a woman with concerns about how your spinal cord injury will affect your sexuality and ability to have children consult with a fertility specialist or an obstetrician gynecologist.