Trauma

Trauma (quick injury) is a common cause of spinal injuries. Automobile accidents, falls, gunshots, diving accidents, war injuries, sports injuries and any injury involving the stretching, bruising, application of pressure and severing of the spine are considered trauma. Traumatic spinal injuries are classified into five types, according to the American Spinal Injury Association (ASIA).

General Wear and Tear

Discal herniations can occur from general wear and tear, such as jobs that require constant sitting, but especially jobs that require lifting. Traumatic injury to lumbar discs commonly occurs from lifting while bent at the waist, rather than lifting while using the legs. Minor back pain is an indicator of general wear and tear that may result in a traumatic event from bending to pick up a heavy backpack from the floor or even just a pencil. When the spine is straight, such as standing or lying down, internal pressure is equalized on all parts of the discs. While sitting or bending to lift, internal pressure on the disc can move from 17 psi (lying down) to over 300 psi (lifting with a rounded back).

The common “slipped disc” (contents of the disc move or slip into the spinal nerve canal) occurs when the disc membrane covering (the annulus fibrosis) is compressed on the front (stomach side) while sitting or bending, and extruded (stretched) thinly on the rear (back side). The combination of membrane thinning from stretching and increased internal pressure results in the rupture of the confining membrane (annulus fibrosis). The jelly-like contents of the disc then move into the spinal canal, pressurizing the spinal nerves, producing intense and usually disabling pain.

Tumor

Spinal tumors, including meningiomas (usually benign tumors that develop in the membrane that surrounds the spinal cord and brain), ependymomas (a tumor that arises from the ependyma, a tissue of the central nervous system and is spinal when found in adults and intracranial in children), astrocytomas (a tumor of the central nervous system), and metastatic cancer (disease that has spread from one part of the body to another through blood vessels or the lymphatic system) can result in back pain.

Ischemia

Ischemia is the restriction of blood supply to an area and can lead to damage or dysfunction of tissue around the spinal cord. Dissecting aortic aneurysms, emboli and arteriosclerosis are just some ways that blood supply could be restricted from the tissue around the spinal cord.

Developmental Disorders

Spinal injuries that occur while the spine is developing can be considered birth disorders, like spina bifida and can often be corrected by surgery soon after birth.

Neurodegenerative Diseases

Friedreich’s ataxia and spinocerebellar ataxia are genetic diseases that affect motor movement and muscular coordination. In the former, the spinal cord becomes thinner and nerve impulses are reduced due to lack of insulation around the nerve cells.

Additional Causes of Spinal Injuries and Back Pain

• 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

The American Spinal Injury Association (ASIA) defined an international classification based on neurological levels, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, i.e. shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), elbow extension (C7) and hip flexion (L2). Traumatic spinal cord injuries are classified into five types by ASIA and the International Spinal Cord Injury Classification System.

• A indicates a “complete” spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5. Since the S4-S5 segment is the lower segmental, absence of motor and sensory function indicates “complete” spinal cord injury.
• 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.
• 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 deficit with completely normal motor and sensory scores.

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 of 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 Spinal 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 infectious 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. 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.

The prevalence of spinal cord injury is not well documented in many large countries. In some countries, such as Sweden and Iceland, registries are available. About 450,000 people in the USA live with spinal cord injury (1 in 670), and there are about 11,000 new spinal cord injuries every year (1 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.

Anatomical Overview of the Spine

The spine holds the weight of the upper body, supports its structure and posture and protects the nerves of the spinal cord.

The vertebral column, also known as the backbone, is a column of 24 vertebrae, the sacrum, intervertebral discs, and the coccyx situated in the dorsal aspect of the torso. These parts are separated by spinal discs which, as a whole, protect and house the spinal cord. Viewed laterally, there are several curves in the spine, each of which represents a different segment of the spine. These segments include the cervical (making up the upper part of the spine and the neck), thoratic (the upper to mid-back), lumbar (the low back, and a more defined curve in women than men) and the pelvis, ending in the coccyx. The thoracic and pelvic curves are termed primary curves, because they alone are present during fetal life. The cervical and lumbar curves are compensatory or secondary, and are developed after birth, the former when the child is able to hold up its head (at three or four months) and to sit upright (at nine months), and the latter at twelve or eighteen months, when the child begins to walk.

The Spinal Anatomy Index has a complete list of the anatomical elements that make up the spine and links to detailed explanations of each.

The basic movements of the entire body can be traced back to a region on the spine.  The the spinal segments correlate specifically to bodily movement functions.  If movement in one part of the body is inhibited or numbed, a very specific region of the spine could be the source of injury.

• Paralysis
• Loss of sensation
• Loss of reflex function
• Loss of autonomic activity
• Breathing difficulty
• Loss of bowel control
• Loss of bladder control
• Pain
• Sensitivity to stimuli
• Muscle spasms
• Sexual dysfunction

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 and side effects. Read more…

Function Regarding Spinal Injury

The different segments of the spinal cord have specific levels and functions. If the motion or function of a certain body part is impaired, it is possible to trace the problem back to a specific location on the spine. Read more…

Classification of Spinal Injury

The extent of injury can be described by the ASIA Impairment Scale:

A= Complete: No motor or sensory function is preserved in the sacral segments S4-S5.
B= Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
C= Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
D= Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
E= Normal: Motor and sensory function is normal.

Cervical Symptoms

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.

Thoracic Symptoms

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 Symptoms

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.

Acute spinal cord injury can be treated by Methylprednisolone (Medrol). It is a corticosteroid that, if given within eight hours of injury, seems to cause some recovery in people. Methylprednisolone decreases inflammation near the site of injury and reduces damage to nerve cells. Injections of cortisone (a hormone naturally produced by the adrenal gland reduces inflammation in the short term and dissolves scar tissue in the long term) may prove to be beneficial as well. Cortisone has also been shown to reduce pain for long periods of time; up to several years.

Spinal Surgery

Spine surgery used to mean large (or open-back) incisions and long recovery times. Thanks to new technology like laser spinal surgery, small incisions make many patients candidates for minimally invasive spinal surgery. Procedure and recovery time can still vary. For example, lumbar surgeries can take from one to eight hours. An orthopedic surgeon can inform you of the best options for you.

Rest

Rest is key to recovery from any injury. By allowing the body to heal internally and not challenge it externally (by exercising, driving to work or dealing with stress), recovery speed can increase and overall health during the recovery can maintain steady. Some patients are required to not move around at all, while others are asked to keep their activity to a minimum.

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Rehabilitation and Physical Therapy

Rehabilitation centers are often affiliated with surgical hospitals. Choosing a treatment center is important, especially if the spinal injury requires long-term recovery. Equipment, staffing and the amount of time the patient is able to work on physical therapy are factors in choosing a center.

Traction/Immobilization

Traction and Immobilization are two forms of rehabilitating a spinal injury through the use of machines that either provide pressure to a point on the skull or spine, or that can keep the spine completely still.

Traction is a form of rehabilitation through the application of pressure to certain areas of the spine and skull to realign and correct spinal injuries. Some patients undergo traction while in a rehabilitation center, while others have home machines where they can apply pressure to the advised portion of the skull.

Motor vehicle accidents are a huge cause of spinal injury, so seat-belt usage and safe, alcohol-free driving are important to reducing the chance of a spinal injury. Prevent falls, another leading cause of spinal injuries, by: wearing proper shoes with good soles, making sure banisters are tightly secured and installing window guards to reduce the chance of secondary injury should a fall occur. Exercising the muscles used in balance is a wonderful preventive measure. Keeping firearms unloaded and ammunition in a different location will keep spinal injuries caused by firearms to a minimum. For all sports and recreational activities, avoid head-first maneuvers like diving into unknown depths, sliding into first base and tackling head first. Wearing a helmet during sports can also save lives and prevent injuries.

Muscular Strengthening

Strengthening back muscles can help prevent spinal injury, but strengthening abdominal muscles can be even more effective as a preventive measure. With a strong core, balancing and weight bearing movement will be distributed more evenly between the back and the abdominals, and the muscle groups will work together instead of being stressed individually.

Diet

Many people suffer from bowel management issues after a spinal cord injury. To help bowels move more naturally, take care to eat a variety of foods and to drink plenty of liquids. Incorporate foods into the diet that can help soften or harden bowel movements (raw vegetables, dark chocolate, whole grains, cereal and beans will soften while applesauce, dairy, white bread and white creams and sauces will harden). Maintaining a healthy and diverse diet will increase comfort and provide the body with the fuel required to heal.

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The Reeve-Irvine Research Center is one facility embarking on improving the lives of those living with spinal injury. One study has investigators working on having patients gain back autonomic functions like bowel movement and sexual activity — functions that would greatly improve quality of life. The center is also studying the enhancement of regeneration of damaged nerve cells, researching how to limit the secondary degeneration that occurs after spinal cord injury, and working on building a stem-cell research facility.

Spinal Injuries in the News

A variety of online blogs and websites keep up-to-date information on spinal injury research. Some of them accept comments where users can post concerns, questions and ideas.

There are many products available to aid in one’s mobility during spinal injury recovery or while pain is preventing full mobility. Canes, walkers, crutches, wheelchairs and patient lifters are designed to take some or most of the weight off of the individual. Many companies provide such products at discounted rates. Vehicles can also come equipped with designs and devises to aid in mobility assistance. Honda has a special mobility assistance program to help those in need.

Hiring Assistance

Individuals with spinal injuries may find the need to hire additional assistance. There are several alleys to explore when hiring someone to provide care. Friends and family, social agencies (church or community center) or schools may have resources based on referrals. There are also independent contractors and care agencies that can be contacted. Background checks, credit checks, calls to references, work history, level of education and personality are important factors in hiring an assistant. When you do, it’s important to speak with an insurance professional to be sure that they and you are covered in the case of injury, theft or other incidents.

Spinal Injury Support Groups

Support groups come in two main forms: online and in-person. There are a variety of forums and blogs that allow people to tell their stories, compare rehabilitation success and discuss living with a spinal injury. In-person community groups are meeting groups that do the same thing — provide support and comfort to those with spinal injuries, and to those supporting loved ones with spinal injuries.

• 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.
• C1 and C2 injuries 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

Different segments of the spine are basically responsible for flexion or extension of joints, or adduction or abduction of the thigh.  Appropriately, the higher regions of the spine are associated with movement in the neck and upper body while lower regions of the spine correlate to movement in the lower body.  The upper region of the spine correlate to movement in the joints of the upper body including the elbows, wrists and shoulders.  The middle segments of the spine are responsible for abdominal (torso and core) movement. The next lowest segment deals with thigh movement- adduction, abduction and flexion. The lowest part of the spine relates to foot and ankle movement.

Knowing how each part of the body relates back to the spine is key in knowing what portion of the spine is affected by injury. Lack of movement, numbness or sharp pain in, for example, the wrist, can indicate a specific issue with the C6 or C7 spinal segment.  See the image below for specific locations on the spine and their relative area of function.

Divisions of Spinal Segments

Segmental Spinal Cord Level and Function

Level    Function

Cl-C6 Neck flexors

Cl-C7,

Tl         Neck extensors

C3-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-T12,

L1        Abdominal muscles

L1-L4 Thigh flexion

L2-L4 Thigh adduction

L4-L5, S1        Thigh abduction

L5,

S1-S2 Extension of leg at the hip (gluteus maximus)

L2-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