Understanding spinal cord injuries

What does a spinal cord injury entail? What are the consequences of a spinal cord injury? What is the best way to treat people with spinal cord injuries? A quick and concise guide to spinal cord injury

Ansicht Wirbelsäule und Lähmungshöhen

The severity of spinal cord injury

A spinal cord injury can turn a person’s life completely upside down. You lose the inability to walk and – at best – can only use your arms in a restricted manner. Many bodily functions are also affected. In the past, spinal cord injuries often resulted in death. Today, at least in countries like Switzerland, people who suffer spinal cord injuries can expect to go on living fulfilling and productive lives.

  • In the 1930s, the American neurosurgeon Dr. Donald Munro of Boston City Hospital became the first doctor to successfully treat patients with spinal cord injuries.

    In 1944, Sir Ludwig Guttmann created a ward especially for people with spinal cord injuries at Stoke Mandeville Hospital in England. Thanks to this new ward, the mortality rate for people with spinal cord injuries (which hitherto had been fixed at around 80%) began to decline.

    • The nursing staff turned the patients over every two hours.
    • Skin care was also available for the patients.
    • Guttman introduced techniques for improving bladder management.
    • Using physio- and occupational therapy, he succeeded in helping patients to regain certain functions.
    • Thanks to comprehensive treatment, patients began to find that their social and economic needs could also be met.

    Sport as therapy

    Guttmann placed great importance on the use of physical activity as therapy. He founded the Stoke Mandeville Games, which led to the creation of the Paralympic Games in 1960.


    Model for the Swiss Paraplegic Centre

    Such events served as models for the treatment of people with spinal cord injuries in the UK, USA and other countries. This was also the case for the Swiss Paraplegic Centre in Nottwil.

    Sir Ludwig Guttmann and Guido A. Zäch, the founder of the Swiss Paraplegic Foundation, first met in 1976 during a ceremony at which Guttmann was named an honorary doctor by the medical faculty at the University of Basel. Guido A. Zäch saw Guttmann as the “father of paraplegics” and a genuine trailblazer in the field of spinal cord injury.

    Guido A. Zäch mit seinem grossen Vorbild und Mentor in fachlichen Fragen: Sir Ludwig Guttmann

    Guido A. Zäch (right) with Sir Ludwig Guttmann

People with spinal cord injuries are living longer

Today, people with spinal cord injuries are not just living longer. They are living more fulfilling and productive lives than the generations of people with spinal cord injuries who came before them. This change is attributed to the following factors:

  • Improvements in medical care New medical care allows patients to survive their spinal cord injury, and even to go on living fulfilling lives.
  • Improvements in emergency medical care
  • Improvements in healthcare and rehabilitation
  • The availability of newer technologies such as mechanical ventilation devices and custom wheelchairs
  • An increase in the number of social services and a more accessible environment
     

A new attitude toward disabilities

Over the past few decades, disabilities have come to be seen in a brand new light. People with disabilities have fought for inclusion and the right to participate in all areas of society. A disability is no longer viewed as an individual defect, but

“the result of the complex interaction between a person’s individual health characteristics and functional capacities and the aspects of their physical, social and behavioural environments".
 

Prevention

The best way of preventing a spinal cord injury is to avoid certain situations such as traffic accidents, falls and fights. The WHO report recommends the following preventive measures, which are also applicable for the workplace or playing field:

  1. Avoid or eliminate the cause of spinal cord injury before the injury can occur, e.g. by taking measures to reduce traffic accidents.
  2. Allow for early diagnosis and treatment and limit the disability. In other words, by quickly recognising that a spinal cord injury may have occurred during an accident. In the event of an accident, secure a professional means of transport to carry the injured person to a suitable facility and allow for access to initial rehabilitation.
  3. After rehabilitation, reduce complications and help patients to successfully reintegrate into their family, social and professional lives.

Key facts regarding spinal cord injury

  • The brain is the body’s control centre. It uses the spinal cord to control the extremities, as well as internal processes such as breathing, circulation and digestion. If the spinal cord is damaged, then information is no longer (or only partially) sent to the body. As a result, paralysis occurs in the arms and legs. This paralysis is independent of the level at which the injury occurs on the spinal cord (injury level). Areas affected by paralysis include:

    • arms, legs and trunk
    • internal functions (bladder, bowel and sexual functions)
    • senses

    Spinal cord injuries occur when the spinal column is damaged during falls (traumatic), or by illnesses such as tumours, haemorrhages and infections (non-traumatic).

    wirbelsaeule-und-koerperfunktionen
  • All across the world, most of the falls which lead to spinal cord injuries occur in the workplace. Such falls are more likely to happen in industries such as construction, agriculture and mining. The two most common external causes are falling from a high place or being hit by a falling object.

    During leisure and sporting activities, spinal cord injuries may be caused by:

    • vehicle crashes (e.g. motorcycles or racing cars)
    • common falls, i.e. during sports such as rugby or skiing
    • falls/stumbles/jumps from a height of less than one metre, such as diving into shallow water
    • falls/stumbles/jumps or being pushed from a height of one metre or more, such as while rock climbing or paragliding.

     

    Traumatic (accident-related) causes

    This type of spinal cord injury is caused by incidents such as:

    • traffic accidents
    • falls
    • violence.

    Other causes include:

    • everyday falls, such as stumbling over a rug
    • falls from low heights, e.g. a staircase
    • falls from one metre or more, such as from a horse or building
    • falls caused by external surroundings, such as a mineshaft collapsing.

    Spinal cord injuries are also frequently caused by firearms, knives and bomb blasts.

     

    Rücken Tattoo mit Unfallursache

    A campaign by the Swiss Paraplegic Foundation highlights the causes of accidents.

    Non-traumatic (illness-related) causes

    All across the world, these causes include: 

    • communicable diseases, such as tuberculosis or HIV
    • non-communicable diseases, such as cancer, degenerative diseases of the spinal cord, cardiovascular diseases
    • malnutrition, e.g. neural tube defects or vitamin B12 deficiency
    • healthcare-related complications
  • The nervous system is split into two main parts, the central nervous system and the peripheral (outer) nervous system. 

    The central nervous system

    The central nervous system consists of the brain and the spinal cord. It collects, processes, stores and transmits information. Together with the hormones, it controls the activities of all the organs, and adapts to meet the requirements of the environment.

    The spinal cord is part of the central nervous system. It plays a vital role in sending sensitive information to the brain, and subsequently in controlling motor and autonomic functions.

    The spinal cord

    The spinal cord itself is a nerve centre. Among other things, it controls standing/walking, bladder, bowel and sexual functions and breathing, and regulates the body’s temperature and circulation.

    It extends downwards from the brain to the area near the first and second lumbar vertebrae L1-L2 (see diagram below). The cauda equina (aka the “horse's tail") runs from the tip of the spinal cord to the spinal canal.

    Position of the spinal cord

    The spinal cord is a 40–45 cm long, 8–10 mm wide, and 5–7 mm thick rod located in the spinal canal. The spinal canal protects the delicate spinal cord against mechanical damage. It is usually found directly in the axis of movement to ensure the spinal cord does not become disconnected or rotated, even during extreme deformations of the spine which can occur while practising sports like acrobatics or gymnastics.

    Division of the spinal cord into segments

    darstellung-wirbelsaeule

    The spinal cord itself is subdivided into different neurological segments, depending on the nerve roots which flow from the spinal column between the individual vertebrae. There are 31 pairs of nerve roots:

    • 8 cervical (C1- C8)
    • 12 thoracic (Th1- Th12)
    • 5 lumbar (L1 – L5)
    • 5 sacral nerve roots (S1 – S5)
    • 1 near the tail bone.

    The neurological level of the spinal segments is not necessarily determined by the various lengths of the spinal cord and spinal column.

    The structure of the spinal cord

    darstellung-rueckenmark-02

    Structure of the spinal cord

    The spinal cord is made up of white matter and butterfly-shaped grey matter.

    The grey matter mostly contains nerve cells. It is the “switchgear” of the spinal cord. Distinctions are made between the elements which make up the grey matter.

    • The nerves that run through the anterior horn service the skeletal muscles. They contain the nerve cells that are responsible for motor functions.
    • The posterior horn receives the nerve fibres from the periphery of the spinal cord. These fibres are responsible for sensory functions. In order to be felt or understood, sensory pulses and information must first be sent to the cerebrum. Once there, they can enter our consciousness as sensory perception.

    The white matter contains the ascending and descending nerve fibres. It acts as a line connector within the spinal cord.

    The peripheral nervous system

    The peripheral nervous system is made up of two parts:

    1. the somatic system, which controls our voluntary actions
    2. the autonomic system, which automatically controls the body’s internal processes and regulatory systems without a person being able to consciously control it.

    The somatic nervous system

    The somatic nervous system is made up of a sensory part that is responsible for our senses, i.e. our ability to feel physical contact, pain, hot and cold, vibrations, etc. The somatic nervous system sends these sensory sensations to the brain. If the sensory part is not working properly, then the brain lacks the information it needs to make decisions.

    The motor part is responsible for controlling the skeletal muscles as per the commands we send it. If the motor part is not working properly, then the muscles become paralysed.

    The autonomic nervous system

    Finally, the autonomic nervous system controls and regulates the body’s internal processes which we cannot deliberately control, such as: 

    • heart rate
    • blood pressure, regulation of respiration, digestion
    • gland secretion 
    • sweating
    • urination and defecation
    • sexual functions

    The autonomic nervous system mainly consists of two parts: the sympathetic and the parasympathetic systems.

     

    sympatikus-parasympatikus

    Diagram of the sympathetic and parasympathetic systems

    The sympathetic system (“sympathicus”) allows us to work, stay aware and react quickly. It also enables our bodies to perform efficiently.

    The parasympathetic system (“parasympathicus”) is the counterpart of the sympathetic system, and thus lets us rest, sleep, digest, relax and recuperate.

    In healthy people, the sympathicus and parasympathicus work in a complementary fashion, with each one counteracting the other to achieve a proper balance. In people with spinal cord injuries, this balance is disrupted. As a result, many problems, sometimes life-threatening, can occur.

  • Paraplegia/tetraplegia with varying injury levels

    Wirbelsäule unterteilt in Para- und Tetraplegie

    Paraplegia

    Lähmungshöhe Paraplegie

    In paraplegics, the lower half of the body – legs, buttocks, stomach or lower chest area (depending on the injury level) – are affected by the spinal cord injury.

    In this case, the injury is located in the thoracic, lumbar or sacral region. People with paraplegia have unrestricted arm functions.

    Tetraplegia

    Lähmungshöhe Tetraplegie

    In the case of tetraplegia, the injury occurs near the neck (cervical spine). In addition to the legs and entire trunk, the hands and arms are also affected.

    The extent to which the arms are affected depends on the injury level. The lower the injury, the more functional capability the arms will retain. In the event of tetraplegia, the respiratory muscles are also affected. If the paralysis is located above C3 at the level of the 3rd cervical vertebra, then breathing is so badly restricted that the person will be dependent upon mechanical ventilation.

    Impact on organs

    Spinal cord injuries can also wreak havoc with the organs, as the nerves that service organs also run through the spinal cord. In injuries above the 6th thoracic vertebra, the autonomic nervous system is affected. This can cause the circulatory system to malfunction. Bladder, bowel and sexual functions are often disrupted regardless of the injury level, as the nerves that control these functions flow out of the sacral region at the bottom of the spinal column.

  • Spinal cord injury does not necessarily lead to paralysis...
     

    Complete spinal cord injury

    In the case of a complete spinal cord injury, the person loses all motor and sensory functions. The spinal cord is completely severed.

    Incomplete spinal cord injury

    With an incomplete spinal cord injury, the person may still have certain motor and sensory functions below the level of the injury. Nevertheless, the injury is just as serious and can also result in considerable damage.

    Classification of paralyses

    Nowadays, complete or incomplete paralyses are categorised from A to E according to criteria established by the ASIA (American Spinal Injury Association).

    • AIS A

      Komplette Lähmung, keinerlei motorische oder sensible Funktionen.

    • AIS B

      Inkomplette Lähmung, sensible Funktionen bleiben erhalten, aber keine motorischen Funktionen unterhalb des Lähmungsniveaus vorhanden.

    • AIS C

      Inkomplett, sensible und motorische Funktionen unterhalb des Lähmungsniveaus sind erhalten. Die Kennmuskeln sind jedoch so schwach, dass sie funktionell nicht eingesetzt werden können.

    • AIS D

      Inkomplett, sensible und motorische Funktionen unterhalb des Lähmungsniveaus bleiben erhalten. Die Kraft in den Kennmuskeln ist so stark, dass sie funktionell eingesetzt werden können. Etwa stehen für Transfers, evtl. Gehen mit Hilfsmitteln.

    • AIS E

      Normal, motorische und sensible Funktionen sind normal.

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