Spinal cord injury

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Spinal cord injury_table_infobox_0

Spinal cord injurySpinal cord injury_header_cell_0_0_0
SpecialtySpinal cord injury_header_cell_0_1_0 NeurosurgerySpinal cord injury_cell_0_1_1
TypesSpinal cord injury_header_cell_0_2_0 Complete, incompleteSpinal cord injury_cell_0_2_1
Diagnostic methodSpinal cord injury_header_cell_0_3_0 Based on symptoms, medical imagingSpinal cord injury_cell_0_3_1
TreatmentSpinal cord injury_header_cell_0_4_0 Spinal motion restriction, intravenous fluids, vasopressorsSpinal cord injury_cell_0_4_1
FrequencySpinal cord injury_header_cell_0_5_0 c. 12,000 per year (USA)Spinal cord injury_cell_0_5_1

A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Spinal cord injury_sentence_0

Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury. Spinal cord injury_sentence_1

Injury can occur at any level of the spinal cord and can be complete, with a total loss of sensation and muscle function at lower sacral segments, or incomplete, meaning some nervous signals are able to travel past the injured area of the cord up to the Sacral S4-5 spinal cord segments. Spinal cord injury_sentence_2

Depending on the location and severity of damage, the symptoms vary, from numbness to paralysis, including bowel or bladder incontinence. Spinal cord injury_sentence_3

Long term outcomes also range widely, from full recovery to permanent tetraplegia (also called quadriplegia) or paraplegia. Spinal cord injury_sentence_4

Complications can include muscle atrophy, loss of voluntary motor control, spasticity, pressure sores, infections, and breathing problems. Spinal cord injury_sentence_5

In the majority of cases the damage results from physical trauma such as car accidents, gunshot wounds, falls, or sports injuries, but it can also result from nontraumatic causes such as infection, insufficient blood flow, and tumors. Spinal cord injury_sentence_6

Just over half of injuries affect the cervical spine, while 15% occur in each of the thoracic spine, border between the thoracic and lumbar spine, and lumbar spine alone. Spinal cord injury_sentence_7

Diagnosis is typically based on symptoms and medical imaging. Spinal cord injury_sentence_8

Efforts to prevent SCI include individual measures such as using safety equipment, societal measures such as safety regulations in sports and traffic, and improvements to equipment. Spinal cord injury_sentence_9

Treatment starts with restricting further motion of the spine and maintaining adequate blood pressure. Spinal cord injury_sentence_10

Corticosteroids have not been found to be useful. Spinal cord injury_sentence_11

Other interventions vary depending on the location and extent of the injury, from bed rest to surgery. Spinal cord injury_sentence_12

In many cases, spinal cord injuries require long-term physical and occupational therapy, especially if it interferes with activities of daily living. Spinal cord injury_sentence_13

In the United States, about 12,000 people a year survive a spinal cord injury. Spinal cord injury_sentence_14

The most commonly affected group are young adult males. Spinal cord injury_sentence_15

SCI has seen great improvements in its care since the middle of the 20th century. Spinal cord injury_sentence_16

Research into potential treatments includes stem cell implantation, engineered materials for tissue support, epidural spinal stimulation, and wearable robotic exoskeletons. Spinal cord injury_sentence_17

Classification Spinal cord injury_section_0

Spinal cord injury can be traumatic or nontraumatic, and can be classified into three types based on cause: mechanical forces, toxic, and ischemic (from lack of blood flow). Spinal cord injury_sentence_18

The damage can also be divided into primary and secondary injury: the cell death that occurs immediately in the original injury, and biochemical cascades that are initiated by the original insult and cause further tissue damage. Spinal cord injury_sentence_19

These secondary injury pathways include the ischemic cascade, inflammation, swelling, cell suicide, and neurotransmitter imbalances. Spinal cord injury_sentence_20

They can take place for minutes or weeks following the injury. Spinal cord injury_sentence_21

At each level of the spinal column, spinal nerves branch off from either side of the spinal cord and exit between a pair of vertebrae, to innervate a specific part of the body. Spinal cord injury_sentence_22

The area of skin innervated by a specific spinal nerve is called a dermatome, and the group of muscles innervated by a single spinal nerve is called a myotome. Spinal cord injury_sentence_23

The part of the spinal cord that was damaged corresponds to the spinal nerves at that level and below. Spinal cord injury_sentence_24

Injuries can be cervical 1–8 (C1–C8), thoracic 1–12 (T1–T12), lumbar 1–5 (L1–L5), or sacral (S1–S5). Spinal cord injury_sentence_25

A person's level of injury is defined as the lowest level of full sensation and function. Spinal cord injury_sentence_26

Paraplegia occurs when the legs are affected by the spinal cord damage (in thoracic, lumbar, or sacral injuries), and tetraplegia occurs when all four limbs are affected (cervical damage). Spinal cord injury_sentence_27

SCI is also classified by the degree of impairment. Spinal cord injury_sentence_28

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), published by the American Spinal Injury Association (ASIA), is widely used to document sensory and motor impairments following SCI. Spinal cord injury_sentence_29

It is based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of the muscles that control key motions on both sides of the body. Spinal cord injury_sentence_30

Muscle strength is scored on a scale of 0–5 according to the table on the right, and sensation is graded on a scale of 0–2: 0 is no sensation, 1 is altered or decreased sensation, and 2 is full sensation. Spinal cord injury_sentence_31

Each side of the body is graded independently. Spinal cord injury_sentence_32

Spinal cord injury_table_general_1

Muscle strengthSpinal cord injury_header_cell_1_0_0 ASIA Impairment Scale for classifying spinal cord injurySpinal cord injury_header_cell_1_0_2
GradeSpinal cord injury_header_cell_1_1_0 Muscle functionSpinal cord injury_header_cell_1_1_1 GradeSpinal cord injury_header_cell_1_1_2 DescriptionSpinal cord injury_header_cell_1_1_3
0Spinal cord injury_header_cell_1_2_0 No muscle contractionSpinal cord injury_cell_1_2_1 ASpinal cord injury_header_cell_1_2_2 Complete injury. No motor or sensory function is preserved in the sacral segments S4 or S5.Spinal cord injury_cell_1_2_3
1Spinal cord injury_header_cell_1_3_0 Muscle flickersSpinal cord injury_cell_1_3_1 BSpinal cord injury_header_cell_1_3_2 Sensory incomplete. Sensory but not motor function is preserved below the level of injury, including the sacral segments.Spinal cord injury_cell_1_3_3
2Spinal cord injury_header_cell_1_4_0 Full range of motion, gravity eliminatedSpinal cord injury_cell_1_4_1 CSpinal cord injury_header_cell_1_4_2 Motor incomplete. Motor function is preserved below the level of injury, and more than half of muscles tested below the level of injury have a muscle grade less than 3 (see muscle strength scores, left).Spinal cord injury_cell_1_4_3
3Spinal cord injury_header_cell_1_5_0 Full range of motion, against gravitySpinal cord injury_cell_1_5_1 DSpinal cord injury_header_cell_1_5_2 Motor incomplete. Motor function is preserved below the level of injury and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.Spinal cord injury_cell_1_5_3
4Spinal cord injury_header_cell_1_6_0 Full range of motion against resistanceSpinal cord injury_cell_1_6_1 ESpinal cord injury_header_cell_1_6_2 Normal. No motor or sensory deficits, but deficits existed in the past.Spinal cord injury_cell_1_6_3
5Spinal cord injury_header_cell_1_7_0 Normal strengthSpinal cord injury_cell_1_7_1 Spinal cord injury_header_cell_1_7_2 Spinal cord injury_cell_1_7_3

Complete and incomplete injuries Spinal cord injury_section_1

Spinal cord injury_table_general_2

Level and completeness of injuriesSpinal cord injury_table_caption_2
Spinal cord injury_cell_2_0_0 CompleteSpinal cord injury_header_cell_2_0_1 IncompleteSpinal cord injury_header_cell_2_0_2
TetraplegiaSpinal cord injury_header_cell_2_1_0 18.3%Spinal cord injury_cell_2_1_1 34.1%Spinal cord injury_cell_2_1_2
ParaplegiaSpinal cord injury_header_cell_2_2_0 23.0%Spinal cord injury_cell_2_2_1 18.5%Spinal cord injury_cell_2_2_2

In a "complete" spinal injury, all functions below the injured area are lost, whether or not the spinal cord is severed. Spinal cord injury_sentence_33

An "incomplete" spinal cord injury involves preservation of motor or sensory function below the level of injury in the spinal cord. Spinal cord injury_sentence_34

To be classed as incomplete, there must be some preservation of sensation or motion in the areas innervated by S4 to S5, e.g. voluntary external anal sphincter contraction. Spinal cord injury_sentence_35

The nerves in this area are connected to the very lowest region of the spinal cord, and retaining sensation and function in these parts of the body indicates that the spinal cord is only partially damaged. Spinal cord injury_sentence_36

Incomplete injury by definition includes a phenomenon known as sacral sparing: some degree of sensation is preserved in the sacral dermatomes, even though sensation may be more impaired in other, higher dermatomes below the level of the lesion. Spinal cord injury_sentence_37

Sacral sparing has been attributed to the fact that the sacral spinal pathways are not as likely as the other spinal pathways to become compressed after injury due to the lamination of fibers within the spinal cord. Spinal cord injury_sentence_38

Spinal cord injury without radiographic abnormality Spinal cord injury_section_2

Spinal cord injury without radiographic abnormality exists when SCI is present but there is no evidence of spinal column injury on radiographs. Spinal cord injury_sentence_39

Spinal column injury is trauma that causes fracture of the bone or instability of the ligaments in the spine; this can coexist with or cause injury to the spinal cord, but each injury can occur without the other. Spinal cord injury_sentence_40

Abnormalities might show up on magnetic resonance imaging (MRI), but the term was coined before MRI was in common use. Spinal cord injury_sentence_41

Central cord syndrome Spinal cord injury_section_3

Central cord syndrome, almost always resulting from damage to the cervical spinal cord, is characterized by weakness in the arms with relative sparing of the legs, and spared sensation in regions served by the sacral segments. Spinal cord injury_sentence_42

There is loss of sensation of pain, temperature, light touch, and pressure below the level of injury. Spinal cord injury_sentence_43

The spinal tracts that serve the arms are more affected due to their central location in the spinal cord, while the corticospinal fibers destined for the legs are spared due to their more external location. Spinal cord injury_sentence_44

The most common of the incomplete SCI syndromes, central cord syndrome usually results from neck hyperextension in older people with spinal stenosis. Spinal cord injury_sentence_45

In younger people, it most commonly results from neck flexion. Spinal cord injury_sentence_46

The most common causes are falls and vehicle accidents; however other possible causes include spinal stenosis and impingement on the spinal cord by a tumor or vertebral disk. Spinal cord injury_sentence_47

Anterior cord syndrome Spinal cord injury_section_4

Anterior cord syndrome, due to damage to the front portion of the spinal cord or reduction in the blood supply from the anterior spinal artery, can be caused by fractures or dislocations of vertebrae or herniated disks. Spinal cord injury_sentence_48

Below the level of injury, motor function, pain sensation, and temperature sensation are lost, while sense of touch and proprioception (sense of position in space) remain intact. Spinal cord injury_sentence_49

These differences are due to the relative locations of the spinal tracts responsible for each type of function. Spinal cord injury_sentence_50

Brown-Séquard syndrome Spinal cord injury_section_5

Brown-Séquard syndrome occurs when the spinal cord is injured on one side much more than the other. Spinal cord injury_sentence_51

It is rare for the spinal cord to be truly hemisected (severed on one side), but partial lesions due to penetrating wounds (such as gunshot or knife wounds) or fractured vertebrae or tumors are common. Spinal cord injury_sentence_52

On the ipsilateral side of the injury (same side), the body loses motor function, proprioception, and senses of vibration and touch. Spinal cord injury_sentence_53

On the contralateral (opposite side) of the injury, there is a loss of pain and temperature sensations. Spinal cord injury_sentence_54

Posterior cord syndrome Spinal cord injury_section_6

Posterior cord syndrome, in which just the dorsal columns of the spinal cord are affected, is usually seen in cases of chronic myelopathy but can also occur with infarction of the posterior spinal artery. Spinal cord injury_sentence_55

This rare syndrome causes the loss of proprioception and sense of vibration below the level of injury while motor function and sensation of pain, temperature, and touch remain intact. Spinal cord injury_sentence_56

Usually posterior cord injuries result from insults like disease or vitamin deficiency rather than trauma. Spinal cord injury_sentence_57

Tabes dorsalis, due to injury to the posterior part of the spinal cord caused by syphilis, results in loss of touch and proprioceptive sensation. Spinal cord injury_sentence_58

Conus medullaris and cauda equina syndromes Spinal cord injury_section_7

Conus medullaris syndrome is an injury to the end of the spinal cord, located at about the T12–L2 vertebrae in adults. Spinal cord injury_sentence_59

This region contains the S4–S5 spinal segments, responsible for bowel, bladder, and some sexual functions, so these can be disrupted in this type of injury. Spinal cord injury_sentence_60

In addition, sensation and the Achilles reflex can be disrupted. Spinal cord injury_sentence_61

Causes include tumors, physical trauma, and ischemia. Spinal cord injury_sentence_62

Cauda equina syndrome (CES) results from a lesion below the level at which the spinal cord splits into the cauda equina, at levels L2–S5 below the conus medullaris. Spinal cord injury_sentence_63

Thus it is not a true spinal cord syndrome since it is nerve roots that are damaged and not the cord itself; however, it is common for several of these nerves to be damaged at the same time due to their proximity. Spinal cord injury_sentence_64

CES can occur by itself or alongside conus medullaris syndrome. Spinal cord injury_sentence_65

It can cause low back pain, weakness or paralysis in the lower limbs, loss of sensation, bowel and bladder dysfunction, and loss of reflexes. Spinal cord injury_sentence_66

Unlike in conus medullaris syndrome, symptoms often occur on only one side of the body. Spinal cord injury_sentence_67

The cause is often compression, e.g. by a ruptured intervertebral disk or tumor. Spinal cord injury_sentence_68

Since the nerves damaged in CES are actually peripheral nerves because they have already branched off from the spinal cord, the injury has better prognosis for recovery of function: the peripheral nervous system has a greater capacity for healing than the central nervous system. Spinal cord injury_sentence_69

Signs and symptoms Spinal cord injury_section_8

Spinal cord injury_table_general_3

Actions of the spinal nervesSpinal cord injury_table_caption_3
LevelSpinal cord injury_header_cell_3_0_0 Motor FunctionSpinal cord injury_header_cell_3_0_1
C1C6Spinal cord injury_header_cell_3_1_0 Neck flexorsSpinal cord injury_cell_3_1_1
C1T1Spinal cord injury_header_cell_3_2_0 Neck extensorsSpinal cord injury_cell_3_2_1
C3, C4, C5Spinal cord injury_header_cell_3_3_0 Supply diaphragm (mostly C4)Spinal cord injury_cell_3_3_1
C5, C6Spinal cord injury_header_cell_3_4_0 Move shoulder, raise arm (deltoid); flex elbow (biceps)Spinal cord injury_cell_3_4_1
C6Spinal cord injury_header_cell_3_5_0 externally rotate (supinate) the armSpinal cord injury_cell_3_5_1
C6, C7Spinal cord injury_header_cell_3_6_0 Extend elbow and wrist (triceps and wrist extensors); pronate wristSpinal cord injury_cell_3_6_1
C7, T1Spinal cord injury_header_cell_3_7_0 Flex wrist; supply small muscles of the handSpinal cord injury_cell_3_7_1
T1T6Spinal cord injury_header_cell_3_8_0 Intercostals and trunk above the waistSpinal cord injury_cell_3_8_1
T7L1Spinal cord injury_header_cell_3_9_0 Abdominal musclesSpinal cord injury_cell_3_9_1
L1L4Spinal cord injury_header_cell_3_10_0 Flex thighSpinal cord injury_cell_3_10_1
L2, L3, L4Spinal cord injury_header_cell_3_11_0 Adduct thigh; Extend leg at the knee (quadriceps femoris)Spinal cord injury_cell_3_11_1
L4, L5, S1Spinal cord injury_header_cell_3_12_0 abduct thigh; Flex leg at the knee (hamstrings); Dorsiflex foot (tibialis anterior); Extend toesSpinal cord injury_cell_3_12_1
L5, S1, S2Spinal cord injury_header_cell_3_13_0 Extend leg at the hip (gluteus maximus); Plantar flex foot and flex toesSpinal cord injury_cell_3_13_1

Further information: Dermatome (anatomy) Spinal cord injury_sentence_70

Signs (observed by a clinician) and symptoms (experienced by a patient) vary depending on where the spine is injured and the extent of the injury. Spinal cord injury_sentence_71

A section of skin innervated through a specific part of the spine is called a dermatome, and injury to that part of the spine can cause pain, numbness, or a loss of sensation in the related areas. Spinal cord injury_sentence_72

Paraesthesia, a tingling or burning sensation in affected areas of the skin, is another symptom. Spinal cord injury_sentence_73

A person with a lowered level of consciousness may show a response to a painful stimulus above a certain point but not below it. Spinal cord injury_sentence_74

A group of muscles innervated through a specific part of the spine is called a myotome, and injury to that part of the spinal cord can cause problems with movements that involve those muscles. Spinal cord injury_sentence_75

The muscles may contract uncontrollably (spasticity), become weak, or be completely paralysed. Spinal cord injury_sentence_76

Spinal shock, loss of neural activity including reflexes below the level of injury, occurs shortly after the injury and usually goes away within a day. Spinal cord injury_sentence_77

Priapism, an erection of the penis may be a sign of acute spinal cord injury. Spinal cord injury_sentence_78

The specific parts of the body affected by loss of function are determined by the level of injury. Spinal cord injury_sentence_79

Some signs, such as bowel and bladder dysfunction can occur at any level. Spinal cord injury_sentence_80

Neurogenic bladder involves a compromised ability to empty the bladder and is a common symptom of spinal cord injury. Spinal cord injury_sentence_81

This can lead to high pressures in the bladder that can damage the kidneys. Spinal cord injury_sentence_82

Lumbosacral Spinal cord injury_section_9

The effects of injuries at or above the lumbar or sacral regions of the spinal cord (lower back and pelvis) include decreased control of the legs and hips, genitourinary system, and anus. Spinal cord injury_sentence_83

People injured below level L2 may still have use of their hip flexor and knee extensor muscles. Spinal cord injury_sentence_84

Bowel and bladder function are regulated by the sacral region. Spinal cord injury_sentence_85

It is common to experience sexual dysfunction after injury, as well as dysfunction of the bowel and bladder, including fecal and urinary incontinence. Spinal cord injury_sentence_86

Thoracic Spinal cord injury_section_10

In addition to the problems found in lower-level injuries, thoracic (chest height) spinal lesions can affect the muscles in the trunk. Spinal cord injury_sentence_87

Injuries at the level of T1 to T8 result in inability to control the abdominal muscles. Spinal cord injury_sentence_88

Trunk stability may be affected; even more so in higher level injuries. Spinal cord injury_sentence_89

The lower the level of injury, the less extensive its effects. Spinal cord injury_sentence_90

Injuries from T9 to T12 result in partial loss of trunk and abdominal muscle control. Spinal cord injury_sentence_91

Thoracic spinal injuries result in paraplegia, but function of the hands, arms, and neck are not affected. Spinal cord injury_sentence_92

One condition that occurs typically in lesions above the T6 level is autonomic dysreflexia (AD), in which the blood pressure increases to dangerous levels, high enough to cause potentially deadly stroke. Spinal cord injury_sentence_93

It results from an overreaction of the system to a stimulus such as pain below the level of injury, because inhibitory signals from the brain cannot pass the lesion to dampen the excitatory sympathetic nervous system response. Spinal cord injury_sentence_94

Signs and symptoms of AD include anxiety, headache, nausea, ringing in the ears, blurred vision, flushed skin, and nasal congestion. Spinal cord injury_sentence_95

It can occur shortly after the injury or not until years later. Spinal cord injury_sentence_96

Other autonomic functions may also be disrupted. Spinal cord injury_sentence_97

For example, problems with body temperature regulation mostly occur in injuries at T8 and above. Spinal cord injury_sentence_98

Another serious complication that can result from lesions above T6 is neurogenic shock, which results from an interruption in output from the sympathetic nervous system responsible for maintaining muscle tone in the blood vessels. Spinal cord injury_sentence_99

Without the sympathetic input, the vessels relax and dilate. Spinal cord injury_sentence_100

Neurogenic shock presents with dangerously low blood pressure, low heart rate, and blood pooling in the limbs—which results in insufficient blood flow to the spinal cord and potentially further damage to it. Spinal cord injury_sentence_101

Cervical Spinal cord injury_section_11

Spinal cord injuries at the cervical (neck) level result in full or partial tetraplegia (also called quadriplegia). Spinal cord injury_sentence_102

Depending on the specific location and severity of trauma, limited function may be retained. Spinal cord injury_sentence_103

Additional symptoms of cervical injuries include low heart rate, low blood pressure, problems regulating body temperature, and breathing dysfunction. Spinal cord injury_sentence_104

If the injury is high enough in the neck to impair the muscles involved in breathing, the person may not be able to breathe without the help of an endotracheal tube and mechanical ventilator. Spinal cord injury_sentence_105

Spinal cord injury_table_general_4

Function after complete cervical spinal cord injurySpinal cord injury_table_caption_4
LevelSpinal cord injury_header_cell_4_0_0 Motor FunctionSpinal cord injury_header_cell_4_0_1 Respiratory functionSpinal cord injury_header_cell_4_0_2
C1–C4Spinal cord injury_cell_4_1_0 Full paralysis of the limbsSpinal cord injury_cell_4_1_1 Cannot breathe without mechanical ventilationSpinal cord injury_cell_4_1_2
C5Spinal cord injury_cell_4_2_0 Paralysis of the wrists, hands, and tricepsSpinal cord injury_cell_4_2_1 Difficulty coughing, may need help clearing secretionsSpinal cord injury_cell_4_2_2
C6Spinal cord injury_cell_4_3_0 Paralysis of the wrist flexors, triceps, and handsSpinal cord injury_cell_4_3_1
C7–C8Spinal cord injury_cell_4_4_0 Some hand muscle weakness, difficulty grasping and releasingSpinal cord injury_cell_4_4_1

Complications Spinal cord injury_section_12

Complications of spinal cord injuries include pulmonary edema, respiratory failure, neurogenic shock, and paralysis below the injury site. Spinal cord injury_sentence_106

In the long term, the loss of muscle function can have additional effects from disuse, including atrophy of the muscle. Spinal cord injury_sentence_107

Immobility can lead to pressure sores, particularly in bony areas, requiring precautions such as extra cushioning and turning in bed every two hours (in the acute setting) to relieve pressure. Spinal cord injury_sentence_108

In the long term, people in wheelchairs must shift periodically to relieve pressure. Spinal cord injury_sentence_109

Another complication is pain, including nociceptive pain (indication of potential or actual tissue damage) and neuropathic pain, when nerves affected by damage convey erroneous pain signals in the absence of noxious stimuli. Spinal cord injury_sentence_110

Spasticity, the uncontrollable tensing of muscles below the level of injury, occurs in 65–78% of chronic SCI. Spinal cord injury_sentence_111

It results from lack of input from the brain that quells muscle responses to stretch reflexes. Spinal cord injury_sentence_112

It can be treated with drugs and physical therapy. Spinal cord injury_sentence_113

Spasticity increases the risk of contractures (shortening of muscles, tendons, or ligaments that result from lack of use of a limb); this problem can be prevented by moving the limb through its full range of motion multiple times a day. Spinal cord injury_sentence_114

Another problem lack of mobility can cause is loss of bone density and changes in bone structure. Spinal cord injury_sentence_115

Loss of bone density (bone demineralization), thought to be due to lack of input from weakened or paralysed muscles, can increase the risk of fractures. Spinal cord injury_sentence_116

Conversely, a poorly understood phenomenon is the overgrowth of bone tissue in soft tissue areas, called heterotopic ossification. Spinal cord injury_sentence_117

It occurs below the level of injury, possibly as a result of inflammation, and happens to a clinically significant extent in 27% of people. Spinal cord injury_sentence_118

People with SCI are at especially high risk for respiratory and cardiovascular problems, so hospital staff must be watchful to avoid them. Spinal cord injury_sentence_119

Respiratory problems (especially pneumonia) are the leading cause of death in people with SCI, followed by infections, usually of pressure sores, urinary tract infections and respiratory infections. Spinal cord injury_sentence_120

Pneumonia can be accompanied by shortness of breath, fever, and anxiety. Spinal cord injury_sentence_121

Another potentially deadly threat to respiration is deep venous thrombosis (DVT), in which blood forms a clot in immobile limbs; the clot can break off and form a pulmonary embolism, lodging in the lung and cutting off blood supply to it. Spinal cord injury_sentence_122

DVT is an especially high risk in SCI, particularly within 10 days of injury, occurring in over 13% in the acute care setting. Spinal cord injury_sentence_123

Preventative measures include anticoagulants, pressure hose, and moving the patient's limbs. Spinal cord injury_sentence_124

The usual signs and symptoms of DVT and pulmonary embolism may be masked in SCI cases due to effects such as alterations in pain perception and nervous system functioning. Spinal cord injury_sentence_125

Urinary tract infection (UTI) is another risk that may not display the usual symptoms (pain, urgency, and frequency); it may instead be associated with worsened spasticity. Spinal cord injury_sentence_126

The risk of UTI, likely the most common complication in the long term, is heightened by use of indwelling urinary catheters. Spinal cord injury_sentence_127

Catheterization may be necessary because SCI interferes with the bladder's ability to empty when it gets too full, which could trigger autonomic dysreflexia or damage the bladder permanently. Spinal cord injury_sentence_128

The use of intermittent catheterization to empty the bladder at regular intervals throughout the day has decreased the mortality due to kidney failure from UTI in the first world, but it is still a serious problem in developing countries. Spinal cord injury_sentence_129

An estimated 24–45% of people with SCI suffer disorders of depression, and the suicide rate is as much as six times that of the rest of the population. Spinal cord injury_sentence_130

The risk of suicide is worst in the first five years after injury. Spinal cord injury_sentence_131

In young people with SCI, suicide is the leading cause of death. Spinal cord injury_sentence_132

Depression is associated with an increased risk of other complications such as UTI and pressure ulcers that occur more when self-care is neglected. Spinal cord injury_sentence_133

Causes Spinal cord injury_section_13

Spinal cord injuries are most often caused by physical trauma. Spinal cord injury_sentence_134

Forces involved can be hyperflexion (forward movement of the head); hyperextension (backward movement); lateral stress (sideways movement); rotation (twisting of the head); compression (force along the axis of the spine downward from the head or upward from the pelvis); or distraction (pulling apart of the vertebrae). Spinal cord injury_sentence_135

Traumatic SCI can result in contusion, compression, or stretch injury. Spinal cord injury_sentence_136

It is a major risk of many types of vertebral fracture. Spinal cord injury_sentence_137

Pre-existing asymptomatic congenital anomalies can cause major neurological deficits, such as hemiparesis, to result from otherwise minor trauma. Spinal cord injury_sentence_138

In the US, Motor vehicle accidents are the most common cause of SCIs; second are falls, then violence such as gunshot wounds, then sports injuries. Spinal cord injury_sentence_139

In some countries falls are more common, even surpassing vehicle crashes as the leading cause of SCI. Spinal cord injury_sentence_140

The rates of violence-related SCI depend heavily on place and time. Spinal cord injury_sentence_141

Of all sports-related SCIs, shallow water dives are the most common cause; winter sports and water sports have been increasing as causes while association football and trampoline injuries have been declining. Spinal cord injury_sentence_142

Hanging can cause injury to the cervical spine, as may occur in attempted suicide. Spinal cord injury_sentence_143

Military conflicts are another cause, and when they occur they are associated with increased rates of SCI. Spinal cord injury_sentence_144

Another potential cause of SCI is iatrogenic injury, caused by an improperly done medical procedure such as an injection into the spinal column. Spinal cord injury_sentence_145

SCI can also be of a nontraumatic origin. Spinal cord injury_sentence_146

Nontraumatic lesions cause anywhere from 30 to 80% of all SCI; the percentage varies by locale, influenced by efforts to prevent trauma. Spinal cord injury_sentence_147

Developed countries have higher percentages of SCI due to degenerative conditions and tumors than developing countries. Spinal cord injury_sentence_148

In developed countries, the most common cause of nontraumatic SCI is degenerative diseases, followed by tumors; in many developing countries the leading cause is infection such as HIV and tuberculosis. Spinal cord injury_sentence_149

SCI may occur in intervertebral disc disease, and spinal cord vascular disease. Spinal cord injury_sentence_150

Spontaneous bleeding can occur within or outside of the protective membranes that line the cord, and intervertebral disks can herniate. Spinal cord injury_sentence_151

Damage can result from dysfunction of the blood vessels, as in arteriovenous malformation, or when a blood clot becomes lodged in a blood vessel and cuts off blood supply to the cord. Spinal cord injury_sentence_152

When systemic blood pressure drops, blood flow to the spinal cord may be reduced, potentially causing a loss of sensation and voluntary movement in the areas supplied by the affected level of the spinal cord. Spinal cord injury_sentence_153

Congenital conditions and tumors that compress the cord can also cause SCI, as can vertebral spondylosis and ischemia. Spinal cord injury_sentence_154

Multiple sclerosis is a disease that can damage the spinal cord, as can infectious or inflammatory conditions such as tuberculosis, herpes zoster or herpes simplex, meningitis, myelitis, and syphilis. Spinal cord injury_sentence_155

Prevention Spinal cord injury_section_14

Vehicle-related SCI is prevented with measures including societal and individual efforts to reduce driving under the influence of drugs or alcohol, distracted driving, and drowsy driving. Spinal cord injury_sentence_156

Other efforts include increasing road safety (such as marking hazards and adding lighting) and vehicle safety, both to prevent accidents (such as routine maintenance and antilock brakes) and to mitigate the damage of crashes (such as head restraints, air bags, seat belts, and child safety seats). Spinal cord injury_sentence_157

Falls can be prevented by making changes to the environment, such as nonslip materials and grab bars in bathtubs and showers, railings for stairs, child and safety gates for windows. Spinal cord injury_sentence_158

Gun-related injuries can be prevented with conflict resolution training, gun safety education campaigns, and changes to the technology of guns (such as trigger locks) to improve their safety. Spinal cord injury_sentence_159

Sports injuries can be prevented with changes to sports rules and equipment to increase safety, and education campaigns to reduce risky practices such as diving into water of unknown depth or head-first tackling in association football. Spinal cord injury_sentence_160

Diagnosis Spinal cord injury_section_15

A person's presentation in context of trauma or non-traumatic background determines suspicion for a spinal cord injury. Spinal cord injury_sentence_161

The features are namely paralysis, sensory loss, or both at any level. Spinal cord injury_sentence_162

Other symptoms may include incontinence. Spinal cord injury_sentence_163

A radiographic evaluation using an X-ray, CT scan, or MRI can determine if there is damage to the spinal column and where it is located. Spinal cord injury_sentence_164

X-rays are commonly available and can detect instability or misalignment of the spinal column, but do not give very detailed images and can miss injuries to the spinal cord or displacement of ligaments or disks that do not have accompanying spinal column damage. Spinal cord injury_sentence_165

Thus when X-ray findings are normal but SCI is still suspected due to pain or SCI symptoms, CT or MRI scans are used. Spinal cord injury_sentence_166

CT gives greater detail than X-rays, but exposes the patient to more radiation, and it still does not give images of the spinal cord or ligaments; MRI shows body structures in the greatest detail. Spinal cord injury_sentence_167

Thus it is the standard for anyone who has neurological deficits found in SCI or is thought to have an unstable spinal column injury. Spinal cord injury_sentence_168

Neurological evaluations to help determine the degree of impairment are performed initially and repeatedly in the early stages of treatment; this determines the rate of improvement or deterioration and informs treatment and prognosis. Spinal cord injury_sentence_169

The ASIA Impairment Scale outlined above is used to determine the level and severity of injury. Spinal cord injury_sentence_170

Management Spinal cord injury_section_16

Prehospital treatment Spinal cord injury_section_17

The first stage in the management of a suspected spinal cord injury is geared toward basic life support and preventing further injury: maintaining airway, breathing, and circulation and restricting further motion of the spine. Spinal cord injury_sentence_171

In the emergency setting, most people who has been subjected to forces strong enough to cause SCI are treated as though they have instability in the spinal column and have spinal motion restricted to prevent damage to the spinal cord. Spinal cord injury_sentence_172

Injuries or fractures in the head, neck, or pelvis as well as penetrating trauma near the spine and falls from heights are assumed to be associated with an unstable spinal column until it is ruled out in the hospital. Spinal cord injury_sentence_173

High-speed vehicle crashes, sports injuries involving the head or neck, and diving injuries are other mechanisms that indicate a high SCI risk. Spinal cord injury_sentence_174

Since head and spinal trauma frequently coexist, anyone who is unconscious or has a lowered level of consciousness as a result of a head injury is spinal motion restricted. Spinal cord injury_sentence_175

A rigid cervical collar is applied to the neck, and the head is held with blocks on either side and the person is strapped to a backboard. Spinal cord injury_sentence_176

Extrication devices are used to move people without excessively moving the spine if they are still inside a vehicle or other confined space. Spinal cord injury_sentence_177

The use of a cervical collar has been shown to increase mortality in people with penetrating trauma and is thus not routinely recommended in this group. Spinal cord injury_sentence_178

Modern trauma care includes a step called clearing the cervical spine, ruling out spinal cord injury if the patient is fully conscious and not under the influence of drugs or alcohol, displays no neurological deficits, has no pain in the middle of the neck and no other painful injuries that could distract from neck pain. Spinal cord injury_sentence_179

If these are all absent, no spinal motion restriction is necessary. Spinal cord injury_sentence_180

If an unstable spinal column injury is moved, damage may occur to the spinal cord. Spinal cord injury_sentence_181

Between 3 and 25% of SCIs occur not at the time of the initial trauma but later during treatment or transport. Spinal cord injury_sentence_182

While some of this is due to the nature of the injury itself, particularly in the case of multiple or massive trauma, some of it reflects the failure to adequately restrict motion of the spine. Spinal cord injury_sentence_183

SCI can impair the body's ability to keep warm, so warming blankets may be needed. Spinal cord injury_sentence_184

Early hospital treatment Spinal cord injury_section_18

Initial care in the hospital, as in the prehospital setting, aims to ensure adequate airway, breathing, cardiovascular function, and spinal motion restriction. Spinal cord injury_sentence_185

Imaging of the spine to determine the presence of a SCI may need to wait if emergency surgery is needed to stabilize other life-threatening injuries. Spinal cord injury_sentence_186

Acute SCI merits treatment in an intensive care unit, especially injuries to the cervical spinal cord. Spinal cord injury_sentence_187

People with SCI need repeated neurological assessments and treatment by neurosurgeons. Spinal cord injury_sentence_188

People should be removed from the spine board as rapidly as possible to prevent complications from its use. Spinal cord injury_sentence_189

If the systolic blood pressure falls below 90 mmHg within days of the injury, blood supply to the spinal cord may be reduced, resulting in further damage. Spinal cord injury_sentence_190

Thus it is important to maintain the blood pressure which may be done using intravenous fluids and vasopressors. Spinal cord injury_sentence_191

Vasopressors used include phenylephrine, dopamine, or norepinephrine. Spinal cord injury_sentence_192

Mean arterial blood pressure is measured and kept at 85 to 90 mmHg for seven days after injury. Spinal cord injury_sentence_193

The treatment for shock from blood loss is different from that for neurogenic shock, and could harm people with the latter type, so it is necessary to determine why someone is in shock. Spinal cord injury_sentence_194

However it is also possible for both causes to exist at the same time. Spinal cord injury_sentence_195

Another important aspect of care is prevention of insufficient oxygen in the bloodstream, which could deprive the spinal cord of oxygen. Spinal cord injury_sentence_196

People with cervical or high thoracic injuries may experience a dangerously slowed heart rate; treatment to speed it may include atropine. Spinal cord injury_sentence_197

The corticosteroid medication methylprednisolone has been studied for use in SCI with the hope of limiting swelling and secondary injury. Spinal cord injury_sentence_198

As there does not appear to be long term benefits and the medication is associated with risks such as gastrointestinal bleeding and infection its use is not recommended as of 2018. Spinal cord injury_sentence_199

Its use in traumatic brain injury is also not recommended. Spinal cord injury_sentence_200

Surgery may be necessary, e.g. to relieve excess pressure on the cord, to stabilize the spine, or to put vertebrae back in their proper place. Spinal cord injury_sentence_201

In cases involving instability or compression, failing to operate can lead to worsening of the condition. Spinal cord injury_sentence_202

Surgery is also necessary when something is pressing on the cord, such as bone fragments, blood, material from ligaments or intervertebral discs, or a lodged object from a penetrating injury. Spinal cord injury_sentence_203

Although the ideal timing of surgery is still debated, studies have found that earlier surgical intervention (within 24 hours of injury) is associated with better outcomes. Spinal cord injury_sentence_204

Sometimes a patient has too many other injuries to be a surgical candidate this early. Spinal cord injury_sentence_205

Surgery is controversial because it has potential complications (such as infection), so in cases where it is not clearly needed (e.g. the cord is being compressed), doctors must decide whether to perform surgery based on aspects of the patient's condition and their own beliefs about its risks and benefits. Spinal cord injury_sentence_206

In cases where a more conservative approach is chosen, bed rest, cervical collars, motion restriction devices, and optionally traction are used. Spinal cord injury_sentence_207

Surgeons may opt to put traction on the spine to remove pressure from the spinal cord by putting dislocated vertebrae back into alignment, but herniation of intervertebral disks may prevent this technique from relieving pressure. Spinal cord injury_sentence_208

Gardner-Wells tongs are one tool used to exert spinal traction to reduce a fracture or dislocation and to reduce motion to the affected areas. Spinal cord injury_sentence_209

Rehabilitation Spinal cord injury_section_19

Main article: Rehabilitation in spinal cord injury Spinal cord injury_sentence_210

SCI patients often require extended treatment in specialized spinal unit or an intensive care unit. Spinal cord injury_sentence_211

The rehabilitation process typically begins in the acute care setting. Spinal cord injury_sentence_212

Usually, the inpatient phase lasts 8–12 weeks and then the outpatient rehabilitation phase lasts 3–12 months after that, followed by yearly medical and functional evaluation. Spinal cord injury_sentence_213

Physical therapists, occupational therapists, recreational therapists, nurses, social workers, psychologists, and other health care professionals work as a team under the coordination of a physiatrist to decide on goals with the patient and develop a plan of discharge that is appropriate for the person's condition. Spinal cord injury_sentence_214

In the acute phase physical therapists focus on the patient's respiratory status, prevention of indirect complications (such as pressure ulcers), maintaining range of motion, and keeping available musculature active. Spinal cord injury_sentence_215

For people whose injuries are high enough to interfere with breathing, there is great emphasis on airway clearance during this stage of recovery. Spinal cord injury_sentence_216

Weakness of respiratory muscles impairs the ability to cough effectively, allowing secretions to accumulate within the lungs. Spinal cord injury_sentence_217

As SCI patients suffer from reduced total lung capacity and tidal volume, physical therapists teach them accessory breathing techniques (e.g. apical breathing, glossopharyngeal breathing) that typically are not taught to healthy individuals. Spinal cord injury_sentence_218

Physical therapy treatment for airway clearance may include manual percussions and vibrations, postural drainage, respiratory muscle training, and assisted cough techniques. Spinal cord injury_sentence_219

Patients are taught to increase their intra-abdominal pressure by leaning forward to induce cough and clear mild secretions. Spinal cord injury_sentence_220

The quad cough technique is done lying on the back with the therapist applying pressure on the abdomen in the rhythm of the cough to maximize expiratory flow and mobilize secretions. Spinal cord injury_sentence_221

Manual abdominal compression is another technique used to increase expiratory flow which later improves coughing. Spinal cord injury_sentence_222

Other techniques used to manage respiratory dysfunction include respiratory muscle pacing, use of a constricting abdominal binder, ventilator-assisted speech, and mechanical ventilation. Spinal cord injury_sentence_223

The amount of functional recovery and independence achieved in terms of activities of daily living, recreational activities, and employment is affected by the level and severity of injury. Spinal cord injury_sentence_224

The Functional Independence Measure (FIM) is an assessment tool that aims to evaluate the function of patients throughout the rehabilitation process following a spinal cord injury or other serious illness or injury. Spinal cord injury_sentence_225

It can track a patient's progress and degree of independence during rehabilitation. Spinal cord injury_sentence_226

People with SCI may need to use specialized devices and to make modifications to their environment in order to handle activities of daily living and to function independently. Spinal cord injury_sentence_227

Weak joints can be stabilized with devices such as ankle-foot orthoses (AFOs) and knee-AFOs, but walking may still require a lot of effort. Spinal cord injury_sentence_228

Increasing activity will increase chances of recovery. Spinal cord injury_sentence_229

Prognosis Spinal cord injury_section_20

Spinal cord injuries generally result in at least some incurable impairment even with the best possible treatment. Spinal cord injury_sentence_230

The best predictor of prognosis is the level and completeness of injury, as measured by the ASIA impairment scale. Spinal cord injury_sentence_231

The neurological score at the initial evaluation done 72 hours after injury is the best predictor of how much function will return. Spinal cord injury_sentence_232

Most people with ASIA scores of A (complete injuries) do not have functional motor recovery, but improvement can occur. Spinal cord injury_sentence_233

Most patients with incomplete injuries recover at least some function. Spinal cord injury_sentence_234

Chances of recovering the ability to walk improve with each AIS grade found at the initial examination; e.g. an ASIA D score confers a better chance of walking than a score of C. The symptoms of incomplete injuries can vary and it is difficult to make an accurate prediction of the outcome. Spinal cord injury_sentence_235

A person with a mild, incomplete injury at the T5 vertebra will have a much better chance of using his or her legs than a person with a severe, complete injury at exactly the same place. Spinal cord injury_sentence_236

Of the incomplete SCI syndromes, Brown-Séquard and central cord syndromes have the best prognosis for recovery and anterior cord syndrome has the worst. Spinal cord injury_sentence_237

People with nontraumatic causes of SCI have been found to be less likely to suffer complete injuries and some complications such as pressure sores and deep vein thrombosis, and to have shorter hospital stays. Spinal cord injury_sentence_238

Their scores on functional tests were better than those of people with traumatic SCI upon hospital admission, but when they were tested upon discharge, those with traumatic SCI had improved such that both groups' results were the same. Spinal cord injury_sentence_239

In addition to the completeness and level of the injury, age and concurrent health problems affect the extent to which a person with SCI will be able to live independently and to walk. Spinal cord injury_sentence_240

However, in general people with injuries to L3 or below will likely be able to walk functionally, T10 and below to walk around the house with bracing, and C7 and below to live independently. Spinal cord injury_sentence_241

New therapies are beginning to provide hope for better outcomes in patients with SCI, but most are in the experimental/translational stage. Spinal cord injury_sentence_242

One important predictor of motor recovery in an area is presence of sensation there, particularly pain perception. Spinal cord injury_sentence_243

Most motor recovery occurs in the first year post-injury, but modest improvements can continue for years; sensory recovery is more limited. Spinal cord injury_sentence_244

Recovery is typically quickest during the first six months. Spinal cord injury_sentence_245

Spinal shock, in which reflexes are suppressed, occurs immediately after the injury and resolves largely within three months but continues resolving gradually for another 15. Spinal cord injury_sentence_246

Sexual dysfunction after spinal injury is common. Spinal cord injury_sentence_247

Problems that can occur include erectile dysfunction, loss of ability to ejaculate, insufficient lubrication of the vagina, and reduced sensation and impaired ability to orgasm. Spinal cord injury_sentence_248

Despite this, many people learn ways to adapt their sexual practices so they can lead satisfying sex lives. Spinal cord injury_sentence_249

Although life expectancy has improved with better care options, it is still not as good as the uninjured population. Spinal cord injury_sentence_250

The higher the level of injury, and the more complete the injury, the greater the reduction in life expectancy. Spinal cord injury_sentence_251

Mortality is very elevated within a year of injury. Spinal cord injury_sentence_252

Epidemiology Spinal cord injury_section_21

Worldwide, the number of new cases since 1995 of SCI ranges from 10.4 to 83 people per million per year. Spinal cord injury_sentence_253

This wide range of numbers is probably partly due to differences among regions in whether and how injuries are reported. Spinal cord injury_sentence_254

In North America, about 39 people per every million incur SCI traumatically each year, and in Western Europe, the incidence is 16 per million. Spinal cord injury_sentence_255

In the United States, the incidence of spinal cord injury has been estimated to be about 40 cases per 1 million people per year or around 12,000 cases per year. Spinal cord injury_sentence_256

In China, the incidence is approximately 60,000 per year. Spinal cord injury_sentence_257

The estimated number of people living with SCI in the world ranges from 236 to 4187 per million. Spinal cord injury_sentence_258

Estimates vary widely due to differences in how data are collected and what techniques are used to extrapolate the figures. Spinal cord injury_sentence_259

Little information is available from Asia, and even less from Africa and South America. Spinal cord injury_sentence_260

In Western Europe the estimated prevalence is 300 per million people and in North America it is 853 per million. Spinal cord injury_sentence_261

It is estimated at 440 per million in Iran, 526 per million in Iceland, and 681 per million in Australia. Spinal cord injury_sentence_262

In the United States there are between 225,000 and 296,000 individuals living with spinal cord injuries, and different studies have estimated prevalences from 525 to 906 per million. Spinal cord injury_sentence_263

SCI is present in about 2% of all cases of blunt force trauma. Spinal cord injury_sentence_264

Anyone who has undergone force sufficient to cause a thoracic spinal injury is at high risk for other injuries also. Spinal cord injury_sentence_265

In 44% of SCI cases, other serious injuries are sustained at the same time; 14% of SCI patients also suffer head trauma or facial trauma. Spinal cord injury_sentence_266

Other commonly associated injuries include chest trauma, abdominal trauma, pelvic fractures, and long bone fractures. Spinal cord injury_sentence_267

Males account for four out of five traumatic spinal cord injuries. Spinal cord injury_sentence_268

Most of these injuries occur in men under 30 years of age. Spinal cord injury_sentence_269

The average age at the time of injury has slowly increased from about 29 years in the 1970s to 41. Spinal cord injury_sentence_270

Rates of injury are at their lowest in children, at their highest in the late teens to early twenties, then get progressively lower in older age groups; however rates may rise in the elderly. Spinal cord injury_sentence_271

In Sweden between 50 and 70% of all cases of SCI occur in people under 30, and 25% occur in those over 50. Spinal cord injury_sentence_272

While SCI rates are highest among people age 15–20, fewer than 3% of SCIs occur in people under 15. Spinal cord injury_sentence_273

Neonatal SCI occurs in one in 60,000 births, e.g. from breech births or injuries by forceps. Spinal cord injury_sentence_274

The difference in rates between the sexes diminishes in injuries at age 3 and younger; the same number of girls are injured as boys, or possibly more. Spinal cord injury_sentence_275

Another cause of pediatric injury is child abuse such as shaken baby syndrome. Spinal cord injury_sentence_276

For children, the most common cause of SCI (56%) is vehicle crashes. Spinal cord injury_sentence_277

High numbers of adolescent injuries are attributable in a large part to traffic accidents and sports injuries. Spinal cord injury_sentence_278

For people over 65, falls are the most common cause of traumatic SCI. Spinal cord injury_sentence_279

The elderly and people with severe arthritis are at high risk for SCI because of defects in the spinal column. Spinal cord injury_sentence_280

In nontraumatic SCI, the gender difference is smaller, the average age of occurrence is greater, and incomplete lesions are more common. Spinal cord injury_sentence_281

History Spinal cord injury_section_22

SCI has been known to be devastating for millennia; the ancient Egyptian Edwin Smith Papyrus from 2500 BC, the first known description of the injury, says it is "not to be treated". Spinal cord injury_sentence_282

Hindu texts dating back to 1800 BC also mention SCI and describe traction techniques to straighten the spine. Spinal cord injury_sentence_283

The Greek physician Hippocrates, born in the fifth century BC, described SCI in his Hippocratic Corpus and invented traction devices to straighten dislocated vertebrae. Spinal cord injury_sentence_284

But it was not until Aulus Cornelius Celsus, born 30 BC, noted that a cervical injury resulted in rapid death that the spinal cord itself was implicated in the condition. Spinal cord injury_sentence_285

In the second century AD the Greek physician Galen experimented on monkeys and reported that a horizontal cut through the spinal cord caused them to lose all sensation and motion below the level of the cut. Spinal cord injury_sentence_286

The seventh-century Greek physician Paul of Aegina described surgical techniques for treatment of broken vertebrae by removing bone fragments, as well as surgery to relieve pressure on the spine. Spinal cord injury_sentence_287

Little medical progress was made during the Middle Ages in Europe; it was not until the Renaissance that the spine and nerves were accurately depicted in human anatomy drawings by Leonardo da Vinci and Andreas Vesalius. Spinal cord injury_sentence_288

In 1762 a surgeon named Andre Louis removed a bullet from the lumbar spine of a patient, who regained motion in the legs. Spinal cord injury_sentence_289

In 1829 the surgeon Gilpin Smith performed a successful laminectomy that improved the patient's sensation. Spinal cord injury_sentence_290

However, the idea that SCI was untreatable remained predominant until the early 20th century. Spinal cord injury_sentence_291

In 1934, the mortality rate in the first two years after injury was over 80%, mostly due to infections of the urinary tract and pressure sores. Spinal cord injury_sentence_292

It was not until the latter half of the century that breakthroughs in imaging, surgery, medical care, and rehabilitation medicine contributed to a substantial improvement in SCI care. Spinal cord injury_sentence_293

The relative incidence of incomplete compared to complete injuries has improved since the mid-20th century, due mainly to the emphasis on faster and better initial care and stabilization of spinal cord injury patients. Spinal cord injury_sentence_294

The creation of emergency medical services to professionally transport people to the hospital is given partial credit for an improvement in outcomes since the 1970s. Spinal cord injury_sentence_295

Improvements in care have been accompanied by increased life expectancy of people with SCI; survival times have improved by about 2000% since 1940. Spinal cord injury_sentence_296

In 2015/2016 23% of people in nine spinal injury centres in England had their discharge delayed because of disputes about who should pay for the equipment they needed. Spinal cord injury_sentence_297

Research directions Spinal cord injury_section_23

Main article: Spinal cord injury research Spinal cord injury_sentence_298

Scientists are investigating various avenues for treatment of spinal cord injury. Spinal cord injury_sentence_299

Therapeutic research is focused on two main areas: neuroprotection and neuroregeneration. Spinal cord injury_sentence_300

The former seeks to prevent the harm that occurs from secondary injury in the minutes to weeks following the insult, and the latter aims to reconnect the broken circuits in the spinal cord to allow function to return. Spinal cord injury_sentence_301

Neuroprotective drugs target secondary injury effects including inflammation, damage by free radicals, excitotoxicity (neuronal damage by excessive glutamate signaling), and apoptosis (cell suicide). Spinal cord injury_sentence_302

Several potentially neuroprotective agents that target pathways like these are under investigation in human clinical trials. Spinal cord injury_sentence_303

Stem cell transplantation is an important avenue for SCI research: the goal is to replace lost spinal cord cells, allow reconnection in broken neural circuits by regrowing axons, and to create an environment in the tissues that is favorable to growth. Spinal cord injury_sentence_304

A key avenue of SCI research is research on stem cells, which can differentiate into other types of cells—including those lost after SCI. Spinal cord injury_sentence_305

Types of cells being researched for use in SCI include embryonic stem cells, neural stem cells, mesenchymal stem cells, olfactory ensheathing cells, Schwann cells, activated macrophages, and induced pluripotent stem cells. Spinal cord injury_sentence_306

Hundreds of stem cell studies have been done in humans, with promising but inconclusive results. Spinal cord injury_sentence_307

An ongoing Phase 2 trial in 2016 presented data showing that after 90 days, 2 out of 4 subjects had already improved two motor levels and had thus already achieved its endpoint of 2/5 patients improving two levels within 6–12 months. Spinal cord injury_sentence_308

Six-month data is expected in January 2017. Spinal cord injury_sentence_309

Another type of approach is tissue engineering, using biomaterials to help scaffold and rebuild damaged tissues. Spinal cord injury_sentence_310

Biomaterials being investigated include natural substances such as collagen or agarose and synthetic ones like polymers and nitrocellulose. Spinal cord injury_sentence_311

They fall into two categories: hydrogels and nanofibers. Spinal cord injury_sentence_312

These materials can also be used as a vehicle for delivering gene therapy to tissues. Spinal cord injury_sentence_313

One avenue being explored to allow paralyzed people to walk and to aid in rehabilitation of those with some walking ability is the use of wearable powered robotic exoskeletons. Spinal cord injury_sentence_314

The devices, which have motorized joints, are put on over the legs and supply a source of power to move and walk. Spinal cord injury_sentence_315

Several such devices are already available for sale, but investigation is still underway as to how they can be made more useful. Spinal cord injury_sentence_316

Preliminary studies of epidural spinal cord stimulators for motor complete injuries have demonstrated some improvement. Spinal cord injury_sentence_317

In 2014 Darek Fidyka underwent pioneering spinal surgery that used nerve grafts, from his ankle, to 'bridge the gap' in his severed spinal cord and olfactory ensheathing cells (OECs) to stimulate the spinal cord cells. Spinal cord injury_sentence_318

The surgery was performed in Poland in collaboration with Prof. Geoff Raisman, chair of neural regeneration at University College London's Institute of Neurology, and his research team. Spinal cord injury_sentence_319

The OECs were taken from the patient's olfactory bulbs in his brain and then grown in the lab, these cells were then injected above and below the impaired spinal tissue. Spinal cord injury_sentence_320

See also Spinal cord injury_section_24

Spinal cord injury_unordered_list_0


Credits to the contents of this page go to the authors of the corresponding Wikipedia page: en.wikipedia.org/wiki/Spinal cord injury.