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Spinal Cord Injury Interventions (Spinal Unit)
The back (vertebral column) consists of 24 vertebrae or bones, which is referred to by their region (e.g. cervical (C), thoracic (T), lumbar (L), and sacrum), and by number counting the bones in the region from their position to the head (i.e. C7 or T4). The sacrum and coccyx are seen as one bone, though there are 5 sacral nerve roots.
The spinal cord is an extension of the brain that runs down the back. It is surrounded and protected by the vertebral column, as well as a fluid which surrounds, and acts as a buffer to protect the delicate nerve tissue. The spinal cord is millions of nerve fibres which transmit information between the body (including organs), and the brain.
The spinal nerves come out of the spinal cord and exits the cord between two bones (vertebras) in the spinal column. They carry information to and from the spinal cord:
- Cervical nerves (nerves in the neck) supply movement and feeling to the arms, neck and upper trunk
- Thoracic nerves (nerves in the upper back) supply the trunk and abdomen
- Lumbar and sacral nerves (from the lower back) supply the legs, the bladder, bowel and sexual organs.
There are myotomes (nerves supplying muscles) and dermatomes (nerves supplying skin). The skin regions can be depicted on the illustration below:
- Level of injury
We describe the level of the injury by referring to the last spinal cord segment where the movement and feeling are normal. For example, if your injury is called “C5” this means that you would be able to bend your elbow normally and would have normal feeling to around the level of your elbow but below that the movement and feeling would be reduced.
- Tetraplegia / Quadriplegia
Injury to the spinal cord in the neck causes a condition known as tetraplegia or quadriplegia. These terms mean exactly the same thing, one is a Greek term and the other is Latin. There is injury to the spinal cord between the spinal cord segments C1 and T1. This causes paralysis and loss of feeling involving all 4 limbs as well as the bladder, bowel and sexual organs.
Injury to the spinal cord below the neck causes paraplegia. There is injury to the spinal cord below the T1 cord segment. This causes weakness and loss of feeling in the trunk, legs and bladder, bowel and sex organs, but the arms and hands are not affected.
- What do the terms Complete and Incomplete mean?
An incomplete injury is one in which there is some movement or feeling below the level of the injury in the genital region. This implies that the damage in the spinal cord does not involve the whole spinal cord and that some messages are getting past the area of damage. The chances of improvement and recovery are better if the injury is incomplete.
A complete injury is one in which there is no movement or feeling in the genital region. This means that the damage in the spinal cord involves the whole spinal cord and that no messages are getting past the area of damage. The chance of improvement and recovery if the injury is complete is much lower.
Spinal Cord Inury
A spinal cord injury occurs:
- If pressure is applied to the spinal cord (e.g. spinal tumours, etc.)
- If blood supply is affected (blood supplies the spinal cord with e.g. oxygen)
- If the spinal cord was cut/severed (e.g. motor vehicle accident, assault, etc.)
The spinal cord injury may cause:
- Paralysis (loss of movement) below the level of the injury
- Loss of sensation (feeling) below the level of injury, e.g. the ability to:
- Feel touch or pain on the skino Tell the difference between hot and cold
- Know what different body parts are doing and what the position is, without looking (proprioception).
- Bowel and bladder function can be altered
- Sexual function can be altered, as well as fertility
Depending on the level of injury:
- Temperature control and sweating may be altered
- Breathing may be affected
- Blood pressure and circulation may be altered
- Autonomicdysreflexia may occur.
Spinal Cord Injury Rehabilitation
At RHP Rehab, we assist people with various spinal cord injuries, whether traumatic (e.g. car or diving accident, etc.) or non-traumatic (e.g. spinal cord tumours, transverse myelitis, Guillain-Barre Syndrome, spinal infarctions and multiple sclerosis, etc.).
After a spinal cord injury, you will need to attend a rehabilitation journey to recover optimally and reintegrate into your residential and community environment in a possibly adapted way. Inpatient rehabilitation is only one part of the rehabilitation journey. To achieve this, our unit uses an interdisciplinary approach, using the ICF (International Classification of Function) model from the WHO (World Health Organisation) and an outcome-based rehabilitation approach. Your team may consist of a general practitioner with a special interest in rehabilitation, physiotherapist, occupational therapist, speech therapist, nurses, care workers, social worker and psychologist, communicating and coordinating your treatment plan with you.
- Treatment plan following a 3-day assessment which includes:
- Individual therapy sessions
- Group therapy / group-based classes
- Meeting with immediate family / primary companion to facilitate optimal planning for reintegration upon discharge
- Comprehensive training and education specific to your condition / injury, with yourself, your family, and possibly caregivers
- Emotional support to yourself and immediate family members / companions
- Psychology intervention, including sexual health education and changes associated with relationship dynamics
- Equipment trialling and recommendations for yourself and your home and possibly work environment, following a seating assessment
- Home / school / work visit as necessary, where appropriate recommendations are made.
- Periods at home as part of residential integration, once cleared by the whole team, with the prescribed and required grading of time periods at home to implement therapy recommendations (home adaptations, equipment trials, education and training, home programmes, etc.)
- Introduction to local support resources
- Outpatient therapy programme as part of the recommendations upon discharge, where appropriate.
- Specialised services
- A seating assessment
- Neurogenic bowel and bladder management (including e.g. a uro-dynamic study)
- Spasticity management
- Tendon and nerve transfers
- Assisted outings as part of community reintegration
- Peer support programmes
- Unweighted treadmill training
- Therapeutic electrical stimulation
A spinal cord injury not only causes major trauma to the neck and spinal cord but also effects the way the whole body functions. Other injuries can also complicate the problems. Because of this, the acute period soon after the injury is very important and there are many things that must be done in the first few weeks after the injury to ensure that you do not have other complications.
Some of these include:
- Regular blood tests to check blood count and blood chemistry.
- X-rays of the fracture, chest and other injuries.
- Skin: Special care must be taken of the skin because of loss of feeling, especially when in bed. The nurses will assist to turn the body every 2-3 hours to prevent pressure sores.
- Joints: If the limbs cannot be moved, they can become stiff and eventually would freeze in one position (a contracture). The physiotherapist and occupational therapist move the joints regularly to prevent this from happening.
- Circulation: Inability to move limbs also means that the blood does not circulate as well as usual. This can lead to blood clots in the legs called Deep Vein Thrombosis or DVT. This can cause swelling and discomfort in the leg. The physiotherapist will also help to prevent this. Medication assists to prevent blood clots.
- Breathing and chest: The ability to breathe may also be affected after spinal cord injuries. This applies to all people with injuries above T12 due to paralysis of the abdominal (stomach) and intercostal (between the ribs) muscles. The higher the injury above T12 the more severe the breathing difficulty will be. The ability to cough well may also be affected. The physiotherapist will assist with respiratory hygiene, including to train methods of assisted coughing.
- Bladder: All activity in the bladder stops during the “spinal shock” phase of a spinal cord injury and the bladder will not empty by itself. To allow the bladder to drain an Indwelling Catheter (IDC) is put into the bladder. This will remain in place until further investigation of the bladder can occur 6 weeks after your injury and an optimal bladder regime will be implemented.
- Bowel: The activity in the lower bowel and rectum may also be affected immediately after the injury. This means that medication such as tablets, suppositories or an enema will assist the bowel to work. The nurses will assist with this in bed as movement will initially be restricted to the bed.
What About Improvement and Recovery?
Initially it may be difficult for your doctors to tell you exactly how severe the injury is and therefore, what the chances of improvement and recovery are. This is particularly true if the spinal cord injury is incomplete.
- All spinal cord injuries are different and what happens with one person does not necessarily happen with another.
- The nerves in the spinal cord are very delicate and when they are injured, spontaneous recovery may be limited. At present, there are few things that doctors can do to help the nerves in the spinal cord to repair themselves.
- Recovery depends on how seriously the spinal cord has been damaged and whether the nerves can recover (outside the spinal cord).
- Unfortunately, total recovery from a spinal cord injury is very rare. • Complete spinal cord injuries are more severe and the more time that passes after the injury the less chance there is of significant recovery.
- People with incomplete injuries generally get more recovery than those with complete injuries but it is impossible to know exactly how much recovery there will be or how long it will take to happen. It is usually said that after 2 years there is little chance of further improvement.
- Unfortunately, at present there is no cure for spinal cord injury but there are many doctors and researchers around the world looking for ways to help the nerves to heal themselves and recover.