Spinal Cord Injury: Everything You Need to Know

Falls. Car accidents. Sports injuries. These are the terms we think of when we hear “spinal cord injury.” This is what gets the headlines, like when actor Christopher Reeve fell off his horse in a riding competition and was paralyzed from the neck down.

While this type of injury happens about 50 times every day in the United States, the reality is that far, far more people sustain spinal cord injuries (SCIs) from non-traumatic causes.

“The incidence of traumatic SCI in North America: 54 cases per 1 million people,” says neurosurgeon Michael G. Fehlings, M.D., Ph.D., vice chair of research for the Department of Surgery at the University of Toronto. “On the other hand, the incidence of non-traumatic SCI is about 1,227 cases per million people for Canada alone" (data for the rest of North America is not available).

If you or a loved one has been diagnosed with a SCI, we’re here to help. Here’s what you need to know about spinal cord injuries.

A spinal cord injury disrupts messages between the brain and the body by severing. Put simply, “Without the spinal cord, the brain is no longer connected to the body,” explains neurosurgeon David Stidd, M.D., medical director of the AtlantiCare Neurosciences Institute in New Jersey.

To understand why spinal cord injuries are so devastating, it helps to understand a bit of spinal anatomy. Your spinal cord is a thick bundle of nerves that run through a hollow space in the vertebral column called the spinal canal. The spinal cord carries messages and instructions from the brain to the rest of the body via the peripheral nervous system and transmits sensations from the peripheral nervous system back to the brain.

A traumatic spinal cord injury (SCI) can happen when you get a hard blow to your back. If that injury dislocates or fractures your vertebrae, pieces of bone can pierce spinal cord tissue or disrupt nerve signals. Common causes of traumatic SCI include:

• Vehicle crashes

• Falls

• Sports- and recreation-related injuries

• Violent acts, such as a gunshot wound or stabbing

“We see spinal cord injuries that are the result of slips, falls, and other accidents in fall- and winter-related outdoor hunting, icy or bad weather, and holiday decorating,” says James Eakins, M.D., a trauma surgeon at AtlantiCare Regional Medical Center in New Jersey. “We had a slight uptick in people falling off of ladders at the beginning of the [2020 coronavirus] lockdowns, which could have been from [an increase in] home improvement or home maintenance efforts."

Some watersports can also be surprisingly risky. “Bodysurfing is easily our most common cause of water-related spinal cord injuries every summer. The ocean is powerful and can drive a bodysurfer’s head into the bottom, snapping his or her neck,” Dr. Eakin says.

Some common non-traumatic SCI injuries include:

• Spinal tumors

• Infections like enteroviruses (like polio), mosquito-borne diseases like West Nile (5% of those infected experience meningitis or paralysis), syphilis (though far rarer today than in the past), tuberculosis, and parasitic infections like schistosoma, Echinococcus granulosus, and cysticercosis (i.e., infection caused by eggs of the pork tapeworm), among others.

• Vascular ischemia (poor blood or oxygen supply to spinal cord) from cerebral infarction (like embolism, atherosclerosis, and vasculitic disorders) or more rarely, spinal cord infarction from severe systemic hypotension or cardiac arrest.

• Degenerative cervical myelopathy, which is like a “slow motion spinal cord injury” resulting from compression of the cervical spinal cord from arthritic or congenital conditions.

• Conditions such as degenerative disc disease, spondylosis, osteoporosis, and transverse myelitis.

Short of locking yourself in a tower for life, you’re always going to be at some risk of spinal cord injury—and any other injury. Falls, car accidents, infections, violence: Sometimes, there’s little you can do to prevent them.

You can, however, make good, common-sense choices to reduce your risk of serious injury. For example, don’t text and drive. Wear grippy shoes on snow and ice. If you have to climb a ladder, be extra cautious about reaching and balancing.

SCI symptoms vary depending on the location and severity of the injury. Initially, a patient may experience spinal shock, causing loss of feeling, muscle movements, and reflexes below the level of injury—lasting anywhere from several hours to several weeks. But as this period of shock subsides, other symptoms appear and the severity of the SCI becomes more apparent.

Usually, the higher up the level of injury to the spinal cord, the more severe the symptoms—i.e., an injury at C2 or C3 (the second and third vertebrae in the spine) affect the respiratory muscles and ability to breathe. A lower injury, however, in the lumbar vertebrae, may only affect nerve and muscle function in the bladder, bowel, and legs, likely not impacting respiratory function at all.

Spinal cord injuries are classified according to the type of motor or sensory function loss—these are the main types of classifications:

Quadriplegia

Loss of movement and feeling in all four limbs (both arms and both legs), a common result of SCI at the cervical spine, usually a result of injury at T1 or above.

Paraplegia

Loss of movement and sensation in both legs, a common result of SCIs at the level of your thoracic spine (mid-back) and below, typically a result of injury at T1 or below.

Triplegia

Loss of movement and feeling in one arm and both legs, often a result of an incomplete SCI.

Monoplegia

Loss of movement or sensation in a single area of the body, typically one limb. Those with monoplegia often regain control over the rest of their body but are unable to move or feel sensation in the affected limb.

In addition to problems moving or feeling your arms and legs, you may also experience:

• Loss of bowel or bladder function

• Loss of feeling in your trunk

• Problems with heart rate and blood pressure

• Chronic pain

A traumatic spinal cord injury needs medical attention right away.

A doctor will give you a brief physical exam, checking the strength and feeling in your arms and legs. You may also get imaging tests, such as an X-ray, CT (computed tomography) scan, and/or an MRI (magnetic resonance imaging) scan.

SCIs fall into two main groups: complete or incomplete. A complete spinal cord injury is more severe than an incomplete one. It means you can’t feel anything below the spot where you got hurt–the level of the injury. An incomplete spinal cord injury means you may still be able to move and feel below the level of the injury.

The extent of damage—whether from a traumatic or non-traumatic cause—is further described by a classification system known as the AIS, or ASIA (itself an acronym for American Spinal Injury Association) Impairment Scale.

• AIS A: A complete injury in which you have no strength or sensation, including rectal sensation, below the level of injury.

• AIS B: An incomplete injury in which you maintain some sensation below the level of injury, particularly rectal sensation. However, you won’t have rectal tone/strength.

• AIS C: An incomplete injury in which you maintain both rectal sensation and rectal tone/strength. You also have some strength in the muscles below the injury level (though they tend to be quite weak).

• AIS D: An complete injury similar to AIS C, but with more strength.

• AIS E: This implies that you’ve recovered fully from an SCI.

Traumatic Spinal Cord Injury: Primary and Secondary Injuries

A traumatic SCI doesn't just damage your spinal cord at the point of initial impact. The primary injury also can set off what’s known as a secondary injury cascade: a series of related biological changes that occur weeks and months afterward that may also interfere with the spinal cord's ability to recover, potentially leading to nerve pain and dysfunction.

• Cells that support signaling in your spinal cord begin to die.

• Blood vessels in your spinal cord lose function.

• Blood vessel injury leads to inflammation of the spinal cord.

• Inflammation causes spinal cord compression and worsens the primary injury.

The primary injury is the structural damage to your spine, such as dislocation or fracture of a vertebral body with subsequent spinal cord compression, caused by the initial traumatic event.

In addition to the primary structural injury(ies), nearby glial cells and nerve cells in your spinal cord become injured and prevent your spinal cord from getting the blood it needs. Glial cells provide nutrients and other support to the nerve cells in your central nervous system, which consists of your brain and spinal cord.

It’s this initial structural and cellular damage that triggers the secondary injury cascade. As the name suggests, the secondary injury cascade is a series of changes—often developing one after the other—that begin within just a few hours after the SCI and may continue more than six months past the initial injury.

The primary and secondary damage caused by traumatic SCI occurs in the following phases:

• Acute injury phase (less than 48 hours after the traumatic event)

• Subacute injury phase (48 hours to 14 days after)

• Intermediate injury phase (14 days to six months after)

• Chronic injury phase (six months after and beyond)

Patients with traumatic and non-traumatic spinal cord injuries benefit from the same rehabilitation program. While there are initial differences in how care is handled, with time, these differences lessen, and both groups can make significant improvement using the same rehabilitation protocols. Treatment for SCI can involve many doctors and specialists over time. Here’s a brief look at what you can expect.

• Immediate care. Those first few days in the hospital, you may get surgery to stabilize the spine or decompress the spinal cord. If your breathing is compromised, you may need a ventilator. You’ll also get medications depending on your needs at the time.

• Inpatient rehab. This could include physical therapy, occupational therapy, and other therapies for three hours, six days a week, according to spine medicine specialists at Hudson Medical in New York City. The goal is to help you get stronger and re-learn daily living activities such as dressing, eating, toileting, bathing, adjusting to your medical equipment, and becoming as independent as possible. Your rehab team will likely include:

  • Rehabilitation doctors, also known as physiatrists — medical doctors who have have completed Physical Medicine and Rehabilitation training and, in the case of SCI, have subspecialty certification in Brain Injury Medicine, Neuromuscular Medicine, Pain Medicine, Pediatric Rehabilitation Medicine, and/or Spinal Cord Injury Medicine.

  • Rehabilitation nurses who specialize in helping prevent complications and assist patients to be functional. These nursing professionals are a resource for patient advocacy, case management, counseling, and education. As patient advocates, they help you gain access to quality medical care and communicate with health care providers to coordinate services.

  • Physical therapists who help restore function, improve mobility, and limit permanent physical disability. Physical therapists promote fitness and health.

  • Rehabilitation psychologists who offer patient and family support to help everyone adjust to change. Patients and their partners may receive sexual and/or family planning counseling.

  • Case managers who coordinate care with insurance carriers and equipment providers.

• Outpatient therapy: After you leave the hospital, you’ll likely need weekly physical and occupational therapy sessions for months. This willl help you keep up with those newly learned exercises and skills.

• Regular checkups: Expect follow-up visits with an SCI specialist or physiatrist for skin checks (for potential pressure sores), pain management, and other health concerns. These checkups will be frequent at first, less so as time goes on.

Many people turn to complementary and alternative medicine (CAM) to help relieve symptoms associated with SCIs. Research suggests there may be some benefit to these non-traditional approaches.

“A large amount of resources and research is spent investigating new treatments for spinal cord injury,” shared Dr. Stidd. “Stem cell therapy is currently being evaluated as a possible means to rejuvenate the injured segment of the spinal cord. A variety of medications are being evaluated that potentially improve spinal cord function and outcome after an injury. Brain-computer interfaces are being developed to link signals directly from the brain to a computer, which then can be used to control devices such as wheelchairs, robotic arms, or mechanical exoskeletons.”

These modalities have also been found to be helpful:

• Acupuncture may improve a range of post-SCI complications, including spasticity, motor and sensory dysfunction, and pain.

• Massage may reduce swelling, relax muscles, improve blood circulation, improve range of motion, and reduce pain.

• Chiropractic treatment, if and when your doctor deems it safe for you, may relieve some pressure on your spinal cord, improve blood circulation, and reduce pain

• Hypnosis may reduce chronic pain associated with SCI.

Western medicine also offers opportunities to try therapies you can’t get in your regular doctors’ offices. Clinical trials, for example, enable you to try promising treatments and technologies. And here’s some good news: current research supports the spine’s ability to self-heal.

Can You Walk After Spinal Cord Injury?

Spinal cord injury often causes leg paralysis, preventing you from walking. But if you have an incomplete SCI, great medical care, and a strong commitment to physical and occupational therapy, walking may be possible.

Expect “active rehabilitation,” which facilitates the connection of nerves.

"The [patient] is supported in a harness, which looks like a swing apparatus, and is positioned over a moving treadmill. With the assistance of a robot or therapist, the patient's feet are placed on the treadmill, with their body weight partially supported. These patients are often able to re-learn how to walk," explains Dr. Fehlings. "This has become a standard of care in the last 10 to 15 years."

You may get electrical muscle stimulation, too. This sends signals to the brain and spinal cord from the point of stimulation, helping to re-engage the communication between the two. This therapy “can sometimes restore walking for those not able to walk and may be able to help with neuropathic pain and other SCI-related problems,” says Dr. Fehlings.

Other types of electrical stimulation, including implantable stimulation devices, show promise on the research front. Patients with complete SCI have exhibited good response to functional electrical stimulation, also known as FES, for restoring muscular activity below the level of injury.

After a spinal cord injury, life will look a lot different. There’s no point in sugar-coating this: Even the strongest people will have physical and emotional challenges as they adjust to life with disability. But there is plenty of reason for hope.

Part of your rehab will focus on helping you deal with the emotional impacts of SCI. You may feel sad, angry, frustrated, even grief-stricken. It’s healthy and helpful to share these emotions, ideally through counseling and support groups. Connecting with people who are also dealing with SCI can be an immense help on many levels, from learning about new therapies to having a dependable support network.

Ongoing sadness or depression can happen when dealing with a spinal cord injury. It’s important to tell your doctor or someone else on your care team so that you can get the help you need. And if you are a caregiver for someone with a spinal cord injury, don’t forget to take care of yourself as well. Consider joining an SCI caregiver support group to help you cope.

And about having a family: Ask your doctor for advice on the best ways to make that happen, based on your injury and circumstances. Men usually cannot ejaculate after spinal cord injury, but their sperm are usually just fine. Many women can get pregnant after SCI, but close monitoring is important due to an increased risk of complications like urinary tract infections, hypertension, preeclampsia, and pre-term labor.

Studies increasingly show that the spine has an ability to self-heal and finding ways that therapeutically support the spinal cord’s internal repair processes are a focus of current spinal cord injury research.

Life will look different, but don’t be discouraged: You can still have a full, satisfying life after a spinal cord injury. You may even be able to start a family, if you want. A good rehabilitation team will support the transition to your new normal with training, resources, and tools to thrive again.

What happens if your spinal cord is damaged?

A spinal cord injury, or SCI, involves damage to any part of the spinal cord. This often causes permanent changes in sensation, strength, and other bodily functions below the site of the injury. Depending on where the injury occurs, you could have including paralysis, weakness, sensory abnormalities, disruption of bowel and/or bladder function, and more.

Can a spinal cord injury heal?

There’s no way to repair a traumatic spinal cord injury, but there are numerous treatments to help restore some functioning if you have a partial, or incomplete, spinal cord injury. If you suspect that someone with you has suffered a SCI, seek emergency medical attention. Immediate treatment can reduce long-term effects and improve outcomes.

Are spinal cord injuries permanent?

A spinal cord injury often causes permanent changes in strength, sensation, and other body functions below the site of the injury. This may not always be the case, though. Research in regenerative medicine and stem cell therapy show a lot of promise for SCI.

What can cause spinal cord injury?

Trauma to the spine can cause spinal cord injury, but it’s not the only cause. Diseases and conditions, including spinal tumors, can also lead to SCI.

Can you walk again after spinal cord injury?

Some people with less severe spinal cord injuries may be able to walk again. Rehabilitation therapies, such as active rehabilitation and possibly electrical stimulation, will help you put one foot in front of the other.