Spinal cord injury

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Spinal cord injuries
View of the vertebral column and spinal cord
Classification and external resources
Specialty Neurosurgery
ICD-10 G95.9, T09.3
DiseasesDB 12327 29466
MedlinePlus 001066 000029
MeSH D013119







  • C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level, and MORE than half of key muscles below the single neurological level of injury have a muscle grade less than 3 (i.e. M 0 - no contraction, no muscle movement, M 1 - trace of contraction, but no movement, or M 2 - movement with gravity eliminated).
  • D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles ( more than 50 percent of the key muscles) below the neurological level have a muscle grade of 3 or more (I.e. M3, M4 or M5, muscle can movement against gravity (3) or with additional resistance (4 & 5)).


Signs and symptoms[edit]

Gray 111 - Vertebral column-coloured.png
Actions of the spinal nerves edit
Level Motor Function
C1-C6 Neck flexors
C1-T1 Neck extensors
C3, C4, C5 Supply diaphragm (mostly C4)
C7, T1 Flexes wrist; supply small muscles of the hand
T1 - T6 Intercostals and trunk above the waist
T7 - L1 Abdominal muscles
L1 - L4 Thigh flexion



A complete injury frequently means that the patient has little hope of functional recovery.[10] The relative incidence of incomplete injuries compared to complete spinal cord injury has improved over the past half century, due mainly to the emphasis on faster and better initial care and stabilization of spinal cord injury patients.[11] Most patients with incomplete injuries recover at least some function.[10]





Patients with complete injuries above C7 typically cannot handle activities of daily living making functioning independently very difficult in the absence of substantial environmental modification with the use of specialized devices.

Additional signs and symptoms of cervical injuries include:




Typically lesions above the T6 spinal cord level can result in autonomic dysreflexia.[12]




Spinal cord injury without radiographic abnormality (SCIWORA)[edit]

Spinal cord injury without radiographic abnormality (SCIWORA) represents a specific subtype of spinal cord injuries. It may present as a complete or incomplete spinal cord injury.

First, it was described in children with a clinico-radiological mismatch by Pang and Wilberger.[17] Later, a similar condition was reported in adults. However, there seem to be relevant differences between pediatric and adult SCIWORA. In particular, adults often present with degenerative changes of the spinal column resulting in predisposing spinal stenosis.[18]

The application of MRI plays a significant role in the early diagnosis and treatment of SCIWORA in children and adults. Recently, systematic reviews on SCIWORA described the clinical and radiological patterns and correlations with neurological outcome.[19][20] Boese and Lechler proposed a MRI-based classification for SCIWORA which correlated with the neurological outcome:[19]

Type 1 No detectable abnormalities.
Type 2 a Extraneural abnormalities.
Type 2 b Intraneural abnormalities.
Type 2 c Extraneural and intraneural abnormalities.

Other syndromes of incomplete injury[edit]




Ischemia of the spinal cord is reduced blood flow to the spinal cord. Blood flow is supplied by the anterior spinal artery and the paired posterior spinal arteries. This condition may be associated with arterioscleorosis, trauma, emboli, diseases of the aorta, and other disorders. Prolonged ischemia may lead to infarction of the spinal cord tissue.[21] Ischemia of the spinal cord affects its function and can lead to muscle weakness and paralysis. The spinal cord may also suffer circulatory impairment if the segmental medullary arteries, particularly the great anterior segmental medullary artery are narrowed by obstructive arterial disease. When systemic blood pressure drops severely for 3-6 min, blood flow from the segmental medullary arteries to the anterior spinal artery supplying the midthoracic region of the spinal cord may be reduced or stopped. These people may also lose sensation and voluntary movement in the areas supplied by the affected level of the spinal cord.[22] Ischemia brought on by misalignment of the spinal column is a major cause of paralysis and other nerve-related impairments. Thus, in the case of any significant injury, proper spinal column alignment is established initially, and much care is taken to preserve alignment in the transfer to hospital facilities.


Anterior cord syndrome is often associated with flexion type injuries to the cervical spine, causing damage to the anterior portion of the spinal cord and/or the blood supply from the anterior spinal artery.[23] Below the level of injury motor function, pain sensation, and temperature sensation are lost, while touch, proprioception (sense of position in space), and sense of vibration remain intact.

Posterior cord syndrome can also occur, but is very rare. Damage to the posterior portion of the spinal cord and/or interruption to the posterior spinal artery causes the loss of proprioception and epicritic sensation (e.g.: stereognosis, graphesthesia) below the level of injury.[23] Motor function, sense of pain, and sensitivity to light touch remain intact.[23]

Brown-Séquard syndrome usually occurs when the spinal cord is hemisectioned or injured on the lateral side. True hemisections of the spinal cord are rare, but partial lesions due to penetrating wounds (e.g.: gunshot wounds or knife penetrations) are more common.[23] On the ipsilateral side of the injury (same side), there is a loss of motor function, proprioception, vibration, and light touch. Contralaterally (opposite side of injury), there is a loss of pain, temperature, and crude touch sensations. The loss on the contra lateral side begins several dermatome section below the level of injury. This discrepancy occurs because the lateral spinothalamic tracts ascend two or four segments on the same side before crossing[24]











  • is unconscious as a result of a head injury
  • has been injured in a high-speed motor vehicle accident





People are immobilized at the scene of the injury until it is clear that there is no damage to the highest portions of the spine.[30] This is traditionally done using a device called a long spine board and a semi-rigid cervical collar, such as an X-Collar, Stifneck or Wizlock.









One experimental treatment, therapeutic hypothermia, is used but there is no evidence that it improves outcomes.[34][35] Maintaining mean arterial blood pressures of at least 85 to 90 mmHg using intravenous fluids, transfusion, and vasopressors to ensure adequate blood supply to nerves and prevent damage is another treatment with little evidence of effectiveness.[36]





Corticosteroid drugs are used within 8 hours of the injury.[27] This practice is based on the National Acute Spinal Cord Injury Studies (NASCIS) I and II, though other studies have shown little benefit and concerns about side effects from the drug have changed this practice.[38][39] High dose methylprednisolone may improve outcomes if given within 6 hours of injury.[40] However, the improvement shown by large trials has been small, and comes at a cost of increased risk of serious infection or sepsis due to the immunosuppressive qualities of high-dose corticosteroids. Methylprednisolone is no longer recommended in the treatment of acute spinal cord injury.[41]


SCI patients often require extended treatment in specialized Spinal Unit or an intensive care unit.[42]



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.[44] Also, there is great emphasis on airway clearance during this stage of recovery.[45] Following a spinal cord injury, the individual’s respiratory muscles may become weak, making the patient unable to cough effectively and allowing secretions to accumulate within the lungs.[46] Physical therapy treatment for airway clearance may include manual percussions and vibrations, postural drainage,[45] respiratory muscle training, and assisted cough techniques.[46] Patients are taught to increase their intra-abdominal pressure by leaning forward to induce cough and clear mild secretions.[46] The quad cough technique is done with the patient lying on their back and the therapist applies pressure on their abdomen in the rhythm of the cough to maximize expiratory flow and mobilize secretions.[46] Manual abdominal compression is another effective technique used to increase expiratory flow which later improves cough.[45] Other techniques used to manage respiratory dysfunction include respiratory muscle pacing, use of an abdominal binder, ventilator-assisted speech, and mechanical ventilation.[46]


Outcome measures[edit]

The Functional Independence Measure (FIM) is an assessment tool that aims to evaluate the functional status of patients throughout the rehabilitation process following a stroke, traumatic brain injury, spinal cord injury or cancer.[48] Its area of use can include skilled nursing facilities and hospitals aimed at acute, sub-acute and rehabilitation care. It serves as a consistent data collection tool for the comparison of rehabilitation outcomes across the health care continuum.[48] Furthermore, it aims to allow clinicians to track changes in the functional status of patients from the onset of rehab care through discharge and follow-up. The FIM’s assessment of degree of disability depends on the patient’s score in 18 categories, focusing on motor and cognitive function. Each category or item is rated on a 7-point scale (1 = <25% independence; total assistance required, 7 = 100% independence).[48] As such, FIM scores may be interpreted to indicate level of independence or level of burden of care.


Further information: Anejaculation

For anejaculation in spinal cord injury, the first-line method for sperm retrieval include is penile vibratory stimulation (PVS).[16] The penile vibratory stimulator is a plier-like device that is placed around glans penis to stimulate it by vibration. In case of failure with PVS, spermatozoa are sometimes collected by electroejaculation, or surgically by per cutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE).[16]







Spasticity, the uncontrollable tensing of muscles below the level of injury, results from lack of input from the brain to quell muscle responses to stretch reflexes.[50] It can be treated with drugs and physical therapy.[50]

Tetraplegia (quadriplegia)[edit]

The ASIA motor score (AMS) is a 100-point score based on ten pairs of muscles each given a five-point rating. A person with no injury should score 100. In complete tetraplegia, a recovery of nine points on this scale is average regardless of where the patient starts. Patients with higher levels of injury will typically have lower starting scores.[49]







Many people suffer transient loss of function ("stingers") in sports accidents or pain in "whiplash" of the neck without neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant hospitalization. Spinal injury can also occur without trauma, for example it can be caused by loss of blood flow to the tissue.

In North America, about 39 people per every million get SCI traumatically each year, and in Western Europe this incidence (number of new cases) is 16 per million.[51] 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.[52][53] In China, the incidence of spinal cord injury is approximately 60,000 per year.[54] The prevalence (number of people living with the condition) is not well known in many large countries. However, in some countries, such as Sweden and Iceland, registries are available. In North America the prevalence is 853 per million people and in Western Europe it is 300 per million.[51] In the United States there are around 250,000 individuals living with spinal cord injuries.[28][55]

The average age at the time of injury has slowly increased from a reported 29 years of age in the mid-1970s to a current average of around 40. Men are at more risk for spinal cord injury than women.[56][57] Over 80% of the spinal injuries reported to a major national database occurred in males.[58] Most of these injuries occur in men under 30 years of age.[59]

Research directions[edit]

Scientists are investigating various avenues for treatment of spinal cord injury. Numerous articles in the medical literature describe research, mostly in animal models, aimed at reducing the paralyzing effects of injury and promoting regrowth of functional nerve fibers.[60] Despite the devastating effects of the condition, commercial funding for research investigating a cure after spinal cord injury is limited, partially due to the small size of the population of potential beneficiaries.[citation needed] Some experimental treatments, such as systemic hypothermia, have been performed in isolated cases in order to draw attention to the need for further preclinical and clinical studies to help clarify the role of hypothermia in acute spinal cord injury.[61] Despite the limitation on funding, a number of experimental treatments such as local spine cooling and oscillating field stimulation have reached controlled human trials,[62][63]


Stem cells[edit]

Around the world, proprietary centers offering stem cell transplants and treatment with neuroregenerative substances are fueled by glowing testimonial reports of neurological improvement. It is also evident that when stem cells are injected in the area of damage in the spinal cord, they secrete neurotrophic factors, and these factors help neurons and blood vessels to grow, thus helping repair the damage.[65][66][67] Bone Marrow Stem cells, especially the CD34+ cells, have been found to be relatively more in men compared to women in the reproductive age group among spinal cord injury patients.[57]

In 2009 in the US, the FDA approved the country's first human trial on embryonic stem cell transplantation into patients suffering from varying levels of traumatic spinal cord injury.[68] The trial however came to a halt in November 2011 when the company, which was financing the trial, announced the discontinuation of the trial due to financial issues.[69] There were not scientific or ethical reasons for the discontinuation.[70]

Transplantation of tissues such as olfactory ensheathing cells from the olfactory bulbs have been shown to produce beneficial effects in spinal cord injured rats.[71] Trials have also begun to show success when olfactory ensheathing cells are transplanted into humans with severed spinal cords.[72] People have recovered sensation, use of formerly paralysed muscles, and bladder and bowel function after the surgeries.[73]

Independent validation of the results of the various stem cell treatments is lacking.[74][75] However, current approaches on cell and tissue based therapies for clinical application for spinal cord injury need to establish the underlying efficacy and mechanisms.[70]

Engineering approaches[edit]

Recent approaches have used various engineering techniques to improve spinal cord injury repair. The general hypothesis of this is that bridging the lesion site using a growth permissive scaffold may promote axonal extension and in turn improve behavioral function. Engineered treatments are ideal for spinal cord injury repair because they do not induce an immune response like biological treatments, and they are easily tunable and reproducible. In-vivo administration of hydrogels or self-assembling nanofibers has been shown to promote axonal sprouting and partial functional recovery.[76][77] In addition, administration of carbon nanotubes has shown to increase motor axon extension, decrease the lesion volume, and not induce neuropathic pain.[78] In addition, administration of poly-lactic acid microfibers has shown that topographical guidance cues alone can promote axonal regeneration into the injury site.[79] However, all of these approaches induced modest behavioral or functional recovery suggesting that further investigation is necessary.




The technology for creating bionic suits, more commonly known as exo-skeletons, is currently making some significant advances. There are products available, such as the Ekso, which allows individuals with up to a C7 complete (or any level of incomplete) spinal injury to stand upright and make technologically assisted steps.[81][82] The initial purpose for this technology is for functional based rehabilitation, but as the technology develops, so will its uses.[81] A significant downside for the users of these systems is that they find themselves extremely tired after a very short time. This is because the muscles they are using have atrophied, and have little stamina.

Spinal cord implant[edit]

Spinal cord implants, such as the e-dura implants, are designed for implantation on the surface of the spinal cord. Scientists from the Swiss Federal Institute of Technology in Lausanne (EPFL)] are studying the usage of e-Dura implants in individuals paralyzed following a spinal cord injury.[83] E-dura implants can also be implanted into the brain. Human studies have not yet been done.

E-dura implants are designed using methods of soft neurotechnology], in which seven electrodes in a 3-1-3 configuration and a single channel microfluidic delivery system are distributed along the spinal implant.[84] Brain implants differ in the electrode configuration along the implant and instead follow a 3x3 matrix pattern. The e-dura implants, unlike previous surface implants, closely mimic the physical properties of living tissue and can deliver electric impulses and pharmacological substances simultaneously. Artificial dura mater was constructed through the utilization of PDMS and gelatin hydrogel.[84] The hydrogel simulates spinal tissue and a silicone membrane simulates the dura mater. These properties allow the e-dura implants to sustain long-term application to the spinal cord and brain without leading to inflammation, scar tissue buildup, and rejection normally caused by surface implants rubbing against nerve tissue.The cracked gold electric conducting tracks allow the implants to be stretched and pulled. This resembles the flexible and stretchable nature of living tissue. The electrodes themselves consist of silicon and platinum microbeads which can withstand physical deformations in any direction and still ensure optimal electrical conductivity.

Chemical stimulation of the spinal cord is administered through the microfluidic channel of the e-dura.

The implant can also be used to monitor electrical impulses from the brain in real time.[83] When e-dura implants were inserted into the brain, scientists were able to extract the animal’s motor intention with accurate precision before it was translated into movement.


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