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SpinalCordInjuries
Author:LawrenceSChin,MD,FACSChiefEditor:BrianHKopell,MDmore...
Updated:Jul07,2015

PracticeEssentials
Spinalcordinjury(SCI)isaninsulttothespinalcordresultinginachange,eithertemporaryor
permanent,inthecordsnormalmotor,sensory,orautonomicfunction.Patientswithspinalcord
injuryusuallyhavepermanentandoftendevastatingneurologicdeficitsanddisability.
TheimagebelowillustratestheAmericanSpinalInjuryAssociationmethodforclassifyingspinal
cordinjury(SCI)byneurologiclevel.

Signsandsymptoms
TheextentofinjuryisdefinedbytheAmericanSpinalInjuryAssociation(ASIA)Impairment
Scale(modifiedfromtheFrankelclassification),usingthefollowingcategories[3,4]:
A=Complete:NosensoryormotorfunctionispreservedinsacralsegmentsS4S5[5]
B=Incomplete:Sensory,butnotmotor,functionispreservedbelowtheneurologiclevel
andextendsthroughsacralsegmentsS4S5
C=Incomplete:Motorfunctionispreservedbelowtheneurologiclevel,andmostkey
musclesbelowtheneurologiclevelhaveamusclegradeoflessthan3
D=Incomplete:Motorfunctionispreservedbelowtheneurologiclevel,andmostkey
musclesbelowtheneurologiclevelhaveamusclegradethatisgreaterthanorequalto3
E=Normal:Sensoryandmotorfunctionsarenormal
Definitionsofcompleteandincompletespinalcordinjury,asbasedontheaboveASIA
definition,withsacralsparing,areasfollows[3,4,5]:
Complete:Absenceofsensoryandmotorfunctionsinthelowestsacralsegments
Incomplete:Preservationofsensoryormotorfunctionbelowthelevelofinjury,includingthe
lowestsacralsegments
Respiratorydysfunction
Signsofrespiratorydysfunctionincludethefollowing:
Lossofventilatorymusclefunctionfromdenervationand/orassociatedchestwallinjury
Lunginjury,suchaspneumothorax,hemothorax,orpulmonarycontusion
Decreasedcentralventilatorydrivethatisassociatedwithheadinjuryorexogenous
effectsofalcoholanddrugs
Adirectrelationshipexistsbetweenthelevelofcordinjuryandthedegreeofrespiratory
dysfunction,asfollows:
Withhighlesions(ie,C1orC2),vitalcapacityisonly510%ofnormal,andcoughis
absent
WithlesionsatC3throughC6,vitalcapacityis20%ofnormal,andcoughisweakand
ineffective
Withhighthoraciccordinjuries(ie,T2throughT4),vitalcapacityis3050%ofnormal,and
coughisweak
Withlowercordinjuries,respiratoryfunctionimproves
WithinjuriesatT11,respiratorydysfunctionisminimalvitalcapacityisessentiallynormal,
andcoughisstrong
SeeClinicalPresentationformoredetail.

Diagnosis
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Laboratorystudies
Thefollowinglaboratorystudiescanbehelpfulintheevaluationofspinalcordinjury:
Arterialbloodgas(ABG)measurementsMaybeusefultoevaluateadequacyof
oxygenationandventilation
LactatelevelsTomonitorperfusionstatuscanbehelpfulinthepresenceofshock
Hemoglobinand/orhematocritlevelsMaybemeasuredinitiallyandmonitoredseriallyto
detectormonitorsourcesofbloodloss
UrinalysisCanbeperformedtodetectanyassociatedgenitourinaryinjury
Imagingstudies
Imagingtechniquesinspinalcordinjuryincludethefollowing:
PlainradiographyRadiographsareonlyasgoodasthefirstandlastvertebraeseen,
therefore,radiographsmustadequatelydepictallvertebrae
Computedtomography(CT)scanningReservedfordelineatingbonyabnormalitiesor
fracturecanbeusedwhenplainradiographyisinadequateorfailstovisualizesegments
oftheaxialskeleton
Magneticresonanceimaging(MRI)Usedforsuspectedspinalcordlesions,ligamentous
injuries,andothersofttissueinjuriesorpathology
SeeWorkupformoredetail.

Treatment
Emergencydepartmentcare
AirwaymanagementThecervicalspinemustbemaintainedinneutralalignmentatall
timesclearingoforalsecretionsand/ordebrisisessentialtomaintainingairwaypatency
andpreventingaspiration
HypotensionHypotensionmaybehemorrhagicand/orneurogenicinacutespinalcord
injuryadiligentsearchforoccultsourcesofhemorrhagemustbemade
NeurogenicshockJudiciousfluidreplacementwithisotoniccrystalloidsolutiontoa
maximumof2Listheinitialtreatmentofchoicemaintainadequateoxygenationand
perfusionoftheinjuredspinalcordsupplementaloxygenationand/ormechanical
ventilationmayberequired[6,7]
HeadinjuriesAmnesia,externalsignsofheadinjuryorbasilarskullfracture,focal
neurologicdeficits,associatedalcoholintoxicationordrugabuse,orahistoryoflossof
consciousnessmandatesathoroughevaluationforintracranialinjury,startingwith
noncontrastheadCTscanning
IleusPlacementofanasogastric(NG)tubeisessentialantiemeticsshouldbeused
aggressively
PressuresoresTopreventpressuresores,turnthepatientevery12hours,padall
extensorsurfaces,undressthepatienttoremovebeltsandbackpocketkeysorwallets,
andremovethespineboardassoonaspossible
Pulmonarymanagement
Treatmentofpulmonarycomplicationsand/orinjuryinpatientswithspinalcordinjuryincludes
supplementaryoxygenforallpatientsandchesttubethoracostomyforthosewithpneumothorax
and/orhemothorax.
Surgicaldecompression
Emergentdecompressionofthespinalcordissuggestedinthesettingofacutespinalcord
injurywithprogressiveneurologicdeterioration,facetdislocation,orbilaterallockedfacets.The
procedureisalsosuggestedinthesettingofspinalnerveimpingementwithprogressive
radiculopathy,inpatientswithextradurallesionssuchasepiduralhematomasorabscesses,
andinthesettingofthecaudaequinasyndrome.
SeeTreatmentandMedicationformoredetail.

Background
Spinalcordinjury(SCI)isaninsulttothespinalcordresultinginachange,eithertemporaryor
permanent,initsnormalmotor,sensory,orautonomicfunction.Patientswithspinalcordinjury
usuallyhavepermanentandoftendevastatingneurologicdeficitsanddisability.Accordingtothe
NationalInstitutesofHealth(NIH),"amongneurologicaldisorders,thecosttosocietyof
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automotiveSCIisexceededonlybythecostofmentalretardation."[8]
AfterasuspectedSCI,thegoalsaretoestablishthediagnosisandinitiatetreatmenttoprevent
furtherneurologicinjuryfromeithermechanicalinstabilitysecondarytoinjuryfromthedeleterious
effectsofcardiovascularinstabilityorrespiratoryinsufficiency.

SCIterminologyandclassification
TheInternationalStandardsforNeurologicalandFunctionalClassificationofSpinalCordInjury
(ISNCSCI)isawidelyacceptedsystemdescribingthelevelandextentofinjurybasedona
systematicmotorandsensoryexaminationofneurologicfunction.[3,4]Thefollowingterminology
hasdevelopedaroundtheclassificationofspinalcordinjuries:
Tetraplegia(replacesthetermquadriplegia):Injurytothespinalcordinthecervicalregion,
withassociatedlossofmusclestrengthinall4extremities
Paraplegia:Injuryinthespinalcordinthethoracic,lumbar,orsacralsegments,including
thecaudaequinaandconusmedullaris
ThepercentageofspinalcordinjuriesasclassifiedbytheAmericanSpinalInjuryAssociation
(ASIA)isasfollows:
Incompletetetraplegia:29.5%
Completeparaplegia:27.9%
Incompleteparaplegia:21.3%
Completetetraplegia:18.5%
ThemostcommonneurologiclevelofinjuryisC5.Inparaplegia,T12andL1arethemost
commonlevel.ThefollowingimagedepictstheASIAclassificationbyneurologiclevel.

AmericanSpinalInjuryAssociation(ASIA)methodforclassifyingspinalcordinjury(SCI)byneurologic
level.

SeealsoHypercalcemiaandSpinalCordInjury,SpinalCordInjuryandAging,Rehabilitationof
PersonsWithSpinalCordInjuries,CentralCordSyndrome,BrownSequardSyndrome,and
CaudaEquinaandConusMedullarisSyndromes.

HistoricalinformationinSCIclassification
In1982,ASIAfirstpublishedstandardsforneurologicclassificationofpatientswithspinalinjury,
followedbyfurtherrefinementstodefinitionsofneurologiclevels,identificationofkeymuscles
andsensorypointscorrespondingtospecificneurologiclevels,andvalidationoftheFrankel
scale.In1992,theInternationalMedicalSocietyofParaplegia(IMSOP)adoptedthese
guidelinestocreatetrueinternationalstandards,followedbyfurtherrefinements.Astandardized
ASIAmethodforclassifyingspinalcordinjury(SCI)byneurologiclevelwasdeveloped(seethe
imageabove).

Anatomy
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Thespinalcordisdividedinto31segments,eachwithapairofanterior(motor)anddorsal
(sensory)spinalnerveroots.Oneachside,theanterioranddorsalnerverootscombinetoform
thespinalnerveasitexitsfromthevertebralcolumnthroughtheneuroforamina.Thespinalcord
extendsfromthebaseoftheskullandterminatesnearthelowermarginoftheL1vertebralbody.
Thereafter,thespinalcanalcontainsthelumbar,sacral,andcoccygealspinalnervesthat
comprisethecaudaequina.Asaresult,injuriesbelowL1arenotconsideredspinalcordinjuries
(SCIs),becausetheyinvolvethesegmentalspinalnervesand/orcaudaequina.Spinalinjuries
proximaltoL1,abovetheterminationofthespinalcord,ofteninvolveacombinationofspinal
cordlesionsandsegmentalrootorspinalnerveinjuries.

Neuropathways
Thespinalcorditselfisorganizedintoaseriesoftractsorneuropathwaysthatcarrymotor
(descending)andsensory(ascending)information.Thesetractsareorganizedsomatotopically
withinthespinalcord.Thecorticospinaltractsaredescendingmotorpathwayslocatedanteriorly
withinthespinalcord.Axonsextendfromthecerebralcortexinthebrainasfarasthe
correspondingsegment,wheretheyformsynapseswithmotorneuronsintheanterior(ventral)
horn.Theydecussate(crossover)inthemedullabeforeenteringthespinalcord.
Thedorsalcolumnsareascendingsensorytractsthattransmitlighttouch,proprioception,and
vibrationinformationtothesensorycortex.Theydonotdecussateuntiltheyreachthemedulla.
Thelateralspinothalamictractstransmitpainandtemperaturesensation.Thesetractsusually
decussatewithin3segmentsoftheiroriginastheyascend.Theanteriorspinothalamictract
transmitslighttouch.Autonomicfunctiontraverseswithintheanteriorinteromedialtract.
SympatheticnervoussystemfibersexitthespinalcordbetweenC7andL1,whereas
parasympatheticsystempathwaysexitbetweenS2andS4.
Injurytothecorticospinaltractordorsalcolumns,respectively,resultsinipsilateralparalysisor
lossofsensationoflighttouch,proprioception,andvibration.Unlikeinjuriesoftheothertracts,
injurytothelateralspinothalamictractcausescontralaterallossofpainandtemperature
sensation.Becausetheanteriorspinothalamictractalsotransmitslighttouchinformation,injury
tothedorsalcolumnsmayresultincompletelossofvibrationsensationandproprioceptionbut
onlypartiallossoflighttouchsensation.Anteriorcordinjurycausesparalysisandincomplete
lossoflighttouchsensation.
Autonomicfunctionistransmittedintheanteriorinteromedialtract.Thesympatheticnervous
systemfibersexitfromthespinalcordbetweenC7andL1.Theparasympatheticsystemnerves
exitbetweenS2andS4.Therefore,progressivelyhigherspinalcordlesionsorinjurycauses
increasingdegreesofautonomicdysfunction.

Vascularsupply
Thebloodsupplyofthespinalcordconsistsof1anteriorand2posteriorspinalarteries.The
anteriorspinalarterysuppliestheanteriortwothirdsofthecord.Ischemicinjurytothisvessel
resultsindysfunctionofthecorticospinal,lateralspinothalamic,andautonomicinteromedial
pathways.Anteriorspinalarterysyndromeinvolvesparaplegia,lossofpainandtemperature
sensation,andautonomicdysfunction.Theposteriorspinalarteriesprimarilysupplythedorsal
columns.Theanteriorandposteriorspinalarteriesarisefromthevertebralarteriesintheneck
anddescendfromthebaseoftheskull.Variousradiculararteriesbranchoffthethoracicand
abdominalaortatoprovidecollateralflow.
Theprimarywatershedareaofthespinalcordisthemidthoracicregion.Vascularinjurymay
causeacordlesionatalevelseveralsegmentshigherthanthelevelofspinalinjury.For
example,alowercervicalspinefracturemayresultindisruptionofthevertebralarterythat
ascendsthroughtheaffectedvertebra.Theresultingvascularinjurymaycauseanischemichigh
cervicalcordinjury.Atanygivenlevelofthespinalcord,thecentralpartisawatershedarea.
Cervicalhyperextensioninjuriesmaycauseischemicinjurytothecentralpartofthecord,
causingacentralcordsyndrome.
SeealsoTopographicandFunctionalAnatomyoftheSpinalCord.

Pathophysiology
Spinalcordinjury(SCI),aswithacutestroke,isadynamicprocess.Inallacutecordsyndromes,
thefullextentofinjurymaynotbeapparentinitially.Incompletecordlesionsmayevolveinto
morecompletelesions.Morecommonly,theinjurylevelrises1or2spinallevelsduringthe
hourstodaysaftertheinitialevent.Acomplexcascadeofpathophysiologiceventsrelatedto
freeradicals,vasogenicedema,andalteredbloodflowaccountsforthisclinicaldeterioration.
Normaloxygenation,perfusion,andacidbasebalancearerequiredtopreventworseningofthe
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spinalcordinjury.
Spinalcordinjurycanbesustainedthroughdifferentmechanisms,withthefollowing3common
abnormalitiesleadingtotissuedamage:
Destructionfromdirecttrauma
Compressionbybonefragments,hematoma,ordiskmaterial
Ischemiafromdamageorimpingementonthespinalarteries
Edemacouldensuesubsequenttoanyofthesetypesofdamage.

Neurogenicshock
Neurogenicshockreferstothehemodynamictriadofhypotension,bradycardia,andperipheral
vasodilationresultingfromsevereautonomicdysfunctionandtheinterruptionofsympathetic
nervoussystemcontrolinacutespinalcordinjury.Hypothermiaisalsocharacteristic.This
conditiondoesnotusuallyoccurwithspinalcordinjurybelowthelevelofT6butismorecommon
ininjuriesaboveT6,secondarytothedisruptionofthesympatheticoutflowfromT1L2andto
unopposedvagaltone,leadingtoadecreaseinvascularresistance,withtheassociated
vasculardilatation.Neurogenicshockneedstobedifferentiatedfromspinalandhypovolemic
shock.Hypovolemicshocktendstobeassociatedwithtachycardia.

Spinalshock
Shockassociatedwithaspinalcordinjuryinvolvingthelowerthoraciccordmustbeconsidered
hemorrhagicuntilprovenotherwise.Inthisarticle,spinalshockisdefinedasthecompleteloss
ofallneurologicfunction,includingreflexesandrectaltone,belowaspecificlevelthatis
associatedwithautonomicdysfunction.Thatis,spinalshockisastateoftransientphysiologic
(ratherthananatomic)reflexdepressionofcordfunctionbelowthelevelofinjury,withassociated
lossofallsensorimotorfunctions.
Aninitialincreaseinbloodpressureduetothereleaseofcatecholamines,followedby
hypotension,isnoted.Flaccidparalysis,includingofthebowelandbladder,isobserved,and
sometimessustainedpriapismdevelops.Thesesymptomstendtolastseveralhourstodays
untilthereflexarcsbelowtheleveloftheinjurybegintofunctionagain(eg,bulbocavernosus
reflex,musclestretchreflex[MSR]).

PrimaryvssecondarySCIs
Spinalcordinjuriesmaybeprimaryorsecondary.Primaryspinalcordinjuriesarisefrom
mechanicaldisruption,transection,ordistractionofneuralelements.Thisinjuryusuallyoccurs
withfractureand/ordislocationofthespine.However,primaryspinalcordinjurymayoccurinthe
absenceofspinalfractureordislocation.Penetratinginjuriesduetobulletsorweaponsmay
alsocauseprimaryspinalcordinjury.Morecommonly,displacedbonyfragmentscause
penetratingspinalcordand/orsegmentalspinalnerveinjuries.
Extraduralpathologymayalsocauseaprimaryspinalcordinjury.Spinalepiduralhematomasor
abscessescauseacutecordcompressionandinjury.Spinalcordcompressionfrommetastatic
diseaseisacommononcologicemergency.
Longitudinaldistractionwithorwithoutflexionand/orextensionofthevertebralcolumnmayresult
inprimaryspinalcordinjurywithoutspinalfractureordislocation.Thespinalcordistethered
moresecurelythanthevertebralcolumn.Longitudinaldistractionofthespinalcordwithor
withoutflexionand/orextensionofthevertebralcolumnmayresultinspinalcordinjurywithout
radiologicabnormality(SCIWORA).
SCIWORAwasfirstcoinedin1982byPangandWilberger.Originally,itreferredtospinalcord
injurywithoutradiographicorcomputedtomography(CT)scanningevidenceoffractureor
dislocation.Howeverwiththeadventofmagneticresonanceimaging(MRI),thetermhas
becomeambiguous.FindingsonMRIsuchasintervertebraldiskrupture,spinalepidural
hematoma,cordcontusion,andhematomyeliahaveallbeenrecognizedascausingprimaryor
secondaryspinalcordinjury.SCIWORAshouldnowbemorecorrectlyrenamedas"spinalcord
injurywithoutneuroimagingabnormality"andrecognizethatitsprognosisisactuallybetterthan
patientswithspinalcordinjuryandradiologicevidenceoftraumaticinjury.[9,10,11]
Vascularinjurytothespinalcordcausedbyarterialdisruption,arterialthrombosis,or
hypoperfusionduetoshockarethemajorcausesofsecondaryspinalcordinjury.Anoxicor
hypoxiceffectscompoundtheextentofspinalcordinjury.

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Completevsincompletespinalcordsyndrome
Oneofthegoalsofthephysicianistoclassifythepatternoftheneurologicdeficitintooneofthe
cordsyndromes.Spinalcordsyndromesmaybecompleteorincomplete.Inmostclinical
scenarios,physiciansshoulduseabestfitmodeltoclassifythespinalcordinjurysyndrome.
Acompletecordsyndromeischaracterizedclinicallyascompletelossofmotorandsensory
functionbelowthelevelofthetraumaticlesion.Incompletecordsyndromeshavevariable
neurologicfindingswithpartiallossofsensoryand/ormotorfunctionbelowthelevelofinjury
theseincludetheanteriorcordsyndrome,theBrownSquardsyndrome,andthecentralcord
syndrome.
Anteriorcordsyndromeinvolvesalesioncausingvariablelossofmotorfunctionandpainand/or
temperaturesensation,withpreservationofproprioception.
BrownSquardsyndrome,whichisoftenassociatedwithahemisectionlesionofthecord,
involvesarelativelygreateripsilaterallossofproprioceptionandmotorfunction,with
contralaterallossofpainandtemperaturesensation.
Centralcordsyndromeusuallyinvolvesacervicallesion,withgreatermotorweaknessinthe
upperextremitiesthaninthelowerextremities,withsacralsensorysparing.Thepatternofmotor
weaknessshowsgreaterdistalinvolvementintheaffectedextremitythanproximalmuscle
weakness.Sensorylossisvariable,andthepatientismorelikelytolosepainand/or
temperaturesensationthanproprioceptionand/orvibration.Dysesthesias,especiallythosein
theupperextremities(eg,sensationofburninginthehandsorarms),arecommon.

Othercordsyndromes
Theconusmedullarissyndrome,caudaequinasyndrome,andspinalcordconcussionarebriefly
discussedbelow.
Conusmedullarissyndromeisasacralcordinjury,withorwithoutinvolvementofthelumbar
nerveroots.Thissyndromeischaracterizedbyareflexiainthebladder,bowel,andtoalesser
degree,lowerlimbs,whereasthesacralsegmentsoccasionallymayshowpreservedreflexes
(eg,bulbocavernosusandmicturitionreflexes).Motorandsensorylossinthelowerlimbsis
variable.
Caudaequinasyndromeinvolvesinjurytothelumbosacralnerverootsinthespinalcanalandis
characterizedbyanareflexicboweland/orbladder,withvariablemotorandsensorylossinthe
lowerlimbs.Becausethissyndromeisanerverootinjuryratherthanatruespinalcordinjury,the
affectedlimbsareareflexic.Caudaequinasyndromeisusuallycausedbyacentrallumbardisk
herniation.
Aspinalcordconcussionischaracterizedbyatransientneurologicdeficitlocalizedtothespinal
cordthatfullyrecoverswithoutanyapparentstructuraldamage.

Etiology
Since2005,themostcommoncausesofspinalcordinjury(SCI)remain:(1)motorvehicle
accidents(40.4%)(2)falls(27.9%),mostcommoninthoseaged45yorolder.Olderfemales
withosteoporosishaveapropensityforvertebralfracturesfromfallswithassociatedSCI(3)
interpersonalviolence(primarilygunshotwounds)(15.0%),whichisthemostcommoncausein
someUSurbansettings.Amongpatientswhohadsufferedanassault,spinalcordinjuryfroma
penetratinginjurytendedtobeworsethanthatfromabluntinjury[12](4)andsports(8.0%),in
whichdivingisthemostcommoncause).[13]Spinalcordinjury(SCI)duetotraumahasmajor
functional,medical,andfinancialeffectsontheinjuredperson,aswellasanimportanteffecton
theindividual'spsychosocialwellbeing.[14,15,16]
Othercausesofspinalcordinjuryincludethefollowing:
Vasculardisorders
Tumors[17]
Infectiousconditions
Spondylosis
Iatrogenicinjuries,especiallyafterspinalinjectionsandepiduralcatheterplacement
Vertebralfracturessecondarytoosteoporosis
Developmentaldisorders
Injuriesoftenassociatedwithtraumaticspinalcordinjuryalsoincludebonefractures(29.3%),
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lossofconsciousness(17.8%),andtraumaticbraininjuryaffectingemotional/cognitive
functioning(11.5%).
Therateofalcoholintoxicationamongindividualswhosustainspinalcordinjuriesis1749%.

Epidemiology
TheincidenceofspinalcordinjuryintheUnitedStatesisapproximately40casespermillion
population,orabout12,000patients,peryearbasedondataintheNationalSpinalCordInjury
database.[13]However,thisestimateisbasedonolderdatafromthe1990sastherehasnot
beenanynewoverallincidencestudiescompleted.[13]Estimatesfromvariousstudiessuggest
thatthenumberofpeopleintheUnitedStatesalivein2010withspinalcordinjurywasabout
265,000persons(range,232,000316,000).[13]
SpinalcordinjuriesoccurmostfrequentlyinJulyandleastcommonlyinFebruary.Themost
commondayonwhichtheseinjuriesoccurisSaturday.Spinalcordinjuriesalsooccurmore
frequentlyduringdaylighthours,whichmaybeduetotheincreasedfrequencyofmotorvehicle
accidentsandofdivingandotherrecreationalsportingaccidentsduringtheday.

Racial,sexual,agerelateddifferencesinincidence
Asignificanttrendovertimehasbeenobservedintheracialdistributionofpersonswithspinal
cordinjury.Since2005,66.5%arewhite,26.8%areblack,8.3%areHispanic,and2.0%are
Asian.[13]
Malesareapproximately4timesmorelikelythanfemalestohavespinalcordinjuries.Overall,
malesaccountfor80.7%ofreportedinjuriesinthenationaldatabase.[13]
Since2005,theaverageageatinjuryis40.7years,reflectingtheriseinthemedianageofthe
generalpopulationintheUnitedStates.[13]About50%ofspinalcordinjuriesoccurbetweenthe
agesof16and30years,3.5%occurinchildrenaged15yearsoryounger,andabout11.5%in
thoseolderthan60years(11.5%).Greatermortalityisreportedinolderpatientswithspinalcord
injury.
PediatricSCIdata
Thepediatricdataparallelsthatoftheadultdataonspinalcordinjuries.Usinginformationfrom
theKids'InpatientDatabase(KID)andtheNationalTraumaDatabase(NTDB),Vitaleand
colleaguesfoundthat,withregardtotheannualpediatricincidencerateasignificantlygreater
incidenceofspinalcordinjurieswasfoundinblackchildren(1.53casesper100,000children)
thaninNativeAmericanchildren(1.0caseper100,000children)andHispanicchildren(0.87
caseper100,000children),andthefrequencyinAsianchildrenwassignificantlylowerthanthat
inallotherraces(0.36per100,000children).[18]Inaddition,thelikelihoodthatboyswouldsuffer
spinalcordinjuries(2.79casesper100,000)wasfoundtobemorethantwicethatofgirls(1.15
casesper100,000).[18]
TheoverallincidenceofpediatricSCIis1.99casesper100,000USchildren.Asestimated
fromtheabovedata,1455childrenareadmittedtoUShospitalsannuallyfortreatmentofspinal
cordinjuries.
Vitaleetalalsolookedatthemajorcausativefactorsofpediatriccases,reportingthefollowing
incidences[18],againparallelingadultdata:
Motorvehicleaccidents56%
Accidentalfalls14%
Firearminjuries9%
Sportsinjuries7%
Amongchildreninthestudy,67.7%ofthoseinjuredinamotorvehicleaccidentwerenot
wearingaseatbelt.[18]Alcoholanddrugswerefoundtohaveplayedarolein30%ofall
pediatriccasesofspinalcordinjuries.

Otherepidemiologicdata
Marital,educational,andemploymentstatusofpatientswithspinalcordinjuriesarediscussed
below.
Maritalstatus
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Singlepersonssustainspinalcordinjuriesmorecommonlythandomarriedpersons.Research
hasindicatedthatamongpersonswithspinalcordinjurieswhoseinjuryisapproximately15
yearsold,onethirdwillremainsingle20yearspostinjury.ThemarriagerateafterSCIisannually
about59%belowthatofpersonsinthegeneralpopulationofcomparablegender,age,and
maritalstatus.
Marriageismorelikelyifthepatientisacollegegraduate,previouslydivorced,paraplegic(not
tetraplegic),ambulatory,livinginaprivateresidence,andindependentintheperformanceof
activitiesofdailyliving(ADL).
Thedivorcerateannuallyamongindividualswithspinalcordinjurywithinthefirst3years
followinginjuryisapproximately2.5timesthatofthegeneralpopulation,whereastherateof
marriagescontractedaftertheinjuryisabout1.7timesthatofthegeneralpopulation.
Thedivorcerateinthosewhoweremarriedatthetimeoftheirinjuryishigherifthepatientis
younger,female,black,withoutchildren,nonambulatory,andpreviouslydivorced.Thedivorce
rateamongthosewhoweremarriedafterthespinalcordinjuryishigheriftheindividualismale,
haslessthanacollegeeducation,hasathoraciclevelinjury,andwaspreviouslydivorced.
Educationalstatus
Therateofinjurydiffersaccordingtoeducationalstatus,asfollows:
Lessthanahighschooldegree:39.8%
Highschooldegree:49.9%
Associatedegree:1.6%
Bachelorsdegree:5.9%
Mastersordoctoratedegree:2.1%
Otherdegree:0.7%.
Employmentstatus
PatientswithspinalcordinjuryclassifiedasAmericanSpinalInjuryAssociation(ASIA)levelD
aremorelikelytobeemployedthanindividualswithASIAlevelsA,B,andC(seeNeurologic
levelandextentofinjuryunderClinical).Personsemployedtendtoworkfulltime.Individualswho
returntoworkwithin1yearofinjurytendtoreturntothesamejob.Thoseindividualswhoreturn
toworkafter1yearofinjurytendtoworkforadifferentemployeratadifferentjobrequiring
retraining.[19]
Thelikelihoodofemploymentafterinjuryisgreaterinpatientswhoareyounger,male,andwhite
andwhohavemoreformaleducation,higherreportedintelligencequotient(IQ),greater
functionalcapacity,andlesssevereinjury.Patientswithgreaterfunctionalcapacity,lesssevere
injury,historyofemploymentatthetimeofinjury,greatermotivationtoreturntowork,nonviolent
injury,andabilitytodrivearemorelikelytoreturntowork,especiallyaftermoreelapsedtime
followinginjury.

Prognosis
Patientswithacompletespinalcordinjury(SCI)havealessthan5%chanceofrecovery.If
completeparalysispersistsat72hoursafterinjury,recoveryisessentiallyzero.Intheearly
1900s,themortalityrate1yearafterinjuryinpatientswithcompletelesionsapproached100%.
Muchoftheimprovementsincethencanbeattributedtotheintroductionofantibioticstotreat
pneumoniaandurinarytractinfection(UTI).
Theprognosisismuchbetterfortheincompletecordsyndromes.
Ifsomesensoryfunctionispreserved,thechancethatthepatientwilleventuallybeablewalkis
greaterthan50%.
Ultimately,90%ofpatientswithspinalcordinjuryreturntotheirhomesandregain
independence.
ProvidinganaccurateprognosisforthepatientwithanacuteSCIusuallyisnotpossibleinthe
emergencydepartment(ED)andisbestavoided.

Lifeexpectancyandmortality
Approximately1020%ofpatientswhohavesustainedaspinalcordinjurydonotsurviveto
reachacutehospitalization,whereasabout3%ofpatientsdieduringacutehospitalization.
Originallytheleadingcauseofdeathinpatientswithspinalcordinjurywhosurvivedtheirinitial
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injurywasrenalfailure,but,currently,theleadingcausesofdeatharepneumonia,pulmonary
embolism,orsepticemia.Heartdisease,[20,21]subsequenttrauma,suicide,andalcoholrelated
deathsarealsomajorcausesofdeathinthesepatients.[22,23]Inpersonswithspinalcordinjury,
thesuiciderateishigheramongindividualswhoareyoungerthan25years.
Amongpatientswithincompleteparaplegia,theleadingcausesofdeatharecancerandsuicide
(1:1ratio),whereasamongpersonswithcompleteparaplegia,theleadingcauseofdeathis
suicide,followedbyheartdisease.
Lifeexpectanciesforpatientswithspinalcordinjurycontinuestoincreasebutarestillbelowthe
generalpopulation.Patientsaged20yearsatthetimetheysustaintheseinjurieshavealife
expectancyofapproximately35.7years(patientswithhightetraplegia[C1C4]),40years
(patientswithlowtetraplegia[C5C8]),or45.2years(patientswithparaplegia).[13]Individuals
aged60yearsatthetimeofinjuryhavealifeexpectancyofapproximately7.7years(patients
withhightetraplegia),9.9years(patientswithlowtetraplegia),and12.8years(patientswith
paraplegia).
A2006studybyStraussandcolleaguesreportedthatamongpatientswithspinalcordinjury,
duringthecriticalfirst2yearsfollowinginjury,a40%declineinmortalityoccurredbetween1973
and2004.[24]Duringthatsame31yearperiod,therehadbeenonlyasmall,statistically
insignificantreductioninmortalityinthepost2yearperiodforthesepatients.

Lifesatisfaction
Studieshavefoundthatpatientswithspinalcordinjurywhosufferfrompainhavelesslife
satisfactionthandopatientsinwhompainiswellcontrolledthismayalsoaffectthepatients'
generaloutlookonlife.[25,26]

Rehabilitation
Patientsyoungerthan65yearswithmusclegradeof3orgreaterinthemyotomeL3andS1,
andlighttouchsensationinthedermatomeL3andS1within15daysofinjury(allwithin
AmericanSpinalInjuryAssociation[ASIA]impairmentscaleD),aremorelikelytobe
independentindoorwalkerswithinayearofinjury.[27]Rehabilitationgoalsinthisgroupshould
thereforebegearedtowardfunctionalcapacityandwithinexpectedindependentwalking.

BraincomputerinterfaceforSCI
SCIcanleavepatientswithsevereorcompletepermanentparalysis.Braincomputerinterface
(BCI)canpotentiallyrestoreorsubstituteformotorbehaviorsinpatientswithahighcervical
SCI.[28]RecentstudieshaveshownthatpatientswithSCIareabletocontrolvirtualkeyboards,
[29] acomputercursor,[28] andalimbprostheticdevice[30] usingBCItechnologies.TheBCI
outputsareaccomplishedbyacquiringneurophysiologicalsignalsassociatedwithamotor
processinthecerebralcortex,analyzingthesesignalsinrealtime,andsubsequentlytranslating
themintocommandsforalimbprosthesis.Thesearepromisingfindingsinthefuture,BCImay
provideapermanentsolutionforrestorationofmotorfunctionsinSCIpatients.

Walkingassistancesystems
In2014,theFDAapprovedawearable,motorizeddevicetohelpindividualswithparaplegia
duetoanSCIsit,stand,andwalkwithassistancefromacompanion.[1,2]Thedevice,whichis
intendedforpatientswithSCIsatlevelsT7L5andforthosewithlevelT4T6injurieswhenused
onlyinrehabilitationinstitutions,consistsofthefollowing:
Fittedmetalbracethatsupportsthelegsandpartoftheupperbody
Motorsthatprovidemovementtothehips,knees,andankles
Tiltsensor
Computerandpowersupplywornontheback
Beforeusingthedevice,caregiversandpatientsarerequiredtoundergoextensivetraining.

PatientEducation
Aspartofinpatienttherapy,patientswithspinalcordinjury(SCI)shouldreceivea
comprehensiveprogramofphysicalandoccupationaltherapy.
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Prevention
Manyspinalcordinjuriesresultfromincidentsinvolvingdrunkdriving,assaults,andalcoholor
drugabuse.Spinalcordinjuriesfromindustrialhazards,suchasequipmentfailuresor
inadequatesafetyprecautions,arepotentiallypreventablecauses.Unfenced,shallow,orempty
swimmingpoolsareknownhazards.
ClinicalPresentation

ContributorInformationandDisclosures
Author
LawrenceSChin,MD,FACSRobertBandMollyGKingEndowedProfessorandChair,
DepartmentofNeurosurgery,StateUniversityofNewYorkUpstateMedicalUniversity
LawrenceSChin,MD,FACSisamemberofthefollowingmedicalsocieties:AlphaOmega
Alpha,AmericanAssociationfortheAdvancementofScience,AmericanAssociationfor
CancerResearch,Children&#039sOncologyGroup,SocietyforNeuroOncology,Congress
ofNeurologicalSurgeons,AmericanAssociationofNeurologicalSurgeons,American
CollegeofSurgeons,PhiBetaKappa
Disclosure:Nothingtodisclose.
Coauthor(s)
SegunToyinDawodu,MD,JD,MBA,LLM,FAAPMR,FAANEMAssociateProfessorof
RehabilitationMedicineandInterventionalPainMedicine,AlbanyMedicalCollege
SegunToyinDawodu,MD,JD,MBA,LLM,FAAPMR,FAANEMisamemberofthefollowing
medicalsocieties:AmericanCollegeofSportsMedicine,AmericanAcademyofPhysical
MedicineandRehabilitation,RoyalCollegeofSurgeonsofEngland,AmericanAssociationof
NeuromuscularandElectrodiagnosticMedicine,AmericanMedicalAssociation,American
MedicalInformaticsAssociation,AssociationofAcademicPhysiatrists,InternationalSociety
ofPhysicalandRehabilitationMedicine
Disclosure:Nothingtodisclose.
FassilBMesfin,MD,PhDAssistantProfessorofNeurosurgery,DirectorofComplexSpine
andSpineOncologyProgram,UniversityofMissouriColumbiaSchoolofMedicine
FassilBMesfin,MD,PhDisamemberofthefollowingmedicalsocieties:AlphaOmega
Alpha,AmericanAssociationforCancerResearch,AmericanAssociationofNeurological
Surgeons,AmericanMedicalAssociation,NationalMedicalAssociation,Congressof
NeurologicalSurgeons,AmericanAcademyofNeurologicalSurgery
Disclosure:Nothingtodisclose.
ChiefEditor
BrianHKopell,MDAssociateProfessor,DepartmentofNeurosurgery,IcahnSchoolof
MedicineatMountSinai
BrianHKopell,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAssociationofNeurologicalSurgeons,InternationalParkinsonandMovement
DisorderSociety,CongressofNeurologicalSurgeons,AmericanSocietyforStereotacticand
FunctionalNeurosurgery,NorthAmericanNeuromodulationSociety
Disclosure:ReceivedconsultingfeefromMedtronicforconsultingReceivedconsultingfee
fromStJudeNeuromodulationforconsultingReceivedconsultingfeefromMRIInterventions
forconsulting.
Acknowledgements
DeniseICampagnolo,MD,MSDirectorofMultipleSclerosisClinicalResearchandStaff
Physiatrist,BarrowNeurologyClinics,StJoseph'sHospitalandMedicalCenterInvestigator
forBarrowNeurologyClinicsDirector,NARCOMSProjectforConsortiumofMSCenters
DeniseICampagnolo,MD,MSisamemberofthefollowingmedicalsocieties:AlphaOmega
Alpha,AmericanAssociationofNeuromuscularandElectrodiagnosticMedicine,American
ParaplegiaSociety,AssociationofAcademicPhysiatrists,andConsortiumofMultiple
SclerosisCenters
Disclosure:TevaNeuroscienceHonorariaSpeakingandteachingSeronoPfizerHonoraria
SpeakingandteachingGenzymeCorporationGrant/researchfundsinvestigatorBiogenIdec
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Grant/researchfundsinvestigatorGenentech,IncGrant/researchfundsinvestigatorEliLilly&
CompanyGrant/researchfundsinvestigatorNovartisinvestigatorMSDxLLCGrant/research
fundsinvestigatorBioMSTechnologyCorpGrant/researchfundsinvestigatorAvanir
PharmaceuticalsGrant/researchfundsinvestigator
DanielJDire,MD,FACEP,FAAP,FAAEMClinicalProfessor,DepartmentofEmergency
Medicine,UniversityofTexasMedicalSchoolatHoustonClinicalProfessor,Departmentof
Pediatrics,UniversityofTexasHealthSciencesCenterSanAntonio
DanielJDire,MD,FACEP,FAAP,FAAEMisamemberofthefollowingmedicalsocieties:
AmericanAcademyofClinicalToxicology,AmericanAcademyofEmergencyMedicine,
AmericanAcademyofPediatrics,AmericanCollegeofEmergencyPhysicians,and
AssociationofMilitarySurgeonsoftheUS
Disclosure:Nothingtodisclose.
MiltonJKlein,DO,MBAConsultingPhysiatrist,HeritageValleyHealthSystemSewickley
HospitalandOhioValleyGeneralHospital
MiltonJKlein,DO,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademy
ofDisabilityEvaluatingPhysicians,AmericanAcademyofMedicalAcupuncture,American
AcademyofOsteopathy,AmericanAcademyofPhysicalMedicineandRehabilitation,
AmericanMedicalAssociation,AmericanOsteopathicAssociation,AmericanOsteopathic
CollegeofPhysicalMedicineandRehabilitation,AmericanPainSociety,andPennsylvania
MedicalSociety
Disclosure:Nothingtodisclose.
RichardSalcido,MDChairman,ErdmanProfessorofRehabilitation,Departmentof
PhysicalMedicineandRehabilitation,UniversityofPennsylvaniaSchoolofMedicine
RichardSalcido,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
PainMedicine,AmericanAcademyofPhysicalMedicineandRehabilitation,American
CollegeofPhysicianExecutives,AmericanMedicalAssociation,andAmericanParaplegia
Society
Disclosure:Nothingtodisclose.
TomScaletta,MDChair,DepartmentofEmergencyMedicine,EdwardHospitalPast
President,AmericanAcademyofEmergencyMedicine
TomScaletta,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine
Disclosure:Nothingtodisclose.
DonaldSchreiber,MD,CMAssociateProfessorofSurgery(EmergencyMedicine),
StanfordUniversitySchoolofMedicine
DonaldSchreiber,MD,CMisamemberofthefollowingmedicalsocieties:AmericanCollege
ofEmergencyPhysicians
Disclosure:AbbottPointofCareIncResearchGrantandSpeakersBureauSpeakingand
teachingNanosphereIncGrant/researchfundsResearchSingulexIncGrant/researchfunds
ResearchAbbottDiagnosticsIncGrant/researchfundsNone
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraska
MedicalCenterCollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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