Injuries to the spinal cord can affect many bodily functions. These include:
Normally, messages are sent from the brain through the spinal cord to parts of the body and this results in movement. When the spinal cord is damaged, the message from the brain cannot get through. The spinal nerves below the level of injury receive signals, but they are not able to go up the spinal tracts to the brain. Reflex movements may occur, but these are not movements that you control. The reflex movement may occur when the foot is touched or with coughing.
This is the temporary loss of all spinal cord reflexes below the level of injury. This could last from days to weeks. When spinal shock ends, spasticity or stiffness starts to occur below the level that the spinal cord was injured. Spinal shock cannot be prevented and must resolve on its own.
The muscles (diaphragm, intercostal, and abdominal) needed for breathing and coughing may become weak after a spinal cord injury. Coughing is needed to clear the lungs of secretions and bacteria. If you have a weak cough or are unable to clear secretions from your lungs, you will be more at risk for infection, such as pneumonia. (Fig. 23)
An injury at C4 or higher will affect the diaphragm (the muscle that moves your lungs for breathing). A T1-T11 injury will affect the intercostal muscles (muscles between the ribs). A T7-T12 injury will affect the abdominal muscles. The body needs the diaphragm, the intercostal muscles, and the abdominal muscles to breath and cough well.
If the spinal cord injury is cervical (in the neck), it may be necessary to assist and support breathing temporarily or permanently with a ventilator. If a ventilator is necessary, a breathing tube will be placed in your mouth or nose, and then attached to the ventilator. If the ventilator is needed for a long time or you have a lot of lung secretions, you may need a tracheostomy (trach). (Fig. 24) A trach is a tube placed in the trachea (windpipe). It will make it easier for you to cough up phlegm. It also allows the nurse to suction the lungs. Initially, you will be unable to talk while the trach is in place. As you improve, a talking trach may be used. A trach may not be permanent.
If you are not on a ventilator, you will be encouraged to cough and deep breath hourly while awake to help keep the lungs healthy and prevent infection. You may also be asked to use an incentive spirometer, a plastic breathing device. You can see on the device how much air is being taken into the lungs. The nurse or therapist will help you to set goals for using this breathing device. Families are welcomed to be involved in helping you use the incentive spirometer.
Neurogenic Shock (Low Heart Rate and Low Blood Pressure)
Areas in the brain normally control blood pressure and heart rate. Signals from the brain send messages through the spinal cord to constrict blood vessels and increase your heart rate to keep your blood pressure and heart rate normal. When these signals are interrupted, low blood pressure and slow heart rate result. This may be present with spinal cord injury.
Blood pressure may drop when the head of bed is raised suddenly because blood vessels below the level of injury are dilated. They cannot constrict fast enough to prevent low blood pressure. This is called orthostatic hypotension. To reduce this, the head of the bed is gradually raised and an abdominal binder may be used.
Altered Temperature Regulation:
The ability to sweat or to make goose bumps may be lost below the level of injury. Your body cannot adjust your temperature. You may feel cold and require blankets, and then later, feel hot and request a fan or to be uncovered.
Autonomic Hyperreflexia (also known as Autonomic Dysreflexia or Hyperdysreflexia)
Patients that are most at risk for this condition are those with spinal cord injuries above T6. This tends to occur after the spinal shock phase. Autonomic hyperreflexia occurs because nerve messages that were once able to go up the spinal cord to the brain are blocked. (Fig. 25)
Conditions, below the level of injury, that may lead to autonomic hyperreflexia include:
Symptoms may include:
Each patient may present with slightly different symptoms of autonomic hyperreflexia.
Autonomic hyperreflexia is a serious condition and needs immediate treatment. Prevention and looking for signs of this condition are very important. Stroke, heart attack, or seizures can develop if left untreated. This is a condition that may occur throughout the rest of your life.
Deep Vein Thrombosis (DVT)
Often caused by a lack of movement, a deep vein thrombosis (DVT) is a blood clot that can develop in the legs and arms. Elastic stockings (TEDs), sequential compression devices (SCD's or Kendall's), and/or foot pumps will be placed on your legs or feet to help prevent a DVT. A blood thinning medicine may be used or a filter may be placed in a blood vessel. Regular exercise of the arms and legs and turning will also be done to help prevent DVT's from forming.
Sometimes after spinal cord injury, the stomach and intestine will stop working for a short time. This is called an ileus. Even though the stomach may not be working, it continues to make acid. The acid may damage the stomach lining and cause stomach ulcers if it is not removed. A nasogastric (NG) tube may be placed through the nose into the stomach. This tube will be used to help remove stomach acids. Medications may also be given to help prevent stomach ulcers.
Higher cervical injuries may cause difficulty in swallowing. If this happens, a nasogastric (NG) tube may be needed for nutrition and medications. The tube is placed through the nose into the stomach. Liquid formula will be given either continuously or several times a day. The hospital dietician helps the healthcare team to select a formula based on your calorie and fluid needs. If long term tube feeding is necessary, a gastric tube (G-tube or PEG Tube) may be placed surgically through the wall of the abdomen into the stomach.
Changes in bowel control may occur after injury. You may experience constipation or diarrhea. A bowel training program including diet, medicines and digital stimulation may be used. Digital stimulation means to touch inside the rectum to help your bowels move. Developing a bowel training program takes time, but can be successful.
Spinal cord injury may also cause the messages between your bladder and brain to be changed. Normally, when your bladder gets full, nerves in the bladder send a message up the spinal cord to the brain signaling the need to urinate. The message to the brain may be lost after your injury. There is also no bladder tone when spinal shock is present.
Initially, after a spinal cord injury, a urinary (Foley) catheter will be placed to drain the bladder. As your body starts to adjust to the injury, the catheter will be removed. The nurses will check your bladder volume. If the bladder is full, a catheter will be put into your bladder to drain the urine and then the catheter will be removed. Eventually, a bladder training plan will be started.
Bladder tone may or may not return depending on the level of your spinal cord injury. The bladder may be flaccid (weakened) or spastic (hyperactive). A urologist may be asked to evaluate the bladder and medications or surgery may be recommended.
Skin is a protective covering for your body. Too much pressure on the skin or too much heat or wetness can lead to skin breakdown (bedsores or pressure ulcers) due to a lack of blood flow and oxygen. The skin ulcer can then become infected. Because your body cannot warn of dangers to the skin, you will need to do a regular routine of repositioning, turning, and careful, thorough cleaning after you urinate or have a bowel movement
Muscles and Tendons
Spasticity can occur after a spinal cord injury when signals from the brain to the muscles are blocked. Usually, this is not seen until spinal shock resolves (See page 18). When spasticity occurs, there is resistance to stretching the muscles. This can be painful and can lead to contractures, a shortening of the muscles and tendons (See page 29).
If spasticity is a problem, treatment may be helpful. Repositioning may be done and medication, such as Baclofen, may be given. Botox injections may also be used to treat spasticity.
Bones and Joints
When there is a lack of motion in joints due to prolonged bed rest, hard calcium deposits (bone spurs) can occur. This process is called heterotopic ossification. It can lead to pain, spasms, and a reduced ability to function. Heterotopic ossification occurs when calcium lost from the bones build up in muscles, tendons, or joints. This usually begins between 2 weeks to 4 months after injury. The most common places where this process may occur in the body are in the hips, knees, shoulders, and elbows.
With spinal cord injury, pain may be acute or chronic. Acute pain may be caused by bruising, broken bones, surgery, or positioning. Chronic pain may be caused by overuse of joints and muscles, or changes in muscles, joints and ligaments. Treatments vary depending on the type and cause of the pain. The most important thing to remember is that your pain is real and there is a physical cause. If you are experiencing pain, be sure to tell your healthcare provider.
Many patients who have had severe trauma to their neck and back may also have injuries to their brain. These injuries can range from a mild concussion to more severe injuries, resulting in difficulty with memory, concentration, communication or personality changes.
Love and intimacy are basic needs that everyone shares. A patient with spinal cord injury continues to have sexual needs. There may be loss of sensation to the genital area for both men and women. Each person's injury affects his or her sexuality in a different way.
Usually, both males and females will still be able to have sexual intercourse. Males will have erections, some uncontrolled, that may be brought on by sexual thoughts or as a reflex with catheterization or erotic stimulation. The ability to maintain an erection may be difficult. This is called erectile dysfunction (ED). There are many medical treatments available to help with this. The ability to ejaculate may also change. Therefore, men may have difficulty with fertility (the ability to have children). These functions all depend on the level and extent of injury.
For women, nothing prevents sexual intercourse, but vaginal secretions may be less. Women may still be able to have orgasms. For women of child-bearing age, menstrual periods often are disrupted and may not resume for 3-6 months. Women can still get pregnant and have children, and may deliver vaginally.
Though sexual intercourse is important, love and intimacy can be shared in many ways. Activities such as touching a loved one's face and hair, kissing, being hugged, sharing ideas and problems, memories, and laughing together are also important.
During the acute phase of your injury, it may not be possible for your healthcare provider to foresee the degree of sexual function you will have. As you get further along in your rehabilitation, it will be more likely to predict your level of function. You can discuss any changes you might notice with your healthcare provider. Many rehabilitation centers have sexual counseling programs for patients and families, which help them to understand and cope with these changes.