During 2007-08, 362 new cases of SCI were registered with 77 (21%) of these resulting from non-traumatic causes where SCI was secondary to medical conditions such as vascular disorders (22%), infectious conditions (17%) and spinal canal stenosis (23%). Other conditions associated with non-traumatic SCI were related to disc herniation (17%), myelopathy (8%) and cancer (13%).

Where neurological levels and extent of injury were reported (241 cases), the most common neurological category was incomplete tetraplegia (38%), followed by incomplete paraplegia (27%), complete paraplegia (20%) and complete tetraplegia (15%).

The total number of registered cases incurring SCI from traumatic causes, and over the age of 15, was 285 of which 19 either did not survive (6 cases), were non-Australian residents (7 cases) or survived with no neurological deficit (6 cases). Of these cases, 84% were male and 16% female. The causes of injury were:

• 66 (23%) were motor vehicle occupants involved in traffic and non-traffic land transport related incidents;
• 64 (23%) were unprotected road users (motor cyclists, pedal cyclists or pedestrians) involved in traffic and non-traffic land transport related incidents;
• 29 (10%) resulted from low falls;
• 52 (18%) resulted from high falls (from a height of one metre or more);
• 25 (9%) resulted from being hit or struck by an object;
• 27 (9%) were water-related; and
• 22 (8%) were from other causes.

The type of activity being undertaken at the time of injury included working for income (39 cases), other types of work (16 cases), sports (22 cases), leisure (48 cases), personal activity (11 cases) and other or unspecified activity (149 cases).

Citation: Norton, Lynda 2010, Spinal cord injury, Australia 2007–08, Injury Research and Statistics Series, Number 52, Canberra, AIHW (INJCAT 128)

Click here for a full copy of the report.

Each person with a disability is different. Each will have different needs in levels of care and equipment.

"Care" comes in various forms: personal, domestic, household, respite, nursing, community access.

• Personal care: showering, toileting, transferring, feeding.
• Domestic services: meal preparation, shopping, cleaning, ironing.
• Household support: gardening, home cleaning, home maintenance.
• Community access: transport, companion.
• Nursing: medication.
• Respite: for time spent away from home.
• Other: childcare and workplace or education support.

People with paraplegia will need little or no personal care, but will need assistance with domestic duties.

People with high cervical injury can require 24 hour care.

Equipment needs include manual or power wheelchair with battery charger, portable ramps, hoist, pressure relief cushion, shower chair, catheter, adjustable bed, air conditioning, ventilator, physiotherapy, home automation (possible voice controlled), computer, modified vehicle.

The NSW Motor Accidents Authority has published its assessment of the future care and equipment needs of people with SCI—Guidelines for levels of attendant care for people with spinal cord injury.

Also see our pages on Equipment and Technology.

People with high injuries usually need a power wheelchair for independent mobility. People with low C SCIs and below may be able to use manual wheelchairs.

Manual chairs are more convenient as they cost and weigh less and are easy to fold for transport. However the independence provided by a power chair to the person who needs it outweighs any limitations.

Some people walk using crutches and leg braces. This does not mean they will never use a wheelchair, perhaps preferring them only for longer distances.

SCI is damage to the spinal cord that results in a loss of function such as mobility or feeling. Frequent causes of damage are trauma (car accident, falls, diving etc.) or disease (polio, spina bifida, Friedreich's Ataxia etc.).

Quadriplegia (also referred to as tetraplagia) is loss of function below the neck.
Paraplegia is loss of function below the chest.

The spinal cord does not have to be severed in order for a loss of functioning to occur. In fact, in most people with SCI, the spinal cord is intact, but the damage due to compression or bruising to it results in loss of functioning. SCI is very different from back injuries such as ruptured disks, spinal stenosis or pinched nerves.

A person can "break their back or neck" yet not sustain a spinal cord injury if only the bones around the spinal cord (the vertebrae) are damaged, but the spinal cord is not affected. In these situations, the individual may not experience paralysis if bone damage is treated correctly.

The adult spinal cord is about 50 centimetres long and extends from the base of the brain to about the waist. It is the major bundle of nerves that carry messages between the brain and the rest of the body. Nerves within the spinal cord (upper motor neurons) carry messages back and forth from the brain to the spinal nerves along the spinal tract. Lower motor neurons branch out from the spinal cord to the other parts of the body, carrying sensations (from the skin and other body parts and organs to the brain) and instructions (to the various body parts to initiate actions such as muscle movement).

Injury to the spinal cord causes loss of function of the nerves, limbs and organs below the site of the injury.

The spinal cord lies within vertebrae. These rings of bones are together called the spinal column or back bone. In general, the higher in the spinal column an injury occurs, the more dysfunction a person will experience.

There are seven vertebrae in the neck—the Cervical Vertebrae—C1 (at the top) to C7. Injury in this region usually causes loss of function to the arms and legs (quadriplegia or tetraplegia).

There are twelve Thoracic Vertebrae. The highest (T1) is where the top rib attaches. Injury to the thoracic region affects the chest and the legs.

Between the thoracic vertebrae and the pelvis lie the 5 Lumbar Vertebrae. The 5 Sacral Vertebrae run from the pelvis to the end of the spinal column. Injury to nerves in the lumbar and sacral vertebrae generally results in loss of functioning in the hips and legs.

Loss of function in the chest, hips and legs is Paraplegia.

The effects of SCI depend on the type and level of the injury.

Spinal cord injury is commonly referred to as either complete or incomplete. In a complete SCI there are no signals below the point of injury between the brain and the body—no sensation and no voluntary movement. A person with an incomplete injury may be able to move one limb more than another, may be able to feel parts of the body that cannot be moved, or may have more functioning on one side of the body than the other. With the advances in acute treatment of SCI, incomplete injuries are becoming more common.

The level of injury is very helpful in predicting what parts of the body might be affected by paralysis and loss of function. There is a wide range of variation.

The degree of function after injury is measured according to the five-level ASIA Impairment Scale. They are:

• A - Complete: No motor or sensory function in the lowest sacral segment (S4-S5).
• B - Incomplete: Sensory function below neurologic level and in S4-S5, no motor function below neurologic level.
• C - Incomplete: Motor function is preserved below neurologic level and more than half of the key muscle groups below neurologic level have a muscle grade less than 3.
• D - Incomplete: Motor function is preserved below neurologic level and at least half of the key muscle groups below neurologic level have a muscle grade 3.
• E - Normal: Sensory and motor function is normal

Read more about the ASIA Scale 

A person with a SCI above C4 may require a ventilator to breathe. C5 injury often leaves shoulder and biceps control, but no control at the wrist or hand. C6 injury leaves control of the wrist, but not the hand. C7 and T1 injuries leave the ability to straighten the arms, but have only limited hand and finger dexterity.

Injuries below T1 result in paraplegia. At T1 to T8 there is most often control of the hands, but lack of abdominal muscle control leaves poor trunk control. Lower T injuries leave good control of the trunk and abdominal muscles. Injuries at the Lumbar and Sacral vertebra reduce control of the hip flexors and legs.

Besides a loss of sensation or motor functioning, SCI produces other changes. There can be bowel and bladder dysfunction. Sexual functioning is also frequently affected by SCI. Men may have their fertility affected, while women's fertility is generally not affected. Very high injuries (C1, C2) can result in a loss of many involuntary functions including the ability to breathe, necessitating breathing aids such as mechanical ventilators or diaphragmatic pacemakers. Other effects of SCI may include low blood pressure, inability to regulate blood pressure effectively, reduced control of body temperature, inability to sweat below the level of injury, and chronic pain.

At the time of injury, the spinal cord swells. When the swelling goes down, some functioning may return. This can for as long as 18 months after the injury. However, only a very small fraction of people with SCIs recover all functioning.

Most body parts and organs can repair themselves after they are injured. However the central nervous system cannot. Attempting to repair the damage caused by a brain or spinal cord injury is a puzzle that has not yet been solved.

Nevertheless the damage caused by an SCI can be reduced by limiting immediate cell death and reducing the inflammation of the injured cord.

Attempts to regenerate function in the damaged area are focusing on regrowing nerves, blocking the mechanism that stops neurons from regrowing themselves, inserting new cells and bypassing the damaged area.

Exercise programs can assist in the recovery of independent functional abilities.  Intensive exercise has been shown to:

• Increase central nervous system activity
• Increase muscle mass
• Increase muscle activity
• increase blood circulation
• increase sensation
• prevent a decrease in bone mineral density
• improve quality of life
• Increase independence in activities of daily living and occupational activities
• Decrease skin tissue breakdown and other health problems associated with spinal cord injury.

Before World War II, most people who sustained SCI died within weeks of their injury due to urinary dysfunction, respiratory infection or bedsores. However modern antibiotics and materials such as plastics and latex, and better procedures for dealing with the everyday issues of living with SCI, mean many people approach the lifespan of the general population. Most who survive the first 24 hours are still alive 10 years later.

 Call an ambulance (000) or get to an emergency room if symptoms persist. 

Autonomic dysreflexia (AD) can occur in SCI at or above T6. It arises due to the loss of control mechanisms for blood pressure and heart function. It causes the blood pressure to rise to dangerous levels.

AD can be caused by any bodily pain or discomfort. Common causes are a full bladder, bladder infection, severe constipation, or pressure sore. Anything that would normally cause pain or discomfort below the level of the spinal cord injury can trigger dysreflexia.

The symptoms of AD are related to the types of responses that happen in the autonomic nervous system. Pounding headache, blurred vision and spots before the eyes result from the high blood pressure that occurs when blood vessels below the injury constrict. The body responds by dilating blood vessels above the injury, causing flushing of the skin, sweating, and occasionally goosebumps. Some people also report anxiety and nasal stuffiness.

The primary risk of AD is stroke. If AD is not treated, the body attempts to control blood pressure by decreasing the heart rate. This, combined with uncontrolled high blood pressure, can be fatal. It is vital to treat this condition as soon as possible.

TREATMENT

Treatment of AD is to remove the reason for it. Sitting naturally decreases blood pressure. Check the catheter for kinked tubing. Check for distended bowel. Treatment algorithm for autonomic dysreflexia.

Preventing AD 

The best way to prevent AD is for people with high SCIs to take good care of themselves. Monitor bladder output, maintain a regular bowel program, do regular skin checks to prevent pressure sores from occurring.

Further Information

* NSW Rural Spinal Cord Injury Project, Treatment of Autonomic Dysreflezia for adults & adolescents with spinal cord injuries, Dec 2010. 
* NSW State Spinal Cord Injury Service, Autonomic Dysreflexia Safety Notice 14/10 (incorporating the Treatment Algorithim for Autonomic Dysreflexia), Nov 2010. 
* AD Medical Emergency Card. A wallet sized AD Medical Emergency card is available for people with spinal cord injury, developed to alert health care professionals to the principles of management of AD. Cards are available from the NSW State Spinal Cord Injury Service.

People with SCI above T12 have reduced breathing muscles. Above C4, the diaphragm and intercostals can be paralysed. The essential function of this system is breathing and the ability to cough.

Reduced breathing can stop oxygen being produced. Inability to cough enables secretions to build up in the lungs, risking pneumonia.

Injuries above the C-4 level may require a ventilator or electrical implant for the person to breathe.

Resources

Australian Ventilator Users Network Inc - http://www.avun.org.au/.

The Respiratory System - http://www.apparelyzed.com/respiratory.html.

People with SCI may not have voluntary control of their bladder. They must learn to be highly regimented in their bladder care to avoid accidents.

"Neurogenic" bladders contract hyperactively when there is little urine in the bladder, or may be like a flaccid balloon that leaks when it overfills. The sphincter holding the urine in the bladder may also not synchronise with bladder contractions, causing abnormal pressures. If the bladder pressure continues to be abnormally high, some urine may reflux back into the kidneys, which can lead to infections and cause damage to them. These conditions can be managed with medication, catheters (either irregularly or permanently in place), or sometimes surgery.

Proper management and regular check-ups are important to ensure that you will not get serious bladder and kidney infections.

Further reading

See our page on Continence care for information on how to manage your bladder.

After SCI, the nerves in the bowel are not able to communicate messages that the bowel is full and that it is time to go to the toilet. There may also be no control over the rectum (the muscle that controls when you have a bowel movement).

The degree of loss will depend on the level and extent of the nerve damage.

For example, with an injury above T12, the bowel will continue to empty when stimulated, but there will be reduced or no control. There will also be no message telling that the bowel is full. The muscle that controls the opening and closing of the anus stays tight. When the bowel gets full it will empty automatically. This is called an upper motor neuron type bowel or reflexic hypertonic bowel.

With injury below T12 the bowel will not completely empty even when stimulated. That condition is lower motor neuron type bowel or flaccid hypotonic bowel.

With incomplete or around T12 injury, there may be a mixed upper and lower motor neuron type functioning.

A regular bowel management program will help to ensure that you will not experience bowel accidents or impaction. The program can include regular timing, good diet, exercise, proper fluid intake, and the use of laxatives and rectal stimulants.

Further reading

See our page on Continence care for information on how to manage your bowel.

After periods of reduced weight-bearing activity, bones begin to lose condition and become brittle. Any activity that increases the load on the bones can slow down osteoporosis.

Heterotopic ossification: HO is a condition not well understood that occurs in acute spinal cord injury. Bone grows further than the normal skeleton, usually on large joints such as the hips or knees. HO can cause joint stiffening and fusion (where joints become fused in a certain position). In this case a surgical release is necessary to allow range of motion to occur. Activities that are used to prevent the development of HO include range of motion exercise programs and other functional activities that move the joints within a functional range.

Q: What can I do to help me lose weight?

A: The basic news is that weight maintenance for wheelchair users has the same principles as for the general population—diet is the main avenue. As our diet, good or bad, has developed over a long time, improving it requires a lot of commitment. It is a lifestyle change that, as well as addressing weight, will also promote improved overall health.

Establishing a healthy diet that will help you to lose weight and maintain weight loss requires behavioural changes, long-term food planning and participation in physical activities. Physical activity alone won’t help. A diet limited to 1,500–1,800 calories will reduce weight in most people with SCI.

Your new healthy diet will also assist with bowel, bladder and skin breakdown issues, as well as other general health benefits such as reducing the potential for some forms of cancer, heart disease, diabetes and high blood pressure.

However before embarking on a new diet and exercise regime it is important to consult your doctor to obtain specific information for your condition and body type.

There are many good documents on the net including Weight Management following SCI. Contact SCInfo for more resources.

Although SCI damages the cord at the level of the injury, the nerves above and below the injury still carry messages. However after injury the nerves can be more sensitive than before, causing neuropathic pain. This can range from pins and needles to strong pain below the injury level.

Treatment can be relaxation, medication or muscle stimulation.

Further Information

* NSW State Spinal Cord Injury Service, Managing Pain for Adults with Spinal Cord Injury, June 2008. 
* Australian Pain Management Association.
* Spinal Cord Injury Network Australia and New Zealand: Pain Information.
* Christopher & Dana Reeve Foundation: Information and resources on Pain. 

The extent to which sexual function is impaired by injury to the spinal cord depends on the level of injury and the degree of nerve damage. It is different in males and females.

As with other physiological functions, sexual sensation is changed after SCI. Some people retain sensations in their genitals, others notice they are reduced or absent. Some have heightened sensations in other parts of the body.

Sexual enjoyment after SCI can be as good as pre-injury. Necessity in many cases encourages people to concentrate on "holistic" sexual experiences rather than genital-specific sex. Many report that they can still achieve orgasm. The best way to explore your own likes, dislikes and needs is with a loving partner.

Female Sexuality

Female sexual activity is less likely to be affected by SCI. Ability to have intercourse is as easy as before, although additional lubrication may be needed. Alternative body positions may have to be considered.

The woman with SCI will still be able to conceive. Unless she is sensitive to latex, condoms may be the easiest method of birth control. She could use spermicidal foam, sponges or a diaphragm and jelly, but this will be difficult for a woman with quadriplegia. IUDs, the pill and hormone implants should only be used in consultation with an experienced practitioner. Both SCI and the pill cause vascular complications; IUDs are particularly a problem because a lack of sensation or inability to check its positioning may cause a woman to be unaware of slippage or puncture. Slippage may decrease their effectiveness and a puncture can be life threatening.

The fertility of women is usually not affected by spinal cord injury. Periods may cease for a while after injury, but will normally resume within a few months. If a woman with SCI does not conceive, the simpler fertility treatments such as intrauterine insemination will often be sufficient to achieve a pregnancy. Only a few will require more sophisticated treatment like in vitro fertilization (IVF).

Most spinal cord injured women conceive normally, have normal pregnancies and most will deliver normally. The choice between vaginal and caesarian delivery is influenced by many factors including the mother's general health and the position of the baby in the womb. The greatest risk in childbirth for women with SCI is autonomic dysreflexia. A competent physician who is experienced in labour and delivery is essential for women with SCI contemplating having children.

Male Sexuality

Male sexual functioning is more changed. Some can achieve erections quite easily, others only occasionally. Some are unable to achieve erections at all after SCI. Various methods, medications and equipment can help. These include vacuum pumps, injections and implants.

Although the level and severity of injury can indicate whether he will be able to have erections, the best way is for him know his body and learn how it reacts to certain situations. His doctor can advise about the physiological limitations, but he and his partner need to explore his responses. Although talking about sexual function is sometimes difficult, complete and open communication between partners is the best way to explore sexual possibilities available after injury.

Sperm from men with SCI may be of poorer quality than before injury; sometimes the semen disappears, which can affect fertility. If they have fertility problems they may still be a parent through artificial insemination.

Further reading:

See our links page for other sites with sexuality/fertility information.

Prolonged pressure on the skin and the underlying tissue causes it to lose condition. If the pressure is not relieved the skin can break down, producing a pressure sore.

If not treated, pressure sores can ulcerate, leading to a medical emergency and prolonged hospital stay.

The risk is reduced by using pressure-relieving mattresses and cushions, and by the person shifting off their weight, or being turned if they cannot move independently.

Further Information

* Christopher & Dana Reeve Foundation: Information on Skin Care.

Spinal cord injury disconnects the nerve cells below the level of injury from the brain. Spasticity is a reflexive response to stimuli. After SCI this response is exaggerated.

Pain, stretch, or other sensations from the body are transmitted to the spinal cord. Because of the disconnection, these sensations will cause the muscles to contract or spasm. Muscle spasms are particularly noticeable when muscles are overstretched or in response to any irritation to the body below the injury.

Some things, however, can make spasticity more of a problem—bladder or kidney infection, and skin breakdown increase spasm.

Some spasticity may always be present. It can be reduced by regular exercise, and by avoiding bladder infections, skin breakdowns, or injuries.

Medications used to treat spasticity include Baclofen, Diazepam, Dantrolene and Clonidine.

However there are some benefits to spasticity. It can serve as a warning mechanism to identify pain or problems in areas where there is no sensation. Many people know when a urinary tract infection is coming on by the increase in muscle spasms. Spasticity also helps to maintain muscle size and bone strength. It does not replace walking, but it does help to prevent osteoporosis. Spasticity helps maintain circulation in the legs and can be used to improve certain functional activities such as performing transfers or walking with braces. Treatment for spasticity is only needed if interferes with sleep or a person's functional capacity.

Syringomyelia is enlargement of the central canal of the spinal cord. It occurs in approximately 1–3% of all spinal cord injuries.

The primary risk of syringomyelia is damage above the level of the original spinal cord injury. For example, a person with a T SCI may feel numbness and weakness involving the arms and legs. The condition is progressive and needs to be treated aggressively through surgical drainage. Often the condition of people with early evidence of a syrinx will be monitored to evaluate its progression.

Significant syringomyelia is treated with surgical decompression and the placement of a drainage tube into the spinal cord.

For more information please contact SCInfo. SCInfo is available on 02 9661 8855; 1800 819 775 or fax 02 9661 9598, email information@scia.org.au, or discuss in the Health section of our Forum.