Understanding spinal cord injuries

In the 1930s, the American neurosurgeon Dr. Donald Munro of Boston City Hospital became the first doctor to successfully treat patients with spinal cord injuries.

In 1944, Sir Ludwig Guttmann created a ward especially for people with spinal cord injuries at Stoke Mandeville Hospital in England. Thanks to this new ward, the mortality rate for people with spinal cord injuries (which hitherto had been fixed at around 80%) began to decline.

• The nursing staff turned the patients over every two hours.
• Skin care was also available for the patients.
• Guttman introduced techniques for improving bladder management.
• Using physio- and occupational therapy, he succeeded in helping patients to regain certain functions.
• Thanks to comprehensive treatment, patients began to find that their social and economic needs could also be met.

Sport as therapy

Guttmann placed great importance on the use of physical activity as therapy. He founded the Stoke Mandeville Games, which led to the creation of the Paralympic Games in 1960.

Model for the Swiss Paraplegic Centre

Such events served as models for the treatment of people with spinal cord injuries in the UK, USA and other countries. This was also the case for the Swiss Paraplegic Centre in Nottwil.

Sir Ludwig Guttmann and Guido A. Zäch, the founder of the Swiss Paraplegic Foundation, first met in 1976 during a ceremony at which Guttmann was named an honorary doctor by the medical faculty at the University of Basel. Guido A. Zäch saw Guttmann as the “father of paraplegics” and a genuine trailblazer in the field of spinal cord injury.

The brain is the body’s control centre. It uses the spinal cord to control the extremities, as well as internal processes such as breathing, circulation and digestion. If the spinal cord is damaged, then information is no longer (or only partially) sent to the body. As a result, paralysis occurs in the arms and legs. This paralysis is independent of the level at which the injury occurs on the spinal cord (injury level). Areas affected by paralysis include:

• arms, legs and trunk
• internal functions (bladder, bowel and sexual functions)
• senses

Spinal cord injuries occur when the spinal column is damaged during falls (traumatic), or by illnesses such as tumours, haemorrhages and infections (non-traumatic).

All across the world, most of the falls which lead to spinal cord injuries occur in the workplace. Such falls are more likely to happen in industries such as construction, agriculture and mining. The two most common external causes are falling from a high place or being hit by a falling object.

During leisure and sporting activities, spinal cord injuries may be caused by:

• vehicle crashes (e.g. motorcycles or racing cars)
• common falls, i.e. during sports such as rugby or skiing
• falls/stumbles/jumps from a height of less than one metre, such as diving into shallow water
• falls/stumbles/jumps or being pushed from a height of one metre or more, such as while rock climbing or paragliding.

 

Traumatic (accident-related) causes

This type of spinal cord injury is caused by incidents such as:

• traffic accidents
• falls
• violence.

Other causes include:

• everyday falls, such as stumbling over a rug
• falls from low heights, e.g. a staircase
• falls from one metre or more, such as from a horse or building
• falls caused by external surroundings, such as a mineshaft collapsing.

Spinal cord injuries are also frequently caused by firearms, knives and bomb blasts.

 

Non-traumatic (illness-related) causes

All across the world, these causes include: 

• communicable diseases, such as tuberculosis or HIV
• non-communicable diseases, such as cancer, degenerative diseases of the spinal cord, cardiovascular diseases
• malnutrition, e.g. neural tube defects or vitamin B₁₂ deficiency
• healthcare-related complications

The nervous system is split into two main parts, the central nervous system and the peripheral (outer) nervous system. 

The central nervous system

The central nervous system consists of the brain and the spinal cord. It collects, processes, stores and transmits information. Together with the hormones, it controls the activities of all the organs, and adapts to meet the requirements of the environment.

The spinal cord is part of the central nervous system. It plays a vital role in sending sensitive information to the brain, and subsequently in controlling motor and autonomic functions.

The spinal cord

The spinal cord itself is a nerve centre. Among other things, it controls standing/walking, bladder, bowel and sexual functions and breathing, and regulates the body’s temperature and circulation.

It extends downwards from the brain to the area near the first and second lumbar vertebrae L1-L2 (see diagram below). The cauda equina (aka the “horse's tail") runs from the tip of the spinal cord to the spinal canal.

Position of the spinal cord

The spinal cord is a 40–45 cm long, 8–10 mm wide, and 5–7 mm thick rod located in the spinal canal. The spinal canal protects the delicate spinal cord against mechanical damage. It is usually found directly in the axis of movement to ensure the spinal cord does not become disconnected or rotated, even during extreme deformations of the spine which can occur while practising sports like acrobatics or gymnastics.

The spinal cord itself is subdivided into different neurological segments, depending on the nerve roots which flow from the spinal column between the individual vertebrae. There are 31 pairs of nerve roots:

• 8 cervical (C1- C8)
• 12 thoracic (Th1- Th12)
• 5 lumbar (L1 – L5)
• 5 sacral nerve roots (S1 – S5)
• 1 near the tail bone.

The neurological level of the spinal segments is not necessarily determined by the various lengths of the spinal cord and spinal column.

The spinal cord is made up of white matter and butterfly-shaped grey matter.

The grey matter mostly contains nerve cells. It is the “switchgear” of the spinal cord. Distinctions are made between the elements which make up the grey matter.

• The nerves that run through the anterior horn service the skeletal muscles. They contain the nerve cells that are responsible for motor functions.
• The posterior horn receives the nerve fibres from the periphery of the spinal cord. These fibres are responsible for sensory functions. In order to be felt or understood, sensory pulses and information must first be sent to the cerebrum. Once there, they can enter our consciousness as sensory perception.

The white matter contains the ascending and descending nerve fibres. It acts as a line connector within the spinal cord.

The peripheral nervous system is made up of two parts:

1. the somatic system, which controls our voluntary actions
2. the autonomic system, which automatically controls the body’s internal processes and regulatory systems without a person being able to consciously control it.

The somatic nervous system

The somatic nervous system is made up of a sensory part that is responsible for our senses, i.e. our ability to feel physical contact, pain, hot and cold, vibrations, etc. The somatic nervous system sends these sensory sensations to the brain. If the sensory part is not working properly, then the brain lacks the information it needs to make decisions.

The motor part is responsible for controlling the skeletal muscles as per the commands we send it. If the motor part is not working properly, then the muscles become paralysed.

Finally, the autonomic nervous system controls and regulates the body’s internal processes which we cannot deliberately control, such as: 

• heart rate
• blood pressure, regulation of respiration, digestion
• gland secretion 
• sweating
• urination and defecation
• sexual functions

The autonomic nervous system mainly consists of two parts: the sympathetic and the parasympathetic systems.

 

The sympathetic system (“sympathicus”) allows us to work, stay aware and react quickly. It also enables our bodies to perform efficiently.

The parasympathetic system (“parasympathicus”) is the counterpart of the sympathetic system, and thus lets us rest, sleep, digest, relax and recuperate.

In healthy people, the sympathicus and parasympathicus work in a complementary fashion, with each one counteracting the other to achieve a proper balance. In people with spinal cord injuries, this balance is disrupted. As a result, many problems, sometimes life-threatening, can occur.

Impact on organs

Spinal cord injuries can also wreak havoc with the organs, as the nerves that service organs also run through the spinal cord. In injuries above the 6th thoracic vertebra, the autonomic nervous system is affected. This can cause the circulatory system to malfunction. Bladder, bowel and sexual functions are often disrupted regardless of the injury level, as the nerves that control these functions flow out of the sacral region at the bottom of the spinal column.

Spinal cord injury does not necessarily lead to paralysis...
 

Complete spinal cord injury

In the case of a complete spinal cord injury, the person loses all motor and sensory functions. The spinal cord is completely severed.

Incomplete spinal cord injury

With an incomplete spinal cord injury, the person may still have certain motor and sensory functions below the level of the injury. Nevertheless, the injury is just as serious and can also result in considerable damage.

Nowadays, complete or incomplete paralyses are categorised from A to E according to criteria established by the ASIA (American Spinal Injury Association).

Swiss Paraplegic Centre (ed.) (2017).  Life with a spinal cord injury: Chap. 1/2 (1st edition). Nottwil: Swiss Paraplegic Centre.

Koch, H. G. (2018). A quick and easy guide to spinal cord injury. Unpublished manuscript, Swiss Paraplegics Association. (Available for purchase in the fall of 2018)