Nerves – What They Are and What They Do

The nervous system comprises two main parts: the central nervous system, made up of the brain and spinal cord, and the peripheral nervous system, made up of all the nerves that branch off from the spinal cord.[i] Nerves are long string-like branching structures and are the body’s conduits for information, taking sensory data to the brain and conveying impulses for voluntary control of the body. The nervous system is also responsible for many of the involuntary functions, reflexes and innate physiology of the body.

Nerve cells

Nerves are made up of specialised cells called nerve cells or neurons. Each neuron has three main parts: the main body known as the soma which contains the nucleus; the dendrites – long, branched ‘input’ structures which receive impulses from other cells; and an axon – a long, thin, branched ‘output’ structure responsible for creating and passing on impulses. Nerve cells connect together to form the nerve tissue or nerves, which are long, flexible, branching structures; these supply and receive messages around the body in the form of electrical impulses. Nerve tissue is made up of these neurons, together with glia or glial cells, which support the function of the nerve cells themselves.[ii]

[i] Mai, J. K., & Paxinos, G. (Eds.). (2011). The human nervous system. Academic press.

[ii] Biga, L. M., Dawson, S., Harwell, A., Hopkins, R., Kaufmann, J., LeMaster, M., … & Runyeon, J. (2020). Anatomy & physiology. OpenStax/Oregon State University.

nerve cell anatomy

There are different types of neurons which provide slightly different functions. Motor neurons, as the name implies, are responsible for movement or motor control; both voluntary, deliberate movement and some reflexes. Sensory neurons are responsible for sensation and correspond to receptors for senses such as those for pressure, temperature, and pain.

The spinal cord is a bundle of nerves which extends from the brain down through most of the length of the spinal column, and pairs of nerves branch off roughly at each vertebra to supply nervous impulses for the body. Each pair of nerves is responsible for a specific area of the body, and this is determined by the point that they branch away from the spinal cord bundle. Some of the nerves that branch off from the spinal cord bunch together with others to form complex bundles and networks of nerves.

There are 31 pairs of nerves branching from the spinal cord, numbered according to the point at which they branch off: there are eight nerve pairs in the cervical spine, numbered C1 – C8 from the top down; twelve thoracic nerve pairs numbered

T1 – T12, five lumbar nerve pairs, numbered L1 – L5; and a single nerve pair known as the coccygeal nerves towards the bottom of the spine.[i]

[i] Nógrádi, A., & Vrbová, G. (2006). Anatomy and physiology of the spinal cord. In Transplantation of neural tissue into the spinal cord (pp. 1-23). Springer, Boston, MA.

spinal nerves chart

The nerve roots – the point at which the nerves branch away from the spinal cord – are numbered according to the point at which they diverge from the spinal cord, but they then combine and network with other nerves from different roots, creating the complex and intricate nervous system, and those nerve groups are more commonly named according to their function.

Autonomic nervous system

The central and peripheral nervous system are also connected to a complementary involuntary functional system of nerves, known as the autonomic nervous system.[i] This is effectively our involuntarily control system for basic life functions and responses. It comprises three parts:

  • Sympathetic nervous system (SNS) – the intrinsic ‘fight or flight’ reflexes, controlling our body’s innate response to stressors with changes in heart rate, blood pressure, and blood sugar. The SNS is responsible for the processes that prioritise immediate physical need over longer-term needs like digestion and rest.
  • Parasympathetic nervous system (PNS) – the PNS is the system responsible for our body’s longer-term needs and processes – the ‘rest and digest’ model of function. The PNS lowers our resting heart rate and blood pressure, regulates blood sugar against the needs of the SNS, and returns function to our daily physical needs – digestion, rest, recovery.
  • Enteric nervous system (ENS) – this is responsible mainly for digestive functions, controlling the muscles and processes of the gut including blood supply, secretion and absorption.[ii]

Regions of the peripheral nervous system

The areas of the skin which are supplied by different nerves are known as dermatomes, which also relate roughly to some of the internal body parts linked to the nerves. Each dermatome is the area supplied by a single nerve root. The dermatomes can vary somewhat from person to person and there can be some inconsistencies and overlap, but dermatome maps are useful for identifying which nerve serves which area of the body. Nerves have a combination of sensory and motor impulse functions, with some concentrating mainly on one or the other function.

Cranial nerves

There are twelve pairs of cranial nerves – these are nerves that branch directly from the brain, not the spinal cord.[iii] They pass through the skull in channels, and are numbered according to the point at which they diverge from the brain, from front to back.

  • CNI – the olfactory nerve, a sensory nerve responsible for smell.
  • CNII – the optic nerve, a sensory nerve responsible for vision.
  • CNIII – the oculomotor nerve, a motor nerve linked to both voluntary and reflex eye movement.
  • CNIV – the trochlear nerve, a motor nerve which allows for control of the left-right and up-down eye movements.
  • CNV – the trigeminal nerve, which allows for sensation around the cheeks and movement of the jaw.
  • CNVI – the abducens nerve, allowing for further eye movement.
  • CNVII – the facial nerve, responsible for some facial and eye movements, tear ducts and salivation, the auditory reflex, and which contributes to our sense of taste.
  • CNVIII – the vestibulocochlear nerve relates to our sense of hearing and balance.
  • CNIX – the glossopharyngeal nerve, is responsible for our ability to swallow and contributes to our sensation of taste.
  • CNX – the vagus nerve, which is an important interface with the parasympathetic nervous system, and which affects unconscious activities like heart rate and the digestive system.[iv]
  • CNXI – the accessory nerve has a role in the movement of some of the neck muscles.
  • CNXII – the hypoglossal nerve is responsible for motor control of the tongue.

There is also a ‘terminal’ cranial nerve, labelled CN0 which doesn’t have a clear function in humans, although it is theorised to have some role in sensing pheromones and in the regulation of sex hormones, and which may be a largely vestigial remain from earlier in our evolution.[v]

Cervical spine

The eight nerves of the c-spine each have their own area of innervation.[vi]

  • C1 – The first pair of nerves to branch off from the spinal cord as it extends away from the brain supply the head and scalp, pituitary gland, inner and middle ear and part of the impulses for the sympathetic nervous system. C1 does not have a dermatome, as other nerves are responsible for the sensory organs of the skin near the areas supplied by C1. The C1 nerve pair originate from above the C1 vertebra.
  • C2 – is responsible for sensation at the back of the head.
  • C3 – this is responsible for sensation at the scalp area and the sides of the face.
  • C4 – this is one of the nerves that controls the diaphragm, as well as giving motor control over some shoulder movement. A spinal cord injury at C4 or above is likely to have a profound impact on breathing.
  • C5 – controls and provides sensory relay for the shoulders and the upper part of the upper arm and biceps.
  • C6 – controls wrist extension movements and has some control over the biceps. Its dermatome covers the thumb area.
  • C7 – has some input into the triceps and wrists, with a dermatome that extends down the arm to the middle finger.
  • C8 – controls the hands and gripping action of the fingers. The dermatome of C8 covers the side of the hand towards the little finger.

Thoracic Spine

  • T1 and T2 supply nerve function to the top part of the chest, and some nerve function into the arms.
  • T3, T4, T5 are largely responsible for supplying the chest and the upper organs of the thoracic cavity, with dermatomes covering the upper chest and back. The upper thoracic nerves play a part in breath control, but someone with a spinal cord injury at this level is likely to be able to control their breathing well.
  • T6, T7, T8 provide the nerve network for some of the chest and abdomen, and belt-like dermatomes around the middle of the abdomen.
  • T9, T10, T11, T12 are the nerves responsible for the lower abdomen and their dermatomes cover the mid-back and lower-abdomen.

Lumbar spine

  • L1 – the first lumbar nerve is responsible for sensations around the groin and genitals, and has a role in motor control of the hips.
  • L2, L3, L4 convey sensation for the front and inside of the thighs, and extend to the inner aspect of the lower legs.
  • L5 nerve region covers the outside of the thighs extending into the outer aspect of the top of the lower legs. [vii]

Sacral Spine

  • S1, S2, S3, S4, S5 nerves provide some nerve supply to the genitals, as well as the anus, sacrum, buttocks and the backs of the thighs. The pudendal nerve is the nerve bundle comprising nerves from S2-S4 and which is the primary nerve of the perineal area.

Coccygeal nerve pair

The spinal cord ends with one final branched pair of nerves which extend to its dermatome immediately around the area of the coccyx. They also provide part of the nerve supply for some of the pelvic organs.[viii]

Spinal cord cross-sections

The spinal cord is a long bundle of nerves that runs down the length of the spinal column, and within that bundle, different nerves are grouped together. A cross section of the spinal cord can show that there is a central bundle, left and right sections, an anterior and a posterior section.

An injury to the spinal cord, depending on how extensive the damage across the section of cord, will affect some or all nerve function below the point of injury. In partial spinal cord injuries, the section of the spinal cord injured predicts the effect it will have.

  • Central cord – when only the central spinal cord is affected, the result is usual limited to muscle weakness and has a generally good prognosis.[ix]
  • Anterior (front portion) cord – anterior cord syndrome – damage to the front 2/3 of the spinal cord – causes loss of motor function and significant loss of sensation, particularly of pain and temperature.[x]
  • Posterior (rear portion) cord – impacts light touch sensation and can have a significant impact on coordination of movement.
  • Left or right-sided spinal cord – one-sided injury is known as Brown-Sequard Syndrome. It is usually caused by traumatic injury, and may only affect movement and sensation in that side of the body, leaving the other side with completely or near-completely normal function.[xi]

Spinal cord injuries (SCI)

Injury to the spinal cord affects the nerves from that point downward, so the higher the injury, the more impact on function. People with very high c-spinal cord injuries may need full or partial respiratory support, with loss of control or sensation from the neck down. Spinal cord injuries at lower points, i.e. below the level of the nerves that are most responsible for breathing and the upper limbs may retain upper body function but lose motor control and sensation for their lower limbs, affecting sexual function, continence, and digestion.

The completeness of an SCI, i.e. how much of the spinal cord is damaged also plays a large part in determining the impact of the SCI on physical function. A complete spinal cord injury means that there is effectively no nerve communication from the brain beyond the point of injury, and can cause immediate health problems, as well as predisposing the injured person to long-term health challenges and care needs.

[i] Karemaker JM. (2017) An introduction into autonomic nervous function. Physiol Meas.

[ii][ii] Lake JI, Heuckeroth RO. (2013) Enteric nervous system development: migration, differentiation, and disease. Am J Physiol Gastrointest Liver Physiol.

[iii][iii] Monkhouse, S. (2005). Cranial nerves: functional anatomy. Cambridge University Press.

[iv] Breit, S., Kupferberg, A., Rogler, G., & Hasler, G. (2018). Vagus Nerve as Modulator of the Brain-Gut Axis in Psychiatric and Inflammatory Disorders. Frontiers in psychiatry, 9, 44. https://doi.org/10.3389/fpsyt.2018.00044

[v] Sonne, J., Reddy, V., & Lopez-Ojeda, W. (2017). Neuroanatomy, cranial nerve 0 (terminal nerve).

[vi] Bland, J. H., & Boushey, D. R. (1990, August). Anatomy and physiology of the cervical spine. In Seminars in arthritis and rheumatism (Vol. 20, No. 1, pp. 1-20). WB Saunders.

[vii] Waxenbaum, J. A., Reddy, V., Williams, C., & Futterman, B. (2017). Anatomy, back, lumbar vertebrae.

[viii] Wooten, C. (2015). Anatomy of the Coccygeal plexus. In Nerves and Nerve Injuries (pp. 659-661). Academic Press.

[ix] Brooks, N. P. (2017). Central cord syndrome. Neurosurgery Clinics, 28(1), 41-47.

[x] Pearl, N. A., & Dubensky, L. (2020). Anterior cord syndrome.

[xi] Shams, S., & Arain, A. (2021). Brown Sequard Syndrome. In StatPearls [Internet]. StatPearls Publishing.

Spinal Cord Injury Illustration: Complete And Incomplete Cord Injury

Whether someone has a high spinal injury with complex long-term care needs, or a lower spinal injury with the ability to live completely independently, an SCI can be profoundly life changing. Care packages specialising in supporting people with complex care needs can mean living a full and satisfying life, even with extra needs. Whatever the impact of a spinal cord injury, professional help and peer support groups can help as life goes on.

[1] Mai, J. K., & Paxinos, G. (Eds.). (2011). The human nervous system. Academic press.

[1] Biga, L. M., Dawson, S., Harwell, A., Hopkins, R., Kaufmann, J., LeMaster, M., … & Runyeon, J. (2020). Anatomy & physiology. OpenStax/Oregon State University.

[1] Nógrádi, A., & Vrbová, G. (2006). Anatomy and physiology of the spinal cord. In Transplantation of neural tissue into the spinal cord (pp. 1-23). Springer, Boston, MA.

[1] Karemaker JM. (2017) An introduction into autonomic nervous function. Physiol Meas.

[1][1] Lake JI, Heuckeroth RO. (2013) Enteric nervous system development: migration, differentiation, and disease. Am J Physiol Gastrointest Liver Physiol.

[1][1] Monkhouse, S. (2005). Cranial nerves: functional anatomy. Cambridge University Press.

[1] Breit, S., Kupferberg, A., Rogler, G., & Hasler, G. (2018). Vagus Nerve as Modulator of the Brain-Gut Axis in Psychiatric and Inflammatory Disorders. Frontiers in psychiatry, 9, 44. https://doi.org/10.3389/fpsyt.2018.00044

[1] Sonne, J., Reddy, V., & Lopez-Ojeda, W. (2017). Neuroanatomy, cranial nerve 0 (terminal nerve).

[1] Bland, J. H., & Boushey, D. R. (1990, August). Anatomy and physiology of the cervical spine. In Seminars in arthritis and rheumatism (Vol. 20, No. 1, pp. 1-20). WB Saunders.

[1] Waxenbaum, J. A., Reddy, V., Williams, C., & Futterman, B. (2017). Anatomy, back, lumbar vertebrae.

[1] Wooten, C. (2015). Anatomy of the Coccygeal plexus. In Nerves and Nerve Injuries (pp. 659-661). Academic Press.

[1] Brooks, N. P. (2017). Central cord syndrome. Neurosurgery Clinics, 28(1), 41-47.

[1] Pearl, N. A., & Dubensky, L. (2020). Anterior cord syndrome.

[1] Shams, S., & Arain, A. (2021). Brown Sequard Syndrome. In StatPearls [Internet]. StatPearls Publishing.

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What is a Neck Fracture, and Can You Recover?

A neck fracture can be one of the most serious and debilitating injuries a person can suffer, but what does it mean to fracture or break your neck, and what are the symptoms, treatment, and prognosis?

All about the neck

To understand how a neck fracture can affect somebody, it’s helpful to understand a little about the form and function (anatomy and physiology) of the neck.[i]

There are seven spinal bones (vertebrae) in the neck; these are known as the cervical vertebrae, and are numbered c1 down to c7, beginning at the base of the skull. The spinal vertebrae play two main roles in the body – they provide structure and allow the body to move appropriately, and they protect the spinal cord. Each vertebra has a hole through it meaning that the spinal column has a channel running through the length of it which houses and protects the spinal cord.

The spinal cord is a long bundle of nerves which takes messages to and from the brain, and is responsible for physical impulses, bodily control, movement and sensation. A pair of nerves extends from the spinal cord at each vertebra, controlling specific areas of the body. If the spinal cord is injured, some or all of the signal pathways going between the brain and the body below the point of injury are broken, resulting in loss of function, movement and sensation. Read more about complete vs incomplete spinal cord injuries here…

What does it mean to fracture your neck?

A ‘neck fracture’ usually refers to a fracture in one of the cervical bones; it does not necessarily mean that there is injury to the spinal cord. A fracture to the c-spine vertebrae is nearly always the result of trauma, such as a car accident or serious sports injury.[ii] Non-traumatic or low-impact c-spine injuries are rarer, and where they do occur they tend to affect people who are frail and elderly, and those with underlying conditions affecting the bones, such as severe osteoporosis.[iii]

fractured neck

Having one or more fractured cervical vertebrae can be referred to as a neck fracture, but that isn’t a very useful term as there is such a wide range of extent and impact of a ‘neck fracture’. A fracture may be stable, where appropriate treatment can help keep the bones in place thus avoiding damage to the spinal cord. It may be unstable, where the bones are likely to move and cause further damage without effective treatment. Damage to the bony structures of the neck does not always affect the spinal cord, but where the spinal cord is damaged there can be an extreme range in the impact and treatment of the injury, so it’s important to be clear about the exact position and extent of the injury. Those facing severe spinal cord damage will most likely require a tailored package of complex care at home to support them in their day to day life.

Symptoms of a neck fracture

As a neck fracture is usually the result of a traumatic injury, there are immediate symptoms that can vary depending on the nature of the event leading to the injury. There may be loss of consciousness, but people who remain conscious throughout can experience a number of symptoms immediately after the event:

  • Pain – Breaking a bone can be very painful, and a spinal bone in particular can cause pain both at the site and radiating to nearby parts of the body.
  • Numbness – loss of sensation occurs particularly with injury or swelling impacting the spinal cord or nearby nerves.
  • Tingling – an injury which affects nerves can cause different sensations such as tingling or a feeling of pins and needles. These can occur in almost any part of the body depending on the position and severity of the injury, and don’t necessarily occur in a predictable pattern.
  • Swelling – broken bones and damaged soft tissue trigger an inflammatory response and may be accompanied by internal bleeding and bone bruising. An injury to the spine can have a significant amount of swelling, both deep internal swelling and shallower palpable or visible swelling. Some of the symptoms of neck injury can resolve somewhat as swelling settles.
  • Trouble breathing – a suspected neck injury should always be treated as a medical emergency, and when accompanied by breathing problems can become critical very quickly.

neck injury

There are a few different reasons why someone might feel short of breath after a serious injury, some more serious than others. A high spinal cord injury can affect the way we use the muscles that are responsible for breathing and diaphragm control, and people with high spinal cord injuries often need to have long-term respiratory support.[iv]

  • Difficulty moving – someone with a high spinal injury should be immobilised immediately after the event, so shouldn’t try to move around at all. An injury which affects the spinal cord can have a profound impact on movement, and a total spinal cord injury means no control over movement in any part of the body below the level of injury. Partial spinal cord injuries, or short-term injury caused by swelling can impact movement in different ways, positions, and to different degrees.

Can a neck fracture heal?

Broken bones can heal, but there is currently no reliable way of mending severed nerves.

A stable c-spine vertebral injury that hasn’t affected the spinal cord will have a very high likelihood for full recovery with the right treatment. An unstable fracture to the vertebrae that has not affected the spinal cord can also be expected to mend well in a healthy person, with some very careful management.

Immediately after an injury that affects the spinal cord, there is likely to be some shock and inflammation affecting the function of the nerves. This can improve with time and treatment so the immediate effect of an injury to the spinal cord is not always a good predictor of the lasting impact. However, serious damage to the spinal cord, especially where the nerves are partially or totally severed or crushed, will not be expected to resolve.

Spinal cord injury management continues to be at the forefront of medical research, and the treatment and prognosis are improving all the time.

Treatment for a neck fracture

The kind of treatment offered for a neck fracture depends on the extent and nature of the injury, and may also be guided by the underlying health of the affected person.[v]

The immediate management of a suspected neck fracture is crucial; a fracture does not necessarily injure the spinal cord, but moving somebody with an unstable break can cause broken bones to shift which can cause damage, or further damage, to the spinal cord. Anyone with a suspected spinal injury needs emergency medical treatment. Paramedics and Accident and Emergency departments have special equipment for immobilising people with spinal damage to prevent movement of fractures; a suspected spinal injury should be presumed to be unstable and immobilised until proven otherwise.

Bony fractures can be identified by x-ray in hospital, but more detailed information about damage to nerves and soft tissues requires a CT or MRI scan.

After the immediate stage of stabilising and managing the injury, medical and surgical teams will use a combination of patient input, physical examination, and medical imaging to inform the course of treatment. When teams have more information about the placement and extent of the damage and the underlying health and ability of the patient, they can tailor treatment to meet individual needs and wishes.

Neck fractures fall into one of several categories depending on the position and character of the fracture within the neck, and different types of injury require different types of treatment.[vi] Broadly, management for cervical vertebral injuries varies depending on whether the fracture is stable or unstable, and may be conservative (non-surgical) or surgical.

A neck fracture which has caused damage to the spinal cord requires complex treatment. The bony injury needs to be stabilised and managed alongside special care to manage the impact of a damaged spinal cord. Someone with a new spinal cord injury will usually be managed initially in an intensive care unit, either in an acute hospital setting or in a specialist spinal unit. A high spinal cord injury can cause permanent total or partial loss of nerve function, with accompanying loss of motor and sensory ability to the body below the level of injury. The impact, treatment and prognosis for someone with a spinal cord injury is complex and requires a carefully tailored approach from a specialist team.

Some cervical spine injuries can be surgically managed, which involves surgically realigning the spine and stabilising it with surgical fixing devices like pins and plates. Surgery for a c-spine injury where the spinal cord has been affected also aims to decompress the nerve tissue. Where surgical interventions are medically indicated for spinal fractures, they can have excellent results.[vii]

How long does it take for a neck fracture to heal?

Everyone’s healing times are a little different, depending on underlying general health and medical conditions, but all being well, a person with a stable fracture supported by a neck brace can expect to take the brace off safely after around 8 weeks. Treatment for a vertebral fracture can be led by a combination of medics and orthopaedic surgeons, with specialist nurses and physiotherapists. Follow-up for a simple fracture may be in-person or increasingly at a ‘virtual’ clinic – this is where further medical imaging is reviewed by specialists and if there are no concerns, following consultations may be by telephone or video.

surgical stabilisation with halo

Someone with an unstable fracture – one that might cause more severe damage if not carefully immobilised – will need treatment which keeps the neck bones fully stabilised while they heal. This can involve a more rigid type of brace known as a halo vest which stabilises the head and neck relative to the shoulders and chest, providing very good stability while bones knit together.  Halo vests are usually in place for around 12 weeks, with regular follow-up visits to ensure correct positioning and avoid complications.

 

Some underlying conditions can affect the amount of time it takes for fractures to heal; osteoporosis in particular tends to increase the healing time for bony injuries, and other medical conditions including vascular disease, diabetes, or malnutrition.

Damaged vertebrae; damaged spinal cord?

The phrase ‘neck fracture’ is highly emotive and people are likely to associate the phrase with an injury that is always profoundly debilitating or fatal. In reality, the impact that a fractured cervical vertebra or vertebrae can take many forms. The impact of a c-spine injury is on a spectrum of effect, variable and individual. A neck fracture – fractured c-spine vertebra – does not always mean spinal cord damage, and with effective immediate care further damage from a simple bony injury can be prevented.

Recovering from a neck injury

An injury to the bones of the neck will require a period of stabilisation with a high degree of caution over physical activity. Follow-up appointments with further imaging can confirm healing and guide people resuming normal activities. A period of time in a neck brace can affect muscle tone so specialist physiotherapists can recommend exercises to increase muscle strength and range of movement after time in a neck brace or after spinal surgery.

A neck injury that affects the spinal cord may have a profound and permanent effect on movement, sensation, and function. The rehabilitation: physiotherapy, physical and emotional support, lifestyle modifications and sometimes very complex care, can last a lifetime. On the other hand, a stable injury affecting only the bones of the neck can be expected to heal well.

The immediate management of a neck injury can make a huge difference to the overall outcome, and getting the right help is key. After the emergency care and stabilisation period of a neck fracture, some people need a short period of extra care to support them while their movement and ability is temporarily restricted. People with high spinal cord injuries resulting in problems with mobility, sensation, and breathing function will need extra support, specialist care and equipment, often for the rest of their lives. Complex care needs can increasingly be met with support and appropriate equipment at home, and people with even the most profound injuries can expect adjustments to help them live full and fulfilled lives.

[i] Bogduk, N. (2016). Functional anatomy of the spine. Handbook of clinical neurology, 136, 675-688.

[ii] Passias, P. G., Poorman, G. W., Segreto, F. A., Jalai, C. M., Horn, S. R., Bortz, C. A., … & Lafage, V. (2018). Traumatic fractures of the cervical spine: analysis of changes in incidence, cause, concurrent injuries, and complications among 488,262 patients from 2005 to 2013. World neurosurgery, 110, e427-e437.

[iii] Torlincasi AM, Waseem M. Cervical Injury. (Updated 2021 Nov 7). StatPearls, Treasure Island (FL). https://www.ncbi.nlm.nih.gov/books/NBK448146/

[iv] Berlowitz, D. J., Wadsworth, B., & Ross, J. (2016). Respiratory problems and management in people with spinal cord injury. Breathe (Sheffield, England), 12(4), 328–340. https://doi.org/10.1183/20734735.012616

[v] Yelamarthy, Chhabra, H. S., Vaccaro, A., Vishwakarma, G., Kluger, P., Nanda, A., Abel, R., Tan, W. F., Gardner, B., Chandra, P. S., Chatterjee, S., Kahraman, S., Naderi, S., Basu, S., & Theron, F. (2019). Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society—Spine Trauma Study Group position statement. European Spine Journal, 28(10), 2390–2407. https://doi.org/10.1007/s00586-019-06085-z

[vi] Nemani, V. M., & Kim, H. J. (2014). The Management of Unstable Cervical Spine Injuries. Clinical Medicine Insights: Trauma and Intensive Medicine. https://doi.org/10.4137/CMTIM.S12263

[vii] Dobran, M., Iacoangeli, M., Nocchi, N., Di Rienzo, A., di Somma, L. G., Nasi, D., Colasanti, R., Al-Fay, M., & Scerrati, M. (2015). Surgical treatment of cervical spine trauma: Our experience and results. Asian journal of neurosurgery, 10(3), 207–211. https://doi.org/10.4103/1793-5482.161192

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Tracheostomy Care at Home

What is a Tracheostomy?

A tracheostomy is a surgical opening made into the trachea (windpipe) through the skin at the front of the neck. The procedure for creating the opening is a tracheotomy, the opening itself is a tracheostomy. Tracheostomies can be performed rapidly in emergency situations, or can be done as a planned procedure in an operating theatre. Having a planned tracheostomy usually requires the same planning as any surgical procedure, and the surgical team will give specific instructions for the individual – usually stopping blood thinners for a few days and fasting for a few hours before the procedure.

Tracheostomy uses

The main use of a tracheostomy is to bypass the oral-nasal route for breathing, and to enable mucous and secretions in the airway to be easily cleared.[i] Tracheostomies can be short term, to manage acute illness requiring ventilation which bypasses the oral route, or can be long-term or permanent.

Short-term

A tracheostomy can be placed when normal oral/nasal breathing is restricted, such as when there is a blockage in the upper airway due to cancers of the mouth and throat or when there is no alternative during a choking episode or swelling in the mouth and throat from anaphylaxis. Some people who spend an extended amount of time on a hospital ventilator have a tracheostomy fitted for mechanical ventilation; this is usually safer and easier to manage in the longer-term than a ventilator tube in the throat.

A tracheostomy performed to help manage an emergency or short-term, acute illness may be removed when no longer needed, and the tracheostomy hole in the throat can be stitched or left to heal, usually leaving only a small scar.

Long-term

A tracheostomy can also be made as an alternative to normal (mouth and nose) breathing for people who are unable to breathe independently, perhaps because of degenerative neurological conditions, high spinal cord injuries[ii], or brain damage.[iii] It can also be made for people who have significant blockages or narrowings in the upper airways, perhaps due to tumours of the mouth and throat.

Living with a lifelong tracheostomy will mean making some adjustments, and the adjustments needed can also depend on the reason for the tracheostomy.

Types of Tracheostomies

The main difference between types of tracheostomy tubes is whether they are ‘cuffed’ or ‘uncuffed’.

A cuffed tracheostomy tube is held in place with a small balloon inflated inside the trachea. The cuff is essential for people who have ventilation at pressure – positive pressure ventilation is where the ventilator pushes air into the lungs, and requires a tracheostomy which is cuffed to prevent leaks. Cuffed tracheostomy tubes stay in place by having an outer flange and inner cuff, and a thin tube passing through the tracheostomy opening in between.

A fenestrated tracheostomy is a cuffed tube that has small fenestrations or ‘windows’ within the tube which allows air to pass the tracheostomy tube and be expelled through the mouth or nose – this is useful for someone who has some ability to breathe independently but needs some ventilation or suction, and usually helps to preserve someone’s ability to speak. An insert can be used to cover these windows to allow for mechanical ventilation.

An uncuffed tracheostomy tube is held in place with a neck strap and aren’t suitable for people who need positive pressure ventilation. They are useful for helping clear mucous and secretions on the chest in people who have some ability to breathe independently but who cannot easily clear secretions from their lungs.

Tracheostomies can also have either a single or double cannula – a single cannula tracheostomy tube is a simple tube, usually for shorter-term use. A double cannula tracheostomy tube has a fitted tube with a further, removable insert which lines the outer tube and can be removed to make it easier to clean and to stop it becoming clogged up.

Going Home with a Tracheostomy

When someone is medically stable, finding the best place and way for them to live is the next step. Learning to live with a tracheostomy[iv] may just be one part of a larger rehabilitation programme, especially after a life-changing event or illness. Rehab means helping someone get as stable and functional as possible, and then working out how to support any ongoing extra needs. Some people with complex care needs may find that a long-term care home or assisted living facility is the best place to meet their needs safely and effectively. Now, however, more and more people with complex care needs are living safely at home with support from specialist carers to make up any new self-care deficits.

When medically stable and planning to go home after a tracheostomy, a person with a permanent tracheostomy or their family and carers will have to be able to care for and manage their tracheostomy at home. This will include cleaning and changing the tracheostomy equipment, and may also mean managing ventilators, suction machines, and knowing what to do in an emergency. Getting used to a tracheostomy can take a little time, but they can soon become a normal part of life.

People who rely on home ventilation should tell their energy suppliers, and will be prioritised in the event of any disruption to service, and will always be kept informed of planned works. They may also be able to get free regular gas and electricity safety checks and other practical and financial support. Ventilators are considered life support equipment and so good battery life and back up is essential.

Tracheostomy Equipment at Home

Going home with a tracheostomy, especially when it is used for mechanical ventilation, usually means making space for some new equipment! Some of the equipment for tracheostomies and home ventilation includes:

  • Spare tracheostomy tube parts: tracheostomy tubes need to be regularly changed and cleaned, and so having spares of every part is essential.
  • A ventilator: this needs to have a reliable power source so mains power is usually backed up by rechargeable battery packs. Ventilation units can be quite large, but smaller, portable machines are available, and especially useful for continuing to get out and about.
  • Tubing: the tubing and parts for fitting the tubing to the tracheostomy are essential and having spares is important.
  • Suction equipment: There are various kinds of suction machines and tubing. A long, thin catheter is used to remove any secretions from the tracheostomy and airways. The secretions are sucked into a closed chamber.
  • Humidifier: Positive pressure ventilation can be very drying to the delicate tissues of the throat and lungs, and so people who spend a lot of time on a ventilator may have a humidifier attachment to make the inhaled air slightly warm and moist.
  • Oxygen: some people with extra respiratory needs also require a higher concentration of oxygen than room air, and also have an oxygen concentrator, and large and portable cylinders containing pure oxygen. They are easily fitted to tubing and to a ventilator or to a tracheostomy, face mask, or nasal oxygen tubing.

All equipment used for a tracheostomy needs to be kept scrupulously clean, and some equipment is disposable or for single use only.

As well as equipment, someone with a tracheostomy needs someone competent and confident in tracheostomy care and the use of any necessary equipment. This can be the person with the tracheostomy themselves, or they may need the support of family members or a dedicated care team. People who are ventilator-dependent are at higher risk from any malfunction or problems, and so should be able to have immediate support for any problems – a round-the-clock care package is often the best solution for people who are ventilator-dependent.

Life with a Tracheostomy

Living with a tracheostomy takes some adjustment and is often only a small part of a larger change in health, function, and lifestyle.

Talking

It can take a little time to adapt to speaking with a tracheostomy – normally, to speak, air passes the vocal cords and out of the mouth; we have control over the movements of the vocal cords and our mouths and so it’s easy to form sounds and words. People who still have the use of their upper airways can have a special type of tracheostomy tube or attachment fitted which acts as a valve allowing them to breathe out through their mouth instead of most of the air going through the tracheostomy; this allows them to speak relatively normally, although the voice is usually somewhat changed and may not have the same strength and control.

Depending on the reason for the tracheostomy, it may not be possible to speak this way – people with neurological disorders or spinal cord injuries may not have enough control over their diaphragm – the muscle responsible for breathing – to form words. Alternatives for communication can include writing, typing, and sign language for people who have control over their hand and arm movements. A speech and Language Therapist (SALT) will be able to help find the best solutions to communication difficulties.[v]

Eating

Having a tracheostomy, and the underlying reason for a tracheostomy, can have a significant impact on swallowing. A speech and language therapy team can help find solutions to impaired swallow, or plan alternatives to oral nutrition and hydration, such as feeding tubes.

Breathing

Some people with tracheostomies need them to support breathing and respiratory function for some or all of the time. People who are completely unable to breathe on their own will need to be on a ventilator all the time, except for very short breaks for suction or cleaning the tracheostomy site and tube.

People with tracheostomies can be on permanent or part-time mechanical ventilation, or they may be able to breathe independently through their tracheostomy, or they may be able to breathe normally through their mouth and nose some or all of the time.

Some people with tracheostomies breathe room air, whether that is through normal respiration or through a mechanical ventilator, or they may require air that is mixed with a higher percentage of oxygen, in which case they also need home oxygen supplies.

Home Ventilation

More people than ever before live at home with complex care needs, including ventilation.[vi] There are lots of different types of home ventilators[vii] – some of which are fairly large and difficult to move, and some of which are smaller portable units with a good battery life. This means that needing home ventilation, even if it’s full-time, doesn’t mean that a person can’t get out and about, even go away on holiday, as long as they have the right equipment, spares and support.

Emotional Support

Having a tracheostomy – and having the sort of illness or incident that means that a person needs a tracheostomy – can be traumatic and overwhelming. A tracheostomy is usually quite a visible sign that someone has been acutely unwell, and some people can feel self-conscious about it. Some people prefer to hide their tracheostomy under a loose scarf or similar, whereas others find this feels restrictive. There is no right or wrong way to feel about any changes to your body or function, but if you’re having negative feelings about your changing health and needs, you’re not alone and there are numerous support networks to access.

Supported Care with a Tracheostomy

There are lots of reasons why someone might need a tracheostomy, and some of those reasons might mean that a person has other extra care needs, and that they are unable to manage their tracheostomy themselves. Some people are able and comfortable cleaning, suctioning and generally caring for their own tracheostomy, whereas others may need others to care for their tracheostomy, and sometimes to help with other care needs too.

Care packages are available which specialise in complex care needs, and tracheostomy care is a common part of that kind of package. Carers and nursing teams which are chosen specially to meet the needs of an individual can be highly trained in those specific care requirements, and so a provider which allocates teams for full-time care of an individual are best placed to meet that person’s needs.

Living with a tracheostomy requires adjustment, but support is available to cover any extra needs a person has, and so having a tracheostomy fitted doesn’t have to mean accepting poor quality of life. The right care can facilitate a happy, healthy lifestyle.

[i] Durbin, C. (2010) Tracheostomy: Why, When, How? http://rc.rcjournal.com/content/55/8/1056/

[ii] Zimmer, M. B., Nantwi, K., & Goshgarian, H. G. (2007). Effect of spinal cord injury on the respiratory system: basic research and current clinical treatment options. The journal of spinal cord medicine, 30(4), 319-330.

[iii] Koutsoukou, A., Katsiari, M., Orfanos, S. E., Kotanidou, A., Daganou, M., Kyriakopoulou, M., Koulouris, N. G., & Rovina, N. (2016). Respiratory mechanics in brain injury: A review. World journal of critical care medicine, 5(1), 65–73. https://doi.org/10.5492/wjccm.v5.i1.65

[iv] American Thoracic Society. (2016) Living with a Tracheostomy. https://www.thoracic.org/patients/patient-resources/resources/tracheostomy-in-adults-2.pdf

[v] Morris, L. L., Bedon, A. M., McIntosh, E., & Whitmer, A. (2015). Restoring speech to tracheostomy patients. Critical care nurse, 35(6), 13-28. https://doi.org/10.4037/ccn2015401

[vi] Kuluski, K., Ho, J. W., Hans, P. K., & Nelson, M. L. (2017). Community care for people with complex care needs: bridging the gap between health and social care. International journal of integrated care, 17(4).

[vii] Gregoretti, C., Navalesi, P., Ghannadian, S., Carlucci, A., & Pelosi, P. (2013). Choosing a ventilator for home mechanical ventilation.

 

 

 

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What Is Complex Care?

The term ‘complex care’ encompasses a range of needs requiring ongoing essential specialist support. In the past, people with complex needs were confined to formal care settings and their care was highly medicalised. People with complex needs have one or more conditions which mean they are dependent on specially trained carers.  ‘Complex’ means they may be also dependent on medical technology and may require full time care[i]. In addition to their complex needs, they are also likely to need support with their basic care needs.

Advances in technology have enabled people with even very profound additional needs to remain in their own homes while receiving essential treatment and ongoing adaptive management of their conditions.

Care planning

Enabling people with complex care needs to live in their own home and live the kind of life they want requires some careful planning. Plans of care must be based on a thorough assessment and understanding of the person needing care. This assessment should follow a holistic framework – i.e. it should be a ‘whole person’ approach which takes social and societal needs and desires into account as much as physical and medical requirements[ii].

Planning a complex package of care is a multi-disciplinary health and social care team undertaking.[iii] When planning a discharge home from a rehabilitation setting or a transfer from another care provider, all the needs of the individual should be assessed, and this requires input from a range of professionals. Additionally, a person-centred approach means putting the actual wishes of the individual at the forefront of all decisions made.[iv]

When a person is leaving hospital or a rehab facility with new complex care needs, their medical team will be heavily involved in discharge planning. Physiotherapists are essential contributors to long-term care planning, as they take responsibility for the care of respiratory conditions, ventilation and cough-assist devices as well as movement and physical therapy. Occupational therapists are a key part of the team involved in getting a person into their own home or an adapted living environment with every aid to accessibility and ease of care. Nurses and social care managers take all the different needs of the individual into account to make the best possible plan for their day-to-day care going forward.

Meeting an individual’s needs in the community
Creating an environment where a person can return to their home and have all their care needs met requires a practical assessment of their basic care needs, social and emotional needs, and their complex or medical requirements. Understanding what an individual needs is the first step towards meeting those needs through an adaptive and professional care package.

Basic care needs

When creating plans for care, healthcare professionals often talk about ‘ADLs’, or ‘Activities of Daily Living’. The ADLs are, broadly, a person’s most basic requirements to remain comfortable and in the best possible physical health. The care team must, as a minimum, ensure that any ADLs that a person is unable to manage independently are met by carers. The basic ADLs are usually considered to be:

Hygiene: many people require assistance in their own homes with washing and bathing, teeth, nails and haircare. Carers who assist with these needs should aim to maintain the standards that the individual would maintain themselves if they were able to.

Nutrition: Whether unable to acquire food and prepare meals or physically feed themselves, meeting nutritional needs is an incredibly important part of a carer’s role. Liaising with dieticians and nutritionists may be required for people at risk of under-nourishment. Observing the dietary preferences, ethical and religious choices people make in their diets is essential and an absolute human right which could be easily overlooked for people who are unable to advocate for themselves. The role of a carer is to advocate in the person’s best interests, in line with their choices.

Movement: Someone with reduced or little control over their own mobility may require regular positional changes and pressure area care to prevent wounds. Following physiotherapy plans to maintain healthy muscles and joints can fall under the remit of formal or informal carers. Carers who are dedicated to a single client can become well versed in their need for movement and mobility aids, helping them to maintain as active a lifestyle as possible, and enabling continued outdoor time, travel, social interactions and more.

Continence: Meeting care needs includes assistance with continence aids and managing basic bowel and bladder care.

Dressing: Not only part of a person’s physical personal care needs, dressing and choosing clothing and appearance is socially and culturally incredibly important. The way we dress can express a lot about who we are. Carers who can really get to know an individual and their family and social circle are well-placed to help maintain the social as well as physical aspects of their client’s appearance.

Social and emotional care needs

In addition to universal basic care needs, everyone should have the right to try and attain the kind of lifestyle they desire. If it’s possible for a person with extra care needs to continue to maintain their position in their family and friendship groups, social interests, career ambitions and education, then putting care in place to enable these goals to be realised is essential.[v]

 

 

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My Personal Experience of Spinal Cord Injury

After working for TCC for over 6 years and being aware of our clients’ experiences; not in a hundred years did I think I would have experience in my own family of a spinal cord injury. Yet in March this year my youngest son (age 30) was travelling home from work at 9.15pm in the heavy snow, travelling at 10 miles per hour due to the drifts on the road, when his car slid sideways and his front wheel went down a ditch. He got out of his car and tried to rock the car back and forth hoping to push it out himself and continue home. However; as he rocked the car, he then spread his arms and pushed, feeling something snap in his neck.  He called the AA out and eventually got towed out of the ditch at 1.15am, after which he drove home.

He continued for 4 days doing his usual things of working and enjoying time with the family. By the 4th day his neck ached and shoulders hurt but he thought nothing of it. He went to bed on the Monday night and when he woke up the next day his legs felt dead. He thought he had laid funnily on them, and tried to get out of bed and fell on the floor. He dragged himself to the landing and shouted his dad. An ambulance was called but because he was conscious, despite not being able to feel anything from his chest down, the ambulance did not arrive for 6 hours. The fire brigade were called to help lift him downstairs as he is a 6 foot gentle giant, and 6 men had to lift him.

He was taken to a local hospital where he stayed for 3 nights with no neck brace although they had done an xray and then a CT scan which showed damage to his vertebrae. Alex was transferred to LRI Hospital in the middle of the night and had a 6 hour operation to remove a disc at level C5. He then was ventilated in intensive care for 6 days where he was in a critical condition. Thankfully he was strong and continued to progress, he was taken off the ventilator and was then moved to the Spinal Ward. During this time he suffered a blood clot in his lung, a chest infection then Pneumonia, several urine infections and a grade 3 pressure sore which took months to clear up. We seemed to go from one problem to the next; but all through it Alex coped incredibly well and the staff at LRI  were brilliant and had a great rapport with Alex. I started a diary recording everything that happened during his stay and took photos every day, so that when Alex had bad days and felt he was not getting anywhere I could show him previous photos and how he had made great improvement. As he had been on bed rest Alex had been unable to have a shave or hair cut or shower, just having bed baths.  A very kind Nurse came in on her day off to shave and give Alex a haircut the day before he was due to transfer to Stoke Mandeville. Wow did he look different.

On May 30th he was transferred to Stoke Mandeville hospital to start his rehabilitation. He started having physio at first in his bed, and I was with him when he was first hoisted into a wheelchair. How emotional that was; Alex and I were in tears, with happiness that he was at last out of bed but reality also hit us that life would be very different for Alex from now on.

Alex now has physio every day, hydrotherapy (which he loves) once a week, occupational therapies and wheelchair skills. His upper arm strength has greatly improved and everyone is amazed at how well he has come on. He was told he would not be able to transfer initially, but with determination he has now amazed staff and can transfer from bed to wheelchair, and from wheelchair into a car.

The support that the Physios, O.Ts, Psychologists, Doctors and Nurses have given has been amazing.   Alex can now wheel himself around the hospital, and he has some use of his hands, although with dexterity issues. He still has no feeling from his chest down and it is unlikely that will change. But in his own words; life goes on but just in a different way. He has now completed his rehab.

Alex had already gone through life challenges before his accident, and following 10 years of extreme mental illness had been attending college to train as a Mental Health Counsellor He had started working for MIND and was so happy, he felt his life had just started to turn round when this tragedy struck. However his training was put to good use and he has helped other people on his ward by talking to them and helping them cope with the challenges they all face. He is always thinking of others and I am very proud of him.

We have taken Alex out a few times in The Barbara bus, which was quite emotional for him after being in hospital for 8 months. He had forgotten there is an outside world, having been in a protected bubble in hospital. Each trip was a challenge and exhausting for him but worth it to see his face when he tucked into a mixed grill for the first time, his words were “decent food at last! When can we come again?”

Alex has had a few dramas whilst in hospital, one being doing wheelchair skills trying to get up a kerb he fell backwards and landed on top of his physio breaking 3 of her fingers, but only shaking himself up. Another time we had ordered a wheelchair friendly taxi and when it arrived the driver put 2 ramps onto the side frame of the taxi and whilst pushing Alex up the ramps one fell off – luckily his Dad was there to stop him from falling. He will now only order a taxi if it has a lift ramp at the back for him to get in. Then one day he was being hoisted out his bed when the bar holding him snapped off from the main hoist frame causing him to fall to the floor. Luckily again he was not badly injured.

Following these experiences, I have realised even more so how hard it is for the families of Spinal Injured patients as well.  As well as the emotional impact there is also the travelling involved to get to see their loved ones, and how expensive it can be having to stay at local hotels and the transport costs of getting to and from the hospital.

Whilst Alex has been in Stoke Mandeville we have watched the progress of the construction of the new garden area, which was opened by Mary Berry in September. The gardens are beautiful and a lovely place for patients to relax with friends and family. Have a look for yourself at www.horatiosgarden.org.uk.

We hope that Alex will get home before Christmas and are waiting for his care package to be put in place. He has had funds turned down by the CCG and has been passed to Social services. We are in the process of appealing the CCG decision. As many of you will know; these processes are not quick and are very stressful for the patient involved. We seem to be fighting all the time to get the help Alex needs/deserves.

All of the family are looking forward to Alex getting home and spending Christmas all together. I know it is going to be a huge adjustment for him going home after 9 months in hospital; but with all our support and his ability to adjust to situations he will do well. He is looking to going back to work next year and do the job he loves and excels in. I know he is 30 and a grown man but he is and always will be my little boy.

I hope everyone has a wonderful Christmas and a Happy New Year

 

Fiona Howe – Recruitment Administrator

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