A spinal cord injury (SCI) is an injury which affects the spinal cord – whether acute and traumatic or the result of degenerative disease. The spinal cord is housed within a canal running through the vertebrae, the bones of the spinal column. As the spinal cord is the conduit for nerve function between the brain and the rest of the body, an injury to the spinal cord affects motor control and sensation, as well as some of the unconscious processes of the autonomic nervous system.

The more severe an injury to the spinal cord, the more function is affected. Where damage to the spinal cord is complete, a person loses all nerve function below the point of injury. This causes total loss of movement and sensation. The higher up the spinal cord the injury occurs, the more of the body is affected, as function between the brain and the point of injury is largely preserved, and function from the point of injury downward is impaired or lost.

Common causes of spinal cord injuries

The causes of spinal cord injuries can either be from traumatic external events, or from intrinsic changes within the body. An external event causing spinal cord injury must be severe enough to cause damage to the spine and spinal cord, which is normally well protected within the vertebral canal.

Road traffic accidents, sports injuries, and falling from a height are potential culprits. As the kind of activities which can cause traumatic spinal injury tend to be those undertaken by a certain demographic, people who suffer traumatic spinal cord injuries tend therefore to be younger and more frequently male compared to the general population.[i] Intrinsic factors causing spinal cord injuries may be degenerative neurological diseases or conditions where body processes cause damage to the spinal cord, such as spinal stenosis or tumours.

Bone density after spinal cord injury

Bone mineral density is the term used to describe how strong our bones are. It refers literally to the density of the tissues that make up our bones. Bones comprise a matrix of an overlapping network of structural supports, made mainly of collagen and calcium.

This framework supports further organic and mineral deposits, mainly calcium which gives the bones their strength. When we have more mineral deposits per area of bone tissue, our bones have greater mass per volume; they are denser, and therefore stronger.

We can begin to lose bone density for several reasons, and some people are more at risk than others. Reduced bone density means lower levels of mineral deposits on the underlying matrix, but also affects the structural architecture within the bones. SCI is a significant independent risk factor for reduced bone density.

One of the main factors influencing our bone density is the amount of weight bearing exercise we take; weight-bearing exercise improves bone density. This is the factor most influenced by a spinal cord injury, or any condition which significantly impacts a person’s ability to weight-bear. An SCI which substantially impacts our motor control can mean total or partial loss of movement and mobility, and so our capacity for weight-bearing exercise after an SCI may be minimal.

Without weight-bearing, our bones very quickly lose density, at a rate of approximately 1% per week, continuing for several years after the injury until bone density is severely reduced.[ii] Bones become very brittle and fragile, and are easily broken.

Osteopenia is the term for mildly reduced bone density. Osteoporosis is the term used for severely reduced bone density. People may also refer to ‘brittle bones’, or bone fragility.

Fracture risk after spinal cord injury

Fragility fractures are common in people with bone mineral density loss following an SCI. Reduced bone mineral density means that fractures can happen easily through various mechanisms. A person with very severe bone density loss – with profound osteoporosis – can develop fractures simply through the pressure of their own body weight or from minimal movement.

Compression fractures in the spine – especially unstable wedge or ‘burst’ type fractures can have their own independent impact on the spinal cord and may change the nature of an existing spinal cord injury.[iii]

New fractures caused by traumatic injury are naturally less common in people who have very limited movement after an SCI – the usual external causes of traumatic fracture, i.e. falls and accidents, are less likely in people whose independent movement is very restricted. Where someone with a high and relatively complete spinal cord injury has traumatic, rather than fragility, fractures from injuries, that may raise questions about the nature of the care they receive.

Osteoporosis and fractures

The more we lose bone density, the more prone we are to fractures. As mineral deposits throughout the structure of our bones thin out, the bones become fragile and friable. The more fragile our bones are, the more prone to breaking they are. It takes less and less impact to cause fractures, and fractures are more likely to be complex and to heal poorly.

The factors which make us more at risk of reduced bone density and fractures include:

• Sex – being female, especially post-menopause, increases bone density loss.
• Low body mass index – partly as a predictor of malnutrition, partly because bones are physically less protected in people with very low levels of body fat. Having adequate fat reserves is also linked to production of some of the hormones that regulate bone density. On the other hand, obesity is linked to lower bone strength adjusted for body weight so maintaining a healthy BMI is optimal.[iv]
• Diet – Poor nutrition and nutritional absorption leads to deficiencies in bone health-specific nutrients, including calcium. Alcohol consumption and smoking cigarettes are also linked to osteoporosis.
• Vitamin D deficiency – made by our skin in the sunshine, and also part of a healthy diet, vitamin D is essential for the body’s uptake and use of calcium in bone-building.
• Being sedentary – as weight-bearing exercise is one of the best ways to maintain or improve bone density, people whose mobility is profoundly reduced by SCI are particularly affected by this risk factor.

A history of fractures is also an indicator of future risk, as is a family history of osteoporosis. Many other diseases are linked to osteoporosis risk through various mechanisms, including inflammatory and autoimmune diseases, cardiovascular disease, and diabetes.[v]

The coccyx, or tailbone

The coccyx, or ‘tailbone’ is at the very end of the spinal column – as the name suggests, it’s where our tails would be if we had them! It’s an important part of the spine as it supports mobility and is partly responsible for our sitting balance. Due to its position, size and shape, damage to the coccyx isn’t uncommon. An injury to the coccyx can cause some serious problems.

Coccyx injuries associated with spinal cord injuries contribute significantly to pain and subsequent functional and mobility problems relating to the injury.[vi] Good management, early recognition, and effective physiotherapy can help reduce the impact of a coccyx injury in many people, although those with an existing SCI may have some restrictions to rehabilitation of coccyx injuries.

Can a broken tailbone cause paralysis?

The nerves responsible for motor control and sensation diverge from the spinal column above the level of the coccyx, so damage solely to the coccyx should not be able to cause paralysis.

Symptoms of an injury to the coccyx can include pain and tenderness in the area; bruising; discomfort associated with sitting, and pain on moving the bowels, which can contribute to constipation or other problems with continence. A coccyx injury can also make sex painful.

Can a broken tailbone cause problems with continence?

A broken tailbone or other painful coccyx injury can cause problems with continence. Although the nerves responsible for sensation or control of the bowels and bladder may be preserved, problems with pain, mobility, and pelvic floor dysfunction can be caused by coccyx damage and pain.[vii]

There are various different points across the coccyx where fractures can occur, and the position and severity of the fracture predicts the type of impact that the fracture has. The position can influence continence problems and challenges with both male and female sexual function.[viii]

Constipation is a common occurrence in people with coccyx injuries, and is often related to increased pain when using the toilet. A healthy diet with plenty of fluids and fibre can help improve gut health and make bowel movements easier. Stool softeners or other medication may be necessary too.

Painkillers given for spinal injuries can also cause severe constipation; opioid painkillers are the most likely to cause constipation, and these include codeine, tramadol, and morphine.

Constipation can cause serious problems for people with spinal cord injury, including bowel perforation and autonomic dysreflexia, so it’s important to manage bowel function carefully. There are lots of different products and methods available for managing continence and bowel habits after an SCI.

What are Bone Spurs, and why do they form?

A bone spur or ‘osteophyte’ is a growth of bone that protrudes from an existing bony structure. They can grow on any part of bone but are typically found in areas of movement, i.e. near joints and on or within the spinal column. They can occur without causing any problems, and may only be discovered as an incidental finding, for example when having an x-ray for an unrelated reason.

When bone spurs grow enough to rub against other bones and joints, or where they cause pressure on nerves or other tissues, they can begin to cause symptoms, which range in severity. Symptoms can include pain in and around joints, and where bone spurs affect nerves, they can cause pain, weakness, and odd sensations like pins and needles or areas of numbness.

Bone spurs that grow in areas with less protective tissue, like on the fingers, may cause lumps and bumps which can damage the tissues and skin and create wounds. Bone spurs can affect mobility and quality of life through pain and by restricting range of motion in some joints.

Bone spurs can affect anyone, but risk factors include malnutrition, advancing age, being female, and having existing osteoarthritis.[ix] Osteophytes which are causing problems, particularly when they are compressing nerves, may be surgically removed (resected), but considering surgery always requires a pragmatic risk-benefit analysis, particularly people with existing conditions which might increase their risk from surgery and general anaesthetic.

Protecting bone health after a spinal cord injury

As with many medical conditions, there are a number of different factors which can impact a person’s bone health, irrespective of whether that person also has a spinal cord injury. Some of these risk factors are unchangeable, for example, being post-menopause (although HRT may modify risk to some degree[x]). Other risk factors may be modifiable – for example, having low vitamin D levels has a significant impact on bone density, and is an easily treatable condition.

Medical imaging specifically for evaluating bone health is increasingly sophisticated, and can guide treatment plans to help maintain good bone health. There are also emerging treatments which aim to maintain bone density by mechanical-loading physiotherapy which mimics normal weight-bearing, or vibration stimulation therapies.[xi]

There are a number of pharmacological treatments which can slow deterioration or even improve bone density, and the medical professionals who help look after a person with an SCI should consider the potential benefits of these treatments.[xii] While someone with severe limitations to their independent mobility, i.e. someone who is tetraplegic may be at very low risk of traumatic injury from external factors, their potential for severe osteoporosis and fragility fractures should not be underestimated. Bisphosphonate medications, calcium and vitamin D supplements have been used in preventing bone density loss after spinal cord injury, with good results.[xiii]

Living with a spinal cord injury takes many adjustments to a person’s lifestyle and circumstances, and it’s important to do everything possible to reduce the impact of subsequent conditions relating to the injury. This should include managing bone and joint health.[xiv] Anyone with questions about protecting their bone health with reduced mobility should consult their GP as there may be options for improving or protecting their existing bone mineral density.

 

 

[i] Kang, Y., Ding, H., Zhou, H., Wei, Z., Liu, L., Pan, D., & Feng, S. (2018). Epidemiology of worldwide spinal cord injury: a literature review. Journal of Neurorestoratology, 6(1), 3.

[ii] Bauman WA, Cardozo CP. (2015) Osteoporosis in individuals with spinal cord injury. Journal of Injury, Function, and Rehabilitation, 7(2), 188–201

[iii] McCARTHY, J., & Davis, A. (2016). Diagnosis and management of vertebral compression fractures. American family physician, 94(1), 44-50.

[iv] Frotzler, A., Krebs, J., Göhring, A. et al. Osteoporosis in the lower extremities in chronic spinal cord injury. Spinal Cord 58, 441–448 (2020). https://doi.org/10.1038/s41393-019-0383-0

[v] Pouresmaeili, F., Kamalidehghan, B., Kamarehei, M., & Goh, Y. M. (2018). A comprehensive overview on osteoporosis and its risk factors. Therapeutics and clinical risk management, 14, 2029.

[vi] Tekin, L., Yilmaz, B., Alaca, R., Ozçakar, L.., & Dinçer, K. (2010). Coccyx fractures in patients with spinal cord injury. European Journal of Physical and Rehabilitation Medicine, 46(1), 43-46.

[vii] Dean, L. M., Syed, M. I., Jan, S. A., Patel, N. A., Shaikh, A., Morar, K., & Shah, O. (2006). Coccygeoplasty: treatment for fractures of the coccyx. Journal of vascular and interventional radiology, 17(5), 909-912.

[viii] Wright, J. L., Nathens, A. B., Rivara, F. P., MacKenzie, E. J., & Wessells, H. (2006). Specific fracture configurations predict sexual and excretory dysfunction in men and women 1 year after pelvic fracture. The Journal of urology, 176(4), 1540-1545.

[ix] Wong, S. H. J., Chiu, K. Y., & Yan, C. H. (2016). osteophytes. Journal of orthopaedic surgery, 24(3), 403-410.

[x] Wu, F., Ames, R., Clearwater, J., Evans, M. C., Gamble, G., & Reid, I. R. (2002). Prospective 10‐year study of the determinants of bone density and bone loss in normal postmenopausal women, including the effect of hormone replacement therapy. Clinical endocrinology, 56(6), 703-711.

[xi] Battaglino, R. A., Lazzari, A. A., Garshick, E., & Morse, L. R. (2012). Spinal cord injury-induced osteoporosis: pathogenesis and emerging therapies. Current osteoporosis reports, 10(4), 278–285. https://doi.org/10.1007/s11914-012-0117-0

[xii] Bouxsein, M. L., Eastell, R., Lui, L. Y., Wu, L. A., de Papp, A. E., Grauer, A., … & FNIH Bone Quality Project. (2019). Change in bone density and reduction in fracture risk: a meta‐regression of published trials. Journal of bone and mineral research, 34(4), 632-642.

[xiii] Ashe, M. C., Craven, C., Eng, J. J., Krassioukov, A., & the SCIRE Research Team (2007). Prevention and Treatment of Bone Loss after a Spinal Cord Injury: A Systematic Review. Topics in spinal cord injury rehabilitation, 13(1), 123–145. https://doi.org/10.1310/sci1301-123

[xiv] Frotzler, A., Krebs, J., Göhring, A. et al. (2020) Osteoporosis in the lower extremities in chronic spinal cord injury. Spinal Cord 58, 441–448. https://doi.org/10.1038/s41393-019-0383-0

 

The spinal cord – the bundle of nerves that extends down from the brain and branches off to supply nerve function to every part of the body – runs through a canal in the middle of the spine. Each vertebra – bone of the spine – has a hole in it and together they form a long, protective passageway for the spinal cord.

Sometimes, this passageway can become narrower than it should be, and this can put pressure on the nerves of the spinal cord, which can cause a range of problems. This narrowing is known as spinal stenosis.

What causes spinal stenosis?

• Arthritis: The most common cause of spinal stenosis is changes in the bones caused by arthritis. Rubbing and deterioration caused by arthritis can cause thickened, raised areas of bone known as bone spurs which can cause pressure on the spinal cord.
• 

  Illustration showing spinal canal stenosis lumbar vertebra with intervertebral disc and herniated nucleus pulposus

  Injury: An injury that affects the bones of the spine can cause movement or inflammatory changes that affect the width of the spinal canal. Surgery on the spine for any reason also increases the risk of developing spinal stenosis in future.

• Tumours: Tumours can be cancerous or benign growth; either way, they can invade the spinal canal and put pressure on the cord.
• Paget’s Disease: Bones are just like other tissues of the body in that they are broken down and renewed. In people with Paget’s disease, the cells are broken down faster than they’re renewed, which causes thinning of the bones, making them very fragile. These weak, fragile bones gradually change shape, sometimes causing movement and pressure within the spinal column itself, or changes in the way the spine curves.
• Hypertrophy of the ligaments: This means a thickening and hardening of the ligaments, and when it affects the ligaments of the spinal column it can cause narrowing of the spinal canal.

Types of Spinal Stenosis

Spinal stenosis affects either the vertebrae that make up the neck – known as the cervical or c-spine, or the vertebrae at the lumbar or l-spine. Some people have stenosis in both of these areas of the spine.

Cervical

The cervical spine is the part of the spine that makes up the neck, and comprises the top seven vertebrae below the skull.

Lumbar

The lumbar spine is the 5 vertebrae that make up the lower back above the sacrum.

Symptoms of spinal stenosis

Symptoms of cervical spinal stenosis include:

• Neck pain
• Numbness
• Odd sensations like pins and needles or tingling in the one or more limbs
• Back pain
• Changes to gait and balance

Symptoms of lumbar spinal stenosis include:

• Cramping pain in one or both legs
• Lower back pain

Spinal stenosis can sometimes cause problems with bladder or bowel control, and occasionally with sexual function. The pain associated with spinal stenosis can become very severe, and can have a significant negative impact on a person’s life, mobility, fitness, and general health.

The majority of cases of spinal stenosis are caused by arthritis or other chronic degenerative bone disease. In these cases it begins slowly so there can be a fairly significant narrowing of the spinal canal before symptoms are really noticeable. When they do begin they usually develop gradually and worsen over time.

Spinal stenosis that is caused by injury can start much more quickly if the injury leads to long-term narrowing of the spinal canal. When someone has an injury involving the spine, there are short-term inflammatory processes which can cause compression on the spinal cord but don’t necessarily mean there will be long-term spinal stenosis.

Spinal stenosis caused by a tumour can also cause symptoms to develop more quickly than stenosis caused by chronic deterioration.

Diagnosing spinal stenosis

A person’s symptoms and risk factors for spinal stenosis will be considered when they first present, normally at their GP. A physical examination, usually to demonstrate the movement of the spine and any accompanying symptoms, will also help to suggest a diagnosis.[i]

An absolute diagnosis can be confirmed with the use of medical imaging. The type of imaging requested can depend on whether there is any suspicion of certain other conditions or causes. Tests can include:

• X-rays – these give a good picture of the bones, and so can be used to spot any changes in bone structure that might cause pressure on the spinal cord.
• CT (computed tomography) scans – these give a more detailed picture of the structures around the spinal cord, and can show problems like herniated discs and tumours.
• MRI (magnetic resonance imaging) scans – these give a very detailed picture of the tissues of the body, and can give doctors a lot of detail about any changes in the bones and the soft tissues. MRI scans can indicate areas of damage or inflammation, tumours and other problems.

A doctor might also request blood tests which can include measuring inflammatory markers and markers for autoimmune causes of arthritis.

How bad can spinal stenosis get?

The symptoms of spinal stenosis, such as pain, numbness, mobility problems, and problems with continence, can become very severe. The impact of these kind of symptoms can have a profound effect on someone’s life. Reduced mobility can cause other problems with the muscles, bones and joints.

Problems with bowel and bladder control, particularly combined with reduced mobility, can also be associated with a risk of other problems like pressure damage, moisture lesions, and have a serious impact on a person’s mental health and quality of life.

Chronic pain can be difficult to manage, and even more difficult to live with. Spinal stenosis can seriously affect a person’s quality of life, and ultimately their independence.

Risk Factors for Spinal Stenosis

Most people who develop spinal stenosis do so because of long-term degenerative changes in the bones of the spine, most often caused by arthritis. Arthritis is usually – but not always – associated with the processes of aging, which means that spinal stenosis tends to affect people more as they age. It also affects women more than it affects men, which may be for a range of reasons, including under-diagnosis in men.[ii]

People who have had previous surgery on their spine are more likely to develop spinal stenosis, and it is also more common in people who are overweight or obese.[iii]

People who have curvature of the spine (kyphosis or scoliosis) or other structural changes are also more likely to experience problems from compression of the spinal cord. Rarely, people can be born with unusually narrow spinal canals, and may have problems with pain and movement from a very young age.

Stages of Spinal Stenosis

Once spinal stenosis has developed, it will gradually get worse without treatment.

Treatment depends on the cause, but where spinal stenosis is caused by chronic irreversible degenerative bone disease like osteoarthritis, treatment is only likely to slow progression or manage symptoms.

Spinal Stenosis Treatment

The treatment for spinal stenosis depends on the cause. Most causes of spinal stenosis are not reversible, i.e. cannot be completely removed by treatment. Treatment, therefore, usually focuses on slowing progression, alleviating symptoms, and reducing the risk of complications or side-effects.[iv]

Conservative (non-surgical) treatment

• Medication – anti-inflammatory medication can help reduce compression on the spinal cord and also independently reduce pain. Chronic severe pain can also be managed with stronger pain medication, and there are specialist teams of healthcare professionals whose job is to help people manage chronic pain. Sometimes medications that are usually used for depression or to prevent seizures are also used to manage chronic pain.[v]
• Injections – some medicines are best given as injections, and steroid injections at the site can be very effective, and usually only need to be given every few months.

• Physiotherapy – physiotherapy is an important part of the treatment of spinal stenosis and some of its associated symptoms. Exercises can help to strengthen the muscles supporting the spine, and to maintain good movement and flexibility. Physiotherapy can also help with problems with gait and balance that can arise in people with spinal stenosis and related conditions.[vi]

Surgery for spinal stenosis

Surgery can widen the spinal canal somewhat, but the effectiveness can depend on the cause of the spinal stenosis.[vii] Surgery for spinal stenosis is something of a last resort, and generally only considered when more conservative treatment has been unsuccessful.

Surgery to widen the spinal canal is performed under a general anaesthetic and it can take some months to fully recover. The surgery is performed on the lamina – this is the arched back section of each vertebra. This can take the form of:

• Laminectomy – where the lamina of the affected vertebra or vertebrae is removed, creating more space around the spinal cord. This may be replaced with specially designed surgical metalware which bridges the gap created and maintains strength in the backbone.
• Laminotomy – this is where a small amount of interior arch the lamina is removed, creating a wider spinal canal but leaving the outer part of the vertebra intact.
• Laminoplasty – This is only used in the bones of the c-spine; one side of the lamina is ‘hinged’, opened outwards a few degrees and metalware is used to maintain that position.

If the spinal stenosis is cause by a tumour then removal of the tumour may cure the spinal stenosis. Sometimes tumours around the spine are associated with other areas of thickening and cell overgrowth so some people may have continuing symptoms.

Exercise

Professional physiotherapy can be incredibly beneficial in spinal stenosis, strengthening the muscles around the spinal column, maintaining mobility, and managing pain. Referral to a physiotherapist means that treatment and exercise can be tailored to the individual and adjusted over time. There are also some useful exercises to try at home, but a personal physiotherapy plan from a professional is the ideal, especially if there are other complications or conditions affecting a person’s ability to exercise.

Good exercises for most people with spinal stenosis usually focus on maintaining or improving range of motion, so stretching and bending – within an individual’s limits – will make up some of an exercise plan.

Some people with spinal stenosis find that they’re most comfortable bent slightly forward, so cycling, whether on a stationary exercise bike or outdoors, can be a comfortable way of increasing strength.

Swimming is good low impact exercise and can be a comfortable way of improving symptoms and increasing strength and fitness.

Exercise classes that focus on slow, core-strengthening exercises like Pilates or yoga can be helpful, and a gym membership that includes access to a personal trainer with experience in supporting people with spinal problems is ideal.

Exercises to avoid

Everyone has different limits, and while exercise is very beneficial to most people with spinal stenosis, very high impact exercises like running on pavements can cause more pain than they relieve.

Living with Spinal Stenosis

Spinal stenosis is fairly common, so if you’re living with the condition, you’re not alone. There are lots of treatment options, and there are teams of healthcare professionals who specialise in conditions relating to the spine and nerves, to chronic pain, and to improving symptoms with physical therapy and other treatment.

There are also support groups for people living with conditions affecting their usual ability, and the internet is a good place to start to look for online, national, or local organisations or groups.

Whatever your symptoms, there will be some choices for helping to manage them. It’s always okay to ask for support, and it’s a good idea to keep your GP or specialist in the loop if symptoms change, as there might be other ways to manage them.

As with any chronic disease, looking after yourself is key. Maintaining a healthy lifestyle is good for both mental and physical health, and if you’re able to be proactive in gaining treatment, there is help at hand. If you’re unable to easily advocate for yourself, it might be important to ask a family member or friend to help support you with accessing healthcare services.

Maintaining your quality of life is key, and that might require a multi-pronged treatment plan. It’s also important to acknowledge other symptoms that can accompany spinal stenosis – these can include depression, sleeplessness, loneliness and reduced mobility. If you’re able to talk about these problems, there’s always a way to try and make things better.

 

[i] Haig, A. J., & Tomkins, C. C. (2010). Diagnosis and management of lumbar spinal stenosis. Jama, 303(1), 71-72.

[ii] Sekiguchi, M., Yonemoto, K., Kakuma, T., Nikaido, T., Watanabe, K., Kato, K., … & Konno, S. I. (2015). Relationship between lumbar spinal stenosis and psychosocial factors: a multicenter cross-sectional study (DISTO project). European Spine Journal, 24(10), 2288-2294.

[iii] Wang, C., Chang, H., Gao, X., Xu, J., & Meng, X. (2019). Risk factors of degenerative lumbar scoliosis in patients with lumbar spinal canal stenosis. Medicine, 98(38). https://doi.org/10.1097/MD.0000000000017177

[iv] Melancia, J. L., Francisco, A. F., & Antunes, J. L. (2014). Spinal stenosis. Handbook of clinical neurology, 119, 541-549.

[v] Hylands-White, N., Duarte, R. V., & Raphael, J. H. (2017). An overview of treatment approaches for chronic pain management. Rheumatology international, 37(1), 29-42.

[vi] Özden, F., Tümtürk, İ., Yuvakgil, Z., & Sarı, Z. (2022). The effectiveness of physical exercise in patients with lumbar spinal stenosis: a systematic review. Sport Sciences for Health, 1-12.

[vii] Wei, F. L., Zhou, C. P., Liu, R., Zhu, K. L., Du, M. R., Gao, H. R., … & Qian, J. X. (2021). Management for lumbar spinal stenosis: a network meta-analysis and systematic review. International Journal of Surgery, 85, 19-28.

Paralysis as a symptom of spinal cord injury (SCI) specifically refers to lack of motor control causing reduced ability to move one’s body – this is, of course, inextricably linked to sensation and an injury to the spinal cord that severs motor control will also affect sensory perception.[i] When talking about paralysis it is useful to describe the region or regions of the body affected as well as the severity or ‘completeness’ of the impact.

Degrees of paralysis

The cause, and in the case of SCI, the completeness of the injury, informs the severity of the motor control loss.[ii] Someone with a complete spinal cord injury – that is, an injury severe enough to completely discontinue nerve function – will lose all sensation and control below the point of injury. An injury that disrupts nerve function in only one part of a cross section of spinal cord will have a different effect, with the impact depending on the region of the spinal cord cross-section affected. Someone with injury to one or the other side of the spinal cord may have paralysis on one side only, with little or no impact on the other side of their body. Injuries to the front, back, or central core of the spinal cord have, in turn, various other effects.

• Anterior cord syndrome is usually typified by weakness with preserved, though reduced, motor control.[iii]
• Brown-Sequard syndrome describes the impact of a left- or right-sided SCI; an injury only affecting the nerve bundle at one side of the spinal cord may only affect that side.[iv]
• Posterior cord syndrome is rarer and primarily affects sensation and proprioception (the innate awareness of the body’s position and movement).[v]
• Central cord syndrome is the most common SCI associated with degenerative spinal changes and aging as well as traumatic injury, and its effects can range from minimal loss of fine movement control to paralysis.[vi]

Regions of paralysis

The definition of paralysis can be applied to any part of the body that has lost movement, but is usually broadly labelled by its impact on the limbs. The regions of paralysis are predicted by the region of impact of injury.[vii] However, paralysis extends beyond deliberate limb movement to affect more innate functions like breathing, continence, and the sexual organs.

Tetraplegia/quadriplegia

Tetraplegia describes a condition where all four limbs are affected. High SCI in the C1-C4 vertebral levels will have a significantly impaired or total loss of nerve pathways below that point. That affects not only the sensation and motor control for limbs and other voluntary movements, but involuntary motor control as well, including conscious and unconscious breathing control, and the functions of the pelvic organs. People with SCI affecting the lower cervical vertebrae – C5-C8 – may have degrees of preserved nerve function to parts of the arms and hands, so it can be more useful to describe the actual preserved function for an individual.

Formerly, tetraplegia was more commonly referred to as quadriplegia. Both prefixes mean ‘four’, as in the four limbs affected; the difference is etymological rather than medical, to maintain consistently Greek, rather than Latin and Greek combined, word-roots for conditions of paralysis.

Paraplegia

Paraplegia refers to paralysis of the lower limbs, i.e. lack of motor control of the legs. People with paraplegia also experience impact on the nervous system relating to the pelvic organs, so bowel and bladder problems including constipation, incontinence, and urinary retention are common. Paralysis affecting the lower limbs also affects the nerves of the reproductive system, so sexual function is affected.

Paraplegia can be caused by an SCI that occurs below the level that would affect the upper limbs. People with an SCI at the levels of the high thoracic vertebra – T1-T5 – usually have preserved function of the arms and hands, but some impact on the muscles of the chest and abdomen. People with lower thoracic SCI – T6-T12 – may still have some impact on back and abdominal muscles, but retain normal function above that point. With intact upper limb function and no concerns about breathing, self-care is usually a lot more straightforward.

Right or Left Hemiplegia

Damage affecting only the right or left side of the spinal cord is less common. If only those nerves affecting one side of the body are damaged, then the paralysis would only affect that sided of the body, from the point of injury down. More commonly, a spinal cord injury that affected one side would not be that precise, and there may be some degree of global impact.

Monoplegia

Monoplegia describes paralysis of only one limb, and can be the result of injury to the brain, spinal cord, or damage to the peripheral nervous system relating to that limb. Cerebral palsy is the most common cause of monoplegia.

Lower spinal cord injuries

Injuries to the lower spinal cord may have a lesser impact on lower limb function; different nerve pairs supply sensation and motor control to different areas of the legs. People with SCI affecting the lumbar or sacral spinal cord, depending on the level of injury, may retain good control over the muscles of the leg but are likely to have reduced control over their bowels and bladder.

Sexual function is likely to be altered with any spinal cord injury; this may mean lack of sensation or control, erectile dysfunction, vaginal dryness, and other issues arising from the impact of SCI and paralysis.

As well as paralysis stemming from spinal cord injury, damage to a nerve root after it diverges from the spinal cord can cause regions of paralysis, though this will apply to a specific area rather than the classic signs of spinal cord injury, i.e. an injury affecting a single nerve will not affect other areas of nerve function.

 

Does a fractured spine always mean paralysis?

A vertebral fracture – damage to the bones of the spine – does not necessarily affect the spinal cord. The spinal cord is the conduit for movement and sensation signals, and so only when the spinal cord is damaged do you get paralysis. A vertebral fracture or traumatic injury affecting the spine can, however, cause damage to the spinal cord, whether it is an acute traumatic injury or a degenerative, progressive condition.

Other causes of paralysis

Spinal cord injury is just one of the possible causes of paralysis[viii]; other causes include:

• Stroke: particularly a one-sided loss of motor control.
• Brain injury: the brain and spinal cord form the continuous central nervous system and a brain injury can have a range of impact, including paralysis which can be regional or widespread.
• Degenerative diseases affecting the nerves, like motor neurone disease or Huntington’s disease.
• Autoimmune conditions which affect the nerves, such as Guillain-Barre syndrome or multiple sclerosis.

Risks associated with paralysis

Being unable to move independently is associated with a number of significant health conditions and outcomes.[ix] Without control over movement, a person is at risk of:

• Pressure damage to the skin and underlying tissues.[x]
• Moisture damage to the skin, from sweat and incontinence, plus an increased risk of fungal skin infections.
• Obesity, coupled with muscle degeneration.
• Depression – becoming paralysed triggers a number of huge lifestyle changes which can be overwhelming and can contribute to significant mental health problems. A life-changing injury, alongside permanent disability, changes in lifestyle and which can affect family life, recreational activities, and work or education, takes time and support to come to terms with.

Higher spinal cord injuries which affect the muscles involved with breathing have their own risks and are associated with higher incidence of serious illness.

• Pneumonia – alongside an inability to cough and clear mucous, and which may be exacerbated by inability to change position and poor sitting balance.
• Aspiration – an impaired swallow means that food or fluid can enter the respiratory tract and cause aspiration pneumonia.
• Difficulty managing complex care needs – some people with high spinal cord injuries have tracheostomies, and some need part- or full-time mechanical ventilation. Some people with high spinal cord injuries need to have their nutrition and hydration needs met through an alternative to the oral route – usually a percutaneous endoscopic gastrostomy (PEG). While this can all be well-managed with a trained care team, it does inevitably mean that activities take a little more planning and organisation than for people without complex care needs.

Some of the risks associated with paralysis can often be prevented, or at least reduced, by provision of good care. Pressure or moisture damage can be minimised with regular positional changes, good continence care, and appropriate pressure-relieving equipment like mattresses and cushions. A team of specialised carers can support people living with paralysis to stay healthy and active.

There is a range of solutions to problems with urinary or faecal incontinence, constipation and urinary retention, and they are tailored to the individual. Problems associated with immobility can be reduced with an appropriate healthy diet, physiotherapy and management of other issues. A person with reduced physical function should also be able to continue having a healthy sex life, although the impact of a spinal cord injury means that there usually have to be some adjustments – and a little imagination – in the way people have sex.

Depression and other mental health problems can be associated with trauma, injury, immobility, a changing body and changing abilities, feelings of self-worth, and changes to position in society, the workplace, and the home. There is no right or wrong way to feel after a life-changing injury or with changing care needs for any reason. It may take time to realise that a person with extra care needs is as valued and valuable as anyone else in society, and that a person’s potential does not have to be linked to their physical abilities. Feelings of depression and other negative emotions can be transient or can last a long time and become a serious problem. Asking for help when struggling with mental health is a positive, responsible action, and there is lots of support available.[xi]

Living with paralysis after a spinal cord injury

The world has almost always been designed by, and for, able-bodied people. In more recent years, efforts have been made to create a more accessible and inclusive infrastructure, but living with any level of paralysis will require some adaptation. Equipment is better than ever, with an overwhelming number of devices aimed at improving quality of life for people with complex restrictions and extra care needs.

While it requires practical, physical, and emotional solutions to adapting to life with any degree of paralysis, the kind of care a person receives has a huge influence on their quality of life and abilities. The aim of good nursing care teams is to make for any deficits in self-caring abilities; if carers can ‘fill the gaps’, then a person with complex care needs can continue to live a full and fulfilling life. Everyone – from the fittest, most physically able people to those with the most severe disabilities – requires some sort of support to live, and care packages are not designed to reduce independence, but rather to facilitate independence with support.[xii]

A care package designed to support people with paralysis will be built to respect an individual’s wishes and with their lifestyle and values in mind, while meeting their functional needs. Care packages can be built to support people in their own home, out and about, and even going on holiday. For someone with ongoing care needs, a care team can become familiar and valued, promoting and facilitating the kind of life the individual wants to lead. Health and social care services, specialist care providers, and in-person or online professional or peer support groups can help with the social and practical side of life with these kind of new care needs, and people with spinal cord injuries causing paralysis can expect their care providers to help them live the lives they want.

[i] Alizadeh, A., Dyck, S. M., & Karimi-Abdolrezaee, S. (2019). Traumatic spinal cord injury: an overview of pathophysiology, models and acute injury mechanisms. Frontiers in neurology, 10, 282.

[ii] Bryden, A., Kilgore, K. L., & Nemunaitis, G. A. (2018). Advanced assessment of the upper limb in tetraplegia: a three-tiered approach to characterizing paralysis. Topics in Spinal Cord Injury Rehabilitation, 24(3), 206-216.

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

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

[v] McKinley, W., Hills, A., & Sima, A. (2021). Posterior cord syndrome: Demographics and rehabilitation outcomes. The Journal of Spinal Cord Medicine, 44(2), 241-246.

[vi] Avila, M. J., & Hurlbert, R. J. (2021). Central Cord Syndrome Redefined. Neurosurgery Clinics, 32(3), 353-363.

[vii] Kirshblum, S. C., Burns, S. P., Biering-Sorensen, F., Donovan, W., Graves, D. E., Jha, A., … & Waring, W. (2011). International standards for neurological classification of spinal cord injury (revised 2011). The journal of spinal cord medicine, 34(6), 535-546.

[viii] Armour, B. S., Courtney-Long, E. A., Fox, M. H., Fredine, H., & Cahill, A. (2016). Prevalence and causes of paralysis—United States, 2013. American journal of public health, 106(10), 1855-1857.

[ix] Sezer, N., Akkuş, S., & Uğurlu, F. G. (2015). Chronic complications of spinal cord injury. World journal of orthopedics, 6(1), 24.

[x] Cowan, L. J., Ahn, H., Flores, M., Yarrow, J., Barks, L. S., Garvan, C., … & Stechmiller, J. (2019). Pressure ulcer prevalence by level of paralysis in patients with spinal cord injury in long-term care. Advances in Skin & Wound Care, 32(3), 122-130.

[xi] Post, M. W. M., & van Leeuwen, C. M. (2012). Psychosocial issues in spinal cord injury: a review. Spinal cord, 50(5), 382-389.

[xii] Barclay, L., McDonald, R., & Lentin, P. (2015). Social and community participation following spinal cord injury: a critical review. International Journal of Rehabilitation Research, 38(1), 1-19.

Bowel management, particularly addressing challenges like constipation and incontinence, is one of the most important considerations after a spinal cord injury (SCI). The primary and secondary consequences of bowel problems can be profound and have a severe impact on physical and mental health.

How can a back injury affect the bowels?

Injury to the spinal cord can profoundly affect all nerve function between the brain and nerves below the point of injury. There is loss of control and sensation, meaning that the injured person has no voluntary control over movement, and also loss of some of the intrinsic nervous system activity of the bowels. Losing sensation also means loss of that feeling of pressure in the bowels, which is what helps us know when to go to the toilet; knowing when to perform bowel care is a large part of managing continence for people with or without an SCI. A spinal cord injury also has an intrinsic effect on muscle and anal tone.

The point at which the spinal cord is affected has a significant impact on the nature and severity of the impact on the bowel. The higher the injury, the more impact on physical function, movement, and sensation. Aside from SCI, acute neurological events or chronic neurodegenerative conditions can result in similar bowel management challenges.

The completeness of the spinal cord injury also affects the impact of the injury on the bowel. The nerves which form a feedback loop conveying sensation and impulses for movement between the brain and the bowel, as well as some reflexive action, can be severed or damaged in a way that means that there is no control beyond that point. The damage can be partial, affecting only a portion of the bundle of nerves which comprise the spinal cord, and so some sensation, control, or tone may be retained.

Bowel problems after a spinal cord injury

There are three main contributing factors to bowel management difficulties after a spinal cord injury:

• An SCI damages our ability to sense our need to go to the toilet, meaning that we can become incontinent, passing stool before we’re prepared. An SCI can also affect our ability to control the complex voluntary mechanisms controlling bowel movements. We need intact spinal cord nerves to allow us to tense and relax our abdominal muscles, to deliberately increase muscular pressure within the abdomen, to relax the anal sphincter and to push stool out.
• An SCI that affects our mobility and motor control can make it harder to manage the physical practicalities of managing continence, including simply getting to the toilet or managing continence care. The extent of effect of the SCI might mean that the right management techniques are different from person to person depending on their levels of physical mobility and independence as well as the type of care input they have from others. Someone with intact movement and sensation in their upper body may be able to independently manage complex bowel management after a spinal cord injury, whereas someone with a high spinal cord injury affecting movement will need a different management plan with more input from carers.
• The involuntary side of the digestive process is also affected by spinal cord injury. This affects peristalsis, the movement which conveys matter through the digestive system. This affects the speed of the bowel – the rate at which the contents of the digestive system move from one end to the other. It also affects every reflex part of the process, which can include aspects like the reflexive opening – or tightening – of the anal sphincter after different forms of stimulation. The level of the SCI affects the nature of the bowel dysfunction, and a dysfunctional bowel caused by damage or disease affecting the nerves is known as a neurogenic bowel.

The Neurogenic Bowel

The area of impact of spinal cord injury affects the type of bowel dysfunction a person experiences.[i] Neurogenic bowel can also be caused by other conditions which affect the nerves of the bowel, including multiple sclerosis and stroke.

Neurogenic bowel can be grouped into two broad categories – upper motor neurone bowel and lower motor neurone bowel.[ii]

Upper motor neurone bowel syndrome, or hyper-reflexive bowel, is caused by injury above the conus medullaris – it is characterised by increased tone to the walls of the bowel and anus. Gut motility is reasonable but without voluntary control of a highly toned anal sphincter, bowel evacuation can be a challenge, and upper motor neurone bowel is associated with faecal retention and constipation. People with upper motor neurone bowel can have good results from bowel evacuation techniques which employ stimulation to promote reflex opening of the anal sphincter.

Lower motor neurone bowel, or a reflexive bowel, results from injury at the conus medullaris and/or cauda equina. People with lower motor neurone bowel have disruption to the peristaltic action of the gut triggered by higher spinal cord activity, and so gut motility is poor and stool passage time is slow, meaning constipation can be a significant problem. Lower motor neurone bowel also results in an atonic, flaccid anal sphincter and so incontinence is more likely and more difficult to manage.

The level of higher spinal injuries has an impact on a person’s voluntary bowel motility, as reduced physical movement and an inability to deliberately increase intraabdominal pressures through diaphragm control, Valsalva-type manoeuvres, or positional changes create more challenges.

Complications of bowel problems after a spinal cord injury

Continence requires careful management for people with injury to the spinal cord, and the repercussions of poor bowel management can be profound.

• Severe constipation – a build-up of hard stool in the bowel can cause serious problems without effective intervention, leading to faecal impaction, bowel perforation, and potentially serious illness.
• Damage to skin – incontinence is a huge risk factor for damage to the skin and underlying tissues, causing moisture lesions and contributing to pressure damage, fungal infections and bacterial skin infections.
• Autonomic dysreflexia – in people with cervical or high thoracic spine injuries, autonomic dysreflexia is a potentially severe complication of bodily stress which can result from various problems including constipation or tissue damage.[iii]
• Impact on daily life – if constipation, incontinence, or a lengthy and complex bowel management regime are a problem, that can have a significant impact on quality of life and a person’s ability to continue any of their usual activities. Social and family life, work and mental and physical health can suffer.

Some of the interventions used for bowel management after nervous system damage can carry their own risks as well as benefits; some of the ‘last resort’ type treatments can include surgical interventions.

Managing bowel problems after a spinal injury

Specialist care teams will always recommend the safest, least invasive methods of bowel management first, but it can take some trial and error to find an effective and acceptable method for an individual. Managing constipation and continence after SCI requires a two-pronged approach – firstly, to ensure that stool is moving through the bowel at a reasonable rate to avoid constipation, and secondly to enable effective and safe emptying of stool from the bowel.

The first – maintaining healthy bowel motility – can often be effectively managed with a healthy diet and some oral medications including stool softeners and various forms of laxative. Other non-invasive techniques like abdominal massage and positional changes can help stool propulsion.

Evacuating the bowel can be more difficult at times, as it’s important to find the right balance between constipation and the possibility of incontinence, and this depends largely on the level and completeness of the injury, or the severity of other conditions causing spinal cord damage. People with reflexive bowel emptying may always require some incontinence pads and other products, and to plan for the possibility of incontinence, but a good bowel care routine can make a huge difference. Planning bowel evacuation procedures to follow patterns of peristalsis and likely timing of the need to remove stool from the rectum can help prevent accidents. Bowel management for people with spinal injuries can involve one or more of the following[iv]:

• Diet and adequate fluid intake – a healthy diet can have a significant impact on gut motility and stool volume. For people with neurogenic bowel, a healthy diet and adequate fluid intake alone will not be enough to ensure effective bowel emptying, but can help reduce the risk of constipation and make management a little easier.
• Abdominal massage – this can be effective in supporting passage of stool through the gut and raising the pressure within the abdomen to improve expulsion of stool.[v]

• Positioning – just the pressure of stool in the rectum can trigger anal opening for some people, and so sitting on a toilet, upright and with hips and knees bent can help move stool towards, or sometimes through, the anus.
• Digital stimulation – using a gloved, lubricated finger inserted a few centimetres into the anus, then swirled around for around 30 seconds can stimulate reflex anal relaxation and result in a bowel movement. However, this reflex is not present in people with lower motor neurone bowel.
• Manual evacuation – a gloved, lubricated finger can be inserted into the anus to manually remove stool using a scooping motion.
• Suppositories – there are various types of suppository, which work to soften the stool or stimulate the bowel, with varying efficacy. Glycerin suppositories work by lubricating the rectum and anus and softening the stool, so can be useful for evacuating hardened stool in the rectum. Bisacodyl suppositories work by increasing bowel contractions approximately half an hour after insertion, but are associated with more risk of incontinence as their duration of action is not entirely predictable.
• Enemas – another way of delivering small amounts of stimulant in liquid form into the rectum, enemas can have good results for managing bowel evacuation. Larger volume enemas can be effective in some circumstances but carry more risk of bowel damage, poor retention, and, occasionally, autonomic dysreflexia.
• Trans-anal bowel irrigation – the introduction of a set volume of warm water through a balloon-cuffed rectal catheter increases the volume and fluidity of bowel contents, literally washing out the bowel.

 

If severe constipation is still a problem despite trials of simple and minimally invasive methods of management, some surgical interventions may be considered. These can include implanted sacral nerve root stimulation devices or a MACE – an irrigation tube implanted to flush the large bowel from the appendix.[vi] A colostomy or ileostomy are sometimes considered a last resort, but have had good results in improving quality of life for people with spinal cord injuries.[vii]

Care and support

Management of continence and constipation is one of the most important considerations after a spinal cord injury and can have a profound impact on physical and mental health and quality of life. People with spinal cord injuries who retain good use of their arms and hands may be able to perform bowel evacuation procedures independently, whereas others will need support from carers. An effective care package is one designed to work around the individual, actually enabling supported independence and covering any self-care deficits to enhance quality of life.

Bowel habits are traditionally a sensitive, even taboo subject so it’s very natural for many people to feel shy or embarrassed about having new bowel care needs and incontinence. Support groups, acceptance and openness, disability activists and social media personalities with SCI have helped make this an acceptable topic for frank discussion. The impact of continued constipation, incontinence, and the other potential problems associated with bowel dysfunction cannot be understated. Quality of life and mental health are paramount after a spinal cord injury, and poor continence management is associated with poor quality of life and mental health outcomes.[viii]

Bowel care needs a holistic and person-centred approach. The method needs to be effective, preventing constipation and incontinence; practical and practicable in terms of care input and availability of an appropriate setting and equipment; and acceptable to the individual. Effective care includes monitoring, essential for early identification and management of emerging problems. Abdominal distention, autonomic dysreflexia, new patterns of incontinence and constipation can all indicate problems that need to be addressed.

_____________________________________________________________________________________________

[i] Hughes M. (2014). Bowel management in spinal cord injury patients. Clinics in colon and rectal surgery, 27(3), 113–115. https://doi.org/10.1055/s-0034-1383904

[ii] Krassioukov, A., Eng, J. J., Claxton, G., Sakakibara, B. M., & Shum, S. (2010). Neurogenic bowel management after spinal cord injury: a systematic review of the evidence. Spinal cord, 48(10), 718-733.

[iii] Cragg, J., & Krassioukov, A. (2012). Autonomic dysreflexia. Cmaj, 184(1), 66-66.

[iv] Krassioukov, A., Eng, J. J., Claxton, G., Sakakibara, B. M., & Shum, S. (2010). Neurogenic bowel management after spinal cord injury: a systematic review of the evidence. Spinal cord, 48(10), 718-733.

[v] Ebert, E. (2012). Gastrointestinal involvement in spinal cord injury: a clinical perspective. Journal of Gastrointestinal & Liver Diseases, 21(1).

[vi] Hughes M. (2014). Bowel management in spinal cord injury patients. Clinics in colon and rectal surgery, 27(3), 113–115. https://doi.org/10.1055/s-0034-1383904

[vii] Hocevar, B., & Gray, M. (2008). Intestinal diversion (colostomy or ileostomy) in patients with severe bowel dysfunction following spinal cord injury. Journal of Wound Ostomy & Continence Nursing, 35(2), 159-166.

[viii] Gurcay, E., Bal, A., Eksioglu, E., & Cakci, A. (2010). Quality of life in patients with spinal cord injury. International Journal of Rehabilitation Research, 33(4), 356-358.

Spinal cord injuries (SCI) classically affect function – movement, control and sensation – of all parts of the body which use the nerves at and below the level of injury. This means that, although the brain’s communication with some parts of the body may be permanently and partially or completely obstructed, there is not necessarily any effect on pure brain function.

In some instances, a traumatic incident which results in SCI may also cause traumatic brain injury (TBI); the number of people who suffer both injuries seems to be increasing[i]. There is also a risk of brain injury without obvious evidence on medical scans – ‘occult brain injury’[ii] being overlooked or underdiagnosed, and symptoms being ascribed purely to the spinal cord injury.

However, even when an acute injury is clearly below the level of the brain and there was no direct injury to the head, some people do find that they develop degrees of memory loss, altered thought processes, and ‘brain fog’. The effects of a spinal cord injury can, therefore, have short- or long-term effects on certain cognitive function[iii].

Many people who experience spinal cord injury have no cognitive symptoms at all, and lead full, rewarding lives with adjustments for any new physical needs. Indeed, people with cognitive impairment should also be able to expect to lead the kind of life they want to with adjustments and support for any changes in their ability.

Symptoms like memory loss, cognitive impairment, and fatigue may have a profound effect on a person’s contentment and quality of life. There are many incredible adjustments that can be made to enable a person to engage in normal activities despite physical restrictions and even very complex care needs. However, overcoming cognitive and psychological barriers can be even more complicated.

The association between spinal cord injury and cognitive impairment is often overlooked. Perhaps this is because the effects on other parts of the body can be so profound; advice and management after a spinal cord injury focuses on maximising independence and quality of life by managing physical changes and restrictions. A failure to recognise and understand the cognitive changes that sometimes accompany a spinal cord injury can make people living with these symptoms feel very isolated; understanding a condition makes it easier to live with that condition.

How do Spinal Cord Injuries Affect Brain Function?

The likely reasons for changes in brain function after a spinal cord injury are complex and multifaceted. Someone who sustains a spinal cord injury with no direct effect on the brain might still notice some symptoms relating to their thought processes and memory. Some of the factors that are thought to cause cognitive symptoms include:

• Inflammatory changes triggered by spinal cord injury which can affect the entire central nervous system.
• Management of chronic post-SCI symptoms[iv] with strong painkillers, antidepressants, or other medications which might cause drowsiness, memory problems or mood changes.
• Damage from reduced oxygen supply, either from respiratory arrest at the time of the injury or subsequent difficult airway or ventilation management.
• The mental health impact of a traumatic injury or when adapting to life with a spinal cord injury.

Inflammatory Complications

Spinal cord injury causes inflammation which can affect the whole nervous system – this includes the brain, and the brain can be very sensitive to inflammation and pressure. The effects of spinal cord injury on the brain have been studied in animal models[v], and have a strong correlation to apparent changes in mood and problem-solving processes.

Using animal models to study mood and thought patterns comes with obvious restrictions; without verbal and other forms of communication which are inherently and exclusively human, effective assessment of the impact on higher brain processes is difficult.

What the studies do show, however, is that a precise injury below the level of the spinal cord that should directly affect the brain does cause changes in processing and behaviour, and that this seems to be related to an inflammatory process which can affect the whole nervous system.

The Effect of Medications

A spinal cord injury can have a profound and widespread effect on physical health, and polypharmacy[vi] – the use of a high number of different types of medication – is very common after an SCI. Some of the medications commonly used long-term for people with a spinal cord injury can have a significant impact on the way a person feels.

Any medicines that affect sleep patterns and mood can cause changes in the way a person functions. Medicines that make people drowsy particularly cause feelings of fatigue, and difficulty concentrating, and even changes in word-finding and simple problem-solving abilities.

The sheer number of medications people typically take after an SCI is associated with a high risk of side-effects[vii]. Medications commonly prescribed for symptoms after a spinal cord injury which can cause apparent changes in brain function include:

Opiates: Many medications for pain can affect mental clarity and cause extreme fatigue and problems concentrating. Opioid medicines[viii] in particular come in a range of forms, long- and short-acting, and are associated with drowsiness and ‘brain fog’.

Anti-convulsants: These are commonly used in the management of pain following spinal cord injury. Gabapentin and Pregabalin have been proved to be especially effective in decreasing neuropathic pain and other secondary outcomes in people with spinal cord injuries.

Anti-convulsant medications have side effects that produce symptoms commonly associated with brain injury and cognitive impairment: patients given Gabapentin are significantly more likely to experience dizziness, somnolence and, less frequently, ataxia including slurred speech, gait disturbance, stumbling and lack of coordination. However, these symptoms appear to be transient.

Anti-depressants: Common antidepressants and medications to help stabilise the mood include:

• Selective Serotonin Reuptake Inhibitors (SSRIs) such as citalopram, fluoxetine, and sertraline.
• Tricylic drugs – like amitriptyline and clomipramine.
• Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) such venlafaxine and duloxetine.

• Benzodiazepines – often used for anxiety or to help with sleeping problems, diazepam, temazepam, and lorazepam are all common benzodiazepines.

Nearly all medications prescribed specifically for mood and mental health conditions have reported side effects including fatigue and concentration difficulty. The side effects of these drugs, however, often closely mimic some of the symptoms commonly associated with the depression and mood disorders they are intended to treat. Weighing up the risks and benefits of taking antidepressant medication is sometimes a matter of trial and error; although the side effects of drugs used in mental health medicine can be significant, antidepressants can also be lifesaving.

Anti-spasmodics: Spasticity affects roughly two thirds of patients with spinal cord injury. This is characterised by exaggerated tendon stretch reflexes and involuntary muscle spasms.

Antispasmodics (also commonly called anticholinergics) and muscle relaxants can be used to reduce the effects of spasticity after spinal cord injury.

Commonly used antispasmodic medications include temazepam, clorazepate, baclofen, phenobarbital, tizanidine, cyclobenzaprine and metaxalone.

Use of antispasmodic medication in the treatment of post trauma spinal cord injury patients has a negative impact on neurological and functional outcomes at and after discharge. Antispasmodic medications work to reduce spasticity by inhibiting neural networks and neural activity. Recovery from acute SCI and other injuries to the central nervous system is determined by neural plasticity which depends upon neural activity.

While spasticity affects two thirds of patients with spinal cord injury only a minority of those report that it appreciably effects their quality of life and it seems that clinicians may prescribe medications for signs of spasticity without consideration of the long term reduction in neurological functioning.[ix]

Hypoxic Brain Injury

A high spinal cord injury can have a serious and severe impact on a person’s ability to breathe independently. A period of reduced ventilation or respiratory arrest following a spinal cord injury – for example, if there is any delay in medical care – can cause profound brain injury as a secondary result of a spinal cord injury.

Acute hypoxic brain injury – damage to the brain caused by a lack of oxygen supply – may resolve fully or partially, but extended periods with a lack of oxygen to the brain can cause irreversible damage. This secondary effect can cause changes in mood, behaviour, even personality.

As a direct secondary effect, the link between high spinal cord injury and lack of oxygen to the brain seems straightforward. There are also other mechanisms which might be considered a ‘tertiary’ effect of SCI on the brain – for example, the longer-term changes in nervous system control in people with injuries above T1 – the top vertebra of the thoracic spine – are associated with low blood pressure (hypotension) and a slow heart rate (bradycardia). Some association has been shown between these kind of cardiovascular findings and impaired cognitive function[x].

Mental Health Problems

Whether or not a spinal cord injury has physical effects on the brain, the impact of any serious life-changing event can have a significant impact on mental health. People with acute or chronic mental illness, particularly major depression, consistently show worse results in tests for memory and cognitive function than they do when they have good, stable mental health. This is irrespective of any other health problems, but the high rates of depression experienced among people with spinal cord injury mean that the effects of mental illness on cognitive function are likely to have a considerable impact on some people with spinal cord injury.

Autonomic Dysreflexia

Autonomic Dysreflexia (AD) describes a situation where the body’s unconscious nervous system has an exaggerated and uncontrolled reflex response to a problem, a damaging or irritating stimulus. This response can cause very elevated blood pressure (hypertension) leading to seizures, stroke and cardiac arrest.

Individuals with a spinal core injury are at high risk of AD: the direct risk caused by the nerve damage of their initial injury. This means they have the potential to experience serious physical problems without any sensation or ‘early warning signs.’ Indirectly, they are at higher risk of AD because of the results of their neurological injury – a higher likelihood of bowel or bladder dysfunction, for example.

AD can cause delirium and other symptoms associated with neurological functioning. This should, however, be able to be resolved by the quick and effective identification and treatment that is critical to deal with AD.

Symptoms of AD should be treated as a medical emergency. Having a care package with a dedicated team who can provide continuity of care – a partnership with an individual, a family, and carers – means that everyone involved in a person’s care is in a good position to spot signs of AD.

Avoidance and treatment of AD relies upon good nursing care: monitoring the patient’s symptoms, bowel and bladder emptying, skin and pressure care – support with positional changes and identifying early signs of high blood pressure and heart rate.

Living with Cognitive Impairment

People do report symptoms like brain fog and memory problems after spinal cord injuries, and there are certainly reasons why that might happen. However, it is important to remember that for many people, an injury that only affects the spinal cord does not cause cognitive symptoms.

This is reassuring for many, but also a sign that people who are experiencing memory or mood problems should report their symptoms to their doctors, as there may be ways of improving the symptoms or further investigating the cause. There are many potential chronic post-SCI complications[xi][xii] which can cause or exacerbate cognitive dysfunction, and careful management with continued input from specialist neurological rehabilitation teams is important.

Anyone with a significant spinal cord injury, especially higher injuries affecting breathing, can benefit from a comprehensive care package with a team of nurses and healthcare assistants who have had specialist training in the care of people with complex care needs after a spinal cord injury. Care and input from family members can also be helpful for some people.

Having the option of full professional support, however, can help everybody maintain the kind of relationships they value the most. The resilience of family and close social circles after traumatic, life-changing injuries cannot be valued highly enough[xiii] and professional carers understand and bolster those support networks.

Like to know more?

[i] Hagen, E. M., Eide, G. E., Rekand, T., Gilhus, N. E., & Gronning, M. (2010). Traumatic spinal cord injury and concomitant brain injury: a cohort study. Acta Neurologica Scandinavica, 122, 51-57. https://doi.org/10.1111/j.1600-0404.2010.01376.x

[ii] Macciocchi, S., Seel, R. T., Thompson, N., Byams, R., & Bowman, B. (2008). Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence. Archives of physical medicine and rehabilitation, 89(7), 1350-1357. https://doi.org/10.1016/j.apmr.2007.11.055

[iii] Heled, E., Tal, K., & Zeilig, G. (2020). Does lack of brain injury mean lack of cognitive impairment in traumatic spinal cord injury?. The Journal of Spinal Cord Medicine, 1-8. https://doi.org/10.1080/10790268.2020.1847564

[iv] Sezer, N., Akkuş, S., & Uğurlu, F. G. (2015). Chronic complications of spinal cord injury. World journal of orthopedics, 6(1), 24–33. https://doi.org/10.5312/wjo.v6.i1.24

[v] Wu, J., Zhao, Z., Sabirzhanov, B., Stoica, B. A., Kumar, A., Luo, T., Skovira, J., & Faden, A. I. (2014). Spinal cord injury causes brain inflammation associated with cognitive and affective changes: role of cell cycle pathways. The Journal of neuroscience : the official journal of the Society for Neuroscience, 34(33), 10989–11006. https://doi.org/10.1523/JNEUROSCI.5110-13.2014

[vi] Cadel, L., C. Everall, A., Hitzig, S. L., Packer, T. L., Patel, T., Lofters, A., & Guilcher, S. J. (2020). Spinal cord injury and polypharmacy: a scoping review. Disability and rehabilitation, 42(26), 3858-3870. https://doi.org/10.1080/09638288.2019.1610085

[vii] Kitzman, P., Cecil, D., & Kolpek, J. H. (2017). The risks of polypharmacy following spinal cord injury. The Journal of Spinal Cord Medicine, 40(2), 147-153. https://doi.org/10.1179/2045772314Y.0000000235

[viii] Cardenas, D. D., & Jensen, M. P. (2006). Treatments for chronic pain in persons with spinal cord injury: A survey study. The journal of spinal cord medicine, 29(2), 109–117. https://doi.org/10.1080/10790268.2006.11753864

[ix] Theriault, E. R., Huang, V., Whiteneck, G., Dijkers, M. P., & Harel, N. Y. (2018). Antispasmodic medications may be associated with reduced recovery during inpatient rehabilitation after traumatic spinal cord injury. The journal of spinal cord medicine, 41(1), 63–71. https://doi.org/10.1080/10790268.2016.1245010

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