The Spinal Cord and Traumatic Injury

• Approximately 20,800 people are estimated to be living with a spinal cord injury in Australia today
• There are likely to be around 380 new incidences this year
• More than 80% of spinal cord injuries under 65 years of age are from traumatic causes
• Almost one quarter (23%) of people with a spinal cord injury are under 35 years old
• The most likely age of injury is 15 to 25 years of age
• 80% of injuries are male

Source: https://treasury.gov.au/sites/default/files/2021-05/171663_the_australian_spinal_cord_injury_research_collaborative_supporting_document_3.pdf

The Australian spinal cord injury survey of Australians living with an SCI found that people rated bladder or bowel control, chronic pain and lack of hand function (for tetraplegic injuries) as the most significant factors impacting their quality of life and would prefer to regain these three functions over all other functions.

Source: https://treasury.gov.au/sites/default/files/2021-05/171663_the_australian_spinal_cord_injury_research_collaborative_supporting_document_3.pdf

Sudden injuries, such as traumatic SCIs, are likely to impact a person’s mental health and wellbeing. Beyond Blue estimates that up to 40% are likely to suffer PTSD and 30%are at risk of depression.

Source: https://treasury.gov.au/sites/default/files/2021-05/171663_the_australian_spinal_cord_injury_research_collaborative_supporting_document_3.pdf

Following a spinal cord injury people can experience increased challenges with their mental health. This might include sleep disturbance and cognitive problems. There may be grief and loss, trauma, pain, financial impact, isolation, additional physical deterioration, and family impacts. Some people will experience depression. All of these are very common and take time and help to overcome.

“Life with a spinal cord injury is challenging but challenges can be rewarding, satisfying and fun. Lean into the discomfort and you will find your way, there are so many opportunities to find beauty and enjoyment.” Person with L1 paraplegia

To read Case Study see page 13 of the report here

After a spinal injury, a client may not have the same control over their bladder. This is called a neurogenic bladder.
Bladder control happens at the sacral nerve level, and it is a reflex responding to the filling of the bladder. If an injury is higher than the sacral area then there should be no problem with this reflex. However, the brain controls the reflex helping a person to hold on and telling you when to empty.

There are two types of neurogenic bladder:

1. Overactive- hyperreflexic, when the injury is above T12. The bladder will hold less urine because it spasms with the reflex controlled by the spinal cord, filling and emptying frequently.
2. Underactive -areflexia, injury below T12, where the bladder muscles are sluggish or do not work causing bladder to overfill and leak.

Things to consider: A client may have a permanent catheter or catheterise intermittently, infection is the major concern to monitor for, as well as blocks to the catheter.

The sacral nerves are responsible for bowel movements. There are two types of problems after spinal cord injury and is called a Neurogenic bowel.

1. Reflex bowel, occurs if the injury is higher than T12. The bowel will empty when the rectum reflex senses it is full, this may not be at a convenient time and the brain can not get the message to tell it to wait.
2. A non-reflex bowel, occurs if the injury is below T12. The damage to sacral nerves means the rectum and sphincter will be relaxed and do not respond. The rectum will overfill and leak, causing an accident.

Things to consider: The importance of a bowel routine and watch for signs of constipation.

The decreased or lack of sensation and movement increases the risk of skin issues.

The lack of sensation can mean a client will not notice if they bump themselves or cut themselves and they are more at risks of burns from hot and cold items.

Pressure from not moving can cause areas of redness and develop into pressure sores where the skin and tissue under the skin is damaged, breaking down to form an ulcer.

There is a reduced capacity to sweat or shiver causing difficulties with maintaining body temperature.

Things to consider:

• Relieve pressure using devices appropriate for this and adjusting position regularly.
• Good skin hygiene and eating well are important for skin integrity.
• Avoid heat packs, electric blankets and icepacks, and check water temperature for personal care and other activities.
• Cover up in the cold and change wet clothes quickly.
• During hot days monitor client and environment temperatures and prevent overheating.

It would seem a little ironic that people with a spinal cord injury and little to no sensation can feel pain, but they can, and it is common. Studies suggest that two thirds of people with spinal cord injury experience chronic pain and one third severe pain.

Pain can be experienced above the level of injury, at the level of injury or below the level of injury.
Feeling pain is also linked to a complete or incomplete spinal injury. Sensory loss can vary in an incomplete injury from minimal loss to complete loss.

Different types of pain after spinal cord injury include:

• Musculoskeletal pain; caused by muscle tightness often described as dull and consistent. Upper extremity pain, above level of injury, is usually due to overuse or spasms of the muscles the client now relies on.
• Visceral pain; pain from internal organs, caused by issues usually relating to the bowel and bladder.
• Neuropathic pain; caused by the damage to the spinal cord. At the level of injury or below, the nerve signals to the brain are disrupted, the brain misinterprets sensory signals and perceives these as pain. It is often described as sharp, stabbing, or burning sensation even from areas where clients have lost sensation. People with neuropathic pain may also be very sensitive to touch or cold, and experience pain due to a stimulus that would not normally be painful, such as light brushing of the skin.

Things to consider: Bladder infection, constipation, fatigue, depression and anxiety and stress can make pain worse. Medications or being distracted or using gentle movement/exercise can reduce pain.

Autonomic dysreflexia (also known as hyperreflexia) is a medical condition that causes a sudden rise in blood pressure in a person with a spinal cord injury, at or above, the T6 spinal level.

It is an important condition to understand as it is considered life threatening.

People with a complete spinal cord injury have a much higher incidence of autonomic dysreflexia: 91% with a complete injury versus 27% with an incomplete injury.

Autonomic dysreflexia is most commonly triggered by a cause related to the bladder or bowel.

Bladder causes

• Overfull bladder from kinked or blocked catheter or full leg bag
• Urinary tract infection
• Kidney stones
• Procedures such as catheter change or tests where the bladder is distended.

Bowel and abdominal causes

• Constipation
• Irritation from rectal examination or
  enema insertion
• Inflamed haemorrhoids
• Stomach ulcers, gallstones or appendicitis.

Other causes

• Excess pressure from contact with hard or sharp objects
• Broken bones
• Pressure injuries
• Ingrown toenails
• Burns or exposure to sudden heat or cold
• Insect bites.
• Sexual activity

• High blood pressure
• Pounding headache
• Flushed face
• Sweating above the level of injury
• Pale and goose bumps below the level of injury
• Nose stuffiness
• Nausea
• A slow pulse