Complete spinal cord injury

Disease Description (Causes and Pathophysiology, Main Symptoms)

• Summary of definition: Complete spinal cord injury is a condition in which motor, sensory, and autonomic functions below the level of injury are completely lost, with nerve transmission blocked below the injury site.
• Main causes: Approximately 70% are traumatic (including approximately 45% due to traffic accidents), while the remainder are due to nontraumatic causes such as tumors and infections. The proportions of trauma (younger people) and falls (older people) differ by age.
• Pathophysiology: Mechanical damage to the spinal cord and secondary inflammation and ischemia cause damage to neurons and glial cells. High cervical injuries (e.g., C3–C5) affect the diaphragm (and indirectly respiration), creating a high risk of respiratory failure. Complete injury causes loss of all sensory, motor, and autonomic functions below the injury, including bladder, bowel, body-temperature, and vascular regulation.
• Main symptoms: Paralysis of the limbs or lower extremities (quadriplegia or paraplegia depending on the level of injury), sensory loss, difficulty breathing (especially with high cervical injuries), neurogenic bladder and bowel, urination and defecation disorders, abnormal vital signs (hypotension, bradycardia, spinal shock), pain, spasticity, and impaired temperature regulation.

Treatment Methods (Standard Treatment · Medication · Procedures · Rehabilitation · Lifestyle Management · Precautions)

• Initial (emergency) care
  • Secure the airway, breathing, and circulation (endotracheal intubation and mechanical ventilation if necessary), immobilize the spine (cervical collar and specialized stretcher), and rapidly evaluate the lesion with imaging (CT and MRI).
  • Hemodynamic stabilization: Correct hypotension and bradycardia (fluids, vasopressors, phenylephrine, etc.), and prevent DVT and PE (early anticoagulation and mechanical prophylaxis).
  • Surgical treatment: In cases of fractures with nerve compression or instability, early decompression and spinal fixation (considered within 24 hours if possible) may be beneficial for neurological outcomes.
  • Steroids (methylprednisolone): Although widely used in the past, recommendations vary by guideline. In general, high-dose steroids are not routinely recommended for all patients; the decision is made in some situations by considering potential benefits and harms. The decision should follow the treating physician’s most current guidance.
• Medication treatment (management of symptoms and complications)
  • Pain (neuropathic pain): Gabapentin, pregabalin, tricyclic antidepressants (amitriptyline), SNRIs (such as duloxetine), etc.
  • Spasticity and muscle spasms: Baclofen, tizanidine, Botox (local treatment), etc.
  • DVT prevention: Low-molecular-weight heparin or other anticoagulants (as indicated).
  • Appropriate antibiotics when necessary, such as for urinary tract infections.
• Rehabilitation (multidisciplinary)
  • Physical therapy: Maximize remaining function, maintain muscle strength and joint mobility, gait training (for incomplete injuries), and respiratory rehabilitation (for patients with high cervical injuries).
  • Occupational therapy: Improve independence in activities of daily living (ADLs), and train in the use and adaptation of assistive devices and wheelchairs.
  • Respiratory therapy: Increase vital capacity, assist coughing, and manage secretions.
  • Urination and bowel management: Individualized plans including intermittent self-catheterization, indwelling catheterization, bladder rehabilitation, and medications (such as anticholinergics).
  • Psychosocial support: Depression and anxiety support, vocational rehabilitation, and family education.
• Lifestyle management and precautions
  • Pressure-ulcer prevention: Change position (as a general guideline, every 2 hours), use pressure-distributing mattresses and cushions, and care for the skin.
  • Infection prevention: Careful urinary management (for urinary tract infection prevention), and pneumonia prevention (respiratory rehabilitation and recommended vaccinations).
  • Caution regarding autonomic dysfunction: Autonomic dysreflexia can cause high blood pressure, headache, sweating, and facial flushing and requires immediate treatment (sitting the person upright, removing the trigger, using antihypertensive medication, etc.).
  • Thrombotic and cardiovascular risk management: Monitor for DVT/PE during the initial and rehabilitation phases.
  • Provide sexual-function and reproductive counseling and rehabilitation.
• Prognosis
  • Prognosis is strongly influenced by the level and completeness of the injury (complete vs. incomplete), the initial neurological status, and the timing of treatment (especially early decompression). In complete spinal cord injury, the possibility of functional recovery is limited.

Checklist Before an Outpatient Visit (Items to Prepare and Information to Obtain — Including Example Questions)

• Essential items and preparations
  • List of medications currently being taken (including doses and times of administration)
  • Previous test results and imaging (CT, MRI, and surgical records), if available, in film or CD/digital-file format
  • Recent neurological examination results (a document stating the ASIA classification is useful, if available)
  • Urine culture results and a voiding diary (catheterization frequency and residual urine volume), and bowel pattern records
  • Photos or records of wounds (pressure ulcers), and a pain diary (timing, intensity, and characteristics)
  • Information on the ability to perform activities of daily living and use of assistive devices (such as wheelchair specifications)
• Key information to organize in advance that the doctor may ask about during the visit
  • When the injury occurred and its course, current changes in symptoms (breathing, sensation, and movement), and whether fever or urinary abnormalities are present
  • Whether there is any newly developed pain, swelling, or skin changes (suspicion of a pressure ulcer)
  • Recent signs suggestive of DVT or pulmonary embolism (leg swelling, chest pain, and difficulty breathing)
• Information that is useful to measure before the outpatient visit
  • Weight, blood pressure, pulse, and respiratory rate (if possible), and urine volume and residual urine volume on bladder ultrasound (if performed)

Examples of General Questions to Ask the Doctor

• What is the location of my injury (spinal cord/spinal level), and what is my ASIA classification? How can my prognosis be predicted?
• What are the goals and expected effects of this treatment (surgery, medication, and rehabilitation)?
• What are the main side effects and precautions for the medications I am currently taking?
• What activities should I avoid in daily life, and what safety measures should I follow?
• How can I prevent and respond early to pressure ulcers, urinary tract infections, blood clots, and autonomic dysreflexia?

Examples of Disease-Specific Questions (1–2)

• At my level of injury, which method of urination and bowel management (intermittent self-catheterization, indwelling catheterization, bladder augmentation surgery, etc.) is most appropriate, and how can I prevent urinary tract infections?
• If autonomic dysreflexia occurs, what actions should I take immediately, and is there emergency medication that can be used at home (e.g., a fast-acting antihypertensive)?

(Note: The information above is general information compiled from the latest recommendations and clinical practices. The diagnosis and treatment plan for an individual patient should be determined in consultation with the treating medical professionals.)