Spinal cord injury: treatment, effects and rehabilitation

NICE guideline NG41 covers the first hours. It says people with suspected acute traumatic spinal cord injury should be transported with full in-line spinal immobilisation to a major trauma centre irrespective of transfer time, unless they need an immediate lifesaving intervention, and that people should not be transported on a longboard or other extrication device, which should only be used to extricate.

After the early phase, a specialist spinal cord injury centre leads rehabilitation. NICE says the surgeon at the trauma centre should contact the linked spinal cord injury centre consultant within 4 hours of diagnosis to establish a partnership of care, and that all people with a spinal cord injury should have lifelong personalised care guided by a spinal cord injury centre. NICE guideline NG211 on rehabilitation after traumatic injury says to assign a named rehabilitation coordinator or key worker as soon as possible and within 72 hours of admission.

Rehabilitation starts in hospital and continues in the community. It usually includes physiotherapy, occupational therapy, nursing for bladder, bowel and skin care, psychological support and planning for home adaptations and equipment. The Royal National Orthopaedic Hospital (RNOH) spinal centre publishes advice for GPs on managing long-term problems in the community.

Spinal Injuries Scotland compares the spinal cord to a telephone cable linking the brain to the body: nerves from the neck supply the arms, neck and upper trunk, those from the upper back supply the trunk and abdomen, and those from the lower back supply the legs, bladder, bowel and sexual organs. So the position of the injury shapes the result. Beyond movement and feeling, the RNOH describes these long-term effects:

• Bladder: loss of control and risk of urine infections or stones. Many people use intermittent self-catheterisation.

• Bowel: a regular bowel routine is important to prevent constipation, impaction and incontinence, which can lead to complications including autonomic dysreflexia, increased spasticity and pressure sores.

• Skin: loss of sensation and movement raises the risk of pressure ulcers. The RNOH advises that anyone with a pressure ulcer keeps off it at all times until healed.

• Breathing: the RNOH says all patients with a spinal cord injury above L1 will have some form of lung dysfunction; assisted coughing may be needed.

• Pain and spasticity: neuropathic pain is characterised by burning, stinging, pins and needles, electric shocks or band-like pain.

• Heart and circulation, and mood: the RNOH covers cardiovascular health and low mood, which can be treated.

Spinal Injuries Scotland classifies injuries by level and completeness. With an incomplete injury some movement or feeling remains, which is why outcomes vary so much between people.

NICE and the specialist centres focus on traumatic injury, such as falls, road collisions or sports injuries. NICE lists dangerous mechanisms including a fall from a height, and a high-risk factor of being aged 65 or older when assessing for cervical spine injury. The sources read for this page do not list non-traumatic causes, so this page does not describe them; ask your care team about your own case.

The RNOH describes autonomic dysreflexia as an uninhibited sympathetic nervous system response to noxious stimuli in people with spinal cord injury at the sixth thoracic level (T6) and above. For an episode it advises sitting the person upright (keeping them upright until blood pressure returns to normal), loosening or removing tight clothing, monitoring blood pressure every 2 to 5 minutes, and checking the bowel and bladder, including catheter kinks, blockages or bladder distension. If you are unsure or it does not settle, treat it as an emergency and call 999.

Call 999 if someone may have injured their neck or back, especially after a dangerous fall or collision, and do not move them unless they are in immediate danger. NICE advises assessing for spinal pain, weakness or altered feeling and other injuries that may hide symptoms. Someone with a suspected spinal cord injury goes first to a major trauma centre or trauma unit, where the spinal team contacts the linked spinal cord injury centre.

How much function returns varies, particularly after an incomplete injury, and your rehabilitation team can discuss what to expect. Practical issues the RNOH covers include support for carers, social services and continuing healthcare assessments, travel, and contraception and fertility. Peer support matters too: the Spinal Injuries Association lists a support line, information on clinical aspects of injury and help with finding the right care package.

Acute spinal cord injury care in the UK is delivered through NHS major trauma networks and specialist spinal cord injury centres. It is an emergency pathway and is not arranged privately. Private care is more relevant afterwards, for example private physiotherapy, neurological rehabilitation or an extra urology or neurology opinion. These work best when they communicate with the specialist spinal centre that provides lifelong follow-up.