Brain and Spinal Cord Injury
Basics
Traumatic brain injury is sudden physical damage to the brain. The damage can result from a closed head injury, such as that caused by impact of the head with an object like the windshield or the dashboard of a car. The damage can also result from a penetrating brain injury, such as that caused by a bullet piercing the skull. Approximately 200,000 people die each year in the US from brain injuries, with an additional 500,000 hospitalized for treatment. About 10% of surviving individuals have continuing disabilities that may impair their ability to live independently.
Traumatic spinal cord injury is damage to the spinal cord that results in loss of mobility or feeling. In most cases, the spinal cord remains intact, but the damage results in loss of nerve function. The spinal cord is a dense bundle of nerves that lies in a narrow canal in the center of the vertebrae. The spinal cord carries all of the major nerve pathways that connect the brain to the rest of the body. Injuries to the neck or back may damage the spinal cord, causing loss of function of the nerves below the injury. In the US, approximately 8,000 new cases of spinal cord injury occur each year, and an estimated 450,000 people in the country live with the condition.
Causes
Automobile accidents are the most common cause of brain and spinal cord injuries. Other common causes of brain and spinal cord injuries include acts of violence and sports injuries. In infants, toddlers, and elderly people, brain injury is often caused by falls in or around the home. Very young children who are violently shaken can experience severe and potentially permanent brain damage.
Spinal column fracture or dislocation resulting in spinal cord compression (such as that caused by diving into shallow water) can cause injury to the spinal cord. Severe spinal cord injury usually occurs after dislocation or compression of the spinal cord. Severing the spinal cord results in immediate paralysis and loss of sensation below the break. Less severe damage to the spinal cord generally results in less severe loss of function.
The extent of secondary damage such as inflammation or hemorrhage following brain or spinal injury often determines the permanence of the initial damage. One of the body’s responses to injury is inflammation. Inflammation occurs when certain cells of the immune system move towards the area of injury and release potent chemicals. Among other effects, these chemicals cause fluid to build up in the injured area. Because both the brain and spinal cord are confined in tight spaces, inflammation or internal bleeding can cause pressure on the nerves. If the pressure does not subside, the nerves will start to die in a few hours. Rapid treatment to reduce the pressure caused by inflammation or internal bleeding may prevent permanent damage to the brain or spinal cord.
Symptoms
The symptoms of brain injury depend on the areas of the brain that are damaged Table 01. A brain injury can be localized to a single area (focal damage), or can spread out over a wide area of the brain (diffuse damage). Localized damage usually occurs at the place where an object strikes the head or penetrates the brain. When this type of damage occurs, the function performed by that part of the brain may be temporarily or permanently lost.
The brain moving within or colliding with the skull usually causes diffuse damage. Because the speech and language areas of the brain sit in pockets of the skull that allow the most movement, they are the most common areas to be injured. As a result, difficulty communicating is a common symptom of closed head injuries. Other symptoms of brain injury may include difficulty swallowing, loss of coordination or balance, blurry or double vision, loss of consciousness, impaired memory, confusion or drowsiness, slurred speech, vomiting, changes in ability to smell, or fluid or blood leaking from the nose or ears. In the most severe cases, heartbeat and breathing may stop, and the injured person may enter a coma or die.
Table 1. Symptoms of Brain Injury
| Minor injury (80%) | More severe injury (10%) | Injury requiring emergency medical care (10%) |
|---|---|---|
| Mild headacheCuts or bruises on scalp | Difficulty communicatingTemporary confusion or memory lossLoss of coordination or balanceBlurry or double visionChanges in smell | Severe head or facial bleedingLoss of consciousness, even if only temporaryConfusion or memory loss lasting more than a few minutesBlack and blue marks below the eyes or behind the earsBlood or clear fluid leaking from the ears or nose (not as a result of a direct blow to the nose)Heartbeat or breathing stops |
The type and severity of spinal cord injury will determine the kinds of symptoms that emerge Table 02. Typical symptoms of whiplash injuries include headache, neck or back pain, swelling in the affected area, and bruising on the neck or back. Compression injuries, dislocation injuries, or severe whiplash may result in weakness, tingling, or numbness in the arms or legs. Other symptoms may include loss of bladder or bowel control and difficulty breathing. In the most severe cases, spinal cord injury results in total paralysis and loss of sensation below the site of damage.
Table 2. Symptoms of Spinal Injury
| Headache; pain in the neck or back |
| Swelling in the affected area |
| Bruises on head, neck, shoulders, or back |
| Weakness, tingling, or numbness in the arms or legs |
| Loss of bowel or bladder control |
| Difficulty breathing |
The extent of damage depends upon the location of the damage to the brain or spinal cord Table 03 Figure 01. Nerves run from the brain through the spinal cord to specific areas of the body. Some nerves travel a relatively short distance through the spinal cord; others, like those that control leg movement, travel long distances through the cord. When the spinal cord is injured, nerve function is affected, causing weakness, paralysis, and loss of sensation below the injury. Consequently, the lower the injury is in the spinal cord, the more localized the symptoms. For example, an injury to the lower spine may affect only leg movement and sensation, whereas an injury to the neck may cause paralysis of the arms, legs, and chest muscles.
Table 3. Symptoms of Spinal Injury by Location
| Neck (cervical region) | Chest (thoracic region) | Lower back (lumbar region) | Tailbone (sacral region) |
|---|---|---|---|
| Loss of sensation and paralysis in the arms, legs, and chest | Loss of sensation and paralysis in the legs and chest | Loss of sensation and paralysis in the legs | Loss of sensation in sacral region and paralysis in the feet |
| Loss of bladder and bowel controla | - | - | - |
aLoss of bladder and bowel control can occur with severe injury anywhere in the spinal cord.
Symptoms of brain injury usually develop soon after the trauma. In some cases, however, an injured person will have no symptoms at first, only to develop serious symptoms hours or days later. In minor cases, a person with a head injury may have a mild headache, a lump on the head, and a bruise or a cut on the scalp. The absence of major physical symptoms, however, does not rule out a serious brain injury. Especially in cases where an injury causes fluid to build up within the brain, symptoms may not appear until much later. For this reason, a person who has experienced a brain injury should be watched closely for any sign of delayed symptoms.
Figure 01. The spinal cord
Risk Factors
Although anyone can experience brain or spine injuries, most injuries occur in young men between the ages of 15 and 24, presumably because many young men engage in active, high–risk lifestyles.
Young children and adults over 75 years of age are more susceptible to brain injuries because of their increased risk of falling.
Failure to use protective gear such as seat belts while riding in automobiles or helmets while riding a bike increases your risk of sustaining serious head or spinal cord injury should an accident occur.
Diagnosis
Traumatic brain injury is sudden physical damage to the brain. The damage can result from a closed head injury, such as that caused by impact of the head with an object like the windshield or the dashboard of a car. The damage can also result from a penetrating brain injury, such as that caused by a bullet piercing the skull. Approximately 200,000 people die each year in the US from brain injuries, with an additional 500,000 hospitalized for treatment. About 10% of surviving individuals have continuing disabilities that may impair their ability to live independently.
Traumatic spinal cord injury is damage to the spinal cord that results in loss of mobility or feeling. In most cases, the spinal cord remains intact, but the damage results in loss of nerve function. The spinal cord is a dense bundle of nerves that lies in a narrow canal in the center of the vertebrae. The spinal cord carries all of the major nerve pathways that connect the brain to the rest of the body. Injuries to the neck or back may damage the spinal cord, causing loss of function of the nerves below the injury. In the US, approximately 8,000 new cases of spinal cord injury occur each year, and an estimated 450,000 people in the country live with the condition.
Automobile accidents are the most common cause of brain and spinal cord injuries. Other common causes of brain and spinal cord injuries include acts of violence and sports injuries. In infants, toddlers, and elderly people, brain injury is often caused by falls in or around the home. Very young children who are violently shaken can experience severe and potentially permanent brain damage.
Spinal column fracture or dislocation resulting in spinal cord compression (such as that caused by diving into shallow water) can cause injury to the spinal cord. Severe spinal cord injury usually occurs after dislocation or compression of the spinal cord. Severing the spinal cord results in immediate paralysis and loss of sensation below the break. Less severe damage to the spinal cord generally results in less severe loss of function.
The extent of secondary damage such as inflammation or hemorrhage following brain or spinal injury often determines the permanence of the initial damage. One of the body’s responses to injury is inflammation. Inflammation occurs when certain cells of the immune system move towards the area of injury and release potent chemicals. Among other effects, these chemicals cause fluid to build up in the injured area. Because both the brain and spinal cord are confined in tight spaces, inflammation or internal bleeding can cause pressure on the nerves. If the pressure does not subside, the nerves will start to die in a few hours. Rapid treatment to reduce the pressure caused by inflammation or internal bleeding may prevent permanent damage to the brain or spinal cord.
The symptoms of brain injury depend on the areas of the brain that are damaged Table 01. A brain injury can be localized to a single area (focal damage), or can spread out over a wide area of the brain (diffuse damage). Localized damage usually occurs at the place where an object strikes the head or penetrates the brain. When this type of damage occurs, the function performed by that part of the brain may be temporarily or permanently lost.
The brain moving within or colliding with the skull usually causes diffuse damage. Because the speech and language areas of the brain sit in pockets of the skull that allow the most movement, they are the most common areas to be injured. As a result, difficulty communicating is a common symptom of closed head injuries. Other symptoms of brain injury may include difficulty swallowing, loss of coordination or balance, blurry or double vision, loss of consciousness, impaired memory, confusion or drowsiness, slurred speech, vomiting, changes in ability to smell, or fluid or blood leaking from the nose or ears. In the most severe cases, heartbeat and breathing may stop, and the injured person may enter a coma or die.
Table 1. Symptoms of Brain Injury
| Minor injury (80%) | More severe injury (10%) | Injury requiring emergency medical care (10%) |
|---|---|---|
| Mild headacheCuts or bruises on scalp | Difficulty communicatingTemporary confusion or memory lossLoss of coordination or balanceBlurry or double visionChanges in smell | Severe head or facial bleedingLoss of consciousness, even if only temporaryConfusion or memory loss lasting more than a few minutesBlack and blue marks below the eyes or behind the earsBlood or clear fluid leaking from the ears or nose (not as a result of a direct blow to the nose)Heartbeat or breathing stops |
The type and severity of spinal cord injury will determine the kinds of symptoms that emerge Table 02. Typical symptoms of whiplash injuries include headache, neck or back pain, swelling in the affected area, and bruising on the neck or back. Compression injuries, dislocation injuries, or severe whiplash may result in weakness, tingling, or numbness in the arms or legs. Other symptoms may include loss of bladder or bowel control and difficulty breathing. In the most severe cases, spinal cord injury results in total paralysis and loss of sensation below the site of damage.
Table 2. Symptoms of Spinal Injury
| Headache; pain in the neck or back |
| Swelling in the affected area |
| Bruises on head, neck, shoulders, or back |
| Weakness, tingling, or numbness in the arms or legs |
| Loss of bowel or bladder control |
| Difficulty breathing |
The extent of damage depends upon the location of the damage to the brain or spinal cord Table 03 Figure 01. Nerves run from the brain through the spinal cord to specific areas of the body. Some nerves travel a relatively short distance through the spinal cord; others, like those that control leg movement, travel long distances through the cord. When the spinal cord is injured, nerve function is affected, causing weakness, paralysis, and loss of sensation below the injury. Consequently, the lower the injury is in the spinal cord, the more localized the symptoms. For example, an injury to the lower spine may affect only leg movement and sensation, whereas an injury to the neck may cause paralysis of the arms, legs, and chest muscles.
Table 3. Symptoms of Spinal Injury by Location
| Neck (cervical region) | Chest (thoracic region) | Lower back (lumbar region) | Tailbone (sacral region) |
|---|---|---|---|
| Loss of sensation and paralysis in the arms, legs, and chest | Loss of sensation and paralysis in the legs and chest | Loss of sensation and paralysis in the legs | Loss of sensation in sacral region and paralysis in the feet |
| Loss of bladder and bowel controla | - | - | - |
aLoss of bladder and bowel control can occur with severe injury anywhere in the spinal cord.
Symptoms of brain injury usually develop soon after the trauma. In some cases, however, an injured person will have no symptoms at first, only to develop serious symptoms hours or days later. In minor cases, a person with a head injury may have a mild headache, a lump on the head, and a bruise or a cut on the scalp. The absence of major physical symptoms, however, does not rule out a serious brain injury. Especially in cases where an injury causes fluid to build up within the brain, symptoms may not appear until much later. For this reason, a person who has experienced a brain injury should be watched closely for any sign of delayed symptoms.Figure 01. The spinal cord
Although anyone can experience brain or spine injuries, most injuries occur in young men between the ages of 15 and 24, presumably because many young men engage in active, high–risk lifestyles.
Young children and adults over 75 years of age are more susceptible to brain injuries because of their increased risk of falling.
Failure to use protective gear such as seat belts while riding in automobiles or helmets while riding a bike increases your risk of sustaining serious head or spinal cord injury should an accident occur.
Because brain and spinal cord injuries are often life–threatening medical emergencies, the doctor must make a rapid initial diagnosis. The doctor or emergency medical technician (EMT) will normally first ask questions about how the injury occurred. If the injured person is unconscious or unable to respond, the doctor or EMT will ask witnesses for details about what happened. If a brain injury has occurred, the doctor will be particularly interested in the timing and duration of any loss of consciousness. For example, a person who was alert immediately after the injury but lost consciousness later may be experiencing bleeding or other fluid build–up within the brain.
After obtaining the initial history, the doctor will assess the patient’s neurological function. The doctor will examine the patient’s pupils for response to light, ask questions to determine whether the patient is confused or disoriented, and will test the patient’s motor responses. A high level of neurological function indicates a minor injury. Patients with impaired neurological function are normally given additional diagnostic tests, and are admitted to the hospital for observation.
A physical examination can identify the likely location of a spinal cord injury. During the initial diagnosis, the physician will test for the patient’s ability to feel or move the arms, legs, and other areas of the body to determine the most likely area of injury.
When brain or spinal cord injury is suspected, the physician will order computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, or x–rays of the affected area. A CT or MRI scan can identify swelling, bleeding, blood clots, or compression in the brain or spinal cord. X–rays can identify fractures of the skull or spine.
Because excessive pressure can quickly cause permanent nerve damage, the physician will normally insert a gauge inside the skull of someone with a severe injury. Reducing pressure within the brain or spinal cord may prevent the secondary damage to nerves that can result in permanent disability. A pressure–monitoring gauge can identify and track inflammation and bleeding within the brain, and is a critical part of intensive care.
Many brain and spinal cord injuries can be prevented by using proper protective gear. Consistent use of seat beats in automobiles can reduce the risk of injuries during accidents. Proper use of car seats can reduce the risk of injury to infants and toddlers. Wearing a helmet while biking, motorcycling, or skating can significantly reduce the risk of head injuries associated with these activities. The risk of injury during contact sports (e.g., football) or other sports with fast–moving projectiles (e.g., hockey or baseball) can be reduced with the use of appropriate helmets and padding.
Injuries that occur in the home can often be prevented. Most brain and spinal injuries that occur in the home result from falls, especially on stairs, in bathrooms, and off ladders or stepstools. Infants, toddlers, and the elderly are especially at risk for falls inside the home. Protective barriers, railings, and handholds can help prevent falls and subsequent injury. Proper use of ladders and stepstools can minimize the risk as well.
Accidents and injuries associated with alcohol use can often be prevented. Alcohol use is a contributing factor in many brain and spinal cord injuries. Driving while under the influence is a major cause of automobile accidents. Excessive alcohol consumption is also often a factor in accidents around the home. Avoiding alcohol before driving or performing other activities that require good judgment or coordination can reduce the risk of accidents that lead to many brain and spine injuries.
Do not dive into shallow water.
Prevention and Screening
Many brain and spinal cord injuries can be prevented by using proper protective gear. Consistent use of seat beats in automobiles can reduce the risk of injuries during accidents. Proper use of car seats can reduce the risk of injury to infants and toddlers. Wearing a helmet while biking, motorcycling, or skating can significantly reduce the risk of head injuries associated with these activities. The risk of injury during contact sports (e.g., football) or other sports with fast–moving projectiles (e.g., hockey or baseball) can be reduced with the use of appropriate helmets and padding.
Injuries that occur in the home can often be prevented. Most brain and spinal injuries that occur in the home result from falls, especially on stairs, in bathrooms, and off ladders or stepstools. Infants, toddlers, and the elderly are especially at risk for falls inside the home. Protective barriers, railings, and handholds can help prevent falls and subsequent injury. Proper use of ladders and stepstools can minimize the risk as well.
Accidents and injuries associated with alcohol use can often be prevented. Alcohol use is a contributing factor in many brain and spinal cord injuries. Driving while under the influence is a major cause of automobile accidents. Excessive alcohol consumption is also often a factor in accidents around the home. Avoiding alcohol before driving or performing other activities that require good judgment or coordination can reduce the risk of accidents that lead to many brain and spine injuries.
Do not dive into shallow water.
Treatment
When a suspected spinal cord injury occurs, it is important not to move the injured person unless absolutely necessary until qualified emergency medical personnel can evaluate the situation. Moving the injured person before stabilizing the injury can cause additional damage to the spinal cord. If the person is in immediate danger and must be moved, immobilizing the head and neck first may minimize the risk of additional injury.
Emergency medical treatment for brain or spinal cord injury can make the difference between recovery and permanent disability or death. In cases of severe brain or spinal cord injury, a person may stop breathing, and his or her heart may stop beating. Cardiopulmonary resuscitation (CPR) can keep the person alive until emergency medical help arrives. The emergency medical technicians (EMTs) or paramedics will immobilize the injury, stabilize the patient’s heart rate and breathing, take measures to prevent shock, and transport the patient to an emergency room.
In the emergency room or intensive care unit, the physicians and other health care professionals will continue to work to stabilize the patient’s blood pressure, heart rate, breathing, fluid and electrolyte balance, and pressure within the skull or spine to promote healing. Mechanical ventilation may be required, and drugs may be administered to reduce inflammation and pressure on the nerves in the brain or spinal cord.
Mild head injuries can be treated at home. Mild headaches caused by minor blows to the head can be safely treated with acetaminophen to relieve the pain. Nonsteroidal anti–inflammatory pain relievers such as aspirin, ibuprofen, or naproxen should not be taken because they can make any bleeding inside the brain worse. If you or someone you are with loses consciousness after an injury, however briefly, or have any of the other symptoms of a serious head injury [Table 1], you should seek medical care immediately.
Mild whiplash injuries can be treated with bed rest and regular monitoring. Medical evaluation and treatment should be sought whenever spinal cord injury is suspected. If, upon examination, the injury is minor and confined to the muscles or ligaments supporting the spine, bed rest and regular monitoring may be the only treatments needed.
Seek medical care if you start having signs of complications from your head injury Table 04. Even if your head injury was not serious, new symptoms and unexpected complications can develop hours or even days after the injury. The first 24 hours are the most crucial, and you should remain with a reliable companion during this period.
If there is a swelling at the site of injury, apply an ice pack, making sure that there is a cloth or towel between the ice pack and the skin. If swelling increases markedly in the spite of the ice pack application, call your doctor or go to the hospital.
Table 4. Signs of Complications of a Head Injury
|
Feeling drowsy, or having an unusally difficult time waking from sleep |
| Nausea or vomiting |
| Having seizures or convulsions |
| Clear fluid or blood draining from the ears or nose |
| Severe headaches |
| Numbness, weakness, or decreased movement in an extremity |
| Feeling confused, or behaving strangely |
| Visual disturbances or changes in pupil size (unequally-sized pupils) |
| A very slow or very rapid pulse, or an unusual breathing pattern |
Your doctor is the best source of information on the drug treatment choices available to you.
Speech therapy, physical therapy, and occupational therapy may help people with brain or spinal cord injuries to recover and live independent lives. Many people who have impaired speech as a result of an injury can benefit from intensive speech therapy. Physical therapy can help to maintain muscle tone, avoid atrophy or weakening of the muscles, and improve circulation. Occupational therapy can help an injured person learn how to perform practical tasks and live as independently as possible.
Support and counseling may help people cope with their changed circumstances after severe brain or spinal cord injury. It is common for a person to experience depression, anxiety, and other behavioral changes after a severe brain or spinal cord injury. Professional care and support may help the injured person adjust to his or her new circumstances. In some cases, antidepressants, anti–anxiety drugs, or drugs designed to reduce agitation may help as well.
Surgery may be required to relieve pressure in the brain or spinal cord. Increased pressure in the brain or spinal cord is a serious complication of traumatic injury. In fact, the pressure caused by swelling following the injury may cause more nerve damage than the original trauma. Surgery may be required to open the skull or spine to relieve the pressure. Blood clots in the brain may also accompany head injury. In these cases, surgery may be required to remove the clot and ensure adequate blood flow to all the areas in the brain.
Surgery may be required to treat penetrating head injuries Figure 02. In the US, gunshot wounds are the most common cause of penetrating head injuries. The amount of damage depends on the caliber of the weapon, the distance from which it was fired, the type of ammunition used, and the trajectory of the bullet. Surgery may be required to remove the bullet or bone fragments from the brain, repair damaged blood vessels, and close the wound.
Surgery may be required to realign damaged vertebrae after spinal injury. If the spinal injury damaged the vertebrae or caused them to be dislocated, surgery may be required to stabilize the bones, to remove bone fragments from the spinal cord, or to realign the vertebrae to prevent any additional damage to the spinal cord.
Figure 02. Gunshot Wound
Athletes who suffer concussions as a result of contact sports must seek a doctor’s advice about whether they can return to the sport. Athletes who have had a concussion are at increased risk of having another concussion, and of having brain damage as a result of subsequent concussions.
Doctors must follow standard guidelines when managing athletes who have suffered concussions. According to the severity of, and number of concussions suffered, a doctor may recommend that an athlete stay on the sidelines for the remainder of the game, not return to the sport for the entire season, or refrain entirely from that particular sport or any collision sport.
Most people with a minor head injury recover completely within a few days. While the prognosis for more severe injury is difficult to predict, about half of people who experience severe brain injury survive. It is possible for people who survive a severe head injury to experience near–complete recovery. This is because many brain functions can be performed by more than one area of the brain, and uninjured areas sometimes take over functions of regions that have been lost. This process, however, is unpredictable. It may take years, and some residual disability usually remains. Some brain functions, such as vision and limb movement, can only be performed by specific brain areas, and damage to these regions usually results in permanent loss of function.
The most severe cases of brain injury may result in permanent paralysis or coma. Persistent total unconsciousness, also known as persistent vegetative state, is the most serious consequence of nonfatal head injury. It results when the upper brain (the part that controls high–level mental function) is destroyed, but the thalamus and brain stem (the parts of the brain that control breathing, temperature control, heart rate, etc.) are uninjured. If the state lasts for more than a few months, it is highly unlikely that the person will ever regain consciousness.
The prognosis for spinal injury depends on the extent of the injury. Spinal injury involving only muscles and ligaments is likely to resolve completely within several weeks. Spinal fractures usually heal within two months. Rehabilitation and physical therapy may reverse some paralysis. If the paralysis lasts for more than six months without improvement, however, it is likely to be permanent.
The frequency of follow–up depends on the nature and severity of the original injury. Minor head or neck injuries generally do not require follow–up. People with more severe injuries should undergo regular follow–up to monitor recovery and to look for signs of potential complications.