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The spinal cord extends from the brainstem to the lower back and is a vital highway of nerves that transmits information from the brain to the body and return. Damage to the spinal cord can result in temporary and/or permanent change in function within the spinal cord which impacts various other areas of the body.

Spinal cord injury can be classified in a variety of ways dependent on the mechanism of injury, location and severity of injury (among other factors). There is approximately 20,800 people in Australia living with a spinal cord injury.

The spine is divided into four regions which are the cervical, thoracic, lumbar and sacral regions and the location of injury dictates part of the classification of SCI as mentioned above. This is where the terms “tetraplegia” and “paraplegia” are most important. If a person sustains a SCI in their cervical spine (upper spine) it will result in tetraplegia, meaning the arms, legs, trunk and pelvic organs may be affected. If a person sustains an injury in another part of the spinal cord i.e. thoracic, lumbar or sacral areas this will result in paraplegia, meaning the leg, pelvic organs or trunk may be affected but the upper limb is not.

Causes of SCI

Spinal cord injuries can be classed as either traumatic or non-traumatic dependent on the mechanism of injury.

Traumatic causes:

  • Road traffic accidents. This is more common for younger Australians (particularly males) and research suggests this category accounts for approximately 46% of traumatic-SCI cases.
  • Falls (especially in older adults)
  • Sports injuries (such as diving into shallow water or skiing accidents)
  • Acts of violence

Non-traumatic causes:

  • Infections (e.g., spinal abscess, tuberculosis)
  • Inflammatory conditions (e.g., transverse myelitis)
  • Tumours pressing on the spinal cord
  • Vascular disorders like spinal cord infarction

Factors such as age, general health, and pre-existing spinal conditions may influence both the risk and severity of injury.

Grading of Spinal Cord Injury (ASIA Impairment Scale)

Health professionals including Physiotherapists use the ASIA Impairment Scale (AIS) to describe the degree of motor and sensory function loss. This system, developed by the American Spinal Injury Association, uses the following categories:

  • AIS A (Complete): No motor or sensory function preserved below the level of injury, including the sacral segments S4–S5.
  • AIS B (Sensory Incomplete): Sensory but not motor function is preserved below the neurological level, including the sacral segments.
  • AIS C (Motor Incomplete): Motor function is preserved below the injury level, and more than half of key muscles below the level of injury have a muscle grade less than 3 (i.e., they can’t move against gravity).
  • AIS D (Motor Incomplete): Motor function is preserved, and at least half of the key muscles below the injury have a muscle grade of 3 or more.
  • AIS E (Normal): Motor and sensory functions are normal, but the person had prior deficits.

This classification helps guide prognosis and rehabilitation planning.

It is important to note that ASI A impairment grading can be variable in the acute stage of injury known as “spinal shock”. Spinal shock occurs within minutes to hours post injury and is a temporary loss of all reflex activity below the level of the injury. This can affect ASI A grading as this scale is based off motor and sensory testing, and the results of testing may differ once spinal shock has resolved.

Further Classification – Incomplete Injury

Depending on the location of the injury within the spinal cord there can be various patterns/presentations that are important in planning for rehabilitation. Below are just some of the common presentations:

Central Cord Syndrome

  • Most common incomplete injury, especially in older adults with cervical spine arthritis
  • Greater weakness in the arms than the legs
  • Some sensory and bladder dysfunction may be present
  • Often results from falls or hyperextension injuries

Anterior Cord Syndrome

  • Damage to the front (anterior) portion of the spinal cord
  • Loss of motor function and pain/temperature sensation
  • Preservation of touch, vibration, and proprioception (body awareness)
  • Often results from flexion injuries or disruption to the anterior spinal artery

Brown-Séquard Syndrome

  • Injury to one side of the spinal cord
  • Motor loss and proprioception difficulty on the same side as the injury
  • Pain and temperature loss on the opposite side
  • May result from stab wounds or lateral compressive injuries

Posterior Cord Syndrome

  • A rare condition which involves damage to the back (posterior) of the spinal cord
  • Preserved motor function but loss of proprioception and vibration
  • May lead to poor coordination or balance

Conus Medullaris Syndrome

  • Damage to the bottom tip of the spinal cord (conus medullaris)
  • Causes mixed motor and sensory loss in the lower limbs
  • Bladder and bowel dysfunction is common

Cauda Equina Syndrome

  • Affects the bundle of nerves (not the spinal cord itself) just below the conus
  • Often caused by disc herniation or trauma
  • Results in asymmetrical weakness, sensory changes, and severe bladder or bowel dysfunction
  • Requires urgent medical attention

Prognosis

The outlook for someone with a spinal cord injury depends heavily on:

  • The level and completeness of the injury
  • How quickly medical care was provided
  • The presence of complications such as infections or pressure injuries
  • Rehabilitation engagement and access to supportive services

Those with incomplete injuries (AIS B–D) generally have a better chance of regaining function compared to those with complete injuries (AIS A). Most improvements occur within the first 9-12 months post-injury, though gains can continue for years with appropriate therapy and motivation.

Treatment

Emergency Care

  • Immediate immobilisation of the spine
  • Surgical intervention may be required to relieve pressure or stabilise the spine
  • Intensive care management to prevent complications

Medical Management

  • Pain management
  • Management of spasticity, infections, blood pressure regulation
  • Bladder and bowel care routines
  • Respiratory support if needed

Physiotherapy and Rehabilitation

Physiotherapy plays a critical role in both the acute and long-term management of SCI. Interventions are tailored based on the individual’s specific needs, goals, and level of function.

In the early stages:

  • Chest physiotherapy to assist breathing and prevent infections
  • Positioning and movement to prevent contractures and pressure injuries
  • Passive range of motion exercises to maintain joint health
  • Education for the person and family

As recovery progresses:

  • Strengthening and functional training to improve what voluntary movement is available
  • Wheelchair mobility and transfers training
  • Balance and coordination exercises
  • Standing and gait training, including use of parallel bars, bodyweight-supported treadmills and/or other supportive equipment.
  • Pain and spasticity management
  • Hydrotherapy may be used to help regain movement in a gravity-reduced environment.

Physiotherapists also work closely with occupational therapists, speech therapists, psychologists, and medical specialists to create a multidisciplinary rehabilitation plan.

Assistive Technologies and Supports

  • Wheelchairs, orthoses, and mobility aids
  • Environmental modifications for home and workplace
  • Assistive communication tools if speech is affected
  • Community reintegration support