Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Spinal Cord Injuries and the resulting paralysis. For the rest of the Mangled Mondays series, [click here].
Complete Spinal Cord Injury
3–5, depending on the level at which the spine is cut.
What Is It?
A spinal cord transection is an injury in which the spinal cord is cut. A complete spinal cord injury (SCI) is one in which the spinal cord is totally severed and no signals pass from the brain to the distal nerves; this is as opposed to a partial SCI, in which a significant portion of the cord is damaged but other parts remain intact.
This article deals specifically with complete SCIs.
The spinal cord is a bundle of nerves that carry messages between the tissues of the body and the brain. It’s housed within the backbone, the protective vertebrae of the spine, and is well protected.
However, when the spinal cord is severed, the messages are cut off. The brain sends messages, but they are no longer received, and thus the brain can no longer control the muscles or organs below the wound. The nerves below also cannot transmit sensations up to the brain.
The effects of this on functioning are severe, multifold, and permanent. They are also almost entirely dependent on where in the spinal cord the injury occurs.
A spinal cord transection will eliminate sensation and control of all elements below it. For example, a transection at the level of T9 – the 9th thoracic vertebra, level with the 9th rib – will cut off all sensation and skeletal muscle control at or below the level of the belly button.
Dermatomes. OpenStax Anatomy and Physiology, 8th Edition, 2016. Licensed via Creative Commons Attribution 4.0 license.
A spinal cord transection…
will eliminate sensation and control of all elements below it. For example, a transection at the level of T9 – the 9th thoracic vertebra, level with the 9th rib – will cut off all sensation and skeletal muscle control at or below the level of the belly button.
(There are 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 fused sacral bones where the spine meets the hip, and 4 fused vertebrae of the coccyx [cox-ix], or tailbone.)
There’s a saying in emergency medicine: “C5 stays alive.” The muscles of the diaphragm are controlled by the C5 nerves, which exit the spinal cord between the 5th and 6th cervical vertebrae; if the injury is above this point, breathing function will be impaired or completely destroyed. Characters with high cervical spinal cord injuries will be ventilator-dependent if they survive.
The arms are controlled by nerves at the level of C6, C7, and C8; if the injury occurs between C5 and T1, characters will have partial function of their arms. Note: there is no C8 vertebra, but by the naming convention, each nerve is named for the vertebra above it. C8 nerves exit the spine between the C7 and T1 vertebrae.
Injuries below the level of T1 will leave characters the full use of their arms.
- Paralysis below the level of the injury. Loss of tendon reflexes.
- Blood vessels below the injury dilate, leaving the area warm or even flushed at first.
- If the injury is high enough, the character may go into neurogenic shock (also known as spinal shock), wherein blood pressure falls due to dilation of the blood vessels and the inability to regulate heart rate.
- Loss of bladder control. This often leads to urinary retention (inability to pee), but initially causes urination during the event.
- Loss of bowel control.
- If in neurogenic shock: low blood pressure, slow heart rate (~50 beats per minute), warm and flushed skin.
- Numbness and lack of sensation below the injury.
- Pain at the injury site (if there’s an associated fracture).
How Does It Happen?
In order to sever the spinal cord, the character must receive an injury in the back. This might be a cutting type of injury, such as a knife or sword wound. It may also be the result of a gunshot wound to the spine (where the bullet often lodges); gunshot wounds can come from the front or the back of the torso. Shrapnel from explosions may also sever the spinal cord.
Blunt trauma can cause a transection of the spinal cord as well. This typically involves fracturing the bone with enough force that two adjacent vertebrae shear the character’s spinal cord and cut through it. These injuries could happen in a direct impact, such as being hit by a baseball bat or golf club, or a fall from significant height.
In pediatric characters, this can actually occur and show no evidence on an X-ray, a condition known as SCIWORA, for “spinal cord injury without radiographic abnormality.”
That’s because the spines of younger children are very flexible; with the right kind of trauma, the vertebrae may shear the cord and then return to their original position. This can lead to doctors staring, confused, over a child’s X-rays and wondering what happened.
Lastly, cervical spine (neck) fractures may come from compression of the vertebrae. Force is applied to the top of the head, which can cause the vertebrae to come down and transect the cord. This is known as an axial loading injury. Lumbar (lower back) fractures causing transection can also come from axial loading injuries, such as attempting to land heel-first in a fall.
Field care for a spinal cord transection depends on two things: whether the character has control over their respiratory muscles, and whether the character is in neurogenic shock.
The character’s cervical spine will be stabilized with a rigid collar to prevent further injury.
Strapping patients to rigid backboards was the standard of care for many years, but is falling out of favor as new data shows no evidence of benefit and increasing evidence of harm. Instead characters will be carefully moved with rigid collars and breakapart metal-framed transfer devices, called scoop stretchers, onto the EMS cot.
Characters will get field evaluations and IVs from EMS. If they have any other trauma, that will get initial treatment as well, such as hemorrhage control.
If the character’s not breathing: Bystanders might give mouth-to-mouth resuscitation, and EMS will ventilate the patient with a bag-valve-mask (BVM). Paramedic or doctor characters with the proper equipment can intubate, or place a breathing tube, down the character’s throat. If a ventilator is available, it will be used.
Some of the manual maneuvers, such as opening the airway, change if a spinal injury is suspected. Instead of tilting the character’s head back to open the airway and initiate breaths, they’ll actually thrust the jaw forward, a procedure known as the manual jaw thrust.
If the character is in neurogenic shock: EMS will administer a large volume of IV fluids to try to “fill the tank” and raise the blood pressure. The more advanced systems allow paramedics to give a medication called norepinephrine (Levophed), which works to constrict the blood vessels and also is aimed at raising blood pressure.
Surgery / Hospitalization
This character’s hospital stay will be prolonged, with a lengthy stay in the ICU.
The very first step is stabilizing them with medications, airway interventions, and IV fluids. Then, when they’re close enough to “regular and normal,” the broken areas of the spine will have to be stabilized with surgery. That may happen within 24 hours, but may be as much as a week later.
The character will have a Foley catheter placed, multiple IVs inserted, possibly an arterial line to monitor blood pressure. They’ll have a nasogastric, or NG, tube for feeding, as eating and drinking present a risk for aspiration (inhaling the foreign substance) and choking.
They will be given an orthopedic brace for the chest and back to protect their spine while it heals. They may be given a “halo” device to immobilize the head if the injury is in the neck.
Then will come physical and occupational therapy to use what muscles remain.
In the Austere Environment
Characters who require life support due to respiratory paralysis will die in the field.
Characters who suffer from neurogenic shock may, but will not definitely, die in the field.
Characters who suffer bodily paralysis will require the aid of others to help them move to safer environments. Recovery is possible in remote locations, but the character will lack the assistance of specialists such as neurosurgeons, spine surgeons, occupational therapists, etc. Their recovery will be significantly prolonged by this.
The Rocky Road to Recovery
The injured character will retain use of areas above the injury. Characters with injuries in the C7–C8 range will retain partial, but not complete, use of their arms; injuries below T4 will not affect the arms.
Unless there is direct trauma to the brain or the character was unable to breathe and suffered brain damage from hypoxia, neurocognitive status should remain intact.
Characters whose injuries are below the level of T1 will have the ability to use a standard wheelchair, and may be strong enough to move themselves from bed to wheelchair and vice versa.
With complete SCIs, the disabilities are permanent, not temporary. See below.
Characters with a spinal cord transection are permanently paralyzed, barring science fiction interventions or some form of magical healing (for instance, nanobots, healing magic, or some form of advanced neuroregenerative surgery or therapy).
Unused muscles will atrophy, and will eventually appear significantly smaller than the parts of the body that are able to exercise.
Features of Recovery: Hospital Stay
Paralyzed characters will spend some time in ICU until their blood pressures stabilize. They may require a number of medications, including steroids, which reduce inflammation, and vasopressors, which maintain strong blood pressure.
They will also get regular injections of an anticlotting agent to prevent blood clots from forming in their legs from lack of motion.
Features of Recovery: PT/OT
Occupational therapy will focus on strengthening the muscles the character is able to use and helping them learn to use mobility aids such as wheelchairs.
Characters with high-level injuries who are unable to use their arms may use their mouths to use “straw-powered” chairs, such as those used by paralyzed actor Christopher Reeve.
The New Normal
Paralyzed characters’ lives are significantly affected by their injury.
They may require a home attendant for round-the-clock care, along with a visiting nurse, to take care of tasks like cooking and feeding. Alternatively, family members may take care of one or all of these tasks.
They may opt to have a series of catheters to collect their urine, including Foley catheters (all anatomies); a Texas catheter or condom catheter (bepenised persons); or suprapubic catheters, which enter the bladder through the lower abdomen.
Similarly, they must choose how they wish to manage their feces. Some characters may simply wear a diaper and have a caretaker clean them when they defecate, over which they have no control. Some may choose to have a caretaker manually stimulate defecation by stimulating the anus, allowing them some (but not total) control over when they defecate. Some may decide to have a colostomy put in, which is a surgical opening, through the skin and into the colon, that allows them to collect feces into a bag that can be discarded.
Characters who menstruated before paralysis will continue to menstruate. In fact, they are perfectly capable of becoming pregnant and giving birth to healthy children. Delivery may have to be by C-section, since the ability to “push” is diminished or nonexistent.
Anatomic males will not be able to get erections arising from mental stimulation such as thoughts or words, but will be able to get erections from direct stimulation of the penis and potentially of other erogenous zones such as the nipples. Ejaculation is almost never possible in those with spinal cord transections. Yet 1 in 3 males will be able to orgasm.
As for anatomic females, control of the vaginal muscles is lost, and the ability to produce lubrication may be reduced or lost entirely. Sensation is significantly reduced.
(Note: the terms “anatomic male” and “anatomic female” are used here, but I understand and support the positions of trans, nonbinary, gender nonconforming, and intersex persons. Your character’s identity is not necessarily tied to their anatomy, but their physiology inherently is.)
Characters may find that their sexual focus changes, however, to be less about their genitalia and more about physical intimacy. Oral-genital intercourse is common among couples where one partner is paralyzed.
Characters of all genders and orientations may experience reduced sex drive and frustration at their inability to feel their genitalia; medications such as sildenafil (Viagra) or its cousins can help.
Characters will always be at risk of blood clots in the dormant legs. Those clots can break off, travel to the lungs, and kill them. (Pulmonary embolism)
Characters will always be at risk of pressure sores (decubitus ulcers, aka bed sores) on parts of the body that they are unable to move. Decubitus ulcers can lead to bone infections, known as osteomyelitis, which can necessitate amputation or other major surgery.
Characters may be prone to fainting caused by the movement of blood into and from the legs during motion (orthostatic, or postural, hypotension).
Characters who choose to use catheters to manage their urine will be at risk of urinary tract infections from bacterial colonization of the catheter, which can quickly turn to sepsis and become life-threatening.
Characters who choose not to use catheters risk skin damage around the buttocks and thighs due to urine irritation. They will also be at risk of UTIs (urinary tract infections).
Characters with colostomies to manage their feces run the risk of bleeding, leaking, and other unpleasantness. It’s also possible to develop infection and sepsis at the ostomy site (opening from the bowel to the bag).
Characters with injuries above the level of T6 are at risk of autonomic dysreflexia, a response to irritation below the level of paralysis (such as bladder irritation or constipation), which causes goosebumps below the level of injury, high blood pressure, flushed face, pounding headache, and a slow pulse. AD can be lethal, because the elevated blood pressure associated with it can cause a stroke.
Almost all paralyzed characters will have episodes of spasticity, in which muscles below the injury tighten and may flail. Many will take muscle-relaxing medications such as baclofen to prevent spasticity.
Finally, the vast majority of paralyzed characters will have depression in some form and for some duration following their injury; whether this is a direct result of the injury itself or because of the changes in their lifestyle isn’t clear. For some it goes away with time and adaptation; others continue to struggle for a long time after their injury.
Total Recovery Time (Typical)
2–6 months to “new normal”.
Characters may lose consciousness when they’re injured and see multicolored spots or stars as they do so; this may be described as a “fade to black.”
Characters in ICUs often develop a sickly sweet odor of “sickness”; this is far from unique to spinal cord injury patients. The scent may reoccur if they become septic later on.
Characters may void their bowels or bladder at the time of injury, and will smell accordingly.
If some of the muscles of respiration are paralyzed (T1-C5), breaths may sound like gurgling.
“C-spine” refers to the cervical spine, or neck. A “C-collar” is a stiff, rigid collar that keeps the neck still.
A halo vest is a device with a metal “halo” and pins that bolt it into the skull, which is attached to a device worn around the torso. It is used to immobilize the head, neck, and spine after a cervical fracture.
- Complete spinal cord transections are permanent and do not improve with time.
- Which body parts are paralyzed depends on the level of the injury. The higher the injury, the more of the body is paralyzed.
- SCIs do not affect the brain unless there is other trauma or the brain is injured by shock or respiratory failure.
- A body map of “dermatomes” is a visual representation of what nerves enervate what parts of the body; see earlier in this entry.
- Injuries below C5 preserve the ability to breathe unassisted.
- Injuries below T1 preserve motion and strength of the arms.
- Characters with spinal cord transections may be dependent on others to care for them to various degrees. Some characters with lower lesions may be able to manage their own toilet care, while others may not.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.