Spinal cord injury
- Every year, around the world, between 250 000 and 500 000 people suffer a spinal cord injury (SCI).
- The majority of spinal cord injuries are due to preventable causes such as road traffic crashes, falls or violence.
- People with a spinal cord injury are two to five times more likely to die prematurely than people without a spinal cord injury, with worse survival rates in low- and middle-income countries.
- Spinal cord injury is associated with lower rates of school enrollment and economic participation, and it carries substantial individual and societal costs.
Understanding spinal cord injury
The term ‘spinal cord injury’ refers to damage to the spinal cord resulting from trauma (e.g. a car crash) or from disease or degeneration (e.g. cancer). There is no reliable estimate of global prevalence, but estimated annual global incidence is 40 to 80 cases per million population. Up to 90% of these cases are due to traumatic causes, though the proportion of non-traumatic spinal cord injury appears to be growing.
Symptoms of spinal cord injury depend on the severity of injury and its location on the spinal cord. Symptoms may include partial or complete loss of sensory function or motor control of arms, legs and/or body. The most severe spinal cord injury affects the systems that regulate bowel or bladder control, breathing, heart rate and blood pressure. Most people with spinal cord injury experience chronic pain.
Males are most at risk in young adulthood (20-29 years) and older age (70+). Females are most at risk in adolescence (15-19) and older age (60+). Studies report male-to-female ratios of at least 2:1 among adults, sometimes much higher.
Mortality risk is highest in the first year after injury and remains high compared to the general population. People with spinal cord injury are 2 to 5 times more likely to die prematurely than people without SCI.
Mortality risk increases with injury level and severity and is strongly influenced by availability of timely, quality medical care. Transfer method to hospital after injury and time to hospital admission are important factors.
Preventable secondary conditions (e.g. infections from untreated pressure ulcers) are no longer among the leading causes of death of people with spinal cord injury in high-income countries, but these conditions remain the main causes of death of people with spinal cord injury in low-income countries.
Health, economic and social consequences
Spinal cord injury is associated with a risk of developing secondary conditions that can be debilitating and even life-threatening—e.g. deep vein thrombosis, urinary tract infections, muscle spasms, osteoporosis, pressure ulcers, chronic pain, and respiratory complications. Acute care, rehabilitation services and ongoing health maintenance are essential for prevention and management of these conditions.
Spinal cord injury may render a person dependent on caregivers. Assistive technology is often required to facilitate mobility, communication, self-care or domestic activities. An estimated 20-30% of people with spinal cord injury show clinically significant signs of depression, which in turn has a negative impact on improvements in functioning and overall health.
Misconceptions, negative attitudes and physical barriers to basic mobility result in the exclusion of many people from full participation in society. Children with spinal cord injury are less likely than their peers to start school, and once enrolled, less likely to advance. Adults with spinal cord injury face similar barriers to economic participation, with a global unemployment rate of more than 60%.
Existing data do not allow for global cost estimates of spinal cord injury, but they do offer a general picture.
- The level and severity of the injury have an important influence on costs--injuries higher up on the spinal cord (e.g. tetraplegia vs. paraplegia) incur higher costs.
- Direct costs are highest in the first year after spinal cord injury onset and then decrease significantly over time.
- Indirect costs, in particular lost earnings, often exceed direct costs.
- Much of the cost is borne by people with spinal cord injury.
- Costs of spinal cord injury are higher than those of comparable conditions such as dementia, multiple sclerosis and cerebral palsy.
The leading causes of spinal cord injury are road traffic crashes, falls and violence (including attempted suicide). A significant proportion of traumatic spinal cord injury is due to work or sports-related injuries. Effective interventions are available to prevent several of the main causes of spinal cord injury, including improvements in roads, vehicles and people’s behaviour on the roads to avoid road traffic crashes, window guards to prevent falls, and policies to thwart the harmful use of alcohol and access to firearms to reduce violence.
Improving care and overcoming barriers
Many of the consequences associated with spinal cord injury do not result from the condition itself, but from inadequate medical care and rehabilitation services, and from barriers in the physical, social and policy environments.
Implementation of the UN Convention on the Rights of Persons with Disabilities (CRPD) requires action to address these gaps and barriers.
Essential measures for improving the survival, health and participation of people with spinal cord injury include the following.
- Timely, appropriate pre-hospital management: quick recognition of suspected spinal cord injury, rapid evaluation and initiation of injury management, including immobilization of the spine.
- Acute care (including surgical intervention) appropriate to the type and severity of injury, degree of instability, presence of neural compression, and in accordance with the wishes of the patient and their family.
- Access to ongoing health care, health education and products (e.g. catheters) to reduce risk of secondary conditions and improve quality of life.
- Access to skilled rehabilitation and mental health services to maximize functioning, independence, overall wellbeing and community integration. Management of bladder and bowel function is of primary importance.
- Access to appropriate assistive devices that can enable people to perform everyday activities they would not otherwise be able to undertake, reducing functional limitations and dependency. Only 5-15% of people in low- and middle-income countries have access to the assistive devices they need.
- Specialized knowledge and skills among providers of medical care and rehabilitation services.
Essential measures to secure the right to education and economic participation include legislation, policy and programmes that promote the following:
- physically accessible homes, schools, workplaces, hospitals and transportation;
- inclusive education;
- elimination of discrimination in employment and educational settings;
- Vocational rehabilitation to optimize the chance of employment;
- micro-finance and other forms of self-employment benefits to support alternative forms of economic self-sufficiency;
- access to social support payments that do not act as disincentive to return to work; and
- correct understanding of spinal cord injury and positive attitudes towards people living with it.
WHO works across the spectrum from primary prevention of traumatic and non-traumatic causes of spinal cord injury, improvements in trauma care, strengthening health and rehabilitation services, and support for inclusion of people with spinal cord injuries. WHO:
- works in a multisectoral manner, in partnership with national stakeholders from a variety of sectors (e.g. health, police, transport, education) to improve prevention of spinal cord injury including of road traffic injuries, falls , violence and neural tube defects;
- guides and supports Member States to increase awareness of disability issues, and promotes the inclusion of disability as a component in national health policies and programmes;
- facilitates data collection and dissemination of disability-related data and information;
- develops normative tools, including guidelines and good practice examples to strengthen primary prevention (road traffic crashes, falls and violence), trauma care, health care, rehabilitation and support and assistance;
- builds capacity among health policy-makers and service providers;
- promotes scaling up of community-based rehabilitation; and
- promotes strategies to ensure that people with disabilities are knowledgeable about their own health conditions, and that health-care personnel support and protect the rights and dignity of persons with disabilities.