Spinal Cord Injuries

• Author: Samuel D. Hodge, Jr./Jack E. Hubbard
• Profession: Skilled litigator, is chair of the department of legal studies at Temple University/Professor of Neurology at the University of Minnesota
• Pages: 517-560

Spinal Cord Injuries

Virginia Graziani Lowe, Samuel D. Hodge Jr., and Jack E. Hubbard

I think a hero is an

ordinary individual

who finds strength

to persevere and

endure in spite

of overwhelming

obstacles.

Christopher Reeve

10

Adam Taliaferro lay motionless on the green carpet of the college football field with

no feeling below his neck as more than 100,000 people watched in stunned silence. His

promising football career had just begun, but his life had changed in an instant—with

little hope of ever walking again. Instant replay revealed that Adam’s helmet had con-

tacted the opposing player’s knee during the play. The resulting blow fractured a cervical

vertebra, injuring his spinal cord. With such a devastating injury, the physicians were

not optimistic that he would ever walk again. However, this young athlete proved them

wrong: eight months later, Adam got out of bed and walked.1 But the story does not end

here. He eventually returned to college and graduated with honors. Today, this inspiring

individual is an attorney, an elected official in the township where he lives, and founding

board member of the Adam Taliaferro Foundation, which offers emotional, financial, and

educational assistance to student-athletes who suffer catastrophic head or spinal injuries.2

Some would say that this individual’s recovery is a miracle and not the typical outcome of

a spinal cord injury patient. However, his story does offer hope to those tragically afflicted

with similar conditions.

Introduction

A spinal cord injury (SCI) involves trauma to this important structure with a loss of or

impairment in function resulting in reduced mobility or feeling. The term SCI most

commonly refers to a traumatic injury to the spinal cord, such as an injury that occurs

from a car accident or a gun shot, although certain disease processes, such as polio or

spina bifida, can also affect the spinal cord.3 Even a minor injury can produce trauma to

the spinal cord if the spine is weakened from a condition such as rheumatoid arthritis or

osteoporosis or if the spinal canal shielding the spinal cord has narrowed too much as the

result of spinal stenosis.4 Contrary to popular belief, the spinal cord does not have to be

severed to sustain a loss of function. Most individuals with an SCI have a spinal cord that

is intact, but the cellular harm to the structure causes a loss of functioning. An SCI is a

devastating and life-changing event.

Although the resultant paralysis from an SCI is the most obvious consequence and

what people would consider the most devastating effect, individuals with SCI also face

a disruption in almost every other aspect of their lives.5 After all, the spinal cord is the

major pathway through which motor and sensory signals travel between the brain and the

body and is integral in the control of movement, sensation, bowel and bladder activity,

and autonomic functions such as temperature and blood pressure control. Any disruption

of this structure, therefore, can have devastating emotional, psychological, physical, and

financial consequences. In addition to the obvious impairment of mobility, individuals

also suffer from a variety of related medical issues such as respiratory, bowel, skin, bladder,

and sexual problems. The psychological significance of SCI also challenges victims with

518 ◆ CHAPTER 10

the task of acknowledging their lost mobility, accepting a new dependency on others, and

learning to establish altered goals for their lives.6

At one time, a paralyzing SCI was usually a death sentence because of the likelihood of

pneumonia, infection from pressure sores, urinary tract infection, or kidney failure. Since

World War II, however, an advanced understanding of the pathological processes that

occur in the spinal cord immediately following injury and the utilization of antibiotics

have made long-term survival possible for most people with SCI. Nevertheless, the recov-

ery potential for those with a total loss of motor control and sensation below the area of

the injury remains grim because of the inability of the spinal cord to regenerate itself.7

The legal issues involving SCI can arise in relation to all aspects of the injury, from the

cause of the injury, the immediate and subsequent medical care, secondary complications,

and insurance coverage to issues surrounding death. The financial toll is also enormous,

from the cost of multiple hospitalizations to the need for caregivers, and these sums must

be considered in establishing the value of a claim. Lawyers can best represent SCI clients

by understanding the complex nature and long-term consequences of the injury and how

the problem so comprehensively changes the lives of those affected.

This chapter is designed to act as an introduction to the topic and is divided into two

sections to provide a multifaceted overview of an SCI. The first part presents a medical

overview of traumatic SCI, including epidemiology and etiology, evaluation and treat-

ment, systems affected, and prognosis. The second segment explores some of the legal

issues that arise with SCI.

Spinal Cord Injury

There is no mandatory reporting of spinal cord injuries in the United States. However,

the National Institute for Disability Rehabilitation and Research currently funds centers

across the country to provide specialty care for patients with SCI, called SCI Model

System Centers. Currently 14 such funded centers have been established. One of the

requirements for being funded as an SCI Model System Center is the ability to provide

comprehensive rehabilitation services, including emergency medical services, acute care,

vocational and other rehabilitation services, community and job placement, and health

maintenance. Additionally, centers are required to conduct spinal cord research, includ-

ing clinical research and the analysis of standardized data.8 The National Spinal Cord

Injury Statistical Center (NSCISC) supports and directs the collection, management, and

analysis of the world’s largest SCI database gathered from these centers.9 The Shriners

Hospital system also collects data on pediatric SCI.10

Epidemiology

Some 12,000 spinal cord injuries occur annually in the United States.11 This incidence has

remained relatively stable over the past 30 years.12 Nevertheless, this number is quite small

compared to the 1.7 million traumatic brain injury patients per year. Although the major-

ity of traumatic brain injury patients are treated in the emergency room and released,

275,000 per year suffer injuries significant enough to warrant hospitalization.13 The num-

ber of people in the US who are currently living with spinal cord injury, however, has

been estimated to be approximately 265,000 despite the much smaller population pool.14

The incidence of SCI is lowest for the pediatric age group, is highest in the late teens

and early 20s group, and declines steadily in older ages.15 The mean age at time of injury

is 32.4 years; however, observers report a substantial trend toward increasing age at the

time of injury in recent years.16 Approximately 80 percent of spinal cord injuries occur in

men, and this four-to-one ratio of male to female SCIs has remained relatively constant

over time.17

Etiology

Ten specific causes of traumatic SCI accounted for the vast majority of new cases enrolled

in the NSCISC database in 2010. Not surprisingly, motor vehicle accidents ranked first

SPINAL CORD INJURIES ◆519

(33.8 percent), followed by falls (20.9 percent), gunshot wounds (15.8 percent), diving

mishaps (6.3 percent), motorcycle accidents (5.9 percent), being hit by a falling/flying

object (2.9 percent), medical/surgical complication (2.5 percent), pedestrians who were

struck by motor vehicles (1.6 percent), bicycle accidents (1.3 percent), and person to per-

son contact (1 percent). All other causes of SCI accounted for less than 1 percent each.18

When considering etiology by age group, different trends emerge. In 2010, vehicu-

lar accidents caused 46.4 percent of SCIs in the 16–30 year age group compared to 30

percent in the 61–75 year group. Violence accounted for 23.5 percent of injuries in

the younger group compared to 2.7 percent in the older group; sports-related injuries

accounted for 14.4 percent in the younger group compared to 2.3 percent in the older

group, and falls accounted for 10.6 percent of SCI in the younger group compared to

49.4 percent in the older group. In the 76–98 year age group, falls accounted for 64.4

percent of all injuries.19

In the larger category of recreational sports, diving was the cause of 57.1 percent of

all SCIs reported between 1993 and 1996. Snow skiing ranked second (9.7 percent),

followed by surfing (including body surfing) (4.1 percent), wrestling (3.1 percent), and

football (2.8 percent).20 Diving, football, and trampoline injuries have declined since the

1970s, whereas injuries due to skiing and surfing have increased. The change of football

rules in 1976 that banned “spearing” most likely contributed to the decrease in football

injuries, and the removal of trampolines from schools in some states likely contributed to

the decrease seen in those injuries.21

Life Expectancy

The life expectancy of those with SCI has improved significantly over the past several

decades but remains below the average population. The mortality rate during the first

year post injury is conservatively estimated to be 6.3 percent.22 The death rate signifi-

cantly decreases in the second year post injury, to 1.7 percent. Predictors of mortality

include advanced age, being male, sustaining the injury by an act of violence, having a

higher injury level in the spine, having a more severe injury, being ventilator dependent,

and having either Medicare or Medicaid coverage.23 Higher mortality rates in subsequent

years after an SCI are seen in patients with lower satisfaction with life, poor health,

emotional distress, poorer adjustment to their disability, more dependence on others for

care.24

With increasing injury severity, as determined by the neurologic level and complete-

ness of the injury, life expectancy declines steadily. For example, a 25-year-old able-

bodied person has a remaining life expectancy of 52.4 years compared to 41.8 years in

a paraplegic patient, 37 years in a C5-C8 quadriplegic patient, 33.1 years in a C1-C4

quadriplegic individual, and 23.5 years in a ventilator-dependent patient at any level.

Additionally, as age increases, the percentage reduction in life expectancy in each neuro-

logic category also goes up. For example, in C1-C4 tetraplegics,25 life expectancy is 68.8

percent of normal for a 10-year-old patient, 60.8 percent of normal for a 30-year-old

patient, 47.8 percent of normal for a 50-year-old patient, and 31.2 percent of normal for

a 70-year-old patient.26

Causes of Death

Respiratory issues are the leading cause of death following SCI, accounting for 20.8

percent of all deaths. The majority of these deaths are due to pneumonia. Heart dis-

ease, including hypertensive and ischemic types, accounts for 20.6 percent of deaths.

Infections cause 8.8 percent of deaths, with 90 percent of these being due to septicemia

(blood infection), and are usually associated with pressure sores, urinary tract infections,

and respiratory infections. Diseases of the pulmonary circulation cause 6.2 percent of

deaths. The vast majority of pulmonary circulation deaths are due to pulmonary emboli,27

which usually occur before discharge from the hospital and decline sharply with time

after injury.28 These clots to the lungs usually develop in the veins of the motionless legs

and travel to the lungs.