Spinal cord injury

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Spinal cord injuries
Classification and external resources
Spinewithcord.jpg
View of the vertebral column and spinal cord
ICD-10 G95.9, T09.3
DiseasesDB 12327 29466
MedlinePlus 001066 000029
eMedicine emerg/553 neuro/711 pmr/182 pmr/183 orthoped/425
MeSH D013119

A spinal cord injury (SCI) is an injury to the spinal cord resulting in a change, either temporary or permanent, in the cord's normal motor, sensory, or autonomic function.[1] Common causes of damage are trauma (car accident, gunshot, falls, sports injuries, etc.) or disease (transverse myelitis, polio, spina bifida, Friedreich's ataxia, etc.). The spinal cord does not have to be severed in order for a loss of function to occur. Depending on where the spinal cord and nerve roots are damaged, the symptoms can vary widely, from pain to paralysis to incontinence.[2][3] Spinal cord injuries are described at various levels of "incomplete", which can vary from having no effect on the patient to a "complete" injury which means a total loss of function.

Treatment of spinal cord injuries starts with restraining the spine and controlling inflammation to prevent further damage. The actual treatment can vary widely depending on the location and extent of the injury. In many cases, spinal cord injuries require substantial physical therapy and rehabilitation, especially if the patient's injury interferes with activities of daily life.

Research into treatments for spinal cord injuries includes controlled hypothermia and stem cells, though many treatments have not been studied thoroughly and very little new research has been implemented in standard care.

Classification[edit]

The spinal cord (highlighted in dark red) runs from the base of the brain down through the spine in the back. It connects the brain to the nerves throughout the body.

The American Spinal Injury Association (ASIA) first published an international classification of spinal cord injury in 1982, called the International Standards for Neurological and Functional Classification of Spinal Cord Injury. Now in its sixth edition, the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is still widely used to document sensory and motor impairments following SCI.[4] It is based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of the muscles that control ten key motions on both sides of the body, including hip flexion (L2), shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), and elbow extension (C7).[5] Traumatic spinal cord injury is classified into five categories on the ASIA Impairment Scale:

  • A indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5.
  • B indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. This is typically a transient phase and if the person recovers any motor function below the neurological level, that person essentially becomes a motor incomplete, i.e. ASIA C or D.
  • C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and fewer than half of key muscles below the neurological level have a muscle grade of 3 or more (active movement with full range of motion against gravity).
  • D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
  • E indicates "normal" where motor and sensory scores are normal. It is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores.[4]

Dimitrijevic[6] proposed a further class, the so-called discomplete lesion, which is clinically complete but is accompanied by neurophysiological evidence of residual brain influence on spinal cord function below the lesion.[7]

Signs and symptoms[edit]

Divisions of Spinal Segments
Gray 111 - Vertebral column-coloured.png
Segmental Spinal Cord Level and Motor Function
Level Motor Function
C1-C6 Neck flexors
C1-T1 Neck extensors
C3, C4, C5 Supply diaphragm (mostly C4)
C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates)
C6, C7 Extends elbow and wrist (triceps and wrist extensors); pronates wrist
C7, T1 Flexes wrist
C7, T1 Supply small muscles of the hand
T1 -T6 Intercostals and trunk above the waist
T7-L1 Abdominal muscles
L1, L2, L3, L4 Thigh flexion
L2, L3, L4 Thigh adduction
L4, L5, S1 Thigh abduction
L5, S1, S2 Extension of leg at the hip (gluteus maximus)
L2, L3, L4 Extension of leg at the knee (quadriceps femoris)
L4, L5, S1, S2 Flexion of leg at the knee (hamstrings)
L4, L5, S1 Dorsiflexion of foot (tibialis anterior)
L4, L5, S1 Extension of toes
L5, S1, S2 Plantar flexion of foot
L5, S1, S2 Flexion of toes

Signs recorded by a clinician and symptoms experienced by a patient will vary depending on where the spine is injured and the extent of the injury. These are all determined by the area of the body that the injured area of the spine innervates. A section of skin innervated through a specific part of the spine is called a dermatome, and spinal injury can cause pain, numbness, or a loss of sensation in the relevant areas. A group of muscles innervated through a specific part of the spine is called a myotome, and injury to the spine can cause problems with voluntary motor control. The muscles may contract uncontrollably, become weak, or be completely paralysed. The loss of muscle function can have additional effects if the muscle is not used, including atrophy of the muscle and bone degeneration.

A severe injury may also cause problems in parts of the spine below the injured area. In a "complete" spinal injury, all functions below the injured area are lost. An "incomplete" spinal cord injury involves preservation of motor or sensory function below the level of injury in the spinal cord.[8] If the patient has the ability to contract the anal sphincter voluntarily or to feel a pinprick or touch around the anus, the injury is considered to be incomplete. The nerves in this area are connected to the very lowest region of the spine, the sacral region, and retaining sensation and function in these parts of the body indicates that the spinal cord is only partially damaged. This includes a phenomenon known as sacral sparing which involves the preservation of cutaneous sensation in the sacral dermatomes, even though sensation is impaired in the thoracic and lumbar dermatomes below the level of the lesion.[9] Sacral sparing may also include the preservation of motor function (voluntary external anal sphincter contraction) in the lowest sacral segments.[8] Sacral sparing has been attributed to the fact that the sacral spinal pathways are not as likely as the other spinal pathways to become compressed after injury.[9] The sparing of the sacral spinal pathways can be attributed to the lamination of fibers within the spinal cord.[9]

A complete injury frequently means that the patient has little hope of functional recovery.[citation needed] The relative incidence of incomplete injuries compared to complete spinal cord injury has improved over the past half century, due mainly to the emphasis on better initial care and stabilization of spinal cord injury patients.[10] Most patients with incomplete injuries recover at least some function.[citation needed]

Determining the exact "level" of injury is critical in making accurate predictions about the specific parts of the body that may be affected by paralysis and loss of function. The level is assigned according to the location of the injury by the vertebra of the spinal column closest to the injury on the spinal cord.

Cervical[edit]

Cervical (neck) injuries usually result in full or partial tetraplegia (Quadriplegia). However, depending on the specific location and severity of trauma, limited function may be retained.

  • Injuries at the C-1/C-2 levels will often result in loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing.
  • Injuries at C3 and above typically result in loss of diaphragm function, necessitating the use of a ventilator for breathing.
  • C4 results in significant loss of function at the biceps and shoulders.
  • C5 results in potential loss of function at the biceps and shoulders, and complete loss of function at the wrists and hands.
  • C6 results in limited wrist control, and complete loss of hand function.
  • C7 and T1 results in lack of dexterity in the hands and fingers, but allows for limited use of arms.

Patients with complete injuries above C7 typically cannot handle activities of daily living making functioning independently difficult and not often possible.[citation needed]

Additional signs and symptoms of cervical injuries include:

Thoracic[edit]

Complete injuries at or below the thoracic spinal levels result in paraplegia. Functions of the hands, arms, neck, and breathing are usually not affected.

  • T1 to T8 : Results in the inability to control the abdominal muscles. Accordingly, trunk stability is affected. The lower the level of injury, the less severe the effects.
  • T9 to T12 : Results in partial loss of trunk and abdominal muscle control.

Typically lesions above the T6 spinal cord level can result in autonomic dysreflexia.[11]

Lumbosacral[edit]

The effects of injuries to the lumbar or sacral regions of the spinal cord are decreased control of the legs and hips, urinary system, and anus.

  • Bowel and bladder function is regulated by the sacral region of the spine. In that regard, it is very common to experience dysfunction of the bowel and bladder, including infections of the bladder and anal incontinence, after traumatic injury.
  • Sexual function is also associated with the sacral spinal segments, and is often affected after injury. During a psychogenic sexual experience, signals from the brain are sent to the sacral parasympathetic cell bodies at spinal levels S2-S4 and in case of men, are then relayed to the penis where they trigger an erection. A spinal cord lesion of descending fibers to levels S2-S4 could, therefore, potentially result in the loss of psychogenic erection. A reflexogenic erection, on the other hand, occurs as a result of direct physical contact to the penis or other erotic areas such as the ears, nipples or neck, and thus not involving descending fibers from the brain. A reflex erection is involuntary and can occur without sexually stimulating thoughts. The nerves that control a man's ability to have a reflex erection are located in the sacral nerves (S2-S4) of the spinal cord and could be affected after a spinal cord injury at this level.[12][13][14] The rate of anejaculation in spinal cord injury varies with the level of the spinal cord injury, with for example complete lesions strictly above Onuf's nucleus (S2 – S4) being responsive to penile vibratory stimulation in 98%, but in no cases of complete lesion of the S2 – S4 segments.[15]

Other syndromes of incomplete injury[edit]

Central cord syndrome is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs. This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly.

Most often the damage is to the cervical or upper thoracic regions of the spinal cord, and characterized by weakness in the arms with relative sparing of the legs with variable sensory loss.

This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord (the large nerve fibers that carry information directly from the cerebral cortex). Corticospinal fibers destined for the legs are spared due to their more external location in the spinal cord.

Ischemia of the spinal cord is reduced blood flow to the spinal cord. Blood flow is supplied by the anterior spinal artery and the paired posterior spinal arteries. This condition may be associated with arterioscleorosis, trauma, emboli, diseases of the aorta, and other disorders. Prolonged ischemia may lead to infarction of the spinal cord tissue.[16] Ischemia of the spinal cord affects its function and can lead to muscle weakness and paralysis. The spinal cord may also suffer circulatory impairment if the segmental medullary arteries, particularly the great anterior segmental medullary artery are narrowed by obstructive arterial disease. When systemic blood pressure drops severely for 3-6 min, blood flow from the segmental medullary arteries to the anterior spinal artery supplying the midthoracic region of the spinal cord may be reduced or stopped. These people may also lose sensation and voluntary movement in the areas supplied by the affected level of the spinal cord.[17]

This clinical pattern may emerge during recovery from spinal shock due to prolonged swelling around or near the vertebrae, causing pressures on the cord. The symptoms may be transient or permanent.

Anterior cord syndrome is often associated with flexion type injuries to the cervical spine, causing damage to the anterior portion of the spinal cord and/or the blood supply from the anterior spinal artery.[18] Below the level of injury motor function, pain sensation, and temperature sensation are lost, while touch, proprioception (sense of position in space), and sense of vibration remain intact.

Posterior cord syndrome can also occur, but is very rare. Damage to the posterior portion of the spinal cord and/or interruption to the posterior spinal artery causes the loss of proprioception and epicritic sensation (e.g.: stereognosis, graphesthesia) below the level of injury.[18] Motor function, sense of pain, and sensitivity to light touch remain intact.[18]

Brown-Séquard syndrome usually occurs when the spinal cord is hemisectioned or injured on the lateral side. True hemisections of the spinal cord are rare, but partial lesions due to penetrating wounds (e.g.: gunshot wounds or knife penetrations) are more common.[18] On the ipsilateral side of the injury (same side), there is a loss of motor function, proprioception, vibration, and light touch. Contralaterally (opposite side of injury), there is a loss of pain, temperature, and crude touch sensations.

Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from infectious diseases such as syphilis, causing loss of touch and proprioceptive sensation.

Conus medullaris syndrome results from injury to the tip of the spinal cord, located at the L1 vertebra.

Causes[edit]

Falling as a part of recreational activities can cause spinal cord injuries.

Spinal cord injuries are most often traumatic, caused by lateral bending, dislocation, rotation, axial loading, and hyperflexion or hyperextension of the cord or cauda equina. Motor vehicle accidents are the most common cause of SCIs, while other causes include falls, work-related accidents, sports injuries, and penetrating trauma such as stab or gunshot wounds.[19] SCIs can also be of a non-traumatic origin, as in the case of cancer, infection, intervertebral disc disease, vertebral injury and spinal cord vascular disease.[20]

Diagnosis[edit]

A radiographic evaluation using an X-ray, MRI or CT scan can determine if there is any damage to the spinal cord and where it is located. A neurologic evaluation incorporating sensory testing and reflex testing can help determine the motor function of a person with a SCI.[21][22]

Management[edit]

If a suspected spinal cord injury is inappropriately or incompletely immobilized, handled, packaged or transported further damage may occur. Deterioration of the initial lesion often occurs during the initial management of injuries; therefore, effective procedures need to be established for the transportation and care to reduce the risk of secondary neurologic damage. A 1988 study estimated that as many as one in four spinal cord injured persons deteriorated between the time of their accident or injury and their arrival in hospital.[23] While some of this is due to the nature of the injury itself, particularly in the case of multiple or massive trauma, some of it reflects the failure to suspect that a spinal injury occurred in the first place and to treat the injured person appropriately.

Health personnel may suspect spinal cord injury in a number of circumstances, in particular if the person:

  • is unconscious as a result of a head injury
  • has been injured above the clavicle (collarbone) on either side
  • has been injured in a high-speed motor vehicle accident
  • has been injured in any manner known to cause spinal-cord injury.

The first stage in the management of a suspected spinal cord injury follows the basic life support principles of resuscitation.

These are represented by the initials DRSABC (which stand for danger, response, send for help, airway, breathing, circulation) but in the context of suspected spinal cord injuries, we add a plus to the A to remind us that we need to look after the airway PLUS add cervical spine control. As a basic principle, the head should be maintained in the neutral position, where spine is neither flexed, extended, latterly flexed to either side or rotated. The head should be supported with manual inline support to maintain this position. Traction (pulling on the neck) is not used because injury can be caused by forces which separate the spinal vertebrae and compromise the spinal cord. Critically, the neck is immobilized at, above and below the suspected level of injury, using spinal immobilization equipment. The majority of this management deals with cervical spine injuries, given that they are not only the most common, but being high in the neck they potentially affect all four limbs: in most cases they are therefore the most significant clinically. However, the same principles apply to the thoracic and lumbar spine.

Once the need for resuscitation has been established and attended to if necessary, the person with a suspected spinal cord injury has to be appropriately immobilized. For the first-aider or untrained bystander, this may entail only the positioning of the head in the neutral position and then maintaining it there until more professional help arrives. This is accomplished with manual inline support (MILS), which is to say holding the head using your hands so that it does not move relative to the body. This may be all that can be done at this stage but represents a significant action in preventing further damage through inadvertent movement of the person prior to a higher level of care being present.

Modern trauma care includes a step called clearing the cervical spine, where a person with a suspected injury is treated as if they have a spinal injury until that injury is ruled out. The objective is to prevent any further spinal cord damage.

People are immobilized at the scene of the injury until it is clear that there is no damage to the highest portions of the spine.[24] This is traditionally done using a device called a long spine board and a semi-rigid cervical collar, such as an X-Collar, Stifneck or Wizlock.

If the injured person is still inside a vehicle or other confined space, an Extrication Device may be required. This combines a short backboard and flexible, enveloping "wings" which enclose the thorax and are then tensioned using straps, as well as head immobilization device and straps. A minimum of four straps which can be tightened over the person are required to ensure adequate immobilization. A spineboard should not be used without the straps except when sliding an injured person out of an enclosed space or vehicle (in this circumstance it is being used as for rescue or extrication).

Some spineboards are in a single piece, while others that can be scooped under the injured person (or scissored at one end) have locking mechanisms which can be opened and closed to allow the spineboard to be split into two.

The other important piece of equipment used to help mobilize the injured person is the head immobilization device or "headbed". This device has a base plate which is strapped to the underlying spineboard, and typically two blocks of foam which are placed on either side of the injured person's head. Velcro or adhesive straps are then placed over the top of these blocks to hold the head in position.

If the entire head, neck, and body are appropriately immobilized in this fashion, and the straps tightened to ensure no movement has occurred during the fitting process, it is then appropriate to remove the first responder’s hands from providing manual inline support, as the injured person is effectively "packaged" and can be transported knowing that inappropriate movement has been restricted and in most cases eliminated.

A vacuum mattress is a whole-body bean bag mattress that can have the air removed by a pump from within it, leaving a harder outside shell which conforms to the injured person's shape. It is ideally used when an injured person is going to spend a long time during the process of transport as it diminishes the potential for pressure over bony prominences while lying face up.

There are arguments in the medical literature about the efficacy of collars, spineboards and head immobilization devices. It is important to ensure they are properly applied as they can then provide a more secure method of transporting an injured person. The alternative is requiring a first responder to stay at the head of the injured person and apply manual in line support for what may be a great deal of time and maintain vigilance when moving the injured person, loading them into and out of an ambulance and accompanying all the way into a hospital.

Before the protective cervical collar is removed, the spine must be "cleared", which is to say the potential for instability and (further) damage to the delicate spinal cord eliminated. This is usually done according to a protocol derived from studies of spinal injury,[citation needed] including the NEXUS[25] and Canadian C Spine[26] studies.

Techniques of immobilizing the affected areas in the hospital include Gardner-Wells tongs, which can also exert spinal traction to reduce a fracture or dislocation.[27]

One experimental treatment, therapeutic hypothermia, is used but there is no evidence that it improves outcomes.[28][29] Maintaining mean arterial blood pressures of at least 85 to 90 mmHg using intravenous fluids, transfusion, and vasopressors to ensure adequate blood supply to nerves and prevent damage is another treatment with little evidence of effectiveness.[30]

Surgery[edit]

Surgery may also be necessary to remove any bone fragments from the spinal canal and to stabilize the spine.[31]

Steroids[edit]

Inflammation can cause further damage to the spinal cord, and patients are sometimes treated with drugs to reduce swelling.

Corticosteroid drugs are used within 8 hours of the injury.[21] This practice is based on the National Acute Spinal Cord Injury Studies (NASCIS) I and II, though other studies have shown little benefit and concerns about side effects from the drug have changed this practice.[32][33] High dose methylprednisolone may improve outcomes if given within 6 hours of injury.[34] However, the improvement shown by large trials has been small, and comes at a cost of increased risk of serious infection or sepsis due to the immunosuppressive qualities of high-dose corticosteroids. Methylprednisolone is no longer recommended in the treatment of acute spinal cord injury.[35]

Rehabilitation[edit]

SCI patients often require extended treatment in specialized Spinal Unit or an intensive care unit.[36]

When treating a patient with a SCI, repairing the damage created by injury is the ultimate goal. By using a variety of treatments, greater improvements are achieved, and, therefore, treatment should not be limited to one method. Furthermore, increasing activity will increase chances of recovery.[37]

The rehabilitation process following a spinal cord injury typically begins in the acute care setting. Physical therapists, occupational therapists, nurses, social workers, psychologists and other health care professionals typically work as a team under the coordination of a physiatrist to decide on goals with the patient and develop a plan of discharge that is appropriate for the patient’s condition.

In the acute phase physical therapists focus on the patient’s respiratory status, prevention of indirect complications (such as pressure ulcers), maintaining range of motion, and keeping available musculature active.[38] Also, there is great emphasis on airway clearance during this stage of recovery.[39] Following a spinal cord injury, the individual’s respiratory muscles may become weak, making the patient unable to cough effectively and allowing secretions to accumulate within the lungs.[40] Physical therapy treatment for airway clearance may include manual percussions and vibrations, postural drainage,[39] respiratory muscle training, and assisted cough techniques.[40] Patients are taught to increase their intra-abdominal pressure by leaning forward to induce cough and clear mild secretions.[40] The quad cough technique is done with the patient lying on their back and the therapist applies pressure on their abdomen in the rhythm of the cough to maximize expiratory flow and mobilize secretions.[40] Manual abdominal compression is another effective technique used to increase expiratory flow which later improves cough.[39] Other techniques used to manage respiratory dysfunction include respiratory muscle pacing, use of an abdominal binder, ventilator-assisted speech, and mechanical ventilation.[40]

Depending on the neurological level of impairment (NLI), the muscles responsible for expanding the thorax, which facilitate inhalation, may be affected. If the NLI is such that it affects some of the ventilatory muscles, more emphasis will then be placed on the muscles with intact function. For example, the intercostal muscles receive their innervation from T1–T11, and if any are damaged, more emphasis will need to placed on the unaffected muscles which are innervated from higher levels of the CNS. As SCI patients suffer from reduced total lung capacity and tidal volume[41] physical therapists teach SCI patients accessory breathing techniques (e.g. apical breathing, glossopharyngeal breathing, etc.) that typically are not taught to healthy individuals.

Outcome measures[edit]

The Functional Independence Measure (FIM) is an assessment tool that aims to evaluate the functional status of patients throughout the rehabilitation process following a stroke, traumatic brain injury, spinal cord injury or cancer.[42] Its area of use can include skilled nursing facilities and hospitals aimed at acute, sub-acute and rehabilitation care. It serves as a consistent data collection tool for the comparison of rehabilitation outcomes across the health care continuum.[42] Furthermore, it aims to allow clinicians to track changes in the functional status of patients from the onset of rehab care through discharge and follow-up. The FIM’s assessment of degree of disability depends on the patient’s score in 18 categories, focusing on motor and cognitive function. Each category or item is rated on a 7-point scale (1 = <25% independence; total assistance required, 7 = 100% independence).[42] As such, FIM scores may be interpreted to indicate level of independence or level of burden of care.

Anejaculation[edit]

Further information: Anejaculation

For anejaculation in spinal cord injury, the first-line method for sperm retrieval include is penile vibratory stimulation (PVS).[15] The penile vibratory stimulator is a plier-like device that is placed around glans penis to stimulate it by vibration. In case of failure with PVS, spermatozoa are sometimes collected by electroejaculation, or surgically by per cutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE).[15]

Prognosis[edit]

Spinal cord injuries frequently result in at least some incurable impairment even with the best possible treatment. In general, patients with complete injuries recover very little lost function and patients with incomplete injuries have more hope of recovery. While the prognosis of complete injuries is generally predictable since recovery is rare, the symptoms of incomplete injuries can vary and it is difficult to make an accurate prediction of the outcome. Some patients that are initially assessed as having complete injuries are later reclassified as having incomplete injuries.

The location of the injury on the spinal cord determines which parts of the body are affected. The severity of the injury determines how much the body will be affected. Consequently, a person with a mild, incomplete injury at the T5 vertebra will have a much better chance of using his or her legs than a person with a severe, complete injury at exactly the same place.

Recovery is typically quickest during the first six months; very few patients experience any substantial recovery more than nine months after the injury.[43]

Complications[edit]

Complications of spinal cord injuries include neurogenic shock, respiratory failure, pulmonary edema, pneumonia, pulmonary emboli and deep venous thrombosis, many of which can be recognized early in treatment and avoided.

Spasticity, the uncontrollable tensing of muscles below the level of injury, results from lack of input from the brain to quell muscle responses to stretch reflexes.[44] It can be treated with drugs and physical therapy.[44]

Tetraplegia (quadriplegia)[edit]

The ASIA motor score (AMS) is a 100 point score based on ten pairs of muscles each given a five point rating. A person with no injury should score 100. In complete tetraplegia, a recovery of nine points on this scale is average regardless of where the patient starts. Patients with higher levels of injury will typically have lower starting scores.[43]

In incomplete tetraplegia, 46 percent of patients were able to walk one year after injury, though they may require assistance such as crutches and braces. These patients had similar recovery in muscles of the upper and lower body. Patients who had pinprick sensation in the sacral dermatomes such as the anus recovered better than patients that could only sense a light touch.[43]

Paraplegia[edit]

Holly Koester incurred a spinal injury as a result of a motor vehicle collision and is now a wheelchair racer.

In one study on 142 individuals after one year of complete paraplegia, none of the patients with an initial injury above the ninth thoracic vertebra (T9) were able to recover completely. Less than half, 38 percent, of the studied subjects had any sort of recovery. Very few, five percent, recovered enough function to walk, and those required crutches and other assistive devices, and all of them had injuries below T11. A few of the patients, four percent, had what were originally classified as complete injuries and were reassessed as having incomplete injuries, but only half of that four percent regained bowel and bladder control.[43]

Of the 54 patients in the same study with incomplete paraplegia, 76 percent were able to walk with assistance after one year. On average, patients improved 12 points on the 50 point lower extremity motor score (LEMS) scale. The amount of improvement was not dependent on the location of the injury, but patients with higher injuries had lower initial motor scores and correspondingly lower final motor scores. A LEMS of 50 is normal, and scores of 30 or higher typically predict ability to walk.[43]

Epidemiology[edit]

Spinal injury can occur without trauma. Many people suffer transient loss of function ("stingers") in sports accidents or pain in "whiplash" of the neck without neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant hospitalization.

The prevalence of spinal cord injury is not well known in many large countries. In some countries, such as Sweden and Iceland, registries are available. In the United States, the incidence of spinal cord injury has been estimated to be about 40 cases (per 1 million people) per year or around 12,000 cases per year.[45][46] In the United States there are around 250,000 individuals living with spinal cord injuries.[22][47] In China, the incidence of spinal cord injury is approximately 60,000 per year.[48]

The average age at the time of injury has slowly increased from a reported 29 years of age in the mid-1970s to a current average of around 40. Men are at more risk for spinal cord injury than women.[49][50] Over 80% of the spinal injuries reported to a major national database occurred in males.[51] Most of these injuries occur in men under 30 years of age.[52]

Research directions[edit]

Scientists are investigating various avenues for treatment of spinal cord injury. Numerous articles in the medical literature describe research, mostly in animal models, aimed at reducing the paralyzing effects of injury and promoting regrowth of functional nerve fibers.[53] Despite the devastating effects of the condition, commercial funding for research investigating a cure after spinal cord injury is limited, partially due to the small size of the population of potential beneficiaries.[citation needed] Some experimental treatments, such as systemic hypothermia, have been performed in isolated cases in order to draw attention to the need for further preclinical and clinical studies to help clarify the role of hypothermia in acute spinal cord injury.[54] Despite the limitation on funding, a number of experimental treatments such as local spine cooling and oscillating field stimulation have reached controlled human trials,[55][56]

Advances in identification of an effective therapeutic target after spinal cord injury have been newsworthy, and considerable media attention is often drawn towards new developments in this area. Inflammation and glial scar are considered important inhibitory factors to neuroregeneration after SCI. However, aside from methylprednisolone, none of these developments have reached even limited use in the clinical care of human spinal cord injury in the U.S.[57]

Stem cells[edit]

Around the world, proprietary centers offering stem cell transplants and treatment with neuroregenerative substances are fueled by glowing testimonial reports of neurological improvement. It is also evident that when stem cells are injected in the area of damage in the spinal cord, they secrete neurotrophic factors, and these factors help neurons and blood vessels to grow, thus helping repair the damage.[58][59][60] Bone Marrow Stem cells, especially the CD34+ cells, have been found to be relatively more in men compared to women in the reproductive age group among spinal cord injury patients.[50]

In 2009 in the US, the FDA approved the country's first human trial on embryonic stem cell transplantation into patients suffering from varying levels of traumatic spinal cord injury.[61] The trial however came to a halt in November 2011 when the company, which was financing the trial, announced the discontinuation of the trial due to financial issues.[62] There were not scientific or ethical reasons for the discontinuation.[63]

Other than stem cells, transplantation of tissues such as olfactory ensheathing mucosa have been shown to produce beneficial effects in spinal cord injured rats.[64]

Independent validation of the results of the various stem cell treatments is lacking.[65][66] However, current approaches on cell and tissue based therapies for clinical application for spinal cord injury need to establish the underlying efficacy and mechanisms.[63]

Engineering approaches[edit]

Recent approaches have used various engineering techniques to improve spinal cord injury repair. The general hypothesis of this is that bridging the lesion site using a growth permissive scaffold may promote axonal extension and in turn improve behavioral function. Engineered treatments are ideal for spinal cord injury repair because they do not induce an immune response like biological treatments, and they are easily tunable and reproducible. In-vivo administration of hydrogels or self-assembling nanofibers has been shown to promote axonal sprouting and partial functional recovery.[67][68] In addition, administration of carbon nanotubes has shown to increase motor axon extension, decrease the lesion volume, and not induce neuropathic pain.[69] In addition, administration of poly-lactic acid microfibers has shown that topographical guidance cues alone can promote axonal regeneration into the injury site.[70] However, all of these approaches induced modest behavioral or functional recovery suggesting that further investigation is necessary.

BCI[edit]

Recent research shows that combining brain–computer interface and functional electrical stimulation can restore voluntary control of paralyzed muscles. A study with monkeys showed that it is possible to directly use commands from the brain, bypassing the spinal cord and enable limited hand control and function.[71]

Exo-skeleton[edit]

The technology for creating bionic suits, more commonly known as exo-skeletons, is currently making some significant advances. There are products available, such as the Ekso, which allows individuals with up to a C7 complete (or any level of incomplete) spinal injury to stand upright and make technologically assisted steps.[72][73] The initial purpose for this technology is for functional based rehabilitation, but as the technology develops, so will its uses.[72] A significant downside for the users of these systems is that they find themselves extremely tired after a very short time. This is because the muscles they are using have atrophied, and have little stamina.

References[edit]

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