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Spinal cord injury

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Spinal cord injury
SpecialtyEmergency medicine, neurosurgery Edit this on Wikidata

A Spinal cord injury (SCI) refers to any injury to the spinal cord that is caused by trauma instead of a disease.[1] 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.

Spinal cord injuries have many causes, but are typically associated with major injuries from motor vehicle accidents, falls, sports injuries, and violence. It can also be involved in minor injuries, such as whiplash. 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

The American Spinal Injury Association (ASIA) defined an international classification based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, including hip flexion (L2), shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), elbow extension (C7). Traumatic spinal cord injury is classified into five categories by the American Spinal Injury Association and the International Spinal Cord Injury Classification System:

  • 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 more than half of key muscles below the neurological level have a muscle grade of less than 3, which indicates 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. Note that it is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores.

Dimitrijevic[4] 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. [5]

Signs and symptoms

Actions of the spinal nerves
Level Motor function
C1–C6 Neck flexors
C1–T1 Neck extensors
C3, C4, C5 Supply diaphragm (mostly C4)
C5, C6 Move shoulder, raise arm (deltoid); flex elbow (biceps)
C6 externally rotate (supinate) the arm
C6, C7 Extend elbow and wrist (triceps and wrist extensors); pronate wrist
C7, C8 Flex wrist; supply small muscles of the hand
T1–T6 Intercostals and trunk above the waist
T7–L1 Abdominal muscles
L1–L4 Flex hip joint
L2, L3, L4 Adduct thigh; Extend leg at the knee (quadriceps femoris)
L4, L5, S1 abduct thigh; Flex leg at the knee (hamstrings); Dorsiflex foot (tibialis anterior); Extend toes
L5, S1, S2 Extend leg at the hip (gluteus maximus); flex foot and flex toes

Signs observed by a physician 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 unresponsive. 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 function below the injured area are lost. In an "incomplete" injury, some or all of the functions below the injured area may be unaffected. 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.

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.[6] Most patients with incomplete injuries recover at least some function.[citation needed]

In addition to sensation and muscle control, the loss of connection between the brain and the rest of the body can have specific effects depending on the location of the injury.

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. While the prognosis of complete injuries are 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.

Cervical

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.
  • C3 vertebrae and above : Typically results 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 shoulders and biceps, 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 and cannot function independently.[citation needed]

Additional signs and symptoms of cervical injuries include:

Thoracic

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.

Lumbarsacral

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 spinal levels T10-L2 and in case of men, are then relayed to the penis where they trigger an erection. A reflex 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. 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.[7]

Other syndromes of incomplete injury

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.

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 also an incomplete spinal cord injury. Below the injury, motor function, pain sensation, and temperature sensation is lost; touch, proprioception (sense of position in space), and vibration sense remain intact. Posterior cord syndrome can also occur, but is very rare.

Brown-Séquard syndrome usually occurs when the spinal cord is hemisectioned or injured on the lateral side. 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 deep touch sensations. In addition, there are several clinical syndromes associated with incomplete spinal cord injuries.

Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from infection 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 L1 vertebra.

Causes

The cause of spinal cord injury is a trauma, one form of this is blunt spinal injury which can be caused by hyperflexion, hyperextension, rotation, and compression.[8] Another example is a penetrating spinal cord injury, caused by a foreign object coming in contact with the spinal cord such as a bullet or knife.

Diagnosis

A radiographic evaluation using a 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.[9][10]

Management

Modern trauma care includes a step called clearing the cervical spine, where a patient 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. Patients are immobilized at the scene of the inury until it is clear that there is no damage to the highest portions of the spine.[11] This is traditionally done using a device called a long spine board.

Once the patient is brought to a hospital and immediate life-threatening injuries have been addressed, they are evaluated for spinal injury, typically by x-ray or CT scan. 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. SCI patients often require extended treatment in an intensive care unit.[12]

Surgery may also be necessary to remove any bone fragments from the spinal canal and to stabilize the spine.[13] Inflammation can cause further damage to the spinal cord, and patients are sometimes treated with a corticosteroid drug such as methylprednisolone to reduce swelling. The drug is used within 8 hours of the injury.[9] 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.[14][15] A food dye, brilliant blue G, has also been shown to have some effect at reducing inflammation after spinal injury.[16][17]

One experimental treatment, therapeutic hypothermia, is used but there is no evidence that that it improve outcomes.[18][19] 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. [20]

Rehabilitation

Performing daily activities can be difficult for an individual with a spinal cord injury. However, through the rehabilitation process individuals with SCI may be able to live independently in the community with or without full-time attendant care, depending on the level of their injury.[21] Occupational therapy plays an important role in the management of SCI. [22]

Recent studies emphasize the importance of early occupational therapy, started immediately after the client is stable. This process includes teaching of coping skills, and physical therapy.[23]

In the first step, acute recovery, the focus is on support and prevention. Inteventions aim to give the individual a sense of control over a situation in which the patient likely feels little independence.[21] Techniques for prevention of pressure sores in bed and in wheelchairs are also taught.

The next interventions focus on support and education for the individual and caregivers.[21] This includes an evaluation of limb function to determine what the patient is capable of doing independently, and teaching the patient self-care skills.[24] Independence in daily activities like eating and bowel/bladder management as well as mobility. Obtaining competency in self-care tasks contributes significantly to an individual's sense of self confidence and independence.[21] Quality of life issues such as sexual health and function are also addressed.[25]

Assistive devices such as wheelchairs have a substantial effect on the quality of life of the patient, and careful selection is important.[26] Teaching the patient how to transfer from different positions, such as from a wheelchair into bed, is an important part of therapy, and devices such as sliding transfer boards and grab bars can assist in these tasks.[24] Individuals who are able to transfer independently from their wheelchair to the driver's seat using a sliding transfer board may be able to return to driving. Complete independence with driving also requires the ability to load and unload one's wheelchair from the vehicle.[21]

The patient's living environment can also be modified to improve independence. For example, ramps or lifts can be added to a patient's home, and part of rehabilitation involves investigating options for returning to previous interests as well as developing new pursuits.[25] Community participation is an important aspect in maintaining quality of life.[27]

Prognosis

In general, patients with complete injuries recover very little lost function and patients with incomplete injuries have more hope of recovery. Some patients that are initially assessed as having complete injuries are later changed to incomplete injuries.

Recovery is typically quickest during the first six months, with very few patients experiencing any substantial recovery more than nine months after the injury.[28]

Tetraplegia

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.[28]

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. [28]

Paraplegia

In one study on 142 individuals after one year of complete paraplegia, none of the patients where the initial injury was 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.[28]

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.[28]

Epidemiology

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.[29][30] The most common causes of spinal cord injury are motor vehicle accidents, falls, violence and sports injuries.[30] The average age at the time of injury has slowly increased from a reported 29 years of age in the mid-1970's to a current average of around 40. Over 80% of the spinal injuries reported to a major national database occurred in males.[31] In the United States there are around 250,000 individuals living with spinal cord injuries.[10][32] In China, the incidence of spinal cord injury is approximately 60,000 per year.[33]

Research directions

Scientists are investigating many promising 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.[34] 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 draw attention to the need for further preclinical and clinical studies to help clarify the the role of hypothermia in acute spinal cord injury.[35] Despite the limitation on funding, a number of experimental treatments such as local spine cooling and oscillating field stimulation have reached controlled human trials, [36] [37]

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. 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. [citation needed]. 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 neurotrophic factors help neurons and vessels grow, thus helping repair the damage.[38][39][40] Independent validation of the results of these treatments is lacking.[41]

References

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  34. ^ Knoller, N, Auerbach, G, Fulga, V, et al. Clinical experience using incubated autologous macrophages as a treatment for complete spinal cord injury: phase I study results. J Neurosurg Spine 2005; 3:173. PMID 16235699
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  38. ^ Abraham S (2008). "Autologous Stem Cell Injections for Spinal Cord Injury - A multicentric Study with 6 month follow up of 108 patients". 7th Annual Meeting of Japanese Society of Regenerative Medicine, Nagoya, Japan. {{cite journal}}: Unknown parameter |month= ignored (help)
  39. ^ R Ravikumar, S Narayanan and S Abraham (2007). "Autologous stem cells for spinal cord injury". Regenerative Medicine. 2 (6): 53–61. {{cite journal}}: Unknown parameter |month= ignored (help)
  40. ^ Abraham S (2007). "Autologous Bone Marrow Mononuclear Cells for spinal cord injury- A case report". Cytotherapy. 9 (1). {{cite journal}}: Unknown parameter |month= ignored (help)
  41. ^ Dobkin, BH.; Curt, A.; Guest, J. "Cellular transplants in China: observational study from the largest human experiment in chronic spinal cord injury." Neurorehabilitation and Neural Repair, v. 20 issue 1, 2006, p. 5-13.
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