SPINAL CORD INJURIES

I. WHAT IS THE SPINAL CORD?

The spinal cord is an extension of the brain running down the body and stretching from the base of the scull in adults up to about the level of the first lumbar vertebrae. The main function of the spinal cord is to relay messages from the brain to the rest of the body and to carry information from the rest of the body back up to the brain where the messages are interpreted. The best analogy one can use to describe the spinal cord is that of a very intricate telephone wire. Any damage to this telephone wire causes messages not to be relayed and thus information cannot get from the periphery or from the rest of the body to the brain and the brain does not have control of functions below where the level of injury is and thus paralysis ensues. The spinal cord is a very important structure in the body and thus is protected by the vertebrae which are stacked on top of one another.

The vertebral column is classically divided into various levels. There is 7 neck or cervical vertebrae, 12 chest vertebrae or thoracic vertebrae, 5 lumbar vertebrae or lower back vertebrae and then there is 5 sacral vertebrae which are fused together to form one solid bone called the sacrum and then 4 coccygeal vertebrae again which is fused together to form the coccyx. Between each vertebra there is a disc that allows some movement between the different bones of the back bone.

As mentioned previously the spinal cord runs within these vertebrae and at each level between the vertebrae it gives off a nerve that basically provides function to certain parts of the body. Thus is all the arm functions are related via the cervical vertebrae and most of the leg functions via the lumbar vertebrae.

II. WHAT CAUSES INJURY TO THE SPINAL CORD?

Any mechanism that causes injury to the vertebral column or the bones in the back can damage the spinal cord. Thus the most common causes in South Africa at this stage are either motor vehicle accidents where the bones are broken or gunshot injuries where the bullet damages the spinal column and the spinal cord. Other common causes include stabs, falls from heights, diving accidents all of which contribute to the diverse possible causes of a spinal cord injury.

Non-traumatic causes of spinal cord injury include tumors, which affects the bones and then causes pressure on the nerve structure or the spinal cord itself. Other possible causes are a hernia at the disc that sometimes causes pressure on the spinal cord and lastly but not as uncommon as the other is that there is vascular cause, in other words that the blood supply to the cord is damaged be that from an injury to the blood supply during surgery or other traumatic causes of the disruption of the blood supply which then disrupts the function of the spinal cord.

Children are a particular sub group of patient’s who can sustain a spinal cord injury without a major bony abnormality being present. What happens is that due to the pliability and malleability of the child’s skeletal system he can have a stretching out of the bones and ligaments in the vertebral column that then causes trackie injury to the spinal cord without any obvious bony pathology. This is the so called “Sciwora” deformity.

III. WHAT TYPES OF SPINAL CORD INJURIES ARE THERE?

The first and most common distinction in type of spinal cord injuries either a tetraplegic or in old term a quadriplegic or a paraplegic.

This refers to the situation where a tetraplegic where both the arms and the legs are paralyzed to a certain degree. A paraplegic the arm function and upper limbs functions are normal and only the lower limb function is affected.

A further distinction that is made is between a complete and an incomplete injury. A complete lesion means that below the level where the injury is there is no function or sparing. There is no sensation and no movement or voluntary control of movement below the level of the injury.

In an incomplete legion however, sometimes some of the messages do get through via the telephone wire and thus the patient might be able to feel or have sensation below the lesion. There might even be some motor function or movement below where the level of the injury is. Thus the lesion is not complete termed an incomplete legion.

Obviously there is a vast array of different types of incomplete legions. In some cases there is only sensory sparing without any motor- or movement sparing. In far lighter cases there is virtually normal movement but a slight loss of power on the other side of the scale.

Furthermore especially in the vascular causes of a spinal cord injury it might be that in a cervical central cord type pattern that the arms are worse effected than the legs and that there is some normal movement in the legs but the arms are weak. This is a classical central cord type of spinal cord injury. In cases where only the anterior part of the spinal cord is damaged there is a complete motor paralyses, in other words no movement but there might be some preservation of light touch and position sense due to the posterior or back part of the spinal cord still be intact.

IV. HOW ARE INJURIES TO THE SPINAL COLUMN MANAGED?

As stated previously the most common cause of spinal cord injury is a fracture or a dislocation of the bones of the vertebral column. Although many people will have fractures of the vertebral column without sustaining an injury to the spinal cord itself. Up to 20 % of people with a fracture will have some varying degrees of injury to the spinal cord. The way of managing these fractures depend a lot on whether the injury is deemed to be stable or unstable.

Again a case is to be made to stabilize unstable injuries via surgery as soon as the patient is medically stable, in other words that there is no other life threatening conditions. This enables the patient to be mobilized out of bed and to partake in a rehabilitation program soon after the injury. It limits time in hospital although it does not mean that the surgery performed will necessarily enhance the recovery of the damaged spinal cord itself. It must always be remembered that surgery to stabilize a fractured vertebrae does not necessarily mean that the damaged spinal cord will recover.

There is also a point to be made to manage these fractures conservatively. This means that the patient does not undergo the risks involved in an operation. The negative effect of this does however mean that the patient will need to stay in bed for up to three months with regular turning. This can result further complications especially pneumonia, bedsores and repeated urine tract infections. If a conservative route is followed it is best that the patient be managed in a unit where there is a clear understanding of the importance of conservative management and that the staff in the unit is trained properly to take care of the unstable fracture.

In our modern socio economic situation in South Africa at this stage very few of these fractures are managed conservatively unless they have been stable from the start because of the length of stay involved in managing these fractures conservatively.

V. HOW IS THE ACUTE SPINAL INJURED PATIENT MANAGED, AND WHAT POSSIBLE COMPLICATIONS CAN THERE BE?

In the ideal circumstances an acute spinal injured patient should be transferred to a dedicated spinal injuries unit where these patients are cared for by a team of professionals who have experience in managing the unique problems associated with a spinal cord injury. The ideal should be that the patient must be admitted to a High Care or Intensive Care Unit. Initially the patient might develop what is called “spinal shock”. Due to the paralyses and loss of reflex activity in the damaged spinal cord blood pressure tends to be on the lowish side and this is associated with a low heart rate. As long as the blood pressure is maintain above renal per fusion pressure which is about 80-mm of mercury this condition termed of spinal shock can be managed without the intervention of inotropic drugs but it should be monitored carefully. Spinal shock can last for a period of between three to four weeks and is usually self limiting. Also the more proximal legion is in other words the higher the legion is more severe the spinal shock and spinal shock phase.

The second most common complication and one that is often overlooked, is called a “Paralytic ileus”. What happens is that due to the loss of innervations of the movement of the small bowels, the small bowels become temporarily paralyzed. This result in an accumulation of gas and fluid in the abdomen and obviously distention of the abdomen. Especially in the quadriplegic patient this is an absolute disaster as this event splints the diaphragm. The complication is easily enough managed by passing a naso gastric tube, in other words the tube running via the nose and the esophagus into the stomach to decompress the abdominal contents.

The next possible complication is what’s called an acute peptic ulceration. Approximately 3 to 5 % of patients with spinal cord injury will have an acute peptic ulcer. This can be prevented by prophylactic administration of antacids either via the nose tube or via the intravenous route.

The next possible complication is over distention of the bladder. All patients who have a spinal cord injury confirmed or suspected should have a urinary catheter in- situ. This has 2 functions. It makes sure that the bladder and the kidneys are adequately drained preventing the build-up of urine and over distention and damage of the bladder wall. Secondly it is important to monitor the amount of urine produced on an hourly basis by the patient. This should be at least one-ml per kilogram per hour. If this occurs one can safely assume that the patient is adequately resusitated.

The ventilator system of a patient, especially a quadriplegic patient is very complex and should be managed by a specialist in the field. A quadriplegic patient usually has paralysis of the inter costal muscles, in other words the muscles of the chest wall that helps with breathing the only muscle that still functioning in the majority of cases of the cervical spinal cord injury is the diaphragm. Often especially the initial phases the diaphragm itself is not powerful enough and does not provide adequate ventilatory support. This might necessitate that the patient be intubated and ventilated for a period of time. The majority of cases the patient can be weaned off the ventilator once the spinal shock phase has past. However, this might take a long period and much longer than is normally the case in a ventilator dependant patient.

The next possible complication is venous drainage complications. The most common cause of the problems and death in the spinal cord injured patient is a deep venous thrombosis and pulmonary embolism. What this means is that due to the lack of muscle contractility and movement in the lower limbs that the blood in the veins of the leg clots and forms and thrombus. This then can brake off and cause a blood clot to the lung which can be fatal. This is managed by preventing these clots from forming with the most commonly used drug at this stage is a daily subcutaneous administration of low molecular weight Heparin. The initial starting time of this should be at about day 5 after the injury. If it is started earlier there might be secondary bleeds into the spinal column itself worsening the neurological fall out. If it is started later than day 5 it might be too late to prevent the formation of deep venous thrombosis. Again this should be discussed on an individual patient to patient case with the Physicians taking care of the patient in the Intensive Care Unit.

VI. WHAT ABOUT BLADDER FUNCTION?

As it is obvious from the above the spinal injured patient’s in the majority of cases have no voluntary control over there bladders. Usually what happens is that they developed a large over distended bladder because they have no sensation that the bladder is full and it might empty spontaneously in what we called an over flow incontinence. To prevent this from happening a catheter should be placed immediately or as soon is possible after injury. The catheter should be of a high quality silicone coated variety as this can be left in-situ for up to 6 weeks.

Regarding the long term management of the bladder function the ideal would be to be catheter free as far as possible. This can be achieved in several ways which should be discussed with the Urologist forming part of the rehabilitation team.

The most common way of managing this is to do what is called “clean intermittent self catheterization”. This means that every 3 to 4 hours the patient goes and passes the catheter drains the bladder and then remove the catheter again. This obviously implies that the patient has very good hand function has good mobility. He is able to transfer him in and out of a toilet and has the mental capacity to manage this.

Again this is one of many options. The other option is to leave an indwelling catheter in-situ. This ideally should be a supra pubic catheter and not a trans urethral catheter to prevent further complications. Basically the final decision of how the bladder should be managed should be made in conjunction with an Urologist. The ideal is at 6 weeks post injury to perform what is called an urodynamic study where the behavior of the bladder is evaluated and appropriate suggestions can then be made.

VII. HOW WILL WE MANAGE THE BOWEL MOVEMENTS?

As stated previously and there is obvious a spinal cord injured there is no sensation when a bowel movement occurs or when the bowel motion will happen. In the majority of cases in supra sacral legions, in other words legions above the sacrum one has what is called a hyper tonic external sphincter once the spinal shock phase has passed. This means that the patient can be taught to be continent. Bowel movements are reestablished by using an alternate day regime of laxatives that is taken the evening before the bowel movement is to occur to make the stool bulk soft and then a movement is initiated by placing a suppository via the anus. This is the old and trusted method of managing a bowel movement and will in most cases insure that the patient is continent regarding fecal control.

Another option is to use what’s called a bowel irrigation system where a manual wash out of the lower colon and rectum is performed by inserting a plastic tube and warm saline is washed through the bowel. Again this is an option that should be investigated and will form part of the rehabilitation program in an appropriate designed unit.

VIII. WHAT ARE PRESSURE SORES AND WHAT SHOULD BE DONE ABOUT IT?

Pressure sores are a brake down in the skin area over lying bony prominence. The main cause of pressure sores as the name states is undue pressure on an affected area. In initial phases after injury the patient is unable to turn himself and to relief pressure thus should be done in a spinal unit via 2 hourly turns relieving the pressure areas. Once the patient is mobile in a wheelchair he needs to be taught how to manage his pressure areas. This is usually done by pressure relieving maneuvers showed to him by therapists and should be done a minimum of twice every hour. The patient should have adequate education and how to manage these pressure areas as prevention is far better than cure.

Once a pressure sore does occur however, the treatment is conservatively first of all. One has to take the patient off the pressure sore and this means usually prolong period bed rest. The area should be debrided and cleaned and wound management principles instigated. Chronic anemia associated with the pressure sores should be addresses as well as a high protein diet. Once all this has been done surgery might be an option either by direct closure or local skin flaps to close the pressure sore area.

Once this has been done rehabilitation should then again be re-instituted to make sure that the patient understands the importance of pressure relief.

IX. WHAT ARE SPASMS, HOW ARE THEY MANAGED?

Spasticity is a usual part of the spinal cord injury or except for the very low level lumbar spine type injuries where lower motor neuron injury has occurred. This usually being distal or lower than the L1 level. In the levels above T12 spasticity usually returns within 6 weeks to 3 months after the injury. The reason for this is that there is no central inhibition of the reflex arc. If one should stimulate the skin of a patient the message travels via the nerve root back to the spinal cord where usually it is inhibited by the brain but the brain has no inhibition on this arc no and the message then just shunted out via the same nerve back to the muscle and this causes a jumping motion. Spasticity is usually a useful sign that the spinal cord is busy recovering. It is also in certain cases very useful to help with activities of daily living such as transferring in and out of a motorcar or in out of the chair. Thus all spasticity or spasms is not usually a bad thing.

When spasticity needs to be treated it is when it interferes with normal activities of daily living. The first line of treatment is active physiotherapy where one has to ensure that the entire joint affected by the spastisity has a full range of movement is stretch out to the maximum length. Also factors that might aggravate spasticity such as urine tract infection, pressure sores, kidney stones or bowel impaction should be excluded.

The next line of treatment is medication where certain drugs can be used to alleviate the spasms and depress the activity of the reflex arc. Again this should not be used before all the physical measures have been tried.

The last option in management of spasticity is to use an implantable device where a small pump is inserted under the abdominal skin with a catheter into the spinal cord delivering certain drugs into the spinal cord area itself and thus alleviating the spasms. This is usually a last resort.

X. WHAT ABOUT SEX AND FERTILITY?

Sex and fertility in the spinal cord injured patient’s as with all the previous topics is a huge topic that virtually needs a discussion document on its own. If one looks at the male spinal cord injured patient in a complete legion the patient after the spinal shock phase will be able to achieve reflex erections. This will not however be accompanied by any sensation.

In the incomplete legion there might be varying degrees of sensation and ability to achieve emission and orgasm depending where the level and what the completeness of the level of injury is. This does not however mean that the patient cannot be sexually active. There are several drugs and mechanical devises on the market to help the patient to achieve an erection and to maintain it if he is not able by reflex activity to achieve an erection.

As far as fertility goes up until 10 years ago it was stated that all males spinal cord injured patients are infertile however, with technology available these days, especially regarding IVF and semen harvesting techniques it is no longer true even patients that have been wheelchair bound in spinal cord injured for an extended periods of time. This however, remains an area of spinal cord medicine that needs further investigation and that will in future play a far greater role than is currently envisaged.

Regarding the female with a spinal cord injury sexual function and fertility usually return and is quite normal except for lubrication which might require some help. Fertility should not be effect by a spinal cord injury however pregnancy can be complicated especially in the high quadriplegic patient.

XI. WHAT ABOUT LIFE EXPECTANCY AND COMPLICATIONS?

Up until the Second World War the life expectancy of a quadriplegic patient was less than 3 months, the paraplegic patient less than 6 months. However, with modern techniques of managing bladder problems and with managing pressure sores this is no longer true. In first world developed countries the life expectancy of a quadriplegic and paraplegic spinal cord injured patient is very close to normal.

Possible complications is usually related to renal function where improper bladder and kidney care will result in renal failure and the expiry of the patient however, if the techniques taught in rehab to the patient is strictly adhered is regular follow-ups is undertaken by the patient there is no reason for him not to expect normal kidney function well into old age. Respiratory care in a quadriplegic patient is another area of problem or cause for concern where complications might develop and once again if techniques taught in the rehabilitation process are adhered to a normal life expectancy can be expected.

XII. WHAT DOES A REHABILITATION TEAM DO AND WHAT SHOULD IT CONSIST OF?

Rehabilitation is a multi faceted labour intensive undertaking that should be conducted by individuals who have the necessary knowledge and experience in managing spinal cord injuries. As these injuries are very uncommon and not necessarily something that the general medical personal deal with on a day to day basis it is imperative that centers of excellence or rehab centers be established where one can take care of the needs of these patients. Furthermore one individual with one specific professional inclination will not be able to address all the needs of a spinal cord injured patient thus ideally a rehab team should consist of the following persons.

Firstly a medical doctor with a special interest in rehabilitation medicine. This doctor should function as a team leader to access the rehabilitation process and further make sure that the medical problems of the patient is addressed. He should have frequent access to other specialties including an Urologist, Othropaedic Surgeon, Neuro-Surgeon and a Physician on an as needed basis to make sure that the medical needs and problems of the patient is adequately addressed. Furthermore he should facilitate the rehabilitation process and act as a team leader.

Secondly a Physiotherapist is an important part of the rehabilitation team. The Physiotherapist role is that to make sure that the patient’s physical condition is adequate and that his joint function and functional abilities are adequately rehabilitated and the patient must be strong enough to do transfers to maintain his posture and balance and to have the necessary physical skills so cope with life in a wheelchair.

An Occupational Therapist is the third important part of the rehabilitation team. The Occupational Therapist role is to ensure that the patient is independent in regards of his activities of daily living. He or she must the taught how to manage dressing, wheelchair skills need to be addressed and necessary assistive devises for the home environment should be provided. Also the Occupational Therapist will need to make sure that the home environment to which the patient returns meets his of her needs.

Fourthly a Social Worker is also an important part of the rehabilitation team. The Social Worker will need to help with the social reintegration of the patient back into society. Also to help with liaison between the rehabilitation team and the patient’s employer and make sure that all the necessary social grants and activities is addressed during the rehabilitation process.

Fifthly a Psychologist is necessary to help the patient through the traumatic events surrounding his injury and to help the family cope with emotional stresses and strains that are inherent in adapting to life with a spinal cord or disabled individual.

Sixthly a seating specialist is helpful giving the patient advise as to what possible wheelchairs and assistive devises are available on the market.

This team should have regular interaction with one another and with the patient forming a central part in the team approach to the rehabilitation process.

XIII. WHAT DOES THE FUTURE HOLD?

At this moment as far as one can reasonably access there is no known cure for a spinal cord injury. Research is ongoing and there are a lot of promising new avenues are being discovered virtually on a daily basis. Several different drug therapies have been tried and do show promise. These include calcium channel blocky antibiotics such as Minomycin have been shown to be beneficial in spinal cord injuries. Surgical techniques including bridging the gap where the defect in spinal cord is with silicone implants have shown some promise but all these techniques at this stage are still experimental.

The most commonly asked and commonly propagated cure for spinal cord injury is stem cells. Once again one has to remember that this is still an experimental therapy. Stem cells show great promise and is possibly one of the most exciting and promising avenues of research at this stage. The clinical use of stem cells at this stage is still in what is termed phase 2 studies. Phase 2 studies mean that there is some laboratory evidence but it cannot be condoned as clinical use at this stage. Hopefully in future this recommendation will change and we will find a cure.

I am sure that this cure is not far off at this stage but one has to weigh the scientific evidence very carefully and make sure that the therapy propagated has stood the test of clinical science

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