Introduction to Spinal Cord Injury

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Introduction

The spinal cord injury (SCI) results in loss of muscles' abilities to generate power, loss of sensation, and loss of the ability to control the bowel and bladder. Efforts of rehabilitation are concentrated on preventing secondary complications due to mobility loss. The use of state-of-the-art technology allows providing mechanical assistance for patients to relearn walking or moving arms.

The spinal cord injury treatment was first developed by Theodor Kocher (Switzerland) and William Wagner (Germany), but it all started back in classical times.

History of Spinal Cord Injury Rehabilitation

• Edwin Smith's surgical papyrus in Egypt about 3000 BC describes paraplegia following injury to the spine.
• Hippocrates (circa 460–370 BC) describes traction in the treatment of spinal cord injury.
• Paul of Aegina (AD 625–690) uses a windlass for spine dislocation and suggests laminectomy.
• Avicenna (980–1037) defines paralysis following a spine fracture as a fatal injury.

• Roland of Parma (circa 1230) from Salerno used manual extension in the spinal cord injury treatment. He was a pioneer of early intervention.
• Ambroise Paré (1564–1598) proposed laminectomy for the treatment of spinal cord injury.
• Astley Cooper (1768–1841) and Charles Bell (1774–1842) wanted to introduce a spinal cord injury treatment in London teaching hospitals. Bell focused on accurate diagnostic procedures. According to him, the surgery was dangerous. He was teaching that renal failure was the cause of death following a spinal cord injury.
• Henry Cline (1750–1827) first performed laminectomy for the treatment of spinal cord injury.
• Wilhelm Wagner (1848–1900) in Germany developed the first treatment protocol for spinal cord injuries. Together with Paul Stolper (1865–1906), he co-authored a book on spinal cord injury which included the anatomy, the pathology, the mechanism of injury and the practical treatment.
• Theodor Kocher (1841–1917)from Switzerland is known for his research related to the anatomy and physiology of the spinal cord injury.
• First World War: helped to develop the concept of the modern management of spinal injuries due to a high number of war casualties with spinal cord injury.
• Period between the first and the second World War: custodial care for patients with a spinal cord injury continues in the UK post-war.
• Charles Frazier (1870–1936) in the US provided a statistical analysis on the outcomes of the surgery, prognosis, life expectancy, and discharge home and work. A page and a half in his book included information on the physical management of spinal cord injury.
• George Riddoch (1888–1947) is known for his work on rehabilitation and the pathophysiology of spinal cord injuries.
• Donald Munro (1889–1973) is the father of the treatment of paraplegia.
• Ludwig Guttmann (1899–1980) is considered a founder of the modern treatment of spinal injuries. He formed dedicated spinal cord injury units managing the spine, bladder, bowel, skin, education, and rehabilitation. Conservative management progressed from traction, bed rest, and bracing to surgical management and bracing, shortening patient's the time on bedrest.

Aetiology

The traumatic causes of spinal cord injury include:

• falls: falls from height or simple falls
• motor vehicle accidents (MVA's)/motor vehicle crashes
• sports-related accidents
• violence
• other remaining causes of injury.

MVA's and falls are the most common causes of injury accounting for nearly equal percentages. In developed countries, the main cause of SCI used to be MVA's, but recently are falls. In low-income countries, falls are the most common cause of SCI.

The non traumatic causes of spinal cord injury include:

• degenerative
• inflammatory or auto-immune
• neoplasms
• vascular
• infection
• tuberculosis (Sub-Saharan Africa).

Patients' demographics

• Developed countries:
  • male to female ratio: from 1.10:128 to 6.69:121
  • mean age : from 14.630 to 67.631 years

• Low-income countries:
  • male to female ratio: from 1.00:126 to 7.59:1.29
  • mean age: from 29.532 to 46.033 years.

Level and severity of the injury

• the most common: the cervical level of spinal cord injury in both developed countries and non-developed countries
• lower percentage of complete injury vs incomplete injury
• tetraplegia was more common than paraplegia in both developed countries and non-developed countries
• motor-complete injuries (America Spinal Injury Association Impairment Scale [AIS]-A or -B) were more common for patients with traumatic SCI, while there were more motor- incomplete injuries (AIS-C or-D) for patients with non-traumatic SCI.

Epidemiology

Developed countries:

• Incidence: from 13.121to 163.420 per million people
• Prevalence: from 49024 to 52625 per million population
• Mortality: from 3.1% to 22.2%.

Low-income countries:

• Incidence: from 13.019 to 220.022 per million people.
• Prevalence:about 440.026 per million people
• Mortality: 1.4% to 20.0%.

Examples of life expectancy for a 20-year-old:

• healthy individual: 79.5 years
• individual with incomplete spinal cord injury: 72.9 years
• individual with paraplegia: 65.5 years
• individual with low tetraplegia: 60.7 years
• individual with high tetraplegia (C5 and above): 56.9 years.

Complications of Spinal Cord Injuries

• Respiratory complications: are the main comorbidities among individuals with cervical and high thoracic injury. It includes pneumonia, atelectasis and other respiratory complications. With higher level of spinal cord injury there is an increase risk of respiratory complications.
• Decubitus ulcers: is defined as a localized injury to the skin and/or the underlying tissue. It usually develops over a bony prominence, as a result of pressure and/or shear.
• Contractures: joint contractures leads to pain, deformity, loss of function, decreased levels of independence and lower quality of life. Tetraplegic patients are especially exposed to shoulder and elbow joint contracture.
• Myositis ossificans: is characterised by new extra osseous (ectopic) bone being formed in soft tissue surrounding peripheral joints . The pathophysiology of this condition is not well defined.
• Autonomic dysreflexia: an episode of hypertension in response to unmodulated sympathetic reflexes after spinal cord injury.
• Syringomyelia: abnormal circulation of the cerebrospinal fluid with sensory symptoms, including decreased sensitivity to temperature and pain.
• Urinary tract infections due to repeated or prolonged use of catheters, both indwelling and intermittent catheterisation. There is a high risk of introducing different types of bacteria to the urinary system which leads to urinary track infections.
• Pyelonephritis: kidney inflammation caused by a bacterial infection. It occurs when urinary track infection spreads from the bladder to the kidneys
• Kidney and bladder stones: there is an increased risk of bladder stone formation and morbidity from the surgeries to remove them in persons with spinal cord injury. This occurs in the first year after SCI, but the natural history of bladder stones among this patient population is poorly defined.
• Kidney failure
• Bladder carcinomas: development of the neurogenic bladder after a spinal cord injury can lead to development of the bladder cancer.
• Incontinence or constipation: bowel dysfunction in one of the most prevalent secondary complications post spinal cord injury and improving bowel dysfunction is considered one of the highest priorities among persons with SCI.
• Nociceptive and neuropathic pain: it may occur in up to 60% of patients with a spinal cord injury. Among these individuals 58% reported nociceptive pain (musculoskeletal pain), neuropathic pain at or below the damage level was observed from 5% to 53% of patients.
• Spasticity: is a frequent complication after spinal cord injury and it usually occurs a few weeks after acute onset of SCI and may develop over months or years.
• Postural hypotension
• Impaired temperature control: Individuals with high level of spinal cord injury demonstrate an increase in body temperature together with increased heat retention.
• Depression: is relatively common after SCI (over 70% individuals with SCI) and it affects the mood, ambitions, views, problem­ solving abilities and energy level.
• Osteoporosis: rapid bone loss and elevated risk of fracture have been related to SCI. Significant increase in bone resorption and deficiency in bone anabolic activity leads to a rapid bone loss following SCI, especially in distal femurs and proximal tibias.
• Sexual dysfunction: need for sexual expression and intimacy declines. It is related to biological consequences of SCI and emotional disorder or lack of interpersonal contacts.

Classification of Spinal Cord Injuries

The American Spinal Injury Association (ASIA) and the International Spinal Injury Society (ISCoS) introduced standardised classification for individuals with a spinal cord injury called the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). It allows to determine, based on the neurological examination, the level and the severity of the spinal cord injury and it can be used in all phases of post injury recovery. It includes:

• Sensory testing in twenty eight dermatomes
• Muscle functions of ten key muscles of the upper and lower extremities for both sides of the body.

The purposes for classification standardisation of spinal cord injuries are:

• standardisation for clinical documentation
• standardisation for communication of SCI-related neurological impairments
• defining inclusion and exclusion criteria for research purpose
• defining outcome assessment in research studies.

The final revision of ISNCSCI was released in 2019 and is included in the International Standards Training e-Program (InSTeP).

The following are impairment scales:

• A: Complete injury where no sensory or motor function is preserved in the sacral segments S4–S5.
• B : Sensory incomplete characterised by preserved sensory function, but not motor function at the most caudal sacral segments S4–S5 AND no motor function present more than three levels below the motor level on either side of the body.
• C : Motor incomplete with a motor function preserved at the most caudal sacral segments on voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4–S5), with sparing of motor function more than three levels below the motor level on either side of the body.
• D : Motor incomplete as above with at least half of key muscle functions below the single neurological level of injury having a muscle grade ≥ 3.
• E :Normal sensation and motor function in all segments and the patient had prior deficits, then the AIS grade is E. Someone without an SCI does not receive an AIS grade.

Read here about detailed ISNCSCI assessment. You can download the ASIA form from ASIA website.

Resources

• Rehabilitation Evidence https://scireproject.com/evidence/rehabilitation-evidence/
• American Spinal Injury Association. International Standards Training e-Program 2019: https://asia-spinalinjury.org/learning/.

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