Spinal Cord Injury

Original Editor - Killian Borms, Lisa De Pelsemaeker, Boris Coessens, Cedric Cludts

Top Contributors - Borms Killian, Naomi O'Reilly and Wendy Walker  

Definition/Description

Spinal cord injury is defined as traumatic damage to the spinal cord or nerves at the end of the spinal canal. This affects conduction of sensory and motor signals across the site(s) of lesion(s).
There are two types: incomplete and complete injury. [1]
• Incomplete lesion: not all the nerves are severed or the nerves are only slightly damaged. Recovery is possible, but never to pre-injury level.
• Complete lesion: the nerves are severed and there is no motor or sensory function preserved of this point.

Clinically Relevant Anatomy

The spinal cord is the major conduit through which motor and sensory information travels between brain and body. The spinal cord contains longitudinally oriented spinal tracts (white matter) surrounding central areas (gray matter) where most spinal neuronal cell bodies are located. The gray matter is organized into segments comprising sensory and motor neurons. Axons from spinal sensory neurons enter and axons from motor neurons leave the spinal cord via segmental nerves or roots. The roots are numbered and named according to the foramina through which they enter/exit the vertebral column.
Each root receives sensory information from skin areas called dermatomes. Similarly, each root innervates a group of muscles called a myotome.
The spinal cord is divided into four regions: cervical (7 vertebrae), thoracic (12 vertebrae), lumbar (5 vertebrae) and sacral (5 vertebrae). [2]

Epidemiology/Etiology

A systematic review by Singh et al. (2013) found the prevalence of SCI to be dependent on the region the studies were conducted, ranging from 906 per 1million (USA) to 250 per million (Rhone-Alpes, France).[3]  Annual incidence rates also varied significantly between region, ranging from 49.1 per million (New Zealand) to 8.0 per million (Spain). [3]
Another review by Furlan et al. (2014) found similar results with prevalence ranging from 1298 per million to 50 per million and incidence ranging from 246 per million to 3.3 per million.[4]
These results indicate that the incidence, prevalence and causation of SCI can differ significantly between developing and developed countries (high in developed countries).

Furlan et al. found strong inconsistencies in data when analysed between countries but reported that the most frequent causes are, in order; motor vehicle crashes, falls, sports, violence, self-harm, and work-related accidents.[4]
Data from the National Spinal Cord Injury Statistical Center (USA) from 2010-2014 provided the following statistics for etiology (illustration)
Other interesting statistics from this report include:
• Males account for 80% of new cases
• Average age at injury has gone up from 1970 (29years old) to today (42years old)
• Only about 12% of patients are employed 1 year after trauma, rising to 34.4%, 20years after trauma
• Life expectancy decreases for all SCI patients, compared to people without SCI
  The decrease is steeps in younger patients and in patients with the most severe disabilities.

Characteristics/Clinical Presentation

As spinal cord injuries are by definition caused by traumas, the primary examination and presentation will be done in an emergency response setting. Initial evaluation includes pulmonary evaluation to determine loss of ventilatory function and/or lung injury. Signs of haemorrhage and neurogenic shock are also checked in this initial evaluation.
Finally, and most relevant to physical therapy, neurologic assessment is done which includes checking motor function, sensory evaluation, deep tendon reflexes and perineal evaluation.[5]
The ASIA (American Spinal Injury Association) has established an international standard neurological which can be used to classify the lesion according to a specific cord syndrome. This includes motor and sensory evaluation. This also includes an impairment scale which indicates severity of the lesion.
(for more information see article)

Differential Diagnosis

• Aortic artery dissection
• Epidural and Subdural Infections
• Spinal Cord Infections
• Syphilis (tertiary)
• Vertebral Fracture
Transverse myelitis
Acute intervertebral disk herniation
• Spinal abscess (spinal cord compression)

Medical Management

The ideal management of acute SCI is a combination of pharmacological therapy, early surgery, aggressive volume resuscitation and blood pressure elevation to maximize spinal cord perfusion, early rehabilitation and cellular therapies.[6]

Pharmacological agents:
There is still no commonly accepted pharmacological agent.[6]
The most important candidates are:
Glucocorticoids (methylprednisolone)
Glucocorticoids suppress many of the ‘secondary’ events of spinal cord injury. These are inflammation, lipid peroxidation and excitotoxity. Randomised clinical trials are contradictory in their results and so are the opinions of experts.[7]
Thyrotropin-releasing hormone (TRH)
It shows antagonistic effects against the secondary injury mediators.[6]
For more information, see article.


Polyunsaturated Fatty Acids (PUFA)
Docosahexanoic acid (DHA) has been recently explored for SCI management. It causes a better neurological recovery: increase neuronal and oligodendrocyte survival and decrease the microglia/macrophage responses, reduce axonal accumulation of b-amyloid precursor protein (b-APP) and increase synaptic connectivity.
Eicosapentaenoic acid (EPA) increases synaptic connectivity, to restore neuro-plasticity.[8]


Surgical intervention
Early surgical decompression results in a better neurological outcome.


Cellular therapies:
The aim of cell therapies is to provide functional recovery of deficit by an axonal regeneration and restoration.
Schwann cell
One of the most widely used cell types for repair of the spinal cord.
Olfactory ensheating cells
They are capable of promoting axonal regeneration and remyelination after injury.
Bone marrow derived mononuclear cells (BM-MNC’s) transplantation
It is feasible, safe and have a good degree of outcome improvement.
Stimulated macrophages
They invade the impaired tissue.[6]

Diagnostic Procedures

Imaging technology is an important part of the diagnostic process of acute or chronic spinal cord injuries. Spinal cord injuries can be detected using different types of imaging which depends on the type of underlying pathology. MRI has become the golden standard for imaging neurological tissues such as the spinal cord, ligaments, discs and other soft tissues. Only MRI sequences of sagittal T2 were found to be useful for prognosticative purposes. [9] Spinal fractures and bony lesions are better characterized by computed tomography (CT) and vascular injuries van be detected by using an MR angiography or by a CT scan.[10]

Outcome Measures

Cite instrument related to ICF classification
- Instruments to measure impairments
- Instruments to measure disability

Spinal Cord Independence Measure (SCIM)[11]
• Spinal Cord Injury Lifestyle Scale (SCILS)[12]

• WHOQOL-BREF[12]

Examination

A diagnosis can be made through a thorough history and examination. By performing a neurological examination, if possible to participate in a reliable physical neurological examination, for the sensory and motoric functions of the body in the corresponding area of complaints. After the examination we can make a judgement of the severity and the location of the injury.[13] If the place of injury is diagnosed we can perform some extra examinations as described on the following pages:
Cervical examination
Lumbar examination
Thoracic examination

Physical Therapy Management

The rehabilitation of patients who had a spinal cord injury depends on which level of the spine the injury occurred . Also the therapy depends on whether it was a complete or an incomplete spinal cord injury. In case of an incomplete spinal cord injury 25% do not become independent ambulators.
The therapies differ according to where the lesion happened, cervical, thoracic or lumbar. The rehabilitation of SCI is a multidisciplinary approach! [14][15] (level of evidence 2A en 1A)

Possible upper incomplete SCI therapy:
When the cervical spine is injured, the consequences for the patient are life changing. Patients need therapy for movement and strength recovery of the upper body and probable respiratory training.[15][16] (level of evidence 2C en 1A)
Respiratory muscle training consists of inspiratory, expiratory or both improvement in muscle strength and endurance. Normocapnic hyperpnoea is a method of respiratory muscle endurance training that simultaneously trains the inspiratory and expiratory muscles. This device consists of a re-breathing bag that works at 30 to 40% of the patient’s vital capacity and is connected to a tube system and mouthpiece.[17] (level of evidence 2B) The patient must fill and empty the bag completely with each breath. Other respiratory muscle training exists and are also effective.[18] (level of evidence 1A)
Training of the upper limb after SCI consists usually of specific exercises or conventional therapy using Bobath principles combined with functional electrical stimulation.[15] (level of evidence 2C)


Possible lower incomplete SCI therapies:
The main limitations with lower incomplete SCI patients, is that they have a reduced coordination, leg paresis and impaired balance.[14] (level of evidence 2A)
These limitations can be worked on with the use of braces and tilt tables. If the leg strength improves, therapists can use braces, parallel bars and other walking aids to work on the balance weight bearing of the patient. In combination with those instruments, the therapist needs to train the patient using repetitive and intensive practice of gait. The use of a treadmill with overhead harness is applied to certain SCI cases and only by choice of the therapist. Thanks to the harness, patients can more easily focus on their gait under supervision of their therapist. In addition to this therapy, the use of functional electrical stimulation is needed to optimize rehabilitation of the patient.[14][19] (level of evindence 2A en 1B)

New therapies are emerging and showing positive evolution, such as the robotic-assisted gait training. This therapy uses a treatment of 40 minutes twice a day at a rate of 5 times a week. 3 days using the robotic-gait training and 2 days regular physical therapy. Included in the regular physical therapy are, functional electrical stimulation and physical therapy using the Bobath principles.[14][19] (level of evidence 2A en 1B)

Complete recovery after incomplete or complete SCI is never attainable.[14][19][16](level of evidence 2A, 1B en 1A)

Key Research

- Singh, A. et al. “Global prevalence and incidence of traumatic spinal cord injury”, Clin. Epidemiol. 2014; 6: 309-331. (level of evidence  1A)
- Furlan, J.C. et al. “Global incidence and prevalence of traumatic spinal cord injury.” Can J Neurol Sci. 2013 Jul;40(4):456-64. (level of evidence = 1A)
- V. Cheung et al., Methylprednisolone in the management of spinal cord injuries: Lessons from randomized, controlled trials. (level of evidence =1A)
- Xiao Lu et al., effects of training on upper limb function after cervical spinal cord injury: a systematic review, clinical rehabilitation 2015, vol. 29(1) 3-13 (level of evidence = 1A)
- J.C.Shin et al., effect of robotic-assisted gait training in patients with incomplete spinal cord injury, Ann Rehabil Med 2014;38(6):719-725 ( level of evidence = 1B)
- Berlowitz D et al., respiratory muscle training for cervical spinal cord injury, Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD008507. DOI: 10.1002/14651858.CD008507.pub2.(level of evidence 1A)
- Anthony B. et al., The Role of Magnetic Resonance Imaging in the Management of Acute Spinal Cord Injury, J Neurotrauma. 2011 Aug; 28(8): 1401–1411. (level of evidence 1B)
- M R Hill et al., Quality of life instruments and definitions in individuals with spinal cord injury: a systematic review, Spinal Cord (2010) 48, 438–450 (level of evidence 1A)

Resources

ASIA - International Standards for Neurological Classification of SCI (ISNCSCI) Exam
http://www.asia-spinalinjury.org/elearning/isncsci_worksheet_2015_web.pdf

Article Exploring additional pharmacological options
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303789/pdf/WJO-6-42.pdf

Website of National Spinal Cord Injury Statistical Center (NSCISC) - Accessed 18/11/2015
https://www.nscisc.uab.edu/Public/Facts%202015%20Aug.pdf

Clinical Bottom Line

Spinal cord injuries are a serious, widespread health issue resulting in a large amount of disfunction and as such have a big socio-economic impact.
Therapy is multidisciplinary and focus should be on regaining of function (relevant to the patient!), as tissue recovery is often impossible.

Recent Related Research (from Pubmed)

PubMed RSS FEED : « Physical Therapy OR Physiotherapy AND Spinal Cord Injury »

References

  1. Frederick M Maynard et al., International Standards for Neurological and Functional Classifi-cationof Spinal Cord Injury, American Spinal Injury Association, 1996
  2. Francisco de Assis Aquino Gondim et al., Topographic and Functional Anatomy of the Spinal Cord, Medshape, 2015
  3. 3.0 3.1 Singh, A. et al. “Global prevalence and incidence of traumatic spinal cord injury”, Clin. Epi-demiol. 2014; 6: 309-331
  4. 4.0 4.1 Furlan, J.C. et al. “Global incidence and prevalence of traumatic spinal cord injury.” Can J Neurol Sci. 2013 Jul;40(4):456-64
  5. J.W. McDonald et al. Spinal-Cord Injury. Lancet 2002 Fed2;359(9304):417-25 (level of evidence = 5)
  6. 6.0 6.1 6.2 6.3 Yilmaz T., et al., Current and future medical therapeutic strategies for the functional repair of spinal cord injury, 2015, World J Orthop. 2015 Jan 18;6(1):42-55
  7. V. Cheung et al., Methylprednisolone in the management of spinal cord injuries: Lessons from randomized, controlled trials Surg Neurol Int. 2015; 6: 142
  8. W.-Y. Yu et al., Current trends in spinal cord injury repair. Eur Rev Med Pharmacol Sci 2015; 19 (18): 3340-3344
  9. Anthony B. et al., The Role of Magnetic Resonance Imaging in the Management of Acute Spi-nal Cord Injury, J Neurotrauma. 2011 Aug; 28(8): 1401–1411
  10. Andrew L G. et al., Advances in Imaging of Vertebral and Spinal Cord Injury, J Spinal Cord Med. 2010 Apr; 33(2): 105–116
  11. M. Itzkovich et al., The Spinal Cord Independence Measure (SCIM) version III: Reliability and validity in a multi-center international, Disability and Rehabilitation Volume 29, Issue 24, 2007
  12. 12.0 12.1 Pruitt SD. Et al., Health behavior in persons with spinal cord injury: development and initial validation of an outcome measure, Spinal Cord [1998, 36(10):724-731]
  13. Joost J. van M. et al., Diagnosis and Prognosis of Traumatic Spinal Cord Injury, Global Spine J. 2011 Dec; 1(1): 1–8
  14. 14.0 14.1 14.2 14.3 14.4 Mehrholz J et al., locomotor training for walking after spinal cord injury (review), Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD006676 (level of evidence 2A)
  15. 15.0 15.1 15.2 Xiao Lu et al., effects of training on upper limb function after cervical spinal cord injury: a systematic review, Clinical Rehabilitation 2015, vol. 29(1) 3-13 (level of evidence = 1A)
  16. 16.0 16.1 Martin G et al., Medical, psychosocial and vocational aspect of disability, Athens GA, Third Edition, 2009, p. 291 ( level of evidence 2C)
  17. Koppers R. et al., Tube breathing as a new potential method to perform respiratory muscle training: Safety in healthy volunteers, Respiratory Medicine (2006) 100, 714-720 (level of ev-idence 2B)
  18. Berlowitz D et al., respiratory muscle training for cervical spinal cord injury, Cochrane Data-base of Systematic Reviews 2013, Issue 7. Art. No.: CD008507 (level of evidence 1A)
  19. 19.0 19.1 19.2 J.C.Shin et al., effect of robotic-assisted gait training in patients with incomplete spinal cord injury, Ann Rehabil Med 2014;38(6):719-725 ( level of evidence = 1B)