Spine Conditions
Monday, 24 June 2013

a) Herniated Disc

The bones (vertebrae) that form the spine in your back are cushioned by small discs. These discs are round and flat, with a tough, outer layer (annulus) that surrounds a jellylike material called the nucleus. Located between each of your vertebra in the spinal column, discs act as shock absorbers for the spinal bones. Thick ligaments attached to the vertebrae hold the pulpy disc material in place.

A herniated disc (also called a slipped or ruptured) disc is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture. Discs that become herniated usually are in an early stage of degeneration. The spinal canal has limited space, which is inadequate for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on spinal nerves, often producing pain, which may be severe.

Herniated discs can occur in any part of the spine. Herniated discs are more common in the lower back (lumbar spine), but also occur in the neck (cervical spine). The area in which you experience pain depends on what part of the spine is affected.

Causes

A single excessive strain or injury may cause a herniated disc. However, disc material degenerates naturally as you age, and the ligaments that hold it in place begin to weaken. As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture.

Certain individuals may be more vulnerable to disc problems and, as a result, may suffer herniated discs in several places along the spine. Research has shown that a predisposition for herniated discs may exist in families, with several members affected.

Herniated Disc Symptoms

Symptoms vary greatly depending on the position of the herniated disc and the size of the herniation. If the herniated disc is not pressing on a nerve, you may experience a low backache or no pain at all. If it is pressing on a nerve, there may be pain, numbness or weakness in the area of the body to which the nerve travels. Typically, a herniated disc is preceded by an episode of low back pain or a long history of intermittent episodes of low back pain.

Lumbar spine (lower back): Sciatica frequently results from a herniated disc in the lower back. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that radiates from the buttock into the leg and sometimes into the foot. Usually one side (left or right) is affected. This pain often is described as sharp and electric shock-like. It may be more severe with standing, walking or sitting. Along with leg pain, you may experience low back pain.

Cervical spine (neck): Symptoms may include dull or sharp pain in the neck or between the shoulder blades, pain that radiates down the arm to the hand or fingers, or numbness or tingling in the shoulder or arm. The pain may increase with certain positions or movements of the neck.

Diagnosis

Diagnosis is made by a neurosurgeon based on your history, symptoms, a physical examination and results of tests, including the following:

  • X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, i.e. tumors, infections, fractures, etc.
  • Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads X-rays; can show the shape and size of the spinal canal, its contents, and the structures around it.
  • Magnetic resonance imaging (MRI): A diagnostic test that produces 3-D images of body structures using powerful magnets and computer technology; can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration, and tumors.
  • Myleogram: An X-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces; can show pressure on the spinal cord or nerves due to herniated discs, bone spurs or tumors.
  • Electromyogram and Nerve Conduction Studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury or whether there is another site of nerve compression.

Treatment

Fortunately, the majority of herniated discs do not require surgery. However, a very small percentage of people with herniated, degenerated discs may experience symptomatic or severe and incapacitating low back pain, which significantly affects their daily life.

The initial treatment for a herniated disc usually is conservative and nonsurgical. Your doctor may prescribe bed rest or advise you to maintain a low, painless activity level for a few days to several weeks. This helps the spinal nerve inflammation to decrease.

A herniated disc frequently is treated with nonsteroidal anti-inflammatory medication if the pain is only mild to moderate. An epidural steroid injection may be performed utilizing a spinal needle under X-ray guidance to direct the medication to the exact level of the disc herniation.

Your doctor may recommend physical therapy. The therapist will perform an in-depth evaluation, which, combined with the doctor's diagnosis, will dictate a treatment specifically designed for patients with herniated discs. Therapy may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation, and stretching exercises. Pain medication and muscle relaxants also may be beneficial in conjunction with physical therapy.

Surgery

Your doctor may recommend surgery if conservative treatment options, such as physical therapy and medications, do not reduce or end the pain altogether. He or she will talk to you about the types of spinal surgery available and, depending on your specific case, will help to determine what procedure might be an appropriate treatment for you. As with any surgery, a patient's age, overall health and other issues are taken into consideration when surgery is considered.

The benefits of surgery always should be weighed carefully against its risks. Although a large percentage of patients with herniated discs report significant pain relief after surgery, there is no guarantee that surgery will help every individual.

You may be considered a candidate for spinal surgery if:

  • Back and leg pain limits normal activity or impairs your quality of life
  • You develop progressive neurological deficits, such as leg weakness and/or numbness
  • You experience loss of normal bowel and bladder functions
  • You have difficulty standing or walking
  • Medication and physical therapy are ineffective
  • You are in reasonably good health

Surgical Terms

  • Artificial disc surgery — Surgical replacement of a diseased or herniated lumbar disc with a manufactured disc. The CHARITÉ artificial disc consists of a plastic core between two chrome plates that lock into the spine. The PRODISC-L is an artificial intervertebral disc made from metal and plastic that is used to treat pain associated with degenerative disc disease (DDD).
  • Discectomy — Surgical removal or partial removal of an intervertebral disc.
  • Laminectomy — Surgical removal of most of the bony arch, or lamina of a vertebra.
  • Laminotomy — An opening made in a lamina, to relieve pressure on the nerve roots.
  • Spinal Fusion — A procedure in which bone is grafted onto the spine, creating a solid union between two or more vertebrae; and in which instrumentation such as screws and rods may be used to provide additional spinal support.

Lumbar Spine Surgery

Lumbar laminotomy is a procedure often utilized to relieve leg pain and sciatica caused by a herniated disc. It is performed through an incision down the center of the back over the area of the herniated disc. During this procedure, a portion of the lamina may be removed. Once the incision is made through the skin, the muscles are moved to the side so that the surgeon can see the back of the vertebrae. A small opening is made between the two vertebrae to gain access to the herniated disc. After the disc is removed through a discectomy, the spine must be stabilized. Spinal fusion often is performed in conjunction with a laminotomy. In more involved cases, a laminectomy may be performed.

In artificial disc surgery, an incision is made through the abdomen, and the affected disc is removed and replaced. Only a small percentage of patients are candidates for artificial disc surgery. You must have disc degeneration in only one disc, between L4 and L5, or L5 and S1 (the first sacral vertebra). You must have undergone at least six months of treatment, such as physical therapy, pain medication or wearing a back brace, without showing improvement. You must be in overall good health with no signs of infection, osteoporosis or arthritis. If you have degeneration affecting more than one disc, or significant leg pain, you are not a candidate for this surgery.

Cervical Spine Surgery

The medical decision to perform the operation from the front of the neck (anterior) or the back of the neck (posterior) is influenced by the exact location of the herniated disc, as well as the experience and preference of the surgeon. A portion of the lamina may be removed through a laminotomy, followed by a discectomy. After the disc is removed, the spine often needs to be stabilized. This is accomplished using a cervical plate and screws (instrumentation), and, often, spinal fusion.

Postsurgery

Your doctor will give you specific instructions postsurgery and usually prescribe pain medication. He or she will help determine when you can resume normal activities such as returning to work, driving and exercising. Some patients may benefit from supervised rehabilitation or physical therapy after surgery. Discomfort is expected while you gradually return to normal activity, but pain is a warning signal that you might need to slow down.

Prevention Tips

Once you have recovered from surgery and checked with your doctor, you may resume moderate exercise. The following tips may be helpful in preventing low back pain and herniated discs.

  • Do crunches and other abdominal-muscle strengthening exercises to provide more spine stability. Swimming, stationary bicycling and brisk walking are good aerobic exercises that generally do not put extra stress on your back.
  • Use correct lifting and moving techniques, such as squatting to lift a heavy object. Don't bend and lift. Get help if an object is too heavy or awkward.
  • Maintain correct posture when you're sitting and standing.
  • If you smoke, quit. Smoking is a risk factor for artherosclerosis (hardening of the arteries), which can cause lower back pain and degenerative disc disorders.
  • Avoid stressful situations if possible, as this can cause muscle tension.
  • Maintain a healthy weight. Extra weight, especially around the midsection, can put strain on your lower back.

 

b) Spinal Tumors
 

A spinal tumor is an abnormal mass of tissue within or surrounding the spinal cord and spinal column. These cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells. Spinal tumors can be benign (non-cancerous) or malignant (cancerous). Primary tumors originate in the spine or spinal cord, and metastatic or secondary tumors result from cancer spreading from another site to the spine.

Spinal tumors may be referred to by the area of the spine in which they occur. These basic areas are cervical, thoracic, lumbar and sacrum. Additionally, they also are classified by their location in the spine — anterior (front) and posterior (back). Clinically, they are divided into three major groups according to location: intradural-extramedullary, intramedullary and extradural.

Intradural-extramedullary: These tumors develop in the spinal cord's arachnoid membrane (meningiomas), in the nerve roots that extend out from the spinal cord (schwannomas and neurofibromas) or at the spinal cord base (filum terminale ependymomas). Although meningiomas are often benign, they can be difficult to remove and may recur. Nerve root tumors are also generally benign, although neurofibromas may become malignant over time. Ependymomas at the end of the spinal cord can be large, and the delicate nature of fine neural structures in that area may complicate treatment.

Intramedullary: These tumors grow inside the spinal cord or individual nerves, most frequently occurring in the cervical (neck) region. They typically derive from glial or ependymal cells that are found throughout the interstitium of the cord. Astrocytomas and ependymomas are the two most common types. They are often benign, but can be difficult to remove. Intramedullary lipomas are rare congenital tumors most commonly located in the thoracic spinal cord.

Extradural: These lesions are typically attributed to metastatic cancer or schwannomas derived from the cells covering the nerve roots. Occasionally, an extradural tumor extends through the intervertebral foramina, lying partially within and partially outside of the spinal canal.

Metastatic spinal tumors

The spinal column is the most common site for bone metastasis. Estimates indicate that at least 30 percent and as high as 70 percent of patients with cancer will experience spread of cancer to their spine. Common primary cancers that spread to the spine are lung, breast and prostate. Lung cancer is the most common cancer to metastasize to the bone in men, and breast cancer is the most common in women. Other cancers that spread to the spine include lymphoma, melanoma and sarcoma, as well as cancers of the gastrointestinal tract, kidney and thyroid.

Prompt diagnosis and identification of the primary malignancy is crucial to overall treatment. Numerous factors can affect outcome, including the nature of the primary cancer, the number of lesions, the presence of distant non-skeletal metastases and the presence and/or severity of spinal-cord compression.

Pediatric spinal tumors

Primary spinal tumors are rare in children and are challenging to treat. Incidence and outcome vary by histological subtype, a listing of which can be quite broad but include the following:

Unlike adults, children have not achieved complete skeletal growth, which doctors must take into account when considering treatment. Other factors to consider are spinal stability, surgical versus nonsurgical interventions and preservation of neurological function.

Incidence and Prevalence

Intracranial (brain) tumors account for 85 to 90 percent of all primary central nervous system (CNS) tumors. Primary tumors arising from the spinal cord, spinal nerve roots and dura are rare compared to CNS tumors that arise in the brain. Overall prevalence is estimated at one spinal tumor for every four intracranial lesions. About 10,000 Americans develop primary or metastatic spinal cord tumors each year.

Intramedullary tumors are rare, accounting for only five to 10 percent of all spinal tumors. Benign tumors such as meningiomas and neurofibromas account for 55 to 65 percent of all primary spinal tumors.

Meningiomas most frequently occur in women between the ages of 40 and 70.

Metastatic spinal tumors are the most common type of malignant lesions of the spine, accounting for an estimated 70 percent of all spinal tumors.

Causes

The cause of most primary spinal tumors is unknown. Some of them may be attributed to exposure to cancer-causing agents. Spinal cord lymphomas, which are cancers that affect lymphocytes (a type of immune cell), are more common in people with compromised immune systems. There appears to be a higher incidence of spinal tumors in particular families, so there is most likely a genetic component. In a small number of cases, primary tumors may result from presence of these two genetic diseases:

Neurofibromatosis 2: In this hereditary disorder, benign tumors may develop in the arachnoid layer of the spinal cord or in the supporting glial cells. However, the more common tumors associated with this disorder affect the nerves related to hearing and can inevitably lead to loss of hearing in one or both ears.

Von Hippel-Lindau disease: This rare, multi-system disorder is associated with benign blood vessel tumors (hemangioblastomas) in the brain, retina and spinal cord, and with other types of tumors in the kidneys or adrenal glands.

Symptoms

Non-mechanical back pain, especially in the middle or lower back, is the most frequent symptom of both benign and malignant spinal tumors. This back pain is not specifically attributed to injury, stress or physical activity. However, the pain may increase with activity and is often worse at night. Pain may spread beyond the back to the hips, legs, feet or arms and may worsen over time — even when treated by conservative, nonsurgical methods that can often help alleviate back pain attributed to mechanical causes.

Depending on the location and type of tumor, other signs and symptoms can develop, especially as a malignant tumor grows and compresses on the spinal cord, the nerve roots, blood vessels or bones of the spine. Impingement of the tumor on the spinal cord can be life-threatening in itself. Additional symptoms can include the following:

  • Loss of sensation or muscle weakness in the legs, arms or chest
  • Difficulty walking, which may cause falls
  • Decreased sensitivity to pain, heat and cold
  • Loss of bowel or bladder function
  • Paralysis that may occur in varying degrees and in different parts of the body, depending on which nerves are compressed
  • Scoliosis or other spinal deformity resulting from a large, but benign tumor

Diagnosis

A thorough medical examination with emphasis on back pain and neurological deficits is the first step to diagnosing a spinal tumor. Radiological tests are required for an accurate and positive diagnosis.

  • X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, i.e. tumors, infections, fractures, etc. X-rays are not very reliable in diagnosing tumors.

  • Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads X-rays, a CT/CAT scan can show the shape and size of the spinal canal, its contents, and the structures around it. It also is very good at visualizing bony structures.

  • Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. An MRI can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration, and tumors.

After radiological confirmation of the tumor, the only way to determine whether the tumor is benign or malignant is to examine a small tissue sample (extracted through a biopsy procedure) under a microscope. If the tumor is malignant, a biopsy also helps determine the cancer's type, which subsequently determines treatment options.

Staging classifies neoplasms (abnormal tissue) according to the extent of the tumor, assessing bony, soft tissue and spinal canal involvement. A doctor may order a whole body scan utilizing nuclear technology, as well as a CT scan of the lungs and abdomen for staging purposes. To confirm diagnosis, a doctor compares laboratory test results and findings from the aforementioned scans to the patient's symptoms.

Nonsurgical treatment

Nonsurgical treatment options include observation, chemotherapy and radiation therapy. Tumors that are asymptomatic or mildly symptomatic and do not appear to be changing or progressing may be observed and monitored with regular MRIs. Some tumors respond well to chemotherapy and others to radiation therapy. However, there are specific types of metastatic tumors that are inherently radioresistant (i.e. gastrointestinal tract and kidney), and in those cases, surgery may be the only viable treatment option.

Surgery

Indications for surgery vary depending on the type of tumor. Primary spinal tumors may be removed through complete en bloc resection for a possible cure. In patients with metastatic tumors, treatment is primarily palliative, with the goal of restoring or preserving neurological function, stabilizing the spine and alleviating pain. Generally, surgery is only considered as an option for patients with metastases when they are expected to live 12 weeks or longer, and the tumor is resistant to radiation or chemotherapy. Indications for surgery include intractable pain, spinal-cord compression and the need for stabilization of impending pathological fractures.

For cases in which surgical resection is possible, preoperative embolization may be used to enable an easier resection. This procedure involves the insertion of a catheter or tube through an artery in the groin. The catheter is guided up through the blood vessels to the site of the tumor, where it delivers a glue-like liquid embolic agent that blocks the vessels that feed the tumor. When the blood vessels that feed the tumor are blocked off, bleeding can often be controlled better during surgery, helping to decrease surgical risks.

The posterior approach allows for the identification of the dura and exposure of the nerve roots. Multiple levels can be decompressed through an epidural, and a posterior multilevel segmental fixation can be performed. The anterior approach is excellent for decompressing ventral tumors and effectively reconstructing the anterior column. This approach also allows placement of short-segment fixation devices. Thoracic and lumbar spinal tumors that affect both the anterior and posterior vertebral columns are a challenge to resect completely. Traditionally, a posterior (back) approach followed by a separately staged anterior (front) approach has been utilized surgically to treat these complex lesions.

Recovery

The typical hospital stay after surgery to remove a spinal tumor is about 5-10 days, depending on the patient's case. A required period of post-surgery physical rehabilitation may involve a stay in a physical rehabilitation hospital for a period of time.   In other cases, physical therapy may take place at an outpatient facility or at the patient's home. The total recovery time after surgery may be as short as three months or as long as one year, depending on the complexity of the surgery and the patient's overall health.

Outcome

Outcome depends greatly on the age and overall health of the patient and on whether the spinal tumor is benign or malignant, primary or metastatic. In the case of primary tumors, the goal is to remove the tumor completely, leading optimally to the potential cure of the malignancy. In the case of metastatic tumors, the goal is almost always palliative. At best, treatment may provide the patient with an improved quality of life and prolonged life expectancy.

 

c) Spinal Cord Injury

According to the National Spinal Cord Injury Association, as many as 450,000 people in the United States are living with a spinal cord injury (SCI). Other organizations conservatively estimate this figure to be about 250,000. Every year, an estimated 11,000 SCIs occur in the United States. Most of these are caused by trauma to the vertebral column, thereby affecting the spinal cord's ability to send and receive messages from the brain to the body's systems that control sensory, motor and autonomic function below the level of injury.

According to the Centers for Diseases Control and Prevention (CDC), SCI costs the nation an estimated $9.7 billion each year. Pressure sores alone, a common secondary condition among people with SCI, cost an estimated $1.2 billion.

Incidence

  • The incidence of SCI is highest among persons age 16-30, in whom 53.1 percent of injuries occur; more injuries occur in this age group than in all other age groups combined.
  • Males represent 81.2 percent of all reported SCIs and 89.8 percent of all sports-related SCIs.
  • Among both genders, auto accidents, falls and gunshots are the three leading causes of SCI, in that order. Among males, diving accidents ranked fourth, followed by motorcycle accidents. Among females, medical/surgical complications ranked fourth, followed by diving accidents.
  • Auto accidents are the leading cause of SCI in the United States for people age 65 and younger, while falls are the leading cause of SCI for people 65 and older.
  • Sports and recreation-related SCI injuries primarily affect people under age 29.

The Spinal Cord

The spinal cord is about 18 inches long, extending from the base of the brain to near the waist. Many of the bundles of nerve fibers that make up the spinal cord itself contain upper motor neurons (UMNs). Spinal nerves that branch off the spinal cord at regular intervals in the neck and back contain lower motor neurons (LMNs). The spine itself is divided into four sections, not including the tailbone:

  • Cervical vertebrae (1-7), located in the neck
  • Thoracic vertebrae (1-12), in the upper back (attached to the ribcage)
  • Lumbar vertebrae (1-5), in the lower back
  • Sacral vertebrae (1-5), in the pelvis

Types and Levels of SCI

The severity of an injury depends on the part of the spinal cord that is affected. The higher the SCI on the vertebral column, or the closer it is to the brain, the more effect it has on how the body moves and what one can feel. More movement, feeling and voluntary control are generally present with injuries at lower levels.

  • Tetraplegia (a.k.a. quadriplegia) results from injuries to the spinal cord in the cervical (neck) region, with associated loss of muscle strength in all four extremities.
  • Paraplegia results from injuries to the spinal cord in the thoracic or lumbar areas, resulting in paralysis of the legs and lower part of the body.

Complete SCI

A complete SCI produces total loss of all motor and sensory function below the level of injury. Nearly 50 percent of all SCIs are complete. Both sides of the body are equally affected. Even with a complete SCI, the spinal cord is rarely cut or transected. More commonly, loss of function is caused by a contusion or bruise to the spinal cord or by compromise of blood flow to the injured part of the spinal cord.

Incomplete SCI

In an incomplete SCI, some function remains below the primary level of the injury. A person with an incomplete injury may be able to move one arm or leg more than the other, or may have more functioning on one side of the body than the other. An incomplete SCI often falls into one of several patterns.

Anterior cord syndrome results from injury to the motor and sensory pathways in the anterior parts of the spinal cord. These patients can feel some types of crude sensation via the intact pathways in the posterior part of the spinal cord, but movement and more detailed sensation are lost.

Central cord syndrome usually results from trauma and is associated with damage to the large nerve fibers that carry information directly from the cerebral cortex to the spinal cord. Symptoms may include paralysis and/or loss of fine control of movements in the arms and hands, with far less impairment of leg movements. Sensory loss below the site of the SCI and loss of bladder control may also occur, with the overall amount and type of functional loss related to the severity of damage to the nerves of the spinal cord.

Brown-Sequard syndrome is a rare spinal disorder that results from an injury to one side of the spinal cord. It is usually caused by an injury to the spine in the region of the neck or back. In many cases, some type of puncture wound in the neck or in the back that damages the spine may be the cause. Movement and some types of sensation are lost below the level of injury on the injured side. Pain and temperature sensation are lost on the side of the body opposite the injury because these pathways cross to the opposite side shortly after they enter the spinal cord.

Injuries to a specific nerve root may occur either by themselves or together with a SCI. Because each nerve root supplies motor and sensory function to a different part of the body, the symptoms produced by this injury depend upon the pattern of distribution of the specific nerve root involved.

"Spinal concussions" can also occur. These can be complete or incomplete, but spinal cord dysfunction is transient, generally resolving within one or two days. Football players are especially susceptible to spinal concussions and spinal cord contusions. The latter may produce neurological symptoms including numbness, tingling, electric shock-like sensations, and burning in the extremities. Fracture-dislocations with ligamentous tears may be present in this syndrome.

Penetrating SCI

"Open" or penetrating injuries to the spine and spinal cord, especially those caused by firearms, may present somewhat different challenges. Most gunshot wounds to the spine are stable, i.e., they do not carry as much risk of excessive and potentially dangerous motion of the injured parts of the spine. Depending upon the anatomy of the injury, the patient may need to be immobilized with a collar or brace for several weeks or months so that the parts of the spine that were fractured by the bullet may heal. In most cases, surgery to remove the bullet does not yield much benefit and may create additional risks, including infection, cerebrospinal fluid leak, and bleeding. However, occasional cases of gunshot wounds to the spine may require surgical decompression and/or fusion in an attempt to optimize patient outcome.

Diagnosis

When SCI is suspected, immediate medical attention is required. SCI is usually first diagnosed when the patient presents with loss of function below the level of injury.

Signs and Symptoms of Possible SCI

  • Extreme pain or pressure in the neck, head or back
  • Tingling or loss of sensation in the hand, fingers, feet, or toes
  • Partial or complete loss of control over any part of the body
  • Urinary or bowel urgency, incontinence, or retention
  • Difficulty with balance and walking
  • Abnormal band-like sensations in the thorax - pain, pressure
  • Impaired breathing after injury
  • Unusual lumps on the head or spine

Clinical Evaluation

A physician may decide that significant SCI does not exist simply by examining a patient who does not have any of the above symptoms, as long as the patient meets the following criteria: unaltered mental status, no neurological deficits, no intoxication from alcohol or other drugs or medications, and no other painful injuries that may divert his or her attention away from a SCI.

In other cases, such as when patients complain of neck pain, when they are not fully awake, or when they have obvious weakness or other signs of neurological injury, the cervical spine is kept in a rigid collar until appropriate radiological studies are completed.

Radiological Evaluation

The radiological diagnosis of SCI has traditionally begun with x-rays. In many cases, the entire spine may be x-rayed. Patients with a SCI may also receive both computerized tomography (CT or CAT scan) and magnetic resonance imaging (MRI) of the spine. In some patients, centers may proceed directly to CT scanning as the initial radiological test. For patients with known or suspected injuries, MRI is helpful for looking at the actual spinal cord itself, as well as for detecting any blood clots, herniated discs, or other masses that may be compressing the spinal cord. CT scans may be helpful in visualizing the bony anatomy, including any fractures.

Even after all radiological tests have been performed, it may be advisable for a patient to wear a collar for a variable period of time. If patients are awake and alert but still complaining of neck pain, a physician may send them home in a collar, with plans to repeat x-rays in the near future, such as in one to two weeks. The concern in these cases is that muscle spasm caused by pain might be masking an abnormal alignment of the bones in the spinal column. Once this period of spasm passes, repeat x-rays may reveal abnormal alignment or excessive motion that was not visible immediately after the injury. In patients who are comatose, confused, or not fully cooperative for some other reason, adequate radiographic visualization of parts of the spine may be difficult. This is especially true of the bones at the very top of the cervical spine. In such cases, the physician may keep the patient in a collar until the patient is more cooperative. Alternatively, the physician may obtain other imaging studies to look for radiologically evident injury.

Treatment

Treatment of SCI begins before the patient is admitted to the hospital. Paramedics or other emergency medical services personnel carefully immobilize the entire spine at the scene of the accident. In the emergency department, this immobilization is continued while more immediate life-threatening problems are identified and addressed. If the patient must undergo emergency surgery because of trauma to the abdomen, chest, or another area, immobilization and alignment of the spine are maintained during the operation.

Intensive Care Unit Treatment

If a patient has a SCI, he or she will usually be admitted to an intensive care unit (ICU). For many injuries of the cervical spine, traction may be indicated to help bring the spine into proper alignment. Standard ICU care, including maintaining a stable blood pressure, monitoring cardiovascular function, ensuring adequate ventilation and lung function, and preventing and promptly treating infection and other complications, is essential so that SCI patients can achieve the best possible outcome.

Steroid Therapy

Methylprednisolone, a steroid drug, became available as a treatment for acute SCI in 1990 when a multicenter clinical trial showed better neurological change scores in patients who were given the drug within the first eight hours of injury. These studies have been criticized in part because this increase in scores has never been shown to translate into better functional outcomes for patients. This area remains controversial. Perhaps clinicians should consider methylprednisolone infusion if its potential benefits are felt to outweigh the risks of potential associated complications.

Surgery

Occasionally, a surgeon may wish to take a patient to the operating room immediately if the spinal cord appears to be compressed by a herniated disc, blood clot, or other lesion. This is most commonly done for patients with an incomplete SCI or with progressive neurological deterioration.

Even if surgery cannot reverse damage to the spinal cord, surgery may be needed to stabilize the spine to prevent future pain or deformity. The surgeon will decide which procedure will provide the greatest benefit to the patient.

Outcome

Persons with neurologically complete tetraplegia are at high risk for secondary medical complications. The percentages of complications for individuals with neurologically complete tetraplegia have been reported as follows:

  • 60.3 percent developed pneumonia
  • 52.8 percent developed pressure ulcers
  • 16.4 percent developed deep vein thrombosis
  • 5.2 percent developed a pulmonary embolism
  • 2.2 percent developed a postoperative wound infection

Pressure ulcers are the most frequently observed complications, beginning at 15 percent during the first year postinjury and steadily increasing thereafter. The most common pressure ulcer location is the sacrum, the site of one third of all reported ulcers.

Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, Annual Statistical Report, June 2004

Neurological Improvement

Recovery of function depends upon the severity of the initial injury. Unfortunately, those who sustain a complete SCI are unlikely to regain function below the level of injury. However, if there is some degree of improvement, it usually evidences itself within the first few days after the accident.

Incomplete injuries usually show some degree of improvement over time, but this varies with the type of injury. Although full recovery may be unlikely in most cases, some patients may be able to improve at least enough to ambulate and to control bowel and bladder function. Patients with anterior cord syndrome tend to do poorly, but many of those with Brown-Sequard syndrome can expect to reach these goals. Patients with central cord syndrome often recover to the point of being ambulatory and controlling bowel and bladder function, but they often are not able to perform detailed or intricate work with their hands.

Once a patient is stabilized, care and treatment focuses on supportive care and rehabilitation. Family members, nurses, or specially trained aides all may provide supportive care. This care might include helping the patient bathe, dress, change positions to prevent bedsores, and other assistance.

Rehabilitation often includes physical therapy, occupational therapy, and counseling for emotional support. The services may initially be provided while the patient is hospitalized. Following hospitalization, some patients are admitted to a rehabilitation facility. Other patients can continue rehab on an outpatient basis and/or at home.

Mortality

Mortality associated with SCI is influenced by several factors. Perhaps the most important of these is the severity of associated injuries. Because of the force that is required to fracture the spine, it is not uncommon for a SCI patient to suffer significant damage to the chest and/or abdomen. Many of these associated injuries can be fatal. In general, younger patients and those with incomplete injuries have a better prognosis than older patients and those with complete injuries.

Respiratory diseases are the leading cause of death in people with SCI, pneumonia accounting for 71.2 percent of these deaths. The second and third leading causes of death, respectively, are heart disease and infections.

The cumulative 20-year survival rate for SCI patients is 70.65 percent, but due to underreporting and cases that are lost in follow-up, the mortality rates may be higher.

Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, Annual Statistical Report, June 2004

Prevention

While recent advances in emergency care and rehabilitation allow many SCI patients to survive, methods for reducing the extent of injury and for restoring function are still limited. Currently, there is no cure for SCI. However, ongoing research to test surgical and drug therapies continues to make progress. Drug treatments, decompression surgery, nerve cell transplantation, nerve regeneration, stem cells, and complex drug therapies are all being examined in clinical trials as ways to overcome the effects of SCI. However, SCI prevention is crucial to decreasing the impact of these injuries on individual patients and on society.

Motor Vehicle Safety Tips

  • Always wear a safety belt and make sure all passengers are wearing safety belts.
  • Ensure that infants, toddlers and young children are properly restrained in an approved child safety seat that is installed correctly in the back seat.
  • Ensure that all children 12 and younger ride in the back seat, properly restrained.
  • Ensure that all children that have outgrown child safety seats are properly restrained in booster seats until they are age 8, or over 4'9" tall.
  • Obey speed limits and follow rules of the road at all times.
  • Never drive under the influence of drugs or alcohol or ride as a passenger in a vehicle with a driver who is under the influence.

Tips to Prevent Falls in the Home

  • Keep the floor clear and free of debris. Reduce clutter and move telephone and electrical cords out of walkways.
  • Keep the floor clean, but do not apply floor wax. Clean up grease, water and other liquids immediately.
  • Use non-skid throw rugs to reduce your chance of slipping on linoleum.
  • Install handrails in stairways and grab bars in the bathroom (by toilets and in tub/shower.)
  • Make sure living areas are well lit because it is easy to trip in the dark.
  • Be aware that climbing and reaching high places will increase your chance of a fall. Use a sturdy step stool with hand rails when these tasks are necessary.
  • Follow medication dosages closely. Using medication incorrectly may lead to dizziness, weakness and other side effects. These can all contribute to falls.

Water and Sports Safety Tips

  • Do not dive in water less than 12 feet deep or in above-ground pools.
  • Follow all rules at water parks and swimming pools.
  • Do not participate in sports when you are ill or very tired.
  • Wear proper safety gear approved for the specific sport.
  • Avoid uneven or unpaved surfaces when cycling or skateboarding.
  • Football players should receive adequate preconditioning and strengthening of the head and neck muscles.
  • Proper football blocking and tackling techniques must be taught and followed.
  • Check sports fields, playgrounds and equipment regularly for safety.
  • Discard and replace sporting equipment or protective gear that is damaged.

Firearms Safety

  • Always point the muzzle in a safe direction; never point a firearm at anyone or anything you don't want to shoot.
  • Keep your finger off the trigger and outside the trigger guard until you are ready to shoot.
  • Keep the action open and the gun unloaded until you are ready to use it.
  • Keep guns unloaded in a secure location so that children cannot access them.
  • Store bullets in a separate, secure location so that children cannot access them.
  • Explain to children that guns are dangerous and that they should never touch them, either at home or in any other environment, such as at friends’ houses.
  • Talk with your teenager about ways to solve arguments without violence or guns.

SCI Resources

Apparelyzed: Spinal Cord Injury Peer Support
Christopher Reeve Paralysis Foundation
Foundation for SCI Prevention, Care & Cure
International Center for Spinal Cord Injury
The National SCI Association (NSCIA)
The Travis Roy Foundation

 

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