Spinal cord injury and its management -detailed technical article.
- Long-term issues in spinal cord injury
- Conclusion and future prospects
- Further reading
Spinal cord injury most commonly affects young men as a consequence of road traffic accidents, violence, and sports injuries; falls are a common cause in older patients.
Early acute management
Appropriate management of the individual at the scene of an accident is vital to avoid unnecessary worsening of a spinal cord injury. Those who are unconscious should be assumed to have a cervical spine injury until proven otherwise, with (1) the head and neck held firmly (as far as possible) in a neutral position using (if available) a semi-rigid collar, and (2) transportation on a spinal board with a head immobilizer.
Investigation—spinal injury cannot be determined solely by examination. There are often very few local signs, hence radiological investigation is essential. Plain radiography will usually reveal the fracture or dislocation, but bony abnormalities are occasionally minimal or absent; MRI is now recognized to be the best imaging technique.
Treatment—injuries to the cervical spine will usually receive skeletal traction applied through skull calipers; thoracic and lumbar injuries require simple support of the patient in the correct posture. Other interventions include (1) surgery—e.g. fusion and internal fixation, anterior or posterior decompression (or some combination of these); practice varies considerably, but many spinal centres recommend surgical intervention if neurological symptoms are deteriorating; (2) steroids—high-dose methyl prednisolone, started within 8 h of injury, improves neurological outcome.
Management in the spinal cord injury centre
Spine—in the neurologically intact person, surgery allows the individual to be mobilized more quickly, but there is no convincing evidence that the endpoint of rehabilitation is delayed by conservative treatment.
Medical problems during the period of immobilization—these include (1) Respiratory—the intercostal muscles and (in high cervical lesions) diaphragm may be paralysed; regular chest physiotherapy is vital as the commonest cause of a decline in respiratory function is the retention of secretions; prophylactic anti-coagulation is advisable. (2) Pressure sores—these ought to be preventable. (3) Bladder—key matters to be considered are (a) is there impairment of renal function?; (b) is there failure of bladder emptying?—residual urine can predispose to infection or stone formation and contributes to impairment of renal function; most cases of failure of bladder emptying require mechanical drainage, preferably by intermittent clean self-catheterization; and (c) is there detrusor hyperreflexia?—anticholinergics (e.g. oxybutynin) are generally most effective. (4) Bowel care—in the initial period of spinal shock the bowel remains flaccid and should not be allowed to over-distend. (5) Autonomic dysreflexia—most commonly seen with cervical cord injuries above the sympathetic outflow and characterized by an exaggerated autonomic response to a stimulus below the level of the lesion; management consists of trying to avoid precipitating stimuli and use of antihypertensive agents. (6) Spasticity and contractures—passive stretching of the spastic muscles and regular standing regimes can be helpful; advise from a neurological physiotherapist on appropriate positioning and seating is essential; antispastic drugs should be used with care because they induce significant tiredness and weakness. (7) Pain and dysaesthesia—usually respond reasonably well to the use of carbamazepine, tricyclic antidepressants, gabapentin, or pregabalin.
Rehabilitation—a coordinated multidisciplinary team can improve functional outcome. Principles are based around the concepts of impairment, activity and participation restriction, with the aim being to work with the disabled person and their family in partnership, a key element being the setting of realistic goals that should be specific, measurable, achievable, relevant, and time limited (SMART).
Spinal cord injury affects all domains of life, so a very wide range of issues may need to be addressed, including those related to discharge home, emotional problems, sexual life, fertility, leisure pursuits, driving, employment, and information. Later medical complications include pathological fractures, post-traumatic syringomyelia, and respiratory compromise (in those with high cervical cord lesions).
With appropriate management, initial mortality from spinal cord injury is less than 5%. Life expectancy in paraplegia is only modestly reduced, although people with tetraplegia still die prematurely. The major causes of late death are now those experienced by the general population (e.g. cancer, myocardial infarction), although excess deaths from renal failure or respiratory infection persist in those with tetraplegia.
Remarkable improvements can be made to the survival of patients with spinal cord injury; great advances have also been made toward improving the quality of life of those so injured, principally as result of contemporary interventions used in rehabilitation medicine.
In the early part of the 20th century about 9 out of every 10 people with a spinal cord injury died within 1 year and only 1% survived in the long term. With the advent of spinal cord injury centres, these outcomes have been greatly improved. Coordinated, multidisciplinary care provided at such centres has significantly reduced mortality and improved quality of life. However, it is only the last decade or so that modern rehabilitation techniques have reduced initial mortality to less than 5%. Indeed, life expectancy has improved to the extent that the major causes of late death in spinal injury are now those experienced by the general population, such as cancer and myocardial infarction.
Excess deaths from renal failure or respiratory infection persist in those with tetraplegia, and although life expectancy in those with paraplegia is only modestly reduced, people with tetraplegia still die prematurely. A 20-year-old male would normally be expected to live for a further 65 years, but this is reduced to about 50 to 55 years in those with paraplegia. The best survival figures in tetraplegia are about 80% of normal, but figures from some centres report less than two-thirds of those injured have a normal life expectancy. Nonetheless, results continue to improve and a recent study from Australia reports an 86% overall 10 year survival.
The annual incidence of spinal cord injury varies and has been reported between 10 and 50 cases per million population per year. The mean age of injury is about 33 years although the mode is 19 years. Most injuries occur in males (c.82%). The most common cause is road traffic accidents (c.40%). Regrettably, spinal cord injury from violence (either self-harm or criminal assault) is increasing, particularly in the United States of America. In the older age group falls become more common. Table 1 summarizes the leading causes.
The proportion of injuries from road traffic accidents has seen a modest reduction in recent years, probably due to the introduction of seat-belt legislation and improved safety features on cars. Hopefully improved safety of vehicles and improved traffic regulation, particularly speed control in urban areas, will further reduce the incidence in coming years. There is some evidence in the last decade that the incidence of spinal injury has plateaued, having been increasing in previous decades. There seems, however, to be an increase in the incidence of elderly people who sustain spinal injuries during falls mainly at home, many of whom develop tetraplegia. Regrettably the commonest result of spinal injury is tetraplegia (c.60%) and the proportion of tetraplegia compared to paraplegia is still increasing.
Early acute management
The appropriate management of the individual at the scene of an accident is vital in order to avoid unnecessary worsening of a spinal cord injury. If the individual is unconscious then it should be assumed there is an injury to the cervical spine until proven otherwise. Until this diagnosis can be ruled out the head and neck should, as far as possible, be held firmly in a neutral position. This is normally achieved at the scene of an accident by immobilization in a semi-rigid collar, but if this is not available alternative improvised methods of stabilizing the head and neck should be initiated. The individual should not be placed in the coma position, as this will rotate the cervical spine, but is best placed, if other injuries allow, in a lateral position with the head kept in line with the spine by the underlying arm. If any movement is necessary the person should be ‘log rolled’ to ensure that the spine is kept in a straight and neutral position at all times. Usually transportation is on a spinal board with a head immobilizer. Speed of evacuation is important, particularly if there are other life-threatening injuries. Preferably the individual should be transferred to a regional spinal injuries unit but obviously they may need resuscitation and other life-threatening injuries may need treatment at the nearest Emergency Department. It is worth recalling that the diagnosis of intra-abdominal injury can be very difficult in people with spinal cord injuries. The initial phase of spinal shock will tend to give rise to paralytic ileus and abdominal distension, which can further confuse the situation if abdominal injury is suspected.
|Table 1 Causes of spinal cord injury—comparison of causes in the United Kingdom and the United States of America|
|Cause||UK (%)||USA (%)|
|Road traffic accidents||35||43|
|Falls (domestic and industrial)||36||19|
Obviously both a general and neurological examination is vital—particularly to determine the neurological level of the lesion. Table 2 summarizes likely functional outcome according to lesion level.
Spinal injury, however, cannot be determined solely by examination and often there are very few local signs. There may be some bruising, tenderness or deformity but equally there may be no clue on examination about the actual nature and extent of the underlying bone injury. Thus, radiological investigation is essential and should preferably only be undertaken in a unit familiar with the management of those with spinal injury. In a radiology department it is still important to remember that spinal movement must be minimal. Usually radiography will clearly reveal the fracture or dislocation, although occasionally bony abnormalities are minimal or absent. This is particularly true in older people with underlying cervical spondylosis when tetraplegia can result from hyperextension injury without fracture or dislocation. Radiographic examination can also be normal in children when spinal traction injury can occur without evidence of bony damage. MRI is now recognized to be probably the best investigation technique for spinal cord injury.
Initial management of people with injuries to the cervical spine usually consists of skeletal traction applied through skull calipers. Traction will help to stabilize and splint the spine and can also reduce fractures and dislocations. There are a number of different calipers available.
The amount of traction applied will vary according to the type, level and extent of injury but will be in the order of 0.5 to 2 kg for upper cervical injuries and somewhat more, around 4 kg, for lower cervical spinal injuries. Sometimes if the spine is dislocated reduction is achieved by incrementally increasing the weight of traction every few minutes under close neurological monitoring. Mobilization in a halo brace can be safely used instead of traction in people with compression fractures of the cervical spine. It is advisable, however, to await recovery from spinal shock before mobilizing a person with neurological damage.
For thoracic and lumbar injuries standard treatment is simple support of the individual in the correct posture, usually with a pillow under the lumbar spine to maintain the normal lordosis.
Surgical compared with conservative treatment
In most cases skull traction for cervical injuries and conservative postural treatment for thoracolumbar injuries is quite sufficient and operative intervention is not necessary. It has long been a source of controversy whether operative intervention and fusion aids neurological recovery. Practice varies from country to country and indeed from centre to centre. In a broad-based survey in the United States of America, 60% of people underwent spinal surgery; most of them underwent fusion and internal fixation. Increasing numbers also undergo anterior or posterior decompression of the spinal cord with or without internal fixation and fusion. However, practice in the United States of America tends to be more orientated towards surgical intervention than practice in the United Kingdom and other parts of western Europe. In the United Kingdom surgical intervention will tend to be reserved for those with unstable displaced fractures, and conservative management would be the normal practice for stable and/or undisplaced fractures. However, if the neurological symptoms are deteriorating then many spinal centres would now recommend surgical intervention.
|Table 2 Expected residual functional ability according to the level of lesion|
|Level of injury—complete lesions|
|Lesion below C3||Dependent on others for all care|
|Diaphragm paralysed, needs permanent ventilation or diaphragm pacing|
|Chin-, head-, or breath-controlled electric wheelchair|
|Lesion below C4||Dependent on others for all care|
|Can breathe independently using diaphragm|
|Can shrug shoulders|
|Can use electric wheelchair with chin control|
|Can type/use computer with a mouth stick|
|Environmental control system operated by shoulder shrug or mouthpiece|
|Lesion below C5||Can move shoulders and flex elbows|
|Can eat with a feeding strap/universal cuff|
|Can wash face, comb hair, clean teeth—using feeding strap/universal cuff|
|Can write using individually designed splint and wrist support|
|Can help in dressing upper half of body|
|Can push manual wheelchair short distances on the flat provided that pushing gloves are used with capstan rims on the wheels|
|May be able to transfer across level surfaces using sliding board and a helper|
|Electric wheelchair needed for functional mobility|
|Lesion below C6||Can extend wrists|
|Still needs strap to eat and for self-care|
|Can write using individually designed splint but may not need wrist support|
|Can dress upper half of body unaided|
|Can help in dressing lower half of body|
|Can propel wheelchair up gentle slopes|
|Can be independent in bed, car, and toilet transfers|
|Can drive with hand controls|
|Lesion below C7||Full wrist movement and some hand function, but no finger flexion or fine hand movements|
|Can do all transfers, eat, and dress independently|
|Can drive with hand controls|
|Lesion below C8||All hand muscles expect intrinsics preserved|
|Wheelchair independent, but difficulty in going up and down kerbs|
|Can drive with hand controls|
|Lesion below T1||Complete innervation of arms|
|Totally independent wheelchair life|
|Can drive with hand controls|
Use of steroids
Another treatment intervention that can be considered in the very early stages after injury is a short course of high-dose methyl prednisolone. There is some evidence that such intervention, started within 8 h of injury, improves neurological outcome. However, this is not totally accepted and there is wide variation in practice between centres. The results of definitive trials are still awaited.
Management in the spinal cord injury centre
Initial management will consist of resuscitation, treatment of associated injuries, and containment of the biomechanical instability of the spine by either conservative or by surgical means. However, the individual should be transferred to a recognized spinal injury centre as soon as possible. There is clear evidence that outcome is maximized, both physically and psychologically, if individuals are managed in such centres as opposed to a less coordinated and less experienced approach in other hospital settings.
Problems in management
The injured person will either be managed conservatively or surgically. The advantage of surgery in the neurologically intact person is that the individual can be mobilized more quickly. If a conservative approach is adopted mobilization is delayed and active rehabilitation is obviously difficult in the first few weeks. There is, however, no convincing evidence to suggest that the endpoint of rehabilitation is delayed by conservative treatment. Cervical spine traction is normally maintained for around 6 weeks and then monitored for signs of bony union and stability. Once the fracture site is stable the individual can be gradually sat up in bed while continuing with cervical support. A profiling bed, which enables a more natural seated position, is most useful. In the early few weeks a halo brace can be used instead of skull traction. The advantage of this brace is to allow early mobilization. The halo brace is kept on for 10 to 12 weeks until the site is stable. In those with thoracolumbar injuries, usually managed conservatively, the period of bed rest will usually last from 6 to 12 weeks followed by bracing and gradual mobilization, assuming that the fracture site is stable.
Over this initial period of immobilization a number of medical problems can occur.
Respiratory insufficiency can occur in people with injuries of the cervical cord. Intercostal muscles may be paralysed and in high cervical lesions the diaphragm can also be paralysed. However, even in people with lower lesions respiratory problems can still occur from associated injuries such as rib or sternal fractures. In the early hours and days respiratory function should be monitored carefully and ventilation may be required. Respiratory function can decline several hours or even days after injury and can be due to the development of spinal cord oedema. Regular chest physiotherapy is vital at this time as the commonest cause of a decline in respiratory function is the retention of secretions. Pulmonary embolism is also a risk, particularly in those who are immobilized, and prophylactic anticoagulation is advisable from an early stage prior to mobilization.
Regrettably, the development of pressure sores still occurs but really ought to be preventable. Sores are commonest where there are bony prominences near the skin such as the ischial tuberosity, greater trochanter, sacrum, heel, and sometimes at the back of the head in those with skull traction. A key to prevention is awareness of the potential problem, vigilance, and regular changes of position in bed and regular lifting in the wheelchair. There are now a large range of commercial mattresses and wheelchair cushions that relieve pressure. When lifting or positioning, shear forces should be avoided as far as possible and obviously the individual should never be dragged over sheets or from the wheelchair. The skin should be kept clean and particular care should be taken to avoid any urine or faecal soiling. If a sore does occur the area must be kept clean, any dead tissue removed, and there should be complete relief of pressure from that area until it is fully healed. Occasionally surgery is indicated for larger or deeply infected sores which otherwise will take too long to heal. Education of the injured person and their family is essential. Despite awareness of the problem, around 25% of people still develop a pressure sore during their rehabilitation phase. About 15% of people will develop a pressure sore in the 1 year following discharge and this figure increases still further with time such that by year 10 about 15% of those with incomplete lesions and 28% of those with complete lesions will have developed at least one pressure sore. Septicaemia from the pressure sores is still responsible for around 10% of spinal injury deaths.
In the early part of the 20th century problems, usually infection, of the urinary system were responsible for at least half of spinal cord injury deaths. There has been very significant progress in the management of bladder and kidney disorders, but nevertheless urinary tract complications are still a residual cause of mortality and morbidity.
In the period of spinal shock the bladder is usually noncontractile and over this time catheterization may be appropriate. Once spinal shock begins to wear off the commonest problem is of detrusor hyperreflexia, which usually gives rise to frequent passage of small quantities of urine associated with urgency. However, other possibilities include detrusor sphincter dyssynergia and detrusor hyporeflexia. The latter will tend to occur when there is damage to the sacral nerves S2, 3, and 4.
The management of urinary disorders usually involves satisfactory answers to three questions: (1) Is there impairment of renal function? (2) Is there a failure of bladder emptying? (3) Is there detrusor hyperreflexia? Is there impairment of renal function?
Screening of the upper urinary tract is important both in the short and long term. Intravenous urography should be used in the early months after injury, but long-term follow-up can often be carried out by renal ultrasound scanning or plain abdominal radiography. Late complications are possible, such as renal calculi. Cystometrography is also vital for determining the exact nature of the underlying bladder and sphincter condition. Is there a failure of bladder emptying? Residual urine greater than 100 ml is generally accepted as the level at which intervention is necessary.
Residual urine can predispose to infection and stone formation and contributes to impairment of renal function, particularly if the failure to empty is associated with high intravesical pressure and back-pressure up to the kidney. Occasionally failure of emptying can be managed by artificial stimulation such as suprapubic tapping or perineal stimulation. However, in most cases failure of bladder emptying requires mechanical drainage. The most useful method is intermittent clean self-catheterization. This is carried out by the disabled person or sometimes by a carer four or five times every 24 h such that volumes in the bladder are kept to less than 500 ml. Intermittent self-catheterization has revolutionized the management of the bladder problems in those with spinal injury. Occasionally anticholinergic drugs such as propantheline, oxybutynin, or imipramine may help to reduce detrusor activity. Condom drainage in the male is helpful to prevent leakage between catheterization. If intermittent self-catheterization is not possible, a silastic indwelling catheter might need to be used. However, suprapubic catheterization is far better in the long term and associated with fewer problems. Regrettably there are many problems of catheterization including leakage, blockage, stone formation, and infection. Is there detrusor hyperreflexia?
A small number of people can control minor problems with the detrusor hyperreflexia by rigid bladder drill, emptying the bladder at frequent and regular intervals. However, most people need some form of oral medication; anticholinergics are the most effective and oxybutynin the most common. Propantheline and imipramine are alternatives. Once again, protection against the embarrassment of leakage is often necessary and is more readily achieved in men with the use of condom drainage. In women a variety of absorbent pads can be worn. Advice from a specially trained nurse continence adviser can be invaluable, whatever the nature of the problem.
A whole variety of surgical techniques may be applicable in particular circumstances. An endoscopic distal sphincterotomy can be useful in those with reflex bladder emptying. The technique of bladder augmentation with an ileocystoplasty can also be helpful to allow for sufficient capacity for intermittent clean self-catheterization. Urinary diversion techniques are fortunately now needed less frequently. Recent advances include artificial urinary sphincters for treating neuropathic incontinence. Some centres also now employ sacral anterior nerve root stimulators which can be used in some people with supra sacral cord lesions. The individual has a radio linked implant to stimulate the S2, S3, and S4 anterior nerve roots and by activating the implant the bladder can be emptied. Occasionally a similar implant can also be used to assist in defecation and in obtaining penile erection.
Incontinence can be a major disability and handicap, and indeed if it is not treated properly the complications can be life threatening. Long-term follow-up is essential and proper management can make significant reductions in long-term risks and produce major improvements in the quality of life.
In the initial period of spinal shock the bowel remains flaccid and should not be allowed to overdistend, with the risk of constipation and overflow incontinence. Manual evacuation is usually carried out until bowel activity returns. Eventually reflex emptying can occur in those with predominant upper motor neuron lesions or the bowel can remain flaccid in those with lower motor neuron involvement. In the former, bowel evacuation can usually be triggered by glycerine suppository and/or by anal digital stimulation. In those with flaccid bowel there is a continuing need to evacuate manually or by straining using abdominal muscles. Advice on proper diet is also required. A good quality high-fibre diet together with a high fluid intake is the most helpful.
This is a potentially fatal problem most commonly seen in those with cervical cord injuries above the sympathetic outflow but can occur in those with high thoracic lesions above T6. It is characterized by an exaggerated autonomic response to a stimulus below the level of the lesion. Stimuli can include distension of the pelvic organs such as bladder, colon, and rectum. Such distension induces sympathetic activity resulting in vasoconstriction and hypertension. Other stimuli include catheterization, urinary infections, sexual intercourse, pressure sores, and even tight clothing. Surgical procedures can also induce the reflex. Symptoms will include headaches, sweating, vasodilatation, nasal obstruction, paraesthesia, and anxiety. Significant hypertension occurs. The problem occurs in around 50 to 80% of those at risk and most cases occur between 2 months and 12 months after injury. Other than awareness of the problem and avoidance of the necessary stimuli, attention is directed to reduction of the blood pressure. Sitting the person upright is usually helpful. Sublingual nifedipine can be used, or in more severe cases intravenous hydralazine. Chlorpromazine, nitroprusside and diazoxide are also possibilities. Occasionally the sympathetic reflex activity may have to be blocked by spinal epidural anaesthetic.
Spasticity and contractures
Spasticity occurs in an upper motor lesion with intact spinal reflex arcs below the level of the lesion. It is usually worse in those with incomplete lesions. Spasticity can be functionally useful and the individual can sometimes use flexor or extension spasms as an aid to dressing. However, usually spasticity produces functional problems as well as causing pain. In the long term there is a significant risk of muscle contractures. Initial management focuses on removing any unnecessary exacerbating factors such as pressure sores, tight catheter leg bags, or even urinary infections and constipation. Treatment should always involve the use of an expert neurological physiotherapist who will advise on appropriate positioning and seating. In the early stages passive stretching of the spastic muscles and regular standing regimes can be helpful and in the longer term such regimes can often be carried out by the disabled person and their carers. Antispastic drugs should always be used with care as they induce significant tiredness and weakness. However, they can provide some useful background antispastic effect. Baclofen, dantrium, and tizanidine are the commonest prescribed. Oral cannabis (or at least a 50:50 ratio of THC and cannabidiol) may also be helpful and positive trials have been undertaken, but the agent is not yet licensed (except in Canada for neuropathic pain management).
However, often spasticity is localized and focal treatment is more appropriate. Nerve blocks with phenol and alcohol can be used. However, the intramuscular use of botulinum toxin is probably the most useful agent in the management of focal spasticity. The toxin is injected directly into the muscle and will block the release of acetylcholine from the nerve endings. This produces muscle relaxation over 3 or 4 days which lasts about 3 months. Occasionally more severe spasticity will need other measures such as the use of intrathecal baclofen. If contractures have resulted then often surgical correction by tenotomy, tendon lengthening, or muscle division is the only method that will get the limb back into a functionally useful position. Aggressive early management of spasticity is important in order to maximize any neurological recovery and prevent unnecessary complications.
This term is used when bone develops in an abnormal anatomical position in soft tissues. The prevalence in spinal cord injury is reported to vary between 5 and 50%. It commonly occurs around the hips and knees. It will cause a decrease range of movement as well as localized swelling and joint effusion. It will normally occur in the first few months after the injury and will only rarely begin later than one year post injury. Unfortunately treatment is difficult. Etidronate disodium is probably the most useful treatment. In severe cases surgical intervention can be required but is usually unsatisfactory. Some centres now use prophylactic etidronate disodium for about a year.
Deep venous thrombosis
Deep venous thrombosis (DVT) still remains a significant complication after spinal injury, with a small risk of death from pulmonary embolism. The risk is highest in the early days and weeks. Low-molecular-weight heparin or warfarin are usually used as a prophylactic, but some centres now use external pneumatic calf compression.
Pain and dysaesthesia
Peripheral pain is quite common in the early weeks after injury. Unfortunately burning pain can also continue for some months. It usually responds reasonably well to the use of carbamazepine, tricyclic antidepressants, gabapentin, or pregabalin. Pain from other sources such as osteoarthritis can also occur. It should be remembered that people with spinal cord injury do not always appreciate pain, or it is manifested in different ways, such as autonomic dysreflexia or worsening of spasticity. Other modalities such as transcutaneous nerve stimulation, acupuncture, and psychological techniques, such as relaxation and hypnotherapy or alleviation of depressive illness, can all help. Spinal cord stimulation is occasionally used and sometimes surgical techniques, such as dorsal root entry zone radiofrequency coagulation can be used. Other causes of pain such as nerve root compression should also be borne in mind.
There is no evidence that rehabilitation can promote natural recovery, but there is ample evidence that a coordinated multidisciplinary team can improve functional outcome for the person with a spinal cord injury. The team can ensure that functional abilities are maximized and that physical and psychological complications are kept to a minimum. The coordinated team input is vital in the early weeks and months after injury, but it is equally important that the team maintains contact over the period of discharge and indeed into the longer term.
Principles of rehabilitation
There is not room in this chapter to dwell on the basic principles of rehabilitation. However, it is important to state that modern rehabilitation practice is somewhat different from other medical specialities. It is based on the principles of education, and is a process in which the disabled person and the family must be involved for it to have any meaning. Rehabilitation should go beyond the narrower confines of physical disease but should also deal with the psychological consequences of physical disability and with the social milieu in which the disabled person has to operate. Rehabilitation is based around the concepts of impairment, activity, and participation restriction as outlined by the World Health Organization (WHO) in 2001. ‘Impairment’ is a simply a term that describes loss or abnormality of psychological, physiological, or anatomical structure or function.
Rehabilitation must go beyond impairment and should place such impairment within a functional context. ‘Participation’ describes the social context of disability. Rehabilitation can be defined as an active and dynamic process by which a disabled person is helped to acquire knowledge and skills in order to maximize physical, psychological, and social function. The basic nature of rehabilitation is to work with the disabled person and their family in partnership.
The professional should impart accurate information and advice, give guidance on prognosis and natural history, and help the individual establish realistic goals in an appropriate social context. A key to successful rehabilitation is goal setting. The first goal should be a long-distance strategic aim. In the context of spinal cord injury this could, for example, include enabling the person to return to their previous home fully competent in wheelchair use. The overall strategic goal can also have a number of long-term subgoals in different spheres of life such as employment, home, and leisure. Once the long-term goal has been determined, steps will need to be defined in order to achieve that goal which in turn will involve the setting of a number of short- and medium-term goals. These shorter-term aims should be clearly stated. A useful mnemonic is SMART, which implies the goals should be Specific, Measurable, Achievable, Relevant, and Time limited.
The implication of goal setting is that the team and indeed the disabled person should know when the goals have been achieved. Thus, valid and reliable outcome measures are important tools. It is not possible or desirable to outline tools that should always be used in spinal cord injury. The outcome measures will depend on the goals set. However, it is often useful to employ a general disability measure such as the Functional Independence Measure or, in the short term, the more physically orientated Barthel Score. Some of the standard scales employed in spinal cord injury are frankly of little value in monitoring progress. First to be developed was the Frankel Score. This has now been modified, at least in the United States of America, by the 1992 revised American Spinal Injury Association classification (see Table 3). This scale is now widely quoted in the spinal cord literature, but mainly in terms of helping to determine natural history and prognosis; it is not a tool for monitoring goal attainment.
|Table 3 American Spinal Injury Association classification (modified Frankel classification)|
|Grade||Loss of function||Comments|
|A||Complete||No sensory or motor function preserved in sacral segments S4/5|
|B||Incomplete||Sensory but not motor function is preserved below the neurological level and extends through the sacral segments S4/5|
|C||Incomplete||Motor function is preserved below the neurological level and the majority of key muscles below the neurological level have a muscle grade less than 3|
|D||Incomplete||Motor function is preserved below the neurological level and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3|
|E||Normal||Sensory and motor function is normal|
Note: the key muscles are C5 (elbow flexors), C6 (wrist extensors), C7 (elbow extensors), C8 (finger flexors), T1 (small finger adductors), L2 (hip flexors), L3 (knee extensors), ankle dorsiflexors, long toe extensors and ankle plantar flexors.
Obviously medical input is vital to the team, particularly in the early acute stages of management. Spinal cord injury consultants are now trained rehabilitation specialists and do not necessarily have surgical qualifications, at least in the United Kingdom. However, the training is comprehensive and obviously the consultants are able to manage the day-to-day medical, surgical, and rehabilitation aspects of spinal injuries. Spinal cord injury centres will always need input from a variety of other medical and surgical consultants. Nursing staff on the ward, who will have 24-h daily contact with the patients, are also clearly vital and many nurses will now have additional spinal cord injury or other specialist qualifications such as continence advisers or expertise in the management of sexual problems. The physiotherapist comes into play in the very early stages of management to minimize chest complications, particularly in those with high cervical cord lesions.
Physiotherapy advice is helpful for appropriate positioning in bed and to prevent the complication of spasticity. However, once a patient is beginning to mobilize, the physiotherapist will be the key person to advise on wheelchair choice and teaching the individual to become familiar with the wheelchair and how to control the wheelchair in different circumstances. There are a number of advanced wheelchair skills that will eventually be learnt, such as back wheel balancing to allow manoeuvrability over rough ground and up kerbs, and sideways jumping for manoeuvrability in limited space. In those with lower cord lesions the physiotherapist could be involved in limited gait training using calipers and crutches.
Orthotic devices such as the reciprocating gait orthosis (RGO) and hip guidance orthosis (HGO) may be considered in some cases. Recent development of the use of supported body weight gait training also emphasizes the key role of the physiotherapist. The physiotherapist can also help in the context of social participation by encouraging and assisting with the development of sporting activities. However, this latter assistance clearly overlaps with the role of the occupational therapist. The occupational therapist is usually concerned with assisting people to reach the highest level of physical and psychological independence, particularly with regard to personal care and appropriate adaptation of the home, work, and leisure environments. For example, the occupational therapist will be involved in the design of appropriate splinting to assist those with high cord lesions, such as writing or typing splints and feeding straps.
There are now a significant variety of increasingly sophisticated assistive technology devices, which will enable even those with profound disabilities to remain reasonably independent. For example, environmental control equipment enables an individual to control simple aspects of life around the house, such as a door intercom, turning lights on and off, turning the pages of a book, controlling the television and telephone, and using a computer. These devices can now be controlled even by those with high tetraplegia using mouth sticks or breath control. The occupational therapist will often be involved in such advice, particularly at the time of discharge back into the home environment.
If necessary, a psychologist may be particularly useful in enabling the person to make an emotional adjustment to their new disability. The social worker is likely to be involved with the family as a whole and only a small part of the job is to advise on disability benefits. Most of the social worker’s task is to ensure that the disabled person and family integrate and adapt to the new disability as smoothly as possible. Others, such as vocational advisers, specialist nurses, and dietitians will all need to be involved at some point as part of a comprehensive spinal injury team.
Long-term issues in spinal cord injury
A particularly difficult time for the injured person is discharge home. Often the person will have spent several weeks or months in a spinal cord centre and returning home can be a traumatic process both for them and their family. Brief trial home visits will almost certainly have been carried out beforehand. These are particularly important to ensure that the house is appropriately adapted. Obviously in some cases a new house or bungalow will need to be purchased. A number of adaptations regarding access, both internal and external, hoisting gear, adaptations to the toilet, bathroom, and kitchen may all be required before the individual can return home. Environmental control equipment may need to be prescribed and installed.
Psychological support is also vital over this period, not only for the injured person but also for their family. Anxiety and depressive illness are both quite common and will need active intervention. The community services and the primary care team will need to be involved. Planned discharges are vital and should involve a case conference between the hospital and community staff in order to ensure a smooth handover. However, at this time many people with spinal cord injuries will wish to move away from the more paternalistic hospital care that was important in the first few weeks after their injury. Most will choose to live as independently as possible, albeit with the help of their family or a personal assistant. Advice on the available financial support is important. If financial compensation from a personal injury claim is ongoing then (in the United Kingdom) a solicitor can be helpful at this point in order to arrange interim payments from the Court towards home adaptations, transport, and personal care.
Obviously there are profound changes in a person’s life following spinal cord injury. The refocusing of life ambitions can be a frustrating, anxious or depressing time. The attitude of family and friends will have further bearing over the period of adjustment. Regrettably, clinical depression is common and at some point occurs in at least 50% of individuals. Suicide can also occur. Although such problems are not always preventable, anxiety, depression, and adjustment problems can be alleviated by appropriate intervention. The role of medication, at least in the short term, can be helpful but probably most assistance can be gained from cognitive therapy or other forms of counselling and psychological support. Contact with others in similar circumstances can often be helpful and may be facilitated through the various peer support groups.
Sexual ability depends on the level and completeness of the spinal lesion. Sexual readjustment is an important part of the rehabilitation process for both men and women and for both the injured person and their partner. Self-image and self-confidence can be severely affected. Individuals should be counselled about the totality of sexuality, as there is a tendency for discussions to focus on penetrative sexual intercourse. In both sexes absence of genital sensation can be compensated for by use of other erogenous zones such as the breasts, neck, and mouth.
Orgasm is sometimes possible even in complete spinal cord lesions. In women problems can result from lack of vaginal lubrication. For men there are various techniques and devices to restore erectile capacity. Most people with complete upper motor neuron lesions will have reflex but not psychogenic erections, but these are often not always sustained or strong enough for intercourse. In those with parasympathetic lesions reflex erections are usually not possible. Satisfactory erection can often be achieved either by the use of intracavernosal drugs or mechanical means such as vacuum erection aids and compressive retainer rings. However, the introduction of sildenafil has reduced the need for mechanical or injected assistance.
Fertility is not usually reduced in women, although some can go through a time of amenorrhoea. However, fertility is generally reduced in men who have low sperm counts with diminished motility. Sometimes if ejaculation is not possible during intercourse it can be induced by direct stimulation or by electroejaculation. Fertility can also be improved by some of the modern assistive conception techniques such as in vitro fertilization and intracytoplasmic sperm injection. Women with spinal cord injury who become pregnant may have some problems in labour, particularly if the lesion is complete above T10. Autonomic dysreflexia is also a risk during labour. However, spinal cord injury is not in itself an indication for caesarean section.
Later medical complications
All the complications listed above in the acute phase can of course occur later. This is why it is so important for the multidisciplinary team to keep an overview of the individual in the long term. A few other problems are more likely to occur in the long term.
- Pathological fractures—there is a higher risk of osteoporosis in paralysed limbs and thus pathological fractures may occur with minimal trauma. For example, a minor fall from a chair or even a flexor spasm secondary to spasticity can result in a fractured leg. Treatment should usually be conservative.
- Post-traumatic syringomyelia—this occurs in about 4% of people and consists of an ascending myelopathy due to secondary cavitation in the central part of the spinal cord. The problem is commonly delayed several years after injury. It usually presents with pain in the arm with a characteristic disassociated sensory loss—reduced pain and temperature sensation but preservation of proprioception. Motor loss occurs of the lower motor neuron type and occasionally sensory loss can spread up to the face (syringobulbia). Additional motor loss can occur which is of the lower motor neuron type. Surgical treatment including decompression and drainage of the cavity may be necessary.
- Respiratory management—those with high cervical cord lesions with lost diaphragmatic function obviously require long-term ventilatory support. There are modern portable ventilators that can be readily mounted on a wheelchair. Speech is entirely possible with an uncuffed tracheostomy tube, which allows air to escape to the larynx. In some people it is possible to implant a phrenic nerve stimulator to achieve diaphragmatic ventilation. Regrettably, it is still the case that individuals with long-term ventilator dependent requirements have significantly more morbidity and mortality than those with lower lesions.
There are now a wide variety of leisure pursuits possible for those with spinal cord injury. Integration to able-bodied clubs and pursuits is obviously to be encouraged. However, there are also a reasonable range of sports and other clubs for those with spinal injuries. Wheelchair skills can be finely tuned to develop expertise in a variety of sports. Slowly physical access is improving to leisure and social outlets. Recent legislation, such as the Disability Discrimination Act in the United Kingdom, should further improve the situation.
Access to a motor vehicle is vital in modern society. Driving should be entirely possible for people with spinal cord injury, with the probable exception of those with very high cervical cord lesions. Automatic transmission is vital and hand controls are usually essential. Hand controls enable the individual to control the accelerator and brake functions from a lever or other device near the steering wheel. A variety of infrared devices to control secondary functions such as windscreen wipers, lights, and horn are now available. Very light powered steering makes life easier for those with weak grip. Those with higher cord lesions who still retain some useful shoulder and upper arm function can still drive a car using a variety of commercial devices attached to the steering wheel. A number of techniques can be taught to stow wheelchairs safely for those with paraplegia, and for those with higher lesions there are a number of mechanical wheelchair stowage devices. It is also quite possible to adapt a suitable vehicle to enable people to drive from their wheelchair. Financial advice is often required, combined with advice on the range and type of adaptations. In the United Kingdom there are now a number of driving assessment centres, often attached to rehabilitation centres.
Overall between 25 and 35% of people with spinal cord injuries return to work, either in their original occupation or into a new job after a period of retraining. The chances of employment are higher in the younger population and in those who already had a job at the time of injury. There is also positive correlation with the number of years in education. Employment should become more prevalent as the ability to work at home becomes more readily acceptable. The individual should be encouraged to contact the disablement employment advisers (in the United Kingdom) who can provide both advice and financial help in order to return to work. In other cases careers advice or retraining to obtain new qualifications may be more appropriate.
The key to independence is access to good-quality information. In most countries there are now voluntary organizations that can provide good quality information and advice. These organizations can also act as pressure groups and many have been instrumental in promoting increased awareness and improved legislation for disabled people. The internet now provides an excellent source of information and advice, and training in computer literacy should certainly be encouraged by the rehabilitation team.
Conclusion and future prospects
Spinal cord injury can cause a range of challenges to the multidisciplinary rehabilitation team. As yet we cannot repair the injured spinal cord in humans, but developments in basic neuroscience are beginning to translate into practice. Repair of spinal injury, e.g. by transplant of glial cells cultured from the adult olfactory system, may be possible in the near future. There is also progress in the use of neuroprotective agents in the acute phase. Other modalities, such as the use of anti-NOGO monoclonal antibodies to augment plasticity and regeneration may also have a role to play in the future. However, our current inability to influence natural history should certainly not inhibit active and dynamic rehabilitation in order for the spinal cord injured person to resume as normal a life as possible. Significant improvements to overall survival and quality of life have been achieved in recent years with the application of modern rehabilitation and surgical practice as well as greater social awareness and understanding.
Baptiste DC, Fehlings MG (2007). Update on the treatment of spinal cord injury. Prog Brain Res, 161, 217–33. [a very good update on future repair possibilities.]
Blackwell TL, et al. (2000). Spinal cord injury desk reference: guidelines for life care planning and case management. Demos Medical Publishing, New York. [Probably the best guide to longer-term spinal issues—American orientated.]
Ditunno JF (1999). Predicting recovery after spinal cord injury: a rehabilitation imperative. Arch Phys Med Rehabil, 80, 361–363. [A source of references regarding natural history.]
Dobkin B, et al. (2006). Weight-supported treadmill training vs over-ground training for walking after acute incomplete SCI. Neurology, 66, 484–93. [A useful summary of this important new technique for gait training.
Phys Med Rehabil Clin North Am. May 2007 issue. [A thoroughly up-to-date review of spinal cord injury issues. the May 2006 issue of Prog Brain Res also covers many related topics.]
Sisto S, Druin E, Macht-Sliwinski M (2008). Spinal cord injuries:management and rehabilitation. Mosby, St Louis. [The most up-to-date textbook.]
Trieschmann RB (1988). Spinal cord injuries—psychological, social and vocational rehabilitation, 2nd edition. Demos Medical Publications, New York. [One of the few volumes to thoroughly discuss the psychological, social and vocational problems after spinal injury; despite its age, it still remains very relevant.]
Wade DT (1992). Measurement in neurological rehabilitation. Oxford University Press, Oxford. [An invaluable textbook outlining a number of important and useful outcome scales.]
World Health Organization (1998). The world health report. Life in the 21st century—vision overall. WHO, Geneva. [A useful reference for a number of world health issues and in particular includes a discussion of the new classification of impairments, activities and participation.]
Spinal Injuries Association. SIA House, 2 Trueman Place, Oldbrook, Milton Keynes, MK6 2HH, UK. Telephone 0845 678 6633; fax 0845 070 6911; freephone advice line 0800 980 0501; http://www.spinal.co.uk [The association for spinal cord injured people—a good source of further information and advice.]