Spinal Cord Injury Explained

Injury to the spinal cord can be caused by acute (sudden) or chronic (developing) trauma as well as medical conditions. Frequent causes of chronic compression injuries are herniated disks and primary or secondary tumors. Compromised blood perfusion, the delivery of nutritive arterial blood to capillary bed, as in anterior spinal cord syndrome can also be severely detrimental to spinal cord function. However the most damaging Spinal Cord Injury is one of acute trauma resulting in permanent paralysis.

SPINAL CORD INJURY CLASSIFICATION

Traumatic spinal cord injury have been classified into five categories by the American Spinal Injury Association and the International Spinal Cord Injury Classification System:

• A – COMPLETE

  Spinal cord injury where no motor or sensory function remains in the sacral segments S4-S5.

• B – INCOMPLETE

  Spinal cord injury sensory but not motor function remains below the neurological level and includes the sacral segments S4-S5. Typically a transient phase and if the person recovers any motor function below the neurological level, they’are considered motor incomplete and classified C or D.

• C – INCOMPLETE

  Spinal cord injury where motor function remains below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3, which indicates active movement with full range of motion against gravity.

• D – INCOMPLETE

  Spinal cord injury where motor function exists below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.

• E – NORMAL

  Where motor and sensory scores are normal. It is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores.

SOCIAL IMPACT OF ACUTE SPINAL CORD TRAUMA

The annual incidence rate of spinal cord injury varies from country to country, ranging from 15 to 71 per million (/m). In 2008 the incidence of spinal cord injury in the United Kingdom around 13 /m, Australia 14 /m, Canadi 35 /m, China 65 /m and the United States 35 /m per year. This suggests around 40 per million or 52,000 spinal injuries occur every year globally.   

Of the 12,000 new cases of paraplegia and quadriplegia that occur in the United States each year 4,000 patients die before reaching hospital. Causes of acute spinal cord injury include motor vehicle accidents, work-related accidents, recreational accidents, falls and violence (shootings and stab wounds).   

Paralysis occurs our times as often in males as females where about 60% of victims are under 30 years of age and 5% under 13 years of age (the pediatric age group). Falls from a height greater than their own is the largest cause of spinal trauma amongst the pediatric age group. A long-term outcome study of patients aged 25 to 34 who had suffered acute traumatic SCI before the pediatric age showed an employment rate of 54% while the employment rate in the general population for the same age group was 84%.   

Limitation or complete loss of the capability to achieve economic independence following SCI combined with additional medical costs causes severe economic hardship for many living with paralysis and their immediate family. Further limitations to living a full social life are architectural barriers, buildings only accessible by stairs and a lack of ramps on sidewalks for example.   

Increased awareness through education has played a key role in resolving these barriers and those created by negative or overprotective attitudes of healthy, non-injured people toward persons with spinal cord injury. When persons with spinal cord injury cannot fully participate society suffers. Not only are ethical standards, artistic and financial contributions to society lost, huge expenses for specialised lifelong care are incurred.   

80% of SCI occur in people under the age of 30. The average life-time cost of thoracic paraplegia is $1.25 million and high level cervical quadriplegia such as those on ventilators $25 million USD. In 1990 the cost for acute and long term care of surviving spinal cord injury victims was estimated at $4 billion in the United States alone.   

SPINAL CORD INJURY STATISTICS

Road traffic accidents 45%   

• Motorcycle 20%
• Car, van, coach, truck 16%
• Bicycle 6%
• Pedestrian 2%
• Aircraft, helicopter 1%

Domestic and industrial accidents 34%   

• Domestic: falls from stairs, trees, ladders, roofs etc. 22%
• Industrial: work falls from scaffolding, ladders, crush etc. 12%

Sporting injuries 15%   

• General:?gymnastics, motocross, skiing, etc, 7%
• Diving into shallow water 4%
• Horse riding 3%
• Rugby 1%

Self harm and criminal assault 6%   

• Self harm 5%
• Criminal assault 1%

THERAPEUTIC APPROACHES AND CHANGING ATTITUDES

Ancient Egyptian Edwin Smith Papyrus

The first known description of acute spinal cord trauma and resulting neurological deficits was in the Edwin Smith papyrus which is believed to be more than 3,500 years old. In this ancient Egyptian document Smith accurately described the clinical symptoms and traumatic effects of quadriplegia (tetraplegia) “an ailment not to be treated.” An indication of the feelings helplessness medical practitioners suffered at the time, a doctor’s value measured by the extent of cure achieved.  

No strategies ensuring longterm survival for patients with spinal cord injury existed. A view which prevailed well into the early 1900’s. In the First World War the mortality rate for those with a spinal cord injury was 95%, mainly attributed to urinary sepsis and complications from pressure sores. Less than 1% survived for more than twenty years.  

During World War II the number of casualties from spinal cord injuries both military and civilian increased dramatically in Europe. Specialized hospital units known as “peripheral nerve centers” developed between the wars in Germany and the United States demonstrating the advantages of concentrating special needs patients under specialized care. Great importance was placed on the unique opportunities offered by these specialized units. Gaining new insight in the natural course of the disease and further development of new therapeutic strategies.  

Building on those experiences, specialized spinal cord injury units started opening throughout England in the 1940s. Mortality rates from a spinal cord injury were recorded at 35% in the 1960s. Today nearly every capital city operates an acute care spinal unit.  

Sir Ludwig Guttmann

Dr. Ludwig Guttmann and his colleagues at the Spinal Cord Unit of Stoke Mandeville Hospital developed new treatment approaches including frequent repositioning of paralyzed patients to avoid developing bedsores, a potential source of sepsis and intermittent sterile catheterization to prevent urinary sepsis. The success in patient survival was dramatic enough to require development of completely new strategies for social reintegration of patients with spinal cord injury. Adapted workplaces and wheelchair accessible housing championed in the 1940s and 1950s by the English Red Cross has today become an integral component in the framework of social politics in most industrialized countries. Respiratory complications are now the leading cause of death in patients admitted with SCI. Secondary are heart disease, septicemia (blood poisoning), pulmonary emboli (blood clot in lungs), suicide, and unintentional injuries.  

THE PARALYMPIC GAMES

Paralympic Games Wheelchair Athletes

Dr. Guttmann and his colleagues viewed physical rehabilitation as the basis of social reintegration both physically and psychologically. Supporting the idea of athletic competition in disciplines adequate and adapted to the physical capacity of their patients. Starting with two teams a competition in 1948 paralleling the Olympic Games in England, the idea of competitive sports for the paralyzed developed rapidly.  

In 1960 the first Paralympic Games were held in Rome. The Paralympic games were held in the same year as the Olympic Games for the able-bodied using the same facilities, a tradition that has been followed ever since. The idea of competitive sports was extended to include people with a multitude of physical handicaps other than spinal cord injury emerging as the Paralympics we know today.  

INITIATIVES AND PUBLIC AWARENESS

In many countries initiatives have risen at communal and national levels with the intent to decrease the incidence of spinal cord trauma and offer support and advice to both those with spinal cord injuries and their families. Many generously offer financial support for scientific and clinical research.  

The prevention oriented “Think First” initiative, Canadian-based CORD and Wheels in Motion, the Christopher Reeve Paralysis Foundation, the U.K. Spinal Cord Trust, and the Paralyzed Veterans of America all maintain informative web sites with valuable information on the subject of spinal cord injury.  

Although the overall incidence of SCI has not noticeably decreased the severity of injuries has deceased overall. Fewer now suffer complete injuries and survival rates have increased. This is mostly attributed to improvements in prehospital care including widespread instruction of first aid principles as well as the introduction of spinal cord immobilization and administration of advanced medicines during rescue and transport. Increased public awareness of risk factors leading to head trauma and spinal cord injury, the introduction of mandatory use of safety belts and installation of air bags in modern vehicles has also served to decrease trauma severity.  

SPINAL CORD INJURY CURE AND TECHNOLOGICAL RESEARCH

Stem Cells Neuron Chain

Until recently research suggested once spinal cord trauma had occurred nothing could be done to alter the natural course of developing pathology, that damage to the central nervous system was permanent and repair impossible. At the beginning of the twenty-first century this belief came to change in the minds of scientists, clinicians, patients and their families. Research laboratories around the world adopted two new approaches:  

1. Prevention of secondary injury and repair of manifest damage. The term secondary injury describes the observation that central nervous system structures that survived the primary mechanical trauma die at a later point in time due to deterioration of the milieu (nerve ending sheath) at the site of injury.  

2. The amount and severity of secondary injury damage can be significantly larger than that of the primary injury. Researchers focused on identification of substances and therapeutic methods that help minimize secondary injury effects. In the field of cell biology, isolation and manipulation of specific cell types is being undertaken in effort to induce certain cell types, including stem cells and olfactory ensheathing cells to help repair damaged central nervous system structures.  

Clinical research continues to improve outcomes for those with a spinal cord injury, such as stimulators for bladder control, orthopedic correctional procedures and physical mobilization. Integration of biomedical research like pattern generators, mechanics and kinetics of movement with the latest developments in computer science and engineering has given rise to neuronal networks. Neuroprostheses are being developed which enable paraplegics to move about and walk.  

RESOURCES

• Gary L. Albrecht. 2006. Encyclopedia of Disability. University of Illinois, Chicago.
• Go, B. K., Michel J. DeVivo, and Scott J. Richards. 1995.  The Epidemiology of Spinal Cord Injury. Clinical Outcomes from the Model Systems, edited by Samuel L. Stover, Joel DeLisa, and Gale G. Whiteneck. Gaithersburg, MD: Aspen.
• Sekhon, Lali H. S. and Michael G. Fehlings. 2001.  Epidemiology, Demographics, and Pathophysiology of Acute Spinal Cord Injury.
• Stripling, Thomas E. 1990.  The Cost of Economic Consequences of Traumatic Spinal Cord Injury.  Paraplegia News.
• Vogel, Lawrence C., L. J. Klaas, John P. Lubicky, and C. J. Anderson. 1998. Long-term outcomes and life satisfaction of adults who had pediatric spinal cord injuries. Archives of Physical Medicine & Rehabilitation.

WEBSITES

• Christopher Reeve Paralysis Foundation, http://www.christopherreeve.org
• CORD – Canadaian Organization for Rare Disorders, http://www.raredisorders.ca
• Paralyzed Veterans of America, http://www.pva.org
• Rick Hansen Man in Motion Foundation, http://www.rickhansen.com