A spinal cord injury ( SCI ) is damage to the spinal cord that causes temporary or permanent changes in function. Symptoms may include loss of muscle function, sensation, or autonomic function in parts of the body served by the spinal cord below the level of injury. Injuries can occur at each level of the spinal cord and may become total injury , with total loss of muscle and sensation, or incomplete , which means some neural signals can travel across the area cord injury. Depending on the location and severity of the damage, the symptoms vary, from numbness to paralysis to incontinence. Long-term outcomes also range widely, from full recovery to permanent tetraplegia (also called quadriplegia) or paraplegia. Complications may include muscle atrophy, pressure sores, infections, and respiratory problems.
In most cases, the damage occurs due to physical trauma such as car accidents, gunfire, falls, or sports injuries, but can also be caused by nontraumatic causes such as infections, inadequate blood flow, and tumors. More than half of the injuries affect the cervical spine, while 15% occur in each of the thoracic spine, the boundary between the thoracic and lumbar spine, and the lumbar spine. Diagnosis is usually based on symptoms and medical imaging.
Efforts to prevent SCI include individual actions such as using safety equipment, social measures such as safety rules in sports and traffic, and equipment repairs. Treatment begins by limiting the further motion of the spine and maintaining adequate blood pressure. Corticosteroids have not been found to be beneficial. Other interventions vary depending on location and level of injury, from bedrest to surgery. In many cases, spinal injuries require physical therapy and long-term occupation, especially if it interferes with daily life activities.
Approximately 12,000 people in the United States per year survive with spinal injuries. The most commonly affected group is the young adult male. SCI has seen great improvements in its treatment since the mid-20th century. Research on potential treatments including stem cell implantation, engineering materials for tissue support, epidural spine stimulation, and robotic exoskeleton can be used.
Video Spinal cord injury
Classification
Spinal cord injuries can be traumatic or nontraumatic, and can be classified into three types based on causes: mechanical, toxic, and ischemic (from lack of blood flow). Damage can also be divided into primary and secondary injury: immediate cell death that occurs immediately in the original injury, and a biochemical cascade initiated by the original insult and cause further tissue damage. These secondary injury pathways include ischemic cascade, inflammation, swelling, cell suicide, and neurotransmitter imbalances. They can last for a few minutes or weeks after an injury.
At each level of the spinal cord, the spinal cord branched off both sides of the spinal cord and exited between a pair of vertebrae, to supply certain parts of the body. The skin area is innervated by a specific spinal cord called the dermatome, and the muscle group is innervated by a single spinal cord called myotome. Parts of the spinal cord are damaged according to the spinal cord at that level and below. Injuries can be 1-8 cervical (C1-C8), thoracic 1-12 (T1-T12), lumbar 1-5 (L1-L5), or sacral (S1-S5). A person's injury rate is defined as the lowest level of full sensation and function. Paraplegia occurs when the foot is affected by spinal cord damage (on thoracic, lumbar, or sacral), and tetraplegia occurs when all four limbs are affected (cervical damage).
SCI is also classified according to the degree of damage. The International Standard for Neurological Classification of Spinal Cord Injuries (ISNCSCI), published by the American Spinal Injury Association (ASIA), is widely used to document sensory and motor impairment after SCI. It is based on neurological responses, touch and needle puncture sensations tested in each dermatome, and muscle strength that controls the main movements on both sides of the body. Muscle strength is rated on a 0-5 scale according to the table on the right, and sensation is rated on a 0-2: 0 scale of no sensation, 1 altered or decreased sensation, and 2 is full sensation. Each side of the body is judged independently.
Complete and incomplete injuries
In "complete" spinal cord injury, all functions below the area of ​​injury disappear, whether the spinal cord is cut or not. Spinal cord injury "incomplete" involves the preservation of motor or sensory functioning below the level of injury in the spinal cord. To be classified as incomplete, there must be some sensation or movement preservation in the area supplied by S4 to S5, e.g. external anal sphincter contractions voluntarily. The nerves in this area connect to the lower regions of the spinal cord, and maintaining the sensations and functions in these body parts indicates that the spinal cord is only partially damaged. An incomplete injury by definition includes a phenomenon known as sacral sparing: some degree of sensation is maintained in the sacral dermatoma, although the sensation may be more disturbed in other dermatomes higher below the lesion level. Sacral sparing has been linked to the fact that the sacral spinal path is unlike other spinal pathways becoming compressed after injury due to fiber lamination in the spinal cord.
Spinal cord injuries without radiographic abnormalities
Spinal cord injuries without radiographic abnormality existed when SCI was present but there was no evidence of spinal cord injury on radiography. Spinal injury is a trauma that causes bone fractures or ligament instability in the spine; this can coexist with or cause injury to the spinal cord, but any injury can occur without the other. Abnormalities may appear on magnetic resonance imaging (MRI), but this term was coined before MRI was used in general.
Cord syndrome
Central cord syndrome, almost always caused by damage to the cervical spinal cord, is characterized by a weakness in the arm with relative avoidance of the foot, and escapes the sensation in the area served by the sacral segment. There is a loss of sensation of pain, temperature, light touch, and pressure below the level of injury. The spinal tracts that serve the arms are more affected because of their central location in the spinal cord, while the corticospinal fibers destined for the foot are spared due to their more external location. The most common of incomplete SCI syndromes, central nervous syndrome is usually the result of neck hyperextension in the elderly with spinal stenosis. In younger people, most commonly due to neck flexion. The most common causes are falls and vehicle accidents; Other possible causes include spinal stenosis and spinal cord collision by tumors or vertebral disks.
Anterior rope syndrome
The anterior rope syndrome, due to damage to the front of the spinal cord or decreased blood supply from the anterior spinal artery, may be caused by a vertebral fracture or dislocation or disc herniation. Under the level of injury, motor function, pain sensation, and temperature sensation disappear, while sense of touch and propiosepsi (sense of position in space) remain intact. This difference is due to the relative location of the spinal tract responsible for each type of function.
Brown-SÃÆ' Â © quard syndrome
Brown-SÃÆ' Â © quard syndrome occurs when the spinal cord is injured on one side more than the other. It is rare for the spinal cord to actually get cut off (cut off on one side), but partial lesions due to penetrating injuries (such as gunshot wounds or knives) or fractures or tumors are common. On the ipsilateral side of the injury (same side), the body loses motor function, propiosepsi, and feel vibration and touch. On the contralateral side (opposite side) of injury, there is a loss of pain and temperature sensation.
Posterior umbilical cord syndrome
The posterior rope syndrome, in which only the dorsal columns of the spinal cord are affected, is usually seen in cases of chronic myelopathy but may also occur with posterior spinal artery infarction. This rare syndrome causes a loss of proprioception and a sense of vibration below the level of injury while motor function and pain, temperature, and touch sensations remain intact. Usually a posterior injury injury results from insults such as illness or vitamin deficiency rather than trauma. Tabes dorsalis, due to injury to the posterior part of the spinal cord caused by syphilis, causes loss of touch and proprioceptive sensation.
Conus medullaris and cauda equina syndromes
The medullary con's syndrome is an injury to the spinal cord, located around the T12-L2 vertebra in adults. This region contains segments of the S4-S5 spine, responsible for the intestines, bladder, and some sexual function, so this can be impaired on this type of injury. In addition, Achilles sensations and reflexes may be impaired. Causes include tumors, physical trauma, and ischemia.
Cauda equina syndrome (CES) results from a lesion below the level where the spinal cord is divided into cauda equina, at L2-S5 level below the medullary cone. Thus it is not the correct spinal cord syndrome because it is a damaged nerve root rather than the umbilical cord itself; However it is common for some of these nerves to be damaged at the same time due to its proximity. CES can occur by itself or with concomitant medullary syndrome. May cause lower back pain, weakness or paralysis in the lower limbs, loss of sensation, bowel and bladder dysfunction, and loss of reflexes. Unlike medullary constra- cus syndrome, symptoms often occur on only one side of the body. The cause is often compression, for example by a disc or an erupted intervertebral tumor. Because the damaged nerves at CES are actually peripheral nerves because they are already branched from the spinal cord, the injury has a better prognosis for functional recovery: the peripheral nervous system has a greater capacity for healing than the central nervous system.
Maps Spinal cord injury
Signs and symptoms
The signs (observed by the doctor) and symptoms (experienced by the patient) vary depending on where the spine is injured and the extent of the injury. The part of the skin that is supplied through a particular part of the spine is called the dermatome, and injury to the spine can cause pain, numbness, or loss of sensation in the associated area. Paresthesia, a tingling or burning sensation in the affected area of ​​the skin, is another symptom. A person with a low level of consciousness may show a response to a painful stimulus above a certain point but not below it. A group of muscles innervated through a particular part of the spine is called myotome, and injury to the part of the spinal cord can cause problems with movements involving the muscles. The muscles can contract uncontrollably (flexibility), become weak, or completely paralyzed. Spine shock, loss of nerve activity including reflexes below the level of injury, occurs immediately after injury and usually disappears within a day.
The specific parts of the body that are affected by the loss of function are determined by the degree of injury.
Lumbosacral
The effects of injury at or above the lumbar or sacral areas of the spinal cord (lower back and pelvis) include decreased control of the legs and hips, genitourinary system, and anus. People injured below L2 level may still use flexor muscles and extensor knees. The function of the bowel and bladder is regulated by the sacral region. It is common to experience sexual dysfunction after injury, as well as bowel and bladder dysfunction, including fecal and urinary incontinence. It may also be that the bladder fails to empty, causing a dangerous buildup of urine. One sign of spinal injury that emergency service providers can find is priapism, penile erection.
Thoracic
In addition to problems found in lower-level injuries, chest spine lesions (high chest) can affect the muscles in the trunk. Injuries at T1 to T8 levels result in an inability to control the abdominal muscles. Stability of the stem may be affected; even more in higher level injuries. The lower the level of injury, the less widespread the effect. Injuries from T9 to T12 cause partial loss of stem and abdominal muscle control. Thoracic spine injury causes paraplegia, but the functions of the hands, arms, and neck are unaffected.
One condition that occurs usually in lesions above T6 level is autonomic dysreflexia (AD), where blood pressure rises to dangerous levels, high enough to cause potentially lethal strokes. This results from an over-reaction of the system to a stimulus such as pain below the level of injury, since signaling inhibition of the brain can not pass through the lesion to dampen the response of the excitatory sympathetic nervous system. AD signs and symptoms include anxiety, headache, nausea, ringing in the ears, blurred vision, reddened skin, and nasal congestion. May occur immediately after injury or not until many years later.
Other autonomous functions may also be impaired. For example, problems with body temperature regulation mostly occur in injuries in T8 and above. Another serious complication that can occur due to a lesion above T6 is neurogenic shock, which results from an output disturbance of the sympathetic nervous system responsible for maintaining muscle tone in the blood vessels. Without sympathetic input, the vessels are relaxed and enlarged. Neurogenic shock arises with harmful low blood pressure, low heart rate, and blood pooling of the limbs - causing insufficient blood flow to the spinal cord and potentially causing further damage.
Cervix
Spinal cord injuries at the level of the cervix (neck) produce full or partial tetraplegia (also called quadriplegia). Depending on the specific location and severity of the trauma, limited functionality can be maintained.
Additional signs and symptoms of cervical injury include low heart rate, low blood pressure, body temperature regulation problems, and respiratory dysfunction. If the injury is high enough in the neck to damage the muscles involved in breathing, the person may not be able to breathe without the help of an endotracheal tube and a mechanical ventilator.
Complications
Spinal injury complications include pulmonary edema, respiratory failure, neurogenic shock, and paralysis below the site of injury.
In the long run, loss of muscle function can have additional effects of not being used, including muscle atrophy. Immobility can cause pressure sores, especially in the bone area, which require precautions such as extra cushioning and rotating in bed every two hours (in acute settings) to reduce pressure. In the long run, people in wheelchairs should shift periodically to reduce pressure. Other complications are pain, including nociceptive pain (indication of potential or actual tissue damage) and neuropathic pain, when the nerves affected by the damage carry the wrong pain signal in the absence of dangerous stimulation. Spasticity, uncontrollable muscle tension below the level of injury, occurs in 65-78% of chronic SCI. This results from a lack of input from the brain that extinguishes the muscle response to stretch the reflex. May be treated with medication and physical therapy. Spasticity increases the risk of contractures (shortening of muscles, tendons, or ligaments caused by lack of use of the limbs); this problem can be prevented by moving the limbs through various movements several times a day. Other problems that less mobility can cause are loss of bone density and changes in bone structure. Loss of bone density (bone demineralization), presumably due to lack of input from weakened or paralyzed muscles, may increase the risk of fractures. In contrast, the poorly understood phenomenon is the overgrowth of bone tissue in soft tissue areas, called heterotopic ossification. This occurs below the level of injury, possibly as a result of inflammation, and occurs at a clinically significant level in 27% of people.
People with SCI are at very high risk for respiratory and cardiovascular problems, so hospital staff should be vigilant to avoid them. Respiratory problems (especially pneumonia) are the leading cause of death in people with SCI, followed by infection, usually press injuries, urinary tract infections and respiratory infections. Pneumonia may be accompanied by shortness of breath, fever, and anxiety.
Another potentially deadly threat to respiration is deep venous thrombosis (DVT), in which blood forms clots in the immobile legs; the clot can break and form the pulmonary embolism, stay in the lungs and cut off the blood supply to the lungs. DVT is a very high risk for SCI, especially within 10 days after injury, occurring in more than 13% in acute care settings. Preventive measures include anticoagulants, pressure hoses, and moving the patient's limbs. The usual signs and symptoms of DVT and pulmonary embolism can be covered in the case of SCI because of effects such as changes in pain perception and nervous system function.
Urinary tract infection (UTI) is another risk that may not show the usual symptoms (pain, urgency and frequency); it may be associated with worsening spasticity. The risk of UTI, possibly the most common complication in the long run, increases with the use of urinary catheters dwelling. Catheterization may be necessary because the SCI interferes with the ability of the bladder to empty when too full, which can trigger autonomic dysreflexia or permanently damage the bladder. The use of intermittent catheterization to periodically empty the bladder throughout the day has decreased mortality due to renal failure from UTI in the first world, but is still a serious problem in developing countries.
It is estimated that 24-45% of people with SCI suffer from depression, and the suicide rate is as much as six times that of the other populations. The risk of suicide is the worst in the first five years after injury. In young people with SCI, suicide is the leading cause of death. Depression is associated with an increased risk of other complications such as UTI and pressure ulcers that occur more when self-care is ignored.
Cause
Spinal cord injuries are most often caused by physical trauma. The force involved can be hyperflexion (head forward movement); hyperextension (retreat); lateral stress (lateral movement); rotation (turning head); compression (force along the spinal axle down from the head or up from the pelvis); or disorder (pulling apart from the spine). SCI trauma can cause bruises, compression, or stretching. This is a major risk of many types of vertebral fractures. Pre-existing asymptomatic congenital anomena can cause major neurological deficits, such as hemiparesis, due to minor trauma.
In the US, motor vehicle accidents are the most common cause of SCI; both fall, then violence like a gunshot wound, then a sports injury. In some countries fall more commonly, even exceeding vehicle accidents as the main cause of SCI. The level of SCI-related violence is highly dependent on place and time. Of all the sports-related SCIs, shallow water dives are the most common cause; Winter sports and water sports have increased as a temporary cause of football associations and trampoline injuries have declined. Hanging may cause injury to the cervical spine, as it may occur in suicidal attempts. Military conflict is another cause, and when they occur they are associated with an increase in SCI level. Another potential cause of SCI is an iatrogenic injury, caused by improper medical procedures such as injections into the spine.
SCI can also be derived from nontraumatic. Nontraumatic lesions cause between 30 and 80% of all SCI; the percentage varies by place, influenced by attempts to prevent trauma. Developed countries have a higher percentage of SCI because of degenerative conditions and tumors than in developing countries. In developed countries, the most common cause of nontraumatic SCI is degenerative disease, followed by tumors; in many developing countries the main causes are infections such as HIV and tuberculosis. SCI may occur in intervertebral disc disease, and spinal vascular disease. Spontaneous hemorrhage may occur inside or outside the protective lining lining the umbilical cord, and the intervertebral disc may undergo a herniation. Damage can occur due to vascular dysfunction, such as arterial malformations, or when blood clots are caught in the blood vessels and cut off the blood supply to the umbilical cord. When systemic blood pressure decreases, blood flow to the spinal cord may be reduced, potentially leading to loss of sensation and voluntary movement in the area supplied by the affected spinal cord level. Congenital conditions and tumors that suppress the umbilical cord may also cause SCI, such as vertebral spondylosis and ischaemia. Multiple sclerosis is a disease that can damage the spinal cord, as well as conditions of infection or inflammation such as tuberculosis, herpes zoster or herpes simplex, meningitis, myelitis, and syphilis.
Prevention
SCI related vehicles are prevented by actions including public and individual efforts to reduce driving under the influence of drugs or alcohol, impaired driving, and drowsy driving. Other efforts include improving road safety (such as marking hazards and adding lighting) and vehicle safety, both to prevent accidents (such as routine maintenance and anti-lock brakes) and to reduce collision damage (such as headbands, airbags, seatbelts), and child safety seat). Waterfalls can be prevented by making changes to the environment, such as anti-skid and crossing bars in bathtubs and showers, fencing for stairs, child doors and safety for windows. Armor-related injuries can be prevented by conflict resolution training, gun safety education campaigns, and technological changes in weapons (such as triggering keys) to improve their safety. Sports injuries can be prevented with changes to rules and sports equipment to improve safety, and educational campaigns to mitigate risky practices such as deep water diving or head-first tackling in associate football.
Diagnosis
Radiographic evaluation using X-rays, CT scans, or MRIs can determine if there is damage to the spine and where it is located. X-rays are generally available and can detect the instability or misalignment of the spine, but do not provide very detailed images and may miss injuries to the spinal cord or the displacement of ligaments or discs that have no spinal damage accompanying them. So when the X-ray findings are normal but SCI is still suspected because of pain or symptoms of SCI, CT scan or MRI is used. CT provides greater detail than X-rays, but exposes the patient to more radiation, and still gives no picture of the spinal cord or ligaments; MRI shows the body structure in the greatest detail. Thus it is standard for anyone who has a neurological deficit found in SCI or is suspected of having an unstable spinal column injury.
Neurologic evaluation to help determine the level of disorder performed initially and repeatedly in the early stages of treatment; This determines the level of improvement or deterioration and informs care and prognosis. The ASIA Impairment Scale described above is used to determine the extent and severity of the injury.
Management
Pre-hospital treatment
The first stage in the handling of suspected spinal cord injuries is directed to support basic life and prevent further injury: maintaining airway, breathing, and circulation and limiting the further motion of the spine. In emergency settings, most people who have experienced strength strong enough to cause SCI are treated as if they have instability in the spine and have restricted spinal movements to prevent damage to the spinal cord. Injuries or fractures in the head, neck, or pelvis as well as a penetrating trauma near the spine and falling from altitude are assumed to be associated with an unstable spine until ruled out in the hospital. High speed vehicle accidents, sports injuries involving head or neck, and diving injuries are other mechanisms that indicate a high risk of SCI. Because head and spine trauma often co-exist, anyone who is unconscious or has a low level of consciousness as a result of head injury is the limited movement of the spine.
Rigid cervical collar is applied to the neck, and the head is held with blocks on both sides and the person is tied to the board. Widening devices are used to move people without excessively moving the spine if they are still in a vehicle or other confined space. The use of cervical collars has been shown to increase mortality in people with penetrating trauma and is thus not recommended routinely in this group.
Modern trauma care includes a step called cleansing the cervical spine, ruling out spinal cord injury if the patient is fully conscious and not under the influence of drugs or alcohol, shows no neurological deficits, has no pain in the middle of the neck and no other. a painful injury that can distract from neck pain. If these are all absent, no restriction of spinal motion is necessary.
If an unstable spinal cord injury is removed, damage can occur in the spinal cord. Between 3 and 25% of SCI does not occur during initial trauma but later during treatment or transportation. While some of this is due to the nature of the injury itself, especially in cases of multiple or massive trauma, some of which reflect failure to limit spinal movements adequately. SCI can damage the body's ability to stay warm, so a warm-up blanket may be needed.
Initial hospital care
Initial care in hospitals, such as in pre-hospital settings, aims to ensure adequate respiratory, respiratory, cardiovascular, and spinal cord restrictions. Spinal imaging to determine the presence of SCI may need to wait if emergency surgery is needed to stabilize other life-threatening injuries. SCI requires acute care in the intensive care unit, especially injury to the cervical spinal cord. People with SCI require ongoing neurologic assessment and treatment by neurosurgeons. People should be removed from the spine as quickly as possible to prevent complications from their use.
If systolic blood pressure falls below 90 mmHg within days of injury, the blood supply to the spinal cord may be reduced, resulting in further damage. It is thus important to maintain the possible blood pressure by using intravenous fluids and vasopressors. The used vasopressor includes phenylephrine, dopamine, or norepinephrine. Mean arterial blood pressure was measured and stored at 85 to 90 mmHg for seven days after the injury. Treatment for shock from blood loss differs from neurogenic shock, and can harm people with the latter type, so it is necessary to determine why a person is shocked. However, it is also possible for both causes to exist at the same time. Another important aspect of care is the prevention of oxygen deprivation in the bloodstream, which can remove the spinal cord from oxygen. People with high cervical or thoracic injury may experience very slow heart rates; treatment to speed it up may include atropine.
Methylprednisolone corticosteroid drug has been studied for use in SCI in the hope of limiting swelling and secondary injury. Because there seems to be no long-term benefit and this drug is associated with risks such as gastrointestinal bleeding and infection of its use is not recommended by 2018. Its use in traumatic brain injury is also not recommended.
Surgery may be necessary, for example, to reduce excess pressure on the umbilical cord, to stabilize the spine, or restore the spine to its proper place. In cases involving instability or compression, failing to operate can lead to deteriorating conditions. Surgery is also necessary when there is something pressing on the umbilical cord, such as bone fragments, blood, ligaments or intervertebral discs, or nesting objects from penetrating injuries. Although the ideal operating time is debatable, studies have found that previous surgical interventions (within 24 hours after injury) are associated with better outcomes. Sometimes a patient has too many other injuries to become an operating candidate as early as possible. Surgery is controversial because it has potential complications (such as infection), so in cases where it is not obviously necessary (eg the cable is being compressed), clinicians must decide whether to perform surgery based on aspects of the patient's condition and their own beliefs about the risks and benefits. In cases where a more conservative approach is chosen, bed rest, cervical collar, motion restriction device, and optional traction are used. The surgeon may choose to place traction on the spine to relieve pressure from the spinal cord by placing the spine dislocated back into alignment, but intervertebral disc disc herniation can prevent this technique from relieving pressure. Gardner-Wells clamp is one tool used to deploy spinal traction to reduce fractures or dislocations and to reduce movement to the affected area.
Rehabilitation
SCI patients often require additional care in specialized spinal units or intensive care units. The rehabilitation process usually begins in an acute care setting. Usually the hospitalization phase lasts 8-12 weeks and then the outpatient rehabilitation phase lasts 3-12 months after that, followed by annual medical and functional evaluation. Physical therapists, occupational therapists, recreational therapists, nurses, social workers, psychologists and other health care professionals work as a team under the co-ordination of physiotherapists to decide on the patient's shared goals and develop an appropriate disposal plan for the patient's condition..
In the acute phase the physical therapist focuses on the patient's respiratory status, prevention of indirect complications (such as pressure ulcers), maintaining the range of motion, and keeping the muscles active.
For people whose culprits are high enough to interfere with breathing, there is great emphasis on cleaning the airways during this recovery phase. Weakness of the respiratory muscles impairs the ability to cough effectively, allowing secretion to accumulate in the lungs. Because SCI patients suffer from a decrease in total lung capacity and tidal volume, physical therapists teach them additional breathing techniques (eg apical breathing, glossopharyngeal breathing) that are not normally taught to healthy individuals. Physical therapy therapy for airway cleaning may include manual and vibration percussion, postural drainage, respiratory muscle training, and assisted cough techniques. Patients are taught to increase their intra-abdominal pressure by leaning forward to induce coughing and discharge of mild fluid. The quad cough technique is done lying on the back with the therapist applying pressure on the abdomen in cough rhythm to maximize the expiratory flow and mobilize the secretions. Manual abdominal compression is another technique used to increase expiratory flow which then increases cough. Other techniques used to manage respiratory dysfunction include the respiratory muscles, the use of narrowed abdominal binders, ventilator-assisted speech, and mechanical ventilation.
The amount of functional recovery and independence achieved in terms of daily life activities, recreational activities, and occupations is affected by the extent and severity of the injury. Functional Independent Measurement (FIM) is an assessment tool that aims to evaluate the patient's function during the rehabilitation process after a spinal injury or other serious illness or injury. It can track patient progress and independence levels during rehabilitation. People with SCI may need to use specialized devices and make modifications to their environment to handle daily life activities and function independently. Weak joints can be stabilized with devices such as ankle orthosis (AFO) and knee AFO, but walking may still require a lot of effort. Increasing activity will increase the chances of recovery.
Prognosis
Spinal cord injuries generally produce at least some disorders that can not be cured even with the best treatment. The best predictor of prognosis is the extent and completeness of the injury, as measured by the scale of the ASIA decline. Neurologic score on preliminary evaluation performed 72 hours after injury is the best predictor of how many functions will return. Most people with ASIA A (total injury) scores do not have functional motor recovery, but improvement may occur. Most patients with incomplete injuries recover at least some function. Opportunities for restoring walking ability increase with each SIA score found on initial examination; for example ASIA D score gives better chance to walk than score C. Symptoms of incomplete injury can vary and it is difficult to make accurate predictions about the results. A person with a mild and incomplete injury in the T5's vertebra will have a much better chance of using his legs than a person with severe severe injury in the exact same spot. Of incomplete SCI syndrome, Brown-SÃÆ' Â © quard syndrome and central cord syndrome have the best prognosis for recovery and anterior cable syndrome has the worst. People with noncontrastic causes of SCI have been found to be less likely to suffer complete injuries and some complications such as pressure sores and deep vein thrombosis, and have shorter hospital stays. Their scores on functional tests are better than those with traumatic SCI after admission, but when they are tested upon return, those with traumatic SCI have increased in such a way that the outcomes of both groups are the same. In addition to the completeness and extent of injury, age and health problems simultaneously affect the extent to which a person with SCI will be able to live independently and run. However, in general people with injuries to L3 or below may be able to function functionally, T10 and below to walk around the house with bracing, and C7 and below to live independently.
One of the important predictors of motor recovery in an area is the sensation there, especially the perception of pain. Most motor recovery occurs in the first year of post-injury, but modest remedies may continue for many years; sensory recovery is more limited. Recovery is usually the fastest during the first six months. The spinal cord, in which the reflex is suppressed, occurs immediately after the injury and heals within three months but continues to improve gradually over the course of 15 months.
Sexual dysfunction after spinal cord injury is common. Problems that may occur include erectile dysfunction, loss of ability to ejaculate, inadequate vaginal lubrication, and reduced sensation and impaired ability to orgasm. Nevertheless, many people learn how to adapt their sexual practices so that they can live a satisfying sex life.
Although life expectancy has improved with better care options, it is still not as good as the unharmed population. The higher the level of injury, and the more complete the injury, the greater the reduction in life expectancy. Death is very high in one year due to injury.
Epidemiology
Worldwide, the number of new cases since 1995 SCI ranges from 10.4 to 83 per million per year. This large number of numbers may be partly due to differences between regions of whether and how injuries are reported. In North America, about 39 people per million each bring SCI traumatically each year, and in Western Europe the incidence is 16 per million. In the United States, the incidence of spinal cord injury is estimated to be about 40 cases per 1 million people per year or about 12,000 cases per year. In China, the incidence is around 60,000 per year. Estimates of the number of people living with SCI in the world range from 236 to 4187 per million. Estimates vary greatly because of differences in how data is collected and what techniques are used to extrapolate numbers. Little information is available from Asia, and even less than Africa and South America. In Western Europe, the estimated prevalence is 300 per million people and in North America 853 per million. It is estimated at 440 per million in Iran, 526 per million in Iceland, and 681 per million in Australia. In the United States there are between 225,000 and 296,000 people living with spinal cord injury, and different studies have estimated prevalence from 525 to 906 per million.
SCI is present in about 2% of all cases of blunt object trauma. Anyone who has experienced enough strength to cause a thoracic spine injury is at high risk for other injuries as well. In 44% of SCI cases, other serious injuries persisted at the same time; 14% of SCI patients also suffered head trauma or facial trauma. Other commonly related injuries include chest trauma, abdominal trauma, pelvic fracture, and long bone fractures.
Men are responsible for four of the five traumatic spinal injuries. Most of these injuries occur in men under 30 years old. The median age at the time of injury gradually increased from about 29 years in the 1970s to 41. The lowest level of injury in children, the highest in late adolescence to early twenties, then decreased in older age groups; But the rate may increase in the elderly. In Sweden between 50 and 70% of all cases of SCI occur in people under 30, and 25% occur in those over the age of 50. While the SCI rate is highest among people ages 15-20, less than 3% of SCI occurs in people under 15 years of age. Neonatal SCI occurs in one in 60,000 births, eg from breech birth or injury by forceps. Differences in rates between the sexes were reduced in injuries by age 3 and younger; the same number of girls hurt as a boy, or maybe more. Another cause of pediatric injuries is child abuse such as the shaken baby syndrome. For children, the most common cause of SCI (56%) is vehicle accidents. The high number of teenage injuries caused by the majority of traffic accidents and sports injuries. For people over 65, falling is the most common cause of traumatic SCI. Parents and people with severe arthritis are at high risk for SCI because of defects in the spine. In nontraumatic SCI, gender differences are smaller, mean age of incidence is greater, and incomplete lesions are more common.
History
SCI has been known to be devastating for thousands of years; Ancient Egyptian Edwin Smith Papyrus from 2500 BC, the first known description of the injury, says "not treated". The Hindu text since 1800 BC also mentions SCI and explains the traction technique to straighten the spine. The Greek physician Hippocrates, born in the fifth century BC, described SCI in his Corpus Hippocrates and invented traction tools to straighten the bones of dislocations. But it was not until Aulus Cornelius Celsus, born 30 BC, noted that cervical injuries resulted in the rapid death that the spinal cord itself was involved in the condition. In the 2nd century AD, Greek physician Galen experimented on monkeys and reported that the horizontal pieces through the spinal cord caused them to lose all the sensations and movements below the wound level. Seventh-century Greek physician Paul of Aegina described surgical techniques to treat vertebral fractures by removing bone fragments, as well as surgery to reduce the pressure on the spine. Little medical progress was made during the Middle Ages in Europe; it was not until the Renaissance that the spine and nerves were accurately portrayed in the images of human anatomy by Leonardo da Vinci and Andreas Vesalius.
In 1762, a surgeon named Andre Louis removed a bullet from the patient's lumbar spine, which regained movement in the legs. In 1829, surgeon Gilpin Smith performed a successful laminectomy that enhanced the patient's sensation. However, the notion that SCI can not be treated remains dominant until the early 20th century. In 1934, the death rate in the first two years after injury was more than 80%, mostly due to urinary tract infections and pressure sores. Only in the second half of this century, breakthroughs in imaging, surgery, medical care, and rehabilitation drugs contribute to substantial improvements in SCI care. The incidence is relatively incomplete compared to the complete injury has increased since the mid-20th century, mainly due to the emphasis on faster and better early treatment and stabilization of spinal cord injury patients. The provision of emergency medical services to transport people to hospitals is professionally given a partial credit for improving outcomes since the 1970s. Improvement in care has been accompanied by an increase in life expectancy of people with SCI; survival time has increased by about 2000% since 1940. IN 2015/2016 23% of people in nine central spinal cord injuries in the UK are postponed due to late disputes over who should pay for the equipment they need.
Direction of research
Scientists are investigating ways to treat spinal cord injury. Therapeutic research is focused on two main areas: neuroprotection and neuroregeneration. The first seeks to prevent the harm that occurs from secondary injury within minutes to weeks after insult, and the latter aims to reconnect damaged circuits in the spinal cord to allow the function to return. Neuroprotective drugs target secondary effects of injury including inflammation, damage by free radicals, excitotoxicity (nerve damage by excess glutamate signals), and apoptosis (cell suicide). Some potentially neuroprotective agents targeting such pathways are being investigated in human clinical trials.
Stem cell transplantation is an important avenue for SCI research: the goal is to replace missing spinal cord cells, allow reconnection in damaged neural circuits by growing axons, and to create a favorable tissue environment for growth. The key to SCI research is the study of stem cells, which can differentiate into other cell types - including cells lost after SCI. The types of cells studied for use in SCI include embryonic stem cells, neural stem cells, mesenchymal stem cells, olfactory ensheathing cells, Schwann cells, activated macrophages, and induced pluripotent stem cells. Hundreds of stem cell studies have been performed on humans, with promising but unconvincing results. The ongoing Phase 2 Phase 2 trial presents data that shows that after 90 days 2 of 4 subjects have increased two motor levels and thus have reached the end point of 2/5 patients who increased two levels in 6-12 months. Six-month data is expected in January 2017.
Another type of approach is network engineering, using biomaterials to help scaffold and rebuild damaged tissue. Biomaterials under investigation include natural substances such as collagen or agarose and synthetic ones such as polymers and nitrocellulose. They fall into two categories: hydrogels and nanofibers. These materials can also be used as vehicles to provide gene therapy to the tissues.
One avenue that is being explored to enable people with paralysis to walk and to assist in the rehabilitation of people with walking ability is the use of usable exoskeleton robots. The tools, which have motorized connections, are placed on top of the legs and provide resources for moving and walking. Some such devices are readily available for sale, but investigations are ongoing about how they can be made more useful.
Early studies of epidural spinal cord stimulation for complete motor injury have shown some improvement.
References
Bibliography
External links
- spinal cord injury in Curlie (based on DMOZ)
- Cochrane Injuries Group, a systematic review of the prevention, treatment and rehabilitation of traumatic injuries
- Spinal Cable Infarcts: Fiber Laminates
Source of the article : Wikipedia
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