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R E H A B I L I TAT I O N A RT I C L E

Management of Traumatic
Spinal Cord Injuries:
current standard of care revisited
raumatic spinal cord injuries (TSCI) are life bers as well as implications for the cost to treat compli-

T changing events. With expert, early, simultane-


ous Active Physiological Conservative
Management (APCM) of the injured spinal cord and
cations, the methods of prevention of which have been
known for over six decades.

its effects, the impact on the patient and family Effects and special characteristics of spinal
members can be minimised in both the short and cord injuries
long term.Without surgical, pharmacological, or bio- A SCI causes widespread physiological impair-
logical intervention over 70% of patients with com- ments, medical and non medical problems. The
Wagih El Masri
plete motor paralysis but with sparing of pin prick functioning of the various systems of the body
leads the Midlands Centre for
Spinal Injuries at the RJAH sensation in the first 72 hours of injury recover depends on reflex activity of the spinal cord seg-
Orthopaedic Hospital in motor power to ambulate. Those presenting within ments distal to the lesion as well as on the intrinsic
Oswestry. He graduated from 72 hours of injury with motor sparing, however min- properties of the systems themselves. Changes in
Cairo University Medical School
imal, have an even better chance to walk, also with- levels of reflex activity of the spinal cord occurs
and trained at Guys Hospital,
London, Oxford, Stoke out surgical, pharmacological or biological inter- throughout the patient’s life with unpredictable
Mandeville and in the USA. He is ventions. Patients who do not recover ambulation changes in the functioning of systems of the body.
currently the President of the can, with APCM, ongoing expert monitoring, care Continuing change of function invariably occurs
International Spinal Cord Society.
and support, lead healthy, fulfilling, productive and during the transition between spinal shock and full
Correspondence to: competitive lives. return of reflex activity, hence the need for close
Mr W S El Masri, monitoring and constant recalibration of manage-
FRCS Ed, FRCP, Active Physiological Conservative ment of the various systems of the body throughout
Consultant Surgeon in Spinal
Management the first few months following injury.
Injuries,
Director, Midland Centre for Active simultaneous, non surgical management, The sensory loss below the injury presents diag-
Spinal Injuries, from the early hours of injury, of nostic challenges to the clinician. Conventional
RJ & AH Orthopaedic Hospital, • the injured spine, symptoms and signs of pathology are absent. This
Oswestry,
• the multisystem neurogenic effects of spinal can result in a delay of diagnosis, usually with
Shropshire, UK.
cord injury on respiratory, cardiovascular, urinary, unpleasant consequences.
gastrointestinal, dermatological, sexual, repro- Each system malfunction is a source of one or
ductive functions, more disabilities and a potential source of a wide
Acknowledgements:
• the associated psychological, effects, range of complications of varying severity.
For their support and help I
acknowledge my consultant • rehabilitation and Impairment of bladder function for example, can
colleagues in the Midland Centre • environmental modifications result in urinary incontinence, embarrassment and
for Spinal Injuries, and those at loss of confidence, bladder infections, pyelonephri-
the RJ & AH orthopaedic Hospital
Unfortunately surgery has become the preferred tis, calculi, hydronephrosis and renal failure.
in particular the Consultant
Spinal Surgeons, Radiologists, as method of management, also known as the In the acute stage complications such as hypoxia,
well as my staff, my personal “Standard of Care”, of traumatic spinal injuries. hypotension and sepsis can cause further neurologi-
assistant Mrs H Edwards and my Currently, about 80% of patients with TSCI are surgi- cal deterioration or lack of recovery.
wife, Dr Bettina Eldeeb.
cally decompressed and stabilised without the When a complication develops, the absence of
This paper was supported by
SPIRIT, a charity that promotes rigours of adequate research methodology or higher co-ordinating and moderating functions of
education, training and clinical demonstration of superiority of neurological and/or the brain over the spinal cord segments below the
research in spinal injuries. other outcomes over APCM. This can be contrasted injury usually result in multiple and/or cascading
with practice in my orthopaedic institution (with intersystem effects that are rarely seen in other con-
four dedicated spinal surgeons) where less than ditions.These are seldom easy to diagnose and man-
15% of patients are surgically managed and the age. For example, an anal fissure, while painless in a
majority of patients undergo APCM. tetraplegic or high paraplegic patient, can neverthe-
Currently, resources are relatively easily found for less cause autonomic dysreflexia and/or excess
surgical implants and surgical procedures in both the spasticity which in turn may cause a fall and frac-
developing and developed world. However, it is ture of a long bone. Alternatively or concomitantly if
increasingly difficult to find resources for the manage- excess spasticity involves the pelvic floor muscles it
ment of the effects of the SCI and the rehabilitation of can result in urinary infection, urinary retention,
the patient in both the acute stage and in the long autonomic dysreflexia and possibly a cerebral
term. Consequently, the devastatingly wide range of haemorrhage. Almost all complications following
medical effects and the psychological, social, emotion- SCI are preventable or can be minimised. Many are
al, financial, vocational, environmental and economic iatrogenic due to unfamiliarity with the pathophysi-
consequences are inadequately managed. Such inad- ology of the spinal man/woman. The non-medical
equacy of management has implications for quality of effects of spinal cord injury are equally devastating
outcomes, quality of life of patients and family mem- to patients and family members.

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R E H A B I L I TAT I O N A RT I C L E

Fortunately, the incidence of spinal cord Traumatic biomechanical instability of with the degree of neurological impairment,
injuries is the lowest of all major trauma. The the spinal column does not prevent neurological recovery and
incidence in the UK ranges between 10-15 per The degree of BI is usually based on radiologi- does not result in neurological deterioration
million head of population per year. A district cal investigations at the time of the presenta- were published by El Masri et al in 1992.7,8 The
general hospital serving a population of tion of the patient. It is perhaps worthwhile not- same conclusions were made by reviewing the
250,000 is likely to receive fewer than four ing that most vertebral fractures heal within 6- outcome of conservative treatment of 50 consec-
newly injured patients per year. Unfortunately 12 weeks from injury when biomechanical sta- utive patients with between 10% to 90% canal
this small incidence limits the expertise bility (BS) is restored. Ligamentous injuries, encroachment in Frankel C, D and E groups;
required by a wide range of disciplines out- however, can take much longer to heal. BI is patients in Frankel C&D group recovered ambu-
side spinal injury centres. therefore time related. During active physiolog- lation and none of the patients deteriorated neu-
ical conservative management (APCM) con- rologically or otherwise.9 Other groups have
Aims of the management of the spinal tainment of the BI is safely maintained in since published similar findings.10,11,12 There is no
injury recumbency for 4-6 weeks followed by bracing evidence to suggest that surgical decompression
The ultimate goals of management are to during mobilisation for a further six weeks. The achieves better or earlier neurological recovery
ensure maximum neurological recovery and great majority of injuries become biomechani- than APCM in humans with incomplete cord or
independence, a pain free flexible spine, safe cally stable and pain free. There is no evidence cauda equina injury. There is no evidence to sug-
functioning of the various systems of the body to suggest that surgical stabilisation enhances gest that surgical decompression is beneficial to
with minimal or no inconvenience to patients the speed of healing or achieves stability earli- humans with complete traumatic cord or cauda
and prevention or minimisation of complica- er than with APCM. equina injury.
tions. It is equally important to enable patients Admittedly the incidence of kyphotic defor-
to regain assertiveness, take control of their mities is lower following surgical stabilisation Traumatic spinal cord compression
own lives, re-engage in activities of their than following APCM, however the greatest In humans cord compression does not appear
choice and whenever possible compete in majority of these kyphotic deformities are to prevent neurological recovery in patients
some spheres of life. The importance of educa- painless. The discrepancy between deformity with traumatic incomplete cord injuries.13,6,14
tion of patients and ongoing support to main- and pain has been known for some time.6 A Since the installation of the MRI scanner in
tain health and independence following dis- painless kyphotic deformity enhances wheel- our institution we have been monitoring (both
charge cannot be overemphasised. chair bound patients’ independence and is prospectively and retrospectively) the neuro-
certainly, much preferable to a stiff straight logical progress of conservatively managed
Factors influencing management of the SCI neck or back following surgery. patients with cord compression. The prelimi-
The majority of those who manage SCI nary results indicate that the same clinical
patients in the acute phase have concerns Traumatic spinal canal encroachment prognostic indicators of recovery apply
about the biomechanical instability (BI) at Some of the first case reports to suggest that trau- whether there is cord compression or not.
the fracture site, further displacement and matic canal encroachment as demonstrated by Some advocate, however, early surgical
damage to neural tissues. Many strongly computerised tomography does not correlate decompression within four hours of injury. This
believe that canal encroachment and cord is based on experimental findings in rodents,
compression can prevent neurological recov- cats and dogs with 20-60 million years of evolu-
ery or indeed cause neurological deteriora- 1. ‘Complete’ (A). tion behind humans. Translation from the labo-
tion. The injured cord with cellular and cell This means that the lesion was found to ratory animal to the clinical situation requires
membrane disturbances, loss of auto regulato- be complete, both motor and sensory, caution.23 Surgical decompression does not
ry functions and disruption of blood brain below the segmental level marked. If seem to be beneficial in either the laboratory
there was an alteration of level but the
barrier is physiologically unstable.1 It cannot animal or humans when the severity of the ini-
lesion remained complete below the new
protect itself from complications outside the tial impact force is beyond a certain magni-
level, then the arrow would point up or
spinal canal such as hypoxia, hypotension, down the ‘complete’ column. tude, as recovery will not occur. 15,16, 17
hypertension, sepsis and hypothermia. These
complications can potentially be as damag- 2. ‘Sensory only’ (B) Natural history of complete and
ing to neural tissues through the physiological This implies that there was some sensa- incomplete cord injuries
instability (PI) of the injured cord as the tion present below the level of lesion but Fewer than 10% of patients initially with clini-
potential mechanical damage from the BI of that the motor paralysis was complete cally complete spinal cord injuries (Frankel
the injured column. below that level. This column does not grade A, “FA”) improve to make a significant
apply when there is a slight discrepancy
recovery to ambulate.18 Many more however,
between the motor and sensory level but
Prognostic indicators of recovery recover cord functions in one to four
does apply to sacral sparing.
The neurological findings at 48-72 hours from myotomal distributions below the level of the
injury are essential in predicting neurological 3. ‘Motor Useless’ (C ) injury or improve to FB & FC.
recovery. Over 80% of tetraparetic patients This implies that there was some motor Although increasingly since the 1980s ante-
who present in the first 72 hours from injury power present below the lesion but it was rior surgical decompression and arthrodesis
with any distal movement, however little and of no practical use to the patient. have become established practice based on
patchy (Frankel C, see Table to right), and over suggestions that surgery resulted in motor
70% of patients who present 48-72 hours from 4. ‘Motor Useful’ (D) zonal improvement; to date there is no evi-
This implies that there was useful motor
injury with no motor power but with preserva- dence that surgery provides added value. A
power below the level of the lesion.
tion of pin prick sensation down to S3 (Frankel series of 53 consecutive patients with com-
Patients in this group could move the
B) will recover to walk again2,3,4 if they have lower limbs and many could walk, with or plete traumatic tetraplegia, admitted to one
not been harmed by the treatment. Patients without aids. centre within two days of injury, demonstrated
with complete cord injury (Frankel A) and pin that similar results can be achieved without
prick sensation in the zone of partial preserva- 5. ‘Recovery’ (E) surgical decompression or arthrodesis.5
tion will recover significantly and have useful This implies that the patient was free of Patients with incomplete cord injuries make
motor power in these myotomes.5 A neurolog- neurological symptoms, i.e no weakness, significant neurological recovery irrespective
ical level higher than the bony level of fracture no sensory loss, no sphincter disturbance. of the degree of canal stenosis, canal
Abnormal reflexes may have been present.
is another good prognostic indicator of zonal encroachment, malalignment or cord com-
recovery.5 pression3,6,9,14 provided both the BI of the spinal

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column and the PI of the spinal cord are well encouraged to consider the option. Conclusions
maintained. See case report and Figures 1-11 Neurologically intact patients with physiologi- The favourable neurological outcome of TSCI
on the following page. cally stable cord but unstable injured spine with APCM has been known for over four
Although almost every patient is given a are less at risk from physiological deteriora- decades.18
choice between conservative and surgical tion than the neurologically impaired, do not A significant majority of patients who present
management the majority (85%) of patients require intensive prolonged treatment and with sensory sparing with or without motor
with SCI in our institution are treated with rehabilitation, and can be discharged a few sparing within the first 72 hours of injury will
APCM irrespective of malalignment, the days following surgery. The uncontrolled recover good motor power to ambulate irre-
degree of canal encroachment and the degree epileptic, the mentally challenged and spective of the degree of canal stenosis,
of cord compression. patients who are unable to comply with bed encroachment, malalignment or cord compres-
rest are safer following surgical stabilisation sion and without surgical, pharmacological,
Early mobilisation than with conservative management. Patients biological or other intervention. Surgery to the
Early mobilisation is advantageous to neuro- with biomechanical instability from pure liga- injured human spine usually in isolation from
logically intact patients with stable fractures or mentous injuries without bony injury are at the multitude of needs of the patient has
following surgical stabilisation in unstable risk of developing late painful deformities become the Current Standard of Care without
fractures. These patients can be discharged and indeed may benefit from early surgery. credible evidence of proof of superiority of out-
ambulating soon after surgery. Patients who exhibit signs of neurological comes (neurological or otherwise). Although
Patients with paralysis, general physiological deterioration with evidence of further neuro- the possibility of benefit from very early surgery
impairment and multisystem malfunction do logical compression of neural tissues on MRI in rodents, cats and dogs cannot be ruled out,
not benefit from early mobilisation, which may benefit from surgical decompression. the outcomes of early surgery in both the labo-
indeed may be counter productive. Early ratory animal and in humans are still debat-
mobilisation of patients is associated with a Systems of management able.22 Furthermore, translation from the labora-
reduction of vital capacity19 and a potential The simultaneous management of the spinal tory to the clinical situation requires caution.23
drop of oxygen saturation and / or postural injury and all its effects by a group of coher- I believe that it is appropriate to revisit both
hypotension. Individually or in combination ently managed multidisciplinary professional the science scientific and clinical evidence
these may further impair cord functions. Early experts familiar with the patho-physiology of that led to the change of management of TSCI
mobilisation does not result in early comple- the SCI patient and proficient at treating all from APCM to surgical management, given the
tion of rehabilitation nor earlier discharge of aspects of paralysis under one roof remains lack of credible evidence that surgery pro-
patients with SCI.1,6,7 the safest, most efficient and most cost effec- vides better outcomes and/or is not without
tive system of provision of service to these risks and considering that the good outcomes
Indications for surgery at the Robert patients.6 Irrespective of the method of treat- of APCM are well established and predictable.
Jones and Agnes Hunt Orthopaedic ment of the spine, patients with spinal injuries It is equally necessary to stop the fragmenta-
Hospital have less complications when treated compre- tion of treatment and to manage patients in ade-
Until credible evidence demonstrates superi- hensively in SCI centres than when their man- quately resourced specialised centres, capable
ority of outcome with one method of treat- agement is fragmented.6,7,20,21 The attention of of offering informed choice to patients, equally
ment of the injured spine over the other, health economists to this small group of good surgical management when indicated by
patients should be encouraged to make an patients which is perceived as expensive to the patient or required, together with APCM of
informed choice between the various meth- treat is long overdue. It is essential to deter- the spinal cord injury and all its effects in an
ods of management, assuming that the patient mine the monetary and human costs of man- integrated and effective manner. These centres
will receive treatment in an institution that agement and compare these between the inte- should also be capable of conducting multicen-
can provide equally good APCM and surgical grated system of management in specialised tre quality research, to address the real needs of
management. Certain groups of patients are centres and the fragmented system of manage- patients with spinal cord injury as well as the
likely to benefit from surgery and should be ment that is increasingly prevailing. various controversies in their management. l

REFERENCES

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injured spinal cord. Paraplegia 1993;31:273-5. rological significance of bony canal encroachment follow- DF. Comparison of surgical and conservative management
ing traumatic injury of the spine in patients with Frankel of 208 patients with acute spinal cord injury. Can J Neurol
2. Folman Y, El Masri WS. Spinal cord injury: prognostic indi-
C, D and E presentation. J Neurotrauma Sci 1987;14(1):60-9.
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1996;21:2346-51. deficit in a consecutive series of vertebral fractures patients
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ing with motor paralysis and sensory sparing following 1996;35:92-5. tem of the spinal cord patient. In: Bloch RF, Basbaum M
cervical spinal cord injuries. Paraplegia 1995;33:506-9. 12. Boerger TO, Limb D, Dickson RA. Does canal clearance Eds, Management of spinal cord injury. Baltimore:
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servative treatment of cervical cord injuries. J Bone Joint tures. J Bone Joint Surg Br 2000;82B:629-35. 20. Carvell JE, Grundy DJ. Complications of spinal surgery in
Surg Br 1994;76B:225-8. 13. El Masry WS, Osman AE. Clinical perspectives on spinal acute spinal cord injury. Paraplegia 1994;2:389-95.
injuries. In: Cassar-Pullicino V, Imhof H. Spinal trauma: 21. Aung TS, El Masry WS. Audit of a British centre for spinal
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14. Ibrahim A, Li Y, Li D, Raisman G, El Masry WS. Olfactory
7. El Masri W S, Jaffray, D. Recent developments in the man- ensheathing cells: ripples of an oncoming tide? Lancet decompression for cervical spinal cord injury: update with
agement of injuries of the cervical spine. In: Vinken PJ, Neurol 2006;5:453-7. a review of recent clinical evidence. Injury 2005;36: S-
Bruyn GW, Klawans HL, Frankel HL, editor. Spinal cord B13–26.
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CASE REPORT
This 44-year-old lady sustained a fall in 1992 to the ASIA scale. The dislocation was not balance. She discarded the crutches four
resulting in Frankel C tetraparesis from a C6/7 reduced and the alignment was not restored. weeks later having recovered full motor power
unilateral facet dislocation. She presented with She was treated with six weeks of bed rest and and good sphincter functions. She continues
weakness in both hands, profound paresis in APCM followed by six weeks in a Minerva cast. to enjoy a pain free full range of movement,
both lower limbs and paralysis in the right On discharge home (eight weeks following the unsupported ambulation and is able to run 17
ankle and foot. She was admitted the day of accident) she had regained most of the motor years following the accident with unrelieved
injury. Her motor score was 66/100 according power and was walking with two crutches for cord compression.

Figure 1 (left): Lateral Xray revealing Unilateral Dislocation


C6/C7.
Figure 2 (middle): Oblique Xrays confirming the unilateral
dislocation.
Figure 3 (right): Lateral CT confirming the malalignment and the
canal encroachment.

Figure 4: Lateral MRI 3 years later confirms ongoing thecal and cord Figures 5 & 6: Lateral Flexion and Extension Xrays confirming restored stability in the dislocated position.
compression.

Figures 7 & 8: Demonstrating ability to stand unsupported on Figures 9, 10 & 11: Demonstrating unrestricted painless range of movement of the cervical spine.
one leg at a time.

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