Case Study: Spinal Cord Injury

Lauren Styczynski

ABSTRACT
The spinal cord is a critical relaying component for sensory information, and for motor
pathways. When the spinal cord is damaged, however, trouble can ensue, and surgical
intervention is often necessary. In this case, a 65 year old male presented following a
fall down the stairs while intoxicated, and presented with weakness of the upper
extremities. Following examination, the scans showed that central cord syndrome was
present at the C2 fracture, thus the patient was taken to the operating room for a
decompression operation. The literature indicates that the proper course of treatment is
to operate in this situation. This report investigates the recent literature about what the
protocol of a patient with spinal cord injury and central cord syndrome, and the
controversies surrounding the clinical course.

PATIENT HISTORY
A 65 year old male, JH, presented, following a tumble down the stairs while likely
intoxicated. His neighbors found him the following day. Following his arrival in the
emergency department, the patient was noted to have have difficulty moving both his
upper and lower extremities with full strength. The patient’s prior medical history was
alcoholism, and was on a low dose, 25 mg of hypertension medication. The patient had
quite a family history, with father deceased due to Parkinson’s disease, and the mother
deceased due to breast cancer. Patient was divorced, with a 35 year old daughter living
out of state. Patient was not re-married. Patient works at Rhinegeist brewery as a
master brewer of “Cougar” beer.

CLINICAL COURSE
A. EXAM
The patient presented alert and oriented x1, as he presented with slurred speech, and
thus could not tell the physician where he was, or what year it was, but could state his
name. However, it should be noted that the patient came in to the emergency room
intoxicated, and thus that could be the reason for alert and oriented x1. The patient’s
pupils were equal, round, and reactive to light. Extraocular movements were intact.
Patient’s face was symmetrical, and tongue was midline.
Right and left upper extremities presented as deltoid ⅖, Bicep ⅖, Tricep ⅖, Grip ⅕.
Bilateral lower extremities presented 5/5. Patient’s rectal tone was intact, and no saddle
anesthesia was present at the time of the exam.

B. IMAGING
Due to images needed quickly since this seems to be acute, a CT of the cervical spinal
cord without contrast was taken, and a CT of the head was taken as well. The CT
C-spinal indicated that osteophytes were grown, and there was a C2 left body fracture
and a C5 left articular fracture. The CT of the head indicated no abnormality. The
fracture in the lamina goes into the facet, which is indicative of a bad fracture, and this
patient being very sick.
To gather more imaging to see the fracture with more visibility, and since the patient
doesn’t seem to be going down quickly, a MRI without contrast was taken, which was
indicative of spinal signal at C4/5, extending up and down, with subluxation (a partial
dislocation) and spinal cord contusion.

C. OPERATION
In the pre-op holding area, the patient was noticeably weaker, and could no longer hold
his legs antigravity.
Due to the spinal cord contusion, the patient was then taken to the operating room, and
his spinal cord was decompressed from C3 to C6. A C4/5 laminectomy, C3-6 fusion
was performed, and ligaments were taken off so that way the spinal cord could expand
and decompress, and decompression was confirmed with intraoperative ultrasound.
Additionally, screws were placed to fuse C3-6, to increase mechanical stability.
A laminectomy the removal of the lamina over the affected levels. A laminectomy is
typically performed by utilizing an anterior approach, since the cervical vertebrae are
affected, and an incision is made in the anterior neck and the dissection is carried down
to the vertebral bodies​2​. ​A laminectomy essentially​ creates space by removing the
lamina — the back part of the vertebra that covers your spinal canal. Also known as
decompression surgery, laminectomy enlarges your spinal canal to relieve pressure on
the spinal cord or nerves. Laminectomies are also perfect to consider, like in the case of
our patient, when symptoms are both severe and worsening.

D. OUTCOMES AND POST-OPERATIVE NOTES

Following the procedure, the patient was given delirium tremens (DT) due to his
alcoholism, and to prevent severe withdrawal symptoms. A mean arterial pressure
(MAP) goal was met, and soon the patient was sent to acute rehab to work with physical
therapy and occupational therapy to help the patient return to full strength and to
improve his quality of life following the major spine operation. On average, a patient
​
leaves the hospital after 11 days, and is finished with rehabilitation after 35 days. 19
The expected outcome is that the patient will make a full recovery, and will follow up
with CT scans and MRI scan in approximately three months. 3​

DISCUSSION

INTRO TO SPINAL CORD

The spinal cord fills nearly half of the spinal canal in the cervical and thoracic spine, and
cerebrospinal fluid fills the rest.​19, 20​ The spinal cord is a part of the central nervous
system, and within the spinal cord, live all the motor neurons needed to move muscles,
as well as interneuron populations, and autonomic efferent populations that are
important to process sensory information and relay it via projection neurons to the brain.
An adult human spinal cord is approximately 42 to 45 cm long, but 1 cm in diameter at
its widest point. The spinal cord is segmented, like a worm, and each portion of the cord
that extends into spinal cord is considered to be a segment. In the human, there are 31
segments: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. Additionally, the
spinal cord is shorter than the vertebral column, as the spinal cord ends around L1-L2,
and below until S2 is a collection of both dorsal and ventral roots, called the cauda
equina (which is where a spinal tap will take place to collect cerebrospinal fluid).​2, 25

SPINAL CORD INJURY

Spinal cord injuries can be classified as either being complete, or incomplete. Complete
injury is defined as “the absence of sensory and motor function below the level of
injury”​20​. Incomplete spinal cord injury is defined as “some neurologic function
remain[ing] below the level of injury”.​2​ Incomplete injuries can consist of central cord
syndrome, anterior cord syndrome, posterior cord syndrome and Brown-Sequard
syndrome, and these three are historically the most studied.
Central cord syndrome is to be covered following this section.
Therefore, anterior cord syndrome is when injury occurs to the ventral two-thirds of the
cord, and spares the posterior column. Anterior cord syndrome is present in 2.7% of all
traumatic spinal cord injuries, and presents with motor function being lost distally to the
site of the injury. However, since the posterior column remains intact, common
sensations and perceptions remain (like vibration) but there is often a loss of pain
sensation and temperature sensation.​3
Posterior column syndrome is essentially the opposite of anterior cord syndrome, but is
considered to be incredibly rare. Posterior column syndrome often affects those with
neck hyperextension injuries. However, in exact opposite to anterior cord syndrome, the
sensations of pain and temperature remain intact, but vibration and other higher-order
sensations are lost.​3
Brown-Sequard syndrome accounts for 1-4% of all spinal cord injuries that are
considered traumatic, and is where a lateral half of the cord is affected and damaged.
Brown-Sequard syndrome typically affects the cervical spinal cord and is typically due to
blunt force trauma or a disk herniation. Patients typically present with a loss of tactile
discrimination, position sense, loss of vibration sensation and the loss of temperature
and pain sensations, often on the contralateral aspect of the body. However, the
outcome and overall prognosis of Brown-Sequard has considerably the best motor
function recovery, especially when compared to the other spinal cord syndromes.​3
Essentially, the higher up the lesion occurs the more extensive the range of
impairments will be. Cervical spinal cord injury will commonly cause sensory and motor
loss (paralysis, and sometimes complete) in the arms, body and legs, which is
tetraplegia - quadriplegia is considered to be an outdated term.​28​ Unfortunately, a
patient with C4 or higher lesions could require a ventilator to breathe since the lesion
directly interferes with autonomic control, because C1, C2, and C3 control the head and
neck, and C4 contributes to the diaphragm.
A thoracic spinal cord injury often causes paraplegia: sensory and/ or motor loss in the
trunk and legs. A lumbar spinal cord injury then typically causes sensory and motor loss
in the hips and legs. And, unfortunately, all forms of spinal cord injury may often also
result in chronic pain. However, it should be noted that the extent and severity of the
sensory and motor and autonomic deficits depend on the level of injury to the spinal
cord, and on whether the injury is “complete” or “incomplete.”
Spinal cord injuries are also described to a set scale, the American Spinal Injury
Association (ASIA) Impairment Scale, which also happens to be modified from the
Frankel classification. This scale provides set clinical standards for physicians to use
when classifying spinal cord injuries.
The ASIA Scale follows these categories:​ “
Grade A is a complete injury where no sensory or motor function is preserved in sacral
segments S4-S5. Grade B is an incomplete injury where sensory, but not motor,
function is preserved below the neurologic level and extends through sacral segments
S4-S5. Grade C is also an incomplete injury where otor function is preserved below the
neurologic level, and most key muscles below the neurologic level have a muscle grade
of less than 3. A Grade D injury is an incomplete injury where motor function is
preserved below the neurologic level, and most key muscles below the neurologic level
have a muscle grade that is greater than or equal to 3. Finally, a grade E spinal cord
injury is considered to be a normal injury where sensory and motor functions are
normal”. 13​

CENTRAL CORD SYNDROME

Central cord syndrome is the most common type of incomplete spinal cord injury, and
makes up between 15% to 25% of incomplete spinal cord injury cases, 20​ ​ and is 6.6% of
3​
pediatric spinal cord injuries.​ Central cord syndrome is often is characterized by
disproportional weakness in the arms compared to the legs (which is why central cord
syndrome can also be called man in a barrel syndrome​ 3, 17​) following a hyperextension
injury without any evidence to the bony spine fracture, but with canal stenosis (abnormal
narrowing of the spinal canal 18​ ​ ). Most cases of central cord syndrome occur in older
adults (>60), but can occur in younger people that sustain a “higher-energy trauma
​ . These high-injury events include but are not
resulting in spinal fractures or instability” 17​
limited to high-speed motor collisions, falls, athletic injuries, diving injuries, gunshot
wounds, and assault cases.​17
In central cord syndrome, particularly in older patients, the injury may result from
anterior compression of the cord by osteophytes or pinching of the cord posteriorly by
the ligamentum flavum (​a strong ligament that connects the laminae of the vertebrae​27​).
Typically, there is already present chronic cervical spondylosis and stenosis.​17​ This,
combined with the low-energy hyperextension itself then results​ in bleeding into the
central part of the cord or with axonal disruption in the lateral columns of the spinal cord.
Injuries associated with syndrome are typically stable and require immobilization with a
hard collar. Since the sacral areas are spared, central cord syndrome is considered to
be an incomplete spinal cord injury.​18
Also present with the presentation of central cord syndrome often bladder dysfunction
“in the form of urinary retention”​17​, as well as bowel dysfunction.​28
Surgical decompression is often then performed, as in this case.​8​ However, that did not
begin until 1997. Prior to 1997, when Chen and his team performed a decompression
operation in a pediatric case, central cord syndrome was treat very conservatively.
However, after Chen’s successful operation, did surgery become an option for patients
with central cord syndrome.​17
It should be noted that follow an operation, if motor status resolves, upper extremity
function will be the last to return and, often, only partial hand functional improvement will
be present.​18
EPIDEMIOLOGY
In the United States in 1977, prevalence, the number of people with a spinal cord injury
that are currently alive, was estimated to likely to be some 500 per million, with an
average of more than 4 of 5 traumatic SCI patients surviving ten years with an average
of almost 18 years if treated.
However, the average remaining years of life for persons with a spinal cord injury,
complete or incomplete have not improved since the 1980s and remain significantly
below life expectancies of persons without spinal cord injury. Mortality rates are
significantly higher during the first year after injury than during the following years,
particularly for those patients with the most severe neurological impairments.​19 ​However,
in 2014,​ There average post spinal cord injury lifespan of a patient was 30.2 years (as
of 2014) and calculated prevalence as 906 per million in 2014.​24 ​ Additionally, it should
be noted that when analyzed states that reported incidence of spinal cord injury, Alaska
and Mississippi had much higher reported incidences of 83 per million and 77 per
million, respectively, compared to incidence in Oklahoma which was 40 per million) and
Utah, which was 43 per million.​24​ A likely increase of this is due to more people moving
out of the cities, into the suburbs and having to drive into the city for work, as well as the
introduction of cell phones being used as distractions, resulting in car accidents. This
statistic is important, since approximately half the cases of spinal cord injury are due to
motor accidents.​15
In Australia, it was estimated a prevalence of 681 per million in 1997. In Iceland, the
crude prevalence was 526 per million in 2009.​24​ However, it should be noted that due to
increases in life expectancy, these numbers are likely slight overestimates.​9 ​In Europe
overall, the average incidence, the number of new cases, of spinal cord injury is 16
cases per million population, which is a similar number to the incidence of spinal cord
injury in the Middle East, Fiji, Australia, and South Africa. However, in the United States,
the numbers of incidence among states varies: in West Virginia there are 25 new cases
of spinal cord injury per million, but in Mississippi there are 59 new cases per million.
Overall, this results in an incidence rate of 40 cases per million. The reason for the fact
that there is lower incidence rate of spinal cord injury in the rest of the world is likely due
to the fact that in the United States, more injuries are caused by acts of violence.
However, in other countries, most spinal cord injuries are self-inflicted and are due to
failed suicide attempts, and typically are not due to aggressive acts of violence.​9​ It also
should be noted that the numbers of incidence and prevalence of spinal cord injury in
lesser developed countries could be skewed because they might die at the scene, but
due to transportation advances in the United States, the patients could get to the
hospital in time. It should also be noted that when calculating for incidence in the
literature, those that die at the scene are not included in the numbers.​19​ In comparison
of races, 64.9% of white people had a spinal cord injury, 18.6% of african american had
a spinal cord injury, 13.6% of hispanic descent and 1.9% of asian descent had a spinal
cord injury. Additionally, nearly 45% of all spinal cord injury is due to motor vehicle, with
19.4% due to falls (the remaining due to violence and sports at 16.6% and 10.9%
respectively).​8, 19
The average age at injury is 32.4. It has also been found that the average age at the
time of the spinal cord injury is increasing with the aging population. Additionally, the
proportion of cervical injuries is increasing, but the proportion of neurologically complete
injuries is decreasing. In the most recent years, spinal cord injuries due to falls are
increasing. And unlike the increase in life expectancy that has been seen in the average
population, has not been seen in the population of those with spinal cord injury. Thus,
the treatment and outcomes are changing as a result of the increasing age and the
recent changes in US health care delivery. Those who reach older ages will typically
have incomplete and/ or lower level injuries, and will have relatively high degrees of
independence and overall good health.​9, 17
In terms of the severity of injury, 53.1% of spinal cord injuries happen at C1-C8 level,
and 49.8% are complete.
In comparisons between sexes, men have a higher predominance for spinal cord injury
in the United States. In West Virginia, in fact, men have a 4.6 to 1 higher incidence.
However, across the globe, this statistic remains the nearly the same, where the ratio of
men to women is 4 to 1. It also happens that 79.6% of all patients with spinal cord
​
injuries are male.​9, 19​ However, in China, the male to female ratio of incidence is 3:1. 29

ECONOMICAL BURDEN OF SPINAL CORD INJURY

There are both direct and indirect costs of spinal cord injury, and both play a crucial role
in accurately assessing the economic and social burden of spinal cord injuries as a
whole.​19, 28
Direct costs often include health and rehabilitation services, more expensive
transportation options, special diets, and personal assistance for the patients, such as
an in-home nurse. Indirect costs, both economic and non-economic costs, can include
lost productivity due to premature death or disability, social isolation and added stress to
the patient and loved ones.
It should also be noted that tetraplegia is associated with higher costs than paraplegia,
likely due to more assistance needed for the patient; studies have shown that lifetime
costs for a person injured at age 25 are $4.6 million for tetraplegia compared to $2.3
million for paraplegia.
Some studies have even found that costs are higher for complete spinal cord injury
compared to incomplete spinal cord injury.
In addition to the initial treatment (whether that be surgery or non-invasive treatments),
there are also the continuous costs of aids, equipment, and often long-term care. The
long term care could consist of assisted accommodation, respiratory assistance, and
other supportive services. Thus, the costs of patients with spinal cord injury tend to be
quite high even after the initial high direct costs begin to decrease.
The costs of non-traumatic spinal cord injury tend to be lower than those for traumatic
spinal cord injury, likely due to the age of onset. Since non-traumatic spinal cord injury
typically affects older, retired populations, with fewer costs yet to pay (and not many
years left anyways). However, there is always an exception to the norm, and this
exception is spina bifida, because it begins in infancy and the expected life span with
ailment is longer. Table 1 presents the yearly expenses from 2013 based upon on
location and severity of the spinal cord injury. It is indicative that regardless, a C1-C4
traumatic spinal cord injury is the most cost expensive injury out of the spinal cord
injuries.

Figure 1. Average yearly expenses of traumatic spinal cord injury based upon the severity of the injury
from 2013.​19, 28

It should also be noted that the mortality risk that comes with spinal cord injuries varies
widely by country, income status, and also depends on the availability of quality clinical
care and rehabilitation services.​19, 28

RECOVERY
Fortunately, following a spinal cord injury, some degree of motor and sensory recovery
is common. However, the overall recovery generally plateaus between 1 to 2 years. The
most important factors most commonly associated with improvement after central cord
syndrome spinal cord injury are: the age of the patient (younger is better to make a
more full recovery), the severity of initial neurologic presentation, and the MRI findings.
Although most patients will achieve recovery to some degree, there is still a risk of
persistent weakness, difficulties with ambulation, spasticity, bladder dysfunction,
sensory dysfunction, and neuropathic pain. 86% of patients will recover the ability to
ambulate, and 80% of patients will have recovered functional independence. Persistent
and chronic neuropathic pain was seen in 47% of patients. Spontaneous bladder
emptying was seen in 68% of patients, according to a study done in 2016. 21, ​ 22
Since the severity of the central cord syndrome presentation can often predict the
outcome, it was found that in multiple studies, patients that presented with mild to
moderate motor impairment were likely to have a good recovery following a
decompressive procedure.​5,8
Additionally, when it comes to factors that are given in recovery, younger patients are
more likely to have a better recovery than older patients. A study by Brooks and his
team found that patients younger than 50 years had more improvement in neurologic
function (walking, independence in activities of daily living, and control of bowel or
bladder) than patients older than 50 years. Generally speaking, younger patients had
minimal sensory complaints at 3 months. Additionally, ninety percent of young patients
(<40 years) recover walking in 3.4 days versus 4.9 days in older patients (>40 years). A
partial recovery of hand activities of daily living was obtained in 3 days for young
patients and 12 days for older patients.​22
Favorable rehabilitation outcomes were associated most frequently with younger age,
preinjury employment, absence of lower extremity impairment on admission, and
documented upper or lower extremity strength recovery during rehabilitation. Overall, it
is seen that central cord syndrome generally has a good prognosis for neurologic and
functional improvement during rehabilitation.​22
During rehabilitation, it is recommended that for adults with spinal cord injury participate
in at least 30 minutes of moderate aerobic exercise, for cardiometabolic health.​23

SURGICAL V. NON-SURGICAL TREATMENT

The literature has many debates between the benefits and disadvantages of
decompressive surgery versus managing the symptoms non-invasively in the ICU of
spinal cord, specifically for central cord syndrome. However, currently there is a trend
towards surgery for central cord syndrome, and the extent of the decompression and
the stabilization should be dependent on the pathology. A few indications that point to
the fact that surgery is necessary for the presentation of central cord syndrome are
progressive neurological deficits, cervical instability, and a structural cord compression
(which would be seen on a MRI) of spondylosis or chronic stenosis. The current results
of operating for central cord syndrome show that the best results in younger patients
and those with compressive lesions.
Additionally, there is sound evidence to indicate that early surgical intervention is safe
and feasible and can improve clinical and neurological outcomes (and, subsequently
reduce an economical burden).​10​ Based on the current clinical data, it is the
recommendation early surgical intervention should be considered in all patients from 8
to 24 hours following an acute traumatic spinal cord injury.​10
In late decompressive surgical treatment of the cervical spine, where the cervical cord
was pre-compressed, it was found that ​surgical treatment has an advantage for patients
following traumatic cervical spinal cord injury with severe cord compression. In contrast,
surgical efficacy is not proved for cervical spinal cord injury patients without severe cord
compression​. 14 ​
The current non-surgical intervention for central cord syndrome consists of: rigid
cervical immobilization, and to prevent any potential motion injury for 6 weeks or “until
the resolution of pain and neurologic symptoms”.​17​ The patient would be confined to ICU
monitoring with mean arterial blood pressure goals of 85 to 90 mmHg for the first week
after injury to achieve maximal cord perfusion. If MAP goals are achieved, then that
would thus improve chance for optimal neurologic recovery is the most recommended
standard at this time, according to the literature. Also to be considered for non-surgical
treatment of central cord syndrome are IV steroids, to manage symptoms and
compression, though this is not the standard of treatment, according to recent
literature.​18, 21
If a non-surgical treatment plan is being followed for central cord syndrome, then early
neurologic improvement and absence of MRI cord signal changes are positive
prognostic factors for the patient. Regardless of being the course of treatment, or
following an operation, ​an intensive care unit (or highly monitored setting) for the
management of patients with acute central cervical spinal cord injuries, particularly
patients with severe neurological deficits, is the current recommendation.
Additionally, the early reduction of fracture-dislocation injuries is recommended when
treating a patient for central cord syndrome. However, giving all of the ​literature a
surgical decompression of the compressed spinal cord, particularly if the compression is
focal and anterior, is the recommended course of action. 12 ​
Regardless, it should be noted that even though s​urgical technique can help to minimize
these complications, the best surgical techniques do not entirely prevent serious
complications. Promptly recognizing a neurologic complication and managing it
accordingly are vital to ensuring the best possible outcome. 23 ​

MEDICATIONS
Immediately, following a spinal cord injury, ​methylprednisolone, an anti-inflammatory
corticosteroid medication may be given. However, since a spinal cord injury is often life
altering, there can be many secondary conditions that occur for patients after the initial
diagnosis and injury.
Autonomic Dysreflexia (AD) causes over-activity of the autonomic nervous system, and
can occur in the part of the body that is above the spinal cord injury. If AD occurs could
mean that basic bodily functions, like as breathing, blood pressure, and heart rate
become unregulated. Drugs to decrease heart rate and relax the blood vessels can be
used to treat AD. Since, unfortunately, chronic pain caused by the injury, even in areas
where there is no sensation or feeling is limited, is common. Some spinal cord injury
patients that use wheelchairs may develop shoulder or arm pain like tendonitis.
Therefore, some medications prescribed may include NSAIDS, muscle relaxants,
antidepressants, and painkillers, like narcotics. Following a major injury, there is often a
shock to the mental state. Thus, depression is common in spinal cord injury patients,
but there are many medications that can be used to treat it. Patients could then be
prescribed SSRIs, tricyclic drugs, SSNIRIs, and anxiety medications.
If going the route of non-surgical treatment explored above, then high-doses of IV
steroids can be considered. However, it should be noted that that is not the standard of
treatment, but it can be considered. Standard of treatment is to operation with a
decompressive surgery. 12,​ 15, 23, 27, 28

COMPLICATIONS
Unfortunately, re-hospitalization of patients with spinal cord injury is fairly common. It
was found that “about 30% of persons with spinal cord injury are re-hospitalized one or
more times during any given year following injury.” Among those rehospitalized the
length of hospital stay averages about 22 days. Diseases of the genitourinary system
(such as from UTIs) are the leading cause of rehospitalization, followed by
dermatological issues. Also common causes for rehospitalization are respiratory,
digestive, circulatory, and musculoskeletal issues.​19
Another recent study has recently found that half of adults with spinal cord injury will
have pain in both shoulders, and often the pain lasts longer than one year. Shoulder
pain can develop any time after an spinal cord injury, but it is most common to develop
within the first five years after the initial injury. Shoulder pain is often the most intense
during activities of daily living, including like while reaching overhead. Additionally,
patients with spinal cord injury and shoulder pain often have injured rotator cuff
tendons.​26
As if not going through enough with their initial spinal cord injury, people with spinal cord
injuries are at a high risk of deep vein thrombosis (DVT), particularly during the phases
of the injury when changes in the normal neurological control of the blood vessels and
immobility can result in DVT. However, there are many factors that help or hurt a
patient’s chances of developing DVT, like “age, obesity, the presence of lower limb
fractures, pregnancy and a previous history of DVT”. 28​ ​ DVT can also lead to a
pulmonary embolism and then potentially to death.
Urinary tract infections (UTIs) are common among spinal cord injury patients
post-operation and are often a major reason for re-hospitalization. Since spinal cord
injury has such an impact on bladder function, many patients use catheterization to
manage.
Patients with spinal cord injuries are at high risk of developing skin pressure ulcers as a
result of impairments in sensation and mobility. The presence of other factors, such as
smoking, nutritional deficiencies (malnutrition, anemia), infection, can increase the risk
of pressure ulcers. Pressure ulcers may occur at any time and can have a significant
role, and can lead to rehospitalization.​19, 28

FUTURE DIRECTIONS
The age of those with spinal cord injury will increase slowly. This, in part, has to do with
the increase of median age in the overall population. Necessary precautions and
in-hospital practices should be taken to meet the demanding needs.
Additionally, the literature currently suggests that surgical interventions to prevent and
reduce the mechanisms that perpetuate secondary injury, such as preventing shoulder
injuries and preventing DVT, among others, are likely going to be important future
directions for research.
Additionally, given that there are standard scales and grades to analyze spinal cord
injuries, there are currently no set standards of care in regards to the timing and
indications of surgical decompression in acute cases of spinal cord injury existing. But, it
has been found that early surgical decompression may play a significant role in
functional recovery, and those standards and guidelines should be set.
Since it has been established that surgical intervention is the set standard of treatment
for spinal cord injuries and central cord syndrome, therefore the optimal combination of
decompression along with other therapies, such as the use of corticosteroids, has not
yet been established and should be.
A recent paper has found that grafting neural stem cells in the sites of spinal cord injury
can re-establish neuronal connections in monkeys, and could provide future help for
humans with spinal cord injury.​22, 27
Again, a way to prevent secondary issues, and to prevent rehospitalization, and to
improve the quality of life for patients following a spinal cord injury should be set.
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