Spinal cord injury and disease

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9 Spinal cord injury and disease

CHAPTER CONTENTS

Part 1: Spinal cord injury (SCI) 152
Definition 152
Incidence and mortality 152
Risk factors 152
Diagnosis and prognosis 152
Medical treatment 153

Early interventions 153
Pharmacology 153
Surgery 153
SCI and physiotherapy 153
Acupuncture in SCI 155

Body acupuncture 155
Scalp acupuncture 155
TCM approach 155
Case study 9.1: level 1 case study: partial spinal cord injury 156

Functional ability 156
Presenting symptoms 156
Treatment 156
Outcome 157
Part 2: Transverse myelitis 157
Definition 157
Incidence and mortality 157
Risk factors 157
Diagnosis 157

Differential diagnosis 157
Tests 157
Medical treatment 157
Prognosis 157

Impact on the patient 157
Transverse myelitis and physiotherapy 158
Acupuncture in transverse myelitis 158

TCM approach 158
Part 3: Spinal cord stroke 158
Definition 158
Aetiology 158
Incidence 158
Mortality 158
Clinical presentation 158
Treatment 159
Prognosis 159
Spinal stroke and physiotherapy 159
Acupuncture in spinal stroke 159

KEY POINTS

• Spinal cord injury is both a serious and complex event treated intensively in physiotherapy departments, but with long-term support as the goal.
• Some of the residual problems will respond to acupuncture.
• Some of the side-effects produced by drug therapy will also respond to acupuncture.
• Treatment will be a mixture of traditional Chinese medicine and Western theory but since prognosis is so dependent on level of injury (or inflammation damage, as in transverse myelitis), often a Western approach is more helpful.

Part 1 Spinal cord injury (SCI)

This is clearly a devastating event which can have a major effect on the quality of the future existence of the patient. A complex neural network involved in transmitting, coordinating and modifying the sensory, motor and autonomic signals is abruptly disrupted.

Definition

SCI is defined in several ways; most simply, it is defined by the resulting loss of function. Paraplegia is the impairment or loss of motor, sensory or autonomic function of thoracic, lumbar or sacral segments of the spinal cord. Upper-limb function is spared but the trunk, pelvis and lower limbs will be affected.

Tetraplegia or quadriplegia will show similar damage, affecting the upper limbs as well. In high cervical lesions respiration will also be impaired.

Incidence and mortality

SCIs affect only a small percentage of the population, with a male-to-female ratio of 5:1. A total of 17.2 people per million of the population in Europe suffer a traumatic SCI and 8.2 per million experience a non-traumatic SCI (figures from 2001: [1]).

Risk factors

It is difficult to describe these causes as ‘risk’ exactly because this injury is so often the result of an accident: about 80% of SCIs are due to trauma. Gunshots and stabbings can cause this type of damage and falling from a height, whether accidentally or deliberately, is also a cause. However diseases where there is degeneration of the spinal structures such as cervical spondylosis also contribute to the statistics.

Diagnosis and prognosis

Diagnosis is dependent upon the completeness of the lesion and must take into account the infinite variations of this. Prognosis is irretrievably linked with this. The most useful current classification is the American Spinal Injuries Association (ASIA) Impairment Scale (Table 9.1). This scale is reasonably predictive of diagnosis and makes for a logical subclassification of incomplete spinal column injuries into clinical syndromes:

• Central cord: upper limbs are more profoundly affected than the lower limbs. The condition is typically seen in older patients with cervical spondylosis. A hyperextension injury compresses the cord in a spinal canal that is already limited by osteophytes and other degenerative changes.
• Brown-Séquard: this is an incomplete lesion often affecting the cervical spinal. The hemisection damage to the cord is commonly caused by a stabbing injury, although it may result from infection or local inflammation. It is characterized by ipsilateral hemiplegia with contralateral pain and temperature sensation deficits. This is because of the crossing of the fibres of the spinothalamic tract. The associated morbidity and mortality will be related to the accompanying injuries. Morbidity is associated with the resulting paralysis whereas mortality may be the direct result of serious haemorrhage.
• Anterior cord syndrome: characterized by ventral cord damage affecting spinothalamic and corticospinal tracts. There is complete motor loss below the lesion and usually loss of pain and temperature sensation. Since the posterior tracts are preserved there will still be some proprioception and vibratory perception. Motor recovery is generally poor unless evident within the first 24 hours.
• Conus medullaris and cauda equina syndromes are quite similar in that they offer a confusing mixture of signs and symptoms. The conus medullaris is the distal part of the spinal cord and injuries to this area often produce a mixture of upper motor neurone (UMN) and lower motor neurone (LMN) symptoms. Cauda equina lesions are predominantly LMN since they affect the peripheral nervous system [2].

Table 9.1 American Spinal Injuries Association (ASIA) impairment scale

A Complete: no motor or sensory function is preserved in the sacral segments S4–S5
B Incomplete: sensory but not motor function is preserved below the neurological level and extends through the sacral segments
C Incomplete: motor function is preserved below the neurological level, and the majority of key muscles below this level have a muscle grade less than 3
D Incomplete: motor function is preserved below the neurological level, and the majority of key muscles below this level have a muscle grade greater than or equal to 3
E Normal: motor and sensory function is normal

Medical treatment

Early interventions

A recent study by Tederko et al. [3] came to the following conclusions:

The primary zone of traumatic spinal damage enlarges due to local vascular disturbances, hypoxia, and the resulting inflammation. Secondly, inflammation in the region of secondary injury, apart from having a destructive impact, is the source of substances which may induce neural tissue repair, and finally the administration of methylprednisolone and surgical decompression of the spinal cord within several hours after SCI improves functional and neurological outcomes in patients with incomplete neurological deficits.

There are a number of things that must be checked and corrected, if possible, in the first 24–48 hours after injury. Haemorrhage from associated injuries must be dealt with quickly. Sympathetic paralysis below the level of the lesion can lead to neurogenic shock and hypotension. Thromboembolism can be prevented by elastic stockings and low-dose anticoagulants. Initial bladder management usually involves catheterization.

Pharmacology

Methylprednisolone is given at the time of the acute injury for up to 48 hours as one of the strategies for neuroprotection [4].

Surgery

Surgery, other than that required to stabilize the fracture site, is relatively rare. If pressure sores become serious, with infection, slow healing or infected bone, then surgery will be indicated.

SCI and physiotherapy

The following is a list of common medical problems which will delay or impede rehabilitation but is by no means exhaustive:

• Respiratory difficulty in the early stages is dealt with by assisted coughing to clear secretions and breathing exercises to prevent atelectasis or infection.
• Pressure sores: denervated skin is at risk from pressure damage within 30 minutes of injury. This means that pressure care is most important in this group of patients and a vigilant watch is kept for any areas of reddened skin. Where the patient retains the ability, pressure lifting is taught, with the patient lifting the buttocks clear from the wheelchair or chair every 30 minutes.
• Unilateral lower-extremity swelling with associated deep-vein thrombosis (DVT): prophylaxis, wearing pressure stockings and mobilizing as early as possible may help to prevent this.
• General mobility and independence will be enhanced by strengthening the unaffected muscles and encouraging standing and wheelchair use.
• Heterotopic ossification with possible fractures: calcification occasionally occurs in UMN-disordered muscles and may be confused with a DVT as the signs are often swelling and local heat. Most patients experience a degree of osteoporosis 2 years after injury, probably due to long periods of immobilization. Extra care must be taken during transfers and, if weight-bearing standing is undertaken after a long period, careful work progressing with the use of a tilt table is necessary.
• Spasticity: this is a common problem depending on the level of injury. Lower vertebral injuries, from the level of T12 downwards, give rise to LMN injuries and are generally classified as peripheral nerve damage presenting with flaccid paralysis or muscle weakness only. UMN injury, at the level of T12 or above, will involve damage to the cord itself and may present with a varying amount of spasticity in affected muscles.
• Autonomic dysreflexia: hypertension produced by a dysfunction in the sympathetic nervous system. This reaction may include palpitations, sweating, headache, piloerection and capillary dilation above the level of the lesion. Autonomic dysreflexia can occur with any noxious stimulus such as bladder or rectal distension. If it occurs during treatment, the patient should be sat up, given appropriate medication and the underlying cause treated. This hypertension can be sufficient to induce cerebral haemorrhage so it should always be treated as an emergency. Very mild symptoms can indicate the need for toileting.
• Pain: where pain is present initially, for instance in fractured ribs, treatment including the application of transcutaneous electrical nerve stimulation may be used. Common syndromes include mechanical instability, muscle spasm, visceral pain and central dysaesthesia syndrome – pain associated with the central nervous system and spinothalamic pathways.
• Contractures and malposition of the joints will be prevented by passive movements daily through full range.

Given the complexity of the possible changes, a clear knowledge of anatomy and associated nerve roots is vital. In order to know what can reasonably be expected by way of recovery, accurate location of the level of the spinal cord lesion is very important. Table 9.2 offers the range of possible goals and should be considered in conjunction with Table 2.2 in Chapter 2.

Table 9.2 Functional goals of rehabilitation in relation to the level of spinal cord lesion

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Management of psychological issues will be necessary and must take place with the help of qualified personnel. However the use of acupuncture may be valuable as long as the other staff know that it is being used. Maintaining a positive approach with realistic expectations is essential but hard to do.

Acupuncture in SCI

The use of acupuncture under these circumstances is by no means common and there has been little research. Acupuncture has been considered for pain control, a logical enough application, and also for bladder control, which might cause more comment.

The studies have been small but suggestive of a positive role for acupuncture [5]. A group of 22 patients with SCI who experienced moderate to severe pain of at least 6 months’ duration were given a course of 15 acupuncture treatments over a 7-week period. In a more general review of complementary therapies for SCI, Nayak et al. suggest that, while acupuncture may have a place in pain control, massage has been shown to be even better and is apparently rarely used [6].

The combination of acupuncture technique and ‘moving cupping’ (see Chapter 12) could be very useful.

The same research group also looked into the effect of acupuncture on autonomic dysreflexia [7], and decided that, although none of their – admittedly small – sample of 15 patients went on to develop symptoms of autonomic dysreflexia, three of the total did display an acute elevation of blood pressure, making it desirable to monitor this type of patient carefully in future.

Achieving bladder control is an important issue for both the patients and their carers and there has been a preliminary study which offered a role for acupuncture. The potential mechanism, through afferent stimulation at the same segmental level using the points CV 3 and CV 4 and also reflex stimulation of the splanchnic nerves at sacral level using BL 32, seems logical in both anatomical and traditional Chinese medicine (TCM) terms. The trial has been criticized for general lack of rigour but they did observe in post hoc analysis that those patients receiving acupuncture within the first 3 weeks did better with achieving bladder balance [8].

Body acupuncture

Acupuncture points, mainly on Yang meridians, can be used, as in all neurological diseases, to tackle the superficial musculoskeletal symptoms. Both pain and movement problems can be addressed. The points can be selected according to symptoms and Table 9.3 gives some of the alternatives.

Table 9.3 Spinal cord injury, transverse myelitis, spinal stroke – useful points

image

Many problems are directly caused by the medical interventions and points for these have also been listed. Electroacupuncture may be used at some of the points; the recommended frequency for body points is 2 Hz while that for scalp points is 100 Hz, although they may be alternated.

As with all the conditions in this book, there is a danger of the list of acupoints becoming endless, so only the most specific points are given. These are selected for completeness from both Western medicine approaches and those more traditionally Chinese. Those that relate directly to the following TCM syndromes are also mixed in.

Scalp acupuncture

The authors have been unable to find any convincing evidence for the use of scalp acupuncture in SCI. There is some anecdotal evidence, provided by practitioners of Yamamoto New Scalp Acupuncture (YNSA), of success with neurological conditions, but this technique of scalp acupuncture is slightly different to the Chinese version (see Chapter 12) and has a very limited evidence base. The main claim seems to suggest a change in neuroplasticity.

TCM approach

TCM regards injury to the spinal column as a direct injury to the Du meridian; thus points associated with that meridian, such as SI 3 Houxi and BL 62 Shenmai, can be used. The Huatuojiaji points are seen as valuable, being closely situated as they are, and this fits well with the neuroanatomy of the problem. The Huatuojiaji points are described as being able to ‘activate the primordial energy’ in the Du meridian [9]. Generally one would not needle the Du points but some authorities recommend this, choosing points above and below the level of damage and combining these with Huatuojiaji points.

The paralysed state is seen as a combination of obstruction to the meridian and the sudden stagnation of the Qi/Blood circulation, thus depriving the four limbs of nutrients and limiting normal movement. Needling the back Shu points and powerful points on the limbs themselves can be helpful. Passive and active movements are seen as part of the therapy.

Normal applications of acupuncture for pain, muscle hypertonicity, respiratory discomfort, insomnia and anxiety will include the usual points.

The most likely TCM syndromes involved will be Qi and/or Blood deficiency and Liver and Kidney Yin deficiency [10].

In practical terms this means that the symptoms of these syndromes, described elsewhere in this book, can be tackled with acupuncture and have a chance of influencing the well-being of the patient.

Case study 9.1: level 1 case study: partial spinal cord injury

A 53-year-old woman presented with difficulty sleeping. She had sustained a traumatic partial SCI 5 months previously at the level of L2. She presented with lower-limb weakness, no ankle movement and impaired lower-limb sensation; the left side was worse than the right.

Functional ability

The patient was able to walk short distances with two sticks and bilateral ankle foot orthoses. She was able to complete simple daily activities independently; she needed assistance with shopping.

Presenting symptoms

She had difficulty sleeping; she had problems falling asleep as well as waking frequently during the night. Her tongue had a purplish hue.

Treatment

Physiotherapy to improve mobility.

Seven acupuncture treatments were provided over 4 weeks.

Points: Bilateral ST 36, LR 3, LI4, SP6, SP9.

Manual acupuncture for 25 minutes; stimulated initially for Deqi then again at 5-minute intervals.

Outcome

The patient experienced a rapid improvement in sleep quality after two treatments; these improvements were sustained at the end of the course of treatment. She also reported feeling generally better and ‘more like her old self’ since before the accident.

Part 2 Transverse myelitis

Definition

This is a neurological syndrome caused by inflammation of the spinal cord at a specific level. The inflammation may have many causes and may occur in isolation or be associated with another illness.

Incidence and mortality

Transverse myelitis can occur at any age, in adults and children, male or female. Conservative estimates of incidence per year vary from 1 to 5 per million population [11].

Risk factors

There are many possible causes, including viral infections, abnormal immune reactions or insufficient blood flow through the blood vessels located in the spinal cord. Transverse myelitis may also occur as a complication of syphilis, measles, Lyme disease and some vaccinations, including those for chickenpox and rabies. It can also occasionally develop in association with human immunodeficiency virus (HIV).

Diagnosis

Differential diagnosis

As with many neurological conditions, diagnosis depends more on eliminating other possibilities than anything definite.

Tests

Magnetic resonance imaging (MRI) scans can be used to rule out lesions outside the spinal cord and can sometimes show an inflammatory lesion within the cord. Lumbar puncture may be performed to obtain fluid for studies including a white cell count, cultures to check for infections and tests to check for abnormal stimulation of the immune system. An MRI of the brain may be performed to screen for lesions suggestive of multiple sclerosis, even though it has been suggested that some sufferers from transverse myelitis may develop multiple sclerosis. If none of these tests is convincing the patient is presumed to have idiopathic transverse myelitis.

Medical treatment

Corticosteroids may be used in the early stages in an attempt to decrease the inflammation.

Prognosis

Recovery is often good and should commence within 1–3 months after onset. It may be partial or can be complete but the prognosis is relatively poor if there is no sign by 3 months [12]. In fact most patients will make a reasonable recovery but there may be a tendency to relapse if there is underlying serious illness.

Impact on the patient

Almost all patients will develop leg weakness of varying degrees of severity. The arms are involved in a minority of cases and this is dependent upon the level of spinal cord involvement. Sensation is diminished below the level of spinal cord involvement in most patients. Some experience tingling or numbness in the legs. Pain sensation and temperature sensation are diminished in most patients. Appreciation of vibration (as caused by a tuning fork) and joint position sense may also be decreased or spared. Bladder and bowel sphincter controls are disturbed in most patients. Many patients with transverse myelitis report a tight banding or girdle-like sensation around the trunk and that area may be very sensitive to touch.

Transverse myelitis and physiotherapy

As there is currently no effective cure for transverse myelitis, all that can be offered to patients is a support system in order to:

• treat any underlying cause, if known
• halt the progression of the damage to the spinal cord
• offer strategies and further support to cope with the physical and psychological issues that may result.

The common medical problems which will have an effect on rehabilitation include pressure sores, unilateral lower-extremity swelling with associated DVT, heterotopic ossification, possible fractures, spasticity, autonomic dysreflexia, orthostatic hypotension and pain.

Acupuncture in transverse myelitis

This will follow previous patterns, for stroke or for SCI, utilizing points for specific symptoms or those at appropriate spinal levels. Where pain is a major symptom, acupuncture should be utilized.

There is no supporting research for acupuncture in this condition but a very detailed case report was published recently where acupuncture was used to treat sleep disturbance and support a rehabilitation programme [13].

TCM approach

It is worth noting that the symptoms described are quite explicit and sound very like those associated with problems affecting the extraordinary meridians.

Needling GB 41 and TE 5 bilaterally would be helpful in opening the Dai Mai and Yang Wei Mai and encouraging the descent of Yang energy. The Yang Wei Mai is considered as a secondary vessel to the Urinary Bladder meridian and is described as a network winding around the body, keeping the muscles tight [14]. Alternatively the Du and Yang Chiao Mai meridians could be used, associated with the central nervous system as they are. Use SI 3 and BL 62 bilaterally to open this pairing.

As with all the conditions in this book, the addition of sundry Yang points to deal with local/superficial problems on the upper or lower limbs is always of benefit, particularly as sensation returns.

Part 3 Spinal cord stroke

Definition

A spinal cord stroke is a vascular event affecting the blood supply to the spinal cord. The spinal cord may be damaged due to blockage of the blood vessels leading to infarction of the cord, or due to haemorrhage within or around the cord causing damage. It more commonly affects the anterior spinal artery.

Aetiology

Spinal cord infarction is usually caused by arteriosclerosis of the major arteries of the spinal cord. Other causes include embolism, acute systemic hypotension, aortic pathology or associated with spinal or aortic surgery [15]. Spinal cord haemorrhage may be caused by coagulopathies, trauma or vascular malformations such as spinal artery aneurysms or dural arteriovenous malformation [16].

Incidence

Spinal strokes are rare, with an estimated incidence of 1–2% of all admissions for vascular pathology of the nervous system.

Mortality

Mortality figures range from 9% to 22% [15, 17].

Clinical presentation

Patients usually present with sudden onset of sharp spinal pain associated with weakness, sensory disturbance, loss of deep tendon reflexes and sphincter disturbance [18]. Presentation will be determined by spinal level involved. Most strokes affect the thoracic or thoracolumbar regions and will result in lower-limb weakness. Less commonly the cervical spinal cord is affected and this would result in weakness and sensory changes in all four limbs.

Treatment

Management will involve maximizing functional ability and minimizing the development of secondary complications. Physiotherapy and occupational therapy may be required to support the individual to regain as much functional ability as possible. Specific interventions to address continence issues may also be required, but these will be like those for SCI, described above. The pathology is vascular but the resulting disabilities are similar, depending on the severity of the presentation.

Prognosis

Recovery depends on the degree of spinal cord damage, as indicated by initial neurological examination. Presence of proprioceptive deficit, walking impairment or bladder dysfunction at outset is associated with poorer long-term outcome [18]. Some authors suggest that female sex and advanced age are negative indicators for recovery [15, 17]. A long-term follow-up of 57 patients with spinal cord infarction showed that 41% of patients were fully ambulant, 30% were able to walk with walking aids and 20% were wheelchair-dependent [17]. Pain is often problematic in the longer term.

Spinal stroke and physiotherapy

This will be essentially supportive therapy, utilizing the capabilities of the patient and attempting to maximize those in order to support independence and mobility where possible.

Acupuncture in spinal stroke

This will follow previous patterns, for stroke or for SCI, utilizing points for specific symptoms or those at appropriate spinal levels. Where pain is a major symptom, acupuncture should always be tried.

There is no supporting research for acupuncture in this field.

References

[1] The University of Alabama National Spinal Cord Injury Statistical Center. http://www.sci-info-pages.com/facts.html, 2002. Available online at: [Accessed 24 November 2009]

[2] American Spinal Injuries Association. International Standards for Functional Neurological Classification of Spinal Cord Injury. Chicago: ASIA, 1992.

[3] Tederko P., Krasuski M., Kiwerski J., et al. Strategies for neuroprotection following spinal cord injury. Ortop Traumatol Rehabil. 2009;11(2):103-110.

[4] Paddison F., Middleton F. Spinal cord injury. In: Stokes M., editor. Physical Management in Neurological Rehabilitation. Edinburgh: Elsevier Mosby; 2004:125-152.

[5] Nayak S., Shiflett S.C., Schoenberger N.E., et al. Is acupuncture effective in treating chronic pain after spinal column injury? Arch Phys Med Rehabil. 2001;82(11):1578-1586.

[6] Nayak S., Matheis R.J., Agostinelli S., et al. The use of complementary and alternative therapies for chronic pain following spinal cord injury: a pilot survey. J Spinal Cord Med. 2001;24(1):54-62.

[7] Averill A., Cotter A.C., Nayak S., et al. Blood pressure response to acupuncture in a population at risk for autonomic dysreflexia. Arch Phys Med Rehabil. 2000;81(11):1494-1497.

[8] Cheng P.T., Wong M.K., Chang P.L. A therapeutic trial of acupuncture in neurogenic bladder of spinal cord injured patients – a preliminary report. Spinal Cord. 1998;36(37):476-480.

[9] Kong Y., Ren X., Lu S. High Paraplegia. The acupuncture treatment for paralysis. Beijing: Science Press, 1996;191-192.

[10] Maciocia G. The Practice of Chinese Medicine. Edinburgh: Churchill Livingstone, 1994.

[11] Jeffery D.R., Mandler R.N., Davis L.E. Transverse myelitis: retrospective analysis of 33 cases, with differentiation of cases associated with multiple sclerosis and parainfectious events. Arch Neurol. 1993;50(5):532-535.

[12] Berman M., Feldman S., Alter M., et al. Acute transverse myelitis: incidence and etiologic considerations. Neurology. 1981;8:966-971.

[13] Vaghela S.A., Donnellan C. Acupuncture for back pain, knee pain and insomnia in transverse myelitis – a case report. Acupuncture Med. 2008;26(3):188-192.

[14] Hopwood V. The extra meridians – the deepest level. Acupuncture in Physiotherapy. Edinburgh: Butterworth Heinemann, 2004;73-88.

[15] Salvador de la Barrera S., Barca-Buyo A., Montoto-Marques A., et al. Spinal cord infarction: prognosis and recovery in a series of 36 patients. Spinal Cord. 2001;39(10):520-525.

[16] Kim J.S., Lee S.H. Spontaneous spinal subarachnoid hemorrhage with spontaneous resolution. J Korean Neurosurg Soc. 2009;45(4):253-255.

[17] Nedeltchev K., Loher T.J., Stepper F., et al. Long-term outcome of acute spinal cord ischemia syndrome. Stroke. 2004;35(2):560-565.

[18] Masson C., Pruvo J.P., Meder J.F., et al. Spinal cord infarction: clinical and magnetic resonance imaging findings and short term outcome. J Neurol Neurosurg Psychiatry. 2004;75(10):1431-1435.

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