Spinal cord injury and disease

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9 Spinal cord injury and disease

CHAPTER CONTENTS

Part 1: Spinal cord injury (SCI) 152

Incidence and mortality 152

Risk factors 152

Diagnosis and prognosis 152

Medical treatment 153

Early interventions 153

Pharmacology 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

Part 2: Transverse myelitis 157

Incidence and mortality 157

Risk factors 157

Differential diagnosis 157

Medical treatment 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

Clinical presentation 158

Spinal stroke and physiotherapy 159

Acupuncture in spinal stroke 159

• 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.

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