Spinal Cord Injury
Definition:
Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function. The injury causes myelopathy or damage to nerve roots or myelinated fiber tracts that carry signals to and from the brain. A spinal cord injury creates fractures or dislocates vertebrae. The moment of injury begins the damage when displaced bone fragments, disc material, or ligaments bruise or tear into spinal cord tissue. Axons are cut off or damaged beyond repair, and neural cell membranes are broken. Blood vessels may rupture and cause heavy bleeding in the central grey matter, which can spread to other areas of the spinal cord over the next few hours. The spinal cord swells and fills the spinal canal cavity at the injury level. This swelling cuts off blood flow, which also cuts off oxygen to spinal cord tissue. Blood pressure drops as the body loses its ability to self-regulate. As blood pressure continues to lower, it interferes with the electrical activity of neurons and axons. These changes can cause a condition known as spinal shock that can last from several hours to several days. Spinal shock appears to occur in approximately half the cases of spinal cord injury, and it is related to the size and severity of the injury. During spinal shock, even undamaged portions of the spinal cord become temporarily disabled and can't communicate normally with the brain. Complete paralysis may develop, with loss of reflexes and sensation in the limbs.
The crushing and tearing of axons is part of the injury. The initial physical trauma sets off a cascade of biochemical and cellular events that kills neurons, strips axons of their myelin insulation, and triggers an inflammatory immune system response. Days or weeks later, after this second wave of damage has passed, the injured area usually increases to encompass several segments above and below the original injury.
After the injury, an excessive release of glutamate, an excitatory neurotransmitter, may cause additional damage by overexciting nerve cells. Excessive glutamate triggers excitotoxicity, disrupting normal processes and killing neurons and protective oligodendrocytes. At the same time, the broken blood vessels break the blood-brain barrier allowing immune system cells to enter the spinal cord and trigger an inflammatory response. Neutrophils, T-cells, macrophages and monocytes clean up and fight off infection. They also trigger the release of cytokines. And eventually astrocytes that produce scar tissue. This inflammatory response also signals cells to overproduce free radicals that attack and disable necessary molecules. The injury also sets off apoptosis, killing oligodendrocytes and stripping the myelin from intact axons.
Restricted blood flow, excitotoxicity, inflammation, free radical release, and apoptosis increase the area of damage in the injured spinal cord. Damaged axons become dysfunctional, either because they are stripped of their myelin or because they are disconnected from the brain. Glial cells cluster to form a scar, which creates a barrier to any axons that could potentially regenerate and reconnect. A few whole axons may remain, but not enough to convey any meaningful information to the brain.
The injury may also damage the gray matter in the central part of the cord, causing segmental losses of interneurons and motorneurons.
The International Standards for Neurological and Functional Classification of Spinal Cord Injury is a widely accepted system describing the level and extent of injury based on a systematic motor and sensory examination of neurologic function (see diagnosis).
Epidemiology
The most common causes of traumatic spinal cord injury are:
Motor vehicle accident (44.5%), falls (18.1%), violence (16.6%), and sports injuries (12.7%).
Most common causes of non-traumatic spinal cord injury are:
Vascular disorders, tumors, infectious conditions, spondylosis, iatrogenic injuries, vertebral fractures secondary to osteoporosis, and developmental disorders.
Traumatic SCI is more common in persons younger than 40 years, while nontraumatic injury is more common in persons older than 40 years. The incidence of traumatic SCI in the United States is 30-60 new cases per million population, or 10,000 cases per year in the United States. Research has also shown that in the United States, 66.4% of SCIs occur in whites; 21.1%, in African Americans; 8.8%, in Hispanics; 1.6%, in Asians; 1.1%, in Native Americans; 1% in other populations; and 80% of persons with SCI are male. More than 50% of all cases of SCI occur in persons aged 16-30 years with the median age being 26.4 years old. The incidence of pediatric SCI in African Americans is 1.53 cases per 100,000 children, Native Americans are 1.0 case per 100,000 children and Hispanics are 0.87 case per 100,000 children. The frequency in Asians is 0.36 per 100,000 children. Boys that suffer SCI is 2.79 cases per 100,000 children and girls that suffer a SCI is 1.15 cases per 100,000 children.
The major causes of pediatric SCI are :
Motor vehicle accidents (56%), accidental falls (14%), firearm injuries (9%), and sports injuries (7%). Among children in the study, 67.7% of those injured in a motor vehicle accident were not wearing a seatbelt. Alcohol and drugs were found to have played a role in 30% of all pediatric SCI cases. Other injuries are often associated with traumatic SCI, including bone fractures (29.3%), loss of consciousness (17.8%), and traumatic brain injury affecting emotional/cognitive functioning (11.5%)
Single persons sustain SCIs more commonly than do married persons. The marriage rate after SCI is annually about 59% below that of persons in the general population of comparable gender, age, and marital status. The divorce rate annually among individuals with SCI within the first 3 years following injury is approximately 2.5 times that of the general population. The rate of injury according to educational status is: less than a high school degree is 39.8%, with a high school degree is 49.9%, with an associates degree is 1.6%, with a bachelors degree is 5.9%, with a masters or doctorate degree is 2.1%, and other degree is .7%.
Signs and symptoms
Loss of movement; loss of sensation, including the ability to feel heat, cold and touch;
loss of bowel or bladder control; exaggerated reflex activities or spasms; changes in sexual function, sexual sensitivity and fertility; pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord; difficulty breathing, coughing or clearing secretions from your lungs.
Signs and symptoms following an accident
Extreme back pain or pressure in your neck, head or back; weakness, incoordination or paralysis in any part of your body; numbness, tingling or loss of sensation in your hands, fingers, feet or toes; loss of bladder or bowel control; difficulty with balance and walking; impaired breathing after injury; an oddly positioned or twisted neck or back.
Diagnosis
A spinal cord injury may be diagnosed from either one or a combination of MRI, CT scan, or Xrays, with or without contrast. The International Standards for Neurological and Functional Classification of Spinal Cord Injury is a widely accepted system describing the level and extent of injury based on a systematic motor and sensory examination of neurologic function.
The level of injury may be classified as either:
Tetraplegia (replaces the term quadriplegia) - Injury to the spinal cord in the cervical region, with associated loss of muscle strength in all 4 extremities
Paraplegia - Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris
The extent of injury (as defined by the ASIA Impairment Scale) may be classified as:
A - Complete: No sensory or motor function is preserved in sacral segments S4-S5
B - Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5.
C - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3.
D - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3 (muscle strength is graded using the Medical Research Council scale of 1-5).
E - Normal: Sensory and motor functions are normal.
Some other classifications of SCI may include the following:
Central cord syndrome: associated with a cervical region injury and leads to greater weakness in the upper limbs than in the lower limbs, with sacral sensory sparing.
Brown-Séquard syndrome: associated with a hemisection lesion of the cord, causes a relatively greater ipsilateral proprioceptive and motor loss, with contralateral loss of sensitivity to pain and temperature.
Anterior cord syndrome: associated with a lesion causing variable loss of motor function and sensitivity to pain and temperature; proprioception is preserved.
Conus medullaris syndrome: associated with injury to the sacral cord and lumbar nerve roots leading to areflexic bladder, bowel, and lower limbs, while the sacral segments occasionally may show preserved reflexes (eg, bulbocavernosus and micturition reflexes).
Cauda equina syndrome: due to injury to the lumbosacral nerve roots in the spinal canal, leading to areflexic bladder, bowel, and lower limbs.
Prognosis
Approximately 10-20% of patients do not survive to reach acute hospitalization, while about 3% of patients die during acute hospitalization. Patients aged 20 years at the time they sustain an SCI have a life expectancy of approximately 33 years (patients with tetraplegia), 39 years (patients with low tetraplegia), or 44 years (patients with paraplegia). Individuals aged 60 years at the time of injury have a life expectancy of approximately 7 years (patients with tetraplegia), 9 years (patients with low tetraplegia), and 13 years (patients with paraplegia). The annual death rate for patients with acute SCI is 750-1000 deaths per year in the United States. The leading causes of death in patients with SCI are pneumonia and other respiratory conditions, followed by heart disease, subsequent trauma, and septicemia. Suicide and alcohol-related deaths are also major causes of death in patients with SCI.
Treatment
Standard Medical Treatment
Immediately following injury: Transport in supine position, with a rigid collar and backboard immobilizing the spine. If the neck is injured, respiratory support via intubation may be required. Methylprednisolone may be given within 8 hours of injury to reduce inflammation and suppress immune cell overactivity.
After surviving a spinal cord injury, patients may have chronic problems with breathing, pneumonia, irregular heart beat and low blood pressure, blood clots, spasms, autonomic dysreflexia, pressure ulcers, pain, bladder and bowel problems, and reproductive and sexual function issues.
Following diagnosis: immobilization to stabilize the injured area with or without traction and special harnesses, may need surgery to remove bone fragments, foreign objects, herniated discs, or fractured vertebrae that may be compressing the spine, or to stabilize the spine to prevent further deformity and/or pain.
Ongoing Standard Medical Treatment: ongoing treatment focuses on preventative maintenance. Secondary problems may be atrophy, blood clots, deconditioning, spasms, pressure ulcers, bowel, bladder, respiratory, reproductive, and sexual issues.
Standard Care of Physical Therapy
Rehabilitation is focused on enhancing the function and lifestyle of the patient. We are focusing on the ability to achieve most ADL. The goal is to reach a point where the disability is no longer the main focus of the patients life. To achieve this, we must provide information in an environment designed to foster independence and have clinets work as partners with their clinicians. Outcome goals are related to future lifestyle changes. Continuous blood pressure and heart rate monitoring is necessary to watch for signs of orthostatic hypotension and AD. In intensive care, the PT will focus on mobilization with emphasis on postural drainage, and assisted coughing. An active program to increase strength of inspiration and diaphram muscles is appropriate at this time. In the early program, ROM, beginning strength and endurance, and education of patient and family are covered. The goal of early intervention of to prevent secondary disorders such as pressure ulcers or contractures that would interfere with the rehab process and to begin to prepare the musculoskeletal system for a different method of mobility. Bilateral reach has the strongest relationships to ADL and should be taught extensively. Activity Based Recovery (ABR) is based on the theory that patterned neural activity assists the system in optimizing cellular regeneration. FES helps this process. Neuroprostheses via surgically implanted FES device have the potential to increase independence. Body weight-supported treadmill training provide potential for improved locomotion. Exercise is critical to maintain cardiac fitness levels. Circuit resistance training is a convenient and efficient method to maintain cardiac levels.
Age, employment status, motor level and completeness of injury ,and ambulatory mode are independently associated with health-related quality of life scores. Chronic cough ,chronic phlegm, persistent dyspnea with ADL, lower forced expiration and forced vital capacity are each associated with a lower HRQoL score. The importance of staff qualities, the need for a vision of future life possibilities, the importance of peers, the necessity for relevant program content, and the importance of the ability to reconnect the past to the future has been documented by individuals with SCI. If rehab services are to be evidence based, relevant, and effective in meeting the needs of people with SCI, they must be informed by the perspectives of people with SCI. the most important dimension of rehab for people with SCI is the caliber and vision of the rehab staff.
Article one about Spinal Cord Injury and Stem Cell Transplants
Article and relationship of research to Spinal Cord Injuries:
This is a fascinating and thoroughly written article describing, in detail, the structure and function of the spinal cord and its corresponding cells. The author does great job at explaining the complicated biochemical processes happening during a spinal cord injury.
She explains two strategies for using stem cells harvested from different areas and their corresponding affect on different phases on the injury.
The first strategy is to repair the damaged spinal cord by stimulating axon regrowth in order to reestablish the broken connection. Her argument is based upon scientists recent discovery that new neurons are continuously added to two specific regions of the adult mammalian brain. The research proves that neurotrophin 3 and 4 are responsible for axon growth during development. Researchers induced lesions on an adult rats spinal cord and transplanted geneticly modified grafts to create NT-3. The rat showed improvement in motor skills and axon growth at the injured area up to 8mm.
The second strategy is to use undifferentiated embryonic stem cells from fetal spinal cord tissue in hopes it will generate into spinal and nerve cell structures. Her argument is based upon a scientist experiment with an adult rat. The scientists induced a thoracic spinal cord injury of 2.5mm resulting in paralysis. Nine days later, they injected 1 million stem cells at the injured site. Two weeks later, the stem cells occupied the area that was normally scarred and many cells died. However, enough lived to become neurons and allow the rat to have limited function of his legs.
Article two about Spinal Cord Injury and Stem Cell Transplants
This article is thought provoking and objective. The author lists several detriments as well assets to using stem cell transplantation in a spinal cord injury. Big chunks of the article are the same as the previous article. However, this author examines the use of bone marrow stem cells instead of hippocampus and embryonic stem cells. He plainly states a very important fact: during a spinal cord injury, the blood brain barrier is destroyed, which allows the stem cells to cross the barrier repeatedly through the blood stream instead of surgically invading the CNS multiple times. That ease of injection makes the treatment applicable to many different people with different disorders.
Ethical and legal implications regarding SCI and stem cell transplants
I think the Code of Ethics govern the implications moreso than the state of Indiana practice act, in this instance. There are obvious basic things outlined in the state practice act, like don’t perform surgery, that we cant do. We cant inject stem cells into patients. Our code states that we shall not make misleading representations. If I tell a patient that stem cell research is good, they assume it is, without me giving them the facts. Our code outlines that we have a duty to educate our patients objectively, honestly, and with integrity. It also states we are to respect their religious and cultural beliefs. Some patient may be offended to know my opinion about stem cell transplants. So I am obligated to inform and educate objectively without my personal biases or beliefs interfering with what is in their best interest or their beliefs. I must also respect their privacy and confidentiality. If I know a patient is planning a pregnancy or abortion in order to harvest embryonic stem cells and they ask my advice, I can educate and inform objectively without my own personal biases interfering. If I share this private information with others unnecessarily, that will have a negative impact on my career and disgrace others in my field.
Reference Page
1. Goodman C.C., Fuller K.S. Pathology: Implications for the Physical Therapist. Third Edition.
St. Louis, MO: Saunders Elsevier Books; 2009.
St. Louis, MO: Saunders Elsevier Books; 2009.
2. Jesse Owens Ph. Adult stem cells and spinal cord injury treatment. Spinal Cord Society. Available at:
http://www.spinalcordsociety.org/documents/Adultstemcellsandspinalcordinjurytreatment.pdf. Accessed March 5, 2010.
http://www.spinalcordsociety.org/documents/Adultstemcellsandspinalcordinjurytreatment.pdf. Accessed March 5, 2010.
3. Sheltering Arms Physical Rehab. Hospital therapy for spinal cord injury in Richmond, Virginia. Sheltering Arms Website. 2010. Available at:
http://www.shelteringarms.com/inpatient.php?dbid=2. Accessed March 5, 2010.
http://www.shelteringarms.com/inpatient.php?dbid=2. Accessed March 5, 2010.
4. Spinal Cord Injury- Wikipedia, the free encyclopedia. Spinal cord Injury. Wikipedia Foundation, Inc. Website. 2010. Available at:
http://en.wikipedia.org/wiki/Spinal_cord_injury. Accessed March 5, 2010.
http://en.wikipedia.org/wiki/Spinal_cord_injury. Accessed March 5, 2010.
5. Mayo Clinic Staff. Spinal cord Injury. MayoClinic.com Website. 2010. Available at:
http://www.mayoclinic.com/health/spinal-cord-injury/DS00460. Accessed March 5, 2010.
http://www.mayoclinic.com/health/spinal-cord-injury/DS00460. Accessed March 5, 2010.
6. National Institutes of Health. Spinal cord Injury:Hope through Research. National Institute of Neurological Disorders and Stroke (NINDS)MayoClinic.com Website. 2010. Available at:
http://www.mayoclinic.com/health/spinal-cord-injury/DS00460. Accessed March 5, 2010.
http://www.mayoclinic.com/health/spinal-cord-injury/DS00460. Accessed March 5, 2010.
Synopsis
Spinal Cord Injury is a disturbance to the spinal cord. It may be caused from a traumatic or non traumatic injury. There are several classifications of spinal cord injury based upon the level and extent of the injury. Obvious signs and symptoms of spinal cord injury are loss of involuntary body functions, like bladder, bowel function and loss of feeling or sensations. The extent of the damage to the cord depends upon the timing of the treatment and diagnosis. Rapid treatment with muscular and joint stabilizers along with medications give the patient a better chance of recovery. Accurate early diagnosis also helps to provide the best treatment options in the quickest amount of time. Standard medical treatment focuses on reducing the secondary problems, such as pressure ulcers, spasms, blood clots, respiratory and reproductive system issues. Physical therapy treatment will focus on achieving a high level of independence. To do so, we must educate and retrain the patient to achieve ADL as soon as possible. Innovative and creative strategies may need to be used to facilitate the patients specific needs. Stem cell transplants are extremely beneficial to SCI. SCI is uniquely able to accept stem cells through its already damaged blood brain barrier. The ease of injection directly into the blood stream provides a more accessible delivery method than previously used for stem cell transplants. As a PTA, the controversy over stem cell transplant in the general public population must be respected. As a PTA, it is my duty to educate objectively and without opinion or personal bias. Being aware of my patients cultural, religious, and social backgrounds and preferences may help me to educate them in a way that is respectful and sensitive to their needs and eastablished lifestyles while informing them of new developments in science and medicine and how it relates to their condition.
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