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Spinal Cord Injury (SCI) Day is an annual event held on 5^th September, which raises much needed awareness for people affected by spinal cord injury. Indian Association of Physical Medicine and Rehabilitation (IAPMR) is group of PM&R Doctors (Physiatrist) working with a wide range of spinal cord injury patients, peer groups, NGOs and various central and state organizations across India to raise awareness of spinal cord injury and the effects.

Spinal Cord Injury Day is an opportunity for us all to make positive changes in the lives of people with SCI, their families and to improve prevention programs of SCI around the country. As part of this day we have written this blog to address some doubts around SCI management.

Spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compression, incision or contusion. As a result of the injury, the functions performed by the spinal cord are interrupted at the distal level of the injury. SCI causes serious disability among patients.

Every year, about 40 million people worldwide suffer from SCI. Most of them are young men, typically aged from 20 to 35, although 1% of these populations are children.

PM&R physicians (Physiatrist) have been pioneers in the treatment and management of spinal cord injuries. Typically, the physiatrist is brought in within 24–48 hours after the injury to coordinate any non-surgical treatment and continues as the patient’s primary attending physician.

Causes of Traumatic Spinal Cord Injury?

·         Spinal cord injury is classified as 2 types: traumatic and non-traumatic.

Traumatic SCI: Motor vehicle accident, Falls, Violent acts, Sports and recreation, Medical/surgical complications. * SCI in Indian scenario is different from western countries with major cause being fall.

Non-traumatic SCI: SCI can also be caused by non-traumatic diseases in the spine - Vascular disorders, Tumors, Infective conditions, Degenerative spine disorders, Iatrogenic injuries, especially after spinal injections and epidural catheter placement, Vertebral fractures secondary to osteoporosis, Developmental disorders. * Spine tuberculosis is very common cause in India 

Signs and Symptoms of Spinal Cord Injury: Spinal cord injury can cause partial or complete loss of sensation and function (paralysis) below the injury, and nerve dysfunction throughout the body depending on where the injury occurred.

For example, injuries in upper cervical spine (neck) can cause nerve dysfunction in diaphragm (chest), and injuries above your lumbar spine (low back) can cause nerve problems in abdomen leading to breathing and digestion issues.

SCI can also disrupt the nerves serving bladder and bowel and can lead to urinary and fecal incontinence, sexual dysfunction and fertility issues along with pressure ulcers.

Spinal Cord Injury Diagnostic Process: Often, first responders or emergency medical technicians will check vital signs, monitor breathing, and stabilize spine with a rigid neck brace and spinal board for transport in the ambulance. Proper immobilization of spine during transportation is very important.

Once at the hospital, patient will undergo a complete physical and neurological examination to assess ability of patient to move (ie, functional capacity) and determine any loss of feeling (sensation), such as in arms and legs. If attending doctor suspects spinal cord injury, imaging tests are performed.

Tests to Confirm Spinal Cord Injury: The three most common imaging tools used to diagnose SCI are X rays, CT scans, and magnetic resonance imaging (MRI). With regard to laboratory studies - Arterial blood gas (ABG), Lactate levels, Hemoglobin and/or hematocrit, Urinalysis and Electrophysiology studies may be helpful

You’ve Been Diagnosed with a Spinal Cord Injury - Now What? Learning you’ve suffered a traumatic SCI is scary and can be overwhelming, but there is hope. PM&R Doctor can help you understand your prognosis and path forward. Surgery and Rehabilitation may help you to manage pain and protect your quality of life.

PM&R Doctors all over the world classify SCI using a method developed by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and assess the patient as per ASIA Impairment Scale A to E.

Severity of Spinal Cord Injury: The severity of SCI depends on where the spinal cord is damaged, and if the injury is complete or incomplete.

·         A complete SCI means you have completely lost feeling of sensation and movement below the affected area.

·         An incomplete SCI means you still feel some sensation or can move below the affected part of the body.

SCI damage may cause paraplegia or tetraplegia.

·         Paraplegia is paralysis (the inability to move) of both legs.

·         Tetraplegia also known as quadriplegia, means paralysis of both arms and both legs.

Most common results of traumatic SCI: Complete paraplegia, Complete tetraplegia, Incomplete paraplegia, Incomplete tetraplegia, Normal sensation and function.

Initial management of the SCI: The immediate resuscitation phase follows the basic principles of ‘ABC’.

Spine Stabilization: Spine surgery plays an essential role in the traumatic spinal cord injury (SCI) treatment plan. Spine surgery may be used to resolve issues by a) Decompressing the spinal cord b) Re-stabilizing the spine. Sometimes a spinal decompression surgery is all that is needed. However, if your spine is unstable, spinal stabilization surgery, often with spinal fusion is performed following decompression. For many injuries of the cervical spine, traction may be indicated to help bring the spine into proper alignment followed by bracing.

Rehabilitation following SCI:  This period begins with admission to hospital and stabilization of the patient. Rehabilitation of patients after SCI is multipronged and begins with education, followed by implementation of early rehabilitation intervention. Rehabilitation goals after SCI include maximizing physical independence, becoming independent in direction of care, and preventing secondary complications.  An interdisciplinary team approach is the model that has historically been used in the rehabilitation treatment of persons with SCI to achieve these goals. The team is optimally led by a physiatrist.

The inpatient rehabilitation setting is the cornerstone of the rehabilitation process for persons with SCI. Rehabilitation begins in the intensive care setting and includes addressing the SCI-specific needs to help the individual meet their potential in terms of medical, physical, social, emotional, recreational, vocational, and functional recovery and receive life-long out-patient medical care.

Complications and Rehabilitation Management after Traumatic Spinal Cord Injury

Neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis (DVT), spasticity, heterotrophic ossification, contractures, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders are frequent complications after SCI.

The most common and important complication during early phase of SCI hospitalization is the development of joint contractures and stiffness. Passive exercises are done to resolve contractures, muscle atrophy and pain during the acute period of hospitalization. Positioning of the joints is important in order to protect them and maintain the optimal muscle tone. Sand bags, pillows and splints can be useful in positioning.  The most important point is strengthening of the upper extremities which are done to help in independent transfer from bed.

In order to prevent pressure ulcers, the patient’s position should be changed every 2-3 hours and proper skin care should be practiced. In the acute phase, early goals include upright position tolerance, bed mobility, endurance training, and transfer training (bed to chair and chair to commode). Independent sitting on the edge of the bed is very important for wheelchair use, enabling wheelchair transfer. The purpose of this rehabilitation period is to focus on stability and strength education for sitting and transportation. Wheelchairs, walkers and crutches are used for out of bed transferring of patients. An incomplete SCI patient has the potential to walk with the help of braces and assistive devices. The beginning of functional ambulation level is considered to be T12.

Activity of daily living (ADLs): Patients are trained to utilize specialized equipments compensatory strategies to assist with transferring from one surface to another, dressing, bathing, grooming, eating, and preparing food. Wheelchair training and home accessibility modifications including ramps, shower chairs, and other accommodating equipments are done to make the patient independent in his/her daily activities.

Speech language and respiratory rehabilitation: have an important role especially in the treatment of patients with cervical SCI. The goals of these therapies are voice production, secretion clearance, ventilator weaning, resistive expiratory muscle training, and utilization of assisted communication devices.

Goals of rehabilitation based on neurological level of injury in patients with complete SCI

Medical issues management by Physiatrist

Pulmonary: Respiratory complications associated with SCI are the most important cause of morbidity and mortality. Pneumonia is cited as the primary cause of death during chronic SCI.

Every effort are directed at prevention of respiratory complications including proper positioning and postural changes, breathing techniques, spontaneous cough and cough assistance, secretion management, respiratory muscle training, ventilation techniques and education, vaccinations, and pharmacological interventions.

Cardiovascular: Individuals with SCI also are at high risk of multiple cardiovascular complications including thromboembolism, autonomic dysreflexia, orthostatic hypotension, impaired cardiovascular reflexes and sensation of cardiac pain, and loss of and cardiac atrophy.

Autonomic dysreflexia (AD): typically occurs in complete SCI with lesions at T6 and above. Symptoms are due to a spinal reflex mechanism typically initiated by noxious stimulus (e.g., bladder distention) below the level of injury. Eliminating noxious stimuli and ensuring prompt blood pressure control are key in management.

Orthostatic hypotension (OH): Up to 80% of patients with tetraplegia and 50% of patients with paraplegia develop OH. Arm exercises during tilt table use, body weight support treadmill training, abdominal binders or compression stockings, and use of salt tablets have not been proven effective in the treatment of OH.

Thromboembolic Disease: Thromboembolic disease is common following SCI. DVT most commonly occurs in the initial few weeks following SCI, with a much lower risk in persons with chronic injury. A prophylactic strategy can address venous stasis and hypercoagulability. Pneumatic compression devices can be used for the first 2 weeks, followed by use of a compression hose. Unfractionated heparin or a low-molecular-weight heparin such as enoxaparin can be administered for 2-3 months following injury.

Bladder dysfunction: Detrusor or sphincter hypereflexia and/or areflexia are the etiologic basis for most forms of neurogenic bladder. Urodynamic studies are the gold standard to diagnose the precise etiology of neurogenic. Ultimate goal of bladder management is to adequately drain the bladder to preserve upper tract function and maintain continence. Clean intermittent catheterization (CIC) is the safest bladder emptying method for SCI patients who cannot void independently but indwelling catheters, medications, and additional surgical options are also utilized.

Bowel dysfunction: affects up to half of patients with SCI leads to constipation/ incontinence. Treatment is tailored to symptoms and includes a high fiber diet, digital rectal stimulation and manual evacuation, rectal suppositories, timed toileting program, laxatives, stool softeners, and electrical stimulation.

Spasticity: Spasticity usually affects patients in the chronic phase of injury and can cause considerable pain and disability as well as abnormal postures, contracture, and pressure ulcers. Interventions such as - Passive range of motion, prolonged standing on a tilt table or standing frame, serial casting, and electrical stimulation can also be beneficial. Pharmacologic management includes oral, intramuscular, and intrathecal agents. Surgical intervention, typically to release contracture, can be utilized when other methods fail.

Pain: Musculoskeletal and neuropathic pain are the commonest type of pain and are often treated with a combination of analgesics, NSAIDS, anticonvulsants, opioids, spinal cord stimulation, and physical modalities.

Skin: Pressure ulcers and skin diseases were reported as the second commonest reason for hospital readmission after SCI. In chronic patients, the ischium, trochanters, sacrum, and heel are the principle areas where pressure ulcers develop. Risk factors include immobility, skin moisture, impaired sensation, poor nutrition, and muscle atrophy. Diligent skin care is essential to preventing skin breakdown. In advanced ulcers, surgical debridement may be necessary.

Osteoporosis: Bone loss is very common after SCI and occurs most aggressively in the first 1–2 years. Disuse as well as non-mechanical factors including nutrition deficiency and endocrine disorders contributes to bone loss. Bisphosponates are central to pharmacologic therapy, weight-bearing exercises, functional electrical stimulation, and pulsed electromagnetic fields have also been studied in the literature.

Heterotopic Bone Formation (HO): is the formation of new bone in soft-tissue planes surrounding a joint it most commonly involves the hips. The main clinical problem is the loss of movements which may complicate bed and chair positioning and can make dressing and bathing difficult. Treatment includes use of medications, exercises and irradiation. Severe loss of movements can be treated surgically.

Sexual Issues: Sexual drive persists after SCI, though sexual physiology may be altered. In men erections in response to local stimulation (reflex erections) are common, whereas erections in response to stimuli, such as thoughts and sights (psychogenic erections), are lost. Management of erectile dysfunction can include exploration of sexual expression not involving erection. Few medications are proven effective for improving erectile function. A substantial proportion of women retain the capacity for orgasm following SCI, regardless of severity of injury

Fertility: Men can be infertile following SCI as a consequence of ejaculatory dysfunction and problems with the quantity and quality of sperm. Techniques are available to induce ejaculation in men with SCI and semen can then be used for in-vitro fertilization.

After an SCI, most women typically experience menstrual stoppage that can last as long as 1 year and then begins again. Pregnancy in a female with an SCI should be considered a high-risk pregnancy. A woman with SCI may not sense the usual indicators of labor, which raises the possibility of an unattended preterm delivery.

Prognosis: Will I ever walk again? Will I be able to move & sense my fingers and toes? Are questions frequently posed by SCI patients? The prognosis for neurological recovery depends mostly on the initial severity of the neurological injury: The more severe the initial nerve damage, the worse the prognosis. Most patients who suffer a traumatic SCI experience most of their nerve function recovery during the first 6 months after their injury, though some nerve health can return up to 5 years later.

Recent advancements: Worldwide research on spinal cord injury management is being conducted in following areas - neuroprotective and neuroregenerative pharmaceuticals, neuromodulation, stem cell-based therapies, and various external prosthetic devices. Lately, therapeutic strategies are being mainly focused on two major areas: neuroregeneration and neuroprotection. Despite recent advancements, more clinical trials on a larger scale and further research are needed to provide better treatment modalities for SCI management.