Spinal Cord Trauma and Related Diseases

No Results

No Results

processing….

Spinal cord disease can result from diverse pathologic processes including trauma. Irrespective of the pathogenesis, it can lead to significant impairment of motor, sensory, or autonomic function.

This review focuses on the clinical description of common patterns of spinal cord involvement. Considerable differences exist in terms of clinical complications after traumatic and nontraumatic spinal cord injury (SCI). In this article, the general principles of management of traumatic SCI are emphasized. For specific nontraumatic neurologic diseases that affect the spinal cord, see Multiple Sclerosis, Amyotrophic Lateral Sclerosis, and other articles listed in Differentials.

Trauma to the spinal cord typically leads to a combination of symptoms and signs resulting from immediate and delayed injury.

The initial mechanical trauma is secondary to traction and compression forces. Direct compression of neural elements by bone fragments, disc material, and ligaments damages both the central and peripheral nervous systems. Blood vessel damage also leads to ischemia. Rupture of axons and neural cell membranes also occurs. Microhemorrhages occur within minutes in the central gray matter and progress over the next few hours. Massive cord swelling happens within minutes. The cord fills the whole spinal canal at the injury level and leads to further secondary ischemia. Loss of autoregulation and spinal shock cause systemic hypotension and exacerbate ischemia.

Ischemia, toxic metabolic compounds, and electrolyte changes cause a secondary injury cascade. Hypoperfusion of gray matter extends to the surrounding white matter and alters the propagation of action potentials along the axons, contributing to spinal shock. Glutamate is a key element in the excitotoxicity. Massive release of glutamate leads to overstimulation of neighbor neurons and production of free radicals, which kill healthy neurons. Excitotoxic mechanisms kill neurons and oligodendrocytes, leading to demyelination. AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid) glutamate receptors play a major role in oligodendrocyte damage. Additionally, recent evidence has shown that a wave of apoptosis further affects the oligodendrocytes up to 4 segments from the trauma site days and weeks after the initial trauma. Syringomyelia may develop as one outcome of this cascade.

United States

Traumatic SCI accounts for an estimated annual incidence of approximately 40 cases per million population, or approximately 12,500 new cases each year, in the United States (published figures range from 28-55 cases per million people). This number excludes those who died at the scene of an accident. Currently, 240,000-337,000 patients with SCI are alive in the United States. ^[1]

International

SCI incidence is estimated at 15-40 cases per million population. In Australia, recent statistics report an age-adjusted rate of 14.5 cases per million population.

In 1927, Harvey Cushing described an 80% mortality rate for World War I soldiers with SCI in the first few weeks because of infections from bedsores and catheterization, with survival restricted to partial lesions. Today, in well-organized spinal cord centers, 94% of patients survive the initial hospitalization.

Recent statistics show the cost of the care of patients with C1-4 tetraplegia at approximately $1,048,259 in the first year and approximately $182,033 for each subsequent year. ^[1] Estimated lifetime costs for high tetraplegia are $4,651,158 for 25-year-old individuals and $2,556,197 for 50-year-old individuals. This amount does not include indirect costs such as loss of productivity, which vary with the educational background. Overall, lifetime costs range from $500,000 to $2 million, depending on the extent of injury and the location. Total direct costs for patients with SCI in the United States exceed $7 billion per year.

Life expectancy is greatly decreased, although major advances of medical management have markedly prolonged survival. Mortality rates are significantly higher during the first year after injury than during subsequent years. An Australian study found, among first-year survivors, overall 40-year survival rates were 47 and 62% for persons with tetraplegia and paraplegia, respectively. The most significant increases in mortality were seen in those with tetraplegia and American Spinal Injury Association Impairment Scale (AIS) grades A-C lesions, with SMRs between 5.4 and 9.0 for people < 50 years, reducing with advancing attained age. ^[2]

In the past, renal failure was the leading cause of death after SCI. Currently, pneumonia, pulmonary emboli, and septicemia surpass renal failure. For further details of the epidemiology, please see information provided by the National Spinal Cord Injury Association.

Recent statistics show a rising incidence of SCI in African American people in the United States. Currently, about 24% of SCIs occur among blacks. ^[1]  

According to the National Center for the Dissemination of Disability Research, from 1973-1978, 77.5% of the persons in the database were white people, 13.5% were black people, 5.7 % were Hispanic people, and 0.8% were Asian people. However, since 1990, only 59.1% were white people, while 27.6% were black people, 7.7% were Hispanic people, 0.4% were American Indian people, and 2.1% were Asian people.

Traumatic SCI is more common in young adult males, who are usually at a higher risk for motor vehicle accidents, violence, falls, and injury from recreational activities such as diving. Approximately 79% of spinal cord injuries occur among males. The male-to-female ratio in the United States is 4:1. ^[1]

The average age at injury has increased from 29 years during the 1970s to 42 years since 2010. ^[1]

National SCI Database. Spinal Cord Injury (SCI) Facts and Figures at a Glance. The National SCI Statistical Center. Available at https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202014.pdf. August 2014; Accessed: December 28, 2015.

Middleton JW, Dayton A, Walsh J, Rutkowski SB, Leong G, Duong S. Life expectancy after spinal cord injury: a 50-year study. Spinal Cord. 2012 Nov. 50 (11):803-11. [Medline].

O’Connor P. Incidence and patterns of spinal cord injury in Australia. Accid Anal Prev. 2002 Jul. 34(4):405-15. [Medline].

Todd NV. Priapism in acute spinal cord injury. Spinal Cord. 2011 Oct. 49(10):1033-5. [Medline].

Collignon F, Martin D, Lenelle J, Stevenaert A. Acute traumatic central cord syndrome: magnetic resonance imaging and clinical observations. J Neurosurg. 2002 Jan. 96(1 Suppl):29-33. [Medline].

Spivak JM, Weiss MA, Cotler JM, Call M. Cervical spine injuries in patients 65 and older. Spine (Phila Pa 1976). 1994 Oct 15. 19(20):2302-6. [Medline].

Tator CH, Fehlings MG. Review of clinical trials of neuroprotection in acute spinal cord injury. Neurosurg Focus. 1999 Jan 15. 6(1):e8. [Medline].

Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. 1997 May 28. 277(20):1597-604. [Medline].

Aarabi B, Hadley MN, Dhall SS, et al. Management of acute traumatic central cord syndrome (ATCCS). Neurosurgery. 2013 Mar. 72 Suppl 2:195-204. [Medline].

Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013 Aug. 60 Suppl 1:82-91. [Medline].

McKinley WO, Tewksbury MA, Godbout CJ. Comparison of medical complications following nontraumatic and traumatic spinal cord injury. J Spinal Cord Med. 2002 Summer. 25(2):88-93. [Medline].

McDonald JW, Sadowsky C. Spinal-cord injury. Lancet. 2002 Feb 2. 359(9304):417-25. [Medline].

Brown TG. On the nature of the fundamental activity of the nervous centres; together with an analysis of the conditioning of rhythmic activity in progression, and a theory of the evolution of function in the nervous system. J Physiol. 1914 Mar 31. 48(1):18-46. [Medline]. [Full Text].

Edgerton VR, Harkena SJ, Dobkin BH. Retraining the human spinal cord. Lin VW, ed. Spinal Cord Medicine: Principles and Practice. New York, NY: Demos; 2003. 817-26.

Ito Y, Sugimoto Y, Tomioka M, Kai N, Tanaka M. Does high dose methylprednisolone sodium succinate really improve neurological status in patient with acute cervical cord injury?: a prospective study about neurological recovery and early complications. Spine (Phila Pa 1976). 2009 Sep 15. 34(20):2121-4. [Medline].

Sugarman B. Medical complications of spinal cord injury. Q J Med. 1985 Jan. 54(213):3-18. [Medline].

Ginis KA, Hicks AL, Latimer AE, et al. The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord. 2011 Nov. 49(11):1088-96. [Medline].

Biering-Sorensen B, Kristensen IB, Kjaer M, Biering-Sorensen F. Muscle after spinal cord injury. Muscle Nerve. 2009 Oct. 40(4):499-519. [Medline].

Petropoulou KB, Panourias IG, Rapidi CA, Sakas DE. The phenomenon of spasticity: a pathophysiological and clinical introduction to neuromodulation therapies. Acta Neurochir Suppl. 2007. 97:137-44. [Medline].

Giuliano F, Rubio-Aurioles E, Kennelly M, et al. Efficacy and safety of vardenafil in men with erectile dysfunction caused by spinal cord injury. Neurology. 2006 Jan 24. 66(2):210-6. [Medline].

Atkinson PP, Atkinson JL. Spinal shock. Mayo Clin Proc. 1996 Apr. 71(4):384-9. [Medline].

Ditunno JF Jr, Formal CS. Chronic spinal cord injury. N Engl J Med. 1994 Feb 24. 330(8):550-6. [Medline].

Garshick E, Kelley A, Cohen SA, et al. A prospective assessment of mortality in chronic spinal cord injury. Spinal Cord. 2005 Jul. 43(7):408-16. [Medline]. [Full Text].

Groah SL, Stiens SA, Gittler MS, Kirshblum SC, McKinley WO. Spinal cord injury medicine. 5. Preserving wellness and independence of the aging patient with spinal cord injury: a primary care approach for the rehabilitation medicine specialist. Arch Phys Med Rehabil. 2002 Mar. 83(3 Suppl 1):S82-9, S90-8. [Medline].

Hagen EM, Faerestrand S, Hoff JM, Rekand T, Gronning M. Cardiovascular and urological dysfunction in spinal cord injury. Acta Neurol Scand Suppl. 2011. 71-8. [Medline].

Harrop JS, Sharan A, Ratliff J. Central cord injury: pathophysiology, management, and outcomes. Spine J. 2006 Nov-Dec. 6(6 Suppl):198S-206S. [Medline].

Hartkopp A, Bronnum-Hansen H, Seidenschnur AM, Biering-Sorensen F. Suicide in a spinal cord injured population: its relation to functional status. Arch Phys Med Rehabil. 1998 Nov. 79(11):1356-61. [Medline].

Krause JS, Broderick L. A 25-year longitudinal study of the natural course of aging after spinal cord injury. Spinal Cord. 2005 Jun. 43(6):349-56. [Medline].

Lee BY, Ostrander LE. The Spinal Cord Injured Patient. Comprehensive Management. 2nd ed. Philadelphia, Pa: WB Saunders; 2001. 97(2 Suppl): 252-65.

McDonald JW, Becker D, Sadowsky CL, Jane JA Sr, Conturo TE, Schultz LM. Late recovery following spinal cord injury. Case report and review of the literature. J Neurosurg. 2002 Sep. 97(2 Suppl):252-65. [Medline].

McKinley WO, Gittler MS, Kirshblum SC, Stiens SA, Groah SL. Spinal cord injury medicine. 2. Medical complications after spinal cord injury: Identification and management. Arch Phys Med Rehabil. 2002 Mar. 83(3 Suppl 1):S58-64, S90-8. [Medline].

Platz A, Kossmann T, Payne B, Trentz O. Stab wounds to the neck with partial transsection of the spinal cord and penetrating injury to the esophagus. J Trauma. 2003 Mar. 54(3):612-4. [Medline].

Previnaire JG, Soler JM, Leclercq V, Denys P. Severity of autonomic dysfunction in patients with complete spinal cord injury. Clin Auton Res. 2012 Feb. 22(1):9-15. [Medline].

Raviv G, Madgar I, Elizur S, Zeilig G, Levron J. Testicular sperm retrieval and intra cytoplasmic sperm injection provide favorable outcome inspinal cord injury patients, failing conservative reproductive treatment. Spinal Cord. 2013 May 21. 10:1038/sc.2013.44.

Reis AJ. New surgical approach for late complications from spinal cord injury. BMC Surg. 2006 Oct 23. 6:12. [Medline]. [Full Text].

Rodrigues CL, Gondim FA, Leal PR, et al. Gastric emptying and gastrointestinal transit of liquid throughout the first month after thoracic spinal cord transection in awake rats. Dig Dis Sci. 2001 Aug. 46(8):1604-9. [Medline].

Rozzelle CJ, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Ryken TC. Spinal cord injury without radiographic abnormality (SCIWORA). Neurosurgery. 2013 Mar. 72 Suppl 2:227-33. [Medline].

Shields RK, Dudley-Javoroski S. Musculoskeletal deterioration and hemicorporectomy after spinal cord injury. Phys Ther. 2003 Mar. 83(3):263-75. [Medline].

Francisco de Assis Aquino Gondim, MD, MSc, PhD, FAAN Professor Adjunto of Neurology and Clinical Skills, Department of Internal Medicine, Universidade Federal do Ceará, Brazil

Francisco de Assis Aquino Gondim, MD, MSc, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, International Parkinson and Movement Disorder Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Consultant for Pfizer<br/>Serve(d) as a speaker or a member of a speakers bureau for: Speaker for Shire and BSL Beringer<br/>Received travel grants from for: Aché, Biogen, Genzyme, Ipsen, Novartis, Baxter, Teva, Pfizer.

Florian P Thomas, MD, PhD, MA, MS Chair, Neuroscience Institute and Department of Neurology, Director, Multiple Sclerosis Center and Hereditary Neuropathy Centers, Hackensack University Medical Center; Founding Chair and Professor, Department of Neurology, Hackensack Meridian School of Medicine at Seton Hall University; Professor Emeritus, Department of Neurology, St Louis University School of Medicine; Editor-in-Chief, Journal of Spinal Cord Medicine

Florian P Thomas, MD, PhD, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Spinal Cord Trauma and Related Diseases

Research & References of Spinal Cord Trauma and Related Diseases|A&C Accounting And Tax Services
Source

Share on Facebook

Tweet

Follow us