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Acute Spinal Cord Injury

Wise Young, MD, PhD

I receive many calls and emails from people and families with spinal cord injury.  It is better today compared to 1977 when I took care of my first spinal-injured patient and had to tell the family that there was nothing that we could do.  Here is what I say to families now. 

•  Focus on solvable problems.  Make sure that methylprednisolone is given within 8 hours after injury (this drug may improve recovery by 20%).  Find the best and most experienced surgeon.  If the spinal cord is compressed, make sure that it is decompressed as soon as possible.  Prevent complications by insisting on aggressive care of lung, bladder, and skin.  Start rehabilitation as soon as possible.

•  Recovery is the rule and not the exception in spinal cord injury.  
Most people recover some function after spinal cord injury.  On average, people with "complete" injuries recover 8% of the function they had lost, compared to 21% if they received methylprednisolone.  People with "incomplete" injuries recover 59% of lost function, compared to 75% if they received methylprednisolone.  Recovery takes a long time and work.  Many people recover function for 2 or more years after spinal cord injury.

•  Do not give up hope.
 Most scientists believe that it is not a matter if but a matter of when therapies will be available to restore function in spinal cord injury.  Clinical trials are testing therapies to restore function after injury.  Weigh potential risks and benefits carefully before participating in such trials.  Remember that the therapies will get better over time. 

What to ask your doctor?

Families and friends often don't even know what questions to ask the doctors.  Here are some questions to ask in the first hours after injury:

•  Was methylprednisolone given?  This is the high-dose steroid (30 mg/kg intravenous bolus followed by 5.4 mg/kg/hour for 23 hours if it is started within 3 hours and for 47 hours if between 3 to 8 hours after injury).  It should not be started more than 8 hours after injury.  Clinical trials have shown that this treatment improves recovery by about 20% when given within 8 hours after injury but does not help when started more than 8 hours after injury.  While methylprednisolone is not a cure, every little bit helps.  Complications are minimal.

•  What is the level and severity of spinal cord injury?  The consequences of spinal cord injury depend on the level and severity of injury.  Surgeons determine injury levels from the fracture site on the spinal column.  This may differ from neurological level determined from sensory and motor loss.  Spinal cord injury causes loss of sensation and voluntary movement below the injury site.  If the person has motor or sensory function below the injury level at the time of admission, the likelihood of substantial recovery is high. 

•  Has the spinal cord been decompressed?   The spinal cord injury usually results from fracture of vertebral bones that compress the spinal cord.  Continued spinal cord compression increases tissue damage and reduces functional recovery.  If the neck or cervical segments are fractured, traction may straighten out and decompress the vertebral column.  Chest or thoracic fractures cannot be decompressed by traction.  Surgery may be necessary to decompress and stabilize the spinal cord.

•  Has anticoagulation been started?  Blood clots may form in the legs and migrate to the lungs.  This is a serious complication that can be prevented by giving anticoagulants such as heparin or coumadin.  It may be necessary to place a filter (Greenfield filter) in the vein to the heart to catch clots.

•  Pulmonary, bladder, and skin care?   Spinal cord injury may compromise breathing and coughing.  After cervical spinal cord injury, artificial respiration may be necessary and pneumonia is common.  Spinal cord injury paralyzes the bladder and a catheter must be placed in the bladder to drain urine.  Continued pressure causes skin sores called decubiti.  Cushioning vulnerable areas and regular turning prevents this.

Some frequently asked questions and answers

Families and friends often search the Internet and encounter a bewildering array of information that is often out of date and contradictory. Here are some commonly asked questions and quick answers:

•   Will he/she recover?
 Recovery is the rule and not the exception after spinal cord injury.  The probability of recovery is high, especially after "incomplete" spinal cord injury.  Clinical trial data indicate that if a person had even slight sensation or movement below the injury site shortly after injury, they will recover an average of 59% of the function they lost and, if they receive high-dose methylprednisolone, they will recover an average of 75% of what they had lost.  People admitted to hospital with no motor or sensory function below the injury site recover an average of 8% of the function they had lost but will recover an average of 21% if they received methylprednisolone.

•   How long will recovery take?
   Recovery takes a long time.  Most recovery occur within 6 months but many people continue to recover function for a year or more.  A recent poll of the CareCure Community suggests that 61% recovered function more than one year after injury.  In another poll, 16-18% of people who are "complete" spinal cord injury recovered additional function 3 or more years after injury.  A recent study detailed how Christopher Reeve recover function over 7 years after his injury.  So, recovery frequently continues for years after injury.

•   What experimental clinical therapies are available?  
Several clinical trials are assessing therapies that are applied within 2 weeks after injury.  These include activated macrophages (which may help repair the injured cord), alternating currents (to stimulate regeneration), and AIT-082 (a drug that may stimulate growth factors and stem cell proliferation).  The macrophage trial is limited to people with "complete" thoracic spinal cord injury and requires surgery.  Please consider the risk and benefits of the trial carefully, including the risk of moving somebody to another center.

•   Do therapies have to be applied shortly after injury?
 Several experimental therapies are aimed at restoring function in chronic spinal cord injury, when recovery has stabilized a year or more after injury.  These include 4-aminopyridine (a drug that increases excitability of demyelinated axons), porcine fetal stem cell transplants (stem cells from pigs), and olfactory ensheathing glial transplants (cells from the nasal mucosa or from olfactory bulbs).  Other experimental therapies are being planned, including drugs and chemicals that block growth inhibitors.  Thus, there will be many opportunities to participate in clinical trials. 

How is acute spinal cord injury treated?  

Acute spinal cord injury refers to hours or days after spinal cord injury during which continued deterioration or tissue damage may occur.  Shortly after an injury, the spinal cord often does not appear to be severely damaged even though there may be immediate functional loss.  The injury initiates a cascade of chemical and cellular responses that contribute to further tissue damage, including inflammation, free radicals, and swelling (edema). The spinal cord may be compressed during this period.  Compression or decreased perfusion (blood flow) of the spinal cord aggravates the injury.  These causes of progressive tissue damage can and should be relieved as rapidly as possible.  The goal of acute spinal cord injury care is to stabilize the spinal cord to prevent further damage, save as much tissue as possible, and prevent complications of spinal cord injury.

•  Emergency management.  The first objective of emergency management of spinal cord injury is to establish ABC (airway, breathing, and circulation).  The spine must be immobilized to prevent further injury.  The patient must be transported rapidly to the nearest medical center, preferably a Level 1 Trauma Center.  If blood pressure is low, fluid and drug therapies must be given to maintain blood flow in the spinal cord.  In cervical spinal cord injuries that affect breathing, ventilatory support may be necessary.  A foley catheter is usually placed in the bladder to drain urine.

•  Methylprednisolone therapy. The patient should receive intravenous high-dose steroid methylprednisolone (30 mg/kg bolus followed by 5.4 mg/kg/hour for 23 hours) as soon as possible. This therapy improves neurological recovery by about 20%. If the methylprednisolone is started between 3-8 hours after injury, the infusion should be extended to 48 hours. If the methylprednisolone cannot be started within 8 hours, it should not be given. Therapy beyond 8 hours does not improve functional recovery.

•  Decompression of the spinal cord. If the spinal cord is compressed by bone or disc, every effort must be made to decompress the cord as soon as possible. Cervical spinal injuries can often be decompressed by traction of the spinal column to realign the vertebral bodies. However, thoracic and lumbosacral spinal fractures usually cannot be decompressed by traction alone. Surgery may be necessary to decompress the cord or spinal roots. Thoracic or lumbosacral spinal cord decompression may require opening the chest cavity or retroperitoneal space, requiring a team of surgeons. Some surgeons delay surgery for this reason, particularly patients that have so-called "complete" spinal cord injury. I believe that "complete" injuries should be treated as aggressively as incomplete spinal cord injuries.

To read more about spinal cord injury:

What is the Spinal Cord

What is Spinal Cord Injury

Spinal Cord Injury Levels and Classification

Acute Spinal Cord Injury

Chronic Problems of Spinal Cord Injury

Recovery and Treatment

Recovery from Spinal Cord Injury

Spinal Cord Injury and Family

Ten Frequently Asked Questions Concerning Cure of Spinal Cord Injury

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