Introduction
The spinal cord transmits signals from the brain to the body’s peripheral parts. The spinal cord is enclosed and safeguarded by layers of tissue known as the meninges and a column of vertebrae (spinal bones). The most common cause of a spinal cord injury is a rapid, severe impact on the vertebrae. Therefore, the spinal cord and its nerves are harmed by the fractured (broken) bones. Spinal cord damage may split or entirely tear it in some rare circumstances.
Types of SPI
There are two types of spinal cord injuries:
- Complete: Total paralysis (loss of all motor and sensory function) below the level of the injury results from a complete injury. Both sides of the body are impacted. Complete damage may result in the paralysis of the lower body (paraplegia) or all four limbs (quadriplegia). Nearly half of all SCIs are complete injuries. The spinal cord is rarely severed or transected, even with a complete SCI. Most frequently, a spinal cord contusion or disruption of blood flow to the injured area of the spinal cord results in loss of function.
- Incomplete: One or both sides of the body still have some function after an incomplete injury. There are still some channels of communication between the body and the brain.
The American Spinal Injury Association (ASIA) grading scale, which rates the severity of the injury, is used to evaluate SCIs. Letters are used to rate the scale:
- ASIA A: Injury is defined as a total loss of sensory or motor function in the spinal cord.
- ASIA B: A sensory incomplete damage with total motor function loss.
- ASIA C: A motor incomplete injury in which there is considerable mobility but only about half of the muscle groups are anti-gravity (can lift up against the force of gravity with a full range of motion).
- ASIA D: More than half of the muscle groups with motor incomplete damage are anti-gravity.
- ASIA E: Normal.
The probability of recovery decreases with the severity of the injury.
Causes
Below are a few potential causes of spinal cord injury, listed in order from most to least frequent:
- Vehicle accident injuries, particularly injuries to the face, head, neck, back, or chest.
- Falls.
- Shots from a gun.
- Sports injuries.
- Complications after surgery.
- Diving too deeply and hitting bottom in shallow water
- Electricity shocks
- Severe twisting of the torso in the midsection.
- Infections that result in spinal cord abscesses
Symptoms
The body loses a number of vital processes if nerves and the brain can no longer communicate as a result of an injury. The kind (complete or incomplete) and location of the damage determine the symptoms of a spinal cord injury.
- Arrhythmia
- Issues while walking
- The inability to control the bowels or bladder
- Being unable to move the limbs
- Numbness or tingling that spreads to the extremities
- Unconsciousness
- Headache
- Back or neck discomfort, tightness, and pain
- Symptoms of shock
- Abnormal bumps along the spine and an unnatural head position.
- Trouble breathing
- Concussions of the spine can also happen. These can be either complete or partial, but spinal cord dysfunction is temporary and usually goes away within a day or two. The latter may lead to neurological symptoms like burning in the limbs, numbness, twitching, and electric shock-like experiences.
Clinical Presentation
Since traumas are by definition, the cause of spinal cord injuries, the initial examination and presentation will take place in a crisis response environment. A pulmonary evaluation is part of the initial assessment to ascertain whether there has been lung damage or loss of ventilatory function. In this initial assessment, bleeding symptoms and neurogenic shock are also looked for.
The final step, which is most important to physical therapy, is a neurologic assessment, which includes examining perineal function, sensory processing, deep tendon reflexes, and motor function.
Diagnostic Approaches
Acute or chronic spinal cord injuries can be diagnosed with the help of imaging technology. Depending on the specific pathology, multiple imaging techniques can be used to detect a spinal cord injury.
The gold standard for imaging neurological tissues, including the spinal cord, ligaments, discs, and other soft tissues, consists of an MRI scan.
Only sagittal T2 MRI sequences were shown to be effective for prognosis.
Computed tomography (CT) is superior at identifying spinal fractures and bone lesions, while a CT scan or an MR angiography can find vascular damage.
Outcome Measures
- Cite an instrument associated with the ICF classification.
- Instruments for measuring deficits
- Instruments for measuring disability
- Spinal Cord Independence Measure (SCIM)
- Scale of the Spinal Cord Injury Lifestyle (SCILS)
- WHOQOL-BREF
Medical Administration
A combination of pharmaceutical therapy, early surgery, intensive volume restoration, blood pressure elevation to maximize spinal cord perfusion, early rehabilitation, and cellular therapies is the best way to treat acute spinal cord injuries.
Pharmacological Management
There is yet no pharmaceutical agent that is widely used.
The most significant contenders are:
- Glucocorticoids (Methylprednisolone): They largely reduce the “secondary” effects associated with spinal cord damage. These include excitotoxicity, lipid peroxidation, and inflammation. Both the conclusions of randomized clinical trials and those of experts are uncertain.
- Thyrotropin-releasing Hormone (TRH): Demonstrates antagonistic actions against the mediators of subsequent damage.
Docosahexaenoic Acid (DHA), one type of polyunsaturated fatty acid, has lately been investigated for the therapy of spinal cord injuries. The improved neuronal and oligodendrocyte survival and reduced microglia/macrophage reactions, which lessen the axonal buildup of B-Amyloid Precursor Protein (b-APP) and boost synaptic connection, are thought to improve neurological recovery. Similar to this, Eicosapentaenoic acid (EPA) boosts synaptic connections to reestablish neuroplasticity.
Surgical Intervention
A better neurological prognosis is obtained with early surgical decompression.
On rare occasions, a surgeon could decide to take a patient straight to surgery if it looks like a herniated disc, blood clot, or other lesion has compressed the spinal cord. Patients with an incomplete SCI or gradual neurological deterioration are the ones who have this procedure the most frequently. Even if surgery cannot repair spinal cord damage, it might still be necessary to stabilize the spine to avoid further pain or deformity. The procedure that will benefit the patient the most will be chosen by the surgeon.
Interventions using Cellular Therapy
Traumatic SCI is characterized by diverse and intricate pathophysiology. Although pre-clinical research on SCI has been continuing for more than a century, in the last several decades our understanding of SCI processes has grown significantly. This is mostly attributable to the creation of fresh transgenic and preclinical animal models, which has sped up the understanding of SCI processes. Even though SCI research has come a long way, much more effort is still required to apply what has been learned from trials on animals to clinical settings including people
Through axonal regeneration and restoration, cellular therapies seek to enable functional recovery of the deficiency.
One of the cell types most frequently used for spinal cord repair is the Schwann cell.
Examination
A comprehensive history and examination can lead to a diagnosis. By conducting a neurological examination, and if feasible, taking part in a trustworthy physical neurological examination, for the body’s sensory and motor functions in the relevant region of complaints. We can determine the extent and location of the injury after the examination. If the site of the injury is identified, we can carry out some additional examinations as detailed on the pages that follow:
- The Cervical Exam
- The Lumbar Exam
- The Thoracic Exam
Physical Therapy Management
Depending on the level of the spine where the injury occurred, people who have experienced a spinal cord injury must undergo rehabilitation. The type of therapy also relies on whether the spinal cord injury was complete or incomplete. 25% of people who have incomplete spinal cord damage never regain independent mobility. The treatments vary depending on whether the lesion occurred in the cervical, thoracic, or lumbar regions. It takes a multidimensional approach to treat SCI.
Possible Treatment for Upper Incomplete SCI:
The effects on the patient are severe when the cervical spine is hurt.
Patients require therapy for upper body movement and muscle restoration as well as maybe breathing exercises.
Muscle strength and endurance gains through respiratory muscle training might be inspiratory, expiratory, or a combination of the two.
Normocapnic hyperpnea is a technique for building respiratory muscular endurance that works both the inspiratory and expiratory muscles at once.
This apparatus consists of a re-breathing bag attached to a tube system and mouthpiece that operates at 30 to 40% of the patient’s vital capacity.
With each breath, the patient must completely fill and empty the bag.
There are also useful methods for strengthening the respiratory muscles.
The clinical rehabilitation programme for people with SCI is guided by the study by Holmlund T et al. in order to reach the necessary physical activity levels.
In patients with bone or ligament injuries, spinal immobilization should be the main goal, along with avoiding the possibility of spinal cord injury.
Training the upper limb after SCI typically involves performing particular exercises or receiving conventional therapy that combines functional electrical stimulation and Bobath principles.
Possible Treatment for Lower Incomplete SCI:
Lower partial SCI patients’ main drawbacks are decreased coordination, leg paresis, and poor balance.
Braces and tilt tables can be used to overcome these constraints.
If the patient’s leg strength increases, therapists can concentrate on improving their weight-bearing balance by using braces, parallel bars, and other walking aids.
Along with these tools, the patient must be trained by the therapist, utilizing intense, repetitive gait exercises.
Only in specific SCI situations, and only at the therapist’s discretion, is the use of a treadmill with an overhead harness appropriate.
The harness makes it easier for patients to concentrate on their stride while being monitored by their therapist.
To maximize the patient’s rehabilitation, functional electrical stimulation must be used in addition to this therapy.
Robotic-assisted gait training is one of the new therapies that is evolving positively.
This therapy uses a 40-minute session twice daily, or once every five days. 3 days of conventional physical therapy and 2 days of robotic-gait training.
Functional electrical stimulation and physical treatment based on the Bobath Principles are both included in routine physical therapy.
After partial or total SCI, full recovery is never possible.
