Minimizing the damage done by an injury to the spinal cord requires fast action and advanced technology.
“Time is spine.” That's a favourite phrase of University of Toronto neurosurgeon Michael Fehlings, who uses it to stress the urgency of immediate action for victims of a spinal cord injury. “From the moment of injury the clock is ticking.”
Traumatic injury to the spinal cord is a two-step process. The immediate damage from an accident is mechanical. This 'core injury' can lead to irreversible damage to a portion of the spinal cord, but the best medical care can limit the overall physical consequences. Within minutes of the injury, however, a secondary phase of damage begins (see 'Chemical brace,' page S10). In many cases, surgery soon after a spinal injury can improve the patient's outcome, but medics must also act quickly to deal with potential problems beyond the patient's spine. Only an inclusive approach can ensure that someone with a spinal injury can make the best possible recovery.
Although doctors have long known that rapid treatment helps recovery, Fehlings says it is only in the past 25 years that we have started to understand just how crucial time is. He says that “a shift in practice” is emerging, based on research showing that the damage from a spinal cord injury can be limited by early action. Consequently, a combination of advances in surgical procedures and neuroprotective drugs may mean that even patients with serious spinal injuries have a better chance of making a full recovery.
Getting the right early treatment requires quick action by a comprehensive team of spinal specialists, which includes emergency medical professionals at the scene of the accident, and nurses, physicians, imaging experts, neurosurgeons and physical therapists at the hospital. Laura Pimentel, an emergency-room physician at the University of Maryland School of Medicine in Baltimore, emphasizes the importance of properly trained emergency medical personnel in helping to limit damage after a spinal cord injury.
For any trauma patient, emergency medical staff follow standard immobilization procedures before transport to a trauma centre, Pimentel says. More than half of the spinal cord injuries in the United States involve the cervical (neck) vertebrae, because human anatomy allows more movement in the neck than elsewhere in the spine, leaving it more vulnerable. Moreover, injuries to the first two to three cervical vertebrae can interfere with breathing, she says, and the airway must be evaluated and protected before transport.
At the hospital, a precise neurological evaluation is crucial for understanding the extent of the damage, from vertebral fractures to spinal cord damage, says John Ditunno, professor of rehabilitation medicine at Jefferson Medical College, Thomas Jefferson University, in Philadelphia. Modern evaluation often includes imaging studies.
The type of imaging technology used depends on the nature of the injury. In developed countries with an ageing population, trauma centres are seeing an increase in spinal injuries resulting from falls. “The most common injury that we are now seeing among the baby-boom generation is something called a cervical central cord injury,” says Pimentel. Here, a combination of arthritis-induced narrowing of the bony passage for the spinal cord, possible age-related damage to intervertebral discs, and a fall can result in an incomplete injury in the spinal cord in the neck.
It is difficult to use imaging to assess the damage in these circumstances. “Particularly in older patients, there are too many false-negative X-rays,” Pimentel says. “It becomes a little difficult to distinguish a change on an X-ray that is the result of ageing, arthritis and osteoporosis from a fracture.” But finding any fracture could mean life or death. As Pimentel says, “If you miss a fracture in a person's neck and they end up with a second spinal cord injury, that patient is quadriplegic, or it can even be fatal.” In the past five to ten years, computed tomography (CT) scans have started to replace simple X-rays as the standard way to assess cervical spine damage.
But even a more sensitive CT scan cannot show everything that could be damaged in a spinal cord injury. “CT scans are very good when it comes to identifying bony injuries — fractures — but when it comes to actually evaluating the cord itself and soft tissues, such as discs, then MRI [magnetic resonance imaging] is actually a much better technology,” says Pimentel. Since the early 1990s, physicians have recognized the value of MRI for assessing soft-tissue damage, particularly when there is neurological damage but no apparent fracture.
Surgery can be recommended after a spinal cord injury for various reasons, including removing bone fragments or repairing fractured vertebrae. The question of when to operate after a spinal cord injury has been the subject of debate, but consensus seems to be building towards early surgery. A recent survey of 971 neurosurgeons indicated that more than 80% would operate to take pressure off the spinal cord, even for an incomplete injury, within 24 hours of the injury occurring1. “An important clinical breakthrough is the idea that surgical decompression can influence recovery from traumatic spinal cord injury,” says Fehlings.
In fact, a multicentre, international, prospective cohort study that examined the timing of surgery in adults with cervical spinal cord injury showed that surgical intervention within 24 hours of injury increased the odds of a significant neurological recovery almost three-fold compared with delayed intervention2. This study followed 313 patients for six months after surgery to release pressure on the damaged area of the spinal cord. “The important impact of operating early is that once the spine is stabilized, the patient can be mobilized,” says Fehlings, the study's lead author. For patients with these injuries, “early surgery reduces complications and length of stay in the ICU [intensive care unit].” For central cord injury, on the other hand, the value of early surgery is much less clear.
The findings in emergency medicine reveal a surprising aspect of treating spinal cord injuries: it is not exclusively about the spine. Unless it is very high in the neck, “few patients under 50 die exclusively of spinal cord injury,” says Ditunno. These injuries can affect all the major systems of the body. Consequently, standard treatments now include stabilization of blood pressure and insertion of a catheter into the bladder to reduce the chance of bladder infection, which is one of the leading causes of complications and death in patients with spinal injuries. According to Ditunno, complications from bedsores, blood clots moving to the lungs from the legs, and infections of the bladder, kidneys and lungs can now be prevented.
“We teach that pressure sores are 100% preventable,” Ditunno says. “These things matter.” Many people don't realize that three hours of being immobilized on a backboard without being turned can create a pressure sore. The actor and spinal cord injury campaigner Christopher Reeve died from complications caused by a pressure ulcer. So although this information has been around for several years, some medical experts still need to pay more attention to it. “A lot of people talk about the neurological [issues], but these other things result in much longer hospital stays,” Ditunno says.
Part of the problem with the emphasis on speed is that some doctors might get left behind.
Part of the problem with the emphasis on speed is that some doctors might get left behind. “If you are at an emergency room that doesn't necessarily see spinal cord traumas all the time, then the physicians may not be aware of all the advances that have been made, so they may stick with the training that they had 20 years ago,” says Kim Anderson-Erisman, associate professor in the Department of Neurological Surgery at the University of Miami School of Medicine in Florida. She often serves as a liaison between the research team, the referring physicians and the community of patients with spinal cord injuries. At the age of 17, Anderson-Erisman was involved in a car crash that left her with a cervical spinal cord injury and quadriplegic paralysis.
“Having a spinal cord injury myself, it kind of keeps everybody real,” she says. As an advocate for patients with these injuries, she champions a range of outcomes as successes. From a patient poll, for example, she identified areas such as the use of the hands, control of the bladder and bowels, and the ability to live independently as important3.
To increase the odds that patients can maintain those capabilities, immediate and ongoing care should be coordinated within a team of medical specialists. The latest advances in treating spinal cord injuries must be widely disseminated. To help with that, some professional groups provide electronic-learning (e-learning) resources. For example, the International Spinal Cord Society (ISCoS) in Aylesbury, UK, has developed elearnsci.org, a web-based educational resource for medical and paramedical professionals who are involved in spinal cord injury treatment. Creating such a resource requires worldwide collaboration, and ISCoS's e-learning tool arose from the support of several organizations: the Asian Spinal Cord Network in Fermanagh, UK; the Indian Spinal Injuries Centre in New Delhi, India; the University of Sydney in Australia; and Livability, an organization based in London that campaigns for the disabled.
In addition, the American Spinal Injury Association (ASIA) in Atlanta, Georgia, has established an International Standards Training e-Learning Program (InSTeP), which is a six-module course designed to enable clinicians to perform accurate and consistent neurological examinations of adults with spinal cord injury. ASIA also provides a paediatric evaluation tool called WeeSTeP, and its free online courses include assessments and a course completion certificate.
Such resources will help medical professionals stay informed as research into trauma care for spinal injuries continues. For example, neuroprotective agents against secondary injury remain in their infancy. Advances there alone might keep many more patients with spinal injuries walking in the next 25 years.
Fehlings, M. G. et al. Spine 35, S166–173 (2010).
Fehlings, M. G. et al. PLoS ONE 7, e32037 (2012).
Anderson, K. D. J. Neurotrauma 21, 1371–1383 (2004).
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Hede, K. Emergency medicine: The need for speed. Nature 503, S14–S15 (2013). https://doi.org/10.1038/503S14a
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