Injuries to the spinal cord can be debilitating, devastating and sometimes fatal. Those who survive such traumatic events are often faced with extended periods of recovery, irreversible limitations in activities, and the daunting prospect of re-learning to complete tasks associated with daily living. There is hope, however, for those facing the aftermath of such injuries as skilled local medical professionals offer expert surgical and rehabilitation care in an effort to return patients to the highest quality of life possible.
Patience and Skilled Care Battle Unexpected Traumas
By Mike Haskew
Although no one expects to sustain a catastrophic injury to the spinal cord, such trauma takes place every day. An estimated 10,000 to 12,000 injuries to the spinal cord occur each year in the United States, while a quarter of a million Americans are currently living with some degree of spinal cord injury. Statistics indicate that men are far more likely to suffer such injuries than women. Perhaps because of a greater willingness to engage in risky behavior, men sustain more than 80 percent of all spinal cord injuries, and 55 percent of these are among the age group from 16 to 30.
In addition, 38.5 percent of all spinal cord injuries are the result of automobile accidents, while nearly 25 percent are sustained due to violence involving guns and knives. Smaller percentages are due to hunting accidents, work related mishaps, accidents in the home, and other misfortunes.
In short, most spinal cord injuries are related to accidents, which in many cases are preventable. However, as they continue to occur, there are treatment options and positive outcomes.
Dr. Michel Paré of Chattanooga Neurosurgery and Spine says that in severe spinal cord injuries, recovery is dependent on the regenerative ability of the neuronal tissue, which unfortunately is very limited even though research has studied the problem extensively for the last 30 years. Consequently, prevention is of the utmost importance. He says that studies of the demographics of spinal cord injuries show that the highest incidence of injuries occurs in young males, ages 16 to 30 whose injuries are a result of their own risky behavior.
In Northwest Georgia, a chapter of the ThinkFirst Foundation, a nationally sponsored injury prevention program, has been recently instituted. It offers information and education to youth about decision-making skills and brain and spinal cord safety. Each year ThinkFirst chapters provide thousands of educational presentations to schools, businesses, organizations, conferences and community events to help people reduce their risk of catastrophic injury.
Life and Death Injuries
“Spinal cord injuries are moderately common,” remarks Dr. Brian Kalla, physiatrist at Siskin Hospital for Physical Rehabilitation. “They are not as common as strokes or broken hips or some of the other things we see here at Siskin, but we do see such injuries as often as a couple of times a month.”
While they are fewer in number than other conditions treated at Siskin, the tragedy of a spinal cord injury may present lingering disability such as complete or partial paralysis. “They may be among the fewest types of conditions we see, but they have some of the most profound effects on people’s lives,” continues Dr. Kalla.
“There are different levels of spinal cord injury, and an injury to the neck is much worse than to the lower back. In the neck, all four extremities can be affected. Sometimes there is total paralysis with no sensation, or there may be incomplete paralysis with either bruising or some level of trauma. Some function may remain with tingling, numbness or weakness that is greater than normal.”
According to Dr. Kalla, the difference between life and death may depend largely on the area of the spine which is injured. An injury above the level of the C-5 cervical vertebra can affect breathing to the extent that a patient is unable to breathe on their own. Immediate access to a ventilator is imperative in such cases. The injury sustained by actor Christopher Reeve is a prime example of the potential devastation suffered with damage to the spinal cord above C-5.
“Other patients may be able to move a little bit, which is better than not at all,” says Dr. Kalla, “or they may be able to walk with a walker or with braces on their legs or a cane. Some patients with more serious injuries may die during the initial recovery period due to complications such as pneumonia or an infection somewhere due to a wound that won’t heal but not directly from the spinal injury itself. I have had a few patients with such injuries get sick and die, but less than five percent of those who make it into rehabilitation do not survive.”
According to Dr. Daniel Kueter, a neurosurgeon with Chattanooga Neurosurgery and Spine, the most common injuries to the spinal cord are broken bones in the neck and back or disrupted discs. If the injury is severe, then the spinal cord will be compressed or injured as it is traveling through the spine.
“We define a severe injury as one in which the spinal cord has been severely compressed or transected,” Dr. Kueter adds. “In those instances, a patient will lose bodily function at the point of injury and at all bodily sections below that level. If someone sustains an injury in the upper neck area, that can be devastating with paralysis from the neck down.”
The health of the spinal cord is essential to normal function, and any serious trauma to it may have extensive repercussions. As the primary highway for the body’s sensory and motor functions, it relays signals to and from the brain. “When damaged,” Dr. Paré says, “regeneration is dismal. Neurons have been shown to possess some intrinsic ability to regrow but the distance they have to cover to form functional connections and the inhibitive scar formation which occurs after injury greatly limits this potential.”
“The spinal cord is the major electrical conduit that connects the brain to the rest of the body,” explains Dr. Kueter. “It allows the brain to perceive what is going on in the outside environment. The spinal cord also allows the brain to control the body and interact with the outside world. If the spinal cord is injured, then there is a disconnect between the brain and the body. The spinal cord is composed of hundreds of millions of tiny nerve fibers all working in unison to relay information between the brain and the body.”
When a spinal cord injury occurs, time is of the essence. Immediate assessment and appropriate care on the scene can improve a victim’s chances for at least a partial recovery.
Dr. Amjad Munir, medical director at HealthSouth Chattanooga Rehabilitation Hospital, comments, “The first step in the treatment of a spinal cord injury is to keep a high degree of suspicion at the site of the accident. Proper airway, breathing and circulation are maintained at the scene by paramedics. The injured spine is immobilized on a spine board, and the patient is transported to the hospital. Once at the hospital, after medical stabilization, the level and type of injury are determined. Depending on the type of injury, a person may need surgery.”
Spinal surgery, says Dr. Kueter, consists of two processes: an un-pinching or decompression of the spinal cord and an instrumentation or fusion of the broken spinal segments. Once surgery is completed, a period of waiting and observation ensues with the hope that the spinal cord can repair some of the damage sustained on its own. The most rapid degree of improvement takes place during the first three to six months of recovery; however, the spinal cord may take up to two years to reach its highest degree of improvement.
Dr. Munir says, “Rehabilitation goals include maximizing physical independence, becoming independent in the direction of care, and preventing complications which can be life threatening. A person with a spinal cord injury can greatly benefit from an inpatient acute rehabilitation program using an interdisciplinary team approach. A rehabilitation team typically consists of a rehabilitation physician, physical therapist, occupational therapist, speech pathologist, respiratory therapist, rehabilitation nurse, psychologist and orthotist. Patients and family members are crucial members of the rehabilitation team as well.”
“The best two things for spinal cord injuries are time and physical rehabilitation,” says Dr. Kueter. “The spinal cord will try to heal itself, but this is a slow process. If you break your arm bone, the doctor puts it in a cast and it takes about eight weeks to heal up. The spinal cord is a much more complicated structure composed of millions of nerve fibers all trying to reconnect themselves and repair their damage. So, the most important thing is to put the spinal cord in a safe environment and allow it to heal without getting pinched or bruised. During this waiting time, an aggressive rehab program is very important. We work closely with all of the rehab hospitals and physical therapy clinics in town to ensure a comprehensive program to optimize muscle function and mobilization.”
For some patients, the extent of recovery revolves around the ability to care for themselves to the best of their ability. A return to the highest level of functionality is the goal of a rehabilitation program.
“From the rehab doctor’s point of view, the things I focus on are teaching the activities of daily living,” relates Dr. Kalla. “There are certain things that people do every day, like go to the bathroom, feed ourselves, dress ourselves and clean ourselves. For those that need it, we spend a lot of time working on transferring them from the bed to a chair and back, on bathing themselves, and other things. Another problem that people run into is spasticity, the contraction of the muscles where they want to draw up on the patient. Sometimes we have to deal medically with that spasticity and with problems of bladder and bowel control either using medicine or teaching the patient how to catheterize themselves.
“Although most patients with spinal cord injuries continue to have life-long impairments, with good quality rehabilitation and proper medical care they usually can regain significant independence and a reasonably good quality of life.”
Groundbreaking research and treatment protocols for spinal cord injuries are emerging, and of particular interest is the introduction of stem cells which has shown promise among laboratory animals and may indeed regenerate nerve cells in humans. A leader in spinal cord research is the Miami Project, which was founded at the University of Miami by Nick Buoniconti, a former linebacker with the Miami Dolphins of the National Football League whose son Mark was paralyzed due to a football injury in 1985.
The most recent data available on spinal cord injury outcomes is generated by the STASCIS trial (Surgical Treatment for Acute Spinal Cord Injury Study). Preliminary results indicate that a quarter of the patients who receive decompression and stabilization surgery within 24 hours of their injury experience a “2 grade” improvement (each grade relates to level of function) in their long-term outcome. Only four percent of patients who undergo delayed surgery show this degree of improvement. The final results of the study are to be published in 2011 and are expected to reinforce the early findings.
“Working in the rehabilitation field over a period of time, I have seen several success stories of persons who were quite disabled initially due to a spinal cord injury,” comments Dr. Munir. “Gradually, they have regained some of their function and integrated into the community. They become more independent in self care, mobility and other activities of daily living and engaged in vocational activities.”
The Good and the Bad
“We see great outcomes every month,” acknowledges Dr. Kueter, “and unfortunately we also see poor outcomes every month. In general, younger people heal better than the elderly, and this is true with just about every medical process. There are certainly times that we see people come in with no movement in the arms and legs. If we can get the patient treated quickly and appropriately, then there is always a chance that they can improve with time.
“Just about every month,” he reflects, “someone comes into the clinic walking when they couldn’t walk in the hospital. Unfortunately, just about every month we also see someone in the clinic who hasn’t made much progress from their injury. We do our best with every patient and do surgery to give the spinal cord the opportunity to heal and repair itself. Sometimes the damage is too severe to overcome, but sometimes we are pleasantly surprised and are witnesses to great outcomes.”
Although the long-term effects of a serious spinal cord injury may be catastrophic, new research, surgical techniques, and rehabilitation care are improving the recovery and quality of life for those inflicted by this type of injury. Patience, perseverance and skilled care offer the best opportunity for regaining function and enjoying everyday life.
Mike Haskew is a graduate of the University of Tennessee at Chattanooga and holds a degree in history. He is a native Chattanoogan and is currently an executive with First Citizens Bank.