Axial and three-dimensional CT scans could reveal the shape of spinal canal and vertebral facet joints. For combined injuries, CT scan should be performed.
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MRI is the preferred examination for SCI patients, by which the location, severity, and extent of the injury of the cord can be observed clearly. Usually, the damaged disc and ligament or its displaced debris in the canal can be observed through MRI.
Incidence and mortality
However, the SEP examination could only test the sensory function, and not the locomotor function. ASIA grade B indicates that some sensation is preserved but motor score is zero below the injury level. The SCI therapeutic outcome partly depends on the number of surviving axons — the more the number of surviving axons, the more the neurological functions might be restored. The principles of SCI treatments include early reduction and fixation, combined extramedullary and intramedullary decompression, cell transplantation, early rehabilitation treatment, and complication prevention.
Neuroprotection is essential which aims at minimizing and even preventing secondary medullary lesion extension through medical measures which prevent apoptosis and cellular death, and promote neural survival. High-dose methylprednisolone MP therapy at early stage was once considered to be positive for neurological restoration in acute phase of SCI. So far, no undeniable proof supports its routine application.
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Latest research revealed that there was not enough medical evidence supporting that high-dose MP certainly improves neurological restoration in acute SCI; however, complications such as infection, respiratory impairment, gastrointestinal bleeding, and even death can happen more likely in patients who undergo high-dose MP therapy. Hence, high-dose MP therapy has no longer been used routinely in acute SCI, but it is still an optional therapeutic method. There is not enough clinical evidence supporting that GM-1 certainly improves neurological restoration and lowers mortality in acute SCI; therefore, GM-1 is not recommended for routine use in acute SCI.
Erythropoietin EPO has glioprotective and neuroprotective properties, which reduces medullary cavitation, cellular infiltration, and neuronal apoptosis. However, no definite conclusion has been drawn due to the insufficient number of the subgroups of patients. In addition, clinical trials of minocycline, naloxone, and tirilazad have shown limited therapeutic effects on patients with SCI.
Mannitol could alleviate secondary spinal cord edema, which supports its early application in the absence of contraindications. Rebuilding the stability of the spinal column with reduction and fixation of the vertebrae could restore the volume of the spinal canal with laminoplasty or laminectomy. Decompression of the spinal cord after acute SCI attenuates secondary injury, preserving neurological functions of the survived axons and preventing further spinal cord tissue destruction.
Decompression of the extradural elements is the primary focus in the management of patients with acute SCI. Little attention has been given to the potential deleterious secondary injury from spinal cord necrosis and hemorrhage. Following SCI, the resulting spinal cord swelling and any sustained external pressure may block normal cerebrospinal fluid flow and further increase spinal cord edema. Myelotomy and early debridement of necrosis may be beneficial in preventing complete paralysis by stopping further expansion of secondary injury, reducing the pressure of spared tissue and cerebrospinal fluids, preserving survived axons and spared spinal cord tissue, delaying the glial cell death in white matter, and providing conduction basis for neurological recovery.
Some data have showed that decompression of dura may limit the level of secondary injury in human and animal SCI. Clinical studies have reported the neurological improvement in acute SCI patients with myelotomy. Since complete transection of the spinal cord is quite rare in clinic, intramedullary decompression should be performed under microscope, while combining with findings of CT and MRI, to preserve survived axons in neurologically impaired patients.
Here are four types of surgical interventions for injured spinal cord and their effects:. Since the border between contusion and normal spinal cord is not clear at early stage, the range of the intramedullary decompression should not be extended too much. Intraoperative neurophysiological evaluation of acute or subacute SCI patients can provide information about spinal cord function that is not retrievable by other clinical methods and can correctly predict neurological outcome.
Cell therapy is a promising therapeutic option for acute and subacute SCI. There are a few clinical trials of cell therapy for acute or subacute SCI, with 33 or without positive outcome. The mechanisms of cell therapies for SCI include axonal remyelination and regeneration, neuroplasticity, neuroprotection, neuromodulation, neurorepair, anti-inflammatory response, neurogenesis, angiogenesis, reducing scar and cavity formation, and cell replacement. The neurologic system relies on biological electricity for information transfer, and local electric stimulation may improve and induce nerve axon regrowth.
Postoperatively, passive rehabilitation therapy such as massage and pressure therapy can not only reduce incidence of pressure sore and deep venous thrombosis but also restore neurological functions. The recommended positive training method is active movement-target enhancement-neurorehabilitation therapy, which can help patients to maximize functional neurorestoration. Acupuncture 36 and laser puncture 37 may promote functional recovery for patients with acute or subacute SCI with rare risks.
After cervical SCI, activities of sympathetic nerves are suppressed, while parasympathetic nerves are not affected; as a result, the patient would have more sputum, slower heart rate, and decreased blood pressure. The symptoms usually would be improved including increased heart rates and mean arterial pressure, and reduced sputum.
Hyponatremia often occurs at 6. In general, hyponatremia would disappear after Factors related to hyponatremia are level of cervical SCI, infections, use of ventilator, and medications such as dehydrating agent and diuretic. However, these two types of syndromes are difficult to distinguish, and fludrocortisone added into normal saline is safe and effective for agnogenic hyponatremia. Preventive measures for DVT include limb exercise and wearing elastic stockings. Once DVT occurs, anticoagulant therapy should be applied.
The thrombus may fall off, leading to embolisms of the heart, lung, and brain, and hence, caution is required. Difficult breathing and pulmonary infection are the main respiratory system complications after spine injury and SCI. Patients with cervical SCI up to C4 level or above might suffer from diaphragm muscular paralysis, and weakened or even disappeared cough reflex, leading to dyspnea and lung infection.
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At this point, it is necessary to apply tracheotomy, in order to facilitate sputum suction and ventilator support. Urinary tract infection is the main complication of urinary system after spine injury and SCI. It is critical to use urinary catheter, and to change the catheter every week, as well as performing bladder washing at regular intervals in order to avoid hydronephrosis and renal failure.
MRI can clearly show the current condition of the injured cord, such as atrophy, myelomalacia, cystic cavity, or even a syringomyelia, formatted scar, and cord compression if present. Paravertebral SEP can assess and judge the sensory level of injured cord, and electromyography can assess and judge the motor level of injured section.
The chronic SCI diagnosis includes the level and severity of the injury of the spinal cord and judging whether there is still compression in the injured spinal cord. If patients with chronic SCI still have serious cord compression, decompression might most likely help in neurological functional recovery. There are mainly three methods. Task-specific training with epidural stimulation might reactivate previously silent spared neural circuits or promote plasticity. These interventions could be a viable clinical approach for functional recovery for patients with complete chronic SCI.
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Brain—machine interfaces with neuroprosthetic limbs could help patients with long-term paralysis to perform several of the required activities of daily living. Recently, a study showed that muscle activation could be controlled by using intracortically recorded signals in a paralyzed human. Cell therapy has become an important therapeutic option for chronic SCI.
Thoracic and Lumbar Spine and Spinal Cord Injuries
Partial functions and the quality of life have been improved following transplantation of cells into cord parenchyma, intrathecal administration of cells lesion area or lumbar subarachnoid space , intravascular infusion of cells, and by multiple routes of administration. Several attempts have been made to deliver substrates around the injured cord via intrathecal injection. Intramedullary transplanted cells seem to be optimal for transplantation, which can directly interact with the host environment to activate or trigger dysfunctional neurons or axons, help axons to regenerate and sprout, remyelinate axons, and replace some kind of lost cells.
However, inappropriate cellular injections can be damaging, which induce technical failure with false results and conclusion. Risks of intrarparechymal injections include additional injury due to needle penetration, spinal cord motion during injection, creation of intraparenchymal pressure gradients and hydrodynamic dissection, and possible cord ischemia. Understanding these variables can maximize the safety of injections and avoid injury to spared structure.
Intensive exercise and biofeedback training can improve motor functions for patients with chronic incomplete SCI. While the beneficial effects of intensive exercise alone are limited in people with chronic SCI, many investigators believe that such exercise may be essential for motor recovery in people who have received restorative therapies. Multimodal intensive exercise can significantly improve motor function in subjects with chronic complete SCI, which might have therapeutic value for these patients as an adjunct to other restorative therapies.
An individual with chronic SCI ASIA grade A improved his over-ground walking ability following intensive physical therapy and robotic locomotor training. Yet, these studies were performed with small sample sizes, and so more studies are necessary. The degree of clinical neurological recovery by a single neurorestorative therapy is still limited. Preliminary results of combination therapies for complete chronic SCI are promising for more functional recovery, which include identical cell transplantation by two or more routes, two or three appropriate kinds of cells being transplanted in synergy, cell therapy with neurorehabilitation, cell therapy with laser puncture, and neurorehabilitation.
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