Neurological outcomes of acute traumatic spinal cord injuries with active physiological conservative management and without interventions

Historical:

Before WWII the great majority of patients with acute traumatic spinal cord injuries died within a year or two from injury. However for many decades prior to WWII there was no shortage of Physicians and Surgeons experimenting with the management of the injured spine. The survival of patients was made possible during the 2nd World War when a Holistic Model of Service Delivery was developed by Sir Ludwig Guttmann (an experienced neurosurgeon) who studied in depth the patho-physiological and other medical and non-medical effects of condition. In order to achieve best results, Guttmann found it necessary to ensure the simultaneous management of the injured spine as well as the systemic medical and non-medical effects of cord and cauda equina damage from the early hours or days of injury. This is to prevent complications that can cause further morbidity as well as prevent further neurological damage of the injured and physiologically unstable neural tissue. His Model of Holistic Service Delivery and Methods of Management were had significantly improved outcomes to be adopted by many other Centers in the UK and overseas. These Centres Guttmann had demonstrated that patients not only survived but could also lead healthy, enjoyable, dignified, contributory and often competitive long lives . The long term survival of patients enabled clinicians and scientists to study the condition further in the short, medium and long term.

Hans Frankel and colleagues in 1965 onward studied the neurological outcomes of 612 patients with acute spinal cord and cauda equina injury admitted to Stoke Mandeville Hospital within two weeks of injury and treated by Guttmann and his methods of management. They observed that most patients who were admitted with sensory sparing and without any visible, palpable or voluntary motor power invariably recover motor power useful for function and many will walk again. They published what has been known as the Frankel Classification demonstrating that neurological recovery which results in functional improvement is predictable within the first two weeks of injury.

Characteristics of Patients with ATCSCI

The incidence of Acute Traumatic spinal cord injuries (TSCI) and Cauda Equina Injuries (CEI) is small ranging between 10-50/million of population/year. The effects of acute TSCI and CEI are however devastating and life-changing medically, physically, psychologically, socially, financially, vocation ally, environmentally, sexually & matrimonially. The combination of consequent Multi-System Physi ological Impairment and Malfunction and sensory impairment/loss renders the patient at risk of a wide range of potential complications, morbidity and death as well as a wide range of disabilities. Patients are particularly vulnerable in the acute stage following injury and during the transition between the stage of Spinal & Autonomic Shock and the return of these reflexes. The sensory impairment/loss in particular prevents patients from exhibiting the expected symptoms and signs of complications. This results in delayed diagnosis and treatment that usually lead to increased morbidity, disability and added psychological devastation and potential mortality. The Principles of management of the spinal injury being different in patients with and without neurological damage, the Principles of management of complications in patients with and without neurological damage also being different and the very small incidence of the condition together present significant difficulties and challenges to clinicians who have not trained in the field of spinal injuries and have not observed the outcomes of various mod els and methods of treatment in a large number of patients in the short, medium and long term after the injury.

No correlation between the Radiological & Neurological Presentations & outcomes:

One of the most important observations Frankel and his colleagues made is that the radiological presen tation on Xrays did not correlate with the neurological presentation of the patient nor the neurological outcome. El Masri & Katoh subsequently demonstrated that there was no correlation between the neurological and the radiological presentations on CT and on MRI. In other words patients with a sig nificant degree of malalignment, canal encroachment or both can present with incomplete cord inju ries and recover further without any intervention on the injured spine.

El Masri explains the discrepancy between the radiological and neurological presentation and out comes of patients with incomplete spinal cord and cauda equina injuries is due to the loss of energy of the force that damages the bony spine with a lesser force reaching the neural tissues.

Improvement of motor functions in patients with incomplete injuries:

Recovery of some motor power is almost assured in patients with sensory sparing and complete mo tor loss. Significant improvement in functionally useful motor can be assured in patients with sensory and any degree of motor sparing. This is provided:

• No further damage to the neural tissues is caused by poor management of the injured spine. And
• No further damage by systemic complications due to the poor medical management the systemic medical effects of cord and cauda equina damage. It must be appreciate that systemic complications such as hypotension, hypoxia, generalised sepsis, hypothermia, electrolyte imbalance can further cause non-mechanical damage to the acutely injured and physiologically unstable neural tissues.

Requirements of Management by a multidisciplinary team of professionals:

The combination of a small number of patients, diagnostic difficulties due to sensory impairment/loss, impaired physiology of the various Systems of the body, multiple system malfunction, multiple disabilities, dynamics between the psychological social and medical effects of neural tissue damage ne cessitates the provision of management by a Multi-disciplinary well managed and well coordinated team of trained and experienced Health Care Professionals with the appropriate attitude to patients with such devastating problems. It is paramount that all the members of this team are familiar with all medi cal and non-medicals aspects of the condition and provide the necessary service to patients in a humane and effective way. I will in my presentation discuss in some details the effects of acute TSCI &CEI, the methods of man agement, the discrepancy between the radiological and neurological findings, the prevention of further neurological damage and theexpected neurological with Active Physiological Conservative Management of the injured spine and the multi-system effects of neural tissue damage.

Prof W S El Masri FRCS Ed, FRCP currently Hon. Clinical Professor of Spinal Injuries (SI), Keele University has trained between 1971 & 1983 in the Oxford group of hospitals, Guys & Stoke Mandeville hospitals and the USA. He obtained the first accreditation in Spinal Injuries and General Surgery in 1982. Appointed Consultant Surgeon in Spinal Injuries at the Midland Centre for Spinal Injuries in 1983. He personally treated 10,000 patients with. He published 145 manuscripts. He the author of the: Concepts of “Physiological Instability of the Spinal Cord”, “Time related Biomechanical Instability”, “Micro-instability of the injured spine” and published the largest series of Bladder cancer in SCI patients. He has repeatedly demonstrated and published on the discrepancy between the radiological and neurological presentation of patients in support of the hypothesis that the initial force of the impact and the quality of the management of both the injured spine and the effects of cord injury are the two majpr determinants of the initial neurological loss and the neurological outcome. He is Past-President of the International Spinal Cord Society; Past Chairman British Association of Spinal Cord Injury Specialists and has lectured world-wide. He won many National and International awards.