Abstract:
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 the condition in depth and developed the established methods of 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. His model of Service Delivery and Methods of Management were adopted in many Centers in the UK and overseas. They all demonstrated that patients can readjust and live healthy, enjoyable, productive, dignified and often competitive long lives . This 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 treated by Guttmann. They observed that most patients who present initially with sensory sparing and no motor power invariably recover motor power 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 provided patients are admitted and treated by the same methods of management
Characteristics of Patients with ATCSCI: The incidence of Acute Traumatic spinal cord injuries ATSCCEI is small ranging between 10-50/ million of population/year. The effects of ATSCCEI are however devastating and life-changing medically, physically, psychologically, socially, financially, vocationally, environmentally, sexually & matrimonially. The combination of consequent Multi-System Physiological Impairment and Malfunction is not only responsible for a wide range of disabilities but also renders the patient at risk of a wide range of potential complications, morbidity and death. 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 prevents patients from exhibiting the expected symptoms and signs of complications. This results in delayed diagnosis and treatment leading to increased morbidity, mortality and psychological devastation. The principles of management of the spinal injury are different in patients with and without neurological damage. The principle of management of complications in patients with and without neurological damage are also different.
Requirements of Management by a multidisciplinary team of professionals: The combination of a small number of patients, diagnostic difficulties, 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 necessitates the provision of management by a Multi-disciplinary 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 medical and non-medicals aspects of the condition and provide the necessary service to patients on a coordinated way.
Prognostic Indicators of Recovery: The prognostic indicators of neurological improvement and recovery with what can be describe as Active Physiological Conservative Management (APCM) of the injury and all the effects of neural tissue damage have been extensively studied over the last five decades.
Frankel et al studied and published in 1969 the neurological outcome of 682 consecutive patients admitted with various degrees of paralysis within 14 days of injury. They were able to predict, document and publish recovery of ambulation in patients with complete and incomplete motor paralysis of lower limbs (LL). They had found that between 6% and 9% of patients presenting with complete motor and sensory loss below the level of injury recovered some sensation and motor power. However over 60% of patients with complete motor loss but long tract sensory sparing and over 70% of those with sensory and motor long tract sparing on admission recovered enough motor power to enable them to stand or to stand and walk again. These results were achieved irrespective of the radiological presentation on admission and without any surgical, cellular, pharmacological, biological, chemical, immunological, hormonal or other intervention. They were achieved with what can be described as the simultaneous Active Physiological Conservative Management (APCM) of the injured spine and each of the systemic effects of the neurological damage well as the multisystem physiological impairment and malfunction of the cord injury. The predictive value of the long tracts sparing as well as the outcomes were subsequently confirmed by many groups.
Neurological examination within 72 hours from injury demonstrating pin prick sensory sparing was subsequently found to be of even better prognostic value irrespective of the degree of spinal canal stenosis, encroachment or cord compressionand without any surgical or other interventions.4, 9,10, 11 . This is provided no further mechanical or non-mechanical damage occurs during the management of the injured spine or by systemic complications that further damage the physiologically impaired and unstable neural tissues
Recent literature confirms the superiority of the neurological outcomes of the system of care to the injured spine and the neurological effects with APCM is far superior to the system of care that is fragmented and give priority to surgical intervention of the injured spine ,early mobilisation, rehabilitation and discharge.
I will in my presentation discuss in some details the methods of management and their expected neurological and other outcomes
Biography:
Professor W. S. El Masri (Y), MB, BCH, FRCS, FRCP, PHF, is a Clinical Professor of Spinal Injuries at Keele University and an Emeritus Consultant Surgeon in Spinal Injuries at the Robert Jones and Agnes Hunt Orthopaedic Hospital. He also served as Past President of the International Spinal Cord Society. WEM specifically trained between 1971 and 1983 in the specialty of traumatic spinal injuries (tSCI) and its allied specialities at Stoke Mandeville, Oxford, Guys Hospitals in the UK & the USA. WEM lectures worldwide in developed and developing countries. He contributed to the literature with 155 publications. He held the offices of: President of the International Spinal Cord Society, Chairman of the British Association of Spinal Cord Injury Specialists and Executive Member of the BSRM; Founder Member and trustee of SPIRIT Educational Charity in Spinal Injuries and Transhouse Charity as well as Trustee of the Institute of Orthopaedics at the Robert Jones and Agnes Hunt Orthopaedic Hospital in Oswestry, Shrop., UK.
He was advisor to WHO‘s & Co-author of the WHO International Perspectives on Spinal Cord Injury which was published in 2013 and was Member of the NICE Guideline Developing Group on acute spinal injuries. He received a number of awards including: An "A" Excellence award of the NHS, Medal of the International Spinal Cord Society, National Hospital Doctor Team Award for Innovation, Paul Harris Fellowship of the Rotary Club, Outstanding achievement award from the Chinese Society of Spinal Injuries, Outstanding Consultant Achievement award by the Spinal Injury Association, Hon. Presidency of the Romanian Spinal Cord Society. He was commended for his Service twice in the House of Lords as example of good practice(Hansard) on the 8th April 2003, vol 647, no.79, p204 and 9th March 2006 vol 679, no 117, p88 and 28th February 2009.
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