Spinal cord injuries-trauma-damage

The job of the Central Nervous System is to collect information from all over the body and coordinate the body's functions.

The spinal cord connects the brain to the peripheral nerves and muscles.

When there is damage to the spinal cord, the commands - information from the brain to the peripheral nerves and muscles are not transmitted. As a result, the muscles become paralyzed.

The most common causes of spinal cord injury are car accidents with fractures or vertebral dislocations, falls from height and gunshot wounds to the spine.

The consequences

They are very serious.

- The muscles below the level of the spine where the spinal cord is damaged become paralysed.
- The patient cannot feel his/her legs and/or arms depending on the level of damage to the spinal cord
- The muscles of the bladder and bowel do not function properly, resulting in disorders in urination and defecation
- There is pain that has the sensation of pressure or burning".

Acute treatment

Treatment for spinal cord injury starts at the scene of the accident.

Attention is needed!

To prevent irreversible damage or worsening of damage to the spinal cord:

Before the injured person is moved, the neck and spine must be stabilized with a neck collar or a roughly constructed equivalent and the injured person must be moved with the help of 3-4 people supporting and aligning the spine. Otherwise, it is preferable that the correct movement is performed by qualified ambulance personnel.

At the hospital, in the emergency department, the targets are:

- Maintaining respiratory function
- The prevention of shock
- Stabilising the spine to prevent further damage

Depending on the patient's condition, surgery may be required to remove fragments from the fractured vertebra, decompress the spinal cord and stabilise the spine.

From the first few hours, the process of inflammation and swelling in the area of damage begins, leading to nerve cell death.

Subacute treatment and rehabilitation

At this stage, the patient is admitted to the Rehabilitation Centre.

The Scientific Team of Wellness, consisting of Rehabilitation Doctors (Physiatrists), Pathologists, Orthopedics, Neurologist, Neurologist, Pulmonologist, Cardiologist, Urologist, Microbiologist, Radiologist and therapists, physiotherapists, occupational therapists, Pool therapists, Nutritionists, Psychologists, will evaluate the consequences of the injury, the functional status of the patient and determine the goals of treatment, the Rehabilitation Program and instructions for the prevention of complications.

The functional status - i.e. which muscles will be paralysed - depends on the level of the damaged spine (paraplegia - quadriplegia) and the type of damage (complete damage - incomplete damage).

Quadriplegia involves trauma to the spinal cord of the cervical spine that causes partial muscle paralysis below the level of the lesion, incomplete damage or total muscle paralysis in complete damage, as well as impaired sensation in the arms, trunk and legs.

Paraplegia involves trauma to the spinal cord of the thoracic or lumbar spine and causes disturbances in muscle mobility and/or sensation. Impaired mobility causes partial muscle paralysis below the level of the lesion, in incomplete lesion and complete muscle paralysis in complete lesion. In the case of paraplegia, the hands function normally.

In cases of complete damage to the spinal cord, there is a loss of all motor and sensory functions below the level of damage.

While in cases with incomplete damage, some motor or sensory function is preserved below the level of damage.

The problems caused by spinal cord injury are classified and rated internationally using the American Spinal Injury Association (ASIA) scale, which describes the severity of the injury.

- Classification A. The injury is complete. The patient has no movement and sensation below the level of the lesion.
- Classification B. The injury is incomplete. The patient feels below the level of the lesion, but cannot move the muscles.
- Classification C. The injury is incomplete. The patient has movement, but very weak in less than 50% of his muscles.
- Classification D. The injury is incomplete. The patient has weak movement in more than 50% of the muscles.
- Classification E. The patient has movement.

Often, it is not possible to immediately predict the patient's condition. This depends on the spinal shock.

In cases where there is improvement, the rate of improvement is faster in the first 6-9 months. Some patients continue to improve slowly for longer.

Upon admission to the Wellness Rehabilitation Centre and after the evaluation of the patient's condition, the Medical Scientific Team informs the patient and his/her family about the consequences of the injury, the complications that may occur, the prognosis, the progression and the time of rehabilitation, the quality of life and the patient's independence.

The goal is to return to his life, his family, his work.

It takes patience and strength.

It requires cooperation between the patient and the family and the scientific team.

Together they will overcome every obstacle to achieve the basic goal of independence.

The factors that determine the level of independence in each individual are:

- The level of damage
- The age
- The general state of health
- The spasticity and
- the will to engage in activities

The management and treatment of spinal cord injury is a complex process and takes time. It varies depending on the severity of the lesion, the area of the spine damaged, the complications and the specific problems that will occur.

Complications - special problems

- Confluences
- Spasticity
- Pressure ulcers
- Orthostatic hypotension
- Pain
- Neurogenic function of the bowel and bladder
- urinary tract infections
- Venous thrombosis
- Respiratory and cardiac problems
- Heterotopic ossification
- Autonomous dysreflexia
- Ossification - fractures
- Metabolic problems
- Fertility
- Psychological and emotional state

The initial goals of rehabilitation in the subacute phase are:

- Good emotional state and improved mood
- The prevention of complications and
- maintaining body weight (no extra pounds)

A key element of the rehabilitation process is the psychological and emotional support of the patient.

The patient has anxiety, anxiety, anger, denial of his condition, mood problems, depression. Needs management, adjustment and guidance every day. It takes time.

30% of patients, show depression in the first months after the accident. Depression is seen as a complication that needs to be treated.

The most common complication - but extremely important at this time - is adhesions (anchorages).

The correct positions of the arms and legs in bed are important to protect the joints and maintain muscle tone. Special pillows or splints are used for this purpose.

In trauma to the cervical spine, adhesions in the shoulders, elbows, wrists and fingers are common. Convulsions in the legs most commonly involve the hips and hamstrings and less often the knees and manifest either in quadriplegia or paraplegia. However, despite prevention and treatment care, more than 60% of people with spinal cord trauma experience adhesions in a joint.

The muscles are loose - flabby due to paralysis in the acute phase. Later, spasticity develops and the flaccid muscles become very tight because the muscle tone increases much more than normal. The muscles become stiff and it is difficult for the therapist to bend the patient's knee and hip. Also, shaking of the legs occurs due to spasticity and personal hygiene becomes difficult.

Spasticity is affected and increased in intensity by complications (such as pressure ulcers, urinary tract infections) or problems (such as constipation, urinary retention).

A key goal of rehabilitation is also to maintain proper lung function.

The rehabilitation programme in the subacute phase is intensive and proportional to the strength of each patient.

For pressure ulcers, the patient is trained to change from a supine to a lateral position every 2 hours to avoid wounds to the skin from the pressure applied by the body weight on the mattress, so the skin does not bleed properly and is damaged, creating wounds that are difficult to heal.

The installation of a special pressure redistribution air mattress is an additional preventive measure against subsidence along with the changes of position.

The onset of bedsores is a common complication and is easily created within a few hours. Their healing is a long process, painful and inconvenient for the patient. For these reasons, the patient is informed of the risks and educated about the procedure for changing the bed position.

The next important rehabilitation step is the maximum strengthening of the upper limbs in cases of complete paraplegia. It is the necessary factor for the patient's independence in many daily activities, such as carrying the patient to bed, to the toilet, to move around. Orthostatic hypotension, is the drop in blood pressure when the patient sits up in bed from the supine position. He feels dizzy, feels like he's going to faint, has discomfort. The treatment of this condition is achieved with the help of the tilt-table, a special treatment bed that has the ability to stabilize the patient at any inclination from supine to upright position. In this way, the blood pressure is adjusted and regulated, starting from the inclination where the patient starts to feel the symptoms. Gradually, the inclination is increased and the blood pressure is adjusted until the patient is able to sit up without symptoms. Then he or she is trained in balance exercises in the sitting position - static and dynamic - several times a day.

Orthostatic hypotension delays the progress of the rehabilitation programme for several days or weeks. Balance in the sitting position is an important factor of independence because it allows, together with the increase in upper limb muscle strength, training in wheelchair transfer and mobility.

Orthotics is the next step of rehabilitation. For safe training, a device is used that suspends the patient's body and allows the patient's weight to be reduced in the early stages of treatment.

The upright position has significant benefits for reducing spasticity, bowel function, bladder function, prevention of pressure ulcers, osteoporosis and the psycho-emotional mood of the person. This is followed by gait training for patients who meet the criteria according to their condition.

For this purpose, robotic assisted mobility systems, suspension systems, splints, guardians, F.E.S, multi-application F.E.S, exoskeletal systems are used with the main goal of maximum independence of the person and improvement of quality of life.

The rapid development of technology (sensors, robotics, artificial intelligence) provides the possibility of constantly new applications and systems today and in the future.

Pain is a common problem and in some people it is excruciating.

Pain increases spasticity and increasing spasticity increases pain.

Other factors that increase spasticity are infections, constipation, urinary retention, skin wounds, etc.

For treatment, depending on the patient's condition and the intensity of the pain, we use:

- medication for chronic pain
- medication to reduce spasticity
- therapeutic techniques to reduce spasticity
- surgical treatment
- neuroerethism

The bowel and bladder function is not normal because there is no sensation of the bladder being filled with urine or bowel respectively, but the muscles of the bladder and bowel are either paralysed or spastic.

Various techniques are used for defecation as well as mild laxatives, which the patient is trained to use.

For the bladder, more information is needed, such as the urine residue after urination, measurement of fluid intake and output, urodynamic testing to measure bladder pressures and bladder muscle function and cooperation, so that decisions can be made to properly regulate the urinary system to protect the kidneys from damage.

The patient is trained in techniques to empty the bladder or performs catheterisation himself several times a day in combination with medication.

The complication, referred to as heterotopic ossification, is bone formation around the joints.

Inflammation, pain in the joint with every attempt to move and calcium salts deposited in the connective tissue between the muscles and tendons that attach to the joint, resulting in the joint being immobilised in one position (ankylosis).

Heterotopic ossification can affect several joints at the same time, shoulders, elbows, hips, knees, etc., in cases of quadriplegia or paraplegia. Joint immobilisation causes serious problems in personal hygiene, transport, mobility and even the ability to sit in a wheelchair.

This condition progresses for months, distresses the patient and is considered a disorder of the autonomic nervous system.

Autonomic dysreflexia is a complication as a consequence of a disorder of the autonomic nervous system. The autonomic nervous system (sympathetic - parasympathetic) is different from the central nervous system (brain - spinal cord).

The autonomic nervous system regulates many functions of the body in particular situations. Depending on the predominance of the sympathetic or parasympathetic system, different symptoms are manifested.

Autonomic dysreflexia occurs suddenly and is manifested by a high increase in blood pressure, bradycardia, headache and sweating above the level of the lesion. It occurs most frequently in tetraplegia and high paraplegia, i.e. in injuries to the cervical and thoracic spine. It can endanger a person's life and is an emergency situation.

Fractures from osteoporosis are not common, but sometimes they do happen. For this reason, preventive measures for osteoporosis are in place.

Metabolic problems include insulin resistance, dyslipidemia, obesity. The main goal of recovery is for the patient not to gain extra weight.

The collaboration of the GP with the nutritionist, psychologist and the patient is usually effective in providing a diet suitable for each patient.

Long-term counselling and rehabilitation

And after discharge, the Wellness Science Team is by your side.

You may need modifications to your home in order to improve your quality of life.

Contact us to advise you.

Spinal cord injuries need long-term support and counselling.