Recovery of functioning in traumatic (SCI) depends on two critical factors: the type of injury, meaning both the severity and the etiology, 2 and on timely and appropriate medical, surgical and rehabilitative interventions. 3 4 5 6 7 Such interventions begin at the scene of the accident and continue through to the completion of rehabilitation.
Type of Injury and Recovery
Factors in predicting recovery in the first year after a traumatic SCI include initial neurologic injury level, muscle strength and whether the injury is complete or incomplete. 8
The level of injury, defined as the first spinal segment that demonstrates an abnormal neurological deficit, describes the region(s) of the body that are affected. Spinal segments are divided into four main groupings: the cervical segments (C1 to C8), thoracic segments (T1 to T12), lumbar segments (L1 to L5) and sacral segments (S1 to S5). For details go the section "Spinal Cord Injury (SCI)". In persons diagnosed with complete SCI at the acute stage, the greatest recovery occurs in those with cervical injuries or injuries from C1 to C8. Thoracolumbar injuries (T10-L2), on the other hand, show the least degree of healing. Irrespective of injury level, recovery of persons diagnosed with incomplete SCI at the acute stage is related to the severity of initial neurological deficits. The fewer the deficits at the acute stage, the higher the rate of recovery. 9
"The fewer the deficits at the acute stage, the higher the rate of recovery."
A person's recovery can occur early i.e. within hours and days of injury or late i.e. over weeks and months. In 80% of the cases most of a person's overall recovery will take place within the first three months. However, it is also important to note that improvement of neurological functions can take place up to 18 months post-injury and longer. Recovery could be characterised in different ways. For example, it could be characterised as a conversion from having a neurologically complete SCI to an incomplete SCI. In one study, it was observed that 80% of the persons studied showed some conversion in the first three months. 10
"...most of a person's overall recovery will take place within the first three months."
To optimise the prognosis for recovery after SCI, a thorough neurological examination is necessary. This includes the use of magnetic resonance imaging (MRI). 11 The ideal time point for an examination to predict recovery is 72 hours post-injury. Predictions of recovery based on an examination within 24 hours post-injury has shown to be unreliable. 10 12 13
Choosing the Right Interventions at the Right Time and Recovery
I remember lying on the edge of that mountain slope. I couldn’t move my head, my hands, nor my legs anymore – nothing…
Mr. Seiler recalling the accident
Besides the injury type, recovery from an acute SCI can be influenced by the timely provision of appropriate interventions. 3 4 5 6 7 For example, arterial spasms or pressure on veins caused by oedema following an acute SCI can lead to ischaemia due to an interruption of the spinal cord blood supply. Ischaemia can, in turn, lead to paraplegia. Immediate or rapid restoration of the blood supply to the spinal cord can possibly reverse or reduce the severity of ischaemia-caused paraplegia after traumatic SCI. 14 This is one example that illustrates the need to provide interventions as soon as possible after injury to prevent permanent damage or loss of functioning. In fact, 25 % of SCI damage can occur or is aggravated after the initial event. 3 15 Post-SCI damage can occur during the transport of the person from injury site to the hospital, or even in the early period of treatment and evaluation. Given this, it cannot be emphasised enough that for persons with traumatic SCI, rehabilitation begins at the scene of the accident. This means that it is essential that laypersons at the scene of the accident take proper steps e.g. minimise moving the injured person to prevent further damage.
"...rehabilitation begins at the scene of the accident."
Emergency first responders also need to exercise pre-hospital management procedures appropriate for suspected SCI, undertaking proper immobilisation and transport procedures when indicated. Persons suspected of having an SCI need to be transported securely and rapidly (in some cases by helicopter) ideally to a regional spinal cord trauma centre or otherwise to the nearest emergency care department. 3 6 16 17 18
Pre-hospital Management and Traumatic SCI
The primary goal of pre-hospital management of persons who have experienced trauma is to deliver care and appropriate interventions as soon as possible in order to maximise the person's chance of survival as well as improve outcomes. For persons after a traumatic SCI, pre-hospital management is important for both reducing existing neurological deficits and preventing further damage. 3 19
In the event that a traumatic SCI is suspected, it is essential that critical steps are taken by emergency first responders to prevent further injury. Some guidelines include but not limited to the following:
For lay first responders: 20
- Call the local emergency medical helpline.
- The person suspected of a SCI should be kept still, if possible by placing heavy towels on both sides of the neck or by holding the neck to prevent movement.
- Appropriate first aid should be provided as much as possible, whereby avoiding tilting back the head if opening the person's airway is not required. If the person is not breathing, actions to prevent potential SCI is less of a priority. The first priority is to get the person breathing again as soon as possible by implementing appropriate first aid procedures.
- If a person is wearing a helmet, it should not be removed.
- If necessary to avoid danger or further injury, moving the person suspected of SCI should be done with at least two people to help keep the person's head, neck and back aligned.
- A primary evaluation of the person's vital functions such as breathing should be done, and appropriate first aid (the "ABCs" or airway, breathing and circulation) should be performed to control and restore vital functions.
- A secondary more thorough examination should be performed and documented. This includes considering the complaints or indication of symptoms communicated by the injured person e.g. pain in the neck or back, observe if there is sensitivity to palpation, muscle weakness, paralysis or altered sensations, incontinence, priapism, increased skin warmth or flushing, and other superficial signs of injury.
- In addition, to determine a potential cervical SCI the presence of the following should be evaluated: altered mental state, intoxication, extremity fracture or distracting injury, localized neurological deficit or spinal pain and tenderness.
- The entire spine of the person suspected of a SCI should be immobilized in a neutral position at the scene of injury as well as during the transport to the nearest emergency care department or spinal cord trauma centre.
- Any movement of the person suspected of a SCI, whether for removal from injury site or during transport, must be undertaken with extreme care and in a systematic way. Immobilisation can be facilitated by using a range of devices including cervical collars, rigid spinal boards with straps, vacuum splints and sandbags. A combination of a cervical collar with supportive blocks on a rigid spinal board with straps is recommended for immobilising the person during transport. Immobilization devices should be removed should a SCI is ruled out or as soon as definitive treatment is initiated.
- Respiratory management is vital. SCI of the upper cervical region can be accompanied by acute respiratory failure and hypoxia. Interventions such detection and monitoring of hypoxia using pulse oximetry (technology for monitoring oxygen level in the blood), administering oxygen via a face mask, intubation and/or controlled ventilation may be warranted. Should intubation of the trachea to open up the person's airway is required, immobilization devices should be opened while manually maintaining the cervical spine in a neutral position, if possible by two people.
- Persons who experience SCI are also at risk for cardiovascular problems such as neurogenic shock. Appearance of these problems can be countered by carefully laying the person on the back with the feet higher than the head and by administering intravenous fluids (called fluid resuscitation).
- Hypotension should be prevented and treated if already present. The first-line treatment is fluid resuscitation; this should not include infusion of glucose due to the risk of oedema and hyperglycaemia. Ideally the glucose level is measured and appropriate treatment is provided only once admitted to the hospital.
- Due to potential for impaired thermoregulation after a SCI, it would be essential to monitor and regulate the injured person's temperature.
- The choice of the mode of transportation and decision about the type of trauma centre depends on the status of the person suspected of having a SCI. Stable injured persons are preferably transported to the nearest level 1 trauma centre even if the transport time is longer. Level 1 trauma centres offer the highest level of care, has a full range of equipment as well as specialists available 24 hours a day, and admits a minimum required annual volume of severely injured patients. Unstable injured persons should be transported to the nearest trauma centre irrespective of level; the goal here is to achieve haemodynamic stabilisation of the injured person before transferring to a level 1 centre.
Acute Care Management at the Trauma Centre
The care that begins upon admission to the hospital or trauma centre builds upon the efforts of the emergency first responders. Ideally, persons with SCI are admitted to a trauma centre that specialises in spinal injuries. Studies have demonstrated that those admitted to specialised centres have a lower rate of subsequent complications, reduction of required acute care and shorter length of stay. 3 8 22
Acute care management aims to minimise the damage of the SCI, manage any acute consequences of the SCI and apply interventions that will avert expected complications, for example through conservative pharmacological treatment or more aggressively through a surgical intervention. 6
Following admission to the hospital or trauma centre, the determination of location, extent and severity of the SCI and the adequacy of the blood supply to the spinal cord can be made using various assessment and diagnostic tools. This includes but not limited to the American Spinal Injury Association (ASIA) impairment scale and imaging technology (e.g. MRI). With the data generated using these tools, a more accurate diagnosis as well as a prognosis for recovery can be made. 11 14 An accurate diagnosis and prognosis are critical for making decisions on the appropriate interventions, 6 12 such as pharmacological treatment, surgery or other less invasive interventions. 5 23 24 25
From Acute Care to Rehabilitation
In addition to treatment decisions, the appropriate time point for admission to early post-acute rehabilitation must be decided. Studies have shown that rehabilitation that starts early on can lead to better functioning outcomes and an improved rate of recovery, even in cases in which the medical status of the injured person has not yet been completely stabilised. 4 26
This case study of Mr. Seiler, a 65-year old retired butcher with incomplete tetraplegia, illustrates how proper and timely acute care, beginning at the injury site, and early rehabilitation can contribute to improved recovery and optimal functioning.