As the recovery from neurological deficits depends upon the severity of injury, completeness and level of injury are important factors. Whether the injury is complete or incomplete contributes to future outcomes.
In other words those with ASIA B or D SCIs (incomplete) often show a more substantial recovery than those with ASIA A (complete) injuries.2
... the fewer the deficits at the acute stage regarding to initial level of injury, motor strength and whether the injury is complete or incomplete, the higher the rate of recovery.
The level of injury, defined as the first spinal segment that demonstrates an abnormal neurological deficit, describes the regions of the body that are affected. With acute and complete SCIs, the greatest level of recovery occurs most frequently in those having cervical injuries. Thoracolumbar injuries, on the other hand, show the least degree of healing.3
In addition, a patient’s recovery can also be related to the severity of his or her initial neurological deficits: the fewer the deficits at the acute stage regarding to initial level of injury, motor strength and whether the injury is complete or incomplete, the higher the rate of recovery. 45
Beside the physical destruction of the spinal cord itself, there are also secondary conditions that can, through cell death, lead to the loss of neurological functioning.6 Through mechanisms such as arterial spasms or pressure on veins caused by edema, the interruption of spinal cord blood supply can lead to ischemia and a loss of neurological functions.
Given this fact, the restoration of the blood supply to the spinal cord as soon as possible is essential for recovery.6
In general, an individual’s recovery can be divided into two phases: early (within hours and days of onset) and late (over weeks and months). The time point of recovery will vary depending upon the type of SCI. For example, mild and incomplete SCIs are frequently associated with earlier recoveries.
...the majority of a patient's overall recovery will occur in 80 percent of cases within the first three months.
In order to best assess the prognosis for recovery from acute spinal cord injuries, a thorough neurological examination is necessary. 15 However, making a determination about the severity of injury as it relates to prognoses shortly after injury is not possible.
The ideal examination time has been defined as seventy-two hours post-injury in order to make the best predictions regarding recovery.7 In general, the majority of a patient’s overall recovery will occur in 80% of cases within the first three months. However, it is also important to note that improvement of neurological functions can take place up to 18 months after the incident and even beyond. 8
Often prognoses are based on outcomes in other SCI patients with similar impairments.9 Beside the differences in lesion severity, recovery of acute SCI can vary greatly due to the timely and appropriate interventions used, such as those aiming to maintain or restore the spinal cord blood supply. 11011
Choosing the right interventions — contributions to recovery
Twenty-five percent of damage in spinal cord injuries can occur or be aggravated following the initial event. This may occur during transport of the patient or even in the period of early treatment and evaluation.
Given this, it cannot be emphasized enough that for traumatic SCI, rehabilitation begins at the scene of the accident. This can mean that the laypersons who are at the scene of the accident may or may not take proper steps (such as minimizing the movement of the patient) to prevent further spinal cord injury.
Emergency first responders, on the other hand, need to exercise expertise in the area of pre-hospital management for SCI and undertake proper immobilization and transport procedures when indicated.121314 The transportation of those suspected of having an SCI needs to be undertaken both safely and rapidly. In some instances this can even mean evacuation by helicopter to the nearest spinal cord trauma center.
The primary goal of pre-hospital management of patients suffering from trauma is to both minimize the time it takes for the patient to receive care and maximize the chances that he or she reach the hospital alive.
Early interventions by emergency first responders intend to save lives and support essential organ functions. For traumatic SCI patients, pre-hospital management is important for both reducing existing neurological deficits and preventing further harm.
Box 1 – Aspects of optimal pre-hospital management
In the event that a traumatic SCI is suspected through a fall or other accident, it is essential that critical steps are taken by emergency first responders, as well as anyone administering first aid, to prevent further injury. One emergency first
responder offers these guidelines:
- For the non-medic at the scene, if an SCI is suspected the casualty should not be moved unless their life is in danger; he should be advised to keep still. With the non-medic kneeling behind, the casualty’s head may be supported with hands on either side and keeping the head, neck and spine aligned; he should be covered with a blanket; an ambulance should be called.16
- A rapid, primary evaluation of the patient that includes signs (meaning indications observed by the first responder) and symptoms (meaning those indications given by the injured person). Patients will often know intuitively that something is wrong with their spinal cord and automatically immobilize themselves. It is also important to learn of the accident’s kinematics. (i.e. How did they fall and what occurred as they fell? Possibilities may include injury kinematics such as hyperflexion, hyperextension, lateral flexion and rotation, axial loading and distraction). Such kinematics can be assessed through observation and brief interviews. Critically, the resuscitation of vital functions will take precedence at the primary evaluation. This includes what is known as the ABCs - airway, breathing, circulation (or DR: ABC - check first for dangers and response). Officially, the circulation check has been replaced by compression or CPR, meaning that a non-breathing casualty is suspected to also have no circulation and instantly receives Cardio-pulmonary resuscitation. In any person complaining of a sore neck, neck pain, or “pins and needles,” an SCI must be considered a possibility. The patient should be immobilized and properly examined.
- First aid specialists evaluate the patient more thoroughly in a secondary examination, as soon as arriving to the place of accident. This is known as a whole body check or head-to-toe check. Here a patient should be assessed for the possibility of an SCI. These findings need to be carefully documented. Such an assessment should include an evaluation of neck or back pain, bruising, swelling or tenderness over the spine, muscle weakness and spasm, paralysis, altered sensations (including “pins and needles” or tingling above the injury site), incontinence, priapism for lumbar SCIs, increased skin warmth/flushing (which are general signs of neurogenic or hypovolemic shock) and any superficial injury signs.
- For any potential SCI patient, extraction, movement and transportation must all be undertaken with extreme care and never be conducted by a single person. Immobilization of the entire spine is critical. The patient may be moved as much as necessary to get him or her out of imminent danger. However, any movement should be minimized and undertaken slowly and carefully, avoiding any jarring or rotation of the head and lower limbs. A lead first responder should immobilize the head, organize colleagues, assistants and bystanders and give commands based upon his or her assessments. Four persons to move a patient— one for each limb — is considered ideal. Today, immobilization is accomplished with a spectrum of devices ranging from cervical collars and backboards to vacuum splints and sandbags.
- Respiratory management is vital. SCI is associated with both acute respiratory failure and hypoxia for a variety of reasons including hypoventilation, aspiration and/or impaired neurologic function. Thus, it is imperative that the cervical vertebrae from C3 through C5 be stabilized — these keep the diaphragm alive. Interventions such as monitoring pulse oximetry, pre-oxygenation with a face mask,intubation and/or controlled ventilation may be warranted.
- Patients suffering from SCI are also at risk for cardiovascular problems including neurogenic and hypovolemic shock. This can be countered with cardiovascular support through fluid resuscitation. A generous oxygen supply, warmth, rest and reassurance can also help to alleviate such problems. Care must be taken when using suction devices on SCI patients as this may cause vagal stimulation which can lead to cardiac arrest.
- Pharmacological treatment may be beneficial. If the first responder is authorized and properly trained, dispensing drugs such as methylprednisolone have been shown to have positive effects.
- Rapid and safe transportation to trauma center — this may be via helicopter or ground transport. When determining where to transport the patient, his or her stability needs to be considered. First responder should provide all information collected through primary and secondary survey when handing over casualty. lumbar SCIs, increased skin warmth/flushing (which are general signs of neurogenic or hypovolemic shock) and any superficial injury signs.
In the event that a traumatic SCI is suspected through a fall or other accident, it is essential that critical steps are taken by emergency first responders, as well as anyone administering first aid, to prevent further injury. One emergency first responder offers the guidelines found in Box 1.
Arrival at the trauma center: acute care management
The steps that begin on admission to the hospital or trauma center build on the efforts of the emergency first responders. Ideally, SCI patients should be admitted to a trauma center specializing in spinal cord injuries. Studies have demonstrated that those admitted to specialized centers have a lower rate of subsequent complications and a reduction in the degree of acute care needed and the length of stay.2
Following admission, a determination can be made based on MRI technology as to both the type of spinal cord injury present and the adequacy of the blood supply to the spinal cord.26 With this data, an accurate diagnosis as well as a prognosis on recovery can be made. 10
The accuracy of the diagnosis is critical for making decisions on appropriate courses of treatment and interventions. The acute care management that begins at the trauma center aims to accomplish a specific set of goals: supporting organ function, decompressing the spinal cord and neuroprotection of the spinal cord. 51718 For example, whether the SCI be treated conservatively through pharmacological treatment or more aggressively through a surgical intervention.17192021
The start of early post-acute 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 started early on can lead to improved recoveries through better functional outcomes.22
This will often occur immediately following a patient’s acute care where vital functions are stabilized, in a phase termed early post-acute. Although much depends upon the course of the acute phase, early rehabilitation tends to hasten and promote improvements in the activities of daily living either directly or indirectly and thus should be started as soon as possible.23
The physical therapy and exercise involved promote motor recovery, which in turn help synapse growth. Early functional recovery is dependent upon such growth. 2224 So while rehabilitation can be thought of as beginning immediately after an accident, the formal, early post-acute care rehabilitation will have an immense impact on recovery and functional outcomes.