Title : Acute traumatic spinal injuries - Outcomes based evidence of the holistic active physiological conservative management of the injury and its neurological effects
Abstract:
Traumatic Spinal Injuries can present with or without neural tissue damage. Both the force and the direction of the impact determine the presence or absence of neurological damage. The principles of management of the injured spine and of the patients with or without neural tissue damage are very different and are likely to have an impact on the neurological and a range of other outcomes of the management. Traumatic Spinal Cord (tSCI) or Cauda Equina Injuries (tCEI) are life-changing events with medical, physical, psychological, social, financial, vocational, environmental & matrimonial effects. The combination of small incidence (10-50/million population), consequent pan-physiological impairment, multi-system malfunction, sensory impairment/loss, multiple disabilities, together with their non-medical effects impose challenges to patients and clinicians alike. This challenge is magnified during the transitional period between the spinal and autonomic areflexia (shock) and the return of these reflexes. During this period, which lasts a few days to weeks the patient is at a much higher risk of a range of complications than following the return of autonomic and spinal reflex activity.
Fortunately with simultaneous adequate management of the injured spine together with each of the effects of cord damage, by a knowledgeable well-trained and experienced team of clinicians and health care professionals; almost all complications can be prevented or diagnosed and treated before deterioration, morbidity and neurological deterioration occur. Neurological Recovery is not uncommon following tSCI & tCEI, is predictable and depends on:
•The quality of management of the multisystem physiological impairment and malfunction to prevent systemic and iatrogenic complications that cause further non-mechanical damage to neural tissues by destabilising the Physiologically Unstable Injured neural tissue
•The adequacy of the management of the Biomechanical Instability of the injured spine to prevent further mechanical damage of the neural tissue from bony or ligamentous structures
Early prediction of ambulation is important to patients and family members. Neurological Recovery is not uncommon following tSCI & tCEI, is predictable and depends on the method and quality of management of the multisystem physiological impairment and malfunction as well that of the spinal injury. In the mid-sixties Frankel and colleagues made an astute observation that with good conservative management of the injured spine and the multisystem malfunctions, patients presenting within 15 days of injury with complete motor paralysis but sensory sparing made spontaneous motor recovery from reactivation of the myotomes adjacent to the functioning dermatomes irrespective of the radiological presentation on XRays on admission and on discharge. The same observations including observations on the discrepancy between the CT and MRI scans and the neurological presentation have since been repeatedly confirmed by many other international groups.
The prognostic indicators of neurological recovery, its extent and the factors that prevent recovery or cause neurological deterioration as well as the role of CT and MRI will be discussed.
In the last four decades, routine surgical stabilisation and decompression have been carried out on patients with and without traumatic cord damage supported by claims that surgical intervention is necessary to prevent neurological deterioration and enhance recovery. The rationale and evidence for justifying these claims will be discussed and compared with those of the simultaneous Active Physiological Conservative Management the injury and each of the Multisystem physiological malfunctions caused by the cord damage.
