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ORIGINAL ARTICLE
Year : 2016  |  Volume : 16  |  Issue : 2  |  Page : 128-132

Recovery patterns of spinal cord injury after traumatic cervical cord injury in a developing country


1 Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Orthopaedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
4 Department of Gynaecology and Obstretics, ESI Hospital, Durgapur, West Bengal, India
5 Department of Community Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India

Date of Web Publication13-Apr-2016

Correspondence Address:
Dr. Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-6308.180178

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  Abstract 

Background: Traumatic cervical cord injury (CCI) management requires extended acute care and lifelong chronic care. Aims: The present study was aimed to find out that after traumatic CCI, if neurological recovery takes place, how early it starts, how long it continues, and after how many weeks we can safely prognosticate that no more recovery will take place. Materials and Methods: Different epidemiological factors, radiological evidence of trauma, types of injury, cause, mechanism of injury, and level were recorded. The patients were examined every week to record any neurological recovery, either as per Frankel's or ASIA grading. These recordings were done till 6 weeks of admission. Cervical fractures were usually treated by continuous skull traction either by Crutchfield tong traction or by head halter traction giving adequate weight according to the level of vertebral fracture. At the end of 2 years, we followed the recovery pattern in 126 CCI patients. Results: 20.00% of patients showed signs of recovery and 56.36% patients did not show any sign of recovery in complete lesion. 69.01% of patients showed sign of recovery and 25.35% patients did not show any sign of recovery in incomplete lesion. 53.84% of patients showed the first sign of neurological recovery within 1 st week, 32.30% in 2 nd week, 9.23% in 3 rd week, and 4.61% in 4 th week. In upper cervical spine lesion, 22.22% of patients showed first sign of neurological recovery within 1 st week, 55.55% in 2 nd week, 16.11% in 3 rd week, and 5.55% in 4 th week. In lower cervical spine lesion, 65.95% of patients showed the first sign of neurological recovery within 1 st week, 23.40% in 2 nd week, 8.51% in 3 rd week, and 2.12% in 4 th week. Conclusions: In traumatic CCI, patients' level of lesion, type of injury, and nature of injury may be helpful in the early prediction of recovery pattern of patients and careful monitoring of these patients may reduce the social burden in developing countries and reduce morbidity and mortality of these patients.

  Abstract in Arabic 

طرق علاج إصابات النخاع الشوكي بعد إصابات النخاع العنقي في الدول النامية :
خلفية البحث: يتطلب علاج اصابات حوادث النخاع العنقي (CCI) عناية مكثفة وعناية مزمنة مدى الحياة.
الاهداف: هدفت الدراسة المتقدمة ايجاد أن بعد اصابات حوادث النخاع العنقي كيف يتم الشفاء للاعصاب ومتى تبدأ وكم سيستمر وبعد كم من الاسابيع يمكن بسلامة أن نتوقع أنه لايمكن حوث شفاء اكثر من ذلك.
الطرق والمواد: تم تسجيل عوامل وبائية مختلفة ، صورة الاشعة للاصابة ، نوع الإصابة.
المسببات ، طريقة الاصابة ، والمستوى وتم الكشف على المرضى اسبوعياً لتدوين أي شفاء عصبي سواء عن طريق فرانكل أو جدول آسيا تم عمل المدونات خلال ستة اسابيع من الإدخال. و في العادة تتم معالجة الكسور العنقية بإستخدام الشد المتواصل للجمجمه بإستخدام ملقط كروتشفيلد للشد أو خذوة شد الرأس بإعطاء اوزان كافية حسب مستوى الكسر الفقري. بعد عامين تتبعنا طرق الشفاء في 126 مريضاً بإصابات حوادث النخاع العنقي .
النتائج : في حالات الضرر الكامل اظهر 20% من المرضى علامات شفاء كما لم يظهر 56.36% أي علامة شفاء في حالات الضرر غير الكامل، أظهر 69.01% علامات شفاء كما لم يظهر 25.35% أي علامات شفاء. 53.84% أظهرو أول علامات الشفاء العصبي في الاسبوع الأول ، 32.30% في الاسبوع الثاني ، 9.23% في الأسبوع الثالث ، 5.55% في الاسبوع الرابع. في حالات ضرر النخاع العنقي العلوي أظهر22.22% من المرضى أول علامات الشفاء العصبي في الاسبوع الاول، 55.55% في الاسبوع الثاني ، 16.11% في الاسبوع الثالث، 5.55% في الاسبوع الرابع.
الخلاصة: في حالة حوادث اصابات النخاع العنقي مستوى الضرر لدى المريض ونوع الاصابة وطبيعتها قد يكون من المفيد جداً في التوقعات المبكرة للشفاء وطرقه كما تقلل من نسبة الوفيات والاصابات لدى هؤلاء المرضى.

Keywords: Cervical cord injury, developing country, management, tetraplegia


How to cite this article:
Kumar I, Chaudhuri A, Acharya S, Ghosh PK, Acharya PP, De A. Recovery patterns of spinal cord injury after traumatic cervical cord injury in a developing country. Saudi J Sports Med 2016;16:128-32

How to cite this URL:
Kumar I, Chaudhuri A, Acharya S, Ghosh PK, Acharya PP, De A. Recovery patterns of spinal cord injury after traumatic cervical cord injury in a developing country. Saudi J Sports Med [serial online] 2016 [cited 2022 Oct 6];16:128-32. Available from: https://www.sjosm.org/text.asp?2016/16/2/128/180178


  Introduction Top


Spinal cord being a part of the central nervous system is refractory to regeneration. Neurological recovery after spinal cord injury (SCI) remains unpredictable. The initial tissue disruption (primary injury) triggers a cascade of interrelated process. Local tissue elements undergo structural and chemical changes. [1],[2],[3],[4] Changes in local blood flow, tissue edema, chemical mediators, and metabolite concentration propagate interdependent reactions. This pathophysiologic response to the primary tissue disruption can propagate further destruction and functional loss (secondary injury). [2],[3],[4],[5],[6],[7],[8] The ability to regain ambulation correlates with the amount of white matter remaining after injury and regeneration potential of the injured spinal cord. Incomplete injury keeps the hope alive and such patients can go back to society after full recovery. However, if cessation of neurological function is due to traumatic edema or mechanical compression, there remains a chance of neurological recovery, if proper planned care is taken. [1],[2],[3],[4],[5],[6],[7],[8]

A tetraplegic patient is more disabled than a paraplegic patient. If the lesion is in the cervical segments of the cord, there is impairment of function in the arms, legs, trunk, and pelvic organs. Any injury to the spinal cord at or above the C3, C4, and C5 segments, leading to paralysis of diaphragm (phrenic nerves) can stop breathing. People with these injuries need immediate ventilatory support. When injuries are at the C5 level and below, diaphragm function is preserved, but breathing tends to be rapid and shallow and patient becomes prone to respiratory failure as they cannot cough and clear secretions from their lungs because of weak thoracic muscles. [3],[4],[5],[6],[7]

The development of permanent neurological deficit is the most serious and debilitating complication of spinal injury leading to partial or complete invalidity of the patients. Apart from this, SCI patients develop a variety of other complications such as pressure sores, urinary tract infection, chest infection, joint contractures, deformity, osteoporosis sexual dysfunction, and neurological bowel. Some of the complications are directly related to the injury and others due to prolonged recumbency. These complications are the leading cause of morbidity and mortality in these patients. With proper nursing care and early rehabilitation, most of these complications can be avoided or at least reduced. [1],[2],[3],[4],[5],[6],[7],[8],[9]

The significant differences in the presentation of spinal injury in a developing country as compared to more advanced nations lies in the epidemiological factors. Different epidemiological studies by different authors have shown that the causes of the injury vary according to the geographical area, social customs, habits, and due to activities the person get involved into. [10],[11],[12] In developing country such as India, a large majority of cases belongs to the lower socioeconomic strata, thus, unfortunately, the "catastrophe" afflicts most commonly the poorer socioeconomic group.

It is important for the clinician to know the recovery patterns after traumatic SCI to predict outcome and to develop a realistic, comprehensive rehabilitation program. In addition, knowledge of expected recovery helps determine the effectiveness of various interventions. Hence, predicting the patients' future needs is extremely important. Keeping in the view of above query, the present study was aimed to find out that after traumatic cervical cord injury (CCI), if neurological recovery takes place, how early it starts, how long it continues, and after how many weeks we can safely prognosticate that no more recovery will take place.


  Materials and Methods Top


All the patients of CCI admitted through orthopedic emergency in a tertiary care hospital of Eastern India were included for present study after taking institutional ethical clearance and inform consent of the subjects. All the CCI patients were separated and kept in tetraplegia ward.

Different epidemiological factors, for example, age, sex, radiological evidence of trauma, types of injury, cause, mechanism of injury, and level were recorded. The patients were examined every week to record any neurological recovery, either as per Frankel's or ASIA grading. These recordings were done till 6 weeks of admission. Cervical fractures were usually treated by continuous skull traction either by crutch-field tong traction or by head halter traction giving adequate weight according to the level of vertebral fracture. The traction given continuously for 6 weeks, followed by molded cervical collar or SOMI brace was given to wear for further 8-12 weeks. At the end of 2 years, we followed the recovery pattern in 126 CCI patients.

Neurological status at the time of admission and discharge (as per modified Frankel's grade)

  • Grade A: Complete
  • Grade B: Motor complete, sensory incomplete
  • Grade C: Motor useless
  • Grade D: Motor useful
  • Grade E: Normal.


Radiological type of vertebral injury

For this, we prescribed every patient's plain X-ray, true anteroposterior, and true lateral views. Factors studied in this group were:

  • Vertebral wedging: <30%; more than 30%
  • Vertebral displacement: <25%; 25-50%; more than 50%; complete displacement
  • Retropulsion
  • Interspinous distortion
  • Least vertebral injury - undisplaced fracture.



  Results Top


The observation of the present study was based on the patients admitted in SCI ward between May 2007 and April 2009. Initially, 207 patients were included on random selection basis. The final observation was based on 126 cases. Incidence of spinal injury - 4.51/100 patients of skeletal trauma; incidence of tetraplegics - 52.42%; and incidence of paraplegics - 47.58%.

About 13.39% of CCI patients were in <20 years age group, between the age group of 20 and 40 years, we had 48.48% of patients and between 40 and 60 years, we had 29.36% of patients. In the age group of above 60 years, we had 8.73%. Ninety-eight were male patients and 28 were female patients, which give a ratio of 3.54:1. Male patients constituted 78% of all CCI patients. Fall from height (FFH) constituted 50.79% of CCI, FFH <10 ft 17.46%, FFH >10 ft 33.33%, fall of heavy object (FHO) was 14.28%, fall while carrying heavy object (FCHO) was 13.49%, road traffic accident (RTA) was 18.25%, and fire arm injury (FAI) was 1.58%. Lower CCI constituted 67% of patients and upper CCI constituted 37% of patients. In the present study, flexion injury constituted 39.68% of CCI, extension 13.49%, flexion-rotation 31.74%, flexion-distraction 7.14%, and compression 7.93%.

About 46.82% patients showed fracture-dislocation type of injury, 8.73% with interspinous distortion, 12.70 without vertebral lesion, 18.25% with wedging, and 13.49% with compression fracture. 47.61% of CCI patients showed neurological recovery and 38.88% did not recover. 20.00% of patients showed signs of recovery and 56.36% patients did not show any sign of recovery in complete lesion. 69.01% of patients showed sign of recovery and 25.35% patients did not show any sign of recovery in incomplete lesion. 53.84% of patients showed the first sign of neurological recovery within 1 st week, 32.30% in 2 nd week, 9.23% in 3 rd week, and 4.61% in 4 th week. After that, neurological recovery was nil. In upper cervical spine lesion, 22.22% of patients showed the first sign of neurological recovery within 1 st week, 55.55% in 2 nd week, 16.11% in 3 rd week, and 5.55% in 4 th week. After that, neurological recovery was nil.

In lower cervical spine lesion, 65.95% of patients showed the first sign of neurological recovery within 1 st week, 23.40% in 2 nd week, 8.51% in 3 rd week, and 2.12% in 4 th week. After that, neurological recovery was nil. Overall rate of recovery was highest in vertebral-dislocation <25% (71.42%), followed by SCI without radiological abnormality (SCIWORA) (62.50%), wedging <30% (61.53%), interspinous distortion (54.54%), vertebral-dislocation 25-50% (50%), compression fracture (47.05%), vertebral-dislocation >50% (45.83%), wedging >30% (30%), and complete dislocation (28.87%). 72.72% patients showed neurological recovery in FFH <10 ft, 56.14% showed recovery in FFH >10 ft, 50.00% recovery in FHO, 44.44% recovery in FCHO, 34.78% recovery in RTA, and in FAI recovery was nil.


  Discussion Top


The present study aimed to predict the neurological recovery in CCI patients. It was also intended to answer certain question which is always raised in the treating surgeons mind and also by the attendants of CCI. For example - what is the window period within which an injured cord must show the first sign of recovery it has to recover? what is the minimum period after which we can say that no recovery is going to occur in conservative treatment? If a cord is showing the signs of recovery how long it will continue? We studied 126 patients of CCI between May 2007 and April 2009 and observations were made on those patients.

The cause of SCI varies from country to country, and basically depends upon the social customs and mode of living. A fast moving vehicle is less common in many parts of our country and is even rarer in remote villages from where most of our patients come from. FFH is the most common mode of injury because people work in high-rise buildings and other construction works without adequate protection, people climb tree for collecting juice, and people sleep on roof top which has no parapet. In India, still many people carry heavy weight on their back or on their head as a method of earning livelihood, and accidents during work causes CCI which is another leading cause of CCI in our social structure, which is not commonly seen in the developed world.

In the present study, we had varied causes of CCI such as FFH, FFH <10 ft 17.46%, FFH >10 ft 33.33%, FHO 14.28%, FCHO 13.49%, and RTA 18.25%. Lower CCI constituted 67% and upper CCI constitutes 37% of total patients. We observed 55 patients (43.65%) having complete lesion (Grade-A) and 71 patients (56.34%) having incomplete lesion (Grades B-D). Overall, 47.61% of CCI patients showed neurological recovery, the overall recovery in upper cervical (C1-C4) was 39.13% (18/46) and lower cervical was 58.75% (47/80), neurological recovery in complete lesion was 21.18%, and in incomplete lesion it was 69.01%. Thus, incomplete lesions showed more recovery than complete lesion. In the case of cervical spine, overall, 53.84% of patients showed the first sign of neurological recovery within 1 st week, 32.30% in 2 nd week, 9.23% in 3 rd week, and 4.61% in 4 th week. In upper cervical spine lesion, 22.22% of patients showed the first sign of neurological recovery within 1 st week, 55.55% in 2 nd week, 16.11% in 3 rd week, and 5.55% in 4 th week. In lower cervical spine lesion, 65.95% of patients showed the first sign of neurological recovery within 1 st week, 23.40% in 2 nd week, 8.51% in 3 rd week, and 2.12% in 4 th week. Thus, injury to the lower cervical spine started showing the signs of recovery earlier than the upper cervical spine. The overall rate of recovery was highest in FFH <10 ft (72.72%), followed by FFH >10 ft (56.14%), FHO (50.00%), FCHO (44.44%), RTA (34.78%), and least recovery was seen in FAI. Rate of recovery was highest in vertebral-dislocation <25% (71.42%), followed by SCIWORA (62.50%), wedging <30% (61.53%), interspinous distortion (54.54%), vertebral-dislocation 25-50% (50%), compression fracture (47.05%), vertebral-dislocation >50% (45.83%), wedging >30% (30%), and complete dislocation (28.87%).

A study by Whiteneck et al. in 2011 [10] aimed at providing information on a large sample of patients treated by specialty rehabilitation inpatient programs. Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient was encountered. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Average length of stay (LOS) was 55 days, during which 180 h of treatment were received or 24 h/week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics. They concluded that variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics.

Recent advances in roadside management and resuscitation techniques have resulted in an increased survival rate of people with high CCI. A few become partially or permanently ventilator dependent. Not only are these people-dependent on assisted ventilation, but their speech is also compromised, along with the loss of voluntary control and many other bodily functions, as they are tetraplegic. Using recent technological advancements, such as portable ventilators, phrenic nerve stimulation, environmental controls, and specialized wheelchairs, it has been possible to manage such patients at home. Recent published reports indicate the factors other than the clinical state that may prevent such patients from taking advantage of modern advances; the main issues appear to be cost factors, community care provision, and ethical considerations. [12]

A study by Samuelkamaleshkumar et al. in 2010 [13] showed that people with SCI in rural South India who have completed comprehensive, mostly self-financed, rehabilitation with an emphasis on achieving functional ambulation, family support, and self-employment, and who attend a regular annual follow-up show a high level of community reintegration in physical independence, social integration, and cognitive independence. Craig Handicap Assessment and Reporting Technique scores in the domains of occupation, mobility, and economic self-sufficiency showed lower levels of community reintegration.

Impressive efforts have been made in the last decade to establish new outcome measurements to document improvement in functions and activities in patients with SCI. A large part of these improvements can be attributed to the rehabilitation program, but it is still unclear which pieces out of this complex rehabilitation jigsaw puzzle deliver the largest contribution to the improvement. The most important outcome of the rehabilitation process should be to achieve the highest level of independence in the activities of daily living for the patient, while taking into account the individual impairments and limitations of the patient. High functional independence is a significant determinant of a positive course of life satisfaction after discharge. [14]

Limitations and future scope

This study was conducted in one tertiary care hospital of Eastern India. Further multicentric studies on recovery pattern of traumatic cervical SCI patients may be done and if our observations are supported, it will be a boon for SCI patients and for hospitals treating them.


  Conclusions Top


In traumatic CCI, patients' level of lesion, type of injury, and nature of injury may be helpful in the early prediction of recovery pattern of patients and careful monitoring of these patients may reduce the social burden in developing countries and reduce morbidity and mortality of these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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