Incomplete Spinal Cord Injury; Diagnosis, Treatment

Incomplete spinal cord injury
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Incomplete spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion. The most common causes of SCI in the world are traffic accidents, gunshot injuries, knife injuries, falls and sports injuries. There is a strong relationship between functional status and whether the injury is complete or not complete, as well as the level of the injury. The results of SCI bring not only damage to independence and physical function, but also include many complications from the injury. Neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis, spasticity, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders are frequent complications after SCI. SCI leads to serious disability in the patient resulting in the loss of work, which brings psychosocial and economic problems. The treatment and rehabilitation period is long, expensive and exhausting in SCI. Whether complete or incomplete, SCI rehabilitation is a long process that requires patience and motivation of the patient and relatives. Early rehabilitation is important to prevent joint contractures and the loss of muscle strength, conservation of bone density, and to ensure normal functioning of the respiratory and digestive system. An interdisciplinary approach is essential in rehabilitation in SCI, as in the other types of rehabilitation. The team is led by a physiatrist and consists of the patients’ family, physiotherapist, occupational therapist, dietician, psychologist, speech therapist, social worker and other consultant specialists as necessary.

 

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Spinal Cord Injury Anatomy: The Basics

Though you might think of your spinal cord as one single piece, it’s actually a column of nerves protected by a sheath of myelin and then further secured by 31 butterfly-shaped vertebrae (singular: vertebra).

Medical providers divide the spinal cord into four distinct regions. Knowing the region in which the injury is located is often the key to understanding diagnosis and treatment. The four spinal cord regions are:

  • The cervical spinal cord This is the topmost portion of the spinal cord, where the brain connects to the spinal cord, and the neck connects to the back. This region consists of eight vertebrae, commonly referred to as C1-C8. All spinal cord numbers are descending, so C1 is the highest vertebra, while C8 is the lowest in this region.
  • The thoracic spinal cord This section forms the middle of the spinal cord, containing twelve vertebrae numbered T1-T12.
  • The lumbar spinal cord This is a lower region of the spinal cord, where your spinal cord begins to bend. If you put your hand in your lower back, where your back bends inward, you’re feeling your lumbar region. There are five lumbar vertebrae, numbered L1-L5.
  • The sacral spine This is the lower, triangle-shaped region of the spine, also with five vertebrae. While the lumbar cord bends inward, the vertebrae of the sacral region bend slightly outward. There is no actual spinal cord in this section, it is made up of nerve roots which exit the spine at their respective vertebral levels.
  • The coccygeal region – sometimes known as the coccyx or tail bone, consists of a single vertebra at the very base of the spinal cord.

Causes of Spinal Cord Injuries

Spinal cord injuries occur for many different reasons. Depending upon the severity of the injury, patient’s symptoms may be mild, moderate, or severe enough to cause death. Spinal cord injuries should be treated as quickly as possible to avoid further damage. Some patients may experience temporary symptoms while others will be left with lifelong symptoms.

Causes for spinal cord injuries are characterized as ‘traumatic’ or ‘non-traumatic.’ Traumatic injuries are caused by an abrupt traumatic hit to the spine which results in damage to one or more of the vertebrae, or a severing of the spinal cord. Non-traumatic injuries are the result of slow internal damage to the spinal cord region.

Traumatic spinal cord injuries occur due to

  • Motor vehicle accidents (Motor vehicle accidents (38%)-Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for more than 35 percent of new spinal cord injuries each year.
  • Falls ,Slips/falls (30.5%)- Spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause more than one-quarter of spinal cord injuries.
  • Acts of violence,Acts of violence (13.5%)- Around 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife wounds, according to the National Spinal Cord Injury Statistical Center.
  • Sports and recreation injuries,Sports-related injuries (9%)- Athletic activities, such as impact sports and diving in shallow water, cause about 9 percent of spinal cord injuries.
  • Alcohol,Medical / surgical (5%)- Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
  • Diseases,Other (4%)- Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.

Non-traumatic spinal cord injuries occur due to

Level of Spinal Cord Injury…………………………………. 

Vertebrae are grouped into sections. The higher the injury on the spinal cord, the more dysfunction can occur.

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High-Cervical Nerves (C1 – C4)

  • Most severe of the spinal cord injury levels
  • Paralysis in arms, hands, trunk and legs
  • Patient may not be able to breathe on his or her own, cough, or control bowel or bladder movements.
  • Ability to speak is sometimes impaired or reduced.
  • When all four limbs are affected, this is called tetraplegia or quadriplegia.
  • Requires complete assistance with activities of daily living, such as eating, dressing, bathing, and getting in or out of bed
  • May be able to use powered wheelchairs with special controls to move around on their own
  • Will not be able to drive a car on their own
  • Requires 24-hour-a-day personal care

Low-Cervical Nerves (C5 – C8)

  • Corresponding nerves control arms and hands.
  • A person with this level of injury may be able to breathe on their own and speak normally.
C5 injury
  • Person can raise his or her arms and bend elbows.
  • Likely to have some or total paralysis of wrists, hands, trunk and legs
  • Can speak and use diaphragm, but breathing will be weakened
  • Will need assistance with most activities of daily living, but once in a power wheelchair, can move from one place to another independently.
C6 injury
  • Nerves affect wrist extension.
  • Paralysis in hands, trunk and legs, typically
  • Should be able to bend wrists back
  • Can speak and use diaphragm, but breathing will be weakened
  • Can move in and out of wheelchair and bed with assistive equipment
  • May also be able to drive an adapted vehicle
  • Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment
C7 injury
  • Nerves control elbow extension and some finger extension.
  • Most can straighten their arm and have normal movement of their shoulders.
  • Can do most activities of daily living by themselves, but may need assistance with more difficult tasks
  • May also be able to drive an adapted vehicle
  • Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment.
C8 injury
  • Nerves control some hand movement.
  • Should be able to grasp and release objects
  • Can do most activities of daily living by themselves, but may need assistance with more difficult tasks
  • May also be able to drive an adapted vehicle
  • Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment
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Thoracic vertebrae are located in the mid-back.

Thoracic Nerves (T1 – T5)

  • Corresponding nerves affect muscles, upper chest, mid-back and abdominal muscles.
  • Arm and hand function is usually normal.
  • Injuries usually affect the trunk and legs(also known as paraplegia).
  • Most likely use a manual wheelchair
  • Can learn to drive a modified car
  • Can stand in a standing frame, while others may walk with braces

Thoracic Nerves (T6 – T12)

  • Nerves affect muscles of the trunk (abdominal and back muscles) depending on the level of injury.
  • Usually results in paraplegia
  • Normal upper-body movement
  • Fair to good ability to control and balance trunk while in the seated position
  • Should be able to cough productively (if abdominal muscles are intact)
  • Little or no voluntary control of bowel or bladder but can manage on their own with special equipment
  • Most likely use a manual wheelchair
  • Can learn to drive a modified car
  • Some can stand in a standing frame, while others may walk with braces.
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Lumbar Nerves (L1 – L5)

  • Injuries generally result in some loss of function in the hips and legs.
  • Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment
  • Depending on strength in the legs, may need a wheelchair and may also walk with braces

Sacral Nerves (S1 – S5)

  • Injuries generally result in some loss of functionin the hips and legs.
  • Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment
  • Most likely will be able to walk

 Symptoms of an acute spinal cord injury

Symptoms vary depending on the severity and location of the SCI. At first, the patient may experience spinal shock, which causes loss of feeling, muscle movement, and reflexes below the level of injury. Spinal shock usually lasts from several hours to several weeks. As the period of shock lessens, other symptoms appear, depending on the location of the injury.

Generally, the higher up the level of the injury to the spinal cord, the more severe the symptoms. For example, an injury at C2 or C3 (the second and third vertebrae in the spinal column), affects the respiratory muscles and the ability to breathe. A lower injury, in the lumbar vertebrae, may affect nerve and muscle control to the bladder, bowel, and legs.

SCI is classified according to the person’s type of loss of motor and sensory function. The following are the main types of classifications:

  • Quadriplegia (quad means four). This involves loss of movement and sensation in all four limbs (arms and legs). It usually happens as a result of injury at T1 or above. Quadriplegia also affects the chest muscles and injuries at C4 or above require a mechanical breathing machine (ventilator).
  • Paraplegia (para means two like parts). This involves loss of movement and sensation in the lower half of the body (right and left legs). It usually happens as a result of injuries at T1 or below.
  • Triplegia (tri means three). This involves the loss of movement and sensation in one arm and both legs and usually results from incomplete SCI.
    Level Motor Function
    C1–C6 Neck flexors
    C1–T1 Neck extensors
    C3, C4, C5 Supply diaphragm (mostly C4)
    C5, C6 Move shoulder, raise arm(deltoid); flex elbow (biceps)
    C6 externally rotate (supinate) the arm
    C6, C7 Extend elbow and wrist (triceps and wrist extensors); pronatewrist
    C7, T1 Flex wrist; supply small muscles of the hand
    T1–T6 Intercostals and trunk above the waist
    T7–L1 Abdominal muscles
    L1–L4 Flex thigh
    L2, L3, L4 Adduct thigh; Extend leg at the knee (quadriceps femoris)
    L4, L5, S1 abduct thigh; Flex leg at the knee (hamstrings); Dorsiflexfoot (tibialis anterior); Extend toes
    L5, S1, S2 Extend leg at the hip (gluteus maximus); Plantar flex foot and flex toes

The following are the most common symptoms of acute spinal cord injuries. However, each individual may experience symptoms differently. Symptoms may include:

  • Muscle weakness or paralysis in the trunk, arms or legs
  • Loss of feeling in the trunk, arms, or legs
  • Muscle spasticity
  • Breathing problems
  • Problems with heart rate and blood pressure
  • Digestive problems
  • Loss of bowel and bladder function
  • Bedsores
  • Chronic pain
  • Headaches
  • Changes in mood or personality
  • Loss of libido or sexual function
  • Loss of fertility
  • Nerve pain
  • Chronic muscle pain
  • Pneumonia (more than half of cervical spinal cord injury survivors struggle with bouts of pneumonia)
  • Sexual dysfunction
  • Loss of movement
  • Loss of sensation, including the ability to feel heat, cold and touch
  • Loss of bowel or bladder control
  • Exaggerated reflex activities or spasms
  • Changes in sexual function, sexual sensitivity and fertility
  • Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
  • Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms

Emergency signs and symptoms of spinal cord injury after an accident may include:

  • Extreme back pain or pressure in your neck, head or back
  • Weakness, incoordination or paralysis in any part of your body
  • Numbness, tingling or loss of sensation in your hands, fingers, feet or toes
  • Loss of bladder or bowel control
  • The difficulty with balance and walking
  • Impaired breathing after injury
  • An oddly positioned or twisted neck or back

The symptoms of SCI may resemble other medical conditions or problems. Always talk with your healthcare provider for a diagnosis.

Types of Spinal Cord Injuries

All spinal cord injuries are divided into two broad categories: incomplete and complete.

  • Incomplete spinal cord injuries: With incomplete injuries, the cord is only partially severed, allowing the injured person to retain some function. In these cases, the degree of function depends on the extent of the injuries.
  • Complete spinal cord injuries: By contrast, complete injuries occur when the spinal cord is fully severed, eliminating function. Though, with treatment and physical therapy, it may be possible to regain some function.

Knowing the location of your injury and whether or not the injury is complete can help you begin researching your prognosis and asking your doctor intelligent questions. Doctors assign different labels to spinal cord injuries depending upon the nature of those injuries. The most common types of spinal cord injuries include:

  • Tetraplegia: These injuries, which are the result of damage to the cervical spinal cord, are typically the most severe, producing varying degrees of paralysis of all limbs. Sometimes known as quadriplegia, tetraplegia eliminates your ability to move below the site of the injury, and may produce difficulties with bladder and bowel control, respiration, and other routine functions. The higher up on the cervical spinal cord the injury is, the more severe symptoms will likely be.
  • Paraplegia: This occurs when sensation and movement are removed from the lower half of the body, including the legs. These injuries are the product of damage to the thoracic spinal cord. As with cervical spinal cord injuries, injuries are typically more severe when they are closer to the top vertebra.
  • Triplegia: Triplegia causes loss of sensation and movement in one arm and both legs, and is typically the product of an incomplete spinal cord injury.

Injuries below the lumbar spinal cord do not typically produce symptoms of paralysis or loss of sensation. They can, however, produce nerve pain, reduce function in some areas of the body, and necessitate several surgeries to regain function. Injuries to the sacral spinal cord, for instance, can interfere with bowel and bladder function, cause sexual problems, and produce weakness in the hips or legs. In very rare cases, sacral spinal cord injury survivors suffer temporary or partial paralysis.

Types of Incomplete Spinal Cord Injuries

Muscle strength ASIA Impairment Scale for classifying spinal cord injury
Grade Muscle function Grade Description
0 No muscle contraction A Complete injury. No motor or sensory function is preserved in the sacral segments S4 or S5.
1 Muscle flickers B Sensory incomplete. Sensory but not motor function is preserved below the level of injury, including the sacral segments.
2 Full range of motion, gravity eliminated C Motor incomplete. Motor function is preserved below the level of injury, and more than half of muscles tested below the level of injury have a muscle grade less than 3 (see muscle strength scores, left).
3 Full range of motion, against gravity D Motor incomplete. Motor function is preserved below the level of injury and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
4 Full range of motion against resistance E Normal. No motor or sensory deficits, but deficits existed in the past.
5 Normal strength

Knowing that a spinal cord injury is “incomplete” isn’t in and of itself enough to know the severity of the injury. Incomplete injuries manifest in myriad ways. Some of the most common include

The American Spinal Injury Association/International Spinal Cord Society Neurological Standard Scale (Better known as the “ASIA Impairment Scale”)
ASIA Impairment Scale Lesion
A
  • No motor or sensory function is preserved in the sacral segments S4–S5
Complete
B
  • Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4–S5
Incomplete
C
  • Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3
Incomplete
D
  • Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more
Incomplete
E
  • Motor and sensory functions are normal
Normal
The Frankel Scale for Spinal Cord Injury That Classifies the Extent of the Neurological/Functional Deficit into Five Grades
Frankel Scale
A
  • Complete
No motor or sensory function below the level of the lesion
B
  • Sensory only
No motor function, but some sensation preserved below the level of the lesion
C
  • Motor useless
Some motor function without practical application
D
  • Motor useful
The useful motor function below the level of the lesion
E
  • Recovery
Normal motor and sensory function may have reflex abnormalities

Anterior cord syndrome: causes injury to the front of the spinal cord, interfering with sensations of touch, pain, and temperature. Most anterior cord injury survivors can recover some movement.

A condition characterized by

  • motor dysfunction
  • dissociated sensory deficit below level of SCI

Pathophysiology

  • injury to anterior spinal cord caused by direct compression (osseous) of the anterior spinal cord anterior spinal artery injury anterior 2/3 spinal cord supplied  by the anterior spinal artery

Mechanism

  • Usually, result of flexion/ compression injury
  • Examination of lower extremity affected more than upper extremityloss >LCT (motor) >LST (pain, temperature)preserved >DC (proprioception, vibratory sense)

Prognosis

  • worst prognosis of incomplete SCI
  • most likely to mimic complete cord syndrome
  • 10-20% chance of motor recovery

Posterior cord syndrome: causes injuries to the back of the spinal cord. Most posterior injury survivors maintain good posture and muscle tone, as well as some movement but struggle with poor coordination.

  • Introduction very rare loss proprioception preserved motor, pain, light touch

Central cord syndrome: This injury is an injury to the center of the cord, and damages nerves that carry signals from the brain to the spinal cord. Loss of fine motor skills, paralysis of the arms, and partial impairment—usually less pronounced—in the legs are common. Some survivors also suffer a loss of bowel or bladder control, or lose the ability to sexually function.

diagram of vertebrae and spinal nerves

Epidemiology

  • incidence >the most common incomplete cord injury  
  • demographics >often in elderly with minor extension injury mechanisms due to anterior osteophytes and posterior infolded ligament flavum

Pathophysiology

  • believed to be caused by spinal cord compression and central cord edema with selective destruction of lateral corticospinal tract white matter
  • anatomy of spinal cord explains why upper extremities and hand preferentially affected hands and upper extremities are located “centrally” in corticospinal tract

Presentation

  • symptoms of weakness with hand dexterity most affected, hyperpathia, burning in distal upper extremity
  • physical exam > loss of motor deficit worse in UE than LE (some preserved motor function) hands have more pronounced motor deficit than arms preserved, sacral sparing

Late clinical presentation

  • UE have LMN signs (clumsy)
  • LE has UMN signs (spastic)

Treatment

  • nonoperative vs. operative extremely controversial

Prognosis

Final outcome  good prognosis although full functional recovery rare

  • Usually ambulatory at final follow up
  • Usually, regain bladder control
  • Upper extremity and hand recovery is unpredictable and patients often have permanent clumsy hands recovery occurs in the typical pattern of lower extremity recovers first, bowel and bladder function next, proximal upper extremity next, hand function last to recover

Brown-Sequard syndrome: This variety of injury is the product of damage to one side of the spinal cord. The injury may be more pronounced on one side of the body; for instance, the movement may be impossible on the right side but may be fully retained on the left. The degree to which Brown-Sequard patients are injured greatly varies from patient to patient.

  • Caused by complete cord hemi transection usually seen with penetrating trauma

Examipsilateral deficit

LCS tract > motor function >dorsal columns

  • proprioception
  • vibratory sense

Contralateral deficit

  • LST> pain, temperature, spinothalamic tracts cross at spinal cord level (classically 2-levels below)
  • Prognosis of excellent prognosis 99% ambulatory at final follow up, the best prognosis for function motor activity
  • Cauda equina lesion: damages the nerves between the first and second lumbar regions of the spine, resulting in a loss of sensation, but not a loss of movement. It may be possible to repair or regenerate some nerves to improve function.

Treatment Spinal  Cord Injury

Non-surgical

  • Rest – It is important that patient take proper rest and sleep and avoid any activities which will further aggravate the disc bulge and its symptoms. Many minor disc bulges can heal on their own with rest and other conservative treatment.
  • Cervical Pillow – It is important to use the right pillow to give your neck the right type of support for healing from a cervical disc bulge and also to improve the quality of sleep.

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Specific treatment for lumbar disk disease will be determined by your health care provider based on

  • Your age, overall health, and medical history
  • Extent of the condition
  • Type of condition
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

Typically, conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.

  • Ice & Moist Heat Application

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Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provide the same benefit.

  • Hot Bath

Taking a hot bath or shower also helps in dulling the pain from a disc bulge. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.

  • Traction

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  • Massage therapy – may give short-term pain relief, but not a functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
  • Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
  • Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
  • “Back school” –  is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective or not.
  • Patient education on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
  • Physical therapy – which may include ultrasound, massage, conditioning, and exercise
  • Weight control
  • Use of a lumbosacral back support

Medications for Spinal Cord Injury

  • Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
  • Antidepressants: A Drugs that block pain messages from your brain and boost the effects of eorphins (your body’s natural painkillers).
  • Medication – Common pain remedies such as aspirinacetaminophen, ibuprofen , and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications,including muscle relaxants and anti-seizure medications, treat aspects of spinal stenosis, such as muscle spasms and damaged nerves.
  • Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your back or neck. Steroids make inflammation go down. However, because of side effects, they are used sparingly.
  • Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time.
  • Muscle Relaxants – These medications provide relief from spinal muscle spasms.
  • Skeletal muscle relaxers –  may also be used.Their short term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side-effects.
  • Neuropathic Agents: Drugs(pregabalin & gabapentine) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
  • Antibiotic –  to the management of bowel & bladders control and protect further infection. Infection causes should be treated with appropriate antibiotic therapy
  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
  • Calcium & vitamin D3 – to improve bones health and healing fracture.
  • Glucosamaine & diacerine – can be used to tightening the loose tenson and regenerate cartilage or inhabit the further degeneration of cartilage.
  • Corticosteroid – to healing the nerve inflamation and clotted blood in the  joints.
  • Diatery suppliment -to remove the general weakness & improved the health.
  • Lesion debulking –  is required for space-occupying lesions – eg, tumours, abscess.
  • If surgery cannot be performed – radiotherapy may relieve cord compression caused by malignant disease.
  • Radiation therapy and Chemotherapy – may have a role in treatment if the cauda equina  syndrome is caused by the tumor.
  • Support or brace – A pelvic belt can be used to stabilize a joint that is too loose until the inflammation and pain subside.
  • Joint injections – Numbing injections into the sacroiliac joint are used diagnostically to help identify the cause of the but are also useful in providing immediate pain relief. Typically, an anesthetic is injected along with an anti-inflammatory medication.

Other treatment options

  • Other treatment options –  may be useful in certain patients, depending on the underlying cause of the CES
  • Weakness – Physiotherapy may be helpful if there is no inflammatory component such as that found in arachnoiditis where exercise might exacerbate the condition and cause flare-ups.
  • Sensory Loss – Little conventional treatment exists for sensory loss in cauda Equina syndrome, although in conditions such as Multiple Sclerosis use of vitamin B complex is considered to have potential beneficial effects.
  • Sore Feet – Loss of muscle tone and control over the movement of the foot may lead to foot pain. If foot drop is a notable issue, a brace to hold it in position may help. It is important; however, to attempt to maintain as much muscle tone as possible as well as a range of movement (ROM). Exercises might help.
  • Sexual Dysfunction – Sexual dysfunction is very hard for people to talk about at times. It might be best to pursue advice from specialists. If no physical treatment is feasible for improving function, the person and their sexual partner might pursue counseling which might help to lessen the impact of this disability on not only the person affected, but their partner.
  • Depression – Depression is an understandable reaction to a form of debilitating illness. Antidepressant medication should be reserved for severe depression. Counseling and support are the preferred method of managing depression. Sharing experiences may help people with cauda Equina syndrome to come to terms with the disabilities associated with cauda Equina syndrome.
  • Poor Circulation – Poor circulation is a common issue in cauda Equina syndrome. The person’s feet may be cold and turn white, then red when re-warmed (also known as, ‘Raynaud’s syndrome,) as well as chilblains. Some medications exist that can be taken, yet it is most likely best to use general measures such as avoiding getting cold feet and foot massage with warm oil to help improve the person’s circulation. Avoid extremely hot baths after the feet have been cold because it will most likely cause chilblains.
  • Postoperative care – includes addressing lifestyle issues (eg, obesity), and also physiotherapy and occupational therapy, depending on residual lower limb dysfunction.
  • Prolotherapy – the practice of injecting solutions into joints (or other areas) to cause inflammation and thereby stimulate the body’s healing response – has not been found to be effective by itself, although it may be helpful when added to another therapy.
  • Herbal medicines – as a whole, are poorly supported by evidence.The herbal treatments Devil’s claw and white willow may reduce the number of individuals reporting high levels of pain; however, for those taking pain relievers, this difference is not significant. Capsicum, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.
  • Behavioral therapy – may be useful for chronic pain. There are several types available, including operant conditioning, which uses reinforcement to reduce undesirable behaviors and increase desirable behaviors;
  • Cognitive behavioral therapy – which helps people identify and correct negative thinking and behavior; and respondent conditioning, which can modify an individual’s physiological response to pain. Medical providers may develop an integrated program of behavioral therapies. The evidence is inconclusive as to whether mindfulness-based stress reduction reduces chronic back pain intensity or associated disability, although it suggests that it may be useful in improving the acceptance of existing pain.
  • Tentative evidence supports neuroreflexotherapy (NRT) – in which small pieces of metal are placed just under the skin of the ear and back, for non-specific low back pain

Complications

At first, changes in the way your body functions may be overwhelming. However, your rehabilitation team will help you develop the strategies you need to address the changes caused by the spinal cord injury. Areas often affected include:

  • Bladder control – Your bladder will continue to store urine from your kidneys. However, your brain may not be able to control your bladder as well because the message carrier (the spinal cord) has been injured. The changes in bladder control increase your risk of urinary tract infections. They also may cause kidney infections and kidney or bladder stones. During rehabilitation, you’ll learn new techniques to help empty your bladder.
  • Bowel control –  Although your stomach and intestines work much as they did before your injury, control of your bowel movements is often altered. A high-fiber diet may help regulate your bowels, and you’ll learn techniques to optimize your bowel function during rehabilitation.
  • Skin sensation – Below the neurological level of your injury, you may have lost part of or all skin sensations. Therefore, your skin can’t send a message to your brain when it’s injured by certain things such as prolonged pressure, heat or cold. This can make you more susceptible to pressure sores, but changing positions frequently — with help, if needed — can help prevent these sores. You’ll learn proper skin care during rehabilitation, which can help you avoid these problems.
  • Circulatory control – A spinal cord injury may cause circulatory problems ranging from low blood pressure when you rise (orthostatic hypotension) to swelling of your extremities. These circulation changes also may increase your risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus. Another problem with circulatory control is a potentially life-threatening rise in blood pressure (autonomic hyperreflexia). Your rehabilitation team will teach you how to address these problems if they affect you.
  • Respiratory system. Your injury may make it more difficult to breathe and cough if your abdominal and chest muscles are affected. These include the diaphragm and the muscles in your chest wall and abdomen.Your neurological level of injury will determine what kind of breathing problems you may have. If you have cervical and thoracic spinal cord injury, you may have an increased risk of pneumonia or other lung problems. Medications and therapy can treat these problems.
  • Muscle tone. Some people with a spinal cord injury experience one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity).
  • Fitness and wellness. Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility may lead to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes.A dietitian can help you eat a nutritious diet to sustain an adequate weight. Physical and occupational therapists can help you develop a fitness and exercise program.
  • Sexual health. Sexuality, fertility and sexual function may be affected by spinal cord injury. Men may notice changes in erection and ejaculation; women may notice changes in lubrication.Doctors, urologists and fertility specialists who specialize in spinal cord injury can offer options for sexual functioning and fertility.
  • Pain. Some people experience pain, such as muscle or joint pain, from overuse of particular muscle groups. Nerve pain, also known as neuropathic or central pain, can occur after a spinal cord injury, especially in someone with an incomplete injury.
  • Depression. Coping with all the changes spinal cord injury brings and living with pain causes some people to experience depression. Therapy and medications are available to treat depression associated with living with a spinal cord injury.

References

Incomplete spinal cord injury

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