Title : Predictors of neurological recovery following traumatic spinal cord
Abstract:
During the second WW Guttmann demonstrated that with a holistic simultaneous Active Physiological Conservative Management of the spinal injury together with the medical and nonmedical effects of cord damage to prevent systemic complications; patients with Traumatic Spinal Cord Injuries (TSCI) can not only survive but also live healthy, dignified, enjoyable, productive and often competitive long lives. Guttmann also observed that many patients improved neurologically. The interest in this neurological recovery, its prognostic indicators its extent has grown and been extensively studied since. Frankel et al in 1969 based on the Medical Research Council neurological examination studied the neurological presentation and outcomes of 682 consecutive patients admitted to Stoke Mandeville Hospital within 14 days of injury . 2 They observed significant spontaneous neuro-functionally useful recovery in over 65% of patients who presented with sensory sparing but complete motor paralysis of lower limbs (LL) and even better recovery in patients presenting with various degrees of motor sparing below the level of injury2 . They found significantly fewer patients with clinically complete injuries on presentation recovered motor power that is neuro-functionally useful. They astutely observed that this neurological recovery occurs irrespective of the radiological presentation of the injury on Xrays in patients managed conservatively without any surgical, cellular, pharmacological, biological, chemical, immunological, hormonal or other intervention intervention. Based on their observation they published their seminal Frankel classification in 1969. Their findings have been regularly confirmed confirmed by many groups of dedicated clinicians to the management of patients with TSCI since. Folman and El Masri have since studied the differential prognostic value of the sensory modalities spared in patients admitted within 48 hours of injury. They demonstrated that patients with pin prick sensory sparing and without motor sparing at or below the level of injury recover neuro-functionally useful motor power at and/or below the level of injury. They hypothesised that this spontaneous neurological recovery was achieved by the recovery of the initially dormant myotomes adjacent to the spared dermatomes at and/or below the level of injury. They demonstrated that the motor recovery of patients with posterior column sensory sparing is of poorer than that of patients with pin prick sensory sparing. Our observation was published in 1989, repeatedly confirmed by many groups since and Pin Prick sparing has since been included in the AIS Classification. The development of CT, MRI, range of Instrumentation, Safer Anaesthesia have resulted in a significant increase of Surgical interventions on the injured spine in the hope of improving the neurological and other outcomes of patients. The rationale was based on some findings in the animal model others and/or from the advantages of Spinal Surgery in neurologically intact patients without cord damage. Our Group opted to evaluate the significance of CT and MRI findings on the predictable neurological outcomes of patients treated with APCM and without interventions. Our findings have been widely published having demonstrated that spinal malalignment, canal encroachment, cord compression do not prevent significant neurological recovery nor cause neurological deterioration; provided the Biomechanical Instability of the injured spine is well contained and the patient’s multisystem malfunction is adequately managed to prevent non-mechanical damage by systemic complications. Unfortunately to date there is no evidence to suggest that surgical intervention on the spine of patients with cord damage results in equal or added value to the APCM of patients and there are risks of further neurological damage during surgery and from post-operative systemic complications. I will discuss the necessary evidence required to determine the value of various Surgical Interventions on the injured spine of patients with Traumatic Spinal Cord Injuries.
