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Thread: Thoracic Spinal Cord Injury: Diagnosis & Treatment

  1. #1

    Thoracic Spinal Cord Injury: Diagnosis & Treatment

    Diagnosis and Treatment of Thoracic Spinal Cord Injury
    By Wise Young, Ph.D., M.D.
    W. M. Keck Center for Collaborative Neuroscience
    Rutgers University, Piscataway, New Jersey
    http:sciwire.com, last updated 23 July 2005

    Many people have been asking for an article about diagnosis and treatment of thoracic spinal cord injury. The following is a short description of upper and mid-thoracic spinal cord injury, emphasizing the anatomy, the neurology, treatment, recovery, and long-term changes, and hope for recovery and therapies.

    Anatomy

    The thoracic spinal cord is situated in the T1-T9 thoracic spinal canal. The thoracic vertebral segments form the chest wall and have ribs. The thoracic segments are the best protected of all the vertebral segments because of the ribs. It takes enormous forces to fracture the thoracic spinal vertebral bodies. Traumatic injuries of the upper thoracic spinal cord are relatively rare, accounting for only 10-15% of spinal cord injuries (compared to 40% due to cervical, 35% due to thoracolumbar injuries, and 5% due to lumbosacral injuries). Thoracic spinal cord injuries occur as a result of high-speed motor vehicular accidents, tumors that have compressed the spinal cord, and ischemic injuries of the spinal cord. When traumatic injuries of the thoracic spinal cord occur, they generally are severe and often result in complete loss of neurological function below the injury site.

    Details of the anatomy are worthwhile noting. The C1 roots exit the spinal column just above the C1 vertebral body, that there is a C8 spinal segment but no C8 vertebral segment. The C8 root therefore exits the vertebral column between C7 and T1. The T1 root exits the spinal column below T1. The thoracic spinal roots form the intercostal nerves (nerves that run on the underside of the ribs). Although many clinicians say and believe mistakenly that the thoracic segments do not have a significant motor component and that all they control are the intercostal muscles for breathing, this is not true. As it turns out, the thoracic segments control muscles that attach to the ribs (which include the abdominal muscles, as well as most of the back muscles).

    Neurology

    Injury to the thoracic spinal cord causes paraplegia, or loss of motor and sensory function in the lower half of the body. Because the thoracic cord is situated some distance from the brain and lumbar cord, sensory and motor axons have a long ways to regenerate before they can restore function. Nevertheless, substantial sensory and motor recovery occurs in a majority of people with mid-thoracic injuries, even those with initially "complete" spinal cord injury. For example, recovery of 4-6 dermatomes of sensory function and upper trunk/abdominal muscles is common. Diagnosis of spinal cord injury usually is based on sensory examination. The axillary (armpit) region is T2, the nipples T4, the bottom of the rib cage is T8, the umbilicus (belly button) is T10, and the suprapubic region is T12.

    The cervical segments innervate superficial trunk muscles such as the scapula and the latissimus dorsi. Multiple overlapping thoracic segments innervate most deeper trunk muscles. Injury to the thoracic spinal cord will cause partial paralysis of deeper trunk muscles such as the cervicis (T1-5), splenius (T3-T6), erector spinae and iliocostalis (T6-12), spinalis (T1-9), semispinalis, transversospinal, and segmental (T1-12) muscles. The thoracic segments and upper lumbar segments innervate the abdominal muscles including the rectus abdominus (T4-L3), external oblique (T6-L3), transverse abdominis (T9-L3), and internal oblique (T12-L3). The posterior oblique (T6-10) and the anterior oblique (T4-8) muscles attach to the lower and upper thoracic ribs respectively. In general, muscles above the belly button are innervated by T5-T11 while muscles below the belly button are innervated by T12 and L1.

    Causes of Injury

    Decompression of the thoracic spinal cord often requires surgery because traction alone often cannot reposition the thoracic vertebral segments. Because surgery on the thoracic spinal column usually requires the opening of the thoracic cavity, decompression of thoracic spinal cord injury may be delayed by many hours, days, or even weeks after injury. Continued compression of the spinal cord contributes to the damage. In my opinion, delays in decompressing the spinal cord contribute to neurological loss in thoracic spinal cord injuries. Compression of the spinal cord causes ischemia or loss of blood flow to the spinal cord. Pressure on the spinal cord exceeding blood pressure will reduce or stop blood flow to the spinal cord. Continued compression for many hours, days, or even weeks is likely to cause further damage to the spinal cord.

    The thoracic spinal cord is vulnerable to ischemic injuries. In humans, the artery of Adamkiewicz is a major source of blood to the thoracic spinal cord and usually enters the spinal cord at T6. Compromise of this artery by traumatic aortic aneurysms, for example, can cause an infarct of the thoracic spinal cord. Arteriovenous malformations (AVM) often occur in the thoracic spinal cord. AVM's cause ischemia by "stealing" blood from the capillaries and increasing venous pressure. Finally, tumors of the spinal cord often occur in the thoracic spinal cord and they compress the cord, reducing blood flow. Ischemic injuries to the spinal cord may outnumber traumatic spinal cord injuries.

    Treatment

    The first goal of treating thoracic spinal cord injury is protection of the spinal cord. This includes treatment with high-dose methylprednisolone if the treatment can be started within 8 hours after injury. If there is continuing compression of the spinal cord, the spinal cord should be decompressed. It may be necessary to open the thoracic cavity to approach the thoracic spinal column from the front. In the United States, such surgery usually involve a thoracic surgeon as well as a spinal surgeon, and the surgery may be delayed until the patient is stable and major surgery can be scheduled. In lower thoracic spinal cord injuries, it is often possible to straighten out and stabilize the spinal column from the back, using posterior rods and screws. Care must be taken to evaluate the screws and whether or not they impinge on the spinal cord and roots.

    Thoracic spinal cord injury disconnects the lower thoracic and lumbosacral spinal cord from the brain. While paraplegia (paralysis of the lower limbs) is the most obvious outcome of spinal cord injury, loss of sacral functions including bowel and bladder function are the most troublesome and a major cause of death before the 1970's. With the advent of antibiotics and intermittent catheterization, as well as better emergency care, most people with thoracic spinal cord injuries today survive their injuries and can live close to normal lifespan. Because the injury does not involve the lumbar and sacral spinal cord, lumbosacral reflexes are usually preserved and spasticity is frequently present. Thus, people with thoracic spinal cord injuries are good candidates for regenerative therapies aimed regrowing descending motor axons from the injury site to the lumbosacral segments or ascending sensory axons from the injury site to the brain.

    Recovery

    Most clinicians tend to be quite pessimistic about recovery from thoracic spinal cord injury. Part of this may be because most people with thoracic spinal cord injury were involved in severe high-speed motor vehicular accidents and prolonged compressions of the spinal cord. In the past, many clinicians often did not even decompress thoracic spinal cords. This has changed in recent years as many studies, particularly the work of Bohlman, et al. at Case Western University, have reported that decompressing thoracic spinal cords even up to 3 years after injury may result in some functional improvement in patients. Up to 80% of the patients got better from such decompressive surgery and only 10% got worse. Most had reduction of pain after the surgery.

    Part of the pessimism associated with thoracic spinal cord injury derives from inadequate neurological examination of patients with thoracic spinal cord injuries. Many clinicians examine only the legs and not the trunk or abdominal muscles or thoracic sensory levels. In my experience, most people with thoracic spinal cord injuries regain 4 or more dermatomes below the initial injury level. For example, a person with a T4 injury (sensory level at the nipples) often regains back the T8 (bottom of the rib cage) or even T10 (umbilicus) dermatomes. Likewise, they often get back upper abdominal muscles representing T5-11. Although many patients with T2-T5 injuries show improved trunk control over several years after injury and many can even stand with bilateral knee-ankle-foot orthoses and a walker, suggesting that they have regained some hip control, these are often not credited as recovery of function. Individuals with T6-T12 injuries often recover lower abdominal muscles and may be able to ambulate short distances. Some with T9-T12 injuries become household walkers (Source).

    Long-term Changes

    White matter (myelinated axons) normally occupies over 90% of the thoracic spinal cord. About half of the axons are ascending sensory fibers from dorsal root ganglia sensory neurons situated just outside the spinal cord and the remainder come from neurons in the lower spinal cord. The rest are descending motor axons that come from brain, brainstem, and cervical spinal cord. Thoracic spinal cord injury interrupts most of these axons. The parts of axons that have been separated from their cell bodies will die. The neurons from which the axons come do not die and the neurons that they contact usually survive. Nevertheless, there is often substantial atrophy of the spinal cord at and around the injury site. This is natural and not something to be worried about.

    Routine MRI and x-rays of the spinal cord and spine are important for people with thoracic spinal cord injury. In children, thoracic spinal cord injuries frequently lead to scoliosis. In older patients, there are progressive changes in the vertebral bodies that may need to be surgically corrected to prevent deformities or compression of the cord. Particularly if the spinal cord is not decompressed, adhesive scars may form between the spinal cord and the surrounding arachnoid/dura mater at the injury site. Such adhesions may interrupt cerebrospinal fluid flow between the upper and lower spinal cord. In such cases, syringomyelic cysts may develop. These are enlargements of the central canal in the spinal cord, usually a thin and barely detectable canal in the middle of the cord. Due to shunting of cerebrospinal fluid into central canal, the canal enlarges and may compress the cord.

    Reasons for Hope

    As pointed out above, people with thoracic spinal cord injury are good candidates for regenerative therapies in clinical trials. A number of recent clinical trials have chosen to focus on people with upper and midthoracic spinal cord injuries. For example, the Proneuron trial that transplanted activated macrophages and the Purdue trial that applied alternating electrical currents chose to focus on patients with thoracic spinal cord injuries. Many clinical investigators focus on thoracic spinal cord injuries for the following reasons. First, because of the pessimism surrounding recovery from thoracic spinal cord injury, any recovery of the lower limbs would be generally perceived as being a positive effect of therapy. Second, because the thoracic spinal cord is considered to be less crucial to body functions, any complications that might cause ascent of lesion level would not be as devastating. Third, the lumbosacral spinal cord is intact and therefore should be available to receive connections from regenerating axons from above.

    People with thoracic spinal cord injuries have much reason to be hopeful. They will probably be among the first to benefit from experimental regenerative therapies of the spinal cord. Because their lumbosacral spinal cords are intact, they should have some atrophy and should not have as much muscle atrophy. Regenerative therapies alone should be sufficient to restore substantial function in many people with thoracic spinal cord injury. The regeneration distances for descending axons to travel from the thoracic spinal cord to the lumbosacral cord are shorter than from the cervical spinal cord. Many will recover trunk function and even proximal hip function without experimental therapies and hence can more easily engage in weight-supported ambulation training, swimming, and other exercises that can maintain bone and muscle.

    Summary

    Thoracic spinal cord injuries represent only 10-15% of people with spinal cord injuries. Because the ribs protect the thoracic segments, most thoracic spinal cord injuries are a result of high-speed motor vehicular accidents, aggravated by continued compression of the spinal cord. Perhaps because most thoracic spinal cord injuries are severe and frequently are not decompressed until late, clinicians tend to be pessimistic about the outcome of thoracic spinal cord injuries. However, most people with upper thoracic spinal cord injury do recover at least 4 dermatomes, improved trunk control, and upper abdomen muscles after the injury. Some with mid-thoracic injuries may recover proximal muscles of the legs. Because the lumbosacral spinal cord remains intact, most people with thoracic spinal cord injuries retain reflexes and spasticity in the lower limbs. Clinical trials of regenerative and other cell transplant therapies often focus on patients with thoracic spinal cord injuries because an ascent of lesion level typically is not as devastating as for cervical levels. Thus, people with thoracic spinal cord injury are likely to be amongst the first to benefit from experimental regenerative therapies of the spinal cord.
    Last edited by Wise Young; 07-23-2005 at 06:43 PM.

  2. #2
    Senior Member Schmeky's Avatar
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    Dr. Y,

    Thank you very much. Didn't know I was a 10-15%'er.

  3. #3
    Dr. Young , thank you , for your hard work on this information.
    oh well

  4. #4

    God Bless You

    Thank you so much Dr. Young.

    Your article provides a lot of insight and hope. Sarah's injury was not caused by an accident, but by a 'bump' during initial, aborted, scoli surgery (7/28/04). She is now fused from T3 to L3 (done 9/21/04), but has great posture...I quess thats good.

    She first moved her left leg at 3 weeks, right leg at 3 months. Took her first steps at 4 months.

    Her return has been good thus far. This Thursday (7/28) will be her one yr anniversary. She's 6 weeks into a 9 nine week stint at PW. 2 hrs of therapy, 4 days a week. She's getting stronger, and is meeting goals established at PW. Her abductors seem to overrule other muscles (knees rub while walking, right foot tends to want to cross left when taking steps), but this is improving. Quads are strong, hamstrings weak. Brown Sequard symdrom is probable, left leg is much better than right, while the right is more 'sensitive'.

    The goal this summer was to get to a point where she could go from sit to stand (using walker or crutches), self ambulate, then sit wherever. Then she could do without her wheelchair for the most part (which she didn't want to bring to high school with her this fall). She can sit to stand very easily with a bolted down paralell bar, not so good with walker. But she's improving and thats the important thing.

    Her sacral (B&B) sensations are good, but no controls yet. Still uses self caths and bowel program. We're really hoping these turn back on at some point.

    Being 14 (13 at time of injury) should help as well, right?

    Question: Can you tell me a little about 'Spinal Shock'? What is the duration and could it still be a factor for Sarah?

    Your a wonderful researcher and a true hero IMO. Thank you for always being here for us.

    Rick
    Last edited by rickhemi; 07-25-2005 at 11:55 AM.
    Rick

    GO FORWARD! 2 FIGHT! PARALYSIS!

  5. #5
    Quote Originally Posted by rickhemi
    Thank you so much Dr. Young.

    Your article provides a lot of insight and hope. Sarah's injury was not caused by an accident, but by a 'bump' during initial, aborted, scoli surgery (7/28/04). She is now fused from T3 to L3 (done 9/21/04), but has great posture...I quess thats good.
    • You are very welcome. Fusion of T3 to L3 is a lot. What she should be most careful about and she should get regular x-rays to evaluate her spinal column above and below the fused segments. This is because all her back movements are now concentrated on the segments just above and below, that part of her spinal column will be at a high risk of degenerative changes. Normally, back movements are distributed over the entire spinal column and thus minimize the stress on individual vertebral joints.

    She first moved her left leg at 3 weeks, right leg at 3 months. Took her first steps at 4 months.

    Her return has been good thus far. This Thursday (7/28) will be her one yr anniversary. She's 6 weeks into a 9 nine week stint at PW. 2 hrs of therapy, 4 days a week. She's getting stronger, and is meeting goals established at PW. Her abductors seem to overrule other muscles (knees rub while walking, right foot tends to want to cross left when taking steps), but this is improving. Quads are strong, hamstrings weak. Brown Sequard symdrom is probable, left leg is much better than right, while the right is more 'sensitive'.

    The goal this summer was to get to a point where she could go from sit to stand (using walker or crutches), self ambulate, then sit wherever. Then she could do without her wheelchair for the most part (which she didn't want to bring to high school with her this fall). She can sit to stand very easily with a bolted down paralell bar, not so good with walker. But she's improving and thats the important thing.
    • All this is wonderful news. She should be able to regain more function in the coming months and year. May I ask whether she received methylprednisolone when they realized that she had lost function after the surgery? Let me me comment briefly on what causes injury in scoliosis surgery. In medical school and in the 1980's, I spent much of my time with orthopedic surgeons studying scoliosis and doing somatosensory evoked potential monitoring of patients during surgery. In my opinion, it is not usually a "bump" during surgery that compromises function. Rather, it comes from trying to straighten the spinal column too much. When scoliosis develops, the spinal cord has to follow the contours of the curving canal. Because parts of the spinal cord may be pressed against bone, adhesions sometimes develop between the spinal cord and spinal roots with the surrounding arachnoid. When the spinal column is then straightened out, these adhesions pull on the spinal cord and causes compression of the cord. The compression sometimes result in reduction in blood flow to the spinal cord and the damage probably results from ischemia or loss of blood flow. Usually white matter (the fiber tracts) of the spinal cord are relatively resistant to ischemia (up to about 30 minutes) and don't require as much blood flow as gray matter (the part of the spinal cord that contains most of the neurons). However, oligodendroglia (the cells the myelinate axons) are susceptible to ischemia and may die, causing demyelination. One possibility is that your daughter may have demyelination of axons and remyelinative therapies may help her. There is the possibility that 4-aminopyridine, which is a drug that increases excitability of axons so that demyelinated axons can conduct signals, may also help restore some sensation and motor control. She is young and there is little experience with the use of 4-aminopyridine in young people but this might be something worthwhile considering. Finally, as you know, there are a number of regenerative and remyelinative therapies that have been shown to restore function in animal studies and we need to get these into clinical trials so that we can optimize them and determine which is the best for restoring function in humans.

    Her sacral (B&B) sensations are good, but no controls yet. Still uses self caths and bowel program. We're really hoping these turn back on at some point.
    • I hope so as well.

    Being 14 (13 at time of injury) should help as well, right?
    • Absolutely.

    Wise.

  6. #6
    Quote Originally Posted by Wise Young
    • You are very welcome. Fusion of T3 to L3 is a lot. What she should be most careful about and she should get regular x-rays to evaluate her spinal column above and below the fused segments. This is because all her back movements are now concentrated on the segments just above and below, that part of her spinal column will be at a high risk of degenerative changes. Normally, back movements are distributed over the entire spinal column and thus minimize the stress on individual vertebral joints.


    • All this is wonderful news. She should be able to regain more function in the coming months and year. May I ask whether she received methylprednisolone when they realized that she had lost function after the surgery? Let me me comment briefly on what causes injury in scoliosis surgery. In medical school and in the 1980's, I spent much of my time with orthopedic surgeons studying scoliosis and doing somatosensory evoked potential monitoring of patients during surgery. In my opinion, it is not usually a "bump" during surgery that compromises function. Rather, it comes from trying to straighten the spinal column too much. When scoliosis develops, the spinal cord has to follow the contours of the curving canal. Because parts of the spinal cord may be pressed against bone, adhesions sometimes develop between the spinal cord and spinal roots with the surrounding arachnoid. When the spinal column is then straightened out, these adhesions pull on the spinal cord and causes compression of the cord. The compression sometimes result in reduction in blood flow to the spinal cord and the damage probably results from ischemia or loss of blood flow. Usually white matter (the fiber tracts) of the spinal cord are relatively resistant to ischemia (up to about 30 minutes) and don't require as much blood flow as gray matter (the part of the spinal cord that contains most of the neurons). However, oligodendroglia (the cells the myelinate axons) are susceptible to ischemia and may die, causing demyelination. One possibility is that your daughter may have demyelination of axons and remyelinative therapies may help her. There is the possibility that 4-aminopyridine, which is a drug that increases excitability of axons so that demyelinated axons can conduct signals, may also help restore some sensation and motor control. She is young and there is little experience with the use of 4-aminopyridine in young people but this might be something worthwhile considering. Finally, as you know, there are a number of regenerative and remyelinative therapies that have been shown to restore function in animal studies and we need to get these into clinical trials so that we can optimize them and determine which is the best for restoring function in humans.


    • I hope so as well.


    • Absolutely.

    Wise.
    Wise, you're beautiful.

    You're right, it may not have been a bump. The first surgeon said she didn't know what happened, that the injury "wasn't even where I was working". But the 2nd surgeon pointed out that the injury was indeed where she was working as shown in the OR report. The first hook was inserted exactly where the injury took place. So who knows, but your post certainly may shed some additional light on this.

    Xrays since the fusion have shown that while her neck and fused portion of her back is nice and straight, the L4 on down still is curved, so this is being monitored. But the last xray (taken while standing) showed the curve is getting better. The first followup xray was taken from a sitting position before Sarah started walking and didn't look too good. Dr. Abel mentioned something about perhaps fixing that and we kinda cut him off, just can not handle anymore surgeries at this point. He completely understood and backed up and said that it's nothing to consider right now, but needs to be monitored.

    Yes, Sarah started receiving the steriod within an hour or so after the injury, and continued with the treatment for about 6 days.

    Can you tell me anything about spinal shock? What is the duration and could this be affecting Sarah?

    Thanks for being you.

    Rick
    Last edited by rickhemi; 07-25-2005 at 12:22 PM.
    Rick

    GO FORWARD! 2 FIGHT! PARALYSIS!

  7. #7
    Quote Originally Posted by rickhemi
    Wise, you're beautiful.

    You're right, it may not have been a bump. The first surgeon said she didn't know what happened, that the injury "wasn't even where I was working". But the 2nd surgeon pointed out that the injury was indeed where she was working as shown in the OR report. The first hook was inserted exactly where the injury took place. So who knows, but your post certainly may shed some additional light on this.

    Yes, Sarah started receiving the steriod within an hour or so after the injury, and continued with the treatment for about 6 days.

    Can you tell me anything about spinal shock? What is the duration and could this be affecting Sarah?

    Thanks for being you.

    Rick
    Rick, spinal shock was first described by Sir Charles Sherrington. (By the way, Sir Charles is sort of like my scientific grandfather. He helped train Sir John Eccles. Sir John trained my mentor, Rodolfo Llinas, who was my PhD advisor). Sir Charles noted that when he cut the thoracic spinal cord of monkeys, they initially showed a flaccid areflexic paralysis of the lower limbs. He suggested that there was some effect of the injury that caused a "shock" of the whole spinal cord. Unfortunately, the term and condition has been twisted around over the years to mean all sorts of non-specific changes in the spinal cord. For example, in critical care medicine, there is a term called "shock" which refers to central nervous system shutdown when there has been global ischemia. Today, many clinicians use the term of "spinal shock" loosely to refer to any kind of distant loss of function that they cannot explain. Generally, spinal shock should last only several weeks and should gradually recover. Personally, I do not believe that the term should be used for long term neurological deficits.

    I don't think that your daughter has spinal shock now because she clearly is able to move some of her leg muscles and she probably has reflexes in her legs. The term shock implies that the cells themselves have not been damaged and they are simply not functioning. If so, one would expect recovery of function as the "shock" wear off. So, it is a term of convenience that is making a lot of unjustified assumptions concerning the loss of function that your daughter has. By the way, the term shock has also been used to argue against the possibility of regeneration or remyelination being responsible for the recovery of function after spinal cord injury. Some clinicians suggest that the recover of function that occurs during the months after spinal cord injury results from the diminishing of "spinal shock". In my opinion, there is little data to support this view and it is entirely possible that some regeneration and remyelination does occur after spinal cord injury and is responsible for the partial recovery of function that many people get after injury.

    In any case, the explanation of the recovery doesn't really matter for your daughter. What matters is that your daughter is recovering some function and, we are all grateful. From the viewpoint of research, however, I have long felt that if we can understand why some people recover and others do not, we would have the answer to the cure of spinal cord injury.

    Wise.

  8. #8
    Quote Originally Posted by Wise Young
    Rick, spinal shock was first described by Sir Charles Sherrington. (By the way, Sir Charles is sort of like my scientific grandfather. He helped train Sir John Eccles. Sir John trained my mentor, Rodolfo Llinas, who was my PhD advisor). Sir Charles noted that when he cut the thoracic spinal cord of monkeys, they initially showed a flaccid areflexic paralysis of the lower limbs. He suggested that there was some effect of the injury that caused a "shock" of the whole spinal cord. Unfortunately, the term and condition has been twisted around over the years to mean all sorts of non-specific changes in the spinal cord. For example, in critical care medicine, there is a term called "shock" which refers to central nervous system shutdown when there has been global ischemia. Today, many clinicians use the term of "spinal shock" loosely to refer to any kind of distant loss of function that they cannot explain. Generally, spinal shock should last only several weeks and should gradually recover. Personally, I do not believe that the term should be used for long term neurological deficits.

    I don't think that your daughter has spinal shock now because she clearly is able to move some of her leg muscles and she probably has reflexes in her legs. The term shock implies that the cells themselves have not been damaged and they are simply not functioning. If so, one would expect recovery of function as the "shock" wear off. So, it is a term of convenience that is making a lot of unjustified assumptions concerning the loss of function that your daughter has. By the way, the term shock has also been used to argue against the possibility of regeneration or remyelination being responsible for the recovery of function after spinal cord injury. Some clinicians suggest that the recover of function that occurs during the months after spinal cord injury results from the diminishing of "spinal shock". In my opinion, there is little data to support this view and it is entirely possible that some regeneration and remyelination does occur after spinal cord injury and is responsible for the partial recovery of function that many people get after injury.

    In any case, the explanation of the recovery doesn't really matter for your daughter. What matters is that your daughter is recovering some function and, we are all grateful. From the viewpoint of research, however, I have long felt that if we can understand why some people recover and others do not, we would have the answer to the cure of spinal cord injury.

    Wise.
    Please read edit on prev. post about her back.

    Rick
    Rick

    GO FORWARD! 2 FIGHT! PARALYSIS!

  9. #9
    [QUOTE=Wise Young

    Let me me comment briefly on what causes injury in scoliosis surgery. In medical school and in the 1980's, I spent much of my time with orthopedic surgeons studying scoliosis and doing somatosensory evoked potential monitoring of patients during surgery. In my opinion, it is not usually a "bump" during surgery that compromises function. Rather, it comes from trying to straighten the spinal column too much. When scoliosis develops, the spinal cord has to follow the contours of the curving canal. Because parts of the spinal cord may be pressed against bone, adhesions sometimes develop between the spinal cord and spinal roots with the surrounding arachnoid. When the spinal column is then straightened out, these adhesions pull on the spinal cord and causes compression of the cord. The compression sometimes result in reduction in blood flow to the spinal cord and the damage probably results from ischemia or loss of blood flow. Usually white matter (the fiber tracts) of the spinal cord are relatively resistant to ischemia (up to about 30 minutes) and don't require as much blood flow as gray matter (the part of the spinal cord that contains most of the neurons). However, oligodendroglia (the cells the myelinate axons) are susceptible to ischemia and may die, causing demyelination. One possibility is that your daughter may have demyelination of axons and remyelinative therapies may help her. There is the possibility that 4-aminopyridine, which is a drug that increases excitability of axons so that demyelinated axons can conduct signals, may also help restore some sensation and motor control. She is young and there is little experience with the use of 4-aminopyridine in young people but this might be something worthwhile considering. Finally, as you know, there are a number of regenerative and remyelinative therapies that have been shown to restore function in animal studies and we need to get these into clinical trials so that we can optimize them and determine which is the best for restoring function in humans.


    [/QUOTE]

    Wise,

    If this was the scenerio for Sarah, is there not anyway to detect this prior to surgery? How may a surgeon detect that one is 'correcting' too much?

    One thing thats seems to run against this scenario is that before the first surgery, the expected outcome was a 50% correction from an initial curve of 71 degrees. And Sarah was injured.

    The second go round, Sarah went in with an 85 degree angle and it was reduced to a 23 degree angle. Pretty amazing I think, and no further damage to her cord. In fact, Dr. Abel was hoping that the signal would get stronger after the correction, but it just maintained the weak signal.

    The first surgeon used a proceedure with hooks and rods, where as the second surgeon said that they havn't used that proceedure for the last 5 yrs., they considered it riskier than the current way of using anchors.

    Just thinking out loud.

    Rick
    Rick

    GO FORWARD! 2 FIGHT! PARALYSIS!

  10. #10
    Quote Originally Posted by rickhemi
    Wise,

    If this was the scenerio for Sarah, is there not anyway to detect this prior to surgery? How may a surgeon detect that one is 'correcting' too much?

    One thing thats seems to run against this scenario is that before the first surgery, the expected outcome was a 50% correction from an initial curve of 71 degrees. And Sarah was injured.

    The second go round, Sarah went in with an 85 degree angle and it was reduced to a 23 degree angle. Pretty amazing I think, and no further damage to her cord. In fact, Dr. Abel was hoping that the signal would get stronger after the correction, but it just maintained the weak signal.

    The first surgeon used a proceedure with hooks and rods, where as the second surgeon said that they havn't used that proceedure for the last 5 yrs., they considered it riskier than the current way of using anchors.

    Just thinking out loud.

    Rick
    Rick, that is quite a correction from 85 to 23 degrees. Anything over a 35-degree curvature is generally considered to require correction. Most scoliosis surgeons go with the goal of keeping the curvature less than 35 degress. What did they use on the second go-around if they did not use hooks and rods?

    Let me review briefly the instrumentation that is usually used for scoliosis correction. The Harrington rod procedure places a rod on the convex side of the curve with hooks placed in the lateral vertebral process and the curve is then "distracted" to straighten out the curve. Developed in the 1960's by Paul Harrington, this approach is still being used by some surgeons. Because there is only two point fixation, this approach requires fusion of the vertebral processes and use of a body brace for 3 months or longer until the fusion is stable. In the mid-1970's, Eduardo Luque developed a system where two flexible L-shaped rods are placed on either side of the spine and wires are then threaded through the spinal canal and the rods, helping straighten the spine through multiple points of fixation. The surgery is more invasive and many surgeons are nervous about putting wires that penetrate the spinal canal but the procedure produces more stable correction of the curve. In the 1980's, Yves Cotrel and Jean Dubousset developed a flexible rod with multiple hooks, to get around the problem of having to thread wires into the spinal canal. Other orthopedic groups developed variants of this rod and hook methods, including the Texas Scottish Rite and isola system. These methods have the advantage of controlling not only scoliosis but kyphosis and lordosis. Finally, a number of surgeons do what is called an anterior procedure where they may remove discs or cut part of the vertebral bodies in order to adjust the curve. Dr. Klaus Zielke developed a rod and hook system that is on the other side of the convexity, for use with an anterior procedure. The use of each of these instrumentation systems depend on the situation and the experience of the surgeons. http://www.scoliosis.org/resources/m...ionsystems.php

    Over the years, I have witnessed a number of cases where neurological deficits have occurred as a result of scoliosis surgery. During the surgery, because the patient is anesthetized, the surgeon often does not know that something has happened. For this reason, in the 1980's, they started to use somatosensory evoked potential monitoring during surgery to assess the function of the spinal cord. Otherwise, the only method is to wake the patient up in the middle of surgery and ask the patient to move a leg. In almost all cases, damage to the spinal cord have occurred as a result of over-correcting the curvature.

    Wise.

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