Traumatic Paraplegia
Modern Trends In Orthopaedics
The history of broken spine with paralysis of limbs is bleak. There was no hope of reversing paralysis due to spinal cord injury. The hopelessness and helplessness experienced by patient and doctor until the present time has been expressed by the writer of the Edwin Smith surgical papyrus in 1700 BC when he indicated that it was an ailment not to be treated. There was no hope of stabilizing broken spine to prevent further paralysis or complications that soon took the life of paralyzed person. Ambroise Par’e (1510-1590) paraphrased the Edwin Smith papyrus by writing: By symptoms of numbness and palsy of the limbs and the Urine and excrement coming against there will and Knowledge, you may foretell that death is at hand for Reason that spinal marrow is hurt. Having made such a Prognostique, you may make an incision and take forth The Splinters of the broken vertebra in cases where the neural Arch was injured, which are driven in and press the spinal Marrow and nerves thereof.
Spinal injuries is one of the most disabling conditions, which can afflict mankind. It not only physically disables the individual, but also shatters the individual and his whole family psycho-socially and economically. If not given proper comprehensive management, many of them succumb to the fatal complications(respiratory and urinary tract infections, bed sores). Disability due to spinal cord injury is estimated at between 20 per million of population. At this rate, there would be around 18,000 fresh spinal cord injured patients added every year. In India majority of patients sustain these injuries due to fall from a height but with increasing use of motor vehicles and poor road conditions now more number of patients suffer these injuries due to road traffic accidents. What is more disturbing in case of spinal cord injuries is available facilities are grossly inadequate. This highlights the urgency and necessity of taking very far reaching and urgent measures for the benefit of these patients. Creation of an appropriate institutional infrastructure is an absolutely necessary. This has become all the more important with the enactment of the persons with disabilities act, 1995, under which the Central as well as the States Governments have a number of specific obligations to provide various services to the disabled. With this background in mind Ministry of Social Justice and Empowerment, Govt. of India and Ministry of Foreign Affairs, Government of Italy is planning to set up four regional spinal cord injury centers in India one each in Punjab, Uttar Pradesh, Madhya Pradesh and Orissa. The objectives of these Centers apart from comprehensive care of spinal cord injured is to create awareness that the disabled can be productive, if given opportunities and support and to cope up with problems of daily living and relieve family members of the burden of constantly looking after them. Apart from Government support it is emphasized that role of Non Government Organization is vital to render necessary support to disabled persons. Untill about four decades ago the outcome was death in 85% of cases while few lingered in institutions from which as many medical personnel as possible kept away. But today it is proved beyond doubt that this pessimism is unfounded. The present position is exactly the opposite, optimisim, complications reduced, healthy and productive future. if they have good upper limbs and are intelligent they can be assured of an ability to walk though perhaps with appliances; they will gain complete 24 hours control of bowel and bladder; and they will earn there own living and lead an almost normal life. Surely this is an amazing reversal of attitude; a reversal now generally accepted and acknowledged. Unlike the sole survivor of traumatic paraplegia from the first world war, of the 4000 American soldiers paralysed from spinal cord injury in the second world war, more than 2000 survived and of these, 80 percent became able to walk and hold down jobs. Today we are able to diagnose spinal cord injury accurately with x-ray studies, computed tomography (CT Scan) and magnetic resonance imaging (MRI). The accurate diagnosis of fractured spine and the identification of degree of paralysis have lead to philosophy of stabilization of broken spine by operative means either from front and back with special metal implants to prevent further damage to spinal cord. Finally we are able to prevent the complications of recumbency ( bed sores, urinary infection,) that in the past quickly claimed the lives of many patients with paralysis due to fractured spine.
The earliest responsibility for the management of a spinal cord injured patient immediately after an accident usually falls to a person trained in first aid or occasionally to a doctor. Patient who has suffered a major accident should be fully examined for spinal injury. Movements of the spine can be dangerous – it may further damage the cord. Hence field health staff must ensure transportation of these patients on wooden plank or on a stretcher ‘in one piece’ as shown in fig.1. This must be followed strictly during transportation until spinal injury has been ruled out by emergency staff by careful examination and suitable tests i.e. X-Rays, CT Scan or MRI. Unconscious patients should be treated as if they had spinal cord injury until and unless proved otherwise. Early Management of spinal cord injured patient includes administration of first aid by trained staff, careful positioning of patient in bed and judicious use of drugs. It has been shown that administration of steroids in high dosages with in 8 hours of injury has significant improvement in weakness. Once patient’s general condition is stable plan for definitive stabilization of spine can be made. This can be achieved by various modalities either by postural methods or by surgery. Today with better understanding of biomechanics of spine, better instruments and excellent anaesthesia, surgery has become very safe. It is generally agreed that one goal of surgery in addition to decompression of spinal cord is patients can be mobilized out of bed early thus leading to reduction in complications of recumbency and facilitation of nursing care. Whereas surgical stabilization of spine is one aspect of treatment success of treatment depends on total rehabilitation of the patient (enabling him live life independently). This is best achieved in comprehensive spinal cord injury centers where attention is paid to complete care of spinal cord injured.
These centers are meant to provide specialized treatment to spinal cord injured patients. In the specialized spinal unit treatment is aimed at preventing life threatening complications. Most effective method of spinal stabilization for early mobilization is coordinated with specialized nursing, occupational therapy, physical therapy and medical psychological readjustment. Efforts are made to encourage paraplegics, participate in various national and International sporting events. This type of approach enables the patient to cope with his or her disability. Counseling sexual rehabilitation is of utmost importance to these patients, most of whom are young and healthy. Group discussions of common difficulties encountered in adjustment to a new way of life help the patient and family to cope. Vocational rehabilitation begins before discharge from the hospital. The patient is advised about occupations that can be performed from the wheel chairs. The functional rehabilitation in specialized centers ensures these patients a much greater life expectancy than was possible several years ago. With the increase of violent accidents in our mechanized society and the constantly improving medical care, the size of this patient group will continue to increase. At the present time they require expert medical care. In the future, it is hoped that techniques will evolve for prevention and reversal of spinal cord paralysis. New research in the horizon may enable us to prevent the catastrophic permanent functional loss of limbs due to Post traumatic paralysis. Newer surgical techniques will provide immediate rigid stability of the injured spine thus providing better environment for recovery from incomplete cord injury, mobilizing the patient early, and then rehabilitation to provide maximum functional independence.
Dr Raj Bahadur is Professor and Head, Dept. of Orthopaedics, Govt. Medical College and Hospital, Chandigarh.
Dr Mohinder Kaushal , Ex Registrar Dept. Of Orthopaedics, Govt. Medical College & Hospital, Chandigarh
*Dr Raj Bahadur* is Professor and Head, Dept. of Orthopaedics, Govt. Medical College and Hospital, Chandigarh.
*Dr Mohinder Kaushal* , Ex Registrar Dept. Of Orthopaedics, Govt. Medical College & Hospital, Chandigarh
