When that cord gives way

Confined to his hospital bed for two years now after a fall from a coconut tree injured his spine, Sugathadasa (38) is at the Accident Service of the National Hospital. Both his legs are numb. He turns tearful eyes on us, asking "Mata aayeth rassawak karala mage lamai dennata kanna denna puluwan wei da?" (Will I be able to work and feed my two kids?).

In the very next cubicle lies a well-built young man, just 29. His eyes are full of energy, but below his neck it is a different story, both arms and legs cannot be moved. He had been pushed into a swimming pool at a party and sustained injury to his neck.

The two stories are tragic; both caused by injuries to the spinal cord. The spinal cord is a unique structure that belongs to the nervous system, carrying nerve fibres from and to the brain to other structures of the body below the neck. It also contains the cells to maintain the functional integrity of the nervous system. The spinal cord acts like a cord which transmits messages between the brain and the rest of the body below the neck. It also carries out certain functions on its own like taking away a hand or another body part when it meets with a harmful stimulus, like a hot surface, for instance.

When this spinal cord gets damaged or compressed by something that impinges on it, the body parts below the level of the lesions get affected. Both the arms and legs can get paralyzed and numb with a lesion at the level of the neck. Legs can undergo the same problem with lesions from chest downwards which could also affect bladder and bowel control.

The severity of the problem depends on the extent of the injury or damage. Whether it is a reversible loss of function depends on the cause of the disease or the type of lesion. It's often impossible for your doctor to make a precise prognosis right away. Recovery, if it occurs, typically starts between a week and six months after the injury. Impairment remaining after 12 to 24 months is likely to be permanent.

However, some people do experience small improvements for up to two years or longer. Trauma, accounts for the majority of such tragedies all around the world. Road traffic accidents account for almost half of such injuries globally with war injuries and falls adding to the list. All these affect the young, and hence the workforce of a country. It has been proven that the most number of spinal injury patients in the world are between 16 to 30 years of age.

There is a second peak, after the age of 60, when your bones get weaker and you are more prone to non-traumatic causes of spinal injuries. Trauma, is almost always, preventable. Once it has occurred, proper first aid can prevent further injuries. Especially when a patient sustains injury to his spine, the bones may be fractured and unstable, but the pieces may not have been displaced to such an extent as to impinge on or sever into the spine. In such an instance if you move the patient, the bone pieces can get displaced causing injury to the spinal cord. Thus while taking a patient to hospital, a normal spinal cord can get damaged.

Apart from trauma, other causes of spinal fractures too can press on the cord and cause paralysis and numbness. Most frequently, these occur in the aged, due to osteoporosis. Other metabolic diseases can also reduce the bone strength leading to fractures.

Moreover, tumour of the bones, cancers from elsewhere can spread onto the spine and cause fractures, with minor or without any noticeable trauma. These are not as common as trauma induced injuries. Although very rarely seen nowadays, infections of the spine too can lead to such problems.

Other than fractures causing bony fragments to cause bone damage, there can be other new growths pressing on the cord from outside. There can be tumours, sometimes cancerous, or even harmless. Tumours within the spinal cord, like brain tumours, can damage the normal structures of the cord.

Despite our inherent suspicions about cancer, the chances of it causing cord spinal cord damage is far less common than traumatic lesions. Cancers leading to spinal cord symptoms are usually seen among the elderly. Many fear that conditions like disc prolapse can cause cord damage, but the usual clinical picture is due to the disc pressing on a nerve on one side. This condition called sciatica causes a radiating pain from the back down the leg. Intervertebral discs are fibrous structures that act as shock absorbers, in between two vertebrae or the small bones in the spine. Due to degenerative changes the disc can protrude from its original location into the canal in the spine, which transmits the spinal cord.

As the causes are diverse, the presentation could also be diverse. In trauma, cord damage is very straightforward, with patients presenting to the emergency or accident units, with the structures below the level of the spinal injury, numb and powerless. Following the injury inflammatory changes take place and swelling occurs within the cord giving rise to cord compression like features.

But the features can be subtle in other instances, where patients suffer sudden severe back pain. However, back pain is never synonymous with cord damage. It is so common that the proportion of people having a sinister condition among those with back pain is very minimal. Most backaches are due to mechanical reasons - poor posture, musculoskeletal reasons, and usually nothing to do with the spinal cord. But the few who present with backache with an underlying cause which needs prompt attention, could be identified by the following symptoms.

Then again, this needs evaluation by a doctor, and just one symptom does not mean you are going to end up in a wheelchair. Even if it is a problem with the spinal cord, non- trauma cord lesions can be treated to a significant extent because there is something that compresses maybe a disc. If it's serious to the extent of causing neurological deficit, there is neurosurgery to remove the structure that impinges. This way even certain fractures can be stabilized so that it does not cause cord damage.

Investigations that are needed vary from a simple x-ray of the spine, which may be sufficient to diagnose straightforward fractures or MRI scans in subtle cases to see a better view. MRI or CT scans are always needed before neurosurgery. Management or treatment is the most challenging aspect in cord compression. Unfortunately, in trauma, if the cord has been transected, or damaged but not just compressed, there is hardly anything that can be done. In this case, the patient would need a great deal of emotional support and rehabilitation. Being wheelchair-bound at a young age does not mean they are disabled. With proper training they can be independent and attend to their activities of daily living. There are such courageous people who head organizations, serving many a worthy cause, moving around on wheel chairs.

Whenever there is a fracture in the spine, people are kept in hospital, immobilized, with traction applied to the spine to hold the small bony pieces in place. This helps to maintain the alignment when the fracture is healing and prevent further spinal cord damage. They may need metal braces, traction applied to the vertebral column, for weeks sometimes.

They are given physiotherapy to maintain muscle strength and to stand up on their own feet once the fractures are healed. People with disc prolapses are treated with simple pain killers, rest and training to maintain good posture. They will need surgery only if they have neurological deficit or severe symptoms leading to impending disability, as decided by a doctor.

Other causes leading to cord compression like tumours need further evaluation and may need surgery. Pathological fractures in old age can too be stabilized by surgery but it all depends on the patient's suitability to undergo surgery and possibility of treating the underlying condition.

The most dreaded aspect in spinal injury with spinal cord damage is complications of immobility. Psychological problems of being dependent play a major part. At the same time, patients are more prone to get urinary tract infections, respiratory infections, due to inability to empty the bladder properly, and inability to clear lung secretions. Blood can get clotted within leg vessels and bed sores can occur, complicating the picture.

Still it is not the end of the life. Although some simply succumb, due to complications, some do fight back. With advancement of technology and better nursing care, they can survive.