Spinal cord injury
Spinal cord INJURED patients
Progress in the treatment of SCI
Spinal cord injuries (SCIs) are a debilitating medical condition that arises as a result of damage to the spinal cord, and it can have profound consequences for the individual. This article delves deeper into the complex world of SCIs by examining the background of current treatment options available in Denmark and presenting future perspectives on research in the field. There are approximately 3000 people with spinal cord injuries in Denmark, and each year, about 130 people sustain such injuries. About 40% of cases result from an accident, while about 60% are due to disease. Men have a higher prevalence of SCIs compared to women [1].
What are Spinal Cord Injuries?
Imagine that our spinal cord is like the body's internal highway—a key component in our ability to move, feel, and function. Unfortunately, this complex highway can be suddenly disrupted by an unfortunate event, leading to what we call spinal cord injuries (SCIs).
It all begins with a traffic accident on this internal highway—an acute mechanical impact. This can be like a violent collision that triggers a domino effect of events in our body. The primary injury, the crash itself, is only the beginning. When you knock down a domino, a complex series of pathophysiological processes is activated— the body's internal emergency procedures trying to deal with the sudden intrusion.
In addition to the collision itself, secondary injury processes are activated. Imagine little firefighters (inflammatory reactions) rushing to the accident site immediately to extinguish the fire and save as much as possible. However, as in any rescue operation, the rescue team can also cause unintended damage. Cell death becomes a byproduct of this intense rescue operation, where we see how the damage takes an even deeper dimension. Unfortunately, these secondary processes can have lasting consequences. They can exacerbate the original injury and result in long-term neurological effects that can alter the lives of those experiencing an SCI.
The differentiation of SCIs depends on where the traffic accident has precisely occurred [2]. Imagine figuring out which specific parts of the highway have been damaged. If the collision has hit the upper area of the road (high cervical injury), it can affect the ability to breathe and may even result in complete paralysis. If it's the middle area (low cervical injury), it could mean that certain functions, such as hand function, may be preserved. If the collision is lower down (thoracic and lumbar injuries), it can result in issues with trunk muscles or lower extremities, with varying degrees of preservation or dysfunction.
SCIs are most commonly seen among young people and most frequently among men. They are usually the result of traffic accidents, falls, or diving into shallow water. SCIs can also be associated with other conditions, such as inflammatory changes, degenerative changes, or cancer [3].
About the Spinal Cord
The nervous system includes the brain, spinal cord, peripheral nerves, and the autonomic nervous system, which regulates the unconscious functions of internal organs. The central nervous system consists of the brain and spinal cord.
The spine is composed of several vertebrae, forming the spinal column together. This consists of 7 cervical vertebrae, 12 thoracic vertebrae, five lumbar vertebrae, the sacrum, and the coccyx.
Inside the spinal column is a cavity containing the spinal cord surrounded by fluid and protective membranes. Pairs of nerve roots exit from the spinal cord between two vertebrae, one on the right and one on the left. Each nerve supplies a specified area of the body with two sets of nerves [4]:
Sensory nerves, also called sensory nerves, transmit information about touch, pain, temperature, proprioception, and more to the central nervous system.
Motor nerves send signals to muscles and tendons.
Between each vertebra, cartilage discs act as shock absorbers.
Consequences of a Spinal Cord Injury
Regardless of the cause of your spinal cord injury, the physical consequences can include paralysis, sensory disturbances, and changes in bladder, bowel, and sexual function. The location of the damage on the spinal cord and whether it is complete or incomplete play a crucial role in the extent of the consequences [1]. Therefore, it is not guaranteed that you will experience an impact on all the areas mentioned below, and the degree of consequences can vary significantly.
Psychological Aspects: After a spinal cord injury, most people experience concerns, frustrations, hopelessness, a sense of meaninglessness, anger, and similar feelings regarding their new situation. Many find it essential to have someone to talk to about these emotions, which can be a family member, a friend, healthcare personnel, or a hospital chaplain. Having a family member present during discussions with the medical staff can also be beneficial.
Spinal Shock: Immediately after the injury, the spinal cord goes into shock, known as 'spinal shock.' This causes the muscles below the injury site to become flaccid, temporarily losing all reflexes. This affects blood pressure, pulse, bladder, and bowel function. Spinal shock typically subsides over up to 6 weeks, but the duration can vary. Subsequently, some patients experience some recovery.
Breathing: The injury can affect breathing and cough strength depending on the location. Respiratory physiotherapy may be necessary to improve breathing and cough strength, helping to prevent pneumonia.
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Blood Pressure: In the first week after admission, blood pressure is frequently monitored to maintain adequate blood supply to the spinal cord. This may require medication to keep blood pressure high. After a week, the drug is reduced, and the patient is gradually adjusted to lower blood pressure possibly. Blood pressure drops can significantly lead to dizziness and palpitations when first rising from bed.
Temperature Regulation: Due to the injury, the body may have difficulty regulating its temperature, affecting the ability to retain or release heat in the paralysed part of the body.
Activity: A spinal cord injury results in complete or partial paralysis of muscles, which can lead to reduced functionality. Rehabilitation begins when the condition allows, focusing on daily activities like personal care. Physiotherapists and occupational therapists work to restore lost functions or train alternative techniques and assistive devices.
Bladder and Bowel: Both the bladder and bowel are affected by a spinal cord injury, requiring assistance for urination and defecation. Initially, a catheter is used; later, disposable catheters may be necessary.
Pain: Pain associated with a spinal cord injury can include surgical pain, muscle and joint pain, and pain due to spasticity and nerve pain. Pain relief medication, physiotherapy, and changes in lying or sitting positions can help alleviate pain.
Spasms/Spasticity: After a period, spasms/spasticity can develop, manifesting as involuntary muscle contractions, especially in the legs. Exercise and training can help relieve spasticity, but in some cases, medical treatment may be necessary.
Skin: Altered sensation and reduced muscle strength increase the risk of pressure sores. Regular changes in position and using an air mattress in the initial phase lessen the risk.
Food and Drink: Initially, nausea and reduced appetite may affect you. Collaboration with the medical staff is essential to find appropriate food and drink to maintain necessary nutrition.
Sexual Life: A spinal cord injury can affect sexual life, with reduced or no sensitivity in the genital area. It is important to note that a satisfying sexual life is still possible, and there is an opportunity for counselling and guidance on sexuality, including professional assistance from a sexologist.
Treatment Options for Spinal Cord Injury
In Denmark, the treatment of spinal cord injuries (SCIs) is characterised by a careful and integrated approach that extends from immediate acute intervention to a prolonged rehabilitation phase. Each treatment modality serves its purpose and addresses different aspects of this complex medical condition [1,3].
Acute Intervention: In acute spinal cord injuries, the primary goal is stabilising the patient and limiting further damage. This is achieved through advanced spinal surgery, where surgical procedures stabilise the spine, reduce pressure on the spinal cord, and decrease the risk of complications. This phase is critical to minimise the immediate consequences of the injury and establish a foundation for subsequent rehabilitation.
Neurorehabilitation: Neurorehabilitation is crucial to restore function and optimise the patient's quality of life after the acute phase. This includes intensive training, where specialised physiotherapists work with the patient to retrain movements, strengthen muscles, and improve body control. Electrical stimulation, using electrical impulses to stimulate muscle contraction, and advanced technologies such as robot assistance play a significant role in optimising neuroplasticity, the brain's ability to adapt and compensate for lost functions.
Pharmacological Treatment: Pharmacological treatment is an integral part of SCI treatment, aiming to relieve symptoms, reduce inflammation, and protect the damaged tissue. This includes the use of anti-inflammatory drugs to limit the inflammatory response, neuroprotective agents to minimise further neurological damage, and pain-relieving medication to manage the often associated chronic pain. As an exciting alternative, medical cannabis has shown neuroprotective properties and can be a valuable element in pain management.
Overall, this integrated approach to treating SCIs represents a holistic strategy that addresses this complex medical condition's acute and long-term aspects. By combining advanced surgical procedures, specialised rehabilitation, and the latest technological advances, Denmark seeks to optimise outcomes for those facing the challenges of a spinal cord injury.
Medical Cannabis and Spinal Cord Injuries
Spinal cord injuries pose a severe health condition with significant consequences for the affected person's quality of life. In recent years, medical cannabis has emerged as a potentially effective pain treatment, and a growing body of scientific evidence points to its beneficial effects in spinal cord injuries.
Cannabinoids interact with the body's endocannabinoid system, which regulates various physiological processes, including pain perception. By influencing this system, cannabinoids can potentially reduce the perception of pain and improve the quality of life for individuals living with spinal cord injuries.
There are only a few assessments that medical cannabis may be a relevant treatment for spinal cord injuries [5,6]. Still, cannabis appears to help with several symptoms in patients with paraplegia, especially nerve pain and painful muscle stiffness. However, a more extensive study with 116 participants found no effect of Sativex (an oromucosal spray containing THC and CBD) compared to placebo [7].
A significant study published in the journal Spinal Cord in 2019 confirmed that medical cannabis can be an effective treatment for pain in spinal cord injuries. Participants using medical cannabis reported a significant reduction in pain intensity compared to the placebo group [9]. Additionally, participants noted improved sleep quality and reduced consumption of traditional pain medications. Despite these positive aspects, participants expressed concerns about the irregularity of supply and inconsistent dosages.
However, it should be noted that the use of medical cannabis for the treatment of pain in spinal cord injuries remains a controversial topic, and further research is needed to understand the long-term effects and optimal dosages specifically for this condition. It is crucial to consult with a doctor or specialist knowledgeable in medical cannabis before starting treatment.
Criteria for Prescribing Medical Cannabis
In Denmark, medical cannabis has been legalised and can be prescribed by doctors for the treatment of certain medical conditions, including chronic pain. This opens up the possibility for individuals with spinal cord injuries to access medical cannabis as an integrated part of their pain management, provided it is deemed appropriate by a doctor. The responsibility for medical cannabis treatment lies with the treating doctor. Therefore, it is the doctor who determines whether a patient should be treated with medical cannabis.
According to the cannabis guidance from the Danish Medicines Agency:
Relevant approved marketed drugs should be tried before attempting treatment with medical cannabis.
Cannabis should not be used for children and young people under 18 years of age due to a lack of knowledge about long-term effects, including cognitive development.
A doctor can prescribe a maximum of one month's supply on one prescription.
As a rule, doctors should not treat with medical cannabis outside their area of expertise.
Furthermore, the Danish Medicines Agency has approved a few patient groups and indications, including spinal cord injury, for the use of medical cannabis as a patient in Denmark. You can read more about relevant indications for prescription here.
References
Rygmarvsskadede i Danmark: Hjælp og viden (ryk.dk)
Snedecor SJ, Sudharshan L, Cappelleri JC et al. Systematic review and comparison of pharmacologic therapies for neuropathic pain associated with spinal cord injury. J Pain Res. 2013:6; 539–547
Thomas, Pavithra A et al. A scoping review on the effect of cannabis on pain intensity in people with spinal cord injury. The journal of spinal cord medicine vol. 45,5 (2022): 656-667.
ClinicalTrials.gov. A study of cannabis based medicine extracts and placebo in patients with pain due to spinal cord injury. NCT01606202. Accessed January18, 2020.
Andresen SR, Biering-Sørensen F Hagen EM et al. Cannabis use in persons with traumatic spinal cord injury in Denmark. J Rehabil Med 2017; 49:152-160.
Bourke, J. A., Catherwood, V. J., Nunnerley, J. L., Martin, R. A., Levack, W. M. M., Thompson, B. L., & Acland, R. H. (2019). Using cannabis for pain management after spinal cord injury: a qualitative study. Spinal cord series and cases, 5, 82.