Title : What is required for the current management of the injured spine of patients with traumatic cord injury be considered evidence based?
Traumatic spinal cord injuries (TSCI) are life-changing events from medical, physical, psychological, social, financial, vocational, environmental & matrimonial effects. The combination of consequent generalised physiological impairment, multi-system malfunction, multiple disabilities, wide range of potential complications, sensory impairment together with the non-medical effects impose challenges to patients, carers and clinicians. Early prediction of ambulation is important to the patient especially during the transition between spinal and autonomic shock and the return of these reflexes during the first few weeks following injury. Neurological Recovery is not uncommon following spinal cord damage, is predictable and depends on the method and quality of management of the multisystem physiological impairment and malfunction as well as of the spinal injury. In the mid-sixties Frankel and colleagues made an astute observation that with good conservative management of the injured spine and the multisystem malfunctions, patients presenting within 15 days of injury with complete motor paralysis but sensory sparing made spontaneous motor recovery from reactivation of the myotomes adjacent to the functioning dermatomes irrespective of the radiological presentation on admission and on discharge. The same observations were made irrespective of the degree of canal encroachment or cord compression since the development of CT and MRI scans. Currently surgical interventions are carried out on patients with and without traumatic cord damage with claims that surgical intervention is necessary to prevent neurological deterioration and enhance recovery despite the potential hazards from anaesthesia and para surgical mishaps. These claims are unfounded and not supported by the comparative outcomes between Active Physiological Conservative Management of both the injury and the Multisystem physiological impairment and malfunction.
The prognostic indicators of neurological recovery, its extent and the factors that enhance, prevent or cause neurological deterioration and the value of CT and MRI will be discussed.
I will also discuss the necessary requirements for the current surgical management of the injured spine of patients with cord damage to be considered as evidence based.