Paraplegia

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Classification according to ICD-10
S14 Injury to the nerves and spinal cord at neck level
S24 Injury to the nerves and spinal cord at chest level
S34 Injury to the nerves and lumbar spinal cord at the level of the abdomen, lumbosacral region and pelvis
G82 Paraparesis and paraplegia, tetraparesis and tetraplegia
ICD-10 online (WHO version 2019)

Under a spinal cord injury (including paraplegia , spinal spinal cord injury , Querschnittläsion or Transversalsyndrom ) is meant a resulting from damage to the spinal cord cross section image paralysis with loss of motor, sensory, or autonomic functions. The cause can be injuries to the spinal cord (e.g. vertebral fractures ), but also tumors and other special diseases (e.g. multiple sclerosis ).

Part of the symptom complex of the cross-sectional syndrome (QS)

The science and medical specialization that deals with the paraplegic syndrome is called paraplegiology , the umbrella organization is the German-speaking Medical Society for Paraplegia (DMGP).

The following important information is missing from this article or section:
Information about history z. B. First mention of historiography, medical literature, dealing with paraplegia in antiquity, the Middle Ages and early modern times are completely absent.
Help Wikipedia by researching and pasting it .

General

Damage to the spinal cord can result in a loss of active control over muscles and muscle groups controlled by nerves passing through the injury site in the spinal cord.

Depending on the location of the damage, the muscles of the arms, the auxiliary breathing muscles, the muscles of the abdomen and back, and the muscles of the legs can be affected. Depending on the severity of the paralysis, the loss of motor function can extend to the complete inability of the affected extremities (arms, legs) to move.

In addition, the spinal cord damage can impair sensitivity . This means, on the one hand, that the skin's sensitivity to touch can be reduced or eliminated, and on the other hand, pain stimuli from internal organs (for example in appendicitis) cannot be perceived by the person affected.

As a further functional group, the vegetative functions can be affected. Here, too, the specific damage pattern is again essentially dependent on the location of the damage site on the spinal cord. In the foreground of the so-called vegetative functional disorders are bladder disorders with urinary retention or incontinence. The bowel function is also affected and the patient loses control over bowel movements. Other important vegetative functions are the control of blood pressure, e.g. B. through failure of the tonic function of the vessels (vegetative circulatory dysfunction) in the legs and the loss of temperature regulation through corresponding sweating.

Paraplegia cannot be equated with wheelchair dependency. Spinal cord damage can leave so much muscle function intact, despite significant deficits in other areas, that the person affected can still walk. These people, too, must be given the option of paraplegia-specific treatment in one of the specialist centers for paraplegics in order to avoid long-term damage and complications.

Classification of paraplegia

Paraplegia is described according to its level (with regard to the location of the damage in the spinal cord) and its severity. The division of the spinal cord into segments, which are based on the segments of the spinal column and the respective nerve exit points of the so-called spinal nerves, is used for height localization. There are eight neurological segments on the cervical spine, twelve on the thoracic spine, five on the lumbar spine and four in the sacrum area. To describe the paraplegia, the last completely intact spinal cord segment is given.

In addition to the motor function, the level of paralysis is determined by the “sensitive level”. It refers to the last intact dermatome. A dermatome is an area of ​​skin that represents the supply area of ​​a particular spinal nerve. The dermatomes shown in the figure differ in terms of their spinal nerve supply and therefore always relate to a specific spinal cord segment. Their examination is suitable for assessing the height of the lesion in the case of spinal cord damage. The dermatomes are examined by means of cold stimulation, touch or needle prick stimulation. These three sensory qualities can lead to different results in the affected dermatome, which would suggest incomplete damage to the spinal cord. Paraplegia does not lead to a reduction in cognitive functions, as only the functions below the level of the lesion are affected.

In addition, the paralysis is described as complete (no function below the spinal cord damage) or incomplete (remaining function below the spinal cord damage). Since the touch sensitivity on the anus corresponds to the “deepest” segments, a diagnosis of complete paraplegia requires that the loss of touch sensitivity around the sphincter is proven. In addition to the rather rough division of paraplegia into complete and incomplete , several international classifications are in use. They were initially given by Hans Fraenkel (Stoke Mandeville, England). They were later adopted by the American Spinal Cord Association (ASIA) and are used in publications as the ASIA classification, with the AIS as the ASIA impairment score :

  • ASIA A: No muscle function and no sensitivity below the spinal cord damage
  • ASIA B: No muscle function below the damage to the spinal cord, limited sensitivity
  • ASIA C: Little, irrelevant muscle function below the paralysis site, sensitivity (partially) present.
  • ASIA D: Functionally relevant muscle functions below the spinal cord damage site (partially preserved sensitivity below the spinal cord damage)
  • ASIA E: Fully preserved or restored functions below the spinal cord lesion.

As the functional description through the AIS score is quite rough, the ASIA has proposed a more differentiated assessment based on the functional score, which has now been renamed "International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)". It describes the functions of the identification muscles and the sensitivity in the dermatomes with a point system. The point values ​​determined are added up and result in a score. In addition to the pure functional description, other functional scores (for example: SCIM - Spinal Cord Independence Measure) are used to describe the functional deficit of paraplegics in everyday life. This consists of 19 items and asks about activities of daily living, incontinence and coordination. The score varies from 0 to a maximum of 100 points.

Paraplegia does not lead to a reduction in cognitive functions.

Causes of the emergence

In Germany around 1,800 people are newly affected by spinal cord injury every year, around 60% of whom are men.

External violence on the body can cause damage to the spinal cord with destruction of the integrity of the spine or without destruction of the spine ( contusion injuries ). A special form of such injuries is damage to the spinal cord with corresponding loss of function, without a correlate being found in X-ray and other imaging examinations ( SCIWORA ). Half of the causes are accidents with spinal trauma from a vertebral fracture . One possible subdivision is:

  • Linear fractures: by shifting vertebral bodies in the longitudinal axis of the bony spine, the spinal cord is damaged by the step formation of the vertebral bodies. All forms of damage to the spinal cord are conceivable.
  • Compression fractures of the cervical spine are often the result of jumping into shallow water. This accident mechanism is based on excessive flexion of the spinal column.
  • Bursting or comminuted fractures with displacement of debris segments into the spinal canal almost always lead to severe neurological disorders.

Non-traumatic causes

About 50% of all paraplegia are not caused by an accident, but by an illness:

  • Tumors : Tumors are a common cause of paraplegia. As a rule, these are metastases from other tumors that have spread into the spinal cord or the adjacent vertebral bodies. Local manifestations of lymphoma or leukemia can also lead to paraplegia. Tumors that originate from nerve tissue or accompanying nerve tissue and develop directly near the spinal cord or in the spinal cord, or bone tumors that can also lead to compression of the spinal cord, are less common.
  • Infection : Bacterial infections of the spine and intervertebral discs ( spondylodiscitis ), as well as accumulations of pus in the spinal canal, can damage the spinal cord. People whose immune system is compromised, e.g. B. in diabetes mellitus or long-term cortisone intake are particularly at risk. Fungal infections also occur.
  • Spinal ischemia (local oxygen deficiency) and spinal infarction as a stroke of the spinal cord occur due to the occlusion of supplying or draining blood vessels with subsequent insufficient blood supply to the spinal cord.
  • Spinal bleeding, also postoperatively
  • Herniated disc : Due to compression of the nerve roots draining from the spinal cord, herniated discs often lead to isolated nerve root damage. However, especially in the area of ​​the cervical spine, very large herniated discs can rarely lead to compression of the spinal cord itself. Damage to the spinal cord caused by herniated discs in the thoracic vertebrae is less common. In the lumbar spine, the usual locations for herniated discs are between the third lumbar vertebra to the sacrum (L3 to S1). There is no longer any spinal cord in the spine; it ends at the level of the first lumbar vertebra. Therefore, the most common lumbar spinal disc herniations usually do not lead to spinal cord injuries, but can lead to cauda equina syndrome .
  • Inflammation and autoimmune diseases
  • Psychological genesis
  • iatrogenic (due to incorrectly performed medical measure)

The proportion of types of damage in the total population of paraplegics has shifted significantly over the past thirty years. In the past, trauma consequences dominated with almost eighty percent. Today more and more acute spinal cord injuries are caused by a disease.

In addition to the causal effects of damage, a number of biological processes also play a role in the formation of the damage and the inadequate regeneration of the disturbed neuronal tissue:

  • Apoptosis: The stimulation of the Fas receptor of oligodendrocytes and neurons by substances called Fas or APO-1, which can be detected in the damaged area, leads to the controlled, internally controlled cell death ( apoptosis ) of these cell populations. This increases the neurological damage. A therapy is currently being researched and could consist of the administration of Fas receptor blockers.
  • Inflammation: Methylprednisolone can be used against this, but its effect is questionable and is no longer recommended.
  • Factors that prevent the regeneration of neurons: Nerve cells do not tend to regenerate on their own after being damaged. Therapies based on the inhibition of this physiological phenomenon (namely not regenerating by itself) are also currently being researched.
  • Scarring blocks preformed nerve paths through connective tissue septa. This prevents an orderly and functionally replacing sprouting of nerves.

Accumulation of certain types of origin

While traffic accidents make up the majority of the causes of accidents with subsequent paraplegia in industrialized nations with well-developed infrastructure, an accumulation of cervical vertebrae injuries caused by falling while carrying heavy objects on the head is reported in Bangladesh.

Systematics

Type of spinal cord damage

In the past, trauma consequences dominated with almost 80 percent of spinal cord injuries. Today, more than 50 percent of acute spinal cord injuries are caused by an illness. A total of around 1800 people in Germany are affected by a newly developed spinal cord injury every year, the ratio of men to women is 60:40. The epidemiological data diagram (reference) is collected and evaluated at the contact point for paraplegics at the accident hospital in Hamburg.

Expression

The extent of the paralysis varies with the extent of damage to the spinal cord. Based on the severity of this key symptom , a classic distinction is made between plegia (complete motor paralysis) and paresis (incomplete motor paralysis). In the course of the disease, initially flaccid paralysis can turn into spastic paralysis .

Furthermore, spinal cord damage can occur too

  • Disturbances of the motor reflexes with loss of internal and external reflexes
  • Failure or disruption of control of the rectum and bladder (can lead to uncontrolled stool and urine leakage)
  • Loss of sensitivity (feeling e.g. pain, cold-warm, wet-dry and tactile sensation).

For the systematic classification of neurological damage, the International Standards for Neurological Classification of Spinal Cord Injury from the American Spinal Injury Association (ASIA) are used, above all the ASIA Impairment Scale:

Degree
A. Complete paralysis: no motor or sensory function in segments S4 / 5
B. Sensitive incomplete paralysis: Preserved sensitivity in the sacral segments S4 / 5
C. Incomplete motor paralysis: residual motor skills below the neurological level and more than half of the key muscles below the neurological level have a strength level of less than 3
D. Incomplete motor paralysis: Residual motor skills below the neurological level and at least half of the key muscles below the neurological level have a strength level greater than or equal to 3.
E. Normal: normal motor skills of the key muscles and normal sensitivity. Pathological reflexes can persist

localization

Describing the symptoms, a distinction is made between paraplegia or paraparesis (paralysis of the lower extremities when deeper sections of the spinal cord are damaged, approx. 60% of cases) and tetraplegia or tetraparesis (paralysis of all four extremities when the cervical cord is damaged, approx. 40% of cases) .

Identification muscle for determining the height of the lesion
segment Identification muscle function
C5 M. biceps brachii Flexion in the elbow
C6 M. extensor carpi radialis Dorsal flexion or extension in the wrist elbow
C7 M. triceps brachii Extension in the elbow
C8 M. abductor minimi Spreading the little finger

The height of the lesion is defined by the last intact segment of the spinal cord . The diagnosis “paraplegia at level C5” indicates that segment C5 is still intact.

The assessment of the lesion height according to body functions is used to examine the identification muscles and the dermatomes .

The impossibility of active arm flexion suggests z. B. indicates a lesion at C5, as the arm flexor muscle (biceps muscle) can no longer be addressed (see table). In this case, the lesion height would be C4.

The damage from and above C4 leads to failure of the phrenic nerve . This nerve is normally responsible for the functioning of the diaphragm . A lack of control of the phrenic nerve leads to the failure of diaphragmatic breathing. At this level of damage, however, all other muscles that are supplied from the spinal cord segments below C4 are also paralyzed, including the intercostal nerves that supply the intercostal muscles. Such trauma is acutely life-threatening as active breathing becomes completely impossible. Artificial ventilation is required as immediate life-sustaining therapy .

Dermatomes

A dermatome is an area of skin that represents the supply area of ​​a particular spinal nerve . The dermatomes shown in the figure differ in terms of their spinal nerve supply and therefore always relate to a specific spinal cord segment. Their examination is suitable for assessing the height of the lesion in the case of spinal cord damage. The dermatomes are examined by means of cold stimulation, touch or needle prick stimulation. These three sensory qualities can lead to different results in the affected dermatome, which would suggest incomplete damage to the spinal cord.

Brown-Séquard syndrome is one of the rare unilateral incomplete spinal cord injuries . It is characterized by a dissociated sensitivity disorder. Sensation of touch and position fall on the side of the spinal cord damage, senses of temperature and pain on the other half of the body. This pattern begins a few spinal cord segments below the spinal cord lesion. At the level of the damaged segment, all four sensitivity qualities of the damaged side failed.

SCIWORA

After violence on the spinal cord, for example in an accident, symptoms of paraplegia can occur, although no damage to the spine and spinal cord can be seen in the radiological imaging using X-rays and CT . This syndrome is known as "spinal cord injury without radiographic abnormality" (SCIWORA). The MRI imaging, allows the discrimination of patients with post-traumatic changes of the spinal cord and those without. This syndrome was first described in children but has also been observed in adult patients. The prognosis for the injury seems to depend on the type and extent of the spinal injury. In addition, meta-analyzes showed a connection with pre-existing degenerative changes in the spine. Overall, the prognosis is to be classified as positive with normal MRI. According to Boese & Lechler, the syndrome can be divided into two patterns:

Type 1 Inconspicuous MRI. The prognosis is usually good.
Type 2 a Exclusively extraneural changes (e.g. degenerative narrowing of the spinal canal).
Type 2 b Exclusively intraneural changes (e.g. edema, bleeding, contusion, tear).
Type 2 c Combination of intra- and extraneural changes. The prognosis is the worst.

course

The course depends on the extent of the damage to the spinal cord. A fully developed spinal spinal syndrome with a high lesion (cervical spine area) has three phases:

Hypertension This phase only lasts a few minutes
Spinal shock Hypotonic crises, flaccid paralysis in dependent segments, failure of the muscle reflexes, loss of control of the bladder and rectum, duration: weeks to months
Spasticity , hyperreflexia Spastically excessive muscle tone, excessive self-reflexes, autonomic hyperreflexia, e.g. B. with blood pressure peaks when manipulating the bladder

The spinal shock (acute phase) is characterized by the failure of regulatory processes. The vessels in the affected area are widened because the vascular muscles relax. If there is insufficient compensation from the unaffected parts of the body, this can lead to a drop in blood pressure and circulatory shock. Dreaded consequences are acute kidney failure , shock lung (ARDS) etc. This phase can therefore make intensive medical treatment necessary.

In contrast, the chronic phase is characterized by excessive regulation. On the part of the vascular system, blood pressure peaks are possible, the voluntary muscles can react with uncontrollable flexor synergies that have a seizure-like character.

Course of the disease:

In the case of traumatic spinal cord injuries, the damage occurs in the second of the accident. The force acting on the spinal cord at this moment ultimately determines the prognosis of the disease. As a rule, the failure symptoms appear immediately. They manifest themselves in a loss of feeling, loss of motor functions and a spontaneous urinary retention. The muscles are slack in this phase.

An increasingly worsening paralysis after the accident with increased failures and increasingly complete paralysis, with initially incomplete or deeper paralysis, indicates a secondary event such as B. a hemorrhage in the injury area. In these cases particular urgency in diagnosis and treatment is required.

The phase in which the paraplegia is manifested as flaccid peripheral paralysis, without reflexes and sensitivity and also flaccid bladder paralysis, is known as "spinal shock". The term shock has no correspondence with the common medical term e.g. B. Shock associated with major blood loss. The injury phase of spinal shock can last for several weeks to months. It turns into a clinical picture in which so-called spastic increases in tone of the muscles can increasingly be observed. This means that the muscle fibers from cells of the spinal cord that are still intact are stimulated to contract without any superordinate control and tense in an uncontrolled manner by the patient. These spinal spasticity can lead to considerable passive restrictions of movement ( contractures ) in the joints.

If the level of damage is so deep that nerve fibers that have already left the spinal cord are affected without exception (damage to the cauda equina, below L 1), no change in paralysis from flaccid to spastic can be observed.

If the damage to the spinal cord is paralyzed, at which the central control for the maintenance of body functions (heart rate and pressure regulation) is affected, this leads to a restriction of the respiratory function and a loss of circulatory adaptation to spontaneous cardiac arrest. In the first few months after the onset of paralysis, many patients are particularly affected by the consequences of inadequate blood pressure regulation. Due to the paraplegia there is no blood pressure adjustment when standing up. What this means for patients is that they can easily collapse when they get out of bed and into the wheelchair. After a few weeks or months, secondary compensation mechanisms take over the regulation and the patients become more resilient.

In the course of paraplegia, blood pressure derailments can also occur. This so-called "vegetative dysregulation" can also cause excessive sweat secretions, facial reddening, blood pressure peaks or the like. When blood pressure rises, the first thing patients notice is a headache. This complication is usually triggered by manipulation or overstretching of hollow organs (bladder, rectum, gall bladder). It requires prompt, careful treatment.

therapy

Emergency treatment

In an emergency, the patient's vital functions must first be secured. Careful, gentle transport (usually by helicopter) must avoid additional injuries to the spinal cord. The rules apply as in other heavy accident victim and the injured person should be directly to a trauma center or a specialized center to be transported for spinal cord injuries, where a standardized emergency room can be done -supply and associated injuries can be supplied. The administration of high doses of methylprednisolone was standard in emergency situations for many years. Since the effectiveness could not be proven by studies, it is no longer carried out in many cases.

As long as the patient is awake and responsive, it is usually possible to pinpoint the location of the damage to the spine by means of an orienting clinical examination. Based on the imaging diagnostics (X-ray, CT, MRT) of the first treating hospital, the extent of the damage is then determined and the necessary treatment steps are initiated.

Since the second half of the last century, more and more efficient possibilities have been available to surgically restore the integrity and stability of the spine after spinal injuries and to relieve the spinal cord or the nerves accompanying the spinal cord from pressure damage. The hope of being able to at least partially reverse the spinal cord injury through rapid surgical treatment has not been confirmed. This is probably due to the fact that ultimately the extent of the damage is already determined by the force applied to the spinal cord in the second of the accident. Nevertheless, the aim of emergency care for paraplegics must remain to bring about competent, permanent, stable care for the spinal injury as quickly as possible. A purely conservative care for spinal injuries is still possible today and is practiced in many parts of the world due to the lack of access to operative care measures. It does not necessarily lead to poorer long-term results, but for the patient it often means a period of lying down for months until the spine has healed accordingly.

Due to the multiple accompanying damage and failures in spinal cord injuries mentioned above, complications with regard to vital functions must always be expected in the first phase of a paraplegia. As a rule, the patient must therefore be monitored by intensive care medicine. A special warning signal is the secondary worsening of the paralysis situation, which is atypical for the course after spinal cord trauma and usually indicates complications such as B. indicates bleeding. The treatment team must react quickly here. In the case of paraplegia caused by the disease, the onset of symptoms is often very protracted. The challenge for the treating doctors and therapists is often the diagnosis itself. This is especially true when it comes to patients who are already immobile, bedridden and z. B. are supplied with an indwelling urinary catheter. The treatment strategy here depends on the cause and consists e.g. B. with compression of the spinal cord by tumors from the operative relief or the radiation of the spinal column section. Infections also usually have to be relieved surgically and then systemically remedied by administering antibiotics. In all unconscious and unconscious patients, spinal damage must first be assumed if the accident resulted. A spinal emergency can be expected in 6–10% of all traumatic brain injuries. That is why a supply with a cervical spine is always required here. Likewise, if the thoracic spine (thoracic spine) is damaged, a thoracic trauma and if the lumbar spine (lumbar spine) are injured a retro peritoneal hematoma must be expected.

Methylprednisolone
initial 30 mg / kg BM over 15 minutes
continuously 5.4 mg / kg KM / h as an infusion over 23 hours.

The benefit of treatment with methylprednisolone (e.g. Urbason ) is not evidence based. Up to now, however, it has been recommended if it is initiated within the first three hours - no later than eight hours - after the trauma. However, studies have shown that patients treated with methylprednisolone are more prone to wound infections and pneumonia. The use of other substances (e.g. polyethylene glycol , uric acid ) has not yet left the animal experiment stage. The administration of high doses of methylprednisolone was standard in emergency situations for many years. Since its effectiveness has not been proven by studies, it is now rarely carried out.

If there is also a brain injury in the context of a so-called craniocerebral trauma , cortisone treatment is to be viewed as critical, since treatment with methylprednisolone showed a higher mortality rate in patients with such injuries.

Post-acute initial treatment of paraplegics

The emergency care for spinal cord injuries is only one component of the initial treatment for a fresh spinal cord injury. In addition to maintaining vital functions, the prophylaxis of secondary complications is of enormous importance. Paraplegics are extremely at risk from complications such as thromboembolic events and pressure damage to the skin, especially in the sacrum area. In addition, initial rehabilitation treatments should begin in an intensive care unit. They are of the utmost importance for dealing with the disease problem, the regular administration of psychotropic drugs to dampen the emotional stress is counterproductive. If possible, a paraplegic person should be treated in a special center suitable for this purpose. In these, the regulation of bladder and intestinal continence through appropriate neuro-urological examination and treatment methods (intermittent self-catheterization) is taken into account with particular competence.

Lifelong aftercare

Another important component in the treatment of paraplegics is lifelong aftercare. Paraplegia is a disease that permanently affects the patient and is dangerous. In the special centers for paraplegics, outpatient clinics are therefore offered that bundle the necessary measures and, in addition to neuro-urological control, also provide aids and reintegration assistance. The treatment of paraplegia is very complex and varies with the circumstances of the individual case. Nevertheless, the statement of the founder of modern cross-sectional treatment, Sir Ludwig Guttmann (Stoke Mandeville, England), also applies to highly paralyzed patients that patients should become taxpayers again. This statement expresses that the reintegration of paraplegics into everyday life is the primary treatment goal and also includes social professional reintegration. The science and therapy that deals with spinal cord injuries is called paraplegiology.

Operative and conservative care

There is currently no evidence- based statement about the benefits and timing of conservative or surgical care for spinal injuries.

Both groups of methods must pursue the goal of permanently reversing the functional failures of the spinal cord and spine, or at least not allowing them to progress any further. So act z. B. Bone fragments displaced into the spinal canal also later damage the spinal cord. Another example is the avoidance of misalignments that can lead to compression of the spinal cord and gibbus formation (extreme curvature of the spine, "hump"). A gibbus can also have negative consequences for breathing as far as it affects the thoracic spine.

The conservative treatment has is that here no irritation occurs strengths of the spinal cord through the OP. However, due to the use of orthotics, it requires the patient to be immobilized, at least in part, for weeks. The halo body jacket , with which the cervical spine is immobilized, is known here. However, the system is very bulky and severely hinders intensive care in bed.

The operative options also pursue the goals of decompression of the spinal cord and stabilization of the spine. The advantage of the operative solutions lies in the usually faster and more comprehensive mobilization options and thus rehabilitation of the patient.

The decompression surgery is based on the hope that z. B. by straightening steps (with displacement in the longitudinal axis of the spine (see above)) pressure-related circulatory disorders can be eliminated. Another approach to improving blood flow is to use drugs to increase blood pressure for a few days (e.g. with phenylephrine ) if there is no contraindication.

An early stabilization operation offers advantages for intensive medical treatment. On the one hand, airway management can be optimized through tracheotomy , and on the other hand, there are no problems with changing position in pneumonia prophylaxis and care. Various trauma surgical methods of osteosynthesis are used, namely dorsal, ventral and combined dorso-ventral osteosynthesis, which can also be divided into short and long-range osteosyntheses. The goal is always first to stabilize and, in the long term, to stiffen the affected spinal column.

It is discussed that the success of such operations is greatest when done within three days of the trauma.

Experimental treatment of paraplegia

In the past 30 years, attempts have been made in many places to overcome the fateful permanent damage to the spinal cord. Due to increasingly better understood mechanisms, treatment approaches z. B. with inhibition of growth-blocking proteins (anti no go treatment), implantation of stem cells and other immunomodulating substances have been undertaken. So far, none of these treatment strategies have "cured" spinal cord injury. The Paraplegic Center at the Balgrist University Hospital maintains and regularly updates a list of current experimental methods and treatment approaches, which it also evaluates scientifically.

For those affected and their relatives, it is important to know that good, clinically supervised studies on paraplegics are usually characterized by the fact that no healing promises are made and that patients can participate in the study treatment or only in the study free of charge. The regeneration treatments, which are often extremely expensive, are usually ineffective, and individual descriptions of cases are evidence of success. However, such recoveries are often observed spontaneously. They are not proof of the effectiveness of a method.

Experimental drug treatment

Recently (2005), the neurotherapeutic drug Cordaneurin , which is supposed to promote the regeneration of nerve cells, has apparently been successfully tested for the first time in preclinical trials on acute spinal cord injuries . According to the manufacturer, the first clinical studies began in 2006. In animal experiments, erythropoietin , NSAIDs , anti-CD11d antibodies, minocycline , progesterone , estrogen , magnesium , riluzole , polyethylene glycol , atorvastatin , inosine and pioglitazone were also tried out.

Experimental treatment with stem cells

So far there is no internationally recognized treatment with stem cells for acute or chronic paraplegia. All stem cell treatments previously offered commercially (for a fee) have not been tested for their effectiveness and are not recognized as treatments by medical societies. However, there are first very serious clinical studies with the use of stem cells in humans, which are now being examined and, after several studies, could possibly result in recognized treatments.

A study started on October 11, 2010 to determine the effectiveness of embryonic stem cells in the treatment of recent traumatic spinal cord injuries. The stem cells are introduced into the spinal cord lesion with a specially developed injection aid. In animal experiments , this procedure had improved mobility, up to and including complete recovery. For the time being, 20 patients are planned for this study.

In spring 2011, the world's first study with mature neural stem cells in chronic spinal cord injury was started. The patients were injected with 20 million stem cells into the tissue around the spinal cord injury. Periodic examinations were then performed to measure any changes in neurological function in the injury area. The primary aim is to prove that such stem cell transplants can be carried out with the highest level of security - the first promising findings are already available. The study also intends to evaluate the long-term effects of the therapy. At the beginning of October 2013, the US Food and Drug Administration granted the authorization for the first clinical phase of this stem cell therapy in the USA.

rehabilitation

The targeted rehabilitation of paraplegia was first carried out by Sir Ludwig Guttmann in Stoke-Mandeville and further developed in a targeted manner. Guttmann realized that the consequences of paralysis were being misunderstood and treated incorrectly. He set up a lifelong follow-up program called “Comprehensive Care”.

Nursing rehabilitation

Nursing rehabilitation includes the care of bladder and rectal paralysis, taking over the activities of daily living (ATL), as long as these are not possible independently for those affected, as well as the prevention of complications and consequential damages, e.g. B. bedsores ( bedsores ) or contractures (stiffening of joints ).

Social rehabilitation

The early active involvement of the patient in the rehabilitation process should be of particular importance in the entire treatment concept in order to develop self-esteem, motivation and lasting health competence at an early stage . Sport plays an important role in compensating for the physical, psychological and social functions that are disturbed by paraplegia, in preventing secondary damage, in promoting health-oriented behavior and as a motor for integration.

Achieving the greatest possible individual independence and quality of life for those affected is the focus of social rehabilitation. Sex is also a topic that gains in importance at the latest after initial treatment and return to everyday life, contrary to the widespread prejudice that a man with paraplegia can no longer have sex.

Vocational rehabilitation

Comprehensive somatic rehabilitation is generally followed by vocational rehabilitation.

Physiotherapy with massages, physiotherapy and swimming, as well as occupational therapy with training of the ATL, supply and adaptation of aids (e.g. wheelchair , home furnishings) are also involved to a significant extent in rehabilitation, as in lifelong aftercare . A team that rehabilitates fresh spinal cord injuries also includes social workers and psychologists.

Life expectancy

In the industrialized nations and countries with Western standards of medical care, the life expectancy of a paraplegic or deep quadruped is generally approximately the same as that of the usual population. Higher paralysis with z. B. Compulsory ventilation lead to a considerable reduction in the survival prognosis. In developing countries and countries with insufficient resources for the treatment of paraplegics, the chance of survival is significantly reduced, as even simple pressure points often lead to severe septic disease and / or inappropriate bladder emptying measures can lead to kidney damage and even to dialysis. Modern medical treatment options also make it possible for paraplegic men and women to have children.

International usage

The term paraplegia is not common in other languages, the direct translations transverse lesion (en) or paralysie transversale (fr) are not in use. On the other hand, paraplegia (en) or paraplégie (fr) and paraplejía (es) are usually used as generic terms, with quadriplegia or tétraplégie (fr) and tetraplejía (es) representing a specification. The English language version of traumatic paraplegia is spinal cord injury ; in French one speaks of a lésion médullaire , or the paraplegic is the blessé médullaire .

Scientific societies

The German-speaking Medical Society for Paraplegiology (DMGP) is a multi-professional specialist society in the German-speaking region for research and imparting knowledge. It publishes (within the framework of the AWMF) guidelines for the treatment of paraplegics. The International Spinal Cord Society (ISCOS) is the international specialist society that deals with the medical issues of spinal cord injuries. Several foundations support research into topics related to paraplegia, in Germany the German Foundation for Paraplegia (DSQ); in Austria Wings for Life and in Switzerland the Swiss Paraplegic Foundation (SPS).

See also

literature

Web links

Individual evidence

  1. ↑ L. Guttmann: Spinal cord injuries: comprehensive management and research . Blackwell Scientific, 1973.
  2. ^ German-speaking Medical Society for Paraplegia DMGP
  3. ↑ a b H. J. Gerner: The paraplegia: first aid, treatment strategy, rehabilitation . Blackwell Science, 1992.
  4. ↑ treatment centers
  5. ^ WP Waring, F. Biering-Sorensen, S. Burns, W. Donovan, D. Graves, A. Jha u. a .: 2009 review and revisions of the international standards for the neurological classification of spinal cord injury. In: The journal of spinal cord medicine. 33 (4), 2010, pp. 346-352.
  6. ↑ HL Frankel, DO Hancock, G. Hyslop, J. Melzak, LS Michaelis, GH Ungar a. a .: The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. In: Paraplegia. 7 (3), 1969, pp. 179-192.
  7. ↑ (ASIA) ASIA. Chicago [cited 2016 January 19, 2016] ( Memento of the original from April 30, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF) @1@ 2Template: Webachiv / IABot / www.asia-spinalinjury.org
  8. ↑ A. Catz, M. Itzkovich, E. Agranov, H. Ring, A. Tamir: SCIM spinal cord independence measure: a new disability scale for patients with spinal cord lesions. In: Spinal cord. Volume 35, Number 12, December 1997, pp. 850-856. PMID 9429264 .
  9. ↑ E. Aidinoff, L. front, M. Itzkovich, V. Bluvshtein, I. Gelernter, J. Hart, F. Biering-Sorensen, C. Weeks, MT Laramee, C. Craven, SL Hitzig, E. Glaser, G . Zeilig, S. Aito, G. Scivoletto, M. Mecci, RJ Chadwick, WS El Masry, A. Osman, CA Glass, BM Soni, BP Gardner, G. Savic, EM Bergström, P. Silva, A. Catz: Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions. In: Spinal cord. Volume 49, Number 8, August 2011, pp. 893-896, doi: 10.1038 / sc.2011.32 , PMID 21483443 .
  10. ↑ F. Högel, O. Mach, D. Maier: Functional outcome of patients 12 and 48 weeks after acute traumatic tetraplegia and paraplegia: data analysis from 2004-2009. In: Spinal cord. Volume 50, number 7, July 2012, pp. 517-520, doi: 10.1038 / sc.2011.171 , PMID 22249330 .
  11. ↑ P. Hollstein: Stop the fateful cell death. In: Spectrum of Science. September 16, 2004.
  12. ^ MF Hoque, Z. Hasan et al. a .: Cervical spinal cord injury due to fall while carrying heavy load on head: a problem in Bangladesh. In: Spinal cord. Volume 50, Number 4, April 2012, pp. 275-277, ISSN  1476-5624 . doi: 10.1038 / sc.2011.153 . PMID 22143680 .
  13. ↑ Working group for paraplegia of the German Social Accident Insurance (Head of R Tiedje). Hamburg 2014.
  14. ↑ a b c d e J. Büttner: Management of paraplegia. In: Anästh Intensivmed. 45, 2004, pp. 190-204.
  15. ↑ SC Kirshblum u. a .: Reference for the 2011 revision of the International Standards for Neurological Classification of Spinal Cord Injury. In: J Spinal Cord Med. 34 (6), 2011, pp. 547-554.
  16. ↑ Pang and Wilberger: Spinal cord injury without radiographic abnormalities in children. In: J Neurosurg. 57, 1982.
  17. ↑ CK Boese, M. Nerlich, SM Klein, A. Wirries, S. Ruchholtz, P. Lechler: Early magnetic resonance imaging in spinal cord injury without radiological abnormality in adults: A retrospective study. In: The Journal of Trauma and Acute Care Surgery . 74, 2013, pp. 845-848, doi: 10.1097 / TA.0b013e31828272e9 .
  18. ↑ a b c Christoph Kolja Boese, Philipp Lechler: Spinal cord injury without radiologic abnormalities in adults: a systematic review . In: The Journal of Trauma and Acute Care Surgery . tape 75 , no. 2 , August 1, 2013, ISSN  2163-0763 , p. 320-330 , doi : 10.1097 / TA.0b013e31829243c9 , PMID 23702634 .
  19. ↑ CK Boese, J. Oppermann, J. Siewe, P. Eysel, MJ Scheyerer, P. Lechler: Spinal cord injury without radiologic abnormality in children: a systematic review and meta-analysis. In: Journal of Trauma and Acute Care Surgery. 75, 2013 doi: 10.1097 / TA.0000000000000579 .
  20. ↑ PC Strohm, M. Jaeger, W. Köstler, N. Südkamp: SCIWORA syndrome. In: The trauma surgeon. 106, 2003, pp. 82-84, doi: 10.1007 / s00113-002-0506-4 .
  21. ↑ a b H. S. Chhabra: ISCoS Textbook on Comprehensive Management of Spinal Cord Injuries. 1st international edition. Wolters Kluwer, Haryana (India) 2015.
  22. ↑ N. Evaniew, EP Belley-Cote, N. Fallah, VK Noonan, CS Rivers, MF Dvorak: Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Systematic Review and Meta-Analysis. In: J Neurotrauma. 2015.
  23. ↑ M. Keil, L. Szczerba, G. Kraus, R. Abel: Therapy of septic paraplegia. In: Orthopedist. 41 (9), 2012, pp. 742-748.
  24. ^ German-speaking Medical Society for Paraplegiology DMGP
  25. ↑ K. Schwertfeger et al. a .: Spinal trauma. In: Intensivmed. 41, 2004, pp. 71-80.
  26. ↑ His Spinal Cord Injury Was Serious. But Gen. Hugh Shelton Has Backbone. Retrieved December 8, 2010 .
  27. ↑ Interview with General Hugh Shelton. Archived from the original on September 1, 2012 ; Retrieved December 8, 2010 . At the beginning he talks about the treatment of his spinal cord injury at the Walter Reed Army Medical Center.
  28. ↑ Experimental Therapies for Spinal Cord Injury . balgrist.ch. Retrieved September 24, 2019.
  29. ↑ BK Kwon, EB Okon et al. a .: A systematic review of directly applied biologic therapies for acute spinal cord injury. In: Journal of neurotrauma. Volume 28, Number 8, August 2011, pp. 1589-1610, ISSN  1557-9042 . doi: 10.1089 / new 2009.1150 . PMID 20082560 . PMC 3143411 (free full text).
  30. ^ Shepherd Center, October 11, 2010 press release: Patient Treated in Geron Clinical Trial . accessed on October 12, 2010 Template: dead link /! ... nourl ( page no longer available )
  31. ↑ World's first study with neural stem cells in spinal cord injury . ( Memento of the original from August 12, 2014 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF) Center for Paraplegia Balgrist, press release of March 16, 2011; accessed on August 11, 2014. @1@ 2Template: Webachiv / IABot / www.balgrist.ch
  32. ↑ Stem cell research: third study partner in the USA . Center for Paraplegia Balgrist, blog of November 6, 2013; accessed on August 11, 2014 Template: dead link /! ... nourl ( page no longer available )
  33. ↑ Klaus Röhl: MDR broadcast “self-determined” about prejudices accessed on April 8, 2011.
  34. ↑ Example for vocational rehabilitation (PDF; 224 kB). Template: dead link /! ... nourl ( Page no longer available )