New horizons lie ahead for the management of spinal cord injuries, according to eminent Perth researcher Emeritus Professor Byron Kakulas.
Injury of the spinal cord resulting in complete or partial paralysis of the lower limbs (paraplegia) or all four limbs (tetraplegia) is a devastating life-changing event. Spinal cord injuries (SCI) pose a massive worldwide problem, in both human and economic terms.
It is estimated that there are 20,800 people in Australia living with SCI and between 250,000 and 500,000 worldwide. Most spinal cord injuries are due to preventable causes such as road traffic crashes, diving accidents, falls or violence. The economic burden of SCI in Australia is calculated to be $74.5 billion, representing health care costs and loss of productivity.
The standard treatment of SCI in the acute phase is surgical decompression undertaken as soon as possible after injury followed by intensive clinical care. Rehabilitation begins when the injury is stabilised. Partial recovery of neurological functions is usual in the weeks and months post-injury and some further improvement may be expected for up to a year.
Many years ago, in pioneering work, Sir Ludwig Guttmann in London and our own Sir George Bedbrook in Perth concluded from their own experience that early surgical decompression is of no apparent benefit in promoting recovery and may even aggravate the neurological state of the patient.
Their experience is supported by the neuropathology of SCI which demonstrates that there is no lesion in the damaged spinal cord or vertebral column which would benefit from surgery.
The usual and conventional view of those attending to SCI is that the spinal cord is totally transected due to the trauma in ‘complete SCI’. However, this view was shattered by the neurophysiological findings of my long-time collaborator, Professor Milan Dimitrijevic of Baylor Medical College, Houston, Texas, who clearly demonstrated that neurological signals may pass through the level of injury both in caudal and rostral directions.
He coined the term ‘discomplete SCI’ to describe this clinical state. Professor Dimitrijevic’s findings were considered so radical that initially he had great difficulty in having his observations published.
This situation changed when it was shown from my post-mortem studies that of a total of 220 SCI autopsies, 53 (24%) were in fact anatomically discomplete with some degree of white matter being found to traverse the level of the lesion, thus supporting Professor Dimitrijevic’s observations and most importantly the preserved nerve fibres providing a substrate for the application of the methods of restorative neurology.
Most prominent among the restorative techniques is epidural spinal cord electrical stimulation, which when applied to patients with complete paralysis improves neurological function below the level of injury with a return of voluntary movement in the paralysed lower limbs. In a number of SCI cases, the effect of electrical stimulation is so dramatic that complete SCI becomes incomplete.
Epidural electrical treatments are of great benefit in SCI rehabilitation. Since the early discoveries, electrical stimulation has been refined to the extent that transcutaneous stimulation is effective. Furthermore, in recent years, Professor Dimitrijevic’s work has been widely accepted and improved upon all around the world.
ED: Emeritus Professor Byron Kakulas, who turned 90 this year, is founding director of the Perron Institute for Neurological and Translational Science.