SECOND OPINIONS BLOG

The thoracic spine runs from just below our neck down to just above our low back; it is our middle back.  It is what anchors our rib cage.  The rib cage along with the spine protects the internal organs located in the torso.  When the thoracic spine is injured, it has an effect on other organs in your body. 

The nerves of T1-T5 affect muscles of the upper chest, mid-back and abdomen which control the rib cage, lungs, diaphragm and the muscles that control breathing.  Injuries to T1-T5 usually affect the abdominal and lower back muscles and legs, typically resulting in paraplegia.  Arm and hand function usually remains normal.

T6-T12 nerves affect abdominal and back muscles.  These are important for balance and posture, and they help you cough or expel foreign matter from the airway.  Injury to T6-T12 usually results in paraplegia with little or no voluntary control of bowel or bladder. 

The prognosis and recovery from thoracic injuries differs from person to person based on the type of injury and level of severity.  General overall health is also an important factor in determining level of independence achieved after injury.

Lateral lumbar interbody fusion (XLIF) is a minimally invasive option to lumbar surgery.  This procedure is done from the side rather than the front or back resulting in reduced time for operation, fewer recovery days, minimal scarring, reduced blood loss, less post-operative pain, and quicker return to daily activities.  It is an outpatient procedure which is not appropriate in every situation. 

This procedure is performed with one or more tiny incisions and a medical device called a retractor that’s used to spread apart overlying tissue to give the doctor a clear view of the spine.  The retractor and dilator system used in the lateral lumbar interbody fusion is called MaXcess™ which allows the surgeon to reach the spine via a lateral view from the side with minimal muscle and ligament tampering and no disruption to abdominal muscles.

The recovery process is quicker than with traditional surgery.  The patient can get up and walk immediately following the procedure, minor pain afterwards, and the results are immediately apparent rather than having to wait for a gradual return to normalcy as in the traditional fusion surgery.

Over 400 published clinical studies support the procedure, documenting positive clinical outcomes as comparted to traditional posterior fusion procedures. 

Spinal cord injuries are devastating.  In the U.S. there are approximately 12,000 spinal cord injuries every year in which the injured person survives the initial accident.  For those who survive the initial accident, the road forward is physically demanding, psychologically taxing, and financially burdensome.  A spinal cord injury patient can expect to spend well over a month in hospitals and in-patient rehabilitation (sometimes considerably longer depending on the severity of the injury and whether there are simultaneous cognitive impairments or other comorbidities).  In addition, the lifetime costs of spinal cord injuries are extensive, having a present day value ranging from $4,540,000 for a 20-year-old patient with high tetraplegia (spinal cord injury at C1-C4) to $1,460,000 for a 60-year-old patient with paraplegia.  The occupational effects are profound, with only 35% of spinal cord injury patients able to achieve a similar pre-injury level of employment 20 years post-injury.  Obviously, the costs of spinal cord injury claims are enormous and usually lifelong.  Since the two most common causes of spinal cord injuries are motor vehicle crashes and falls, liability claims are relatively common when spinal cord injuries occur.

Certainly no one did more to raise awareness of spinal cord injuries than Christopher Reeve, who suffered a spinal cord injury causing high tetraplegia (C1-C2) after falling from a horse in 1995.  Periodically high profile athletes suffer spinal cord injuries that thrust the issue back into the national spotlight.  In 2010, Rutgers football player Eric LeGrande sustained a spinal cord injury during a game that initially left him paralyzed from the neck down.  In October 1995, Travis Roy was just 11 seconds into his first shift in his first game as a hockey player for Boston University when he crashed head-first into the boards and suffered a spinal cord injury that also paralyzed him from the neck down. 

More recently, Olympic swimmer and multiple gold medal-winning swimmer Amy Van Dyken suffered a spinal cord injury away from athletics in June 2014 when she fell off the all-terrain vehicle she was driving and down a 5-7 foot embankment.  The accident injured her spinal cord at T11 and left her paralyzed from the waist down. 

These famous athletes and celebrities periodically remind us of both the risk and devastating consequences of spinal cord injury.  Fortunately, progress is being made in managing the post-injury effects of spinal cord injury.  The most frequently reported-on developments typically involve bionic exoskeletons that help the paralyzed person move their limbs.  However, recently medical researchers have been making strides in using electrical stimulation to allow the injured patient voluntarily move paralyzed limbs.  In recently reported research, external electrodes were placed over 5 patients’ spinal columns who have suffered from paraplegia for at least two years.  The electrodes in combination with the drug Buspirone allowed the patients to move their limbs under stimulation, which was not unexpected.  What was remarkable is that the patients retained the ability to move their legs even without electrical stimulation after 4 weeks of treatment.  As lead researcher Prof. V. Reggie Edgerton noted, "The fact that they regained voluntary control so quickly must mean that they had neural connections that were dormant, which we reawakened."  The findings are considered remarkable because the medical and scientific community had accepted that persons with complete paralysis “no longer had any neural connections in the spinal area” suggesting that it may be possible to regain motor function without regenerating spinal neurons or using an exoskeleton system.

This research along with the mind-boggling progress that is being made with patient-controlled exoskeleton devices is changing the landscape for spinal cord injury patients.  These developments are welcome news for patients, their families, and society alike.  As noted above, the occupational and medical costs of spinal cord injuries are enormous.  Anything that can return function to patients has the potential to minimize the occupational impact and long-term medical expenses of spinal cord injuries, which is good news for civil liability systems as well.  Spinal cord injuries are among the most costly injuries to everyone involved.  Improving outcomes in spinal cord injuries will benefit an extraordinary number of individual lives and also the institutions set up to absorb the costs.

The thoracic spine (located between the cervical and lumbar spines) is your middle back, beginning right below your neck and ending at your low back.  The main function of the thoracic spine is to anchor the rib cage and protect the spinal cord, heart and lungs.  It is the longest and most complex region of the spine; made up of 12 vertebral bodies that hold disks (T1-T12).  T1 connects with the cervical spine above at C7 and T12 with the lumbar spine below at L1.

Interestingly, the space between disks (intervertebral opening) is much larger in the thoracic spine as compared to both the cervical and lumbar spines.  A bigger intervertebral opening and smaller nerve root allows more room for spinal nerves and reduces the chance of the nerve becoming pinched or inflamed.  Recent research suggests this might be the reason disk degeneration of the thoracic spine is much less likely to cause pain or other symptoms, unless of course the degeneration causes a disk to push on a nerve.  There are several other causes of thoracic spine pain.

Myofascial pain (muscular in nature) can be caused by poor posture, or any irritation of the large back or shoulder muscles, which would include strains or spasms. Joint dysfunction, thoracic herniated disk, compression fracture, kyphosis, scoliosis, arthritis or osteoporosis can also cause pain.

Symptoms of nerve damage in the thoracic spine include: 

• Stooped posture
• Muscle weakness/spasms
• Pain that is referred to the ribs, shoulder, arm, fingers, neck or legs
• Limited range of motion
• Tingling, numbness, burning or pins-and-needles sensation

Whiplash is not really a medical condition.  It is a term used to describe the sudden acceleration-deceleration mechanism of injury to the neck.  A whiplash injury can range from a muscle sprain to spinal cord contusions to fractured vertebra.  Spinal cord contusions and fractured vertebra can be easily detected, but a muscle sprain cannot.  This means there is no way to prove or disprove most claims of whiplash injury where a muscle sprain is involved.

While a car accident victim can experience neck, head, and back pain following the accident, but can such an energy transfer cause chronic, long-lasting pain, and if so, how?

There is no proven physical reason why a whiplash injury would cause chronic pain.  But, in fact, about 25% of whiplash injury patients suffer chronic pain.  Additionally, whiplash injuries in the United States come with a price tag of about 2.7 billion dollars a year¹.  So, what we know about whiplash is important to lowering claim costs.  

¹ http://www.theatlantic.com/health/archive/2016/03/chronic-whiplash-is-a-medical-mystery/476052/

With more severe concussions, these symptoms may be more severe or worsen with time.  Repeated concussions can cause problems such as lasting cognitive issues.

Rehabilitation is an important part of the recovery process for a TBI patient.  The program should be customized to the person based on their strengths and capacities and modified over time to adapt to changing needs.  This usually involves a team of rehabilitation specialists in multi-specialties.  Individually tailored programs generally include physical therapy, occupational therapy, speech/language therapy, physiatry, psychology/psychiatry, and social support.  There are several options for rehabilitation:  home-based, hospital outpatient, hospital inpatient, comprehensive day programs, supportive living programs, independent living centers, club-house programs, school based programs for kids and others.

The overall goal is to improve the patient’s ability to function at home, work and in society.  This is done through helping the patient adapt to disabilities or to modify their environment to make every day activities easier.  Medications must be carefully prescribed because TBI patients are more susceptible to side effects and may react adversely to some pharmacological agents.  It is also important for family members to provide support for the TBI patient through involvement in their rehabilitation program. 

Here is an article that speaks to a personal experience one may have with TBI injured loved one:  https://www.brainline.org/article/introduction-rehabilitation-healing-brain. 

TBI recovery is slow, with a step-by-step course which progresses from coma, vegetative state, minimally conscious, conscious and then to a post-traumatic confusional state.  The severity of a TBI cannot be determined in the first few days after injury it may take weeks – or even months – to determine how or if a person will recover over time.  Many persons will eventually regain consciousness, but some will not.

Often improvement continues slowly over time.  There is much variation of how people move through each stage and how long each stage lasts.  Some people move quickly or skip stages while others may get stuck in a stage.  Every injury is different and follows its own timeline.  The longer a person remains in a coma or state of impaired consciousness, generally the more likely they will be severely disabled. 

One of the first meaningful behaviors a severely brain-injured person shows is the ability to follow an object with their eyes (visual tracking), is a definite sign of moving toward consciousness.  The earlier a person moves from a coma or vegetative state to a minimally conscious state, the better the long-term outcome.  Even if the disorder of consciousness lasts for several months, improvement can still be shown.  In this case specialized TBI rehabilitation may be beneficial.

Age plays a role in recovery outcome.  Younger people are more likely to return to a more independent, productive life.  Older persons don’t usually fair as well.  However, an accurate diagnosis of level of consciousness is imperative because it helps predict the short and long term outcomes.  This helps in making decisions concerning rehabilitation or whether to stop care altogether.

Throughout the recovery process TBI victims will undergo tests and procedures which will assist with diagnosis, prognosis, and treatment decisions.

Neurological monitoring/neuromonitoring:  Intracranial pressure monitors track the amount of pressure in the brain to help manage brain swelling. 

Neuroimaging studies:  Computed tomography (CT scans) or MRI is used to identify bleeding and injured parts of the brain, and to determine if surgery is necessary.

Electroencephalogram (EEG):  Measure electrical activity in the brain, show location/extent of injury and can be used to diagnose seizures.

Informal bedside neurological exam and formal behavior assessment scale:  Used to determine a person’s level of impaired consciousness.  Typically testing for basic reflexes, following a moving object with the eyes, performing basic commands and communication.

There are a few different systems that doctors use to diagnose the symptoms of TBI.  The Glasgo Coma Scale measures motor response, verbal response and eye opening response.  The Ranchos Los Amigos Scale measures levels of awareness, cognition, behavior and interaction with the environment.  These tests are often used to determine whether the TBI is mild, moderate or severe.

A Mild Traumatic Brain Injury is the most common type of TBI which is often missed at the time of initial injury.  15% of persons with mild TBI have symptoms that last one or more years.  It is classified as a loss of consciousness and/or confusion and disorientation is shorter than 30 minutes.  MRI and CAT scans are often normal even though the individual may have cognitive problems such as headaches, difficulty thinking, memory problems, attention deficits, mood swings and frustration. 

Other names for a mild TBI include:

• Concussion
• Minor TBI
• Minor brain injury
• Minor head trauma
• Minor head injury

Moderate Traumatic Brain Injury is defined as a brain injury resulting in a loss of consciousness from 20 minutes to 6 hours and a Glago Coma Scale of 9 to 12.  The symptoms may be similar to a mild TBI but they do not go away or may even get worse.

Severe Traumatic Brain Injury describes a brain injury with a loss of consciousness of greater than 6 hours and a Glasgow Coma Scale of 3 to 8.

Traumatic Brain Injuries (TBIs) contribute to about 30% of all injury deaths; in fact 153 persons in the US die every day from injuries where TBI was a factor.  Depending upon the severity of injury, survivors can face effects of TBI for a few days or the rest of their lives.  TBI is an injury to the head that disrupts the normal function of the brain.  Interestingly, not all head injuries result in TBI. 

Males represent 78.8% and females 21.2% of all reported TBI accidents.  The leading causes of TBI are:  falls, being struck by an object, and intentional self-harm.  50-70% of all TBIs are the result of motor vehicle accidents.

Of all traumatic deaths, deaths from head injuries account for 34% of all traumatic deaths.  Beginning at age 30, mortality risk after head injury begins to increase.  Persons age 60 and older have the highest death rate after TBI, primarily because of falls.

Reference:  “Facts About Traumatic Brain Injury”  https://www.brainline.org/article/facts-about-traumatic-brain-injury.

Statistically speaking, TBI is an injury of young persons, since incidence rates peak between the ages of 16-25.  It is estimated that there are more than 5 million people in the US with TBI.  As a result of the young age of TBI onset and the sheer numbers of persons with TBI, the economic and personal cost is great. 

Studies conducted show that 50% of persons with severe TBI do not return to the vocational roles they had before the injury.  Additionally, 20% of those with what was categorized as mild-TBI were unemployed.  It is estimated that $56 billion dollars annually are spent as a result of failure to return to work after TBI. 

The challenge to return to work is great because the TBI person with more severe injury have emotional issues and problems with memory, sequencing and judgement.  They may experience fatigue, be dependent on others for activities of daily living as well as transportation. 

The following may aide in the return to work after TBI:

• Vocational Rehabilitation services early in the rehabilitation process
  • On-the-job training
  • Counseling and guidance
  • Job placement services
  • Supportive work environment
  • Cognitive skills training
  • Provide training for and use of assistive technology

Unfortunately many people with TBI fail to return to work.  It is hard to determine why that is as studies are not well-defined, do not use universal definitions for terms, and often do not define a specific path (or pathways) of success with regard to return to work.

Reference:  “TBI Research Review:  Return to Work After Traumatic Brain Injury.”  https://www.brainline.org/article/tbi-research-review-return-work-after-traumatic-brain-injury

A skull fracture is defined as any break in the cranial bone.  There are many types of skull fractures, but they all result from one major cause and that is an impact or blow to the head that’s strong enough to break a bone.  The types include: 

• Linear – a break resembling a thin line or crack
  
  
• Depressed – a break in or crushing injury
  
  
• Basilar – occurs at the base of the bran sometimes causing leakage of cerebral spinal fluid

Skull fractures are not always easily seen.  Following an impact or blow to the head some symptoms which may indicate fracture include:  swelling and/or tenderness around the area of impact, facial bruising, bleeding from the nostrils or ears. 

For mild fractures, pain medication may be the only necessary treatment, but neurosurgery may be required for more serious fractures.

Defined as an accumulation of blood within the brain or between the brain and skull.  They form when a head injury causes blood to accumulate in the brain or between the brain and the skull. 

Here are the different types of hematomas:

• Epidural – a blood clot outside of the brain but under the skull
  
  
• Subdural – located between the brain and the dura
  
  
• Intracerebral – a ruptured blood vessel in the brain that causes bleeding
  
  
• Subarachnoid Hemorrhage – bleeding under the arachnoid layer
  
  
• Intraventricular Hemorrhage – bleeding into ventricles of the brain

Diagnosing intracranial hematoma can be difficult because sometimes people with head injury can seem fine.  And sometimes they are if the hematoma is small and produces no signs or symptoms.  However, symptoms can appear or worsen days or even weeks after the injury, which is why following a head injury the person should be watched for neurological changes, to have intracranial pressure monitored, and undergo repeated head CT scans. Sometimes surgery is required to drain the blood.

The Cerebrum is the largest part of the brain.  Divided into two hemispheres, the outermost layer, the cerebral cortex, has four lobes:

• Occipital used for processing visual information
  
  
• Temporal, one close to each ear, used for auditory processing, but may also be involved in emotion, learning and pronunciation/ learning a new language.
  
  
• Frontal used for solutions to complex tasks, voluntary movements, forming complete sentences when talking and personality traits
  
  
• Parietal for general sensation and feeling

The Cerebellum is located behind the top part of the brain stem where the spinal cord meets the brain and is made up of two hemispheres.  It receives information from the sensory systems, spinal cord and other parts of the brain and then regulates motor movement.  The cerebellum coordinates voluntary movement such as balance, coordination, posture, and speech, resulting in smooth and balanced muscular activity.

The Brainstem lies underneath and behind the cerebellum.  It controls the flow of messages between the brain and the rest of the body.  The brainstem also controls basic bodily functions such as breathing, swallowing, heart rate, blood pressure, consciousness, and state of sleepiness.