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SPINAL CORD INJURIES AND SPINAL CORD PARALYSIS

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    Epiduroscopy

    Epiduroscopy is the name of the diagnostic and treatment method that allows access to the spinal canal.

    SPINAL CORD INJURIES AND SPINAL CORD PARALYSIS Advanced spinal cord injury is the disruption of the transmission circuits in nerve cells locally within the spinal cord white matter and the development of paralysis or paralysis below the area of damage. Clinically, the effectiveness of standard physical therapy and rehabilitation applications is extremely limited in patients whose motor functions have completely disappeared, and it is not possible to walk independently or control voluntary movements with these methods. Today, many studies are being conducted to ensure that nerve cells in the spinal cord white and gray matter renew themselves. Medical care in spinal cord paralysis is focused on preventing and treating secondary complications that develop in these patients. A large number of these patients cannot regain their motor functions and live their lives with the hope that they will one day be able to perform voluntary movements again. Today, treatment is focused on restarting transmission or reorganization in the damaged area through the spinal cord anatomical structures that remain intact after the damage. Even after very advanced damage in the white matter, most of the spinal cord neurons are found intact and scattered below the area of damage. In the gray matter, most of the motor neurons and the interneuronal transmission network are intact. A series of physiological, biochemical and cellular changes develop in the neurons and transmission circuits beneath the lesion site. Reorganization of neural connections A rapid renewal process begins in receptors and genes.   In the neural transmission network formed by spinal cord elements; Neural signal transmission capacity after trauma, Processing of sensory signals, Motor movement redevelopment, Activity-dependent re-stretching ability are alive.   Studies have shown that voluntary motor movements can be partially restored with pharmacological and epidural spinal cord stimulation methods.   Spinal cord stimulators have been used successfully in the treatment of chronic pain and movement disorders for over 40 years. Spinal cord stimulators can restart voluntary motor movements by using the intact neuronal transmission network under the lesion area in cases with spinal cord damage. Under normal conditions, it is not necessary for the brain to be intact in the initiation and repetition of voluntary motor movements. Voluntary motor movements and their rhythmic continuation are provided by spinal cord neuronal pain. Scientific findings have confirmed that voluntary motor movements are also provided by the spinal cord in humans. Studies have shown that epidural electrical stimulation applied to the back of the spinal cord can initiate coordinated flex/ext movements of the hip, knee, and ankle in the supine position. The best treatment method that can now be used for this is spinal cord stimulators that can be placed inside the body. In humans, intact spinal cord neuronal circuits can initiate rhythmic activity in a very short time with appropriate stimulation.   Spinal cord stimulators mechanism of action Electrical stimulation of the posterior part of the spinal cord activates medium and large diameter sensory fibers located in the posterior roots. These stimuli ignite reflex and interneuronal circuits through connections between nerves, regulate stimuli, and initiate motor neuronal stimulation, thus contraction and relaxation movements occur with the organization of neuronal circuits in multiple muscle groups. Voluntary neural circuits are activated with tonic stimuli applied at appropriate frequency ranges with spinal cord stimulators, and spinal cord reflexes stimulated at multiple levels can work together and in harmony. Spinal cord stimulators create rhythmic movement responses in the lower extremities in correctly adjusted stimulation programs. It has been shown that voluntary movements can be initiated in fully paralyzed volunteer patients in the supine position even in the absence of position stimuli and brain stimuli. It has been shown with EMG that these stimuli initiate rhythmic flex/ext movements with appropriate programming. Many studies have shown that patients who have received spinal cord stimulators benefit from robotic rehabilitation, can walk actively with the robot, but it takes a long time for them to walk independently. This period can range from a few weeks to 2-4 years. While increasing body weight gradually during robotic rehabilitation allows patients to walk with minimal support, it has been shown that robotic rehabilitation alone without electrical epidural spinal cord stimulation cannot initiate voluntary movements in the patient. As a result; the human spinal cord can initiate rhythmic flex/ext movements in response to electrical epidural stimulation, with appropriate programs, strong extension, locking movements in the hip and knee joints can be achieved in patients with complete paralysis who are loaded with full body weight, and the patient can stand. However, spinal cord stimulation alone cannot initiate walking without support. Sensory feedback signals from the legs regulate the adaptation and activation of the spinal cord motor neuron pool through reflex circuits during walking. Therefore, robotic rehabilitation is extremely important for ensuring the continuation of reflex signals in patients who receive spinal cord stimulation, and the combined application of stimulation and robotic rehabilitation will increase success.  

    TO WHOM IS IT APPLIED?

    • Patients who do not have any cardiovascular or lung problems that would prevent them from doing standing and walking exercises.
    • Patients who do not use antispastic medication
    • Non-progressive spinal cord injury between C7-L1 segments
    • ASIA (American Spinal Injury Association) class A and B, some C
    • Lack of response to sensory evoked potentials
    • Segmental reflexes are intact below the level of injury.

     

    TO WHOM IT CANNOT BE APPLIED?

    • Pregnancy
    • The patient does not accept
    • Patients under 18 years of age
    • Having fractures in different body parts
    • Osteoporosis (Dexa T score should be below 3.5)
    • Uncontrolled urinary tract infections
    • Those with a history of frequent bed sores
    • Diagnosed clinical depression
    • Medicine addiction
    • Painful musculoskeletal dysfunction that will prevent walking, unhealed fractures, contractures, pressure sores, urinary tract infections
    • Currently taking antispasmodic medication
    • Having a pacemaker
    • Availability of a cardiac defibrillator
    • Presence of other implanted metallic electronic devices (insulin pump)
    • COPD, heart failure, presence of arrhythmias
    • Presence of excessive and uncontrolled autonomic disturbances such as symptomatic hypotension, dizziness, hypertension, and bradycardia

     

    ASIA (American Spinal Injury Association) classification Stage A: Loss of all motor and sensory functions below the level of injury, including the anal region Stage B: Some sensory functions are preserved below the level of injury Stage C: There are some irregular muscle movements below the level of injury (However, the movements of these muscles against gravity are less than 50%) Stage D: More than 50% of the muscles have movement Stage E: All neurological functions have returned to normal.   CLINICAL APPEARANCE BY INJURY LEVEL   High cervical nerves (C1 – C4)

    • This is the level where injuries occur most frequently.
    • The arms, hands, trunk and legs are paralyzed.
    • Patients may not be able to breathe normally, cough, and have impaired bowel and bladder functions.
    • The ability to speak may be impaired.
    • When both arms and legs are affected it is called tetraplegia or quadruplegia.
    • They are dependent on active support for all activities of daily living.
    • Use of a special wheelchair is mandatory.
    • It is impossible for them to drive a vehicle.
    • They must be under 24-hour surveillance.

     

    Lower cervical nerves (C5 – C8)

    • The nerves controlling the arms and hands are affected
    • Breathing and speech may be normal.

    C5 Injury

    • They can use their arms and wrists.
    • There is partial or complete paralysis in the hands, wrists, trunk and legs.
    • Can speak using diaphragm, breathing is weak
    • Depends on active assistance for daily activities, but can move independently with a power wheelchair

    C6 Injury

    • Wrist extension is affected.
    • The hands, trunk, and legs are typically paralyzed.
    • Can speak using diaphragm, breathing is weak.
    • They can move independently with an electric wheelchair.
    • They can use specially equipped vehicles.
    • There is no bladder or bowel control, special equipment is required.

    C7 injury

    • There are wrist and some finger movements.
    • There are shoulder and arm movements.
    • They can meet most of their daily living needs themselves.
    • Can use specially equipped vehicles.
    • There is no bladder or bowel control, special equipment is required.

    C8 injury

    • Can control hand movements.
    • Can hold and release some objects.
    • They can meet most of their daily living needs themselves.
    • Can use specially equipped vehicles.
    • There is no bladder or bowel control, special equipment is required.

     

    Thoracic vertebra injuries Thoracic nerves (Th1 – Th5)

    • The upper half of the chest, abdominal and back muscles are affected.
    • Arm and hand movements are generally normal.
    • Usually the trunk and leg muscles are paralytic (paraplegia).
    • A normal wheelchair is sufficient.
    • They can learn to use modified wheelchair.
    • They can walk using special immobilizers.

     

    Thoracic nerves (Th6 – Th12)

    • Abdominal and back muscles are affected.
    • They are usually paraplegic.
    • Upper body movements are normal.
    • Control and balance of trunk movements in a sitting position are good.
    • If their abdominal muscles are normal, they can cough effectively.
    • There is no bladder or bowel control, special equipment is required.
    • A normal wheelchair is sufficient.
    • They can learn to use modified wheelchair.
    • They can walk using special immobilizers.

     

    Lumbar nerves (L1 L5)

    • The injury usually results in loss of hip and leg movement.
    • There is no bladder or bowel control, special equipment is required.
    • They can walk using special immobilizers.

     

    Sacral nerves (S1 – S5)

    • It usually results in some loss of hip and leg movement.
    • There is no bladder or bowel control, special equipment is required.
    • They can usually walk without assistance.

     

     

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