Evolution of the treatment of spinal cord injury and brain damage

Spinal cord injury (SCI) is one of the most catastrophic events with the most serious repercussions, not only in the personal sphere but also in the health, occupational and economic spheres. Moreover, in most cases it occurs unpredictably, producing a loss of motor and sensory functions that are almost always permanent and irreversible, causing the patient partial or complete paralysis of the limbs, loss of sensibility below the level of the lesion, lack of sphincter control, alterations in the sexual sphere and a risk of serious complications for life.

In Spain, the incidence of traumatic LM is about 20-25 new cases per million inhabitants each year, which means that approximately 1,000-1,500 people suffer a serious spinal cord injury each year that will cause serious neurological sequelae. Of all the injuries that occur, 50% are due to traffic accidents and affect mostly men, with 80% of cases, compared to 20% of women and, regardless of sex, more than half are young people under 30 years of age.

To this number of injuries of traumatic origin must be added a further 30-40% of medical origin (myelitis, tumors, spinal cord infarction, etc.), which increases the number of spinal cord injuries to around 2,000 new cases per year.

Traffic accidents are one of the most important causes of death in the western world, and in Spain they occupy fourth place in incidence, behind cardiovascular diseases, neoplasms and respiratory diseases. They are also the leading cause of death among men under 34 years of age and among women under 24 years of age.

A bit of history

For centuries, attempts have been made to answer the serious consequences of a spinal cord injury, and numerous ancient scientific writings have described different aspects. Among these documents, the famous Edwin Smith papyrus stands out, written 5,000 years ago by an Egyptian physician, where he described, in great detail, the symptoms of a cervical spinal cord injury due to vertebral dislocation or fracture: “complete paralysis of the four extremities, absence of sensitivity, loss of bladder control, priapism and involuntary seminal ejaculations”. He even mentioned the phenomenon of conjunctival congestion, which today is known to be due to vasodilatation due to paralysis of vasomotor control in upper dorsal and cervical lesions. In relation to the treatment and prognosis of the lesion, the author concluded the text with a significant phrase: “an ailment that cannot be treated”.

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This defeatist attitude has persisted for many centuries in the minds of medical professionals. Surgeons during World War I clearly described the tragic fate of the war wounded with medullary injuries: 80% died within the first two weeks. Only incomplete injuries survived. Most of the surviving spinal cord injured led a tragic life, without hope, without work and with multiple complications, cut off from society.

The treatment of spinal cord injury has undergone important changes in the last 60 years, going from a situation of irremediable mortality in more than 80% of the people who suffered a spinal cord injury to the current situation, in which, thanks to medical-surgical advances, the mortality rates of these patients have been reduced, approaching the values of the general population.

It was not until 1943 that the British government commissioned Dr. Sir Ludwig Guttmann, a German neurosurgeon of Jewish confession, to organize the first Spinal Injuries Unit at the Ministry of Pensions Hospital in Stoke Mandeville, Aylesbury, near London, in preparation for World War II, as a large number of wounded were expected.

It was inaugurated on February 1, 1944 with 26 beds, introducing the concept, valid to this day, of providing spinal cord injured, paraplegic and quadriplegic patients with comprehensive care based on complete assistance, from the moment of the onset of the injury until hospital discharge and their reintegration into the community as useful people for society. The main objective was not only to prevent their death due to complications, but also to give them a reason to overcome their disability. In short, the patient had to be treated in a comprehensive manner by a multidisciplinary team taking care not only of the medical aspects, but also of the psychosocial aspects essential for a correct socio-domiciliary reintegration.

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At the end of the war, the Stoke Mandeville Hospital already had 100 beds, and progressively increased the number of hospital beds until today, when it has more than 200 beds for the interdisciplinary care of spinal cord injuries, both traumatic and medical.

From the medical-surgical advances introduced by Dr. Guttmann, many other monographic centers were developed, both in Europe and in Australia and the United States, as well as in other parts of the world.

In the United States, the group of Munro, Comarr, Bors and Talbot undertook the organization of different units for the integral approach to spinal cord injury patients towards the end of the 1940s. Donald Munro, a former neurosurgeon at the Boston Municipal Hospital, made numerous contributions that are still valid today, such as rhizotomy for the treatment of severe spasticity resistant to traditional treatments. The Veteran’s Administration created the first units for the care of spinal cord injuries in the Military Veterans Hospitals. Today, there is a specialized model of care in that country, organized by the UAB-SCI Data Management Service in Alabama, which periodically accredits hospitals specializing in the management and treatment of persons who have suffered paraplegia or quadriplegia.

In Europe, the first units were formed around the 1960s, in Germany, Austria, Belgium, France, Holland, Italy and Switzerland. In our country, the first spinal cord injury hospital was founded in Barcelona on November 27, 1965, by Guillermo González Gilbey, a quadriplegic patient who was treated in his initial phase at Stoke Mandeville. The new hospital in Barcelona was named Institut Guttmann, in honor of Dr. Guttmann, and was set up in a hospital for venereal diseases in very poor condition that had to be rehabilitated to house a freestanding paraplegic center. Its first director was Dr. Miguel Sarrias Domingo, a traumatologist and former disciple of Ludwig Guttmann, and the unit began to operate with 25 beds, until it reached 96 beds, the maximum capacity of the building. Subsequently, in May 2002, the current Institut Guttmann Neurorehabilitation Hospital was inaugurated in Badalona, a hospital with more than 150 beds, half of them dedicated to the care of spinal cord injury patients and the other half to the treatment of the sequelae of both traumatic and non-traumatic brain injury.

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Subsequently, other units were created throughout Spain and a new center in Toledo, the Hospital Nacional de Parapléjicos, with more than 200 beds, opened in 1974. Today, in Spain there are two monographic centers and eleven units specialized in the treatment of LM, integrated in general hospitals, within the Rehabilitation Services.