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UK faces spinal injury crisis



After over 45 years in the spinal cord injury (SCI) field, Wagih El Masri is well placed to prescribe what’s needed to improve treatment of the condition; especially in Britain, where the Egyptian-born consultant has trained and worked since 1971.

He is former chairman of the British Association of Spinal Cord Injury Specialists (BASCIS), ex-president of the International Spinal Cord Society and has advised the World Health Organisation on SCIs.

Other achievements include fundraising £4.5m to rebuild the Midland Centre for Spinal Injuries, 136 publications and receiving commendations from the House of Lords for his spinal injuries work.

He was also the last doctor trained by Sir Ludwig Guttmann, the legendary pioneer of the Paralympics and spinal injury centres.

When he suggests ways that SCI could be better managed in the UK, therefore, he speaks with genuine authority built up through years of experience; and NHS decision-makers should perhaps take note, amid increasing annual spinal injury numbers.

Given a hypothetical pot of millions by
NR Times to improve the treatment of SCI, his priorities would not only be to pump funds into emerging technologies or
drug development.

In fact, at the very top of his agenda would be to invest in something far more basic – beds.

“Although the incidence of new injuries is small at 10 to 15 per million per year, I estimate that the prevalence of SCI has almost trebled in the last 30 years. Yet there hasn’t been a single bed for spinal injury patients added to the national stock in that time,” he says.

Some 40,000 people in the UK are living with an SCI, according to the Back Up Trust, with 1,000 people newly injured each year.

Wagih El Masri

Globally, between 250,000 and 500,000 people per year injure their spinal cord.
Such numbers have contributed to a creaking system in the UK, El Masri believes.

“Acutely injured patients and those with long-term paralysis who develop medical complications can no longer be admitted to spinal injury centres as quickly as they could in the past as they are almost always full.

“Patients are therefore spending weeks or months in hospitals or trauma centres which, although well geared to keeping patients alive, don’t have the necessary resources to meet the complex needs of these patients.

“They lack the full complement of trained healthcare professionals with the necessary knowledge, expertise and skills. The right equipment, processes and environment required to meet SCI needs and the challenges are also lacking.

“Although few patients die, a significant number develop complications that are preventable by the time they are admitted to a spinal injury centre, which in turn increases hospitalisation levels.”

As El Masri explains, these complications can be wide ranging, given the spinal cord’s role as the highway of traffic between the brain and all bodily systems.

“Damage causes poor communication or absence of communication between the brain and the various systems of the body. This not only leads to paralysis but also causes a multi-system malfunction affecting almost every system of the body.

“Each malfunctioning system adds to disability and remains vulnerable to further complications unless the patient fully recovers. Many of these complications are a risk to life and a potential source of a range of short and long-term problems. They can cause neurological deterioration and prevent neurological recovery.”

In many cases, patients lose the ability to feel pain, making diagnosis challenging for clinicians looking for signs and symptoms they may have been taught at medical school.

To prevent spinal injuries escalating into a multitude of possible complications – and
to maximise recovery from them – El Masri considers ‘active physiological conservative management’ (APCM) as the optimum approach for patients.

From the early hours of the injury, this involves simultaneous scrupulous care of the injured spine and the effects of the injury on the respiratory, cardiovascular, urinary, gastrointestinal, dermatological, sexual and reproductive functions.
Ideally, says El Masri, this is carried out in spinal injury centres where there is a critical mass of expertise and skills to deal with the spectrum of complex issues.

Unlike many hospitals and trauma centres, the spinal injury centres also have the sheer numbers of SCI cases to maintain their expertise and hone their skills.

“With traditional APCM of the injury and
its wide-ranging effects in spinal injury centres, most patients make some degree of neurological recovery and a significant number regain the ability to walk.

“The great majority of those who did not recover to walk, nevertheless recovered enough to be able to live dignified, productive, enjoyable and o en competitive lives free of pain for decades following their discharge from the centres.

“Unfortunately the restricted bed capacity
in the NHS spinal injury centres and the very limited capacity of a safety net for these patients in the private sector have, in my experience, resulted in a vicious circle of problems that have negatively affected both quality and cost of treatment.

“Over the last two decades, we have also witnessed the increasing fragmentation of the service with patients being operated in general hospitals before being transferred to spinal injury centres – or to a rehabilitation centre before reaching a spinal injury 

“This is despite the fact that almost
all complications can be prevented in spinal injury centres and most patients make a good neurological recovery.

“Surprisingly neither the added human cost nor the monetary cost of such fragmentation leading to the deterioration of outcomes has to-date attracted interest or attention.

One criticism of APCM among some rehab professionals is that patients are required
to spend four to six weeks lying down in a ‘recumbent’ state until full spinal cord reflex activity returns. This period is essential, however, according to El Masri.

“Recumbence ensures rest to injured
tissue and prevents hypotension, a drop in vital capacity, drop in oxygen saturation, pneumonia, generalised sepsis from pressure sores or urinary infections, all of which can cause neurological deterioration or prevent neurological recovery. Rest to injured tissues until natural healing is achieved ensures a pain-free, almost fully flexible spine in the short, medium and long term.

“This pain free flexibility of the spine 
is required to achieve the best level of independence in personal care, hygiene and activities of daily living. Other purposes are to minimise the risk of pressure sores when skin perfusion is most vulnerable because of the absence of sympathetic drive.

“Moreover, during the period of spinal shock, nursing procedures such as assisted coughing, pressure relief, intermittent catheterisation, bladder and bowel care and management
of incontinence, can all be carried out more effectively and safely in patients who are recumbent than in those sitting in
a wheelchair.”

A major source of pressure on capacity in
the UK is the growing number of injuries among older people. Looking after the country’s ageing population is one of the biggest challenges facing the NHS today.

Like so many areas of healthcare, spinal injury treatment faces its own battle in adapting to the gradual upward trajectory of life expectancy.

“We are seeing more and more elderly patients sustaining all sorts of falls. Many UK homes have narrow, steep and potentially dangerous staircases, which don’t help.

“Also, as soon as the sun comes out, increasingly active octogenarians decide to clean the gutters or x the roof. Some patients continue to cycle while in their sixties and seventies and are involved in collisions.”

Statistically, males are most at risk of
spinal cord injury at 70+ and also in young adulthood (20-29 years). For females 60+
is a when most injuries occur, as well as in adolescence (15-19).

Studies report male-to-female ratios of
up to 4:1 among adults. The World Health Organisation puts mortality risk at its highest in the first year after injury and remains
high compared to the general population.

People with SCI are two to five times
more likely to die prematurely than
people without.
With such high stakes facing people at the severe end of the scale, the clamour for
the next breakthrough that could restore functions and preserve life is understandably strong.

Yet all too often patients are left disappointed, says El Masri. 
“There are many exciting experiments and research projects aimed at improving the neurological outcome of SCI. These are to be commended and encouraged.

“But evidence of equality or indeed superiority in all relevant outcomes including cost-efficiency of any new treatment over the traditional APCM treatment is essential if real
progress is to be made and resources are
not to be wasted.

“Unfortunately in 46 years of working with the condition, I haven’t seen anything that produces better neurological outcomes than APCM for the majority of the patients.

“It creates a great deal of unhappiness
and frustration for patients when, every 
few months, they read in the media that someone has discovered the next miracle cure for spinal injury. People have gone to other countries for stem cell treatment or access to new equipment, only to come back at best, as well as they were before.

“It’s understandable that people will do whatever it takes, if they are paralysed. 
But solutions that are often experimental
are portrayed as being the answer and the patients are not well versed in the field enough to be able to see them for what
they are.

“Patients in the first few years after their injury are the most vulnerable to this. Patients who are five or six years down the tend to have adjusted and don’t swallow these claims.”

Of course, there is plenty of ground-breaking work underway to encourage spinal injury patients and their families. Nanotechnology, stem cells, sophisticated orthotic devices and brain computer interfaces are just some of the areas that could improve the outlook for SCI cases in future

For now, though, El Masri believes there is no evidence that any SCI interventions deliver equal or superior outcomes to APCM.

“If a patient presents to a spinal injury centre within 48 hours of injury with no flicker
of movement in their legs, but can feel pinpricks in their seating area, they have a 75 per cent chance of walking again with APCM.

“Patients who present with more than a flicker of movement will do even better. The great majority of patients with less neurological sparing on presentation when treated with APCM will improve neurologically but not necessarily walk.

“Unless you can manage every system of the body affected by the spinal cord damage – as well as is done through APCM – such neurological recovery may not occur.”

El Masri’s stoic belief in APCM comes from years of working with the approach and seeing its results, while also witnessing numerous false dawns of supposed cures. Yet, one underlying factor in the UK continues to hinder its ability to affect change in some patients; attitudes towards post-injury surgery.

Patients with intact neurology but a biomechanically unstable spine can bene t from surgical stabilisation of the spine, enabling them to be discharged from hospital within a few days of surgery.

Surgical decompression of the spinal cord is also common.
In the backdrop, there is a widely-held belief that early surgery of patients with traumatic SCI has advantageous outcomes over late surgery.

This has fuelled the assumption that early surgery must also give better outcomes than APCM.
As El Masri noted in a white paper published earlier this year, consequently, most patients with traumatic SCI are surgically managed before transfer to the spinal injury centre.

This is despite limited evidence of the equality or superiority of outcomes, or of cost benefits, over APCM.

He says: “Surgery is necessary in some cases. The majority of the spinal injury centres have the surgical skills in their host hospital. They are able to manage patients who have been surgically treated while ensuring the simultaneous management of the range of effects of cord damage. This prevents complications and maximises
neurological recovery.”

A recent Cochrane review states that “the current evidence is insufficient to enable the author to comment on the bene ts or harms of spinal fixation surgery in patients with traumatic SCI”.

APCM’s results, meanwhile, are irrespective of the mechanism of injury, biomechanical instability or the presence of
cord compression.

El Masri urges more research to test whether the role of early surgery after SCI can match or eclipse the outcomes of APCM, to justify how commonly it is currently being carried out.

“The current standard of care is surgery, perhaps on the back of the emergence
of CT and MRI scans, which enabled us
to see things we couldn’t previously. Clinicians without the experience of the APCM or of its outcomes who see spinal canal encroachment or compression, understandably assume that these things are harmful to neurological function. Over time, the great majority have continued to operate on this assumption, rather than evidenced assertions.

“The assumptions are logical but, if science didn’t challenge logic, we’d be stuck in the 18th Century. By all means, if people who undergo early surgery do better than they were expected to with APCM, then continue, but in my experience, they don’t. We need more evidence to support both options.

“Until we establish what works best for the individual patient, we need a safety network of beds with supportive t-for-purpose resources to manage the patient holistically, humanely and cost effectively. Regardless of which organisations take responsibility for this extra capacity, it must be managed ethically and follow good governance.”

A final item on El Masri’s hypothetical SCI shopping list is funding for more collaborative studies into exactly what happens in the first few hours after injury.

“We also need to know more about why spinal cord tissue does not regenerate, unlike every other tissue of the body,” he says.