Spine Stabilization for Acute and Chronic Issues

Posted by Nurse Linda in Life After Paralysis on January 26, 2022 # Health

spinal cord xrayStabilization of the spine is necessary if the boney structure (vertebrae) is affected acutely or over time. The spinal cord is the consistency of a really thick jello jiggler, so it can be damaged quite easily. There are several ways that this can occur through injury or disease. Most commonly, injury to the spinal cord is from overstretching, compression, the vertebrae bones pushing against it or lack of blood flow and oxygen loss. These injuries can result from disease or injury. Very rarely is the spinal cord cut (transected), although this can happen from a gunshot or knife wound. A gunshot wound or blast injury can also send a shock wave through the spinal cord and brain.

When the bones around the spinal cord are out of alignment for any reason, stabilization is necessary for protection to prevent injury or further injury. In an acute injury, this may be done in pediatrics immediately by internal application of orthotics (supports) directly to the vertebral bones, by application of an external halo brace or cast to immobilize the spine, or through use of a TLSO (thoracic lumbar sacral orthotic), that is worn externally. TLSOs can sometimes be called turtle shell or clamshell. Spinal instability from the disease usually comes later as the disease progresses or muscle function changes. External stabilization is typically used at first, but internal stabilization is done in later stages. There are some great advances in internal stabilization that are helpful. Be sure to check out last month's pediatric blog about types of braces and orthotics.

In acute injury to the spine, stabilization is done as soon as the child can tolerate the procedure. This keeps further injury from occurring, such as turning, or anybody's movement can further damage the unstable boney structure around the spine. Even breathing can disrupt the spine even if it is just slight movement. Slight injuries can lead to large issues.

Children in the acute phase of an injury are placed on a backboard with their heads and body secure to ensure further spinal damage is not done. Usually, a towel or small blanket is placed under the child’s body from the shoulders down as a child’s head is large compared to the proportions of adults. The line of the spine is disrupted without the extra body elevation. Even at the scene of an injury involving the spine, it is best not to move the child but to have specially educated emergency professionals do the moving to avoid further injury. It can be very difficult not to move or hold your child but keeping them still and calm is imperative. Your support and closeness will be helpful and comforting to your child.

In chronic conditions, such as with disease, issues with spine stabilization become apparent over time. The muscles of the back can become out of balance on either side, with the muscles of one side of the body pulling more strongly than the other side. This can cause the spine to be pulled to one side or spinal rotation and curvature, as in structural scoliosis. Changes in the anatomical structure of the spinal bones lead to breathing difficulties, reduced functional capabilities, and risk of damage to the spinal cord.

Providing strengthening exercises to the back can correct the issue if caught early. Treatment includes evaluation of your child for a range of motion, strength, function, posture, lung function and pain. To treat changes in spine alignment, exercises to strengthen muscle balance are provided.

If the muscles continue to lead the spine to a more severe position, a brace or orthotic will be used to provide ongoing correction throughout the day. Sometimes the support to the outside of the body will be used at night as well. TLSOs or Thoracic Lumbar Sacral Orthotics typically start under the arm extending to the hip to keep the spine in alignment. They can be plastic molded to the shape of your child’s body or made of cast material.

In both acute and chronic surgery for stabilization of the spine, the surgical procedures are basically the same. In a surgical procedure, screws are placed on both sides of the vertebrae bones above and below the level of concern. A rod is attached to hold the spinal vertebrae in place between the above and below vertebrae. This prevents movement of the vertebrae from damaging the soft tissue of the spinal cord. Growing rods will be used if needed for younger children. These rods can be lengthened in a smaller operation to elongate the rods as needed for growth.

The vertebrae of bones of the spine are small bones that work together to provide movement to the back. This is why you can lean to the side, bend over, as well as balance your body. When the rod is supporting vertebrae in the spine, individual vertebrae movement in the stabilized area is eliminated. It accomplishes the goal of protecting the spinal cord. However, without the incremental movement of each vertebra, the vertebral bone immediately above and below the stabilization will have more work to do for movement. Over time, this can become too much workload for the above or below vertebrae, requiring additional stabilization surgery. Disc degeneration can occur. This is termed adjacent-segment disease. It is something to be aware of in the distant future as your child will have a lot of years ahead of them. Later in life, they could run into issues with those above or below vertebrae requiring additional stabilization surgery. If there is pain or changes in function, an assessment of the stabilization surgery looking for adjacent-segment disease should be considered. This does not happen to everyone.

In acute trauma, hard rod stabilization is necessary. Protection of the spinal cord is critical at this time. In chronic issues of the spinal vertebral bones, the goal is to stabilize the spine before an injury to the spinal cord occurs from instability. There is a new stabilization process for chronic conditions such as scoliosis. Semi-rigid rods have been developed for movement within the stabilization. In this procedure, nails are placed in each vertebra requiring stabilization, with a semi-flexible rod placed along the path. The rods are made of polyetheretherketone, which I describe as a somewhat flexible substance sort of like hard plastic. This allows a bit of movement in the vertebrae, which allows for some of the natural flexing of the body. The semi-rigid rod may need to be changed for a longer rod with growth. Since the screws are already in place, growing surgery has a greatly reduced time and fewer incisions.

The benefit to the semi-rigid rod is some motion is present but not enough to damage the spinal cord. Because the flexible rod is affixed to multiple vertebrae, motion can be allowed up to a certain amount. This does not eliminate the risk of adjacent-segment disease but greatly reduces it. With the hard rods, functional movement can be affected especially in long stabilizations over many vertebrae. With the semi-rigid rods, some movement is accommodated, which translates into more function. Another benefit to the semi-rigid rod is the ability for improved imaging. Metal rods can obscure imaging. The downside is that the semi-rigid rod can rub against the screws, weakening it over time.

In chronic spinal issues, you may have the option of hard or semi-rigid rod options. In the future, the semi-rigid rods will be used for acute injury as studies are being conducted to perfect this technique. Some parents are put off by the number of screws used, but the outcomes are hugely significant for mobility and function. Often in the hard rod procedures, there are quite a few screws used as well.

Today spinal stabilization surgery is performed just for the location or locations needed. There could be separate upper spine and lower spine stabilizations in one operation, depending on what is needed. In the past, spines were stabilized by a rod placed at the base of the skull with the other end attached to the pelvis. This left no movement in the back at all. I have actually seen this procedure performed. We have come such a long way and continue to improve to provide more options for flexibility and function. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

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