## 3 Treatments for Spinal Cord Injury
### Epidural Electrical Stimulation (EES)
The stimulator was then connected to the electrode subcutaneously, and the external connection to the temporary stimulator was taken off [24]. All 11 patients in the EES and PT group showed significant signs of improvement in sensory function (\(p<0.01\)) and showed a reduction in muscle plasticity (\(p<0.0001\)). There was evidence of urinary tract function in six out of eleven patients, and from the five patients who experienced neuropathic pain, four experienced reduced pain scores [24]. Though these results show an overall positive outcome from the results, the sample size used may be too small, which limits the validity and generalisability of the findings. The findings also displayed that patients who had less severe injuries responded better to EES, suggesting that EES may be less effective for patients with severe SCI. Additionally, there are surgical risks to the implantation of a medical device, and in this case, the surgical risk is increased with the implantation of an electrode, as well as a stimulator. Due to the device dependency on the pulse-generating stimulator, the battery life of the device is limited to an average of 5 years. Furthermore, a systemic review by [PERSON] et al. explored the efficacy of EES in spinal cord injury rehabilitation. The review included 64 studies with 306 patients who underwent EES [25]. To assess each study, researchers evaluated the locomotor, cardiovascular, pulmonary, and genitourinary functions to determine the impact of EES on neurological recovery. The patients included in each study had chronic SCI; thus, the focus remained on gaining motor and autonomic function improvements. The EES device was implanted onto the dorsal aspect of the lumbosacral spinal cord dura mater, and the electrodes were placed near the lesion site, optimising neuromodulation effects. The device was powered by a pulse generator that was connected to either a subcutaneous or external pulse generator, which allowed for specialised programmable stimulation settings. Within this review, a study by [PERSON] et al. showed that the combination of EES and physical training allowed patients with complete SCI to initiate step-like movements while lying on their side or suspended by a body weight [26]. However, a later study by [PERSON] et al. demonstrated that patients with the same complete spinal cord injury were able to initiate physical positions such as independent standing, different sensorimotor engagement between stepping and standing, as well as bilateral stepping on a treadmill with the addition of EES [27]. [PERSON] et al. reported results from a paraplegic man of 3 years, retaining some sensory function after a 3-month training and EES. Due to this combination, the patients were able to achieve control of some leg movements and full weight bearing with assistance for balance [28]. In addition, a more recent study by [PERSON] et al. was able to make great improvements in the application of EES. This study assessed four patients with complete SCI. Two of these patients reported restoration of walking ability. It was prominent from the study that the ability to walk came from the addition of EES, which illustrates the positive impact EES had on activating intraneuronal lumbosacral spinal networks [29]. This review  
Figure 3: **(a)** X-ray positioning during surgery for a T11-T12 implantation. Image shows a postoperative CT scan in the sagittal, **(b)** a CT scan of the coronal, **(c)** and a CT of the general view. **(d)** MRI scan of the sagittal view performed after the surgery. The red square shows the site of injury in each image, which is the focal point for analysis in this data [24]. discussed various significant advances in the advancement of EES in the rehabilitation of SCI. Future direction in EES requires the establishment of specific parameters for the combination of EES and physical training techniques for optimal results for SCI [25].