Spinal Cord Medicine: Principles and Practice
Authors: Neil Dorward
Journal: Journal of the Royal Society of Medicine (2003)

Spinal cord injury, whether due to trauma, neoplasia or medical conditions, is devastating for the patient, affecting every aspect of physical, social and psychological life. No one who regularly treats such patients can fail to be moved by their struggle to adjust. Since most of the aetiologies are either traumatic or benign, the patient will have a near normal life expectancy if medical complications are avoided. The very existence of Lin's huge textbook testifies to the major advances in spinal cord medicine achieved over the past three decades. This is dramatically illustrated by mortality rates among traumatic paraplegics due to renal complications which stood at 80% for those injured in World War One, fell to 25% during the Korean war and reached very low percentages for the Vietnam conflict. Whereas renal complications formerly prevailed as the cause of death, the main reason for concern in the first six months after injury are now suicide and accidental self-harm. This highlights both the success of medical therapies and the importance of psychological support as an active component of rehabilitation. The manifold physical, medical and psychosocial aspects of spinal cord medicine require the attention of an experienced multidisciplinary team, and in the UK there are several spinal injury units with excellent facilities and experienced dedicated staff. Unfortunately, places are severely restricted and a large proportion of patients with spinal cord injury will never be offered inpatient treatment at such units. For the clinicians struggling to manage spinal cord conditions in a conventional hospital environment Lin's textbook provides an authoritative and contemporary source of knowledge. With seventy-four chapters by 128 authors (most of them from the USA), it proceeds logically from the basic sciences to clinical management including psychosocial issues.

The introductory section includes the anatomy and physiology of the spinal cord, imaging and overviews of epidemiology and outcomes. These chapters are necessary for completeness but are rather general and superficial. The second section on acute management of cord injury deals well with the decision-making process and controversies of surgical decompression and stabilization in spinal cord injury, but naturally does not cover the detail of surgical procedures. The third section entitled ‘Medical Management’ addresses the wide range of medical complications that occur with great regularity in spinal cord injury, dealing with each in turn in good detail. This section includes chapters on frequently overlooked complications such as disordered thermoregulation and the immune system response as well as the commonly appreciated problems of respiratory dysfunction and thromboembolism. Section four deals with bladder, bowel and sexual dysfunction and provides comprehensive advice on all aspects of these difficult management issues. Section five, on the neurological aspects of spinal cord care, is a miscellaneous arrangement of items on physiology, investigations, management of spasticity, various myelopathies and autonomic dysfunction. Whilst some of these provide only an overview others offer in-depth insight into aspects of spinal cord injury that are otherwise not dealt with in detail elsewhere. Section six, on musculoskeletal care, provides an excellent set of chapters about this very important aspect of secondary prevention. Section seven, self-evidently vital, addresses rehabilitation from every angle. Section eight deals with recent advances in spinal cord research, providing analyses of progress in neural regeneration, cord repair and retraining among others. Section nine concerns special topics in spinal cord medicine and incorporates further miscellaneous chapters that demonstrate the comprehensive nature of this text. The final section, on psychosocial issues and support environment, is perhaps the most important and instructive part of the book and is done well.

The breadth, detail and inclusiveness of this text is impressive. Whichever aspect of spinal cord medicine one is faced with, this text will offer management advice and clinical information. In my practice I regularly see patients with spinal cord injury secondary to trauma, neoplasia and inflammatory processes who have to be managed in the neurosurgical unit. With the advice of these experts readily to hand, I shall feel more confident in managing these patients during their lengthy stays.