By: Rawad Rayes

2015

When considering the problems that arise after traumatic spinal cord injuries (SCI), the most commonly addressed issues are numbness and tingling in the extremities, focal weakness, or paralysis, but one of the most persistent and difficult to treat co-morbidities is long term clinical depression. Though there are several possible etiologies for clinical depression in SCI patients, some of the most significant examples include chronic pain syndromes (e.g. Fibromyalgia), and various dysfunctions of the autonomic nervous system which may be referred to under the broader term of dysautonomia. As disparate as these examples may seem at first glance, they each play a role in decreasing an SCI patient’s quality of life, and therefore present a challenge for physicians and researchers to address.

Dysautonomia as a result of spine injuries has the potential to affect all organ systems regulated below the site of injury. This commonly causes a variety of problems including dysregulation of blood pressure, dysregulation of pulse, difficulty breathing, and difficulty regulating body heat, all of which are potentially life threatening conditions (Gurka, Wade, Baguley, Nicholls, Felmingham, Crooks (1999). Without innervation and feedback from the brain, the affected organ systems are unable to function in their normal capacities; as a result, patients may experience short term episodes of dangerous deviation from their homeostatic baseline which may require emergent medical intervention, or long term mild-moderate deviations. These deviations, even when not lethal, may still be detrimental to the patient’s physical and mental health due to the chronic chemical stress placed on the body and brain. Researchers have found a statistically significant correlation between depression and dysautonomia in female patients with a history of mild traumatic brain injury (mTBI). (Sung, Lee, Chiang, Chiu, Chu, Ou, Tsai, Lin, Lin, Chen, Li, Wang (2015). Currently there is no cure for Dysautonomia, but treatments typically involve medication to manage symptoms, changes to diet and fluid intake, or in persistent cases may require surgical intervention. 

Chronic pain in SCI patients may be caused by several factors ranging from damage and physical pressure on areas of the nerve, to clinically diagnosed chronic pain syndromes such as Fibromyalgia Syndrome (FMS). FMS though somewhat ill defined and controversial, is commonly defined by the American College of Rheumatology as a syndrome of chronic pain and tenderness to widespread areas of the body, and is diagnosed by the presence of all appropriate symptoms in conjunction with the exclusion of other known possible causes that may present with the same or similar symptoms. SCI patients have been found to have a significantly increased incidence of FMS, with up to 21.6% of cervical spine trauma patients diagnosed with this syndrome, compared to 1.7% among control groups where test subjects did not have a history of spine injury (Buskila, Neumann, Vaisberg, Alkalay, and Wolfe (1997). Chronic pain though difficult to treat, has been successfully managed with a combination of medication, and various cognitive therapies such as neurofeedback.

This finding of a strong relationship between SCI and chronic pain is known to be a significant factor in predicting Clinical Depression in Spinal Cord Injury (SCI) victims. In fact, when SCI patients’ chronic pain is able to be successfully treated or effectively managed, there is a sharp drop in clinical depression as measured by the Center for Epidemiological Studies Depression Scale (CESD) (Cairnes, Adkins, Scott (1996).

Pathologies such as these remind us that though the brain is insulated by bone, the meninges, and the blood brain barrier, it is never isolated. With this in mind, it becomes clear that to effectively treat clinical depression in patients with complex spine injuries, a holistic approach with comprehensive analysis of all contributing factors is required. Current treatments for clinical depression in SCI patients include traditional anti-depressants, treatment of chronic pain, and therapies such as Coping Effectiveness Training which have proven to be successful (Kennedy, Duff, Evans, Beedie (2010). However, much work remains to be done to continue improving the mental health and quality of life of SCI patients. This is of the utmost importance because mood and motivation are known to play a significant role in not only the healing process, but health itself.

References

1. Buskila, D., Neumann, L., Vaisberg, G., Alkalay, D. and Wolfe, F. (1997), Increased rates of fibromyalgia following cervical spine injury. A Controlled study of 161 cases of traumatic injury. Arthritis & Rheumatism, 40: 446–452.

2. Hagen, E. M. (2015). Acute complications of spinal cord injuries. World Journal of Orthopedics, 6(1), 17–23.

3. Joseph A Gurka, Lauren D Wade, Ian J Baguley, Jodie L Nicholls, Kim L Felmingham, Jenelle Crooks (1999). Dysautonomia After Traumatic Brain Injury: a Forgotten Syndrome? Journal of Neurology Neurosurgery & Psychiatry 1999 67: 39-43

4. Douglas M. Cairns, PhD, a, Rodney H. Adkins, PhD, Michael D. Scott, MD (1996). Pain and depression in acute traumatic spinal cord injury: Origins of chronic problematic pain? Archives of Physical Medicine and Rehabilitation. April 1996 Volume 77 Issue 4 P329-335

5. http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia

6. Kennedy, P., Duff, J., Evans, M. and Beedie, A. (2003), Coping effectiveness training reduces depression and anxiety following traumatic spinal cord injuries. British Journal of Clinical Psychology,

7. http://www.ninds.nih.gov/disorders/dysautonomia/dysautonomia.htm

8. Sung, C.-W., Lee, H.-C., Chiang, Y.-H., Chiu, W.-T., Chu, S.-F., Ou, J.-C., Tsai, S.-H., Liao, K.-H., Lin, C.-M., Lin, J.-W., Chen, G.-S., Li, W.-J. and Wang, J.-Y. (2015), Early dysautonomia detected by heart rate variability predicts late depression in female patients following mild traumatic brain injury. Psychophysiology.