This is the second issue of the Informer, a service for claims handlers dealing with complex injury claims. In each issue we will look at areas of complex injury work and bring together analysis, cases, data and tactics useful for handlers working in this fast-changing area.

Spinal injuries

Introduction

Injuries to the spinal cord are, with severe brain injury, perhaps the most serious injuries a human being can experience. The Judicial College Guidelines, for instance, value damages for PSLA for tetraplegia at just about the same as for very severe brain damage.

Every year, according to the World Health Organisation, between 250,000 and 500,000 people suffer a spinal cord injury. The majority are due to road accidents, falls or violence but can also be caused by disease.[1]

The Royal National Orthopaedic Hospital estimates that every eight hours someone in the UK suffers a traumatic spinal cord injury. This equates to between 1,000 and 1,200 cases a year.[2]

An injury to the spinal cord is usually caused by a coincidental injury to the spine or vertebral column itself, whether a fracture or a dislocation, which presses on or pierces the spinal cord causing damage to the axons (nerve fibres). If these are completely severed then no recovery is possible. If the axons are only partially severed then, as time goes on, some recovery of function can occur. The results of a spinal cord injury are loss of motor power, loss of sensation and paralysis of the bowel and bladder.

The spine and spinal cord - structure

The spine is made up of sections of bone called vertebrae. These give the body support and structure and act as a protective cowl for the spinal cord itself. The vertebral sections are grouped together into four distinct parts:

• Cervical (neck)
• Thoracic (middle back)
• Lumbar (lower back)
• Pelvic or Sacral – (base of the spine)

The spinal cord runs through the vertebrae from the brain to the base of the spine. Its primary function is to relay information about what is going on inside and outside the body to and from the brain. It is a part of the central nervous system and is well-protected by the vertebral column and also by three “envelopes” known as meninges which surround the spinal cord and a clear liquid which acts as a shock-absorber and which circulates between the middle and outer meninges.

The spinal cord has 31 pairs of spinal nerves which connect it to the rest of the body: eight cervical, 12 thoracic, five lumbar, five sacral and one coccygeal. Each connects the spinal cord with a specific region of the body:

• Cervical – back of the head, neck, shoulders, arms, hands and diaphragm (seven vertebrae, eight cervical nerves)
• Thoracic – chest and some areas of the abdomen
• Lumbar – lower back, parts of thighs and legs
• Sacral – buttocks, most areas of legs and feet, anal and genital areas.
• Coccygeal - innervate the skin around the coccygeal region including the tailbone.

Spinal cord injuries

A spinal cord injury (SCI) means that there has been a fracture of the bony vertebral column with resultant damage to the spinal cord, causing interruption of the signals between the brain and other parts of the body. This, in turn, causes a loss of sensation and movement in parts of the body, otherwise known as paralysis.

The level of the spine at which the trauma occurs governs the extent of the resulting paralysis. The higher up the spine, the greater the resulting dysfunction. A SCI at the lower end might mean paralysis of the legs whilst a SCI at the neck might cause paralysis from the chest down.

The two forms of paralysis most often encountered when dealing with SCI are paraplegia and tetraplegia/quadriplegia.

Paraplegia is a type of paralysis which affects the ability to move the lower part of the body, where injury has occurred at any one of lower levels in the spine i.e. thoracic (middle of the back); lumbar (lower back) or sacral (bottom of the spine).

Symptoms associated with paraplegia include:

• loss of feeling in the lower half of the body;
• chronic pain;
• phantom pain;
• bladder and bowel trouble;
• difficulty walking and standing;
• weight gain;
• depression;
• sexual difficulties;
• skin breakdowns;
• infections; and
• high blood pressure.

Tetraplegia/Quadriplegia means that the SCI has occurred in the cervical spine at the neck and all four limbs are paralysed. The symptoms which can arise after an injury causing tetraplegia include:

• incontinence
• inability to sense heat or cold or touch
• sexual dysfunction
• pain caused by injury to nerves in your spinal cord
• coughing and shortness of breath
• muscle spasms
• bed sores and other skin lesions caused by spending too much time seated or lying down in the same position
• muscle atrophy due to a lack of activity
• breathing difficulties that may eventually require a ventilator
• difficulty maintaining a healthy heart rate and blood pressure

You might in addition come across cases involving these other less common types of paralysis:

Monoplegia - affecting only one limb.

Paraparesis - partially affecting both legs.

Diplegia - affecting either both arms or both legs.

Hemiplegia - affecting one side of the body e.g. the left arm and left leg.

Secondary conditions and issues

There are many other conditions which are associated with SCI. Some examples follow:

Autonomic Dysreflexia – sudden onset of excessively high blood pressure triggered by something which would normally be addressed through autonomic processes (involuntary reflexes). Due to the spinal cord being compromised these reflexes no longer function properly or at all.

Kidney, bladder and bowel issues – A compromised autonomic system will result in loss of control of bladder/bowel function leading to incontinence. UTI’s can also be a problem. If left untreated these can be dangerous.

Pressure ulcers and skin care – One consequence of paralysis is that the claimant is unable adjust his or her bodily position when seated or lying down. The resulting prolonged pressure  on one point can lead to pressure sores which, if not treated, can lead to infection.

Spasticity – the loss of regulation of muscle tension can lead to inappropriate spasm or contraction causing pain and/or involuntary movement.

Syringomyelia – a disorder in which a fluid-filled cyst (syrinx) forms within the spinal cord. This can enlarge and cause additional damage to the spinal cord, worsen the existing paralysis and pose a continuing risk which could cause problems many years later.

Other related conditions/problems

Physical

Deep Vein Thrombosis

Hypotension (low blood pressure)

Orthopaedic, e.g. heterotropic ossification, which is the presence of bone in soft tissue where bone does not normally exist and osteoporosis, a condition leading to fragile bones susceptible to fracture because the creation of new bone does not keep up with the loss of the old.

Pulmonary embolism – a blood vessel in the lungs blocked by a blood clot

Inactivity – leading to obesity with associated cardio-vascular problems and diabetes

Mental

Adjustment disorders - stress, hopelessness, loss of appetite and depression which could give rise to suicidal ideation and/or substance abuse.

All of these factors mean that someone with a spinal injury could end up with a higher mortality risk and a reduced life expectancy.

Levels of spinal injury

The location of the injury in the spinal column/cord is significant. Generally, the higher up the spine the injury occurs, the greater the resulting dysfunction.

C1 to C4 - tetraplegia

This is the most severe of the spinal cord injury levels. The injured person has paralysis in their arms, hands, trunk and legs, they may not be able to breathe unassisted, cough, or control bowel or bladder movements. The ability to speak is sometimes impaired or reduced and they require complete assistance with all activities of daily living (ADLs) They may be able to use powered wheelchairs with special controls to move around on their own.

C5 injury

The injured person can raise their arms and bend their elbows. They are likely to have partial or total paralysis of the wrists, hands, trunk and legs. They can speak and use the diaphragm, but their breathing will be weakened. They need assistance with most ADLs, but once in a powered wheelchair they can move from one place to another independently.

C6 injury

This affects the nerves which control wrist extension. The injured person is typically paralysed in the hands, trunk and legs. They can speak and use diaphragm, but their breathing will be weakened. They will have little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment.

C7 injury

This affects the nerves which control elbow extension and some finger extension. Most injured people can straighten their arm and have normal movement of their shoulders. They can carry out some ADLs but will need assistance and may also be able to drive an adapted vehicle. They will have little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment.

C8 injury

The nerves which control some hand movement are affected, but the  injured person should be able to grasp and release objects. They can carry out some ADLs but will need assistance and may also be able to drive an adapted vehicle. They will have little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment.

T1 to T5 - paraplegia

The corresponding nerves affect the upper chest, mid-back and abdominal muscles. Arm and hand function is usually normal, they will most likely use a manual wheelchair and can learn to drive a modified car. They can use in a standing frame, while others may walk with braces.

T6 to T12

The corresponding nerves affect muscles of the trunk (abdominal and back muscles) depending on the level of injury. An injury here usually results in paraplegia but there is  normal upper-body movement. The injured person has fair to good ability to control and balance trunk while in the seated position and should be able to cough productively (if abdominal muscles are intact). They will have little or no voluntary control of bowel or bladder but can manage on their own with special equipment, most likely use a manual wheelchair and can learn to drive a modified car. Some can stand in a standing frame, while others may walk with braces.

L1 to L5

Injuries here generally result in some loss of function in the hips and legs. There is little or no voluntary control of bowel or bladder, but they can manage on their own with special equipment. Depending on strength in the legs, the injured person may need a wheelchair and may also walk with braces.

S1 to S5

As L1 to L5 above but the injured person will most likely be able to walk.

Complete and incomplete injuries

A “complete” SCI means that the spinal cord has been severed at the injury site, meaning brain signals cannot get through. In an “incomplete” injury the cord has been partly severed, leaving residual neural pathways.

There are several types of incomplete injury:

Anterior Cord Syndrome

Usually caused by the fractured vertebra crushing the front of the spinal cord, this causes damage to the nerve pathways at the front of the cord resulting in full paralysis with the loss of hot and cold or pain sensation.

Brown-Sequard Syndrome

This is caused when one half of the spinal cord is damaged more than the other. One side of the vertebra could have unilaterally dislocated or it could be because of a stabbing injury in which one side of the cord is damaged. That side of the body is paralysed along with a loss of light touch and joint position sense. However the paralysed leg will still feel sharp or blunt, hot or cold as these signals travel to the brain on the opposite side of the cord.

Cauda Equina Syndrome

Dislocation of the L1 vertebra will damage the peripheral nerves from L1 to S4/5 and so the legs are paralysed. This also affects the operation of the bladder and rectum. This may be complete or incomplete.

Central Cord Syndrome

Degenerative narrowing of the spinal canal due to bone growth means that minor injuries e.g. hyper-extension of the neck, can cause significant damage to the spinal cord.

Conus Medullaris Syndrome

A fracture at T11/T12 causing damage to the spinal cord at the 5^th lumbar nerve. This means that cord below the injury level has its reflexes but the legs remain paralysed as the peripheral nerves at L1/L2 are damaged so the muscles receive no impulses from the spinal cord.

Posterior Cord Syndrome

This is a rare incomplete condition usually caused by a tumour or lack of blood supply which damages the posterior nerve pathways. There is retention of good muscular power but the injured person cannot feel light touch or vibration and neither do they have joint position sense. There is a difficulty in controlling movement as, for example, he or she cannot feel the ground beneath their feet or how hard to grip a delicate object.

SCI - what’s next?

There is yet no cure for a SCI but there have been advances in its treatment and in how to cope with its effects.

Exo-skeletons

One of the more eye-catching developments in recent years has been the exo-skeleton by the use of which some ability to mobilise on foot can be regained by those suffering from a SCI. Exo-skeletons have been defined as a “device containing electric motors at both hip and both knee joints, which in conjunction with ankle-foot orthoses, provides appropriate joint kinematics for legged locomotion.”

There are pros and cons to exo-skeletons. Their supporters say that they are a useful rehab tool, they improve the inured person’s independence and improve physical activity and quality of life with knock-on benefits for the injured person’s mental health.

Against this, their detractors say that exo-skeletons are still very expensive when compared to other forms of mobility aid and that their usability is, in any event, limited. These things are very slow and heavy. Most have a walking speed of less than 0.2 metres/second. Some are able to move at 0.7 m/s when used by someone with incomplete SCI, but there is only one exo-skeleton designed for people with complete SCI and this has a top speed of only 0.1 m/s. They take time to put on and take off, sometimes half an hour. Their limitations are not well enough understood leading to unrealistic expectations of their efficacy.

Other advances

According to the US Department of Health/National Institutes of Health website, depending on the extent of damage to the spinal tissue, partial or almost complete recovery may occur for some people from a week to six months after an injury. The major developments have been in rehab and improvements in quality of life and research is continuing into the “four principals” of spinal cord repair:

• Protecting surviving nerve cells from further damage;
• Replacing damaged nerve cells;
• Stimulating the regrowth of axons and targeting their connections appropriately; and
• Retraining neural circuits to restore body functions.[3]

Two research areas in particular have attracted attention:

Targeted Epidural Spinal Stimulation (TESS)

TESS uses residual spinal cord function to recover patients’ ability to transmit and receive signals up and down the spinal cord, through the electrical stimulation of the spinal cord using a neuromodulator. TESS has been found to also promote a degree of new cell and fibre growth in some cases.

The recovery of function has been limited in nature.  Multiple patients have recovered the ability to weight bear.  Some patients have recovered the ability to walk but only over short distances, with the assistance to support their weight and in a clinical environment.  In addition, in many instances the neuromodulator has to be active in order to achieve those ends, which can give rise to a degree of pain for the patient and may mean that recovered function will only be transient.

The long term effects of TESS are currently unknown and there is also not yet a clear understanding of which SCI patients will likely benefit from TESS, early trials covering patients with injuries more than two years old and giving rise to differing levels of paralysis.  The impact of TESS on anatomical functions linked to ancillary health concerns arising out of SCIs (and with that life expectancy) is also currently unclear.

There are a number of barriers to the rolling out of TESS into clinical practice.  Those include developing the technology to a point where it can be put into mass production; reaching defined patient selection and treatment pathways; compiling appropriate Standard Care Guidance; and obtaining regulatory approval of both the technology and the treatment.  The treatment also needs to reach a point whereby the benefits from the treatment and the resultant savings in terms of clinical costs are sufficient to offset the cost of the treatment in economic terms.

There is uncertainty around if and when the treatment is likely to be adopted into clinical practice but in all likelihood it will be another 10 years before the technology is available and at least another 10 years beyond that before it becomes commonplace. 

There is further uncertainty around the cost of the treatment but we envisage a start-up cost of at least £20,000 with follow-up treatment of at least £250,000 to £500,000, possibility higher in the early stages and with associated maintenance costs after the treatment has been delivered. 

Stem Cell Transplanting (SCT)

SCT is similarly in the relatively early stages of development.  It centres around the harvesting and multiplying of stems cells that are then re-introduced into the body at the site of spinal cord injuries, with the aim of promoting nerve cell regeneration at the site of the SCI, thereby bringing about a degree of recovered motor function and/or sensation.  Again, a number of competing research groups have undertaken a number of different trials, which have led to varied degrees of success and some instances of recovered function, albeit again on a modest scale. 

As with TESS, research around SCT remains ongoing, the long term impact of the treatment remains unknown and there are challenges to overcome before the treatment will be even close to being rolled out into wide spread clinical practice (around immunosuppression requirements in particular).  Whilst Japan has licenced the commercial use of the treatment it is likely to be many more years before there is wider uptake, with the likely costs of the treatment being similarly opaque but probably not dissimilar to that associated with TESS. 

Example quantum cases

Tetraplegia

LR (As Administrator of the Estate of DR, Deceased) v (1) LS (2) Advantage Insurance Co Ltd (2021)(Out of court settlement)

DR had been rendered C4 tetraplegic in a RTA in December 2015. He had been a passenger in a car, driven by a friend whom DR knew to have been drunk. In addition he was not wearing a seatbelt. Settlement had originally been reached in July 2020 on the basis of a 72.5/27.5 split in DR’s favour for £10.25m. DR died two days after the settlement had been reached and before any payment had been made. Issues arose as to potential frustration and misrepresentation. DR’s representatives agreed to accept £4m taking into account the litigation risk.

DR suffered C4 tetraplegia and associated conditions including a neurogenic bladder, autonomic dysreflexia, poikilothermia (inability to maintain a constant core temperature) and a high risk of developing syringomyelia. He was reliant on 24/7 care and needed special accommodation.

On a full liability basis the damages are reported as follows:

Pankhurst v White (2009) (Court award)

The 48 year-old claimant (P) suffered catastrophic spinal injuries in a road accident with a C4 quadriplegia and fractures to four further cervical and five thoracic discs. He also suffered rib fractures, haemopneumothorax (presence of blood and air in the chest cavity) and a hypoxic brain injury. As a result of his quadriplegia he was wheelchair dependent, suffered from double incontinence, needed extensive care, could not feed himself and had problems swallowing. He had, however, made an excellent recovery from his brain injury.

He was awarded £225,000 for PSLA, worth around £335,000 today. There are no further details on quantum in the report.

Paraplegia

Kotula v EDF Energy Networks (EPN) plc [2011] EWHC 1546

The claimant, 24 at the date of the accident, had suffered a spinal cord injury in a road traffic accident whilst wheeling his bicycle through road works left in a dangerous condition by the defendant. He suffered permanent paralysis affecting both legs and a left brachial plexus injury leading to a reduction in power in his left arm. The claimant was in hospital for seven months. He was dependent on a wheelchair for mobility and was unlikely ever to be able to walk. It was accepted that K had a risk of suffering post-traumatic syringomyelia, the development of a syrinx, within the spinal cord as a future complication of the spinal injury.

The settlement provided for a lump sum payment of £2.5m with a PPO linked to ASHE 6115 as follows:

(i) £30,000.00 pa until the Claimant’s 45th birthday

(ii) £40,000.00 pa from 45 to 55

(iii) £60,000.00 pa from 55 to 65

(iv) £85,000.00 pa from aged 65.

Periodical payments were also agreed for future loss of earnings at the rate of £16,000.00 pa until the age of 65.

There was a dispute between the parties about whether the risk that the claimant would go onto develop a syringomelia was more than “fanciful”. The court ruled that it was impossible to say that it was and this was the risk that Parliament had in mind when permitting damages awards to be made on a provisional basis. In the circumstances the claimant was entitled to treat the lump sum as provisional and would also have the right to seek to vary the PPO if he developed serious consequences as a result of syringomelia.

Joseph Smith v St Regis Paper Co Ltd (2011) (Out of court settlement - approved)

The 32 year-old claimant (S) was crushed by the hydraulic mechanism of a milling machine. He suffered catastrophic injuries to his spine and lower body, leaving him T4/L5 paraplegic. He suffered a traumatic amputation of his right leg at the hip, a tear of the inferior vena cava, transaction of the aorta, bowel, urethra and rectus abdominus and psoas muscles, comminuted fractures of the left acetabulum and liver contusions. He also suffered widespread muscle necrosis and endocarditis. He required extensive reconstructive surgery and spent 11 months in hospital. Whilst there he suffered a brachial plexus injury as a result of the extended nursing position.

S was left with permanent paraplegia and consequent wheelchair dependency. He lost bowel and bladder function, required self-catheterisation and colostomy, lost all sexual function and suffered severely debilitating phantom limb pain. He required daily professional nursing care, specialist physiotherapy and aids and equipment. He needed permanent full-time care and his life expectancy was reduced by 11 years. He had no future earning capacity.

He received a lump sum of £2.1m with a PPO of £35,000/year to age 50, £65,000/year to age 55, £80,000/year to age 60 and £120,000/year for the rest of his life.

Jonathan Makin v Constantina Panagi (2011) (Out of court settlement)

The 20 year-old claimant was injured in a road accident, suffering fracture of T3 causing paraplegia, with multiple other fractures of thoracic and cervical spine and a broken clavicle. He was an incomplete paraplegic. This condition was permanent. He would probably suffer a deterioration of the shoulders and his clavicle injury would have an effect on transfers which meant he would need increased care from age 50. His life expectancy was reduced by four years.

M underwent surgical stabilisation of the fractures two weeks post-accident. He developed infection around the implants and the following year developed a chronic discharging sinus. The infection caused general malaise and lethargy with pain in the neck and shoulders. He underwent surgical removal of the implants at 22 months post-accident after which his condition improved.

He received a lump sum payment of £2,215,752 (worth £2,981,551 now). PSLA was assessed at £170,000 (£228,754). In addition a PPO was agreed in respect of care costs and case management: £25,000/year to age 50 and £50,000/year thereafter indexed to ASHE 6115 80^th percentile.

David Tolley v Claire Carr and others (2010) (Court award)

The 48 year-old claimant was injured in a road accident when two cars hit him. He suffered a fractured spine at T7/T8 causing an incomplete spinal cord injury which left him with permanent paralysis of his lower limbs. He also suffered multiple other fractures including other spinal.

He was an incomplete T7 paraplegic, who was able to stand but unable to walk any distance and needed to use a wheelchair for mobility. He had extreme neuropathic pain and hypersensitivity below the injury level. He was at risk of developing a syrinx but with yearly reviews of MRI scans and clinical reviews the risk would be reduced. He was at risk of needing shoulder surgery and his life expectancy was reduced by five years as a result.

He could not return to his job as an engineer or to any other work. His care needs would increase, probably from around age 55 and he would need live in support by the time he was 70.

He was awarded a lump sum of £3m (worth £4,262,542 now) including PSLA of £170,000 (£241,542).

If you wish to discuss this further, please feel free to get in contact with our Complex Injury Team at DAC Beachcroft Claims Limited.

[1] https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury

[2] https://www.rnoh.nhs.uk/application/files/2415/7235/8259/traumatic_vs_non-traumatic.pdf

[3] https://www.nichd.nih.gov/health/topics/spinalinjury/more_information/other-faqs