Spinal Cord Injury Rehab
There are about 40 cases per 1 million people in the US per year. People living with spinal cord injury who are living with the disability are about 219,000 to 279,000 persons. Those with spinal cord injuries have a markedly reduced life expectancy, especially those with neck injuries. Male individuals have a higher rate of spinal cord injury with 4:1 times the incidence when compared to females.
The most common cause of spinal cord injuries is motor vehicle accidents followed by falls, acts of violence, and sports injuries. The most common injury is incomplete tetraplegia followed by complete paraplegia, incomplete paraplegia, and complete tetraplegia. The spinal cord does not have to be cut in order to have a complete injury because circulation deficits, bleeding, and crush injuries can cause complete lesions. The only real acute treatment for spinal cord injuries is to give IV methylprednisolone, which has been found to reduce free radical damage and lipid peroxidation when given shortly after the injury.
Neurological Classification of Spinal Cord Injuries
Doctors determine the neurologic level of injury by doing a careful motor and sensory examination. The level of injury is determined by the last caudal segment with intact motor and sensory innervation. Initial examination occurs at about 72 hours after the injury and should be done with the patient lying down. The injury is incomplete if there is sparing of the sensory or motor function below the neurological level that includes the low segments of the sacrum.
There is a common neurological method of classifying spinal cord injuries known as the ASIA scoring system. It helps determine the level and type of injury to the spinal cord. “According to ASIA scoring, the muscles in a given area must have at least strength against gravity in order to be determined as having adequate nerve supply.
Clinical Syndromes that can result from Spinal Cord Injury
There are about six different clinical syndromes that can come from a spinal cord injury. Each one carries its own prognosis and impacts treatment. These are the syndromes:
- Central cord syndrome. This results from hyper extension of the neck with blood clot formation to the central part of the spinal cord. The upper body muscles are weaker than the lower body muscles.
- Brown Sequard syndrome. This is when half of the spinal cord has been damaged and the other half is intact. This results in weakness, spasticity and light touch deficits on one side of the body with decreased pain and temperature sensation on the opposite side of the body.
- Cauda Equina Syndrome. This results from lesions below the conus medullaris that result in lower motor neuron symptoms, including flaccid lower extremities and loss of bowel and bladder control.
- Conus medullaris Syndrome. The results in lesions at the lower level of the spinal cord and results in bowel and bladder symptoms along with symptoms involving the legs.
- Anterior Spinal Artery Syndrome. This results from an injury to the anterior spinal artery. There is weakness, spasticity, and loss of pain and temperature sensation to the lower body.
- Dorsal Column Syndrome. This is a rare syndrome that occurs when there is a lesion to the back one third of the spinal cord. It causes motor weakness and a loss of posterior column sensory function.
Management Issues in the Acute Phase
The acutely injured patient needs treatment of the whole body. They need an evaluation of the stability of the spinal cord, the neurological exam, musculoskeletal examination, lung evaluation, heart evaluation, abdominal evaluation, skin assessment, and assessment of the urinary tract. The physiatrist can help with these types of examinations. Initial rehabilitation is crucial in preventing later complications and to help the patient have future good health and well-being.
Evaluation of spinal stability involves x-rays and CT scan of the spinal column to identify fractures. The MRI is used to evaluate the patient for injuries to ligaments. Based on the type and extent of the injury, it is determined if the injury requires surgery versus external orthotics to stabilize the spine. After surgery, the patient will require 10-12 weeks for complete healing so an external orthotic device is used to reduce motion in the surgical area. There are collars and vests that can be used to prevent movement of the spine. X-rays can determine when the spine has become stable. Then the patient can be weaned off the brace because the underlying muscles will be weak.
Spasticity is a common complication of spinal cord injury. A reflex hammer can be used to identify this condition. Spasticity can be set off by medical conditions, including a bladder infection, extra bone formation in the muscles, pressure ulcers or a noxious stimulus such as an ingrown toenail.
Assessment of musculoskeletal pain after spinal cord injury is complicated. It must be distinguished from pain related to the nerves. The treatment is different, depending on the type of pain the client has. Musculoskeletal pain is usually set off by activity and varies according to a change in position. Spinal cord injury patients usually describe the neurological pain as being burning, tingling, radiating or a pressure sensation but this can vary from patient to patient. Discrete skeletal pain requires x-ray evaluation for fracture as fractures can be missed in the early stages following the injury.
The most frequent lung problem following spinal cord injury is pneumonia. This is because the spinal cord injury patient has a lesser degree of ability to breathe and to cough. The higher the level of injury, the greater is the problem with pneumonia. Injuries below the T12 level usually don’t have problems with the lungs. Those high cervical lesions often require a ventilator, even if it is temporary. Head injury increases the chance of aspiration and pneumonia. Bedside lung function tests should be done shortly after the injury to see what the lung function is like. Swallowing studies should be done because the spinal cord lesion could have resulted in an increased risk of aspiration.
Early detection of a deep vein thrombosis of the leg can prevent the development of a serious pulmonary embolism. Pulmonary embolism is a common cause of death after a spinal cord injury due to immobility and blood clot formation in the legs. An ultrasound can be done to check for deep vein thrombosis and a D-dimer test usually rules out the possibility of a deep vein thrombosis or pulmonary embolism. A ventilation perfusion scan or CT scan of the chest can check for a pulmonary embolism.
Orthostatic hypotension is common after spinal cord injury because of the loss of the ability of the sympathetic nervous system to produce constriction of the blood vessels after the injury. Things like dehydration can also cause low blood pressure in the patient. Low heart rate is also a common finding after spinal cord injury. This is also because of a lack of sympathetic nervous system function and its action on the heart. Sometimes a pacemaker is required if the low heart rate is severe.
A catheter should be placed in the initial stage of the injury when spinal shock is likely to occur. A kidney ultrasound and x-rays of the kidneys, ureters, and bladder or CT scan can detect injuries to these areas. These tests are often done after the spinal shock has resolved. Studies of the muscles of the bladder and blood flow can help determine the treatment necessary.
Patients with spastic quadriplegia may wish to continue having a catheter in place rather than rely on an attendant to perform intermittent catheterizations to drain the bladder because they will lack the hand function to do it themselves.
Sexual functioning is usually affected by a spinal cord injury, since neve function is responsible for erections and ejaculations. Sixty to ninety percent of men will have reflex erections but they will be short lived. Only with incomplete lesions can the possibility of normal sexual function be possible. Vaginal lubrication will be impaired in women. Electrical stimulation can improve the rate of ejaculations.
During the period of spinal shock immediately after the injury, it is common to have paralytic ileus. This usually resolves within a week. During the first three weeks of hospitalization, the most common gastrointestinal problems are ileus, peptic ulcer disease, and gastritis. Pancreatitis can also occur as a serious complication.
A scheduled bowel program should be established as soon as possible to help maintain regular bowel movements. If the person has spasticity, and a spastic anal sphincter, there is likely a lower motor neuron injury and stool softeners/suppositories will need to be used in order to have bowel movements. Digital stimulation of the rectum may also be necessary. This routine should be done daily or every other day. Manual disimpaction of stool may be necessary in some cases.
People with spinal cord injuries are at risk for pressure sores and shear injuries to the skin, especially over bony prominences. The person should be on a special mattress and should be turned every two hours. The wheelchair must be fitted with a special cushion to prevent buttocks pressure sores. Weight must be shifted every 15-20 minutes.
Spinal Cord Injury with Traumatic Brain Injury
The spinal cord injured patient needs to learn a lot of tasks to keep them healthy. This may not be possible if the individual also has a traumatic brain injury. The traumatic brain injury is often under-diagnosed because the efforts are focused on the spinal cord injury. Often a mild traumatic brain injury isn’t diagnosed until it is found that the patient is unable to learn in the rehabilitation phase. Tests must be done on the person’s memory, problem solving skills, and attention. In addition, cognitive difficulties can exist before the spinal cord injury and can impact rehabilitation.
About 40-50 percent of spinal cord injured patients have some type of cognitive difficulty. Potential causes include a brain injury at the time of the trauma, history of alcohol abuse or other substance abuse, history of learning disability or the use of medications that influence the brain.
A brain injury affects the individual’s ability to learn, attend to issues, and process information. It can also cause emotional and behavioral consequences that can have an impact on rehabilitation. These individuals can have impaired judgment and impaired safety awareness as well as problems with impulse control. Speech therapists can help with cognitive rehabilitation so that the patient can better manage their spinal cord injury.
The prognosis of improvement and functional outcome following a spinal cord injury is complicated and multi-faceted. Tests, such as the MRI exam, electrophysiological tests, have not been shown to be better than a good physical examination in predicting motor recovery. The rate of improvement is another important factor, with most motor recovery occurring in the first 3-6 months after the injury. Incomplete injuries do better when it comes to ambulation and a better prognosis overall when compared to complete injuries.
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