Friday, February 23, 1996
When it comes to treating patients who have spinal cord injuries, "unfortunately there are no miracles at this time," said Herndon Murray, MD, assistant medical director at the Shepherd Center in Atlanta. "If the spinal cord tissue is injured, we don't have a whole lot we can do."
Dr. Murray was one of the presenters during Thursday's session "Spinal Cord Injury: Initial Treatment to Community Integration," one of the educational courses for nurses and allied health professionals offered by the National Association of Orthopaedic Nurses and the Academy.
In the emergency department, family members of spinal cord injury patients inevitably ask physicians and nurses two questions: whether the spinal cord is severed, and whether the patient will walk again, Dr. Murray said. "You'll be able to answer both questions in the ER, based on the neurological exam," he said.
Although severed spinal cords are extremely rare, not having a severed cord is no guarantee of rehabilitation, Dr. Murray said. Patients with complete spinal cord injuries - i.e., no sensation or voluntary motor function - have a very poor prognosis for recovery.
"There is normal tissue on both sides of the injury, but when the injury heals, it heals in scar tissue," he said. "It's really hard for patients and families to understand why they won't walk again when the cord is not severed."
The likelihood of recovery is greater if the patient's injury is incomplete. The poorest prognosis is found with anterior cord syndrome, and patients with central cord syndrome have a fair prognosis. The best prognosis is found in patients with Brown-Sequard syndrome, he said.
Dr. Murray raised two red flags about ER treatment of patients with spinal cord injuries. First, watch for these injuries in severely intoxicated and unconscious patients because their injuries may not become apparent until they wake up. In one malpractice case, "the family said the ER staff carried the patient around like a sack of potatoes," he said. "It just went downhill from there."
Also important is preventing thromboembolism. Techniques include using pneumatic hose, subcutaneous heparin and coumadin. "There is no real standard, but you need to do something to prevent it," Dr. Murray said.
Some complications arise in all patients with spinal cord injuries, said David F. Apple Jr., MD, medical director at the Shepherd Center. One of these is compromised bladder function, which initially is treated with catheterization. During rehabilitation, patients can take advantage of a reflex pattern by tapping their abdomens to stimulate urination.
Bowel function is another universal complication. Again, many patients can use digital stimulation of the anal sphincter, or a device, to produce reflex elimination, Dr. Apple said.
Compromised bowel function is the most important quality-of-life issue for patients with spinal cord injuries, said Nancy Gilvin, RN, education coordinator at the Shepherd Center. "Patients say their greatest concern is the inability to control their elimination, so much so that they will socially isolate themselves," she said. "This is a big barrier that must be overcome with these patients."
To do so, Gilvin said, it is important to initiate a bowel management program immediately. Additionally, the program must be one that will be most effective for the patient in his or her own home, not one that meets the short-term needs of hospitalization.
A final universal complication is skin breakdown. "There must be a constant awareness of the skin to prevent bedsores," Dr. Apple said. "The patients need padding at the appropriate pressure points."
Dr. Apple also identified a number of common alterations in spinal cord injury patients:
Deep venous thrombosis and pulmonary embolus. The swelling in patients' legs should be measured to determine their risk, and tests such as venography also may be used. If indicated, anticoagulation therapy should last about 30 days.
Spasticity. This complication usually becomes evident as reflex activity increases in the patient, Dr. Apple said. Appropriate medications include dantrium as well as baclofen administered by a pump.
Heterotopic ossification. This is most common around the hip but also may be found around the shoulder and knee. Other signs include swollen extremities.
Pain. Dr. Apple recommended using non-narcotic agents to control pain in spinal cord injury patients, but "we don't really understand why it occurs or how to treat it well."
Sexual function. Men with spinal cord injuries above L1 lose their erectile function, Dr. Apple said, although they do experience reflex erections. Women with these injuries lose the ability to have an orgasm, but they remain fertile.
Autonomic dysreflexia. This only occurs in patients with injuries above T6, but because of the potential for stroke, it is a very serious complication. "Patients can die if this is unrelieved," he said.
Respiratory problems. Respiratory complications occur especially in patients with injuries at C4 or higher, and they can arise even in patients who are not ventilator-dependent. These complications occur less frequently as the amount of time from the injury increases, Dr. Apple said.
Dr. Apple also cautioned attendees to watch for these less-frequent complications: cardiovascular system alterations, contractures, fever, cysts and fractures.
The etiologies of spinal cord injuries have shown some changes in the last few years, according to Gilvin. Motor vehicle accidents, which once accounted for 50 percent of these injuries, now cause 38 percent. On the other hand, violent acts are now the cause of 25 percent of spinal cord injuries. Falls account for about 20 percent.
To help patients and their families better understand the injuries they have suffered, Gilvin suggested this analogy: "Tell your patients to think of the spinal cord as a utility cable," she said. "Can you fix a broken utility cable? With all those fibers, there is no way to match them up and sew them together."
||1996 Academy News Index|
Last modified 27/September/1996