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Originally Processed With FOIA(s): FOIA Number: S S FOIA MARKER This is not a textual record. This is used as an administrative marker by the George Bush Presidential Library Staff. Record Group/Collection: Donated Historical Materials Collection/Office of Origin: Frieden, Lex, Collection Series: Printed Materials Subseries: Papers/Books OA/ID Number: 52111 Folder ID Number: 52111-006 Folder Title: "Comprehensive Management of Spinal Cord Injury" [1982] Stack: Row: Section: Shelf: Position: CLINICAL SYMPOSIA CIBA Volume 34 Number 2 1982 Reprint Comprehensive Management of Spinal Cord Injury William H. Donovan, MD Sir George Bedbrook, OBE, FRACS © CIBA CLINICAL SYMPOSIA CIBA VOLUME 34 NUMBER 2 1982 Comprehensive Management of Spinal Cord Injury William H. Donovan, MD Sir George Bedbrook, OBE, FRACS Illustrated by Frank H. Netter, MD Edited by Barbara Bekiesz Rescue 2 Immediate Care 4 Spine 4 Cardiovascular 16 Respiratory 16 Gastrointestinal 18 Genitourinary 18 Skin 19 Posture 19 Physical and Occupational Therapy 19 Psychosocial Counseling 19 Rehabilitation 21 Spine 21 Cardiovascular 23 Respiratory 26 Gastrointestinal 26 Genitourinary 27 Skin 29 Musculoskeletal 30 Physical and Occupational Therapy 33 Psychosocial Counseling 33 Sexual Readjustment 33 Follow-up Care 35 Prevention of Injury 36 Alister Brass, MD, Directing Editor Mary E. McKinsey, Editorial Manager CLINICAL SYMPOSIA is published solely for the medical profession by CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation, Summit, New Jersey 07901. Address all correspondence to Medical Education Division, CIBA Pharmaceutical Company, 14 Henderson Drive, West Caldwell, New Jersey 07006. ©COPYRIGHT 1982 CIBA PHARMACEUTICAL COMPANY, DIVISION OF CIBA-GEIGY CORPORATION. ALL RIGHTS RESERVED. PRINTED IN U.S.A. Comprehensive Management of Spinal Cord Injury WILLIAM H. DONOVAN, MD Associate Professor of Rehabilitation Medicine Co-Director, Regional Spinal Cord Injury Center The Institute for Rehabilitation and Research Houston, Texas SIR GEORGE BEDBROOK, OBE, FRACS Emeritus Chairman, Department of Orthopaedic Surgery Founding Director, Spinal Cord Injury Center Royal Perth (Rehabilitation) Hospital Perth, Western Australia In the past 25 to 30 years, the medical profes- or no rehabilitation cannot necessarily be sion has become increasingly aware that spinal applied to patients with motor and sensory cord injury must be managed somewhat differ- impairment. ently from other injuries and illnesses. Spinal To date there is no cure for spinal cord cord trauma requires management of not only damage. Once paralysis and anesthesia occur, the vertebral injury but also the dysfunction of the degree of recovery depends mainly on three other organ systems caused by the cord pathol- factors: the extent of the pathologic changes ogy. The latter "secondary" problems often have induced by the trauma; the prevention of further more effect on morbidity and mortality than trauma during rescue; and the prevention of does the spinal cord injury itself. complications that could further compromise the A few individuals, particularly Dr. Donald function of neural tissue, particularly hypoxia Munro, Sir Ludwig Guttmann and Dr. Ernest and hypotension from any cause. Since medical Bors, have recognized the need for a comprehen- and surgical intervention cannot reverse the first, sive, multidisciplinary approach to the manage- most critical factor, the remaining two become ment of patients with spinal cord injury, and more significant. have emphasized the importance of caring for these patients in a spinal cord center that is RESCUE prepared to cope with all their special needs. The combination of back or neck pain and General recognition of the importance of the loss of sensation or motor control, or both, in an multidisciplinary approach, however, remains injured person must alert all rescuers to the like- too limited, and many patients are still cared for lihood of a spinal cord injury. If the pain is in community hospitals, which do not have the severe, even though there is no neurologic defi- resources for specialized care. cit, the trauma victim should be regarded as The concept of comprehensive care applies to having a spinal cord injury until it has been injuries involving the spinal cord, as opposed to proved otherwise. trauma to the bones, ligaments and musculature While evacuating the injured person (Plate 1), of the neck and back that causes no neurologic rescuers must make every effort to prevent all impairment or impairment of only segmental or active and passive movement of his spine. After peripheral nerves. Methods of management insuring that ventilation and circulation are devised for patients who are ambulatory, who do adequate, they should logroll the victim onto his not have neurologic impairment or problems back and place the extremities in the anatomic with other organ systems, and who require little position if no resistance is met, or "splint them 2 CLINICAL SYMPOSIA Plate 1 Suspected Spinal Injury: Management at Accident Site Three-man lift: useful if limited help available for placing patient on board or carrying patient short distances. Head, trunk and legs must be aligned in straight line, and head must be supported from under- neath and laterally Prolo cervical stabilization traction board applied in sitting position before removing patient from car Patient's head held securely between attendant's elbows; shoulders supported by attendant's hands during lift. Cervical collar applied before lift © CIBA VOLUME 34, NUMBER 2 3 where they lie" if the extremities resist move- should be seen by a neurosurgeon or orthope- ment. If the victim's neck is injured, his head dist, or both; a urologist; and a chest physician or should be maintained in a midline position (see cardiologist.) CLINICAL SYMPOSIA, Volume 31, Number 1, 1980, "Acute Cervical Spine Injuries"). The natural IMMEDIATE CARE hollows of the cervical and lumbar lordoses On the patient's arrival at a trauma center, should be supported using towels or clothing, immediate assessment of his respiratory status, without hyperextending or flexing the spine. circulatory status and level of consciousness is Before removing a victim from an automobile or necessary to determine the need for support a pile of rubble, rescuers should strap him to a treatment such as ventilatory assistance after board or prepared splint placed behind or under intubation, cardiac monitoring, vasoactive drugs his back and neck. or use of a transvenous pacemaker. When the In some instances it may be necessary to move respiratory and circulatory systems are deter- a person with a suspected spinal cord injury mined stable, the spinal cord injury and function without a board to support the neck and back, of all other systems are assessed. for example, when rescuing him from a diving or surfing accident or from a confined area where Spine there is danger of fire or a cave-in. The victim Assessment. An experienced clinician should can still be moved relatively safely, however, if conduct a detailed neurologic examination of the he is lifted by three or four people, as shown in patient, recording the precise level of sensory Plate 1. If resuscitation is necessary, rescuers and motor injury using standard dermatome and may have to extend the injured neck to ventilate myotome references (Plates 2, 3 and 4). He the lungs or press on an injured chest and spine should ascertain whether any sensory or motor to support the circulation, or both, but once the function is preserved below this level, including threat to life is removed, normal precautions for sensory function in the sacral area, i.e., sensation handling an injured spine must be resumed. to sharpness and light touch in the perineum and The injured person must be transported by proprioception during rectal examination, and the most expedient means possible to the near- motor control of the sphincter ani. All deep est medical facility, where medical personnel tendon reflexes and superficial reflexes should should insure the adequacy of the patient's air- be checked, including those of the superficial way, administer oxygen, start an intravenous abdominal, the cremasteric, the plantar (Babin- infusion, and perform any other lifesaving mea- ski response) and the bulbocavernosus reflex. sures, such as inserting an intrathoracic tube if The spine should also be carefully examined pneumothorax or hemothorax is present. They for tenderness and gaps between the spinous should not attempt to "replace volume" or "treat, processes. shock" unless blood loss has occurred. Fluid When the neurologic level for all functions overload must be avoided. A blood pressure of has been established clinically, x-ray examination 100/60 mm Hg is to be expected after quadriple- of the vertebral areas involved should be gia. Vital signs should be monitored every 5 done. The same rules for positioning the patient minutes until the patient is stable. during rescue apply in positioning him on the Unless taken to a fully equipped trauma facil- x-ray table; if necessary, sandbags used to stabi- ity, the patient should remain at the facility lize the head may be removed and the patient's administering emergency care only long enough neck placed in a Glisson sling. Radiographic for the respiratory and cardiovascular systems to examination of cervical injuries must include be stabilized, for insertion of a nasogastric tube, good views of the first two vertebrae and the and for placement of an indwelling catheter cervicothoracic junction. Oblique films, in addi- connected to a closed system for urinary drain- tion to the conventional anteroposterior (AP) age. Only the laboratory work necessary to meet and lateral cervical views, are needed for visual- the patient's immediate clinical needs should be ization of the facets or neural arch joints. It is not done. The patient should then be transferred for necessary to turn the patient to obtain these immediate care to a hospital with 24-hour emer- views. A lateral film with the arm closest to the gency and intensive care facilities capable of tube fully abducted alongside the head ("swim- handling trauma victims, preferably one that is mer's view") may be required in some cases closely affiliated with a spinal cord injury center when C7 is not well visualized on the lateral film. where he also can be rehabilitated. (When the To rule out associated injuries to the trunk or patient cannot be transferred early to a center, he limbs, standard views should be taken of the 4 CLINICAL SYMPOSIA Plate 2 Sensory Impairment Related to Level of Spinal Cord Injury Key indicators Dermal segmentation C2 Cervical segments C3 C5-Anterolateral shoulder C6-Thumb C4 C5 C7-Middle finger T1 C8-Little finger T2 T3 Thoracic segments T4 T1-Medial arm C6 T5 T3-3rd, 4th interspace T6 T4-Nipple line, T7 4th, 5th interspace T8 T6-Xiphoid process C8 T9 T1 T10-Navel T10 T12-Pubis T11 Lumbar segments T12 L1 C6 L2-Medial thigh C8 L3-Medial knee S2 C7 S L4-Medial ankle 3 Great toe L2 L5-Dorsum of foot T12 L3 L1 Sacral segments L2 L3 S1-Lateral foot L4 L5 S2-Posteromedial thigh S1 S3, 4, 5-Perianal area L4 S3 S2 S4 5 L5 S2 S1 L L4 L5 2 L 3 S1 L5 Netter CIBA VOLUME 34, NUMBER 2 5 Plate 3 Motor Impairment Related to Level of Spinal Cord Injury Function Muscles Segments Inspiration Diaphragm C3, 4, 5 Biceps brachii Elbow flexors Brachialis C5, 6 Wrist extensors Extensor carpi radialis longus and brevis C6, 7 Elbow extensor Triceps brachii C7, 8 Interossei Hand intrinsics Thenar group C8, T1 Hip adductors Adductor longus and brevis L2, 3 Knee extensors Quadriceps L3, 4 Ankle dorsiflexors Tibialis anterior L4, 5 Great toe extensor Extensor hallucis L5, S1 longus Ankle Gastrocnemius S1, 2 plantarflexors Soleus Sphincter ani Anal sphincter externus S2,3,4 Netter CIBA G Beevor's sign If patient actively flexes neck, abdominal muscles reflexly contract. If lower abdominal musculature (below T9) is relatively weaker than upper abdominal musculature, navel moves up (positive Beevor's sign) If upper abdominal musculature is and lower abdominal musculature is then Beevor's sign is Normal Normal Negative Normal Weak or nonfunctioning Positive Weak Nonfunctioning Positive Nonfunctioning Nonfunctioning Negative 6 CLINICAL SYMPOSIA Plate 4 Motor Impairment Related to Level of Spinal Cord Injury (continued) Cervical Injuries If these muscles are and these muscles are and these muscles are then the motor level normal weak nonfunctioning is Diaphragm C1 or C2 Diaphragm Elbow flexors C3 or C4 Diaphragm Elbow flexors Wrist extensors C5 Elbow flexors Wrist extensors Elbow extensor C6 Wrist extensors Elbow extensor Hand intrinsics C7 Elbow extensor Hand intrinsics C8 Hand intrinsics T1 or below Dorsolumbar Injuries If these muscles are and these muscles are and these muscles are then the motor level normal weak nonfunctioning is Hip adductors L1 or above Hip adductors Knee extensors L2 Hip adductors Knee extensors Ankle dorsiflexors L3 Knee extensors Ankle dorsiflexors Great toe extensor L4 Ankle dorsiflexors Great toe extensor Ankle plantarflexors L5 Great toe extensor Ankle plantarflexors Anal sphincter S1 Ankle plantarflexors Anal sphincter S2 Anal sphincter Not applicable All muscles shown except diaphragm and sphincter ani are innervated by two segments, or roots (left-hand page). Strength is normal if each muscle's two segments are functional. If only one segment is functional, muscle is weak. If neither segment is functioning, muscle is paralyzed. Motor level is determined by knowing status of muscles on same horizontal line; e.g., if elbow flexors (C5, 6) are normal, wrist extensors Netter © CIBA (C6, 7) are weak, and elbow extensors (C7, 8) are paralyzed, motor level is C6 VOLUME 34, NUMBER 2 7 unaffected areas of the spine (and of the extremi- comparing surgical and conservative treatment ties when indicated). Routine films of the pelvis in randomly selected patients has not been done. and the spine below the level of injury alert the Physicians who advocate surgery believe clinician to hidden fractures in anesthetic areas. operation is necessary (1) to restore alignment to Routine films of areas above the injury reveal as near an anatomically correct position as possi- any congenital anomalies or less obvious injuries ble, (2) to decompress neural tissue, (3) to stabi- that could explain a "rise in neurologic level." lize the spine by fusion and, in some cases, During the first 24 to 48 hours after injury, the instrumentation, and (4) to allow mobilization dysfunction may "ascend" one or two levels, earlier than would be possible with spontaneous perhaps as a result of vascular changes in and healing of the fractured vertebrae. This earlier around the zone of injury. This function usually mobilization is believed to shorten the period of returns over time if only conservative treatment rehabilitation and hospitalization. is carried out. The dysfunction noted immedi- Those who advocate conservative manage- ately after injury, however, may or may not ment counter with the following: return, depending entirely on the extent of tissue 1. In many cases, reduction and satisfactory destruction, precautions taken during rescue, alignment can be attained by traction and pos- and prevention of complications. Loss of func- turing or by manipulation under general anes- tion higher than two segments above the level of thesia within the first 24 to 48 hours post injury. injury or the appearance of a second level of cord 2. There is no need to remove fragments of dysfunction usually indicates that the cord has bone or disc from within the neural canal after been injured at two locations. cord trauma, since it has never been demon- Tomograms at the level of the injury should strated that they cause further injury or retard probably be obtained in all patients at a time recovery if recovery is possible. The damage to determined by the clinical need and the man- the neural tissue has already been done, the tis- agement planned. Tomograms are particularly sue is not "under pressure," and realignment is useful for identifying injuries to the cervico- sufficient to optimize chances for any possible thoracic junction and the dorsolumbar spine. recovery and prevent future deformity. The role of myelography in evaluating spinal 3. Most injuries, except some subjected to cord injury has been much discussed. With one flexion and rotation, are inherently stable. For or two exceptions, myelography seems to be example, upper thoracic and midthoracio inju- most useful in investigating disorders of the ries are stable unless severe deformity or multi- spinal cord due to causes other than trauma. ple fractures are present. This stability can be Hemorrhage and edema, contrary to common insured with proper posturing in bed and by belief, do not exert "pressure" at the level of teaching the patient to splint the paraspinal injury but can extend freely up and down the muscles during turning procedures. entire spinal column. Therefore, when the radio- 4. The external orthotic devices used during graphic studies mentioned reveal a bony injury the first few months after injury, whether or not at the appropriate level, knowledge of an surgery is performed, are restrictive and often obstruction to the flow of contrast material fol- impede rehabilitative training. The impairment lowing trauma is of no help in making manage- of postural adjustment because of sympathetic ment decisions. In the past, when laminectomy nervous system insufficiency in quadriplegics was believed to be helpful in spinal injury, mye- and high paraplegics also slows progress. Thus, lography was used to determine the extent of operation does not significantly hasten the start swelling in the subarachnoid space, but laminec- of the rehabilitation process, particularly after tomy has largely been discarded as a treatment cervical and high-level thoracic injuries. for closed spinal injuries, as it does not improve 5. Some "mobilization" can be achieved the chance of recovery any more than conserva- through active physiotherapy while the patient tive treatment and is associated with long-term is still confined to bed. complications, mainly progressive deformity. Thus, the proponents of conservative treat- Acute care. Although most injuries to the ment maintain that unless an operation, with its spinal cord follow closed trauma, both conserva- attendant risks, can be proved advantageous, it tive and surgical methods of acute treatment should not be done. have been advocated, and management of these Both schools of thought agree that surgery is injuries remains controversial. (See CLINICAL clearly indicated in some situations: failure to SYMPOSIA, Volume 33, Number 1, 1980, "Acute reduce a fracture-dislocation or restore accepta- Cervical Spine Injuries.") A controlled study ble alignment by closed methods; failure to carry 8 CLINICAL SYMPOSIA Plate 5 Mechanisms of Spinal Injury (only cervical illustrated) A. Flexion or flexion-rotation injury Occupant not restrained by seat belt. Head strikes steering wheel, windshield or roof in head-on collision of moving vehicle with stationary or moving object. Head hyperflexed on trunk Nettor CIBA Blow to back of head, e.g., from falling against wall or hard surface when balance is compromised VOLUME 34, NUMBER 2 9 Plate 6 Mechanisms of Spinal Injury (continued) Netter CIBA B. Hyperextension injury Forward fall causing hyperextension and backward thrust of neck, fracturing posterior elements of cervical vertebrae and/or rupturing anterior longitudinal ligament and disc of one or more vertebrae. Spinal cord impairment more common in elderly patients with degenerative spinal changes D. Penetrating injury Bullet in neural canal. Penetrating C. Compression injury wound (as from bullet or knife) Vertical blow to head (particularly in upside down damaging spinal cord and blood position as in diving, surfing, trampolining), vessels. Shock waves from producing a shock greater than discs and muscles high-velocity missiles can damage can absorb and resulting in crush or dispersion cord even if missile misses neural fracture of one or more vertebrae canal 10 CLINICAL SYMPOSIA out closed reduction early enough (within the of the vertebral body as seen on the lateral first 2 or possibly 3 days) to achieve acceptable x-ray indicates a bilateral facet dislocation, reduction; instability of a fracture after laminec- and displacement of less than one half suggests a tomy, since the latter increases the chance of unilateral dislocation, particularly if the AP and late-developing deformity, particularly in the lateral views show rotation. dorsolumbar region; a penetrating wound or All patients who have flexion-rotation cervical compound fracture; injury in a restless or unco- injuries initially require closed reduction with operative patient; and progressive deficit ascend- insertion of tongs and traction. The spine is ing beyond two segments above the initial level progressively distracted with the neck in slight of injury or progressive transverse neurologic flexion to unlock the facets; the neck is then deterioration at or near the level of bony injury postured in extension (Plates 9 and 10) and all in a patient initially without neurologic deficit or but 3 to 5 kg of weight is removed. Alternatively, with incomplete deficit. reduction may be done within the first 24 hours For all conditions except progressive deficit, by manipulation under general anesthesia with surgery is intended to correct an abnormality of x-ray control. Failure to achieve closed reduction the bony structure of the spinal column and thus necessitates open reduction. Unilateral disloca- help prevent late deformity, infection or instabil- tion compromises the neural canal much less ity. Whether neurologic improvement or recov- than bilateral dislocation does, and is usually ery will be enhanced has never been proved. stable after reduction. Bilateral dislocation is However, for progressive ascending or trans- potentially unstable after reduction, but less verse deterioration, a condition that occurs only than 10% of patients require surgical stabiliza- rarely, myelography may be indicated to rule out tion for late instability after 12 weeks of conser- pathology other than trauma, and immediate vative treatment (6 weeks of bed rest followed surgery may be necessary to recover the late loss by 6 weeks out of bed with external support). of function. If the myelogram shows nothing "Locked" facets in the dorsolumbar region unexpected, we do not totally reject the place of may be difficult to reduce by conservative mea- surgery in this situation; however, we do urge sures, and surgical reduction is more likely to be calmness and caution, since we have seen recov- necessary. If so, fusion of the injured vertebrae ery without surgery. and Harrington instrumentation should be done Despite this diversity, rational management at the same time. Open reduction, internal fixa- usually can be planned according to the type of tion and posterior fusion, when done by an injury. Injuries to the axial skeleton can gener- expert surgeon, can reduce the worry of a redis- ally be classified biomechanically as vertical location immediately after reduction and after compression injuries, flexion-rotation injuries, sitting (with external support) is permitted, and or hyperextension injuries (Plates 5 and 6), can also shorten the time in bed. However, although most involve a combination of forces. reduction of time in bed and concerns about Compression injuries are due to axial compres- redislocation are less significant if the patient is sion of the spine and may frequently be asso- in a spinal center where he can participate in an ciated with flexion or extension. These lesions active exercise program designed for the bed- are inherently stable since the ligaments remain confined patient and where the nursing staff intact, but cause spinal cord dysfunction when turns and positions patients in adequate hyper- fragments burst posteriorly into the neural canal extension so that redislocation will not occur. If and crush the cord (Plate 7). Compression inju- conservative treatment is chosen, bed rest for 6 ries can be managed conservatively with bed rest to 10 weeks is required. Whether or not surgery for 4 to 6 weeks. Some cervical fractures require is elected, the patient should wear some form of skeletal traction to distract the fragments into external support, preferably a molded plastic better alignment. Alignment of dorsolumbar body jacket, for a period of 6 to 12 weeks. compression fractures in which there is gross Hyperextension injuries (Plate 8) occur mainly deformity can be improved surgically by Har- in the cervical region. They are inherently rington distraction rods, although almost all stable and require only positioning of the neck these fractures heal in acceptable alignment in flexion, especially if the anterior longitudinal without surgery. ligament has been disrupted or there is an Flexion-rotation injuries (Plates 7 and 8) are avulsion fracture of the anterior aspect of the unstable if the posterior ligament complex is vertebrae. These injuries usually occur in indi- severely disrupted. In the cervical region, viduals with osteoarthritis or ankylosing spon- displacement of more than one half the width dylitis and often are associated with hemorrhage VOLUME 34, NUMBER 2 11 Plate 7 Types of Spinal Injury: Pathology A. Compression injury Crush fracture with fragmentation of vertebral body and projection of bone Lateral view showing compression spicules into spinal canal fracture of C5 B. Flexion injury: bilateral anterior dislocation Lateral view showing anterior dislocation of C5 on C6 Anterior dislocation of cervical Nottor CIBA vertebra with compression of spinal cord View from above. Both lateral (zygapophy- seal) articulations Sup. articular facet of C6 dislocated Inf. articular process of C5 Spinal canal compromised Sup. articular facet of C5 12 CLINICAL SYMPOSIA Plate 8 Types of Spinal Injury: Pathology (continued) C. Flexion-rotation injury: unilateral anterior rotational dislocation Upper vertebrae rotated anteriorly. Right lateral mass of axis (C2) prominent Right inferior lateral articular facet of C5 (red) dislocated anteriorly and locked in front of right articular process of C6 (blue) Left lateral articulations of C5-C6 and C6-C7 intact Unilateral anterior dislocation of C5 on C6 View from above. Right lateral intervertebral joint dislocated and upper vertebra (red) rotated anteriorly Superior articular facet of C6 Inferior articular process of C5 Spinal canal not Superior articular facet of C5 severely compromised D. Hyperextension injury Osteophytes © CIBA Hyperextension of cervical spine causing central Lateral view showing osteophytes, and intradural hemorrhage with edematous swelling which contribute to cord injury of spinal cord above and below compression VOLUME 34, NUMBER 2 13 Plate 9 Closed Reduction of Bilateral Cervical Spine Dislocation Anterior longitudinal ligament intact Locked facets A. Patient under general anesthesia with neck flexed 45°. Manual traction applied via tongs as patient's head supported by other hand. Dislocated facets thereby distracted B. To unlock dislocated joints, distraction maintained as neck gradually extended. Soft click heard as facets reengage THE C CIBA C. Neck further extended; facets brought into proper alignment and dislocation reduced. Traction then relaxed and neck maintained in extension 14 CLINICAL SYMPOSIA Plate 10 Closed Reduction of Unilateral Cervical Spine Dislocation Dislocated, locked lateral articular facets on left side A. Head positioned in 45° flexion and turned 45° to side (shown in red). Right lateral opposite dislocation. Manual traction via tongs applied articulations intact in biaxial manner with patient under general anesthesia C CIBA B. To unlock dislocated facets, traction and flexion maintained as head laterally flexed and rotated back toward side of dislocation (around intact articulation, which acts as fulcrum). Soft click heard as facets reengage KS C. Head gradually brought to neutral position and extension. Dislocation reduced and facets brought into proper alignment; traction relaxed D. Following reduction of either unilateral or bilateral cervical dislocation, mechanical traction instituted (3 to 5 kg) with head properly positioned in extension to prevent redislocation VOLUME 34, NUMBER 2 15 into the gray matter, which produces an incom- All patients, particularly those with myocar- plete spinal cord injury known as the central dial ischemia, are sensitive to the effects of cord syndrome (Plate 11). This syndrome is hypoxia and electrolyte imbalance, and arrhyth- characterized by some sparing of function in the mias can result if these conditions develop. sacral and lumbar segments and less function in Cardiac arrest due to severe hyperkalemia has the cervical area of the cord. Vertebral alignment been described from the use of succinylcholine as seen on x-ray is almost always acceptable in as a muscle relaxant during intubation of these patients, most of whom can be managed patients with lower motor neuron injuries. This with an initial period of bed rest in a soft collar drug probably should no longer be used in any for 4 to 6 weeks and then mobilization in the patient with spinal cord injury, since pancuro- same collar for an additional 6 weeks. nium is now available. Cardiovascular Respiratory Spinal cord injury, particularly lesions above Respiratory complications can develop at any T6, compromises the sympathetic nervous sys- time following spinal cord injury but are par- tem. Since the sympathetic outflow occurs ticularly likely in quadriplegics and high-level between T1 and L2, sympathetic tone in quadri- paraplegics during the acute stages, when aspi- plegics and high-level paraplegics is severely or ration, fractured ribs and lung contusions may completely impaired (depending on the com- compound existing problems. pleteness of the injury). This results in hypoten- Initial assessment must include a search for sion and bradycardia-so-called neurogenic factors that would further compound respiratory shock. If the hypotension is not accompanied by insufficiency from the spinal cord injury, such as hypovolemia, blood pressure generally stabilizes obesity or a history of intrinsic lung disease, at 100/60 mm Hg, which is adequate for tissue asthma or smoking. Physical and roentgeno- perfusion in the supine position in young graphic examination of the chest must be done, patients. As long as urinary excretion remains and blood gas measurements should be obtained adequate (at least 30 to 40 ml/hour) and mental initially for all patients and repeated when nec- status is normal, no corrective measures are essary. The vital capacity is an extremely useful necessary. If the mean blood pressure falls index of ventilatory sufficiency and should be below 70 mm Hg, however, fluid replacement determined daily for the first month, and as indi- under central venous pressure monitoring (and cated thereafter. Quadriplegics with high-level cardiac output monitoring if there is a history of lesions (C5 and above) may require ventilatory myocardial disease) is necessary, and other assistance if their vital capacity falls below 1.0 to causes of hypotension should be ruled out. Fluid 1.2 liters or if pneumonia develops. Since such therapy must be given cautiously in order not to assistance is often required for more than 10 overload the patient. Pulmonary edema is a days, tracheostomy should not be needlessly common hazard in quadriplegics and is fre- delayed. Victims injured in water sports must be quently iatrogenic. watched closely even if they appear asympto- Bradycardia in previously healthy people is matic initially. also unnecessary to treat as long as it remains The possibility of respiratory insufficiency sinus bradycardia, unless the heart rate falls must always be considered before a general below 44 to 48. An anticholinergic (such as atro- anesthetic is administered to a patient with acute pine) or an adrenergic (noradrenaline) may be spinal cord injury. used intermittently or a transvenous pacemaker Conditions causing respiratory problems inserted for 3 to 5 days until the cardiovascular include impaired cough effectiveness, increased system accommodates. Since the bradycardia is physiologic arteriovenous shunting or ventila- caused by unopposed vagal tone on the sino- tion-perfusion mismatching, and decreased atrial node, increased vagal stimulation must diaphragmatic excursion and vital capacity. be avoided. Improper tracheal suctioning, for Impaired cough effectiveness permits secretions example, may cause prolonged stimulation to to accumulate in the tracheobronchial tree, a the carinal reflex and lead to sinus arrest. Tra- situation that may be aggravated by the unop- cheal suctioning should be preceded by oxygen- posed vagal tone acting on the bronchial ation and, if necessary, by the administration of secretory cells and by a premorbid hyper- atropine (unless a pacemaker is in place), and secretory state in patients with a smoking his- the heart rate should be closely monitored dur- tory. All patients with impaired cough ing the procedure. effectiveness (that is, all quadriplegics and 16 CLINICAL SYMPOSIA Plate 11 Incomplete Spinal Cord Syndromes Spinal cord orientation Dorsal columns (position sense) Lower limb Trunk Lateral pyramidal tract (motor) Upper limb Lower limb Lateral spinothalamic tract (pain Trunk and temperature) crosses from Upper limb opposite side before ascending Anterior spinal artery Central cord syndrome Central cord hemorrhage and edema. Parts of 3 main tracts involved on both sides. Upper limbs more affected than lower limbs Anterior spinal artery syndrome Artery compressed by bone or cartilage spicules; shaded area affected. Motor function and pain sensation lost bilaterally below injured segment; position sense preserved Brown-Séquard's syndrome One side of cord affected. Loss of motor function and position sense on same side and of pain sense on opposite side Netter CIBA Dorsal column syndrome (uncommon) Position sense lost below lesion; motor function and pain sense preserved VOLUME 34, NUMBER 2 17 paraplegics with a lesion above T10) should Adequate nutrition is extremely important receive intensive respiratory therapy, including during the first weeks after injury, when bone intermittent positive pressure breathing, chest and soft tissue are healing and endogenous pro- percussion, postural drainage, and assisted tein is being catabolized. An average-sized adult coughing every 6 hours, whether or not they male should consume at least 3,000 calories per seem to need it, and more frequently if neces- day. If the patient cannot or will not eat after the sary (Plate 12). These measures are mandatory if fifth day post injury, nasogastric or intravenous respiratory complications and tracheostomy are feeding should be started. (Parenteral nutrition to be avoided. is usually needed only when the patient has Increased physiologic arteriovenous shunting or sustained multiple trauma in addition to spinal ventilation-perfusion mismatching is possibly cord injury.) Nasogastric rather than intravenous related to exclusively diaphragmatic breathing, feeding is preferable because of the potential prolonged recumbency, and scattered atelectasis complications, particularly infection, associated from multiple factors. with the latter. Decreased diaphragmatic excursion and vital Gastrointestinal bleeding and ulcer disease capacity may result from paralytic ileus during may develop in patients with spinal cord injury the first 72 hours post injury. If the stomach during times of acute stress. Early referral to a is not decompressed during this period, the comprehensive spinal unit where the patient patient may vomit and aspirate abdominal trusts the expertise of the staff does much to contents, which may cause chemical pneumo- remove anxiety as a causative factor. Gastroin- nitis and severe bronchospasms. testinal bleeding may also occur with the use of All these complications may lead to severe steroids during the first few days post injury, pneumonia unless the nursing and medical staffs although it may occur (rarely) even if steroids are are trained to anticipate them. not given. Steroid therapy following spinal cord trauma in any case has doubtful value. Cimeti- Gastrointestinal dine has been advocated as a prophylaxis against Following spinal cord injury, peristalsis ceases acid peptic disease, and probably is theoretically either immediately, if the abdomen has been acceptable when the physician feels compelled injured, or within 24 hours, as a result of spinal to use steroids. shock. This usually persists for 3 to 4 days; When surgery for peptic ulcer is necessary, however, if extensive retroperitoneal hemor- gastric resection without vagotomy seems the rhage has occurred with dislocation of a dorso- preferred procedure, to avoid the prolonged lumbar fracture, it may last more than a week. atony that may follow vagotomy. Metoclo- The combination of absent bowel sounds with pramide, however, may relieve the atony. hypotension (in quadriplegics) or decreased hematocrit (in paraplegics with soft-tissue Genitourinary hemorrhage) may mislead the examiner to sus- The contractile ability of the bladder and in pect an acute abdomen. All the clinical evidence some cases the ureters also is lost after spinal should be weighed before proceeding with cord injury, and the bladder may remain are- four-quadrant aspiration. For example, hypoten- flexic for weeks to months, even in patients with sion in quadriplegia is ordinarily associated with upper motor neuron lesions in whom such reflex bradycardia; however, an increased heart rate return is anticipated. signals additional pathology, such as hypovole- Advances in management of the neurogenic mia or infection. bladder have constituted some of the greatest Until good bowel sounds return, a nasogastric developments in the care of the patient with tube should be inserted and left to gravity drain- spinal cord injury, although complications still age or low suction. Abdominal girth should be arise. We believe intermittent catheterization is measured daily. Since most patients will have the preferred method of draining the neurogenic lost both the urge to defecate and voluntary bladder, but we do not start it immediately. We control of the anal sphincter, a bowel program use the indwelling catheter (Plate 13) to check (page 26) to train the bowel to empty regularly fluid balance and avoid overdistention of the and easily should begin as soon as bowel sounds bladder while the patient is receiving IV fluids return and the patient is receiving oral or naso- and undergoing nasogastric drainage and while gastric feedings. Mealtimes should be regular, vital signs are being carefully monitored. When and only food that does not irritate the bowel the patient can take fluids by mouth, quantities should be given. are limited to 150 to 200 ml every 2 hours and the 18 CLINICAL SYMPOSIA patient is catheterized every 4 to 6 hours. This A hospital bed that can be lowered and raised program is continued until adequate voiding to place the patient in the Trendelenburg occurs or urologic surgery to improve bladder and reverse Trendelenburg positions is advan- emptying is done, although some patients may tageous. The former position is needed for be discharged on intermittent catheterization postural drainage and the latter increases the (page 29). patient's endurance in the upright position while Antibiotic or antiseptic solutions instilled after confined to bed. draining the bladder and just prior to catheter Patients can be turned safely and properly in withdrawal reduce the number of microorga- either of two ways: they can be lifted and then nisms present and alter the bladder flora. A logrolled (Plate 16), or logrolled using a draw- regular monitoring program in which cultures sheet (Plate 17). We have not found it necessary and sensitivities are obtained two to three times to use any form of mechanical bed for these per week detects bacteriuria before it becomes patients. In some cases of multiple trauma, such symptomatic. as limb fractures or pneumothorax, when turn- If bacteriuria does develop, it should be ing the patient poses serious problems, the treated with appropriate antibiotics. The pri- recently modified Rotobed, which rotates along mary goals of the antibiotic treatment are to its longitudinal axis, and the Stoke-Egerton bed maintain a healthy bladder endothelium until may offer certain advantages. However, abso- catheterization is no longer necessary and to lutely nothing can replace an alert nursing staff keep the tissue healthy in the event surgery is attending to the patient's needs each time he is required. turned. When an indwelling catheter is required for An acutely injured patient, particularly a more than 3 days, the meatus should be covered quadriplegic, must never be placed in the prone with an antiseptic ointment and the entire closed position, as this often is associated with brady- system should be changed every third day to cardia and hypoxic episodes. keep the urine sterile. This schedule may pre- vent bacteriuria, which is otherwise certain after Physical and Occupational Therapy 4 days' continuous use of an indwelling catheter. Physical therapy must begin the first day after injury, or as soon as medical clearance is given, Skin with passive range-of-motion exercises for joints By far the costliest of all complications of spi- of paralyzed limbs and active range-of-motion nal cord injury is skin breakdown. Unless the exercises for innervated limbs to strengthen nursing staff turns the patient regularly every these muscles as well as the muscles of respira- 2 hours, inspects the skin, and places pillows tion. When medical clearance is given, the head in strategic locations so that pressure over of the patient's bed is progressively raised to bony prominences is avoided (Plate 14), pressure place the patient in the reverse Trendelenburg ulcers can be expected to develop. Pressure position for ½ to 1 hour several times each day ulcers delay the onset of rehabilitation by in order to help him accommodate to the upright prolonging confinement to bed, lengthening position. hospitalization, and making the psychologic Occupational therapy assesses the patient's adjustments to disability far more difficult. functional capabilities and introduces him to adaptive equipment such as prism glasses for Posture use while flat in bed, static splints to prevent Proper positioning of the patient is important contractures, and functional splints that are to prevent contractures of the peripheral joints. designed to help him perform basic tasks. The shoulders require special attention in Patients learn to substitute action of functioning patients with quadriplegia from a lesion at C5 or muscles for action of those muscles not capable above, because the redundant shoulder capsule of moving the appropriate joint. will contract and lead to a painful adhesive cap- sulitis, making full range of motion difficult and Psychosocial Counseling painful. Posturing the arms in 90° abduction for Some of the anxiety or depression experi- 1 to 2 hours three times daily helps prevent this enced by the patient in the acute stage of spinal problem (Plate 15). cord injury can be alleviated by providing both Posturing the patient with the legs slightly family and patient with information on non- elevated facilitates venous drainage and reduces medical concerns: how the hospital and physi- stasis, a cause of deep venous thrombosis. cian fees will be handled, where the family VOLUME 34, NUMBER 2 19 Plate 12 Pulmonary Physical Therapy Intermittent positive pressure breathing (IPPB), chest percussion with postural drainage, and assisted coughing must be initiated for all acutely injured quadriplegics and high-level paraplegics and for all such patients who develop chest infections after acute period IPPB Postural drainage with chest percussion Netter CIBA Assisted coughing 20 CLINICAL SYMPOSIA Plate 13 Catheterization: Indwelling and Intermittent For indwelling catheter, urethral orifice covered with povidone - iodine or chlorhexidine ointment; glans and catheter entry wrapped in gauze taped in Urine in bladder place; catheter taped to shaved area of abdomen. Fluids are forced. Tubing Bacterial growth rate and collection bag kept below level of patient's Filter ©CIBA bladder Urine in bladder increases arithmetically, but bacteria increase logarithmically. With intermittent catheterization, fluid is restricted and bladder Residual urine drained every 4 to 6 hours to minimize multiplication 2 4 6 of bacteria if present. Instillation of antibiotics after drainage may be helpful Time (hours) can obtain temporary quarters if they do not doctor" to a "rehab doctor." This is not true of reside close by, and how to report the injury spinal cord injury. To be effective, care for the to the employer or insurance company. Help- patient with spinal cord injury must flow contin- ing the patient and family deal effectively with uously from one phase to another, with rehabili- all the emotionally unsettling aspects of acute tation conducted in step with the acute care. trauma is part of psychosocial management. Physicians who manage the patient during reha- Even though prognostic statements will be bilitation should be part of the medical team necessary later, there is little point in making treating the patient from the first day. them at the early stage, since the reality of a devastating disability is easier to accept gradu- Spine ally rather than suddenly. Patient and family The length of time a patient should be kept in may be told that it is all right to hope for the bed varies with the type of injury, its location, best, but one must also prepare for the worst. and whether surgery has been performed. Sur- gery to achieve early mobilization is considered REHABILITATION more often for lumbar and dorsolumbar injuries For some illnesses, acute care is separate from than for injuries in other locations, since patients rehabilitation, and the transition from one to the have skin sensation in the area where external other is identified by changing from an "acute support is worn and are able to sit and have VOLUME 34, NUMBER 2 21 Plate 14 Positioning of Paralytic Patient A. Patient lying on back Pillow to support feet at right angle Pins of tongs slightly forward on skull as precaution against foot drop to achieve extension of neck. (Pins placed slightly posterior of mastoid if flexion desired) Pillows under ankles and calves Drawsheet Foam "egg-crate" mattress drawn Detail of foam down to allow for head extension For lumbodorsal Standard if required. Soft roll under neck. lesions only, pillow "egg-crate" mattress hospital (If flexion or neutral position placed under thoraco- mattress required, "egg-crate" mattress lumbar region to moved to head of bed) maintain lordosis Netter CIBA B. Patient lying on side Position of pulley adjusted to maintain proper angle of traction (extension in Pillow to Pillow to maintain patient shown). Pulley moved with each support back ankles at 90° turn to maintain position required Axillary pillow Drawsheet "Egg-crate" Foam wedge under side of Standard mattress face to avoid weight of Pillows between knees and ankles hospital head on tongs to relieve pressure against skin mattress 22 CLINICAL SYMPOSIA Plate 15 Prevention of Contractures Posturing arms in 90° abduction for 1 to 2 hours three times daily helps prevent adhesive capsulitis of the shoulder (frozen shoulder) CIBA proper alignment maintained with such support. Patients who have not had a surgical procedure Cardiovascular can usually be mobilized with external support The cardiovascular system accommodates in 6 to 8 weeks. rather quickly to the effects of sympathetic After cervical injury, we avoid early mobiliza- insufficiency, and treatment of bradycardia can tion for patients with complete lesions or with usually be discontinued after 1 week. However, only sensory or minimal motor sparing. Patients other complications can develop. who are ambulatory or likely to ambulate use Orthostatic hypotension. Syncopal episodes halo devices for 6 to 8 weeks; after this time, if can be expected in all patients with complete or x-rays are favorable, they can wear a sterno- nearly complete quadriplegia when they first sit occipital mandibular immobilizer (SOMI) brace up. Sitting should therefore begin in a reclining for an additional 6 weeks. Selected patients who wheelchair, with the angle of sitting advanced have had surgery with fusion and wiring can use commensurate with the patient's ability to sus- this brace instead of the halo immediately after tain a blood pressure of 80 to 90 mm Hg systolic surgery and for the next 6 to 8 weeks. for 1 hour at that angle. Patients should be For high thoracic or midthoracic injury, we tipped back in their wheelchair any time they use the plastic body jacket only on those patients become lightheaded, which usually occurs who have multiple rib and vertebral fractures; immediately after transfer from the bed to otherwise, depending on the severity of the the chair. fracture, these patients are mobilized without To facilitate venous return, quadriplegics external support after 4 to 6 weeks of bed rest. should wear elasticized stockings during sitting The body jacket is used by all patients with periods until they no longer have pedal edema thoracolumbar or lumbar injuries, when they are after sitting a full day. (Some patients will always ready to begin sitting, whether or not they have require these stockings.) An abdominal binder had surgery; it is generally worn for at least 3 also aids in venous return, since with each inspi- months, and for up to 6 months by patients with ration it increases intraabdominal pressure as severe fracture-dislocations. the diaphragm descends, forcing venous blood The degree of functional independence toward the heart. achieved after mobilization depends on the level Autonomic hyperreflexia. Sometime after and incompleteness of the lesion and the ade- reflex activity has returned, particularly detrusor quacy of training. The function that can be reflex activity, patients with lesions above T6 expected with lesions at different levels is may experience autonomic hyperreflexia, char- summarized on page 27. acterized by hypertension, diaphoresis, goose VOLUME 34, NUMBER 2 23 Plate 16 Lifting Quadriplegic Patient to Turn or Transfer © CIBA Three attendants on one side lift patient simultaneously, taking care not to bend or twist spine. Nurse supports patient's head and maintains its proper alignment with body (in this case, neutral) flesh, severe headache and flushing. This com- during the first 90 days after injury, but throm- plex of manifestations results from an uncon- boembolism can occur after that. trolled increase in sympathetic activity that Pulmonary embolus, a complication of deep cannot be inhibited by the vasomotor center venous thrombosis, has a relatively high mor- because of the spinal cord injury. Compensatory bidity in quadriplegics. Preventive measures bradycardia is triggered by the baroreceptors include elevating the legs while the patient is since vagal innervation remains intact, and this is confined to bed, having the patient wear elastic the only intrinsic protection against the potential hose when sitting, and passive range-of-motion complications of uncontrolled hypertension. exercises. Autonomic hyperreflexia is usually caused by Diagnostic procedures include diligent clinical overdistention of a viscus, usually the bladder or observation, including daily leg and thigh meas- bowel. The problem is treated by relieving the urements; phlebography, which is most reliable obstruction (changing the catheter, removing the for showing the location and extent of a clot; fecal impaction); placing the patient in a sitting radioactive venous scanning, which can be position, if possible, to help relieve the hyper- combined with lung scanning when pulmonary tensive effect on the brain; and using topical embolus is suspected (Plate 18); and Doppler anesthetic in the bowel or bladder to decrease studies. Manifestations of pulmonary embolus noxious afferent stimuli. may be obvious (hemoptysis, pleuritic chest Thromboembolism. Patients with spinal cord pain, pleural effusion) or nonspecific (dyspnea, injury are at special risk of thromboembolic bronchospasm, tachycardia), but diagnosis will disease because of immobilization and trauma to be aided by laboratory findings of a fall in pO₂ the venous endothelium. The risk is greatest below 80 mm Hg, electrocardiographic evidence 24 CLINICAL SYMPOSIA Plate 17 Turning Quadriplegic Patient With Aid of Drawsheet Netter CIBA Nurse holding patient's head instructs assistants when to lift and slide patient and maintains head in proper alignment. From back to side: Slide patient to side of bed opposite direction of turn; roll onto side. Patient should then be in center of bed From side to back: Slide patient to side he is facing; roll onto back VOLUME 34, NUMBER 2 25 of right heart strain, a hyperlucent area or pleu- either of these two parameters begins to fall, the ral effusion on chest x-ray, and, most important, transition is being made too fast, the patient will a pattern of diminished perfusion on lung scan. fatigue, and 21% oxygen will no longer suffice. (For a detailed discussion of thromboembolism, When the vital capacity reaches 1.0 to 1.2 liters see THE CIBA COLLECTION OF MEDICAL ILLUS- and inspiratory force -38 to -40 cm H₂O, the TRATIONS, Volume 7, "Respiratory System.") patient should be able to tolerate 12 hours off the On diagnosis, intravenous heparin must be ventilator; when the vital capacity reaches 1.5 started at once and continued for 4 to 7 days liters, he should not need assisted ventilation if until symptoms subside. Oral warfarinlike the lungs remain uninfected. Vital capacity compounds can then be substituted and contin- should be checked daily for the following 4 ued for 3 to 6 months. After one diagnostic tap, weeks and any time infection is suspected. an effusion need not be removed unless vital Some quadriplegics with very high lesions capacity or oxygenation is compromised. Vital may require mechanical support for 6 to 12 capacity should be determined daily and chest months; some will never be weaned and will x-rays obtained as indicated. Oxygen should be need to use a ventilator permanently. Portable administered until the pO₂ is consistently over ventilators that fit on a wheelchair, condenser 75 to 80 mm Hg on room air. humidifiers that fit into a tracheostomy tube, Available research suggests that administra- adapters that allow the patient with a tracheos- tion of low-dose heparin reduces, but does not tomy tube to talk, and suctioning and oxygen eliminate, the risk of deep venous thrombosis equipment that can be used at home make it and pulmonary embolism. Therefore, unless possible for patients to live outside the hospital, contraindicated, this regimen is generally provided the family can be trained to assist in advised until the patient is mobilized. their care. Respiratory Gastrointestinal Although, in time, the respiratory system Defecation can be regulated in patients with usually accommodates well to the altered upper motor neuron lesions who have reflex breathing mechanics (page 16), upper respira- activity in the pelvic floor (positive bulbocaver- tory infections develop more readily than before nosus and anal cutaneous reflexes). To utilize the injury. If symptoms of a "chest cold" appear, gastrocolic reflex, after the patient has eaten, a chest physiotherapy must be increased and vital suppository containing glycerin or bisacodyl is capacity must be routinely followed. Patients inserted against the rectal wall to stimulate peri- with cervical or dorsolumbar injuries occasion- stalsis; 15 minutes later, a lubricated, gloved ally have unilaterally impaired diaphragmatic finger is inserted high into the rectum to stimu- function, and should undergo fluoroscopic late reflex colonic activity. Digital stimulation examination if the vital capacity is less than can be repeated if no results are achieved the expected, air exchange is unequal, or x-rays first time. The bowel program should be done at show a suspiciously high diaphragm. Differen- a regular time every day, every other day, or tial diagnosis includes partial injury to the rarely every third day (not recommended). phrenic nerve and diaphragmatic herniation. Patients with lower motor lesions, who have Patients with lesions at or above C3 and some a flaccid anus and no reflex activity can try patients with lesions at lower levels may require the same procedure, but it often is ineffective. ventilator support for prolonged periods. A Abdominal straining may work, since the common mistake is weaning a patient from the abdominal muscles are usually functional, but ventilator too rapidly, usually at the cost of stool often must be removed manually. keeping him on concentrations of oxygen above The stool should be kept soft by either a that of room air. Because quadriplegics rely high-fiber diet or use of stool softeners (e.g., completely on the diaphragm for breathing and dioctyl sodium sulfosuccinate), or both. Occa- have no additional respiratory muscle reserve, sionally a patient needs a stimulant (such as they are liable to fatigue easily. Therefore, if a danthron) and, infrequently, an enema. A simple ventilator is required, they should use it until tap water or saline enema should be tried first. they can oxygenate adequately on room air. The patient must not become "dependent" on They can then be taken off the ventilator for 1 enemas, however, because a bowel program will hour two to three times per day, and this time result in consistent evacuations if given time. can be slowly increased while the vital capacity Whether continence can be achieved depends and inspiratory effort are monitored daily. If largely on the patient's ability to adhere to a 26 CLINICAL SYMPOSIA Functional Expectations Following Spinal Cord Injury Level of Injury Functional Expectations Sacral (S2 to S4) Only bowel and bladder function initially impaired. Bowel evacuation via strain or manual removal; bladder satisfactorily emptied by strain and crede. Incontinence a possible problem if bladder neck surgery required. External appliance possibly necessary for male. Normal ambulation. Lumbosacral (L4 to S1) Bowel and bladder controlled as above. Independence in walking possible with two canes or crutches and often with short leg braces (ankle-foot orthoses). Prolonged standing possibly impaired, but wheelchair unnecessary. Lumbar (L1 to L3) Bowel evacuation via suppository and rectal stimulation. Bladder evacuation assisted by stimulating sacral reflexes if present (tapping or anal stretch). Sphincterotomy possibly required or long-term intermittent catheterization used. Walking in long leg braces (knee-ankle-foot orthoses) and with crutches possible for short distances. Complete independence in wheelchair possible. Thoracic (T7 to T12) Bowel and bladder (almost always upper motor neuron-type dysfunction) controlled as for L1 to L3 patients, with complete independence in function possible. Unless lower extremities deformed, independent walking in long leg braces possible but too strenuous to be very functional. Complete independence in wheelchair always expected, including dressing, driving, and transfer out of wheelchair. Thoracic (T2 to T6) Bowel and bladder controlled as for L1 to L3 patients. Wheelchair required as main means of transportation. With extensive training, complete independence possible. Ambulation with orthoses never functional. Cervical (C7 to T1) Bowel and bladder controlled as for L1 to L3 patients. Reflex voiding often too frequent for patient to remain dry between catheterizations. If so, external collection device for male and indwelling catheter for female necessary for injury at this level and above. Self-catheterization difficult for C7 patients because of poor hand dexterity. Wheelchair primary means of transportation. Complete independence possible except in patients with deformities, weakness, obesity or other medical problems. Cervical (C6) Long-term intermittent catheterization usually not practical since most patients lack dexterity, even with orthotic hand devices. External collectors and often bladder outlet surgery required in males. Manual wheelchair with modified hand rims operated with difficulty; electric wheelchair possibly required for ramps and grades. Self-care skills facilitated by orthotic equipment. Complete independence in very few patients. Driving sometimes possible. Cervical (C5) Some assistance required in all activities; living alone not practical. Independent electric wheelchair ambulation possible. Cervical (above C5) Patient totally dependent. Ventilation compromised and special respiratory equipment required in C4 impairment. For some patients, ambulation possible in electric wheelchair fitted with appropriate chin or mouthpiece. scheduled life-style in which meals are eaten at With the use of intermittent catheterization, the the same time each day, foods irritable to the increased knowledge of urodynamics, and the colon are avoided, and the bowel program is improvement in bladder outlet surgery, these done regularly. complications have occurred far less frequently over the past 10 years. Genitourinary Indwelling catheter. Patients who must have In the past, when long-term indwelling ure- an indwelling catheter are certain to have chronic thral or suprapubic catheters were commonly bacteriuria, pyuria, albuminuria and a small, used, chronic infection of the lower genitouri- contracted bladder. To try to eliminate the bacte- nary tract was inevitable and complications such riuria is useless, since it will always return. as epididymo-orchitis, urethral diverticuli, false Instead, the balance of bacteria versus host passages, penoscrotal fistulas, vesicovaginal fis- defenses should be constantly tipped in favor of tulas and bladder calculi were not infrequent. the host, which can be done as follows: VOLUME 34, NUMBER 2 27 Plate 18 Thromboembolism Phlebogram showing dilated deep veins in left lower limb. Multiple attempts at minute collateral vascularization Ventilation scan normal Perfusion scan reveals defects in right lung Characteristic radionuclide scan findings in pulmonary embolization © CIBA 1. Maintain a high fluid intake and a high urine bowel program and during menstruation and to output. If the patient can attain a urine output of keep the area dry throughout the day. 3 liters per day, the resident bacteria in the blad- Despite the disadvantages of an indwelling der will be continuously diluted and washed out. catheter, it may be the only appropriate bladder In this way the rate of dilution, which advances management for quadriplegics (particularly arithmetically, keeps pace with the rate of females), whose hand function and balance are bacterial multiplication, which advances logarith- too limited to allow them to catheterize them- mically. If the urine is permitted to stagnate selves. Indwelling catheterization prevents within the bladder, however, bacterial over- incontinence and its accompanying skin prob- growth easily occurs, and when bacterial con- lems and provides social acceptability. Indwell- centration reaches 10⁵/ml, infection becomes ing catheters are an "evil" in males or females, established and the patient may become "symp- but they are less of an evil in females. (The tech- tomatic," exhibiting fever, hematuria, autonomic nique for establishing and maintaining a closed hyperreflexia and sepsis. urinary drainage system is summarized in 2. Maintain an unobstructed conduit from the CLINICAL SYMPOSIA, Volume 30, Number 6, 1978, bladder to the exterior. Catheters should be "Nosocomial Infections.") changed not only on a fixed time schedule but Intermittent catheterization. Some patients also whenever they are not draining properly. can maintain sterile urine if the bladder is Signs of partial obstruction of the catheter catheterized every 4 to 6 hours until spontaneous include an increase of "bladder spasms" or void- or voluntary voiding occurs. If the procedure is ing around the catheter, transient episodes of done carefully by trained personnel, the urethra autonomic hyperreflexia, and an increase in and bladder will not be damaged and bacteria urinary sediment. If a catheter fails to drain will not be introduced. Instillation of an antibi- properly, bacteria in the stagnant urine will otic (see below) can further reduce the incidence multiply and the higher bladder pressure gener- of bacteriuria. ated by the "spasms" may reflux the infected To avoid overdistending the bladder, patients urine into the kidney. are given 150 to 200 ml of fluids every 2 hours. 3. Keep the perineal area as clean as possible at all Once consistent reflex bladder activity returns times. The bladder is most often invaded by (in patients with reflex bladders), there is no gram-negative organisms (normal bowel flora), longer any risk of overdistention, and fluid which migrate up and around the catheter. It is restriction can be eased or eliminated. If the important to cleanse the perineum after the volume of residual urine that is obtained by 28 CLINICAL SYMPOSIA catheterization consistently falls below 200 ml, collectors. This technique appears to be more the patient can be catheterized every 8 hours. effective in complete paraplegics than in other Reflex voiding can be facilitated by bladder patients with spinal cord injury. tapping or crede (suprapubic manual pressure) Sphincterotomy. Elimination of catheters in every 2 to 4 hours. If the residual urine volume is any form is desirable to decrease the patient's consistently below 80 to 100 ml, intermittent susceptibility to chronic infection and, for quad- catheterization can be discontinued. Reducing riplegics, to eliminate the burden that catheteri- the frequency of catheterization while residual zation imposes on the family members or nurses volume remains high predisposes to infection. caring for the patient. Sphincterotomy alone (for Patients with areflexic or hyporeflexic blad- hypertonic bladders) or combined with bladder ders are taught to empty their bladders by neck resection (for hypotonic bladders) nearly straining and by performing suprapubic crede. always improves flow rates, lowers voiding pres- Most of these patients are paraplegics with low sures, improves residual urine volume, and fre- lesions and can do this themselves. Occasion- quently eliminates the autonomic hyperreflexia ally, a tetraplegic will have an areflexic or hypo- that often accompanies bladder sphincter dys- reflexic bladder, and if the lesion is above C7, synergia (Plate 20). Normally, the sphincter someone else must perform these procedures. relaxes as the bladder contracts, producing a Methenamine mandelate and an acidifying continuous urine flow (20 to 25 ml/second). agent, usually ammonium chloride, can be used When dyssynergia is present, both the detrusor as adjuncts to intermittent catheterization to and external sphincter contract simultaneously, inhibit bacterial growth. Formaldehyde, the interrupting the flow. active breakdown product from the hydrolysis, Consultation with a skilled urologist and eliminates certain bacteria, particularly the urodynamic testing are usually required to pre- gram-negative organisms, if it remains in the dict which patients will respond best to sphinc- bladder long enough. When reflex voiding has terotomy. Patients who have high voiding begun, the value of methenamine is less certain, pressure (over 100 cm H₂O) are routinely offered since the quantity of formaldehyde released and sphincterotomy (alone), even if residual urine the length of time it remains in the bladder are volume is less than 80 ml. Patients with moder- insufficient to overcome all the microorganisms. ate pressure (40 to 100 cm H₂O) are offered sur- In patients with indwelling catheters methena- gery only if residual urine is inadequate, and mine is valueless. those with adequate residual are followed at Long-term intermittent catheterization. If 3-month intervals. Patients with low pressures satisfactory residual urine volume is not consis- generally have inadequate residual volume and tently achieved spontaneously after about 3 to are taught to crede their bladders after sphinc- 6 months of intermittent catheterization, long- terotomy and bladder neck resection. term intermittent catheterization or bladder outlet surgery should be considered. Long-term Skin intermittent catheterization may be the only The fundamental rule in managing skin prob- realistic alternative for female patients, for lems in patients with spinal cord injury is preven- whom satisfactory external collecting devices tion. In a spinal unit with a well-trained nursing still do not exist, as long as reflex activity can be staff, pressure ulcers should never develop, since controlled by the prevention of infection and the an alert staff inspects the patient's skin during judicious use of anticholinergics. every turn and after every increase in sitting Long-term intermittent catheterization may time. Spinal units should also have instruments also be considered in males if reflex bladder for measuring pressure under the wheelchair activity can be controlled, to eliminate the need cushion. for an external collector. However, if reflex blad- Preventive measures for pressure ulcers der activity cannot be suppressed with anticho- include intermittent relief of pressure from linergics and if the residual urine volume is weight-bearing surfaces (as by wheelchair push- acceptable, use of an external collector is advisa- ups and a nighttime turning schedule), and ble, particularly in quadriplegics who are unable visual inspection of the skin twice daily, by to catheterize themselves, since this problem for the patient himself or by a nurse or attendant. males has largely been resolved. Clothing should be loose-fitting and clothing Anal sphincter stretch training (Plate 19) in and bedding made of moisture-absorbent mate- both males and females may obviate the need for rial. Patients should observe proper nutrition both intermittent catheterization and external and moderate intake of alcohol and drugs, so VOLUME 34, NUMBER 2 29 that obesity or undesirable psychologic states do as infection of the urinary tract, skin abra- not interfere with skin care. Ischemia, edema sions and ulcers, fractures, poor postural care and cellular infiltration, anemia and venous and even excessive anxiety. Spasticity invariably thrombosis increase the effects of chronic pres- decreases when these causes are corrected. sure, and should be corrected when possible. Proper positioning in the supine and side- Once pressure ulcers have developed, appro- lying positions and in the prone position after priate radiographic and bacteriologic investiga- respiratory problems have stabilized and the tions should be done. Conservative treatment vital capacity while prone exceeds 1300 ml will consists of complete relief of weight bearing and prevent flexor spasms. Shoulders should be friction, restoration of hemoglobin to normal abducted, the hips extended, and the feet dorsi- values, and adequate protein intake. If the ulcers flexed (Plate 14). Occasionally extra pillows and do not heal with these measures, surgical treat- "spasm sheets" must be used. In some patients, ment is usually required after infection has been however, spasticity may increase despite opti- controlled. (See CLINICAL SYMPOSIA, Volume 31, mum care and may interfere with mobility, pos- Number 5, 1979, "Pressure Ulcers: Prevention ture or self-care; it must then be treated by other and Treatment.") means. Currently used medications include muscle relaxants and antispastics that act cen- Musculoskeletal trally and increase presynaptic inhibition or act Spasticity. The areflexia noted during spinal at the excitation-contraction coupling site. Phe- shock appears to result from an increase nol or alcohol solutions injected intrathecally in presynaptic inhibition (and possibly a under fluoroscopic control or into peripheral decrease in fusimotor drive), and reverses nerves or motor points are also effective. Surgical several weeks after injury. Muscle imbalance treatment may be used for lengthening tendons becomes more apparent after reflexes have of hyperreflexic muscles and sectioning periph- returned, and range of motion of joints, as well eral nerves, nerve roots or the isolated portion of as posturing to counteract the effects of gravity the spinal cord (e.g., the myelotomy described or muscle imbalance, becomes fundamental. by Bischof). Epidural stimulation in the region of With lesions in the spinal cord (upper motor the spinal cord injury is still an experimental neuron lesions), as opposed to lesions in the procedure; however, it has proved successful in cauda equina or conus medullaris (lower reducing spasticity in some patients with incom- motor neuron lesions), hyperreflexia of two plete lesions. types of reflexes affecting the musculoskeletal Heterotopic ossification. Why bone forms system appears after spinal areflexia disappears: in paraarticular connective tissue in some (1) stretch reflexes (activated by proprioceptive patients following spinal cord injury is not sensors, i.e., the nuclear bag and the nuclear known. This disorder occurs in up to 20% of chain located within the muscle spindle) and patients and affects primarily the hips and (2) nociceptive reflexes (activated by cutâneous knees, in that order. Local trauma, infection, stimuli). decubiti, and venous and arterial insufficiency, Stretch reflexes are primarily characterized by especially with hypoxemia, may predispose to extensor muscle activity, and may be phasic its development. Stover has reported para- (repetitive or clonic) and monosynaptic or articular ossification beginning in acutely injured tonic (sustained) and polysynaptic. Nociceptive patients between 1 and 4 months post injury, reflexes are characterized primarily by flexor although it has been seen in patients well muscle activity and are tonic and polysynaptic. beyond this period. These flexion reflexes often reappear before The diagnosis can be suspected when the stretch reflexes; therefore, it is important to pos- muscles about the susceptible joints exhibit an ture patients in extension at the beginning of indistinct swelling that usually is firmer than that treatment. Both nociceptive and stretch reflexes associated with venous thrombi. Serum alkaline are often preceded by the return of reflexes phosphatase levels are usually elevated in the involving muscles attached to the skin, e.g., the early stages, and the bone formation can be bulbocavernosus and cremasteric reflexes, which detected by radionuclide scanning before it is may, in fact, be noted within the first 24 hours evident on x-ray. after injury. Once heterotopic ossification has been identi- Hyperreflexia in complete and incomplete fied, gentle, passive range-of-motion exercises of upper motor neuron lesions may become exag- the affected limb should be done twice daily. gerated as a result of pathologic processes, such Surgical resection can restore useful range of 30 CLINICAL SYMPOSIA Plate 19 Urodynamics 100- Sphincter stretch Cystometrogram 80- showing wide Intravesical fluctuations in 60- elevated intra- pressure I (cm H2O) vesical pressure 40- and corresponding I variations in 20- urethral sphincter tone as bladder is filled. Detrusor 50 100 150 200 250 300 and urethral MI of water instilled into bladder sphincter inhibited Urethral in response to anal sphincter sphincter stretch activity (EMG) Flow rate Technique of anal sphincter stretch One or two fingers gently inserted into anal canal. Sphincter stretched in postero- lateral direction and maintained during voiding trial Netter © CIBA Sphincter Voiding 100- Cystometrogram stretch by tapping showing persistent 80- high sphincter tone Intravesical and little variation pressure in elevated intra- 60- (cm H2O) vesical pressure as bladder is filled 40- (failure of anal sphincter stretch). 20- Patient requires intermittent cath- 50 100 150 200 250 300 eterization and may MI of water instilled into bladder be candidate for sphincterotomy Urethral (particularly if sphincter pressures remain activity (EMG) above 80 cm H2O) Flow rate VOLUME 34, NUMBER 2 31 Plate 20 Procedures to Correct Bladder Sphincter Dyssynergia Sphincter urethrae Sphincterotomy 0 Collin's knife inserted through sheath of resectoscope, cutting through anterior wall of prostatic and membranous urethra and sphincter urethrae. Broken arrow indicates Endoscopic view showing line of incision extent of incision anteriorly at "12 o'clock" (broken line) Ureteral orifice Bladder neck resection C CIBA Electrosurgical cutting loop introduced through sheath of resectoscope; 0.5 cm of bladder neck cut from "3 o'clock" through Endoscopic view showing extent of "6 o'clock" to "9 o'clock," starting about bladder neck to be excised (broken line) 1.5 cm from ureteral orifice 32 CLINICAL SYMPOSIA motion only if the bone is mature, i.e., after times a patient can repeat an exercise. Nothing is many months. However, the surgery is difficult, gained by pushing the patient beyond his capac- blood loss may be considerable, and bone for- ity just to achieve an early discharge, for if his mation may recur. physical state is weakened, the only result will Recently, etidronate disodium has proved to be increased readmissions for medical problems. effectively reduce the incidence of heterotopic bone formation following spinal cord injury and Psychosocial Counseling prevent recurrence after excision of paraarticular Spinal centers differ in the degree to which bone. We routinely give patients this drug as they assume responsibility for psychosocial soon as heterotopic ossification is identified. rehabilitation, depending on the availability of psychiatrists and psychologists and the back- Physical and Occupational Therapy ground of their social workers. The assistance of During rehabilitation of the patient with spi- a psychologist is clearly valuable in the rehabili- nal cord injury, physical and occupational thera- tation of patients with brain damage or chronic pists assume a major role in teaching the patient pain, but most psychosocial problems stemming skills to achieve optimum function. Skills that from spinal cord injury can be handled by a increase mobility include mastery of an appro- well-trained medical social worker if psychologic priate means of ambulation (Plate 21), transfer or psychiatric consultation is available. to various supporting surfaces (commode, bed, Spinal cord injury victims, just as others who sofa), and exercises to improve rolling, coming to sustain a significant loss, pass through phases of a sitting position, range of motion, balance and shock, denial, depression, hostility and gradual kinesthetic sense. Kinesthetic development is acceptance of their condition. Social workers especially important in the trapezius and latissi- therefore must be trained to help with these mus dorsi muscles, since these muscles insert on emotional problems, as well as with questions the thoracic and lumbosacral vertebrae, respec- about sexual identity and body image and prac- tively, and help control the body in a sitting tical matters such as finances, employment position if the paraspinal muscles are compro- potential, and preparation for visits home. mised. Motor skills are reinforced through sports activities. Sexual Readjustment Occupational therapy teaches the patient When the patient is ready, a counselor who skills required for self-care, such as feeding, thoroughly understands the patient's altered grooming, bathing, dressing, and control of a physiology can offer general or in-depth per- modified manual or powered wheelchair if the sonal discussion of sexual rehabilitation. At all patient is quadriplegic. In addition, the patient is injury levels, genital functions are impaired, and provided with adaptive equipment such as func- adjustments in sexual activity are required. tional splints, mobile arm supports, Velcro clo- Spinal cord injury does not generally affect the sures on clothing, and mouth sticks for typing ability of female patients to conceive, since via- and painting. Driving with hand controls is also ble ova are produced once the menstrual cycle taught. returns, about 3 to 8 months after injury. Vaginal Before the patient returns to his home or place delivery is usually possible, particularly if the of business, appropriate architectural adjust- woman is paraplegic and multiparous. Delivery ments should be made. The decision to return to in quadriplegics and paraplegics with high-level school or employment is best deferred for about lesions may require spinal or epidural anesthesia 4 to 6 months after discharge, until the patient and forceps, because autonomic hyperreflexia has adjusted to living at home. can develop, especially during the second stage Perhaps the most crucial concern during reha- of labor, and these patients lack the abdominal bilitation is pacing. The therapist must be aware muscle control required to assist the delivery. of the psychologic and medical barriers to read- Male patients often lose fertility due to a justment and pace the patient so that his rate of reduction in the number and quality of sperm, learning is neither so slow as to be boring or which usually occurs several months after frustrating nor so fast as to produce persistent injury. The reasons for this are not well under- fatigue. Pacing is particularly important for stood. The Leydig cells continue to secrete tes- patients over 50 years of age. Parameters that tosterone, but the germinal epithelium changes should be monitored to guard against overtrain- and few sperm are produced. Further, the syner- ing and fatigue include vital capacity, heart rate, gistic activity required to ejaculate sperm is weight, hemoglobin level and the number of compromised, particularly for quadriplegics, VOLUME 34, NUMBER 2 33 Plate 21 Orthotic Devices, Braces and Wheelchairs Functional wrist orthotic device aids in prehension and in maintaining metacarpophalangeal alignment. Extension of wrist opposes fingers to thumb, providing grasping action Molded polypropylene orthotic device preferred by many patients to conventional braces because of lighter weight and more pleasing cosmetic appearance Paraplegic girl wearing full-length lower limb braces, facilitating ambulation by "swing-through" gait Patient wearing conventional double-metal upright below-knee brace for weakness of foot dorsiflexors and evertors Pegs on hand rim of Quadriplegic in wheelchair allow patient electric wheelchair with paralyzed lower limbs controlled and and weak upper limbs to guided by chin grasp rim and push more attachment on easily switch box C CIBA 34 CLINICAL SYMPOSIA so sperm may be washed into the bladder and infection that has developed into bronchopneu- die in the acid environment. monia, for example, requires more intensive Alterations in potency due to spinal cord treatment than a normal person, because of his injury vary, depending on the incompleteness of difficulty in raising secretions. This special treat- the lesion. In general, erections in complete ment is best obtained at a facility where the quadriplegics are easy to elicit on a reflex basis, nature of the illness is understood and the but ejaculation occurs rarely if at all. With lower patient's other needs can be provided for. lesions, erections are not as easily obtained but ejaculation becomes more possible. Reflex erec- Vocational Training tions and ejaculations are not possible in men Ideally, a spinal center should maintain close with lower motor neuron lesions, although psy- liaison with government vocational rehabilita- chogenic erections have been reported. tion departments and employ a vocational coun- In addition to modifying the traditional posi- selor to help smooth the patient's return to tion for sexual intercourse, some couples have employment. The patient may return to his found various "sexual aids" helpful. Surgically previous employer in a capacity consistent with implanted penile prostheses for patients with the disability or be trained in a new field, such as spinal cord injury are being evaluated. the computer industry, which offers employ- ment potential despite the handicap. At a few FOLLOW-UP CARE centers, "halfway houses" serve as a transition to Not all rehabilitation goals can be completed independence or as a hostel for patients return- during the first hospitalization, because of ing for counseling and evaluation. medical problems, mobility restrictions, or lack Although much emphasis has been placed on of desire on the part of the patient. It is impor- encouraging patients with spinal cord injury to tant during the initial hospitalization that return to the mainstream of life and on encour- patients learn the basic skills of wheelchair inde- aging employers to hire the handicapped, archi- pendence (if this is feasible) and satisfactory tectural and attitudinal barriers still exist. Even if bowel and bladder management, but a 2- to an employer is willing to accommodate the 3-month period at home before advancing to the handicapped, return to open employment may next level is sometimes advisable. This allows prove difficult for many patients, especially the patient to practice the skills he has learned, complete quadriplegics. They may more realis- obtain adequate rest, rebuild protein and hemo- tically consider sheltered employment, where globin levels, regain lost weight, and be ready for facilities are accessible to wheelchairs and pro- further training on return to the center. ductivity is geared to patients' capabilities. Any spinal cord center worthy of the name To reduce the stigma attached to sheltered must be willing to make a commitment to the employment, even if it serves as only a transition patient for life and provide for needs that arise to open employment, the workshops should after the formal rehabilitation period. Although have attractive surroundings and pleasant inte- it is not necessary for every patient to receive all riors, and, more important, the staff must recog- his follow-up care at a spinal unit, especially if nize that different disabilities produce quite he lives some distance away, scheduled out- different needs. Spinal cord injury usually does patient visits or short-term hospital admissions not impair brain function; thus, these patients should be arranged once a year or more often if should be grouped with people with similar needed. At these visits, patients can obtain treat- or compatible handicaps. ment of intercurrent medical problems, Employment is not feasible for some patients advanced functional training, and further voca- with spinal cord injury because of advanced age, tional training and can participate in recreational poor general health or lack of desire. Patients opportunities. The services of a visiting nurse who do not wish to work should be identified operating out of the spinal center help reduce during the follow-up phase so that time and the need for medical readmissions. effort are not wasted in preparing them for work. Assistance should always be available, however, Medical Treatment should their medical status or attitude change. Early stages of an illness that might not be cause for concern in an able-bodied person Recreation become significant in a person with spinal cord The late Sir Ludwig Guttmann long champi- injury because of the potential for complications. oned the value of recreation and sports for the A C6 quadriplegic with an upper respiratory disabled, and many spinal injury centers VOLUME 34, NUMBER 2 35 throughout the world sponsor such programs In the developed countries, motor vehicle acci- during rehabilitative and follow-up treatment. dents account for 45% to 50% of cases, according Spectator activities include concerts, sporting to the National Spinal Cord Injury Data Research events, theatrical presentations and field trips to Center. Urging motorists to wear seatbelts, and a shopping center or park. These outings enable enforcing the lower speed limit and laws against the handicapped person to mix with able-bodied driving while intoxicated will help reduce the people in a protected environment and help number of accidents. him realize that he need not be a recluse. The ultimate aim of all preventive measures is Active recreation includes competitive or to reduce the incidence of spinal cord injury, noncompetitive wheelchair sports such as bas- which is between 15 and 35 persons per million ketball, archery, field events, slalom racing, worldwide. The cost of medical care, equipment tennis and tobogganing. International classifica- and other needs after injury is estimated at tions of ability have made competition more $42,000 to $70,000 for the first year of treatment. even among spinal-injured persons. The loss to the individual and to society is partic- The sense of belonging engendered by team ularly keen when one realizes that spinal cord sports and the opportunity to experience the injury occurs most often in teenagers and young exhilaration of winning as well as the pain of adults. losing in a protected environment are of psycho- logic benefit. Neurologic gains include improve- COMMENT ment in proprioception and motor performance, Spinal cord injury is not simply a malady of especially in those muscles innervated by cervi- the spine. The loss of function of the spinal cord cal roots that cross the level of the lesion, such as alters the function of other body systems, which the latissimus dorsi and trapezius. Active exer- must constantly be considered during all phases cise also improves the cardiovascular system. of treatment. The most effective practitioner to care for a patient with spinal cord injury is the PREVENTION OF INJURY "generalist for the spinal cord-injured," who has Prevention of spinal cord injury is a concept some knowledge of all the systems likely to be easy to discuss but hard to put into practice. affected by the injury and can coordinate consul- Trauma to the spinal cord could be prevented if tation with medical specialists and the activities people avoided the activities that lead to such of allied health professionals. By being able to trauma, but it is unlikely that automobile driving evaluate the long-term effects of the medical or will cease or sports events be discontinued, surgical programs, he provides a comprehensive although accidents from both of these activities program of care and thereby gives the patient the are the leading causes of spinal cord injury. best possible chance for successful adjustment. The x-rays in Plate 7 and the lower x-ray in Plate 8 are reproduced with permission from Cloward RB. Acute cervical spine injuries. Clin Symp 1980; 32(1):1-32. Plate 21 was prepared in collaboration with Thorkild J. Engen, C.O., Director, Orthotics Depart- ment, The Institute for Rehabilitation and Research, Houston, Texas. BIBLIOGRAPHY Bischof W. Die longitudinale Myelotomie, erstmalig zervical In Vinkin PJ, Bruyn GW (eds). Handbook of Clinical Neurol- durchgeführt. Zentralbl Neurochir 1952; 12:205-210 ogy. Amsterdam, North Holland Publishing Company, 1976 Bors E. The spinal cord injury center of The Veterans Admin- Munro D. Treatment of Injuries to the Nervous System. Phil- istration Hospital, Long Beach, California, U.S.A. Facts and adelphia, WB Saunders Company, 1952 Thought. Paraplegia 1967 Nov; 5:126-130 Pearman JW, England EJ. The Urological Management of the Braakman R, Penning L. Injuries of the cervical spine. In Patient Following Spinal Cord Injury. Springfield, III, Charles Vinkin PJ, Bruyn GW (eds). Handbook of Clinical Neurology. C Thomas, Publisher, 1973 Amsterdam, North Holland Publishing Company, 1976 Quimby CW Jr, Williams RN, Griefenstein FE. Anesthetic Griffith BH. Advances in the treatment of decubitus ulcers. problems of the acute quadriplegic patient. Anesth Anal Surg Clin North Am 1963 Feb; 43:245-260 (Cleve) 1973 May-Jun; 52:333-340 Guttmann Sir L. Spinal Cord Injuries-Comprehensive Stover SL, Mataway CJ, Zeiger HE. Heterotopic ossification in Management and Research. Ed 2. Oxford, Blackwell Scien- spinal cord-injured patients. Arch Phys Med Rehabil 1975 tific Publications, 1976 May; 56:199-204 Herceg SJ, Harding RL. Surgical treatment of pressure ulcers. Young JS, Northrup NE. Statistical information pertaining to Arch Phys Med Rehabil 1978 Apr; 59:193-200 some of the most commonly asked questions about SCI. Kakulas BA, Bedbrook GM. Pathology of injuries of the ver- Phoenix, National Spinal Cord Injury Data Research Center, tebral column-with emphasis on the macroscopical aspects. 1979 36 CLINICAL SYMPOSIA CIBA CIBA Pharmaceutical Company Division of CIBA-GEIGY Corporation Summit, New Jersey 07901

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"Comprehensive Management of Spinal Cord Injury" [1982]

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