PM&R plays an essential role in managing the individual with a spinal cord injury (SCI). Receiving care at an acute hospital and a rehabilitation center familiar with SCIs is critical. PM&R can guide the health care team and the patient/family through such a potentially life-changing event. Early consultation can help prevent complications and decrease stay length and mortality. A life-long relationship with the rehabilitation team is often recommended; team members such as navigators and multiple inpatient rehabilitation stays can help enhance care and opportunities for individuals with SCI.
Key points
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An early physical medicine & rehabilitation (PM&R) consultation contributes positively to the patient’s short and long-term outcomes.
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Transfer to a specialized spinal cord injury (SCI) rehabilitation center decreases length of stay, mortality, and secondary complications.
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The role of a nurse navigator (or similar) can enhance the ability to continue caring for an individual with SCI after discharge from inpatient rehabilitation.
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Phased admissions to inpatient rehabilitation can be considered as an alternative to address specific goals for persons with SCI.
Section 1–introduction
A spinal cord injury (SCI) is often a catastrophic event in the life of an individual and its support system. It is challenging enough to go through this experience, let alone understand our complex health care system while attempting to gain access to the best possible care as an inpatient, an outpatient, and beyond. Often, individuals, initially and later on, feel returning to professional or leisure activities is not possible; furthermore, they feel like their function and/or quality of life is or will be nonexistent. PM&R’s intervention can address these and other issues throughout the individual’s life.
Section 2–history
Part 1–Acute Hospital Stage
A PM&R consultation early in the patient’s hospital course is essential for the short -and long-term outcomes-of the individual with an SCI. Many patients with an SCI will present to the hospital through the Emergency Department (ED) with symptoms that may be subacute, such as progressive weakness, imbalance, or diminished sensation in their upper or lower extremities. In contrast, others will be brought in secondary to an acute sentinel traumatic event. These may range from a “benign” fall to a major motor vehicle accident with polytrauma. Imaging will be paramount–Computed Tomography (CT) without contrast will elucidate vertebral abnormalities. When severe enough, this may give enough information to point to SCI. When not immediately certain, a Magnetic Resonance Image (MRI) of the affected spine region can help clarify if there is cord involvement. Without radiographic evidence, looking for clinical signs of SCI, such as weakness, loss of sensation, and bowel or bladder changes, is important. Neurosurgery/Orthopedic Spine should be consulted, and a recommendation should be made on whether the patient will need acute surgical intervention and the timing of it. A decades-long debate regarding the early use of steroids for improved motor outcomes remains ; Bracken’s findings from a meta-analysis would argue for steroid use within 8 hours from the injury and continued for 48 hours (instead of 24 hours). Because of the controversy, corticosteroids are used in many health care systems but have not been universally adopted.
The PM&R or SCI consultant should ideally be involved on postoperativeday 1 to allow the best longitudinal care throughout the patient’s acute hospitalization. It is important to foster a good relationship with the entire trauma team and create awareness of the optimal time for PM&R to be included in the patient’s care. Physical therapy (PT) and occupational therapy (OT) should also be consulted to better represent the patient’s current functional status. Speech/language pathology (SLP) should be consulted in cases of cervical injury, especially (although not exclusively) when requiring anterior surgical fixation; other reasons may include suspicion of concomitant brain injury (that leads to dysfunction in swallowing and/or cognition and/or inability to communicate) as this is estimated to range anywhere between 12.5% and 74.2% based on the diagnostic criteria that are used. In the immediate post-op period, likely before therapy services are appropriate for the patient to work with, the PM&R consultant’s recommendation should be centered around pain, neurogenic bowel, neurogenic lower urinary tract dysfunction (NLUTD), neurogenic skin, contracture prevention, and when appropriate, ventilator weaning.
Additionally, one should consider elements that are arguably vital (yet often overlooked), such as ensuring the patient has access to calling for assistance (eg, sip/puff system, “pancake” call button, and so forth), access to independent suctioning (when applicable), independent water drinking (when appropriate) through sip mechanism as well as access to smartphone, tablet, and so forth for independent communication.
Pain
A multimodal approach to pain is important, with a plan to the transition off of IV pain medications in the anticipation of discharge to acute inpatient rehabilitation. It is important to delineate between nociceptive pain (secondary to the injury or surgical site) and neuropathic pain (primarily from nerves). Nociceptive Pain in the immediate period is best treated with scheduled medications without a patient’s ability to request them. Acetaminophen is an example, and it should not exceed 3 g daily on a continuous basis or 4 g in any 24 hours. This can be supplemented with as-needed (PRN) options for mild, moderate, and severe pain. Local pain control can also be beneficial–if a patient’s pain level can be brought down by a patch or topical agent, it may ultimately reduce the amount of PRN oral or IV medications they require.
On the initial consult, it is important to ask the patient about their level of neuropathic pain. If applicable, gabapentin and pregabalin are common options that can be started at a low dose and titrated up as required.
Neurogenic lower urinary tract dysfunction
SCI can affect the bladder in multiple ways. In the immediate postinjury period, spinal shock is common. In acute care, due to immobility, it is commonplace for an indwelling catheter to be inserted for drainage. Notably, a catheter has no significantly increased risk of infection compared with intermittent catheterization, assuming appropriate hygiene. It is important to consider the patient’s level of neurologic injury and ask for normal subjective sensation in the suprapubic region. Both para and tetraplegic patients, especially those with impaired sensation in the suprapubic region, may need to maintain such a catheter during the entirety of their acute hospitalization and to delay a voiding trial for their inpatient rehabilitation stay. This is due to the need for proper voiding to manage mobility, clothing, hygiene, and, if needed, straight catheterization, which may or may not be feasible depending on the level of injury and/or comorbidities and/or body habitus, and so forth.
If a patient feels confident about their bladder sensation and pursues a voiding trial, postvoid residual (PVR) bladder scans should be performed every 4 to 6 hours with straight catheterization indicated above a volume of 200 cc, as this indicates inadequate emptying. If on an oral diet, the patient should be instructed to keep oral hydration fairly equal throughout the day to eliminate a confounding variable in their PVRs. If the patient begins to void spontaneously, the ratio of their voided volume to the PVR should also be evaluated. There is no specific literature to support the following, but there seems to be a consensus amongst providers (PM&R and Urology) that risk begins around 40% PVR/Bladder Capacity (with bladder capacity being PVR + voided volume). Above this 40%, the risk would be higher. If a patient has 3 consecutive low PVRs, it is reasonable to stop bladder scans. As their bladder function can change over time with their injury, it is still recommended to have a urodynamic study upon urology referral as early as possible. ,
Neurogenic bowel
Establishing whether the patient has an upper motor neuron (UMN), lower motor neuron (LMN), or mixed picture is important to creating a bowel program. A UMN injury retains nascent spinal reflexes that are taken advantage of during a bowel program. In the immediate period, it is reasonable that the patient may still be in spinal shock and thus may be areflexic.
The cornerstone of establishing a UMN bowel program is a rectal bisacodyl suppository and/or digital stimulation done regularly. To aid the bowel program, other agents, such as colonic irritants (eg, senna) given 8 to 12 hrs before desired bowel movement or stool softeners (eg, docusate) multiple times per day, or osmotic agents such as polyethylene glycol can be added (scheduled or PRN) to enhance the program further as needed. The goal should be a moderate-large, soft bowel movement with every suppository (within 45–90 minutes), ideally with no incontinence episodes. Due to the combination of neurogenic bowel and likely opioid medication for pain, patients are at an increased risk for constipation and ileus. If a patient has not had a bowel movement for multiple days, an abdominal X-ray can be ordered to determine the amount of stool burden in the colon.
An LMN bowel program is typically indicated for patients who either have a lower lumbar/sacral level of injury and/or are in spinal shock and, therefore, have flaccid rectal tone (determined by rectal examination). Due to this flaccidity, it is important to incorporate bulking agents (such as psyllium) if the stool consistency is soft or liquid. Assistance from gravity (sitting in a chair) can be used to evacuate the stool, followed by manual evacuation. Performing this regimen multiple times a day can decrease the risk of incontinence.
Contracture prevention
In the immediate period, spinal shock may present as flaccidity in the affected limbs. , However, over time, as spinal shock resolves, spasticity may develop. As a result, it is important to start a passive range of motion with the patient. Even in patients who do not develop significant spasticity, contractures may develop independently due to immobility. PT and OT will be paramount at the beginning of this activity. They will also help determine whether resting braces are necessary to avoid contractures ( Fig. 1 ). If stretching does not completely alleviate spasticity, especially if the patient is the complaining of pain secondary to spasticity, oral medications such as Baclofen (scheduled) can be considered.
Pressure injury prevention
Patients with SCI are at higher risk of skin breakdown due to insensate areas due to their injury. Air-loss beds can shift weight automatically and decrease the risk of pressure ulceration forming, especially in the sacral region. However, these beds may not be as readily available in every hospital. It is important to communicate to the nursing staff to aim to turn the patient every 2 hours on average to prevent pressure ulceration. This is important as skin ulceration can be a source of infection and affect the patient’s ability to sit depending on location and dimensions. Skin breakdown can affect their ability to participate in therapies and transition to an acute inpatient rehabilitation unit/facility, increase the time spent in acute care, and increase the overall cost of hospitalization. Additionally, using bedside chairs in a typical ICU room could significantly increase the risk of pressure injuries to the skin.
Ventilator weaning
Patients with cervical injury are at risk for acute respiratory failure due to compromise of the nerve function to the diaphragm (phrenic nerve, innervation C3-5). Unlike patients who are intubated for intrinsic respiratory pathology (eg, COPD), the ability to wean off of a ventilator for patients with SCI is dependent on the degree to which they have neurologic compromise (ie, restrictive lung disease). Respiratory therapy should be involved in the acute hospital setting. PM&R can assist in the weaning process, avoid complications (eg, Pneumonia), and/or facilitate a transition to one of the few select SCI rehab centers in the United States (US) that will accept ventilator-dependent patients. However, the remainder of ventilator-dependent patients may need to be discharged to a Long-Term Acute Care Hospital (LTACH) prior to going to acute inpatient rehabilitation.
Referral to spinal cord injury specific centers
Available data supports better outcomes for patients with SCI if they receive acute inpatient rehabilitation from a dedicated SCI center or an acute inpatient rehabilitation hospital with a dedicated SCI Unit. In addition to having care from SCI-trained physicians, the rest of the staff is familiar with these patients’ specific medical and therapy-related issues, which helps with medical equipment and troubleshooting the transition of care. A referral from acute hospitalization to the closest SCI center for acute inpatient rehabilitation is paramount, even if the patient will not continue care at that hospital upon transition to home/outpatient. Additionally, this will help the patient have less overall costs over time.
Part 2–Acute Inpatient Rehabilitation
Acute inpatient rehabilitation offers a multidisciplinary approach by the rehabilitation team. Early rehabilitation after SCI enhances patients’ functional status upon discharge. It is appropriate as soon as the individual is medically stable. Patients must tolerate participation in at least 3 hours of therapy for 5 days each week (or a total of 15 hours spread over 7 days) and engage in two or more therapeutic activities, one of which is occupational or physical therapy. The rehabilitation team includes a physiatrist or SCI physician, nursing, PT/OT/(+/−)SLP, neuropsychologist, nutritionist, case manager, and/or social worker at a minimum (additional members can include respiratory and recreational therapists and engineers). Patients with cervical SCI should undergo assessments for swallowing, cognitive, and communication impairments by SLP. This is crucial, particularly due to this population’s heightened risk of silent aspiration. In the US, the estimated stay at the rehabilitation hospital is approximately 31 days.
The physiatrist plays a leadership role and is responsible for preventing and treating medical conditions associated with SCI. A profound comprehension of neuroanatomy and pathophysiology is fundamental for accurately assessing and effectively managing spinal cord injuries. To determine the severity and extent of spinal cord damage, a knowledge of classification systems such as the International Standards for Neurologic Classification of Spinal Cord Injury (ISNCSCI) is indispensable. Physiatrists must also be able to identify and manage potential medical complications linked to SCIs, including but not limited to neurogenic bowel, NLUTD, autonomic dysreflexia (AD), orthostatic hypotension, spasticity, pressure injuries, and respiratory issues. Expertise in pain management, functional assessment, durable medical equipment (DME), psychosocial support, patient education, and discharge planning is essential. 7 Physiatrists also play a crucial role in addressing the prognosis at the bedside or in a formal meeting during hospitalization and advising and educating patients and families about SCI. , , ,
Guideline for physiatrists
Effective collaboration within a multidisciplinary team is imperative for physiatrists in the comprehensive care of individuals with SCIs. Ensuring access to a specialized urologist for consultation on bladder management for NULTD is crucial, and traditional recommendations propose urodynamic studies (UDS) around 3 to 4 months postinjury. However, certain studies examining NULTD with early UDS within the first month of injury have revealed the presence of detrusor overactivity, suggesting potential clinical utility at an earlier stage, considering it might improve urologic outcomes long term. , Psychologists’ involvement is pivotal in helping patients adapt to their medical circumstances and supporting caregivers. They serve as valuable intermediaries between patients and the health care team, addressing specific concerns and providing coping strategies for fear and anxiety during rehabilitation. In acute inpatient rehabilitation hospitals, internal medicine becomes indispensable, especially in facilities with a heightened case mix index (CMI) due to increased medical complexity.
Furthermore, the availability of additional consultants, including plastic surgeons, infectious disease specialists, spine surgeons, and pulmonary specialists, among others, proves invaluable in addressing the diverse needs of the SCI population.
Goals
Appropriate durable medical equipment
Ensuring the appropriate selection of DME for patients is a crucial task carried out by the health care team, primarily PT and OT. This involves considering the patient’s needs, discharge location, and medical insurance coverage. Ideally, patients undergo a personalized evaluation at a wheelchair clinic, and placing orders for DME is started in preparation for discharge. These include equipment for showers and transfers, considering the need for a manual or lift for patients dependent on transfers. Also, a fully electric hospital bed may be recommended. Another suggestion in preparation for home discharge is to conduct a home assessment to determine whether home modifications are necessary, such as the addition of ramps, accessible doors, bathroom adaptations, and so forth. After consulting with the rehabilitation team, it is advisable to pursue home modifications to ensure they align with safety requirements tailored to the patient’s and their family’s specific needs. This comprehensive approach aims to enhance the transition to home and contribute to the patient’s overall well-being.
Family training
It is recommended that this be initiated as early as possible during a hospital stay. This involves preparing the caregivers with the necessary skills for daily care, including turning the patient and relieving pressure, dressing, operating the wheelchair, showering, managing respiratory needs, handling bowel and bladder management, and performing transfers. A practical approach involves implementing an “in-house pass,” particularly tailored for patients with high cervical injuries or those at a lower functional level once basic training has been done. The in-house pass entails the primary caregiver spending 24 hours with the patient, offering comprehensive assistance under the supervision of trained health care professionals, including nurses, respiratory therapists, PTs, OTs, and SLPs. This collaborative approach ensures that the caregiver receives appropriate guidance while actively participating in the patient’s care, enhancing the overall support and understanding of the patient’s needs.
Education
Patient education for SCIs during inpatient rehabilitation is comprehensive and multifaceted. It covers various aspects, including understanding the injury’s nature, medical management including Autonomic Dysreflexia (AD), mobility and rehabilitation techniques, DME, bowel and bladder management, pain management, psychosocial support, nutrition, home modifications, and safety. The goal is to empower patients, enhance self-care skills, and facilitate a smooth transition to postdischarge life. This collaborative effort involves health care professionals, rehabilitation specialists, and the patient’s support system. One recommended option is educational programs consisting of one-hour sessions conducted by non-physician facilitators when possible. These sessions can be tailored to individual needs in one-to-one settings or delivered in a group format, ensuring a well-rounded and personalized patient educational experience.
Part 3–Postinpatient Rehabilitation Stage
It is well established that individuals who experience an SCI benefit the most from being cared for at a specialized SCI center as it relates to decreasing length of stay, mortality, and secondary complications. However, accomplishing this is a challenge in itself. Furthermore, what happens to these individuals, assuming they receive acute care (including rehabilitation) in the “appropriate” setting, once they are discharged back into the community is yet another complex set of circumstances that pose a challenge to the individual and his/her support system; these may include but is not limited to access to care as well as the intricate and complex role the caregiver(s) play in the life of the individual with SCI. , These challenges are compounded further by an aging SCI population.
To the question: “How to increase the likelihood of health and success for those with SCI once they are back in the community?” there are different concepts in the US and beyond that could offer reasonable solutions; a list of currently known options by the authors is as follows.
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Comprehensive nurse navigator program
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Nurse educator
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Social work navigator
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Ongoing use of specialized centers not only for inpatient needs
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Readmitting patients to acute inpatient rehabilitation multiple times during the first 1 to 2 years of their injury/disorder and as needed
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Education (both physiatrists and nonphysiatrists (eg, PCPs) through nonprofit organizations to enhance the ability to care for these individuals
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Adaptive sports
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Performance arts
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State assistance programs (eg, CRS)
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Charity clinics (eg, RSVP), , as lack of insurance is related to higher mortality in general
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Establishment of private or out-of-pocket pay care for an SCI team that performs home visits (This paradigm addresses the lack of inpatient options in Mexico but could be considered elsewhere under certain circumstances)
The above-described list is not all-inclusive and may be missing important option(s) that the authors may not be familiar with; furthermore, some options certainly do not exclude others but can enhance or even synergize their benefit to the individual.
We believe it is essential to recognize that the health care landscape in the US varies significantly in terms of an individual’s ability to access care. (due to geographic limitations, system knowledge, health care insurance access, quality, and so forth). It is also important to acknowledge that some of what is shared and discussed here is, in some cases, information based on experience and expert opinion due to the paucity of information related to this topic.
Initially pioneered by other specialties such as oncology, , then followed, among others, by heart and kidney failure teams , and scarcely used by some physiatrists around the US, the nurse navigator concept offers a solid option for facilitating proper and accessible care once discharged from the hospital environment. The complexities of the health care system can lead to an unsafe “game of telephone” where intended instructions, recommendations, and even prescriptions can result in patients not continuing their care after discharge the way intended; team members such as a nurse. , and/or social work navigator, , a nurse educator , can be invaluable in enhancing information communication, increasing the likelihood of a successful home discharge, and decreasing hospital readmissions and complications.
As a complement to the above (rather than a substitute), it is also important to highlight the role of activities such as sports. , and the arts , can play a role in the well-being of our patients.
There is a strong tendency to focus on the acute and subacute stages of our patient’s journey with an SCI; supporting this is the fact that there has been a 40% decline in the mortality rate during the first 2 years postinjury ; subsequent data has shown different findings regarding long term survival after SCI ; Whether an individual can live a few years or several decades, data supports the importance of their ability to engage in meaningful activities, including recreational ones, which will/can play a significant role in their mental, physical, and emotional health.
For this reason, it is also important to engage our patients with opportunities and activities available in their communities as early as possible to help them explore options available; often, specialized SCI centers will have staff, including recreational therapists, with this kind of expertise. Additionally, while still hospitalized, the knowledge that a patient can re-engage in one of their favorite preinjury activities can motivate them to rehabilitate and reconnect with old activities or discover new, fulfilling ones.
Another item worth highlighting is exploring and providing patients with access to social work (SW) as outpatients; they can provide ongoing recommendations and assistance as SW’s needs do not disappear after discharge from rehabilitation. One of these experts’ many roles is connecting patients to agencies that can provide support in different ways, including “payment of last option” for equipment and services (eg, chairs or therapies). Other cities, counties, and states can provide different options; one of many such programs could be the CRS program in Texas. Additionally, foundations that support patients who meet specific criteria can, once again, provide support that would not be present otherwise. SW can also be of solid significance in facilitating relationships with a vocational agency to open up options for future employment.
Section 3–challenges/recommendations
An SCI, whether traumatic or nontraumatic, is a potentially catastrophic event in the life of an individual and those around him/her that can transform all aspects of his/her existence, either permanently or temporarily. , , Going through the injury and its consequences from a health point of view is challenging enough. However, nowadays, most, if not all, involved must additionally decipher how to navigate the ever-so-complex health care system that exists in the US; doing so is not for the “weak of heart” as, even for trained health care providers and their teams, this remains a consistent source of frustration as a “moving target,” let alone for the lay individual that is not accustomed to the intricacies of such a system. The content above is meant to provide the non-SCI physiatrist involved in working with patients undergoing such injuries travel through the continuum of care in the most efficient way possible to allow for the best short- and long-term outcomes. From the moment of the injury and for the rest of his/her life, it is essential to set up individuals as much as possible for success in function and quality of life; the physiatrists and the rehabilitation team play a pivotal role.
We aim to enhance the patient’s ability to participate in active and functional rehabilitation once medically appropriate while maintaining the highest quality of life and avoiding complications.
Section 4 – important clinics care points
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Comprehensive interventions, spanning acute, rehabilitation, and postacute care, aim to empower patients with SCI and their families by enhancing self-care skills and facilitating a smooth transition after discharge.
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Specialized SCI centers offer significant benefits for individuals with SCI, including reduced length of stay, lower mortality rates, and fewer secondary complications.
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Accurately determining the neurologic level of injury and severity is crucial for tailoring care plans, especially in managing bowel and bladder functions. Proper timing and frequency of care programs can effectively mitigate complications.
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Educating health care staff about the diverse needs of patients with SCI, such as frequent repositioning and pressure relief, is essential. Pressure injuries extend acute care stays and increase overall hospitalization costs.
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Early urodynamic studies within the first month of injury have shown promising results in detecting detrusor overactivity, potentially enhancing long-term urologic outcomes. ,
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Nurse navigator programs are pivotal in ensuring comprehensive and accessible care following discharge.
Section 5–case presentations
Case Presentation 1
Acute hospital stage
An 18-year-old man with no significant medical history was in a car accident and taken to the ED. He was conscious but had shortness of breath, paresthesia in all extremities, and minimal limb movement. A CT showed a C5-6 dislocation fracture, prompting transfer to a Level 1 Trauma Center. He required mechanical ventilation due to labored breathing and oxygen desaturation. An MRI revealed severe spinal cord compression from C4-7, leading to immediate C4-7 posterior spinal fusion. Postoperatively, he needed a tracheostomy and PEG tube and had an indwelling catheter, bowel incontinence, and no sensation during bowel movements. He also reported surgical site pain.
PM&R consultants recommended scheduled acetaminophen and gabapentin for pain, PT/OT to assess function and assist with phone access, and SLP for dysphagia management. An ISNCSCI examination was performed for SCI classification and prognosis. Recommendations included PRAFOs, wrist splints, turning every 2 hours, and a pressure-reducing cushion to prevent contractures and pressure ulcers. The primary team continued bladder management with an indwelling catheter and started a bowel program.
Based on his neurologic level of injury, he had the potential to come off the ventilator. He was determined to benefit from transfer to a specialized SCI center for comprehensive rehabilitation.
Case Presentation #2
Acute inpatient rehabilitation stage
A 24-year-old woman with complete tetraplegia C2 AIS A from an MVA underwent C4-C5 ACDF, decompressive laminectomies C3-C7, and C2-T2 posterior fusion. She developed dysphagia and respiratory failure, requiring a tracheostomy and PEG, later removed, but still needs mechanical ventilation. She was admitted for inpatient rehabilitation phase 1.
During hospitalization, her baseline BP was 100/60 mm Hg. She experienced elevated BP (145/88) consistent with asymptomatic Autonomic Dysreflexia (AD), without headaches, facial redness, diaphoresis, piloerection, or nasal congestion. Initial interventions included sitting her up and loosening her gown. Nurses’ assessments of bowel, bladder, and skin found no abnormalities. BP reached 170/90, and nitropaste was applied. Her menses started that morning, and she was given NSAIDs for 5 days. No further AD episodes occurred.
AD, which can occur in about 40% of cases, can be triggered by stimuli below the injury level. Common sources like bladder or bowel issues were ruled out. In this case, AD was secondary to menstruation, highlighting the need to consider gynecologic causes in female patients. ,
Case #3
Post inpatient rehabilitation stage
A 46-year-old male with T7 AIS An SCI from a gunshot wound 6 months ago visited an outpatient clinic for frequent bowel incontinence. He needs assistance with a bowel program involving suppositories and digital stimulation, which his mother helps with 4 days a week. He takes stool softeners and a stimulant daily but still experiences daily bowel accidents, preventing him from attending church and social activities, so he stays home most days. He has an indwelling catheter but is interested in learning intermittent catheterization.
After his injury, he participated in inpatient rehabilitation but had difficulty with bowel and bladder programs due to spinal orthotic bracing for 12 weeks. His outpatient SCI physician recommended readmission to acute inpatient rehabilitation for bowel and bladder management, known as Phase 2 Admission. This would provide him with the necessary skills for independent bowel and bladder management that he couldn’t achieve during his initial rehabilitation.
Disclosure
The authors have nothing to disclose.
References
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