Physical Medicine Rehab · Supplementary · from Physical Medicine Rehab

Case 1: Spinal Cord Injury Rehabilitation

Patient Presentation

Demographics: 24-year-old male college student and recreational athlete

Chief Complaint: "I can't feel or move my legs after a motorcycle accident"

History of Present Illness: This 24-year-old male college student was involved in a high-speed motorcycle collision 3 weeks ago when he lost control on a wet road and struck a guardrail. He was wearing a helmet. At the scene, he was unable to move his lower extremities and reported no sensation below his chest. He was immobilized with a cervical collar and backboard and transported by air ambulance to a Level I trauma center.

In the emergency department, primary and secondary surveys revealed a T6 burst fracture with posterior ligamentous complex disruption and spinal cord compression. There were no other significant traumatic injuries aside from a left clavicle fracture managed conservatively. He underwent emergent T5-T8 posterior spinal fusion with decompressive laminectomy within 8 hours of injury. Postoperatively, his neurologic examination remained consistent with a complete T6 spinal cord injury.

He is now 3 weeks post-injury and medically stable. He has been weaned from the ventilator (briefly intubated for surgery), his blood pressure has stabilized with discontinuation of vasopressors, and he has been started on a bowel and bladder program. He has been cleared by the spine surgery team for active rehabilitation and is being transferred to the inpatient rehabilitation unit.

Past Medical History:

• No significant past medical history
• No prior surgeries
• No history of psychiatric illness
• Up to date on immunizations

Medications:

• Enoxaparin 40 mg subcutaneous daily (DVT prophylaxis)
• Oxybutynin 5 mg three times daily (neurogenic bladder)
• Docusate 100 mg twice daily
• Bisacodyl suppository every other day
• Gabapentin 300 mg three times daily (neuropathic pain)
• Baclofen 10 mg three times daily (spasticity)
• Famotidine 20 mg twice daily (stress ulcer prophylaxis)
• Acetaminophen 1000 mg every 6 hours as needed

Social History:

• College senior studying engineering
• Varsity soccer player and recreational motorcyclist
• Lives in a second-floor apartment with no elevator (will need accessible housing)
• Non-smoker, occasional alcohol use (social)
• Strong family support system
• No illicit drug use

Family History:

• Non-contributory
• No family history of neurologic disease

Physical Examination

• Vital Signs: BP 108/62 mmHg (supine), 82/50 mmHg (sitting — orthostatic), HR 62 bpm (supine), RR 16/min, Temp 37.0°C, SpO2 98% on room air
• General: Well-developed, well-nourished young male in wheelchair, alert and cooperative. Affect is flat, appears emotionally withdrawn
• Neurologic — Motor (ASIA/ISNCSCI Examination):
• Upper extremities: 5/5 strength in all muscle groups bilaterally (C5-T1 myotomes)
• T1-T6 intercostals: Partially preserved (able to generate some cough)
• T7-T12 abdominal muscles: 0/5
• Lower extremities: 0/5 in all muscle groups bilaterally (L2-S1 myotomes)
• Voluntary anal contraction: Absent
• Neurologic — Sensory:
• Light touch and pin prick: Intact to T6 dermatome bilaterally, absent below T6
• Deep anal pressure: Absent
• Proprioception: Absent in lower extremities
• ASIA Classification: T6 AIS A (complete injury)
• Neurologic Level of Injury: T6
• Reflexes: Upper extremity reflexes 2+ bilaterally. Lower extremity reflexes: absent (spinal shock phase resolving, early hyperreflexia at patellar tendons bilaterally). Babinski positive bilaterally. Bulbocavernosus reflex present
• Skin: Stage I pressure injury over sacrum (non-blanchable erythema, skin intact). No breakdown over ischial tuberosities or heels. Surgical incision T5-T8 well-healed
• Respiratory: Reduced chest expansion. Forced vital capacity 2.1 L (55% predicted). Weak cough
• Musculoskeletal: Left clavicle fracture with palpable callus, non-tender, full ROM of left shoulder. No contractures in lower extremities. Mild ankle plantar flexion tightness bilaterally
• GU: Foley catheter in place, clear yellow urine

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• MRI thoracic spine (post-op): T6 burst fracture status post posterior fusion T5-T8 with pedicle screws. Spinal cord signal abnormality at T6 consistent with myelomalacia. No residual compression
• Lower extremity duplex ultrasound: No evidence of deep vein thrombosis
• Urodynamic studies: Areflexic bladder with capacity 600 mL and no detrusor contractions (consistent with spinal shock phase, will recheck at 3-6 months)
• DEXA scan: T-score -1.8 at femoral neck (osteopenia, expected with acute SCI)
• Pulmonary function tests: FVC 2.1 L (55% predicted), FEV1 1.9 L (58% predicted). Reduced respiratory reserve consistent with T6 level injury
• PHQ-9 Depression Screen: Score 18 (moderately severe depression)

Clinical Image

Diagram illustrating ASIA Impairment Scale classification, T6 spinal cord injury level with corresponding dermatome map, and expected functional outcomes at this level. Source: Educational illustration.

Diagnosis

T6 ASIA Impairment Scale A (Complete) Spinal Cord Injury Secondary to T6 Burst Fracture, Status Post Posterior Spinal Fusion

Key Diagnostic Criteria:

• Complete motor and sensory loss below T6 neurologic level
• No voluntary anal contraction, no deep anal pressure sensation (AIS A classification)
• MRI confirming spinal cord myelomalacia at T6
• Bulbocavernosus reflex present (spinal shock resolving), confirming complete injury prognosis

Treatment Plan

1. Inpatient rehabilitation program (4-6 weeks):

• Physical therapy: Wheelchair mobility training (manual wheelchair), transfer training (sliding board and independent transfers), upper extremity strengthening, sitting balance, pressure relief techniques, standing frame program
• Occupational therapy: ADL independence training, adaptive equipment assessment, upper extremity ergonomics, wheelchair positioning and cushion prescription
• Respiratory therapy: Incentive spirometry, assisted coughing techniques (quad coughing), secretion clearance

1. Neurogenic bladder management: Transition from Foley catheter to clean intermittent catheterization (CIC) every 4-6 hours. Anticholinergic medication to reduce bladder pressures. Renal ultrasound every 6-12 months to monitor for hydronephrosis
2. Neurogenic bowel program: Digital stimulation bowel program every other day. Timed bowel care with bisacodyl suppository. High-fiber diet with adequate fluid intake
3. Skin protection: Pressure-relieving wheelchair cushion (ROHO or JAY), pressure redistribution mattress, weight shifts every 15-30 minutes, daily skin inspection with mirror. Wound care for sacral Stage I pressure injury
4. Psychological support: Individual psychotherapy, peer mentorship with SCI survivor, antidepressant medication (sertraline 50 mg daily initiated), family counseling
5. Medical management: DVT prophylaxis continued, vitamin D supplementation (50,000 IU weekly x8 weeks then 2000 IU daily), calcium supplementation, orthostatic hypotension management (compression stockings, abdominal binder, midodrine if needed), neuropathic pain management optimization, spasticity management with baclofen titration
6. Discharge planning: Home modification assessment (accessible housing, roll-in shower, ramp access), driving evaluation, return-to-school planning with disability services, adaptive sports program referral

Key Learning Points

• The ASIA Impairment Scale (AIS) is the gold standard for classifying spinal cord injuries: A (complete), B (sensory incomplete), C (motor incomplete, majority <3/5), D (motor incomplete, majority >=3/5), E (normal)
• T6 paraplegia patients are expected to achieve independent wheelchair mobility, independent transfers, independent self-care, and community independence with appropriate equipment and training
• Autonomic dysreflexia is a life-threatening emergency that can occur in SCI patients with injury levels at or above T6; it is triggered by noxious stimuli below the injury level (bladder distension, bowel impaction, skin breakdown) and presents with severe hypertension, headache, and bradycardia
• Immobilization hypercalcemia is common in acute SCI (within first 3 months) and should be monitored; early weight-bearing and hydration are preventive measures
• Depression affects 30-40% of SCI patients and is associated with worse rehabilitation outcomes; routine screening and early intervention with psychotherapy and pharmacotherapy are essential components of SCI rehabilitation

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