Neurology · Year 3 · from Neurology

Case 2: Spinal Cord Injury Rehabilitation

Patient Demographics

• Age: 28 years old
• Sex: Male
• Mechanism: Diving accident into shallow water

Acute Event

Mr. Michael Torres sustained a cervical spinal cord injury after diving into shallow water at a lake 4 weeks ago. CT and MRI showed C5-C6 fracture-dislocation with spinal cord injury. He underwent emergent decompression and stabilization surgery. He has been in the acute care hospital for 4 weeks and is now transferring to spinal cord injury rehabilitation.

Current Neurological Status

ASIA (American Spinal Injury Association) Examination:

Motor Level:

Sensory Level: C6 bilaterally (normal sensation through C6 dermatome)

Sacral Sparing: None (no sensation or voluntary anal contraction)

ASIA Classification:

• Motor Level: C6
• Sensory Level: C6
• ASIA Impairment Scale: A (Complete)

Clinical Image

Image: Diagram showing functional expectations at different spinal cord injury levels, from high cervical (ventilator-dependent) through thoracic (paraplegia with upper extremity function) to lumbar (ambulatory potential).

Image Source: Wikimedia Commons Attribution: Medical education, Public Domain URL: https://commons.wikimedia.org/wiki/File:Spinal_cord_injury_levels.png

Functional Expectations for C6 Complete SCI

C6 level preserves wrist extension (tenodesis grasp) which enables many functional tasks

Rehabilitation Goals

Phase 1 (Weeks 1-4):

• Medical stabilization
• Education about SCI
• Range of motion/prevent contractures
• Skin integrity program
• Bowel/bladder program initiation
• Psychological support

Phase 2 (Weeks 5-8):

• Strength training for preserved muscles
• Transfer training (bed, wheelchair, car)
• Wheelchair skills
• Self-care training with adaptive equipment
• Bowel/bladder program independence

Phase 3 (Weeks 9-12):

• Advanced wheelchair skills
• Community reintegration
• Driving evaluation
• Vocational planning
• Discharge planning

Medical Complications Management

1. Neurogenic Bladder:

• Type: Upper motor neuron (reflex bladder)
• Management: Intermittent catheterization every 4-6 hours
• Training patient in self-catheterization with adaptive equipment
• Anticholinergic medication (oxybutynin) for detrusor overactivity

2. Neurogenic Bowel:

• Bowel program: Every other day
• Digital stimulation technique
• Stool softeners and high-fiber diet
• Timed bowel care after meals (gastrocolic reflex)

3. Skin (Pressure Ulcer Prevention):

• Pressure-relieving wheelchair cushion
• Weight shifts every 15-30 minutes
• Daily skin inspection (using mirror for areas patient cannot see)
• Specialized mattress

4. Autonomic Dysreflexia (AD) Education:

• Critical teaching - patient has T6-level injury (above T6 = AD risk)
• Triggers: Bladder distension (#1), bowel impaction, skin breakdown
• Symptoms: Headache, hypertension, flushing above injury, sweating above injury, bradycardia
• Management:

1. Sit patient up
2. Loosen restrictive clothing
3. Check bladder (catheterize if distended)
4. Check bowel (disimpact if needed - use lidocaine gel)
5. If BP remains >150 systolic, give nifedipine
6. If unresolved, emergency care

5. DVT Prevention:

• Low molecular weight heparin (enoxaparin) for 8-12 weeks
• Compression stockings
• Range of motion exercises

6. Spasticity:

• Expected to develop over weeks to months
• Currently minimal
• Will treat if interferes with function (baclofen, tizanidine, botulinum toxin, intrathecal baclofen pump)

Psychological Support

Adjustment to Disability:

• Stages are not linear: shock → denial → grief → adaptation
• This patient currently in grief stage - expressing sadness, anger about lost function
• Support groups with peers (other SCI patients)
• Individual counseling
• Family counseling
• Antidepressant considered if depression criteria met

Vocational Counseling:

• Prior occupation: Construction worker
• Will not be able to return to this occupation
• Vocational rehabilitation referral
• Exploring options: Office work, education, entrepreneurship

Discharge Planning (Week 10)

FIM Scores:

Achieved Goals:

• Independent transfers with sliding board
• Independent wheelchair mobility on flat surfaces
• Modified independent self-catheterization
• Independent bowel program with setup
• Upper body dressing independent; lower body with minimal assist
• Demonstrates autonomic dysreflexia management plan

Discharge Destination: Home (modified apartment)

Home Modifications:

• Wheelchair ramp
• Roll-in shower with shower chair
• Grab bars
• Hospital bed with trapeze
• Widened doorways

Equipment:

• Ultra-light manual wheelchair
• Cushion for pressure relief
• Sliding board
• Reacher
• Catheterization supplies

Follow-up:

• Physiatrist every 3 months for first year
• Urology (annual renal ultrasound, urodynamics)
• Dermatology as needed for skin issues
• Lifetime surveillance for secondary complications

Teaching Points

1. ASIA classification is the standard for SCI:

• A = Complete (no motor/sensory below injury)
• B = Sensory incomplete
• C = Motor incomplete (most muscles <3)
• D = Motor incomplete (most muscles ≥3)
• E = Normal

1. Functional level predicts independence:

• C6: Can be independent in wheelchair and most self-care
• C7: Independent in most activities
• T1+: Upper extremities normal

1. Autonomic dysreflexia is a medical emergency - occurs with injuries T6 and above; can cause stroke if untreated

1. Neurogenic bladder/bowel require lifelong management - prevent complications (UTI, renal damage, skin breakdown)

1. Pressure ulcers are preventable - weight shifts, proper cushion, skin inspection

1. Psychological adjustment is essential - support groups, counseling, vocational rehabilitation

All cases for this lecture as Markdown