aado nurse subcommittee trauma series i spinal injury...
TRANSCRIPT
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AADO Nurse Subcommittee Trauma Series I
Spinal Injury Workshop 22-23 February 2014
Dr. Law Sheung Wai
Consultant Spine and Orthopedic Rehabilitation Team
Department Of Orthopedics and Traumatology
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羅尚尉醫生 香港中文大學醫學院 矯形外科及創傷學系榮譽臨床助理教授
矯形外科及創傷學科顧問醫生
香港中文大學內外全科醫學士
香港外科醫學院院士 英國愛丁堡皇家外科醫學院院士
香港骨科醫學院院士 英國愛丁堡皇家外科醫學院骨科院士
香港醫學專科學院院士(骨科) 香港中文大學流行病學與生物統計學理學碩士
香港中文大學職業醫學碩士 臨床老人學學士後文憑
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Spinal Trauma can be disable
and is a life long event
F /18
C4/5 dislocation
With high Tetraplegia!
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INITIAL MANAGEMENT OF SPINAL INJURY PATIENTS
• ABC, Spinal board, hard collar History • Strongly suspect spinal injury if any major accident,
unconscious patient, fall from a height, sudden jerk of neck after rear end car collision, facial injuries or head injury .
• Ask about neck or back pain, numbness, tingling, weakness, ability to pass urine
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This MRI is the side view
of a patient with an
incomplete spinal cord injury
Had the patient not been
immobilized properly the
injury could have become
complete
Multiple Trauma High Velocity Injury – Spinal Trauma until Proven Otherwise
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Neurological Examination
• LOC • Deteriorating course • Neck, back pain and/or bladder, bowel incontinence
should increase suspicion of sc injury • Define level of lesion • Motor function • Sensory level • Proprioception testing • DTRs • Anogenital reflexes
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Examination
• Logroll- look for bruising, palpate for a step, tenderness
• Repeated neurological examination to determine neurological damage and its progression/resolution
• Thorough overall examination for fractures etc as patient may not feel pain
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NEUROLOGICAL ASSESSMENT IN SPINAL INJURIES
• To determine the level of the lesion- counted as the
lowest level at which neurological function is intact bilaterally
• To determine whether damage is complete/ incomplete
• To determine prognosis • May be difficult until period of spinal shock (flaccidity,
areflexia) is over (24-48 hrs after injury)
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Diaphragm C3-4-5
Shrugging shoulders C4
Flex elbows C5,6
Extend elbows C7
Abduct fingers C8
Active chest expansion T1-T12
Hip flexion L2
Knee extension L3-4
Ankle dorsiflexion L5-S1
Ankle plantar flexion S1-S2
Eversion of foot L5
Inversion of foot L4
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Reflexes
Biceps C5-6
Triceps C6-7
Supinator C5-6
Knee jerk L3-4
Ankle jerk L5-S1
Plantar response If upgoing = UMN lesion
Abdo cutaneous reflexes
If lost = UMN lesion
Bulbo cavernosis reflex
Pull penis, causes anal sphincter tightening If returned, period of spinal shock is over
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Dorsal column
Anterior spino-
thalamic tract
Cortical
spinal tract
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Commonest Incomplete SCI
Central Cord Syndrome
Older patients
Preexisting central
spondylosis
Hyperextension injury
Injury affects central cord>
peripheral cord
Damage to corticospinal
and spinothalamic tracts
Upper extremities>thoracic
>lower extremities>sacral
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CCS
Present with: Decreased strength
Decreased pain and temperature sensation
Upper>lower extremities
Spastic paraparesis/quadriparesis
Maintain bladder and bowel control
Prognosis: GOOD Although fine motor recovery of the upper
extremities is rare
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Complete vs Incomplete Incomplete:
Sensory, motor or both functions are partially present below the neurologic level of injury
Some degree of recovery
Complete: Absence of sensory and motor function below the level of
injury
Loss of function to lowest sacral segment
Minimal chance of functional motor recovery
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If neurological damage
• Catheterise • Note reduced BP and bradycardia due to neurogenic
shock (temporary generalised sympathectomy). Rule out hypotension due to haemorrhage elsewhere. May need treatment with vasopressors, not fluid resuscitation.
• Invasive monitoring required • Give methylprednisolone IV 30mg/kg over 15
mins then 5.4mg/kg/hr for next 23 hours. Needs to be given within 8 hrs. Discuss with the spinal team.
• Attend to skin by turning
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DI
C-spine films as per c-spine rules/nexus
CT
MRI: better for visualizing neurological, muscular and soft tissue
If CT negative and patient has positive neurological findings, this is next step
Important to image entire spine as 10% have 2nd injury
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Management:
• Trauma series X-rays
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Clear c spine if all the following fulfilled
• Alert , not intoxicated
• No neurological symptom or sign
• No midline neck pain or tenderness
• Painless , full range of movement
• Absence of a distracting painful injury
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Adequate Cervical spine X ray
• Lateral- must be good quality and
adequately visualize the base of occiput to upper T1.
• AP- seen spinous process of C2 to C7
• Open mouth- must see the entire dens and lateral masses of C1.
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C1
C2
C3
C4
C5
C6
C7
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Open mouth view
If possible
C2
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Can’t see C7 ?
• Pulled shoulder
• Swimmer view
• CT or MRI
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Swimmer’s View
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Soft tissue swelling
Pull
Shoulder
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C1 Fracture
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Fracture
C1 Fracture
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C1 Fracture
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C 2 fracture
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Fracture line
C 2 fracture
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C 2 fracture
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C 7 Fracture
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C 7 Fracture
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Acute Phase
• Spinal Shock vs Neurogenic shock
• Role of Steroid in management of spinal cord injuries
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Spinal Shock vs Neurogenic Shock
Spinal Shock :
• Transient reflex depression of cord function below level of injury
• Initially hypertension due to release of catecholamines
• Followed by hypotension
• Flaccid paralysis
• Bowel and bladder involved
• Sometimes priaprism develops
• Symptoms last several hours to days
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Spinal Shock Symptoms:
Flaccid paralysis Loss of sensation Loss of DTRs Bladder incontinence Bradycardia Hypotension Hypothermia Intestinal ileus
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Neurogenic shock:
• Triad of i) hypotension
ii) bradycardia
iii) hypothermia
• More commonly in injuries above T6
• Secondary to disruption of sympathetic
outflow from T1 – L2
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• Loss of vasomotor tone – pooling of blood
• Loss of cardiac sympathetic tone – bradycardia
• Blood pressure will not be restored by fluid
infusion alone
• Massive fluid administration may lead to
overload and pulmonary edema
• Vasopressors may be indicated
• Atropine used to treat bradycardia
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Hypotension Must determine cause:
Spinal cord injury
Blood loss
Cardiac injury
Combination of above
Blood loss is the cause of hypotension until proven otherwise!
Vitals are often non specific
R/O other causes with: CXR, FAST, CT
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Corticosteroids
Controversial
Based on NASCIS trials
Methylprednisolone improved both motor and sensory
functional outcomes in complete and incomplete injuries
Benefit dependent on dose and timing of dose
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Corticosteroids NASCIS recommends:
1. Treatment must begin within 8h of injury
2. Methylprednisolone 30mg/kg bolus iv over 15 minutes
3. 45 minute pause post bolus
4. Maintenance infusion 5.4mg/kg/h methylprednisolone is continued x 23h
• Evaluated in blunt injury only
• Large doses of steroids in penetrating injury may be detrimental to recovery of neurological function
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Steroid Therapy as per NACSIS
Attributed to antioxidant effects
Treat for 24h in patients treated within 3h of injury
Treat for 48h in patients treated within 3-8h of injury
Worse outcome if started 8h post injury
Conflicting evidence re benefit therefore more trials required
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Pros Cons Believed to inhibit
formation of free radical-induced peroxidation
May increase spinal cord blood flow
Increase extracellular calcium
Prevent potassium loss from cord
Pneumonia
Sepsis
Wound infection
GIB
Delayed healing
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NASCIS I Bracken et al. 1984. Efficacy of methyprednisolone in
acute spinal cord injury, JAMA, 251:45-52
Prospective, randomized double blind trial with 330 patients
2 treatment arms: 100 mg bolus MP, then 25 mg q6h x 10 d 1000 mg bolus, then 250 mg q6h x 10 d
No sig difference in primary outcomes
4x increase in wound infections in high dose group
“Trend” towards increased sepsis, PE, death in higher dose group
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NASCIS II Bracken NEJM 1990; 322: 1405-11
DBRCT of methylprednisone vs naloxone vs placebo (total N=487)
Methylprednisone 30 mg/kg bolus then 5.4 mg/kg/hr X 23 hours
Outcome = neurological function at 6 weeks and 6 months assess by a neuro function score
NO benefit of naloxone
NO benefit of steroids overall
NO difference in mortality
Trend to more infections and GI bleeds with steroids
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NASCIS II
Post – hoc SUBGROUP ANALYSIS showed a benefit at 6 months in the subgroup treated within 8 hrs Improved motor score: 4 points (p < 0.03)
Improved Touch score: 5 points (p < 0.03)
Improved pin-prick score: 5 points (p < 0.02)
Concluded that steroids were indicated if started within 8hrs
One year data showed similar improvement in motor score but no difference in sensory scores (Bracken. J Neurosurg
1992; 76; 23-31)
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NASCIS III Bracken JAMA 1997: 277(20); 1597-1604
DBRCT of methylprednisone 24hrs vs 48 hrs vs Tirilazad (total N=499)
NO placebo arm
Overall, NO difference between the three groups
Post-hoc subgroup analysis: 48 hour steroid group showed improved motor scores at 6 weeks and 6 months if started between 3-8hrs 6 weeks: 5 points motor score (p <0.04)
6 months: 4.4 points (p <0.01)
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NASCIS III
Adverse outcomes Severe pneumonia higher in 48hr group 2.6% vs 5.8% (p<0.02)
Severe sepsis higher in 48hr group 0.6% vs 2.6% (p< 0.07)
They concluded Steroids indicated for SCI
If started within 3hrs, treat for 24hrs
If started within 3-8hrs, treat for 48hrs
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Cochrane Review “the randomized trials of MPSS in the treatment of acute
SCI provide evidence for a significant improvement in motor function recovery after treatment with the high dose regimen within 8 hours of injury”
Bracken November 2000
Update in Spine 2001 by Bracken
4 trials and 797 patients randomized to get high dose methylpred vs placebo for 24 hours
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Cochrane Review Results
Primary outcome = neurological
improvement at 6 weeks, 6 months, 1
year
Complicated motor and sensory exam
High dose methylpred associated with
4/70 point increase in motor function at
6 weeks, 6 months but not one year
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SCI and Steroids
Clinical relevance? 4 points spread over 14 muscle segments unilaterally
Not validated score
No inter-rater reliability
Conclusions based on post-hoc analysis of small subgroup from 1 trial 65 patients per arm
Data drudging
High risk of alpha error
Serious complications (not statistically significant) GI bleed and wound infection (RR 4.00, 95% CI 0.45-35.58)
Severe pneumonia (RR 2.25, 95% CI 0.71-7.15)
Range of values in CI huge do the risks outweigh the benefits??
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SCI and Steroids Author consultant for Pharmacia (they make
methylprednisolone)
Weak support for use of high dose methylpred in acute SCI + may be increased risk of severe adverse outcomes.
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Bottom Line
CAEP position statement : steroids are NOT
STANDARD OF CARE
There is insufficient evidence to support the use
of high dose methyprednisolone within 8 h of
acute SCI
Significant harm to using steroids
NASCIS subgroup data needs to be validated in
prospective, randomized, blinded trials
No new literature to argue for or against this
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Treatment
Prevent secondary injury
Alleviate cord compression
Establish spinal stability
Assess the neurological deficit and
spinal stability
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Definitive management
• Preserve neurological function, by immobilizing and giving steroids
• Relieve reversible nerve or cord compression by reduction of fracture/dislocation
• Stabilize the spine • Rehabilitate patient
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SCI Goals of Care
There's no way to reverse damage
Treatment focuses on: 1. Preventing further injury
2. Enabling people to return to an active and
productive life within the limits of their disability
68
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Reduction
• Can improve comfort, can relieve nerve tension, can decompress neural structures
• Traction
– 1.Gardner Wells Tongs. 2kg increments with Xray assessment and neurological examination after each increment
– 2. Halo Rings- can later be converted into halo vest config to hold neck as definitive treatment
– 3. Halter traction for C1/2 subluxations
– Ideally MRI compatible
– Open at surgery
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1 cm
Gardner Wells Tong
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Fixation till healing
• External fixation – Hard SOMI collar, (Sterum Occipital Mandibular Immobilisation), if stable fractures
• Halovest, if unstable. Safe, effective. Can be used from acute situation to end of treatment. Not preferred treatment if neurological deficit
• Continued traction in supine position, rarely used these days, but can be used if delay in going to theatre, or patient refuses surgery
• Internal fixation- anterior or posterior fusion (see below)
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• Selection of Holes:
• optimum positioning of the halo is critical to ensure stability, durability and patient comfort
• 4 holes are placed in the scalp, 2 anteriorly and 2 posteriorly
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• anterior pin sites: – centered in groove at upper margin
of eyebrows, between supraciliary ridge and the frontal prominences
– sagitally, the pins should be placed just superiorly to outer half of eyebrows, to avoid the supraorbital nerve and vessels
– placed too inferiorly, the pins might encroach on the orbit
– they should be placed as close to midline of eyebrow as possible, as thickest mass of bone is central
– placed too medially, however, the pins might encroach on the frontal sinus
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• posterior holes: – this placement of halo
ensures that it will be below maximum diameter of skull and the will not migrate
superiorly
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Role of surgical intervention
• Stabilization
• Achieve fusion of Involved segment
• Prevention of pain
• Prevention of deformity
• Allow early mobilization
• Facilitate nursing care
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Urgent Surgery recommended when
• Progressive neurological deficit with persistent dislocation or neurocompression not corrected by closed traction
• Persistence of incomplete spinal cord injury with continued impingement on neural elements
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Less urgent surgery recommended when
• Unstable dislocations which have been reduced. (ligamentous injuries less likely to heal. Fusion indicated)
• Complete spinal injury with unstable fractures, to enable early rehabilitation
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M/25 RTA fracture C7 with tetraplegia
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Spinal Cord Injury Rehabilitation Management
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Regional Centre Programmatic Approach
• Rescue
• Emergency care
• Acute care
• Rehabilitation
• Long Term Care
• Community reintegration
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Rehabilitation-Team Approach
• Ortho Surgeon/Urologist/Plastic Surgeon
• Rehabilitation Physician
• Nurses
• Physiotherapist/Occupational Therapist
• Prosthetist and Orthotist
• Social Worker
• Clinical Psychologist
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Rehabilitation Team 康复团队
康复医师
物理治疗师
作业治疗师
假肢及矫形师
康复护士
心理治疗师
以伤员或病人为中心
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Goal of Rehabilitation
• To reintegration patient back to the society
by 1)To minimize the potential
complication
2)To maximize the remaining potential
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Complication in SCI Respiratory System
• Most common respiratory complication
pneumonia and atelectasis
• Risk factors-neurological level above T10
-smoking history
-obesity
-recent history of GA
• Cough suppression and increase secretion
• Chest physiotherapy
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Complication in SCI DVT and pulmonary Embolism
• DVT in 15% paraplegic and 4% tetraplegic
• High risk for best rest patient
• Regular thigh and calf assessment
• Doppler ultrasonography/venography
• Antiembolic stocking/mechanical pump
• Prophylactic anticoagulation controversial
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Complication in SCI Urinary System
• Most common complication
Urinary Tract infection(66% in paraplegics
and 70% in tetraplegics)
• Spinal shock : flaccid bladder
• Urethral catheterization
• Urodynamic assessment
• Bladder Training
• Intermittent catheterization
• Treatment of asymptomatic bacteriuria
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Complication in SCI Digestive System
• Paralytic ileus ( 3 to 5 days )
• Return of bowel sound : Bowel programme
• Use of H2 blocker/gastric mucosal protection agent to prevent stress ulcer
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Complication in SCI Skin
• Decubitus ulcer(pressure necrosis) • Pressure Vs time relationship • Most costly(5 fold increase of cost) • Dependent area over bony prominences • Prevention by meticulous and alert carers • Turning patient every 2 hours • Regular careful inspection of high risk areas • Redness failed to fade after 15 mins:alter turn prog • Perineum checked for soilage • Intravenous lines inspected • Catheter checked for proper drainage
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Complication in SCI Musculoskeletal System
• Flaccid in acute stage
• Development of joint contracture
• Muscle atropy
• Osteoporosis
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Complication in SCI Autonomic Hyperreflexia
• In lesion above T6
• Precipitated by blockage of urinary catheter with bladder distention,visceral distention from full bowel,irritative pressure sore,IGTN
• Clinical sign: bradycardia,sweating,rhinorrhoea,pounding headache and severe paroxysmal hypertension
• Serious consequences:epileptic fits,CVA,death
• Treatment : Remove the causes,antiHT drug
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Complication in SCI Spasticity
• Gradual increase in tone of paralysed muscle due to excessive reflex activities below level of lesion
• Average time for appearance
Cervical injury-6 weeks
Thoracic injury-10 weeks
• Maximum at 2 years after SCI and gradually diminishes
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Complication in SCI Spasticity
• Almost all cervical injuries have spasms
75% of thoracic lesions
Less than 58% of lumbar lesions
Less than 25% of conus-cauda equina
Partial lesion more severe spasm than complete lesion
• A nuisance to spinal patient affecting positioning and personal hygiene
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Complication in SCI Spasticity
• Treatment
Prevention-full ROM exercise of paralysed
muscle and passive stetching of
spastic muscles
-uprighted posture encouraged
-correct any irritating foci below
level of lesions
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Complication of SCI Spasticity
Conservative treatment Physiotherapy Drugs-valium,baclofen,clonidine,gabapentin Nerve blocks (phenol or alcohol) Motor point blocks Surgical Management Neurectomy Rhizotomy Myelotomy Orthopaedic procedures
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Complication of SCI Psychological system
• Classic phases of reaction: shockdenialangerdepression
gradual elevation of spirits
• Family support
• Doctor-patient relationship
• Keep informed of the medical status of patient
• Hope for the best but prepare for the worst
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Bladder Training • Urodynamic Study
• Early Bladder management
To achieve a catheter-free state,the bladder consistently empties completely,the urine is sterile and the patient remains continent
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Bladder Training Intermittent Catheterization
6 times per 24 hours
Fluid intake restricted to 150-200ml per hr
Gradually fewer catheterization required
1 to 3 months for return of detrusor activity
Bladder stimulated to initiate the reflex detrusor contraction and to empty the bladder completely
Drugs to improve reflex contractions
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Bladder Training • Bladder emptying by external pressure
-by straining (increase intraabdominal pr)
-by direct manual suprapubic pressure
• High residual volume predispose to reflux,back pressure on the kidneys,
persistent UTI and stone formation
• Keep a low residual urine volume ( 10% of the voided volume;actual volume 50 ml)
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Bowel Training • A fixed time pattern instead of cerebrally monitored
urge
• Every-other day evacuation
• Time chosen for evacuation should take advantage of the post-prandial gastrocolic reflex
• A good diet with sufficient bulk necessary for the production of well formed stools
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Bowel Training • Night-before laxatives or stool softener
• Defaecation reflex initiated by local anal stimulation using suppositories or rectal touch technique
• A satisfactory bowel habit by trial and error
• Avoid anything which may upset the habit such as change of diet,poor fluid intake
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Sexual Function
• Sexual rehabilitation involves both patient and sexual partner
• Objective:to understand and manage sexual activity and reproduction • Dependent on level and completeness of lesion • In complete lesion: loss of psychic
erection,orgasm,effective ejaculation and seminal emission
• Lesion above conus:retain reflex erection to cutaneous stimulation of glans penis but no sensation with sexual intercourse
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Sexual Function • In incomplete lesion:variable ability in
erection,ejaculation and orgasm • Usually male patients have adequate erection to
achieve satisfactory intercourse • Psychological factor of being able to satisfy the mate
more important than the genital sensation • Overall:erection 75%;coitus 35%;ejaculation 10%, less than 5% have children • Female much better off:satisfaction from the mind Fertility is unimpaired;pregnancy usually normal
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Establishment of Spinal Cord Injury Rehabilitation Centre
One of the three Spinal
Cord Injury
Rehabilitation Centres in
Hong Kong
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Physical Training
• Postural training
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Physical Training
• Strengthening Exercise
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Physical Training
• Passive stretching exercise
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Physical Training
• Transfer
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Physical Training
• Wheelchair Training
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Physical Training • Mobility Training
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Physical Training
• Balance
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Physical Training
• Pressure relief
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Physical Training
• Pain treatment
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ADL Training
• Feeding
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ADL Training
• Dressing
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ADL Training • Cleansing
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Establishment of Spinal Cord Injury Rehabilitation Centre
Equipped with the
most modernized
facilities and input
from multidisciplinary
specialists
09’ caseload:
26 admissions
ALOS: 91.03 days
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Wheelchair Prescription
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Assistive Devices
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Splintage and Pressure Garment
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Seat Cushion Prescription
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Spinal Cord Injury Rehabilitation Centre
Transitional Residential Service
Providing a
supportive living
environment to
develop their skills
and competence
Facilitate to live
independently in the
community
Capacity: 20 beds
Maximum length of
stay: 12 months
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Vocational Training
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Transportation Training
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Home Modification
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Recreational Training
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The END