Three Key Stages
Three stages need complete attention
Immediately after a possible traumatic spinal cord injury, three broad areas need to be the focus:
01 Prevent worsening of the primary pathology (the immediate first damage)
02 Management of the injury and prevention of additional complications, as a result of the injury.
03 Medical treatment & rehabilitation
In certain cases, all of these may start on the first day itself.
Prevent worsening of the primary pathology (or the immediate first damage)
This should ideally start at the accident site & is also relevant while the injured person is being moved to a hospital.
Assume spinal cord injury: At the accident site, the dictum must be that until proven otherwise, you should always assume it as a spinal cord injury if the above mentioned red-flag symptoms are present.
What you must not do:
- Do not make the injured person sit
- Do not make the person stand.
- Do not give soda, juice, coffee, tea, any other liquid or solid food to an unconscious person; this is the worst thing you can do. It may even cause death. If the injured person has had any liquid or solid food, it may delay surgery. It may cause complications in anesthesia and surgery. There are many instances of persons suffering brain injury due to having been fed fluids or food.
- Injured person may ask for water but it is not essential. What is essential is quickly and safely taking him to a hospital that has the capability for diagnosis and treatment of spinal injuries.
- Do not go to a local clinic or primary health centre asking for bandage for treating small wounds. Do not take the person home for rest. It could delay the process of diagnosis and treatment. Delayed transportation of spinal injury patients to a definitive treatment center is associated with less favorable outcomes, longer hospitalizations, and increased costs.
Positioning & carrying a person: How will you position the injured person? How will you lift the injured person? How will you carry the patient?
There should not be any additional damage to the spinal cord or any other part due to improper handling immediately after the accident.
While extracting from the site of trauma, the person should not be lifted manually. The persons should continue to be strapped to a rigid, flat surface until reaching the hospital. During such transfers to a rigid stretcher or a board, care should be taken to treat the whole person as you would a newborn baby, ensuring that the injured person’s head, neck, upper & lower back and legs are well supported, and like a log of wood that cannot be flexed.
If a stretcher is not available, please get the next best thing to a stretcher. Create a stretcher-like rigid, flat holder, if nothing else is available. Look for a board, piece of wood or bed sheets, and use them for this purpose. Use a stretcher and insert the stretcher under the person’s body gently by lifting the injured person slightly with the help of three persons – one each to hold the head & neck, upper & lower back, and legs.
The person must be moved to the first point of medical care in the same lying down position only. In the vehicle, if the injury appears to be in the neck region, in which case the person may have no or limited movement of his arms, a combination of any type of carefully applied rigid cervical collar, with supportive blocks, on a rigid backboard with straps and tape to immobilize the entire body is effective at achieving safe, effective spinal immobilization for transport. Sandbags with the patient strapped to a rigid backboard are not sufficient and are not recommended as the first line of neck immobilization. Do not ask the person to try and move his neck. The objective is to completely avoid any sort of movement of the neck.(2)
If the injured person has normal hand movements, it is likely the injury will be in the trunk region. Positioning him supine (on his back with head facing the ceiling) should be enough.
The injured person must be taken to the nearest tertiary care hospital that has ortho- or neuro-surgeons. If possible, go to a hospital that offers spine injury treatment, though such hospitals are few and far between.
How you retrieve a person from the site of the accident, how you carry him to the vehicle and how the vehicle goes – these will be absolutely vital steps. Doing these basic steps improperly will cause additional damage.
Please note that immobilization is not needed for trauma patients who do not have the red-flag symptoms mentioned above, and who fulfill all the following criteria:
- are awake, alert, and are not intoxicated
- are without neck or back pain/tenderness
- do not have an reduced muscle power or sensations in their arms/legs
- do not have any significant associated injury that might detract from their general evaluation.
Injury management & prevention of additional complications
Once the injured person has been taken to a tertiary care hospital, the patient, his family and friends must cooperate with the doctors to ensure that they get the best possible treatment. On completing of the initial assessment and x-rays/scans, they should ask for time to talk to the doctor. They must understand the following aspects:
- What is the assessment of neurological status?
- Is it a spinal cord injury?
- If yes, is it complete or incomplete?
- Ask and understand about spinal cord injury, how it will affect movements, sensations, bladder-bowel control and sexual function. A clear understanding of what is possible and what is not is of importance as it would help the injured person and family prepare themselves better for the challenges ahead.
- Discuss and understand the treatment options available. If it is a complete injury, then surgery is unlikely to alter the neurological status. Surgery for the bone is only to stabilize it and other parts that may have also suffered damage, and avoid prolonged immobilization.
- A big risk that a spinal cord injured person faces especially at this stage is the possibility of pressure ulcers or bedsores. Airbeds, Waterbeds, alpha beds and other such variants do not fully address this aspect. Pressure sore prevention protocol is simple and one must make sure the injured person co-operates in the administration of the protocol. Changing positions every two hours is the protocol at this stage. If this is not being done, please check with the doctors about pressure ulcers and its management, as a pressure ulcer at this stage can delay the rehabilitation of the injured person leading to waste of resources, time and effort.
- Ascertain how the injured person would pass urine. Usually catheterizing and using a urine bag is normal practice to prevent urological complications such as distension of bladder or damage to the kidneys. If this is not done, verify if it is safe and good for the patient to void naturally. If the person has been catheterized, make sure the urine bag is emptied at 500 ml, the injured person drinks at least 2 – 3 litres of water / other liquids, strap the catheter at the waist every day with Micropore tape and handle the catheter and bag carefully while turning positions and shifting.
- Proper bowel management is very important. Do whatever it takes to make the person comfortable in the initial period. It could be use of laxatives, suppositories, enema or digital evacuation. Bowel evacuation could be daily or once in two days as long as the injured person is comfortable. This factor (patient comfort) should be prioritized as you will never have a situation where a person dies of bowel failure while he can of kidney failure or infected pressure ulcers.
- Usually steroids are not necessary. It was a fairly common practice some time ago to use steroids based on an American study. But subsequent analysis and other studies have shown that administration of steroids in acute SCI is not useful in improving nerve recovery. On the contrary, steroids could raise the risk of infection. So if offered a choice, it would be better to say `no’ to steroids.
Why you must understand if the injury is complete or incomplete?
Here is how an injured person is assessed to check if the spinal cord injury is complete orincomplete. If a finger is inserted near the anal region or into the anal opening, and the person is unable to identify the sensation consistently, that means it is a complete injury.
More than half of the spinal cord injuries are complete injuries.
Checking the sensation this way helps with prognostication of what to expect in terms of long term recovery.
Spinal cord injured persons who have some sensation on day 1 when presenting at the hospital are more likely to improve nerve functions. A few ball-park figures based on actual data from follow-up study in the US:
- Among those with complete SCI at admission, just over 2% persons improve muscle power that enables them to walk independently by 1 year post-trauma.
- Among those with complete SCI at 1-year post trauma, just about 1% persons improve muscle power that enables them to walk independently by 5 years post-trauma.
- Among those with incomplete SCI at admission, more than 30% persons improve muscle power that enables them to walk independently by 1 year post-trauma.
Thus it is important to get the correct diagnosis of incomplete or complete injury. A correct diagnosis also helps understand the implications and treatment options offered by the doctors better.
Surgery or Not ?
There are instances where persons are advised against surgery, as there no broken bone but only damage to the spinal cord, but they keep going from hospital to hospital in search of surgery. Patient relatives are often keen on a surgery in the hope that it will fix the nerve injury. So an informed approach is important on this vital issue.
Surgery not essential: Contrary to the myth that surgery is essential for nerve recovery following SCI, cumulative results of all scientific evidence do not suggest so. If you believe a surgery will bring the nerves back into operation, then that does not happen except in rare instances. There is no scientific evidence to support the belief that people who have complete injury recover nerve function and walk as result of surgery. Among limited evidence available for recommending surgical fixation for neck level SCI, only those surgeries done to stabilize the bones within 24 hours of trauma appear to accord the benefit.
In this background, it has to be stated that surgery does offer/ provide a few benefits in that the person can be mobilized early (within a week) with proper support and guidance. Without surgery, confinement to bed-rest would be needed, for about two months. This could prolong the risk of other associated complications such as pressure ulcers, blood clots in legs, lung infections.
Surgery would not be necessary if there is no bone injury, or in certain instances of the fractured bone not pressing on the spinal cord, or if surgery is likely to cause more damage than benefits. In such instances, if a reputed doctor is advising against a surgery that could in fact be the best thing to do. Surgery or not, following the skin care protocol of turning every two hours is a must to prevent pressure ulcers.
Post-surgery management is critical: Once cleared by the surgeon, it is perfectly ok to turn a patient after a surgery is done. Surgery is done to mobilize the patient. This is first and foremost necessary to avoid occurrence of pressure ulcers or bedsores.
The process of turning a patient is called ‘log rolling’. At least three persons are required for log rolling – one to support the head, one to support the trunk and one to hold the leg. On the count of 1,2,3, they turn the patient as a log rather than segmental rotation of the head first, body next and legs last. As a log, he is turned to the left or right, and pillows are placed at the back to ensure that he does not roll back.
Persons with complete spinal cord injury are always at risk of pressure ulcers (bed sores). Persons with incomplete injury will be at risk till they get some sensation. So by default in the initial few months turn every spinal injured person once every 2 hours. This has to continue until it is proven that he recovers sensation.
Position changing protocol must also be followed for persons managed non-surgically.
When sitting, to provide some relief for the seating bones (ischium), doing push ups once in 10-20 minutes is a must. Each push up must be for about 20 seconds. Doing pushups vertically may be difficult for those who have not been properly rehabilitated. Till proper training is given they can relive pressure by shifting forward, backward or to the sides for about 20 seconds every time.
Medical Treatment & Rehabilitation:
The treatment and rehabilitation aspects should go hand in hand and as soon as possible after the injury. After the surgery, most of the times if there is no associated complication, ten days post the operation, they are ready to be discharged to a dedicated rehabilitation unit.
The goals for rehabilitation for persons who do not have adequate muscle power to walk independently are:
- to achieve maximum possible independence in mobility (indoor and outdoor) using a wheelchair.
- to achieve independence in timely, safe and adequate management of bladder-bowel functions, when natural means of bowel-bladder emptying are not possible.
- to plan and prepare for earliest possible return to a productive vocation using compensatory strategies learnt during the rehabilitation process.
As there is so much to gain from a good rehabilitation program, the earliest they get to a rehabilitation center the better it is because they will be able to get back to life soon.
There is no point in waiting in the hospital and trying some half-hearted physiotherapy, hoping that some improvement will happen. In some places, the trend is they are in ICU for 10/15 days then come to bed for 10/15 days and then go home and try Ayurveda. If such things can be prevented we can avoid further complications in an efficient way.
If the person is well managed initially, then his rehabilitation will normally take about four to six weeks on an average, assuming there are no complications or pressure ulcers. The actual training is only for about three weeks. Every pressure ulcer can take at least an extra month on an average.
We have to get on with life with whatever neurological deficits there, as there is no scientifically proven treatments in the world that promotes nerve function after a spinal cord injury. Whatever improvements happen will happen by themselves though there is no certainty of happening, degree of improvement or timeframe.
Key aspects to take care at this stage:
- Go to a good rehabilitation centre, even if it means waiting it out.
- Make sure the four pillars of skin care are practiced if necessary with support. The key aspects are:
1. A push up every 10 minutes for 20 seconds or a count of 1 to 20.
2. Changing positions every two hours while lying down.
3. Checking the skin in the parts where there is no sensation and applying a few drops of
coconut oil, especially in the buttock areas.
4. Lying prone, if the doctors have permitted.
- Make sure you do not develop pressure ulcers or bedsores when at home and awaiting admission to a rehab centre.
- Be careful while sitting at home at this stage as balance training is much needed.
- Good nutrition – milk, eggs, fruits vegetables and fish / non-fried chicken (if you eat non-veg) will help. Reducing food intake at night will also be a help.
- Work hard on improving your upper body strength with basic exercises.
- At the rehabilitation centre, interact with your therapists and learn to be as independent as possible in activities of daily living – toileting, bathing, dressing, grooming, feeding, transfers and mobility, to name a few.
- Get quality assistive devices if you are going to be walking regularly.
- Get the right wheelchair and cushion based on advice of therapists.
- Think about home, study and work environment and understand from therapists and doctors how to handle possible hurdles.
- Think about employment, possible new vocation or small business options.
- Prepare yourself well to get integrated into the community when you get home.
Please get in touch with The Spinal Foundation Toll Free 1800 425 1210 or Mobile 0 97909 36844 for guidance by peer group members who have long years of experience in living well with spinal cord injury.
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