Spinal Cord Injury

Additional Info

• Audio File:uab/ua046.mp3
• Doctors:McLain, Amie
• Featured Speaker:Amie McLain, MD
• CME Series:Medical Innovations
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4752
• Guest Bio:Amie McLain, MD is a Chair & Professor, Physical Medicine & Rehabilitation Medical Director
  UAB Spinal Cord Injury Model System.
  
  
  Learn more about Amie McLain, MD 
  
  Release Date: February 22, 2018
  Reissue Date: April 5, 2021
  Expiration Date: April 5, 2024
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Amie B. McLain, MD
  Chair & Professor, Physical Medicine & Rehabilitation; Medical Director, UAB Spinal Cord Injury Model System
  
  Dr. McLain has no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:UAB MedCast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category 1 credit. To collect credit, please visit www.uabmedicine.org/medcast and complete the episode’s post test.
  
  Melanie Cole (Host): Every year, thousands of Americans experience a spinal cord injury. These injuries can be devastating and cause physical and emotional distress. According to the National Spinal Cord Injury Statistic Center at UAB; there are approximately 17,000 new cases of spinal cord injury each year. My guest today, is Dr. Amie McLain. She is the Chair and Professor in Physical Medicine and Rehabilitation and the Medical Director of the UAB Spinal Cord Injury Model System. Welcome to the show Dr. McLain. So, explain a little bit about spinal cord injury and some of the most common causes that you see.
  
  Dr. Amie McLain, MD (Guest): Well the spinal cord, in itself, is part of the central nervous system and it is the major connection through which motor and sensory information of our body travels between the body and the brain. So, when you get a spinal cord injury; then you are going to disrupt that connection and that means that the information can’t get to the brain. When that happens and it can happen at various degrees of injury; the injury in the spinal cord will not allow people to feel things below that level or move things below that level. Over the years, we have seen consistently that the major cause of spinal cord injury is in a motor vehicle accident and that also includes motorcycles or 3-wheelers. But by far, those are the most common ways that people get a spinal cord injury. You also can see the second most common cause being falls and now we are seeing a little bit more population having falls as their cause of spinal cord injury; because it occurs in an older population. So, now that the population has aged some with the Baby Boomers coming through and being the largest – one of the largest groups, they are getting to the age where they fall and they have neck injuries. So, we are seeing more falls than ever before, but still automobile accidents are the most frequent. Other types of injuries that we see are injuries that have occurred from an act of violence and that can be like a blow with some type of object or gunshot wounds; those are very common and the other most common type of etiologies or causes would be sports injuries. And we still, despite all that we are doing to help prevent sports injury related spinal cord injuries; we still do see a small portion of people from sports having spinal cord injuries.
  
  Melanie: So, Dr. McLain, what is level of injury and what’s the difference between a complete and incomplete injury? Why is this important to know the difference?
  
  Dr. McLain: Well, in order to assess what has been damaged from a spinal cord injury; we have a systematic way of examining individuals. And we use a classification system which is called the International Standards for Neurological Classification of Spinal Cord Injury. And this has been developed and refined through the years internationally, so that everybody knows what they are talking about when they give a diagnosis from this classification. This classification is based on the areas in the spinal cord that are still working versus those that are not working. We test them through - we test sensation, and we test how well they can move muscles and if there is a level where there is normal sensation and ability to move muscles above it; but then there is a place that becomes where you don’t see anything or any movement below which is a paralysis; then that becomes the level that we designate for that spinal cord injury.
  
  One of the other things that we want to know is whether or not the injury is complete versus incomplete. This tells us whether there may be a level that we note that has totally normal sensory and motor activity above but below that level, there may still be some preservation of something. The most important thing is that you have to have sensation around your sacral area to be an incomplete but you could also have some movement even though it is not normal. We find this very important because we – it helps us predict how severe that injury to the spinal cord was. If it was very, very complete; then the spinal cord is so damaged that it is not going to come back. After the swelling goes down there is the majority of the time, there is no change and there are some exceptions to this but if you examine this area right after the injury, and there is something that is left over below this totally normal level; then that means that prognosis is very good that as the swelling goes down on the spinal cord, and as time goes on, some of the nerves will come back and some of the repair processes of the body will come into play to where there is a good chance that more movement and sensation will return after the injury.
  
  Melanie: So, what are some current issues in medical management if you determine that someone has paraplegia or tetraplegia; explain a little bit about these and then assess for us the appropriateness of specific treatments that you might use once you detect what is going on.
  
  Dr. McLain: Okay, the terms paraplegia and tetraplegia, and tetraplegia used to be called – we used to use the word quadriplegia, so you still see both those terms. But paraplegia means that there is damage in the spinal cord where you still have the ability to use your hands and your arms and you have sensation and it is normal and you have a level of injury that is lower than the neck. The term tetraplegia means that you have some involvement in the arms that are paralyzed or have lost function. So, that is why we have two separate terms; one that means more damage higher up and you can’t use your arms as well and then paraplegia means that you probably can use your arms and it is very different for what types of things that you may need in the way of equipment.
  
  As far as medical management, there are many issues. There are the issues that are important right after an acute injury; that is roadside protection and getting people to an ICU and an emergency evacuation and to areas that have spinal cord injury specialists to evaluate whether you need surgery or not or just to manage your care. There are also issues that after you are stable and they have decided whether or not you need surgery and if you have had surgery, you are stable from that; that you go into a rehabilitation management. There are treatments that one side is more an acute side to really preserve as much as possible and the surgery is to really not helped with the spinal cord injury per se; but it is to keep everything around the spinal cord, the bones that have been broken around the spinal cord, to keep them from moving or re-damaging the spinal cord. So, when you get into rehabilitation, which is a lot what I do, we start looking at all the secondary complications that occur in an acute paralysis or spinal cord injury.
  
  Melanie: So, speak about some of those secondary complications; whether they involve the gastrointestinal system, or feeding or just give us a little overview of what you are looking at.
  
  Dr. McLain: Well, there are several major things that we look at. When you have the spinal cord injury and you have a paralysis; there is also the communication from the organs – many organ systems that communicate to the brain, that is also disrupted. So, you end up with depending upon where your level of injury is, you usually end up with some dysfunction of either the as you mentioned, the gastrointestinal system, which is the way your bowels work and the predictability. So, you are not aware as much of that in your brain and you actually can become incontinent to where you don’t know when you will have a bowel movement or when that will happen. So, we work with retraining the bowels and putting people on programs so that they can have the predictability; maybe not the awareness, but at least have a predictability of managing that.
  
  The same thing is with the bladder or your urological system. Your kidneys will still work but your bladder does not – is not able to send any type of signal to the brain and the brain is not able to control the bladder. Sometimes, the bladder can start working on its own and you don’t have any control of it and you don’t know when it is working or sometimes the bladder won’t work at all. In either case, you have to have a way of emptying the bladder so you don’t have urinary tract infections and later on problems with your kidneys. So, we manage that and we work with an individual in finding a way to do that according to their lifestyle.
  
  Another major issue that we look at is skin breakdown. People who don’t have sensation are more likely to get pressure sores which can really delay any type of improvement and can become infected. So, we monitor that and we teach about that.
  
  If there is a high level of spinal cord injury, we always are worried about respiratory system. Sometimes people, if their injury level is high enough; they have to go on a ventilator right after their injury and most of the time, they are able to be weaned from the ventilator, but they always have an impaired ability to breathe and so we work with that system to maximize breathing at which ever stage we can. We try to eventually get the – if there is tube in the neck, we try to get that removed so that people can breathe on their own and keep their breathing healthy.
  
  So, I mean the major issues are the different subsystems and as well as preventing infections which are very common and can really set people back and then of course, getting people back psychologically into understanding about their injury and being able to say, “I have this spinal cord injury that has had a great effect on my life, but I can go on with my life and I can still do things that are participating in life and give me a quality of life.”
  
  Melanie: So, in summary Dr., tell other physicians what you would like them to know about spinal cord injury and when to refer to a specialist.
  
  Dr. McLain: Well, I think all individuals with a spinal cord injury should be followed by a specialist in physical medicine and rehabilitation; more as a coordinator of making sure that the preventive things are done and that the things that need to be looked at are performed and in the test. But on the other hand, I feel like all people with spinal cord injury should have a primary care doctor and a specialist that they may need at the time. The issue that I see that is more of a trend and that I have seen studies on is that physicians tend to be a little ill at ease with managing people with spinal cord injury, I think more from a fact that they do not believe that they know the comprehensive way of managing them or that something with their spinal cord injury may impact what they normally do. When that happens sometimes, and that is not everybody, not all physicians; it is just a general sense of discomfort that I feel happens, but when that happens, people do not get the complete care that they need from a primary care physician.
  
  They need every single thing that anybody needs, any able body individual. They need all the preventive healthcare. They need their blood work. They need all the things that we would get at an age appropriate time and just because they are in a wheelchair, it doesn’t mean that they are not human first and need these things. Accessibility is another issue, that they need to make sure that anybody feels that their place of practice is accessible for them and not only is it the law, but also it insures that an individual feels comfortable and is able to be examined correctly and sometimes people- physicians don’t even get people with spinal cord injuries out of their wheelchairs when they come into the office for an annual examination. So, those types of things are very important, I think for the general population and there are also resources online or at other model systems. There are 14 model systems across the country that have a wealth of information for not only people with spinal cord injury but also physicians and practitioners that are at a good clinical level.
  
  Melanie: And tell us about your team. Why is UAB so great to work with?
  
  Dr. McLain: Well, we have a – we do have a great team. We have the longest held model system, which is from the National Institute of Disability and Independent Living for Rehabilitation and Research. We have had our – we apply for this every five years and we collect data on people that have had spinal cord injuries and what and the cause and complications and we have been doing this since the early 70s. We work with an international cohort to look at trends and ways that we can do things better.
  
  Here at UAB, the system is such that we have great care in the field to bring people; we are a level 1 trauma unit. We have amazing intensivists and trauma surgeons, great neurosurgeons and orthopedic surgeons that do nothing but spinal cord surgery and understand so much about the spinal cord and how to do maximized return and then our spinal cord injury rehabilitation unit has been here since the early 60s and we had a long history of understanding secondary complications and if things aren’t done here; we have – we are constantly in contact with the newest research trials across the country or even the world and then some of the things that people shouldn’t be doing in research that’s not really sanctioned by science.
  
  So, our team – we have the team – when you get to rehabilitation; consists of specific spinal cord injury nursing, specific physical and occupational therapists that just do spinal cord injury. We have psychological support, social services support and many other types of health professions that work together on a team to maximize the function and the quality of life of individuals with spinal cord injury.
  
  Melanie: Thank you so much Dr. McLain, for being with us today and a community physician can refer a patient to UAB Medicine by calling the Mist line at 1-800-UAB- Mist. That’s 1-800-822-6478. You are listening to UAB MedCast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician. That’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.
• Hosts:Melanie Cole, MS