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:
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:
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.