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Training Letter On Spinal Cord Injuries And Potential Complications


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<H1 style="MARGIN: 0in 0in 0pt">July 10, 2003</H1>

Director 211A

All VBA Regional Offices and Centers Training Letter 03-04

SUBJECT: Training letter on spinal cord injuries and potential complications

1. This training material was written in cooperation with Dr. Barry Goldstein, Assistant Chief Consultant, Spinal Cord Injury and Disorders Strategic Healthcare Group, Seattle, Washington. It includes primarily medical information on spinal cord injuries and complications from spinal cord injuries. The intent of this letter is to increase rater sensitivity to the catastrophic nature of these types of injuries. This letter is not intended to make policy.

2. If you have any questions or comments about the content of this letter, or note any errors, please check the appropriate calendar pages at: http://152.124.238.193/bl/21/publicat/Letters/TrngLtrs.htm

/S/

Ronald J. Henke

Director, Compensation and Pension Service

Enclosure

An injury or disease that affects the spinal cord may profoundly change one’s life and how one lives it. To insure each veteran with a spinal cord injury receives a fair and accurate rating, it is helpful to have an understanding of complications that can result from this particular type of injury.

Medical information from this training letter is in large part from the Veterans Health Initiative publication titled “Spinal Cord Injury.” For a more detailed discussion regarding spinal cord injuries, please refer to this publication on the Internet at: http://www.va.gov/vhi/.

Most veterans with spinal cord injuries are entitled to special monthly compensation (38 CFR 3.310). Before rating a veteran for a spinal cord injury, it is essential to understand how and when to apply 38 CFR 3.350. The four part video broadcast on special monthly compensation which aired in October of 2000 is available in a condensed format on CD. You can obtain a copy of these CDs through your training co-ordinator. The supplementary training material for this course is available on the intranet at: http://152.124.112.218/C&P_Training/RVSR/SMC.htm

This training letter parenthetically references particular AMIE Worksheets, sections of the Rating Schedule and Diagnostic Codes that you may find useful. Because there are changes from time to time in these, this parenthetical information may have changed.

<H1 style="MARGIN: 0in 0in 0pt">Terminology and Causes</H1>

Traumatic spinal cord injuries (spinal cord injury) and disease processes (spinal cord disorder) may result in spinal cord dysfunction. There are several major causes of traumatic spinal cord injuries (SCI). These include: spinal cord injury caused by a fracture of the vertebral body with the bony fragments impinging on the cord; encroachment on the spinal cord by dislocation of the vertebral bodies; transient narrowing of the spinal canal in the absence of bony fracture and traction on the cord causing damage to the cord. There are other traumatic causes such as gunshot and knife wounds.

Some nontraumatic spinal cord disorders (SCD) include multiple sclerosis, narrowing of the spinal canal with subsequent compression of the spinal cord (spinal stenosis), spinal cord tumor, HIV-related myelopathy, amyotrophic lateral sclerosis (ALS), post polio syndrome, and spinal cord infarction. In some situations, there is shared symptomatology and similarly associated complications between SCIs and SCDs.

<H2 style="MARGIN: 0in 0in 0pt">Neurologic Classification </H2>

The spinal cord is the body’s primary pathway for transmitting information between the brain and the peripheral nervous system. An intact spinal cord is necessary for voluntary movement and to sense the environment. An intact spinal cord is also necessary for proper functioning of internal organs and blood pressure[bG1] . SCIs and disorders (SCI&D) disrupt the ability to move, and the ability to sense pain, temperature, vibration and position. SCI&D can also disrupt functions of internal organs such as the bladder, bowel, and blood pressure regulation.

By convention, the “neurologic level” refers to the first level with normal function. To determine the neurologic level, the examiner tests functions at each neurologic level by testing the function of the corresponding segment of spinal cord and “nerve root”. For motor function, the examiner tests voluntary movement; for sensory function, the examiner tests the ability to sense light touch and pinprick. With reference to the spinal cord, the first neurologic level is designated as cervical 1 (C1), the next level down is cervical 2 (C2), and so on. Cervical levels include C2-C8 and supply the neck and upper limb. This is followed by thoracic levels (T1-T12) which supply the chest and abdominal wall, lumbar levels (L1-L5) which supply parts of the abdominal wall and lower limb, and sacral levels (S1-S5) which supply parts of the lower limb, genitalia, and organs (bladder and bowel).

The level is often different for motor and sensory functions as well as right and left sides due to anatomical differences and asymmetric injuries. Therefore, the examiner will often determine separate motor and sensory functions, as well as for the right and the left sides. The neurologic level for sensation is the level closest to the head with intact light touch and sharp/dull discrimination. For motor function, the neurologic level is the level closest to the head where the examiner indicates the person can move through a full range of motion against gravity.

<H2 style="MARGIN: 0in 0in 0pt">Pathophysiology of Spinal Cord Injuries </H2>

After the initial injury, swelling, bleeding, ischemia and inflammatory reactions can cause additional damage to the spinal cord. It is rare for the cord to be actually severed (“transected”). Worsening of neurologic function may occur months or years after the initial injury by scar formation, traction on the spinal cord, or cavitation within the spinal cord (post-traumatic syringomyelia).

The International Standards for Neurological Classification of Spinal Cord Injury defines “complete” and “incomplete” injury. A complete spinal cord injury is when there is complete absence of sensory function and complete loss of motor function in the lowest sacral segment. An incomplete injury is when there is at least some preserved function in either the motor component or in the sensory component of the lowest sacral segment and some preserved sensory function or some preserved motor function below the neurologic level.

Complications and Consequences of SCIs may include impairment or disability to many body systems including:

1. Neurologic (NEUROLOGICAL CONDITIONS AND CONVULSIVE

DISORDERS)

2. Musculoskeletal (THE MUSCULOSKELETAL SYSTEM)

<H1 style="MARGIN: 0in 0in 0pt">3. Respiratory (THE RESPIRATORY SYSTEM)</H1><H1 style=MARGIN: 0in 0in 0pt">4. Cardiovascular (THE CARDIOVASCULAR SYSTEM)</H1><H1 style="MARGIN: 0in 0in 0pt">5. Gastrointestinal (THE DIGESTIVE SYSTEM)</H1><H1 style="MARGIN: 0in 0in 0pt">6. Genitourinary (THE GENITOURINARY SYSTEM)</H1>7. Dermatologic (THE SKIN)

8. Psychologic (MENTAL DISORDERS)

1. Neurologic (NEUROLOGICAL CONDITIONS AND CONVULSIVE DISORDERS)

(38 CFR 4.124 a Schedule of ratings – neurological conditions and convulsive disorders)

Autonomic Dysreflexia (AD) is potentially a life threatening condition manifested by a sudden and extreme increase in blood pressure. It occurs when an internal or superficial noxious (i.e., painful) stimulus causes a sudden imbalance in the autonomic nervous system. Up to 85% of those with a spinal cord injury at or above the sixth thoracic neurologic level (T6) experience at least one episode of AD. Signs and symptoms of AD include hypertension or hypertensive crisis, headache, visual changes and flushing. In those with long-standing spinal cord injury, AD may cause only minimal symptoms and the only complaint may be that “something is not right.” The stimulus that causes AD may not be sensed as pain; in fact, the stimulus may not be sensed at all. Two common causes of AD are distention of the bladder and distention of the bowel. Some other causes of AD include pressure ulcers, tight clothing, genital stimulation or intercourse, uterine contraction associated with menstruation, and ingrown toenails. AD is treated by searching for the inciting cause and removing it. When simply removing the inciting cause does not eliminate the elevated blood pressure, pharmacologic intervention with blood pressure monitoring is necessary. Proper bladder management, and regular bowel care helps prevent AD. In some individuals, chronic prophylactic medication is necessary.

Chronic pain after a spinal cord injury is common. “Central neuropathic” pain is pain that is caused by injury to or irritation of the nerves. It is characterized as burning, tingling, stabbing and shooting pain. There is no known cure. Several medications are used in the treatment of neuropathic pain. Medications include antidepressants, anticonvulsants, local anesthetics, and narcotics. Of people with SCIs, 10-20% report that narcotics help central pain. Complications of narcotic use may include addiction and constipation.

Spasticity and spasms occur in about 35% of people with SCIs. In some people, spasticity may interfere with transfers, walking, and activities of daily living. Severe spasticity may cause pressure ulcers and other secondary problems. There are several medications available that diminish spasticity. Medications used to treat spasms are often associated with side effects. Common side effects of these medications may include sedation, withdrawal hallucinations and seizures (baclofen), sedation and hypotension (clonidine), and depression and addiction (diazepam).

Invasive treatments for spasticity include neurolytic blocks with ethyl alcohol, phenol, or botulinum toxin, intrathecal baclofen infusion, myelotomy (incising the lumbar cord) or dorsal rhizotomy (cutting the dorsal roots).

Posttraumatic syringomyelia (syrinx) occurs in 3-4% of people with SCI. Syringomyelia is a slowly progressive syndrome where a slowly enlarging fluid filled cavity forms in the central segments of the spinal cord. The syrinx can expand either up or down or radially (outwards) and may compress the spinal cord. This may cause progressive neurologic defects generally consisting of segmental muscular weakness and atrophy along with loss of pain and temperature sensation while sense of touch is preserved. Symptoms and signs depend upon the location of the syrinx and area of spinal cord affected. Post traumatic syringomyelia is treated by percutaneous CT-guided drainage and surgical shunting.

2. Musculoskeletal (THE MUSCULOSKELETAL SYSTEM)

(AMIE WORKSHEETS: SPINE; BONES; JOINTS; HAND)

(38 CFR 4.71a Schedule of ratings – musculoskeletal system.)

Musculoskeletal complications from SCIs often lead to additional functional problems. One factor that is essential in maintaining normal bone mass and strength is weight bearing. Bone loss below the level of the neurologic impairment starts soon after a spinal cord injury and may rapidly progress to osteoporosis. As osteoporosis progresses, minor forces (e.g., slip from a wheelchair or range of motion) can result in a fracture. Falls cause most fractures because people with SCIs have both weak bones and an increased incidence of falls. Complications from fractures include autonomic dysreflexia (AD), skin breakdown, and blood clots. In most people, fractures are treated with a splint and immobilization. Occasionally, surgery is performed. Immobilization, the risk of skin breakdown from a splint, rehabilitation, mobility, and surgery are more involved in people with SCIs.

Neck and back pain are common in people with SCIs. Causes for back pain include mechanical problems following fractures, dislocations, fusion and instrumentation of the vertebral column. After the initial SCI, surgery is sometimes performed to stabilize the back. Hardware may be used during this surgery. Spine pain can occur when this hardware loosens, brakes or gets infected.

Myositis ossificans (DC 5023), at times also referred to as heterotropic ossification, affects approximately 20-30% of people with SCIs. This is the development of ectopic bone within the soft tissues surrounding peripheral joints. Almost half of the time myositis ossificans is identified it is clinically insignificant. When it is clinically significant, signs and symptoms may include decreased range of motion, localized swelling, redness, and/or fever. If pain sensation is intact in the affected area, the person may experience pain. Treatment for HO may include etridronate disodium and / or nonsteroidal anti-inflammatories. Surgery is often performed if the HO causes functional problems. Surgery is associated with significant risks of bleeding, infection, and recurrence. Low dose radiation is also used but the use of low dose radiation in this setting remains controversial.

Repetitive motion disorders of the soft tissues and joints of the upper extremity are common in people with SCI. People with SCI&D, often use their upper limbs for weight-bearing and mobility thus increasing biomechanical stresses on the shoulders, arms, wrists, and hands.

Approximately one-third to one-half of people with SCI have significant chronic shoulder pain that interferes with daily activities and sleep. Frequently there is no preceding trauma. Propelling a wheelchair, transfers, or using crutches may be associated with repetitive motion disorders of the shoulder, wrist, and hand. These injuries include rotator cuff tears, bursitis, tendonitis, carpal tunnel syndrome, and osteoarthritis. Physical therapy intervention is often necessary to change posture, seating, equipment, and home and work environments.

<H1 style="MARGIN: 0in 0in 0pt">3. Respiratory (THE RESPIRATORY SYSTEM)</H1>(AMIE WORKSHEET: RESPIRATORY (OBS, REST)

(38 CFR 4.97 Schedule of ratings – respiratory system.)

Nerves from the upper portion of the spinal cord (C3 to C5) allow a person to breath. C3, C4, and C5 innervate the diaphragm. The ability to cough and to fully expand the lungs comes from abdominal muscles, and intercostals muscles that are innervated by thoracic nerves (T1 – T12).

People with damage to the spinal cord at the C1 to C3 affecting their breathing, require mechanical ventilation. Unilateral or bilateral paralysis of the diaphragm will predispose a person to atelectasis and pneumonia. Cervical and upper thoracic SCI will also predispose a person to respiratory complications like pneumonia due to restrictive pulmonary function and an impaired ability to cough. Ineffective cough leads to retained secretions, mucous plugging, and infections. Restrictive changes with a low forced vital capacity (FVC) may be seen on pulmonary function tests.

4. Cardiovascular (THE CARDIOVASCULAR SYSTEM)

(AMIE WORKSHEETS: HEART; ARTERIES and VEINS)

(38 CFR 4.104 Schedule of ratings - cardiovascular system.)

The spinal cord is vital to proper regulation of heart rate and blood pressure. In response to exercise, and to sustain this physical exertion, the spinal cord and brain work to increase the heart rate and blood pressure. People with SCI&D generally have a reduced exercise capacity. They may experience fatigue and exhaustion after minimal exertion.

People with SCI&D may be at increased risk for coronary artery disease. (DC 7005). Risk factors after SCI&D include physical inactivity, increased low-density lipoprotein levels (LDL), low high-density lipoprotein levels (HDL), obesity, and an increased incidence of glucose intolerance.

Chest and jaw pain are sometimes symptoms of cardiac ischemia. People with SCIs above T5 may not experience these symptoms. Since exercise testing is often not possible after a SCI, a pharmacologic stress test (e.g., adenosine thallium stress test) is used to evaluate cardiac disease.

Edema of the lower extremities (commonly referred to as “peripheral edema” or more simply, “edema”) is common in people with SCIs. Edema is swelling caused by fluid within tissues. Normally the muscles of the lower extremities act to pump fluid out of the legs. In people with SCIs the leg muscles do not work properly. This causes lack of normal pump action and this leads to edema. Edema can lead to skin breakdown. (DC 7899 – 7120). Leg elevation and compression stockings can minimize edema. Diuretics can get rid of excess fluid. However, diuretics lower blood pressure. People with a spinal cord injury generally have a low baseline blood pressure and cannot tolerate any further drop in blood pressure. Therefore, diuretics are not used to treat edema in someone who has a spinal cord injury. Edema may predispose a person to deep venous thrombosis (DVT). DVT can lead to life threatening pulmonary embolism. Though DVT occurs more frequently within the first three months following the acute spinal cord injury, thereafter its incidence still remains increased when compared to the general population. DVT can lead to chronic problems including post phlebitic syndrome. (DC 7121).

<H1 style="MARGIN: 0in 0in 0pt">5. Gastrointestinal (THE DIGESTIVE SYSTEM)</H1>(AMIE WORKSHEETS: RECTUM and ANUS; ESOPHAGUS AND HIATAL HERNIA; STOMACH AND DUODENUM AND PERITONEAL ADHESIONS)

(38 CFR 4.114 Schedule of ratings – digestive system.)

SCIs can affect the nerve supply to the gastrointestinal tract. This can lead to slow gastric emptying, increased acid secretion, ulcers, ileus, and changes in colonic motility. Gastrointestinal complications can be a source of inconvenience, frustration and expense. To avoid constipation and incontinence, most people with an SCI will need a “bowel program”. These programs vary depending on whether the person has an “upper motor neuron bowel” or a “lower motor neuron bowel”. An "upper motor neuron bowel" results from an injury above the S2 level whereas a "lower motor neuron bowel" results from an injury at the S2-S4 levels. Whether upper or lower motor neuron bowel, both result in loss of voluntary anal sphincter control. (DC 7332; See also 38 CFR 3.350 (e) (iv) (2) regarding SMC).

Bowel programs help establish routine bowel movements. These programs often require special equipment (accessible toilet, foam rubber commode cushions to prevent pressure damage to the buttocks) supplies (plastic gloves, lubricant), medications (e.g. suppositories, fiber tablets), and special dietary measures. Bowel care often requires insertion of a well lubricated suppository high up against the mucosa of the rectal wall to start peristalsis. Then 15 minutes later the person should be on the toilet with his or her feet up on a foot stool. This body position helps bowel evacuation. The person with the SCI or the attendant may need to use “digital stimulation”. Digital stimulation involves inserting a gloved, lubricated finger into the rectum. Gentle rotation of the finger in a circular motion pressing all sides results in subsequent bowel evacuation.

People with SCIs have an increased incidence of esophagitis, and intermittent abdominal distention. They also have an increased incidence of hemorrhoids. (DC 7336).

<H1 style="MARGIN: 0in 0in 0pt">6. Genitourinary (THE GENITOURINARY SYSTEM)</H1>(AMIE WORKSHEET: GENITOURINARY)

(38 CFR 4.115a Ratings of the genitourinary system-dysfunctions.)

Genitourinary complications after SCI&D are common. Some of these complications include recurrent infections, stones, incontinence, and high pressure voiding.

Within the first year after the injury, most will have had at least one urinary tract infection.

A spinal cord injury as low as S4 can result in loss of volitional voiding (voiding under voluntary control). Several techniques may be used to avoid incontinence and minimize infections. A person may use intermittent catheterization, indwelling or suprapubic catheters or, (if male) condom catheters. Other voiding techniques include anal sphincter stretch to promote relaxation of the external urethral sphincter and detrusor compression via Crede maneuver (pressure applied over the lower abdominal area over the bladder). (Voiding dysfunction; DC 7542; See also 38 CFR 3.350 (e) (iv) (2) regarding SMC).

Two classes of medications are sometimes used to help manage voiding problems associated with SCIs. Depending on the level of the injury, a person may use either anticholinergic medications (including oxybutynin, propantheline and imipramine) or alpha-adrene

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