DEPARTMENT OF ORTHOPEDIC & TRAUMATOLOGY FACULTY OF MEDICINE UNIVERSITY HASANUDDIN

CASE REPORT MARCH 2011

SPINAL CORD INJURY

By : Khairul Faizi Khairuddin C 111 06 264

Tutors : dr. Ariyanto Arief dr. Rizqi T. Tuahuns

Supervisor : dr.M. Ruksal Saleh, Sp.OT

DEPARTMENT OF ORTHOPEDIC & TRAUMATOLOGY FACULTY OF MEDICINE UNIVERSITY HASANUDDIN MAKASSAR 2011

CASE REPORT
PATIENT IDENTITY

Name Age Sex Date of Admission Registration No. Status

: Mr. S : 65 years old : Male : February 24th , 2011 : 45 85 97 : Jamkesmas

ANAMNESIS Chief complaint : cannot move both of lower limb History taking : Has been suffered since 10 days ago before admitted to Wahidin Hospital due to injury at work. History of unconsciousness (-), nausea (-), vomit (-), prior treatment (-). Mechanism of injury : The patient was repairing his house and suddenly the wood fell down to the back of his neck

PHYSICAL EXAMINATION General status : Severe illness, poor nutrition, well conscious Vital sign : y y y y y Local status Vertebra region: y y I : Wound (-), hematome (-), deformity (-), swelling (-) P : Tenderness (-) Blood pressure Pulse Respiratory rate Temperature : 100/70 mmHg : 80x/minutes : 22x/minutes : 36.90 C (axillar)

Table 1: Motoric physical examination

Table 2: Sensory physical examination

Table 3: Reflex physiologic and pathologic

Rectal toucher : y y y y y sphincter tone was loss Mucous was smooth Ampula filled feses Gloves : Blood(-),slime(-), feces(+) Bulbocavernosus reflex (+)

Laboratory finding (24.2.2011) 8,9 x 103 /uL 4,00 x 106 /uL 12,3 g/dL 37,8 % 133 x 103 /uL 800 200 88 mg/dl 37,0 mg/dl 0,6 mg/dl 30 U/I 34 U/I

y y y y y y y y y y y y DIAGNOSE

WBC RBC HGB HCT PLT CT BT GDS Ureum Creatinin SGOT SGPT

Tetraparese due to spinal cord injury

MANAGEMENT y Methylprednisolon 4mg 3x3 ( 1st 3 days) 3x2 (2nd 3 days) tappering off

3x1 (3rd 3 days) 2x1 (4th 3 days) y y Plan for stabilization anterior Plan for Rehabilitation

SPINAL CORD INJURY

I. DEMOGRAPHICS OF SPINAL CORD INJURY A. Epidemiology

The overwhelming majority of Spinal Cord Injuries occur as a result of trauma. Approximately 10,000 new cases of SCI occur each year in the United States. Recent statistics find that motor vehicle accidents account for 44.5%, falls account for 18.1%, sports related injuries account for 12.7%, and acts of violence account for 16.6%. (Stover SL et al, Spinal Cord Injury: Clinical Outcomes from the Model Systems, 1995) Spinal Cord Injury primarily affects young adults in the 16 to 30 years age group (this group comprises 58.8 % of injuries). 82.2% of spinal cord injury patients are male. The overall racial and ethnic distribution is 70.1% white, 19.6% African-American, and 10.3% other. The incidence of SCI increases as daylight hours increase and temperatures rise, therefore the peak months of the year are June, July and August. Saturday and Sunday are the peak days of the week.

II.

CLASSIFICATION OF SPINAL CORD INJURIES It is important to have a common classification system concerning level of injury of the

spinal cord injured patient. If one segment of care givers talks about bony level of injury and other segment utilizes neurologic level of injury there can be a significant amount of confusion because the two are rarely exactly the same (especially in low thoracic fractures where the terminal part of the spinal cord lives). Also, without a common classification system it becomes nearly impossible to compare outcomes of studies utilizing drugs to improve motor recovery following SCI.

A thorough neurological examination must be performed in order to determine the neurologic level of lesion. The classifications for Spinal Cord Injury used in this chapter are The International Standards for Spinal Cord Injury Classification by the American Spinal Injury Association (ASIA), 1996. According to the American Spinal Injury Association (ASIA), the level of lesion is described in terms of right and left sides of the body and motor and sensory levels.

Definitions:

1)

Tetraplegia (old term Quadriplegia): loss of motor and /or sensory function in the

cervical segments of the spinal cord resulting in impairment of function in the arms as well as the trunk, pelvic organs and legs. 2) Paraplegia: loss of motor or sensory function in the thoracic, lumbar, or sacral

(but not cervical ) segments of the spinal cord resulting in impairment of function of the trunk, pelvic organs and legs (depending on level of injury). This term refers to cauda equina and conus medularis injuries but not to injuries of the peripheral nerves (lumbosacral plexus).

Determining the Sensory Level: Dermatome Diagram In order to determine the sensory level, light touch and pin-prick awareness must be assessed. Again, the last or most caudal intact dermatome will determine the sensory level. Intact means that there is normal sensation preserved at the specific sensory dermatome (see diagram below).

Determining the Motor Level:

In order to determine the motor level, ASIA has established "Key Muscle Groups." In order for the muscle to be considered "intact", a grade of > 3.0 is necessary (given that the key muscle group above is normal). The following is a list of the Key Muscle Groups.

KEY MUSCLES FOR MOTOR LEVEL CLASSIFICATION

SPINAL NERVE C5 C6 C7 C8 T1 T2-L1 L2 L3 L4 L5 S1 S2-S5

MUSCLE Biceps Wrist Extensors Triceps Flexor Profundus Hand Intrinsics Sensory Level Iliopsoas Quadriceps Tibialis Anterior Extensor Halluces Gastrocnemius Sensory Level

ACTION Elbow Flexion Wrist Extension Elbow Extension Finger Flexion at DIP Fifth Finger Abduction

Hip Flexion Knee Extension Ankle Dorsi Flexion Great Toe Extension Ankle Plantar Flexion

For example, a C7 Tetraplegic would be neurologically intact at C4, C5, C6, and C7. This patient would have all movements at the shoulder girdle, be able to flex and extend at the elbow and be able to extend the wrist. Sensation would be intact down to and including the C7 Dermatome (midlle finger). There would be no finger or lower extremity movement. It is also important to determine if the lesion is complete or incomplete. ASIA standards define a complete lesion as the absence of sensory or motor function in the sacral region. International Standards for Spinal Cord Injury Classification define an incomplete lesion as the presence of sensory or motor function in the sacral region. This is also referred to as sacral sparing. Occasionally, in complete injuries, there is some diminished sensation present below the

last intact normal sensory level. This is referred to as the Zone of Partial Preservation. This generally extends down 2 or 3 sensory levels.

ASIA IMPAIRMENT SCALE A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5. B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3. D = Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more. E = Normal: Motor and sensory function are normal.

CLINICAL SYNDROMES Central Cord Syndrome : Central cord syndrome (CCS) is an acute cervical spinal cord injury (SCI) characterized by disproportionately greater motor impairment in upper compared to lower extremities, bladder dysfunction, and variable degree of sensory loss below the level of injury. Although CCS has been reported to occur more frequently among older persons with cervical spondylosis who sustain hyperextension injury, it may occur in persons of any age and can be associated with various etiologies, injury mechanisms, and predisposing factors. CCS is the most common incomplete spinal cord injury syndrome.

Brown-Sequard Syndrome : Brown-Sequard syndrome (BSS) was classically described as spinal cord hemisection causing ipsilateral hemiplegia and contralateral hemianalgesia. This is a relatively uncommon injury estimated to account for only 2-4% of all traumatic SCI.

Anterior Cord Syndrome : A lesion that produces variable loss of motor function and of sensitivity to pain and temperature, while preserving proprioception.

Conus Medullaris Syndrome : Injury of the sacral cord (conus) and lumbar nerve roots within the spinal canal, which usually results in an areflexic bladder, bowel and lower limbs, with lesions. Sacral segments may occasionally show preserved reflexes, e.g. bulbocavernosus and micturition reflexes, with lesions.

Cauda Equina Sydrome : Injury to the lumbosacral nerve roots within the neural canal resulting in areflexic bladder, bowel and lower limbs, with lesions.

SPINAL DOSE STEROIDS: Methylprednisolone Studies Methylprednisolone has been investigated in a number of animal studies as well as two major human studies. The first human study was the National Acute Spinal Cord Injury Study (NASCIS) reported in JAMA in 1984 by Bracken et al. In this study one group received an infusion of 1 gram of Methylprednisolone and the other group received a 100 milligram bolus followed by 10 daily doses of 100 milligrams. There was no significant difference between the two study groups. The problem with the study was that there was no placebo group and the same total doses of Methylprednisolone were given to the two groups over different time intervals. The widely publicized NASCIS 2 study printed in The New England Journal of Medicine in May of 1990 by the same investigators increased the dose of Methylprednisolone. The dose was increased to 30 milligrams per kilogram IV bolus within eight hours of injury, followed by a maintenance dose of 5.4 milligrams per kilogram per hour for 23 hours. In addition, there were two other wings of the study: naloxone and placebo groups. The study groups were larger in number and included from 154 to 171 patients in each group. The study included neurologically complete and incomplete spinal cord injuries.

Motor and sensory function was scored at admission, 6 weeks and 6 months post injury. Methylprednisolone was given within the first 8 hours of injury. It was shown that the group receiving Methylprednisolone showed a significant increase in neurological recovery compared to the other two groups. However, the major criticism of the study is that it was not clear if there were significant functional improvements. Although motor scores improved, it is not certain that this improvement was enough to significantly improved function. Methylprednisolone inhibits lipid peroxidase and hydrolysis which limits cell membrane destruction. Membrane damage peaks at approximately 8 hours and this is the reason the drug must be given within that time period. Steroids were shown to improve blood flow within the spinal cord. This study has changed the way in which acute spinal cord injured patients are currently treated. In fact, every traumatic spinal cord injury patient, at the present time, receives this protocol of Methylprednisolone within the first eight hours of injury. The only exceptions include those patients with penetrating injuries, patients in the pediatric age group (<13 y/o), pregnant females, and patients with fulminant infections such as TB, AIDS, or severe diabetes. The NASCIS 3 Trial is now completed and published (Bracken et al, , JAMA, May 1997) and suggests that if steroids are begun in less than three hours after injury, the 24 hour protocol above remains the same. If however the steroids are begun between 3 and 8 hours, the patient may benefit from 48 hours of methyl prednisodone. Tirilizad mesylate was also tested and showed promise, but no specific recommendations for its use came out of the NASCIS 3 Trial.

III. REHABILITATION OF THE SPINAL CORD INJURED PATIENT The goal of a rehabilitation program is to maximize the patient's independence in basic grooming, hygiene, dressing, feeding skills, bathing, toileting, and transfers. Psychological

support and counseling is provided to aid the patient in their adjustment period. Vocation and social reintegration is encouraged.

The level of independence achieved is related to the patient's level of Spinal Cord Injury. This is tempered by the age, general medical condition, and motivation of the patient. The

following provides guidelines for functional expectation based on the level of the Spinal Cord Injury. C2-C4 Respiratory compromise present to varying degrees, may be ventilator dependent. Patient should be able to operate motorized wheelchair and Environmental Control Units (ECU) with voice control, mouthstick or chin. Environmental Control Units are computerized systems whereby a simple touch of a dial can activate electrical controls in the room. An ECU can allow a tetraplegic patient to turn on and off TV, stereo, or lights from his/her bed.

C5

Light grooming and hygiene possible. Writing and feeding oneself is possible after set up and with upper extremity splints. Use of motorized wheelchair and ECU is possible with adapted hand control. With time, patients can often propel a lightweight manual wheelchair with legs for short distances. Patients generally require maximal assistance in dressing, bathing, bowel and bladder care, and bed transfers.

C6

The presence of wrist extension enables the patient to utilize tenodesis orthoses, thereby increasing their level of independence in grooming, dressing, and bladder care. Patient is dependent in performing bowel program and requires assistance for bed mobility, bathing, and transfers. The patient can propel manual wheelchair, but may need a power chair when they need to go long distances. These patients are generally able to drive an adapted van independently.

C7-T1

Patient has the potential to be completely independent in self-care, dressing, bathing, and toileting. The presence of triceps muscles allows independence in transfers and manual wheelchair use. Wheelchair to floor transfers and back are still difficult at this level. These patients may be able to drive a car with hand controls.

T2-T10

Patient has full use of upper extremities, and can be fully independent in self-care activities at wheelchair level. Can stand for exercise with bilateral KAFOs and forearm crutches/walker.

T11-L2

Complete independence at wheelchair level possible. Ambulation with braces from thighs to feet (KAFO) and crutches, but only for short Ambulation at this level too strenuous for functional activities. distances.

L3-below

Patient has the capacity for functional ambulation with the use of below the knee (AFO) braces at least on one side and crutches. Fully independent in self-care activities.

In summary, the effects of a Spinal Cord Injury can be quite devastating from an emotional, psychological, medical, and financial perspective. The aim of a rehabilitation program is to restore dignity to the patient by assisting them in learning ways to care for themselves to the best of their potential. Many individuals with Spinal Cord Injury are successfully reintegrated into society with respect to their social, vocational, and avocational functioning. The total rehabilitation of a Spinal Cord Injured patient can be very arduous but, with perseverance, these individuals are very capable of living productive lives.

IV.

MEDICAL SEQUELAE OF SPINAL CORD INJURY Every organ system is affected by a Spinal Cord Injury. The following is a systems

approach to the medical sequelae of Spinal Cord Injury. discussed in both the acute and chronic phases.

The problems and treatment are

A.

Integumentary System - Due to immobility and lack of sensation, pressure sores or

decubitus ulcers are frequent among the Spinal Cord population. It has been shown that after 2 hours of immobility, a pressure sore can develop. The mainstay of treatment is prevention.

In the acute phase, turning every 2 hours while in bed is critical. As time goes on, patients can tolerate sitting up most of the day. They need to continue to do pressure reliefs while in the wheelchair. Patients are instructed in "weight-shifts" and "push-ups." Both are techniques used to relieve pressure from sitting areas. Once a decubitus has developed, complete pressure relief is the treatment. Local wound cleansing agents are used to keep away necrotic tissue and allow healthy tissue to granulate. Some decubiti can become so extensive that myocutaneous flap surgery is required.

B.

Urinary System - Due to the interruption of the parasympathetic and sympathetic

innervation of the bladder, urinary drainage is impaired. Poor urinary drainage can lead to chronic urinary tract infections and further increase the risk of bladder and renal calculi. Acutely, during the spinal shock phase of injury, the bladder will be areflexic (flaccid) and is best managed with continuous indwelling drainage (Foley catheter). Chronically, use of an intermittent catheterization program will decrease the risk of infection. Patients can and should be switched from the Foley catheter to an intermittent

catheterization program (ICP) in the acute care setting as soon as IV fluids are off and the patient's urine output is in a manageable range for ICS (<800 cc each shift). Prior to instituting an ICP, the patient should be free from infection. If an infection is present, as is common with a Foley, antibiotics should be given. Fluid intake should be regulated at 2000-2400 cc of fluid per day. The amount of fluid intake will affect the frequency with which catheterizations are done. Usually, intermittent catheterizations are done every 4 hours until the catheterization volumes stabilize and the catheterization frequency can be decreased. Sometimes the ability to perform an ICP is limited by the patients Level of injury/ hand function. In males, if an ICP cannot be done due to upper extremity limitations, an external sheath with a leg bag is recommended once reflex voiding has begun. Urodynamics, along with measurement of bladder pressures is usually necessary to optimize bladder function. Medications to alter the autonomic functioning of the bladder such as the alpha blocker hytrin, or smooth muscle relaxer Ditropan may also be appropriate. In females, if upper extremity function is not sufficient to permit performance of an ICP, a Foley catheter is usually used long

term. The patient is instructed to keep a good fluid intake to prevent infections from the Foley catheter.

C.

Gastrointestinal System - As with the urinary system, the interruption of parasympathetic

and sympathetic innervation of the intestines prevents effective bowel evacuation. In the acute phase, Spinal Cord Injured patients are prone to developing an ileus. Oral intake should not be instituted until active bowel sounds are heard. Diagnosis is based upon the absence of bowel sounds, abdominal distension, nausea and vomiting. Nasogastric tube decompression may be necessary initially until ileus resolves. Due to absent sensation, pain may not be present. Plain x-rays of the abdomen will reveal the presence of ileus. Once the patient is able to tolerate po intake, a bowel program should be started. This is done to promote regular bowel evacuation which prevents incontinence and/or fecal impaction. Patients are started on a stool softener daily, an oral colonic stimulant (like Senokot) and a rectal suppository (or digital stimulation), given at a routine time to aid in evacuation. Patients are maintained on an every day or every other day bowel program throughout their lifetime. Constipation and fecal impaction chronically is the most common GI complication in this patient population and is preventable with a good bowel program. Another potential abdominal problem in the acute phase is stress ulcer. Again, loss of sensation can allow this condition to go undetected until acute hemorrhage occurs. Prophylaxis with an anti-ulcer medication should be given routinely. Acutely patients are also at risk for pancreatitis.

D.

Cardiovascular System

1.

Acutely neurogenic shock is typically seen in patients with high thoracic and cervical

level injuries. The classic triad of Neurogenic shock includes: Hypotension, Bradycardia, and Hypothermia. Hypotension is due to loss of vasomotor tone, bradycardia is due to lack of sympathetic opposition to the vagus nerve, hypothermia may occur due to the extreme vasodilitation these patients experience acutely. Position, judicicious fluid resuscitation and use of vasopressors are the mainstay for treatment of the hypotension.

2.

More chronically as spinal shock resolves and spinal reflexes return health care

professionals must be aware of a problem called Autonomic Dysreflexia - This is a medical emergency and a potentially life-threatening event. It occurs only in lesions above T6. Autonomic dysreflexia results from increased sympathetic activity which cannot be compensated for by supraspinal inhibition, due to the interruption along the spinal cord. Visceral stimuli from the bladder, colon, rectum, uterus and skin enter the spinal cord and ascend by way of the spinothalamic tracts and posterior columns. Reflex motor outflow through the neurons in the lateral horns of the spinal cord causes vasoconstriction below the level of the spinal cord lesion, which leads to severe hypertension. Hypertension is a major concern since seizures or death may occur as a result of cerebral hemorrhage. compensatory response. In the clinical setting, bladder over-distension, fecal impaction, decubitus ulcers, ingrown toenails, and the last stage of labor are the main noxious stimuli. In response to these causes of sympathetic stimulation, the patient develops severe hypertension, bradycardia, pounding headache, sweating and blotching above the level of the lesion. Occasionally, tachycardia, mydriasis, and Horner's syndrome occurs. The treatment of choice is to remove the causative stimuli. This means a bladder Bradycardia develops as a vagal

catheterization must be done. If a Foley catheter is in place, it should be checked for blockage. If bladder distension is not the cause, then the rectum should be checked for fecal impaction. When a life-threatening episode occurs, more aggressive management is necessary and includes placing the patient in a sitting position. Oral procardia and nitroglycerine are

appropriate if medical management of the blood pressure is necessary.

2.

Orthostatic Hypotension

This is seen in both the acute and chronic quadriplegic patient.

Due to impaired

vasomotor reflexes and venous pooling, patients suffer hypotension and dizziness when going from the supine to the upright position.

This problem can usually be overcome by gradually increasing the person's tolerance to the upright position. Abdominal binders and TED stockings are effective in decreasing venous pooling and increasing venous return. Oral salt tablets, mineralcorticoid supplementation, ephedrine or midodrine.

3.

Deep Venous Thrombosis (DVT) The incidence of DVT has been shown to be the greatest during the first three months

post-injury and ranges from 70-100% depending on the study endpoints and method of detection. Virchow's triad of stasis, hypercoaguability and vascular injury is the mechanism leading to DVT. The Spinal Cord Injured patient is at high risk of developing DVT because of venous stasis due to immobilization and loss of calf muscle pump action. In the immediate post-trauma period, the trauma itself is a stimulus to activate the clotting system. Low molecular weight heparin and a method of stimulating venous return in the legs (thigh high pneumatic compressive boots or electrical stimulation of calf muscles) have been the first three months post-injury to prevent DVT. Because pain sensation is usually absent, emphasis on objective evaluation is necessary to diagnosis a DVT. Painless unilateral leg swelling necessitates investigation for the presence of a DVT. Ultrasonography (B mode) plus color doppler allows the ability to image the iliac, femoral and popliteal veins and is a reliable screening tool for DVT. Venography remains the gold-standard. Treatment of DVT is the same as for the non-Spinal Cord Injured patient with full heparinization or with low molecular weight heparin. Pulmonary embolus is a serious consequence of the spinal cord injured patient's immobility. The clinician must rely on the following clues indicating the possibility of a pulmonary embolism: Shortness of breath, chest tightness, unexplained fever and/or tachycardia and cough. Laboratory and radiologic evaluation as well as treatment, is the same for the non-spinal cord injured individual.

E. Respiratory System The diaphragm is innervated by the Phrenic Nerve, which derives nerve roots from C3, C4, and C5. The intercostal muscles are innervated segmentally. The Accessory Muscles are

innervated by the eleventh Cranial Nerve. The diaphragm is the major muscle of inspiration, however in tetraplegics with loss of the intercostals, there is loss of vital capacity and typically a restrictive pulmonary pattern develops. Paradoxical breathing pattern results (AP diameter decreases and abdomen rises with inspiration). Strengthening of functioning inspiratory muscles and improving deep breathing is important (especially to maintain chest wall compliance); in addition an abdominal binder used when the patient is sitting up helps keep the diaphragm elevated in the chest where it is in a position of maximal function. Impairments in respiratory muscles result in alveolar hypoventilation. Loss of the abdominal musculature means loss of effective cough. This predisposes the patients to increased risk of respiratory infections, as the patients are unable to clear their own secretions. Patients must be well hydrated to prevent mucous plugging. Chest PT consists of Percussion and Postural Drainage and In-Exsufflator mechanical assisted cough which assists the patient in clearing his/her own secretions. This should be routinely ordered in the acute phase of high Spinal Cord Injury. In the chronic phase, patients are generally able to manage their own secretions and require assisted cough techniques on a periodic basis.

F. Musculoskeletal System

The evaluation of the swollen lower extremity in the Spinal Cord Injured patient is very important. Because pain sensation is usually absent, objective measures must be relied upon. The differential diagnosis is Deep Venous Thrombosis (DVT), Cellulitis, Heterotopic Ossification, underlying fracture, and intramuscular hemorrhage. After ruling out a DVT, as described above, the remaining conditions can be evaluated. Cellulitis will present as warm, red swollen extremity, much like a DVT. However, a sore may be present as the causative factor, and an elevation in the serum white blood cell count is often present. Heterotopic ossification is an inflammation of extra-articular soft tissue with the laying down of cancellous bone. The etiology is not known. The most common sites of occurrence are hips, knees, elbows, and shoulders. It occurs below the level of the lesion around paralyzed

joints, usually it occurs 1 - 4 months post injury. Diagnosis is made based upon X-ray finding of bone formation adjacent to a joint, but this is a late finding. Acute diagnosis is based upon three phase bone scan and an elevated serum alkaline phosphatase. Didronel (etidronate disodium) inhibits growth of hydroxyapatite crystals and is best given prophylactically for 12 weeks following injury (20 mg/kg/day for first two weeks, 10 mg/kg/day for the remaining ten weeks). Range of motion must be maintained. Joint ankylosis is a possible long-term complication. An underlying fracture may also present as acute swelling. A plain radiograph will detect this. Intramuscular hemorrhage due to rupture of the muscle is rare, but a possible complication. MRI is a useful diagnostic tool. Hemoglobin and Hematocrit should be drawn to check for a drop in the blood count. Spasticity occurs in an upper motor neuron lesion due to loss of inhibitory cortical input on the gamma muscle spindle unit. Clinically, this is seen as involuntary movement in a particular muscle group. It usually involves many large groups at once. Spasticity can be quite troublesome by interfering with a patient's functional activity. Due to the muscle imbalance it produces, joint contractures may develop if routine range of motion is not performed. The treatment of spasticity begins with a good routine of stretching. Individuals frequently report their spasms are less if they perform routine range of motion on arms and legs once or twice daily. The next line of treatment is with medications. It is important to remember and to instruct the patient, that these medications do not totally abolish spasms. The most common and frequently used anti-spasticity drug is Baclofen (Lioresal). It acts at the spinal level to inhibit postsynaptic reflexes (GABA agonist). Baclofen should be started at a low dose and be increased gradually (5 mg. po tid X3 days, then 10mg. po tid) to minimize the side effects. Most common side effects include lethargy, drowsiness, or GI complaints. Once on a stable dose (between 80-150 mg/day), Baclofen must never be discontinued abruptly; it must be tapered slowly. When abruptly discontinued, it can cause hallucinations, seizures, disorientation, and rebound spasticity. Other anti-spasticity agents include Dantrolene Sodium and Catapres. Dantrolene

Sodium has potential side effect of liver toxicity, so LFT's must be closely monitored when the

drug is being started and also when stable. Catapres is frequently used in the patch form and hypotension is its primary side effect. Tizanidine is a new agent being used for spasticity. It is a centrally acting alpha-2 adrenergic agonist. It is believed to reduce spasticity by increasing presynaptic inhibition of motor neurons. The main side effects are hypotension and sedation. effects and hypotension effects are dose related. Spasticity is often exacerbated when the patient is experiencing an underlying medical problem. This is important due to impairment or absent visceral sensation. Oftentimes, the presenting symptoms may be increased spasticity. Before increasing anti-spasticity medications, attention should be paid to ruling out underlying pathology. Common underlying conditions causing increased spasticity are UT1's, decubiti, ingrown toenails, or bowel impaction. An acute intra-abdominal process can also present as marked increase in spasticity. Both the therapeutic

G. Sexuality

A human being's sexuality is much more complicated than simply the mechanics of the sexual act. Sexual desire does not necessarily diminish after a Spinal Cord Injury. In males, the ability to achieve and sustain an erection is altered, depending upon the level of the lesion. In complete upper motor neuron lesions, reflex erections are possible, but the reflex erection and ability to maintain it is diminished. In incomplete lesions, psychogenic erections may possible. In either case ability to ejaculate is often impaired. In females with upper motor neuron complete lesions affecting the sacral segment, it is thought that reflex lubrication persists however psychogenic lubrication is absent. In incomplete lesions, psychogenic lubrication may be possible. For both males and females, the ability to experience intimacy is not impaired. Sexual intercourse and other forms of sexual activity are possible. Orgasm may be achieved, but it is less frequent and may be different from pre-injury. SCI individuals often describe orgasmic feelings as a warm release, tingling, or glowing sensation. Exploration of different erogenous zones may also lead to heightened sexual pleasures. For males with impotence, the use of

vacuum suction, confidence rugs, or pharmacologic erections may be useful. For females with diminished lubrication, a water solvent lubricant may be appropriate.

H. Fertility

In the female, fertility is generally unaffected. Complications during pregnancy include chronic urinary tract infections and possible autonomic dysreflexia during the last stages of labor in Spinal Cord lesions above T6-T8. Meticulous care can usually overcome these problems and result in a successful and happy outcome. Autonomic dysreflexia has been inadvertently confused with preeclampsia and misdiagnosis can be fatal. Meticulous care can usually overcome these problems and result in a successful and happy outcome. In the male, fertility is much more affected. This is due to the inability to achieve erections, inability to ejaculate or retrograde ejaculation, or inefficient seminal emission; hypomotility and impaired spermatogenesis are also problems. Methods to augment ejaculation and methods to obtain semen for SCI men include electroejaculation and vibratory ejaculation. These are coupled with artificial insemination or invitrofertilization and have successfully resulted in impregnation.

I. Psychologic Reactions As with all human emotions, the spinal cord patients' reactions to their disability are quite variable. Chronic depression, anxiety, and aggressive behavior are quite common. The

psychological adjustment takes much longer than the physical adjustment and requires a great deal of understanding and patience on everyone's part.

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2.

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