I'm Susan Garstang. I am an attending PMNR at the VA in Salt Lake City. I did my PMNR residency at Baylor and then I did a spinal cord injury medicine fellowship at Kessler many, many years ago. I'm just gonna tell you guys why I chose spinal cord injury and kind of frame the lecture for you. So when I was in medical school, I loved everything. I particularly, I even liked surgery actually, but I particularly liked medicine. I liked ortho, I liked rheumatology, I liked neurology. And I always kind of wondered like, what happens to them after they have their surgery or their stroke or all the complex medical things. And then I stumbled across PMNR in my fourth year and I was like, oh, this is it. And then I went into PMNR not really knowing what I wanted to do and spinal cord injury just really, it kind of called to me. Those patients, the thing I like about spinal cord patients is that they're cognitively intact generally and they become really good at directing their own care. And I actually really like that sort of the empowered, educated patient because you can partner with them in a really effective way. And it just really was a kind of a happy place for me. And so that's why I chose spinal cord injury. It's very medically complex and has lots of moving parts. And so this lecture is actually gonna go through the systems that are involved in spinal cord injury, a little bit of an overview, a brief anatomy reminder, and then the systems and things, just so you get a sense of kind of the complexity of this, but this is like its entire own field, right? And very, very different physiology than like every other condition that you're gonna see. They become very different. The autonomic nervous system is impacted in a way that really impacts everything. And so I think it's really cool and that's sort of my passion. So let me do my screen sharing, which is everyone's least favorite thing to do. So let's do that and then we'll do that. Okay, I'm hoping that you can see that if you can't color. And you guys can put questions in the chat, but know that while it's in presenter mode, I can't see them. And so I'll do my lecture and then I'll get to the questions at the end if that's okay. And so this is actually kind of a cool picture. This is the Canadian medical journal, like JAMA, except I think it's C-A-M-A. And the title of this picture was autonomic dysreflexia. And I thought it was really cool, just the way they like realize how much it's an emergency. It's a little bit not accurate because this is a spine, not a spinal cord, right? Just being a purist. But still, I thought that was cool that that made it on the cover of a really well-known journal. So epidemiology and there's studies about every 10 years, there's an SCI data center that has all has the, so the United States has what are called spinal cord injury model systems that have data collection sites. And then they feed it into this big national database and every 10 years they run kind of a like current profile. And so you'll see some of these dates are like 2000, 2010, 2020, the closest one we have, just to give you a sense of how things are changing. So as of right now in this country, there's about 54 cases of new spinal cord injuries per million, 17,000 a year. So it's not super common. And then prevalence is about 300,000 people that are living with a spinal cord injury in the United States. This is all told. So this is tetraplegic, paraplegic, very incomplete, totally complete, the whole gamut. The average age is now 43. So in the 70s, it was 29. Back then we had a lot more people that were injured in the military and back then the body armor wasn't great. And so people got shot and got spinal cord injuries. Now we're getting amputees and brain injuries because the body armor is a lot better. We're also getting a lot more people living longer and falling. And so you'll see it's actually, it's a bimodal distribution. So we still have our young people that are skiing and mountain biking and doing all those things. Diving is not good for your spinal cord. And then the older population. So 56% of the population still is between 16 and 30 and 70% male. So this is a sort of a condition of young men. 39% are paraplegic and 61% are tetraplegic and 67% are incomplete. Etiology as it's changed from 2000 to 2019, motor vehicle accidents, it's less likely to cause a spinal cord injury just because the airbag technology has gotten a lot better in the past 20 years. Violence is about the same. This one goes up and down more. And it sort of depends also where you live. If you're in a level one trauma center in a poorer area, you'll see a lot more gunshot wounds causing spinal cord injuries. But it's about the same. And then falls, you can see have gotten higher. I don't know why, like why are older people falling more? Maybe people are living longer, I don't know. Anyway, sports are about the same. That's what we see here in Utah, right? We see the skiing and the mountain biking and all those things. And then there's sort of the miscellaneous other, which has dropped a little bit. But you know, there's always other, something other that causes spinal cord injuries. And notice this is just traumatic for dyslexia. This is not like progressive myelopathy from HIV, for example. Life expectancy. This is a question that patients are always gonna ask you, families will ask you. If you are a paraplegic, as long as you live through the first year, generally means not having a PE, they're here to hospital stay and not having too many infections. Those patients really live a normal lifespan. The things that kill our paras is what kills everybody else, right? Heart disease, stroke. Sadly, I think COVID's now number three, but all of those sort of chronic conditions, right? Hypertension is common. If you are a tetraplegic, so life expectancy is reduced by about 10 years. And so if the average, say the average male in the United States lives to be 70-ish, a tetraplegic male would live to be 60. If you're ventilator dependent, you would live to be 50. So still, it's not like a terminal diagnosis, right? And 85% of patients with spinal cord injuries who make that first 24 hours, get to the trauma center, get appropriate care, get their spine stabilized, are still alive 10 years later. 98% of the non-SCI population, if you age and gender match. Life expectancy, like I said, is significantly below expectancy without SCI and the first year is really the most dangerous. And this just shows you age of injury, your life expectancy. So if you're 20 at injury, you have no spinal cord injury, you're gonna live another 60 years. Your age of D's live another 53 years. Paras, 46, so a little bit less in this study. And then low tetraplegics, high tetraplegics, you can see that vent dependent. If you're 60 years old and you're vent dependent, you're all gonna live to 64. So it really does make a difference. And this is something you can have families go to and look up. There's a, you can look it up if you're trying to counsel a patient. This is the National Spinal Cord Injury Statistical Center that gathers all this data. This is the calculator. And it's a little bit sad too, because they've shown that ethnicity can make a difference. High school education can make a difference. Their type of insurance, which is really sad, right? Like, oh, you've got bad insurance, you're not gonna do as well. And then if they're on a ventilator, and then it'll calculate the score for you. So that again, you can talk to the family and educate them. In terms of employment, if they were employed at injury, most of them remain employed, 58%, unemployed, 41%, depending on if they're a student or not. So it kind of depends on the age. Employed 10 years after injury, paras, 34%, tetras, 24. So more likely to be employed if you're a para, and 34% are still employed 20 years after injury, which is pretty good, right? So a third of them. A lot of times people have an injury, especially if you have a low paraplegia, you can go back and work as long as you can get into the office building, right? And sit at your desk, you can function. May need some accessibility issues, but other than that, we can work there. Just a brief reminder, upper motor neurons are those inside the spinal cord. Once they synapse in the cord, the lower motor neurons are the things that branch out. And then conus and cauda is down near T12L1, and that's the end of the spinal cord. So two types of injuries we see in upper motor neuron injury is injuries either in the brain or in the spinal cord, and they're hyperreflexic, they increase tone, they have spasticity or involuntary spasms. Generally the muscles are preserved, so the muscles look fairly good still. And again, in the brain and in the spinal cord, anything above L1. And the important thing to remember when you're looking at a chart of a patient with a spinal cord injury is that the bony level, so the fracture at say L1 or T12, does not correlate with the end of the spinal cord because the conus and the cauda are T12L1. And so if you have an injury at that level, they may have sort of a mixed picture. Injuries below, so that cauda equina, those are lower motor neuron, and lower motor neuron also applies to like a peripheral nerve injury, plexopathy, peripheral neuropathy. Those are things after the nerves have synapsed and exited the spinal cord, so they have decreased muscle tone, they're reflexic, they're flaccid, right? They have muscle atrophy, which patients really hate. They're unfortunately a lot of times incontinent of bowel and bladder. If that sphincter doesn't have the tone, right? Because it's, again, sphincter tone is a reflex. They can be incontinent. And then there's this very small group, about 4%, that have a lower motor neuron injury above that end of the cord. Those are usually ischemic. So if you have a big infarct, you just knock your cord out, basically. And those people, you'll be like, that's kind of weird. Their sensory level is T4, and yet they're flaccid. Why is that? And it's because they actually got the anterior horn cells in the, you know, the cells inside the spinal cord and they're gone. And then just the terminology briefly, tetraplegic is cervical levels of the cord, not the bone. Right? And just remembering that you have nerve roots down to C8, but bones down to C7, right? And C8, C1 are the hands. And then, or sorry, C8 is the hands, and T1, T2 are actually gonna be paraplegic even though the hands are weak. So you kind of have to think about where it is in the cord. Paraplegic is thoracic, lumbar, or sacral levels. And it used to be quadriplegic, but one of them is like Greek and one of them is Latin or something. And so they, you know, they rectified the terminology. So that's why we say tetraplegic now. And then just a brief reminder, this is pertinent when you do your ASIA exam, which is a standardized exam for classification. And we really look at three things. We look at motor, which is corticospinal. Those are descending tracks. We look at pain and temperature, which is in the spinothalamic, so the innervation and information up to the brain. And then the dorsal columns, another ascending set of columns, posterior, and those are vibration proprioception. Light touch is actually kind of all over the cord. So it's, you can have patients that don't have vibration or proprioception, but they have light touch, and it doesn't necessarily mean it's dorsal column. So it's less specific for, specifically for plantimusus because of the distribution in the cord. And then just briefly, spinal cord injury syndromes. If you guys are studying for your, any of your steps, which is useful, like board material, right? So central cord syndrome occurs with cervical level injuries often in older persons with underlying penile stenosis. Like I was talking about before, this is often a hyperextension injury, so fall or motor vehicle accident. This typically, you'll see weakness in the upper extremities more than the lower. These patients often can walk and they have bowel and bladder preservation. This is the, like the patient who walks up to the doorknob, but they can't reach their hand out to turn it and open the door. So it's like weirdly disabling in ways you don't really think about. Brown saccade is kind of the classic. You guys probably all know this, right? So this is an asymmetric, classically a hemisection, although these aren't always pure. If it's a tumor, sometimes it's pure, but if it's something else, like maybe a gunshot wound, you get cavitation on the other side. But kind of the classic thing is that you have this upper motor neuron weakness, loss of position and vibration. Those are because of those, the dorsal column and where the lateral corticospinal tract is. The spinal filaments actually cross at the level or within a couple levels in the spinal cord. And so you get opposite pain and temp. The teaching point for your patients for this syndrome is that the good side cannot feel temperature. And so they get burned. And so you have to say to them, put the good side in the hot water, make sure it's not too hot. The other side actually may feel the temperature, but they don't think about using that side to check temperature. And a good way to kind of bring this point home for your patients is get a glove and fill it with ice and show them that the temperature sense is actually out on the good side or the opposite side of the issue. Anterior cord is usually damaged to the anterior spinal artery. These patients lose motor function and their spastic. They lose pain and temp, but the dorsal columns are generally intact. And so vibration and proprioception are preserved. They typically have a poor prognosis because again, if you sort of infarct the cord, things don't recover as well as if you kind of stun the cord or if you impact the myelin, which is in some of the other symptoms. Posterior cord, and this is just a reminder, you can see you have one anterior spinal artery, you have paired posterior spinal arteries. And so usually the infarct goes with the anterior spinal artery. There's the artery of the damp with about T8, kind of a classic word question. Somebody comes in, like they have surgery, they cross clamp the aorta, patient wakes up, T8 sensory level, flaccid paralysis below. That's typically artery of the damp with anterior spinal artery infarct. And then again, the posterior is not vascular. Sorry, this slide's a little bit misleading. This is usually either traumatic, V12. There's other things that cause posterior column stuff. And then conus, like we talked about, they're usually, they're lower motor neurons. So they may be a reflexive bowel and bladder. Cauda, acquina, everything's out because it's just the nerve roots. Conus can be kind of mixed. Sometimes you'll have some like sphincter tone is preserved, but the bowel and bladder aren't, or bladder is and bowel's not, it's kind of mixed. And so again, you really want to look at where in the cord, where the cord is, where the nerve and bony levels are, and kind of extrapolate from there. Now moving on to medical management. So right after the spinal cord injury, you have what's called spinal shock. And this is basically the spinal cord kind of goes dormant. So you have a diminution in their reflexes. So every reflex, so muscle stretch reflexes, sphincter tone, bowel and bladder reflexes, sphincter reflexes, everything. So flaccid paralysis, we drop the blood pressure. And we'll talk about that in a sec too. And then the cord comes out of spinal shock over a couple of weeks. And so this is not the 24 hours later, out of spinal shock, good to go. It's a spectrum. And so usually they say about a month. So the faster things come back, the better the prognosis and the less damage you have, because you can tell the spinal cord's like waking up fast, right? Sort of like when somebody has a concussion, right? You could sort of zap the neurons and then they would. So one of the things you can track is when they get return of their reflexes. So instead of being aoreplexic, they start having deep hemorreflexes or muscle stretch. Sometimes it's called a muscle stretch. Then after those come back, you get spasticity and then you'll get bladder reflexes. So they'll start having trouble with leaking between catheterizations. We'll talk about that in a sec. Now neurologic, you can have actually neurogenic shock and spinal shock. So when you first see a patient, like we used to, when I was at Kessler as a fellow, we'd get called page to come into the ER and do an exam. And it was for the model system database. But they found out that those exams were not great for prognosis. Because a lot of times, well, first of all, patients are sick, right? They're in the shock room, like their blood pressure's low and there's 25 people like CTing their entire bodies. And you're like, is it sharp like your face? During the Asia exam, you have to do like pinprick. And so generally it's hard to prognosticate. Usually they're saying now, if we do the Asia exam, it's Asia impairment scale is what that stands for. At about 72 hours, that gets you a little bit better prognostication. That score at 72 hours predicts two to three month outcomes. The Asia impairment exam at one month predicts how they're gonna be in a year. So that's kind of a nice touch point in the rehab state usually, is like now we can look at how you're doing. And again, they really generally run more for their walk. And you can prognosticate that pretty accurately when you're at the one month mark, if anything. So now problem focus. So orthostasis by definition, drop in systolic by 20 or diastolic by 10 millimeters or mercury. They typically, you sit them up, they start saying, God, I feel kind of nauseous or dizzy, lightheaded. Sometimes their vision will start to like tunnel in from the sides. We can only see in the center, everything will gray out. We'll get these weird spots. And you educate the patient to tell you when they have, because sometimes they don't tell you. Like that means you're about to pass out because you're not getting blood to your brain. Very common if you're in a tetraplegic or above T6. T6 is the level in the spinal cord that controls the lower extremity and the abdominal vascular bed. So it helps us regulate blood pressure for the brain. High tetraplegic, sometimes they're orthostatic like for the rest of their lives. You can do mechanical things. You can do like A-strap their legs, do like those compression stockings, abdominal binder, then sit them up, right? So that the blood doesn't pool in their lower extremities and their abdomen. If you go to sit a patient up, just even using like the bed controls and they start having that kind of gray patchy vision, you can use a tilt table. This is a picture. And basically you strap them in and you slowly bring them upright, let them have like a little bit of symptoms and put them back down a little bit more and sort of get their brain used to kind of accommodating for that low blood pressure. You can give them medications before physical therapy because that's usually what happens. You get them out of bed in the rehab unit, sit them up, they pass out, but they can't make it to the gym, right? For PT. So you can do oral meds. You can do something like Afrin nasal spray, which has vasoconstricting properties to help vasoconstrict the vascular beds. And then the medications we use most commonly are Midodrine, which is a direct simulator of vasoconstriction or Florinef, which works at the level of the kidneys for the most part. And that helps their blood pressure stay up. Next thing is kind of the opposite. So it's called autonomic dysreflexia. It is the medical condition in spinal cord injury that can be fatal if it's not recognized. And that's why we put it in this lecture, super important. So generally in patients with injuries above T6, rarely in the acute phase, although every once in a while you'll see somebody in the ICU and you'll be like, that's interesting. They're still flaccid and their blood pressure is 250 over 120. So this is an extreme elevation of blood pressure and it is a response to pain below the level of the injury. And when I say extreme, I mean, so an average tetraplegic after injury is like 90 over 50. It's kind of normal blood pressure. All of a sudden they'll be like 280 over 160. You're like, oh, that's high. Really higher than I thought was possible. And then because that blood pressure goes up, the heart rate will go down to compensate mostly, not always, but mostly. And I'll go through it in a second, the picture. The symptom with the patient will have a horrible, like a migraine, like a pounding headache. They'll get facial flushing. So if you look up at the monitor and they have really high blood pressure and you look at them and their face is flushed, good sign that they're dysreflexic because the vascular beds above the level of injury will sense the blood pressure being high and will dilate to try to bring it down. And that's why you get that flushing. Their nose will start running. Sometimes they'll report like a feeling of doom. You see that in PEs also, by the way. And so it'd be like something is terribly wrong because the body kind of gets a sense of like something is terribly wrong. And this can be an emergency. So there's reports of people having seizures and cranial hemorrhage. Periodically people die from this. And the most common thing is a spinal cord injury patient who like breaks their leg. They present to an emergency room in a small, you know, rural town. Their blood pressure is high and nobody thinks about what to do. And so that, then it remains high and that's what can cause that. And so here's the picture. And so we start here with a full bladder. It's usually something below the level of injury. And the further down the cord, the more additive the impulses are. So your bladder's full or you drop something on your foot, right? It hurts. That, hey, we're having a problem down here signal goes into the spinal cord. And because of the spinal cord injury and the fact that they have this, they're hyperreflexic. This doesn't happen in our lower motor neuron people. They get this massive sympathetic response like, help, we're having pain, we're having pain. It bounces around in the spinal cord, makes the blood vessels contract. That causes high blood pressure. That is sensed above the level of the spinal cord injury up in the carotid arch. So the baroreceptors that says, hey, to the medulla, hey, we've got a problem. The blood pressure's really high. The medulla's like, oh, we got this covered, tells the heart to slow down. And so you get this higher blood pressure, lower heart rate, higher blood pressure, lower heart rate, big vicious cycle. The other thing that happens in normally innervated people is you get a signal from the brain down the spinal cord that says, okay, it's okay. We can relax, vasodilate, everything's fine. But in a spinal cord injury patient, you don't get that descending inhibition. And so it just keeps perpetuating and the blood pressure gets higher and higher and higher. And it's a little scary. I've seen people with a blood pressure, like I was saying, like 290 over 160 and a heart rate of 28. You're like, well, I just don't really know what to do about this. Not going to give them a beta blocker, that's for sure. And so what do we do? Well, the first thing you do is sit them up and take everything off. So remember these patients get orthostatic. So like get rid of the binder, the clothes, the leg bag, like anything, get their head as high as you can, drop their feet, and then you search for the source and relieve it. And so usually it's flatter. It's like, I don't remember the number, maybe 80, 90% of the time it's flatter. So you're going to catheterize them and then their blood pressure will immediately plummet. So you have to be very careful of that. Because once the stimulus is gone, then blood pressure goes back to normal. And you just have to remember that if you're going to give them medication. So you want to have one of those vitals machine that's like cycling. And so it'll keep watching. So you kind of know what's going on as you're working through this. So we generally will use nitro paste and vasodilates, but you can wipe it off. Obviously you don't want to give them anything that causes bradycardia, right? Like a good worker. If it's pain, so let's say they're passing a kidney stone or they just broke their leg, you can treat their pain. You can give them IV pain medication. Morphine, vasodilates, so it actually helps the pain and helps vasodilate. You just have to be careful because if you give them, let's say you give them Quanidine, for example, right? Then you catheterize them and they no longer have that source. Then their blood pressure becomes, you know, 50 over a pound, right? And then what do you do? Then they're in the ICU getting forward intragallular or reverse intragallular. And I have done that to patients. You do that once. It's pretty, pretty dramatic. The other thing just to mention is if you think you're going to do something painful, so you're going to put a cystoscope in and look at their bladder or do something with their kidney stones or they're going to have a surgery or they're going to have a baby, right? Like things that are really painful, you can actually give them medications. You can give them like lidocaine instilled in the bladder. You can do, you know, if they're going to do something with their hemorrhoids, you can do numbing medicine. You can do blood pressure medicine if they're getting neurodynamics and it's going to take an hour or something. So you think about this ahead of time and that makes it much, much better. All right. So now pulmonary. So diseases of the respiratory system are the leading cause of death after a spinal cord injury. 72% due to pneumonia. That's the leading cause of death at all times post-injury and obviously highest in tetraplegic. They can't cough, right? They can't hold their secretions. They can't take a deep breath because they don't have an innervated chest wall. They don't have the abdominal support. Sometimes even their diaphragm is out, kind of depending on the level. And then these patients can also have bronchial hyperactivity. So remember your sympathetic chain runs through your neck. So if you have a cervical spinal cord injury, you get the sympathetic chain. And so they're sort of parasympathetically driven, right? So like the bradycardia with the dysreflexia, you'll see bronchial hyperactivity, lots of other things like endocrine things that are also due to that parasympathetic overdrive, essentially. And then tetraplegics also have sleep disorder breathing. So you can look for, and often it's central and obstructive. So the central causes are things like baclofen causes sleep apnea. Yeah. Lepension causes sleep apnea. Opioids can cause sleep apnea, right? Lots of the medications we give our spinal cord patients cause sleep apnea and they're not able to take a deep breath. So they have an obstructive component. And so that's something to think about if you're, if your patients come in and they're super exhausted all the time, right? Even higher on the list than you would in a, in a naval lobby. In terms of helping people breathe pulmonary toilet. And so you can put them on rotating beds that percuss in the ICU. You can do something, there's a, some of the, we call it a quad cough where you like, it's kind of like a Heimlich to help them cough. You can suction if they, you know, if they have a trachea on the vent, cough assist is a thing that you can put a mask on, blows air into their lungs and then sucks the secretions back out. And so all sorts of things to kind of get everything moving thin their secretions with something like Mucinex, glyphenicin so that you can get the secretions out more easily. Bladder kind of the next system that's impacted again, they're below the level of the spinal cord injury. If they're upper motor neuron, they've got a closed sphincter and a spastic bladder. So you can get what's called the sphincter dyssynergia. And so the bladder contracts and in you and I, the sphincter opens. So it's synergic in spinal cord patients, the bladder contracts, the sphincter contracts, the urine goes back to the, up the ureters and then they get hydronephrosis. And patients used to die from renal amyloid and hydronephrosis and kidney stones and uricepsis. And because of this, we didn't realize that we had to do something about that sphincter. And if the patient's leaking, they may say, oh, I'm fine. I have trouble controlling my bladder, but it's empty. And it's like, yes, it's emptying at a super high pressure. So the goals in these patients is you want some contaminants, right? So dry, good for the skin, good for the, you know, the psyche. You want to make sure that you empty their bladder before the pressure gets too high. You want to make sure they don't have infections. You want to protect the upper tract, so kidneys and nerves. So initially when they come in, they usually, as they're being transported to the hospital, they've usually gotten, you know, 10 liters of fluid, right? And so they'll third space. And then that, that fluid has to come back into the central circulation. So keep it fully in, kind of let them diaries back to their, you know, their, whatever their body weight was before the injury. And then once you can manage their fluid intake and manage how much urine they're making, you can do what's called clean intermittent catheterization. Doesn't have to be sterile. So you don't need betadine. You just want like clean hands, clean catheter. And then they'll have usually every six hours or so you want to keep about 500 CCs of that. And that's just the normal bladder volume. You can measure it. You can put a catheter in and fill the bladder and measure it and just get a sense of what's a safe pressure. And then every year we do an ultrasound and a renal scan, which is a functional measure, or you can do a 24 hour urine and get a sense of what their kidneys are doing before they get hydronecrosis. And then if people have an indwelling catheter for more than five years, especially if they're smokers, bladder cancer rates go much higher. So cystos to be every five years for the life of the patient. Bowel, just like the bladder, upper motor neurons. So the sphincter is tight. They don't really have good peristalsis. So you probably don't remember your autonomic innervation to the bowel very well. But basically like the ascending and the right half of the colon are parasympathetically driven. And so that bypasses the spinal cord. And then the bottom part is, is they usually have reverse like the hospital shuffling and all that happens in the colon. And so you need to help them empty. So you can do a stool softener. You can do something like SENA. You can do duplex, which is an irritant, but then when you do, it's called digital stimulation, you basically stretch the rectum and the anus. It makes the colon contract and that will help them. If their lower motor neuron bowel, they have a flaccid sphincter. And so they're just incontinent, which is like horribly disabled, right? Like you can't leave the house if you're, if you cough, you have a bowel movement. And so these patients generally we constipate them. And then we have them do an enema or something to like empty when they want to. The goal is continence and timing control for the patient. And so this is something that needs super hard to adjust and something we work a lot on in clinic, even though people make fun of PM and R docs for like always asking about bowel movements, but it's super important, right? You don't, you don't think about it until you're in bowel. Then all of a sudden you realize how very important it is. GI system also probably due to increased bagel tone. So they don't have as much of a sympathetic nervous system. So they have GI bleed risk, much higher, 20% in the ICU. They don't have peritoneal innervations. And like, you're like, oh, there's no rebound or guarding. They can't have a, you know, a ruptured ulcer with a GI bleed. Well, it's because they don't have an innervated abdominal wall. Or they, or if they do that, they, it doesn't give you accurate feedback. You palpate, they can't feel pain, right? So it's much harder to diagnose. There is some evidence that early oral feeding can help the issue in spinal cord injuries. A lot of times they have an ileus because they're in spinal shock and can't feed them right away. You can do proton pump inhibitors. People don't love those these days. I think they're, they kind of, we're kind of shying away from using them. But in spinal cord patients, you need to use them because of this additional risk and the delay in diagnosis. Other things, so there's a higher incidence of pancreatitis in the first month post-injury. Lots of reasons for that. Some places patients will get steroids, which can cause pancreatitis. Patients are hypercalcemic, and I'll talk about that in a minute. There's other things, again, I think probably the vagal, increased vagal tone predisposes people to pancreatitis. If patients have an injury of T10, they can have impaired gallbladder emptying. And this is both acutely and chronically in spinal cord patients. So higher rates of cholelithiasis and cholecystitis. If you have a spinal cord injury and you are greater than age 40, your risk of gallstones is three times higher. And again, hard to diagnose, right? They say, you know, I eat, I feel kind of nauseous, but they don't have the pain sensation. So these patients, you really have to think about the pathophysiology and figure out what their complaints mean without necessarily your physical exam being super helpful. So imaging ends up being a lot more helpful. And a tidbit you probably don't know is the gallbladder innervation is T7 to T10, and it's sympathetically mediated. And so if your injury, again, your injury is above T10 in the spinal cord, you don't have the gallbladder contraction associated with meals. And that's why they get these issues. So in terms of skin, so patients have no sensation and often can't move right, or if they move, they can't move well. In addition to this, right after the spinal cord injury, because the spinal shock we talked about, they don't have the reflex arcs through the spinal cord and the auto-regulation of the skin. And so they can have high, high risk of pressure sores because the skin capillaries can't vasodilate, vasoconstrict and kind of protect the skin. So prevention or breakdown is key. So you have to turn them every two hours or, or every 15 minutes, if they're up in the chair, they need to like do a pushup, do a recline, if it's a power chair, you can put them on an air mattress or in the ICU, we'll do a rotating bed. We call them Rotarests. I think that's a company name, but it basically, it has like bolsters on their, on their trunk and their head and their arms and their legs. And so you can turn them side to side and they don't go sliding because if they slide, they'll get skin breakdown, right? You want to make sure they're not sliding. You can do both multi-cotus is just, it's not a brand name, but it's a type of boot that are basically super padded. You can, you can, you know, swaddle their heels and essentially it keeps the heels off the bed so they don't get the skin breakdown on the heels. And then somebody needs to turn them over and look at their skin every shift. And if it's red or getting kind of purpley, get them off their skin for a while. So pillows in bed don't let them sleep on that one side, whatever, whatever it takes. If it's on their sacrum or like over their ischial tuberosities, maybe they need a week of bed rest so their skin can heal before they get a big ulcer. DVT also more common in the first two weeks, the risk is higher than normal for at least two months. Also up to six months, but like the, it's like it's a bell curve of risk. So peaks at about two weeks and then the, the, you know, the bell curve come back to baseline by six months. If you do not prophylaxis these patients up to 100% get a DVT. So you have to do something. Standard of care is low molecular weight heparin and the leading cause of death in an acute STI patient is pulmonary embolism. Again, and especially if they're in a small, like not in a tertiary referral center, more likely they'll not get the prophylaxis or like they had a surgery, the surgeon won't let them get prophylaxis or won't let them get adequate. Like, like the compression, you know, pump squeezy things are not adequate, aspirin, not adequate. And so just remember high index of suspicion for DVT and it's multifactorial, so they're not moving, right? So that's part of it. They have increased platelet aggregation, increased factor VIII. They don't have a good fibrinolytic response. They don't break down clot in the form, probably also something to do with the auto-regulation of the blood vessels, right? So sort of venous pooling because of that acute spinal shock period. And so they're just so prone to DVT. And so you really want to get the prophylaxis as fast as you possibly can. The issues obviously is if they're bleeding, let's say they have a splenic laceration as well, either triglypathic or right into their brain and the surgeons are freaking out, right? So you have to sort of balance those risks out. In terms of treatment, and this is true in all of the PM&R literature, the duration of bed rest is debated. Do you get them up? Do you not get them up, right? Every attending is different. So you just have to know what your attending is going to let you do and you're better for a medical student, right? And then anticoagulation lets the clot organize or stick down to the wall of the vessel. So it does not become a PE. And then treatment, same as the able body. So anticoagulation, low molecular weight, heparin, or ibuprofen, then you can put them on Warfarin or Doac or whatever your medication of choice is. Heterotopic ossification is mature lamellar bone. In other words, cross section under the microscope has the little haversian canals with a little blood vessels in them. So it looks like real bone. It is in soft tissues that are adjacent to a joint that's affected neurologically. So paraplegics, it would be hips, knees, not so much ankles. In tetraplegic, they add shoulders and elbows. We see it in brain injury on the hemiparetic side. And so it's the, it has something, again, we have no idea. We don't know what, what exactly causes it something to do with the impact to the nervous system, and then not moving as well. Some people think maybe trauma, if there's a trauma around the joint same time, and it's between 16 and 53% of people with chronic injury will develop HO. 10 to 20% of those are clinically significant, and three to 5% will fuse. This is horrible when it happens at the hip, because what position would you like to fuse in? Would you like to sit or lie down? Most people go to like 45 degrees and kind of, that's a horrible decision. Usually it happens between one and four months post-injury. Peak occurrence about at two months, and you'll see decreased range of motion, maybe some swelling, like around the knee you'll see swelling, you can't really tell at the hip, maybe some warmth, increased spasticity in the, in the limb. So if it's around the hip, that, you know, that leg would be more spastic. And this is not what it normally looks like. This is one of those like horribly bad cases, but you can see like it's this huge mass of bone around, around the hip. Initially you, they, the patients lay down a, like a matrix that's made of osteoid kind of protein, then they calcify. So x-rays are not generally positive for a couple weeks. You can see it on ultrasound, bedside ultrasound, and then x-rays are said to become positive. Other musculoskeletal issues, so rapid loss of bone density below the injury, totes at about four months. People can lose about a third of their bone density, and it's thought to do both to immobilization, and again, that probably, we don't know, probably that parasympathetic tone without the sympathetic nervous system. They have, these patients have increased osteoplasticity, so they're chewing up their bone. If you look at their urinary calcium, they'll get lots of urinary calcium excretion. And then once you exceed the renal threshold to excrete the calcium, they become hypercalcemic, and then they'll get, it's called immobilization hypercalcemia. They'll get nausea, vomiting, lethargy, increased appetite, polyuria. This is that bone stone, psychic bones, abdominal tones, right, that mnemonic. Most commonly in young males and the sort of like adolescent males, and the theory is that they are laying down the most bone prior to injury, and that they're, you know, sort of their hormonal system is like laying down bone and growing, and so they're more likely to like chew up that bone because the bone's more active generally. And then this is my final slide. This is just to show you, like I just told you all the horrible medical things you see after spinal cord injury, but like there's so many cool things these patients do. Sherry Blauwet is famous. She's the, she's been the chair of the International Paralympic Committee. She was a Paralympian. She's actually a sports medicine doc, practices at Harvard. So she went into PM&R, competed like a rock star, and then went into PM&R. She's an advocate. She speaks nationally. She's really amazing. The upper right is Michelle. She was a C, I should be able to tell right, C, I was going to say five, but she's a six. You can tell because you can see her wrist extensors are innervated on her arms. This is her water skiing. People were kind of worried, but it worked out just fine. The bottom left is Ed, who was a C, I think he was a C4. And he told me the bucket, his bucket list included skydiving, which was complicated because he had an injured fecal backup and pump and the Medtronic company wouldn't let him, like they're like, we can't say you can skydive without a pump in. And he was like, fine, I'll just sign some kind of waiver. Like I'm going skydiving. I was terrified that he was going to fracture both legs on landing, but he didn't. So that was good because he was so osteopenic. But anyway, but he did it pretty awesome. And then Ladd is the one on the right. He's a C3, ventilator dependent on a farm in Texas, living a good life with his grand baby and his dog. So just to remember, these patients can really do whatever they want. And your job as a PM&R doc is to facilitate it, make sure they're medically stable, try to keep them from doing things that are really going to hurt themselves and then let them go and live their best life. I'm going to stop sharing maybe. Let's try that. Yay, there we go. All right. I'm looking at the chat. Thoughts or questions, comments? So you can feel free to unmute also if you have a question you want to ask or pop it in the chat box, whichever you prefer. Questions about PM&R, how to pick up, you know, do you want to do a residency? How do you, what are the fellowships? I'm happy to talk about anything you want. Hi, my name is Paola. I am a first year medical student. Thank you so much for your presentation. First of all, I really enjoyed it. This is my first exposure to PM&R, and I am really interested in the field. I just finished neuro and anatomy, and those were my two favorite classes. I was just wondering, in general, what kind of advice do you have for first year students, how to get involved in the field, research, or throughout the first two years of medical school that is mostly academic lecture-based? Yeah, so probably the two best suggestions I have, the first one would be look in your community for an adaptive sports program. So places that have VA hospitals often have adaptive sports, and then our University of Utah has adaptive sports. And so these are programs where people go out and they do recumbent biking. We do sailing and skiing. There's blind people that ski with partners. We have a sit-see for tetraplegic. There's sporting events you can volunteer for. So there's like national wheelchair games held by the veterans. There's ski clinics that need volunteers. So look in your community for those things. If nobody's doing those things, you can start something, right? So what do you do if you're disabled? Then it doesn't have to be a spinal cord injury. It could be a brain injury, or a mass, or an amputee injury, and get involved that way. And that's a great way to work with patients that have disabilities, to help patients that have disabilities, and then also good exposure for you for that population, right? Kind of get a sense. It's nice to see people out of the medical setting too, right? Like people biking is like kind of a nice thing. And then the second comment is join, find your PM&R interest group at your med school. And if there isn't one, start one, right? And get people together and invite speakers and try to find PM&R. If you don't have a PM&R department, there's probably PM&R docs in your community. And so, you know, get out your phone book, Google the PM&R docs, and, you know, go shadow them, have them come speak, and create a, you know, an interest group. Research is a little bit trickier because it's going to, generally, you have to figure out who's doing research and what at your school. If you want to go into PM&R, it doesn't have to be PM&R research, right? It could be neuro research. It could be lab research looking at neural regeneration. It could be, if you guys have like a physical therapy program, you could look at, you know, functional, like, I don't know, wheelchair propulsion research, right? Like there's so many, PM&R touches so many areas. Just kind of to name a few, like spinal cord injury, I think you're getting some of this this week, but, you know, brain injuries and amputees, musculoskeletal, fine, sports. There's like a whole bunch of things in rehab, and you can reach out to the ortho department and do ortho research, right? Lots of, lots of options. So. Thank you. That's very inspiring. Yeah. All right. It's sort of similar to Alan Grant's comment too. Regenerative medicine. Yeah. So regenerative medicine and SCI has been not super helpful. There's been a lot of studies looking at like stem cells in the spinal cord or like a mental transfers or nasal tissue. Anyway, lots of things are going on in Thailand and Mexico. I've had patients travel to both places to get some kind of new graft to cure their spinal cord injury. Has not been particularly helpful. Probably the most helpful regenerative medicine thing that we do is PRP, so platelet rich plasma, but for joint and connective tissue issues rather than like into the spine or spinal cord itself. So typical day for a PM&R doc that does spinal cord injury, I do outpatient. So really kind of two places you're going to practice. For a while I worked in a trauma center and I did, I worked only in the ICU. And so I did, I was a part of the team. I rounded every day and I did all this sort of SCI related things in the ICU, obviously with the help of the pulmonologists and the ICU docs that like helped with weaning protocols off the vent and help with blood pressure management, fluid balancing to get them pathing, those sorts of things. You can run an acute rehab unit. So if you're someone that has a big rehab hospital, like the Kessler University which has medicine rehab, you can actually run, just like you would run on like a medicine team or a neurology team, you run on your SCI team. All of your patients have spinal cord injuries, work with a therapist, go to the gym, have family meetings, you know, manage the PM&R docs, manage the medical issues in disabled patients while they're recovering. So the therapists are doing therapy and you're dealing with their blood pressure and they're just reflecting their spasticity in their bladder, right? So you're in medical management. And then I do outpatient spinal cord. So they come and see me, I'm essentially like a paramedic doc. I manage their depression. I manage their spasticity in their bowel and their bladder and their UTIs as outpatients. And so it's my favorite place in PM&R is outpatient neuro, following people that have Parkinson's and ALS and all the kind of the neuro things and looking at function, quality of life and the medical management. I think in terms of like making yourself more competitive, I think just do, you know, more stuff on the CV, right? Volunteer activities, specific to PM&R, research. If you can get something published, even if it's like a case report as a medical student, that puts you up right on the list of like, oh, these people have never published and look at these people that have published, right? Again, being the head of an interest group or starting an interest group is actually better because it takes initiative, right? So people that interview for residency programs want to see that drive, that like independence and making things better. And so as much of that as you can do. Let's see, assistive technology. Yes. Lots of things. We do exoskeletal stuff. There's lots of different exoskeletal, like we often, there's different companies now. And so, yeah, there's a huge space in PM&R for assistive technology. So gloves, things, you know, like biomass is like an e-stim device that helps with muscle contractions. There's lots of research going on looking at like brain implants. Like if you look at UPMC pen stuff, like brain implants, where the robot can, or like, sorry, this is sad, but like the monkey can reach out with their arm by thinking about it because they have a brain implant. And so they now have a functional arm, even though they're paralyzed from the neck down. So there's lots of research there too. Um, most challenging aspect of the field, probably two things. Um, I think just trying to get people the resources they need with the limitations and health insurance. So, um, I work at the VA because I can get more stuff for my patients. I can get them a recreation chair and a regular everyday chair. I can get them a power wheelchair and a manual chair or a sports chair for tennis. Um, in the private sector, you have to pick one generally, so they can't get the sports chair and the regular chair that you have to decide. Of course, they're not going to pick the sports chair, right? Because they need the chair they can use in their car to go to work. Um, and so resources can be super frustrating. Um, the other thing about PM&R is that a lot of people don't know what we do. So you'll be explaining to your, like your mom. I, at one point I sent my mom a research paper that I published. She was like, oh my gosh, I had no idea what you actually were doing research. Um, so it's advocating for yourself and like explaining that, you know, that no, I'm not a physical therapist. I'm a physical medicine and rehab doctor. Like that's the other thing you have to kind of have that strong ego because people are like, oh, well you're not a neurosurgeon. You're like, no, no, no, no, I'm better than a neurosurgeon. Um, and just explaining, getting that, like that elevator pitch, right, can be frustrating. So, um, let's see. So James Rodriguez asked about losing a third of bone density. Um, so there are lots of questions. Okay. Let me read this one out loud. You can lose a third of your bone density after spinal cord injury after the month. Is this despite physical therapy mobility? Yes. So thought to be neuro hormonal does not get better with standing, does not get better with vibration, like the standing platforms does not get better with electrical spam and biking. Um, really the answer is something like zolidronic acid on something that actually changes the pathophysiology, the osteocost, osteoblast balance. Um, and then areas in the nation, um, to get hands on experience. Oh, so many, um, lots of places that have big rehab hospitals have rehab centers. You can look up the national spinal for injury, um, system of care, the model systems have a lot of research. Um, and then the, you know, bigger cities obviously that have trauma centers usually have people with UFCI and it may be in the neurosurgery department. If they don't have a seminar department, it may be in medicine. Um, but that, if that population exists, there's going to be providers that know how to do that. Okay. Um, what else? What role do you have in emotionally guiding your patients? Um, that's a tough one. So there's actually a lot of, of debate about the role of hope, right? So like you have a patient, they have an injury, you know, they're never going to walk again. Right. So I've had a few people with transactions or severe injuries, transactions, usually patients know they're not going to walk again, but I would say I've seen maybe three transactions in 25 years. People typically don't, they may have a normal MRI and you do their Asia exam at a month and there's nothing going on. You know, that that patient's not going to walk. What do you do? Do you say, suck it up? You're going to be in a wheelchair. Do you say, and my typical line is like, we never know what's going to happen. It's not likely we're going to prepare for the worst. Right. But there may be, you know, there, we never know, like maybe something will happen. A little bit of hope can be very motivating for people. Usually your patients that come to rehab will tell you that the, that the emergency room doctor told them they were never going to walk and the trauma team day one in the ICU told them they're never going to walk. Um, and those patients are usually mad. They don't want to hear that. They don't want to hear that day one, right? Oh, you're never going to walk again. Have fun on the ventilator in the ICU. Like, really? That's not helpful. Right. Um, and so sometimes you're like repairing relationships and saying, probably a little early to tell, we never know. Right. Like that kind of, you know, giving them back a little bit of hope, maybe educating the providers that like, you don't really need to tell them that, you know, three, three hours after their spinal cord injury. And then sitting down at like a month, right. Or two months when you're like, okay, now we're going home from the rehab hospital. Now let's talk about what you need to be successful. Even if maybe you're not walking right now, right. I always hold out a little bit of hope. I think that's helpful. Um, and, and honestly, some people need, I mean, you can give them guidance and support. You can give them counseling. Peer support is super helpful. Um, so that patient that may not be wanting to get out of bed, they don't see that there's hope, have some wheelchair rugby player coming in and show them murder ball. If you guys haven't watched murder ball, you should, but show them one of the movies that has like wheelchair athletes doing amazing. Show them Sherry Blowett's picture. It's like she was injured at 18 months of age in a farming accident. And she's now like the president of the Olympic committee. Like, you know, like you can do it right. Like, like helping people understand that there's lots of things they can have children after spinal cord injury, like life is not over. And again, peer networks can be super helpful. Um, and sometimes it just takes time, right? Like people adapt to bad news differently. That takes time and that's okay too. So just be open to talking about it. All right. Um, well, if there aren't any other questions, um, we'll go ahead and wrap up today. Dr. Gersing's contact information is on the Google classroom site. So if you have additional questions, feel free to reach out to her with those. I'm sure she'll be glad to talk to you and answer any of those additional questions. Uh, if, uh, nothing else, I will see you guys again on Tuesday. Next week, we're going to be talking about medically complex rehabilitation with Dr. Mayer on Tuesday. So, um, that will be next week and to have a great weekend and thank you so much, Dr. Gersing. It was really great to have you here today. I appreciate it. Yeah, my pleasure. All right. Take care, everybody. Thanks, everybody.

Dr. Susan Garstang

PM&R physician

spinal cord injury

cognitive intact patients

autonomic nervous system

epidemiology

medical management strategies

assistive technology

challenges in PM&R