Spinal Cord Injury

Clinical Case Presentation

Eastern Visayas Medical Center
January 31,2023

Presented by:
Ray Anthony A. Camaliga, MD
1st Year Family Medicine Resident
Objectives

At the end of the session - given a 60-year-old male who presents with body
weakness we should be able to:

● Gather data from history and physical examination

● Formulate impression
● Discuss the pathophysiology of neurogenic bowel of SCI
● Discuss reflexic vs areflexic neurogenic bowel
● Discuss the goals of bowel program
● Discuss the dietary consideration
● Discuss functional outcome of SCI
● GIve take home points
General data

Patient LP, a 60 year old male, married, Filipino , residing at Mationg Samar, roman
catholic
Chief complaint

Body Weakness
History of Present Illness

1 day PTC patient was drinking alcoholic beverage at their house when he noticed a
noisy drunkard outside. The patient went out to call the attention of the man. The
patient was pushed at his back resulting for him to fell on the ground. Patient noted that
he wasn’t able to stand up and move his body and asked for help to brought him inside
the house.
On day of consult, noted persistence of weakness prompting for the patient to be
brought to the hospital and subsequent admission.
Past medical history

No known illness
No previous hospitalization
No allergies
Family History

No known illness
Personal social history

Tricycle driver
Non smoker
Alcoholic beverage drinker
Review of Systems

(-) fever (-) weight loss (-) anorexia (-) generalized body weakness
General (-) easy fatigability
Head & Neck (-) stiffness (-) masses
Eyes (-) blurring of vision (-) discharge

Ears (-) loss of balance (-) discharge (-) tinnitus

Nose & Sinuses (-) colds (-) epistaxis
Mouth & Throat (-) hoarseness (-) sore throat (-) dysphagia
Respiratory (-) dyspnea (-) hemoptysis
CVS (-) palpitations (-) chest pain (-) fainting spells (-) orthopnea
Gastrointestinal (-) nausea (-) vomiting (-) hematemesis (-) bloatedness (-) diarrhea
(-) constipation (-) melena (-) hematochezia

Genitourinary (-) frequency (-) dysuria

Hematologic (-) easy bruising (-) easy bleeding

Endocrine (-) polyuria (-) polyphagia (-) polydipsia (-) heat/cold intolerance

Musculoskeletal (-) joint pains (-) fractures (-) edema

Nervous System (-) headache (-) loss of consciousness (-) seizure, (-) tremors (-) one-
sided weakness (-) slurring of speech

Autonomic (-) fecal and urinary incontinence

Physical Examination

Vital Signs BP: 100/70 HR: 68 RR: 20 Temp 37.5 C O2 sat 100%
Wt: 65kg Ht: 165cm BMI: 24
General Survey: awake, conscious and coherent GCS 15
Chest: symmetrical chest expansion, no adventitious breath sounds
Heart: normal rate and regular rhythm, no murmur
Abdomen: normoactive, soft, nontender
Extremities: (+) mass on the left triceps, no abrasion, no fractures
Radiologic images
Diagnosis

“Traumatic Spinal Cord Injury, incomplete,

Neurological level of injury C5, without
radiologic abnormality secondary to fall from
standing height, AIS-B”
Management

Pharmacologic management
Dexamethasone
Ranitidine
Bisacodyl suppository

Non pharmacologic
For PT
Turn side to side
Burn and fall precuation
Discussion

Spinal cord Injury is a traumatic event that damages the spinal cord that may cause temporary or
permanent disturbance to sensory, motor and autonomic function of the patient.

Fenglings reported that the global annual incidence of acute spinal cord injury of 14-40 per
million.

On another study it is stated that it is common among ages 16-30 which is along the working age
population.

Most common on males and most common due to sports related SCI.
For both gender the 3 leading cause worldwide are auto accidents, falls and gunshot.
Anatomy

The spinal cord is about 18 inches long enclosed within the spinal column.
Divided into 4 sections
Cervical Vertebrae (C1-7)
Thoracic Vertebrae (T1-12)
Lumbar Vertebrae (L1-5)
Sacral Vertebrae (S1-5)

Quadriplegia- paralysis of all four extremities

Paraplegia- paralysis of lower extremities
Neuroanatomy and Physiology of GIT

Gastrointestinal function is coordinated by 3 nervous

systems;
1. Somatic
2. Autonomic
3. Enteric
Enteric Nervous System

Distinct network that has its own set of neurons that coordinate sensory and motor functions

There are 3 types of neurons

1. Sensory
2. Interneurons
3. Motor
Neurogenic Bowel Dysfunction

● It is a result from autonomic and somatic denervation.

● Symptoms may present as fecal incontinence, constipation and difficulty with evacuation.
● Loss of voluntary control over bowel function alters every facet of a person’s life at home, at work, and
in the community.
● Spinal cord injury is among the most common condition causing neurogenic bowel dysfunction
Spinal Cord injuries/ disorders

Primarily affects colonic motility and perineal and anorectal sensation and function.
Spinal cord - related upper GI tract problem is the most frequently recognized
Bowel dysfunction is principally one of motility rather than absorption and secretion.

Upper GI is more involved with tetraplegia than with paraplegia.

Characterized by gastroparesis, impaired gastric emptying, and delayed GI transit times

Dysphagia is common in people with cervical cord lesions in the acute phase and often eventually
resolves

Loss of voluntary control over bowel movements resulting in constipation and FI injury among all
levels
Reflexic vs Areflexic Neurogenic Bowel

Upper Motor Neuron Bowel

- Lesion occurring above the conus medullaris (above spinal level T12)
- Rectoanal reflex are preserved with spinchters being spastic
- Defecatory reflex is intact
- triggering of defecation can be accomplished by digital stimulation, rectal stimulant
medications, enemas, or electrical stimulation.

Lower Motor Neuron Bowel

- Lesion below the conus medullaris (below T12)
- Flaccidity of the spinchters with loss of reflexes
- Most effective way of completely emptying the rectum is through gravity manual
disimpaction with Valsalva
Goals of Bowel Program

1. Regular, planned, bowel movement daily or every other day

2. Adequate stool amount
3. Bowel evacuation at consistent time
4. Complete emptying of rectal vault with every bowel movement
5. Stools are soft, formed and bulky
6. Completing the bowel care within half an hour
7. No episode of fecal incontinence or unplanned bowel movement
Dietary consideration

The main goal is to achieve soft, but well formed bulky stool

Fiber increases stool bulk and plasticity, which tends to decrease colonic pressure, diet
that contains at least 38 g for males and 25 g for females of fiber daily is recommended
(15 g initially and gradually increase as tolerated).

Fluid intake of 3 L for males and 2.2 L for females

Functional outcome of SCI
cont.
cont.
Cont.
cont.
Take Home Points

Spinal cord injury may occur in any ages. Proper history and physical examination
must be done to determine the level affected.

Neurogenic bowel dysfunction is one of the effect of the injury.

Fiber and fluid intake is crucial in helping the patient to improve its health.
Individualized management for each patient. We aim to provide comfort, safety,
privacy and dignity of our patients