03/14/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)
Medical Perspective:
Complete or Incomplete?
Example: The family of a spinal cord injured patient will be told by the neurosurgeon that a spinal cord injury is incomplete. What does this mean and what does that mean for recovery?
First, an incomplete spinal cord injury means that there is sensory sparing on pin prick exam around the anus or there is voluntary motor function lower than the level of injury. A simple example of an incomplete injury is a patient who has a neck injury that affects the function of both of his arms but can still voluntarily move his legs. This is good news because there generally neurologic recovery following this type of injury. Problem is that it is nearly impossible to accurately predict the degree of recovery. The degree of recovery can be negligible and not significantly improve the overall function of the patient to full recovery. During my experience as a rehabilitation physician I cared for a patient who was told she had a complete injury and on my exam one day after decompression surgery she was able to voluntarily wiggle one toe and therefore was not complete but was incomplete. This patient over the next six months became an independent ambulatory with a cane. Compete injuries are unfortunately significantly more certain and the functional goals are determined by the level of the injury.
Functional Level of Injury?: (Because the recovery following an incomplete injury is so diverse this discussion will be based on the assumption that the injury is complete)
Example: The family of a 37 year old spinal cord injured patient will be told by the neurosurgeon that the spinal cord injury is C7 and complete. What does this mean?
In order to understand this it is necessary to understand the basic anatomy of the vertebral column (bones/ligaments) and the spinal cord and nerve roots. First, there are seven cervical vertebrae, twelve thoracic vertebrae, five lumbar vertebrae, and five sacral vertebrae. The function of the vertebrae column is to provide support and protection for the spinal cord. Spinal cord injuries may occur if there is a fracture and a fragment compressing the spinal cord or a result of a subluxation where there is tearing of the ligaments of the spinal canal and there is slippage of one vertebrae on the next that compresses the spinal cord. In this example when the neurosurgeon is telling the family that there is a C7 injury he is referring to the functional level and not necessity the specific vertebrae that is injured. The patient in this example may have a C6 burst fracture but a C7 functional level. Therefore, it is important to understand the functional levels of spinal cord injury.
Functional levels of Spinal Cord Injury (assuming complete lesions):
C1-2: No arm function, ventilator dependent, dependent with all activities
C3,4: No arm function, ventilator dependent because of phrenic nerve involvement (C3,4,5), dependent with all activities
C5-6: Shoulder, biceps, wrist extension intact, dependent with most activities. (able to use electric wheelchair and feed one self with adaptive equipment)
C6: Wrist extension intact, likely dependent with transfers, needs assistance with most activities of daily living. (able to use manual and electric wheelchair)
C7: Elbow extension intact, likely independent with transfers and independent with most activities of daily living. (able to use manual wheelchair)
C8-T1: Hand function intact, likely independent with transfers, independent with most activities of daily living. (able to use manual wheelchair)
T2-T6: Independent at wheel chair level, impaired inspiratory and expiratory function of lung. Sitting balance impaired.
T7-T12: Independent at wheel chair level. May possibly be independent with crutches and braces on legs. Impaired expiratory function of lung.
L1-2: Hip flexion intact. May possibly be independent with crutches and braces on legs.
L3-L4-L5-S1: Likely independent gait with braces on lower extremity.
S2-4: Isolated bowel and bladder dysfunction.
note: spinal cord injuries will cause a neurogenic bowel and bladder and other organ system dysfunction
Decisions on Rehabilitation:
It is this author’s opinion that simply a patient and the family of the patient should seek the best care possible following discharge from the acute care medical surgical hospital. Not all rehabilitation levels of care are equal and not all acute rehabilitation facilities are equal. It is this author’s opinion that rehabilitation discharge destinations today is based on payor source rather than level and quality of care required.
Life Care Planner Perspective:
A properly constructed life care plan will serve as a guide to future medical, rehabilitation, and day to day needs of a catastrophically injured patient. A life care planner’s primary role is an educator or the public and that role requires him to be objective in the evaluation of the needs of the patient, not looking at insurance issues, and provide a guide that is medically necessary and appropriate for the patient. A Life Care Planners come from a variety of back grounds which include nurses, case managers, vocational specialist, and various physician specialties. It is the author’s opinion that a physician who is Board Certified in the field of Physical Medicine and Rehabilitation, called a physiatrist, is the most suitable for constructing a life care plan for a spinal cord patient because they are trained in the management and care, both acutely and during the aging process of these patients. Physiatrist should be able to enhance functional outcomes, decrease pain and suffering, and decrease complication by developing a life care plan that takes into consideration the aging process with a spinal cord injury.
A life care planner in the spinal cord patient will look at the level of injury, determine if it is complete or incomplete, interview the patient and the family to determine their unique desires when developing a plan. It is the author’s that it is essential that the life care planner educate the patient and the medical community that a spinal cord injured patient requires state of the art rehabilitation at a center of excellence that offers mulidisciplinary rehabilitation with a scope of service that includes physiatry, plastic surgery, orthopaedic surgery, neurosurgery, neurourology, neuropsychologist, internal medicine, pulmonary medicine, infectious disease specialist, counseling psychology, physical and occupational therapy, speech therapy, recreational therapy, and vocational counselors. There are several centers of excellence in the United States and it is well worth the sacrifice of a spinal cord patient and their family to temporily go to these centers to maximize functional outcomes, decrease complications, and to be thouroghly educated and trained for the future of living with a spinal cord injury.
Lawyer’s Perspecitive:
It is this author’s opinion that during this stage it is essential that the lawyer to be an advocate of the patient to ensure they get the medical care the patient needs. This can be accomplished by traveling to the acute rehabilitation hospital and with the consent of the patient sitting in on a weekly multidisciplinary team conference. A team conference is that generally run by a treating psychiatrist and the various treating therapist which will outline goals of treatment, future medical and therapy treatments, plans for follow up, required equipment, required medical supplies, required home renovations, and required aid and attendant care if necessary. A lawyer at this stage should consult with a life care planner to ensure that there is nothing overlooked with these recommendations.
Media Information:
Address: 1401 Willow Pass Road, Concord, CA 94520
Phone: 888.990.9410
Url: Lifecare Solutions Group
