PGY??:?????

1
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• PGY???????
• PGY?????(???? ????)
• 2010-03-29

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• ?????
• ??39? (????1971-01-03)
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• ???, ??
• ?????,????

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• ????
• ???
• ????,??????
• ????2005-03-12
• ??????

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• ???????????????
• ???????,???????,??????
• ???????,??????????

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????(1)

• 2001???????????,????????,??????,???????????,??????
  ???????????????????,??,?????,???????
• 2003???????????,?????,????????????,???????????????
  ,?????????,??????C3,C4,???????

6
????(2)

• ?????????????,??????,????????????,???????
• ???????,????????
• ??????????,?????????????,??????????
• ??? 2005??????????

7
????(3)

• ?????????,?????????,??????,????????Suprapubic
  cystostomy,????????,??????????????,??????,????????
  

8
??????

• ??
• Urinary tract infection
• ??
• Traumatic spinal cord injury s/p transection

9
?????

• Smoking(-)
• Alcohol consumption(-)
• Betel nut chewing(-)
• Drug or food allergy denied
• Travel or animal contact history denied

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????

• ????
• Dilantin 100mg 1 qd
• Furide 40mg 0.5 qd
• Bisacodyl (Bisacodyl 5mg) 2 bid

11
????2009-08

• CBC, SMA
• Uric acid 5.3
• Alb 3.8
• Hb 13.2
• U/A
• Clear, yellow
• Bacteria
• WBC 20-30

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????2009-08

• ACTH 43.9(??????adrenal insufficiency)
• Free T4 1.29
• TSH 1.06
• Cortisol 13.1
• Prolactin 23.8
• Renin 2.06
• Aldosterone 124.8

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????

• 2005
• Traumatic spinal cord injury(C3-C4) s/p
  transection
• Frequent urinary tract infection
• Hepatitis B carrier

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???????? (Barthel Index)
?? ??????????????????? 5
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??(100) ??(100) 15
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????????MNA-SF
MNA-SF12 ??
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?????? MNA
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8. ?????????????? 0?? 1?? 0
9. ??????? 0?? 1?? 1
10. ????????????? 0? 1? 1? 2? 2? 3? 2
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?????? MNA
???? ??
11. ?????? ????????????(?????????) ? ?? ??????????????? ? ?? ????????????? ? ?? 1
0.0? 0 ?1?? 0.5? 2?? 1.0? 3?? 1
12. ???????????????? ??? 0?? 1?? 1
13. ???????? (???????? ??? ????) (?? 240 c.c.) 0.0? ???? 0.5? 3 5? 1.0? ??5? 0.5
14. ????? 0? ????????? 1? ?????????? 2? ?????? 0
18
?????? MNA
???? ??
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16. ??????????,??????? ??????? 0.0 ? ??????? 0.5 ? ??? 1.0 ? ????????? 2.0 ? ??????? 1
17. ???MAC ?? 0.0? MAC lt 21 0.5? MAC 21 21.9 1.0? MAC ? 22 1
18. ???C.C. ?? 0? C.C. lt 31 1? C.C. ? 31 1
?? 22.5/30 ??
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Discussion

• Rehabilitation of Persons With Spinal Cord
  Injuries

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(No Transcript)
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Common Medical Problems

• Thromboembolic disease
• Autonomic dysfunction
• Neuropathic pain
• Neurogenic bladder dysfunction
• Neurogenic bowel
• Heterotopic bone formation
• Pressure ulceration
• Spasticity

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Thromboembolic disease

• The risk of death from PE during the first year
  following SCI is more than 200 times that for the
  general population.
• DVT most commonly occurs in the weeks following
  SCI, with a much lower risk in persons with
  chronic injury.

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Autonomic dysfunction

• Problems are most common in those with injuries
  to level T6 and above
• Orthostatic hypotension
• Bradycardia
• autonomic hyperreflexia
• lethal complication
• patients with spinal injuries above T7
• bladder and bowel distention
• headache in the presence of elevated blood
  pressure

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Neurogenic bladder dysfunction

• Detrusor-sphincter dyssynergy
• unable to cause efficient voiding
• Urinary tract calculi
• Hydronephrosis

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Mortality

• Mortality is highest in the first year after
  injury
• In the past
• urinary tract disease and renal failure
• At present
• pneumonia
• Nonischemic heart disease
• Sepsis
• Pulmonary embolus
• leading causes of death for younger patient
  (paraplegia)

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Functional Rehabilitation

• Neurologic recovery
• Patients can be classified based on the ASIA
  impairment scale from A to E
• (1) recovery within the zone of injury
• (2) recovery below the zone of injury
• The zone of injury is typically considered the
  first 3 abnormal dermatomes or myotomes.

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ASIA impairment scale
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Expected levels of function

• Expectations according to injury level
• A person with tetraplegia with injury above the
  level of C5 is dependent upon others for
  activities such as feeding, dressing, and
  bathing, and requires the availability of an
  attendant at all times

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Expected functional recovery following complete
spinal cord injury by spinal level
Spinal level Activities of daily living Mobility/locomotion
C1-C4 Feeding possible with balanced forearm orthoses Computer access by tongue, breath, voice controls Weight shifts with power tilt and recline chair Mouth stick use Operate power chair with tongue, chin, or breath controller
C5 Drink from cup, feed with static splints and setup Oral/facial hygiene, writing, typing with equipment Dressing upper body possible Side-to-side weight shifts Propel chair with hand rim projections short distances on smooth surfaces Power chair with hand controller
C6 Feed, dress upper body with setup Dressing lower body possible Forward weight shifts Bed mobility with equipment Level surface transfers with assistance Propel indoors with coated hand rims
C7 Independent feeding, dressing, bathing with adaptive equipment, built-up utensils Independent bed mobility, level surface transfers Wheelchair use outdoors (power chair for school or work)
C8 Independent in feeding, dressing, bathing Bowel and bladder care with setup Propel chair, including curbs and wheelies Wheelchair-to-car transfers
T1 Independent in all self-care Transfer from floor to wheelchair
T2-L1   Stand with braces for exercise
L2   Potential for swing-to gait with long leg braces indoors Use of forearm crutches
L3   Potential for community ambulation Potential for ambulation with short leg braces
L4-S1   Potential for ambulation without assistive devices
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Sip and puff straws, which are activated by
blowing and sucking air, can help control
everything from the phone to the TV
A powered wheelchair is commonly used by
tetraplegics. In many cases, there is very subtle
control left in one or both hands -- combine that
with an extremely sensitive joystick, and
wheelchair control is possible.
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Gait

• Functional ambulation may become possible for
  patients admitted with ASIA B tetraplegia.
• Sparing of sacral pin sensation may indicate a
  favorable prognosis
• Most patients with no lower extremity function
  are not trained in gait

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Upper extremity reconstructive surgery

• Offers the opportunity to utilize an innervated
  but nonessential muscle to provide a lost
  function.
• not considered until a year following injury
• well developed for the upper limb but not for the
  lower limb

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Example

• A person with a spinal injury level of C5 may
  have good shoulder control and strong elbow
  flexion. Active elbow extension is lacking,
  making overhead activity impossible. Such a
  person may benefit from a transfer procedure to
  the triceps tendon. One of the muscles available
  for transfer is the posterior deltoid.

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Functional neuromuscular stimulation

• Electrical stimulation of intact peripheral
  nerves
• increases contraction in muscles paralyzed by
  upper motor neuron injury.
• transcutaneous, percutaneous, or implanted
  electrodes.
• Stimulation can be useful for exercise and for
  function.

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• Functional neuromuscular stimulation (FNS) can be
  used in the upper extremity to provide lateral
  pinch and palmar grasp to persons with, for
  example, C5 and C6 tetraplegia.
• Upper extremity FNS often is combined with tendon
  transfer surgery

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Prognosis
One-Year Follow-up Frankel Grade One-Year Follow-up Frankel Grade One-Year Follow-up Frankel Grade One-Year Follow-up Frankel Grade
AdmissionFrankel Grade A B C D
A 84 8 5 3
B 10 30 29 31
C 2 2 25 67
D 2 1 2 85
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Life In The Community

• Fertility
• most women typically experience amenorrhea that
  can last for up to a year.
• SCI does not contraindicate pregnancy
• No prospective studies have examined fertility
  rates or pregnancy complications in these
  patients.

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Sexuality

• Vaginal vasocongestion can occur in response to
  local stimulation
• Women with complete injuries above T6
• do not demonstrate vaginal vasocongestion in
  response to psychogenic stimulation alone
• the isolation of the brain from the sympathetic
  outflow to the genitals

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References

• Chronic complications of spinal cord injury
• UpToDate updated Sep, 2009
• Rehabilitation of Persons With Spinal Cord
  Injuries
• E-medicine Updated Nov 4, 2009