Archive for the ‘Paralysis’ Category

FES Equipment Coming to Baltimore’s Mount Washington Pediatric Hospital

Thursday, September 8th, 2011

Author - Sarah Keogh

Back in February, Jon Stefanuca wrote about a study in the Journal of Neurorehabilitation and Neural Repair about Functional Electrical Stimulation (FES) and the benefits it can provide to those individuals who have suffered spinal cord injuries. He explained how FES is able to provide electrical impulses to stimulate paralyzed muscles. The study’s authors found improvements based on using FES that led them to recommend using stimulation therapy in conjunction with occupational therapy for patients with incomplete spinal cord injuries. This technology is now also being used to help people with a wide range of injuries and illnesses including, stroke, multiple sclerosis, traumatic brain injury, and cerebral palsy, in addition to spinal cord injuries. According to the Christopher and Dana Reeves Foundation website, FES works by applying “small electrical pulses to paralyzed muscles to restore or improve their function”. The benefits can be extensive:

FES is commonly used for exercise, but also to assist with breathing, grasping, transferring, standing and walking. FES can help some to improve bladder and bowel function. There’s evidence that FES helps reduce the frequency of pressure sores. From: Christopher and Dana Reeves Foundation website

Improved Technology To Be Locally Available

Since FES was originally developed, the technology improved from being something that was typically integrated into large expensive equipment, such as exercise bikes and wheelchair based equipment, into smaller more portable devices. The good news for individuals with neuro-motor injuries in Baltimore City and the surrounding areas is that this type of FES treatment is about to become more available locally. At the end of August, Mount Washington Pediatric Hospital announced that they have received a “Quality of Life” grant from the Christopher and Dana Reeve Foundation. The article explains:

The money will help Mt. Washington Pediatric Hospital purchase Bioness® equipment for its Adaptive Equipment Rehabilitation Clinic (the clinic). The clinic works with patients with neuro-motor disorders to maximize their movement as much as possible given their physical limitations.

From Bioness.com

The Bioness website explains that they produce a variety of “medical devices designed to benefit people with Stroke, Multiple Sclerosis, Traumatic Brain Injury, Cerebral Palsy, and Spinal Cord Injury. These products use electrical stimulation to help people regain mobility and independence, to improve quality of life and productivity.” While I do not know what particular equipment will be available at the Mount Washington Pediatric Hospital, Bioness makes equipment to assist patients with hand paralysis, foot drop and thigh weakness among other conditions.

MWPH Uses Interdisciplinary Approach Combining FES and Therapy

The article about the grant explains some of the many wonderful things available for patients at the Mount Washington Pediatric Hospital (MWPH):

  • …[an] interdisciplinary approach to the assessment and management of adolescents and children with neuromuscular impairments, paralysis and/or movement disorders
  • … [a] team of 21 experienced specialists in physiatry, occupational therapy, and physical therapy.

The new equipment at MWPH will be used along with the other occupational and physical therapy options available to patients. A study described in US Neurology looked at stroke victims and found the combination of FES and traditional therapies that include repeated motion provide the best results:

Stroke patients with limited voluntary movement could now benefit from technologies such as functional electrical stimulation (fes) combined with necessary repetition of functional tasks (use-dependent plasticity) to enhance the neural repair process and improve outcomes, thus enabling them to begin to overcome their previous limitations and to improve their physical capabilities.

From Bioness.com

The goal at MWPH for children and adolescents is based on a similar idea:

Patients whose muscles can be retrained will require several months of therapy to gain normal range of motion and strength. For those patients with more severe conditions where muscles cannot be retrained, the Bioness® equipment will be used to augment their range of motion. Using these two therapy modalities, patients will acquire greater functionality, range of motion, muscle strength, and the ability to move independently.

This multi-disciplinary approach should allow these children and teens to have the best chances of improved motor use and the most independence in their future lives.

Related Articles:

Coming Soon? Restored Breathing for Spinal Cord Injury Patients

Spinal Cord Injury Updates: More Reasons for Optimism?

New Treatment Holds Promise for Patients With Spinal Cord Injuries

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Coming Soon? Restored Breathing for Spinal Cord Injury Patients

Wednesday, July 20th, 2011

image from msstrength.com

The online version of the journal Nature publishes an article today about a potential breakthrough in the treatment of spinal cord patients. While I do not have access to the full article, medicalnewstoday.com provides an overview of the research work. The highlight is that the researchers from Case Western Reserve University School of Medicine were able to restore breathing in rodents with spinal cord injuries.

This research provides optimism for similar success in humans (clinical trials with humans are hopefully forthcoming). In the recently released studies, the scientists combined “…an old technology a peripheral nerve graft, and a new technology an enzyme” to be able to restore 80-100% of breathing function in the rodents.

Using a graft from the sciatic nerve, surgeons have been able to restore function to damaged peripheral nerves in the arms or legs for 100 years. But, they’ve had little or no success in using a graft on the spinal cord. Nearly 20 years ago, [Jerry Silver, professor of neurosciences at Case Western Reserve and senior author,] found that after a spinal injury, a structural component of cartilage, called chondroitin sulfate proteoglycans, was present and involved in the scarring that prevents axons from regenerating and reconnecting. Silver knew that the bacteria Proteus vulgaris produced an enzyme called Chondroitinase ABC, which could break down such structures. In previous testing, he found that the enzyme clips the inhibitory sugary branches of proteoglycans, essentially opening routes for nerves to grow through.

In this study, the researchers used a section of peripheral nerve to bridge a spinal cord injury at the second cervical level, which had paralyzed one-half of the diaphragm. They then injected Chondroitinase ABC. The enzyme opens passageways through scar tissue formed at the insertion site and promotes neuron growth and plasticity. Within the graft, Schwann cells, which provide structural support and protection to peripheral nerves, guide and support the long-distance regeneration of the severed spinal nerves. Nearly 3,000 severed nerves entered the bridge and 400 to 500 nerves grew out the other side, near disconnected motor neurons that control the diaphragm. There, Chondroitinase ABC prevented scarring from blocking continued growth and reinnervation.

“All the nerves hook up with interneurons and somehow unwanted activities are filtered out but signals for breathing come through,” Silver said. “The spinal cord is smart.”

Three months after the procedure, tests recording nerve and muscle activity showed that 80 to more than 100 percent of breathing function was restored. Breathing function was maintained at the same levels six months after treatment”

From medicalnewstoday.com

This could be life-changing for those spinal cord injury patients who currently need ventilators to survive. If human studies prove the efficacy of such treatment, patients would have the hope of being able to breath on their own again. Not only would this dramatically improve these patients’ quality of life, but it would also provide a dramatically improved outcome for these patients. Currently, “[r]estoration of breathing is the top desire of people with upper spinal cord injuries. Respiratory infections, which attack through the ventilators they rely on, are their top killer.”

The BBC is reporting that “[r]esearchers hope to begin trials in humans. They are also investigating whether bladder function can be restored, which can be lost when the lower spine is damaged.”

The CDC’s most recent statistics, which are a few years old, suggest that there are currently about 200,000 people in the United States who are living with spinal cord injuries. This number increases by approximately 12,000-20,000 new patients annually. If some portion of these individuals could be provided hope for breathing on their own and or regaining bladder function, their lives could be dramatically improved.

Related Articles:

Spinal Cord Injury Updates: More Reasons for Optimism?

New Treatment Holds Promise for Patients With Spinal Cord Injuries

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Brother, will you help me? If you don’t this stroke might kill me.

Thursday, May 12th, 2011

[Writer’s note:   It is my goal to write at least one blog entry each week.  The largest percentage of my time is spent looking for source material.  I want to provide the reader with timely and topical information.  In any given week I review dozens of research studies, medical advances, and cautionary tales.  Every once in a while I read an extraordinary piece that truly hits home.  So much so, I wonder whether or not I should write about it.  An element of vulnerability is revealed.  Maybe this can help someone…]

Mother’s Day is in the rearview mirror.  This past Mother’s Day someone told me a story about how their grandmother fell ill.  It was the holiday season, and as she climbed the ladder to decorate the tree, things took a tragic turn. She stumbled, lost her balance and fell.  She seemed “off.” A few short hours later, at the hospital, it was revealed that she had suffered a stroke.

I am college educated.  I have a law degree too.  I have been trained by some of the best and the brightest. Countless thousands of dollars have been spent on my education.  I am African American, and therefore at an increased risk of stroke. My profession has brought me very close to the medical profession and injured people.

As I listened to that story, I was stymied. Not only because of the shocking nature of the story, but because despite my education and experience I was not sure what I would have done. I am embarrassed to tell you that until a few minutes ago, I might not have acted quickly enough to save my friend’s grandmother. I would like to think that I wouldn’t take the situation lightly and that I would call 911 immediately.  But maybe not, because – simply put – I didn’t know the signs or symptoms of a stroke. Do you?  What would you do?

A recent study says that I am not alone:

Researchers interviewed 230 African Americans in the Washington DC metropolitan area and found that nearly 90 percent said that they would call 911 first if faced with a hypothetical stroke. However, when 100 acute stroke patients (or those who accompanied them to the hospital) were interviewed 75 percent said they called someone else first instead of 911 when they realized something was wrong.  Even more reported they waited a significant amount of time before seeking any medical attention.

Of course 230 people is a small sample set, but these numbers are certainly disturbing. The actual responses of persons confronted with seriously ill people suggest that maybe I wouldn’t act as diligently as I think.

According to the American Stroke Association, someone in the United States is having a stroke every 40 seconds.  It is the third-leading cause of death in the United States. In the United States, the rate of first strokes in African Americans is almost double that of whites, researchers say, because of higher incidences of risk factors such as high blood pressure and obesity. Also strokes tend to occur earlier in life for African Americans. Studies have also shown that fewer blacks than whites receive a treatment that breaks-up the blood clot in the brain causing the stroke, in part because blacks are not getting to the hospital in time.

So what should you do?  First, start by knowing the signs and symptoms of a stroke. According to the American Heart Association, the signs are:

  • Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
  • Sudden confusion, trouble speaking or understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden, severe headache with no known cause

What else?

  • Not all the warning signs occur in every stroke. Don’t ignore signs of stroke, even if they go away!
  • Check the time. When did the first warning sign or symptom start? You’ll be asked this important question later.
  • If you have one or more stroke symptoms that last more than a few minutes, don’t delay! Immediately call 9-1-1 or the emergency medical service (EMS) number so an ambulance (ideally with advanced life support) can quickly be sent for you.
  • If you’re with someone who may be having stroke symptoms, immediately call 9-1-1 or the EMS. Expect the person to protest — denial is common. Don’t take “no” for an answer. Insist on taking prompt action.

So what is the take-home lesson here?  When in doubt, call.  When I say call, I don’t mean to phone a friend.  This isn’t Who Wants to Be a Millionaire. Uncle Stephen might know the answer to Meredith Viera’s question, but he probably can’t help you if I am having a stroke. Please. Please.Please. Pick up the phone.  Call 911. With appropriate intervention, a fully recovery is possible for some. A delayed response time, however, can be life altering.  Please, do not delay.  The life of your mother, brother, father, or spouse can depend on your reaction time.

It doesn’t say “leave a response” down below for nothing. Feel free to let us know YOUR thoughts.

Question: What would you do? Are you certain that you would call 911? Have you ever been faced with a life or death situation?

 

Robot Anesthesiologists?

Tuesday, April 19th, 2011

robotic intubationFor anyone contemplating serious surgery, it can be a scary endeavor. From going through it myself and talking to others, I know that the main fear we have going into it is that the surgeon will make a mistake during the surgery, or that we will develop serious complications such as a hematoma, infection, etc. that leads to death or paralysis. While these are very real risks of many forms of surgery, there is another aspect of surgical procedures that gets less attention from patients – the anesthesiologist. While it may get little notice from patients, anesthesiology is a highly complex field of medicine in which doctors (and certified nurse anesthetists) train for years to be able to do it well. This post will focus on just one aspect of anesthesiology known as intubation, and a new development in robotics that may improve the procedure.

What is intubation?

At its most basic, intubation is the process by which the anesthesiologist places a thin plastic tube into the patient’s windpipe to maintain an airway or to facilitate mechanical ventilation. While this is done in a variety of serious medical situations, it is almost always done during major surgery when the patient is under general anesthesia. During such surgery, the patient is rendered unconscious and is unable to breathe on his or her own. Therefore, the anesthesiologist has to essentially breathe for the patient during the surgery, either using a ventilator or sometimes compressing a bag that replaces natural breathing. The process of intubation allows this artificial breathing to take place. Because intubation itself is a painful procedure (remember – a tube is being inserted far down your throat), the patient is usually given paralytic drugs (drugs to induce paralysis) before intubation. This is a key point we’ll come back to later.

Risks of Intubation

While it may sound as simple as sliding a tube down the throat, intubation carries its own risks separate and apart from the risks of anesthesia itself (risks from anesthesia can include death, paralysis, brain damage and a whole host of other less serious injuries). With intubation, there are minor risks such as chipped teeth, lacerations in the gums and sore throat. However, there are many more serious risks as well, including perforation of the trachea, mistakenly placing the tube down the esophagus (a more common occurrence than you might think), aspiration of stomach contents, vocal cord injury, decreased oxygen and elevated carbon dioxide, and nerve injury. Intubation is a serious procedure that requires a high degree of skill and training to do it well and safely.

What if the tube does not get placed properly?

Inability to secure the airway is a major problem in intubation. To understand why, you have to remember that before the tube is placed, the anesthesiologist paralyzes you with drugs. Therefore, before the tube is placed, you stop breathing on your own. It is then critical that the tube be placed quickly and accurately to ensure that you don’t suffer from a lack of oxygen (or ventilation – the exchange of oxygen and carbon dioxide). So what happens when the anesthesiologist has trouble getting the tube in? It just so happens that I have some personal familiarity with that scenario.

A few years ago I had back surgery. The surgery itself was not complex as far as spine surgeries go (it always amazes me how surgeons are able to describe cutting open your back and operating on your spine as casually as they might describe changing a light bulb). It essentially consisted of trimming off a small piece of disc that was pressing on my spinal cord and causing pain to radiate down into my leg and foot.  I was in and out of the hospital the same day, but of course I was under general anesthesia so I had to spend a couple of hours in the Post Anesthesia Recovery Room (PACU) to make sure that I was not suffering from any ill effects of the anesthesia. While waking up, and still groggy, the anesthesiologist walked up to me and said, “I just want to let you know – you were really hard to intubate. If you ever have surgery again, be sure to tell your doctor that you’re really hard to intubate.”

I asked the doctor what he meant by that. He told me that because of the anatomy of my mouth and throat, he had had a really difficult time getting the tube into my airway. Keep in mind, the tube was placed down my throat after I was given drugs to paralyze me. Even in my post-anesthesia addled state, I knew enough to ask the obvious question – what would have happened if he couldn’t have gotten the tube down in time? He was casual in his response. “Oh, we would have given you drugs to wake you back up.” How comforting. My next thought was, “Maybe you could have checked my anatomy out before you gave me paralyzing drugs.” I didn’t ask that because I am sure they did check me pre-operatively.  That is standard procedure before giving anesthesia to make sure that the anesthesiologist knows the patient’s anatomy and can anticipate problems. Apparently, my anatomy was a little more vexing than he had bargained for. However, he was finally able to get the tube in and the surgery went well.

The use of robotics

Because of the ever-present risk of serious complications, researchers are always working on improving intubation to minimize risk. It has always been a hands-on procedure that depended on the skill of the individual performing it. Now we may be moving into a whole new world of intubation thanks to advances in robotics.

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control. According to Dr. Hemmerling:

The [device] allows us to operate a robotically mounted video-laryngoscope using a joystick from a remote workstation. This robotic system enables the anesthesiologist to insert an endotracheal tube safely into the patient’s trachea with precision.

The system is still in development. It has been widely tested with mannequins that mimic human anatomy, and clinical testing on patients has now begun. Dr. Hemmerling hopes that the new device will allow anesthesiologists to intubate patients using less force and higher precision, which should help to improve patient safety. Even with the use of robotics, I would think that intubation, including pre-operative assessment of individual anatomy, is going to require close hands-on involvement in order to ensure that it is done safely and properly, but it is always exciting to see what was once science fiction being used in real-life surgeries.

What you can do

While robotic anesthesiology is still down the road for most of us, there are still things you can do to minimize your risk of injury. Before agreeing to surgery, most of us do a good job of vetting our surgeon – how experienced he or she is, how many similar procedures he or she has performed. How many times have you heard a friend describe his or her surgeon as “the best?” Yet virtually no one who has been a patient – at least in my experience – makes any inquiry into the experience level of the anesthesiologist, even though a mistake by this person can render you paralyzed or brain-dead (or even dead) in a matter of minutes.

If you are planning on undergoing serious surgery, I would encourage you to discuss the anesthesia care with your surgeon. Find out ahead of time who your anesthesiologist is going to be (if that’s possible), and discuss your situation with that person. No doubt you will be evaluated by the anesthesiology team before your surgery, but it may well be the same day as your surgery, and it will feel like just another routine matter like signing a few forms. Keep in mind, however, that anesthesiology is just as important as the surgery itself. Stay informed and ask questions. Treat your pre-operative session with the anesthesiologist as if your life and health were depending on it – it just may!

And as for robotics, I’m curious what your comfort level would be if your doctor suggested using a robot to intubate you? Would you be willing to try the procedure, or would you prefer the traditional hands-on, human approach?

Image from “Today’s Medical Developments”

Spinal Stroke: An atypical cause of back pain

Monday, April 11th, 2011

When one hears the word stroke, what typically comes to mind is a “brain attack” with slurred speech or numbness and weakness of the right or left side of the body. Well, the spinal cord is considered part of the central nervous system and is truly a direct connection to the brain. All of the data received through nerve endings in our bodies passes through the spinal cord to be interpreted in the brain. Likewise, the messages our brain is sending to our bodies, both consciously and unconsciously (e.g. walk, run, write, speak; and digest food, breath, increase heart rate, etc.), travel through the spinal cord to our peripheral nerves.

The spinal cord is a vital structure that has its own blood supply, much like other organs, including the heart and brain. Just like the blood vessels supplying the other organs, the spinal arteries, especially the anterior spinal artery, can become occluded (i.e. blocked) resulting in spinal cord ischemia or infarction. The nerve information can no longer travel to and from the brain or the body freely; it is interrupted. This equates to a “stroke” of the spinal cord with resultant numbness, weakness, paralysis, as well as bowel and bladder dysfunction below the level of the infarction/stroke.

What causes a “spinal stroke”?

The most common cause of spinal stroke is the same as that for brain stroke or heart attack……atherosclerosis, an accumulation of cholesterol plaque in the arterial wall that ultimately blocks the artery. No blood flow means no oxygen or nutrients to the cells and tissues of the spinal cord resulting in them “starving to death.” There are other causes, as well; anything that compresses one of the supply arteries can block blood flow to a region of the cord and result in “stroke.”

Tumors, either primary or metastatic, can compresses blood vessels and other structures as they grow in the spinal region. Anterior disc herniations and disc ruptures or bone fragments from traumatic fractures of the vertebrae can compress blood vessels in the immediate vicinity.

Collections of pus from infectious processes can interrupt the blood supply either by compressing a vessel or disintegrating the blood vessel.  Small pieces of blood clots (called emboli) can break-off from larger clots (called thrombi) and circulate through the bloodstream until they get “stuck” in a smaller vessel somewhere else in the body; the spinal artery is just one location. Other systemic diseases can result in vasculitis, or an inflammation of the blood vessel, that leads to clotting and occlusion of that vessel, and the spinal artery is just one of the vessels that can be affected.

Surgery and spinal stroke

Interestingly, inter-abdominal and spinal surgical procedures can also lead to spinal cord ischemia and stroke. Individuals undergoing repair of an aortic aneurysm or iliac-to-femoral artery bypass often require “cross-clamping” of the aorta above the level of the surgery. The “golden hour” referred to in heart attack victims can also be applied to other vascular ischemic conditions, like spinal artery ischemia; if complications arise and the cross-clamp time is too long, it can result in ischemia from which the patient may never recover, remaining paralyzed for life. Similarly, an aortic dissection can disrupt blood flow to the smaller arteries branching from the aorta to feed the spinal cord leading to ischemia.

Spinal surgeries take one of two approaches, anterior (going through the belly) or posterior (going through the back). Because of the proximity of all of the vital structures, including the major blood vessels, small errors or retained fragments can lead to occlusion or disruption of the spinal blood supply.

Who is at risk for spinal stroke?

Those individuals with risk factors for heart disease or brain stroke are also at risk for spinal stroke since they share a common etiology. This includes those individuals with poorly-controlled diabetes, high cholesterol or dyslipidemia, abnormal clotting of the blood, peripheral arterial disease or history of aneurysms.

What are the symptoms of a spinal stroke?

Most patients present with sudden, severe pain, much like a heart attack, in either the chest or the back or both. This pain is typically rapidly followed by numbness, or loss of pain sensation and temperature sensation, in the extremities below the level of the stroke. Because of the anatomy of the blood supply, vibration sensation and position sense are maintained in the affected region since the posterior region of the cord has a different blood supply. As the spinal stroke progresses over an hour or so, the extremities affected become weaker and weaker, often experiencing paralysis, and the bowel and bladder lose their innervation leading to dysfunction and incontinence. This is a fairly rapid progression, much different that other myelopathies.

What is the treatment?

Due to the relative rarity of this condition, not many studies have been done regarding treatments. Unlike “heart attack” or “brain attack,” there are no standards of care except for aspirin therapy and (potentially) anti-platelet therapy after the stroke has occurred. More often than not, there is a delay in diagnosing the condition due to the rarity of the condition and the need to confirm the diagnosis by a diffusion-weighted enhanced MRI of the spine, such that “clot-busting” agents are time-excluded from use. Treatments are then focused on preventing additional vascular events, preventing deep vein thromboses in the paralyzed limbs, preventing bladder infections and fecal impactions, preventing decubitus ulcers and soft tissue infections, and preventing the additional morbidity associated with paralysis. This is not a comforting thought!

We are blessed with today’s medical technological advances that allow for so many life-saving procedures and procedures that preserve body function, such as spinal surgery, vascular stenting procedures and epidural injections. Unfortunately, some of these procedures have increased the incidence of spinal strokes due to the nature of the procedures themselves. The current epidemic of obesity and metabolic syndrome is also indicative of more cases of diabetes and atherosclerotic vascular disease which, according to the law of probability, will increase the incidence of this potentially devastating medical condition.

Clinical Trials Underway

Do you know someone who has had a spinal stroke? What was his or her age? What might have precipitated the “attack”? Some individuals have been in their early 20′s when the attack occurred. Needless to say, this is truly devastating! With all of our advanced technology, we should be doing a better job of preventing, diagnosing and treating this condition. The National Institutes of Health (NIH) does offer clinical trials for this condition; please refer to their website for further information. ( http://www.ninds.nih.gov/disorders/spinal_infarction/spinal_infarction.htm)

Image from homebusinessandfamilylife.com

Having an epidural when you deliver your baby? 3 Questions to ask the doctor!

Monday, April 4th, 2011

Be your own advocate - ask questions!

Thousands of women will have an epidural today to help them through their labor, and many of them will have a running epidural after they have their baby delivered. This is especially true in the time period for those who have had a C-Section.

There’s no doubt that epidurals have been a wonderful tool for doctors to provide patients with relief from the pains of labor and the pain and discomfort following delivery – mainly after a C-Section.

Because they have become so commonplace in hospitals throughout this country – and the world – they seem to have been taken for granted as being “safe” – not just effective. For the most part – they are safe, but they clearly have significant risks associated with them.

Some reports claim that the overall complication rate for epidurals is 23%. These complications range from very minor (e.g. some nausea, vomiting, itching, headaches) to the most major of complications – death of the mother and/or her baby. In between these two extremes lie some very devastating injuries to both a mother and her baby. Just some of those reported are damage to the mother’s spinal cord leading to motor (ability to move legs) and/or sensory (ability to feel sensations) injuries, bowel and bladder dysfunction, foot drop and a host of other potential – thankfully rare – complications.

There is a popular book that many expectant mothers have considered their bible over the years – What to Expect When You’re Expecting, which is now in it’s fourth edition, according to Amazon.com. While no doubt this has been a valuable resource for many moms-to-be, one medical author takes some exception to the section on epidurals:

Epidural anesthesia has become increasingly popular for childbirth. The popular book, What to Expect when You’re Expecting, for example, portrays epidurals as perfectly safe. The risks, however, may be greatly underplayed.

It’s been many decades (four in one instance) since I personally went through the “birthing” process as a parent-in-waiting. I must admit, I have not purchased or read the latest edition of this book so I cannot vouch that this portrayal of epidurals being “perfectly safe” is still the message of this popular book. Obviously it was at the time of the quote by this Canadian medical writer.)

What expectations do YOU have for your special day?

I suspect that many of you are like I was in envisioning what your experience will be like when the day arrives. You have your bags packed, back-up coverage in place if needed, car gassed. The moment arrives and off to the hospital you go. You register, get in your room, the fetal monitor is applied, and you pass the time remembering (or trying to remember) all those things you learned in your birthing classes. Your epidural is placed and all goes smoothly. Finally, the time comes for you to deliver your new bundle of joy. You make it through some angst of birth, see your new addition through tears of joy and relief and get ready for the onslaught of family and friends, who want to see the new arrival to your family. After you and your baby are cleared for discharge, off you go to your home, ready to begin your “new life” of nurturing, educating, parenting – aglow with images of pride, joy and a world of opportunities ahead. Hopefully, that’s exactly how we all hope it works out for you and your family.

To increase your odds that this scenario plays out, I would strongly suggest that you not take for granted the part about your epidural going smoothly. While there are probably many other questions you may think to ask – or should think to ask – here are three suggestions I have for you based on my seeing (as a lawyer) what can happen when the epidural doesn’t go smoothly.

How an epidural is performed

Here is one example available on the internet (YouTube) to show you just how an epidural is done. Unfortunately, it is a bit difficult to understand the speaker (at least for me), but having looked at several videos, I think it gives you a pretty good idea of how this procedure is performed by the anesthesiologist.

httpv://www.youtube.com/watch?v=_WRccCADReY&feature=related

“Have you reviewed my medical history, Doctor? Is there anything else I can tell you?”

Some of the known risks of having epidural anesthesia are connected to your medical history. Sure, you’re assuming that the medical history you gave to your OB during the prenatal visits and to the intake nurse when you arrived at the hospital has found it’s way to your medical record. You’re also assuming that your medical history has been carefully reviewed by the anesthesiologist whose about to put the epidural in your back. Is it there? Has it been carefully reviewed? Ask! There are conditions (e.g. spina bifida, scoliosis, certain heart valve problems, sickle cell anemia, etc.) that can increase your risk of a complication from an epidural.  Are you taking or have you recently taken any type of anti-coagulant such as heparin or coumadin? Make sure your anesthesiologist is aware if this is the case since these drugs can increase the risk of a bleeding complication. You don’t want to have a collection of blood around your spinal cord – believe me!

“When should I expect to move my legs or bend my knees? How long will I feel numb?”

In most instances, epidural are given to provide analgesia – pain relief (sensory block) during labor and at times for post-delivery (C-Section) pain relief. They are not intended to block your motor function – that is, your ability to move your legs, flex your ankles, wiggle your toes, flex your hips or bend your knees. During a C-Section the drugs being used for delivery are many times different drugs from the ones you are getting via your epidural infusion. You will have a different block so that surgery can be performed safely. You will likely have both a sensory and a motor block! You need to understand the difference.

These anesthesia drugs (the ones given during your surgery) will usually wear-off (varies depending on the drugs and from patient to patient) in a period of 1 to 4 hours. You will typically be in a post anesthesia care unit (PACU) during your recovery phase from anesthesia.

Key: you should not be discharged from the PACU if you are unable to at least bend your knees. There is a scoring system (Bromage) that the nurses and personnel in the PACU will typically use after examining your ability to move your legs, bend your knees, wiggle your toes, flex your hips, etc. to determine if you can safely be discharged from the PACU or if you need to be seen by a specialist in anesthesia to determine if you have a potentially significant complication.

“What exactly should I expect to feel like if I have an epidural running after I deliver my baby?”

I simply cannot stress enough how important it is for you to understand exactly how you should be feeling after you have been discharged from the PACU to your room. Don’t ask your family or friends; they don’t know – unless they are anesthesiologists. There are so many free, uneducated opinions out there that are simply wrong!

One further piece of advice: do not ask the nurse what you should expect to feel like. There is absolutely no doubt that there are many  very experienced and highly capable nurses out there taking care of moms. Unless you intend to ask for and analyze your nurse’s background, training and experience in anesthesia, don’t do it. The drugs used in administering epidural analgesia can vary significantly. The dosing (concentration, volume per hour, etc.) can also vary. Only a specialist in anesthesia can answer your questions correctly!

Know what to look for so that if there is some change in your condition or you start to encounter a feeling or loss of function or sensation, you can tell your nurse or doctor immediately so that you can be examined right away!

I suspect many parents are so caught up in the labor process, or are so exhausted after the delivery or so caught up in the wonderment of having their baby that these issues relating to an epidural may not be very important. If you are in your 20′s, 30′s or 40′s, how important is it to you that may not be able to walk for the rest of your life? It can happen – rarely, thank goodness, but it can happen. I have been involved in cases in which this is exactly what happened! Frankly – I don’t want to see it happen to anyone else. It is incredibly tragic for a mom, a dad and their child – trust me!

One last point before we leave this discussion on post-delivery (post-operative) analgesia. Some hospitals (the number appears to be declining due to concerns about the inadequacy of monitoring) use what is known as Patient Controlled Anesthesia epidural analgesia. Simply put, this is a device (they vary depending on the manufacturer) permits the patient to push a button a infuse a pre-determined dose of drugs (e.g. bupivacaine and fentanyl) into the epidural space for additional pain relief. A patient is actually limited as to how much drug can be used in the course of an hour (determined by what in called a lock-out interval and maximum dosing parameters per hour). While a fixed lower amount of drug flows each hour (known as the basal rate), many patients may require more relief than the basal rate provides.

That being said, if you find yourself pushing the PCA button numerous times during the course of an hour, you should bring this to the attention of your nurse or doctor. Don’t wait for them to hopefully check the machine to see how many times you pushed in the last hour (many forget to do this!). Be pro-active. If you are pushing your PCA button a number of times in the course of an hour, even though you can’t really overdose yourself because of pre-set limits by the anesthesiologist, this may be an indication that something needs to be checked. For instance, the catheter may have become displaced; the drugs may not be distributing equally; you may be having some problem that someone needs to investigate. Don’t keep hitting the PCA pump; hit the call button!

Get information about the risks, benefits and alternative to an epidural!

Having been there (i.e. childbirth) as a father four times, I know – at least from my perspective – how difficult it is to concentrate on issues such as risks, benefits and alternatives involving an epidural. Common sense tell me the ideal time to have this discussion simply cannot be while mom is in labor. If that’s the only chance you have, then fine – take the time and make the effort and have a real discussion with the anesthesiologist. Even if you just cover the 3 items I have suggested above, that will take you a long way.

I have made this suggestion before, but I’ll make it again: make arrangements to meet with someone from the anesthesia department before you get to the hospital to delivery your baby. Don’t be shy or concerned that you don’t want to bother anybody. Bother somebody! There really are an awful lot of wonderful doctors and CRNA’s, who would be willing to meet with you, educate you and answer your questions.  It’s your health,  your body, your future – so protect it!

There clearly are more than “3 questions” you should ask. Many of you have been through this. Many of you have medical training and experience. What questions do YOU think a mom-to-be should ask about their epidural.

 


 

Spinal Epidural Abscess: A basic primer

Friday, March 11th, 2011

Epidural abscess compressing the spinal cord -courtesy of aafp.org

In a previous blog, I introduced the topic of neck and back pain which can have a host of causes, most of which are mechanical.  This blog attempts to explore an infectious etiology of neck and back pain that can be potentially devastating, resulting in paralysis and even death.

The spine is a complicated structure involving bones, discs, ligaments, muscles, blood vessels and nerves.  It’s two main functions are to provide axial support for the upright stature of the human body and fluid movement of the body parts while also protecting or housing a critical component of the central nervous system, the spinal cord. Oversimplified, the spinal cord is a conglomeration of nerve fibers that act as the “information highway” between the peripheral nerves supplying sensory and motor function to the body parts and the brain. The spinal cord transmits chemical messages from the brain, telling the body what to do and how to function, even functions we are not conscious of doing (digestion, breathing, etc.), and it receives input from all of our senses and interprets the data.  Without the spinal cord or if the spinal cord is affected by an injury, there is disconnect; we lose feeling and movement as well as control of some of our normal unconscious body functions.  The location of the spinal cord damage dictates the level at which the disconnect occurs.  To help you understand the anatomy of the spine, here’s a short video describing the basic anatomy of the spine.

httpv://www.youtube.com/watch?v=Zeo0Im7h4Go

 

An epidural abscess is a collection of pus that occurs as the result of an infectious process involving any part of the  spinal cord from the base of the head to the tailbone; the abscess is located within the protective boney compartment housing the spinal cord, the spinal canal, and the thick outer covering of the spinal cord, the dura.  The dura is comprised of 3 layers, the outer one being very tough, the middle one being very vascular, and the inner one being very “tender.”

Signs and Symptoms:

In the early stages of the infection, a patient will often complain of neck or back pain very specific to the location of the infection, but the pain can be referred due to nerve root irritation.  As the infection grows, it spreads along the axial plane of the spinal canal, but the pressure and swelling of the purulent collection also tends to compress the spinal cord, resulting in numbness, tingling and functional loss below the level of the compression.  This progression can be indolent or rapid, depending on both the virulence of the pathogen and the person’s immune system.  Without emergent treatment, the pus collection can “choke off” the spinal cord and its blood supply, leading to permanent spinal cord injury and paralysis.

How does the infection get there?

Patients who have undergone spinal surgery are at an increased risk of these types of infections, especially during the immediate post-operative period.  Surgical wounds can become infected allowing bacteria to track deep into the tissues and the spine through the operative plane.  If hardware (spinal instrumentation) has been used, these man-made devices become reservoirs or fomites for attachment of the bacteria, and it is extremely difficult to eradicate bacterial pathogens from the hardware.

The bloodstream is another source of migration for bacterial pathogens from peripheral sites (infected gums, endocarditis, bladder infection, skin abscesses/boils) to the spine.  Individuals particularly at risk are those with depleted immune systems (e.g. diabetics, patients with auto-immune diseases on chronic steroids, HIV, etc.) and IV drug abusers (directly inject materials into veins).  Having spinal hardware from a previous spine surgery will increase the risk of seeding to that instrumented site should bacteria become blood-borne.

Direct inoculation can occur if  poor technique is utilized during epidural spinal injections or epidural anaesthesia.  There can also be contiguous spread from adjacent infected tissues (e.g. diskitis, osteomyelitis).

What are the most common pathogens?

Staph aureus, a common skin pathogen, is the most common cause.  It is known to cause skin abscesses/boils, wound infections, sinus infections, bladder infections and even pneumonia!  The relatively recent incidence of MRSA (a very resistent variety of Staph aureus) in the community has changed the way medicine treats common skin ailments; its effect on the incidence and treatment of epidural abscesses has yet to be determined.  If an epidural abscess is suspected, antibiotic coverage for MRSA is now automatically included in the initial treatment due to the bacterial virulence and resistance to treatment.

E. coli ( a common bowel pathogen and cause of bladder infection), fungi (like yeast), and even Mycobacterium tuberculosis are also causes of epidural abscess.  One can also contract mixed infections with aerobic and anaerobic bacteria, depending on the source of the infection (intra-abdominal abscess, perforated appendix).

How is an epidural abscess diagnosed?

The clinician must have a high index of suspicion and keep an open mind.  A thorough history often leads to clues such as recent fevers, a recent skin abscess or cellulitis, IV drug abuse, recent dental extraction or procedure, and neck or back pain without a specific inciting incident.  Physical examination of the patient often reveals point tenderness directly over the affected area of the spine, worse with percussion or tapping on the boney prominences, and often worse in the recumbent position.

Visualization of the spine is best accomplished with an MRI of the spine (above, below and including the tender area); it is non-invasive and very detailed regarding the soft tissues.  Patient weight can be a factor in accessing these machines; they often have a maximum weight limit of 300 lbs.  Many morbidly obese patients, who often have type II diabetes, are at risk for epidural abscesses; they often have to be transported to external facilities for “open MRI” studies.  Claustrophobia can also be a restricting factor, often requiring patient sedation or anaesthesia.  Excruciating pain while lying flat can also be prohibitive.  An alternative study to visualize the spinal cord is a CT-myelogram during which the epidural space is accessed with a spinal needle and dye is injected for visualization under computed tomography.  The CT-myelogram is a higher-risk study and can also be limited by a patient’s weight and sensitivity to contrast dye.  A lumbar puncture should NOT be done since it can lead to spinal cord herniation and permanent spinal injury.

What is the treatment for an epidural abscess?

There are two schools of thought regarding treatment.  One school favors emergent surgical debridement of the abscess along with intravenous antibiotics; this also allows for identification and sensitivity testing of the organism.  The other school suggests that intravenous antibiotics alone can be sufficient if no signs of spinal cord impingement are present; if symptoms progress to the development of neurologic symptoms, then surgery becomes more urgent.

What is the prognosis in epidural abscess?

Prognosis depends on the patient’s underlying medical condition and the degree of spinal cord involvement at the time of diagnosis/intervention.  Obviously, the earlier the intervention and treatment, the better the prognosis; hence, I favor surgical debridement as soon as possible.  Delays in diagnosis often lead to permanent and life-altering neurologic damage and functional loss or even death.  These delays and the permanent neurologic sequellae suffered often become the basis for medical malpractice litigation.

Spinal Cord Injury Updates: More Reasons for Optimism?

Thursday, March 10th, 2011

Spinal Cord Injury: Image Courtesy of iStockphoto and ScienceDaily

[From the Editor: this piece was written by Sarah Keogh, who is a new member of our legal team. Sarah is a lawyer, who has been advocating for public safety and health for years. We are happy and proud to have Sarah join us. Enjoy and learn from her post on Spinal Cord Injury Updates. We look forward to her future posts here in the Eye Opener - Brian Nash]

Spinal Cord Injury Updates:  Sarah Keogh, Esq.

Two new studies are providing spinal cord injury patients with hope for a future treatment and predictions about current recovery.

I recently came across a New York Times video feature called “Patient Voices: Spinal Cord Injury.” In a series of video clips, several men and women talk about their lives following spinal cord injuries.  The videos are a wonderful window in the resiliency and trials of individuals with spinal cord injuries.

It was wonderful to see two exciting updates this week that may impact the lives of these individuals and countless others like them who have suffered spinal cord injuries. However, they also raised some questions. The first is a new study that is showing promise for future treatment of spinal cord injuries. The research is still advancing, but it gives hope that stem cells may eventually be used to help repair damage to the spinal cord and provide increased functioning. The second is a new test that can predict, with claimed 95% accuracy, which individuals who have suffered a spinal cord injury will ultimately be able to walk again.

Sify News has reported that scientists have discovered “a specific type of human cell” that can “provide tremendous benefit, not only repairing damage to the nervous system but helping the animals regain locomotor function as well.” In a study of rats with spinal cord injuries, the researchers have found that one particular type of human astrocytes, a type of central nervous system cell, “provided extensive benefit, including up to a [70%] increase in protection of injured spinal cord neurons, support for nerve fiber growth and recovery of locomotor function, as measured by a rat’s ability to cross a ladder-like track.”  Perhaps equally important, they discovered that other types of astrocytes and undifferentiated stem cells do not work to provide these improvements. The researchers, scientists from both the University of Colorado School of Medicine and University of Rochester Medical Center, have published their findings in the journal PLoS ONE. (ANI).

Until the research advances enough to help provide treatment and improvement to humans with spinal cord injuries, another new study shows that doctors and scientists have worked to better predict which patients who have suffered spinal cord injuries are likely to walk again.  The findings will be published in The Lancet. The early abstract online explains that the doctors were able to create a rule for predicting an individual patient’s likelihood of being able to eventually walk again after a spinal cord injury.  The “prediction rule” takes into account several factors including the patient’s age and the results from several neurological tests to “give an early prognosis of an individual’s ability to walk after traumatic spinal cord injury, which can be used to set rehabilitation goals and might improve the ability to stratify patients in interventional trials.”  The tests needed to predict which patients will walk can be done within 15 days after the spinal cord injury.  An article from The Press Association reports that the European scientists who have developed this new “technique was [found it to be] highly accurate, getting the prediction right 95% of the time.”  This is significantly better than current methods of guessing what patients may recover the ability to walk.

The question left in my mind, after reading about these advances, relates to the question of optimism.  Several of the individuals in the New York Times videos talked about the progress they have made in their recovery.  They had goals and hopes for reaching new levels of independence and recovery.  If the new prediction tests reveal that a patient has a very poor chance of recovering the ability to walk, will that negatively impact their spirit, drive and mental health in the long road of recovery?  The scientific advances seem to be wonderful for the doctors and rehabilitation specialists, but are they equally wonderful for the individuals coping with a new injury who need to adapt to their new lives?  Perhaps the continuing research into using stem cells can provide hope for these men, women and children, who need continued hope that a prediction at the time of their injury may not be the last word on their hopes for a more complete recovery.

 

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Friday, February 11th, 2011

Hope for those with paraplegia?

Researchers in the U.K. have developed a revolutionary microchip muscle stimulator that will enable patients with paraplegia to exercise multiple muscles at the same time. According to the Engineering and Physical Sciences Research Council (EPSRC), the microchip developed by Professor Andreas Demosthenous from University College of London and his team is truly unique.

The microchip chip is small enough (approximately the size of a child’s fingernail) that it can be implanted directly into the spinal canal. Unlike previous models, the new implant incorporates the muscle stimulator and the electrodes into a singular unit.  The unit is properly sealed to protect against moisture, which could lead to corrosion of the electrodes.

The creation of the implant has been made possible by new laser processing technology, which enabled researchers to micro-pack all components into one unit. With this new laser technology, researchers were able to cut much tinier electrodes from platinum. The electrodes are then folded into a 3D shape that resembles pages in a book. Each electrode can be wrapped around a nerve root. The electrode is then welded to the microchip located in the spinal cavity.

Because the implant comes with multiple electrodes, which can be connected to multiple nerve roots, it is capable of controlling entire muscle groups. In patients with paraplegia, the devise can be used to stimulate or trigger multiple paralyzed muscles at the same time. Researchers also claim that the new device will also be used in patients with bladder or bowel incontinence.  Because the device has multiple electrodes, some electrodes can be connected to nerve roots that control bladder muscles or nerves that control bowel capacity.

Although all of this may sound a bit scifi, the implant will be available for pilot studies sometime this year. If you or someone you know is paraplegic, this research is worth following. It clearly promises to offer life-chaining benefits to patients with paraplegia. If you know of other research on similar devices, we’d love for you to share that information with our readers. We’ll try to keep an eye on the progress and implementation of this device from the UK and keep you posted if and when developments occur.

Neck & Back Pain: When is it something more serious?

Wednesday, December 22nd, 2010

Statistically, 4 out of every 5 adults under the age of 50 have experienced at least one episode of neck or back pain.  For most people, the symptoms resolve in a reasonable period of time with or without intervention.  For others, the symptoms become chronic, often leading to surgical procedures and even disability.  Sometimes, there is a specific identifiable incident that incited the pain while in other cases, no particular injury or overuse syndrome could be identified.  Neck and back pain are one of the most common complaints leading to medical evaluations in the emergency room, urgent care center or primary care physician’s office; they are also a significant cause of lost time from work, lost wages and productivity, and high expenditure from a healthcare perspective.

Neck and back pain are symptoms of an underlying problem.  The majority of the causes (~97%) are purely mechanical, that is related to the mechanics of movement of the neck or back, involving the bones, muscles, ligaments, discs and joint spaces.  They include such diagnoses as lumbar strain/sprain, degenerative disc disease, herniated discs, spinal stenosis, spondylolisthesis, osteoporotic compression fracture and traumatic fractures.  Some of these, obviously, are more serious with potential neurologic sequellae than others.  Any condition that results in compression of the spinal cord can cause permanent neurologic injury, including paralysis; these include fractures, stenosis and significant spondylolisthesis. Causes include acute traumatic injuries (car accidents, falls, direct blows), overuse syndromes, poor lifting techniques, poor posture, chronic degenerative arthritis leading to spinal stenosis and spondylolisthesis, and osteoporosis.

The remaining 3% of causes of neck and back pain are considered non-mechanical, but they can be further divided into non-mechanical spinal conditions (1%) and visceral (internal organ-related) conditions (2%).  Of the non-mechanical spinal conditions, neoplasias/malignancies comprise 0.7% while infections and inflammatory arthritides (inflammation of joints due to infectious, metabolic, or constitutional causes) comprise the remaining 0.3%.  Of the 2% visceral complications, etiologies are potentially due to vascular problems (aortic aneurysms, retroperitoneal hemorrhage, coronary syndromes, etc.), prostatitis, endometriosis, pelvic inflammatory disease, kidney stones/infections, pancreatitis, cholecystitis or ulcer perforation.  Thus, the sub-categories of non-mechanical neck and back pain have very small incidences in the global sense, but they are potentially more serious with more ominous consequences, including paralysis and death, making them diagnoses not to be missed or ignored.

So, how can one tell the difference between mechanical versus non-mechanical neck or back pain?

As a general rule, mechanical neck/back pain, since it is related to movement, is typically worse with movement or specific body positions and better with rest or lying supine without the burden of one’s weight causing an axial load on the vertebral column.  Non-mechanical neck/back pain is relatively constant and not related to body position or movement.  Pain in either case can be sharp or dull/aching, and each can have instances in which there is neurologic involvement causing pain to radiate along the nerves that exit the spinal column.  In the neck, nerve pain typically radiates to the arms causing pain, numbness and sometimes weakness.  In the upper to mid-back, nerve pain typically radiates to the anterior chest and abdomen.  In the lower back, nerve pain typically radiates into the pelvis, genital area, and especially the legs.  Radicular pain can be either one-sided or bilateral, the latter of which is more ominous and indicative of spinal cord compression as opposed to a single peripheral nerve root.

What are the “red flags” that raise concern for more serious problems?

There are specific risk factors that, when present, raise concerns for more systemic disease processes.  A history of cancer, for instance, increases the likelihood of the pain being related to a metastatic lesion or tumor.  Presence of a fever increases the likelihood of the pain being related to an infectious etiology.  Unexplained weight loss increases the likelihood of the pain being related to either a primary malignancy or metastatic cancer.  A history of intravenous drug use or even diabetes increases the risk for an acute or chronic infectious cause.  Blood in the urine can indicate a malignancy or other kidney-related problem.  Swollen glands can be indicative of a malignancy or infectious problem.  Anemia can be indicative of an underlying malignancy or vascular problem.  Rashes are often associated with rheumatologic or auto-immune problems that often involve the joints.  Chronic steroid use or other immunosuppression can increase the risk of infectious causes or osteoporosis with compression fracture.  Obviously, a history of trauma increases the risk of fracture, disc rupture/herniation and ligamentous injury leading to spinal instability, but it can also be a cause of intra-abdominal injuries or retroperitoneal injuries that present as back pain.  Any time there are neurologic deficits (numbness, tingling, weakness, muscle atrophy, etc.) beyond sciatica, the risk of nerve compression or spinal cord compression becomes higher.  Abdominal pain associated with back pain can be related to an intra-abdominal process (infection, abscess, aneurysm, ulcer perforation, etc.).  Neck pain that is associated with headache, fever and neck rigidity is often indicative of menigitis.

Overall, there are a plethora of potentially serious causes of neck and back pain.  One can see that the diagnosis of more serious conditions can be a little more complicated, especially since they are much rarer than the  common, everyday, garden-variety mechanical back pain without complications.  There are, however, a variety of clues that can lead one to an accurate and relatively rapid diagnosis.  The intention of this blog has been to introduce the topic and the dilemma faced by a provider when diagnosing these conditions.  Since the topic is broad and more complicated, a series of blogs dedicated to some of the more devastating etiologies of neck and back pain will follow.  The key to diagnosing any condition is an accurate and in-depth history and physical examination with keen attention to specific clues that are typically present.