Archive for the ‘Spinal Cord Injuries’ 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

Service dogs in school — a fresh look

Friday, July 22nd, 2011
Service Dog and Boy

service dogs

A while back I wrote a piece on the topic of service dogs for kids and mentioned the use of service dogs in schools. A regular reader of our blog then wrote in with a number of comments and questions about the propriety of dogs in schools. To help answer her questions, I recently spoke with Nancy Fierer, who is the Director at Susquehanna Service Dogs in Harrisburg, Pennsylvania, which is an organization that trains and places service dogs. Susquehanna is the organization that placed two of the dogs mentioned in this NPR story.

The ADA and dogs in school

I also did a little more research on the Americans with Disabilities Act (“ADA”) and its impact on the issue. The ADA requires that all public facilities allow a disabled person and his or her service dog (not pets) to enter the premises just the same as a non-disabled person. So is a school considered a public facility? It’s an interesting question. On the one hand it is accessible to the public in the sense that parents and students can freely enter a school. However, if you’re not the parent of a child at the school, can you just walk into a school and roam the halls like you might roam around a mall? I think if you tried that, you would get stopped pretty quickly and asked to leave if you had no valid business there. However, the law appears to be settled that schools are considered public facilities at least for those areas that are open to the public such as administrative offices, gymnasiums during sporting events, and auditoriums during public events. Therefore, schools must be accessible to service dogs in these public areas. For class rooms, however, it’s not so clear. While the law appears to favor allowing service dogs in class rooms, it is being decided on a case-by-case basis because there are other considerations as well – the age of the child, the disability at issue, the ability to control the dog, etc.

How much school assistance is necessary?

I have to admit that when I first wrote on this topic, I had envisioned that the dog and child were a self-contained unit that required little in the way of adult assistance. Ms. Fierer indicated that that is usually not the case. Depending on the age of the child and the level of disability, the child may be able to care for the dog independently. However, in most instances an adult (teacher’s aide or nurse perhaps) is required to pitch in with help giving the dog water and taking it out for bathroom breaks. Ms. Fierer indicated that the dog does need water breaks during the day (feeding can be done at home before and after school). This is usually accomplished by keeping a water bowl in a nearby room – perhaps a nurse’s office or a counselor’s office. Several times a day, either the child (if he/she is old enough) or an adult can take the dog for a drink. The same is true for bathroom breaks (pee only; No. 2 is usually taken care of at home). Again, service dogs do require assistance from the school but from what Ms. Fierer told me, the disruption is fairly minimal and can be worked out with proper planning.

Controlling a service dog

A larger issue is the child’s ability to control the dog. Even though service dogs are highly trained, the owner (in this case a child) must still be able to control the dog before being permitted to take a dog into school. These include such basic commands as making the dog sit, stay, come, leave it, and walk on loose leash. These are some of the common commands that all service dogs must know. In addition, a service dog also receives additional training in a particular disability and learns specific commands unique to that disability, e.g., retrieving specific items, pulling a wheelchair, responding to seizures, search and rescue. These commands must be mastered as well. For example, if an autistic child is in need of the dog to put its head in the child’s lap to help calm him/her down, the child (or a trained adult) has to be able to give the dog that command. If the child cannot give that command to the dog, then it undermines the usefulness of the dog in school.

Because of the demands that service dogs place on the child, very young children usually do not take dogs to school unescorted. Ms. Fierer said she would be surprised to see a six-year-old, for example, taking a dog to school alone. Older children can, with proper training, be permitted to take a dog to school alone. To ensure that the child is capable of caring for the dog, Susquehanna utilizes the Assistance Dogs International Public Access Test. This test requires the owner and the dog to perform multiple tests in a variety of settings to ensure that the dog is well-trained and that the owner can properly control the dog. For children, Ms. Fierer indicated that the testing is usually administered with the parent and child because she uses the team approach – the parent, child and dog are a team. For a child taking the dog to school, however, the parent is usually not there so the child must be able to control the dog independently. Only when a child is adept at controlling the dog should the child be permitted to take the dog to school. Even then, parents have to work closely with the child’s teacher and other school staff to coordinate the details of how the dog will be cared for.

Other concerns

Our reader also asked questions about whether service dogs are a distraction in school and whether they can pose a danger to other children. After talking to Ms. Fierer, it’s my opinion that these are not major concerns. As for being a distraction, Ms. Fierer said that is usually not the case. Service dogs are generally introduced into the school gradually, starting with maybe a half-hour per day and building from there. The children get accustomed to the dog and the novelty soon wears off. Also, the other children need to be educated that this is a service dog and not a pet to be played with. Children can easily learn this lesson. As for being a danger to other children, Ms. Fierer said she has never heard of a dangerous incident happening at school such as a dog biting a child. These dogs are amazingly well-trained and the trainers allow zero tolerance for aggressive behavior. If a dog shows any aggression, that dog does not make the cut for being a service dog. Therefore, I don’t believe this concern is a valid reason for denying a child a service dog.

Training a service dog

In terms of the actual training given to the dogs, Ms. Fierer said that when a puppy is eight weeks old, it starts living with a dedicated puppy handler who is responsible for teaching the dog basic manners.  This time includes classes at Susquehanna twice per month.  This arrangement goes on till the dog is 18 months old, at which time the dog receives about six months of intense training.  About 50-60 percent of training is the same for all service dogs. The rest is devoted to the unique needs of each disability. Before a dog is placed, Susquehanna spends about 2 and ½ weeks training the family that is receiving the dog. Even after placement, Susquehanna continues to do follow-up training – at first on a weekly basis and then gradually declining over the next six months. It even does annual re-testing.

I hope this follow-up addresses our readers’ concerns. Ms. Fierer emphasized that service dogs are not the solution for every child. Susquehanna actually does therapy sessions with families before even agreeing to place a dog to ensure that the dog and the family are a good fit. She indicated that it is a big responsibility to own a service dog and it is not a decision that is made lightly by the dog trainers. However, for the right child and the right family, a service dog can be an amazing asset.

Related Nash and Associates Links:

Service Dogs for Kids

 

photo from servicedogtraining.wordpress.com

 

 

 

 

 

 

 

 

 

 

 

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

Why early settlement is a win-win for all

Friday, May 20th, 2011

There is an old adage in the law that cases settle on the courthouse steps. There is a reason for that. When the parties are actually walking into court to try their case, they seem to suddenly recognize that there are significant risks to going to trial, and that there is serious money at stake. When you go to trial, only one side can win. The other side goes home a loser. Faced with such a stark outcome, both sides tend to become more reasonable in their assessment of their case and more willing to talk settlement. After all, despite all the years of experience that trial attorneys amass, no one can ever predict what a jury is going to do in any specific case. As one mediator I know likes to tell the litigants, going to court is like going to Vegas:  you roll the dice and you take your chances. So often times, the closer a case gets to the trial date the more motivated the two sides are to talk settlement. But is there a better way?

A couple of recent cases made me start to think about settlements and how they come about. (If you missed it, Brian Nash wrote an excellent piece on the frustrations of mediation and trying to settle cases). I’ve recently handled two cases that illustrate how settlements work and how two cases can go down dramatically different routes to ultimately get to the same place. Both of these cases are subject to confidentiality agreements so I can’t divulge the names of the parties or the settlement amounts, but they were both seven-figure cases with significant injury.

In the first case, the patient alleged that her doctor failed to timely diagnose stomach cancer over a period of several years. By the time the patient was properly evaluated by another physician, the cancer had progressed to the point that there was virtually no chance of a cure, and the young woman was likely going to die in the next few years. In the second case, the patient alleged that he suffered serious neurological complications (motor and nerve dysfunction in his arms and legs) as a result of post-operative complications that were not treated quickly enough. In both cases, a lawsuit was filed in court.  At that point, the two cases diverged.

Case Example #1 – Getting it done early

In the cancer case, before any depositions had taken place, the defense attorney called and asked if we might be able to talk about resolving the case. That’s always a great call to get as a plaintiff’s lawyer because it means there is a good chance that you will be able to get a nice result for your client, which is always the ultimate goal. Within a matter of weeks, we had reached an agreeable number and the case was over.

Case Example #2 – Grinding it out to the courthouse steps

In the second case, there was no early talk of resolution. The case proceeded through the normal course of litigation, which in the District of Columbia usually means about eighteen months of discovery, depositions, expert meetings, etc. Twenty-five experts were hired to review records and testify. Twenty-seven depositions ended up being taken. The case got all the way up to the Thursday before trial was scheduled to start on the following Monday morning. At that point, the parties finally reached agreement on a number and the case was settled.

Why the difference in approach?

So we have two cases, both with significant injury and both with questionable care. One case settled right away, and one dragged on for almost two years before settling. Is there a simple reason why? Not that I’ve been able to figure out. After years of doing this, I, like every other attorney, get a gut feeling as to what cases are worth, which ones will likely settle, which ones will go to trial. But it’s still a gut feeling; there’s no science involved.

It’s usually a combination of factors – the quality of the medical care, the severity of the injury, the likeability of the plaintiff and the defendant (more important than most people realize), the specific jurisdiction you’re in, etc. On top of these factors you have a myriad of psychological reactions that pop-up in lawsuits and there is no predicting those. Sometimes people get entrenched in fighting for no other reason than to fight. Some people get a number in their head for what a case is worth and don’t want to budge. So even though I can’t sit here and explain why certain cases settle early and some settle late, I do want to talk about the value of early settlements to all sides.

Common Sense and good economics say “get it done early”

It is easy to see why early resolution of cases benefits everyone, and it comes down to the costs of litigation. In today’s world, it can easily cost $75,000 to $100,000 (if not more in many instances) just in expenses to take a case to trial; it can easily be much higher in complex cases. (I know of one attorney who spent $300,000 on a case that he took to trial; he lost the case). These expenses consist primarily of expert fees paid to doctors to review records and testify. Expert doctors routinely charge at least $400 per hour and oftentimes more for their time. For trial testimony, doctors usually charge around $5,000 per day (some substantially more). If it runs into two days, that’s $10,000 just for one witness. It’s not unusual to spend tens of thousands of dollars for expert fees alone.

On top of that there is the cost of court reporters for each deposition, copying charges, obtaining medical records, long-distance calls, travel expenses, etc. Going through litigation is an expensive undertaking, and the longer the case goes on the more expensive it is. On the plaintiff side, all of those expenses are usually advanced by the attorney (in jurisdictions where this is permitted), but they all get paid back by the client at the end of the case (assuming the plaintiff wins; if there is no recovery, the plaintiff’s attorney “eats” those costs). So every dollar spent on litigation comes straight out of the client’s portion of the recovery.

On the defense side, insurers and self-insured institutions (like hospitals) have those same expenses, but on top of that, they also have to pay legal fees to their attorneys. Defense attorneys charge by the hour for everything they do on a file from reviewing records to meeting with clients to talking to experts to taking depositions. The complexity of medical negligence cases means long hours of work on each file, generating substantial legal fees. Those fees get paid to the defense lawyer whether the case is won, lost or settled at the last minute. The longer the litigation lasts, the higher the legal fees.

Of course it always costs money to investigate a case. There is no avoiding that.  Records need to be obtained and reviewed. Experts need to be retained for an initial opinion. But instead of spending $75,000 or $100,000 (or more) on a case, it may cost only several thousand dollars to work-up a case to get it ready to file – that is, to be in a position where early resolution can be discussed with the defendant. If a case can be settled early on, all of those thousands of dollars that would have gone to litigation costs go straight to the client. That is a huge benefit to the client.

The defendant benefits too. No hospital or insurance company wants to spend money needlessly. Early resolution means that the defendant doesn’t have to spend tens of thousands of dollars in expenses and tens of thousands more in legal fees. The only way it makes sense to spend that money is if, at the end of the day, the “defendant” (read insurer/hospital) believes it can either win the case or settle it for less down the road. But here’s the thing – a case can usually settle early on for less than the case would be worth had the case gotten closer to trial. This isn’t always true, of course, but as a general rule, a good case does not become less valuable over time.

Plaintiffs’ attorneys don’t undersell their cases to get an early settlement, but in practical terms, attorneys and clients are usually willing to consider some discount because they know that an early settlement is to their mutual benefit.The plaintiff gets a guaranteed financial payment now rather than waiting eighteen months for a trial and then a possible appeal that may drag the case out another two years. In that circumstance, the plaintiff is usually willing to take a little less money now because it is certain. It’s the age-old question: would you rather have X amount of money now, or wait eighteen months for the chance of getting more? For most plaintiffs, it’s an easy answer. Also the defense can pay less on a case than it would have ended up paying anyway and save thousands in expenses and legal fees by doing so. It’s a win-win for all parties.

Just do the math!

The big secret with early settlements (and which can sometimes be difficult to explain to a client) is that even though an early settlement might be for less than what a jury might award, the client can actually put more money in his or her pocket with a lower settlement amount. Again, we’re back to the issue of litigation costs. If a firm spends $10,000 to investigate a case and get it ready to file rather than $100,000 to take a case to trial, that is an extra $90,000 that goes straight to the client. Also, some law firms will have a contingent fee agreement in which the fee is higher (usually from 1/3 to 40%) when the case goes to trial, which serves to compensate for the additional time,  risk and expense of going to trial. When you consider the higher legal fees and the increased costs of litigation that have to be paid back, it can actually take a substantially larger jury verdict to put the same amount of money in the client’s pocket as he or she would get with a smaller early resolution.

Some cases may just need to be tried

I don’t mean to imply that every case that gets filed should be settled early. Far from it. Some lawyers undoubtedly file cases that are simply without merit and should be defended vigorously. Other cases – while they may be defensible – fall into a middle category where the care may not be the best but the plaintiff has problems with his/her case too. Some cases can be difficult to evaluate without further investigation and discovery to gauge the strength of the case. In those cases, it is entirely appropriate to proceed with litigation – even on a somewhat limited scale through discovery. No doubt there are instances where insurance companies do need to protect the interest of their doctors, and sometimes that means vigorously defending a case all the way through trial.

Some cases, however, – the cases where the medical care is truly egregious and the damages are clear – need to be looked at early on to see if the two sides can be reasonable and find some middle ground. If a case is going to ultimately settle (and believe me, experienced attorneys and claims adjusters can usually identify those cases early on), it makes sense to talk sooner rather than later. It requires compromise on everyone’s part, but the value to both sides is so great that it makes sense to talk early and get it done.

What has been your experience?

I’d be curious to know the experience of our readers. Has anyone been involved in a lawsuit that settled? Did it resolve early on or did it stretch out for years? Do you think the time involved had any impact on the amount of the settlement? Any tips or tricks you might suggest? Let’s hear from you – maybe we can all learn how to get these cases resolved earlier and stop wasting time, resources and money.

You may also want to read these related posts:

Frequently Asked Questions (FAQ’s)

A View from the Shady Side – The Defense Perspective

Every bad outcome does NOT a malpractice case make! Some practical advice

 

Week in Review (April 18 – 22, 2011) The Eye Opener Health and Law Blog

Saturday, April 23rd, 2011

From the Editor:

This past week, our blawgers (guess I’ll use this term now since we are legal bloggers) were busy on their keyboards once again. They covered a number of topics relating to law, medicine, health and patient safety. This week we posted a primer on aortic aneurysms and how they can present as back pain, a blog about “robot” anesthesiology, a disturbing post about how the recent threat of a federal government shutdown was averted but at a cost to those who are in dire need of healthcare, an interesting piece about laughing gas making its way back into the American medical scene for labor and delivery and finally, and a highly read piece on a not-to-often discussed topic but one of potential grave concern – shift switching by nurses and how this might impact patient safety.

Here’s our usual “quick summaries” for you to peruse, click on, read and comment:

Aneurysms – a deadly condition you need to know about!

Our in-house medical specialist, Theresa Neumann, wrote another highly educational and need-to-know piece about a condition that can present as back pain but which has deadly consequences for those who have this condition.

As Theresa’s research made us aware – “1 in every 50 males over the age of 55 have an abdominal aneurysm, this is a more common pathologic diagnosis than some others.  Men also corner the market at an 8-to-1 ratio as compared to women with abdominal aneurysms.”

As is the case with all of Theresa’s writings, we offer through her valuable information from someone who’s “been there” and “done that” in the clinical setting. Don’t miss her post entitled Aneurysms: A Potential Deadly Condition That May Present as Back Pain.

Who’s using remote control and a joy stick to put a breathing tube down your throat?

Mike Sanders brought to our attention a new practice of anesthesiologists – in Canada – that may soon be part of anesthesia management in the United States as well – using robotics to intubate patients. While you can certainly learn about the concept of intubation by reading Mike’s blog, basically, this is placing a small tube down a patient’s airway so that the anesthesiologist can control the airway and provide ventilation to a patient undergoing surgery.

Here’s an except -

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.

For more on this fascinating new project by Dr. Hammerling and his team, read Mike’s post entitled Robot Anesthesiologists?

Government Shutdown Avoided – but who will pay the price for the “deals” that were cut?

The newest member of our blogging team, Jason Penn (fast approaching veteran blawger status) did a fascinating piece of the story-behind-the-story of the recent crisis our country faced when the federal government was on the verge of a shutdown. We all know about deals being cut in the back rooms of congress. We all know that the government avoided a shutdown this time around when the senate and house worked out a compromise that resulted in millions of dollars being earmarked for cuts in the budget.

Jason tells us what programs relating to healthcare will suffer as a result of these negotiated cuts. As some wise person once said, “why is it always those who are least represented who bear the burden of budget cuts?” Maybe it’s because they can’t afford lobbyists to protect them like those who need protection the least can.

Read Jason’s eye opening and no-punches-pulled report on just who will be the victims of the deals in his post of this past week Budget Crisis Avoided, But What About the Babies? Can They Live With $504 Million Less in Funding?

Will moms-to-be now be “laughing” their way through labor and delivery?

One of our seasoned blawgers, who every now and then is driven to report on the off-beat issues of law, medicine and healthcare, Jon Stefanuca, stepped up to the plate once again and took a swing at the return of an old-timer to the arsenal of pain relief for mothers-to-be undergoing labor and delivery – laughing gas!

As Jon’s piece in Eye Opener this past week tells us -

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future.

For more about this return of laughing gas to our obstetrical units, read Jon’s piece Laughing Gas Making Its Way Back Into the Labor and Delivery Department.

Nursing and Sleep Deprivation: Is it a risk factor for patient safety?

I suspect somewhere along the line you have done “an all-nighter” – whether it was getting ready for a big test, a social event, or for some other reason. Remember how you felt as you made it through that night or the next day? Have you ever done it several nights in the same week? How about doing it a few times one week and then do the same thing the next week and the next…. Well you no doubt get the idea. You’ve been exhausted, right? Well what about nurses, who have to do this for a living?

Nurses have lives too. They have children, home responsibilities and obligations, and some form of social life. What happens when they swap shifts or are asked to do “a double”?

Sarah Keogh was back blogging this past week and wrote a fascinating (and concerning) post entitled Nurses Switching Shifts: Does a Lack of Sleep Put Patients at Risk? We invite you to read Sarah’s piece and share your comments. Are you a nurse who lives this lifestyle? What are your thoughts about nurses being allowed to work multiple shifts or back-to-back shifts in terms of patient safety? Should there be restrictions on nurses’ shifts just as there (finally) are work restrictions on doctors-in-training?

A “Sneak Peak” of the week ahead

As part of our continuing effort to “get the word out there” on issues relating to health, medicine, patient safety and the law, we post from time to time more extensive research pieces called White Papers. Well, the time has arrived for another White Paper to be posted on our website. Marian Hogan has completed her piece on a very important topic – Patient Controlled Analgesia in today’s hospital environment. She examines how some hospitals are now heavily marketing a spa-like environment so you choose them over the competition. Yet lurking in the shadows of these facilities which promote flat screen TV’s, valet parking, in-room safes and the like is a very dangerous practice: placing patients on patient-controlled-analgesia (for pain relief) without vital monitoring devices and patient safety practices. It’s at the “printer” now; we hope to have it online this week.

From our blawgers you can expect reports on a disturbing fight between manufacturers and child safety experts over – blinds! After decades of controversy, you’ll find out where the battle lines are now drawn, who’s winning and who the real losers are in this war. Wonder how healthcare safety is doing since the report To Err is Human was published by the Institute of Medicine over a decade ago? Jason Penn will be providing an updated report card, which you should not miss. Alcohol and surgery – not a good combination! Jon Stefanuca plans on posting a piece that looks deeper in the obvious problems with this potentially deadly combination.

This is just a taste of what’s to come. I better wrap-up now. I’m working on finishing the third installment on Medical Technology and Patient Safety. Oh yeah, if time permits, I might even get to post a piece I’ve been working on this past week – a lawyer’s rant about our modern day love affair with mediation practices and trends.

As always, don’t forget - subscribe to the Eye Opener and tell your friends about us too! …and… don’t forget to join our social networking communities on Facebook and Twitter.

Hope you have a great weekend!

Laughing Gas Making Its Way Back Into The Labor And Deliver Department

Thursday, April 21st, 2011

According to a recent article published by MSNBC, laughing gas or nitrous oxide is making its way back into labor and delivery units in American hospitals. Although laughing gas has long been used as a pain relief in various countries, including Canada and the U.K., it has lost its popularity in the U.S. Well, maybe not for much longer.

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future. Dartmouth-Hitchcock’s plan is currently being reviewed by the federal government, and arrangements are presently being made for the procurement of delivery equipment for laughing gas. Vanderbilt University Medical Center may begin offering laughing gas as well later this year.

History

Laughing gas is not a new pain relief method. Its use had become very common in hospitals when Joseph Thomas Clover invented the gas-ether inhaler in 1876. Particularly, its use in the labor and delivery setting had been very common before the introduction of epidural and spinal anesthesia. Because laughing gas is unable to eliminate pain to the same degree as epidural or spinal anesthesia, it simply could not compete with the more sophisticated pain relief alternatives, which entered the marker in the 30s and 40s.

What is laughing gas?

Nitrous oxide, commonly known as laughing gas or sweet air, is a chemical compound with the formula N2O. It is an oxide of nitrogen. At room temperature, it is a colorless non-flammable gas, with a slightly sweet odor and taste. It is used in surgery and dentistry for its anesthetic and analgesic effects. It is known as “laughing gas” due to the euphoric effects of inhaling it, a property that has led to its recreational use as a dissociative anesthetic.

Laughing gas as an important pain relief alternative

Although laughing gas can only take the edge off pain, it just might be an important alternative to other more conventional pain relief methods. The patient does not have to rely on an anesthesiologist to administer the gas. The patient can herself choose how much gas to administer at any time. The effects of the gas are not long-lasting. Therefore, the patient does not have to recover in a post anesthesia care unit. Importantly, there is no associated loss of sensation and motor function during the delivery process. As such, the gas does not interfere with the woman’s ability to breath and push during labor. Laughing gas is also not known to have any adverse effects on the baby in utero.

The administration of laughing gas does not require any invasive medical procedures. By contrast, consider epidural anesthesia: An epidural requires that an epidural catheter be threaded into the epidural space, which is only about 2 mm wide. Any mistake and the consequences can be catastrophic. Epidurals have been known to cause spinal cord injury secondary t0 toxicity, spinal cord infarcts, severe hypotension, paraplegia, epidural bleeding, and even death. None of these complications are associated with the use of laughing gas.

: httpv://www.youtube.com/watch?v=1TO4sOgiIeU]

According to Suzanne Serat, a nurse midwife at Dartmouth-Hitchcock Medical Center:

We have a number of people who don’t want to feel the pain of labor, and nitrous oxide would not be a good option for them. They really need an epidural, and that’s perfect for them. […] Then we have a number of people who are going to wait and see what happens, and when they’re in labor, decide they’d like something and then the only option for them is an epidural but they don’t need something that strong. So they would choose to use something in the middle, but we just don’t have anything in the middle.

Nitrous oxide may just prove to be that middle option for many women who prefer to give birth without the use of powerful and potentially dangerous analgesic/anesthetic agents. If you are an expectant mother, ask your obstetrician if nitrous oxide is a pain relief option that may be available to you during labor.

Image from cartoonstock.com

For more information about epidural anesthesia and epidural complications, you may want to read these posts too:

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

5 Questions to Ask Your Obstetrician Before You Go to the Hospital

Epidural Analgesia – What Should an Expectant Mother Consider? What are the risks?

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.