Life Care Plans in the Spinal Cord Injury (SCI) Setting
Spinal Cord Injury (SCI) is an umbrella term that takes into consideration multiple kinds of injury to the spinal cord. The most accepted way to classify SCI is through the American Spinal Injury Association (ASIA): International Standards for Neurological Classification of Spinal Cord Injury. These standards use the “ASIA impairment scale” to determine the specific kind of SCI the patient suffers from. In this sense, the degree of impairment is assessed as follows:
ASIA A: There is no sensory or motor function in the sacral segments (nor below the level of the lesion).
ASIA B: Sensory but no motor function is preserved below the level of injury and includes the sacral segments.
ASIA C: Motor function is preserved below the neurological level, and more than half of key muscles below the level of injury have a muscle grade less than 3 (i.e., they can’t lift an extremity against gravity).
ASIA D: Motor function is preserved below the neurological level, and at least half of key muscles below the level of injury have a muscle grade greater than or equal to 3 (i.e., they can lift an extremity against gravity).
ASIA E: Normal; sensory and motor function are normal on physical examination.
Radiation myelopathy, transverse myelitis, trauma, epidural abscess, SCI tumors.
The higher in the spinal cord the injury is, the worse will be the impairment for obvious reasons. There are significant impairments classically associated to the location of the injury in the spinal cord.
Manual Wheelchair Propulsion: Typically, the lowest level of cervical cord injury in which the patient will be independent for this task is C6 SCI. There is the possibility the patient will be independent for this task with a C5 SCI, but this is less likely. With SCI above C5, the patient will be independent with power wheelchairs.
Bathing: The SCI patient even with the lowest possible level of injury (C8-T1) will likely be modified independent for this task. At SCI levels above C8-T1, the patient will require total assistance (C1-C4 SCI) to being modified independent (C7 SCI).
Grooming: The patient may be independent at the lowest cervical level (C8-T1), even be modified independent at C7 and C6 SCI. Above the C6 SCI level the patient will require assistance.
Bowel & Bladder: The SCI patient will be completely dependent for this task for levels of injury at or above C5. Below this level, he/she may be modified independent for these tasks.
Feeding: For high SCI (at or above C4 level of injury), the patient will be dependent for this task. Below this level he/she may require adaptive equipment for feeding.
Transfers: For levels of injury at or above C5, the patient will require assistance for transfers. Below C5, the patient may require contact guard assistance and may be independent with board for level surface transfers.
Feeding: At C7, C8, and T1 levels of SCI, the patient is independent for this task. Above C7 SCI, the patient will be either completely dependent (C1-C4 level of SCI) or be modified independent with adaptive equipment (C5-6 level of SCI).
Upper Extremity (UE) Dressing: High SCI (C1-C5) patients will require assistance for UE dressing; below C5 SCI, the patient may be modified independent for this task.
Lower Extremity (LE) Dressing: The highest SCI level for independence to complete this task is C7; above C7 SCI, the patient will require assistance.
Bed Mobility: At high levels of SCI (C1-C5), the patient will require assistance for bed mobility. He/she may require supervision or contact guard assistance below C5 SCI.
Driving: The highest level of SCI where a patient is able to drive modified independent (with vehicle adaptations) is C5.
Weight Shifts: At or below C6 SCI, the patient is independent for weight shifts in a manual wheelchair. There are power wheelchairs that allow for mechanical weight shifting for patients with injuries above C6.
Thoracic/Lumbar SCI and Cauda Equina Syndrome
Although the life of a person who suffered thoracic or lumbar SCI is changed forever, this patient has significantly better outcomes than the cervical SCI population.
Ambulation: The thoracic SCI patient can’t walk, but at T10-L2 injury level, he/she can likely ambulate in the household with orthoses. Below the conus medullaris (L3-S5), or caudal equina level of injury, the patient may be able to become a community ambulator.
Activities of Daily Living (ADLs): All thoracic and lumbar SCI patients should be independent for these tasks.
Bowel and Bladder: All thoracic and lumbar SCI patients should be independent for these tasks.
Transfers: All thoracic and lumbar SCI patients should be independent for these tasks.
Long term sequelae
- Bladder Dysfunction
- Neurogenic Bowel
- Pulmonary Complications
- Sleep Apnea
- Urinary Tract Infections (UTIs)
- Pressure Ulcers
- Sexual Dysfunction
- Orthostatic Hypotension
- Heterotopic Calcification
- Autonomic Dysreflexia
- Insulin Resistance
- Superior Mesenteric Artery Syndrome
- Joint Contractures
- Chronic Pain
- Deep Venous Thrombosis (DVT)
- Pulmonary Embolism (PE)
Potential Costs of Care for SCI Patients
The National Spinal Cord Injury Statistical Center (NSCISC) is an association that supports and directs the collection, management and analysis of the world’s largest and longest spinal cord injury research database. Their data states that incomplete tetraplegia is the most common type of SCI in the United States. Less than 1% of SCI patients had complete neurological recovery by the time of discharge. At one year after injury, only 12% of SCI individuals are employed; the number increases to 33% after 20 years post SCI. About 30% of SCI patients are re-hospitalized one or more times during any given year following the initial injury. The length of hospital stay for these patients averages 22 days. Skin and genitourinary complications are the main admitting diagnoses following SCI.
The NSCISC further concludes that “average yearly expenses (health care costs and living expenses) and the estimated lifetime costs that are directly attributable to SCI vary greatly based on education, neurological impairment, and pre-injury employment history”.
Estimated lifetime costs for high tetraplegia (C1-C4) can range from $2,596,329 to $4,724,181.
Estimated lifetime costs for low tetraplegia (C5-C8) can range from $2,123,154 to $3,451,781.
Estimated lifetime costs for paraplegia can range from $1,516,052 to $2,310,104.
Estimated lifetime costs for motor unction at any level ASIA Impairment Scale (AIS) D from $1,113,990 to $1,578,274.
*Note, these are estimates; the lifetime cost for SCI can be more than the higher limits shown here or they can be lower than the lower limits.
Life Expectancy in SCI
The NSCISC determined that the life expectancy of SCI patients is much lower than the able bodied population.
The normal life expectancy for the able bodied population is around 79 years. For patients surviving the 1st year post injury, life expectancy ranges from 45.3 yrs for ventilator dependent patients to 78.2 yrs for those patients who only have AIS D. These numbers depend on the age of the patient at the time of injury and the neurological level. The most common cause of death in these patients is pneumonia and sepsis.
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West Lake Hills, TX
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