Greg Vigna, MD, JD: Surgery, Steroids, Cooling In Acute Spinal Cord Injuries
03/13/2013 // Concord, CA, USA // LifeCare123 // Greg Vigna, M.D., J.D. // (press release)
Greg Vigna, MD, JD, Bay Area personal injury attorney educates on the medical and surgical management of spinal cord injuries.
Every injured patient who presents to an emergency room will be assessed by the medical staff for stability of their airway, breathing, and circulation. Once these are stabilized and controlled a more detailed medical evaluation will be carried out by way of physical exam and diagnostic tests. The current standard of care for those patients who have been diagnosed with an acute spinal cord injury is IV steroids and early surgical decompression of their spinal cord. Therapeutic hypothermia (cooling) appears to be a safe modality and may potentially decrease the cellular events that cause cell death which may preserve neurologic function and lesson the effects of paralysis.
Incomplete and complete spinal cord injured patients should receive the recommended steroid protocol if administered within eight hours of injury. Those excluded from this protocol include those who are pregnant, suffered gun shot wounds to the spine, patients less than 13, and those with other life threatening injuries. ‘The study concluded that in patients with acute spinal-cord injury, treatment with methylprednisolone in the dose used in this study improves neurologic recovery when the medication is given in the first eight hours.’ Treatment did not increase the patients morbidity and mortality.
Every patient who has suffered a spinal cord injury will likely be evaluated by a neurosurgeon or a orthopedic surgeon trained in spinal surgery in the emergency room. There is clear evidence in the medical literature and a general consensus that early decompression surgery of the damaged spinal cord improves neurologic outcome. ‘The leading study of 313 acute cervical spinal cord injured patients showed improved neurologic outcomes in those who went to surgery within 24 hours of injury compared with those who underwent surgery later than 24 hours.’
It is this author’s opinion that this is a significant study and is helpful in the discussion with family regarding to the timing of surgical intervention. Clearly, most spinal cord injuries are the result of significant trauma that is associated with other injuries. Often surgical intervention is not possible because of other life threatening injuries. The risk versus benefits of early surgical intervention will have to be weighed by the medical providers, the patient, and the families of the injured prior to surgery and this study carries significant weight in this determination.
Currently there is both clinical and laboratory evidence that an acutely injured spinal cord patient who is ‘therapeutically cooled’ (hypothermia) will have preserved neurologic function following a spinal cord injury. This modality gained more acceptance after a professional football player had a good outcome following a spinal cord injury utilizing this modality during the acute management stage. ‘Currently the American Academy of Neurologic Surgeons stance on this therapeutic modality is that there is not enough evidence to recommend or discourage the use in spinal cord injury.’ However, currently the ‘use in spinal cord injury has been showed to be safe when utilized.’
It is this author’s opinion that utilization of therapeutic hypothermia appears to be safe and should be considered as long as it does not detract from the standard of care of early decompression surgery, therapeutic steroids, and the management of associated injuries.
Life Care Planning Perspective:
A Life Care Plan is a concise plan for current and future needs with associated costs for individuals who have experienced a catastrophic injury. It is the author’s opinion that it is unfortunate that life care planners are not involved early in the medical course of a patient when critical decisions regarding discharge planning, rehabilitation options, and plans for follow up are being made. A life care planner’s role is both an expert in case management of present and future needs of a patient and an educator of the public to ensure that the injured patient receives the state of the art care ensuring the best possible outcome and the prevention of complications. At this early stage it is necessary to provide the family and patient with the frame work for future care which will include the best available acute rehabilitation care, psychological support, future vocational options, equipment needs, future rehabilitation management, and likely options for facility care versus home aid and attendant care.
At this early stage medical and family support will take precedent over lawsuit related issues. However, it is necessary for a patient and their family to do the following to preserve their rights going forward: 1) Avoid any potentially damaging admissions, 2) Preserve evidence (such as crash scene evidence) for further evaluation, 3) Verify the accuracy of police reports, and 4) Obtain contact information from witnesses, and 4) Discuss your situation with an attorney who is capable of dealing with the complexity of the medical diagnosis and can provide competent representation in the matter. It is unfortunate that spinal cord injury may have catastrophic financial impact on a families future. It is important for the family to seek services of an attorney to discuss the situation and investigate the insurance issues, the negligent parties resources, and the potential for adding a defective product to the claim that may have contributed to the cause of the spinal cord injury which would provide a ‘very deep pocket.’ Further, an attorney who can identify breaches in the standard of care which may have contributed to the severity of the injury may also provide for another ‘very deep pocket’. It is important to secure your rights and protect the interest of the injured family.
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