Transcript MANAGING SPINAL CORD COMPRESSION

MANAGING SPINAL CORD
COMPRESSION
A Palliative Care Perspective
Current Pathway
SCI
DIAGNOSED
ACUTE
TRAUMATIC
ONSET AND
DIAGNOSIS
DELAYED
TRAUMATIC
ONSET OR
DIAGNOSIS
NON-TRAUMATIC
SCI OR
CORD
COMPRESSION
PROGRESSIVE OR
TERMINAL
CONDITION
Current Pathway
PATIENT
REFERRED
TO SCI CENTRE
TRANSFER TO
SCI CENTRE
ADMIT TO
LOCAL HOSPITAL
FOR 48 HOURS
ADMIT UNTIL
FIT TO TRANSFER
OR TRANSFER
TO LOCAL
TRAUMA CENTRE
AGREE LOCAL
MANAGEMENT
PATHWAY
A Palliative Care Pathway
• When the prospect of living with a
spinal cord injury becomes the need to
confront the reality of dying with a
spinal cord injury
• When a non-progressive condition with
a prognosis of longevity becomes
progressive and mortal
A Palliative Care Pathway
• Where stability and predictability of
bodily functions can change so
frequently as to make all flexible care
provisions unreliable
• Where the patient potential for
developing and maintaining personal
independence and autonomy is
compromised by progressive disease
A Palliative Care Pathway
• Where intense, active inpatient
rehabilitation is expected to enable a
gradual return to community living and
the prospect of growing old
• Is replaced by a priority need for the
patient to achieve sufficient personal
safety, comfort and dignity to enable a
return home until a peaceful death
Spinal Shock
• The initial care requirements are the same as
for any other SCI
• A 48-hour period of spinal shock should be
anticipated for any admission with ‘acute’
(sudden onset) cord compression
• For cases presenting with gradual onset of
neurological symptoms, spinal shock may
follow de-bulking surgery
• Spinal shock can also follow vertebral
collapse due to metastatic disease
Spinal Shock
• Provide an initial period of bed rest to establish
extent of systemic effects
• A minimum 48-hour period of monitoring is required
to establish extent of autonomic compromise and to
complete essential diagnostic tests, neuromuscular
assessment and imaging
• The nature, extent, level of malignancy and
prognosis of the disease must be established before
any rehabilitation effort is attempted
• Spinal shock in advanced malignancy may prove
terminal as much as the disease itself
Spinal Protection
• Protective logrolling is only required where the disease
or surgery has compromised spinal stability
• The usual range of protective handling and transfer
techniques and medical devices employed for traumatic
SCI can also be employed in non-traumatic events
• Particular attention should be paid to patients with known
malignancy who fall in hospital
• Mobilisation of patients with cancers or metabolic
disease that result in vertebral compromise unsuited to
surgical stabilisation may be mobilised once risk of
causing lesion extension has been assessed as
acceptable to all parties or where patient is enabled to
make an informed quality of life decision
Mobilisation
• Diagnosis of terminal cancer with short life expectancy
can either enhance or compromise provision of suitable
wheelchairs and seating systems as well as provision of
Motability vehicles
• Fatigue potential and pain should determine prioritisation
of powered chairs, hoists and sliding boards
• Fatigue due to chemotherapy and radiotherapy means
that levels of independence in manual pushing, sitting
transfers, pressure relief and turning in bed can fluctuate
• Levels of pain and spasticity can compromise wheelchair
safety. Implanted intrathecal pumps available for those
with suitable longevity
Skin Integrity
• Condition and symptoms will dictate level of dependency
on others beyond neurological disability
• Independent patients fatigue and forget when to turn or
to relieve pressure or begin to refuse or resist due to
discomfort
• Full range of pressure relieving devices can be utilised
from the start unless dictated otherwise in potential cord
compromise assessment
• Regular turning to reduce incidence of systemic
complications should be maintained until the inevitability
of death is agreed and patient or representative makes
an informed decision that comfort rather than
compromise should dictate further interventions
Bladder Management
• Indwelling urethral catheter FG14-16 to monitor spinal shock and
protect from bladder distension unless prostate involved (SPC).
• SIC or SPC remains preference for those with sufficient longevity.
SIC dexterity may deteriorate with time and urethral may close due
to prostatic disease.
• ‘Normal’ voiding or ‘reflex’ voiding through external urethral collector
(condom) is unreliable and only permitted if urological monitoring
available
• In progressive disease, metastatic invasion of bladder and kidneys
may impair systemic safety and further compromise patient
morbidity and mortality. Surgical intervention or dialysis only if
beneficial or for palliative support.
• Do not be surprised if patient asks for assistance to overcome
sexual dysfunction due to cord compromise
• Impaired immune system can mean recurring UTIs
Bowel Management
• Daily PR and digital intervention during spinal shock by doctor or
experienced nurse. Essential to know in advance if disease has
invaded bowel or prostate involved before implementing long-term
digital intervention programme
• Standard reflex or flaccid bowel management procedures can be
followed for those with sufficient longevity. Sitting balance, toilet
transfers and dexterity may deteriorate with time and bowel reflex
potential will deteriorate as disease progresses
• Disease progression, chemotherapy, radiotherapy and additional
pharmacological agents can compromise bowel motility and stool
consistency. Use ‘sweetcorn test’ to monitor motility and Bristol Stool
Scale for consistency
• Mobility, gravity, diet, fluid intake, medications and disease
progression all influence bowel motility, continence and stool type
and staff should plan interventions according to level of compromise.
Do not be afraid to default to digital evacuation in all cases. Work to
maintain dignity and faecal continence until the end.
Other Observations
• In patients with established SCI the earliest symptoms of new onset
cancerous disease or the progress of an established diagnosis may
be masked by the presence of paralysis
• Early metastatic lung disease may be masked in ventilator
dependent patients
• Changes in bowel activity may be initially ascribed to ageing with a
neurological condition. Changes to established bowel habit
persisting for more than 6 weeks and/or prevailing after three
changes to management (each of 2 weeks endurance), should be
referred for urgent endoscopy.
• Pain originating below the level of lesion may not be perceived as
such by a non-specialist team but may present via a referred nerve
pathway, increased spasticity or autonomic dysreflexia.
• Cancer can also be misdiagnosed in partners who are also carers
as symptomatic of musculoskeletal wear and tear. Back pain of 6
weeks duration that does not affect handling ability should trigger
specialist assessment and MRI.