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Thread: Spinal stenosis and SCI question

  1. #1
    Guest

    Spinal stenosis and SCI question

    Hi there,
    My brother is 33 years old. 4 years ago he was diagnosed with spinal stensois & had anterior decompression & fusion at C4-6. At the time of surgery he had trouble walking. Over the last 4 years, he's lost more and more function (including some bowel & bladder incontinence, hand weakness, serious spasticity in his legs). He was walking with a walker and living with our parents when, in November, he fell and lost sensation below the neck, which returned and was replaced by "pins & needles" feelings and terrible arm pain. He went to the local hospital (in Michigan) and was given an XRay (no MRI) and discharged, even though he could no longer walk because his arms were too painful to use the walker. The local fire department had to come to get him up the 3 steps to my parents' house. He was readmitted 3 days later, and eventually had posterior lamenoplasty C3-7. He's still in the hospital now, in rehab. I finally got a copy of his most recent MRI and they showed that he had cord compression, increased stenosis above & below the site of former fusion, and now has disc herniation all though his entire thoracic spine, with further cord flattening at around T10.

    My questions are:
    Is his recent new stenosis a result of the first surgery 4 years ago? Is the new disc herniation caused by that surgery? What could be causing all these problems? We've been told it was a congential problem, with arthritis, but no one has any good explanations about why this happened in the first place, why it has gotten so much worse, etc.. Does anyone else have similar experiences? Also, should we sue the hospital for discharging him?
    Any suggestions about where to go for the best rehab? Especially in Michigan?
    Many thanks,
    Heather
    heatherlevmusic@juno.com

  2. #2
    Heather,

    It is difficult to judge from the description whether the hospital or doctors engaged in practice outside of the standard of care. The pain in his arm and pins and needle sensation may not have been due to spinal cord injury. I think that it was unfortunate and inappropriate for the hospital not to have done an MRI on him when he went to the hospital, to have made the diagnosis of spinal stenosis. This is particularly true if he had symptoms of bowel and bladder incontinence, hand weakness, and spasticity in his legs before the incident. On the other hand, it may be difficult to show that anything that they did contributed to his eventual problems because it seems that your brother has both spinal stenosis as well as invertebral disc herniations. I cannot tell from the description whether his new "stenosis" is due to the surgery. However, surgery tends to reduce the flexibility of the spine and this places more stress on the remaining vertebral segments, and hence may accelerate degeneration and herniation.

    Spinal stenosis is a common problem. It is likely to be both congenital and genetic. Congenital means that it occurred during development and genetic of course means that it was influenced by genes. For example, some recent studies suggest that intervertebral herniations have a high heritability. If one member of an identical twin has a herniated disc, there is close to a 70% chance that the other one will also have one.

    The incidence of spinal stenosis in the general population is not known. However, in certain countries, population-based studies have been carried out suggesting an incidence as high as 10 per 100,000 people (Jansson, et al., 2003). Spinal stenosis is also a problem that is increasingly being diagnosed in younger people (LeBan & Imas, 2003).

    There is some disagreement, however, concerning the extent of spinal stenosis that requires surgical decompression. However, many spinal cord injuries resulting from sports occur in people who have spinal stenosis and many people have had warning signs of transient quadriparesis (Kim, et al., 2003; Morganti, 2003) and a number of doctors believe that any player that sustains a "stinger" should stop playing the sport.

    Postoperative neurological results from management of cervical spondylosis are reasonably good (i.e. close to 85% chance of a "good" or excellent" result) but depend on many factors (Epstein, 2002). In my opinion, it is crucial that your brother gets the care of an experienced neurosurgeon or orthopedic surgeon who can guide him and the family through progressively more difficult decisions in the future. Michigan has several good rehabilitation centers from a medical point of view that you can easily find by doing an internet search of spinal cord injury, rehabilitation, and michigan. However, I should leave it to others on this forum to comment about this from the patient perspective.

    I apologize for typographical and other errors because I typed the above pretty quickly.

    Wise.

    • Jansson KA, Blomqvist P, Granath F and Nemeth G (2003). Spinal stenosis surgery in Sweden 1987-1999. Eur Spine J. 12: 535-41. Department of Orthopedics, Karolinska Hospital, 171 76, Stockholm, Sweden. karl-ake.jansson@ks.se. Despite being recognised for many years as a clinical diagnosis, no exact definition of spinal stenosis has yet been agreed, leading to difficulties in interpreting and comparing studies of the incidence, prevalence and treatment. This study presents the first analysis of national data to be reported. It is a retrospective population-based national register study, aimed at analyzing surgical interventions in patients with lumbar spinal stenosis, patient characteristics, subsequent development, and case fatality rate, based on Swedish national data for 1987-1999. Complete follow-up data were obtained of incidence and type of spinal stenosis surgery, rate of multiple operations, mortality, underlying causes of death, length of hospital stay, and case fatality rate by linkage of the National Inpatient Register and Swedish Death Register. The study cohort consisted of 10,494 patients. Laminectomy was performed in 89%, and additional fusion in 11%. The mean annual rate of operations was 9.7 per 100,000 inhabitants, the annual number of operations performed increased from 4.7 to 13.2 per 100,000 inhabitants per year. The case fatality rate within 30 days after surgery was 3.5 per 1000 operations. Cardiovascular disease was the most common cause of death (46%). Relative risk of dying within 30 days of admission was doubled in men, and for fusion surgery, and increased four fold in patients older than 80 years. The relative risk of dying decreased during the study period. The results show that spinal stenosis surgery in Sweden has increased, and is associated with a low risk. Within an ageing group of patients, mortality has declined.

    • Jansson KA, Blomqvist P, Granath F and Nemeth G (2003). Spinal stenosis surgery in Sweden 1987-1999. Eur Spine J. 12: 535-41. Department of Orthopedics, Karolinska Hospital, 171 76, Stockholm, Sweden. karl-ake.jansson@ks.se. Despite being recognised for many years as a clinical diagnosis, no exact definition of spinal stenosis has yet been agreed, leading to difficulties in interpreting and comparing studies of the incidence, prevalence and treatment. This study presents the first analysis of national data to be reported. It is a retrospective population-based national register study, aimed at analyzing surgical interventions in patients with lumbar spinal stenosis, patient characteristics, subsequent development, and case fatality rate, based on Swedish national data for 1987-1999. Complete follow-up data were obtained of incidence and type of spinal stenosis surgery, rate of multiple operations, mortality, underlying causes of death, length of hospital stay, and case fatality rate by linkage of the National Inpatient Register and Swedish Death Register. The study cohort consisted of 10,494 patients. Laminectomy was performed in 89%, and additional fusion in 11%. The mean annual rate of operations was 9.7 per 100,000 inhabitants, the annual number of operations performed increased from 4.7 to 13.2 per 100,000 inhabitants per year. The case fatality rate within 30 days after surgery was 3.5 per 1000 operations. Cardiovascular disease was the most common cause of death (46%). Relative risk of dying within 30 days of admission was doubled in men, and for fusion surgery, and increased four fold in patients older than 80 years. The relative risk of dying decreased during the study period. The results show that spinal stenosis surgery in Sweden has increased, and is associated with a low risk. Within an ageing group of patients, mortality has declined.

    • Kim DH, Vaccaro AR and Berta SC (2003). Acute sports-related spinal cord injury: contemporary management principles. Clin Sports Med. 22: 501-12. Department of Orthopaedic Surgery, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA, 19107-1216, USA. Improvements in helmet and equipment design have led to significant decreases in overall injury incidence, but no available helmet can prevent catastrophic injury to the neck and cervical spine. The most effective strategy for preventing this type of injury appears to be careful instruction, training, and regulations designed to eliminate head-first contact. The incidence of football-related quadriplegia has decreased from a peak of 13 cases per one million players between 1976 and 1980 to 3 per million from 1991 to 1993, mostly as a result of systematic research and an organized effort to eliminate high-risk behavior. An episode of transient quadriparesis does not appear to be a risk factor for catastrophic spinal cord injury. Torg reported that 0 of 117 quadriplegics in the National Football Head and Neck Injuries Registry recalled a prior episode of transient quadriparesis, and 0 of the 45 patients originally studied in his transient quadriparesis cohort have subsequently suffered quadriplegia. The significance of developmental spinal stenosis is unclear. Plain radiographic identification of a narrow spinal canal in a player sustaining cervical cord neurapraxia warrants further evaluation by MRI to rule out functional stenosis. The presence of actual cord deformation or compression on MRI should preclude participation in high-risk contact or collision sports.

    • Castro FP, Jr. (2003). Stingers, cervical cord neurapraxia, and stenosis. Clin Sports Med. 22: 483-92. Tulane University Health Sciences Center, 1430 Tulane Avenue SL-32, New Orleans, LA 70112, USA. Bozothetruth@netscape.net. The risk of sustaining a stinger, CCN, or a more serious catastrophic injury to the cervical spine increases with increasing stenosis. The RR of a player sustaining a second stinger or CCN increases exponentially when compared with the risk of a player sustaining an initial stinger or CCN. Intravenous steroids have no role in the management of stingers or CCN. Players who remain symptomatic after a stinger, players with persistently abnormal diagnostic studies after a stinger, and any player who experiences a CCN should be excluded from further participation in contact sports.

    • Morganti C (2003). Recommendations for return to sports following cervical spine injuries. Sports Med. 33: 563-73. The Orthopaedic and Sports Medicine Center L.L.C., Annapolis, Maryland 21401, USA. The decision of return to play following cervical spine injuries can be one of the most challenging with a wide variation in opinion as far as management. The onus is on the physician to consider the risks of continued play for patients who have experienced a cervical spine injury and who are reluctant to give up their sport of choice. In general, the literature shows agreement for the basic necessities for return to collision sports to include: normal strength, painless range of motion, a stable vertebral column and adequate space for the neurological elements. In addition, return to play in an unsafe environment is contraindicated. Playing with defective equipment or with improper technique has been associated with catastrophic injuries and should be avoided. This particularly includes: spear tackling, diving in unknown or shallow water, diving while intoxicated, checking from behind in hockey or using a trampoline without spotting equipment. However, there is a lack of consensus on returning to play with the following: stenosis, spear tackler's spine, loss of normal lordosis or range of motion, surgically corrected instability, ligamentous instability less than that defined by White/Panjabi, transient quadriparesis, healed disc herniation and congenital fusion. More informed decisions can be made by physician and patient using a basic knowledge of: (i) previous clinical experience, including that outlined in published epidemiological studies and guidelines; (ii) biomechanical data defined in the laboratory; and (iii) the priorities of the patient.

    • Epstein N (2002). Posterior approaches in the management of cervical spondylosis and ossification of the posterior longitudinal ligament. Surg Neurol. 58: 194-207; discussion 207-8. The Albert Einstein College of Medicine, Bronx, New York, USA. BACKGROUND: If the cervical lordotic curvature has been well preserved, spondylostenosis or ossification of the posterior longitudinal ligament, with or without instability, may be approached posteriorly in selected older patients (over 65 years of age). Posterior surgical alternatives include the laminectomy with or without fusion, or laminoplasty. However, in younger patients or in geriatric patients with predominantly anterior disease with kyphosis, direct anterior surgical procedures yield better results. METHODS: Laminectomy with medial facetectomy and foraminotomy is classically performed in cases in which stability is preserved. However, posterior stabilization using either facet wiring or lateral mass fusion may be warranted. Although some consider the "open door" laminoplasty a reasonable alternative for dorsal decompression, limitations include restricted access to the hinged side, a potential for "closing of the door," and it does not offer a "real" fusion. RESULTS: Postoperative neurologic improvement may approximate an 85% incidence of good to excellent results. However, where a posterior decompression has been chosen, particularly in younger individuals with or without a lordotic curvature, or in older patients with kyphosis, they will fail to significantly improve, and will be susceptible to early neurologic deterioration. CONCLUSIONS: Posterior approaches to cervical disease may be successful in geriatric individuals in whom the cervical lordotic curvature has been well preserved. However, it is inappropriate for either older or younger patients with predominantly anterior disease, for whom direct anterior decompression with or without posterior stabilization is indicated. In those patients with significant ventral ossification of the posterior longitudinal ligament (OPLL), direct anterior resection will result in improved neurologic outcomes, whereas posterior decompression will fail to achieve a similar degree of neurologic recovery. Furthermore, dorsal decompression of OPLL may promote a more rapid progression of OPLL growth and concomitant neurologic deterioration.

  3. #3
    Guest
    Thanks so much for the information! I'm really impressed by all the information you gave, plus the speed at which you gave it!
    I have some more questions, and perhaps I can find answers from people in the group:
    My brother has been in a regular community hosital for the last month or so since he went through his most recent surgery (which was done to relieve cord compression due to increased stenosis). He's been getting between half and hour and 3 hours of physical therapy per day, and is now able to walk about 120 feet with a walker and even get up out of the wheelchair himself. However, he's still a lot worse off than before his fall (before the fall, he didn't use a wheelchair at all, just a walker, and had a *lot* more hand functioning). The hospital is talking about releasing him to a "sub-acute care facility" (i.e. a nursing home), I think because his insurance (Blue Cross, Medicare & Medicaid) seem to want to do that. My new questions are:
    should he go to a nursing home? Will he get the treatment he needs there? Should he instead go to a rehab facility? I think the best facility in Michigan is at Ann Arbor's Univ. of Michigan Hospital (a "model" program), but this is about an hour and a half drive from where my parents live, which would put a strain on the family and mean my brother gets fewer friends visiting, something he's worried about. How important is it for him to go to a rehab facility? What kind of care does he need? If insurance refuses to cover it (there's already an insurance battle going on about who should cover his last month and a half of hospitalization), what can we do?
    Any suggestions?
    Thank you so much.
    --Heather

  4. #4
    Heather, I would strongly advise against the placement of a young person with a SCI in a nursing home "sub-acute" rehab unit. He will be lucky to get 1 hour of therapy daily, generally from staff with little or no SCI experience, and the nurse staffing level is at a SNF level (usually 1 RN or LVN for the entire unit, with 1 CNA for 10-15 patients). He will not have any age peers there, or any appropriate activities, and may find that he is one of the few alert and oriented people in the facility. An acute rehab center will provide him with at least 3 hours of therapy daily, and it sounds like he needs this much at this point.

    I would strongly advise getting him referred to the Model System SCI Center you mentioned, both for a re-evaluation of his stenosis and surgical procedures done, and for a comprehensive SCI rehabilitation program. This may not need to be a long admission, but he really needs this type of expert evaluation and treatment. The distance may seem daunting, but it will be worth it in the long run.

    Has anyone mentioned problems such as ankylosing spondylitis? This is a type of arthritis and spontaneous spinal fusion frequently combined with stenosis, occurs in young men primarily, and can often result in significant spinal cord damage with relatively minor trauma, such as a fall.

    (KLD)

  5. #5
    Guest
    Thank you so much again for the information & advice. We haven't heard about ankylosing spondylitis, though I hope we can find out if this is part of the problem soon.
    Part of the trouble with getting my brother transferred to a Model SCI care facility is the insurance battle. He's covered by Blue Cross, Medicare & Medicaid, and none of the three are taking responsibility for his bills for the last 1 1/2 months he's been in the hospital. So my parents have been getting bills for tens of thousands of dollars, and the billing is all stalled. It is very unclear how to deal with the insurances, and my parents seem to be getting overwhelmed with it all. So my next question is, how does a transfer to a better facility take place? How do we know it will be covered by insurance? If they refuse to cover it, do we have any recourse? Has anyone been in this situation, and do they have pointers on battling insurance companies and Medicare?
    Thanks so much for your wonderful support so far.

  6. #6
    As always, I recommend that families that have an SCI occur obtain a FREE copy of this book ASAP. It will give you invaluable information on how to fight the insurance companies. Mr. Romano's office will also provide some limited phone advice:

    Legal Rights of the Catastrophically ill and injured: a family guide

    (KLD)

  7. #7
    Guest
    Update...
    My brother's insurance stuff got worked out, and it looks like, because his primary insurer is Medicare, he can have a longer stay in the hospital. I'm going to put his "discharge manager" in touch with the admissions person at U of Michigan Hospital and hopefully he'll be transferred (both he and my parents now seem to be into this idea, especially because of the post you put in!). And, he's not only able to walk about 190 feet now, they're teaching him how to go up and down steps! So we're all pretty happy and excited; hopefully, he'll continue to improve. BTW I ordered the book you suggested, to be sent to my parents' home. Thanks so much for everything, and I'll keep you all posted.

  8. #8
    Sounds like progress. Keep us up to date.

    (KLD)

  9. #9
    Junior Member Heatherlev's Avatar
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    Hi there,
    Updates on this situation can be found under Care, posted by Purplegirl, with the topic of "pain, can't stand up, emergency?".
    Any input we can get is very important.
    Thanks,
    Heather
    AKA Purple Girl

  10. #10
    Guest
    Heather,

    I am very sorry to hear about your brother. I'm not sure what stage you are at presently, but I did see that you were asking about hospitals in Michigan. I am in Michigan and was in Rehab at the University of Michigan in Ann Arbor. This is a Model hospital and I have absolutely no complaints about the hospital, the doctors, or therapists there.

    Also, I have been going to outpatient PT and OT at Rehab Institute of Michigan, just one of their small therapy sites, but I know they do have an inpatient rehab center in Detroit, I believe. I would reccomend RIM as second choice. Both of these places have been wonderful!!!

    Like I said, I am in Michigan, too...Roseville, just outside of Detroit...so if you have any questions I could help you with, please feel free to email me at XTinaMarie474@aol.com!!

    Best of luck to you and your brother!!

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