PBL 5
Concept: Destructions of the spinal cord results in disruptions of the motor and sensory tracks and loss of reflexes integrated at the level of destructions.
Hypothesis: Spinal cord injury
Area: Descending tracks, ascending tracks, functions of spinal cord, reflexes, burden of disability, functions of spinal cord, ethics of breaking bad news.
Learning issues Basic sciences The motor neurone http://www.kidport.com/reflib/science/HumanBody/NervousSystem/images/MotorNeuron.jpg Motor pathway http://classconnection.s3.amazonaws.com/839/flashcards/464839/png/screen_shot_2012-01-18_at_2.07.18_pm1326931684916.png Sensory mortality and tracks

Dermatomes for L1 and L2
A dermatome is an area of skin that is mainly supplied by a single spinal nerve. Symptoms that follow a dermatome (e.g. like pain or a rash) may indicate a pathology that involves the related nerve root.
L1 - Midway between the key sensory points for T12 and L2.
L2 - On the anterior medial thigh, at the midpoint of a line connecting the midpoint of the inguinal ligament and the medial epicondyle of the femur. http://upload.wikimedia.org/wikipedia/commons/d/db/Dermatomes_and_cutaneous_nerves_-_anterior.pnghttp://upload.wikimedia.org/wikipedia/commons/9/97/Dermatomes_and_cutaneous_nerves_-_posterior.png Muscle supplied by L1 and L2
L2 supplies many muscles, either directly or through nerves originating from L2. They may be innervated with L2 as single origin, or be innervated partly by L2 and partly by other spinal nerves. The muscles are: quadratus lumborum (partly) Iliopsoas (partly) L1 supplies many muscles, either directly or through nerves originating from L1. They may be innervated with L1 as single origin, or be innervated partly by L1 and partly by other spinal nerves. The muscles are: quadratus lumborum (partly) Iliopsoas (partly)

http://www.exrx.net/Images/Muscles/QuadratusLumborum.gifFile:Anterior Hip Muscles 2.PNGiliopsoas muscle quadratus lumborum

Muscles of lower limb http://cnx.org/content/m46482/latest/1123_Muscles_of_the_Leg_that_Move_the_Foot_and_Toes.jpg http://www.medicalexhibits.com/obrasky/2011/11053_01B.jpgNerves supplying lower limb muscles

Reflexes of lower limb Deep tendon reflexes
Use a tendon hammer to strike the tendon of the muscle and look for muscle contraction.
Compare both sides.
Reflexes can be hyperactive (+++), normal (++), sluggish (+) or absent (-). ± is used when the reflex is only present on reinforcement (see below).[1]
In the lower limbs:
Test the knee jerk (L3, L4): flex the patient's knee and support it by using one of your hands in their popliteal fossa. Elicit the reflex by tapping just below the patella.
Test the ankle jerk (S1): with the patient lying down, flex their knee and dorsiflex their ankle, at the same time rotating their leg slightly laterally. Elicit the reflex by tapping over the Achilles tendon just above the heel. If this is difficult to elicit, an alternative method is to ask the patient to kneel on a chair, facing the back of the chair, so that their feet are dangling off the seat of the chair. Tap over the same area in this position.
Interpretation:
Lower motor neurone lesions usually produce a diminished or absent response.
It may be normal to have reduced or absent ankle reflexes in some elderly people, although the frequency and significance of this is disputed.
Isolated loss of a reflex can point to a radiculopathy affecting that segment, e.g loss of ankle jerk if there is an S1 disc prolapse.
Superficial tendon reflexes
In the lower limbs, this is the plantar response.
To elicit this, the patient should be lying down with their legs extended.
Use a blunted point and run this along the lateral border of the foot, starting at the heel and moving towards the big toe.
Stop on the first movement of the big toe.
An extensor plantar response (up going big toe) is pathological and signifies an upper motor neurone lesion.

Role of spinal cord (micturition, defecation, sexual function) bladder control nerves Urination, also known medically as micturition.

Following a spinal cord injury, certain parts of the urinary system process are affected by damage to the spinal cord. The kidneys will continue to filter urine from the blood, and the ureters will continue to push the urine into the bladder for storage until urination takes place. The kidneys and ureters still work, because they are involuntary processes, and do not require signals passed from the brain via the spinal cord.
The main process of the urinary system which is affected following a spinal cord injury is that of emptying the bladder on a voluntary basis in a process called urination.
Urination in a voluntary context requires messages to be sent to and from the brain via the spinal cord. When approximately 250 to 300cc of urine are in the bladder, messages from stretch receptors in the bladder are sent through nerves which enter the spinal cord near its end in the sacral level of the spine. If the spinal cord is damaged, the action of coordinating the relaxation of the sphincter muscle and contracting the detrusor muscle may be affected, resulting in an inability to urinate properly. In addition to not being able to urinate, the sense of a full bladder may also be lost, as sensory signals from the bladder will not be able to travel to the brain through the damaged spinal cord.
The manner in which the bladder works following a spinal cord injury will depend on the level of injury to the spinal cord. Different levels of injury will affect different nerves which allow the bladder to function, and this will be a deciding factor in choosing the right bladder management program. Damage can occur to the nerves that allow a person to control bowel movements. If the spinal cord injury is above the T-12 level, the ability to feel when the rectum is full may be lost. The anal sphincter muscle remains tight, however, and bowel movements will occur on a reflex basis. This means that when the rectum is full, the defecation reflex will occur, emptying the bowel. This is known as a reflex bowel. A reflex bowel can be managed by having the defecation reflex occur at a socially appropriate time and place. A spinal cord injury below the T-12 level may damage the defecation reflex and relax the anal sphincter muscle. This is known as a flaccid bowel. Management of this type of bowel problem may require more frequent attempts to empty the bowel and bearing down or manual removal of stool. Both types of neurogenic bowel can be managed successfully to prevent unplanned bowel movements and other bowel problems such as constipation, diarrhea and impaction.
A spinal cord injury (SCI) affects a man's sexuality both physically and psychologically. After injury, men may face changes in relationships, sexual activity, and their ability to biologically father children. Men can also experience emotional changes that can affect sexuality. All of these issues involve both the man with SCI and his partner. Therefore, it is very important to understand and confront these issues as a part of the overall adjustment to life after injury.
For many men after SCI, having an erection by just thinking about something sexy may not work so well. This is because the area of the spinal cord responsible for erections is located between T11 and L2. Therefore, if your level of SCI is above this level, the message (sexy thoughts) from your brain cannot get through the damaged part of your spinal cord. Community medicine Occupational hazard and patients’ rights
Occupational hazards can be divided into two categories: safety hazards that cause accidents that physically injure workers, and health hazards which result in the development of disease. There is a three-step process for dealing with workplace hazards. First they must be recognized; then they must be assessed; and finally, if necessary, they must be controlled. Recognition involves both identifying a hazard and determining if there is a possibility of workers being affected by it. If there is such a possibility, it must be assessed and if it is found to be significant, the hazard must be controlled.
Personal protective equipment includes items like respirators, hearing protectors, safety clothing and protective clothing. It can reduce a worker's exposure but must be used properly to be effective. Social implication, financial burden to family and state
Spouses of persons with spinal cord injury suffer emotional stress that is comparable to or greater than those of the injured partner. Spouses who are caregivers for people with spinal cord injury may be more depressed than their partners with disabilities. Caregivers have a higher incidence of physical stress, emotional stress, burnout, fatigue, anger, and resentment. Spinal cord injury significantly affects marriages. In general, people with spinal cord injury are less likely to be married and more likely to be divorced. Given the disruptive effects of spinal cord injury on the family, the burden of caregiving being carried by the spouse, and impairment of sexual function. Thus a person whose sense of personal worth is centred upon their appearance or physical prowess might, other things being equal, be more greatly affected by injury than another whose focus in life is intellectual . Trouble they have with travel, stairs, doors, toilets and so forth and this can make going out more trouble than it is worth. Another factor, which is less obvious but was often mentioned, is the difficulty the disabled person has in moving freely within a social gathering and non-active. Support group like SOSCO
Payment of benefits to workers and/or their dependents when tragedy strikes. Those who are not eligible for SOCSO protections are stated below: Government servants Foreign employers Self-employed persons Sole proprietors & Partnership Domestic servants or spouse

What to do in case of accident? Each worker involved in an accident must inform the employer within 7 days from the date of such accident except in the even of fatal accident. An employer must notify the nearest Department of Labour from the place of accident in writing. Such notice must be submitted within 10 days from the date of accident. An employer shall ensure that all information is with full details and supporting documents are enclosed such as medical certificate or death certificate. An employer must ensure that compensation settlement as determined by the Department of Labour are paid direct to the injured worker by depositing such payment to the Department of Labour as directed. However, compensation settlement cannot be paid direct to the wife, children or dependants, but to be deposited to the Department of Labour concerned. Failure to notify the Department of Labour in the event of an accident is an offence and the employer shall be liable, on conviction to a fine of RM5,000 for the first offence and RM10,000 for the second offence.

The community a unit Ethics Breaking bad news in hearing of patient
The patient, not the family, should be the first person to be informed of the news, except in the case of a minor. Patients with an intellectual disability or cognitive impairment, or who are minors, have a right to information regarding their health. This should be approached with special preparation and sensitivity and should involve people who can support the individual, like family members, significant others, or care workers who know the person well.

Start with questions like
• “What did you think was going on with you when you felt the lump?”
• “What have you been told about all this so far?”
• “Are you worried that this might be something serious?” Before you break bad news, prepare your patient that bad news is coming, for example: “The results are not as good as we expected....” “Yes, it could be serious ….” “We are concerned by the test results ….” “Your test results are due back later today…...” “I’m afraid I have bad news ….” This ‘warning’ gives your patient a few seconds longer to psychologically prepare for the bad news.

Patient rights to know
Patients have a right to
• Accurate and true information
• Receive or not receive bad news
• Decide how much information they want or do not want
• Decide who should be present during the consultation, i.e. Family members including children and/or significant others
• Decide who should be informed about their diagnosis and what information that person(s) should receive

Behavioural sciences Consequences of paraplegia, health complication, emotional state of patient, rehabilitation
For most people with paraplegia, the legs and usually parts of the torso are paralyzed. Paralysis means that the muscles in the legs, stomach, back, and possibly also the chest, no longer function. The person affected can no longer walk or stand. The paralysis in the legs is often spastic, which means that the muscles sometimes cramp together. Many people with paraplegia have difficulty sitting up straight. One of the hardest things for people with paraplegia to bear are disorders of the excretory organs. Both the bladder and bowels no longer functions correctly. Men with paraplegia have problems in achieving a full erection. Both men and women can find their capacity for orgasm is impaired. Despite this, many people describe their sex life as satisfying. Men with paraplegia can father children. Women may become pregnant spontaneously. In most cases, both pregnancy and birth proceed normally. Trouble breathing or you are unable to breathe on your own. Because rehabilitation is the ultimate goal for a paraplegic patient, the patient care during the early stages of the disorder must be particularly concerned with preventing complications that may stand in the way of successful rehabilitation. These complications include pressure ulcers, respiratory disorders, orthopedic deformities, urinary tract infections or calculi, and gastrointestinal disorders. The psychological and emotional aspects of paraplegia also must be considered. Many times the paraplegic patient is suddenly thrust into the role of dependence because of accidental injury to the spinal cord. This means that a tremendous adjustment to the condition must be made in a short time. Mental attitude and emotional response to paralysis will greatly affect the success of attempts at rehabilitation. They are encouraged to do as much as possible for themselves. If it is anticipated that the patient will be confined to a wheelchair or will use crutches, transfer techniques for moving from bed to chair and from chair to other surfaces are taught. In some cases the health care provider may request a special orthopedic frame or specialized bed. These devices facilitate daily care but the patient still must be turned frequently and receive special skin care to avoid the development of pressure ulcers.Since these patients have no feeling below the point of damage to the spinal cord, they will not be aware of discomfort or other signs of pressure. Orthopedic Deformities. Until the patient is allowed out of bed and can engage in some form of physical activity, range of motion exercises for all joints should be performed frequently. If there is no control over urination, an indwelling catheter may be the technique of choice for keeping the patient dry, but it also predisposes to infection. A thorough assessment of the patient's status and potential for achieving bladder control should be made before a final choice is made. Ideally, the patient learns to achieve bladder control through an intensive bladder training program designed to fit individual needs. The achievement of bladder control is more difficult than bowel control. Patients with neurogenic bladder are unaware of the need to urinate and therefore require training to initiate urination.

The training program also should include attention to fluid and food intake. The patient learns to avoid foods that produce diarrhea and flatus, and to rely upon a daily intake of fluids sufficient to insure soft, formed stools. Adequate physical exercise also is helpful in establishing regularity of defecation. Social implication, financial burden to family and state, support group

Evidence based medicine Chances of recovery after complete transections of spinal cord
Dramatic improvement Value of alternative medicine in paraplegia