Mr. Meier’s medical history extended back quite a number of years, covering a range of health problems, some of which would have implications for his recovery and rehabilitation from his SCI.
...previous aneurysms, heart disease and thromboembolytic incidents placed him at even greater risk for SCI-associated thromboses.
In 1998, he had suffered from thoracic and abdominal aortic aneurysms which were successfully treated.His history also included ischemic coronory heart disease and repeated thromboembolic incidents (1942, 1963 and 1998), renal cysts, cox arthrosis (leading to a hip joint prosthesis in 1998) and wrist and shoulder arthrosis.
Although none of these medical conditions resulted in a permanent disability at the time they occured, these conditions all had the potential of negatively impacting Mr. Meiers’ recovery.For example, previous aneurysms, heart disease and thromboembolytic incidents placed him at even greater risk for SCI-associated thromboses. His heart disease would impact his tolerance for exercise that could lead to limits in his rehabilitation.
Despite this history, Mr. Meier considered himself quite fit for his age just before his SCI.
I felt relatively healthy before both the aneurysm and the spinal cord injury. I didn’t have any sense of a problem that would require an operation, so I was quite surprised when it came up. There was no discomfort, I wasn’t disabled. I did get a little tired while working. Of course, I thought this was just my age.
Mr. Meier in 2007
Box 2 | Aortic Aneurysm Surgery and SCI
An aneurysm occurs when there is a localized widening of an artery or vein. Such a widening can lead to a weakening or rupture of a vessel wall, including major arteries like the aorta. The aorta is the primary vessel distributing blood from the heart to the rest of the body. While smaller aneurysms may be treated medically, some larger or more aggressive aortic aneurysms may require a surgical intervention to repair the damaged tissue. This procedure replaces the damaged portion of the vessel with a synthetic tube.
Following the surgical repair of aortic aneurysms, spinal cord injuries can be one of the most serious and difficult to predict of post-operative consequences. The life-saving procedure carries with it the devastating risk of paraplegia, and with older age, such post-operative SCIs have been associated with poorer outcomes due to secondary complications.1
The reasons for SCI stem from factors associated with the surgical procedure itself that involve the clamping of the aorta and the disruption of blood flow to the spinal cord.1 Although techniques have been devised to minimize the risk, SCI still occurs in an estimated 3 percent to 18 percent of the cases.1
Based upon the the risks, benefits and treatment options available, health care professionals and the patient together will need to make an informed decision on which intervention is most appropriate for treating a given aortic aneurysm.
In 2007, Mr. Meier underwent his second aortic aneurysm repair. Though the procedure likely saved his life, he found himself afflicted with paraplegia as a result of the intervention. His primary diagnosis was classified as ASIA B, sub TH4 (indicating that sensory but not motor function existed below the injury level).
Following the onset of SCI, a number of secondary complications arose in the early post-acute rehabilitation phase. A direct result of the SCI included autonomic dysregulation that caused an impairment of his circulation and bladder, bowel and sexual functions. One week after the procedure, he was further diagnosed with respiratory global insufficiency and a tracheostomy tube was placed to allow for mechanical ventilation as well as a tube to facilitate feeding (known as a PEG tube that passes directly into the stomach).
Whether and to what degree the complications that arose were based on Mr. Meier's age is impossible to discern.
Whether and to what degree the complications that arose were based on Mr. Meiers’ age is impossible to discern. However, being elderly clearly put him at risk for many of the conditions previously mentioned in addition to the aneurysm itself.
Mr. Meier was medically managed for these complications over the 10 days after the surgery. He was subsequently admitted to a paraplegic center where his rehabilitation would be the focus. At the time, his spinal cord independence measure (SCIM) lay at a low 9 out of 100 points (see Box 1 and Table 2, center column).
Although low, Mr. Meiers’ SCIM score was stable just prior to the start of his rehabilitation, reflecting his significanct degree of dependancy four weeks into the SCI. His respiration continued to be artificially assisted with mechanical ventilation, and feeding could only occur through his PEG tube.
Medical management and rehabilitation proceeded steadily over the course of four months. In this time, his respiration improved and he was able to eventually breathe without the help of a respirator. As a consequence of the tracheotomy tube, he had decreased sensibility of his pharynx and larynx that later resulted in aspiration pneumonia.
This pneumonia required additional medical interventions and was successfully treated. Unfortunately, he continued to suffer from aspiration due to difficulties in swallowing (known as dysphagia).
Box 3 | The Spinal Cord Independence Measure1
The spinal cord independence measure, or SCIM, is a scale or measure of disability commonly utilized to perform functional assessments of patients suffering from paraplegia or tetraplegia. The SCIM was developed and revised in 2001 in order to provide health care professionals with a “valid and highly reproducible measure of daily function in patient’s with spinal cord lesions.”1 The measure has been determined to be particularly sensitive at detecting changes in function of spinal cord lesion patients. The following areas of functioning are evaluated in determining a SCIM score based on 100 possible points:
Self-Care (0-20 points)
Based on feeding, bathing, dressing and grooming Respiration and sphincter management (0-40 points)
Based on respiration, bladder and bowel sphincter management and use of the toilet
Mobility (0-40 points)
Based on motion in bed, sore prevention, transfers from bed to wheelchair and
wheelchair to toilet or bathtub, indoor mobility, outdoor mobility, moderate distance
mobility, stair management and transfer from the wheelchair to a car.
When used by a multidisciplinary team, the SCIM score can be useful for assessing everyday performance over time.
Five months after the start of Mr. Meier’s rehabilitation, his discharge from the rehabilitation center was planned. As his feeding tube was removed, he and the health care team agreed that he would remain one month longer before being discharged. During this period, his health care team prepared for his departure from the center employing the Rehab Cycle. At this time, a new Rehab Cycle was started.
There is a greater risk of diabetes, heart disease, obesity and arthritis above the age of 61.