› Have a high index of suspicion for the leading causes of hospitalization among patients with spinal cord injury and disease (SCI/D). These include respiratory infections, urinary tract infections, and pressure ulcers. A
› Treat respiratory infections early and aggressively in patients with SCI/D; strongly consider inpatient management because of the high risk of respiratory failure. C
› Be alert to atypical signs and symptoms of urinary tract infection in patients with SCI/D, such as fever, chills, spasm, autonomic dysfunction, nausea and vomiting, abdominal discomfort, and fatigue. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
More than 5 million Americans are living with paralysis, and for nearly one in 4 of them the cause is spinal cord injury or disease (SCI/D).1 More common than multiple sclerosis (17%) as a cause for the loss of movement, SCI/D is second only to stroke (29%).1
The percentage of people living with paralysis due to SCI/D is increasing, partly because the population is aging and partly because management of infections has improved. Prior to the 1970s, life expectancy for people with SCI/D was significantly shortened, largely because of urologic and respiratory infections. But improved bladder management, in particular, has increased life expectancy—especially for the least severely injured.2 Respiratory diseases and septicemia remain the leading causes of death, but with increased longevity, other causes, such as endocrine, metabolic and nutritional diseases, accidents, nervous system diseases, and musculoskeletal disorders, are becoming increasingly common.2,3
Primary care’s pivotal role. Given the size of the population affected by SCI/D and the increase in life expectancy, family physicians (FPs) are more likely than ever before to care for these patients, most of whom have highly specific needs. However, little information about the primary care of patients with SCI/D exists. This patient population tends to consume a relatively large share of practices’ resources because of high case complexity.4
A recent Canadian report confirms our clinical experience that FPs report knowledge gaps in the area of SCI/D care, yet the same report found that 90% of people with SCI/D identify FPs as their “regular doctors.”5 Although a large number of patients with SCI/D identify their physiatrist as their primary care physician (PCP), one study reported that fewer than half of physiatrists are willing to assume that role.6 And while more than half of all patients with SCI/D have both specialists and PCPs involved in their care,5 communication breakdowns are a concern for patients receiving medical and rehabilitative direction from multiple health care professionals.
Below we take a closer look at the distinct patient populations affected by SCI/D, summarize several clinical conditions that contribute to hospitalization, and provide clinical management recommendations (TABLE7-26).
2 patient populations, one diagnosis
Paralysis due to spinal trauma occurs predominantly in non-Hispanic white and black males because of vehicular accidents, falls, violence, and sports.2 The mean age of injury has increased from 29 years during the 1970s to 42 years since 2010.2 However, this calculated average is misleading because there is an emerging bimodal distribution of people injured during early adulthood and a new increase in older adults injured primarily because of falls.27 In addition to those injured traumatically, a broader cohort of approximately 1 million patients represents a largely undefined group of people with paralysis due to diseases such as spinal stenosis, cancer, infection, multiple sclerosis, or other non-traumatic causes.
As a result, the population with SCI/D is comprised primarily of young adult males who have relatively few chronic medical conditions at the time of their injury and age with SCI/D, and older patients who are more likely to have already developed chronic medical conditions by the time of their SCI/D. Approximately 60% of SCI/Ds result in tetraplegia (ie, 4 limbs affected), although approximately two-thirds are incomplete, meaning that patients have some residual motor or sensory function below the level of injury.2 Not surprisingly, the level and severity of SCI/D impact life expectancy inversely and lifetime financial costs directly.
High health care utilization. Morbidity data largely parallel mortality data, often resulting in high health care utilization and cost among SCI/D patients.28 In a recent prospective observational study of nearly 1000 people with new traumatic SCI, 36.2% were rehospitalized at least once and 12.5% were rehospitalized at least twice during the 12-month period after discharge following injury.29
Rehospitalization, an outcome often quoted as a proxy for inadequate primary care, remains unacceptably high (36%-50%) for people with SCI/D.29,30 The leading causes of rehospitalization—pneumonia, urinary tract infection (UTI), and pressure ulcers29—have not changed over the years and persist over the lifetime of individuals with SCI/D.30