Medical Conditions Related to Brain Injury
Spinal Cord Injury with Brain Injury
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There is no widely accepted definition or medical term for individuals who have sustained both an Acquired Brain Injury (ABI) and a Spinal Cord Injury (SCI). For the last 5 years at Shepherd Center, individuals who have suffered concomitant ABI and SCI are considered to have a “Dual Diagnosis”. At several other model institutions around the country, the term Combination Injury (CI) is used for these individuals and is synonymous with the term Dual Diagnosis (DD). Therefore depending on the source either term describes this population.
In order to begin to understand what it means to have a Dual Diagnosis (DD) or Combination Injury (CI), it is important to review a couple of definitions. The Central Nervous System (CNS) consists of the brain and spinal cord. First and foremost, the CNS is extremely fragile. Even slight pressure from the primary (original) injury or from the secondary (subsequent) injury in the form of swelling, bleeding or infection can result in permanent and severe neurologic injury. A SCI is an injury from any cause to the CNS below the base of the brain or in more anatomical terms, located distal to the foramen magnum. This does not include injuries to the peripheral nervous system, which is made up of the nerves that leave the spinal cord and run down the arms or legs. An ABI is an injury to the brain from any cause but does not include injuries to the spinal cord, the peripheral nervous system or the cranial nerves.
The DD population has been widely recognized both clinically and in scientific journals for 20 plus years but has not been systematically studied. Thus, the exact incidence and prevalence of DD in the U.S. is not known and has varied considerably in studies. This patient population is difficult to define based on the varying inclusion criteria used for having an ABI or not and even more difficult to measure due to the complexity of having 2 overlapping catastrophic injuries.
The vast majority of the DD patients are the result of trauma with motor vehicle accidents as the leading cause. Depending on the study cited anywhere from 10% to 57% of the individuals who sustained a SCI as a result of trauma also sustained a significant ABI. Less common yet significant alternative sources of trauma in the DD population are falls, gun shot wounds, and acts of violence such as assaults with blunt trauma or knife wounds. Rarely an individual will sustain a DD from lack of blood flow (ischemia), infection, or tumor involving both the brain and spinal cord. As a rough rule of thumb, most physicians who are involved in the care of SCI individuals agree that a DD exists in 20-30% of the cases.
Obviously the first step in recovering from, dealing with or treating a DD is to recognize that one exists in the first place. It is important to realize that skeletal injury does not equal neurologic injury. Skeletal injury and neurologic injury often correlate, but they are not synonymous. A person may have a suffered a severe fracture of the spinal column and have no SCI. A person can have a normal spine column yet have a SCI. Similarly cranial trauma does not equal neurologic injury. A skull fracture or severe scalp laceration may exist with no ABI. Paradoxically MRI and CT scans of the brain may be normal with severe cognitive deficits, and abnormalities on imaging studies be present yet little cognitive dysfunction is present. As mentioned above, exceptions exist, but generally abnormal MRI or CT scans of the brain or spinal cord generally correlate with more severe injuries.
By definition, to have a DD an individual must have sustained both a SCI and an ABI. Paralysis can result from either an ABI or a SCI or both (DD). The patterns of paralysis tend to be different however for a pure ABI vs. a pure SCI. An ABI patient tends to display asymmetrical paralysis and do not have a clear sensory level. For example, the ABI patient may present with hemiplegia where one side of the body has lost both motor and sensory control, and the opposite side is normal. SCI tend to present with more uniform or bilateral paralysis and have a sensory level. Further complicating matters, occasionally a SCI or an ABI patient may sustain injuries to peripheral nerves. This will cause paralysis to one very specific part of the body in addition to whatever neurologic deficits exists as a result of the damage to the CNS (ABI or SCI). In regard to the DD population, most physicians work from the spinal cord side to the brain injury side. The physician first determines if the history, pattern of injury, and paralysis fit with a SCI. Once this has been established, the physician looks for clues that an ABI may also exist. At times this is obvious due to the patient being in a coma or having severe cognitive changes that cannot be attributed to medications or sedation. At times the findings are much more subtle. The following is a partial list of clinical findings consistent with a SCI patient also having an ABI or in other words a DD.
- Decreased level of arousal (Loss of consciousness)
- Altered mental status (Hallucinations)
- Seizures
- Cerebral spinal fluid leak
- Difficulties with language (Aphasias)
- Hemiplegia above the SCI level
- Decreased smell (CN I palsy)
- Abnormal vision (CN II palsy)
- Abnormalities in extra ocular movements (CN III, IV, and/or VI palsies)
- Inability to fully open the eye/ptosis (CN III palsy) or inability to close the eye (CN VII palsy)
- Decreased facial sensation (CN V palsy)
- Facial asymmetry (CN VII palsy)
- Decreased taste (CN IX palsy)
- Abnormal hearing (CN VIII palsy)
- Swallowing dysfunction (CN IX & X palsies)
- Abnormal tongue movements (CN XII palsy)
- Inability to do previously mastered tasks or activities (Motor or speech apraxias)
- Agitation
- Exaggerated pain complaints
- Increased DTR’s (deep tendon reflex) above the level of the SCI
- Asymmetric contractures or spasticity in otherwise complete SCI
- Difficulty weaning from ventilator with a SCI level that normally does not require ventilatory assistance.
- Vertigo +/- nausea/vomiting (Cerebellar dysfunction +/- CN VIII palsy)
- Movement disorder - Resting Tremors - (Basal Ganglia dysfunction)
- Cerebellar dysfunction, such as:
- Nystagmus – eyes twitch either laterally or horizontally or both
- Intention tremor – tremor when trying to do something like write or comb hair. A resting tremor would be like in Parkinson’s disease where the hand shakes only when at rest and then moves smoothly when trying to do something.
- Ataxia – decreased coordination
- Dysmetria (decreased depth perception) +/-dysdiadochokinesia (decreased ability to do rapid alternating movements such as flipping one’s hand over repetitively)
First and foremost, the health care professional, the family of the DD patient and ultimately the DD patient himself needs to constantly be aware that two concurrent catastrophic injuries are present. Consequently the DD patient population has unique needs requiring a unique treatment approach which addresses both of these catastrophic injuries in relation to each other and not in isolation. The treatment regiment must be individually tailored on a case-by-case basis for each DD patient due to the unique overlay of both injuries. Attempts to “fit” the DD patient into either a SCI or an ABI protocol is difficult if not impossible and frequently does not address their unique needs.
DD patients have all the complications of both diagnoses such as seizures, paralysis, cognitive dysfunction, spasticity, neurogenic pain (origin of the problem is lack of nervous control due to an injury to the nervous system), neurogenic bowel etc. with often times fewer medication options. DD patients are at a much higher risk of developing side effects to common medications used to treat pain, insomnia, nausea, neurogenic pain, spasticity and agitation. Medications routinely used for treating conditions related to SCI may be contraindicated for ABI patients like MS Contin, Restoril, Reglan, Elavil, Baclofen, and Haldol. DD patients have a higher incidence of additional trauma such as fractures (extremities, ribs, and face), brachial plexus injuries (injuries to the grouping of nerves that form a plexus in the upper arm), eye injuries, cranial nerve injuries, and dental injuries. Additionally, DD patients have a higher incidence of developing heterotopic ossification (HO or bony overgrowth), decubiti (pressure ulcers or skin sores), DVT (deep vein thrombosis), and contractures. DD patients have a higher incidence of endangering themselves from falls or inappropriate behaviors due to poor judgment. Therefore, the treatment team has to balance each injury and complication against the other in coming up with a treatment plan. Basically the ABI component has to be considered at all times when treating the DD patient in order to maximize outcomes and minimize complications.
Some important considerations relating to the DD Patient as compared to either the SCI or ABI patient are slower to wean from the ventilator, often times have prolonged tube feeding regiments secondary to swallowing dysfunction and require additional procedures, tests, and surgeries which can interrupt the flow of rehabilitation program. The most important consideration relating to the DD patient is that they learn at a much slower rate. Since comprehensive rehabilitation and ultimately life is largely a continual learning experience where each of us is challenged to take care of oneself often times in a totally new and foreign situation. This point cannot be emphasized enough.
Catastrophic injuries permanently alter the lives of the patient and patient’s family and friends. After a DD, all of these people are grieving a substantial loss. Situational depression should be expected in the patient and his/her family, which often requires treatment both in the form of counseling and medications. The importance of family involvement in all aspects of the rehabilitation process with the DD patient should not be under emphasized. Successful outcomes with a DD patient are difficult if not impossible without a good support network, which is ideally provided by the family.
There are few good studies on the DD population largely because this entity is still being defined. Preliminary results at Shepherd Center with the outlined treatment approach show no significant differences in length of stay or functional outcome as compared to matched pure SCI patients. Once this population of patients is more clearly defined, other complex variables need to be investigated such as the need for supervision, return to productive activities such as work and extent of family involvement, and life satisfaction.
Dr. Bowman graduated from John Hopkins University in Baltimore, Maryland and received his doctor of medicine from Duke University in Durham, North Carolina. He completed an internship in transitional medicine at Georgia Baptist Medical Center in Atlanta, Georgia and a residency in physical medicine and rehabilitation at Baylor College of Medicine, in Houston Texas. Dr. Brock Bowman is a staff physiatrist at Shepherd Center. He also serves as attending physician for the Dual Diagnosis team and the Spinal Cord Injury team.