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10.6. Health Management Issues

  1. Referral Guidelines. Referral guidelines below are provided for conditions that should be treated in the SCI Center. These conditions and diagnostic procedures, along with all major surgeries, should only be provided in the SCI Center since specialized knowledge is required or there is significant risk of adverse outcomes. In addition to the list below, please reference Section 13.i. SCI Comprehensive Preventive Health Evaluation, of this Handbook, for additional information regarding care to be provided in the SCI Center.
    1. Amputation;
    2. Annual evaluation (SCI Comprehensive Preventive Health Evaluation);
    3. Autonomic dysreflexia – complex, persistent, does not resolve after appropriate interventions;
    4. Baclofen pump trial; 
    5. Bladder stone(s); 
    6. Colonoscopy and preparation; 
    7. Fertility services; 
    8. Malignancy - new onset; 
    9. Impaction – unresponsive to simple interventions; 
    10. Neurologic level and/or impairment deterioration; 
    11. Pain – chronic, initial evaluation, comprehensive management program; 
    12. Post-surgical care after emergency surgeries;
    13. Pressure mapping, seating;
    14. Pressure ulcer initial assessment and management – Grades III and IV;
    15. Pressure ulcer debridement;
    16. Rectal bleeding – evaluation and treatment;
    17. Rehabilitation (Acute);
    18. Renal stone;
    19. SCI/D – new onset;
    20. Seating evaluation;
    21. Sexual functioning and sexuality;
    22. Sigmoidoscopy;
    23. Spasticity and/or spasm – initial evaluation, change in spasticity and management;
    24. Surgery - all non-emergent genitourinary, plastic, orthopedic, general, and neuro- surgeries;
    25. Ureteral stones;
    26. Urinary tract issue – complex;
    27. Urodynamic studies; and
    28. Wheelchair assessment and prescription.
  2. Medical Record Management. Due to the complexity of medical problems of Veterans with SCI/D, all written and imaging records must be maintained for the life of the patient.
  3. Infection Control. Policies as described by VHA Office of Public Health and Environmental Standards, facility level, and/or SCI Service guidelines for the practice of body substance isolation and effective infection control must be used in the care of this population.
  4. Communication between SCI/D Support Clinic or SCI/D PCT and SCI Center. It is important that providers in SCI/D PCTs are aware of the unique conditions and problems that Veterans with SCI/D may develop related to the underlying spinal cord dysfunction. Some of these conditions can be life-threatening (e.g., autonomic dysreflexia). There are also unique aspects of SCI/D that result in diagnostic challenges (e.g., lack of sensation may result in no or subtle symptoms during an acute abdomen). The following illustrative examples underscore the need to understand these unique issues and importance of close collaboration and communication between SCI/D Support Clinic or SCI/D PCTs and SCI Centers.
    1. Sensory Impairments. Sensory impairments result in diagnostic challenges below the level of neurologic injury. In Veterans with SCI/D, there may be no pain during cardiac ischemia (with neurologic level above T2). There may be no symptoms during cholecystitis (with neurologic level above the mid-thoracic level) or nephrolithiasis. Burns and fractures may not result in typical symptoms or pain. Provocative tests such as abdominal tenderness during palpation or rebound may be absent. Urinary tract infection is often without dysuria. Painful symptoms and signs of joint pathology may be absent (e.g., arthritis, infection, Charcot joint) below the level of injury.
    2. Autonomic Dysreflexia. Despite the lack of symptoms, nociception may result in autonomic dysreflexia for individuals with a neurologic level at or above T6. This is critically important to understand in treating autonomic dysreflexia and in anticipating problems following trauma, during illness, and during diagnostic tests. Treatment of autonomic dysreflexia is well described in the Consortium for Spinal Cord Medicine's clinical practice guideline titled Acute Management of Autonomic Dysreflexia. Severe autonomic dysreflexia may occur during diagnostic tests, and procedures such as cystoscopy, colonoscopy, and arthroscopy. Autonomic dysreflexia may persist following burns, fractures, the development of pressure ulcers, and surgical procedures. Distending a hollow viscus may result in severe autonomic dysreflexia. For example, clamping a Foley catheter or distending the colon with barium or air may result in life- threatening hypertension. Worsening neurological symptoms such as sensation, strength, pain, or spasticity require immediate attention and referral to the SCI Center. Conditions rarely seen in the general population may occur much more frequently in the SCI/D population, such as post-traumatic syringomyelia and tethering of the spinal cord.
    3. Musculoskeletal Problems. New musculoskeletal problems need to be referred to the SCI Center. What may be a relatively minor symptom or problem in someone without an SCI/D is often a serious, challenging problem in a person with SCI/D. For example, rotator cuff tendinitis in a Veteran with paraplegia can cause difficulties with transfers, pressure releases, and wheelchair pushing. Rehabilitation, change in technique, and new equipment may be necessary following the onset of new upper limb pain. Seemingly straight-forward problems may be signs of distant pathology (e.g., syringomyelia presenting as shoulder or neck pain). New spine problems (e.g., instrumentation failure, progressive scoliosis, Charcot joint) are difficult to diagnose and treat.
    4. Neurogenic Bowel. Diagnosis and management of problems related to neurogenic bowel often require subspecialty care and/or input from an expert provider. Since management of the neurogenic bowel involves diet, fluid intake, activity, medications, a bowel program, and specialized equipment, optimal care often requires close communication and coordination between the SCI/D Support Clinic or SCI/D PCT and SCI Center. An apparently simple problem such as diarrhea might be a symptom of impaction. Diarrhea in a person with SCI/D is also complicated by lack of sensation, difficulty in transferring to a commode repeatedly, difficulties to clean up and change clothes repeatedly, and the risk of skin breakdown. A straight-forward prep for colonoscopy is complicated in a person with SCI/D because there may be multiple episodes of incontinence, episodes of autonomic dysreflexia, and no sensation of stool evacuation. Gastroenterological procedures involving the use of barium are to be avoided due to changes in motility and the difficulties involved in clearing contrast medium from the gastrointestinal tract.
    5. Pulmonary Issues. The treatment of pulmonary issues, particularly in Veterans with SCI/D with impaired cough, can be problematic. Impaired cough is a result of paralysis that involves expiratory muscles. Mid-thoracic neurologic injuries and tetraplegia often result in impaired cough resulting in difficulty clearing secretions. Relatively simple upper respiratory infections may result in lower respiratory complications. People with tetraplegia often have unopposed parasympathetic innervation of the bronchial tree resulting in bronchoconstriction. Atelectasis, mucus plugging, and respiratory failure may occur in Veterans with higher level injuries. Techniques such as assisted cough and postural drainage along with specialized equipment (e.g., Cough Assist Mechanical Insufflator-Exsufflator) are often needed.
    6. Urinary Tract Complications. The assessment and treatment of urinary tract complications are often complex and require subspecialty care by physicians and nurses who are experts in Urology and Spinal Cord Medicine. Complex urinary tract problems (e.g., new onset hydronephrosis, recurrent urinary tract infections (UTI), nephrolithiasis, and progressive renal insufficiency) often require specialized diagnostic tests (e.g., urodynamics), trained staff (e.g., transfers and positioning of a person with SCI/D for urodynamics or cystoscopy is often difficult), and close surveillance for complications such as autonomic dysreflexia. Determinations of optimal bladder management (e.g., intermittent catheterization, indwelling catheterization, reflex voiding), botulinum toxin injections, sphincterotomy, the use of electrical stimulation, bladder augmentation, urinary diversion, and other urologic procedures must occur in the SCI Center. Frequent and recurrent urinary stone formation requires systematic and periodic evaluations. Uro-endoscopy and lithotripsy have markedly decreased the indications and need for open surgery.
    7. Collaboration. Close collaboration between SCI/D Support Clinic or SCI/D PCTs (in a non-SCI Center facility) and SCI Centers is important in the ongoing care for Veterans with SCI/D. Often, a care plan will be developed in the SCI Center and follow-up care will be shared between the SCI/D Support Clinic or SCI/D PCT and SCI Center. For example, developing a comprehensive treatment program for chronic neuropathic pain must occur in the SCI Center, however, assessment of changes and treatment over time may involve both settings. The assessment and treatment of spasticity, pressure ulcers, choosing and modifying a wheelchair, pressure mapping, and seating are initiated in the SCI Center and frequently followed in both settings. Close communication between the SCI Support Clinic or SCI/D PCT and SCI Center are critically important in all of these cases as it results in the best possible care for Veterans with SCI/D.
    8. New Onset or Initial Evaluation. Veterans with new onset SCI/D or who are new to VA's health care system need to be referred to an SCI Center. Each Veteran with SCI/D must be offered an annual evaluation in the SCI Center where an interdisciplinary assessment is performed (physical therapy, occupational therapy, therapeutic recreation, social work, psychology, vocational counselor, nurse, physician, etc.) and where sub-specialists are available for consultation (e.g., plastic surgery, urology, neurosurgery, orthopedics, etc.).


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