03/27/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)
Medical Perspective:
Thirty years ago the leading cause of death in the spinal cord injured population was renal failure. This changed as the medical community began to understand the neuroanatomy of the bladder and the effect of a spinal cord injury on normal voiding function and devised treatment plans to prevent chronic repeated kidney damage. Current best practices recommend spinal cord patients to prevent kidney failure and kidney damage by having a urologic work up every one or two years, which would include renal ultrasound, renal scan, and urodynamic evaluation. It is this author’s opinion that every spinal cord patient should be educated on the anatomy and function in normal voiding and how a spinal cord injury affects this function and causes damage without proper management. It is this author’s opinion that a study to determine if the medically indigent and insured patient with a spinal cord injury are getting the recommended urologic evaluation every one or two years to prevent avoidable the complications from renal failure which include the risk of death associated with spinal cord injury and neurogenic bladder.
A patient’s education should start with the understanding that there are two phases in normal voiding, filling (the bladder) and voiding. During the filling phase of the bladder, it can be compared to filling a balloon with water with an un-stretched capacity of 500 milliliters (half a liter). During the filling stage, opening of the balloon will progressively get tighter by the sphincter tightening and contracting to prevent leaking and relaxation of the balloon or the wall of bladder, called the detrusor. With normal filling, a person will usually begin to have sensation that they need to void at 250 milliliters and will have significant urgency to void at 450-500 milliliters. Pressure inside the normal bladder will remain low until full capacity is reached. With overfilling the bladder, the pressure will increase and the balloon will be stretched and the sphincter will contract to prevent leakage. During the voiding phase the sphincter will relax, allowing the opening of the balloon with simultaneous contraction of the balloon (detrusor) allowing for complete voiding. This normal reflex during filling (contraction of the sphincter, relaxation of the detrusor) and voiding (relaxation of the sphincter, contraction of the detrusor) is coordinated by the brain stem.
Spinal cord injuries at or above T12 prevents the brain stem from coordinating this reflex and will more commonly cause something called detrusor sphincter dyssynergia (DSD). DSD is where the reflex is not coordinated; both the sphincter and the detrusor contract spontaneously causing pressures inside the bladder to increase causing the urine to back up (reflux) into the kidneys causing hydronephrosis (dilation of the ureters) and kidney damage. Spinal cord injuries at or above L1, caudal equina syndrome will cause various patterns of bladder dysfunction which may include urinary retention with hydronephrosis, urinary retention without hydronephrosis, and urinary leaking at both high and low bladder volumes with or without hydronephrosis. These patterns of dysfunction are highly variable. Proper management requires urodynamics to determine the pressures in the bladder during both the filling and voiding phases. Only then can a physician best manage the bladder dysfunction to decrease the incidence of bladder infections, decrease risk of reflux, decrease the risk of bladder and kidney stones, and manage the bladder in the most appropriate way to improve independence.
Life Care Planner Perspective:
A properly constructed life care plan will serve as a guide to future medical, rehabilitation, and day to day needs of a catastrophically injured patient. A life care planner’s primary role is an educator of the public; a role that requires him or her to be objective in the evaluation of the needs of the patient regardless of insurance issues, and provide a guide that is medically necessary and appropriate for the patient. The earlier that a life care planner is involved in a spinal cord patient’s care, the better. Following best practices, a spinal cord patient should receive urologic evaluation 3-6 months after spinal cord injury and yearly or every two years thereafter. By optimizing urologic management a patient will have optimum functional outcomes and prevent avoidable medical complications.
Attorney’s Perspective:
These are complicated and involved cases that require competent and accomplished serious injury lawyers who are familiar with all of the complications that can arise from a spinal cord injury. Future medical care and expenses are one of several important components of the damages picture and the prevention of renal failure is critical. Health maintenance related to annual urologic evaluations would be one of the included costs for future damages. A failure to include future medical needs such as this would be disastrous because it would lead to an underfunded settlement or judgment for the catastrophically injured client. In order for potential complications to be compensated a jury would need to be convinced that it would be more likely to occur than not to occur. The cost of preventing urologic complications such as renal failure would need to be included in the future damages because this is reasonably and medically necessary. Because failure to monitor a neurogenic bladder can possibly lead to renal failure (which is a very expensive complication) it is important for attorneys to retain competent expert life care planners who can articulate and explain these very specialized damages.
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