Rehabilitation Management of an Incomplete Cervical Spinal Cord

Injury of Adolescent with Neurogenic Lower Urinary Tract

Dysfunction and Family Conflict Issue

Anisatusholihah1, Ronald Pakasi2 and Indriati Tobing2

1
Physical Medicine and Rehabilitation Department, Faculty of Medicine, Padjadjaran University
2
Rehabilitation Unit, Fatmawati Hospital, Jakarta, Indonesia
anisatusholihah1700@mail.unpad.ac.id

Keywords: Spinal cord injury, Neurogenic lower urinary tract dysfunction, Family Conflict Issue.

Abstract: We report on rehabilitation management of an adolescent with incomplete cervical spinal cord injury. This
patient has neurogenic lower urinary tract dysfunction and family conflict issue. Caring for adolescents with
SCI presents several challenges and requires unique programs. Teenagers with disabilities face problems
that have implications for personal development, family and peer relationships, also healthcare.
Rehabilitation is a lifetime process. It does not end when the patient leaves the rehabilitation facility. He
will need courage, commitment, and a sense of challenge.

1 CASE DIAGNOSIS Traumatic spinal cord injury (SCI) has devastating

A 16 years old teenager was admitted to hospital on
27th June 2019 to train independence in activity daily
living. The patient was got stab wound on his left
neck on 16th December 2018. He felt weakness on
all his extremities. He diagnosed with SCI AIS C
NL C7 due to trauma.
2 CASE DESCRIPTION
For his bladder function, this patient has suprasacral
lesions. USG abdomen in this patient showed mild
hydronephrosis bilateral and cystitis. This patient
still has a good renal function, supported by normal
ureum and creatinine (11 and 0,7 mg/dL), therefore
we must preserve his renal function by promoting
right voiding method. Hospital Anxiety and
Depression Scale (HADS) was 3 for anxiety and 5
for depression.
3 DISCUSSION
consequences for the physical, social well-being of
patients. Pathophysiologically this time is
intermediate (14 days to 6 months) to chronic (>6
months) phases, which is suitable with MRI result
that impressed might be ongoing process of
intermediate through to chronic phases that are
marked by attempts at remyelination, vascular
reorganization, alterations in the composition of the
extracellular matrix (ECM) and remodelling of
neural circuits.
For his bladder function, this patient has
suprasacral lesions. On anamnesis, the patient said
that in March 2019 he complains about urine
retention after aff the catheter. This might be a
spinal shock phase that occurs following an acute
SCI and can last up to 3 months. Autonomic
activation of the bladder by the parasympathetic
nerves is rendered inactive. The bladder becomes
atonic, and there is no conscious awareness of blad-
der filling. Interruption of the neuraxis below the
pons due to SCI eliminates the micturition reflex,
which causes urine retention.
Following spinal shock associated with
suprasacral SCI, reflex bladder function will occur.
The consciousness of bladder filling might not be
totally absent; however, voluntary inhibition of the
2 Chapter Error! No text of specified style in document.
micturition reflex is lost. This explains the following
retention complaint he said that after several weeks
the bladder function was normal again.
Now the patient can feel a sensation of bladder
fullness, but there is a leakage and couldn’t hold the
urine. From the history of voiding, we can assume
that this patient has a problem in urinary
incontinence (storage dysfunction) and urinary
retention (emptying dysfunction). Typical
urodynamic findings in suprasacral lesions include
detrusor overactivity and detrusor striated sphincter
dyssynergia (DESD). The ice water test was done to
stimulate sacral segmental reflex and to know
detrusor activity. The result was positive and there
was nonleakage with a high detrusor pressure, this
may indicate DESD. Even though there was
autonomic dysreflexia on simple cystometry test
(Figure 1), we could assume the result on filling
phase was high pressure of detrusor (56-60 cmH2O),
also detrusor overactivity during filling cystometry
and abnormal detrusor activity with post-void
residual.
70
60
Presuure (cmH2O)
50
40
30
20
10
0 is a period of time full of rapid and dramatic changes
0 10 20
Volume (ml)
Figure 1: Simple Cystometry Chart
Therefore we can conclude overactivity of
detrusor and most probably DESD. Even though,
Lower Urinary Tract function should be assessed
further using urodynamic study. When the catheter
inserted there was suspected the spastic urethra, so
Tizanidine was recommended as muscle relaxant.
In DESD, incoordination between detrusor
smooth muscle and external urethral sphincter
and/or bladder neck induces an obstruction that
determines excessive bladder pressures during
voiding and residual volume. Thereby, the risk of
recurrent urinary tract infections, vesicoureteral
reflux, hydronephrosis, and pyelonephritis increases.
USG abdomen in this patient showed mild
hydronephrosis bilateral and cystitis. This patient
still has a good renal function, supported by normal
Ureum and Creatinine (11 and 0,7 mg/dL), therefore
we must preserve his renal function by promoting
right voiding method. intermittent catheterization is
the preferred method of bladder emptying in SCI
patients. This method improves patient self-care. For
this reason, we prescribed ICP 5 times/day.
Urinary Tract Infection is the most frequent
complication of intermittent catheterization. So we
check urinalysis every week. On 14th July 2019, he
got a fever and we check urinalysis, the result was
symptomatic UTI. Then we give empirical antibiotic
with cotrimoxazole while waiting for culture and
sensitivity result. Regarding the bacteria was
Klebsiella pneumonia and sensitive only to
Piperazillin+Tazobactam, Cefepime, Carbapenem,
Aminoglicide, Fosfomycin, Tigecycline we stop
cotrimoxazole and started Amikacin 2x250 mg iv for
14 days. On 1st August 2019, the result of Urinalysis
was normal and there were no bacteria on culture.
Although this psychosocial assessment of this
patient now is quite good, it needs to do evaluation
deeply to understand more about the risk that made
him being injured. Lost of a father figure since
childhood and hating step-father may be linked with
his social life today. It is should be not the first stab
wound. He remembered that before this he almost
hit by “clurit” also because of involvement in a fight
with his peers. He might be involved in juvenile
delinquency. He has to start trying to deal with step-
father he hates. Also, his step-father also needs
encouragement to support his step-son. For most
teenagers, with or without disabilities, adolescence
30 35
that present many challenges. However, teenagers
with disabilities face unique challenges that have
implications for personal development, family and
peer relationships, and healthcare.
When discharged from hospital on 2nd August
2019, he reached almost all the target of discharge
planning, but for wheeling advance approximately
75%. Detention might be caused the
cardiopulmonary endurance and hand function that
could be trained more. Neurogenic bladder problem
should be assessed further in outpatient. He still
doesn’t want to live with his step-father. He plans to
enter the paraplegic foundation training centre and
also continue his study there. His future goal now is
to be an athlete of paralympic games.
Rehabilitation is a lifetime process. It does not
end when the patient leaves the rehabilitation
facility. He will need courage, commitment, and a
sense of challenge. A spinal cord injury does not
necessarily lessen satisfaction with life. Satisfied
people have been found to take better care of
themselves, maintain their health, and prevent
medical complications.
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4 CONCLUSIONS
Caring for adolescents with SCI presents several
challenges and requires unique programs. Teenagers
with disabilities face unique problems that have
implications for personal development, family and
peer relationships, also healthcare.

ACKNOWLEDGEMENTS
The author would like to thank Lembaga Pengelola Dana
Pendidikan (LPDP) Kementrian Keuangan RI for the
supported. Also thank DR.dr.Vitriana, Sp.KFR(K) and
dr.Farida, Sp.KFR for helpful discussion and advice.

REFERENCES
SA Christopher RJ, N Satoshi, RN Mark Traumatic spinal
cord injury. Nature. 2017.
Taweel WA SR. Neurogenic bladder in spinal cord injury
patients. Research and reports in urology.
JC. T. Practical Manual of Physical Medicine and
Rehabilitation: Mosby; 2006.
TD. FM. Enhancing community re-integration following
spinal cord injury. NeuroRehabilitation 2004;19(2):
103-113.
BS. WGA. A Guide for People with Spinal Cord
Injury2002.
Bryce Thomas N RKT, Stein Adam B, Sorensen Fin
Biering. Spinal Cord Injury. In: Physical Medicine &
Rehabilitation vol 4: Philadelphia: Elsevier Saunders;
2011. p1293-346 p.
Cuccurullo SJ. Physical Medicine and Rehabilitation
Board Review, Third Edition: Springer Publishing
Company; 2014.