Managing spinal injuries Frequently Asked Questions by GP's
Possible urinary tract infection, perform a dipstick and send off a CSU. If the patient is symptomatic treat with broad-spectrum antibiotics until micro results available.
If not a UTI may have bladder or kidney stones and an ultrasound will aid treatment. May need referral to local service for stone removal, discuss with urology team directly.
Are they taking the correct dose of anticholinergics? Are they due for repeat intradetrusor Botox injections?
Is the patient symptomatic? If so yes it would be wise to treat. If asymptomatic then treatment is not required at that time.
Recurrent UTI’s can be due to incomplete emptying, poor ISC technique, kidney and bladder stones, poor perianal hygiene, or poor bowel management technique, SPC not being changed frequently enough.
These all have to be addressed individually. If all the above negative will need review by a specialist.
Patients who have recurrent symptomatic UTIs may require prophylactic antibiotics, however further investigation to cause of this should be performed first, therefore, patients should be referred to a urologist or spinal injury centre for this.
It is recommended that an ISC be performed at least every 4-6 hours with a new catheter each time. However, this is individual and depends on a number of factors. So can be anywhere from 1-8+ per day, average number would be 4-6 per day.
Why does my patient need me to prescribe more than one kind of catheter?
If a patient is on ISC it is beneficial to have access to an IDUC for infection/long distance travel etc, they also may require different types of ISC (bag attached or non attached) depending on access when at work/friends /social etc
Clamping is used to maintain bladder capacity; patients should clamp their catheters daily unless symptomatic UTI or intercurrent illness (e.g requiring IV fluids). Catheter can be left on free drainage overnight. Patients bladder capacity is determined from cystometry, usually between 300-500mls. Patients can build up their clamping times daily by increasing by 15mins each day, they will need to monitor fluid intake to ensure they do not exceed their bladder capacity volume whilst clamped.
Sediment or blockage may indicate UTI or stones and these should be ruled out as soon as possible. Blockage may be cleared by flushing the catheter with 30mls of normal saline / If unable to clear then catheter will need to be changed, if SPC cannot be reinstated then a urethral catheter should be put in. Recurrent blockage from sediment can be managed with daily saline instillations, if this does not help then the patient may require acidic maintenance solution such as 3.23% Citric acid solution (Suby G) bladder instillation (instructions for use) which should be done three times a week which helps prevent the build-up of encrustation and catheter blockage.
Are they following their bowel routine? If not this could be the cause. If they are it is possible that they may have a gastrointestinal infection (take stool sample). Discuss the amount of laxatives and diet. Consider reducing laxatives if stool type >4 for longer than 14 days.
If flaccid (LMN) bowel, patient may benefit from anal plugs; available in small, medium and large. Local Continence nurse and SCIC can be contacted for advice.
Are they following their bowel routine? If not this could be the cause. Are they taking their regular prescribed laxatives? Is there fluid intake sufficient? Dietary changes?
It is important for a patient to maintain a regular bowel regime, this is usually daily or alternate day bowel care.
Daily bowel care is required in patients with an SCI. This is important in order to prevent constipation/impaction/incontinence which in turn can lead to numerous complications including autonomic dysreflexia, increased spasticity, pressure sores, poor QOL etc.
It is important for a patient to maintain a regular bowel regime, this is usually daily or alternate day bowel care.
If this is the prescribed routine, it is essential that the nurses seek training on bowel management for the neurogenic bowel. The local continence team should be able to advise on where to access training. Information for bowel management can be found at www.mascip.co.uk and look up guidelines.
Enemas are not generally prescribed for patients following SCI, there is an increased risk of bowel perforation, large volume enemas are not effective as the fluid is not retained and increase risk of Autonomic dsyreflexia.
Assess as to whether the change is due to change in medication or circumstance, if not the case refer to local gastroenterology services.
If a patient requires digital stimulation and digital removal of faeces either done independently or by a carer they will need gloves for the procedure.
Assess stool type and advise if type 1 or 2 on Bristol stool chart (increase laxatives, fluid intake, dietary advice) as aim is for type 4. If not due to hard stool will require treating e.eg Anusol cream.
If a patient has a pressure ulcer, advice is to keep off at all times until healed. This may necessitate complete bed rest.
If patient is clinically unwell they will need to be admitted to their local hospital for acute treatment of infection and management but you can liaise with the SCIC for advice.
We cannot prescribe dressings without seeing patient, district nurses should be able to assess. A guide to dressings can be found in the Pressure Ulcer and Skin Care section.
We would usually recommend nutritional supplements to aid with wound healing.
Consider emollients, moisturisers and soap substitutes for patients who have persistently dry skin, this is often required in hospitals, nursing homes (due dry humidity) or patients with thermoregulation dysfunction.
Consider barrier creams such as cavilon or proshield barrier cream to protect vulnerable skin areas
Patients can be referred for review by hospital TVN, but we would also advise local TVN input for ongoing support and advice.
Due to increased risk of ingrowing toenails which can lead to increase in spasms and autonomic dysreflexia.
Cardiovascular Health and Respiratory Care
It would be beneficial for your patient to be seen and reviewed by local community dietician for weight management advice. If unable to be seen by local dietician check if patient can be seen by dietician at their spinal centre.
If raised cholesterol on fasting blood test or 10-year Qrisk2 score above 10 %; patient should be started on statin.
Persons with SCI are at an increased risk for CVD; experience an earlier onset of CVD and there is an increased prevalence of CVD in the SCI population. Adrenergic dysfunction, poor diet, and physical inactivity are thought to play key roles in the elevated risk for CVD in SCI. Therefore risk factors should be assessed at every given opportunity. Lipid profiles in persons with SCI have generally been shown to respond favourably to both diet and exercise intervention.
Assess if they elevate legs at night or during the day, does the swelling reduce? Patient may benefit grade 1 compression stockings. Check patients medication list for drugs that may contribute e.g. anti-inflammatories, amlodipine. Can these be changed/stopped?
Newly injured patients will require 3 months of VTE prophylaxis from their date on injury EXCEPT in ambulant patients this may be less than 3 months, or patients with additional risk factors for VTE this may be longer than 3 months. The spinal injury centre can be consulted for advice on this.
Patients with established SCI do not require long-term prophylaxis unless there is a history of thromboembolic disease. Thromboembolic prophylaxis is commenced in patients with established SCI if immobilised with bed rest, admitted for medical illness or surgery (as per hospital policy) and stopped when patient medically well.
All patients with a spinal cord injury above L1 will have some form of lung dysfunction. The higher the level of injury the more severe the lung dysfunction will be. Abdominal binder/splinting (helps increase FVC / reduce residual lung volume in sitting position by elevating abdominal contents, allowing diaphragms to move effectively).
Spinal cord injury at most levels affects innervation of the abdominal muscles severely compromising the ability to generate cough and clear respiratory secretions. Patients who are unable to clear secretions may require assisted coughs.
For ventilation or secretion management. See Respiratory complications section for more information.
Sputum samples may grow pseudomonas, this is a common coloniser of the upper respiratory tract, especially following antibiotics; clinical correlation is advised.
Pain / Spasticity
Assess if their neurology has ascended. Sensory level has ascended? Change in motor power above their level of injury? Is there new neuropathic pain above their level? Any sign of muscle wasting? The concern is they have a syrinx, patient should be seen by local spinal centre for review.
Neuropathic pain is characterised by ‘burning’, ‘stinging’, ‘pins and needles’, ‘electric shocks’, ‘band like pain’. Medications that can be tried include gabapentin, pregabalin, amitriptyline, Duloxetine, Carbemezapine. For localised neuropathic pain Lidocaine patches or Capsaicin cream can be effective.
Local pain clinic or SCIC
Assess for a triggering factor e.g. Bladder – UTI? Bowels – Constipation? Bone – Fracture? Skin- Pressure sore/Ingrowing toenail? Treat the triggering factor and see if spasticity reduces. If not, reassess and review medications for spasticity.
For more information see spasticity section.
If patient has a level of injury above T6, they are at risk of autonomic dysreflexia and should have access to in date Nifedipine 10mg (Sublingual) or GTN spray 1-2 sprays at all times.
Patients may require both Ephedrine and Nifedipine on their regular prescription. Some patients may require Ephedrine when mobilising if they suffer from symptomatic postural (orthostatic) hypotension. These patients may also be at risk of developing Autonomic dysreflexia at any point, therefore will need to have Nifedipine available at all times.
Assess possible trigger factors for autonomic dysreflexia; bladder (blocked catheter/UTIs/Stones), bowels (constipation/haemarroids), pain, spasticity, fractures, pressure sores, ingrowing toenails etc. Treat underlying trigger. If no trigger found or treatment of presumed trigger does not help. Refer to spinal injuries centre.
Social / Mood
What has changed about their social situation: Family carer too old/deceased? Patient deteriorated therefore now needs care input? Explore what care package, if any, patient has at present. Known to social services. Contact social worker if known and if not referral to social services required.
If carer through continuing healthcare (CHC) funding then CHC need to be informed. If not contact social services.
Check with airline what assistance is available for wheelchair users. If patient performs Self intermittent catheterisation then we recommend an indwelling catheter is inserted before start of the journey. Patient must be able to pressure relief throughout the flight and be able to have their own wheelchair cushion on the seat. For Long-haul flights, we usually recommend Enoxaparin the day before and day of flight in each direction. Patient or PA/family member can administer.
The Queen Elizabeth Foundation for Disabled People offers a ‘Try before you fly’ service. Patients may benefit from this. For more information please visit:
Incontinence supplies can be provided by national companies and often specific products will be recommended by the spinal centre. GPs can use their local pharmacy for such products if they prefer. Equipment provision is area based and generally supplied through the community OT.
Patients are assessed by the CHC checklist. GPs can assess their patients for this. The SIA and SCIC will usually be happy to provide advice if required
Can be made by the GP at any time. This is area specific and referral information can be found on most council/county websites.
Not all patients with SCI will be eligible for medical exemption certificate, only those who cannot go out without help of another person may fit the criteria.
If patient does not meet this criteria and require two different prescriptions or more per month then they benefit from applying for a prescription pre-payment certificate.
Patient can be registered at a temporary GP out of area for maximum of three months. This may be required if they will require prescriptions and district nursing support.
Manage low mood as you would for non-spinal cord injured population. There are no preferred antidepressant medications.
Patients will often be discharged from hospital with a sleeping tablet,as they required this in the hospital setting due to noise etc. At home patients should trial weaning off this.
Manage as you would for non-SCI population. Consider other factors that could be contributing such as stress, anxiety, low mood, pain and spasticity. Consider zopiclone or benzodiazepine, caution as the patient may already be on a benzodiazepine for spasticity management. If spasticity is a factor contributing to poor sleep then a benzodiazepine may be preferred.
Sexual function / Fertility
Ideally, patient should be seen by SCIC consultant before pregnancy, advise patient to start taking folic acid
This is up to the individual as all have different risks. Most patients use progesterone only contraception such as the implant. Some use IUD but there is risk when patient has no sensation. Oestrogen products are associated with VTE risk and best avoided
Male fertility may be impaired but still advise contraception if don’t want pregnancy.
Refer to SCIC
The SCIC will be able to advise. Most male patients with upper motor neuron injuries will try Phosphodiesterase-5 inhibitors as first line. If they are effective please continue to prescribe. Some respond to different product so may need to try all 3 before knowing which is best.
Refer to community physiotherapy or back to spinal injuries centre for further assessment.
Information on blue badge application can be found at www.gov.uk/apply-blue-badge
Not everyone with SCI is eligible. Those that can walk more than a 100 yards may not meet the criteria. May require a supporting letter from Spinal Cord Injury Rehabilitation consultant.
Refer to local wheelchair services.
Majority of patients with SCI are vitamin d deficient. Vitamin d supplementation is important to help prevent osteoporosis. If patient is deficient (<25nmol/l) then it is recommended they receive treatment with loading treatment of 300,000 units Cholecalciferol or Ergocalciferol orally. This can be given 50,000 capsules weekly for 6 weeks or 5000u per day form 10 weeks. This should be followed up longer term with maintenance dose of oral Vitamin D, 1000-2000 units per day. Insufficient levels (>25nmol/l <75nmol/l) should be treated with maintenance oral cholecalciferol 1000 units daily.
Calcium supplements not advised unless patient is deficient in calcium or on treatment for osteoporosis.
Majority of patients with SCI will have osteoporotic bones (especially where non-weight bearing e.g. hips) decision to treat should be based on their preference after a discussion on risk of fractures. There are no national guidelines and poor evidence. The SCIC consultant will be happy to discuss this.
Patients with spinal cord injury are also at risk for heterotopic ossification. Highest risk is initially post-injury. This may be found incidentally on radiological investigations. Unless patient is symptomatic e.g swelling over joint or decreased range of motion this does not need to be further managed, if concerned refer to local spinal centre.