Paralysis / Spinal Cord - Demand Letter
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B. SPINAL INJURIES
As part of the medical evidence in this case, the jury will be educated to the fact that there are two separate and distinct severely disabling injuries to Brad Day's back, i.e., a spinal cord injury and a spinal column injury. A clear distinction will be made in the jurors' minds between injuries to the spinal cord and injuries to the spinal column so that they may clearly understand each of the devastating injuries and their combined effect on Brad's future disability. The spinal cord consists of neural tissue, delicate in constitution and complex in action. The spinal column is a dynamic structure consisting of bony vertebrae and supporting ligaments and paravertebral muscles. This musculoskeletal support system affords the human body the wide range of mobility and the amazing flexibility which have been denied to Brad Day for the remainder of his life as a result of the negligence of Sara Glass.
Injuries to the spinal column are rarely produced by an isolated movement, but rather represent dynamic stresses of more than one force, as was the case in Brad's accident. When his spinal column was subjected to compressive loads of torsion and shearing, the effect occurred on his thoracolumbar junction creating major torque forces which caused it to fail. Brad's ligaments tore, intradiscal pressures rose and the L-1 vertebral body was compressed, failed and fractured. Other bony portions of the vertebra including the neural arch, pedicle, lamina and spinous processes were avulsed. The forces in this case were a combination of flexion, extension, lateral bending and axial rotation as well as vertical compression which arose from the impact of Brad's body with Sara Glass' car.
Brad's spinal cord, contained within the spinal canal and protected by this heavy support system, was subjected at the same time to the destabilizing forces. Displacement of Brad's T-12 disc resulting from the severe compression fracture of the L-1 disc severely stretched Brad's spinal cord causing permanent neural failure.
In order for the jury to fully understand Brad's permanent disability and the future complications, we will present evidence as to the functional anatomy of the central nervous system and the positive and negative effects of the lesions which Brad sustained. Although distinguished from one another for purposes of anatomic description, the brain and spinal cord form a functional unit and together comprise the central nervous system. The peripheral (spinal), cranial, and autonomic nerves are extensions of this central nervous system.
Lesions of the nervous system will be explained to the jury in terms of the positive and negative aspects. Death of neurons leads to an absence of their usual function (negative aspects); however, lesions can also lead to positive symptoms because of the irritative effects of cells which are still partially functional (positive aspects).
Some injuries initially involve only partial dysfunction of individual nerves or nerve groups and may exhibit irritative phenomena and hyperactivity. Subsequently, the nerve cells may die and cease to exert their effects. Also, many neurons and pathways are inhibitory in their functions; thus some irritative lesions which may initially result in inhibition of function, subsequently give way to a state of hyperactivity when the inhibitory function is lost as the cells die. Therefore, the pattern of changes in Brad's physical condition with regard to reflex activity, spasms, autonomic control of bladder and bowel function, etc. may change in a complex and bewildering pattern. This makes Brad's future complications from this injury very hard to predict, but under any scenario the complications are depressive and intolerable.
The spinal cord is an extension of the medulla oblongata or brain stem and extends from the opening at the base of the skull down to the first or second lumbar vertebra. Therefore, an injury to the spinal cord at the T-12 - L-1 level is in fact an injury to the lower level of the brain stem.
Each segment of the cord or that area corresponding to its vertebral level gives off two nerve roots on each side of the cord, a dorsal (posterior) root and a ventral (anterior) root. The ventral root is comprised of motor extensions.
Both the posterior (motor) and anterior (sensory) roots join outside of the cord to form peripheral spinal nerves which then exit through the vertebral notch to reach and innervate the skeletal muscles and visceral organs. Thus, spinal nerves are mixed nerves: they contain both sensory and motor fibers; therefore, in an injury such as the one sustained by Brad, he has both loss of feeling and loss of use of his muscular and visceral organs in his entire body below the thoracolumbar junction. The medical evidence will be to the effect that all of Brad's muscles below the thoracolumbar junction which are no longer innervated by the spinal nerves will degenerate into scar tissue.
The spinal cord is extremely fragile and is readily injured when subjected to mechanical trauma. Moreover, when the substance of the cord is destroyed, the functional deficit is permanent as its tissue, like that of the brain, has no powers of regeneration. This will be explained in detail to the jury so that they can clearly understand that Brad will never improve, due to lack of injured spinal cord regeneration, but he will continue to deteriorate due to atrophy, osteoporosis and other inevitable sequelae.
Following Brad's spinal cord injury, a series of pathological changes which interfere with neural function occurred, including: inflammation, swelling, bleeding, disorganization of neural patterns, and actual death of cells or severing of pathways resulting in permanent functional loss. Dr. Fleck indicates that the spinal cord injury is permanent and that Brad has now reached his maximum level of recovery regarding the spinal cord injury, i.e., that his best hope ever is to ambulate only with a walker for approximately 300 feet.
C. SECONDARY COMPLICATIONS OF PARAPLEGIA
Damage such as Brad suffered to his spinal cord is obviously catastrophic in its consequences - resulting in permanent paralysis and loss of sensation for all of the body below the level of injury. Moreover, the total range of untoward effects of spinal cord injury extends into virtually every facet of human life - daily patterns of life, interpersonal relationships, work ability, self-image, and the general feeling tone which colors each day's existence.
In addition to the features of the tragic aftermath of paralysis and loss of sensation, there is a long list of additional medical problems, which contribute to the total picture of the life which the paralytic faces on a daily basis for every day of his life. A brief partial listing of the present and future problems confronting Brad Day include:
1. Loss of Bladder Control.
Problems related to bladder function loom large in the total care and management of the patient with spinal cord injuries. Control of micturition bladder and kidney infection as well as the formation of stones (calculi) are major aspects of the general problem.
The goals of bladder function management are supplemented by the recognition that bladder function directly affects the health of the kidney. Preservation of good function is an overriding consideration as malfunction of these vital organs threatens life.
Catheters which remain in place, residual urine in the bladder, and mechanical trauma to the urinary ducts are all constant sources of bladder and kidney infections. Complications also include penile-scrotal abscesses and urethral fistulas.
Urinary problems are extremely serious in these patients. Not only do they present a threat of massive infectious disease, but even low-grade infection over periods of months or years is damaging to kidney function and may lead to fatal kidney disease (pyelonephritis).
The commonness of low-grade infection in patients who require catheters has led some authorities to suggest that a low-grade infection must be accepted as normal or usual in these patients.
These infections and kidney diseases are also associated with severe elevation of blood pressure. Thus, a leading cause of death among such patients is kidney failure due to pyelonephritis and other kidney disease, combined with the consequences of severe hypertension.
Kidney disease (uremia), hypertension, and infection are the most common causes of death in survivors of spinal cord injuries as proven by autopsy studies of paraplegics who died following prolonged survival of spinal cord injuries. Differential diagnosis is complicated by the fact that blood pressure remains within the normal range until kidney complications (pyelonephritis) become well developed. Such kidney disease is clearly a cause of hypertension, but hypertension appears only rather late in the course of the disease in patients with spinal cord injury.
Thus, Brad Day, who has no control over his bladder, is facing a lifetime of concern over the potential for kidney disease, hypertension and infection, including kidney stones. This concern is compounded by the fact that his normal warning system of such problems is inoperative due to loss of sensation. The result in spinal injury patients is that all too often the initial diagnosis of these problems is made on autopsy.
In order to avoid this, Brad will require an annual hospitalization for a complete physical to achieve early diagnosis of these developing problems.
2. Loss of Control of Bowel Functions
Bowel Dysfunction
After loss of the connections between the brain and nerves serving the bowel resulting from spinal cord injury, voluntary control of bowel function is lost. This loss of control is an important aspect of the disabling sequelae of spinal cord injuries. It results not only in discomfort, inconvenience and embarrassment, but also contributes to infections of the bladder as a result of contamination by bacteria in the bowel contents.
In order to establish a working program of bowel care, enemas are usually used for bowel evacuation. While this method often leads to a successful routine of bowel evacuation, a number of associated undesirable reactions are found. In some instances, administering the enema causes a marked rise in blood pressure. Such enemas often result in sweating, pain experienced in the abdomen and legs, nausea, vomiting and triggering spasms. Some patients "black out" during an enema and feel ill for several days afterward.
Bowel Training
The objective of a bowel training program is to establish bowel evacuation through reflex conditioning. If a cord injury occurs above the sacral segments or nerve roots and there is reflex activity as in Brad's case, the anal sphincter may be massaged to stimulate defecation. The anal sphincter is massaged by inserting a gloved finger into the rectum and moving it in a circular motion or from side to side. It will soon become apparent which area triggers the defecation response. This procedure should be done at the same time after a meal and at a time that will be convenient for the patient when he returns home. Mr. Day was also taught the symptoms of impaction (frequent hard stools; constipation) and cautioned to watch for the development of hemorrhoids. A diet with sufficient bulk is essential to a bowel training program.
3. Loss of Sexual Capability
Patients with spinal cord injuries always have disturbances in sexual functions. Brad's peripheral nerves and reflex pathways serving bladder function are anatomically close to those serving sexual functions, and impairment of the two systems has occurred. Brad cannot achieve erection and has been advised that he can never father children because his testicles began to atrophy as early as four to six months after the accident and the process of spermatogenesis ceased.
During the immediate period after injury, relatively little sexual interest was displayed by Brad due to the general depression and anxiety in the acute recovery period. Now that Brad is attempting to rebuild his life, he has regained his interest in dating, and he finds that he has the mental desire but not the physical capacity for sex.
Males with spinal cord injuries such as Brad, which have resulted in a loss of sensation in the pelvic region and below, do not experience orgasm in the usual sense.
Therefore in addition to the claims for physical disability, Brad will prove as part of his mental anguish in this case the fact that he will never have a normal love relationship and will never be able to father children.
