Paralysis / Spinal Cord - Demand Letter
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4. Muscle Contractions and Deformities
At the time of partial lesion to Brad's spinal cord, voluntary and reflex control below the level of the transection was lost. However, certain aspects of his reflex muscle activity and control which are not dependent upon connections between the spinal cord and the brain are self-contained within the lower segments of the spinal cord, returned to function. Therefore, reflex activity, such as contraction of muscles in response to strong cutaneous stimulation began to return several weeks after the injury. As local reflex activity becomes stronger, the muscles below the thoracolumbar junction alternate between relaxation and tension spasms. These spasms vary between flexor and extensor spasms. In flexor spasms, the toes and legs are folded inward; and in extensor spasms, the opposite muscles extend the legs outward. This extensor spasm regimen is currently being experienced by Brad, and the spasms are extremely troublesome and can lead to deformities, with the accompanying requirement of surgical correction.
In addition to the episodic massive extensor spasms, Brad's muscles remain in a state of hypertonic contraction which can assume a variety of patterns. These sustained spastic muscle groups are unattractive in appearance and interfere with rehabilitation programs and require treatment with specific blockage with phenol solution. A relatively weak solution of phenol is injected into the region, resulting in blockage of the nerve and relief of the spasticity in the affected region. In addition to improving appearance, and aiding in rehabilitation programs and patterns of daily life, such phenol block treatment is also helpful in avoiding contractures.
One of the most troubling aspects of these periodic uncontrollable episodes of massive contraction of muscles is that they are psychologically troubling because of their unpleasant appearance and are often associated with intensification of pain. Further, they place special strains upon the body, and may aggravate skin wounds such as bedsores, or interfere with healing or surgical wounds and dressings. Since spinal cord patients frequently develop bedsores, which can become massive and ulcerated and frequently require surgical treatment, these spasms can seriously interfere with the surgical care of these bedsores and ulcers.
5. Uncontrollable Gross Muscular Spasms.
The term "spasm" usually indicates the occurrence of violent contractions of the muscles withdrawing the limbs into flexion and accompanied by a dramatic increase in reflex activity. From the patient's viewpoint, the term also includes episodes in which there is no movement but the patient is flooded with sensations similar to those which occur during violent muscular contractions. Incidents of this type may eventually put Brad in a position where he has to consider whether or not to have neurological procedures devoted to eliminating or reducing muscle spasm. The problem is that these procedures eliminate the muscular component but do not necessarily eliminate the sensory aspects of spasm which, to the patient, are the most unpleasant aspects of muscular spasticity.
Spasticity in the cord injured patient is not a problem that yet has satisfactory answers. A great variety of treatment techniques are used, including surgery (neurotomies, tenotomies, myotomies, rhizotomies) as well as tranquilizers, exercises or training procedures and muscle relaxant agents.
Our medical evidence will be that in paraplegic patients with a thoracolumbar joint, the frequency of spasmic attacks increases for several years and then gradually diminishes, although they rarely disappear unless surgical treatment is instituted.
The usual pattern of an attack of spasm is initiated with a sudden and violent contraction of the abdominal muscles spreading into the legs with flexion of the hips and knees, bringing the knees up to the trunk of the body with a violent upward movement of the great toe and fanning of the other toes. This initial massive contraction is followed by a partial relaxation and then by several less intense repetitions of the initial violent movement. At the same time the bladder and bowel are forcefully emptied and the affected portions of the body sweat profusely. This spontaneous emptying of the bowel and bladder can be extremely embarrassing to the paralytic.
Studies of the incidence of spasms in patients with cord lesions at various levels show that approximately three-quarters of patients with lesions at the thoracic level experience spasms. Brad Day is certainly in the three-quarters of the patients since he is experiencing muscle spasticity and the accompanying pain and disruption of his physical control of his body on a regular basis.
One of the problems which Brad and his medical team must deal with is how to cope with the frequent bouts of muscle spasms which he endures. The problem poses a dilemma for Brad because a) the relief of frequent severe spasms requires the destruction of additional portions of the nervous system and carries risk of adding to the disability; and b) Brad retains a very strong optimism that his condition is going to improve and he will walk again without further surgery. The medical record in this case is replete with numerous references by Brad that he will return to full function, that he will walk again and his unwillingness to accept the fact that he is permanently paralytic. Thus, he does not want to undergo any treatment which will cause additional long-term neurological deficits.
Methods of coping with Brad's ongoing bout with muscle spasm include a) cordectomy in which the spinal cord is exposed and portions of it totally removed surgically; b) injection of destructively hot sterile water directly into the center of the motor cells in the anterior horn of the spinal cord itself, creating a cavity which separates the two sides of the cord and leads to a degeneration of the motor cells in the anterior horn of the spinal cord; c) phenol and alcohol injected into the subarachnoid space of the spinal cord to destroy the anterior roots which are necessary for spastic movements; or d) severance of the anterior roots by direct surgical transection. Thus, if Brad's uncontrollable muscular spasticity proceeds unabated he may be confronted with choosing the lesser of several evils, i.e., living with the pain or surgical intervention which may result in additional permanent damage.
6. Need for Dietary Supplements.
One of the sequelae of spinal cord injury is that nutritional and metabolic factors become of extreme importance due to the vastly increased need of the metabolism for adequate nutrition. Brad's metabolism, i.e., the build-up of the body structures has shifted to catabolism, i.e., the breakdown of the body structures. Since protein is the building block of the body's metabolism, protein requirements are increased following a devastating traumatic injury to the spinal cord which precipitates catabolism. Since there are no protein stores in the body which do not have a functional role, the loss of protein is always a serious issue. The evidence of protein loss from the body is most conspicuous as loss of muscle substance.
Therefore, it is essential that Brad pay very close attention to his dietary needs and be certain that he is getting substantially increased protein and calcium in his diet. Careful monitoring of this on a regular basis through the analysis of electrolytes and serum protein in the blood must be followed so as to avoid protein and nutritional deficiency.
Brad's dietary needs also include large ingestion of fruit and roughage. The Day family lives on a very tight budget and they have calculated that they average $38.00 per week per person for food. Since Brad's accident, his special dietary needs have increased his average grocery bill to $57.00 per week per person. This does not include any type of vitamin or protein supplement but is merely the increased roughage and fruit.
Monitoring of the metabolic changes in Brad's body is another reason why he has to be hospitalized at least once annually and has to pay particular attention to weight loss.
Even though scrupulous attention is paid to the special requirements of those with spinal cord injury, weight loss occurs inevitably. This is especially significant to Brad since the loss of tissue over bony prominences predisposes him to bedsores and decubitus ulcers. In addition, nutrition is extremely important to his recovery from the injury, healing of wounds associated with the injury, resistance to infection and his overall state of health.
Brad, like most traumatic injury patients, has experienced loss of appetite, particularly a loss of interest in eating meat. Anemia is another common nutritional aspect of spinal cord injury which he has to fight regularly.
The loss of weight associated with spinal cord injury is the result of a number of factors associated with trauma. In addition to the spinal cord injury itself, surgical treatment, infections, fever, loss of appetite, inactivity and disuse atrophy all play a part.
In general, the therapeutic approach to the negative nitrogen balance to loss of muscle substance and other body protein is approached by providing a high protein and a high caloric diet which he is currently attempting to follow.
7. Kidney Infections and Kidney Stones.
One of the major problems facing Brad is the presence of kidney infections and the formation of kidney stones for the reason that, as a result of his loss of sensation below the thoracolumbar junction, he can no longer feel the kidney stones developing. This is another reason for the annual hospitalization for complete physical examination. As part of the annual physical paraplegics normally have an IVP performed in order to check the kidneys. However, in performing the IVP during Brad's hospitalization at Memorial Hospital, it was discovered that he is allergic to iodine, and he had a very adverse reaction to it which left him ill for several days thereafter. Therefore, the doctors will have to find another means of checking his kidneys and searching for the developments of kidney stones during his annual hospitalization.
8. Decubitus Sores and Ulcers.
Among the tragedies of being paralyzed, the decubitus sore lesions are most horrifying because they remain with the paralytic as a constantly recurring problem for a lifetime. The normal protection afforded by sensation (pain, temperature, touch, pressure) that permits one to move the part of the body being irritated is aborted. The paralyzed patient can neither feel nor move, being victimized by his disease. The inciting factor is pressure, light or heavy, transient or protracted. This pressure phenomenon compresses the capillaries and veins within the skin, depriving it and the underlying tissue of an adequate blood supply. At first there is redness, then swelling, and tiny skin hemorrhages. Subsequently, the skin strength weakens, accelerated by secondary bacterial infection which is ever present. The damaged skin begins to slough, leaving an ulcer that enlarges and burrows within the subcutaneous tissue and muscle. The end product may well be bone destruction and infection (osteomyelitis).
9. Dangers arising from Loss of Sensation.
Immediately after injury, sensations in the region below Brad's thoracolumbar junction were greatly disturbed. In all cord pathways which have been cut, bruised or otherwise damaged to such an extent that impulses cannot pass the region of injury upwards to the brain, sensations arising from stimuli delivered to parts of the body below the level of spinal cord injury cannot be perceived.
The danger inherent in the loss of sensation is that Brad can no longer feel sensations in his lower body which would serve the healthy individual as a warning device, such is the formation of kidney stones. The irony to the paralytic is that the only sensations which he can feel are those of pain generated by muscle contraction and spasticity. Sensations of pleasure below the level of the spinal cord injury are lost forever.
10. Bone Degeneration and Atrophy.
The major bones in Brad's body below the thoracolumbar junction are undergoing a process of degeneration and atrophy known as osteoporosis. This is the process in which the bones lose calcium through the urine where they contribute to the formation of kidney stones. As mentioned above, these kidney stones are particularly dangerous to Brad because he cannot feel the pain which ordinarily accompanies them as a warning device to a normally healthy person.
The disuse osteoporosis can be particularly consequential to a young paraplegic for the reason that as the bones atrophy and lose their strength, the likelihood that Brad will ever be able to make use of medical bionics in order to walk again is decreasing. Medical bionics, which are currently in development, will be available within the next two decades for those paraplegics who can afford them and for those individuals who have maintained their body in sufficiently strong condition to utilize the bionic equipment. Brad confronts this loss of calcium daily and will have to try to remain as active as possible considering his severe physical limitations in order to avoid osteoporosis. In order to accomplish this, his testimony will be that he is willing to work hard in rehabilitation for the rest of his life in order to maintain his present physical condition and avoid deteriorating to the point where medical bionics would be of no use to him. However, this requires the access to therapeutic and physical rehabilitation equipment, and we will prove the cost of such equipment as part of our damages herein.
11. Muscular Atrophy.
Brad is facing the same problem with muscular atrophy as he is with osteoporosis in that the development of medical bionics within the next two decades may make it possible for him to walk again if he has sufficient muscles and sufficiently strong bones in order to utilize the bionic equipment.
Medical testimony will be that muscles which fall into disuse and which are not innervated, over time, will lose their shape and form and will become scar tissue. This has the effect of causing deformity in the portions of the body where the scar tissue forms and materially reducing the possibility of ever regenerating the muscles or utilizing medical bionics.
12. Drug Addiction and Alcoholism.
Brad is extremely concerned about taking drugs to such an extent that he becomes addicted. Therefore, he has been very reluctant to get on any type of drug regimen despite the recommendations of his doctors that it would make his pain more bearable and his life easier. However, Brad will relate to the jury the two episodes of hallucinations which he experienced upon awakening in his early days of hospitalization, and he feels certain that those are the result of the morphine which he was being given for pain at that time. Subsequent to that time, he has been very reluctant to take any kind of drugs and chooses to endure more pain rather than run the risk of drug addiction.
