Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And we have a thought leader panel for you today to discuss a case study: “Functional Recovery After SCI Following Abdominal Aortic Aneurysm Repair.”

Joining me in this panel is Dr. Ishaan Hublikar, he's a physical medicine and rehabilitation physician specializing in spinal cord injury at Northwestern Medicine Marianjoy Rehabilitation Hospital; and Dr. Kevin Roy, he's a physical medicine and rehabilitation resident at Northwestern Medicine Marianjoy Rehabilitation Hospital and a member of the class of 2028.

Doctors, thank you so much for joining us today. And Dr. Hublikar, I'm going to start with you. This is a fascinating and challenging intersection of vascular surgery and neurologic outcomes. Can you start by walking us through the case that prompted our discussion today? Tell us about the patient you treated, his diagnosis, the events leading up to his spinal cord infarct, and what made this case particularly complex from a rehabilitation standpoint.

Ishaan Hublikar, DO: Thank you so much for having us today. So, this was a patient who was a 64-year-old male and actually went into the hospital with symptoms that we don't always associate with a spinal cord injury, which is what made it really interesting. The patient came in with abdominal pain and had loss of consciousness. And ultimately, their workup led to a discovery of an abdominal aortic aneurysm rupture, which is a very serious medical event caused by a burst of a large artery essentially, and it can be extremely life-threatening.

After the repair of this happened, the patient actually woke up and was then found to have issues with his lower extremity function. Eventually, that was determined to be secondary to his AAA rupture, which actually led to poor vascularization of his spinal cord. And for this reason, he lost a predominant amount of his nerve function below that point, which tends to be kind of in the lower abdominal area.

So, the reason that this is an interesting case is because there is an overall small percentage of spinal cord injuries that have a vascular etiology. And as a result of it, there are different kinds of ramifications in terms of the injury itself, the medical aspects, and then also as it relates to the psychology of the injury. Because when patients go into the hospital for an unrelated reason to then have a spinal cord injury on top of that is something that can be hard for them to adjust to as well.

Melanie Cole, MS: Well, it is so interesting. So along those lines then, Dr. Roy, what was the underlying cause of his spinal cord injury following the AAA repair? What additional symptoms or medical complications was he experiencing when he first came to Marianjoy?

Kevin Roy, DO: Sure, yeah. The underlying cause of his spinal cord injury following the abdominal aortic aneurysm rupture and repair, similar to what Dr. Hublikar was saying, was poor perfusion to the spinal cord. This poor perfusion was multifactorial. One of those factors being that after both rupture and during the repair, he's subject to low blood pressures from blood loss, which led to poor blood supply and, therefore, poor perfusion to that spinal cord.

Additionally, when the aorta is repaired, a stent graft is used so that stent graft is like a tube that seals off the inside of the aorta and, therefore, can block off openings to arteries that branch off. Fenestrations are made in the graft to allow for blood flow to vital organs, but because the segmental arteries that supply the spinal cord are numerous small and highly variable and where they are anatomically, those fenestrations cannot be feasibly made to accommodate that.

Along with that, the greater the length of the repair, the greater the amount of these arteries that can be blocked off. So for our patient, his affected area was from the distal end of the thoracic aorta to nearly all of the abdominal aorta. So as a result, he was at risk for poor perfusion to the lower thoracic and lumbar regions of his spinal cord.

And then, as for the symptoms that he was experiencing, when he first came into Marianjoy, he had weakness in both legs, right more affected than the left. Additionally, he was unable to completely empty his bladder when he urinated, so he had a Foley catheter in place when he first came in. And also on admission, he was having incontinence issues with his bowel movements.

Melanie Cole, MS: So, Dr. Hublikar, at what point does PM&R get involved? Speak to the role of early and intensive rehabilitation in a case like this and in what ways was Marianjoy so uniquely equipped to manage this complex case, whether it's through clinical protocols or specialized therapy programs, or on-site resources. Tell us about that.

Ishaan Hublikar, DO: Yeah, PM&R really gets involved. We always say the earlier, the better. So whenever a patient is in an acute care hospital like this patient was after his triple AAA rupture and repair, and they get therapy to start working with the patient, we can pretty quickly determine that they are below what we call their functional baseline, which means how they're able to operate in terms of their mobility and their activities of daily living, compared to their baseline level at home.

If they're needing extra support with that, that usually triggers our team to be consulted in the acute setting to then determine among other things, what is going to be the right setting for them to have rehabilitation, following their discharge from acute care. In large part for spinal cord injuries, that tends to be in acute inpatient rehab, somewhere like Marianjoy.

The reason why Marianjoy is a great place for patients like this with a spinal cord injury is really multifaceted. One of the unique aspects that we have is having a spinal cord injury rehab unit. And the reason that's important is because all of the members of our team are very adept and trained in spinal cord injuries. That starts with myself in terms of having the training in spinal cord injuries, having a fellowship in that, and understanding and anticipating what their medical needs are going to be.

Dr. Roy touched on a few of them that we see commonly after spinal cord injuries like this in terms of their neurogenic bladder, their neurogenic bowel. Some of the other aspects that we have to watch out for spinal cord injuries are their inability to, you know, have cell mobility. And in that regard, they're more likely to develop skin issues like pressure injuries. They can have cardiovascular issues from their injuries such as orthostatic hypotension. So being able to recognize the onset of these symptoms is incredibly important in terms of them being able to really get the most out of the rehab for them to participate and really, you know, focus on their rehab because that's our goal.

In addition to the medical team itself, our nursing staff is very adept in regards to their day-to-day care. So, some of the things also that Dr. Roy touched on in terms of neurogenic bladder, some of the aspects of the nursing, you know, our nursing team really spearheads, is checking their bladder every few hours, doing what we call straight catheterizations every few hours if they're having retention of their bladder, which is very common after having an injury.

And then, from a bowel standpoint, for patients that don't have the sensory ability or motor control of their rectum, then we want to try to promote also retraining of their bowels. And so that is going to incorporate daily suppositories. And then really getting them on a regimen in terms of their transferring, either in bed or on a commode to really regain that regularity of their bowels. And also, ultimately, what this leads to is a better quality of life after their injury.

Aside from those aspects of the team, of course, our therapy teams are going to be more familiar with spinal cord injuries. And that's really, really important early on in the recovery. There has been extensive research that's shown that spinal cord injury patients that go to specific SCI rehab centers have better outcomes in the short term and in the long term as it relates to both their therapy as well as their, you know, prevention of secondary medical complications. On top of that, Marianjoy has specific types of technology that can be appropriate to our spinal cord injuries as well.

So really, it's the whole team being cohesive, being adept, having the understanding and having the communication amongst one another to provide that education to the patient, to the family, as well as providing great medical and therapy and nursing care going forward to it.

The last part I will mention in regards to our team, our case management and our psychology teams, they really also work well with us. As I mentioned before, having somebody to help you understand your injury and also to deal with the adjustment of your injury is incredibly, incredibly important, especially right after it happens, because we want to be able to prepare them for when they leave here, to go back home and to regain the most amount of independence and quality of life that is possible.

Melanie Cole, MS: Yeah. That's so interesting. It's a really exciting case. And we're going to talk about the technology in a minute. Before we do, Dr. Roy, as we're thinking about how the patient progressed over the course of his rehabilitation, both clinically and functionally, and some of which was just discussed by Dr. Hublikar, were there any aspects of his recovery that really surprised your team, some decisions that were made early on that you think were really pivotal? Because, what, by day 23 of inpatient rehab, the patient was independently performing the transfers, as Dr. Hublikar just said, walking with a rolling walker about 180 feet and no longer required that structured bowel or bladder programs as Dr. Hublikar just mentioned as well. So, I'd like you to speak about some of those strategies that you feel were most influential in helping him reach those milestones so quickly, and those decisions that you feel were so pivotal.

Kevin Roy, DO: Right. So for some of those rehab strategies that were implemented for him, he had early intensive and multidisciplinary therapy, which played a pivotal role. Like Dr. Hublikar was saying, our staff includes rehab, psychology, PT, OT, nursing, and they are able to help reinforce the functional skills throughout his stay. And additionally, early rehabilitation likely prevented cascade of secondary complications, like Dr. Hublikar was alluding to, such as contractures, pressure injuries, further deconditioning, and also allowed us to manage secondary complications as they came about.

One of them that occurred with this patient is he had a couple instances of orthostatic hypotension that we were able to monitor and treat as it came about. Also, he had test-specific training, which helped build strength and stimulate neural reorganization to enhance his recovery. A third strategy would be the use of adaptive equipment that he used, which allowed for him to progressively reduce the amount of assistance he needed to support his independence while still maintaining safety for him.

And finally, and equally important, was the structured approach to the bowel and bladder management as you had mentioned. We started that early in his course here. As we mentioned before, he came in with a Foley catheter in place. And we transitioned him from a time-voiding schedule with PVRs and intermittent catheterizations initially at every six-hour mark, and then we transitioned him to every four-hour mark. But with the return of his consistent and spontaneous voids, we were eventually able to wean him completely off of that regimen, because he was also having low PVRs with those consistent spontaneous voids.

When it comes to his bowel function, he initially was incontinent, so we took into consideration his normal bowel movement schedule prior to his injury and started him on a morning bowel program with the suppository digital simulation. But by discharge, he was able to be continent of his bowel movements without the use of a suppository or digital stimulation, and he was only requiring oral senna for his bowel regimen.

So, to answer what was most surprising or surprising throughout his rehab stay here, although we understand that the first few weeks to months are where we see the most recovery in this population of patients, the rate of recovery was still surprising, especially when you take into consideration that up to 42% of those with spinal cord infarction after abdominal aortic aneurysm repair still require a wheelchair for mobility at the three-year follow-up mark. And when you also take into consideration that he regained full bladder function when only about 27% of patients with ischemic spinal cord injury achieved that even at the one-year point.

Ishaan Hublikar, DO: Yeah, I was just going to say that, you know, to go along with that too, we typically see for some of these vascular injuries, especially when, you know, you have a vascular injury as severe as an AAA rupture, we graded his spinal cord injury like we always do when an acute spinal cord injury comes to a rehab unit. It's divided up into the neurologic level of injury and the severity score.

For him, the neurologic level of injuries, what we would expect for somebody with AAA rupture, it was at T11, which is just below the umbilicus. And then, the severity, essentially in the real-world goes A through D. There is an E grading that we, you know, rarely see. But A is a complete injury, is the most severe. And he was actually, you know, on the other end of that spectrum, he was a D. So to go along with that, that was, you know, where we initially saw him to then when we did his spinal cord exam. A couple weeks later, we did see a pretty rapid neurological recovery that we could test in terms of real time when we're doing that ISNCSCI or ASIA grading. So, yeah, I would say this is an exception to somewhat of a rule when we consider how bad the average vascular injury for spinal cord injuries can tend to be.

Melanie Cole, MS: Well, it certainly is amazing and speaks to the expertise and dedication of the staff at Marianjoy. And Dr. Hublikar, you mentioned a little bit before, but I'd like you to expand on the rehabilitation technology because that's such an exciting part of what you both do for a living. What role did that play in supporting his motor recovery, his gait training, independence? Speak about some of the exciting technology.

Ishaan Hublikar, DO: Yeah. So, a lot of times what can happen is that in the inpatient setting, because as things have changed in medicine over the last few decades, unfortunately, patients, you know, we would love to keep patients for months and months in acute inpatient rehabilitation, but that's simply not a reality these days.

And so, a lot of times initially when they're coming from the acute care hospital, we are dealing with so many of their secondary medical issues as it relates to their spinal cord injury that we've somewhat touched on. What happens is when they get discharged, and in his case when he got discharged, now as the medical stability is kind of a little more there, the options in terms of the technology available to them become much wider.

So, some of the technology that he used in the outpatient setting — actually after he was discharged, there were two main things as it relates to gait training — he used what's called a ZeroG device, which can help in regards to when patients cannot walk on their own and need a different form of assistance. And so, gradually, the amount of support that they're using can change depending on how they're doing.

In the outpatient setting, over a few months, his gait speed increased. He also was using what we call Lofstrand crutches. And with that, the gait speed increased, his endurance increased. So that's getting him more ready in terms of like that endurance factor and also the amount of support eventually that can be weaned off.

The second main device that he used was what we call the Bertec. And so Bertec helps with balance. The reason that's important is because the spinal cord really is composed of multiple different types of nerves that all control different aspects. So there are different tracks that affect, for example, their motor function. There are some tracks that affect their pain or temperature, sense that we feel. Some of them control light touch. And some of them control the coordination aspects of what we think of. When we think of just walking, we're not always conscious of the different aspects that are at play. There is the actual strength in our body that contributes to us walking. But then, there's also various types of sensation and there's how our body views itself in space.

And so, among other factors, we really have to put all of these into play just to take a simple step without any type of physical assistance. What the Bertec can help do is it helps that balance aspect. Because a lot of times what we'll see in spinal cord injuries is patients may have some preserved strength, they may have some preserved sensation, but then they can't really sense their body in space. And so, you know, that was one of the reasons that this device was used, is for that balance aspect. And so, we're really lucky that in Marianjoy, we have the ability to use some of this more advanced technology for the patients that really need it, whether it's in the inpatient setting for some or as they transition to our outpatient programs as well.

Melanie Cole, MS: Dr. Roy, based on all of what we've been discussing today and how uncertain a prognosis and complex case like this can be, how do you counsel the patients and the families early on about what they can expect? Because, I mean, we don't know, but given your expertise, you all work so hard to give this patient a better quality of life. Tell us a little bit about working with the patient and their families.

Kevin Roy, DO: I think one of the most important things is just starting off with them understanding where we're starting off with in terms of their function, in terms of their bowels, their bladders, as well as their mobility, as well as telling them the timeline to expect some kind of neurologic recovery, but at the same time being honest with the types of neurologic recovery that is seen in these types of spinal cord injuries.

One of the positive things that Dr. Hublikar was able to mention earlier was that he had a pretty good grading on his ASIA score, being an ASIA D. So that helps give us something positive for them to kind of hone in on as they're doing the rehab course. Along with that, we know that early intensive rehab is something that's beneficial for these spinal cord injury patients. So encouraging them to continue to focus and work as hard as they can while they're here is definitely something that we do early on.

Ishaan Hublikar, DO: The other aspect that that I think is really important too is it's a constant discussion. It's a constant education process. The rehab is incredibly, incredibly important. But ultimately, after having a spinal cord injury, and again, especially one where the patient goes in for seemingly unrelated symptoms and an unrelated admission, and comes out of that admission with a spinal cord injury, it is a lot of them understanding what is going on with their own body, what can they expect. And to Dr. Roy's point, some of the aspects that we give are more objective with their ISNCSCI or ASIA grading to go over with them, some of it is as things come up, like low blood pressure, as things change with their bladder and bowel, helping them understand how that's all related to their injury. It can start with simple questions like, "Do you understand why your bladder's not working? Do you understand why your blood pressure is low?" And really gauging what their understanding of how this all is interplayed is really, really important. That's a huge part of what we do in acute rehab.

Being able to take care of the same patient for a couple weeks, you really get to know them. You really get to understand where they are in regards to adjusting to their injury. And so, it's really a team effort to help all of that. In regards to their family too, it's really also a whole team effort. We really encourage families to be here.

Another aspect that we do before patients go home is we have a family education visit. So that closer to their discharge, when we understand, you know, functionally speaking, what level they're going to be at going home, we have the family come in and do hands-on training. And that's with the whole team. That's with physical therapy, occupational therapy, speech therapy, if they need it. With psychology, with nursing, our case manager, we have a wonderful case manager on SCI team as well, who's constantly having discussions with the family in regards to different types of equipment and how, you know, unfortunately, the insurance aspect is a very real aspect that we have to come into play here.

So, all those are included because for some patients, this is very, very life-changing. And so, being able to form those connections with the patient and family and answering all these things that kind of arise as they go through different stages of their injury and also different stages psychologically with what they're ready to discuss about their injury, we are there to help answer those questions and also, again, anticipate what their questions will be.

That goes back to one of the other aspects that we were talking about earlier when you talked about why is it important to go somewhere like Marianjoy, somewhere that has an SCI rehab unit. It's that anticipation of what we know they're going to need, not only now, but maybe a couple weeks from now or a couple months, what questions can we know they're going to have? What equipment are they going to need to have? And understanding that even though they may not realize some aspects of their injury and of their care, that we understand their injury more than them at the beginning and really setting them up for success going home eventually.

Melanie Cole, MS: Well, that was so well said, Dr. Hublikar. And I'd love to give you each a chance for a final thought here. And so, Dr. Roy, for other clinicians listening, some key takeaways that you'd like them to know about from this discussion today and this case study and the unique aspects of Northwestern Medicine Marianjoy Rehabilitation Hospital. What would you like the key takeaways to be?

Kevin Roy, DO: I would say one of the key takeaways is to understand that spinal cord injuries and the deficits or things that come with it is a dynamic process that evolves alongside the neurologic recovery they have. So, we take into consideration data we gain day to day, as well as patient-reported functions we take day to day. And as they evolve during their stay here, either at Marianjoy or in another acute inpatient rehab program, we make changes as they go. And we don't have to necessarily rule them out of things just because maybe the injury they have from the beginning seems like a devastating one. It's a process that starts at acute inpatient rehab and continues to progress. And the patient hopefully would improve over time as they go back home and into the outpatient setting as well.

Melanie Cole, MS: Dr. Hublikar, last word to you, if we were to look ahead, where do you see the field evolving, whether it's prevention, neuroprotection, recovery optimization? I'd like you to speak about what you see happening in this very exciting field and why that interdisciplinary team that we've discussed a few times here is so important for that collaboration to influence your planning and to help these patients.

Ishaan Hublikar, DO: In the current state, the team is really important. The rehab in general is such a multifaceted process, and you could argue that SCI rehab specifically involves a lot of communication between different aspects of our therapy team, our medical team, our case management, our psychology team, not only in acute rehab, as Dr. Roy said, but really longitudinally. We are there for our patients from day one of acute rehab for as long as they need us. And in an ideal world, they don't need us for very long. But for some of them, we do follow them in our outpatient rehab and our outpatient clinic really indefinitely for some of them lifelong.

And so, understanding how and in which ways we can help them get the best quality of life possible is really the underlying tone of all of this. Part of that in the beginning is educating them about their injury and understanding what their medical complications are. And as we get farther out from their injuries, we get to do even more exciting things with them. It goes past a lot of times, just their activities of daily living. For some of them, it's now learning how to drive again or, you know, having adaptations to go back to work. There's so many different aspects that we can help take care of for our spinal cord patients.

And to that point, the field is really, really evolving and growing as we see different types of technology being used. There are multiple different types of studies that are going on in terms of accelerating the recovery after a spinal cord injury or preventing secondary damage from a cellular standpoint after injuries. There's also different types of research right now about chronic injuries where traditionally we felt that they've reached an endpoint of their nerve recovery, and now there's different types of aspects that are coming into play when we think about potentially, you know, restarting that process or optimizing their nerve recovery after a point that wasn't possible before. So I'm really excited to see how the field is growing with technology and seeing what goes on really worldwide in terms of collaboration going forward.

Melanie Cole, MS: Thank you both so much for such a lively discussion. That was so interesting. And thank you for sharing your expertise and telling us about this case study. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/rehabilitation to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.