Complications of SCI: Canadian Paraplegic Association

Complications of SCI

Exerpted in part from "Standards for
Neurological and Functional Classification of SCI"
American Spinal Injury Association

A primer on some of the secondary health concerns associated with spinal cord injury.

In this article, we will discuss several of the common complications for patients with SCI. These include skin breakdown, osteoporosis and fractures, pneunomia, atelectasis, aspiration, heterotopic ossification, spasticity, autonomic dysreflexia, deep vein thrombosis, cardiovascular disease, syringomyelia and neuropathic/spinal cord pain.

Skin Breakdown

Skin breakdowns (also termed "decubitus ulcers") are a major complication associated with spinal cord injury. They occur as a result of excessive pressure, primarily over the bones of the buttock (particularly the ischial tuberosities and the trochanters at the hip).

Following a spinal cord injury, there are not only changes in muscle tone and sensation, but also shifts in the supply of blood to the skin and subcutaneous tissues. Additionally, there is a loss of the normal elastic nature of the tissues underlying the skin. Increased stiffness, vascular alterations and alterations in muscle tone combine to significantly reduce the skin's ability to withstand pressure. It is estimated that the closing "pressure" for skin breakdown is between 40 and 50 millimeters of mercury - the same amount of pressure as placing a stamp onto an envelope. This complication is combated fairly aggressively through the use of pressure-relieving cushions that are either gel based or consist of a number of air bladders to reduce the risk of the person "bottoming out". The cost associated with medical and/or surgical care of a single decubitus ulcer can run anywhere from $10,000 to $50,000 per admission. This does not take into consideration the loss of productivity if the individual is in the work place.

Osteoporosis and Fractures

The majority of people with SCI develop osteoporosis. In people without SCI, the bones are kept strong through regular muscle activity or by bearing weight. When muscle activity is decreased or eliminated and the legs no longer bear the body's weight, they begin to lose calcium and phosphorus and become weak and brittle. It generally takes some time for osteoporosis to occur. In people who use standing frames or braces, osteoporosis is less of a problem. Generally, it takes 2 years following SCI for some degree of bone loss to occur.

Using the legs to provide support in transferring is helpful in increasing the load on the bones, which may reduce or slow down the osteoporotic process. Standing using a standing frame or a standing table also helps prevent weakening of the bones and so does using braces for functional or parallel bar walking. Newer techniques, such as electrical stimulation of the leg muscles, may decrease osteoporosis as well.

Unfortunately, at the present time, there is no way to reverse osteoporosis once it has occurred. The main risk associated with osteoporosis is fracture. Once the bones become brittle, they fracture easily. An osteoporotic bone takes much longer to heal.

Pneumonia, Atelectasis, Aspiration

Patients with spinal cord injuries above the T4 level of injury are at risk to develop restriction in respiratory function, termed restrictive lung disease. This occurs five to 10 years following spinal cord injury and can be progressive in nature. The quadriplegic individual as part of a health care maintenance routine should have pulmonary function studies at yearly or every-other-year intervals between five and 10 years post injury. As the medical treatment of spinal cord-injured individuals continues to improve, respiratory complications of SCI are becoming more prominent. Adequate health maintenance and protection from this complication are appropriate and necessary as part of the long-term care of the spinal cord-injured individual.

Heterotopic Ossification

Heterotopic ossification is a condition, not well understood, that occurs in acute spinal cord injury and consists of the laying down of bone outside the normal skeleton. This occurs generally at large joints such as the hips or knees. The primary problem with heterotopic ossification, or HO, is the risk for joint stiffening and fusion. Should the hip or knee become fused in a certain position, a surgical release is necessary to allow range of motion to occur. Unfortunately, it takes between 12 and 18 months for heterotopic bone to mature once it has developed. Activities that are used to prevent the development of HO include range of motion programs and other functional activities that move the joints within a functional range. Currently treatment is limited with the exception of preventing the joint fusion (termed ankylosis).

Spasticity

After spinal cord injury the nerve cells below the level of injury become disconnected from the brain. Following the period of spinal shock, changes occur in the nerve cells that control muscle activity. Spasticity is an exaggeration of the normal reflexes that occur when the body is stimulated in certain ways. After spinal cord injury, when nerves below the injury become disconnected from those above, these responses become exaggerated.

Muscle spasms, or spasticity, can occur any time the body is stimulated below the injury. This is particularly noticeable when muscles are stretched or when there is something irritating the body below the injury. Pain, stretch, or other sensations from the body are transmitted to the spinal cord. Because of the disconnection, these sensations will cause the muscles to contract or spasm.

Almost anything can trigger spasticity. Some things, however, can make spasticity more of a problem. A bladder infection or kidney infection will often cause spasticity to increase a great deal. A skin breakdown will also increase spasms. In a person who does not perform regular range of motion exercises, muscles and joints become less flexible and almost any minor stimulation can cause severe spasticity.

Some spasticity may always be present. The best way to manage or reduce excessive spasms is to perform a daily range of motion exercise program. Avoiding situations such as bladder infections, skin breakdowns, or injuries to the feet and legs will also reduce spasticity. There are three primary medications used to treat spasticity, baclofen, Valium, and Dantrium. All have some side effects and do not completely eliminate spasticity.

There are some benefits to spasticity. It can serve as a warning mechanism to identify pain or problems in areas where there is no sensation. Many people know when a urinary tract infection is coming on by the increase in muscle spasms. Spasticity also helps to maintain muscle size and bone strength. It does not replace walking, but it does help to some degree in preventing osteoporosis. Spasticity helps maintain circulation in the lefts. It can be used to improve certain functional activities such as performing transfers or walking with braces. For these reasons, treatment is usually started only when spasticity interferes with sleep or limits an individual's functional capacity.

Autonomic Dysreflexia

Autonomic dysreflexia (AD) is a condition that can occur in anyone who has a spinal cord injury at or above the T6 level. It is related to disconnections between the body below the injury and the control mechanisms for blood pressure and heart function. It causes the blood pressure to rise to potentially dangerous levels.

AD can be caused by a number of things. The most common causes are a full bladder, bladder infection, severe constipation, or pressure sores. Anything that would normally cause pain or discomfort below the level of the spinal cord injury can trigger dysreflexia. AD can occur during medical tests or procedures and need to be watched for.

The symptoms that occur with AD are directly related to the types of responses that happen in the sympathetic and parasympathetic nervous systems. Symptoms such as a pounding headache, spots before the eyes, or blurred vision are the direct result of the high blood pressure that occurs when blood vessels below the injury constrict. The body responds by dilating blood vessels above the injury, causing flushing of the skin, sweating, and occasionally goosebumps. Some patients describe nasal stuffiness and will feel very anxious. Uncontrolled AD can cause a stroke if not treated.

The treatment for AD involves removing the reason for the stimulation. One of the first things a patient can do is to sit up. This naturally decreases blood pressure. If there is a catheter in place, it should be checked to be certain that there is no kink in the tubing. If there is not a catheter in place, the patient should be catheterized. The bowels should be checked to be certain there is no stool in the rectum. If the symptoms are caused by skin breakdown, the patient should get to an emergency department as soon as possible.

The primary risk of AD is stroke. It is a potentially life-threatening condition. If AD is left untreated, the body's attempt to control blood pressure will severely decrease the heart rate. This, combined with uncontrolled high blood pressure, can be fatal. For this reason, it is very important to treat this condition as soon as possible. The most important thing patients can do to prevent AD from occurring is to take good care of themselves. Patients should monitor bladder output and should maintain a regular bowel program to fully empties the bowels. They should also do regular skin checks to prevent pressure sores from occurring.

Deep Vein Thrombosis

Deep vein thrombosis (DVT) or pulmonary embolism is a potentially severe complication of spinal cord injury. As mentioned above, there are changes in the normal neurologic control of the blood vessels that can result in stasis or "sludging". Deep vein thrombosis in the lower leg is almost universal during the early phases of recovery and rehabilitation. Thromboses in the thigh, however, are a great concern, as they are at risk for becoming dislodged and passing through the vascular tree to the lungs. A major obstruction of the arteries leading to the lung can potentially be fatal. Therapeutic measures to reduce or eliminate the risk for deep vein thrombosis include Ace wrapping of the legs and the use of pneumatic compression stockings. Medications administered subcutaneously, such as heparin, are useful in reducing blood viscosity and improving flow. In the event that a thrombosis develops, treatment is begun with intravenous heparin. Once adequate anticoagulation is provided, the patient is switched to an oral medication, called Coumadin.

Cardiovascular Disease

Cardiovascular disease is a major long-term risk of spinal cord injury. SCI individuals live in general rather sedentary lives and are at higher risk for cardiovascular disease than the able-bodied population. Therefore, careful assessment of cardiovascular function and the encouragement of exercise programs are appropriate and necessary long-term aspects of spinal cord injury management and care. The prescription of upper extremity exercise programs in spinal cord-injured individuals are similar to those used in other populations with the exception of the use of adaptive equipment such as racing wheelchairs or monoskis.

Syringomyelia

A post-traumatic enlargement of the central canal of the spinal cord is termed syringomyelia. It occurs in approximately 1-3% of all spinal cord-injured individuals. The primary risk of syringomyelia is a loss of function above the level of the original spinal cord injury. For example, in a patient with a thoracic4evel spinal cord injury may complain to his or her physician of numbness and weakness involving the extremities. The condition will progress with time and needs to be treated aggressively through surgical drainage. Often patients with early evidence of a syrinx will be followed to evaluate the progression of the condition. Significant syringomyelia is treated with surgical decompression and the placement of a drainage tube into the spinal cord.

Neuropathic/Spinal Cord Pain

Neuropathic (nerve-generated) pain is a significant problem in some spinal cord-injured patients. Varying types of pain are described in spinal cord injury. Damage to the spine and soft tissues surrounding the spine can cause aching at the left of the injury. Nerve root pain is described as sharp or may be described as having an electric shock-type quality. Occasionally SCI patients will describe phantom limb pain or pain that radiates from the level of the lesion in a specific pattern that is related to injury or dysfunction at the nerve root or spinal cord level. Various medications and nerve block procedures have been described and are of some use in the treatment of neuropathic pain following spinal cord injury.