The bladder muscle, “detruser” and external sphincter are similarly affected. Early drainage occurs with indwelling (“foley”) Catheter. When urine volumes are equal to or less than 400 cc per 4 hr., the patient is converted to an Intermittent Catheterization program (ICP). Control fluid intake is closely monitored, especially at night (due to remobilization of fluid from the legs). Early catheter removal reduces the risk of infection (UTI) and allows for better fluid regulation and restriction if necessary. Early ICP reduces Foley Catheter related complications (erosion, stones, recurrent infections, colonization, resistant organisms).
Joint and muscle contractures can occur rapidly following SCI and complicate Rehabilitation later on. Early stabilization of the spine fracture allows for earlier mobilization and therefore fewer complications. The normal implications of immobility and bed rest are accelerated in SCI and must be prevented by mobilizing the patient as soon as possible. Each complication increases the hospital stay and often increases the rehab stay.
A loss of contractile functioning to the smooth muscle in the small and large intestines results in what is termed an ileus. The normal peristalsis or milking action of the bowel stops and frequently requires a variety of medical measures to re-establish reflexive bowel functioning. Occasionally, obstruction occurs in the acute phase, termed Ogilvie’s Syndrome. This must be treated with decompression through naso-gastric and rectal tubes and rarely, through surgery. Upon resolution of this post traumatic ileus the institution of a daily Bowel program improves bowel evacuation and reduces the chance for obstruction. Every day or every other day bowel programs are instituted as early as possible to encourage “automatic” bowel functioning through Reflex mechanisms.
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.
Deep Vein Thrombosis (DVT)
DVT is clots in the veins that sometimes give rise to clots in the lungs. Possible signs and symptoms of DVT include swelling of the leg, dilation of the veins, increased skin temperature, pain and tenderness, and, rarely, a bluish discoloration of the lower leg. Sometimes, there are no signs or symptoms of DVT. There are also no characteristic signs or symptoms of lung clots, meaning the signs and symptoms are very nonspecific, such as fever, chest pain, cough, or changes in heart beat. Although other measures are sometimes used, the most common form of treatment for DVT is the use of anticoagulants.
More technical: Deep vein thrombosis (DVT) or pulmonary embolism is a potentially severe complication of spinal cord injury. Changes in the normal neurologic control of the blood vessels can result in stasis or “sludging”. DVT 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.
Heterotopic Ossification (HO) & Cysts
Heterotopic ossification (HO) is the development of abnormal bone in soft (non-skeletal) tissue, primarily in the region of the hip and knee joints. It occurs in many spinal cord injured individuals and may develop within days following the injury or several months later. HO occurs below the level of injury and the cause is unknown. Most cases cause no significant additional physical limitations, but in a minority of patients, HO may result in a major limitation of joint motion. Symptoms you may notice is difficulty or limitation in your ability to perform activities of daily living, especially activities that require you to bend at the hips. However, sometimes the onset of HO is more rapid, and symptoms at that time may be swelling of one hip and warmth and redness overlying the swelling. In addition to decreased Range of Motion and swelling in the area of the HO, other symptoms may include increased Spasticity, swelling of the entire leg, and/or elevated temperature. If you suspect you have HO, contact your physician. He or she will do an X-ray of your hips and knees, a special isotope bone scan, and blood tests.
If you have HO, watch your skin closely. The HO can increase the amount of pressure applied to the tissue under certain bony prominences. A significant loss of Motor function could strongly suggest a Cyst. The changes in sensation or motor function may develop gradually. You may notice that it is more difficult to do some of your Functional activities, such as holding a cup or putting on your clothes, or you may notice a change in your balance or find that you are burning yourself in places where you previously had sensation. Be aware of your Sensory Level and muscle strength. If you notice significant changes, contact your physician, and give him or her specific information about the changes you have notices. A muscle and sensory test will be conducted and if you have neurologic deterioration due to a cyst, it may be corrected with surgery. The earlier HO is detected, the easier the treatment.
More Technical: A condition not well understood that occurs in acute spinal cord injury and consists of the laying down of bone outside the normal skeleton, usually occurring 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).
Hyperthermia & Hypothermia
After SCI the temperature of the body has an increased tendency to fluctuate due to the altered function of the Autonomic Nervous System. The higher the level of injury, the greater the tendency for fluctuations in body temperature. Hyperthermia refers to an elevation in body temperature. Hypothermia is the decrease in body temp.
One or more of the following symptoms may indicate hyperthermia: Skin feels hot and dry and appears flushed, feeling of weakness, dizziness and visual disturbances, headache, nausea and elevated temperature. Your pulse is generally rapid and may be irregular or weak. It is important that you attempt to prevent hyperthermia when exposed to an overheated Environment. Be familiar with how long you can be in an overheated environment without symptoms. Drink lots of fluids, wear protective, light-weight clothing (cotton and light colors).
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.
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, though, 2-t years following SCI some degree of bone loss will occur.
Using the legs to provide support in transfering 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 of 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.
Postural (Orthostatic) Hypotension
Postural Hypotension, also known as orthostatic hypotension, is a condition which results in a decrease in blood pressure when you sit or stand. This can cause “light-headedness” or “fainting”. It occurs more commonly when you are first injured, when you are fatigued, or after an illness. There is an increased tendency for postural hypotension if the level of injury is at T-6 or above, but it can occur in all spinal cord injured individuals.
Postural hypotension after a SCI occurs since the blood vessels do not decrease in size, in response to lowered blood pressure, due to the altered function of the autonomic nervous system. Because of this, blood pools in the pelvic region or legs while you are sitting or sanding. Postural hypotension usually occurs when you are initially placed in your wheelchair or on the Tilt Table.
Prevention: Wear elastic hose and an abdominal support and come to sitting or standing positions gradually. If postural hypotension occurs tilt or lay backward until you are nearly horizontal to the floor. This increases blood pressure and the “fainting” will quickly disappear.
Respiratory Dysfunction & Pneumonia
Respiratory complications and infection predominate as post-SCI complications. When the injury involves the upper thorax, the normal breathing pattern is permanently altered. The diaphragm does most of the work in quiet breathing. The chest wall muscles (intercostals) are used primarily for deep breathing or coughing. The abdominal muscles also participate in coughing. When the intercostal and abdominal muscles are paralyzed, the entire load is taken by the diaphragm. This results in poor coughing and a high risk of pneumonia. Pneumonia is one of the most common complications of acute spinal cord injury. Preventive measures are very important to reduce the risk of pneumonia. These include: Percussion and drainage using gravity to assist; assisted coughing (also termed “Quad” coughing); abdominal binders (to increase the resistance against which the diaphragm works); and early mobilization (i.e.; getting the patient out of bed as soon as possible.
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 hlep 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.
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 Thoracic-level 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.
The early stages following spinal cord injury results in a “shock-like” situation (termed spinal shock) wherein all neurological function below the level of the injury essentially stops. This includes loss of nerve supply to blood vessels and other supportive structure such as blood vessel dilatation and constriction. As a result, Edema develops. There is a lack of blood return to the heart when the person is in the sitting position. This is called orthostatic hypotension and can be a persistent problems in some patients after spinal cord injury.