Spinal Cord Injury: an Overview

Spinal Cord Injury: An Overview

By Kristyn Campbell, MD, and Chester Ho, MD

he World Health Organization sometimes also the trunk. Paraplegia is com- defines spinal cord injury (SCI) as monly caused by an SCI in the thoracic or lum- damage to the spinal cord, conus bar regions. medullaris or cauda equina.1 The estimated global incidence of SCI is 40 to Damage to the spinal cord can 80 cases per million annually.1 In Canada, the resultT in loss of sensation and motor control prevalence is approximately 1,298 cases per to the limbs and trunk as well as loss of auto- million.1 Trauma causes include motor vehicle nomic control. This in turn can result in abnor- accidents, falls and violence. Non-traumatic SCIs mal bowel and bladder control, sexual function, may be caused by degenerative changes of breathing, blood pressure, heart rate and tem- the spine, neoplastic tumours, vascular insults, perature control. The extent of these symptoms autoimmune disorders and infections. The inci- depends on the level at which the spinal cord dence of traumatic SCI is higher in adult men, injury occurred as well as the extent to which with at least a 2:1 ratio of male to female injur- the spinal cord is damaged. Tetraplegia (previ- ies.1 The incidence of non-traumatic SCI is also ously known as quadriplegia) is the term used higher in men. Traumatic SCI is most likely to to describe a loss of sensation and motor con- occur in young adults (15 to 29 years) and the trol in all four limbs and the trunk. Tetraplegia elderly (over 60 years), whereas non-traumatic usually results from a cervical SCI. Paraplegia SCI is more common in the elderly. Tetraplegia is used to describe a loss of sensation and/ is slightly more common than paraplegia and or motor control in only the lower limbs and accounts for 52% to 57% of SCI injuries.2

10 Wound Care Canada Volume 16, Number 2 · Winter 2018 How is spinal cord motor function is preserved lateral motor level on either injury classified? in the sacral segments S4–5. side of the body. For AIS C, The extent of SCI is described B = Sensory Incomplete: less than half of key muscle using the International Sensory, but no motor func- functions below the single Standards for Neurological tion is preserved below NLI have a muscle grade ≥ 3. Classification of Spinal the neurological level and D = Motor Incomplete: Motor incomplete status as Cord Injury published by includes the sacral segments defined above, with at least the American Spinal Injury S4–5 (light touch or pin half (or more) of key muscle Association (ASIA). The classifi- prick at S4–5 or deep anal functions below the single cation is based on a systematic pressure) AND no motor NLI having a muscle grade sensory and motor examination function is preserved more ≥ 3. of neurological function. The than three levels below the E = Normal: If sensation and neurological level of injury (NLI) motor level on either side of motor function as test- is the lowest segment of the the body. ed with the International spinal cord with intact sensation C = Motor Incomplete: Motor Standards for Neurological and antigravity muscle strength, function is preserved at the Classification of Spinal Cord provided there is normal motor most caudal sacral segments Injury (ISNCSCI) are graded and sensory function above. for voluntary anal contrac- as normal in all segments, A level of injury from C1 to T1 tion (VAC) OR the patient and the patient had prior results in tetraplegia. A level of meets the criteria for sensory deficits, then the AIS grade injury below T2 results in para- incomplete status (sensory is E. plegia. function preserved at the The severity of the injury is most caudal sacral segments described by the American [S4–S5] by light touch, pin Complications Spinal Injury Association prick or deep anal pressure), Following a Spinal Cord Impairment Scale (AIS), which and has some sparing of Injury includes five scales from A to E: motor function more than In additional to motor and sen- A = Complete: No sensory or three levels below the ipsi- sory impairments, SCI also caus-

Volume 16, Number 2 · Winter 2018 Wound Care Canada 11 es many other impairments and prone to leaking, but intravescial Neurogenic Bowel chronic complications, including pressure remains low. The Impact psychosocial consequences The Implications SCI impairs bowel function such as adjustment, depression, Urinary tract infections are the and can result in poor col- vocation, and caregiver burden most common complication in onic motility, delayed transit issues, can be significant and people with SCIs and are often time, chronic constipation and complex. For the purpose of this heralded by increased spasticity, review, we focus on physiologic- fecal incontinence. Similar to fever, incontinence, autonomic al consequences, which include neurogenic bladder, SCI above dysreflexia and vague abdom- but are not limited to the fol- the sacral segments results in inal discomfort. Other urinary lowing. a UMN bowel pattern, while complications include vesicou- lesions at the sacral segments Neurogenic Bladder reteral reflux, renal and bladder lead to an LMN bowel pattern. calculi, hydronephrosis and In a person with a UMN bowel, The Impact chronic renal failure. voluntary defecation cannot be SCI above the sacral segments initiated, and the anal sphinc- results in an upper motor neur- The Interventions on (UMN) bladder. In a UMN Management of neurogen- ter may be spastic, leading to bladder, there is detrusor muscle ic bladder aims to drain the stool retention. Intrinsic and hyperactivity, with patients pre- bladder sufficiently, to ensure reflex-mediated colonic peri- senting with urgency, frequency continence and to maintain stalsis are intact, however, which and incontinence. Intravesical normal intravesical pressure to allows stool to move through pressures may be elevated. protect the upper urinary tract. the colon and rectum reflexive- Injuries involving the sacral Intermittent catheterization ly in response to distension. In segments from S2 to S4 cause is commonly used for bladder a person with an LMN bowel, a lower motor neuron (LMN) management, but where inter- voluntary defecation and the bladder. In an LMN bladder, the mittent catheterization is not reflexes are impaired. This leads bladder is areflexic and atonic— feasible, some may choose to to an even slower colonic transit so the person cannot voluntarily have an indwelling urethral or time. The anal sphincter is often empty the bladder—and it is suprapubic catheter. atonic and prone to leakage of

12 Wound Care Canada Volume 16, Number 2 · Winter 2018 stool, so incontinence may be a Spasticity occurs in the muscles Focal chemo-denervation with problem. below the level of injury in SCIs botulinum toxin type A is help- The Implications above the cauda equina. ful when specific muscles can be targeted. Intrathecal baclofen is Bowel continence plays a large The Implications another option for those with role in a person’s ability to Spasticity may be painful and diffuse, severe spasticity that is return to former social roles and interfere with activities of daily not well managed with other activities. Neurogenic bowel living, ambulating, positioning conservative treatment options. may also cause chronic con- and transfers. However, spas- stipation, hemorrhoids, rectal ticity may also be helpful for Bone Health prolapse, acute ileus or bowel ambulation and transfers by obstruction. providing more rigid support The Impact An imbalance between bone The Interventions from the lower limbs. Worsening resorption and formation Management of a UMN bowel spasticity is often related to occurs following SCI, leading to involves using stool-softening other complications, such as a increased bone resorption in the laxatives, colonic stimulants to urinary tract infection—hence bones below the level of injury. assist in stool propulsion, and a the importance to rule this out. This may result in symptomatic suppository with digital stimu- The Interventions hypercalcemia typically in the lation to trigger the colonic Non-pharmacological treat- first three to fourth months after reflexes to stimulate evacua- ments for spasticity include SCI, causing symptoms such tion of stool. Management of proper positioning, stretch- as nausea, lethargy, abdomin- an LMN bowel involves using ing and serial casting. al pain, polyuria and anorexia. a bulking agent to achieve a Pharmacological treatments Bone mineral density declines stool consistency that allows for include oral baclofen and other by six weeks post-injury, and manual disimpaction from the anti-spasticity medications. bone loss continues for years. rectum. Adequate fibre and fluid intake also assist with developing bulky, formed stool. A bowel program is individualized to each patient but generally occurs at the same time every day and should take less than one hour to complete. The goals of a bowel program are to efficiently evacuate the colon to prevent incontinence, constipation and complications such as hemorrhoids.

Spasticity The Impact Spasticity is a common complication of SCI characterized by hyperreflexia, velocity-dependent increased resistance to passive stretch and involuntary muscle contractions or spasms.

Volume 16, Number 2 · Winter 2018 Wound Care Canada 13 upper limbs from their work, activities of daily living, and mobilization in a wheelchair. Repetitive motions and recur- rent microtrauma can result in overuse injuries, most commonly in the shoulder, causing rotator cuff impingement, sub- acromial bursitis, osteoarthritis, bicipital tendonitis or capsulitis. The Implications These are common causes for chronic pain after SCI. Contractures may lead to difficulties in positioning, pressure injuries, or limit the use of a joint if delayed motor recovery occurs. Functionally, these may limit activities such as dressing, hygiene and transfers. Overuse injuries may also limit mobilization and activities of daily living. The Interventions Prevention of overuse injuries and contractures is key. Loss of bone density is greater mentation is effective in mini- Prevention of overuse injuries typically in the distal femur and mizing bone loss. Medications can be achieved by appropri- proximal tibia. Tetraplegics may for osteoporosis have been used ate preservation, optimizing also lose bone density in the (e.g., bisphosphonates), but biomechanics and use of upper distal radius and ulna. there is no standard guideline extremities, as well as strength- for their use after SCI. There is The Implications ening exercises. Contractures some evidence that standing, can be prevented by daily Osteoporosis in bones below and use of functional electrical passive range of motion of all the level of injury may cause stimulation, may be helpful. joints, proper positioning, and fragility fractures during move- splinting if necessary. Treatment ments such as repositioning in Musculoskeletal of established contractures may bed or transfers. People with Complications involve serial casting, surgical SCIs have twice the risk of a The Impact tenotomies and/or tendon fragility fracture in the lower Musculoskeletal complica- lengthening. extremity compared to the tions associated with SCI may general population.3 Fragility cause pain and limit function. Pain fractures are more common in Contractures are common in The Impact paraplegics or tetraplegics who paralyzed limbs due to pro- Pain is a very common com- are more active and likely to fall. longed joint immobilization. plication following SCI, with The Interventions People with SCIs often have very approximately 50% of people Vitamin D and calcium supple- high demands placed on their with SCIs experiencing chronic

14 Wound Care Canada Volume 16, Number 2 · Winter 2018 pain that interferes with activ- requiring mechanical venti- cascade leading to hypercoagul- ities.4 The International Spinal lation. Persons with injuries ability.7 As a result, people with Cord Injury Pain Classification between C3 and C5 result in acute SCI have a greater risk of organizes pain following SCI partial respiratory muscle par- developing VTE than persons into nociceptive, neuropathic alysis and may require mech- with other general trauma.8 and other.5 Neuropathic pain anical ventilation during acute The Implications can occur at or below the level hospitalization. Persons with Lack of appropriate VTE prophyl- of injury. It is often described as injuries between C6 and C8 axis may result in pulmonary a burning, shock-like, shooting result in weak forced exhalation, embolism, which may be fatal. sensation and may be accom- but the inspiratory muscles are panied by allodynia and hyper- functional. The Interventions algesia. The Implications VTE prophylaxis with mechanic- The Implications The risk of pulmonary compli- al methods of thromboprophyl- Pain following SCI can present cations, including atelectasis, axis and anticoagulation is rec- acutely and often persists long- pneumonia and pulmonary ommended. Mechanical throm- term. Chronic pain frequently edema, is high for those with boprophylaxis with intermittent interferes with activities and cervical- and (to a lesser extent) pneumatic compression devices work, reducing quality of life.6 thoracic-level injuries. Injuries with or without graduated compression stockings is recom- The Interventions below the thoracic levels typ- mended as soon as feasible after There are a number of ically have little to no respira- acute SCI when not contraindi- non-pharmacologic and phar- tory compromise. Reduced cated by lower extremity injury. macologic treatments for noci- lung and chest wall compliance ceptive and neuropathic pain. results in a restrictive ventilatory Anticoagulation with a low Pregabalin and gabapentin defect. A lack of supraspinal molecular weight heparin (e.g., are two of the most commonly sympathetically mediated bron- enoxaparin) is recommended used medications for treating chodilation may exacerbate res- in the acute care phase after neuropathic pain. An interdisci- piratory difficulties. SCI once there is no evidence plinary approach to chronic pain The Interventions of active bleeding and if there management is recommended. Management of respiratory is no medical contraindication. insufficiency varies depending In the post-acute and rehabili- Respiratory Insufficiency on the extent of injury but may tation phase, low molecular weight heparin, oral vitamin The Impact involve secretion management Respiratory complications are with assisted cough, lung vol- K antagonists (e.g., warfarin) the leading causes of death for ume recruitment and ventilator or a direct oral anticoagulant people with SCI for all years support with non-invasive and/ (DOAC) (e.g., dabigatran) may after injury.8 Respiratory insuffi- or invasive ventilation. be used for anticoagulation. ciency can occur post-SCI due Anticoagulant thromboprophyl- to respiratory muscle weakness, Venous Thromboembolism axis should be continued for changes in ventilator control The Impact at least eight weeks after SCI and changes in lung and chest Patients with acute SCI have for those with limited mobility. wall compliance. The extent of a predisposition to venous People with chronic SCI who respiratory muscle weakness thromboembolism (VTE) due are re-hospitalized for medical depends on the severity and to Virchow’s triad: immobility illnesses or surgical procedures level of SCI. Persons with injur- causing venous stasis in para- should also receive thrombo- ies above C3 result in near total lyzed limbs, endothelial injury prophylaxis during the period of respiratory muscle paralysis, and alterations in the clotting increased risk.7

Volume 16, Number 2 · Winter 2018 Wound Care Canada 15 Orthostatic Hypotension The Impact Low resting blood pressure and orthostatic hypotension can occur due to interruption of excitatory descending sympathetic input.9 Pooling of venous blood in the lower extremities also contributes to lower ven- tricular end-diastolic pressure and stroke volume. Orthostatic hypotension is more common acutely following injury but may persist chronically. The Implications flushed face, and usually brady- al, physiological and practical Orthostatic hypotension can cardia. aspects of sexual function and lead to lightheadedness and The Implications fertility. Men and women with syncope. These symptoms may AD is a medical emergency SCI may experience reduced impair mobilization and increase that, if untreated, can result in sensation, impaired ability to the risk of falls. cerebral hemorrhage, seizures, achieve orgasm and difficulties The Interventions arrhythmias, myocardial damage with self-positioning. Symptomatic orthostatic hypo- and even death. Triggers of AD The Implications tension is treated non-pharma- are most commonly genitourin- Men may experience complete cologically with compression ary or gastrointestinal issues or impaired ability to achieve stockings and abdominal bind- such as bladder distension or an erection and ejaculation, ers to prevent venous pooling, fecal impaction but may range which has implications for fer- or pharmacologically with medi- from ingrown toenails to child- tility. Infertility in men with SCI cations that raise blood pres- birth. is common due to low sperm sure, such as midodrine. The Interventions viability and motility. Women Treatment is aimed at first cor- may have disrupted menstru- Autonomic Dysreflexia recting the trigger. General ation acutely following injury, The Impact measures include emptying the but it usually returns after Autonomic dysreflexia (AD) is bladder or rectum and loos- a few months, and fertility a syndrome caused by imbal- ening tight clothing. If hyper- is unchanged. Pregnancy in anced reflex sympathetic distension persists after these women with SCI is associated charge in response to a noxious measures, antihypertensive with greater risks of complica- stimulus, resulting in a sud- medication may be necessary. tions such as venous throm- den onset of excessively high It is important for patients and boembolism and premature blood pressure. Patients with a caregivers to recognize the labour, which requires special T6 level injury or above are at symptoms of AD and know how considerations. risk. Symptoms of AD include to manage them. The Interventions a pounding headache, blurred Oral and injectable medications vision, sweating above the level Sexual Dysfunction as well as surgical implanta- of injury, goosebumps and cool The Impact tions are available for erectile skin below the level of injury, a SCI can affect the psychologic- dysfunction. Fertility treatments

16 Wound Care Canada Volume 16, Number 2 · Winter 2018 on a motor complete injury. • People with C1 to 4 injuries are expected to be independent in a power wheelchair but dependent on others for transfers and most activities of daily living. • People with C5-level injuries require assistance for most activities of daily living and transfers but are independent in a power wheelchair. Those with a C5 or lower injury are able to drive independently in a specially adapted vehicle. may require semen retrieval involves the use of appropriate • Those with C6-level injuries and insemination. Management surfaces for wheelchairs and are independent for eating, of sexual dysfunction involves mattresses, frequent weight hygiene and dressing the careful discussion with the indi- shifting, proper transfer tech- upper limbs using adaptive vidual and their partner. Patients niques, as well as adequate technologies after receiving should be educated on prepara- skin care, moisture control and assistance with set-up. They tion for sexual activity, manage- nutrition. The Braden Scale is require assistance for other ment of autonomic dysreflexia, often used to predict the risk activities of daily living. They fertility and family planning. of pressure injury and address are able to mobilize independ- underlying causes. Treatment of ently in a manual wheelchair Pressure Injuries pressure injuries involves local indoors and use a power The Impact management of the wound, as wheelchair outdoors. People with SCI have a high well as systemic management • People with injuries at the C7 risk of pressure injuries due such as nutritional treatment, to C8 level are independent to poor sensation, immobility, with a patient-centred approach. for most activities of daily compromised nutrition, muscle Treatment of associated soft tis- living but may require assist- atrophy over bony prominences, sue or bony infections may also ance for bowel and bladder incontinence, spasticity and con- be required. care, dressing and cleaning tractures. Fifty to 80% of people their lower limbs. They are independent in transfers and with SCI will develop a pressure Functional Limitations injury.10 manual wheelchair mobility. Following SCI • People with T1 to T9 injuries The Implications The functional limitations that are independent in all basic Pressure injuries are the second result from SCI vary depending activities of daily living, trans- leading cause of hospitalization on the level of injury. While fers and manual wheelchair 11 acutely and long-term and can every patient is unique, there propulsion. lead to serious complications are general functional outcomes • People with T10 to L5 injuries including osteomyelitis, septic that can be expected based on are able to do the same activ- arthritis, endocarditis and ampu- the level of SCI.12 Since incom- ities as the T1 to T9 level. In tation. plete injuries have variable addition, they may have some The Interventions neurological involvement, these functional ambulation with Prevention of pressure injuries generalizations are made based assistance or even independ-

Volume 16, Number 2 · Winter 2018 Wound Care Canada 17 ently using knee-ankle-foot Numerous adaptive self-care with spinal cord injury. Spinal Cord. orthoses or ankle-foot orthos- devices can be used to com- 1998;36(11):790. es and forearm crutches or a pensate for weak grip, poor 4. Cardenas DD, Bryce TN, Shem K, walker. co-ordination or limited range of Richards JS, Elhefni H. Gender and minority differences in the pain People with SCI use assistive motion, and allow the comple- experience of people with spinal technologies to achieve optimal tion of activities of daily living cord injury. Arch Phys Med Rehabil. 2004;85(11):1774–81. independence to get around with little to no assistance. Some and perform their daily activities. examples include a universal 5. Bryce TN, Biering-Sorensen F, Finnerup NB, Cardenas DD, Defrin R, Lundeberg Wheelchairs are the most com- cuff, built-up handle on a uten- sil, skin inspection mirror and T, et al. International spinal cord injury monly used assistive technology pain classification: Part I. Background and can be manual or powered. digital stimulator. Home modifi- and description. Spinal Cord. Powered wheelchairs may be cations may also be required to 2011;50(6):413. propelled by a joystick or head allow people with SCI to safely 6. Cardenas DD, Bryce TN, Shem K, or chin, or be breath-controlled and efficiently function and Richards JS, Elhefni H. Gender and minority differences in the pain for those who have inadequate move around. experience of people with spinal hand function. The wheelchair cord injury. Arch Phys Med Rehabil. is often customized based on Conclusion 2004;85(11):1774–81. the person’s functional goals, Spinal cord injury is a medically 7. Consortium for Spinal Cord Medicine. environment, age, cognitive complicated and life-altering Prevention of venous thromboembolism in individuals with spinal abilities, spasticity, skin and condition. Although there is no cardiopulmonary endurance. cord injury: Clinical practice guide- cure for SCI, advances in clinical lines for health care providers. 3rd Wheelchairs may recline or practice have reduced morbidity ed. Top Spinal Cord Inj Rehabil. tilt-in-space to accommodate and increased the life expect- 2016;22(3):209–40. pressure relief for the preven- ancy of those with SCI. Through 8. Geerts WH, Code KI, Jay RM, Chen tion of pressure injuries. Transfer effective rehabilitation and E, Szalai JP. A prospective study of venous thromboembolism aids such as sliding boards and health interventions, assistive mechanical lifts allow people after major trauma. N Engl J Med. technologies and more access- 1994;331(24):1601–6. with SCI to safely move from one ible environments, people with 9. Teasell RW, Arnold JMO, Krassioukov place to another with or without SCI can live full and productive A, Delaney GA. Cardiovascular conse- the help of others. lives. quences of loss of supraspinal control A variety of orthoses can be of the sympathetic nervous system used to assist with activities after spinal cord injury. Arch Phys Med such as eating, grooming and References Rehabil. 2000;81(4):506–16. 1. Bickenbach J, Officer, A, Shakespeare, ambulating. Upper limb orthos- 10. Richards S, Waites K, Chen Y, Kogos T, von Groote, P. International S, Schmitt MM. The epidemiology es include static and dynamic Perspectives on Spinal Cord of secondary conditions following Injury. Bickenbach J, et al., ed. splints. Static splints provide spinal cord injury. Top Spinal Cord Inj Geneva, Switzerland: World Health hand and wrist positioning to Rehabil. 2004;10(1):15–29. Organization, The International Spinal prevent contractures. Dynamic Cord Society; 2013. 11. Cardenas DD, Hoffman JM, Kirshblum splints support weak muscles to 2. National Spinal Cord Injury Statistical S, McKinley W. Etiology and incidence facilitate hand function. Lower Center. 2012 Annual Statistical Report of rehospitalization after traumatic limb orthoses include knee-an- for the Spinal Cord Injury Model spinal cord injury: A multicenter analysis. Arch Phys Med Rehabil. kle-foot orthoses and ankle-foot Systems-complete Public Version. Birmingham: University of Alabama at 2004;85(11):1757–63. orthoses that can help support Birmingham; 2013. 12. Lin VW, Bono CM. Spinal Cord weak leg muscles to facilitate 3. Vestergaard P, Krogh K, Rejnmark Medicine: Principles & Practice, Second walking with or without other L, Mosekilde L. Fracture rates and Edition. New York: Springer Publishing gait aids. risk factors for fractures in patients Company; 2010. p. 136–151.

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