Medical Complications in Spinal Cord Injury

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Original Editor - George Prudden

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Introduction

Spinal cord injury results not only in motor and sensory deficits but also in autonomic dysfunctions as a result of the disruption between higher brain centers and the spinal cord. Autonomic dysfunction can include compromised cardiovascular, respiratory, urinary, gastrointestinal, thermoregulatory, and sexual activities. Maintaining optimal health and well-being after sustaining a spinal cord injury can be a challenge.  Common secondary health conditions like pressure sores, spasms, chronic pain, and urinary tract infections often negatively affect quality of life and social participation.

Autonomic Dysfunction

Neurogenic Shock

Autonomic Dysreflexia

Autonomic dysreflexia, also referred to as autonomic hyperreflexia, is a potentially life-threatening condition that can affect people who have had a spinal cord injury at the level of T6 or above, and occurs more frequently in those with a complete injury over those with an incomplete injury, presenting more commonly during the chronic phase of spinal cord injury, around 3 - 6 months. Often unrecognised by many medical professionals, autonomic dysreflexia should be considered a medical emergency that requires immediate intervention. If not treated promptly and correctly, it can lead to significant complications, including stroke, seizures, myocardial ischaemia, and even death. 

It is an acute syndrome characterised by a sudden excessive increase in Systolic Blood Pressure triggered by an ascending sensory, usually "noxious” stimuli below the level of the lesion. Noxious stimuli can include bladder infection, urinary stasis, bowel obstruction, pressure on bony areas or pressure sores, improper positioning, tight clothing, catheter blockage, twisted intercostal drainage tubes, after sudden violent hip range of motion, and extreme hot weather with the most common causes resulting from bladder and bowel related problems.

The noxious stimulus send nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of the spinal cord injury. Since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of the autonomic nervous system. This results in severe vasoconstriction, which causes a sudden rise in blood pressure. Baroreceptors in the heart and blood vessels detect this rise in blood pressure and send a message to the brain. The brain sends a message to the heart, causing the heartbeat to slow down and the blood vessels above the level of injury to dilate. However, the brain cannot send messages below the level of injury, due to the spinal cord lesion, and therefore the blood pressure cannot be regulated. The brain is unable to check the sympathetic response resulting in increased systemic blood pressure. 

This overstimulation of the autonomic nervous system is characterised by sudden onset of severe high blood pressure known as paroxysmal hypertension at least 20 to 40 mmHg above normal resting systolic level. (It is important to remember that Blood Pressure for individuals with tetraplegia or high paraplegia is usually low, around 90 to 100/60 mmHg while lying down and possibly lower whilst sitting). This manifests itself with flushing of the skin, pounding headache, blurred vision, spots in visual field, irritability, pilo erection (goose bumps), profuse sweating above the level of the injury, dry and pale skin caused by vasoconstriction below the level of the injury, blurred vision, nasal congestion, bradycardia, cardiac arrhythmias, atrial fibrillation and often associated with anxiety and feeling sof apprehension. Silent autonomic dysreflexia can also occur with minimal or no symptoms despite elevated blood pressure. (PVA 2001) (Krassioukov et al, 2009) ^[1]

A variety of non-pharmacological and pharmacological strategies can be used to treat autonomic dysreflexia. Immediate treatment recommends identification and removal of the triggering stimuli as soon as possible prior to pharmacological strategies since autonomic Dysreflexia tends to resolve once the inciting stimulus is removed. Sitting the individual upright and with legs over the bedside can reduce help to blood pressure levels and provide partial symptom relief. Tight clothing and stockings should be removed. Catheterization of the bladder, or relief of a blocked urinary catheter tube may resolve the problem. The rectum should be cleared of stool impaction, using anaesthetic lubricating jelly. If the noxious precipitating trigger cannot be identified, drug treatment is sometimes needed until further studies can identify the cause.

When non-pharmacologic treatment methods are not successful in an acute episode of autonomic dysreflexia, pharmacologic agents are required and may include nifedipine, nitrates, and captopril.  Only nifedipine has been supported by controlled trials (Krassioukov et al, 2009).

• Treatment of Autonomic Dysreflexia for Adults & Adolescents with Spinal Cord Injuries

Temperature Regulation

Respiratory Dysfunction

Impaired respiratory function is common following a spinal cord injury. Respiratory function of people with is primarily determined by neurological level of the injury. Paralysis or partial paralysis of key muscles has a marked impact on respiratory function. Respiratory complications in spinal cord injury are common with complications directly correlated with mortality, and both are related to the level of neurologic injury. Pulmonary complications of spinal cord injury include the following:

• Atelectasis secondary to decreased vital capacity and decreased functional residual capacity
• Ventilation-perfusion (V/Q) mismatch due to sympathectomy and/or adrenergic blockade
• Increased work of breathing secondary to decreased compliance
• Decreased cough, which increases the risk of retained secretions, atelectasis, and pneumonia
• Hypoventilation
• Muscle Paralysis
• Muscle Fatigue

Cardiovascular Dysfunction

Deep Vein Thrombosis and Pulmonary Embolism

Orthostatic Hypotension

Gastrointestinal Dysfunction

Paralytic Ileus

Neurogenic Bowel

Upper Motor Neuron Bowel Syndrome

Lower Motor Neuron Bowel Syndrome

Urological Dysfunction

Neurogenic Bladder

Hypereflexia of Detrusor and Sphincter 

Areflexia of Detrusor and Sphincter

Areflexia of Detrusor with Hyperreflexia of Sphincter

Hyperreflexia of Detrusor with Areflexia of Sphincter

Sexual Dysfunction

Fertility

Erectile Dysfunction

Bone Metabolism Dysfunction

Osteoporosis

Heterotrophic Ossification

Heterotopic ossification is when a bone is formed in or around a joint resulting to the absence of movements of that joint this is commonly seen in spinal cord injury patients. It usually presents within joints like shoulder, elbow, knee etc.its first sign is swelling around the joint and reduced range of motion, pain and with or without fever.

Pressure Sores

The National Pressure Ulcer Advisory Panel, U.S (NPUAP) defines a pressure ulcer as an area of unrelieved pressure over a defined area, usually over a bony prominence, resulting in ischemia, cell death, and tissue necrosis. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A pressure sore can develop in a few hours, but the results can last for many months and even cause death. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Guidelines on Prevention and Management of Pressure Ulcers

Pain

Nociceptive

Neuropathic

Psychological

Depression

Anxiety

Post Traumatic Stress Disorder

References