Medical Complications of Spinal Cord Injury

Recent medical advances have greatly improved the prognosisfor people who sustain spinal cord injury (about 10000 peopleinitially survive spinal cord injury each year in the US). Physiciansmay become involved with the acute care of spinal cord injuredpersons or care for complications which develop later. Certainconditions such as heterotopic bone formation and autonomicdysreflexia are seen almost exclusively in this group of patients;other complications such as urinary tract and soft tissue infectionsoccur quite often. Common medical complications of spinal cordinjured persons are reviewed, as well as their diagnosis andtreatment.     

Recent trends in mortality and causes of death among persons with spinal cord injury

OBJECTIVE: To identify and quantify trends in mortality and causes of death among persons with spinal cord injury. DESIGN: Cohort study. SETTING: Model spinal cord injury care systems and Shriner's Hospitals spinal cord injury units throughout the United States. PATIENTS: A total of 28,239 consecutive persons admitted to the model system or to a Shriner's Hospital within 1 year of injury. MAIN OUTCOME MEASURE: Length of survival and cause of death. RESULTS: Among persons who were admitted to the model system within 1 day of injury, the odds of dying during the first postinjury year were reduced by 67% for persons injured between 1993 and 1998 relative to persons injured between 1973 and 1977 after adjusting for trends in age, gender, race, neurologic level of injury, Frankel grade, ventilator status, etiology of injury, sponsor of care, and model system where treatment occurred. However, mortality rates after the first anniversary of injury, which had also been declining from 1973 to 1992, increased 33% for persons injured between 1993 and 1998 relative to persons injured between 1988 and 1992. Respiratory disease was the only cause of death after the first anniversary of injury for which the relative odds increased meaningfully during the latest time period (76% increase over 1988-1992 compared to all other causes). CONCLUSION: While great improvements in life expectancy have been achieved since the Model SCI Systems program began, current data support the need for renewed efforts to improve the prevention and treatment of the complications of spinal cord injury.     

Solitary colonic ulcer in a spinal cord injured patient

Bleeding from the lower gastrointestinal tract is rarely reported in spinal cord injured patients. A case is reported of such bleeding in a quadriplegic man with a solitary colonic ulcer diagnosed by flexible sigmoidoscopy and biopsy. The diagnosis of solitary colonic ulcers is difficult to make in spinal cord injured persons because presenting features may be masked by the neurologic deficits caused by the injury or may be falsely attributed to problems associated with the injury or to iatrogenic trauma. Solitary colonic ulcer should be included in the differential diagnosis of gastrointestinal bleeding in persons with spinal cord injury. Flexible sigmoidoscopy or colonoscopy is recommended for visualization and biopsy of the bleeding lesion.     

The Contribution of Group Learning to the Rehabilitation of Spinal Cord Injured Adults

This study, which involved both quantitative and qualitative methods, investigated the contribution of group learning to the rehabilitation of spinal cord injured adults. The views of spinal cord injured persons, their families, and professional nurses involved in spinal cord injury rehabilitation were compared. A telephone questionnaire that measured attitudes toward group learning and gathered demographic data was administered to 60 adults with spinal cord injuries in northern Illinois. Data analysis indicated a range of positive attitudes for all subjects. Personal interviews then were conducted with 8 spinal cord injured persons, 6 family members, and 8 rehabilitation nurses to compare perceptions about the effects of group learning. All those interviewed stated that contact among spinal cord injured persons is an important factor in adjustment to the injury. Positive attitudes toward group learning were communicated by all three subject groups. Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge that they were not alone were identified as advantages of group learning.     

Spinal cord injury: a comparison of preinjury and postinjury marriages.

A study of the preinjury and postinjury marriages of 55 spinal cord injured persons and their partners revealed several differences between the relationships. Although all patients had comparable levels of spinal cord injury, the disabled persons in preinjury marriages were judged to have less motivation for independence; a larger proportion of them received daily personal care assistance from their spouses. Furthermore, those in postinjury marriages were more likely to be employed and were judged to be better adjusted psychologically. Psychologists' assessment of marriages based on interviews with the spinal cord injured subjects and their spouses revealed that the postinjury marriages were happier than the preinjury marriages. Possible explanations for these findings are discussed, which include age and state of health, the impact of disability on the marital relationship and the personal assets of disabled persons who attract new partners.     

An educational training program for the care at the site of injury of trauma to the central nervous system

The treatment of head and spinal cord injuries must be directed towards prevention of secondary insults which will increase the extent of permanent disability. Improved extrication techniques at the scene of the accident, earlier recognition and treatment of complications and improved transfer management have all reduced the acute morbidity and mortality of injuries to the central nervous system. At the University of Virginia we have implemented a comprehensive training program in the acute care of the head and spinal cord injured patient for Emergency Medical Technicians (EMT), nurses, community referring physicians, and house staff within the medical center. A booklet, prepared for care at the site of injury, outlines the assessment, care and intervention with the head and spinal injury patient for the EMT. Another booklet provides guidelines for care of the patient in the emergency department. Included here are instructions in respiratory care, adequate circulation and spinal splinting. The greatest emphasis is placed on the history and physical examinations, with documentation of the extent of neurologic deficit, including the Glasgow coma scale. Data on 900 pre-hospital calls by volunteer EMTs demonstrate a 90% compliance in basic life support skills outlined in the educational program. A similar compliance has been achieved with referring physicians and house staff in the medical center, in the acute management of the CNS injured patient, due primarily to this educational program and increase in the optimal care of these patients has resulted.     

Care and services for spinal injured people with,and without,neurological deficit

Purpose : To describe the care and service usage characteristics of the spinal injured (SI) population of New South Wales (NSW), Australia, including people without significant permanent neurological deficits. Method : A cross-sectional mailed survey was undertaken with all persons admitted to the two spinal injury hospital units in NSW following traumatic spinal injury in the period 1977 - 1992 who were not known to be deceased ( n =2432). Response was gained from 75.8% of the 932 persons whose address was able to be confirmed ( n =706). Results : SI persons were primarily males who incurred a motor related trauma at a young age. Over one third had minimal or no permanent neurological impairment. Over half of the respondents received assistance with everyday living (59.5%), including older persons with minimal or no motor or sensory problems, and a large number made use of professional services (40.5%). People with lower-level incomplete lesions were more likely to use paramedical services than some groups of people with quadriplegia. Conclusions : The relatively high use of care and paramedical services by some persons with minimal physical functional limitations indicates the importance of including such persons when considering the provision of long-term care and rehabilitation services for people with spinal injury.     

What happens to paraplegics? (AUTHOR'S TRANSL)]

The article presents the results of re-examinations performed on 120 persons with spinal cord injuries due to industrial accidents. Comparisons were made between paraplegis and paraparetics with varyingly long histories of spinal cord damage. Examined was: independence in daily life activities, walking ability, frequence and type of complications, and employment. It was surprising that spinal cord injuries with incomplete lesions were relatively more often associated with complications than paraplegia, the most frequent complication being the urinary tract infection. As was to be expected, all groups of paraparetics were more independent in their daily living activities than the paraplegics. Walking ability diminished with age and also the length of time since injury. Whereas in the sample group D (up to five years after injury) only spinal cord injured persons with incomplete lesions were gainfully employed, in the groups A-C (up to 20 years after injury) the total of 13 paraplegics with complete lesions had a job.     

Nonarticular complication of heterotopic ossification: a clinical review

Heterotopic ossification (HO) is a complication in neurologic lesions such as head injury and spinal cord injury. Limitation of range of motion and ankylosis as results of HO are well documented. In this report, ten instances of nonarticular complications after development of HO are described. There were three instances of vascular compression, five instances of ulnar nerve compression at the elbow, and two instances of suspected lymphedema. Clinical findings and radiographic evidence of these complications are described. Clinicians should be aware of these complications when HO is diagnosed. In addition, HO should be considered in the differential diagnosis of deep venous thrombosis in spinal cord injured and head injured patients.     

Effect of spinal cord injury on the respiratory system

There are >200,000 persons living with a spinal cord injury in the United States, with approximately 10,000 new cases of traumatic injury per year. Advances in the care of these patients have significantly reduced acute and long-term mortality rates, although life expectancy remains decreased. This article will review the alterations in respiratory mechanics resulting from a spinal cord injury and will examine the contribution of respiratory complications to morbidity and mortality associated with various types of spinal cord injury.     

Care and services for spinal injured people with,and without,neurological deficit

Purpose : To describe the care and service usage characteristics of the spinal injured (SI) population of New South Wales (NSW), Australia, including people without significant permanent neurological deficits.

Method : A cross-sectional mailed survey was undertaken with all persons admitted to the two spinal injury hospital units in NSW following traumatic spinal injury in the period 1977 - 1992 who were not known to be deceased ( n =2432). Response was gained from 75.8% of the 932 persons whose address was able to be confirmed ( n =706).

Results : SI persons were primarily males who incurred a motor related trauma at a young age. Over one third had minimal or no permanent neurological impairment. Over half of the respondents received assistance with everyday living (59.5%), including older persons with minimal or no motor or sensory problems, and a large number made use of professional services (40.5%). People with lower-level incomplete lesions were more likely to use paramedical services than some groups of people with quadriplegia.

Conclusions : The relatively high use of care and paramedical services by some persons with minimal physical functional limitations indicates the importance of including such persons when considering the provision of long-term care and rehabilitation services for people with spinal injury.     

Prognostic factors for 12-year survival after spinal cord injury.

A study of 9,135 persons injured between 1973 and 1984 and treated at any of 13 model regional spinal cord injury care systems was conducted to determine both overall survival and the effects of prognostic factors. All subjects survived at least 24 hours, and followup ended December 31, 1985. Cumulative 12-year survival was 85.1% (88.2% of normal). Survival ranged from almost 95% (more than 96% of normal) for persons who were younger than 25 years at time of injury and who had neurologically incomplete lesions, to 18.1% (26.9% of normal) for persons who were at least 50 years old at time of injury and who had neurologically complete quadriplegia. Spinal cord injury mortality rates ranged from 1.68 to 15.98 times higher than corresponding rates for non-spinal-injured persons. Although mortality rates for many persons with spinal cord injuries have declined dramatically during the past few decades, these data confirm the continued poor prognosis for older persons with neurologically complete quadriplegia.     

The meaning of living with spinal cord injury 5 to 10 years after the injury

A phenomenological study was conducted with 20 spinal cord injured persons and their family members to examine the meaning of living with spinal cord injury 5 to 10 years after the initial injury. Seven themes emerged from the data. The themes are looking for understanding to a life that is unknown, stumbling along an unlit path, viewing self through a stained glass window, challenging the bonds of love, being chained to the injury, moving forward in a new way of life, and reaching normalcy. The uncovered meanings enhance our understanding and appreciation that living with spinal cord injury is a continuous learning experience. The study findings may be useful in the development of self-care strategies and ongoing interventions that focus on maintaining physical and psychological health for both spinal cord injured persons and their family members throughout the course of living with the disability.     

Nutrition in acute spinal cord injury

Nutrition in acute spinal cord injury is complicated. Not every aspect of nutrition as it relates to the acutely injured spinal cord patient is known. The stress response to injury, fever, infection, sepsis, and surgery alter nutritional needs, as does the spinal cord injury itself. The sequelae of spinal cord injury, including denervation atrophy and paralysis, glucose intolerance, skin and wound breakdown, poikilothermy, anemia, respiratory paralysis, pneumonia, paralytic ileus, gastrointestinal ulcers and hemorrhage, neurogenic bowel and bladder, and depression, all affect the nutritional needs of the patient. Orthopedic appliances, pharmacologic agents, and other injuries can also alter nutritional requirements. Nutritional assessment in acute spinal cord injury is also complex. It should include medical and diet history, physical examination, intake and output measurements, prediction of energy expenditure and protein requirements, or--even better--measurements of energy expenditure with indirect methodology, using the metabolic cart or pulmonary artery catheter. Application of computerized tomography and radioisotope studies may prove valuable in the future. Finally, the direct relationship between nutrition and physiologic alterations of acute spinal cord injury necessitates that the critical care nurse incorporate nutrition-focused thinking into many aspects of the acute spinal cord--injured patient's care.     

Discharge disposition from model spinal cord injury care system rehabilitation programs.

OBJECTIVE: To identify and quantify factors associated with discharge to a nursing home for people with spinal cord injuries. DESIGN: Case control within a cohort of spinal cord injured persons. SETTING: Model spinal cord injury care systems throughout the United States. PATIENTS: A total 16,633 patients consecutively discharged alive between 1973 and 1996 who were admitted to the model system within 1 year of injury, who were both injured in and resided in the catchment area of the model system, and who were discharged to either a nursing home or a community residence. MAIN OUTCOME MEASURE: Discharge disposition. RESULTS: Overall, 4.3% of patients were discharged to a nursing home. Factors that were significantly associated (p < .0001) with place of discharge were age, race, employment status at injury, bladder management method at discharge, education level, marital status, Frankel grade, functional independence in performing activities of daily living, independent ambulation, geographic region, neurologic level of injury, ventilator dependency, and third-party sponsor of rehabilitation. A multivariate predictive model was developed from these factors and was both 78% sensitive and specific in identifying patients who were discharged to a nursing home. CONCLUSIONS: Knowing the probability of nursing home placement can assist in evaluating the success of a rehabilitation program by allowing adjustment for case-mix differences across facilities.     

The adaptation to pregnancy of spinal cord injured women

This study explored the experiences encountered by spinal cord injured women during pregnancy. The spinal cord injured women experienced complications associated with pregnancy: recurring urinary tract infections, an increase in incontinence, and autonomic dysreflexia. (The first two of these are not unique to spinal cord injury, but are common in all pregnancies.) They neither developed pressure areas nor experienced premature deliveries, major complications predicted by the literature. All felt they were victims of inadequate environmental design that hindered their mobility and inhibited their independence. Many of the psychosocial aspects studied proved to be common to pregnant women in general and not specific to the spinal cord injured population.     

Urinary tract infection in spinal cord injury

Loss of normal bladder function results in increased risk of developing urinary tract infection. Recurrent bacteriuria continues to be a problem in most spinal cord injured persons regardless of the bladder emptying method used. Lower urinary tract complications have decreased with intermittent catheterization, but the effect of increased intravesical pressure and presence of bacteriuria on renal function are still undetermined. Current methods of neurogenic bladder management are often based on professional or institutional presuppositions rather than scientific data. Although there are many unanswered questions about the role of urinary tract infection in spinal cord injury patients, treatment should be based on scientific knowledge, even though the knowledge base is still limited. Preservation of renal function is the ultimate goal of any method of neurogenic bladder management. Although a person with spinal cord injury is described, the material covered is applicable to other neurogenic bladder disturbances.     

Secondary spinal lesions in spinal cord injury patients

On hospital admission, 6 spinal cord injured patients were noted to have second noncontiguous levels of spinal injury that were previously unrecognized. These secondary levels of spinal injury were diagnosed as a result of routine admission total spine radiographic examinations. Two cases are described in detail, one with the secondary spinal lesion above and the other below the primary spinal cord injury. Careful total spine radiographic studies are recommended to prevent complications, in the event that such lesions are initially unrecognized.     

Changes in the urogenital tract of spinal cord injured patient--uro-check-list applied to representative subjects (author's transl)]

On the basis of a URO-CHECK-list drawn up by the rehabilitation centre Tobelbad near Graz, 120 spinal cord injured persons were re-examined with the purpose of identifying changes in the urogenital tract. The classification and evaluation of the urological complications revealed a surprisingly high percentage of severe changes which had occurred during the first decade after the accident. As a consequence, it must be ensured that spinal cord injured persons receive yearly check-ups in a urologically oriented rehabilitation centre where all modern examination methods, including electronic techniques for the measurement of bladder pressure and urethral resistance, are available.