Ali Karabulut - Spinal Cord Injury (SCI) Pages

 

OTHER COMPLICATIONS OF SPINAL CORD INJURY

     In this section you will find information on some of the complications that may occur following SCI: autonomic dysreflexia; deep venous thrombosis (DVT); heterotopic ossification (HO); hyperthermia and hypothermia; medication problems; pain; postural hypotension; and spasticity.

Autonomic Dysreflexia ( Hyperreflexia)

Bony Dysfunction

Cardiovascular Disease

Deep  Venous Thrombosis (DVT)

Hyperthermia/Hypothermia

Heterotopic Ossification (HO)/ Cyst

Medication Problems

Osteoporosis and Fractures

Pain

Postural (Orthostatic) Hypotension

Spasticity

Syringomyelia 

Vascular Dysfunction 
 

AUTONOMIC DYSREFLEXIA (HYPERREFLEXIA)

     Autonomic dysreflexia, also known as hyperreflexia, is a state that is unique to patients after spinal cord injury at a T-5 level and above. Patients with spinal cord injuries at Thoracic 5 (T-5) level and above are very susceptible. Patients with spinal cord injuries at Thoracic 6 - Thoracic 10 (T6-T10) may be susceptible. Patients with Thoracic 10 (T-10) and below are usually not susceptible. Also, the older the injury the less likely the person will experience autonomic dysreflexia.

     Autonomic dysreflexia can develop suddenly, and is a possible emergency situation. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.

     Autonomic dysreflexia means an over-activity of the Autonomic Nervous System. It can occur when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. Since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure. Nerve receptors 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.

SYMPTOMS AND CAUSES

Symptoms and Causes

  • Pounding headache (caused by the elevation in blood pressure)
  • Goose Pimples
  • Sweating above the level of injury
  • Nasal Congestion
  • Slow Pulse
  • Blotching of the Skin
  • Restlessness

     There can be many stimuli that cause autonomic dysreflexia. Anything that would have been painful, uncomfortable, or physically irritating before the injury may cause autonomic dysreflexia after the injury.

     The most common cause seems to be overfilling of the bladder. This could be due to a blockage in the urinary drainage device, bladder infection (cystitis), inadequate bladder emptying, bladder spasms, or possibly stones in the bladder. The second most common cause is a bowel that is full of stool or gas. Any stimulus to the rectum, such as digital stimulation, can trigger a reaction, leading to autonomic dysreflexia.

     Other causes include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications.

In general, noxious stimuli (irritants, things which would ordinarily cause pain) to areas of body below the level of spinal injury. Things to consider include:

  • Bladder (most common) - from overstretch or irritation of bladder wall
    • Urinary tract infection
    • Urinary retention
    • Blocked catheter
    • Overfilled collection bag
    • Non-compliance with intermittent catheterization program
  • Bowel - over distention or irritation
    • Constipation / impaction
    • Distention during bowel program (digital stimulation)
    • Hemorrhoids or anal fissures
    • Infection or irritation (eg. appendicitis)
  • Skin-related Disorders
    • Any direct irritant below the level of injury (eg. - prolonged pressure by object in shoe or chair, cut, bruise, abrasion)
    • Pressure sores (decubitus ulcer)
    • Ingrown toenails
    • Burns (eg. - sunburn, burns from using hot water)
    • Tight or restrictive clothing or pressure to skin from sitting on wrinkled clothing
  • Sexual Activity
    • Over stimulation during sexual activity [stimuli to the pelvic region which would ordinarily be painful if sensation were present]
    • Menstrual cramps
  • Labor and delivery
  • Other
    • Heterotopic ossification ("Myositis ossificans", "Heterotopic bone")
    • Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
    • Skeletal fractures

TREATMENT

     Treatment of autonomic dysreflexia must be initiated quickly to prevent complications.

  • Remain in a sitting position, but do a pressure release immediately. You may transfer yourself to bed, but always keep your head elevated.
  • Since a full bladder is the most common cause, check the urinary drainage system. If you have a Foley or suprapubic catheter, check the following:
    • Is your drainage full?
    • Is there a kink in the tubing?
    • Is the drainage bag at a higher level than your bladder?
    • Is the catheter plugged?

     After correcting an obvious problem, and if your catheter is not draining within 2-3 minutes, your catheter must be changed immediately. If you do not have a Foley or suprapubic catheter, perform a catheterization and empty your bladder.

     If your bladder has not triggered the episode of autonomic dysreflexia, the cause may be your Bowel. Perform a digital stimulation and empty your bowel. If you are performing a digital stimulation when the symptoms first appear, stop the procedure and resume after the symptoms subside.

If your bladder or bowel are not the cause, check to see if:

  • You have a pressure sore
  • You have an ingrown toenail
  • You have a fractured bone.

Identify and remove the offending stimulus whenever possible. Often, this alone is successful in allowing the syndrome to subside without need for pharmacological intervention. It is also good for the person with the symptoms to be sitting up with frequent blood pressure checks until the episode has resolved. [In hospital-based settings or in high-risk individuals / persons who have recurrent episodes, consideration should be given having atropine at the bedside]

Suspected cause = bladder? Check catheter - remove kinks if found, empty urinary collection bag, irrigate catheter. If catheter is not draining, replace it immediately. If an intermittent catheterization program is in place, a straight catheterization should be performed immediately with (slow drainage to prevent bladder spasms).

Suspected cause = bowel? If episode happens during digital stimulation, stop stimulation until symptoms and signs subside. Consider use of a prescribed anesthetic ointment to suppress the noxious stimulus. If the issue is impacted stool, disimpact. If it occurs while doing a bowel program in bed, try commode-based bowel evacuation. Consider use of abdominal massage instead of digital stimulation.

Suspected cause = skin? Loosen clothing. Check for source of potential offending stimulus - check for pressure sores, toenail problems, soles of the feet.

If symptoms persist despite interventions such as the foregoing, notify a physician.

Medications
Medications are generally used only if the offending trigger/stimulus cannot be identified and removed - or when an episode persists even after removal of the suspected cause. Potentially useful agents include:

  • Immediate/emergent
    • Procardia - 10 mg. p.o./sublingual
    • Nitroglycerine - 1/150 sublingual or 1/2 inch Nitropaste topically
    • Clonidine - 0.1 to 0.2 mg. p.o.
    • Hydralazine - 10 to 20 mg. IM/IV
  • Chronic (recurrent episode prevention)
    • Prazosin ("Minipress") - 0.5 to 1.0 mg. daily
    • Clonidine ("Catapres") - 0.2 mg. p.o. b.i.d.

Reminder
If you are unable to find the stimulus causing autonomic dysreflexia, or your attempts to receive the stimulus fail, you need to obtain emergency medical treatment. Since all physicians are not familiar with autonomic dysreflexia (hyperreflexia) and its treatment, you should carry a card in your billfold that describes the condition and the treatment required.

PREVENTION

     The following are precautions you can take which may prevent episodes:

  • Frequent pressure relief in bed/chair
  • Avoidance of sun burn/scalds (avoid overexposure, use of #15 or greater sunscreen, watch water temperatures)
  • Maintain a regular bowel program.
  • Well balanced diet and adequate fluid intake
  • Compliance with medications
  • Persons at risk and those close to them should be educated in the causes, signs and symptoms, first aid, and prevention of autonomic dysreflexia.

  • If you have an indwelling catheter:

    • Keep the tubing free of kinks
    • Keep the drainage bags empty
    • Check daily for grits (deposits) inside of the catheter.
    • If you are on an intermittent catheterization program, catheterize yourself as often as necessary to prevent overfilling.
  • If you have spontaneous voiding, make sure you have an adequate output.
  • Carry an intermittent catheter kit when you are away from home.
  • Perform routine skin assessments.

Reminder
If you are unable to find the stimulus causing autonomic dysreflexia, or your attempts to receive the stimulus fail, you need to obtain emergency medical treatment. Since all physicians are not familiar with autonomic dysreflexia (hyperreflexia) and its treatment, you should carry a card in your billfold that describes the condition and the treatment required.

BONY  DYSFUNCTION


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.

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.

DEEP VENOUS THROMBOSIS (DVT)

     Some patients with SCI develop deep venous thrombosis (DVT), or 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 and symptoms of DVT. There are also no characteristic signs or symptoms of lung clots, i.e. the signs and symptoms are 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, such as heparin and warfarin.

HYPERTHERMIA/HYPOTHERMIA

     Because of your spinal cord injury, the temperature of your body has an increased tendency to fluctuate according to the temperature of the environment. If you are in a hot room your temperature may increase (hyperthermia); if you are in a cold room, your temperature may decrease (hypothermia). This occurs because of the altered function of the autonomic nervous system. The higher the level of injury, the greater the tendency for fluctuations in your body temperature.

Hyperthermia

     Hyperthermia refers to an elevation in body temperature. For example, it may occur on a hot day if you are out-of-doors, sitting in a hot car, or covered with too many blankets.

One or more of the following symptoms may indicate hyperthermia:

  • Skin feels hot and dry and appears flushed.
  • Feeling of weakness
  • Dizziness
  • Visual disturbances
  • Headache
  • Nausea
  • Elevated temperature
  • 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)
  • Wear a hat

HETEROTOPIC OSSIFICATION (HO)/CYST

     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. Heterotopic ossification occurs below the level of injury. The cause of HO is unknown.

     Most cases of heterotopic ossification cause no significant additional physical limitations, but in a minority of patients, HO may result in a major limitation of joint motion. The first symptom 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/shHe will do an X-ray of your hips and knees, a special isotope bone scan, and blood tests. A medication called Didronel is available and can slow down or arrest the process if started early. 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/her specific information about the changes you have notices. A muscle and sensory test will be conducted. If you have neurologic deterioration due to a cyst, it may be corrected with surgery.

MEDICATION PROBLEMS

     A medication is a substance that is taken to prevent or to cure a medical problem. The proper use of medications is a very important aspect of your management after spinal cord injury. Taken correctly, medications have a positive effect on your body. However, if care is not taken, medications can cause many problems.

     Once you leave the hospital, you will be responsible for the medications you take. In order to increase the effectiveness of your medications, it is important that you understand their use. Specifically, you need to know:

  • The name of each medication you are taking
  • The purpose of each medication
  • The possible side effects of each medication, and
  • The problems that could result if the medication is taken in combination with other medications, certain foods, alcohol, etc.

Precautions

     Following are precautions that you, as an individual, can take to ensure that the medications are taken safely:

1. If your doctor prescribes an unfamiliar medication, ask him/her about it. Write down the information he/she gives you. Other sources of information are your nurse, your pharmacist and the literature that may be enclosed with the medication. Questions you should ask include:

  • Can I take this in combination with other medications?
  • Are there any special precautions I need to take when using this medication?
  • Can I drink alcohol while taking this medication?
  • Should it be kept in a refrigerator?
  • Should it be taken before or after a meal?
  • What are the possible side effects of taking this medication?

2. Read and follow the specific directions on the label. Take the medication exactly as directed, at the right time, and for the full length of time prescribed by your doctor. If you are using an over-the-counter (nonprescription) medication, follow the directions on the label, unless otherwise directed by your doctor.

3. Tell each of your doctors and nurses what medications you are or have taken in the past few weeks. Don't forget nonprescription medicines, such as aspirin, laxatives, and antacids.

4. Know all medications to which you are allergic.

5. Report to your doctor any unusual symptoms that occur when taking the medication. Remember: each person reacts differently to each medication.

6. Before having any kind of surgery (including dental surgery) or emergency treatment, tell the doctor or dentist about any medication you are taking.

7. Destroy old medications by flushing them down the toilet. Medications may change characteristics as they age, so an old medication may not only be useless, it may be dangerous.

8. Keep all medications out of reach of children.

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.

PAIN

     On the average, pain occurs in between one third and one half of patients with SCI as a complication of the injury. Only a minority of people with SCI experience pain that is severe or persistent, and pain is relatively rare following discharge from the hospital. However, abnormal phantom sensations (not necessarily pain) in the body and limbs, below the level of the injury, occur in almost all people with SCI.

TYPES OF PAIN

     In general, there are four categories of pain that occurs as a complication of SCI: central, muscle tension, visceral, and psychogenic.

Central Pain

     Central pain, also called dysesthetic pain, is typically a burning, tingling, shooting, stinging, or "pins and needles" sensation. Some people also complain of a stabbing, piercing, cutting, and drilling pain. This type of pain usually occurs within days, weeks, or months of the injury and tends to decrease with time in both frequency and intensity. Central pain is diffuse and occurs most often in the legs, back, feet, thighs, and toes, although it can also occur in the buttocks, hips, upper back, arms, fingers, abdomen, and neck.

      Central pain occurs more frequently in older, more anxious people. It often results from noxious stimuli, such as smoking, bladder and bowel distention, infections, and skin sores, and from heterotopic ossification, deep venous thrombosis, fractures of the arms and legs, prolonged inactivity, spasticity, fatigue, and depression.

Muscle Tension

     Muscle tension, also known as mechanical pain or musculoskeletal pain, is a dull, aching sensation that occurs in people with or without SCI. Muscle tension, that is a complication of SCI, occurs with increased frequency in the shoulder, hip, and hand, although it also occurs in the lower back and buttocks. Muscle tension is probably caused by a combination of factors, such as abnormalities that may have always been there, inflammation, repetitive trauma, excessive activity, vigorous stretching, and contractions due to paralysis, spasticity, flabbiness, disuse and misuse. Generally speaking, muscle tension is usually aggravated by activity and relieved by rest.

Visceral Pain

     Visceral pain is a vague and dull or diffuse sensation, or feeling of discomfort or bloating, in the area of the abdomen, or referred pain felt elsewhere, such as the shoulder. Visceral pain is caused by problems with internal organs, such as the stomach, kidney, gallbladder, urinary bladder, and intestines. These problems include distension, perforation, inflammation, and impaction or constipation, which can cause associated symptoms, such as nausea, fever, and malaise, and pain. Visceral pain is also caused by problems with abdominal muscles and the abdominal wall, such as spasm.
 

Psychogenic Pain

     Psychogenic pain is also known as phantom limb sensations. Its symptoms and causes are variable.

TREATMENT MEASURES

     There are numerous methods of managing SCI pain. Perhaps the most important method involves the commonsense techniques that you can perform to prevent complications and maintain general good health. Other methods include psychological and physical measures, medication, electrostimulation, and surgery.
 

Disease Prevention and Health Promotion

      As you have seen in the above section on the types and causes of pain in SCI, pain can be caused or made worse by infections, skin sores, bladder and bowel distention, smoking, emotional stress, spasticity, excessive use, misuse, or disuse, and other noxious stimuli to the body. Avoiding these problems in the first place and treating them promptly and completely if they do occur are the most important way of preventing and managing pain. In general, this is done by proper nutrition, positioning, exercising, and the methods explained elsewhere in this handbook to care for your skin, urinary tract, bowel, and respiratory system.
 

Psychological and Physical Measures

     As you have also seen in the above section on the types and causes of pain in SCI, pain can also be caused by stress, anxiety, and depression, as well as by improper or excessive activity and inactivity. Therefore, psychological support, recreational and vocational therapy, emphasizing positive or favorable attributes, rather than negative attributes and limitations, training in relaxation techniques, biofeedback, hypnosis, and other ways of achieving your maximum psychosocial adaptation to your injury are also important in the prevention and management of pain in SCI. So too, are physical measures, such as therapeutic exercise to improve your range of motion (ROM), muscle tone, strength, and movement, massage, hydrotherapy, acupuncture, biofeedback, and other physical measures.
 

Medications

     Medications are used to treat pain in SCI if the benefits of the drug are greater than possible side effects. Common drugs, such as aspirin, often provide the necessary relief with a minimum of side effects. Narcotics are prescribed only if the pain is extreme and disabling, such as interfering with the sleep-wake cycle or preventing participation in therapeutic exercise activities. Depending on the type and cause of the pain, other drugs that may be prescribed include antidepressants, tranquilizers, anticonvulsants, and nerve blocks.
 

Electrostimulation and Surgery

Electrostimulation, or the electrical stimulation of nerves in a variety of locations, and surgery on different parts of the nervous system, are sometimes used to treat specific types of severe, persistent, and disabling pain in SCI.

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 any illness. You will have an increased tendency for postural hypotension if your level of injury is at T-6 or above, but it can occur in all spinal cord injured individuals.

     After your spinal cord injury, 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. To prevent this, wear elastic hose and an abdominal support. It is also helpful to come to a sitting or standing position gradually.

     If postural hypotension occurs while you are in a wheelchair, your attendant should firmly grab the handles of the wheelchair and tilt you backward, until your head and neck are nearly horizontal to the floor. This will increase your blood pressure and the "fainting" will quickly disappear. You should then be gradually returned to a sitting position.

     Another problem that may occur as a result of the lowered blood pressure is a decrease in the amount of urine produced by the kidneys. You may notice that there is little or no urine in your urine bag. After you recline, your leg bag may fill quickly. This is a result of the increase in your blood pressure that occurs when you lie down. Watch your drainage bag closely after changing positions to make sure it does not get too full.

SPASTICITY

     Spasticity is common in varying degrees after spinal cord injury. Spasticity is a non-specific symptom, which may occur in many problems associated with spinal cord injury.

     Spasticity is the involuntary movement (jerking) of muscles, which occurs because message can travel from parts of your body to the spinal cord and cause reflex activity (muscle movement). This is possible because the spinal cord has certain normal automatic functions, which are under the influence of the brain. These functions include muscle tone and reflexes. Most spinal cord injured persons have a healthy, intact spinal cord below the immediate area of their injury, and thus these automatic activities can continue to exist. However, they are no longer under the regulating influence of the brain and are thus exaggerated. This is called spasticity.

     Any sensory stimulus below the level of injury can cause spasticity, for example, a change in body position (i.e., movement of an extremity), bladder irritation, pressure sores, fractured bones or a bowel program.

     Sometimes, minor degrees of spasticity may be helpful to you. Due to the muscle movement, your circulation is improved and the movement also helps to maintain the shape and bulk of your muscles. However, if it is severe, spasticity can interfere with functional activities such as transfers, weight shifts, gait training, etc.

     Some stimuli can cause a change in your spasticity. Anything that would ordinarily be uncomfortable or painful can cause an increase in your spasticity. If you experience a major increase in spasticity, possible causes are:

  • Skin problems - a skin sore or ingrown toenail
  • Bladder problems - high residuals, infection or bladder stones
  • Bowel problems - constipation, impactions or hemorrhoids
  • Medical problems - viral syndrome (infection, influenza, intestinal flu), heterotopic ossification or a spinal cyst.

     Although a change in the pattern of your spasticity does not always indicate another problem, it is wise to check all possibilities.

     If your spasticity is severe and interferes with function, there are several medications that may be of help -- Valium, Dantrium, and Lioresal. A surgical procedure called a radiofrequency rhizotomy is sometimes indicated in the treatment of severe spasticity. If you have increased spasticity, which persists, consult your physician.

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 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.

VASCULAR DYSFUNCTION


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. 
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