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Complications of SCI
Skin Breakdown | =
Fractures | =
Pneumonia | =
Heterotopic Ossification
=
Spasticity | =
Autonomic Dysreflexia | =
Deep Vein Thrombosis
=
Cardiovascular Disease | =
Syringomyelia | =
Neuropathic Pain
=
Skin Breakdown
= Skin breakdowns (also termed "decubitus ulcers") are a major complication= associated with spinal cord injury. They occur as a result of excessive = pressure, primarily over the bones of the buttock (particularly the ischi= al tuberosities and the trochanters at the hip). Following a spinal cord = injury, there are not only changes in muscle tone and sensation, but shif= ts in the supply of blood to the skin and subcutaneous tissues. Additiona= lly, there is a loss of the normal elastic nature of the tissues underlyi= ng the skin. Increased stiffness, vascular alterations and alterations in= muscle tone combine to significantly reduce the skin's ability to withst= and pressure. It is estimated that the closing "pressure" for skin breakd= own is between 40 and 50 millimeters of mercury (about the same amount of= pressure as placing a stamp onto an envelope). This complication is comb= ated fairly aggressively through the use of pressure-relieving cushions t= hat are either gel based or consist of a number of air bladders to reduce= the risk of the person "bottoming out". The cost associated with medical= and/or surgical care of a single decubitus ulcer can run anywhere from $= 10,000 to $50,000 per admission. This does not take into consideration th= e loss of productivity if the individual is in the work place.
Osteoporosis and Fractures
The majority of people with SCI develop osteoporosis. In people without S= CI, the bones are kept strong through regular muscle activity or by beari= ng weight. When muscle activity is decreased or eliminated and the legs n= o longer bear the body's weight, they begin to lose calcium and phosphoru= s and become weak and brittle. It generally takes some time for osteoporo= sis to occur. In people who use standing frames or braces, osteoporosis i= s less of a problem. Generally, though, 2-t years following SCI some degr= ee 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 pr= ocess. Standing using a standing frame or a standing table also helps pre= vent weakening of the bones and so does using braces for functional or pa= rallel bar walking. Newer techniques, such as electrical stimulation of t= he leg muscles, may decrease osteoporosis as wel. =
Unfortunately, at the present time, there is no way to reverse osteoporos= is once it has occurred. The main risk of osteoporosis is fracture. Once = the bones become brittle, they fracture easily. An osteoporotic bone tak= es much longer to heal. =
Pneumonia, Atelectasis, Aspiration
= Patients with spinal cord injuries above the T4 level of injury are at ri= sk to develop restriction in respiratory function, termed restrictive lun= g disease. This occurs five to 10 years following spinal cord injury and = can be progressive in nature. The quadriplegic individual as part of a he= alth care maintenance routine should have pulmonary function studies at y= early or every-other-year intervals between five and 10 years post injury= =2E As the medical treatment of spinal cord-injured individuals continues= to improve, respiratory complications of SCI are becoming more prominent= =2E Adequate health maintenance and protection from this complication are= appropriate and necessary as part of the long-term care of the spinal co= rd-injured individual.
Heterotopic Ossification
Heterotopic ossification is a condition not well understood that occurs i= n acute spinal cord injury and consists of the laying down of bone outsid= e the normal skeleton, usually occurring at large joints such as the hips= or knees. The primary problem with heterotopic ossification, or HO, is t= he risk for joint stiffening and fusion. Should the hip or knee become fu= sed 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 us= ed to prevent the development of HO include range of motion programs and = other functional activities that move the joints within a functional rang= e. Currently treatment is limited with the exception of preventing the jo= int fusion (termed ankylosis).
Spasticity
= After spinal cord injury the nerve cells below the level of injury become= disconnected from the brain. Following the period of spinal shock change= s occur in the nerve cells that control muscle activity. Spasticity is a= n exaggeration of the normal reflexes that occur when the body is stimula= ted in certain ways. After spinal cord injury, when nerves below the inju= ry become disconnected from those above, these responses become exaggerat= ed. =
= Muscle spasms, or spasticity, can occur any time the body is stimulated b= elow the injury. This is particularly noticeable when muscles are stretch= ed 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 musc= les to contract or spasm. =
= Almost anything can trigger spasticity. Some things, however, can make sp= asticity more of a problem. A bladder infection or kidney infection will = often cause spasticity to increase a great deal. A skin breakdown will al= so increase spasms. In a person who does not perform regular range of mot= ion exercises, muscles and joints become less flexible and almost any min= or stimulation can cause severe spasticity.
= Some spasticity may always be present. The best way to manage or reduce e= xcessive spasms is to perform a daily range of motion exercise program. = Avoiding situations such as bladder infections, skin breakdowns, or injur= ies to the feet and legs will also reduce spasticity. There are three pri= mary medications used to treat spasticity, baclofen, Valium, and Dantrium= =2E All have some side effects and do not completely eliminate spasticity= =2E =
= There are some benefits to spasticity. It can serve as a warning mechanis= m 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 le= fts. IT can be used to improve certain functional activities such as perf= orming transfers or walking with braces. For these reasons, treatment is = usually started only when spasticity interferes with sleep or limits an i= ndividual's functional capacity. =
Autonomic Dysreflexia
= Autonomic dysreflexia (AD) is a condition that can occur in anyone who ha= s a spinal cord injury at or above the T6 level. It is related to disconn= ections between the body below the injury and the control mechanisms for = blood pressure and heart function. It causes the blood pressure to rise t= o potentially dangerous levels. == AD can be caused by a number of things. The most common causes are a full= bladder, bladder infection, severe constipation, or pressure sores. Anyt= hing that would normally cause pain or discomfort below the level of the = spinal cord injury can trigger dysreflexia. AD can occur during medical t= ests or procedures and need to be watched for. =
= The symptoms that occur with AD are directly related to the types of resp= onses that happen in the sympathetic and parasympathetic nervous systems.= Symptoms such as a pounding headache, spots before the eyes, or blurred = vision are thee direct result of the high blood pressure that occurs when= blood vessels below the injury constrict. The body responds by dilating = blood vessels above the injury, causing flushing of the skin, sweating, a= nd occasionally goosebumps. Some patients describe nasal stuffiness and w= ill feel very anxious. Uncontrolled AD can cause a stroke if not treated.= =
= The treatment for AD involves removing the reason for the stimulation. On= e of the first things a patient can do is to sit up. This naturally decre= ases blood prsessure. If there is a catheter in place, it should be check= ed to be certain that there is not a kink in the tubing. If there is not = a catheter in place, the patient should be catheterized. The bowels shoul= d be checked to be ceratin there is no stool in the rectum. If the sympto= ms are caused by skin breakdown, the patient should get to an emergency d= epartment as soon as possible.
The primary risk of AD is stroke. It is a potentially life-threatening co=
ndition. If AD is left untreated, the body's attempt to control blood pre=
ssure will severely decrease the heart rate. This, combined with uncontro=
lled high blood pressure, can be fatal. For this reason, it is very impo=
rtant to treat this condition as soon as possible. The most important thi=
ng patients can do to prevent AD from occurring is to take good care of t=
hemselves. Patients should monitor bladder output and should maintain a r=
egular bowel program which fully empties the bowels. They should also do =
regular skin checks to prevent pressure sores from occurring. =
Deep Vein Thrombosis
= Deep vein thrombosis (DVT) or pulmonary embolism is a potentially severe = complication of spinal cord injury. As mentioned above, there are changes= in the normal neurologic control of the blood vessels that can result in= stasis or "sludging". Deep vein thrombosis in the lower leg is almost un= iversal during the early phases of recovery and rehabilitation. Thrombose= s in the thigh, however, are a great concern, as they are at risk for bec= oming dislodged and passing through the vascular tree to the lungs. A maj= or obstruction of the arteries leading to the lung can potentially be fat= al. Therapeutic measures to reduce or eliminate the risk for deep vein th= rombosis include Ace wrapping of the legs and the use of pneumatic compre= ssion stockings. Medications administered subcutaneously, such as heparin= , are useful in reducing blood viscosity and improving flow. In the even= t that a thrombosis develops, treatment is begun with intravenous heparin= =2E Once adequate anticoagulation is provided, the patient is switched t= o an oral medication, called Coumadin.Cardiovascular Disease
Cardiovascular disease is a major long-term risk of spinal cord injury. S= CI individuals live in general rather sedentary lives and are at higher r= isk 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 spin= al cord injury management and care. The prescription of upper extremity e= xercise programs in spinal cord-injured individuals are similar to those = used in other populations with the exception of the use of adaptive equip= ment such as racing wheelchairs or monoskis.Syringomyelia
A post-traumatic enlargement of the central canal of the spinal cord is t= ermed syringomyelia. It occurs in approximately 1-3% of all spinal cord-i= njured individuals. The primary risk of syringomyelia is a loss of functi= on 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 h= er physician of numbness and weakness involving the extremities. The cond= ition will progress with time and needs to be treated aggressively throug= h surgical drainage. Often patients with early evidence of a syrinx will = be followed to evaluate the progression of the condition. Significant syr= ingomyelia is treated with surgical decompression and the placement of a = drainage tube into the spinal cord.
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. ==
= Spasticity | = Autonomic Dysreflexia | = Deep Vein Thrombosis
= Cardiovascular Disease | = Syringomyelia | = Neuropathic Pain
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