Our previous articles concerning spinal cord injuries have looked at the anatomy of the spine and types of injury that can arise, as well as the importance of early multi-disciplinary rehabilitation. In this article we will look at the typical complications that can arise following a spinal cord injury and how these can be managed.
Some complications might come and go (ie they are acute in nature), whereas other complications may be more chronic (ie permanent) in nature. These complications can render an already distressing situation for the injured person considerably worse, and it is therefore vital that potential complications are detected early such that they can be averted or promptly treated, or indeed managed appropriately if the complication is chronic in nature.
Typical complications
Tetraplegia (also known as “quadriplegia”)
This is paralysis from the neck down, and involves an injury to the cervical segments of the spinal cord. Such injuries are at the most serious end of the spectrum of sequelae which can flow from a spinal cord injury. A person who has been rendered tetraplegic will typically suffer from, or be at risk of experiencing, the myriad of complications which are discussed below.
Paraplegia
This is paralysis that affects the lower body only, and involves an injury to the thoracic, lumbar or sacral segments of the spinal cord. The complications that flow from an injury at this level of the spine are much more wide-ranging in terms of severity, but typically they affect body functions and abilities from the chest down.
Spasticity and contractures
Spasticity is a form of muscle overactivity. It can cause stiffness, pain, muscle spasms and fatigue. It leads to increased muscle tone which in turn can cause contractures. When contractures occur the joint cannot be fully bent or straightened, and the muscles cannot be stretched to the full length.
Spasticity can impact on a person’s daily activities such as walking, sitting and eating, and if left untreated it can lead to increased immobility and pain. This in turn can impact on skin integrity. It is therefore key that a spinal cord injured person is afforded effective spasticity and contracture management to optimise their mobility and function, and reduce pain and risk of skin lesions.
Spinal (neurogenic) shock
Following a spinal cord injury the body cannot always regulate its own blood pressure, heart rate and temperature. As a result blood flow can become too low and oxygen is not distributed to the body’s organs. This can lead to low blood pressure, a slower heart rhythm, cold/clammy skin, blue tinged lips and fingernails, and ultimately a person can lose consciousness. Without appropriate medical intervention, one or more of the person’s body organs could be permanently damaged and there is a risk of death.
Autonomic Dysreflexia (known as “AD”)
AD symptoms are variable and usually sudden, occurring due to a sudden increase in blood pressure. It is a life threatening condition that can cause death, and it requires urgent medical attention. It is most commonly caused by bladder and bowel distension (ie stretching or enlargement), bladder or kidney stones, a kink in a urinary catheter, infection of the urinary tract, fecal impaction, and pressure sores. Typical warning signs and symptoms include (i) raised blood pressure, (ii) bradycardia, (iii) pounding headache, (iv) flushing, sweating or blotching (above level of injury) and (v) pale, cold skin and goosebumps below the level of injury. The condition usually resolves as soon as the cause is eliminated (eg bladder voided or colon emptied).
Nerve pain (neuropathic pain)
This is a very common and chronic condition in people with a spinal cord injury and is often described as burning, squeezing, aching or tight pain. It is persistent in nature and can affect a person’s day-to-day living, sleep, and mental health and well-being. It is very often resistant to treatment and can therefore have a devastating impact on a person’s life and that of their loved ones.
Pulmonary and respiratory conditions (such as blood clots, DVT)
Pulmonary complications are more common in high-level injuries (C1-C4), and the most frequent issues are pneumonia, atelectasis (collapse of the lung) and ventilatory failure. In short, the higher the level of injury, the greater the impact on respiratory ability. Where respiratory function is impeded, this can result in a need for permanent or temporary mechanical ventilation, whereas those people with lower level injuries are more generally able to maintain spontaneous ventilation.
Cardiovascular
Common cardiovascular complications in the acute phase are (i) bradyarrythmia (an abnormally slow and irregular heartbeat), (ii) hypotension (low blood pressure), (iii) increased vasovagal reflexes (which can lead to lightheadedness and fainting), (iv) supraventricular/ventricular ectopic beats (an extra heartbeat), (v) vasodilation (widening of blood vessels which can lead to a lowering of blood pressure) and (vi) venous stasis (slow blood flow in the veins, usually the legs).
Bladder/bowel dysfunction
A spinal cord injury can often interrupt communication between the brain and the nerves in the spinal cord that control bladder and bowel function. This can lead to a neurogenic bladder or bowel, resulting in problems when emptying the bladder and bowel. As with many complications surrounding a spinal cord injury, the higher up in the spinal cord an injury occurs, the more impact on ability and function below the site of the injury.
Depending on the type and level of injury, it is possible that a person will lose all control and sensation in which case the neurogenic bladder and bowel will have to be carefully managed and monitored. Sound bladder and bowel management will reduce the risk of complications from arising (such as AD) and will enable the injured person to live with dignity and optimal independence.
Pressure sores
Skin integrity is vital in a person with a spinal cord injury. Skin problems are more common in those with a spinal injury due to reduced mobility, sensation and circulation. It is therefore extremely important that skin is closely monitored and kept healthy, to minimise the risk of sores and pressure injuries. Such injuries can become chronic, and place the person with the spinal cord injury at a high risk of infection, sepsis and even death in the worst case scenario.
Management of a spinal cord injury
It is essential that there is effective management of the spinal cord injury at all stages, from the immediate aftermath of the traumatic event giving rise to the injury, through the acute and early rehabilitation phases, and thereafter for the longer term. Clearly there will be different priorities and interventions at each stage.
In the immediate aftermath of the trauma occurring, the priority is often, quite simply, to save the person’s life and to prevent further injury. This will often be achieved through spinal immobilisation, cardiovascular and ventilation support, and ensuring appropriate thermoregulation. Emergency services crew need to be specially trained to identify the possibility of a spinal cord injury at the scene of an incident, and to take precautionary steps to avoid further damage when transferring or transporting the injured person to hospital.
During the acute phase, an early diagnosis of the nature and extent of the spinal trauma should be identified through diagnostic imaging and neurological assessment (with reference to the ASIA Impairment Scale). Emergency surgical intervention may be necessary, often early decompression surgery, and pharmacological management must be considered to prevent deterioration and to encourage neuroprotection. Potential respiratory failure and vascular complications also require close scrutiny and management. Whilst not unique to spinal cord injuries, the risk of pressure sores and skin integrity generally also need to be closely watched.
Once a person has been stabilised a multi-disciplinary team (“MDT”) compromising physiotherapy, occupational therapy, psychology, rehabilitation clinicians, spinal consultant, speech and language therapy etc should be gathered to enable the person to embark on an intense rehabilitation programme at the earliest opportunity. This will not only aid some improvements and prevent secondary complications, but will also play a great role in providing a positive focus for the injured person thereby enhancing mental wellbeing. Longer term, an MDT rehabilitation programme will enable the injured person to make optimal progress in terms of achieving greater function, mobility and function, thereby allowing the person to lead as fulfilling a life as possible notwithstanding their injury, and to facilitate a reintegration into their local community.
The importance of sound management of the spinal cord injury cannot therefore be overstated; fundamentally a person’s ability to achieve their optimal outcome will very much depend on the integrity of the post trauma interventions and rehabilitation that are put in place for them.
