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1. Complications of paraplegia
and its management
chetan

2.  Typically affect young and previously
healthy individuals who now require
urgent and comprehensive
emergency care
 patient is expected to learn to
perform once simple and now
complex tasks of daily living
independently with the goal of
returning home

3. History
 Egyptian physicians long ago labeled SCI as an ailment not to
be treated at all because they feared that the pharaoh would
kill them if they let a patient die under their care.
 Prior to WW I, SCI typically resulted in early death.
 Significant advances in treatment began during WW II & have
continued to progress, allowing many individuals with SCI to
live far longer than previously expected.

4. Def
 Impairment in motor function of the lower extremities and possibly trunk with or without involvement
of sensory system
 Caused by involvement of
 cerebral cortex,
 spinal cord,
 Nerves supplying the muscles of lower extremity
 And the muscle itself directly

5.  Early rehabilitation of spinal cord injury pts begin with prevention
 Preventing secondary complications speeds entry into the rehabilitation phase and improves the
possibility that the patient will become a productive member of society

6. Complications
 Pressure Ulcers
 Pulmonary Complications
 Osteoporosis and Fractures
 Urinary Tract Dysfunction
 Neurogenic Heterotopic Ossification
 Spasticity
 Venous thrombosis
 Upper extremity arthropathies
 Bowel Complications
 Cardiovascular Diseases

7. Pressure ulcer
decubitus ulcer
Bedsore
pressure sore

8. sites
 Early acute phase – sacral area
 Subacte and chronic phases – ischial area

9. Risk factors
Combination of
 Immobility
 Insensitivity
 Moisture from bowel or urinary
incontinence
 Muscle atrophy
 Nutrironal status

10. National Pressure Ulcer
Advisory Panel staging
system
 Stage I: Intact skin with nonblanchable
redness of a localized area usually over a
bony prominence.

11.  Stage II: Partial-thickness
loss of dermis presenting as a
shallow open ulcer with a red
pink wound bed, without
slough

12.  Stage III: Full-thickness tissue
loss. Subcutaneous fat may be
visible, but bone, tendon, or
muscle is not exposed. Slough
may be present

13.  Stage IV: Full-thickness
tissue loss with exposed
bone, tendon, or muscle

14. Prevention
 Assess the patient's skin daily
 Cleanse skin when indicated using a pH-balanced cleanser
 Avoid soap and hot water
 dry by rubbing or patting
 Use emollients to maintain skin hydration

15. Pressure relief
 Support surfaces are divided into 2 categories
 Constant low-pressure (CLP) devices
 Alternating-pressure (AP) devices

16. Cushions for wheelchairs filled with gel, foam, air, or water are available to relieve pressure

17.  A turning schedule should be initiated immediately
 The patient’s position in bed should be initially established for turns to occur every 2 to 3 hours.
 This interval can be gradually increased to 6 hours with careful monitoring for evidence of skin
compromise
 Turning positions include prone, supine, right and left side-lying, semi prone, and semisupine positions

18. Wound care
 Debridement is the first step
 Followed by NPWT
 Surgical management

19. Musculocutaneo
us flap

20. Heterotopic ossification
 transformation of primitive mesenchymal cells in the surrounding soft tissue to mature lamellar
bone
 Early complication occurs within 1 month of rehabilitaition
 Incidence is 50%
 Present - swelling, fever, and reduction in ROM of affected joint(s)

21. Diagnosis
 level of sr creatine phosphokinase early stage -severity of muscle involvement
 Sr alkaline phosphatase –inc bone turnover
 Xray {calcification appears after 3 to 8 weeks progress from peripheral to central}
 Mri- varies as the lesion evolves
 Early T1 poorly defined masses {immaure –complex fluid collection}
 Ct 3d recon
 Three phase technetium bone scan early

22.  Early diagnosis {suspicious} is the key for timely intervention and prophylactic management
 complications such as nerve impingement, joint contractures, pain, and limited range of motion
 Surgical - risks wound healing complications, delayed therapy, rehabilitation, as well as the risk of
recurrence

23.  indomethacin is effective if started early (3 to 4 weeks) after injury
 Etidronate is first-line treatment for management of HO in the acute stage
 aggressive joint motion by physical therapy

24. Osteoporosis and Fractures
 significant bone loss in paralyzed limbs in the early period after injury
 distal femur and proximal tibia
 Bone densitometric studies --bone loss of 30% in the first 3 months
 Patients who actually suffer fractures were found to have even higher bone loss: approx 40% in femoral
shaft and 70% in proximal tibia
The paraplegic fracture: supracondylar femur fracture

25. Prevention and treatment
 Intensive exercise regime and mobilization
 Transient
 Pharmological management
 Non operative
Exoskeleton-Assisted Walking

26. Joint contractures
 Due to presence of weakened and paralyzed muscles
 development of a contracture may result in postural misalignment or impede potential function

27.  prevention includes the use of splints for proper joint alignment,
techniques such as weight bearing and functional excercies

28.  Despite preventive measures if joint contactures occur
 plaster or fiberglass serial casting techniques
 botulinum toxin type A injections {tone reduction}
 Surgical management

29. Respiratory Complications
 most common early and late cause of death after SCI
 Pneumonia is the most common complication in high-level injuries, while atelectasis is seen in all
groups of patients

30. pathophysiology
 restrictive ventilatory dysfunction --muscle paralysis
 inability to cough, which is due primarily to paralysis of abdominal and intercostal muscles
 hypersecretion of mucus--absent sympathetic outflow

31.  Secretions are most commonly removed by tracheal
suctioning, assisted coughing
 Acessory muscle training
Maximal
Inspiratory
effort
Delivers a
manual
thrust to
cough

32.  bronchodilators (β-adrenergic agonists and /or anticholinergics), mucolytic agents, and chest
physiotherapy
 Later in phase of rehabilitation there is decrease mucus production needs assisted cough and
breathing excercises
 yearly vaccination for influenza and vaccination every five years for pneumonia

33. Shoulder arthropathies
 Prevalence is 30 to 60% Shoulder becomes major weight bearing
And often overused
Neuromuscular fatigue leads to decreased stability and superior displacement of the humeral head

34. Shoulder Arthropathies
 Common pathologies include:
 Chronic inflammation (especially supraspinatus)
 Impingement syndrome
 Bursitis
 Rotator cuff tears
 Bicipital tendinitis
 Glenohumeral and acromioclavicular arthritis
 Peripheral neuropathies (carpal tunnel syndrome) are also common

35. Shoulder Arthropathies
 Paraplegic patients with higher levels of shoulder pain reported lower subjective
quality of life and physical activity scores
 Interventions:
 Designing ergonomic ways for patients to transfer
 Wheelchair biomechanics (power)
 Physiotherapy to enhance shoulder stability
 Core body support for patients with high thoracic paraplegia
 Medical management
 Surgical management (cuff repair, subacromial debridement, shoulder arthroplasty)

36. Neurogenic bladder
incontinence

37. Consortium for Spinal Cord Medicine
 Management of fluid intake to maintain daily urine output between 1.5 and 2 L
 Intermittent catheterization using clean or sterile technique
 Indwelling catheter for patients with poor hand control and lack of attendant care
 Suprapubic catheter for, most commonly, patients with urethral lesions
 External (condom) catheter for male patients with UMN bladder with reflex voiding
 Surgery

38. Neurogenic bowel
Following SCI, there is a disruption of the extrinsic influences of the nervous system on the bowel
significant physical distress
Embarrassment
inconvinence

39. UMN
• Voluntary control of bowel is lost in
these patients but conus-mediated reflex
activity and intestinal peristalsis are
intact.
• external anal sphincter becomes spastic
LMN
• Voluntary control of bowel is lost as well
as sacral reflex activity.
• The external anal sphincter becomes
atonic and flaccid

40. Cardiovascular comlications
 related to the disruption of sympathetic control located in the cervical cord
 Most frequent presentations are
 orthostatic hypotension (68%) {passive vasodilatation below the level of injury}
 bradycardia (71%) {uninhibited parasympathetic tone}
 Dizziness
 Blurred vision
Midodrine orally alpha 1 agonist is 1 choice

41. Deep Vein thrombosis
 Incidence is high in acute stages incidence is 47%
 Caution with motor complete injuries, obesity, previous h/o of dvt , lower extremity
fractures heart failure

42.  compression stockings, boots, pneumatic devices
 LMWH is recommended for 8 weeks
 Oral anticoagulants like Warfarin
 Inferior vena cava filter if contraindication to anticoagulants