Potential Complications of Spinal Cord Injury

Most people who have a spinal cord injury (SCI) experience health complications as a result of their injury. Research from 1996 shows that up to 95% of SCI patients report at least one secondary problem, and almost 60% experience three or more.

Obesity, pain, spasticity, urinary tract infections (UTIs), and pressure sores are commonly experienced SCI complications. Other reported problems include

• autonomic dysreflexia
• deep vein thrombosis
• fertility reduction
• heterotopic ossification
• hospitalizations
• osteoporosis
• post-traumatic syringomyelia
• pulmonary difficulties
• scoliosis

And, of course, there are the effects of aging.

While treatment is sought for some complications, others might go untreated. Some can occur without typical signs, which leads to a delay in diagnosis and treatment.

Untreated complications can cause major physical limitations and may compromise your health. It's important to know which complications are common, the symptoms you may have, and where to seek treatment.

Obesity

A very common complication of SCI is weight gain, which may result in obesity. Even physically active SCI men and women have above-average fat mass compared with non-SCI men and women.

There are several reasons for weight gain:

• Activity may be more restricted due to the inability to run or walk.
• Your metabolism slows because you're using fewer large muscle groups, such as those necessary for walking.
• According to a 1997 study by Kocina, bone mineral content decreases, total body water relative to body weight decreases, and total body protein reduces.

There are many recreational activities—including artistic endeavors, outdoor activities, and wheelchair sports—that you can enjoy after your injury stabilizes, but some pre-injury sports or hobbies may be difficult. Unfortunately, many people find themselves watching television more, and being outdoors or performing household chores less.

Disadvantages of Obesity

Obesity can be a major factor in health deterioration. It places a greater strain on your heart, increasing your risk greater for hypertension and cardiovascular disease. Studies confirm the increased risks.

• The prevalence of diseases associated with obesity, such as cardiovascular disease and diabetes mellitus, is higher in the SCI population.
• The mortality rate for cardiovascular disease is 228% higher in the SCI population than the able-bodied population (again, Kocina in 1997).

Obesity also increases the risk of skin breakdown, where there is greater mass resting on the wheelchair or bed surface. Obesity may even make your equipment wear out faster.

Combating Obesity

The loss of mobility, increased physical dependence, diminished social activities, and the lack of fitness can be an obstacle to autonomy following SCI. Here are some ways to maintain fitness.

• It is very important that you follow proper nutritional guidelines, and a consultation with a nutritional counselor is recommended.
• Physical activity is important to maintain metabolism. The most commonly reported benefits of exercise are a reduction in secondary impairments such as loss of cardiorespiratory and muscular function.
• Upper body exercises are important if you use your upper body for transfer, positioning, and propelling your chair. Small weights can be used daily to maintain this strength.
• A fitness gym membership, if possible, may also be a great asset in maintaining strength and weight.

Precautions

When engaged in fitness activities, avoid weather that is too hot, because you may have impairment in thermoregulation functions. That is, your body may have difficulty with the control and maintenance of normal body temperature, and you may not be able to sweat appropriately. Also, during fitness activities, be sure that no part of your body is rubbing against any part of your chair; this can cause sores.

Chronic Pain

"Chronic" pain is pain that lasts more than one month beyond the usual course of an illness or injury, or pain that recurs off and on over months or years.

Chronic pain is a common and significant problem for many people with SCI and is often a challenge for doctors to treat. Many studies have been done on it.

• Research indicates that 25%-45% of people with SCI report severe levels of chronic pain.
• One study indicated that the percentage may be as high as 61%, with the average duration of pain lasting five weeks.
• In another study, pain was reported to be more intense in the evening and at night.
• Individuals with thoracolumbar and incomplete spinal cord lesions reported a higher incidence of pain.
• Inactivity, stress, weather change, and over-activity were identified as aggravating factors, while sleep and rest were reported to help alleviate the pain.

People report chronic pain in the lumbar and thoracic spine areas, upper and lower limbs, and chest. Chronic pain may include burning, throbbing, soreness, stiffness or "shooting pains" in the affected area.

If you're experiencing pain following discharge from the hospital, talk to your primary care physician or physiatrist about pain management. Pain varies from person to person, so it will be important for you to provide a history of your pain to help find its origin, and to exclude other complications.

You may be asked to describe your pain (i.e., burning or tingling) and when the initial onset occurred. The location of the pain is important, as are any factors which may increase or decrease your pain.

Chronic pain programs are available. They use several techniques to minimize pain:

• relaxation and visualization techniques
• water therapy
• splinting
• individual and group counseling
• oral medications and injections

In rare cases, surgical intervention may be recommended.

Spasticity

Spasticity is a commonly reported complication. Among people who reported to the Colorado Spinal Cord Injury Early Notification System between 1986 and 1993, more than 25% reported spasticity or pain.

Spasticity is the involuntary movement (jerking) of muscles. It occurs because the spinal cord is injured and messages to and from the brain may be interrupted.

A message from spinal cord to arms and legs can cause reflex muscle movement. Below the level of injury, automatic functions remain intact in the spinal cord. However, they are no longer under the regulating influence of the brain, so responses may be exaggerated. You may have little or no control over these spastic movements.

Causes

Many things can cause spasticity:

• any sensory stimulus below the level of injury
• anything that would be uncomfortable or painful
• change in body position
• bladder irritation (infections or stones)
• pressure sores
• fractured bones
• skin problems (sores)
• ingrown toenails
• constipation
• hemorrhoids
• spinal cyst
• heterotopic ossification
• influenza or infection

Levels of Severity

The severity of spasticity varies. Minor degrees of spasticity might be helpful. The muscle movement helps maintain the shape and bulk of your muscles and improves your circulation. Through education, you may learn how to use spasticity to shift position or stand.

Severe spasticity, however, can interfere with transfer, weight shift, gait training, etc. A spasm may be strong enough to propel you out of your wheelchair and cause serious injury. If spasticity is severe and untreated, it can cause decreased joint movement. That, in turn, can lead to contractures or inability to move certain joints and limbs.

Treatment Options

If your spasticity is interfering with your function, consult your physician. Daily range of motion (ROM) exercises and stretches are helpful, but seek training to perform them correctly.

If your spasticity is severe, there are medications available, such as Valium (diazepam), Dantrium (dantrolene sodium), or Lioresal (baclophen), to help control it. Injections into the muscle, such as nerve blocks or motor point blocks, may be used. Continuous medication delivered through an implanted spinal stimulator or intrathecal baclofen pump may be recommended. Surgical intervention, in the form of radio frequency rhizotomy, may also be indicated.

Urinary Tract Infections (UTI)

In the past, kidney failure was one of the leading causes of death for individuals with a SCI. Urinary tract infections are still an often reported complication.

Eighty percent of individuals with SCI have bacteria in their urine. Causes of infection include the consistent presence of a catheter, pooling urine without relief, or inadequate flushing of urine due to reduced fluid intake.

Regardless of the bladder program you use, the loss of normal bladder function increases your risk for UTIs. Your bladder program depends on the level of injury and your bladder function, but examples include

• intermittent catheterization
• condom catheter
• indwelling foley or suprapubic catheter

Symptoms and Diganosis

Typically, your physician can diagnose a UTI by its symptoms, a physical exam, or a laboratory test. Symptoms of a UTI may include

• going to the bathroom frequently
• blood in the urine
• fever and/or chills
• spasticity in the lower body
• burning feeling with urination (if you have sensation)
• discomfort in the abdomen or low back
• odorous urine

Urinalysis and urine culture are the typical lab tests for UTI. Other tests of the urological system include a renal scan, renal ultrasound, intravenous pyelography (IVP), kidney, ureter & bladder xray (KUB), or urodynamic evaluation. These may be performed on an outpatient basis at a local diagnostic center, hospital, or medical center.

Treatment

Treatment of UTIs has seen major advances. With timely intervention and proper treatment, many people can effectively manage their bladder programs and reduce the frequency of UTIs.

Medications, including Macrodantin, may be used to prevent infections, while antibiotics are typically used to treat an existing infection. However, excessive use of antibiotics may lead to resistant strains of bacteria.

Consistent bladder management, including frequent visits to the urologist, frequent voiding or catheterization, and proper fluid intake will help prevent UTIs. More than one to two infections per year should alert you that something in your bladder management program needs revision.

Pressure Sores/Skin Breakdown

In 1998, Johnson studied people with SCI who had reported to the Colorado Spinal Cord Injury Early Notification System between 1986 and 1993. The individuals were interviewed at their first, third, and fifth year post injury. More than 10% reported pressure sores at all three time periods.

Causes

There are several causes of pressure sores:

• Pressure sores can occur when you sit or lie in one position too long.
• Shearing is a pressure injury that occurs when the skin moves in one direction and the bone underneath moves in the opposite direction.
• Abrasions occur from activities such as pulling your body across a surface, rather than lifting.
• Heat or moisture can also cause a sore.

A pressure sore, or decubitus ulcer, is a redness or a break in the skin, caused by pressure that is applied to the skin for too long. As a result of SCI damage, messages of pain or discomfort normally sent to your brain do not reach it. You are not signaled that you need to change position. The skin eventually dies because the blood is prevented from reaching it.

Stages of Development

Pressure sores typically develop over time, in stages, but it's important to keep pressure off a sore if it is developing.

• In Stage 1, the red or discolored skin will not fade within 30 minutes after pressure is removed.
• In Stage 2, the top layer of skin is broken, which creates a shallow open sore.
• In Stage 3, the skin is broken and there is full-thickness skin loss. Infection may exist.
• In Stage 4, the sore is deep and involves muscle and possibly bone. A scab may be visible. Infection may exist.

Consult your physician to receive treatment based on the stage of the pressure sore. Dressings that are especially designed to promote healing can be applied to the affected area. Stages 3 and 4 may require surgical treatment, which is necessary but can be costly.

Prevention

Prevention depends on you and your daily routine.

• Good daily hygiene, daily skin inspection, regular evaluation of diet, and frequent inspection of your equipment are all important in pressure sore prevention and treatment.
• Special mattresses and wheelchair cushions provide support over bony areas, although frequent changes in position are important.
• You may also need to learn new ways to change your position in bed or in your chair.
• Nutrition is important and a high-protein diet which includes milk/cheese, meat/fish, and dried beans helps promote healthy skin and heal pressure sores.

Education is critical, so if you have questions concerning transfer, positioning, equipment, etc., contact your physician, therapist, or other health professional.

Remember, early detection is very important. You want to avoid a situation that prevents you from using your chair or even hospitalizes you. At the first sign of pressure sore development, you should contact your local physician or physiatrist (physical medicine and rehabilitation physician).

Autonomic Dysreflexia

Autonomic dysreflexia is an emergency situation. Commonly, it occurs in people with SCI above the T6 level.

Some symptoms are

• a sudden throbbing headache
• hypertension
• a metallic taste in the mouth
• vision changes
• cardiac irregularities
• respiratory distress
• increased spasticity
• "gooseflesh" or chills
• nausea

According to a research conducted by Dunn in 1991, most individuals also report anxiety or impending doom.

If untreated, autonomic dysreflexia can be life threatening, and Dunn indicates it can result in retinal hemorrhage, cerebrovascular accident (CVA), renal failure, seizures, and cardiac dysrhythmias.

This condition usually indicates that another problem exists and should be investigated. Treatment is aimed at discovering the problem responsible for the autonomic dysreflexia, and the bladder is the most common cause.

Other causes are

• distended bowel
• urinary stone
• severe bladder infections
• decubitus ulcers
• ingrown toenails

Research shows that maintaining a good bowel and bladder program and a skin care regimen helps prevent autonomic dysreflexia.

Deep Vein Thrombosis (DVT)

Deep vein thrombosis (DVT) is a common SCI complication in which a blood clot forms. Venous Doppler studies, venograms, and laboratory tests are used to evaluate DVT.

Significant risk factors for DVT are

• edema
• surgery
• fractures
• immobilization

Medications such as Heparin are used in treatment, along with elastic stockings or compression stockings. A person with SCI can also suffer from anemia, and this should be evaluated.

Fertility Reduction

In Females

Until recently, there was very little research on the fertility or sexuality of women with SCI. Recent findings include the following.

• Harrison's 1995 research found that reported sexual dysfunction increased significantly after the SCI, but feelings about sex and its importance were unaffected.
• In 1999, Ruthkowski reviewed the treatment of a group who attended a fertility clinic between 1987 and 1997, seeking to conceive—the group consisted of 31 males and their partners with SCI.
  • In the 31 couples, there were 17 pregnancies in 97 cycle attempts, for an overall pregnancy rate per cycle of 18% and a cumulative pregnancy rate per couple of 55%.
  • Twelve of the pregnancies resulted in 14 live births (one set of twins).
• There are a number of alternative fertilization techniques that may be employed to overcome the sexual dysfunction of either men or women with SCI. In 1997, Sonksen speculated that through ejaculation methods and fertilization techniques, the pregnancy rate per treatment cycle for SCI couples may approach that of natural procreation in healthy and fertile couples.
• Westgren, in 1994, studied all women with SCI in Sweden who became pregnant and delivered live infants during 1980-1991 (26 women). Forty-seven children were delivered during this time. The participants and their families reported rich and complete family lives. The authors concluded that the SCI itself does not preclude the possibility of having a family.

However, if a woman with a SCI becomes pregnant, she must be followed carefully by her OB/GYN, preferably one who has experience with SCI and pregnancy.

In another 1994 study, Craig followed two women with SCI during pregnancy. Pregnancy complaints specific to SCI centered around

• increased urinary incontinence
• autonomic dysreflexia
• delayed wound healing

These conditions can compromise a woman's health and should be monitored throughout the pregnancy. Delivery may also be more complicated, requiring close monitoring.

In Males

Most SCIs occur to men of parenting age, and most experience impairments in erectile and ejaculatory function post-injury. However, their sperm can be used in assisted reproductive techniques to attempt biological fatherhood.

To overcome ejaculatory dysfunction, penile vibratory stimulation or electroejaculation can be used.

• Sonksen's 1997 study reported an ejaculation rate of 100% in 28 post-SCI men via penile vibratory stimulation and electroejaculation. While the ejaculates may have a normal sperm count, there may be more immotile sperm. If so, alternative fertilization techniques can be employed.
• In 1999, Taylor studied 19 couples seeking fertility treatment after the male partner sustained a SCI. Seventy-four percent achieved at least one pregnancy. Pregnancy rates per treatment cycle were 12% for timed intrauterine insemination, 38.9% for gamete intra-Fallopian transfer, and 19.2% for intracytoplasmic sperm injection followed by uterine embryo transfer.
• Brackett's 1998 research focused on SCI men to determine if semen quality progressively declines in the post-injury years. Semen quality of 125 men did not decline after the SCI. Therefore, number of years after injury need not be a determinant in deciding when to start a family.

Men should be evaluated at a center dedicated to assisting men with SCI in this specialty area.

Heterotopic Ossification (HO)

Heterotopic ossification (HO) is a condition where new bone forms in the connective tissues and muscles surrounding joints, where it isn't normally found. It can adversely affect mobility, self-care, functional independence, and vocational activity. Signs of conditions like HO include

• swelling and heat
• pain upon touch
• limitations in range of motion in a certain area

One study reported an incidence of 20% (Wittenberg, Peschke, Botel, 1992). Another reported incidence rates of 20% to 30% (Winkler and Weed, 1999).

HO may lead to other complications, such as pressure sores, respiratory disease, and urinary tract infection. HO commonly occurs in the shoulders, elbows, hips, knees, and ankles. Bone scans, laboratory studies, and X-rays are used for diagnosis and follow-up.

Depending on its severity, HO treatment ranges from some follow-up treatment to surgical intervention. Physical therapy is recommended for range of motion. Medications such as Didronel®, which limits the formation of calcium deposits, may be used.

Hospitalizations

Many people with SCI are hospitalized one or more times during their lifetime, due to complications of the injury.

In 1998, Johnson studied people who reported to the Colorado Spinal Cord Injury Early Notification System between 1986 and 1993. Individuals were interviewed at their first, third, and fifth year post-injury. Hospitalizations of a week or longer were experienced by more than 10% of the participants at each of the three interview years.

Osteoporosis

Osteoporosis may develop following SCI, because weight-bearing activities are limited and bone mass continues to decrease. Osteoporosis makes individuals more susceptible to fractures. It is estimated that 1%-6% of people with SCI develop osteoporosis. However, that number may be low, since some people aren't treated at spinal cord centers.

Post-traumatic Syringomyelia (PTS)

Post-traumatic syringomyelia (PTS), or spinal cyst, is not common but can be life threatening.

PTS is a progressive disease marked by elongated fluid-containing cavities, or cysts, that distend the spinal cord at any level, and even extend into the brainstem.

The most common initial symptom is pain located at or above the SCI. The pain may radiate to the neck or upper limbs. Pain sensation is usually impaired, and there is a increased motor weakness and loss of deep tendon reflexes.

Magnetic resonance imaging (MRI) is the preferred test to diagnose PTS. Surgical treatment is usually recommended. Various types of shunts are used, although the shunts may become blocked with recurrence of PTS.

Pulmonary Difficulties

Pulmonary difficulties are the leading cause of death for individuals with SCI. Pneumonia is one of the leading pulmonary complications. Pulmonary embolism, a serious cardiovascular condition, occurs when a piece of tissue or air travels through the bloodstream and is lodged in a blood vessel.

Pulmonary care is very important, since people with SCI have decreased mobility, impaired cough, and impaired ability to clear secretions. In addition, they aren't able to fully expand their lungs. Thus they are more susceptible to pulmonary complications and recurrent upper respiratory infections.

Abdominal binders can aid you when sitting upright, and help prevent unnecessary pulmonary complications. Medications are also used to reduce complications from pulmonary difficulties.

Scoliosis

Scoliosis is spinal curvature. It occurs more commonly in children with SCI.

A person with scoliosis has uneven posture, which can result in disturbed sitting and balance. The individual may use his/her upper extremities to prop to one side, which can cause skin breakdown and other complications.

Diagnostic tests such as magnetic resonance imaging (MRI) are used to diagnose scoliosis. Physical therapy using range of motion exercise (ROM) and stretches may be utilized as treatment. Surgical intervention may be necessary.

SCI and Aging

With improved medical treatment and increased knowledge about SCI, the SCI population now has a longer life expectancy.

In 1999, Kemp studied life satisfaction among people aging with SCI. He indicates that most people whose disability occurred before age 30 can now expect to live into their 60's, 70's, and beyond. (The average age in the U.S. is late 40's.)

However, age and disability can combine to present increased health risks. These risks can necessitate increased familial or caregiver support, as well as increased medical monitoring. You may need to see your primary treatment team more often for early detection. Medical conditions compromise the health of older SCI individuals more rapidly.

In 1995, Pentland studied the combined effects of age and duration of injury on 83 SCI men. With increasing age, the sample population experienced more symptoms and illnesses and felt less financially secure.