Spinal cord injury causes serious health consequences
KNOWLEDGE CENTRE
CONTINENCE CARE
SPINAL CORD INJURY
Spinal cord injury causes serious health consequences for the injured individuals, and rehabilitation is a demanding process. Physical outcomes of the injury are the most immediate ones that the injured person encounters and faces, so it is important to understand them for a more successful rehabilitation process.
SPINAL SHOCK
Immediately after the injury, all functions of the spinal cord below the site of injury are temporarily interrupted: sensation, movement, and reflexes. Spinal shock is accompanied by a significant drop in arterial blood pressure (orthostatic hypotension) caused by blood pooling in the veins and the absence of vascular resistance. Additionally, bradycardia (slowed heart rate) and hypothermia (body temperature drop) may occur.
The duration of this shock condition can range from a few hours to several months. The return of reflexes usually indicates the end of the shock state.
SPASTICITY
Due to pressure on the skin, muscle, or painful stimuli, the signal/message cannot pass the level of the spinal cord injury and reach the brain. Because the brain cannot regulate the body’s response, there is a return of signals and the occurrence of spasms (involuntary muscle contractions) below the level of injury. Spasms are accompanied by hyperreflexia. Spasm treatment involves exercises and medication.
DIGESTIVE SYSTEM
Spinal cord injury will affect the functioning of the bowels, leading to impaired bowel movements compared to pre-injury state. The level of injury in the spine will determine whether the bowels will retain the reflex for emptying.
If the injury is above the Th12 level, the person loses the ability to sense bowel filling. However, the rectal muscles and anal sphincter remain functional, leading to stool evacuation when the bowel is full. Since the information cannot reach the brain, bowel movements occur reflexively, without the person’s conscious decision.
On the other hand, if the injury occurs below Th12, specifically at the L1 level or below, the reflex for bowel evacuation may be impaired. This means that the bowel will not contract reflexively when stool evacuation is necessary, resulting in stool retention. The sphincter also remains “loose,” which can lead to stool leakage. Digital stimulation and digital bowel evacuation are methods used for emptying. Some common digestive difficulties in these injuries include constipation (hard stool that passes through the intestines with difficulty), impaction (hard stool obstruction in the intestines), fecal incontinence (unplanned stool leakage), and diarrhea.
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RESPIRATORY SYSTEM
One of the most significant outcomes of spinal cord injury can be difficulties related to the respiratory system. The cause is the inability to communicate between the brain, spinal cord, and the muscles involved in breathing. The higher the injury level, the more significant the breathing difficulties.
This is particularly true for injuries in the upper cervical spine (C1-C3), where the use of mechanical ventilation is often necessary. Injuries at the C4-C8 level partially retain the function of the diaphragm (the main breathing muscle), while the diaphragm functions well in injuries below Th1. Difficulties also extend to coughing and sneezing.
It is important to note that pulmonary embolism is one of the most common causes of death in individuals with tetraplegia and paraplegia. To prevent or alleviate respiratory difficulties, recommendations include activity (as much as possible, according to medical advice), avoiding smoking and smoke-filled environments, adequate fluid intake, and dressing appropriately for weather conditions.
GENITOURNARY SYSTEM
Spinal cord injury also affects the functionality of the urinary system. The injury disrupts communication between the spinal cord, brain, and muscles responsible for the proper functioning of the urinary system. As a result, the injured person may lose conscious control over the process of urination.
Dysfunction of the urinary bladder is referred to as neurogenic bladder. Two possible scenarios are an overactive bladder with reflexive urination and an underactive bladder with urinary retention.
Reflexive bladder emptying is likely in cases where the injury occurs above the level of the 12th thoracic vertebra. When the bladder is full, a reflex is triggered for its emptying. Since communication with the brain is impaired, uncontrolled bladder emptying, or urination, occurs.
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CARDIOVASCULAR SYSTEM
Individuals with spinal cord injury (paraplegia and tetraplegia) are generally less active, leading to reduced fitness and a sense of low energy. They have impaired glucose tolerance and lower levels of high-density lipoprotein (HDL), also known as “good cholesterol.” Additionally, they are at increased risk of cardiovascular incidents.
To mitigate these difficulties as much as possible, individuals with spinal cord injury are advised to engage in increased physical activity, regular exercise, and participation in sports.
Why does a severe autonomic dysreflexia occur after an injury?
Autonomic dysreflexia is a severe medical syndrome that most commonly occurs with spinal cord injuries at and above the level of the 6th thoracic vertebra.
This condition is caused by the activation of the sympathetic nervous system due to noxious stimuli arising below the level of the injury. It typically happens when the urinary bladder, bowels, or skin encounter specific issues such as bladder infection, bowel constipation, or prolonged and excessive pressure on the skin.
In the presence of these issues, spinal reflexes and constriction of blood vessels below the level of the injury occur. The narrowed blood vessels impede blood flow, leading to an increase in blood pressure. The brain then sends signals to dilate the blood vessels. However, this information cannot pass the level of the spinal cord injury, resulting in uncontrolled elevation of blood pressure.
This rise in blood pressure is referred to as arterial hypertension and can have serious consequences such as heart attack or stroke, and in some cases, it can be life-threatening.
Symptoms and signs of autonomic dysreflexia include severe headache, sweating, and piloerection (goosebumps) above the level of the injury, elevated blood pressure, feelings of anxiety, blurred vision, and red blotches above the level of the injury.
Autonomic dysreflexia is a medical emergency that requires addressing the specific causes and lowering blood pressure. Moreover, it is crucial to prevent the occurrence of dysreflexia by removing potential triggers. Prevention includes regular and timely emptying of the bladder and bowels, avoiding possible infections, and maintaining proper skin care to prevent excessive pressure and pressure ulcers.
How does injury affect changes in the skin?
In the case of a complete spinal cord injury, the ability to sense is lost below its level. As a result, sensations related to pressure, discomfort, or pain on the skin, which drive us to move and change body position, are absent. Maintaining the same body position can disrupt blood flow in the compressed area of the skin, leading to the formation of pressure ulcers or bedsores. Bony prominences are particularly at risk for developing pressure ulcers.
Below the level of complete spinal cord injury, sweating of the skin is also absent. This can result in dryness and easy cracking of the skin.
To prevent skin injuries, it is recommended to provide proper body care, frequently change body position, examine the skin, wear clothing and footwear that are not too tight, and avoid strong sources of heat and cold that could cause injuries.
Why do difficulties with body temperature regulation occur?
Depending on the cold or hot environment in which it is located, the body sends signals to the brain for heating or cooling. This regulates and maintains a constant body temperature. In the case of a complete injury at the level of Th6 and above, this communication will be absent, and the body below the level of injury will be unable to cool itself through sweating or warm itself through shivering as needed. This can lead to elevated or lowered body temperature.
Due to these difficulties, it is important to ensure an appropriate room temperature for the injured person and to avoid prolonged exposure to cold and sunlight.
Occurrence of chronic pain – what types of pain occur?
In most individuals with a spinal cord injury, there is the presence of chronic pain of varying intensity. It can occur at the level of injury or below and above the level of injury.
Typically, musculoskeletal nociceptive pain (often in the neck and shoulders), neuropathic pain (usually described as burning or tingling), and headache caused by autonomic dysreflexia occur. Pain treatment can be approached pharmacologically using medication and non-pharmacological methods such as physical therapy.
What are neuropathic joints, joint contractures, and heterotopic ossification?
In individuals with an incomplete spinal cord injury, the occurrence of “neuropathic joints” is possible. This happens if a person can walk but has impaired deep sensation.
The absence of this sensation also means the loss of reflexes that usually protect the joint from possible trauma. As a result, the person may not notice the occurrence of minor injuries that damage the joint.
Joint contractures, which limit joint mobility in a specific direction, are also possible and occur in 5% to 10% of individuals with a spinal cord injury. This reduced joint mobility can adversely affect the level of independence in individuals with a spinal cord injury. Stretching exercises and proper positioning in bed are recommended.
Injured individuals may also experience the formation of new bone (heterotopic ossification), most commonly around the joints and below the neurological level of injury. Treatment involves medication, rarely surgery, and it is advised to avoid intense exercises.
Osteoporosis after SCI – why is there an increased risk of fractures?
Osteoporosis, a condition that reduces bone mineral density and thus bone strength, can occur after a spinal cord injury. It can occur as early as the first months following the injury and increases the risk of fractures.
