Chronic Spinal Cord Injury

Epidemiology

  • Prevalence (2014 Data): there are approximately 276k persons with spinal cord injury in the US
  • Clinical Data
    • Study of Traumatic Spinal Cord Injury from 1993-2012 (JAMA, 2015) [MEDLINE]
      • Rate of Traumatic Spinal Cord Injury (2012): 54 cases per million
      • Rate of Traumatic Spinal Cord Injury Remained Stable from 1993-2012: however, due to the increase in population, the total number of cases increased
      • Largest Increase in the Number of Cases of Traumatic Spinal Cord Injury was Observed in Older Patients, Mainly Due to an Increase in the Number of Falls
      • In-Hospital Mortality Rate for Traumatic Spinal Cord Injury Remained High: especially in older patients

Etiology


Physiology

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Diagnosis

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Clinical Manifestations

Cardiovascular Manifestations

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Neurologic Manifestations

Acute Motor Deficit (see Acute Motor Deficit, Acute Motor Deficit)

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Autonomic Dysreflexia (see Autonomic Dysreflexia, Autonomic Dysreflexia)

  • Epidemiology
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  • Physiology
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  • Clinical
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Pulmonary Manifestations

General Comments

  • Epidemiology
    • Pulmonary Complications (and Hospitalizations) are Common After Spinal Cord Injury
      • In a Canadian Study, Approximately 27.5% of Patients with Spinal Cord Injury were Hospitalized within 1 Year After Discharge, with 11.% of the Hospitalizations Being Due to a Respiratory Etiology (Spinal Cord, 2009) [MEDLINE]
      • In the US, the Overall Hospitalization Rate from 5-20 Years After Injury was 20-25%, with 8.1% Being Due to a Respiratory Etiology (Arch Phys Med Rehabil, 2004) [MEDLINE]
    • Pulmonary Diseases are the Second Most Common Cause of Death After Spinal Cord Injury, After Cardiovascular Diseases) (J Spinal Cord Med, 2006): pulmonary disease accounts for 20-30% of the mortality which occurs beyond the first year after injury [MEDLINE]

Atelectasis (see Atelectasis, Atelectasis)

  • Epidemiology: common

Dysphonia (see Dysphonia, Dysphonia))

  • Epidemiology
  • Clinical: in spontaneously breathing cervical cord injury patients with expiratory muscle weakness
    • Decreased Vocal Amplitude
    • Lower Number of Syllables Per Breath

Dyspnea (see Dyspnea, Dyspnea)

  • Epidemiology: common
    • Prevalence of Dyspnea is Usually (But Not Always) Related to the Level of the Spinal Cord Injury (Spinal Cord, 1997) [MEDLINE]

Neurogenic Pulmonary Edema (see Neurogenic Pulmonary Edema, Neurogenic Pulmonary Edema)

  • Epidemiology: rare complication of spinal cord injury
    • In Acute Spinal Cord Injury, Neurogenic Pulmonary Edema is Associated with Complete Cervical Cord Injury
    • In Chronic Spinal Cord Injury, Neurogenic Pulmonary Edema is Associated with Cervical Cord Injury Above T6 in Conjunction with Autonomic Dysreflexia (see Autonomic Dysreflexia, Autonomic Dysreflexia)

Respiratory Failure (see Respiratory Failure, Respiratory Failure)

  • Epidemiology
    • Respiratory Failure is Common After Spinal Cord Injury: both acutely and chronically after the injury
  • Physiology
    • Acute Spinal Cord Injury Results in Flaccid Paralysis of All Muscles Caudal (Distal) to the Site of Spinal Cord Injury, Including the Respiratory Muscles: extent of ventilatory respiratory impairment depends on the level and severity of cord injury
      • Ventilatory Impairment is Most Common and Severe with Complete Cervical Cord Injuries, But May Also Occur in Thoracic Cord Injuries
    • Factors Contributing to Improvement in Respiratory Muscle Function in the Weeks Following Spinal Cord Injury
      • Decreased Spinal Cord Inflammation with Functional Descent of the Level of Neurologic Injury
      • Evolution from Flaccid Paralysis (Spinal Shock) to Spastic Paralysis
        • Abdominal and Intercostal Muscle Become Less Flaccid, Resulting in Rib Cage Stabilization
      • Increased Recruitment of Accessory Ventilatory Muscles
      • Retraining of Deconditioned Muscles

Pneumonia

  • Epidemiology
    • Risk of Pneumonia is the Highest in the First Year After Injury, But Remains High Over the Lifetime of the Patient with Spinal Cord Injury (Arch Phys Med Rehabil, 1994) [MEDLINE]*
    • Pneumonia Complicated 30% of Acute Spinal Cord Injury Cases During a Mean Follow-Up Period of 9.5 mo (J Neurosurg Spine, 2012) [MEDLINE]
  • Risk Factors for Pneumonia
    • Altered Level of Consciousness: due to sedating medications or concomitant head trauma
    • Aspiration (see Aspiration Pneumonia, Aspiration Pneumonia)
    • Bronchial Mucous Hypersecretion: occurs in 20% of acute cervical spinal cord injury cases, due to impairment of the peripheral sympathetic nervous system
    • Concomitant Rib Fractures/Thoracoabdominal Surgery: associated with the traumatic event
    • Decreased Spontaneous Sighing
    • Dysphagia (see Dysphagia, Dysphagia)
    • Expiratory Muscle Weakness: with ineffective cough
    • Ileus (see Ileus, Ileus): limits diaphragmatic excursion and increases the aspiration risk

Sleep-Disordered Breathing

  • Epidemiology
    • Most Cervical Spinal Cord Injury Patients Have Sleep-Disordered Breathing and Poor Sleep (J Clin Sleep Med, 2014) [MEDLINE]: likely related to sleep-associated hypoventilation
  • Clinical

Venous Thromboembolism (Deep Venous Thrombosis and Acute Pulmonary Embolism) (see Deep Venous Thrombosis, Deep Venous Thrombosis and Acute Pulmonary Embolism, Acute Pulmonary Embolism)

  • Epidemiology
    • Risk of Venous Thromboembolism is Increased in Spinal Cord Injury, Relative to General Population (Thromb Res, 2014) [MEDLINE]
      • Risk Appears to Be Highest within the First 3 mo After Injury

Treatment

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References

  • Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery. 1993;33(6):1007 [MEDLINE]
  • Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg. 1997;87(2):239 [MEDLINE]
  • The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators. Spinal Cord. 1999 Apr;37(4):284-8 [MEDLINE]
  • Blood pressure management after acute spinal cord injury. Neurosurgery. 2002;50(3 Suppl):S58 [MEDLINE]
  • Definitive establishment of airway control is critical for optimal outcome in lower cervical spinal cord injury. J Trauma. 2008;65(6):1328 [MEDLINE]
  • Trendelenburg chest optimization prolongs spontaneous breathing trials in ventilator-dependent patients with low cervical spinal cord injury. J Rehabil Res Dev. 2010;47(3):261-72 [MEDLINE]
  • Mechanical insufflation-exsufflation device prescription for outpatients with tetraplegia. J Spinal Cord Med. 2010;33(2):128-34 [MEDLINE]
  • Critical care of traumatic spinal cord injury. J Intensive Care Med. 2013 Jan;28(1):12-23. Epub 2011 Apr 11 [MEDLINE]
  • Respiratory care of patients with cervical spinal cord injury: a review. Crit Care Resusc. 2012 Mar;14(1):64-73 [MEDLINE]
  • Respiratory muscle training for cervical spinal cord injury. Cochrane Database Syst Rev. 2013 [MEDLINE]
  • A comparison of high vs standard tidal volumes in ventilator weaning for individuals with sub-acute spinal cord injuries: a site-specific randomized clinical trial. Spinal Cord. 2016 Mar;54(3):234-8. Epub 2015 Sep 15 [MEDLINE]

  • Consortium for Spinal Cord Medicine. Early Acute Management in Adults with Spinal Cord Injury. Clinical practice guideline for healthcare providers. 2008 [LINK]

  • Consortium for Spinal Cord Medicine. Prevention of Thromboembolism in individuals with Spinal Cord Injury. Clinical practice guideline for healthcare providers. 3rd Edition 2016. [LINK]

  • Consortium for Spinal Cord Medicine. Respiratory Management Following Spinal Cord Injury. Clinical practice guideline for healthcare providers. 2005. [LINK]

  • Consortium for Spinal Cord Medicine. Acute Management of Autonomic Dysreflexia. Clinical practice guideline for healthcare providers. 2nd Edition, 2001. [LINK]