Spinal Cord Injury (Cervical)

CHAPTER 156

Spinal Cord Injury (Cervical) Sunil Sabharwal, MD, MRCP (UK)

Synonyms Tetraplegia Quadriplegia

ICD-10 Codes G82.50 G82.51 G82.52 G82.53 G82.54

Quadriplegia, unspecified Quadriplegia, C1-C4 complete Quadriplegia, C1-C4 incomplete Quadriplegia, C5-C7 complete Quadriplegia, C5-C7 incomplete

gunshot wounds), and recreational sporting activities.2 The proportion of injuries due to falls has increased over time. Cervical injuries occur more frequently than thoracic and lumbar injuries and accounted for about 66% of the SCI database since 2010. The proportion of incomplete injuries has been increasing. Since 2010, the most frequent neurologic category at discharge reported to the database is incomplete tetraplegia (45% of all SCI). International registries and databases provide some information about global epidemiology of SCI, but are only collected in a systematic manner in a few countries and available data is limited for several major global populations. Recent effort to report and compare data from different countries is an important step forward in this regard.3 

Symptoms Definition Cervical spinal cord injury (SCI) results in tetraplegia. The term tetraplegia (preferred to quadriplegia) refers to an impairment or loss of motor or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal.1 The result is impairment of function in the arms as well as in the trunk, legs, and pelvic organs. Impairment of sensorimotor involvement outside the spinal canal, such as brachial plexus lesions or injury to peripheral nerves, should not be referred to as tetraplegia. In a complete cervical SCI, sensory or motor function is absent in the lowest sacral segments S4-S5 (i.e., no anal sensation or voluntary anal contraction is present). If sensory or motor function is partially preserved below the neurologic level and in the lowest sacral segments, the injury is defined as incomplete.1,2 The American Spinal Injury Association Impairment Scale (AIS) is used in grading the degree of impairment (Table 156.1). Central cord syndrome is an incomplete SCI syndrome that applies almost exclusively to cervical SCI. It is characterized by greater weakness in the upper limbs than in the lower limbs and sacral sensory sparing.1 SCI primarily affects young men. However, the average age at injury has increased from 28.7 years in the 1970s to 42.0 years since 2010, and the proportion of new SCI in adults older than 60 years has continued to increase in the national SCI Model Systems database.3 Males account for about 80% of injuries. The most common cause is motor vehicle accidents, followed by falls, violence (primarily 902

Primary symptoms of cervical SCI are related to muscle paralysis, sensory impairment, and autonomic impairment (including bladder, bowel, and sexual dysfunction). The patient with SCI can present in the outpatient setting with a multitude of secondary conditions4,5 and associated problems at any point in the continuum of care. Symptoms may be vague and nonspecific. For example, urinary tract infections may not manifest with classic symptoms of urgency and dysuria, but with increased spasticity, increased frequency of spontaneous voiding, and lethargy.4 The patient with pneumonia may present with fever, shortness of breath, or increasing anxiety. Headache may be indicative of autonomic dysreflexia, which may be the primary or only presentation of a variety of pathologic processes ranging from bladder distention, urinary infection, constipation, or ingrown toenail to myocardial infarction or acute abdominal emergencies.6 Table 156.2 lists common presenting symptoms of autonomic dysreflexia and underlying causes. Because symptoms can reflect a variety of underlying conditions, these need to be evaluated carefully. For example, pain in cervical SCI may be multifactorial and needs to be further assessed by reported characteristics, including quality, location, onset, timing, relieving and exacerbating factors, and associated symptoms. Various SCI pain classification systems have been described. The International SCI Pain classification (Table 156.3) organizes SCI pain into three tiers: tier 1 classifies pain type as nociceptive, neuropathic, other, and unknown; tier 2 includes various subtypes for neuropathic and nociceptive pain; and tier 3 is used to specify the primary pain source or pathologic process.7 

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CHAPTER 156  Spinal Cord Injury (Cervical)

Table 156.1  American Spinal Injury Association Impairment Scale Grade

Category

Description

A

Complete

No sensory or motor function is preserved in the sacral segments S4-S5.

B

Sensory incomplete

Sensory but no motor function is preserved below the neurologic level including the sacral segments S4-S5.

incompletea

C

Motor

D

Motor incompletea

Motor function is preserved below the neurologic level, and at least half of key muscles below the neurologic level have a muscle grade 3 or more.

E

Normal

Sensory function and motor function are normal; the patient may have abnormalities in reflex examination.

aThere

Motor function is preserved below the neurologic level, and more than half of key muscles below the neurologic level have a muscle grade <3.

must be some sparing of sensory or motor function in S4-S5 segments to be classified as motor incomplete.

Table 156.2  Etiology of Common Symptoms in Spinal Cord Injury Symptom

Possible Cause

Fever

Infectious Urinary tract infection Pneumonia Infected pressure ulcer, cellulitis, osteomyelitis Intra-abdominal or pelvic infection Hot environment (due to poikilothermia) Deep venous thrombosis Heterotopic ossification Pathologic limb fracture Drug fever (e.g., from antibiotics or anticonvulsant pain medications)

Fatigue

Nonspecific, but could be the only symptom of serious illness Infection Respiratory or cardiac failure Side effect of medications Depression (inquire about associated dysphoric symptoms)

Daytime drowsiness

Side effect of medications (e.g., narcotics, antispasticity agents) Nocturnal sleep apnea Ventilatory failure with carbon dioxide retention Depression

Shortness of breath

Pneumonia Abdominal distention (e.g., postprandial, obstipation) Pulmonary embolus Ventilatory impairment (can be postural with sitting up if borderline) Cardiac causes

Diarrhea

Altered bowel management schedule Clostridium difficile infection Spurious diarrhea with bowel impaction Side effect of medications (antibiotic, excess laxative or stool softener)

Rectal bleeding

Hemorrhoids Trauma from bowel care Colorectal cancer

Hematuria

Urinary tract infection Urinary stones Traumatic bladder catheterization Bladder cancer

Headache

Autonomic dysreflexia; may be associated with any noxious stimulus below injury level Consider other causes in absence of increased blood pressure Continued

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Table 156.2  Etiology of Common Symptoms in Spinal Cord Injury—cont’d Symptom

Possible Cause

Increased spasticity

Urine infection Pressure ulcer Bowel impaction Any noxious stimulus Syringomyelia

Pain

Multiple nociceptive and neuropathic causes (see Table 156-3)

Unilateral leg swelling

Osteoporotic fracture of the lower extremity Deep venous thrombosis Heterotopic ossification Cellulitis Hematoma Invasive pelvic cancer

New weakness or numbness

Syringomyelia Entrapment neuropathy (median at wrist, ulnar at elbow)

Table 156.3  International Spinal Cord Injury Pain Classification Tier 1: Pain Type

Tier 2: Pain Subtype

Tier 3: Primary Pain Source or Pathologic Process

Nociceptive pain

Musculoskeletal pain

Example: glenohumeral arthritis, lateral epicondylitis, femur fracture

Visceral pain

Example: myocardial infarction, abdominal pain due to bowel impaction, cholecystitis

Other nociceptive pain

Example: autonomic dysreflexia headache, migraine headache, surgical skin incision

At-level SCI pain

Example: spinal cord compression, nerve root compression

Below-level SCI pain

Example: spinal cord ischemia, spinal cord compression

Other neuropathic pain

Example: carpal tunnel syndrome, trigeminal neuralgia, diabetic polyneuropathy

Neuropathic pain

Other pain

Example: fibromyalgia, complex regional pain syndrome type I, irritable bowel syndrome

Unknown pain SCI, Spinal cord injury.

Physical Examination The neurologic examination is conducted by systematic examination of the dermatomes and myotomes (Tables 156.4 and 156.5) in accordance with the International Standards for Neurological and Functional Classification of SCI, published by the American Spinal Injury Association.1 Depending on the presentation, specific elements of the physical examination of various body systems that are relevant in evaluation of SCI-related conditions may include the following.

Table 156.4  Key Sensory Points for Cervical Spinal Segments Level

Key Sensory Point

C2

Occipital protuberance

C3

Supraclavicular fossa

C4

Top of the acromioclavicular joint

C5

Lateral side of the antecubital fossa

C6

Thumb, dorsal surface, proximal phalanx

C7

Middle finger, dorsal surface, proximal phalanx

Neurologic

C8

Little finger, dorsal surface, proximal phalanx

• Determine the level and completeness of the injury. Examination for neurological classification is conducted in the supine position and can be performed with minimal equipment (safety pin and cotton wisp) in almost all clinical settings and phases of care. The examination can be recorded on a standardized worksheet (Fig. 156.1). Serial examinations should be performed as indicated to detect neurological deterioration or improvement. • Sensory examination for pinprick and light touch sensation in key points bilaterally (see Table 156.4)

T1

Medial side of antecubital fossa

• Motor examination for strength in key muscle groups bilaterally (see Table 156.5) •  Neurologic rectal examination (voluntary anal contraction, deep anal sensation) • Determine completeness of injury and AIS grade (see Table 156.1). If the AIS grade is A, determine the zone of partial preservation.

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CHAPTER 156  Spinal Cord Injury (Cervical)

• Additional elements of the neurologic examination include: • Position and deep pressure sensation, testing of additional muscles • Muscle tone and spasticity •  Muscle stretch reflexes, bulbocavernosus reflex, plantar reflex 

Respiratory • Assess respiratory effort, including effect of posture (e.g., sitting versus supine). • Check for paradoxical respiration and chest expansion. •  Auscultate to assess for decreased breath sounds, rales, and wheeze. 

Table 156.5  Key Muscle Groups for Cervical Myotomesa Level

Muscle Group

Positions for Testing Key Muscles for Grades 4 and 5

C5

Elbow flexors (biceps, brachialis)

Elbow flexed at 90 degrees, arm at patient’s side, forearm supinated

C6

Wrist extensors (extensor carpi radialis longus and brevis)

Wrist in full extension

C7

Elbow extensors (triceps)

Shoulder in neutral rotation, adducted, and in 90 degrees of flexion, with elbow in 45 degrees of flexion

C8

Finger flexors (flexor digitorum profundus) to the middle finger

Full-flexed position of the distal phalanx with the proximal finger joints stabilized in extended position

T1

Small finger abductors (abductor digiti minimi)

Full-abducted position of the fifth digit of the hand

aFor

those myotomes that are not clinically testable by manual muscle examination (e.g., C1-C4), the motor level is presumed to be the same as the sensory level.

Patient Name_____________________________________ Date/Time of Exam _____________________________ Examiner Name ___________________________________ Signature _____________________________________

RIGHT

SENSORY

SENSORY

MOTOR

C2 C3 C4 Elbow flexors Wrist extensors (Upper Extremity Right) Elbow extensors Finger flexors Finger abductors (little finger)

UER

C5 C6 C7 C8 T1

Hip flexors Knee extensors (Lower Extremity Right) Ankle dorsiflexors Long toe extensors Ankle plantar flexors

LER

L2 L3 L4 L5 S1

KEY MUSCLES

C2 C3 C4

C2

C5 C6 C7 C8 T1

T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1

Comments (Non-key Muscle? Reason for NT? Pain?):

T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1

C3 C4 T12 L1

S3 L2

S4-5

• Key Sensory Points

L3

S2

MOTOR

(SCORING ON REVERSE SIDE)

SENSORY

(SCORING ON REVERSE SIDE)

(VAC) Voluntary Anal Contraction (Yes/No)

L2 L3 L4 L5 S1

S1

S2 S3 S4-5

MOTOR SUBSCORES MAX (25)

LEFT TOTALS SENSORY SUBSCORES LER

(25)

NEUROLOGICAL LEVELS

Steps 1-5 for classification as on reverse

Knee extensors LEL Ankle dorsiflexors (Lower Extremity Left) Long toe extensors Ankle plantar flexors

(MAXIMUM)

(MAXIMUM)

= UEMS TOTAL

+ UEL

Hip flexors

(DAP) Deep Anal Pressure (Yes/No)

RIGHT TOTALS

UER

2 = normal NT = not testable

0 = absent 1= altered

L5 L5

Elbow flexors Wrist extensors UEL (Upper Extremity Left) Elbow extensors Finger flexors Finger abductors (little finger)

0 = total paralysis 1 = palpable or visible contraction 2 = active movement, gravity eliminated 3 = active movement, against gravity 4 = active movement, against some resistance 5 = active movement, against full resistance 5* = normal corrected for pain/disuse NT = not testable

L4

S2 S3 S4-5

LEFT

MOTOR

KEY SENSORY POINTS Light Touch (LTL) Pin Prick (PPL)

KEY SENSORY POINTS Light Touch (LTR) Pin Prick (PPR)

KEY MUSCLES

MAX (25)

(50)

1. SENSORY 2. MOTOR

R

L

= LEMS TOTAL

+ LEL (25)

3. NEUROLOGICAL LEVEL OF INJURY (NLI)

LTR (50)

MAX (56)

= LT TOTAL

+ LTL (56)

4. COMPLETE OR INCOMPLETE?

Incomplete = Any sensory or motor function in S4-5

5. ASIA IMPAIRMENT SCALE (AIS)

PPR (112)

MAX (56)

ZONE OF PARTIAL PRESERVATION

= PP TOTAL

+ PPL (56)

SENSORY MOTOR

(112)

R

L

This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.

FIG. 156.1  Standard neurologic classification of spinal cord injury. (From American Spinal Injury Association. International Standards for Neurologic Classification of Spinal Cord Injury. Chicago: American Spinal Injury Association; 1996.)

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Muscle Function Grading

0 = total paralysis 1 = palpable or visible contraction 2 = active movement, full range of motion (ROM) with

gravity eliminated 3 = active movement, full ROM against gravity 4 = active movement, full ROM against gravity and moderate resistance in a muscle specific position 5 = (normal) active movement, full ROM against gravity and full resistance in a functional muscle position expected from an otherwise unimpaired person 5* = (normal) active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present NT = not testable (i.e. due to immobilization, severe pain such that the patient cannot be graded, amputation of limb, or contracture of > 50% of the normal ROM)

Sensory Grading

0 = Absent 1 = Altered, either decreased/impaired sensation or hypersensitivity 2 = Normal NT = Not testable

When to Test Non-Key Muscles: In a patient with an apparent AIS B classification, non-key muscle functions more than 3 levels below the motor level on each side should be tested to most accurately classify the injury (differentiate between AIS B and C).

Movement

Root level

Shoulder: Flexion, extension, abduction, adduction, internal and external rotation Elbow: Supination Elbow: Pronation Wrist: Flexion Finger: Flexion at proximal joint, extension. Thumb: Flexion, extension and abduction in plane of thumb Finger: Flexion at MCP joint Thumb: Opposition, adduction and abduction perpendicular to palm Finger: Abduction of the index finger Hip: Adduction Hip: External rotation Hip: Extension, abduction, internal rotation Knee: Flexion Ankle: Inversion and eversion Toe: MP and IP extension Hallux and Toe: DIP and PIP flexion and abduction Hallux: Adduction

C5

C6 C7

C8

T1 L2 L3 L4

ASIA Impairment Scale (AIS) A = Complete. No sensory or motor function is preserved in the sacral segments S4-5. B = Sensory Incomplete. Sensory but not

motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.

C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3. D = Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3. E = Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

Steps in Classification The following order is recommended for determining the classification of individuals with SCI. 1. Determine sensory levels for right and left sides. The sensory level is the most caudal, intact dermatome for both pin prick and light touch sensation. 2. Determine motor levels for right and left sides. Defined by the lowest key muscle function that has a grade of at least 3 (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5). Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal. 3. Determine the neurological level of injury (NLI) This refers to the most caudal segment of the cord with intact sensation and antigravity (3 or more) muscle function strength, provided that there is normal (intact) sensory and motor function rostrally respectively. The NLI is the most cephalad of the sensory and motor levels determined in steps 1 and 2. 4. Determine whether the injury is Complete or Incomplete. (i.e. absence or presence of sacral sparing) If voluntary anal contraction = No AND all S4-5 sensory scores = 0 AND deep anal pressure = No, then injury is Complete. Otherwise, injury is Incomplete. 5. Determine ASIA Impairment Scale (AIS) Grade: Is injury Complete? If YES, AIS=A and can record ZPP (lowest dermatome or myotome on each side with some NO preservation)

Using ND: To document the sensory, motor and

NLI levels, the ASIA Impairment Scale grade, and/or the zone of partial preservation (ZPP) when they are unable to be determined based on the examination results.

Is injury Motor Complete? If YES, AIS=B (No=voluntary anal contraction OR NO motor function more than three levels below the motor level on a given side, if the patient has sensory incomplete classification) Are at least half (half or more) of the key muscles below the neurological level of injury graded 3 or better?

NO

INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY

L5 S1

Yes

AIS=C AIS=D If sensation and motor function is normal in all segments, AIS=E Note: AIS E is used in follow-up testing when an individual with a documented SCI has recovered normal function. If at initial testing no deficits are found, the individual is neurologically intact; the ASIA Impairment Scale does not apply.

FIG. 156.1 cont’d

Cardiac • Blood pressure should be measured in both the seated and supine positions. Low baseline blood pressure is often a “normal” finding in SCI. • Look for orthostatic symptoms or excess fall in blood pressure with sitting or upright position. • High blood pressure may indicate autonomic dysreflexia (Table 156.6). • Examination of peripheral pulses may be especially important for identification of peripheral vascular disease in the absence of claudication and pain symptoms. 

Abdomen •  Examine for abdominal distention; examine bowel sounds for evidence of ileus. • Perform anorectal examination for hemorrhoids and fissures. 

Spine • Identify spinal deformity and tenderness. • Observe spinal precautions if the examination is being conducted in the acute or postoperative state. 

Table 156.6  Symptoms and Signs of Autonomic Dysreflexia Sudden, significant increase in blood pressure Pounding headache Flushing of the skin above the level of the SCI, or possibly below Blurred vision, appearance of spots in the patient’s visual fields Nasal congestion Profuse sweating above the level of the SCI, or possibly below the level Piloerection or goose bumps above the level of the SCI, or possibly below Bradycardia (may be a relative slowing only and still within normal range) Cardiac arrhythmias Feelings of apprehension or anxiety Minimal or no symptoms, despite a significantly elevated blood pressure SCI, Spinal cord injury.

CHAPTER 156  Spinal Cord Injury (Cervical)

Table 156.7  Functional Recovery Priorities of Persons With Cervical Spinal Cord Injury Area of Functional Recovery

Percentage Surveyed Ranking as the Most Important Item

Arm and hand function

48.7

Sexual function

13.0

Trunk stability

11.5

Bladder and bowel

8.9

Walking movement

7.8

Normal sensation

6.1

Chronic pain

4.0

From Anderson KD. Targeting recovery: priorities of the spinal cord– injured population. J Neurotrauma. 2004;21:1371-1383.

Extremities • Examine for range of motion, contractures, and swelling. • Identify nociceptive sources of pain; palpate for tenderness. • Differentiate effects of SCI (pedal edema, cool extremities) from additional pathologic processes. 

Skin •  Examine bone prominences for erythema or skin breakdown. • Describe any pressure injury/ulcers: location, appearance, size, stage, exudate, odor, necrosis, undermining, sinus tracks; evidence of healing in form of granulation and epithelialization; wound margins and surrounding tissues.8 

Functional Limitations Tetraplegia is associated with several functional limitations based on the level and completeness of injury.9 Additional factors, such as age, comorbid conditions, pain, spasticity, body habitus, and psychosocial and environmental factors, can affect function after cervical SCI. A survey of individuals with tetraplegia conducted to rank seven functions in order of importance to their quality of life revealed that the greatest percentage ranked recovery of arm and hand function as their highest priority (Table 156.7).10 The Consortium for Spinal Cord Medicine has developed clinical practice guidelines on outcomes after SCI with expected functional outcomes for each level of injury in a number of domains.9,11 Expected functional outcomes and equipment needs for each level of complete cervical SCI are summarized in Tables 156.8 and 156.9. 

Diagnostic Studies

907

tissues, including ligamentous structures, intervertebral discs, epidural or subdural hematomas, and hemorrhage or edema in the spinal cord. MRI with gadolinium is helpful in diagnosis of post-traumatic syringomyelia. 

Electrodiagnostic Testing Electromyography and nerve conduction studies may be helpful in distinguishing lesions of the peripheral nerves or brachial plexus from those of the spinal cord when patients present with neurologic worsening.12 

Urologic Studies Urodynamic studies assess neurogenic bladder and sphincter dysfunction. Tests to evaluate upper urinary tracts may be indicated on a periodic basis, but consensus on the type or frequency of these tests is currently lacking.4 Periodic cystoscopy may be indicated in those with chronic indwelling urinary catheters because of increased risk of bladder cancer.13 

Pulmonary Function Patients who are at high risk for pulmonary complications, such as those with high tetraplegia or with concomitant chronic obstructive airway disease, may require yearly measurements of forced vital capacity and repeated evaluations when new symptoms arise.14 Chest radiographs will show evidence of pneumonia or atelectasis. Sputum culture and Gram stain will identify the involved pathogens and help guide antibiotic therapy. 

Musculoskeletal Imaging Radiographic evaluation may be needed in case of suspected fracture or to evaluate pain. Heterotopic ossification may be assessed with a bone scan in addition to plain radiographs.4 If a pressure ulcer appears to involve the bone, MRI or bone scan may be helpful to evaluate for osteomyelitis.5  Differential Diagnosis Cervical spondylotic myelopathy Spinal infections, abscess Spinal cord infarction Primary or metastatic tumors Metabolic, toxic, and environmental myelopathies Multiple sclerosis and immune-mediated myelopathies Brainstem disease Motor neuron disease Lesions of the brachial plexus Disorders involving multiple nerves (e.g., polyneuropathy, Guillain-Barré syndrome) Conversion disorders or factitious causes of neurological impairment

Spinal Imaging Radiologic studies are performed to identify and to characterize the site of the pathologic change. The preferred initial imaging study is a high-quality computed tomography (CT). If CT is not available, a three-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended. Magnetic resonance imaging (MRI) is especially helpful to subsequently characterize the injury because of its ability to visualize the soft

Treatment Initial Initial acute management includes adequate spinal immobilization and prevention of secondary injury. Mean arterial pressure should be maintained above 85 mm Hg, while taking care to avoid fluid overload. Pharmacological treatment

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Table 156.8  Pattern of Weakness and Functional Outcomes After Cervical Spinal Cord Injury Domain

C1-C4

C5

C6

C7-C8

Pattern of upper extremity weakness

Total paralysis of extremities

Absent elbow extension and pronation, all wrist and hand movements

Absent wrist flexion, elbow extension, and hand movement

Limited grasp release and hand dexterity due to intrinsic muscle weakness

Respiratory

Ventilator dependent (some C3, many C4 may be able to be weaned off ventilator)

Low endurance and vital capacity; may require assistance to clear secretions

Low endurance and vital capacity; may require assistance to clear secretions

Low endurance and vital capacity; may require assistance to clear secretions

Bowel management

Total assist

Total assist

Some to total assist

Some to total assist

Bladder management

Total assist

Total assist

Some to total assist with equipment; may be independent with leg bag emptying

Independent to some assist

Bed mobility

Total assist

Some assist

Some assist

Independent to some assist

Bed and wheelchair transfers

Total assist

Total assist

Level transfer: some assist to independent Uneven transfer: some to total assist

Level transfer: independent Uneven transfer: independent to some assist

Pressure relief/ positioning

Total assist; may be independent with equipment

Independent with equipment

Independent with equipment or adapted techniques

Independent

Wheelchair propulsion

Manual: total assist Power: independent with equipment

Power: independent Manual: independent to some assist indoors on non-carpet surface; some to total assist outdoors

Power: independent with standard arm drive on all surfaces Manual: independent indoors; some assist outdoors

Manual: independent on all indoor surfaces and level outdoor terrain; may need some assist or power for uneven terrain or long distances

Eating

Total assist

Total assist for setup, then independent eating with equipment

Independent with or without equipment, except total assist for cutting

Independent

Dressing

Total assist

Some assist for upper extremities; total assist for lower extremities

Independent upper extremities; some to total assist for lower extremities

Independent upper extremities; independent to some assist for lower extremities

Homemaking

Total assist

Total assist

Some assist with light meal preparation; total assist for other homemaking

Independent for light meal preparation and homemaking; some assist with heavy household tasks

Driving

Total assist, attendantoperated van (with lift, tie-downs)

Independent with highly specialized modified van

Independent driving a modified van from wheelchair

Car with hand controls or adapted van from captain’s seat

SCI, Spinal cord injury. These outcomes pertain to expected function after motor complete SCI; functional outcomes after incomplete SCI vary on the basis of the extent of motor preservation.

for neuroprotection remains investigational. Physiatric consultation and intervention in an acute setting should address range of motion, positioning, bowel and bladder management programs, clearance of respiratory secretions, ventilatory management, consideration of venous thromboembolic prophylaxis,15 prevention of pressure ulcers, input about functional implications of options for surgery and spinal orthosis, and education of the patient and family.16 Goals of surgical intervention include reducing or realigning the spinal elements, decompressing compromised neural tissue, and/or stabilizing the spine. 

Rehabilitation The International Classification of Functioning, Disability, and Health (ICF) provides a useful conceptual framework for rehabilitation following SCI, with attention to the three domains of body functions and structure, activity, and participation, and to the influence of environmental and personal factors.4 Information about potential for motor recovery can be used to set functional goals and to plan for equipment needs (as described in Tables 156.8 and 156.9), keeping in mind that individual factors

CHAPTER 156  Spinal Cord Injury (Cervical)

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Table 156.9  Equipment Needs After Cervical Spinal Cord Injury Equipment Category

C1-C4

C5

C6

C7-C8

Electric hospital bed, pressure relief mattress

Electric hospital bed, pressure relief mattress

Electric hospital bed or full to king size standard bed, pressure relief mattress or overlay

Electric hospital bed or full to king size standard bed, pressure relief mattress or overlay

Transfers

Power or mechanical lift, transfer board

Power or mechanical lift, transfer board

Mechanical lift, transfer board

Transfer board may be needed

Wheelchair

Power wheelchair with tilt or recline (with postural support and head control devices as needed), vent tray, pressure relief cushion

Power wheelchair with tilt or recline with arm drive control, manual lightweight chair with hand rim modifications, pressure relief cushion

Lightweight manual wheelchair with hand rim modifications, may require power recline or standard upright power wheelchair, pressure relief cushion

Lightweight manual wheelchair with hand rim modifications, pressure relief cushion

Bathing and toileting

Reclining padded showercommode chair (if roll-in shower available), shampoo tray, hand-held shower

Padded shower-commode chair or padded transfer tub bench with commode cutout, hand-held shower

Padded transfer tub bench with commode cutout or padded shower-commode chair, hand-held shower

Padded transfer tub bench with commode cutout or padded shower-commode chair, hand-held shower

Eating, dressing, and grooming

Total assist; specialized equipment, such as a balanced forearm orthosis, may allow limited feeding ability in those with C4 SCI and minimal (< 3/5) strength in deltoid and biceps

Long opponens splint (with pocket for inserting utensils), long-handled mirror, adaptive devices as needed

Short opponens splint, universal cuff, longhandled mirror, adaptive devices as needed

Adaptive devices as needed, long-handled mirror

Communication

Mouthstick, high-tech computer access, environmental control unit

Adaptive devices as needed (e.g., for page turning, writing, button pushing, computer access)

Adaptive devices as needed (e.g., tenodesis splint, writing splint)

Adaptive devices as needed

Transportation

Attendant-operated van (with lift, tie-downs)

Highly specialized modified van with lift

Modified van with lift, tiedowns, hand controls

Modified vehicle

Respiratory

Ventilator (if not ventilator free) and suction equipment

Bed

SCI, Spinal cord injury.

and coexisting conditions may affect achievable goals.9 Important elements of rehabilitation include an interdisciplinary approach, establishment of an individualized rehabilitation program with consideration of unique barriers and facilitators, and inclusion of the patient as an active participant in establishment of goals.11 Initial rehabilitation typically includes attention to strength, endurance, positioning, range of motion, bed mobility, transfers, weight shifts, activities of daily living, wheeled mobility, and may include gait training in those with incomplete tetraplegia. Discharge planning should ensure appropriate patient and family/caregiver education, emergency planning, coordination of follow-up and ongoing support, and provision of appropriate durable medical equipment.4 Home modifications should be instituted to ensure accessibility.11 Specialized equipment needs, based on the level of injury, are summarized in Table 156.9. In addition to the post-acute rehabilitation that follows the injury, lifelong rehabilitation interventions are often indicated to address changes in neurologic status, new goals, changes in living situation, functional decline associated with medical complications and comorbidities, and aging.4 

Ongoing Management and Health Maintenance There is general consensus that comprehensive preventive health evaluations for individuals with SCI are important,4 although uniform agreement about specific elements and optimal frequency is lacking. Because all body systems are potentially affected by cervical SCI, long-term management needs to be comprehensive as summarized below.

Respiratory Respiratory infections should be promptly identified and treated.17 Measures such as smoking cessation and pneumonia and annual influenza vaccinations are important for reducing respiratory problems.4 Manually assisted cough methods can be taught to patients and caregivers. It is important to recognize and to address worsening ventilatory function that may occur with aging or after other complications. 

Cardiovascular Autonomic dysreflexia is a life-threatening emergency, and persons with tetraplegia can be at lifelong risk. Prompt

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identification and management are critical. The Consortium for Spinal Cord Medicine has published clinical practice guidelines for the acute management of autonomic dysreflexia.6 If the patient has signs and symptoms of dysreflexia (see Table 156.6), the blood pressure is elevated, and the individual is supine, immediately sit the person up. Loosen any clothing or constrictive devices. Monitor the blood pressure and pulse frequently. Quickly survey for instigating causes, beginning with the urinary system. If an indwelling urinary catheter is not in place, catheterize the individual. Before the catheter is inserted, instill lidocaine jelly (if it is readily available) into the urethra. If the individual has an indwelling urinary catheter, check the system along its entire length for kinks, folds, constrictions, or obstructions and for correct placement of the indwelling catheter. If a problem is found, correct it immediately. Avoid manual compression of or tapping on the bladder. If the catheter is not draining and the blood pressure remains elevated, remove and replace the catheter. If the catheter cannot be replaced, consult a urologist. If acute symptoms of autonomic dysreflexia persist, including a sustained elevated blood pressure, suspect fecal impaction. If the elevated blood pressure is at or above 150 mm Hg systolic, consider pharmacologic management to reduce the systolic blood pressure without causing hypotension before checking for fecal impaction. Use an antihypertensive agent with rapid onset and short duration (e.g., 2% nitroglycerin ointment) while the causes of autonomic dysreflexia are being investigated, and monitor the individual for symptomatic hypotension. If fecal impaction is suspected, check the rectum for stool. If the precipitating cause of autonomic dysreflexia is not yet determined, check for other less frequent causes. Monitor the individual’s symptoms and blood pressure for at least 2 hours after resolution of the autonomic dysreflexia episode to make sure that it does not recur. If there is poor response to the treatment specified or if the cause of the dysreflexia has not been identified, strongly consider admitting the individual to the hospital to be monitored, to maintain pharmacologic control of the blood pressure, and to

investigate other causes of the dysreflexia. Document the episode in the individual’s medical record. Once the individual with SCI has been stabilized, review the precipitating causes with the individual and caregivers and provide education as necessary.6 Individuals with tetraplegia and their caregivers should be able to recognize and to treat autonomic dysreflexia and be taught to seek emergency treatment if it is not promptly resolved. Treatment of symptomatic orthostatic hypotension4 addresses any exacerbating causes (e.g., medications, dehydration, or sepsis). Non-pharmacologic measures include postural challenges, abdominal binder, compression stockings, and increased salt intake. Pharmacologic treatment is administered if it is needed (e.g., with midodrine or fludrocortisone). Primary and secondary prevention of cardiovascular disease includes smoking cessation, diet and weight control, lipid management, screening for and treatment of hypertension and glucose intolerance or diabetes, and individualized exercise program.4,18 For evaluation of coronary artery disease, a modified or pharmacologic stress test is often needed in these individuals. If a cardiac rehabilitation program is required, it can be adapted for wheelchair users. 

Genitourinary The goals of bladder management (Table 156.10) are to ensure low pressure and complete voiding, to minimize urinary tract complications, to preserve upper urinary tracts, and to be compatible with the individual’s lifestyle (see Chapter 138).13 Anticholinergic medications (e.g., oxybutynin, tolterodine, or one of the newer antimuscarinc agents) may be indicated for detrusor hyperreflexia and α-adrenergic blockers (prazosin, terazosin, tamsulosin) for detrusor-sphincter dyssynergia. Urinary infections should be identified and treated promptly, but antibiotics are generally not recommended for asymptomatic bacteriuria.4 There is little role for prophylactic antibiotics, except before urologic procedures.

Table 156.10  Nonsurgical Options for Management of the Neurogenic Bladder in Spinal Cord Injury Bladder Management

Indications

Intermittent catheterization

Often the first choice, if feasible Need sufficient hand skills or willing caregiver Must be willing and able to follow catheterization time schedule

Indwelling catheterization (urethral or suprapubic)

Consider for poor hand skills and lack of caregiver assistance Not able or willing to follow intermittent catheterization schedule High fluid intake Lack of success with less invasive measures Temporary management of vesicoureteral reflux Choose suprapubic with epididymo-orchitis, prostatitis

Credé and Valsalva

Generally avoided in cervical SCI (unless the patient had sphincterotomy)

Reflex voiding

Hand skills or willing caregiver to put on condom catheter, empty leg bag Confirmed small post-void residual volumes, low voiding pressure Able to maintain condom catheter in place Need to also decrease detrusor-sphincter dyssynergia, if present (e.g., with alpha blocker, botulinum toxin injection, stent, sphincterotomy) Not an option for female patients

CHAPTER 156  Spinal Cord Injury (Cervical)

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Counseling and education are key elements of managing sexual dysfunction.19 Phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil) may be used to treat erectile impairment, although care needs to be taken to avoid simultaneous use of nitrate-based medications to treat autonomic dysreflexia, which could result in severe hypotension.4,19 Other options include intracavernosal injections, devices, and implants. Advances in electroejaculation and fertility care have increased the fertility success rate for men with SCI. Female fertility is not affected once menses return, which typically occurs within 1 year of injury. Pregnancy and delivery in women with SCI carries risks, including autonomic dysreflexia, and close follow-up is recommended.19 

One should beware of fecal impaction presenting as spurious diarrhea and pay due attention to new bowel symptoms. 

Gastrointestinal

If spasticity is painful or continues to interfere with function after institution of a stretching and positioning program and treatment of any exacerbating factors, medications are often indicated.4 Table 156.11 lists commonly used medications. Pregabalin, an anticonvulsant medication that binds to a subunit of the voltage-gated calcium channels in neurons with subsequent reduction in neurotransmitter release, is FDA-approved for treating SCI-related neuropathic pain.

The goals of bowel management are to facilitate predictable and effective elimination and to minimize bowel incontinence (see Chapter 139).20 A scheduled individualized bowel program should be established, which typically includes reflex stimulation maneuvers, laxatives (stool softeners, stimulants), dietary interventions, and adequate fiber intake. Laxatives and enemas should be kept to a minimum.

Skin Patient education, regular pressure relief practices, and prescription of pressure-reducing support surfaces are vital for prevention of pressure ulcers.8 Daily comprehensive skin inspections should be carried out by the patient or caregiver, with particular attention to vulnerable insensate areas (e.g., sacrum-coccyx, ischii, trochanters, and heels). Adequate nutritional intake is important. Management of pressure ulcers is discussed further in Chapter 149. 

Neurologic

Table 156.11  Medications Commonly Used for Spasticity and Pain in Spinal Cord Injury Problem

Drug Class

Medication

Spasticity

GABA related

Baclofen Gabapentin

α2-Agonist

Tizanidine Clonidine

Benzodiazepine

Diazepam Clonazepam

Calcium release inhibitor

Dantrolene

Local injection

Botulinum toxin Phenol, alcohol

Pain

Intrathecal agents

Baclofen

Nonopioid analgesic

Acetaminophen Tramadol Nonsteroidal anti-inflammatory drugs, salicylates

Opioid

Morphine sulfate Oxycodone Hydrocodone Fentanyl (transdermal)

Anticonvulsants—calcium channel ligands

Pregabalin Gabapentin

Anticonvulsants—other

Carbamazepine Other (phenytoin, valproic acid, lamotrigine)

Tricyclic antidepressant

Amitriptyline Nortriptyline

aThe

Local anesthetic

Lidocaine patch

Neuroblocking cream

Capsaicin

Intrathecal agents

Morphine, clonidine

list is not meant to be exhaustive, but includes examples of commonly used medications.

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Chapter 154 provides additional discussion about spasticity. Selective tightening (e.g., wrist extensors for tenodesis or back extensors for sitting balance) may be important for function in tetraplegia. Neurologic worsening (e.g., due to focal neuropathy, syringomyelia) should be investigated and addressed appropriately.4,12 

standing, and walking, as well as for electrophrenic respiration for ventilator-free breathing.23,24 The bionic glove is a neuroprosthetic device that utilizes electrical stimulation of the finger flexors, extensors, and thumb flexors to produce a functional grasp.25 

Musculoskeletal

Locomotor training (LT) may include use of manual assisted or robotic body weight-supported treadmill training (BWSTT). While emerging evidence is promising, further study is needed to establish the clinical role of BWSTT and to determine optimal parameters for training delivery.26 Promising results have been reported in early studies of epidural stimulation of the lumbosacral spinal cord, provided distal to the site of SCI, in conjunction with ongoing LT and repetitive standing.27 

Measures for upper extremity preservation after SCI should be instituted early and followed lifelong. These include optimization of equipment and wheelchair to minimize upper extremity stresses, activity modification to minimize repetitive or excessive upper extremity forces during daily activities and transfers, and individualized exercise program incorporating appropriate flexibility and strengthening components.22 It is important to recognize and to address contributing factors to pain, which is often multifactorial7 (see Table 156.3). Pain medications (see Table 156.11) often do not provide complete or optimal relief.21 Heterotopic ossification is treated with etidronate sodium, nonsteroidals, and occasionally surgical resection, especially if it is interfering with function or comfort (see Chapter 131).11 Pathologic fractures should be recognized and treated with padded splints or bivalved circular casts, monitoring of skin integrity, and often only a limited role for surgical treatment.4 The role for pharmacologic treatment of osteoporosis in SCI is still evolving. Fall prevention (education, wheelchair lap belts) is important to prevent injuries. 

Psychosocial It is important to address environmental barriers (physical and attitudinal), to promote self-efficacy, and to optimize participation and community integration in response to changes in the living situation and social support, functional decline, and aging. Depression should be identified and treated adequately, and substance abuse prevention and treatment programs should be offered.30 

Procedures Pressure Ulcers Sharp débridement of pressure ulcers may be done at the bedside to remove necrotic tissue, although if it is extensive, débridement may need to be done in the operating room. 

Spasticity Motor point or nerve blocks with phenol or alcohol may be helpful in treating localized spasticity that interferes with positioning, mobility, or hygiene. Intramuscular injections of botulinum toxin are another option. 

Pain Shoulder pain due to subacromial bursitis may be temporarily responsive to local corticosteroid injections, as is the discomfort from carpal tunnel syndrome.22 

Technology Functional Electrical Stimulation Functional electrical stimulation (FES) has been used in SCI to improve motor function, including upper limb control,

Body Weight-Supported Treadmill Training

Exoskeletons Exoskeletal-assisted standing and walking over ground is a relatively new technology. It uses a computerized, powered exoskeleton support frame, attached to the pelvis and legs that allows a person with paralysis to stand and walk. Powered exoskeletons may be a viable option for some people with SCI. However, additional research and experience is needed to determine their clinical role, feasibility, effectiveness, and appropriate indications for use.28,29 

Brain-computer Interface Brain-computer interface or neural interface technology is an experimental but exciting technology in which neural signals from the cerebral cortex are recorded and used to control movement of a computer cursor or other external device. It has the potential to bypass the injured spinal cord for control of paralyzed extremities.30 

Surgery Spine Surgery When cervical spine injury is accompanied by mechanical instability, pain, deformity, or progressive neural impairment, surgical decompression and segmental instrumentation may be indicated for reconstruction of spinal alignment, stability, and early mobilization.16 

Pressure Ulcers Plastic surgery may be indicated for deep pressure ulcers. This includes excision of the ulcer and surrounding scar and muscle and musculocutaneous flap closure.8 

Spasticity If spasticity is not controlled with maximum dosages of oral medications, or if a patient is unable to tolerate the medications, the placement of an intrathecal baclofen pump may be considered.31 

Motor Function Reconstructive surgery of the upper extremity with tendon transfers may improve motor function by one level, typically in those with a neurologic level at C5, C6, or C7. Depending on the level of injury, restoration of wrist extension, elbow extension, and key grip strength or improvement of active grasp and hand control may be an appropriate goal.24 

CHAPTER 156  Spinal Cord Injury (Cervical)

Bladder Dysfunction Surgical treatment of urolithiasis includes cystoscopic removal of bladder stones, lithotripsy, and percutaneous nephrolithotomy for larger renal stones. Endourethral stents or transurethral sphincterotomy may be considered in individuals with detrusor-sphincter dyssynergia.13 Electrical stimulation and posterior sacral rhizotomy may be considered for individuals who have problems with catheterization, have good bladder contractions, have no extensive bladder fibrosis, and are willing to lose reflex erections.13 Bladder augmentation may be indicated for intractable bladder contractions with incontinence and in those at high risk for upper tract deterioration. Urinary diversion may be an appropriate option for unsalvageable bladders secondary to urethral fistula and in individuals with bladder cancer requiring cystectomy.13 

913

lipoprotein cholesterol, increased body fat and insulin resistance, decreased physical activity). Diagnosis of cardiovascular disease may be delayed because of confusing or absent symptoms and signs.18 

Genitourinary Neurogenic bladder is associated with loss of voluntary control, detrusor-sphincter dyssynergia, and incomplete bladder emptying. Complications include urinary tract infection, bladder and kidney stones, vesicoureteral reflux, and hydronephrosis with renal impairment. Bladder cancer risk is increased with chronic indwelling catheter, especially in smokers.13 Erectile and ejaculatory dysfunction occurs, and sperm quality may be impaired.4,19 

Bowel Dysfunction

Gastrointestinal

Patients with neurogenic bowel who have significant difficulty or complications with typical bowel care may have improved quality of life after colostomy. Careful selection of patients and individualization are required in consideration of this surgery.20 

There is loss of voluntary bowel control, anorectal dyssynergia, and reduced rectal expulsive force.20 Fecal impaction may occur. Anorectal problems include hemorrhoids, fissures, proctitis, and prolapse. Gallstone risk is increased. Gastroesophageal reflux is common. False-positive results of examination for fecal occult blood may complicate colorectal cancer screening. 

Upper Extremity Pain Surgery may occasionally be considered for chronic upper extremity overuse-related symptoms that are unresponsive to medical and rehabilitative treatment (e.g., for carpal tunnel syndrome or rotator cuff disease). Outcomes are often poor if upper extremity overuse continues.22 

Post-traumatic Syringomyelia Surgical placement of shunts may be indicated for posttraumatic syringomyelia associated with intractable pain or progressive neurologic decline. 

Potential Disease Complications Cervical SCI is associated with multiple complications that can involve every body system.

Respiratory Respiratory problems include atelectasis, mucous plugs, and pneumonia secondary to impaired cough and retention of secretions; ventilatory failure with high tetraplegia; and sleep disordered breathing.17 

Cardiovascular Patients with cervical SCI are prone to multiple cardiovascular complications throughout life.18 Autonomic dysreflexia may occur in SCI above the T6 neurologic level and can be precipitated in response to any noxious stimulus below the level of injury. Symptomatic orthostatic hypotension often resolves after the first few months, but may be persistent in some cases. Although venous thromboembolism risk is reduced after the initial months, it can increase even in chronic SCI in the setting of prolonged immobilization associated with medical illness or in the postsurgical state. Cardiovascular fitness is reduced and cardiovascular risk factors can be adversely affected (e.g., reduced high-density

Skin Pressure ulcers are common and may increase with duration of injury. Previous occurrence of a pressure ulcer is an important predictor of future pressure ulcers.8 

Metabolic and Endocrine Hyponatremia may be a persistent problem in some patients. Carbohydrate and lipid metabolism is affected, and there may be glucose intolerance associated with relative insulin resistance.16 A reduction in bone mineral density with secondary osteoporosis is common in chronic SCI and affects both the upper and lower extremities in those with tetraplegia. 

Neurologic Neuropathic pain can be persistent and have a negative impact on quality of life.21 Entrapment neuropathies (median nerve at wrist, ulnar nerve at elbow) and post-traumatic syringomyelia can result in neurologic deterioration.12 

Musculoskeletal Overuse syndromes include shoulder pain and rotator cuff problems.22 Contractures may occur without due attention to range of motion and positioning. Individuals with C5 level of injury are especially prone to elbow flexion and forearm supination contractures because of unopposed biceps activity. Heterotopic ossification, which is the development of ectopic bone within the soft tissues surrounding peripheral joints, occurs in SCI most commonly around the hip, followed by the knees, elbows, and shoulders.32 It is further discussed in Chapter 131. Pathologic fractures may occur even with trivial injury because of severe osteoporosis.4,33 

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Table 156.12  Pharmacokinetic Changes in Spinal Cord Injury SCI-Related Change

Impact on Pharmacokinetics

Delayed gastric emptying

Rapid absorption of acidic drugs Delayed absorption of basic drugs

Reduced gastrointestinal motility

Increased absorption of drugs that undergo enterohepatic circulation Decreased bioavailability of drugs that are destroyed by gut bacteria

Reduced blood flow to skin and muscle

Less reliable transcutaneous, subcutaneous, and intramuscular drug absorption below injury level

Increased percentage of body fat

Effect on fat- and water-soluble drug distribution

Reduced plasma protein level

Increased free fraction of protein-bound drugs

Impaired kidney function

Reduced renal elimination of drugs

SCI, Spinal cord injury.

Psychosocial SCI can increase the potential for stress, isolation, and depression.34 Alcohol and substance abuse risk seems to be increased.35 

Potential Treatment Complications Spinal pain at the surgical site may result from loosening, infection, or broken hardware. Instability or neurologic deterioration may be due to inadequate spinal immobilization. Surgical shunts can become blocked or infected, and intrathecal pumps or catheters may malfunction. Complications of urethral catheterization include urethral trauma, erosions, strictures, urinary infections, and epididymitis.13 Chronic indwelling catheters increase the risk of stones and squamous cell carcinoma of the bladder. Complications may occur with surgical procedures for SCI-related problems, such as neurogenic bladder. For example, transurethral sphincterectomy may be associated with significant intraoperative and perioperative bleeding and erectile and ejaculatory dysfunction. Posterior sacral rhizotomy done in conjunction with electrical stimulation of the bladder may result in loss of reflex erection and ejaculation and reduction of reflex defecation. Urinary diversion procedures may be followed by intestinal or urinary leak, infection, ureteroileal stricture, stomal stenosis, and intestinal obstruction due to adhesions.13 Because people with SCI are often prescribed multiple medications, drug-related side effects and complications are common. Cervical SCI can result in altered pharmacokinetics4 in multiple ways (Table 156.12), which further increases unpredictability of side effects.

References 1.  International Standards For Neurological and Functional Classification of Spinal Cord Injury. Revised 2011, updated 2015. Atlanta, GA: American Spinal Injury Association; 2015.

2. National Spinal Cord Injury Statistical Center. Spinal cord injury: facts and figures at a glance. J Spinal Cord Med. 2017;40:377–378. 3. Stucki G, Bickenbach J. The International Spinal Cord Injury Survey and the Learning Health System for Spinal Cord Injury. Am J Phys Med Rehabil. 2017:96(2 suppl 1):S2–S4. 4. Sabharwal S. Essentials of spinal cord medicine. New York: Demos Medical Publishing; 2014. 5. Bauman WA, Korsten MA, Radulovic M, Schilero GJ, Wecht JM, Spungen AM. 31st g. Heiner sell lectureship: secondary medical consequences of spinal cord injury. Top Spinal Cord Inj Rehabil. 2012;18(4):354–378. 6. Consortium for Spinal Cord Medicine. Acute management of autonomic dysreflexia: individuals with spinal cord injury presenting to health care facilities. 2nd ed. Washington, DC: Paralyzed Veterans of America; 2001. www.pva.org. 7. Bryce TN, Biering-Sørensen F, Finnerup NB, et al. International spinal cord injury pain classification: part I. Background and description. March 6-7, 2009. Spinal Cord. 2012;50:413–417. 8. Consortium for Spinal Cord Medicine. Pressure ulcer prevention and treatment following spinal cord injury. Clinical practice guidelines for health care professionals. 2nd ed. Washington, DC: Paralyzed Veterans of America; 2014. www.pva.org. 9. Consortium for Spinal Cord Medicine. Outcomes following traumatic spinal cord injury. Clinical practice guidelines for health care professionals. Washington, DC: Paralyzed Veterans of America; 1999. www.pva.org. 10. Anderson KD. Targeting recovery: priorities of the spinal cord–injured population. J Neurotrauma. 2004;21:1371–1383. 11. Kirshblum SC, Priebe MM, Ho CH, et al. Spinal cord injury medicine. 3. Rehabilitation phase after acute spinal cord injury. Arch Phys Med Rehabil. 2007;88(suppl 1):S62–S69. 12. Bursell JP, Little JW, Stiens SA. Electrodiagnosis in spinal cord injured persons with new weakness or sensory loss: central and peripheral etiologies. Arch Phys Med Rehabil. 1999;80(8):904–909. 13. Consortium for Spinal Cord Medicine. Bladder management for adults with spinal cord injury. Clinical practice guidelines for health care professionals. Washington, DC: Paralyzed Veterans of America; 2006. www.pva.org. 14. Consortium for Spinal Cord Medicine. Respiratory management following spinal cord injury. Clinical practice guidelines for health care professionals. Washington, DC: Paralyzed Veterans of America; 2005. www.pva.org. 15. Consortium for Spinal Cord Medicine. Prevention of venous thromboembolism in individuals with spinal cord injury. 3rd ed. Washington, DC: Paralyzed Veterans of America; 2016. www.pva.org. 16.  Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury. Washington, DC: Paralyzed Veterans of America; 2008. www.pva.org. 17. Lanig IS, Peterson WP. The respiratory system in spinal cord injury. Phys Med Rehabil Clin N Am. 2000;11:29–43. 18. Sabharwal S. Cardiovascular dysfunction in spinal cord disorders. In: Lin VW, ed. Spinal cord medicine: principles and practice. 2nd ed. New York: Demos; 2010:241–255. 19.  Consortium for Spinal Cord Medicine. Sexuality and reproductive health in adults with spinal cord injury. Clinical practice guidelines for health care professionals. Washington, DC: Paralyzed Veterans of America; 2010. www.pva.org. 20. Consortium for Spinal Cord Medicine. Neurogenic bowel management in adults with spinal cord injury. Clinical practice guidelines for health care professionals. Washington, DC: Paralyzed Veterans of America; 1998. www.pva.org. 21. Cardenas DD, Felix ER. Pain after spinal cord injury: a review of classification, treatment approaches, and treatment assessment. PM R. 2009;1(12):1077–1090. 22. Consortium for Spinal Cord Medicine. Preservation of upper limb function following spinal cord injury. Clinical practice guidelines for health care professionals. Washington, DC: Paralyzed Veterans of America; 2005. www.pva.org. 23. Ho CH, Triolo RJ, Elias AL, et al. Functional electrical stimulation and spinal cord injury. Phys Med Rehabil Clin N Am. 2014;25(3):631–654. 24. Patil S, Raza WA, Jamil F, Caley R, O’Connor RJ. Functional electrical stimulation for the upper limb in tetraplegic spinal cord injury: a systematic review. J Med Eng Technol. 2014;39(7):419–423. 25. Prochazka A, Gauthier M, Wieler M, Kenwell Z. The bionic glove: an electrical stimulator garment that provides controlled grasp and hand opening in quadriplegia. Arch Phys Med Rehabil. 1997;78(6):608–614.

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26. Swinnen E, Duerinck S, Baeyens JP, Meeusen R, Kerckhofs E. Effectiveness of robot-assisted gait training in persons with spinal cord injury: a systematic review. J Rehabil Med. 2010;42(6):520–526. 27. Harkema S, Gerasimenko Y, Hodes J, et al. Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: a case study. Lancet. 2011;377(9781):1938–1947. 28. Fisahn C, Aach M, Jansen O, et al. The effectiveness and safety of exoskeletons as assistive and rehabilitation devices in the treatment of neurologic gait disorders in patients with spinal cord injury: a systematic review. Global Spine J. 2016;6(8):822–841. 29. Benson I, Hart K, Tussler D, van Middendorp JJ. Lower-limb exoskeletons for individuals with chronic spinal cord injury: findings from a feasibility study. Clin Rehabil. 2016;30(1):73–84. 30. Lobel DA, Lee KH. Brain machine interface and limb reanimation technologies: restoring function after spinal cord injury through development of a bypass system. Mayo Clin Proc. 2014;89(5):708–714.

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31. McIntyre A, Mays R, Mehta S, et al. Examining the effectiveness of intrathecal baclofen on spasticity in individuals with chronic spinal cord injury: a systematic review. J Spinal Cord Med. 2014;37(1):11–18. 32. Citak M, Suero EM, Backhaus M, et al. Risk factors for heterotopic ossification in patients with spinal cord injury: a case-control study of 264 patients. Spine. 2012;37(23):1953–1957. 33. Bauman WA, Cardozo CP. Osteoporosis in individuals with spinal cord injury. PM R. 2015;7(2):188–201. 34. Williams R, Murray A. Prevalence of depression after spinal cord injury: a meta-analysis. Arch Phys Med Rehabil. 2015;96(1):133–140. 35. Lusilla-Palacios P, Castellano-Tejedor C. Spinal cord injury and substance use: a systematic review. Adicciones. 2015;27(4):294–310.