1) Traumatic paraplegia refers to spinal cord injury in the thoracic, lumbar, or sacral regions resulting in loss of muscle strength in the lower extremities. Initial management involves immobilization and transport to the emergency room for evaluation. 2) The bladder is commonly affected after paraplegia, resulting in either a flaccid or spastic bladder depending on the level of injury. Long-term management involves preventing complications like pressure ulcers, spasticity, and blood clots through rehabilitation therapies. 3) Rehabilitation is critical after spinal cord injury and involves a multidisciplinary team to address issues like bladder management, skin care, spasticity management, and prevention of secondary complications. The

1. By- DR ASHUTOSH KUMAR
AP ORTHOPAEDICS DEPARTMENT ,RMCH BAREILLY
TRAUMATIC PARAPLEGIA &
MANAGEMENT OF BLADDER

2. INTRODUCTION
• Spinal Cord Injury is an insult to the spinal cord resulting in a change either
temporary or permanent in the cord’s motor,sensory,or autonomic function.
• The International Standards for Neurological and
functional Classification of Spinal Cord
Injury(ISNCSCI)is a widely accepted system of describing the level and
extent of injury which gave the following terminologies.
• Tetraplegia-injury to the spinal cord in the cervical region with
associated loss of muscle strength in all 4 extremities.
• Paraplegia-Injury to the spinal cord in the thoracic,lumbar or sacral
segments including the cauda equina and conus medullaris.

3. Neural injuries are divided into two broad etiology based
categories.
• Primary Injury-Physical tissue disruption caused by
mechanical forces.
• Secondary Injury-Additional neural tissue injury resulting
from the biologic response initiated by the physical tissue
disruption.
Classification based on the physical Characteristics.
• Concussion-physiologic disruption without anatomic
injury.
• Contusion(most common)-physical tissue disruption
leading to hemorrhage and swelling.
• Laceration(very rare)-loss of physical continuity i.e,
complete transection of neural tissue.

4. • Spinal cord injury predominantly occurs in the
young males,with a male to female ratio of 4:1.
• The most common cause of traumatic spinal
cord injury is a motor vehicle crash-42%.
• Falls-27%
• Gunshot injuries-16%.
• Sports injuries-7%.

5. • The most common site of spinal cord injury is
the cervical spine-50-64%,
• Followed by lumbar region-20-24% and
• Thoracic cord-17 to 19%.

6. Brief Anatomy of the Spinal Cord
• The spinal cord is divided into 31 segments,each with a pair of
anterior and posterior spinal nerve roots.
• On each side the anterior and dorsal nerve roots combine to form the
spinal nerve as it exits from the vertebral column through the neural
foramina.
• The spinal cord extends from the base of the skull to the lower end of
the L1 vertebral body.
• The spinal cord is organized into a series of tracts or neuropathways
that carry motor and sensory information.
• The corticospinal tracts are descending motor pathways which
decussate in the medulla located anteriorly within the spinal cord.
• The dorsal columns are the ascending sensory tracts that transmit
light touch,proprioception,and vibration information to the sensory
cortex.
• The lateral spinothalamic tracts transmit pain and temperature
sensation.
• Sympathetic (thoraco lumbar outflow)exits between the C7 to L1.
• Parasympathetic pathways(Craniosacral outflow) exit between the
S2-S4 segments.

8. • Cervical vertebra-Add 1
to the vertebral level.
• Upper thoracic
vertebrae-Add 2.
• Lower thoracic(T7-T9)-
Add 3.
• At D10-L1 & L2.
• At D11-L3 & L4.
• At D12-L5 cord segment.
• At L1-All Sacral
segments over.
• Below L1-Cauda Equina.

9. Vascular supply
• It consists of the one anterior and two posterior
spinal arteries.
• The anterior spinal artery supplies the anterior two
thirds of the spinal cord.
• It arises from the union of two arteries arising from
the vertebral artery.
• Posterior spinal artery,two in no. and arises directly
from the terminal branch of each vertebral
artery(posterior inferior cerebellar artery).
• The anterior and posterior arteries are
supplemented by the radicular arteries,the largest of
these is the artery of Adamkiewicz which usually lies
on the left side and reinforces the arterial blood
supply to the lower end of the spinal cord.

10. Spinal Cord Injuries Proper
• Complete injury of the spinal cord is defined by the absence of the
sensory and motor function in the lowest sacral segment.
• Sacral sensation refers to the sensation at the anal
mucocutaneous junction and deep anal sensation.
• Sacral motor function is voluntary anal sphincter contraction
on digital examination.
• Incomplete injury have partial preservation of the sensory or
motor in the lower sacral segment.
• For the patient to be sensory incomplete they must demonstrate either
sensory preservation in the S4-S5 or deep anal sensation.
• For the patient to be motor incomplete they must demonstrate either
voluntary anal sphinchter contraction or presence of lower extremity
motor function more than three levels below the designated motor level of
injury.

11. Initial assessment and care-
• All trauma patients are at risk for spinal injury.
• Proper extrication of the patient and immobilization of
the spine are critical to avoid further neurological
injury.
• Immobilizing the patient in a Kendricks
Extrication device is an effective means in spinal
emergencies.
• Other options for immobilization include hard
cervical collar,sandbags,spine board.

14. Logrolling of the patients is an important maneuver in the field transportation
of the patients

15. Emergency room care-
Differences between the neurogenic and
hemorrhagic shock should be identified

16. • The American Spinal Injury Association(ASIA)
provides a useful format for guiding in the
assessment of the neurological injury.

18. • The essential elements in the examination in the
neurologic function include strength assessment of the
5 specific muscles in each limb and pinprick sensation
testing at 28 specific points on each side of the body.
• On each side of the body five muscles representing the
segments of the lumbar cord are score on a 5-point
muscle grading scale.The sum of all 20 muscles yields
a total score for each patient with a maximum possible
score of 100.

22. • For the 28 sensory dermatomes on each side of
the body sensory levels are scored on a 0-2 scale
with a total score of 112.

25. Spinal shock
It was first defined by Whytt in 1750 as a loss of
sensation accompanied by motor paralysis with
initial loss but gradual recovery of reflexes,
following a spinal cord injury (SCI).
Reflexes in the spinal cord caudal to the SCI are
depressed (hyporeflexia) or absent (areflexia)
while those rostral to the SCI remain unaffected.
It should be distinguished from the neurogenic
shock which is characterized by the hypotension
and loss of reflexes below the spinal level of
injury.

29. Bladder in Paraplegia
LMN Bladder or Aitinomous
Bladder or Flaccid Bladder.
• Lesion interupting the reflex
arc(S1-S3).
• Partial emptying of the
bladder.
• Residual volume larger than the
UMN bladder.
• Easy to manually express.
• Loss of voluntary control.
UMN Bladder or Automatic Bladder
or Spastic Bladder.
• Lesion cranial to the S1-S3.
• Detrusor Sphincter Dysynergia.
• Partial voiding(intact local reflex
arc).
• Residual volume.
• Difficulty to express.
• Loss of voluntary control.

32. Diagnostic Modalities.
• 1.Plain Xray-AP and Lateral views of the TL
and LS spine should be obtained.

33. Points to be noted in AP View.
• Isolated fractures of the transverse
process.
• Loss of vertebral height.
• Widening of the interpedicular
distance.
• Vertebral translation.
• Increased interspinous distance.
• Horizontal split in the body at the
level of pedicles.

34. Points to be noted in lateral view
• Loss of anterior vertebral body
height.
• Kyphosis.
• Spinous process widening.
• Loss of posterior vertebral body
height.
• Translation.
• Spinous process fracture.

35. 2.CT Scan.
Advantages:
• Most accurately depicts bony
injuries.
• Sensitivity and specificity > 95% .
• Concomitant multi-slice CT of
chest, abdomen and pelvis can be
done to detect visceral injuries.
• Extent of vertebral body
comminution.
• Retropulsion of bone
fragments.
• Lamina fracture.
• Pedicle fracture.

37. Reverse Cortical sign
• The retropulsed fragment that has rotated
more than 180 degrees so that the cortical
surface is opposed to the cancellous
surface of the main vertebral body.
• Severe disruption of the posterior
ligamentous complex
• Due to 180° rotation the fragment will not
unite with the main vertebral body
• Anterior decompression is usually
preferred.
• Contraindication for ligamentotaxis.

38. 3.MRI-
Indications:
• Patients with neurological deficit.
• Patients with suspicious PLC injury.
Advantages:
• In patients with neurological deficit, MRI accurately depicts the
extent of cord compression, edema, hemorrhage and the presence
of cord transection.
• Determines extent of injury to posterior ligamentous complex. .
• Helps to identify multi-level non-
contiguous injuries.
Disadvantages:
• Cost and availability.
• Delay in definitive management.

39. • Bony compression of spinal
cord.
• Hyperintense signal changes
in cord.
• Hyperintense signal in the
PLC.
• Marrow edema in adjacent
bones.
• Epidural hematoma.
• Cord transection.
• Multilevel injury.

40. Role of Steroids in the Acute Spinal
Cord Injuries

41. • Methylprednisolone is not recommended for the
following circumstances.
• The multiply injured patient.
• Penetrating spinal cord injury.
• Patients with glucose intolerance or diabetes
mellitus.
• Patients with multiple medical comorbidities or with
impaired immune system.
• Elderly patients.
• Patients with a complete thoracic spinal cord injury

42. Thoracolumbar Injuries in Brief
Denis three column concept of stability.

43. McAfee’s Classification of fractures of
Thoracolumbar spine
• 1.Wedge Compression Fractures-
isolated failure of the anterior column and
result from forward flexion.
• 2.Stable Burst Fractures-anterior and middle
columns fail and there is no loss of integrity of the
posterior elements.
• 3.Unstable Burst Fractures-All the three
columns are disrupted.There is a tendency for the
posttraumatic kyposis.

44. • 4.Chance fractures-Horizontal avulsion
injuries of the vertebral bodies caused by
flexion around an axis anterior to the ALL.The
entire vertebra is pulled off by the tensile force.
• 5.Flexion Compression Fractures-Flexion
occurs at an axis posterior to the ALL.The
anterior column fails in compression whereas
the middle and the posterior columns fail in
tension.
• 6.Translational Injuries-these are
characterized by the malalignment of the
neural canal which has been totally
disrupted.all the three columns fail in shear.

46. Management of Thoracolumbar
Injuries
• Stable injuries of the spine can be managed with braces.

47. • The operative decision making is dictated by the
• -Morphology of the fracture.
• -The status of PLC.
• -Neurologic status of the patient.
• -Other medical comorbidities

48. Indirect Decompression
• The indirect approach to decompress the spinal
cord by ligamentotaxis is a technique that
utilizes the posterior instrumentation and a
distraction force applied to the intact posterior
longitudinal ligament to reduce the retropulsed
bone fragments from the spinal canal by
tensioning the posterior longitudinal ligament.

49. • Ligamentotaxis.

50. Direct Decompression
1.Posterior Approach-
• This is one of the most commonly used approach for the
thoracolumbar injuries.
• Advantages are it reduces the morbidity associated with the
anterior approach like decreasing the operative blood
loss,avoids visceral injury.decreases the operative time.
• Transpedicular screw fixation is the gold standard approach
now for the treatment of thoracolumbar injuries.

51. 2.Closed Reduction
• Primary reduction is performed by positioning of
the patient onto a frame to create lordosis.
3.Pedicle screws.
• Pedicle screws are inserted into the vertebrae
cephalad and caudal to the fracture level on both
sides.
4.Rod contouring
• The contouring of the rod depends on the site of
the fracture following the natural curvature of the
spine.

52. 5.Rod insertion
• The rods are introduced to the distal
screw heads on both sides and
tightened.
• The rod is then inserted into the
proximal screw heads without
tightening
.
6.Decompression
• If it is decided to perform an indirect
decompression, this is done at this stage.
If indirect decompression proves to be
insufficient, a direct decompression eg,
posterior or transpedicular
decompression are undertaken.

54. 2.Anterior approach-
• The indications include:
• The presence of a traumatic disc herniation causing
neurologic injury.
• The need to remove a portion or entire vertebral body
followed by reconstruction for stability, or for relief of
symptomatic neural compression
• Ventral epidural hematoma.
• Kyphotic angulation with ventral compression.
• An anterior decompression can be done through a
partial or total corpectomy, both including
discectomies above and below the fractured vertebra.
• If a vertebral body or a disc lesion compresses the spinal
cord, it should be removed with the respective
decompression technique.

56. Step 1: Discectomy
• Discectomy always precedes corpectomy, because it allows the surgeon
to visualize the upper and lower limit of the spinal canal.
• For partial corpectomy, discectomy is done for the disc adjacent to the
fractured end plate.
• For a complete corpectomy, discectomy is done both above and
below that fractured vertebra.

57. Step 2 – Corpectomy
• In a second surgical step, a total or a partial corpectomy is
undertaken.
• A total corpectomy involves removal of the entire vertebral
body and adjacent discs.
• Partial corpectomy involves removal of fractured ends of vertebral
body and adjacent discs.

58. Step 3- Reconstruction.
1.Total corpectomy
• Anterior reconstruction of the disc space or
vertebral body following a complete
corpectomy can be performed using an
autograft or allograft, strut graft, or a
synthetic or metallic cage (expandable or
non expandable).
• Additional bone grafting can be used from
the corpectomized vertebral body and the
removed rib.

59. 2.Partial corpectomy
• The anterior reconstruction of the
vertebral body is performed using a
mesh or tricortical iliac crest bone
graft.
• The bone graft stemming from the
vertebral body is transplanted to
bridge the segment

60. 4 Stabilization
Application of plate
instrumentation
• The appropriate size plate is
chosen by using a measuring
forceps to determine plate
length.
• A plating template is then
applied to the remaining
vertebral bodies to make sure the
plate fits flush on the bone.
• A drill guide is used to drill holes
within the vertebral body.

61. • Anterior rod screw system
• Another form of anterior instrumentation is using a single rod construct
after placing a strut graft with a bone screw above and below the fusion
site. Some fixation systems are designed to place two rods in parallel to
one another to provide the potential for standalone anterior fixation.

62. Rehabilitation in spinal cord injuries.
• Rehabilitation following SCI is most effectively undertaken with a
multidisciplinary, team-based approach, as follows.
• Physical therapists.
• Occupational therapists.
• Rehabilitation nurses.
• Psychologists.
1.Pressure ulceration(Bed Sores).
Stage I: Non-blanchable erythema.
Stage II: Partial thickness.
Stage III: Full thickness skin loss.
Stage IV: Full thickness tissue loss.

63. 2.Spasticity:
• It is a velocity-dependent increase in muscle tone and occurs
commonly following spinal cord injury.
• Regular muscle stretching and joint range of motion prevents
this.
• Oral medication include Baclofen 200mg tid.
3.Thromboembolic disease
• The increased risk of thromboembolism is likely due to venous stasis
and hypercoagulability.
• Pneumatic compression devices can be used for the first 2 weeks.
Unfractionated heparin (5000 U SC every 12 hours) or a low-molecular-
weight heparin (30 mg SC every 12 hours), such as enoxaparin, can be
administered for 2-3 months following injury.

64. 4.Bladder management:
• Acute bladder management is by use of an indwelling catheter, as
the bladder is likely to be flaccid.
• Selection of a bladder drainage method ideally is made following
urodynamic evaluation. Clean intermittent catheterization is a method
available to those with good hand function or to skilled attendants. The
patient is instructed to limit fluid intake, and catheterization is
performed every 4-6 hours.
• Reflex voiding into a condom catheter is an option available to men with
reflex bladder contractions. Problems can include urinary retention or high
intravesical voiding pressure due to detrusor-sphincter dyssynergy.
Voiding pressure sometimes can be decreased by alpha-blocking agents
such as terazosin or tamsulosin .

65. 5.Bowel Management.
• A typical problem is stool that is too hard because of the prolonged
colonic transport time, which leads to drying of the stool.
• Intervention includes maintenance of adequate intake of fluid
and fiber, with fiber acting as a sponge to hold moisture within
the stool. Docusate sodium (100 mg PO bid) can increase the ease
with which water enters the stool.
• Another problem is incontinence. The goal is to establish a set
time for daily bowel evacuation, ideally after a meal to take
advantage of any gastrocolic reflex.

66. 5.Neuropathic Pain.
• Neuropathic pain following spinal cord injury (SCI)
is perceived at or below the level of injury.
• Anticonvulsants may be particularly useful in cases of
lancinating electrical pain. Gabapentin (initial dose of
100 mg PO tid, gradually titrated upward) typically is
used, with precautions for sedation.
• Tricyclic antidepressants like amitryptiline may be
useful for more constant diffuse pain.

67. 6.Functional Rehabilitation:
With regard to recovery below the level of the
lesion, ASIA A patients typically do not show
significant recovery in this area. Individuals who
are in ASIA B have approximately a 31% chance
of improving to grade D at 1-year follow-up,
while those with initial grades of C have a 67%
likelihood.

68. Presenter :Dr.Sri krishna
chaitanya.k Chairman:
Dr.S.V Udapudi
BLADDER IN
PARAPLEGIAAND ITS
MANAGEMENT

69. Anatomy
 The urinary bladder is a smooth muscle chamber
composed of two mainparts:
 (1) the body, the major part, collectsurine
 (2) the neck, a funnel-shaped extension of the body,
passing inferiorly and anteriorly into the urogenital
triangle and connecting with theurethra

70. •The smooth muscleof the bladder iscalled the detrusor
muscle.

71.  On theposteriorwall of
the bladder, lying
immediately above the
bladder neck, is a small
triangular area called the
trigone.
 The trigone can be
identified by the fact that
its mucosa, is smooth, in
contrast to the remaining
bladder mucosa, which is
folded to form rugae.

72.  At the lowermost apex ofthe
trigone, the bladder neck opens
into the posterior urethra, and the
two ureters enter the bladder at
the uppermost angles of the
trigone.
 Each ureter, as it enters the bladder,
courses obliquely through the
detrusor muscle and then passes
another 1 to2 centimeters beneath
the bladder mucosa before
emptying into thebladder.

73. The bladder neck (posterior urethra) is 2 to 3
centimeters long, and its wall is composed of
detrusor muscle interlaced with a large amount of
elastic tissue. The muscle in this area is called the
internal sphincter.

74.  Its natural tone normally keeps the bladder neck and
posterior urethra empty of urine and, therefore, prevents
emptying of the bladder until the pressure in the main part
of the bladder rises above acritical threshold.

75.  Beyond the posterior urethra, the urethra passes
through the urogenital diaphragm, which containsa
layer of muscle called the external sphincter of the
bladder.

76.  This muscle is avoluntaryskeletal muscle, in contrast
to the muscle of the bladder body and bladder neck,
which is entirely smoothmuscle.
 The external sphincter muscle is under voluntary
control of the nervous system and can be used to
consciouslypreventurination evenwhen involuntary
controlsareattempting toempty the bladder.

77. Innervation of the Bladder
 The principal nervesupplyof the bladderis bywayof the pelvic
nerves, which connect with the spinal cord through the sacral plexus,
mainly connecting with cord segments S-2 andS-4.
 Coursing through the pelvic nervesare both sensory nerve fibers
and motor nerve fibers.
 The sensory fibers detect the degree of stretch in the bladderwall.
Stretchsignals from theposteriorurethra are especially strong and are
mainly responsible for initiating thereflexes thatcause bladder
emptying.

78. Innervation of the urinary bladder and its sphincters

79.  The motor nerves transmitted in the pelvic nerves are
parasympathetic fibers. These terminate on ganglioncells
located in the wall of thebladder.
 Short postganglionic nerves then innervate thedetrusor
muscle.
 In addition to the pelvic nerves, two other types of
innervation are important in bladder function. Most
important are the skeletal motor fibers transmitted
through the pudendal nerve to the external urethral
sphincter. These are somatic nerve fibers that innervate
and control thevoluntaryskeletal muscleof the sphincter.

80.  Also, the bladder receives sympathetic innervations
from the sympathetic chain through the hypogastric
nerves, connecting mainly with the L-2 segment ofthe
spinal cord.
 These sympathetic fibers stimulate mainly the blood
vesselsand have little todowith bladdercontraction.
 Some sensory nerve fibers also pass by way of the
sympathetic nerves and may be important in the
sensation of fullnessand, in some instances, pain.

81. The Cystometrogram
 When there is no urine in the bladder,
the intravesicular pressure is about Zero,
but by the time 30 to 50 ml of urine has
collected, thepressurerises to 5 to 10
centimeters ofwater.
 Additional urine—200 to 300 ml—
can collect with onlya small
additional rise in pressure; this
constant level of pressure is caused by
intrinsic tone of the bladder wall
itself.
 Beyond 300 to 400 milliliters, collection
of moreurine in the bladdercauses the
pressure torise rapidly.

82. Micturition Reflex
 As the bladder fills, many superimposed micturition
contractions begin to appear. They are the result of a
stretch reflex initiated by sensory stretch receptorsin
the bladder wall, especially by the receptors in the
posterior urethra when this area begins to fill with
urineat the higher bladderpressures.

83.  Sensory signals from the bladder stretch receptors are
conducted to the sacral segments of the cord through
the pelvic nerves and then reflexively back again to the
bladder through the parasympathetic nerve fibers by
way of these samenerves.

84.  When the bladder is only partially filled, these
micturition contractions usually relax spontaneously
aftera fraction of a minute, the detrusor musclesstop
contracting, and pressure falls back to the baseline.
 As the bladder continues to fill, the micturition
reflexes become more frequentand causegreater
contractions of the detrusormuscle.

85.  Once a micturition reflex begins, it is “self-
regenerative.” That is, initial contraction of thebladder
activates the stretch receptors to cause a greater
increase in sensory impulses to the bladder and
posterior urethra, which causes a further increase in
reflex contraction of the bladder; thus, the cycle is
repeated again and again until the bladder has reached
a strong degree ofcontraction.

86.  Once a micturition reflex has occurred but has not
succeeded in emptying the bladder, the nervous
elementsof this reflex usuallyremain in an inhibited
state for a few minutes to 1 hour or more before
another micturition reflexoccurs.
 As the bladder becomes more and more filled,
micturition reflexes occur moreand moreoften and
more and morepowerfully.

87.  Once the micturition reflex becomes powerful
enough, itcausesanotherreflex, which passes through
the pudendal nerves to the external sphincter to inhibit
it.
 If this inhibition is more potent in the brain than the
voluntaryconstrictorsignals to the external sphincter,
urination will occur. If not, urination will not occur
until the bladder fills still further and the micturition
reflex becomes morepowerful.

88. Facilitation or Inhibition of
Micturition by the Brain
 The micturition reflex is a completely autonomic
spinal cord reflex, but itcan be inhibited or facilitated
by centers in thebrain.
 These centersinclude
 (1) strong facilitative and inhibitory centers in the brain
stem, located mainly in the pons, and
 (2) several centers located in the cerebral cortex that are
mainly inhibitory but can becomeexcitatory

89.  The micturition reflex is the basic cause of
micturition, but the highercenters normallyexert
final control of micturition asfollows:
 1. The higher centers keep the micturition reflex
partially inhibited, except when micturition isdesired.
 2. The highercenters can prevent micturition, even if
the micturition reflex occurs, by continual tonic
contraction of the external urethral sphincter until a
convenient time presentsitself.
 3. When it is time to urinate, the cortical centers can
facilitate the sacral micturitioncenters to help initiatea
micturition reflex.

91. Paraplegia
 Complete Paralysis of the lower half of bodyincluding
both legs,usually caused by damage to spinal cord in
mid and lowerback
 Causes :
 Cerebral disorders:CVA,Brain tumour,Parkinson,MS
 Spinal cord disese orTrauma
 Disorders of peripheral innervation:DM
 Metabolic disturbances:Hypothyroidism,Poryphyria
 Acute infections:GB syndrome
 Heavy metal toxicity,alcholism,SLE

92.  Atherosclerosis
 Herpes Zoster
 Metastasis
 Acute traumatic SCI is the mostcommoncauseof
paraplegia in daytoday orthopaedicpractice.

93. SPINAL CORD INJURY(SCI)
 Mid Cervical & Thoraco Lumbar injuries aremost
common (T12)
 Neurological deficitvaries with level & severityof injury
Level of SCI is described by neurological level of injury&
degree of functional impairment.
o Spinal Column segmentsare numbered by thevertebral
level and have a different relation ship to spinal cord
segmental level at different locations.
o Sacral cord begin at T12 to L1,spinal cord endsat L2

94. Clinical stages
Stage of spinalshock
Stage of reflexactivity
Stage of reflex failure

96. Stage of spinal
shock
 Effects depends on site ofinjury
 Complete transection in cervical region (abovec5) is
fatal paralysis of respiratory muscles
 In transection of spinal cord patient feel as it has been
cut in to two portions, upperportion is unaffected and
in lowerpart all the motoractivitysensations are lost

98. Characteristic effects of spinal
shock
 MotorEffects
 Loss of tone
 A reflexia
Paraplegia,Quadriplegia
Muscles becomeflaccid
All the superficial anddeep
reflexeses arelost
 Sensory Effects All Sensations arelost
below the level of transection

99. Complete lesions above T1 will therefore eliminate all
sympathetic outflow.
Lesions between T1 and T6 will preserve sympathetic tone in
the head and upper extremities but deny it to the adrenals and
the lower extremities.
Lesions between T6 and the lumbar cord will preserve
adrenal innervation but denervate the lower extremities.

100. Vasomotor Effects
 Sympathetic fibers leave the spinal cord between T1
and L2
Sharp fall in blood Transection at the level ofT1
pressure(MBP 40mmhg)
 Cold and cyanosedextremities
 Skin becomes red ,dry and scalyand bed sores may
develops

103.  Bladder is ACONTRACTILE &AREFLEXIC
 Detrusor is paralysed, sphincter is also paralysed but
regains its toneearly leading to urinary retention.
 In complete suprasacral spinal spinal cord lesions this
period may last up to 2-6 weeks, but may last up to 1 or
2 years
 It may lasta shorterperiod of time in incomplete
suprasacral lesion

104. Stage of reflex activity
 Smooth muscles regain functional activityfirst
 Automatic evacuation of urinary bladderand bowel
 Sympathetic tone of blood vessels isregained
 BP is restored tonormal
 In skin sweating starts, bed sores healup

105. Stage of reflex activity
 Skeleton muscletonethen recoversslowlyafter 3- 4 weeks
 Toneof f lexor muscles return first leading to PARAPLEGIA
IN FLEXION(both lower limbs are in state offlexion)
 Reflex activity begins toreturnafterfewweeksof recovery of muscletone
 The first reflex response to appear is often a slight contraction of the leg
flexors and adductors in response toa noxiousstimulus. In some patients, the
knee jerk reflex recovers first.

106. Stage of Reflex Activity
Babiski’s Flexor reflexes returnfirst
reflex(sign) positive.
 Extensor reflexesreturn after a variable period of1-5
weeks of appearance of flexor reflexes
 Initially knee jerk appears, then ankle jerk may return

107. Stage of Reflex Activity
 Mass reflex can beelicited in somecases
 Scratching of theskin overthe lower limbsor the
anterior abdominalwall
 Spasm of flexor muscles of both the limbs,
evacuation of bowel and bladder andprofuse
sweating below the level of lesion

108. Stage of Reflex Failure
 The failureof reflex activity mayoccurwhen general
condition of the patient starts deteriorating due to
malnutrition ,infections
 Reflexes become moredifficult toelicit
 The threshold for stimulusincreases.
 Mass reflex is abolished,and
 The muscles becomeextremely flaccid and undergo
wasting.

109. Dysfunctions of bladder in spinal cord and cauda equina
lesions
 Once thestageof spinal shock has subsided, level and type of cord or conus-
cauda equina lesion, whether complete or incomplete, are determining
factors in pathophysiology of bladder
 Bors and comarr classification:
 Based on 3 factors
 Anatomic location of lesion
 Neurological completeness or incompleteness oflesion
 Whetherlowerurinary tract is balanced orunbalanced i.e.
refers topercentageof residual volumeof urinerelativeto bladder
capacity

111. UMN Bladder
 Refers to pattern of injury tosuprasacral spinal cord
after period of spinal shock haspassed
 Impliesa neurologicallycomplete lesion above the level
of sacro spinal cord that results in skeletal muscle
spasticity below the level of injury
 Features :
 Involuntary bladder filling
 Residual urinevolumegreater than 20% of bladder
capacity
 Occurs with lesions between cervical and sacralspinal
cord

112. LMN Bladder
 Impliesa neurologicallycomplete lesion at the level of
sacrospinal cord orof thesacral roots
 Features:
 Results in skeletal muscle flaccidity below thatlevel
 Detrusorareflexia
 Whateverthe measures the patient may used to increased
intravesical pressure during attempted voiding are not
sufficient todecrease residual urinevolume.

113. Lapides classification
 Sensory neurogenicbladder
 Motor paralyticbladder
 Uninhibited neurogenic bladder
 Reflex neurogenicbladder
 Autonomous neurogenicbladder

114. Sensory neurogenic bladder
 Causes: DM, Tabes Dorsalis, MS, Sub acutecombined
degeneration of cord
 Pathophysiology: Interrupts sensory fibers between
bladderand spinal cord or theafferent tracts of brain
 There’s lack of stretch signals from bladderpreventing
micturition reflexcontraction.
 Features: Impaired sensation of bladderdistension
results in bladder over distension &hypotonicity.

115. Motor paralytic bladder
 Causes: Extensive pelvic surgery/ trauma, herpeszoster
 Pathophysiology: Destruction of parasympatheticmotor innervation of
thebladder
 Features: Painful urinaryretention
 Relative inability to initiate & maintainnormal micturition.
 A large residual urine mayresult.

116. Uninhibited neurogenic bladder
Causes: Injury or disease to Cortico regulatory tract. Brain or Spinal
cord tumour-Parasagittalmenigiomas,
frontal lobe tumour. Parkinson’s disease,Demyelinating disease, anterior
communicating arteryaneursyms.
 Features:
 Frequency, urgency, urge incontinence.
 Residual urine is characteristicallylow.
 The patientcan initiate bladdercontraction voluntarily,
but isoften unable todoso becauseof low urinestorage

117. Reflex neurogenic bladder
 Causes: traumatic spinal cord injury,transverse myelitis
 Pathophysiology: Describes post spinal shock condition
that exists after complete interruption of sensory & motor pathways
between sacral spinal cord &
the brain stem.
 Features: No bladdersensation
 Inability to initiate voluntarymicturition
 Therefore, INCONTINENCE WITHOUT SENSATION results,
because of low volume involuntarycontraction, STRAINED
SPHINCTER DYS-SYNERGIA is therule

118. Autonomous neurogenic bladder
 Causes: Anydiseasewhichdamagesextensivelysacral cord/sacral
roots, pelvic surgery, pelvic malignant disease, spina bifida.
 Pathophysiology: Results from complete &sensory seperation of
bladder from spinalcord.
 Features: Inability to voluntary micturitionintiation,
 no bladder reflexactivity,
 no specific bladdersensation
 Continous dribbling incontinence
 Considerable residual urinevolume
 Loss of sexual function.
 Unfortunately many patients do not exactly “FIT” into oneoranothercategory,
gradations of sensory, motor& mixed lesion'soccur.

119. Lab studies
 Urinalysis and urine culture: Urinary tract infection can
cause irritative voiding symptoms and urgeincontinence.
 Urine cytology: Carcinoma-in-situ of the urinarybladder
causes symptoms of urinary frequencyand urgency.
 Renal profile: Blood urea nitrogen (BUN) and creatinine(Cr)
are checked if compromised renal function issuspected
 Urodynamic studies
 PVR by USG
 Uroflowmetry
 Cystometry

120. PVR
 Thepostvoid residual urine (PVR) measurement isa part of basic
evaluation for urinary incontinence.
 If the PVR is high, the bladder may be contractile or the bladder outlet
may be obstructed. Both of these conditionswill causeurinary retention
withoverflow incontinence.
Uroflowmetry
 Lowuroflow rate mayreflecturethral obstruction,a weak detrusor, or a
combination of both. This test alone cannot distinguish an obstruction from a
contractiledetrusor.

121. Urodynamic studies
 It is the investigation and assessmentof the bladder
and lower urinarytract.
 It measures the intravesical pressure duringbladder
filling (filling cystometrogram) and therelationship
between intravesical pressure and urinary flow rate
during voiding (micturitioncystometrogram).

122. Indication & Timing of Urodynamic Study in SCI
 First Urodynamicstudy
 Mandatory
 Timing
 Immediaately after recovery from spinalshock
 Provides info about bladderdysfunction
 Purpose
 Identifyrisk factors for UTI & Plan future management
 Subsequent Urodynamic study
 Indications
 Whenever symptomsevolve
 Confirmation of effect oftreatment

123. Management
Medications causing urinaryincontinence:
 Sedatives
 Diuretics
 Anticholinergic
 Antipsychotics
 Alphaantagonists

124. Anti incontinent measures:
 Pelvic floorexercises.
 Biofeedback.
 Electrical stimulation.
 Bladdertraining.
 In the case of a flaccid paralysis, bethanechol (Urecholine) produces
contraction of the detrusor by direct stimulation of its muscarinic
cholinergicreceptors.
 In spastic paralysis, the detrusor can be relaxed by propantheline (15 to
30 mg three timesdaily), which acts as a muscarinic antagonist, and by
oxybutynin (Ditropan, 5 mg two to three times daily), which acts
directly on the smooth muscle and also has a muscarinic antagonist
action.
 Atropine, which is mainly a muscarinicantagonist, only partially inhibits
detrusorcontraction.

125. Bladder Management in SCI
Goals in treatment:
 Preservation of upper urinarytract
 Maintainadequate bladdercapacitywith good compliance
 Promote low-pressure micturition
 Avoid bladder over-distension
 Prevent urinary tractinfection
 Minimize use of Foleycatheter
 Choose therapy that minimizes patient risks while
maximizing social, emotional, and vocationalacceptability

126. Important to note that more than 500cc
in the bladder overstretches it and
infection or reflux is more likely.
 Try to maintain intermittent catheterizationsof
250cc-350cc/cath.

127. Bladder Emptying Options
 No Catheter
 Urethral Indwelling Catheters (ID)
 Intermittent Catheterization(IC)
 Suprapubic Catheter(SC)

128. No
Catheter
 Incomplete SCI
 Requires intact sacral micturitionreflex
 Voluntaryvoiding
 Credé andValsalva
• Involuntary voiding
 Reflex Voiding
Conduct a thorough urodynamic
evaluation todeterminewhetherreflex
voiding is a suitable method for a
particular individual
Small post-void residual volume ismust

129. C
C
.
ondom Catheter – Care and
oncerns
Should be applied securely to avoid leakage and constriction
for 24 hours.
To avoid skin maceration and breakdown, the glans is washed daily
when the condom is changed, the skin is aired for 20–30 minutes, and
the condom is reapplied
Interference with social/sexualfunction.
 Urine leakage may occur during sexual activity.
 Use of a regular condom may be an optionfor
management.

130. Urethral Indwelling Catheters (ID)
ID is the firstchoice in acutestageof SCI Strict
asepticprecautions
 Urinary infection rate 5% to 7% / day
Continued
 Till hemodynamicallystable
 During perioperativeperiod
Should beremoved asearlyas possible
 Till fit forIC
Continuing ID beyond 2 weeks requires justification

131. Continuing ID
 Poor hand skills (cervicalSCI)
 High fluid intake
 Cognitive impairmentoractivesubstanceabuse.
 Elevated detrusor pressures managed withanticholinergic
medications or othermeans
 Lackof success with other methods
 Need for temporary management of vesicoureteralreflux
 Limited assistance from acaregiver
 Women with technicaldifficulty
 IC not feasible because of urethralabnormality

132. Care of ID
 Large size and small balloonvolume
 Replace every 2 to 4weeks
 More frequent if catheterencrustationor bladderstones
 Anchoring thecatheter
 Secure thecatheterto theabdomen orthigh
 Alternating sides towhich thecatheteris attached
 Clogged catheters
 Silicone catheterpreferred
 30 ml of Renacidin can be instilled daily for 20–30 minutes
 Irrigation
 Notrecommended because irrigationdenudes the uroepithelium

133. Care of ID
 Intolerance to inflated catheterballoon
 Anticholinergic medication to reduce autonomicdysreflexia
 Personal care
 Genital area is cleaned dailywith mild soap and water
 High fluid intake (> 2000ml)
 Tofacilitate mechanical washout
 Decrease soluteconcentration
 Lessen the likelihood of stoneformation
 Cosmesis
 Leg bag is worn during thedayand a nighttime collection device is used
overnight
 Interference with social/sexual function
 Need to be removed forintercourse

134. Complications of ID
 Urethral
 Diverticula
 Periurethritis
 Fistula
 Erosion
 Strictures
 Bladder
 UTI and Calculi
 Bed restdemineralization
 Infection
 Stasis due to catheterblock
 Diverticuli

135.  Symptoms of bladder infection include foul odour,
purulent urine, and hematuria. Feverwith flank pain
often present.
 If bladder infectionoccurs, change theentirecatheter
and the drainagesystem.
 The urinary drainage bag does not need to be
disinfected to preventinfection

136. Suprapubic Catheterization (SC)
Consider :
hral injury Immedi
issuspec
 Urethral
 Stricture
 False pa
 Bladdern
 Urethral
 Urethral
 Recurren
ately following acute SCI if uret
ted, especially after pelvictrauma
abnormalities
ssages
eckobstruction
fistula.
discomfort.
t urethral
catheterobstruction.
ine: J Spinal Cord Med2006.

137. Suprapubic Catheterization (SC)
Consider
 Difficulty with urethral catheterinsertion.
 Perineal skin breakdown due to urineleakage secondary to
urethral incompetence.
 Psychological considerations
 Body image or personalpreference.
 A desire to improve sexual genitalfunction.
 Prostatitis, urethritis, orepididymoorchitis.
 If bladder capacity is small, with forceful uninhibited
contractions despitetreatment.
Consortium for Spinal Cord Medicine: J Spinal Cord Med2006.

138. I h
n
.

139. IC Care
 Hand washing
 Correct technique
 Cathetercare
 Cleaned with mild soap and water, air-dried,and placed
in a paperbag
 Fluids restriction to 2 L/day
 Timing
 Every 4–6 hours so that theamountof urineobtained with
each collection is less than 500ml

140. Avoid IC
 Inability to catheterizethemselves.
 A caregiverwho is unwilling toperformcatheterization.
 Abnormal urethral anatomy, such as stricture,false passages,
and bladder neckobstruction.
 Bladder capacity less than 200ml.
 Poor cognition, little motivation, or inability or unwillingness
toadhere tothecatheterization time schedule.
 High fluid intakeregimen.
 Adversereaction topassing acatheter intothegenital area multiple
times aday.
 Tendency todevelopautonomicdysreflexia with bladder

141. Complications of IC
 Urinary tractinfections.
 Bladderover-distention.
 Urinary incontinence.
 Urethral trauma withhematuria.
 Urethral false passages.
 Urethral stricture.
 Autonomicdysreflexia.
 Bladderstones.

142. Other Considerations with IC
 Consider anticholinergics if reflux ispresent
 Investigate and provide treatment forindividuals on IC who leak
urine betweencatheterizations
 Monitor individuals using this method ofbladder management
 If bladder volumes consistently exceed 500ml
 Adjust fluid intake
 Increase frequency of IC
 Consider alternative bladder managementmethod

143. Recurrent UTI with IC
 Technique and bladdercheck
 Single-usecatheter
 Single-use hydrophiliccatheter
 Reduces urethral irritation
 Requires sterile water forinjection
 Antibacterial catheter
 Touchlesscatheter
 Fluids intake
 Timing change
Joseph, AC, et al: Spinal Cord Injury Nursing1998.

144. Catheterization Techniques –
Current Evidence
No evidence that any ofthe following strategy isbetter
than anyother forall clinical settings:
• Specific technique (aseptic orclean)
• Catheter type (coated oruncoated)
• Method (single-use ormultiple-use)
• Person (self orother)
Moore, et al: Cochrane Database Syst Rev 2007.

145. Red Flags for Referral to
Urologist
▶ Haematuria
▶ Renal impairment
▶Recurrent urinary tract infections
▶ Bladder stones
▶ Pain thoughtto bearising from the urinary tract
▶ Suspicionof concomitant local pathologiessuch as
bladder outlet obstruction due to prostate enlargement
in men, stress incontinence inwomen
▶Symptoms refractory to treatment

146. Algorithm for Bladder Management
in SCI