Paraplegia results from spinal cord injury and causes impairment of motor function and sensation in the lower extremities. Early rehabilitation is important to prevent secondary complications like pressure ulcers, respiratory issues, osteoporosis, urinary tract dysfunction, and others. Proper management includes preventative measures and treatments for any complications that do arise.

1. Complications of paraplegia
and its management
chetan

2.  Typically affect young and previously
healthy individuals who now require
urgent and comprehensive
emergency care
 patient is expected to learn to
perform once simple and now
complex tasks of daily living
independently with the goal of
returning home

3. History
 Egyptian physicians long ago labeled SCI as an ailment not to
be treated at all because they feared that the pharaoh would
kill them if they let a patient die under their care.
 Prior to WW I, SCI typically resulted in early death.
 Significant advances in treatment began during WW II & have
continued to progress, allowing many individuals with SCI to
live far longer than previously expected.

4. Def
 Impairment in motor function of the lower extremities and possibly trunk with or without involvement
of sensory system
 Caused by involvement of
 cerebral cortex,
 spinal cord,
 Nerves supplying the muscles of lower extremity
 And the muscle itself directly

5.  Early rehabilitation of spinal cord injury pts begin with prevention
 Preventing secondary complications speeds entry into the rehabilitation phase and improves the
possibility that the patient will become a productive member of society

6. Complications
 Pressure Ulcers
 Pulmonary Complications
 Osteoporosis and Fractures
 Urinary Tract Dysfunction
 Neurogenic Heterotopic Ossification
 Spasticity
 Venous thrombosis
 Upper extremity arthropathies
 Bowel Complications
 Cardiovascular Diseases

7. Pressure ulcer
decubitus ulcer
Bedsore
pressure sore

8. sites
 Early acute phase – sacral area
 Subacte and chronic phases – ischial area

9. Risk factors
Combination of
 Immobility
 Insensitivity
 Moisture from bowel or urinary
incontinence
 Muscle atrophy
 Nutrironal status

10. National Pressure Ulcer
Advisory Panel staging
system
 Stage I: Intact skin with nonblanchable
redness of a localized area usually over a
bony prominence.

11.  Stage II: Partial-thickness
loss of dermis presenting as a
shallow open ulcer with a red
pink wound bed, without
slough

12.  Stage III: Full-thickness tissue
loss. Subcutaneous fat may be
visible, but bone, tendon, or
muscle is not exposed. Slough
may be present

13.  Stage IV: Full-thickness
tissue loss with exposed
bone, tendon, or muscle

14. Prevention
 Assess the patient's skin daily
 Cleanse skin when indicated using a pH-balanced cleanser
 Avoid soap and hot water
 dry by rubbing or patting
 Use emollients to maintain skin hydration

15. Pressure relief
 Support surfaces are divided into 2 categories
 Constant low-pressure (CLP) devices
 Alternating-pressure (AP) devices

16. Cushions for wheelchairs filled with gel, foam, air, or water are available to relieve pressure

17.  A turning schedule should be initiated immediately
 The patient’s position in bed should be initially established for turns to occur every 2 to 3 hours.
 This interval can be gradually increased to 6 hours with careful monitoring for evidence of skin
compromise
 Turning positions include prone, supine, right and left side-lying, semi prone, and semisupine positions

18. Wound care
 Debridement is the first step
 Followed by NPWT
 Surgical management

19. Musculocutaneo
us flap

20. Heterotopic ossification
 transformation of primitive mesenchymal cells in the surrounding soft tissue to mature lamellar
bone
 Early complication occurs within 1 month of rehabilitaition
 Incidence is 50%
 Present - swelling, fever, and reduction in ROM of affected joint(s)

21. Diagnosis
 level of sr creatine phosphokinase early stage -severity of muscle involvement
 Sr alkaline phosphatase –inc bone turnover
 Xray {calcification appears after 3 to 8 weeks progress from peripheral to central}
 Mri- varies as the lesion evolves
 Early T1 poorly defined masses {immaure –complex fluid collection}
 Ct 3d recon
 Three phase technetium bone scan early

22.  Early diagnosis {suspicious} is the key for timely intervention and prophylactic management
 complications such as nerve impingement, joint contractures, pain, and limited range of motion
 Surgical - risks wound healing complications, delayed therapy, rehabilitation, as well as the risk of
recurrence

23.  indomethacin is effective if started early (3 to 4 weeks) after injury
 Etidronate is first-line treatment for management of HO in the acute stage
 aggressive joint motion by physical therapy

24. Osteoporosis and Fractures
 significant bone loss in paralyzed limbs in the early period after injury
 distal femur and proximal tibia
 Bone densitometric studies --bone loss of 30% in the first 3 months
 Patients who actually suffer fractures were found to have even higher bone loss: approx 40% in femoral
shaft and 70% in proximal tibia
The paraplegic fracture: supracondylar femur fracture

25. Prevention and treatment
 Intensive exercise regime and mobilization
 Transient
 Pharmological management
 Non operative
Exoskeleton-Assisted Walking

26. Joint contractures
 Due to presence of weakened and paralyzed muscles
 development of a contracture may result in postural misalignment or impede potential function

27.  prevention includes the use of splints for proper joint alignment,
techniques such as weight bearing and functional excercies

28.  Despite preventive measures if joint contactures occur
 plaster or fiberglass serial casting techniques
 botulinum toxin type A injections {tone reduction}
 Surgical management

29. Respiratory Complications
 most common early and late cause of death after SCI
 Pneumonia is the most common complication in high-level injuries, while atelectasis is seen in all
groups of patients

30. pathophysiology
 restrictive ventilatory dysfunction --muscle paralysis
 inability to cough, which is due primarily to paralysis of abdominal and intercostal muscles
 hypersecretion of mucus--absent sympathetic outflow

31.  Secretions are most commonly removed by tracheal
suctioning, assisted coughing
 Acessory muscle training
Maximal
Inspiratory
effort
Delivers a
manual
thrust to
cough

32.  bronchodilators (β-adrenergic agonists and /or anticholinergics), mucolytic agents, and chest
physiotherapy
 Later in phase of rehabilitation there is decrease mucus production needs assisted cough and
breathing excercises
 yearly vaccination for influenza and vaccination every five years for pneumonia

33. Shoulder arthropathies
 Prevalence is 30 to 60% Shoulder becomes major weight bearing
And often overused
Neuromuscular fatigue leads to decreased stability and superior displacement of the humeral head

34. Shoulder Arthropathies
 Common pathologies include:
 Chronic inflammation (especially supraspinatus)
 Impingement syndrome
 Bursitis
 Rotator cuff tears
 Bicipital tendinitis
 Glenohumeral and acromioclavicular arthritis
 Peripheral neuropathies (carpal tunnel syndrome) are also common

35. Shoulder Arthropathies
 Paraplegic patients with higher levels of shoulder pain reported lower subjective
quality of life and physical activity scores
 Interventions:
 Designing ergonomic ways for patients to transfer
 Wheelchair biomechanics (power)
 Physiotherapy to enhance shoulder stability
 Core body support for patients with high thoracic paraplegia
 Medical management
 Surgical management (cuff repair, subacromial debridement, shoulder arthroplasty)

36. Neurogenic bladder
incontinence

37. Consortium for Spinal Cord Medicine
 Management of fluid intake to maintain daily urine output between 1.5 and 2 L
 Intermittent catheterization using clean or sterile technique
 Indwelling catheter for patients with poor hand control and lack of attendant care
 Suprapubic catheter for, most commonly, patients with urethral lesions
 External (condom) catheter for male patients with UMN bladder with reflex voiding
 Surgery

38. Neurogenic bowel
Following SCI, there is a disruption of the extrinsic influences of the nervous system on the bowel
significant physical distress
Embarrassment
inconvinence

39. UMN
• Voluntary control of bowel is lost in
these patients but conus-mediated reflex
activity and intestinal peristalsis are
intact.
• external anal sphincter becomes spastic
LMN
• Voluntary control of bowel is lost as well
as sacral reflex activity.
• The external anal sphincter becomes
atonic and flaccid

40. Cardiovascular comlications
 related to the disruption of sympathetic control located in the cervical cord
 Most frequent presentations are
 orthostatic hypotension (68%) {passive vasodilatation below the level of injury}
 bradycardia (71%) {uninhibited parasympathetic tone}
 Dizziness
 Blurred vision
Midodrine orally alpha 1 agonist is 1 choice

41. Deep Vein thrombosis
 Incidence is high in acute stages incidence is 47%
 Caution with motor complete injuries, obesity, previous h/o of dvt , lower extremity
fractures heart failure

42.  compression stockings, boots, pneumatic devices
 LMWH is recommended for 8 weeks
 Oral anticoagulants like Warfarin
 Inferior vena cava filter if contraindication to anticoagulants