The First Few Weeks

Medical
Soon after a spinal cord injury a patient may develop “neurogenic shock,” which includes significantly low blood pressure (hypotension), significantly low heart rate (bradycardia) and significantly low temperature (hypothermia). Independent of whether neurogenic shock occurs, the patient develops “spinal shock” after a spinal cord injury which may last days to weeks. Spinal shock is a condition that involves the lack of tone or contraction of the muscles below the level of injury, loss of tendon reflexes, and possibly neurogenic shock.

The first week or two after a spinal cord injury is referred to as the “acute” time. There are conditions that occur during that time that require special attention and treatment. Below are some of the issues that occur during this acute time frame and possible interventions that may take place.
Neurogenic shock
As mentioned above, this can include hypotension, bradycardia, and hypothermia. Hypotension most often occurs in individuals with spinal cord injuries from C1 to T6, which includes tetraplegics and mid to high paraplegics. This is thought to occur because of a significant loss of the sympathetic nervous system effect on the blood vessels and heart. Normally the sympathetic nervous system would stimulate the blood vessels to contract and maintain a normal blood pressure. After a spinal cord injury at the T6 or above, the absent or limited sympathetic nervous system input to the blood vessels leads to blood vessel dilation (vasodilation). This vasodilation leads to a drop in blood pressure to potentially dangerous levels. Treatment may include intravenous fluids and medications called “vasopressors,” which cause contraction of blood vessels and increase heart rate. Both conditions will lead to an increase in blood pressure. The heart has nerve supply from both the sympathetic nervous system and the parasympathetic nervous system. After spinal cord injury at T6 and above, the sympathetic nervous system input to the heart is decreased while the parasympathetic nervous system remains the same. Therefore, the net effect is a slowed heart rate with less strength of contraction. This combination contributes to hypotension and bradycardia. Again, vasopressors are used to directly increase heart rate and strength of contraction of the heart during this acute time.

Deep Vein Thrombosis (DVT) 
Deep vein thrombosis is the development of a blood clot in the legs and, less often, in the arms. Patients who have suffered a spinal cord injury are at high risk for developing a DVT. This can be a serious complication if it breaks off from the leg and travels to the heart and eventually to the lungs. If this blood clot travels to the lungs it is called a pulmonary embolism or PE, which can be life-threatening. Therefore, a significant amount of attention is directed at preventing either of these conditions during the first two months after a spinal cord injury. Even with all precautions being taken, these blood clots can still develop. Signs of a DVT may include swelling or redness in the leg. If the patient has any intact feeling in the leg he may experience increased pain in that area. It is possible, however, to develop a DVT without any signs of swelling, redness or pain.

Prevention or prophylaxis includes the early use of sequential compression devices (SCD), which are leg-wraps connected to an air pump that inflates and deflates continuously, keeping blood moving and a clot from forming. Lovenox is started as soon as the surgeon feels the risk of bleeding from the surgical site is lower than the risk of developing a DVT without Lovenox. Once this has started it is usually continued for 8-12 weeks or until leaving rehabilitation depending on several factors. Some individuals considered to be at high risk for developing a DVT may have an Inferior Vena Cava (IVC) filter placed. This filter is placed in a blood vessel that leads to the heart, called the inferior vena cava. Its role is to catch any blood clots that may have developed in the legs and broken off and are now traveling to the heart on their way to the lungs.

If a blood clot does develop in the legs or lungs, a decision has to be made that weighs the risk of treating with more potent blood thinners called anticoagulants. The current mainstay of treatment after the development of a blood clot is the use of warfarin (Coumadin). Treatment of the clot will possibly put the surgical site at risk for bleeding, but not treating is another obvious risk.
    
Orthostatic Hypotension
Orthostatic hypotension is a significant drop in blood pressure when someone goes from the lying position to a more upright position such as sitting or standing. The condition of orthostatic hypotension is caused by blood pooling in the lower extremities and a decrease in blood flow to the brain with a subsequent dizziness or passing out. This is a very common early complication of spinal cord injury that almost always resolves over time, but often interferes with the early phases of the rehabilitative process. This can occur for several reasons after a spinal cord injury. A commonly described cause after spinal cord injury is the interference with the normal processes of the sympathetic nervous system as it relates to the blood vessels. When a person without a spinal cord injury changes from lying down to standing up, the blood attempts to pool in the legs. This condition is detected by the heart and arteries in the neck (carotid arteries) which then causes an increase in the sympathetic nervous system to the blood vessels in the legs. This causes a contraction of the blood vessels, preventing this pooling of blood in the legs and eliminating dizziness and passing out.

It is important to note that the normal range of blood pressure in tetraplegia and high level paraplegia (T6 and above) is often much lower then prior to spinal cord injury. It is not uncommon for a normal systolic blood pressure (that’s the top number, 120 in the reading 120/70) after spinal cord injury to range from 90-110. For example, 95/55 is not an unexpected blood pressure for a C6 tetraplegic.

Relative dehydration or an inadequate fluid intake can also lead to orthostatic hypotension or further complicate the above described condition. Therefore, it is important to make sure that the patient is receiving enough fluids.

The best way to think about this condition of orthostatic hypotension is to think about all the blood vessels in the body as a tank and the blood in the vessels as the fluid in the tank. If the person with a spinal cord injury goes from lying down to sitting up with the legs down, the fluid in the tank pools in the legs. Since the fluid (blood) in the tank remains the same amount, then there will not be enough fluid to reach the brain and dizziness or fainting occurs. Also, if the tank remains the same but there is only half the fluid (blood) in the tank, the fluid will not reach the brain when moving to an upright position.

Treatment often includes a combination of many interventions. It often begins with making sure that the patient has been getting plenty of fluids either by drinking or by intravenous fluids. As mentioned above, the patient's tank must be filled or all other treatment measures will have limited success. The first step in treatment involves gradually increasing the patient's position to upright. This can often start in the intensive care unit. Today many of the hospital beds can transition to a seated position by lowering the legs and raising the head of the bed. Another option in the intensive care unit or on the rehabilitation unit is a tilt-table. This is a long straight padded table that has multiple straps that go across the chest, waist, and legs. Before the patient sits upright or is placed on a tilt-table they have elastic stockings put on the legs and an abdominal binder wrapped around the torso. The elastic stockings and abdominal binder help to prevent blood from pooling when upright. There are also medications that can help to assist maintaining blood pressure, including salt tablets, fludrocortisone and midodrine. All of these medications can cause increased blood pressure when lying flat.

This condition of orthostatic hypotension usually lessens over the first several weeks of rehabilitation but can continue in some circumstances.

Lungs and Breathing
Normal breathing (before a spinal cord injury):

Inspiration is the process of taking in a breath, while expiration is the process of breathing the air out.

Inspiration involves three groups of muscles: the diaphragm (the most important muscle involved with inspiration), the intercostals (the muscles between the ribs), and the accessory muscles (muscles of the neck, upper back and chest).

Expiration mostly occurs passively (the chest that has expanded during inspiration gradually falls back to the starting point before inspiration), but forceful expiration involves the use of abdominal muscles. For example, a cough is a forceful expiration and requires contraction of the abdominal muscles.

The diaphragm is supplied by nerves that come from the spinal cord at the levels C3, C4, and C5. The external intercostal muscles are supplied by nerves T1 through T11. For example, the T1 nerve supplies the intercostal muscles between the ribs T1 and T2. The T10 nerve supplies the intercostal muscles between the ribs T10 and T11. Some of the accessory muscles such as the trapezius are supplied by cranial nerves that come from the brainstem. The abdominal muscles are supplied by nerves from T6 through L1.

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Nerve Supply of Muscle Involved in Breathing:

Muscles                    Nerve Supply

Inspiration

Diaphragm                    C3, C4, C5
External Intercostals      T1-T11
Accessory:
    Trapezius                  Cranial nerve 11 (brainstem)
    Sternocleidomastoid  Cranial nerve 11 (brainstem)
    Pectoralis                  C5-T1
    Scalene                     C3-C8
    
Expiration

        Abdominal            T6-T11

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Changes in Breathing (after spinal cord injury)
Individuals who have suffered a spinal cord injury may have changes in their ability to breathe depending on the area of their spinal cord that is injured. Whether or not breathing is affected depends upon whether the nerves that supply these respiratory muscles are intact and functioning.  

When considering the nerves and muscles mentioned above, take the level of injury and compare it to the nerve levels that go to the particular muscle to see if it works. All muscles below the injury should either not work or work to a limited degree if incomplete. For example, an injury at C5 would mean that muscles supplied by C6 and below will not work.

Damage to the spinal cord at the L1 level or below will not have any effect upon their ability to breathe. Injuries from T6 to T12 may lead to weak abdominal muscles and intercostal muscles, which will limit the ability to make a strong forceful cough. The lower levels will not notice much difficulty, but this will become more of a noticeable problem as the injury becomes higher towards the T6 level. This becomes an even bigger problem from the C5 to T5 levels. Patients with spinal cord injury at C3 and C4 usually require ventilator support initially, but studies (Wicks and Menter) reported that 51% of C3 and 78% of C4 patients were able to be weaned off of the ventilator.

Early Respiratory Complications (after spinal cord injury)
Atelectasis:  this is the condition where the lower part of the lungs are collapsed and without air or air exchange with the blood. After a spinal cord injury this often occurs because the patient has weak breathing and is unable to take deep breaths and expand these areas of the lungs. The lung is made up of alveoli which look like a collection of grapes. There are about 700 million alveoli in the lungs. These alveoli are surrounded by small blood vessels called capillaries. As a person takes a breath, air enters the alveoli and then travels into the blood vessel capillary and supplies oxygen to the blood. Therefore, if these alveoli are deflated or collapsed, air cannot enter the bloodstream at this location. It is important for all acutely injured patients who are not on a ventilator to take extra deep breaths throughout the day. A simple device called an incentive spirometer can be kept at the bedside and used to prevent atelectasis. Patients on ventilators benefit from large volume settings to expand their alveoli. These volume settings are often larger than those chosen for an individual without a spinal cord injury. Studies have shown that higher ventilator volumes in spinal cord injury help to prevent atelectasis, pneumonia, and increase the ability to be weaned off the ventilator.

Pneumonia: this occurs for multiple reasons, but appears to be increased because of atelectasis and a decreased forceful cough. The best way to prevent pneumonia is to avoid atelectasis along with early mobilization of the patient.

Aspiration: this is entry of foreign material into the lungs. This foreign material is often saliva or liquid or food. In people with normal strength this is quickly cleared by a strong cough. After spinal cord injury this cough is often absent or weak and the material cannot be brought back up before it travels down into the lungs causing irritation of the lung or pneumonia.

Treatment and Prevention
Rotating Beds:  In the intensive care unit, beds that intermittently or continuously turn from side to side may be used. The exact reason why this works is not known.

Assisted Cough (Quad Cough): this is a technique to assist the cough of patients with weak or no strength in the abdominal muscles. The assisted cough is accomplished by another person placing his hands on the abdomen between the “belly button” and the lower part of the sternum or rib cage. With the patient lying flat, they take a deep breath in and forcefully attempt to breathe out as if they were forcefully coughing. The person assisting pushes slightly inward and upward during the time that the patient is trying to cough or exhale. This does require some practice but it can be very effective in clearing secretions during a cough. This should not be used if an inferior vena cava filter is in place, because it could dislodge with the increase in pressure.

Cough-Assist machine: this can be used in place of or in addition to a suction catheter going down into the lungs. The cough-assist machine does not go into the lungs but can fit over the mouth or tracheostomy if present. This works by blowing air into the lungs first and then quickly sucking the air out like a vacuum cleaner. The air going into the lungs often acts to expand the lungs and can mobilize secretions in the lower lungs. A study has been done that indicates patients prefer the cough assist to suctioning out the lungs with a catheter. Some people use the Assisted Cough with the Cough-Assist machine.

Abdominal binder: this device is similar to a corset but is softer and secured with Velcro. This is useful in individuals with tetraplegia or high level paraplegia because of the loss of abdominal muscle tone. With loss of abdominal muscle tone the abdominal organs fall outward and downward when sitting upright. This makes it more difficult to breathe because the diaphragm normally travels down until it hits the abdominal organs. Once the diaphragm contacts the abdominal organs it continues to move, but the only structure that can give way is the rib cage which can move outward. As the rib cage moves outward it creates a negative pressure in the lungs causing air to enter the lungs from the mouth or nose. An abdominal binder keeps the abdominal contents in a more normal position and therefore helps to normalize breathing. The abdominal binder can be taken off when the patient is in bed lying flat because the abdominal organs remain in a position closer to normal. Because of this change in abdominal organ position, it is easier for a tetraplegic and high level paraplegic to breathe while lying flat compared to sitting upright without an abdominal binder.

Bladder
Immediately after a spinal cord injury the patient is often in spinal shock, and in this condition the bladder does not contract. It is recommended that the patient have a Foley (indwelling) catheter placed in the bladder to allow continuous drainage of urine. A catheter is a small tube that is inserted into the bladder. A Foley catheter has a small balloon on the end that is inflated once it is inside the bladder to prevent it from sliding out.

It is also important to maintain continuous drainage because emphasis is placed on adequately hydrating the patient as described in the section Orthostatic Hypotension. Later during rehabilitation, other methods to drain the bladder are discussed.

 

Bowel
Immediately after spinal cord injury the patient is often in spinal shock, and in this condition the bowel does not contract normally. This often resolves within days, but it is often recommended not to feed the patient until bowel sounds are heard by the physician. A “bowel program” is often started in the intensive care unit. This usually starts with stool softeners as well as medications that stimulate the bowel to contract. Suppositories are started during this time as well, and may include digital stimulation (see below for bowel program) if the patient does not have sensation.

Stomach Ulcers
There is a possibility that patients who suffer an acute spinal cord injury are at a higher risk of developing a stomach ulcer because of an increase in stomach acid production related to stress. Patients are routinely treated with medications that neutralize or lower the acid content in the stomach and decrease that risk.

Skin
Individuals who lie in one position for a prolonged period of time are at risk for developing skin breakdown and pressure ulcers (bedsores). This is certainly the case for patients who become paralyzed and cannot move or feel the need to move and shift weight. Therefore, it is necessary to turn a patient every two hours. This often continues until the patient is in rehabilitation and has demonstrated increased tolerance to lying longer than two hours in one position. Tolerance is determined by the lack of redness over the bony prominences. Once tolerance is developing, the patient can be gradually allowed to remain in the same position with frequent checking of his skin for redness. Most patients still require being turned at the time of discharge from rehabilitation. Special mattresses that decrease the amount of pressure on bony prominences and decrease the risk of bedsores are generally used in the intensive care setting.

Other injuries
The combination of a spinal cord injury with traumatic brain is not uncommon, although the exact percentages vary. Considering that possibility, an evaluation can be performed by a speech therapist performing a traumatic brain injury screen.

Multiple areas of spinal fractures can occur in individuals who have suffered a spinal cord injury. One study reported a 12% incidence of fractures in addition to the identified fracture that caused the spinal cord injury.  

Another study reported that 64% of patients who had suffered a spinal cord injury also had additional injuries somewhere else in their body.

Surgical 
The goal and scope of this section is not to describe in detail the surgical approach that should be taken for various spinal cord injuries, but to give an overview. It should first be stated that the timing and specific type of surgery remains a controversial topic among surgeons.

Timing of surgery
This remains a controversial topic regarding surgical intervention after spinal cord injury. Some physicians recommend no surgery within the first five days. Other surgeons recommend early intervention. A study was done that compared outcomes between one group of patients who underwent surgery within 72 hours (early group) to another group of patients who underwent surgery on the fifth day or later (late group). There was not a significant difference between the two groups, although surgeons who support early intervention criticize this study because they believe that “early” should be defined as “before 24 hours.”

More recently a study was performed comparing early to late surgical intervention. “Early” surgical intervention was further subdivided into day 1 (<24 hours), day 2 (1-48 hours), day 3 (24-72 hours). There were no significant differences in length of stay or outcome. “Early” (taken as a group) compared to “late” surgical intervention did show a decrease in overall length of stay and lung (pulmonary) complications such as pneumonia and atelectasis. It is agreed upon that individuals who are demonstrating a decline in their neurological status (increased weakness or decreased sensation) should not have their surgery delayed and should immediately be taken to the operating room for decompression (removing the pressure from the spinal cord) and stabilization (placement of bone graft and hardware to prevent movement of the fractured bone).

Spine stability or instability
When deciding if surgery is needed, the first issue that must be determined is whether or not the spine is stable. The cervical spine is divided into two main categories when determining stability. The lower part of the skull rests upon C1 and is referred to as “occipital.” Therefore, the combination of the occipital with C1 and C2 creates the occipital-atlantoaxial complex. The area of the cervical spine below this is referred to as the subaxial cervical spine and includes C3 through C7.  
Occipital-atlantoaxial complex: fractures of C1 (Atlas) are also called Jefferson burst fractures. These are most commonly treated with a halo vest. If the C1 fracture is unstable, then internal stabilization via the back of the neck (posterior approach) is required. Fractures of C2 (Axis) can also be treated with a halo vest or internal stabilization, depending on the location and degree of the fracture.

Subaxial cervical: fractures of this area can include fractured vertebrae or soft tissue injury such as a ligament tear. The location and degree of injury will determine whether a non-surgical neck collar or surgery is used. The most common fracture of the cervical spine is located at C5. Surgical intervention in the subaxial cervical spine can occur either from the front or from the back. Halo vests are often used in upper and mid cervical spine fractures but are avoided in lower cervical spine fractures because of “snaking.” Snaking describes the increased movement or hypermobility of the cervical spine in the area between the fixed or stabilized spine.

The stability of the thoracic and lumbar regions of the spine is often determined by the three-column theory which was described by Denis in a paper published in 1983. This describes the thoracic and lumbar regions as the thoracolumbar spine and divides it into three columns. If two of the three columns are damaged, then this area of the spine is determined to be unstable and requires appropriate intervention.

Thoracolumbar spine: the most common area of injury to the thoracic spine occurs at the T12 vertebra, probably because it is where the stabilizing ribs end. From T1 to T12, ribs attached to the vertebrae help to stabilize and protect the thoracic spine from excessive movement. If the spine is unstable, then surgical stabilization is required. In the upper thoracic spine, surgical intervention usually takes place from the back because of the critical organs that make a frontal approach difficult. In the lower thoracic spine, the surgical approach can take place either from the front or back. A frontal approach requires a thoracotomy (cutting through the front or side of the chest) or entering through the abdominal region. The frontal approach often uses screws and rods that may lead to a shorter segment of stabilization.

In the lumbar spine the most common area of fracture occurs at the L1 vertebra. Surgery for fractures of L1 and L2 is often performed with a frontal approach using screw and rod or a screw plate. Posterior hook and rods can be used in this area and require a longer segment to stabilize. The frontal approach is usually not performed below L3 because of technical difficulties related to large blood vessels. In the lower lumbar region, the surgical approach is usually performed from the back.

Bone graft: in many of these surgeries the surgeon performs a corpectomy (removal of the body of the vertebra) of the fractured vertebra and replaces it with healthy bone from the patient's own pelvis, which is called the iliac crest.

Rehabilitation (Intensive Care Unit):
Rehabilitation starts in the intensive care unit after surgical stabilization, if required.  

Initially therapy begins with simply moving the affected limbs through their normal range of motion. The areas of focus for this range of motion include the shoulders, elbows, hips, knees and ankles. It is important to maintain normal range of motion during this early period so that a lack of range of motion does not slow down or interfere with the rehabilitation process.

As mentioned previously, orthostatic hypotension or a drop in blood pressure when becoming upright is a significant problem immediately after a spinal cord injury. Therefore, the therapist begins to gradually put the patient in an upright position while monitoring blood pressure, heart rate and signs or symptoms of lightheadedness or fainting. This often starts with simply raising the head of the bed and gradually progresses to sitting on the edge of the bed supported by the therapist. Another commonly used intervention is the use of a tilt-table, a padded table that has a footplate and several straps that support the patient and prevent him from falling. The table is gradually inclined while the patient’s blood pressure and symptoms are monitored. Before starting to stand the patient, the nursing staff usually will put compressive stockings and an abdominal binder on the patient to prevent blood from quickly pooling in the legs, leading to a drop in blood pressure.