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RB: A Case of Tetraparesis Block Y. Tagomata. Talan. Tayag. Tolibas. Toledo. Uy. Wi. Yu. Zaldivar. Zamora.

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Presentation on theme: "RB: A Case of Tetraparesis Block Y. Tagomata. Talan. Tayag. Tolibas. Toledo. Uy. Wi. Yu. Zaldivar. Zamora."— Presentation transcript:

1 RB: A Case of Tetraparesis Block Y. Tagomata. Talan. Tayag. Tolibas. Toledo. Uy. Wi. Yu. Zaldivar. Zamora.

2 General Data RB 25/M From Camarines Norte Roman Catholic Married, with 1 child R handed

3 Chief Complaint Inability to walk

4 History of Present Illness 10 mos PTA, (+) intermittent pain on R medial arm, described as “parang binabanat ang ugat”, NPS 10/10, occurring 3x/wk, aggravated by exertion (e.g. reaching out or lifting an object) relieved by an unrecalled analgesic 0/10 (-) numbness, (-) tingling, (-) skin lesions, (-) hx of trauma 2 wks after, development of similar symptoms on L arm and both scapular areas, no consult was done

5 History of Present Illness 9 mos PTA, (+) weakness of R LE, (-) pain, (-) numbness, (-) tingling, (+) sensation of abdominal tightness, (+) dyspnea (-) hx of trauma consult was done at BHC, given vitamins and analgesic

6 History of Present Illness A few days later, (+) weakness of R LE, admitted to LH; CXR, holoab UTZ, cranial CT scan and labs done were allegedly normal discharged and prescribed with unrecalled meds but stopped due to allergy (rashes on both thighs)

7 History of Present Illness 8 mos PTA, inability to walk/stand; assisted on ADLs (+) urinary/bowel incontinence (+) bedsore (approximately 1 cm, sacral) (-) fever

8 History of Present Illness 5 mos PTA, consult was done at V. Luna A> t/c Decompression sickness P> recompression x 10 session However, pt opted to discontinue after the third session due to fear of dyspnea inside the vessel

9 History of Present Illness (+) consult at PGH OPD Ortho A> Pott’s disease P> workup and follow-up x 2 mos

10 History of Present Illness 3 mos PTA, admitted at Spine Unit, started on anti-TB meds co-managed by Rehab 1 mo PTA, s/p anterior decompression, debridement, fusion(C6-T2) with fibular strut graft (7/18/12) Day of admission, admitted at Rehab Ward for further therapy

11 Review of Systems (present)  (-) Cough, colds, fever  (-) headache, blurring of vision, dizziness  (-) chest pain, difficulty of breathing  (-) changes in appetite  (-) heat or cold intolerance, irritability  (-) muscle or joint pain  (-) penile pain, discomfort, erectile dysfunction

12 Past Medical History (-) HPN, DM, BA, CA, previous hosp (-) PTB/Primary Complex (?) drug allergy

13 Family Medical History (+) HPN, father (+) BA, 5 siblings (+) DM, uncle (-) PTB

14 Personal and Social History (-) smoking, alcohol intake, illicit drug use Breadwinner of the family Works as fisherman(diver) Married, with 1 daughter Finished 2 nd yr HS

15 Functional History Previously independent on ADL Previously works as a fisherman (diving, swimming)

16 Environmental History Lives in a 1-storey concrete house Safe from falls

17 Current Physical Exam General: awake, NICRD BP 110/60 HR 90 RR 18 T afebrile HEENT: AS, pink PC, (-) CLAD/NVE (+) surgical scar on L neck to anterior chest Chest/Lungs: DHS, (-) murmur/thrills/heaves ECE, clear BS (-) rales/wheeze/rhonchi Abdomen: Flat, normoactive BS, (-) masses/tenderness Skin/Extremities: FEP, pink NB, (-) edema/cyanosis/jaundice (+) sacral ulcer, healed

18 Current Physical Exam Motor: (R) (L) C5 5/5 5/5 L2 5/5 5/5 C6 5/5 5/5 L3 5/5 5/5 C7 5/5 5/5 L4 4/5 5/5 C8 5/5 5/5 L5 4/5 5/5 T1 5/5 5/5 S1 3/5 5/5 (Score 97) Sensory: ASIA Sensory: pin prick light touch (R) (L) (R) (L) C5-L3 2/2 2/2 2/2 2/2 L3 1/2 1/2 1/2 1/2 L4 1/2 2/2 1/2 2/2 L5-S4 S5 2/2 2/2 2/2 2/2

19 P.E. on Admission & Course

20 Physical Examination on Admission General Survey: Awake, coherent, not in cardiorespiratory distress Vital signs: BP 100/70 HR 87 RR 20 T afebrile HEENT: Anicteric sclerae, pink palpebral conjunctivae, no cervical lymph nodes, no tonsillopharyngeal congestion

21 Chest/Respiratory: Equal chest expansion, clear breath sounds, no thoracic spine deformity Cardiovascular: Adynamic precordium, normal rate regular rhythm, distinct S1 & S2, no murmurs Gastrointestinal: Flat abdomen, normoactive bowel sounds, no tenderness Genitourinary: (+) weak sphincteric tone, (+) BCR Physical Examination on Admission

22 Extremities: Full and equal pulses, no edema, (+) multiple pressure ulcers - sacral area, grade 2 with undermining (+) well healing pressure ulcer on right posterior auricular area, right shoulder (+) grade 1 ulcer on heel, bilateral; medial knee, bilateral; lateral malleolus, bilateral Physical Examination on Admission

23 ASIA Motor RightLeft C55/5 C65/5 C74/5 C83/5 T13/5 L22/5 L32/5 L43/5 L53/5 S13/54/5 Physical Examination on Admission

24 ASIA Sensory Pin Prick Light Touch RightLeft C5-C72/2 C82/21/2 T1-L22/2 L3-S31/2 S4-S51/2 RightLeft C5-C72/2 C82/21/2 T1-L22/2 L3-S31/2 S4-S51/2 Physical Examination on Admission

25 Tone: (+) grade 1 – 1+ spasticity on both lower extremities DTRs : hyporeflexia on both lower extremities, (+) flexor spasm on both lower extremities (+) clonus (-) Babinski (-) Hoffman’s Physical Examination on Admission

26 Laboratory Tests  ESR and CRP: elevated  Sputum AFB x 3: all negative  All else normal

27 Imaging

28 Differential Diagnoses for Tetraparesis  Trauma  Tumors  Infection  Inflammatory  Vascular  Vertebral Disease  Others

29 Radiographic differentiation

30 Trauma  Most common cause of tetraparesis  Ruled out because the patient has no history of trauma

31 Tumors  Usual presentation is pain, often worse when in supine position, which can be axial (skeletal structures affected) or radicular (nerve roots affected)  Usually presents with constitutional symptoms (night sweats, fever, unexplained weight loss, and anorexia)  Radiographic examination is vital  Can be metastatic (from lungs, breast, prostate and kidney) or primary (multiple myeloma, osteogenic sarcoma, vertebral hemangioma, chondrosarcoma, chordoma, ependymoma, astrocytoma, meningioma, schwannoma, neurofibroma)

32 Infection  Bacterial osteomyelitis  a differential if the patient uses IV drugs, immunosuppressed, or undergoing dialysis  usual etiology is Staphylococcus aureus  Check via culture and inflammatory markers  Spinal abscess  Usually epidural; commonly presents with fever  HIV infection  Can present as primary HIV myelitis, vacuolar myelopathy, or as a result of opportunistic infection

33 Inflammatory  Transverse myelitis  Myelopathic process of unknown cause from inflammation of spinal cord  May start as pain or paresthesia in localized body parts and can progress to paresis and plegia  Multiple sclerosis  Immune-mediated demyelinating disorder which may also initially present as pain and progress to weakness of limbs  Systemic lupus erythematosus  Autoimmune illness which usually presents with other systemic symptoms such as pleuritis, hematologic, immunologic or neurologic alterations, and dermatologic signs

34 Vascular  Ischemia of spinal cord not very common; usually associated with anterior cord syndrome; often from:  Anterior spinal artery occlusion  Angioma  AV malformation

35 Vertebral Disease  Vertebral disk prolapse  Usually due to a tear in the outer fibrous ring (annulus fibrosus)  May initially present as pain of extremities and progress to paresis depending on the level of herniation  Spondylosis  Degenerative odteoarthritis of the spine  Presents as pain, paresthesia or muscle weakness  Paget’s disease  Due to excessive breakdown and formation of bone, followed by disorganized bone remodeling  Causes bone pain but very rarely presents as tetraparesis

36 Others  Hereditary spastic paraparesis  characterized by insidiously progressive bilateral lower-extremity weakness and spasticity, with family history of similarly affected individuals  may be transmitted in an autosomal dominant, autosomal recessive, or X-linked recessive manner  Degenerative motor neuron disease  Usually presents in the 6 th -7 th decades of life  heterogeneous group of neurologic diseases characterized by progressive degeneration of upper and lower motor neurons  Usually presents with weakness, atrophy, fasciculations, and hypo/hyperreflexia

37 Others  Decompression syndrome  caused by intravascular or extravascular bubbles that are formed as a result of reduction in environmental pressure  can occur in divers, compressed air workers, aviators, and astronauts  manifestations range from itching and minor pain to neurological symptoms, cardiac collapse, and death  Presents acutely

38 Impression Tetraplegia secondary to multiple compression deformity secondary to Pott’s disease (Asia D) NL: C6, AL: C6-T2, ML: C7, SL: C7 Neurogenic bowel and bladder Nephrolithiasis, right Sacral decubitus ulcer, grade 2

39 Course in the Wards  Upon Ward admission: - noted (+) flexor spasm 1-3x/hr upon movement - able to tolerate sitting > 1 hr. during OT - fair sitting balance unsupported but cannot be totally challenged - still dependent in transition with sitting and transfer from bed - able to eat his dinner, can sit with brace on, independent with setup

40 Course in the Wards Underwent PT exercises during the 1 st month:  Practiced transitions from supine to sitting  sit to stand  Table tilt at 30 o increasing by 15 o  Standing with || bars with PKS on (B) knees, increasing in duration and number of reps  || bars with one PKS  || bars without PKS  Ambulating using walker with PKS  using BAC with 4 pt gait  3 pt gait  (B) Axillary crutches

41 Course in the Wards  8/27 – ASIA MMT: (R) (L) (R) (L) C5 5/5 5/5 L2 2/5 2/5 C6 5/5 5/5 L3 2/5 2/5 C7 4/5 4/5 L4 3/5 3/5 C8 3/5 3/5 L5 3/5 3/5 T1 3/5 3/5 S1 3/5 4/5 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 T1-L2 2/2 2/2 2/2 2/2 L3-S4 S5 1/2 1/2 1/2 1/2 DTR: hyporeflexia on (B) LE (+) flexor spasm (B) LE pathologic reflexes: (+) clonus (-) Babinski (-) Hoffman

42 Course in the Wards  9/18 – (R) (L) (R) (L) C5 5/5 5/5 L2 4/5 4/5 C6 5/5 5/5 L3 4/5 4/5 C7 4/5 4/5 L4 4/5 4/5 C8 4/5 4/5 L5 3/5 4/5 T1 4/5 4/5 S1 4/5 4/5 (Score 83  75) - ASIA Sensory: maintained at Score of 97

43 Course in the Wards Underwent PT exercises during the 2 nd month:  Started stepping exercises  Ambulating using BAC with 3 pt gait  2 pt gait  BAC/3 pt. gait on level surface  up/down stairs using BAC  using quad cane  Quad cane/3 pt. gait with ramp, stairs  (B) axillary crutches  Using Walker

44 Course in the Wards  9/26 – Fall while ambulating in bathroom (+) pain (R) lateral aspect of foot - maintain MMT Score of 87 - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 1/2 1/2 1/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-S4 S5 1/2 1/2 1/2 1/2 A> Quadparesis and SCC secondary to Pott’s disease ASIA D, NLC7 MLC7 SL C8 AL: C6-T1, T4 T5 T8 Sacral decubitus ulcer Gr 2 Cystitis

45 Course in the Wards  10/2 – increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 4/5 5/5 C6 5/5 5/5 L3 4/5 4/5 C7 5/5 5/5 L4 5/5 5/5 C8 5/5 5/5 L5 4/5 4/5 T1 4/5 4/5 S1 3/5 5/5 (Score 91  87) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C2-C7 2/2 2/2 2/2 2/2 C8 2/2 1/2 2/2 1/2 C9-L3 2/2 2/2 2/2 2/2 L4-L5 1/2 1/2 1/2 1/2 S1-S4 S5 2/2 2/2 2/2 2/2 (Score 107  97)

46 Course in the Wards  10/8 – ambulate on level surface with ramp using quad cane. Not Stairs - increase in flexor spasm/ankle clonus ~ (R) LE (R) (L) (R) (L) C5 5/5 5/5 L2 5/5 5/5 C6 5/5 5/5 L3 5/5 5/5 C7 5/5 5/5 L4 4/5 5/5 C8 5/5 5/5 L5 4/5 5/5 T1 5/5 5/5 S1 3/5 5/5 (Score 97  91) - ASIA Sensory: pin prick light touch (R) (L) (R) (L) C5-L3 2/2 2/2 2/2 2/2 L3 1/2 1/2 1/2 1/2 L4 1/2 2/2 1/2 2/2 L5-S4 S5 2/2 2/2 2/2 2/2

47 Course in the Wards  10/21 – ambulate using walker - able to do vocational training - (+) flexor and bladder spasm on CMG  10/24 – ambulate using walker - still with weakness of (R) plantar flexion  10/27 – still with poor proprioception of (B) feet

48 Problem List o Medical s/p ADDT SCC sec to Pott’s Disease C7-T1 Neurogenic Bladder o Altered Body Function Tetraparesis Sensory impairment below C8 Grade I spasticity of bilateral LE Poor proprioception

49 Pott’s Disease  Secondary to an extraspinal source of infection.  Osteomyelitis + arthritis.  Anterior aspect of the vertebral body adjacent to the subchondral plate: usual site  Spreads to adjacent intervertebral disks.  Adults: spreads from the vertebral body.  Children: primary site (disk highly vascuarized)

50 Pott’s Disease  Vertebral collapse and kyphosis, narrowed spinal canal, cord compression  Kyphotic deformity: anterior spine collapse (thoracic > lumbar)  Cervical: minimal collapse  Healing: gradual fibrosis and granulomatous tuberculous tissue calcification  Paravertebral abscess formation is common (Lumbar-psoas fascial sheath; Thoracic- anterior chest wall, parasternal area)

51 Lesion The lesion could be:  Florid - invasive and destructive lesion  Non destructive  Encysted disease  Carries sicca  Hypertrophied  Periosteal lesion 2 Patterns  Classic: spondylodiscitis (SPD)  Atypical: spondylitis without disk involvement (SPwD); more common pattern of spinal TB

52 Regional Distribution 1Cervical 12% 2Cervicodorsal 5% 3Dorsal 42% 4Dorsolumbar 12% 5Lumbar 26% 6Lumbosacral 3%

53 Anatomical 1. Paradiscal - destruction of adjacent end plates and diminution of disc space. 2. Appendeceal (Posterior) - involvement of pedicles, laminae, spinous process. 3. Central - Cystic or lytic, concertina collapse. 4. Anterior –longitudinal lig, Aneurysmal phenomenon 5. Synovitis in posterior facet

54 History  Presentation depends on:  Stage of disease  Site  Presence of complications such as neurologic deficits, abscesses, or sinus tracts  On diagnosis, already with the disease for 3-4 mos.  Back pain- earliest and most common symptom, can be spinal or radicular  Constitutional symptoms (fever and weight loss)

55  50% with neurologic abnormalities (spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, or cauda equina syndrome)  If cervical, can present with pain and stiffness, dysphagia or stridor, torticollis, hoarseness, and neurologic deficits.  HIV positive > HIV negative patients History

56 Pott’s on Imaging XRAY  Signs of infection with lytic lucencies in anterior portion of vertebrae  Disk space narrowing  Erosions of the endplate  Sclerosis resulting from chronic infection  Compression fracture  Continuous vertebral body collapse  Kyphosis; gibbous (severe kyphosis) CT scan  Soft tissue findings: abscess with calcification is diagnostic of spinal TB  Pattern and severity: framentary, osteolytic, localized and sclerotic, and subperiosteal

57 Complications of tuberculosis 1. Paraplegia 2. Cold abscess 3. Sinuses 4. Secondary infection 5. Amyloid disease 6. Fatality

58 Surgical indications 1. No sign of neurologic recovery after trial of 3-4 weeks therapy 2. Neurologic complication during treatment 3. Neurologic deficit becoming worse 4. Recurrence of neurologic complication 5. Prevertebral cervical abscesses, neurological signs, & difficulty in deglutition & respiration 6. Advanced cases: sphincter involvement, flaccid paralysis, severe flexor spasms

59 Other indications  Recurrent paraplegia  Painful paraplegia– d/t root compression, etc  Posterior spinal disease--involving the post elements of vertebrae  Spinal tumor syndrome resulting in cord compression  Rapid onset paraplegia due to thrombosis, trauma, etc.  Severe paraplegia econdary to cervical disease and cauda equina paralysis

60 1Decompression +/- fusion Failed response,Too advanced 2Debridement+/- fusionFailed response after 3- 6 months, doubtful diagnosis, instability 3Debridement +/- DECOMP+/- fusion Recrudescence of disease 4Debridement+/- fusionPrevent severe kyphosis 5Anterior transpostionSevere kyphosis + neural deficit 6LaminectomySTS, secondary stenosis, posterior disease

61 Tuli ’ s recommended approach  Cervical spine –T1  Anterior approch  Dorsal spine –DL junction  Antrolateral approch  Lumbar spine &Lumboscral junction  Extraperitoneal Transverse Vertebrotomy

62 Problem List

63 Medical Problems  Spinal cord compression  Neurogenic bowel  Neurogenic bladder  Pressure ulcers

64 (Possible) Medical Problems  Cardiovascular complications  Hypertension  Deep vein thrombosis and Pulmonary embolism  Orthostatic hypotension  Cardiac arrhythmia  Pulmonary complications  Musculoskeletal complications  Osteoporosis  Fractures  Heterotrophic Ossification

65 Altered Body Structure and Function  Bilateral LE paresis  Bilateral LE loss of sensation  Neurogenic bladder  Neurogenic bowel  Pressure sores  Sexual dysfunction and possible loss of sexual desire  Possible MSK, cardiovascular and pulmonary complications

66 Limitations in Activities of Daily Living  Independence in feeding  Dependence in self-care ADLs  Bathing  Grooming  Dressing up  Dependence in ambulation and transfers  Poor sexual activity

67 Limitations in Instrumental Activities  Independence  Communication (cellphones, etc.)  Entertainment (watching TV, etc.)  Difficulty in child-rearing  Cannot anymore drive his motorcycle

68 Limitations in Participation  Inability to return to previous job  Difficulty in finding another job  Difficulty in community ambulation

69 Long-term Goals  To treat the underlying cause of the SCI  Spinal TB  To implement acceptable bowel and bladder management programs  To address pressure ulcers and maintain skin integrity

70 Long-term Goals  To maintain socially acceptable bladder and fecal continence  To prevent possible complications of neurogenic bladder and bowel  To prevent and treat accordingly the complications that may arise from the thoracic- level SCI  To minimize the functional limitations and allow the patient to complete ADLs independently or with assistive equipment

71 Management of Spinal Cord Injury and Its Various Complications

72 Indications for Surgery 1. Instability 2. Deformity 3. Neurologic symptoms

73 Neurogenic Bladder  When pathologic CNS/PNS conditions cause disruption of the nerve control to the urinary bladder, causing urinary retention and/or urinary incontinence

74 Bladder Innervation Pelvic Nerves  Parasympathetic signals from S2-S3 segments to the detrusor muscles for bladder emptying/voiding Hypogastric Nerves  Sympathetic signals from T11-L2 segments for bladder filling/storage Pudendal Nerves  Somatic nerve fibers from S3-4 segments to voluntary skeletal muscles & external sphincter

75 Management Goals  To prevent urinary tract infections and other long-term urologic sequelae  To maintain a socially acceptable bladder continence  by developing and implementing a bladder management program that will allow patient to reintegrate back into the community

76 Medical/Pharmacologic Management  Targeting the autonomic receptors  For urinary retention  Cholinergics (for detrusor contraction)  Alpha receptor antagonists (for sphincter relaxation)  For urinary incontinence  Anticholinergics ( for detrusor relaxation)  Alpha receptor agonists (for sphincter contraction)

77 Behavioral/Non-Pharmacologic Management  Catheterization programs  Independent intermittent catheterization every 4 to 6 hours, if the patient has preserved hand function and does not have UTI  Limitation of fluid intake  Timed voiding  Schedule voiding  Use of a voiding diary

78 Behavioral/Non-Pharmacologic Management  Bladder training programs  Maneuvers  Valsalva maneuver, suprapubic application of pressure  Use of appliances  Condom, foley, straight catheters

79 Surgical Management When the mentioned medical and behavioral strategies fail…  Augmentation cystoplasty  Artificial sphincter  Sphincterotomy  Pudendal neurectomy  Bladder outlet surgery  Balloon dilatation  Interruption of innervation  Neurostimulation

80 Neurogenic Bowel  When pathologic CNS/PNS conditions cause disruption of the bowel innervation, causing stool incontinence (lax anal sphincter) and constipation (disrupted parasympathetic supply)

81 Management Goals  To achieve socially acceptable fecal incontinence  Prevention of gastrointestinal complications  Fecal impaction (most common)

82 Medical/Pharmacologic Management  Stool softeners (e.g. docusate sodium)  Colonic stimulants (e.g. senna)  Colonic irritants (e.g. glycerin, bisacodyl)  Prokinetic agents (e.g. metoclopramide)  Rectal suppositories  Oral medications

83 Behavioral/Non-Pharmacologic Management  Timed/regular bowel movement  Taking advantage of the gastrocolic reflex (about minutes after meal)  Dietary modification  High fiber diet  Increased fluid intake  Digital stimulation  Manual extraction

84 Surgical Management  Colostomy/ileostomy  Decreases time required for bowel management  Increases independence

85 Pressure Sores  Stages of pressure sores/ulcers (NPUAP)  Stage I : Nonblanchable erythema not resolved within 30 minutes (epidermis intact)  Stage II : Partial thickness skin loss; blisters with erythema, abrasion, shallow ulcer (possibly into dermis)  Stage III : Full-thickness destruction of the skin; deep crater (into subcutaneous tissue)  Stage IV : Full-thickness skin loss with deep-tissue destruction (up to fascia, muscle, bone, joint)

86 Pressure Sores  Management:  Wound cleansing with plain NSS  Debridement  Wound dressing  Topical antibiotics (e.g. Flammazine)  Wound Care Modalities  Whirlpool therapy, UV light, ultrasound  Surgery  skin grafts and skin flaps

87 Pressure Sores  Prevention:  Egg mattress  Proper turning frequency (at least every 2 hours)  Adequate cushioning (e.g. surgical gloves with water)

88 Others  Osteoporosis  Fractures  Heterotopic ossification  Pulmonary complications  Hypertension and coronary artery disease  Deep vein thrombosis  Orthostatic hypotension  Cardiac arrhythmia  Sexual dysfunction  Depression

89 Osteoporosis  Occurs below the level of injury  Cause: reduction of bone mineral content  Immobilization  Lack of weight-loading activities  Effect: Increased risk of lower extremity fracture  Management:  Ambulatory activities  Medications (e.g. Vitamin D, calcitonin, biphosphonates)  Functional electric stimulation

90 Fractures  Occurs in chronic SCI  Common causes:  Osteoporosis  Falls  Vigorous physical therapy  Common in long bones of lower extremity  Management:  Patient and family education  Training in proper transfer and ambulation techniques  Fall prevention  Avoidance of vigorous physical therapy

91 Heterotopic Ossification (HO)  Development of ectopic bone within soft tissues surrounding the joints  Often seen in the first 6 months post-injury  Incidence: 20-30%  Common areas : Hip > Knee > Shoulder > Elbow  Etiology is still unclear but may be due to metabolic, biochemical and circulatory factors  Presentation:  Heat and swelling over the joints  Decrease in ROM  Fever

92 Heterotopic Ossification (HO)  Complications:  Peripheral nerve entrapment  pressure sores  Ankylosis  increased risk of DVT  Management:  ROM Exercises  Medications to limit ossification (e.g. disodium etidronate, indomethacin)  Surgery for mature bone

93 Pulmonary Complications  Depend on the level of the lesion  C4: highest level with spontaneous ventilation  Above C8: loss of abdominal and intercostal muscles  T1-T12: impairment of intercostal muscles, reduced cough, possible paradoxical retraction of chest wall during inspiration  T8-T10: impairment of abdominal muscles  Below T12: no impairment of respiratory function

94 Pulmonary Complications  Management:  Position changes/postural drainage  Deep breathing exercises  Use of incentive spirometry  Cough assist  Glossopharyngeal breathing exercises.  Pneumobelt  Phrenic nerve pacing  Non-invasive ventilatory support

95 CV complications: Hypertension and Coronary Artery disease  Inactivity causes:  Increased cholesterol levels  Increased risk of coronary artery disease  Management:  Exercise/ increased activity

96 CV complications: Deep Vein Thrombosis  3 important factors (Virchow’s triad)  Venous stasis  Hypercoagulability  Vessel wall damage  Highest risk period: 1st 2 weeks  Serious complication: Pulmonary embolism  Risk of death decreases over time  210 times greater in the acute phase  19.1 times 2-5 years post-injury  8.9 times beyond 5 years post-injury

97 CV complications: Deep Vein Thrombosis  Management  Pharmacologic (e.g. heparin, coumadin)  Prophylactic measures  compression stockings, external pneumatic compression, continuous rotation beds  Avoid ROM and strengthening exercises on the affected limb  Bed rest until medications are given

98 CV Complications: Orthostatic Hypotension  Common in higher levels of SCI  Causes:  Ineffective vasoconstriction  Pooling of blood in the lower extremities  Treatment:  Progressive elevation  Use of compression stocking and abdominal binders  Liberal salt and fluid intake  Elevated leg rests  Medications (e.g. NaCl tablets, ephedrine)

99 CV complications: Cardiac Arrhythmias  Common during the acute period (14 days post injury)  Usually in cervical and complete injuries  Cause:  autonomic imbalance  sympathetic and  parasympathetic activity  Prevention:  Use of atropine  Induced hyperventilation  Usually resolved within 6 weeks after injury

100 Sexual Dysfunction  Sexual desire is not necessarily affected but depression, poor body image and fears of inadequacy may alter sexual desire.  Sexual function, however, may be affected.  Erection (parasympathetic)  Ejaculation (sympathetic)  Lubrication (in women)  Complete SCI (no sacral reflexes): more impairment

101 Sexual Dysfunction  Addressing concerns on body image, maintenance of intimate relationships, etcetera  Management options for erectile dysfunction:  Oral medications (e.g. sildenafil)  Vaccum devices  Penile injection programs (papaverine)  Surgically implanted prosthesis

102 Depression Management:  Consultation with appropriate mental health care professional  Continued follow-up.  Prevent and address suicidal tendencies  Anti-depressants may be given

103 Functional Rehabilitation  Focuses on helping the patient to function at optimal levels  Supervised PT and OT to improve strength in all active muscle groups and ROM in all joints  Adaptive equipment  Long-handled shoehorns  Reachers  Ambulation equipment  Low-back wheelchairs are feasible because patients with lower-level SCIs have better truncal stability.

104 Thank You!


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