The body after SCI
Autonomic dysreflexia
AUTONOMIC DYSREFLEXIA CAN CAUSE A STROKE IF IT IS NOT TREATED
Autonomic dysreflexia (AD) can occur in SCI at or above T6. It arises due to the loss of control mechanisms for blood pressure and heart function. It causes the blood pressure to rise to dangerous levels.
AD can be caused by any bodily pain or discomfort. Common causes are a full bladder, bladder infection, severe constipation, or pressure sore. Anything that would normally cause pain or discomfort below the level of the spinal cord injury can trigger dysreflexia.
The symptoms of AD are related to the types of responses that happen in the autonomic nervous system. Pounding headache, blurred vision and spots before the eyes result from the high blood pressure that occurs when blood vessels below the injury constrict. The body responds by dilating blood vessels above the injury, causing flushing of the skin, sweating, and occasionally goosebumps. Some people also report anxiety and nasal stuffiness.
TREATMENT
Get to an emergency room if symptoms persist.
Treatment of AD is to remove the reason for it. Sitting naturally decreases blood prsessure. Check the catheter for kinked tubing. Check for distended bowel.
The primary risk of AD is stroke. If AD is not treated, the body attempts to control blood pressure by decreasing the heart rate. This, combined with uncontrolled high blood pressure, can be fatal. It is vital to treat this condition as soon as possible.
The best way to prevent AD is for people with high SCIs to take good care of themselves. Monitor bladder output, maintain a regular bowel program, do regular skin checks to prevent pressure sores from occurring.
Click here for detailed information on AD from the Motor Accidents Authority.
Airways
People with SCI above T12 have reduced breathing muscles. Above C5, the diaphragm and intercostals can be paralysed. The essential function of this system is breathing and the ability to cough.
Reduced breathing can stop oxygen being produced. Inability to cough enables secretions to build up in the lungs, risking pneumonia.
Bladder
People with SCI may not have voluntary control of their bladder. They must learn to be highly regimented in their bladder care to avoid accidents.
"Neurogenic" bladders contract hyperactively when there is little urine in the bladder, or may be like a flaccid balloon that leaks when it overfills. The sphincter holding the urine in the bladder may also not synchronise with bladder contractions, causing abnormal pressures. If the bladder pressure continues to be abnormally high, some urine may reflux back into the kidneys, causing damage to them. These conditions can be managed with medication, catheters (either irregularly or permanently in place), or sometimes surgery.
Proper management and regular check-ups are important to ensure that you will not get serious bladder and kidney infections.
Detailed information is available from Sci-Info-Pages.
Bones
Osteoporosis and fractures: After periods of reduced weight-bearing activity, bones begin to lose condition and become brittle. Any activity that increases the load on the bones can slow down osteoporosis.
Heterotopic ossification: HO is a condition not well understood that occurs in acute spinal cord injury. It consists of the laying down of bone outside the normal skeleton, usually occurring at large joints such as the hips or knees. The primary risk of HO is joint stiffening and fusion. Should the hip or knee become fused in a certain position, a surgical release is necessary to allow range of motion to occur. Unfortunately, it takes between 12 and 18 months for heterotopic bone to mature once it has developed. Activities that are used to prevent the development of HO include range of motion exercise programs and other functional activities that move the joints within a functional range.
Bowel
After SCI, the nerves in the bowel are not able to communicate messages that the bowel is full and that it is time to go to the toilet. There may also be no control over the rectum (the muscle that controls when you have a bowel movement).
The degree of loss will depend on the level and extent of the spinal lesion.
With injury above T12, the bowel will continue to empty when stimulated, but there will be reduced or no control. There will also be no message telling that the bowel is full. The muscle that controls the opening and closing of the anus stays tight. When the bowel gets full it will empty automatically. This is called an upper motor neuron type bowel or reflexic hypertonic bowel.
With injury below T12 the bowel will not completely empty even when stimulated. The condition will be lower motor neuron type bowel or flaccid hypotonic bowel.
With incomplete or around T12 injury, there may be a mixed upper and lower motor neuron type functioning.
A regular bowel management program will help to ensure that you will not experience bowel accidents or impaction. The program can include regular timing, good diet, exercise, proper fluid intake, and the use of laxatives and rectal stimulants.
Detailed information on bowel programs and how to establish a regular routine is available from the UK Spinal Injuries Association.
Solving Common Bowel Problems is a plain English straight talking resouce tool for people with spinal cord injury, published by the Rehabilitation Nursing Research and Development Unit, Royal Rehabilitation Centre, Sydney. Sections explain types of bowel care issues and their solutions. For your copy contact the National Continence Helpline:1800 330 066.
Pain
Although SCI damages the cord at the level of the injury, the nerves above and below the injury still carry messages. However after injury the nerves can be more sensitive than before, causing neuropathic pain. This can range from pins and needles to strong pain below the injury level.
Treatment can be relaxation, medication or muscle stimulation.
Sexuality and fertility
The extent to which sexual function is impaired by injury to the spinal cord depends on the level of injury and the severity of damage to the cord. It is different in males and females.
As with other physiological functions, sexual sensation is changed after SCI. Some people retain sensations in their genitals, others notice they are reduced or absent. Some have heightened sensations in other parts of the body.
Sexual enjoyment after SCI can be as good as pre-injury. Necessity in many cases encourages people to concentrate on "holistic" sexual experiences rather than genital-specific sex. Many report that they can still achieve orgasm. The best way to explore your own likes, dislikes and needs is with a loving partner.
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Female sexual activity is less likely to be affected by SCI. Ability to have intercourse is as easy as before, although additional lubrication may be needed. Alternative body positions may have to be considered.
The woman with SCI will still be able to conceive. Unless she is sensitive to latex, condoms may be the easiest method of birth control. She could use spermicidal foam, sponges or a diaphragm and jelly, but this will be difficult for a woman with quadriplegia. IUDs, the pill and hormone implants should only be used in consultation with an experienced practitioner. Both SCI and the pill cause vascular complications; IUDs are particularly a problem because a lack of sensation or inability to check its positioning may cause a woman to be unaware of slippage or puncture. Slippage may decrease their effectiveness and a puncture can be life threatening.
The fertility of women is usually not affected by spinal cord injury. Periods may cease for a while after injury, but will normally resume within a few months. If a woman with SCI does not conceive, the simpler fertility treatments such as intrauterine insemination will often be sufficient to achieve a pregnancy. Only a few will require more sophisticated treatment like in vitro fertilization (IVF).
Most spinal cord injured women conceive normally, have normal pregnancies and most will deliver normally The choice between vaginal and caesarian delivery is influenced by many factors including the mother's general health and the position of the baby in the womb. The greatest risk in childbirth for women with SCI is autonomic dysreflexia. A competent physician who is experienced in labor and delivery is essential for women with SCI contemplating having children.
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Male sexual functioning is more changed. Some can achieve erections quite easily, others only occasionally. Some are unable to achieve erections at all after SCI. Various methods, medications and equipment can help. These include vacuum pumps, injections and implants.
Although the level and severity of injury can indicate whether he will be able to have erections, the best way is for him know his body and learn how it reacts to certain situations. His doctor can advise about the physiological limitations, but he and his partner need to explore his responses. Although talking about sexual function is sometimes difficult, complete and open communication between partners is the best way to explore sexual possibilities available after injury.
Sperm from men with SCI may be of poorer quality than before injury; sometimes the semen disappears, which can affect fertility. If they have fertility problems they may still be a parent through artificial insemination.
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See our links page for other sites with sexuality/fertility information.
Skin
Prolonged pressure on the skin and the underlying tissue causes it to lose condition. If the pressure is not relieved the skin can break down, producing a pressure sore.
If not treated, pressure sores can ulcerate, leading to a medical emergency and prolonged hospital stay.
The risk is reduced by using pressure-relieving mattresses and cushions, and by the person shifting off his weight, or being turned if he cannot move independently.
Spasticity
Spinal cord injury disconnects the nerve cells below the level of injury from the brain. Spasticity is a reflexive response to stimuli. After SCI this response is exaggerated.
Pain, stretch, or other sensations from the body are transmitted to the spinal cord. Because of the disconnection, these sensations will cause the muscles to contract or spasm. Muscle spasms are particularly noticeable when muscles are overstretched or in response to any irritation to the body below the injury.
Some things, however, can make spasticity more of a problem—bladder or kidney infection, and skin breakdown increase spasm.
Some spasticity may always be present. It can be reduced by regular exercise, and by avoiding bladder infections, skin breakdowns, or injuries.
Medications used to treat spasticity include Baclofen, Diazepam, Dantrolene and Clonidine.
However there are some benefits to spasticity. It can serve as a warning mechanism to identify pain or problems in areas where there is no sensation. Many people know when a urinary tract infection is coming on by the increase in muscle spasms. Spasticity also helps to maintain muscle size and bone strength. It does not replace walking, but it does help to prevent osteoporosis. Spasticity helps maintain circulation in the legs and can be used to improve certain functional activities such as performing transfers or walking with braces. For these reasons, treatment is usually started only when spasticity interferes with sleep or limits a person's functional capacity.
Syringomyelia
Syringomyelia is a post-traumatic enlargement of the central canal of the spinal cord. It occurs in approximately 1–3% of all spinal cord injuries.
The primary risk of syringomyelia is a loss of function above the level of the original spinal cord injury. For example, a person with a T SCI may complain to his or her physician of numbness and weakness involving the extremities. The condition will progress with time and needs to be treated aggressively through surgical drainage. Often the condition of people with early evidence of a syrinx will be monitored to evaluate its progression.
Significant syringomyelia is treated with surgical decompression and the placement of a drainage tube into the spinal cord.
