Introduction
Spinal cord injury (SCI) is a major medical problem as there currently impossible to repair the central nervous system (CNS) and restore its functions (McDonald, Becker and Huettner, 2013). The severity of spinal cord injury depends on the level of injury, nature of injury and age of a person (Ysasi et al., 2016). Based on the systematic review article done by (Ning, Wu, Li & Feng, 2012), Motor vehicle accidents and falls are the most common cause which contributes to Spinal Cord Injury.
In relation to the case of a 45-year-old man who had involved in an accident had caused him to sustained a spinal cord injury with paralysis to his cervical C5 and C6. Injuries to C5 and C6 would cause some or total paralysis of wrists, hands, trunk and legs. Several complications may also arise from injuries to C5-C6. As stated by World Health Organization, & International Spinal Cord Society (2013) Respiratory complications, autonomic dysreflexia (AD), deep vein thrombosis (DVT), urinary tract infections (UTI), spasticity, osteoporosis, pressure ulcers, muscle atrophy, and chronic pain are the common complications which SCI patients may encounter.
Respiratory
Respiratory complications are the main cause of morbidity and mortality in the acute phase of Spinal Cord Injury (SCI) where estimated two-thirds of the patients will experience complications such as atelectasis, pneumonia and respiratory failure (Vázquez et al., 2013). There are two types of muscles which are responsible for inspiration and expiration. The diaphragm muscle controls the ability to take a deep full breath whereas the expiratory muscles consists of the intercostal and abdominal which allows one to exhale forcefully thus enable us to cough and clear off secretions. Injuries to the level C5-C6 may result in partial function of the diaphragm and malfunction of the intercostal and abdominal muscles.
Atelectasis usually caused by weak and paralyzed diaphragm which does not allow a patient to take a full deep breath thus the air unable to reach to the air sacs at the base of the lungs. Lungs will then collapse and eventually will cause retention of sputum. Sputum retention will result in the accumulation of bacteria in the lungs thus increases the risk of developing pneumonia. However, prolonged bed rest and decreased mobility are other factors which contributes to the development of pneumonia in SCI patients. Palmer, Kriegsman and Palmer (2008) suggest that a combination of antibiotics and chest physiotherapy is the first choice of treatment for pneumonia. Assisted cough such as Quad cough whereby the SCI patient requires assistance to push unto the upper abdomen which helps to expel air forcefully from the lungs thus allowing the ability to cough.
Respiratory failure is an indication for ventilation. This is defined as pO2 less than 50, or pCO2 over 50, by arterial blood gas testing, while the patient is on room air (Marsolais et.al, 2005). The loss of lung compliance contributes to difficulty in breathing which then leads to a rapid exhaustion of the inspiratory muscles causing decrease of vital capacity (VC). It is important to monitor the VC closely as once it reaches 15mls/kg, mechanical ventilation may be required. As compared to a normal VC which is about 50-70mls kg.
Respiratory complications can be managed by encouraging deep breathing exercise by using the incentive spirometry and measure on how well the lungs are able to expel air by using the peak flow meter. Study done by Wadsworth, Haines, Cornwell, Rodwell and Paratz, (2012) mentioned that an individually fitted abdominal binder improved forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximum sustained vowel time in people with newly acquired tetraplegia.
Musculoskeletal
Spinal cord Injury affecting the C5 and C6 may cause partial or total paralysis of wrists, hands, trunks and legs. Several complications may arise related to the musculoskeletal such as muscle atrophy, pressure ulcers, osteoporosis, spasticity and contractures and musculoskeletal pain.
When cell injury occurs, it will slow down the metabolic rate thus increases the risk of SCI patients having metabolic disorder. This resulted in individual to have muscle atrophy as the body will compensate it by breaking down it’s body muscles therefore use it as amino acids to provide energy production to the other organs. Another factor which contributes to muscle atrophy is prolonged bedrest which then causes delay to the rehabilitation process. This will eventually lead to pressure ulcer occurring from atrophy of muscles, thinning of skin, and loss of sensation which will resulted in poor blood circulation. Study has shown that up to 66% of individuals with SCI will have a pressure sore during their lifetime (Kruger et al., 2013). Pressure ulcer assessment, frequent turning and positioning of SCI patient is essential to prevent development of pressure ulcers.
Inability to weight bear will eventually decrease the osteoblast activity in the bones which would then leads to osteoporosis thus increases the risk of fractures. Dudley-Javoroski and Shields (2008) found that fractures may occur often during routine activities of daily living such as bathing, transferring to and from a wheelchair. Most of the SCI patients will also develop spasticity on their limbs due to hyperactivity of their muscles that leads to contracture and therefore contracted limbs involved may cause loss of ability for the patient to perform motor skills and activities of daily living. As a healthcare worker it is important to advice caregiver to be gentle while assisting SCI patients in performing their ADLs and transferring.
Cardiovascular
Cardiovascular disturbances are the leading causes of morbidity and mortality in both acute and chronic stages of Spinal Cord Injury (SCI) (Grigorean et al., 2009). SCI patients may develop neurogenic shock whereby it consists of two factors such as bradycardia and hypotension which is likely cause by a decreased peripheral resistance and cardiac output. This is frequently managed by administering intravenous fluids to temporarily elevate the blood pressure to allow enough blood flow to the brain and other organs. Vasopressors will also be given.
There are also instances whereby a sudden increase of blood pressure would occur on SCI patients. This is often known as Autonomic Dysreflexia (AD). According to Palmer, Kriegsman and Palmer (2008), AD is an abnormal reaction of the part of the nervous system that controls vital functions, resulting from unpleasant body stimuli. SCI patients will have the loss of sensation thus decreases the ability to identify that something is wrong in the body which may eventually lead to a life-threatening result if not managed properly. The trigger mechanisms for AD were somatic pain, faecal impaction, and abdominal distention (Krassioukov, Furlan and Fehlings 2003). However, a study done by Krieger and Krieger, (2000) states that bladder distention, which is considered to be the most common among other associating factors. This is probably due to the kinking of catheter and insufficient replacements of intermittent catheterization. It is vital to be able to recognise the cause and eliminate the triggering factors immediately to prevent further complications.
Due to prolonged bed rest and immobilization, SCI patients may develop deep vein thrombosis (DVT) which could lead to pulmonary embolism. Palmer, Kriegsman and Palmer (2008) suggest that risk of DVT would be reduced by administering anti-coagulants such as (heparin and clexane) to prevent any blood clots from forming. Calf pumps and compression stockings could also reduce the development of DVT.
Neurogenic Bladder
Neurogenic bladder refers to a malfunctioning urinary bladder due to neurologic dysfunction, or insult, resulting from internal or external trauma, disease or injury (Middleton, Ramakrishnan and Cameron, 2014).
Spinal cord injury (SCI) patients may lose its ability to eliminate (urinate and passed motion) like a normal person does. Therefore, the use of urine catheters is essential in the life of a SCI patients to empty the urine in the bladder. These patients are given a time schedule which has been planned for bladder emptying therefore they will need to follow according to prevent incontinence. Failing to comply to the instructions, SCI patients may experience Urinary Tract Infection (UTI). However, the use of catheters also contributes to the risk of UTIs. Urinary tract infections (UTIs) are one of the leading causes of morbidity and mortality in spinal cord injury patients, where the method of urinary drainage proves to be a contributing factor for UTI development (Goetz et al., 2013). This is often managed by consuming antibiotics.
Neuropathic Pain
Spinal cord injury (SCI) patients experiencing neuropathic pain (NP) tends to be a significant concern. It is commonly associated with poorer health, reduced quality of life and depression (Wollars, Post, van Asbeck and Brand, 2007). SCI patients would experience the loss of sensation thus describing the pain that they experiencing are not accurate. However, the symptoms which commonly described are such as shooting pain, burning and cramping.
Pain management are thus essential for SCI patients. Therefore, medications such as Opioids, Nonsteroidal anti-inflammatory drugs (NSAIDS) and anti-spastic drugs are often use to treat the pain.
Conclusion
In conclusion, it is crucial to identify these complications which may arise from patients who sustained cervical spinal injuries. Proper management is also vital to prevent escalation of complications to occur.