Spinal Cord Injury (Thoracic)

Spinal Cord Injury (Thoracic)

CHAPTER 157 Spinal Cord Injury (Thoracic) Marcin Partyka, MD, FRCPC Jesse D. Ennis, MD, FRCPC Shanker Nesathurai, MD, MPH, FRCPC Synonym Paraplegia ...

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CHAPTER 157

Spinal Cord Injury (Thoracic) Marcin Partyka, MD, FRCPC Jesse D. Ennis, MD, FRCPC Shanker Nesathurai, MD, MPH, FRCPC

Synonym Paraplegia

ICD-10 Codes G82.20 G82.21 G82.22

Paraplegia of both lower limbs, unspecified Paraplegia of both lower limbs, complete Paraplegia of both lower limbs, incomplete

Definition Spinal cord injury (SCI) is a lesion of the neural elements in the spinal canal, resulting in temporary or permanent sensory deficit, motor deficit, and/or bowel/bladder dysfunction.1 SCI is a common cause of paralysis, particularly in young men. Motor vehicle accidents continue to be the most common etiology of SCI, followed closely by falls (Fig. 157.1). Over one-third of all injuries to the spinal cord occur at the thoracic level, most commonly at T12.2 With thoracic SCI, 67% of patients will have complete injury, 8% will have a sensory incomplete injury, and 24% will have a motor incomplete injury. Mean age at the time of injury has increased over time: from 2010 to 2015, the mean age was 42 years, compared with 29 years from 1972 to 1979. Overall, there is still higher representation of males with SCI, with 81% of patients being male and 19% being female.2 Compromise to the thoracic spinal cord typically results in paraplegia. Unlike paraplegia that results from compromise of the cauda equina associated with lumbar spine injuries, the clinical findings are consistent with upper motor neuron injury. However, lower limb paralysis is not the only impairment. The thoracic spinal cord also segmentally innervates the intercostal muscles as well as the upper and lower abdominal muscles. The intercostal muscles are innervated by the T1 to T12 spinal segments. The upper abdominal muscles are innervated by the T8 to T10 spinal segments; the T11 to T12 spinal segments innervate the lower abdominal muscles.3 916

A quantitative three-dimensional anatomy of the thoracic spine reveals three distinct zones: the cervicothoracic transition zone, the middle region, and the thoracolumbar transition zone.4,5 The T1 to T4 region is characterized by a narrowing of the vertebral end plate and spinal canal widths.4 The middle thoracic region (T4-T9) is notable for its relatively narrow end plate and small spinal canal. The rib articulations provide an increased degree of protection at this level. An enlargement of the spinal canal characterizes the lower thoracic region (T10-T12).4 There is also less rigidity of the spine at the T11 and T12 segments because of the lack of ventral attachment of the ribs.4 Therefore, there is an increased vulnerability to SCI at the lower thoracic levels. Compared with the cervical and lumbar spinal levels, the blood supply is more tenuous in the thoracic spinal cord, and therefore ischemia poses a greater threat to neurologic function in this area.5 

Symptoms The presenting symptoms of thoracic SCI are consistent with the alteration to the motor, sensory, and autonomic pathways. The chief symptoms are weakness or paralysis of the abdominal and lower extremity musculature and loss of sensation in the lower limbs, thorax, and perineum. Patients may also experience altered bowel or bladder function in addition to spasticity and sexual dysfunction. With lesions above the T6 level, patients may experience symptoms of autonomic dysreflexia. Autonomic dysreflexia is characterized by pounding headaches, nasal congestion, anxiety, visual disturbances, pallor below the level of injury, and sweating and flushing above the level of injury. In patients with an old, stable injury who are experiencing new or progressive symptoms (e.g., pain, increasing weakness, loss of sensation), the clinician should consider the possibility of a syrinx. Patients with SCI are often insensate to the pain that accompanies deep venous thrombosis, and therefore both the clinician and the patient should be attentive to clinical signs such as edema, erythema, and increased tone. Heterotopic ossification may mimic deep venous thrombosis because the symptoms include swelling, warmth, erythema, increased spasticity, pain, low-grade fever, as well as decreased range of movement.

CHAPTER 157  Spinal Cord Injury (Thoracic)

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motor level, and reflex abnormality as well as spasticity. However, there are individuals with radiological evidence of syringomyelia, but no recognizable clinical symptoms. 

4

9 38

Vehicular Falls Violence

13.5

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Sports Medical/surgical Other

30.5 FIG. 157.1  Spinal cord etiology. (Modified from 2015 Annual Statistical Report for the Spinal Cord Injury Model Systems. Birmingham, AL: National Spinal Cord Injury Statistical Center; 2015.)

Pain can originate from musculoskeletal, visceral, or neuropathic pain generators. An analysis of several studies addressing prevalence of pain after SCI showed a variable overall prevalence of pain ranging from as low as 26% to as high as 96%.6 Pain originating from either musculoskeletal or neurologic sources is common. Neuropathic pain resulting from central or peripheral nervous disruption may be described as burning or shooting. Chronic visceral pain is found in approximately 30% of the population and is often associated with constipation, while neuropathic pain is present in 40% to 50% of patients.7 

Physical Examination The diagnosis of a thoracic-level SCI necessitates a thorough physical examination, including a comprehensive American Spinal Injury Association (ASIA) assessment. Findings on physical examination include a motor and sensory level. Depending on whether the injury is partial or complete, there may be sparing of sacral sensation or anal sphincter motor function below the neurologic level of injury. In the acute period, the motor examination is characterized by loss of muscle tone and deep tendon reflexes. During subsequent days and weeks, there is emergence of increased muscle tone, reflexes, and pathologic reflexes. Cutaneous reflexes including the plantar response, cremasteric reflex, and bulbocavernosus reflex are initially depressed and follow a variable course to gradual return. The neurologic level of injury should be reassessed once spinal shock has resolved, as it may be different from previous assessments. The initial evaluation of the patient also includes the assessment of vital signs and the cardiovascular, respiratory, musculoskeletal, gastrointestinal, and genitourinary systems. A thorough examination of the skin is necessary. In thoracic SCI, pressure ulcers are more common over bone prominences such as the sacrum, calcaneus, and greater trochanter. In addition, it is important to evaluate the patient for spasticity and contractures. New neurologic abnormalities on physical examination should alert the clinician to consider imaging studies to exclude syringomyelia. In this case, typical physical examination findings include change in sensory level, change in

Functional Limitations Persons who suffer from thoracic SCI can have significantly different impairments and levels of disability, depending on their degree of paralysis and associated potential complications (e.g., contractures, spasticity). For example, a patient with high thoracic paraplegia (i.e., T2 level) typically has some component of truncal instability; as a result, the patient’s wheelchair requires a high back. In contrast, a person with low thoracic paraplegia generally has preservation of most of the intercostal and abdominal muscles and could opt for a chair with a low back. Intercostal muscle impairment in patients with SCI in the upper thoracic region may cause an impaired cough and a decreased ability to mobilize secretions. Functional goals for individuals with thoracic SCI include the ability to complete activities of daily living and instrumental activities of daily living with or without the use of assistive equipment. At 1 year, approximately 12% of patients return to work and this increases to 34% at 20-year follow-up.2 Tasiemski and colleagues8 have described a positive association of involvement in sports and recreational activities with increased life satisfaction in a community sample of people with SCI. Numerous sports and recreational organizations offer adaptive sports programs for people with disabilities. Bowel and bladder function may cause social embarrassment, leading to self-imposed social isolation. Sexual dysfunction may result in a loss of intimacy. The availability of partners is a concern for many patients because their disability as well as environmental and social barriers may preclude their involvement in some of the more typical dating activities. Depression is common in patients with SCI; a recent meta-analysis found the prevalence of depression to range between 19% and 26%.9 Depression impacts the rehabilitation process, negatively affecting the level of participation in therapeutic programming9 and resulting in poor compliance with self-care activities.8 Referral to mental health professionals is encouraged for patients at risk. 

Diagnostic Studies The diagnosis of thoracic SCI is often corroborated with magnetic resonance imaging (MRI). The stability of the injury is assessed by evaluation of the anterior, middle, and posterior columns of the spine. MRI is also the study of choice when syringomyelia is suspected. Urodynamic testing is commonly used to evaluate bladder function in the individual with SCI. Urodynamic studies involve filling of the bladder with fluid or gas and use of electromyographic and fluoroscopic techniques to evaluate voiding function. Annual evaluations often include an ultrasound examination to further assess the integrity of the renal system. Patients with grade IV pressure ulcers may require a bone scan or MRI study to detect osteomyelitis. The triplephase bone scan is also used in the diagnosis of heterotopic

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ossification (see Chapter 131). Doppler surveillance studies are sometimes performed to detect deep venous thrombosis in this highly susceptible population (see Chapter 128). Computer tomography pulmonary angiogram is employed in cases of suspected pulmonary embolism. Routine colonoscopy and fecal occult blood testing may be appropriate for patients 50 years and older.10 In patients susceptible to autonomic dysreflexia, appropriate precautions must be used during colonoscopy.  Differential Diagnosis

most paraplegic patients are able to independently perform pressure-relieving strategies, such as wheelchair pushups. These techniques should be performed every 15 minutes to minimize excessive pressure. Patients immobilized in bed should be turned and repositioned every 2 hours. Patients who have a pressure ulcer must minimize pressure to that area until the wound is healed. A variety of débridement methods are available for removal of necrotic debris from pressure ulcers (see Chapter 149). 

Pain

Treatment

The presentation of pain among the SCI population can be varied in nature; both neuropathic pain and pain resulting from abnormal mechanical stresses on the musculoskeletal system (e.g., tendinitis) are common. Many times, patients with musculoskeletal pain have a well-defined disorder that is amenable to standard physiatric treatment (e.g., rotator cuff tendinitis, lateral epicondylitis). Non-narcotic analgesics and nonsteroidal anti-inflammatory drugs can be used to treat musculoskeletal causes of pain. Neuropathic pain generally is not responsive to these medications, but there is strong support both for the usefulness and safety of pregabalin.13 Medications such as gabapentin, amitriptyline, and duloxetine may also be effective.13 

Initial

Bladder Management

The initial management of SCI consists of medical stabilization of the patient, immobilization of the spine, and procurement of relevant medical imaging to determine etiology and extent of injury. In the case of traumatic SCI, Advanced Trauma Life Support (ATLS) protocol should be initiated. Any mobilization of the patient should incorporate logrolling to ensure anatomic alignment of the spine. A back board is used for immobilization of the spinal cord, but should be discontinued as soon as possible to prevent pressure ulcers. Imaging of the spine includes computed tomography to visualize bony structures and MRI for soft tissue visualization. Suspected infection and cancer of the spinal cord should warrant blood work, inflammatory markers, and MRI. Damage to the spinal vasculature and thrombosis requires contrast angiography.

Most patients with thoracic-level SCI will have upper motor neuron bladder dysfunction, characterized by low urinary volumes, high bladder pressures, bladder trabeculation, and diminished bladder compliance. Detrusor-sphincter dyssynergia (contraction of the bladder wall with incomplete relaxation of the urethral sphincter) is a common occurrence. This can contribute to vesicoureteral reflux, which may result in hydronephrosis and subsequent chronic renal failure. Detrusor-sphincter dyssynergia can be treated with medical interventions that decrease bladder tone such as antimuscarinics (e.g., oxybutynin) or β3 agonists (e.g., mirabegron), although high level evidence for the latter is lacking.14 Alternatively, α-adrenoreceptor blockers (e.g., terazosin, tamsulosin) may be used if there is evidence of a non-relaxing bladder neck or benign prostate enlargement.14 Detrusor or sphincter chemodenervation through the use of botulinum toxin has also been shown to be beneficial (see Chapter 138).14 Bladder management strategies should be individualized, but intermittent catheterization is the preferred treatment option. A typical intermittent catheterization program requires bladder emptying four to six times per day, with bladder volumes remaining less than 500 mL. Most paraplegic patients have the manual dexterity to perform selfcatheterization; some individuals, because of physical or sociomedical factors, must use indwelling catheters (with suprapubic preferred to urethral). Indwelling catheters are associated with a higher incidence of bladder stones and bladder carcinoma.15 In addition, in men, urethral catheters are associated with prostatitis, epididymitis, and urethral strictures. Long-term use of urethral catheters in women may result in urethral dilation. 

Amyotrophic lateral sclerosis Hereditary spastic paraplegia Post-traumatic syringomyelia Guillain-Barré syndrome Spinal cord infarction Ischemic injury to spinal cord (i.e., secondary to abdominal and thoracic aneurysms) Multiple sclerosis Transverse myelitis

Skin Management The prevention of skin ulcers is paramount. In a long-term analysis of subjects enrolled in the National Spinal Cord Injury Statistical Center database, skin diseases were the second most common cause of re-hospitalization. Gélis and colleagues reported a 15% to 30% prevalence of pressure ulcers in the chronic stages of SCI.11 Common sites for pressure ulcers are the sacrum, greater trochanter, and heels. Excessive pressure, shearing, friction, and maceration can increase the risk for pressure ulcers. Other risk factors include spasticity, impaired sensation, immobility, poor nutrition, heterotopic ossification, weight gain, and incontinence.12 The maintenance of skin integrity is an ever-present goal in patients with SCI. Pressure ulcer formation will lead to the development of scar tissue and an even greater likelihood of ulcer recurrence. Seating surfaces should be reevaluated on a regular basis, ensuring that they have not worn out and still fit the patient’s weight and size. Patients are encouraged to perform daily skin examinations, and

Bowel Management The patient with thoracic-level injuries will most likely have constipation; therefore, a bowel program is necessary. A

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Table 157.1  Oral Adjunctive Bowel Medications Medication

Brand

Mechanism of Action

Strength

Dose

Docusate sodium

Colace

Stool softener

100 mg (capsules)

1 tablet bid

Senna

Senokot

Colonic stimulant

8.6 mg (tablets)

1-2 tablets qhs

Bisacodyl

Dulcolax

Colonic irritant

5 mg (tablets)

2 tablets qd

Polyethylene glycol (PEG 3350)

Lax-A-Day, MiraLax

Osmotic laxative

17 g (powder)

17 g daily (dissolved in liquid)

Psyllium powder

Smooth Texture Sugar-Free Unflavored Metamucil

Bulk-forming agent

3.4 g per tsp

1 tsp qd-tid

Metoclopramide

Reglan

Prokinetic agent

10 mg (tablets)

1 tablet qid

Modified from Bergman S. Bowel management. In: Nesathurai S, ed. The Rehabilitation of People with Spinal Cord Injury. 3rd ed. Whitinsville, MA: Arbuckle Academic Publishers; 2013. Lee-Robichaud H, Thomas K, Morgan J, et al. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev. 2010;7:CD007570.

reasonable goal for a bowel regimen is to achieve socially acceptable fecal continence, with bowel evacuations at least three times per week. A bowel regimen may include medications (Table 157.1). In addition, bowel evacuation is scheduled after a meal to capitalize on the intrinsic increase in peristalsis after meals (i.e., the gastrocolic reflex). Bowel care programs done on a raised toilet seat use the benefits of gravity. Digital stimulation (gentle insertion of the finger) of the rectum or insertion of a suppository can activate the rectocolic reflex by stimulating peristalsis and promoting regular bowel movements. Enemas (Fleet, soapsuds) should not be part of a regular bowel program. However, these agents are useful in emptying the colon before initiation of a bowel program or treatment of fecal obstipation.10 The administration of an enema, suppository, or digital stimulation can precipitate autonomic dysreflexia in susceptible patients. If administration of an oral osmotic laxative is required, consideration should be given to polyethylene glycol 3350 (PEG 3350) over the traditional use of lactulose. This is supported by a recent Cochrane review that demonstrated greater efficacy and less abdominal pain compared with lactulose for all-cause chronic constipation (see Chapter 139).16 

Mental Health Psychosocial adaptation subsequent to SCI is a lifelong process. There is no single “classic” presentation of this phenomenon. Anger, hostility, anxiety, and depression often result from overwhelming losses confronting this population. Suicide is among the leading causes of death in these patients. There is increased risk for suicide after SCI compared to the general population.17 Suicide ideation and suicide attempts are associated with depression severity.17 In addition, suicide attempt in SCI is associated with lower education, younger age at injury, history of concomitant depression, bipolar disorder, and schizophrenia.17 In individuals with depression or other psychological sequelae, consultation with an appropriate mental health care professional is recommended. Continued follow-up is encouraged, when appropriate. 

Sexual and Reproductive Function Sexual desire is not necessarily affected by SCI. However, associated depression, fears of inadequacy, and poor body image may consequently alter sexual desire. Sexual function (e.g., erection and ejaculation in men and lubrication

in women) in patients with thoracic-level injuries may be altered, and in general, is related to the level and completeness of injury. Men with thoracic-level lesions (with intact sacral reflexes) generally can achieve reflex erections with direct genital stimulation. However, many times these reflex erections are of insufficient rigidity and duration for satisfactory sexual function.18 Many patients with SCI have numerous questions and fears about sexuality and sexual function. Treatment should address concerns related to body image, dating, and initiation and maintenance of intimate relationships. Peer counselors can share their experiences, and their advice can be beneficial. Peer counselors may be located through local independent living centers or through advocacy organizations such as the National Spinal Cord Injury Association or Spinal Cord Injury Canada. In addition, mental health professionals (e.g., psychologists, psychiatrists, social workers) can be a valuable resource to the patient and rehabilitation team. Several options available to men with erectile dysfunction include oral medications (e.g., sildenafil, tadalafil, vardenafil),19 vacuum devices, penile injection programs (papaverine),19 and surgically implanted prostheses. Studies have not shown any difference in effectiveness or satisfaction between these oral medications in the SCI population.19 Oral medications and personal lubricants are used most frequently, with vacuums and penile injections being used less often.20 Ejaculatory dysfunction is also common, including retrograde ejaculation into the bladder.21 Chronic SCI is also associated with poor semen quality and decreased spermatogenesis.22 Kathiresan and colleagues compared sperm samples collected through masturbation, penile vibratory stimulation, and electroejaculation to those of healthy controls. They found sperm collected through masturbation to have the best motility, although still lower than the control group. Sperm concentration was decreased in the electroejaculation group.23 Elevated scrotal temperatures (from chronic sitting) and frequent urinary tract infections may negatively affect semen quality. Although studies have indicated that approximately 12% to 15% of men with SCI report ejaculation, fatherhood has become a possibility with use of semen retrieval methods such as penile vibrostimulation and electroejaculation along with improved assisted reproductive technology.24 The risk of autonomic dysreflexia exists among susceptible patients with an injury level

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of T6 and above; therefore, assisted semen retrieval should be initiated by medical teams well trained in semen retrieval methods and the treatment of autonomic dysreflexia.25 Women with thoracic-level lesions may note changes in vaginal lubrication. However, at this level, women may achieve reflex lubrication.18 Direct stimulation of the genital region may result in sufficient lubrication. Of note, Smith et al. found that the majority of women with SCI did not experience difficulty with lubrication.20 A watersoluble lubricant is recommended for patients with complaints of decreased vaginal lubrication. One randomized placebo-controlled study on the use of sildenafil to enhance sexual arousal in women with SCI failed to show a statistically significant benefit,26 despite an earlier pilot study that appeared to show benefit.27 Orgasm for both men and women after injury may be nonexistent or described as a primarily emotional event or a pleasurable sensation in the pelvic region or sensory level with generalized muscle relaxation.18 Women with thoracic-level SCI remain fertile. Contraceptive options include barrier methods (condoms, diaphragm) and possibly oral contraceptives. Intrauterine contraceptive devices are contraindicated because of the lack of sensation and the risk for development of pelvic inflammatory disease. Patients with SCI are at increased risk for the development of thromboembolism, and the administration of oral contraceptives further increases this risk and should be discussed. The care of pregnant women with SCI has special challenges. Potential complications include premature labor, increased risk of urinary tract infection, increased spasticity, autonomic dysreflexia, and constipation. In pregnancy, autonomic dysreflexia is manifested most frequently during labor; therefore, hemodynamic monitoring is considered for all at-risk patients.28 Pregnant women with thoracic SCI levels above T10 may be unable to sense fetal movements and contractions. Therefore, uterine palpation, serial cervical examinations, and fetal monitoring may be recommended. The early use of regional anesthesia can ameliorate autonomic dysreflexia by blocking the transmission of noxious stimuli, and allowing for procedures that would otherwise trigger the sympathetic response of autonomic dysreflexia. These include bladder catheterization, fetal monitoring placement, cervical examination,29 and cesarean section or vaginal delivery. 

Deep Venous Thrombosis SCI predisposes individuals to both deep venous thrombosis and pulmonary embolism. A systematic literature review revealed the prevalence of deep venous thrombosis in SCI to vary from 9% to 100%.30 Of these, it is estimated that only 20% will extend into proximal veins, with associated elevated risk of pulmonary embolism. The rate of pulmonary embolism has been found to be 8% to 14% in acute SCI, with rates of fatal pulmonary embolism as high as 5%.30 Putative mechanisms include immobility as a result of paralysis and failure of the venous-muscle pump as well as the possible contribution of a generalized hypercoagulable state. Patients are administered fractionated or unfractionated heparin during the initial weeks after injury and may use thigh-high compression stockings and pneumatic

compression. Current literature suggests continuation of prophylaxis for 8 to 12 weeks after injury. For more details on the prevention and treatment of deep venous thrombosis, see Chapter 128. 

Spasticity Management Spasticity should be treated when it results in significant pain, contributes to contractures, impairs hygiene, interferes with functional tasks, or impedes nursing care. In the first instance, clinically significant spasticity should be treated by removal of noxious stimuli that may be contributing to the condition, such as urinary tract infection, ingrown toenails, bowel impaction, heterotopic ossification, and tight clothing. Second, physical interventions such as daily terminal sustained stretching of muscles with appropriate bracing can be considered. If these are unsuccessful, medications such as tizanidine and baclofen as well as interventional procedures (e.g., chemodenervation) can be considered (see Chapter 154 for details). 

Heterotopic Ossification Heterotopic ossification is most often seen in the first 6 months after SCI, especially in the first 2 months.31,32 The incidence of heterotopic ossification among individuals with SCI ranges from 10% to 53%.32 It is estimated that 20% to 30% of those with heterotopic ossification will experience a significant loss of joint mobility.31 Treatment may include the administration of etidronate, which limits ossification, gentle physical therapy to maintain range of motion, and surgical resection of mature heterotopic bone (see Chapter 131). 

Osteoporosis Osteoporosis among patients with SCI is common. Immobilization and the lack of weight-loading activities are among the chief causes of osteoporosis. Other factors may include alterations in blood circulation, lack of muscle traction on bone, and hormonal changes.33 Following SCI, there is bone resorption occurring as early as the first 2 weeks.34 Patients with SCI are at significant risk for long bone fracture, and care must be taken to prevent fractures resulting from range of motion exercises and falls. A recent systematic review showed that administration of bisphosphonates reduced bone mineral density loss in the acute setting only.35 However, guidelines for this population have not been developed. In the absence of clear guidelines, investigation, treatment, and monitoring for osteoporosis in SCI patients remains somewhat empirical. Supplementation with vitamin D is often recommended, although calcium supplementation remains controversial because of the associated risk of urinary calculi (see Chapter 141 for further details).34 

Autonomic Dysreflexia For the treatment of autonomic dysreflexia, it is necessary to remove the precipitating noxious stimulus. Patients should be placed in an upright position, if possible, to decrease blood pressure, and a search for a causative agent is initiated. Most cases of autonomic dysreflexia are related to bladder distention or bowel distention.36 However, noxious stimuli such as ingrown toenails, pressure ulcer, and renal calculi are not uncommon. Vasodilating medications such as nitropaste may be required to decrease the blood pressure

CHAPTER 157  Spinal Cord Injury (Thoracic)

while the clinician seeks the causative factor.37 Nitrates are contraindicated in individuals who have ingested phosphodiesterase inhibitors, such as sildenafil, as the nitrates can potentiate the hypotensive effects of sildenafil and cause severe hypotension.37 

Respiratory Health While thoracic SCI spares the diaphragm (C3-C5), the intercostals (T1-T12), upper abdominal (T8-T10), and lower abdominal (T10-T12) muscles may be affected and result in impaired cough, difficulty with secretion clearance, and pneumonia.38 Chest physiotherapy such as assisted cough, percussion, breath stacking, and positional drainage may decrease mucous plugging and secretions.38 There is some evidence to support inspiratory muscle training to improve muscle strength, and to decrease dyspnea and infections.39 Spinal cord patients are also at risk for obstructive sleep apnea (OSA) with a prevalence ranging from 9% to 83%.39 Overnight oximetry and polysomnography should be used to screen for OSA. 

Rehabilitation A comprehensive rehabilitation program is essential to optimize functional independence. The program should address functional goals related to mobility, transfers, and self-care as well as issues related to health maintenance and self-advocacy. Depending on the outstanding treatment goals, the treatment team may include a physical therapist, occupational therapist, orthotist, nurse, and mental health provider. Mobility is a major issue that needs to be addressed both initially and then periodically as the patient’s condition changes (e.g., women who become pregnant may require assistance with functional activities as the pregnancy progresses). Typically, patients with thoracic SCI are able to achieve mobility with a manual wheelchair. Higher levels of thoracic SCI are associated with greater truncal instability. This may affect stability in a wheelchair and should be addressed with the seating prescription. Most patients with thoracic injuries, with training, are able to transfer independently. For assistance with independence in self-care, adaptive equipment, such as long-handled shoehorn reachers and suppository inserters, can be recommended. Home environmental modifications may also be necessary (i.e., ramp to enter home). Patients with thoracic SCI should be able to drive a modified car or van. Passive interventions, such as therapeutic heat and cold as well as transcutaneous electrical nerve stimulation, may be beneficial in the management of pain. However, particular caution must be used with therapeutic heat or cold modalities over insensate areas. As well, with higher levels of injury, there is increasing loss of intercostal muscle innervation and increased level of respiratory impairment. Techniques including incentive spirometry, manual assisted cough, and insufflation-exsufflation can be used to reduce pulmonary complications of thoracic SCI. Physical interventions, such as daily stretching of muscles with terminal sustained stretch, can be considered a

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first-line rehabilitative treatment for spasticity. Positioning as well as serial casting and splinting of the affected limbs can minimize spasticity. Other rehabilitation treatments may also be considered. Body weight-supported treadmill training is prescribed in many centers. This intervention has been shown to be as effective as traditional gait training practices in the first year after injury with regard to functional outcomes.40 The use of lower limb bracing may be an option in individuals with thoracic SCI, predominantly in those with lower thoracic level. 

Procedures A number of procedures can be used to address issues such as spasticity and pain. Interventional approaches for the treatment of spasticity include botulinum toxin injection, motor branch blocks, and peripheral nerve blocks (see Chapter 154). To decrease sphincter tone in men, botulinum toxin can be injected into the sphincter. This treatment in women is associated with an unacceptably high incidence of urinary incontinence. A patient with dysreflexia caused by a bladder stone may require a urologic procedure for stone removal. For men with ejaculatory dysfunction, retrieval of sperm for insemination has been successfully accomplished by electroejaculation and vibrostimulation methods. These procedures may result in dysreflexia and are performed under medical supervision. 

Technology There has been increased interest in the development and research of assistive technologies for the SCI population with the goal of enabling some non-ambulatory individuals to walk. These assistive devices include functional electrical stimulation and robotic exoskeletons such as the ReWalk, Ekso, and Indego models. Functional electrical stimulation may improve muscle strength, decrease muscle atrophy, and improve lower limb endurance.40 There is some evidence supporting the use of functional electrical stimulation to enhance walking speed, distance, and function in the SCI population.40 Various body weight-support gait training strategies have been shown to be beneficial in SCI patients with minimal walking function; however, robotic-assisted treadmill training showed little change in walking speed.40 A recent systematic review showed that while gait speed correlated positively with age, level of injury and training time, the mean speed attained while wearing an exoskeleton was 0.26 m/s, a value not sufficient for community ambulation.41 Research on robotic exoskeletons is still limited because of small studies, lack of comparison between different devices, heterogeneity in training protocols,42 and insufficient data on the effect of robotics on health status.43 

Surgery Pressure ulcers that do not heal with conservative methods may require surgical closure. Direct closure, skin grafts, musculocutaneous flaps, and skin flaps are among the surgical treatments available for wound closure. Mobilization after surgical closure must be done under close supervision, with careful monitoring of the surgical wound.

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A variety of surgical procedures are used in patients who cannot be satisfactorily maintained with an intermittent catheterization program. Sphincter tone can be reduced with a sphincterotomy for men. Men must wear external collection devices after this procedure because it results in continuous incontinence. Sphincterotomies may occasionally require revision because of the development of fibrosis that obstructs outflow. Sphincterotomies may result in erectile dysfunction in some men. In contemporary practice, sphincterotomies are performed less frequently. Bladder augmentation is occasionally performed to increase bladder capacity. A piece of small bowel is interposed with the bladder tissue to increase vesical volume. Patients with chronic dysreflexia resulting from persistent bowel management difficulties, such as frequent impaction, may be candidates for ileostomy or colostomy procedures. Consideration may also be given for Malone antegrade continence enema. This surgical procedure connects the appendix to the abdominal wall through a valve mechanism and allows for catheterization and irrigation of the colon. Patients with hemorrhoids aggravated by digital stimulation occasionally require surgical consultation if the hemorrhoids are not relieved by more conservative methods (e.g., medicated suppositories or topical steroid creams). On occasion, men with erectile dysfunction that is not amenable to less invasive therapies may opt for an implantable penile prosthesis. Again, with the introduction of medications to treat erectile dysfunction, these surgeries are less frequently performed. Surgical placement of an intrathecal morphine or baclofen pump may be beneficial for patients with severe pain or spasticity. Tendon transfers and tendon lengthening procedures may be incorporated in spasticity not responsive to noninvasive treatments. Surgical interventions are indicated in some cases of heterotopic ossification. Patients with functionally limited joint mobility or severe and chronic spasticity may benefit from surgical resection of the lesion. 

Potential Disease Complications Individuals with thoracic-level SCI are more likely to have associated injuries that are serious than are those with cervical or lumbosacral spinal cord lesions. In one study, patients with traumatic thoracic spine fractures had an 86% occurrence of additional traumatic injury, such as rib fractures (42%), pulmonary contusions (37%), pneumothorax or hemothorax (35%), cervical spine injury (31%), lumbar spine injuries (28%), clavicular fractures (12%), sternal fractures (11%), and scapular fractures (10%).44 Thoracic SCI may be associated with a lower life expectancy. The leading causes of death among people with SCI in the national Spinal Cord Injury Model Systems database are respiratory, infectious, and cardiovascular diseases.1 Complications arising from a thoracic-level injury result from immobility, changing sensory patterns, and alterations in autonomic nervous system function. 

Potential Treatment Complications The anticholinergic side effects of tricyclic antidepressants, including dry mouth, blurred vision, and urinary retention, can pose additional difficulties for the patient with

SCI. Sphincterotomies, performed to alleviate detrusorsphincter dyssynergia, may result in urinary incontinence and occasionally sexual dysfunction in men. Voiding by the Credé maneuver may lead to vesicoureteral reflux. The long-term use of indwelling catheters is associated with prostatitis, epididymitis, strictures, bladder stones, and bladder carcinoma. Digital stimulation of the bowel can result in autonomic dysreflexia and hemorrhoids. Medications used to treat autonomic dysreflexia can result in hypotension. The blood pressure must be closely monitored. When the less invasive methods of treating spasticity are ineffective, more interventional approaches to spasticity, including chemodenervation with botulinum toxin or neurolysis with phenol injections, motor branch blocks, peripheral nerve blocks, and intrathecal baclofen pump insertion, may be considered. Injections may result in bleeding or infection. Nerve blocks may result in dysesthesias and weakness. Patients with intrathecal baclofen pumps may experience drowsiness, weakness, catheter breakage, infection, and rare, but potentially life-threatening baclofen overdose or underdose.

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CHAPTER 157  Spinal Cord Injury (Thoracic)

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