Approach
People living with chronic spinal cord injury (SCI) may have several associated medical sequelae that can affect nearly every organ system, and these should be thoroughly assessed. An accurate assessment requires a knowledge of the anatomy and function of the tracts in the spinal cord.[27][28]
History
Primary insult
The initial history of the inciting injury should be documented. This should include mechanism of injury, diagnostic findings such as imaging, treatments and/or surgical interventions, and any complications. Due to the strong correlation between SCI and brain injury, any loss of consciousness, altered memory of events, or cognitive changes should be noted. Most patients will have participated in an acute rehabilitation program, and these records are invaluable in understanding their injury, recovery course, functional status, and medical sequelae.
Neurologic injury
It is important to note that imaging level of injury and neurologic level of injury often do not directly match: the latter is usually at a higher level. Although it is common to use the American Spinal Cord Injury Association (ASIA) classification system and International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) ASIA exam to classify neurologic status after SCI, its prognostic use can only be applied to traumatic injuries.[29] If available, ASIA exam results should be maintained for reference if a neurologic change is suspected. A thorough history will include the mechanism, level of injury, ASIA classification, and neurologic recovery course. Routine follow-up should include a review of any changes noted by the patient, rehabilitation team, or provider.
Functional status
Any activities for which the patient needs assistance and/or use of adaptive equipment (e.g., wheelchair, transfer board, braces) should be documented. Any decline in function or independence requires an in-depth investigation into the underlying cause, such as a new infectious process, musculoskeletal injury, progression of spinal pathology, or new spinal pathology.
Bladder control and renal health
Both upper and lower urinary tract complications are common regardless of the mechanism of SCI. Urinary retention with the inability to void is the most common presentation (reflex neurogenic lower urinary tract dysfunction).[30][31] A careful bladder history will include the ability of the patient to sense a full bladder, how they void (including frequency, typical volumes, and catheter size for intermittent catheterization if applicable), and frequency of incontinent leakage. History of urinary tract infections, including culture results, resistance, and treatments, should be documented. Results from urodynamic testing, renal ultrasounds, kidney scans, or other urologic testing should also be documented.
Bowel control
History should assess the primary goal of predictable bowel movements and social continence. The patient should be asked about their ability to recognize the need to evacuate, level of volitional sphincter control, frequency and consistency of bowel movements, constipation events, episodes of incontinence, and history of hemorrhoids. The history should also include confidence to participate in activities outside the home. Incontinence caused by a new loss of rectal tone requires neurologic assessment.
Spasticity
The patient should be asked whether and how spasticity is affecting them, such as causing pain, preventing sleep, and effects on functional status. The history should also include typical triggers for that patient, and any changes in spasticity and range of motion.
Pain
Pain is common and often complex after SCI. There are often multiple pain generators, and each requires individual attention, assessment, and treatment planning.[32] It can be helpful to group these into three categories:
Pain above the level of injury: often musculoskeletal in nature, such as with healing traumatic injuries, shoulder overuse injuries, or focal overuse neuropathies such as ulnar or median neuropathies
Pain below the level of injury: this is commonly neuropathic in nature with a central generator
Pain at the level of injury: also commonly neuropathic, but it may present as having a distinctly separate character such as tightness or pressure sensation.
History should include effectiveness of medical and nonmedical interventions, and impact on function and quality of life. Loss of pain due to loss of sensation should be evaluated from a neurologic standpoint.
Autonomic dysfunction
Patients living with SCI may have difficulty with regulation of temperature, blood pressure, heart rate, and bronchospasm. This can lead to hyper- or hypothermia, orthostasis, and slowed cardiac response to activity demands.
Autonomic dysreflexia
Patients with a neurologic level at or above T6 may experience a dysautonomic hypertensive emergency called autonomic dysreflexia. This is most commonly caused by constipation, bladder distention, or bladder irritation, but can be triggered by any noxious stimulus below the level of injury. It presents clinically as a relative increase in systolic blood pressure >20 mmHg above baseline and relative bradycardia due to a parasympathetic response. Any history of autonomic dysreflexia should be documented and discussed, including symptoms during the event such as pounding headache, facial flushing, piloerection, anxiety, sweating, stuffy nose, or crying (in the pediatric patient). A history should include triggers and the patient’s emergency plan.
Orthostatic hypotension
It is common for patients to have a resting systolic blood pressure much lower than their pre-injury baseline (e.g., 90 mmHg). Orthostatic hypotension is also common due to decreased neurovascular tone and can have an impact on daily function as well as risk of syncope. The patient should be asked about symptoms and strategies used to control symptoms, such as compression stockings, abdominal binders, increased oral fluids, and any medications.
Venous thrombosis
Risk of venous thrombosis remains elevated lifelong after SCI. Any prior thromboses should be noted, as well as any prior or current implanted devices such as a vena cava filter. All unexplained limb swelling requires investigation.
Cardiovascular disease
Cardiovascular disease is the second most common cause of death in patients living with SCI.[33] A careful cardiac history should be obtained regardless of the patient’s age.
Respiratory health
Respiratory complications (e.g., atelectasis, pneumonia) are the leading cause of morbidity and mortality after SCI.[33] The impact of SCI on the respiratory system varies widely by injury severity, from lifelong ventilator dependence to normal respiratory function. Bronchospasm may be brought on by autonomic dysregulation. Respiratory symptoms and vaccinations against respiratory disease should be documented.
Bone health
There is increased risk of fragility fractures across all ages following SCI, correlated with severity of paralysis. This is due to the rapid and substantial bone density loss following paralysis, decreased physical forces across bone, and other complex neurohumoral factors.[34][35] History should include history of prior fractures, vitamin D levels, bone densitometry results, management such as with bisphosphonates, and any family history of osteoporosis or fragility fractures.
Skin health
Altered sensation and paralysis lead to an increased risk of pressure-related injuries, and incontinence can lead to moisture-related skin breakdown. Patients should be asked about any skin problems, how often they inspect their skin, and pressure-relieving strategies.
Sexual dysfunction and fertility
Sexual function is often impacted by SCI, and this should be discussed if the patient is open to this dialogue. It should be noted that psychological factors can play a confounding role in this population as they do in the general population. Male patients should be asked about erections to include strength, duration, if an erection is possible by psychological arousal, if an erection is possible by direct stimulation, ability for orgasm, and if ejaculate is present. Any medications and blood flow restrictive devices should be noted. Female patients should be asked about lubrication production, if arousal can be obtained through psychological means, if arousal can be obtained through direct stimulation, and ability for orgasm. As sexual interactions can produce autonomic dysreflexia events in both men and women, this should also be discussed. Fertility significantly decreases in males with SCI and an intention for children should be discussed.[36] Females living with SCI do not usually have reduced fertility following an initial phase of amenorrhea, but this may be underinvestigated.[37][38]
Psychological comorbidities
There is increased risk of depression, anxiety disorders, substance use disorders, PTSD, and suicide in patients with SCI.[39][40] Screenings should be conducted at each visit, to include current symptoms and lifetime history.[40]
Social integration
Following SCI, people will face personal, internal, and external barriers to their roles in the home, in work, and in social and leisure activities. Patients should be asked about time and activities outside the home, hobbies, work status, and other social activities they enjoy.
Physical exam
The neuromuscular assessment of people living with SCI uses multiple specialist evaluations. Documentation is important in order to recognize possible neurologic changes and to help stratify urgency of subjective reports of functional decline. A neuralgic change found on exam always requires further assessment.
Assessment of muscle tone
Patients may have flaccidity or spasticity. Spasticity can be assessed and graded using the modified Ashworth Scale:[41]
0: no increase in muscle tone
1: slight increase in muscle tone, with resistance at the end of the range
1+: slight increase in muscle tone, with increased resistance throughout the range
2: marked increase in tone throughout the range
3: increase in muscle tone, passive movement difficult
4: joint rigidly held in flexion or extension.
Spasticity and increased muscle tone is dynamic and can fluctuate. It can lead to joint contractures, loss of function, and increased risk of skin breakdown.
Assessment of muscle strength
The assessment of specific muscles correlates with a specific spinal level. Motor strength of the following muscles is assessed:
Elbow flexors (C5)
Wrist extensors (C6)
Elbow extensors (C7)
Fingertip flexors (C8)
Little-finger abductors (T1)
Hip flexors (L2)
Knee extensors (L3)
Ankle dorsiflexors (L4)
Great-toe extensors (L5)
Ankle plantar flexors (S1).
The motor strength of each muscle group should be scored as follows:
0: no muscle contraction
1: palpable flicker of muscle contraction
2: full range of motion (ROM) with gravity eliminated
3: full ROM against gravity
4: full ROM against resistance, but less than normal strength
5: full ROM and normal strength following added resistance.
Obtaining an accurate score is crucial. The full ROM should be tested. A good approach is to test the full ROM against gravity and either proceed to eliminate gravity if the muscle group is too weak, or apply resistance if there is a full ROM. When testing for a flicker of muscle contraction, gravity should be eliminated in the upper extremities, or the antigravity position used in the lower extremities. If contractures are present that reduce the ROM by >50%, motor strength cannot be accurately assessed; this should be documented. It is important to ensure that the patient is not performing trick movements, which involve using other joints and muscle groups (e.g., extension of the shoulder during testing of elbow extension); if missed, these can lead to an inappropriately high score.
Assessment of sensation
Sensory deficits are produced by involvement of multiple spinal tracts. Pain and temperature are transmitted by the lateral spinothalamic tracts, and light touch by the anterior spinothalamic tract. Proprioception is transmitted by the posterior column. There may be hyperesthesia, hyperalgesia, or numbness.
Light touch and pinprick sensation should be assessed for each dermatome on the left and right, and scored as follows:
0: cannot distinguish if touched or not, on light touch testing; cannot distinguish sharp from blunt ends on pinprick testing.
1: can appreciate if touched on light touch testing, and can distinguish sharp from blunt ends on pinprick testing, but the sensation is diminished compared with the face.
2: can appreciate if touched on light touch testing, and can distinguish sharp from blunt ends on pinprick testing, and the sensation is the same compared with the face.
Sacral sensation and motor function should be assessed to determine whether the injury is complete or incomplete. This is done by assessing voluntary anal contraction, anal tone, and sensation in S4 and S5 dermatomes. If there is an absence of all these sacral elements, the injury is classified as a complete injury. Sacral sparing imparts incomplete injury status.
Assessment of reflexes
In spastic paralysis, the reflexes are brisk and may be associated with clonus. Several pathologic reflexes may also be elicitable. These include Babinski sign (extensor plantar), inverted radial reflex, Hoffman sign (finger flexor), Lhermitte sign, scapulohumeral reflex (indicates a lesion above C4), finger escape sign, and the Oppenheim sign. In flaccid paralysis, the reflexes are absent in the affected extremities. It is again important to document what is “normal” for a patient in order to detect changes in the neurologic exam.
Investigations
Imaging
MRI of the spinal cord should be performed if there is an acute deterioration or new neurologic symptoms.[42]
Electromyography
Electromyography, nerve conduction studies, and somatosensory-evoked potentials can localize the site and type of lesion. Repeat studies can assist in determining if the neurologic status is stable (compared with a baseline obtained 6-12 weeks after the SCI) or if there is any recovery.
Bladder and renal studies
Bladder ultrasound to assess retention and completeness of bladder emptying, and renal ultrasound to detect renal stones, should be performed at least annually, and as needed.[43][44] Invasive assessments that may be considered include a micturition cystourethrogram and urodynamic studies.[43][45]
Bone health
Bone densitometry (DEXA) to assess loss of bone density and response to medical management should be performed every 1-2 years depending on severity of bone loss.[46][47]
Laboratory evaluation
The following should be checked annually as part of health maintenance screening: complete blood count; comprehensive metabolic panel with magnesium, calcium, and phosphorus; liver function panel; lipid panel; hemoglobin A1c; 25-hydroxyvitamin D level.
Metabolic bone markers (e.g., C-telopeptide, osteocalcin, procollagen type 1 N propeptide) may be measured to assess bone turnover.
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