Data detailed are taken from the summary in De Vivo (2007). The ratio of male to female cases is approximately 3:1, with greater male preponderance in young age groups. Spinal cord damage can be traumatic or non-traumatic. The main causes of traumatic injury are shown in Figure 4.1. Gunshots and stabbings also make small but increasing contributions (Harrison, 2000; Whalley Hammell, 1995). A significant number of patients with mental health problems will sustain injury from jumping from a height. The level of injury at the time of discharge from hospital is illustrated in Figure 4.2.

Figure 4.1 Causes of traumatic spinal cord injury. The percentages illustrated were obtained from the references cited in the text.

Figure 4.2 Spinal cord injury level at discharge from hospital. C, cervical; T, thoracic.

The American Spinal Injury Association (ASIA) has produced a classification system for SCI, which is explained below and the classification of injury at discharge is also detailed below (see ‘Diagnosis’).

Non-traumatic aetiology is more common than traumatic. Reported incidence of nontraumatic SCI varies depending on which conditions are included in the study population. Non-traumatic most commonly result from degenerative disc disease and spinal canal stenosis, developmental anomalies (e.g. spina bifida) and congenital anomalies (e.g. angiomatous malformations); inflammation (e.g. multiple sclerosis); ischaemia (e.g. cord stroke); pressure on the cord due to expanding lesions (e.g. abcess or tumour extrinsic or intrinsic to the spinal cord) (New & Sundrajan, 2008). Each condition has distinct management needs and features. Their management will benefit from the knowledge and skills derived from an understanding of traumatic SCI, which is the focus of this chapter.

Terminology

Terms used to describe these patients indicate the general level of the spinal injury listing body functions and structure and a list of domains of activity and participation (International Classification of Functioning, Disability and Health; World Health Organization, 2001).

Paraplegia

Paraplegia refers to the impairment or loss of motor, sensory and/or autonomic function in thoracic, lumbar or sacral segments of the spinal cord. Upper-limb function is spared but the trunk, legs and pelvic organs may be involved.

Tetraplegia

Tetraplegic patients have impairment or loss of motor, sensory and/or autonomic function in cervical segments of the spinal cord. The upper-limbs are affected as well as the trunk, legs and pelvic organs. In high cervical injuries the function of respiration will be affected. The term does not include the brachial plexus or injury to peripheral nerves. ‘Quadraparesis’ and ‘paraparesis’ were terms used previously to describe incomplete lesions and are now discouraged.

Types of spinal cord injury

SCI damages a complex neural network involved in transmitting, modifying and coordinating motor, sensory and autonomic control of organ systems. This dysfunction of the spinal cord causes variable loss of homeostatic and adaptive mechanisms which keep people naturally healthy. Any damage to the spinal cord results in deficits that can only be partly predicted, as described below. The pathology of the cord will influence the presenting impairment and the resulting prognosis. It can be precisely correlated with the neurological picture because of the segmental nature of the spinal cord (Kakulas, 2004). Complete transection of the cord is uncommon. It is useful to note that whilst the incidence of SCI in the population as a whole has largely remained the same, the overall prevelence is increasing. There are an increasing number of older people with SCI, reflecting the increasing ageing of the general population, in addition there are more people surviving with SCI into old age (Box 4.1 & Box 4.2).

Box 4.1 Trends

• Increasing age at time of incidence onset

• Increasing survival of those with high tetraplegia

• Falls increasing as a percentage of the overall aetiology due to the increase in ageing population

Box 4.2 Basic facts and figures

(Data from De Vivo, 2007.)

• Mean age 37 years

• 13% over 60 years old

• Small increase in percentage of females over last 10 years

Over the years there has been a significant reduction in mortality and preservation of neurology in new lesions (Grundy & Swain, 2002; Whalley Hammell, 1995). There are many reasons accounting for this, including:

• changes in vehicle design and usage, as well as greater public knowledge and awareness of the dangers of moving an injured person

• improved medical interventions: broad-spectrum antibiotics, neuroprotective agents and advances in respiratory care

• better paramedical retrieval: improved accident and emergency resuscitation procedures and medical interventions to maintain blood pressure and oxygenation.

A previous trend towards increasing incomplete lesions has now lessened. Recent incidence at time of injury has moved closer to equal numbers of incomplete and complete lesions. It is suggested that people with the more serious injuries are surviving, including a higher number of long-term ventilator-dependant patients. It is thought that the accumulative benefits of improved advanced life support and early interventions have now become fully established. It appears that there are no further influences currently increasing the trend towards an incomplete presentation, although the outcomes of new early restorative interventions will be eagerly awaited. There is a significant trend in the reduction in length of stay in the American Model Managed Care Systems, which also reflects a lower Functional Independence Measure (FIM) score at time of discharge and an increase in complications during the first year post discharge (De Vivo, 2007).

Pathogenesis

A brief outline of the pathological changes that occur with SCI is now given; further details can be found in other texts such as Tator (1998).

Immediate/primary damage

Most traumatic injuries involve contusion or tearing of the underlying cord by displaced bony fragments, disc or ligaments. This results primarily in loss of axons due to damage of the white matter.

Secondary damage

Secondary damage, particularly loss of cells in the grey matter, results from a secondary process comprising changes in the cell membrane permeability, leakage of cell contents, release of chemical factors and arrival of blood cells and agents involved in the response to injury and subsequent repair. This process leads to swelling and increasing cord pressure, affecting the venous and arterial supply, and results in ischaemia, lack of necessary proteins and failure to remove the debris of injury.

Later problems

After some weeks, there is evidence of astroglial scarring with cyst formation producing distorted neural architecture. In some cases, months or years later, a syrinx, an expanding cavity within the spinal cord probably associated with disordered cerebrospinal fluid (CSF) flow, may extend rostrally to produce further spinal cord damage. This posttraumatic syringomyelia may require drainage by shunt to prevent further extension. In view of this possibility, the neurological status should be reassessed periodically (Illis, 1988) and appropriate magnetic resonance imaging (MRI) scanning performed at intervals to minimize further neurological loss.

Spinal cord plasticity

When peripheral nerve is damaged, repair can lead to significant return of function (Battiston et al., 2009; Dahlin, 2008). It has been demonstrated that the central nervous system (CNS) has the capacity to regenerate and recover. It has similarly been hypothesized that there is capacity within the spinal cord to regenerate through a number of mechanisms. Research is ongoing to identify axonal budding, unmasking and interspinal spinal circuits (central pattern generators). For further reading on neuroplasticity see Chapter 11, Adkins et al. (2006), Kleim (2009), and Schwartz and Begley (2003). A summary of research aiming to establish new treatments in the management of spinal cord damage is discussed briefly below.

Treatment approaches in immediate post-injury management

There are four main approaches currently being considered to develop treatments for SCI (Ronsyn et al., 2008):

1. Cell and tissue culture and transplantation, which includes adult and embryonic stem cells, schwann cells and olfactory ensheathing cells

2. Production and provision of nerve growth stimulating factors

3. Elimination of blocking factors which inhibit neuro-regeneration

4. Techniques aimed at modifying the inflammatory response, minimizing neuronal death and scar formation.

Understanding axonal guidance systems that will be required for directed outgrowth and functional reconnection will be essential if useful functional activity is to be regained. Although much progress has been made in the laboratory setting, no techniques applied to humans, despite having been through well researched trials (Fawcett et al., 2007; Lammertse et al., 2007; Steeves et al., 2007; Tuszynski et al., 2007) have yet to emerge showing any consistent results (Johnston, 2001; Ramer et al., 2000; Ronsyn et al., 2008; Tator, 1998).Claims for successful regeneration of the chronically injured spinal cord through late repair, remain contentious. Most studies lack robust pre- and post-intervention measures with many appearing to rely on associated intensive rehabilitation to demonstrate small functional improvements.

Diagnosis

Incomplete versus complete injury classification

It is important to clarify these terms, depending on the context in which they are used. From a therapeutic point of view, a patient can be called functionally incomplete when he or she presents with some motor or sensory sparing below the level of the cord lesion. The therapist should acknowledge such sparing as potential activity, which may offer important functional benefits to the patient.

ASIA Impairment Scale

In terms of diagnosis and prognosis, the classification of SCI has important ramifications. The ASIA Impairment Scale (ASIA, 2008) is the latest updated criteria for assessing and classifying functional levels of SCI, including the definitions of complete and incomplete lesions. The assessment is completed with the patient in supine, to enable testing in the acutely unstable injured person. The assessment comprises of 10 key myotomes and 28 dermatomes (Figure 4.3). Each dermatome is tested for light touch and pin prick sensation. The full description for these classifications will not be detailed here and it is available at www.asia-spinalinjury.org, with the impairment scale and classification outlined in Figure 4.4.

Figure 4.3 The American Spinal Injury Association (ASIA) Dermatome Chart and Impairment Scale.

American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, reprint 2008; Chicage, Il. Reprinted with permission.

Figure 4.4 ASIA classification guide.

American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, reprint 2008; Chicage, Il. Reprinted with permission.

The ASIA system defines that a patient can have neurological sparing below the injury level, but in the absence of the sacral sparing, this is classified as a complete lesion, ASIA A, with zones of partial preservation. Where there is sensory preservation of S4–S5, the patient is classified sensory incomplete, ASIA B. This implies the preservation of the long tracts through the lesion. The classification of incomplete versus complete lesions indicates the presence of sensation in the lower sacral segments S4-S5, which implies significant prognostic indication of potential for neurological improvement. To be classified ASIA C, the patient must be assessed to have preserved S4-S5 sensation and voluntary anal sphincter motor activity. If the voluntary anal activity is absent then there must be preservation of motor function in some muscles innervated more than three levels below the motor classification level. In addition, more than half the key muscles below the neurological level must be grade 1-2/5. Similarly if half the key muscles are grade 3-5/5 then the classification will be ASIA D. The classification of SCI on discharge from hospital is shown in Figure 4.5.

Figure 4.5 American Spinal Injury Association (ASIA) classification at discharge from hospital.

American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, reprint 2008; Chicage, Il. Reprinted with permission.

From a prognostic point of view, research suggests that 72 hours post injury (Brown, 1994; Maynard et al., 1979), and 1 month post injury are good time points for this classification (Waters et al., 1994a, 1994b). Further assessment is advised at 3 months post injury. All patients are assessed immediately on hospital admission, to gain baseline data. The wealth of prognostic statistics is based on data obtained using these time periods.

Incomplete lesions and prognostic indicators

There are recognized patterns of incomplete cord injury which tend to present clinically as combinations of syndromes rather than in isolation. The signs and symptoms are related to the anatomical areas of the cord affected (Figures 4.6 & 4.7). Clinically, patterns of incomplete lesions are referred to as a syndrome.

Figure 4.6 Cross-section of the spinal cord illustrating the main ascending and descending nerve tracts. The functions affected by damage to these tracts are indicated.

Figure 4.7 Spinal column with spinal nerve levels.

Recent statistics show the common patterns of incomplete lesions to be the following:

• Central cord syndrome (44%)

• Cauda equina (25%)

• Brown–Séquard syndrome (17%)

• Anterior cord syndrome around 10%

• Pure posterior cord syndrome being very rare

(McKinley et al., 2007).

Prognosis

Recovery of the incomplete spinal cord injury

It is essential to refer to the evidence of ongoing recovery in SCI and to bear this in mind when treating these patients. Recovery will be at the forefront of a patient’s mind when participating in rehabilitation.

Ninety per cent of incomplete SCI patients have some recovery of a motor level in their upper-limbs, compared to 70–85% of the complete injuries (Ditunno et al., 2000). Pinprick sparing in a dermatome is an excellent indicator of increased recovery of motor strength (Poynton et al., 1997) and it has been found that pinprick preservation below the level of the injury to the sacral dermatomes is the best indicator of useful recovery, with 75% of patients regaining the ability to walk. Fifty per cent of patients who had no sacral sparing regained some motor recovery but not of functional use (Katoh & El Masry, 1995).

Studies have found that incomplete SCI patients showed ongoing improvement in their motor activity, although this tended to slow during the second year post injury, with the exception of incomplete tetraplegics who lacked sharp/blunt discrimination and failed to demonstrate any lower-limb motor recovery. In incomplete paraplegics, there was evidence of 85% of the muscles recovering from a flicker to an antigravity grade within the first year, but if there was no activity initially, only 26% gained an antigravity grade (Waters et al., 1994a, 1994b).

It is widely accepted that incomplete SCI patients will only make useful recovery within the first 2 years post injury, but from the authors’ experiential observation, recovery can continue to occur slowly for at least 5 years or more, particularly in incomplete tetraplegics.

Ambulation recovery

Between 44 and 76% of people with incomplete SCI, with preserved sensation but no motor function, have been reported to achieve ambulation (Maynard et al., 1979; Waters et al., 1994a, 1994b).

Crozier et al. (1991) reported, using ASIA assessment at 72 hours, that 89% of ASIA B–E patients with pinprick preservation went on to ambulate, compared with 11% having preserved light touch but not pinprick.

• The theory behind the significance of sacral preservation is the proximity of the spinothalamic tracts that mediate pinprick to the lateral corticospinal tracts and their shared blood supply. At 1 year post injury, 76% incomplete paraplegics (ASIA B–E) become community ambulators by 2 years, compared to 46% of incomplete tetraplegics who ambulate, probably due to upper-extremity weakness compromising the ability to perform gait (Waters et al., 1994a, 1994b). Age is a significant factor in indication of outcome (Burns & Ditunno, 2001; Ditunno et al., 1994).

Summary of changes in ASIA impairment scale from admission to discharge

• From the number of patients assessed at the time of injury found to be classified as an ASIA A, 8.5 /10 remain ASIA A at time of discharge.

• From the same ASIA A group, only 2 /100 go on to become a functional ASIA D.

• From the group of ASIA B patients, 40 /100 become ASIA C.

• From the group of ASIA C patients, more than 60 /100 become grade D.

• From the group of ASIA B patients, 20 /100 remain grade B but 1 in 5 become grade D at time of discharge

(De Vivo, 2007).

Acute general management

Although the primary damage is to the spinal cord, every organ system can be affected. Antecedent and posttraumatic psychological and social conditions must also be given full consideration as they play their inevitable parts in the success or failure of rehabilitation. Acute and rehabilitation specialties and disciplines are necessary to provide a holistic approach, in which all team members work towards common goals, agreed between the patient and team.

Trauma management

SCI presentation remains a key issue for all professionals, who should be vigilant about the risks of activities in which they may be involved, such as on rugby fields or at swimming pools.

Immediate management

When an accident occurs involving a SCI, other injuries should be suspected and the incident history recorded; pain, bruising and/or palpable spinal deformity are likely features. This is a crucial time for appropriate management to ensure the best chances possible for survival of the spinal cord fibres.

Proper handling will avoid unnecessary further damage, and the following simple advice can be immensely valuable:

• The patient should be advised not to move.

• The airway and breathing should be checked.

• If removal to another site is necessary, the transfer should be gentle, avoiding any twisting. Lifting should be performed by at least four people, with one acting as leader to coordinate the team.

• The patient should be placed in a supine position with the head and body kept strictly in alignment.

• If unconscious, the patient should be strapped to, and supported on, a board to allow tilt and avoid aspiration.

• Normal spinal curvature should be supported by a rolled-up cloth.

• The skin should be protected from pressure and ulceration by removing objects from pockets or by removing clothes.

• Point pressure from heels on hard surfaces, or ‘knocking knees’, should be avoided.

• Various spinal immobilization boards, e.g. the scoop stretcher, and collars are available in ambulances for moving patients.

• Maintenance of oxygenation and blood pressure is essential.

• If possible, a motor and sensory charting should be performed for a baseline neuroassessment with diagrammatic recording.

Continuity of care

It is crucially important that continuity it maintained from site of injury, immediate first aid through ambulance/helicopter retrieval, to A&E/trauma unit, resusitation, investigation and stabilization, with appropriate surgical/non-surgical interventions, then onto admission to specialist continuing care.

Admission to hospital

Currently in the UK, after sustaining an SCI the person is admitted to the local A&E or trauma unit. A full physical and neurological assessment is carried out and a decision is made about referral to a specialist unit. Spinal imaging can provide reliable evidence of stability (X-ray, MRI and/or computed tomography (CT)). The decision for management (conservative or surgical) is made after the appropriate diagnostic testing.

Summary of immediate management

• Immobilization

• Advanced trauma life support

• Decompressive and stabilizing surgery if necessary

• Recent introduction of membrane-stabilizing agents and neuroprotective agents, including steroids. Naloxone and Tirilazad have been investigated. Most recently, ganglioside GM-1 has appeared to be partly helpful, but none have yet achieved the outcome hoped for (McDonald et al., 2002).

Acute hospital management

Acute trauma management guidelines are well established (Moore et al., 1991). Management of the patient with an SCI has special features resulting from spinal cord shock. Full details are described by Grundy and Swain (2002).

Breathing

Paralysis of respiratory muscles may be a feature. Patients with acute cervical cord injuries can fatigue in their breathing. Pulse oximetry is a crude indicator of respiratory distress because it measures only haemoglobin saturation and not partial pressure of oxygen (Po₂) (Hough, 2001). Any evidence of desaturation or of falling saturation should be proactively addressed by the critical care team to maintain oxygenation and prevent further cord damage. Monitoring patients’ breathing rate, pattern and colour, and noting agitation, drowsiness or distressed behaviour, is vital. Arterial blood-gas analysis may be the critical factor in deciding whether to provide ventilatory support. Respiratory failure remains one of the main causes of death in acute tetraplegia, whilst pneumonia is the leading cause of death in all persons with SCI (Jackson et al., 1994). The principles of respiratory management are covered in Chapter 15.

Circulation

The sympathetic nerve supply to the heart is via cervical, cervical thoracic and upper thoracic branches of the sympathetic trunk. Cervical and upper thoracic injuries may produce sympathetic disruption, with impairment of tachycardia response. Therefore, pulse rate may mislead in the presence of circulatory shock. There is skin vasodilation within the dermatomes caudal to the injury. This causes a lowering of blood pressure. Injudicious fluid replacement to augment the blood pressure can cause pulmonary oedema. Pharyngeal suction, urethral catheterization or simply repositioning of the patient can produce vagal overstimulation and lead to bradycardia; intravenous atropine may be required to restore normal heart rate. Tetraplegic patients are unable to maintain their body temperature due to the autonomic disruption, resulting in them taking up the surrounding temperature. This is known as a poikilothermic reaction.

Spinal cord shock

This is the phenomenon of cessation of nervous system function below the level of damage to the cord and may be due to the loss of descending neural influences. It is usually expected that after several seconds to months, the flaccid paralysis and areflexia of spinal shock are replaced by hyperexcitability, seen clinically as hyperreflexia, spasticity and spasms. More recently this has been identified as a critical period when the timing of potential interventions can influence recovering neurological systems. Studies have shown that there is competetive synaptic growth into the synaptic spaces that have been vacated. These transient vacant sites become open to repopulation by spared axons. It is at this moment that interventions should ideally target synapse growth mediating voluntary movement rather than local segmental neurons mediating spasticity and hyperreflexia (Ditunno et al., 2004; McDonald et al., 2002).

Stauffer (1983) noted that it is rare to see patients in total spinal shock and totally areflexic. Strong spasticity almost immediately post injury is indicative of an incomplete SCI. In these patients assessment of voluntary movement requires careful differentiation. In the authors’ experience, development of increased muscle tone and involuntary movements may mislead patients to believe they have functional return of activity. It is important for the therapist to anticipate such reactions and to assess carefully in order to avoid confusion and disappointment.

Skin care

Denervated skin is at risk from pressure damage within 20–30 minutes of injury. If this occurs, it can cause distress and delay in the rehabilitation process. Clinical staff attending should be vigilant in monitoring the skin and should report red marks.

Gastrointestinal tract

SCI can produce ileus and gastric distension that can restrict movement of the diaphragm, further compromising breathing. A nasogastric tube should be placed for decompression if bowel sounds are absent. Gastric stress ulcers can occur and prophylactic treatment with mucosal protectors is recommended.

Bladder

Spinal shock causes retention of urine; the bladder should, therefore, be catheterized routinely in order to monitor fluid output and to protect it from overdistension damage.

Spinal stabilization versus conservative management

Spinal fractures may be classified as stable, unstable or quasistable (i.e. currently stable but likely to become unstable in the course of everyday activity). Disagreement continues between protagonists and antagonists of surgical stabilization of the spine, but surgery is increasingly used (Collins, 1995).

Definition of instability or stability of a spinal lesion has now achieved substantial agreement based on the three column principles (Dennis, 1983). There is general agreement that restoration of the anatomy of the canal is sensible in terms of giving the cord the best opportunity for recovery.

It is debated whether neurological recovery or degree of spinal stability in the long term differs with surgical or conservative management. Surgery aims to minimize neurological deterioration, restore alignment and stabilization, facilitate early mobilization, reduce pain, minimize hospital stay and prevent secondary complications (Johnston, 2001). Review of evidence over the last decade does not identify any specific timing or role for early surgical decompression. Surgical intervention within the first 72 hours after injury has been shown to be safe and a role for urgent decompression has been identified in certain circumstances and may improve neurological outcomes (Fehlings & Perrin, 2006).

From a physiotherapy and psychological point of view, the ability to mobilize a patient against gravity early seems to be a desirable outcome from surgery. This can be achieved by 7–10 days after surgery and results in a shorter inpatient stay.

Management of acute lesions at T4 and above

Surgical stabilization may be achieved by anterior or posterior fixation, or a combination of the two (e.g. Collins, 1995). Patients managed conservatively are immobilized with bed rest; depending on the degree of instability, they may have to be maintained in spinal alignment by skull traction. Traction is applied usually by halo traction, Gardner–Wells or cone calipers (Grundy & Swain, 2002).

Early mobilization may be indicated and can be achieved using a halo brace (Hossain et al., 2004). Care in handling and positioning during physiotherapy is discussed below (see ‘Acute physical management’).

Length of immobilization will vary depending on the extent of bony injury and ligamentous instability, in addition to whether surgery has been performed. There may be several spinal segments affected and this will also influence the length of bed rest. Multiple-level fractures in the cervical spine are usually treated conservatively by halo traction and a period of immobilization in a hard collar. Bed rest is usually for 3 months. On starting mobilization, patients with all levels of injury will usually wear a collar of some type, depending on their stability.

Management of acute lesions at T4 and below

Thoracolumbar fractures are most common at the L1 level, this being the level of greatest mobility. Patients with unstable lesions at T9 and below must not have their hips flexed greater than 30° in order to avoid lumbar flexion (CSP, 1997).

Stable wedge fractures are usually treated conservatively with a brace or plaster of Paris (or similar) jacket. Unstable burst fractures, with cord compression, will justify surgical decompression and fixation. Generally, an anterior and posterior fixation technique will require a brace to be worn for 3 months postoperatively. If the spine is stable anteriorly, it may be sufficient to stabilize posteriorly. In this situation, a brace will be recommended for 6 months.

Bracing techniques vary greatly between institutions. A moulded hard plastic (subortholen) jacket can be made from an individual casting of plaster. Many braces are commercially available ‘off the shelf’ or other materials are used to form a brace, e.g. leather jackets.

Special problems in spinal cord injury

Osteoporosis

Osteoporosis is a loss in bone mass without any alteration of the ratio between mineral and the organic matrix. A text by (Jiang et al., 2006) provides a comprehensive overview of osteoporosis. It is thought that immobilization for long periods and a sedentary life lead to an increase in bone reabsorption, thus causing osteoporosis.

Rapid loss of bone minerals occurs during the first 4 months following SCI. A range of data available from studies include: at 1 year bone mass density reduces in the femoral neck by 27%, mid femoral shaft by 25% and distal femur by 43%. The reduction continues in the pelvis and lower limbs over the 10 years after injury and can reduce by 50%. Tetraplegics can lose up to 16% on their bone mass density in their upper limbs. The osteoporosis may cause fractures of long bones during relatively simple manoeuvres, such as transfer or passive movements (Belanger et al., 2000). The rate of incidence of fractures has been documented to be 1% in the first year post injury, 1.3% per year at 1–9 years, 3.4% per year at 10–19 years, 4.6% per year at 20–29 years (Jiang et al., 2006).

It has been shown that early mobilization with weight bearing might prevent or slow bone-mineral loss (De Bruin et al., 1999). Bone mineral density can be preserved in bones below the level of the lesion (Frey-Rindova et al., 2000). The question is frequently asked whether a patient who has not stood for several years should recommence standing. There is a variety of opinion on how to proceed, either returning straight to standing or commencing a weight-bearing programme using a tilt table, usually combined with bone-enhancing agents, and monitoring using bone densitometry, before returning to standing in a frame. Such advice is empirical and, as yet, despite many studies, no clear guidance has been produced.

Heterotopic ossification

Calcification in denervated or UMN-disordered muscle remains an ill-understood process and commonly occurs in patients with SCI (David et al., 1993). It may be confused in the early stages with deep venous thrombosis, when it presents as swelling, alteration in skin colour and increased heat, usually in relation to a joint. During the active process, analysis of plasma biochemistry shows a raised alkaline phosphatase. It can result in loss of range of movement (ROM) and difficulty in sitting. If ossification occurs around the hips it may lead to further skin pressure problems. Treatment of this condition is discussed by David et al. (1993). It must be emphasized that stretching should be gentle, as overstretching may be a predisposing factor for this condition.

The bladder

Urological complications of SCI are major mortal and morbid risks and the reader is referred to Fowler and Fowler (1993) for a review. Spinal cord damage disrupts the neural controls of bladder function. The objectives of bladder management are to provide a system ensuring safety, continence and least social disruption.

In the acute stage the bladder is catheterized to allow free drainage, to accommodate any fluid input and output fluctuations and to avoid bladder distension. Intermittent catheterization is then established. After spinal shock passes, urodynamic studies are used to identify the emergent bladder behaviour.

Anterior sacral root electrical stimulation may be used, primarily for controlling urinary voiding, but it may also facilitate defecation and penile erection separately. Reflex micturition (by tapping the abdominal wall or stroking the medial thigh) is not favoured because the bladder is unprotected from hyperreflexic complications.

The bowel

Although morbid complications rarely arise in the bowel, social embarrassment is common and often perceived by patients as more devastating than limb paralysis. Laxatives can achieve a bowel frequency within the normal range. For intractable constipation, occasional enemas can be useful. Increasing use of anterior sacral root stimulators and other surgical techniques may be beneficial. The mainstay of bowel care is to produce a predictable pattern, to minimize incontinence, impaction and interference with activities of daily living.

Fertility

Fertility is usually maintained in women, with the ovulatory cycle being normal within 9 months after injury. Fertility in men is, however, a problem (Brindley, 1984). Improvements in fertility rates for men after SCI have been made due to several important technical advances. These include improved methods in the retrieval and enhancement of sperm, such as electroejaculation, and improved means of achieving fertilization with limited sperm quality and numbers through in vitro techniques.