Medical Complications of Spinal Cord Injury: Bone, Metabolic, Pressure Ulcers, and Sexuality and Fertility


Stage

Description

Stage 1

Nonblanchable erythema of intact skin

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury

Stage 2

Partialthickness skin loss with exposed dermis

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions)

Stage 3

Fullthickness skin loss

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue, and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury

Stage 4

Fullthickness skin and tissue loss

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury

Unstageable

Obscured fullthickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed

Deep tissue injury

Persistent nonblanchable deep red, maroon, or purple discoloration

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, stage 3 or stage 4). Do not use deep tissue pressure injury (DTPI) to describe vascular, traumatic, neuropathic, or dermatologic conditions

Medical device-related pressure injury

This describes an etiology

Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system

Mucosal membrane pressure injury

Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these injuries cannot be staged




  1. 1.


    The term pressure injury replaced pressure ulcer. This change was felt to more accurately describe pressure injuries to both intact and ulcerated skin. In the previous staging system, stage 1 and deep tissue injury described injured intact skin, while the other stages described open ulcers. This reportedly led to confusion because the definitions for each of the stages referred to the injuries as pressure ulcers.

     

  2. 2.


    Arabic numbers are now used in the names of the stages instead of Roman numerals.

     

  3. 3.


    The term suspected has been removed from the deep tissue injury diagnostic label.

     

  4. 4.


    Additional pressure injury definitions agreed upon at the meeting included medical device-related pressure injury and mucosal membrane pressure injury.

     




18.4.3 Pressure Injury Prevention


A comprehensive educational program for SCI patients and their family/caregivers is essential, including information on etiology, risk factors, proper positioning, equipment (e.g., cushions), complications, and principles of wound prevention, skin care, treatment, and when to seek medical attention. Prevention recommendations include examining the skin over bony prominences at least daily with the use of a mirror as needed, shifting body weight in bed and wheelchair on a regular basis, keeping the skin clean and dry if there is incontinence, having an individually prescribed wheelchair and pressure redistribution cushion or power tilt/recline mechanism, ensuring all equipment is maintained and functioning properly, nutritionally complete diet and maintaining appropriate body weight, stopping smoking, and limiting alcohol intake [134, 146].

Since pressure injuries occur over bony prominences, the site of injury development depends upon the position. When sitting, the ischial tuberosities (ITs) are at greatest risk; while in side lying, the greater trochanters become at risk; and in the supine position, the sacrum, heels, and occiput (especially in infants) are at risk for PI development. Accordingly, the most common sites of PIs after SCI change based on the amount of time spent in a given position. Acutely after injury, the most common sites are the sacrum, followed by the heels and ischium. At 1 year, the most common sites are the sacrum, ischium, heels, and trochanters and, at year two post-injury, the ischium, sacrum, and trochanters. When in bed, an appropriate mattress should be sought. Pillows can be used to provide additional padding or provide pressure reduction over bony prominences. Most commonly prescribed early after injury is a turn frequency in bed every 2 h. Once discharged, it is common to extend the 2 h turn schedule although there is no documented protocol for this. The prone position has a large surface area of low pressure and is recommended in the chronic patients as tolerated.

Weight shifting, redistributing the pressure off of the IT to other areas to allow for reperfusion of the ischial areas, is extremely important when the patient is seated in the wheelchair and can be performed by the patient via a number of techniques including an anterior, lateral, or push-up weight shift. If the patient is unable to perform their own weight shift, a caregiver can assist or tilt the chair posteriorly so that the patient’s weight is no longer on their IT.

While there is no absolute regarding the frequency and duration required for weight shifting while in the wheelchair, it is recommended that weight shifts be performed every ~15 min for >2 min to allow for adequate tissue reperfusion [147149]. A weight shift in a tilt-in-space wheelchair should be >35° when combined with recline at 100°, or >25° when combined with recline at 120° [150]. This degree of tilt does not seem to increase pressure significantly over the sacrum [149]. When performing a tilt weight shift without any recline mechanism, a minimum of 45° is required for adequate pressure distribution [151].

Cushion selection is extremely important. No one cushion is suitable for all individuals with SCI, and prescription should be based on a combination of pressure mapping results, clinical knowledge of the prescriber, and patient preferences.


18.4.4 Treatment


The general principles of PI treatment are to relieve pressure; eliminate reversible underlying predisposing conditions; avoid friction, shear, and tissue maceration; keep the wound bed moist; manage excessive drainage; and debride devitalized tissue [134, 152] (Table 18.2). In general, stage 1 and 2 PIs are usually treated with local care nonsurgically. Stage 3 and 4 PIs, because of their high rate of recurrence as well as the long duration necessary for wound closure, often require surgical intervention. Involvement of a wound care team early after a pressure ulcer (especially grade 3 and 4) has developed is important.


Table 18.2
Treatment principles































1. Assess and document wound (size, stage, wound bed appearance, wound edges, exudates, necrosis, odor, signs of infection, surrounding skin, undermining, sinus formation, tunneling, and degree of granulation tissue epithelialization)

2. Eliminate direct pressure over the pressure injury through positioning techniques and appropriate support surfaces. Limit time in chair if pressure injury is on the ischial tuberosities

3. Observe and document wound healing progress

4. Avoid antiseptics (povidone-iodine, H2O2, etc.) and cleansers with nontoxic dilutions

5. Keep periwound skin dry, control exudates, and eliminate dead space

6. Use dressings that keep pressure injury bed moist to allow for optimal cell migration, proliferation, and revascularization

7. Clean wound at every dressing change using minimal mechanical force

8. Create optimum wound environment by using modern dressings (hydrocolloids, hydrogels, foams, alginates, soft silicone) rather than gauze

9. Consider adjunctive therapies (i.e., electrical stimulation, negative-pressure wound therapy, etc.) to enhance healing for appropriate wounds

10. Consider a 2-week trial of topical antibiotics (neomycin, bacitracin, or polymyxin B) for clean, nonhealing injuries

11. Consider an infection if nonhealing wound (see below), and if so, manage with wound cleansing, systemic antibiotics, and debridement after diagnosis is made

12. Ensure adequate nutritional intake

13. Remove necrotic tissue by techniques that may include mechanical, autolytic (applying a moisture-retentive dressings, such as a hydrocolloid, or the use of hydrogels to moisturize the devitalized tissue), enzymatic (e.g., use of collagenase), biologic (use of sterilized eggs of Lucilia sericata commonly known as maggot therapy), pulsatile high-pressure lavage, or conservative sharp or surgical debridement

Silver, available in multiple forms (gel, cream of foam), is a nonselective broad-spectrum topical agent that covers gram-positive and gram-negative microorganisms in the management of colonized and locally infected wounds [153]. Silver-impregnated dressings are contraindicated in neonates, in pregnancy, in patients with significant renal or hepatic impairment, and in those with sensitivity to sulfonamides or large open wounds [154].

Systemic antibiotics are generally only warranted when there is bacteremia, sepsis, advancing cellulitis, or osteomyelitis. Swab cultures are not useful in determining the presence of infection of PIs and only reflect the bacteria on the surface of the ulcer. Tissue biopsy can determine if there are bacteria within the tissue, and if the bacterial count is greater than 105, wound healing may be impaired. Advancing cellulitis is indicative of invasive tissue infection and must be treated with appropriate antibiotics.

Approximately 25 % of nonhealing PIs have underlying osteomyelitis, and this should be ruled out if there is reasonable suspicion. Bone biopsy remains the definitive method to diagnose osteomyelitis and identifies the organism, although surgeons are often reluctant to perform this unless there are other compelling indications for surgery. The most common organisms isolated from PIs are Proteus mirabilis, group D streptococci, E. coli, Staphylococcus, Pseudomonas species, and Corynebacterium organisms. Conventional bone scan is more sensitive for osteomyelitis than plain films, although specificity is approximately 50 % because of difficulty differentiating soft tissue infection from bone infection. Indium leukocyte scans improve the sensitivity and specificity. MRI has greater sensitivity and specificity. Treatment of osteomyelitis includes appropriate antibiotics for 6–12 weeks.

While there are numerous adjunctive therapies, only electrical stimulation has merited recommendation and can be considered for clean stage 2, 3, and 4 injuries that are unresponsive to conventional therapy. Electrical stimulation accelerates the healing rate of ulcers when combined with standard wound management [144]. The therapeutic efficacy of hyperbaric oxygen; infrared, ultraviolet, and low-energy laser irradiation; and ultrasonography has not been sufficiently established for recommendation. Ultrasound/ultraviolet C can be considered as an adjunct treatment when PIs are not healing with standard wound care post-SCI.

Platelet-derived growth factors (PDGF) can be applied directly to the wound surface to promote growth of skin, soft tissue, and blood vessels. Becaplermin (Regranex), a commercially prepared biotechnology product with recombinant PDGF as the active ingredient, in conjunction with good wound care, is efficacious in accelerating wound closure of chronic diabetic ulcers [155, 156]. This product, however, carries a warning indicating that patients who use in excess of three tubes may experience increased mortality due to malignancy.

Negative-pressure wound therapy (NPWT) distributes negative (subatmospheric) pressure across a wound surface to promote healing in clean stage III and IV wounds. An airtight system is created using special foam, sterile tubing and canister, and an adhesive film drape. The negative pressure in the wound bed increases blood flow, reduces local tissue edema, decreases bacterial colonization, and increases granulation tissue formation and mechanical wound closure [144]. It is contraindicated on wounds with exposed vital structures, necrotic material, and significant purulence or if it leads to bleeding complications.


18.4.5 Surgical Management


Proper selection of the surgical candidate is important because of the cost and postoperative recovery time, both of which can be extensive. In addition, if musculocutaneous flaps are performed, there are only a limited number that can be performed, which may be of consequence if the individual has repeated PIs.

Musculocutaneous and fasciocutaneous flaps are the procedure of choice for SCI patients who require surgical closure of the pressure injury. Because of their blood supply, these flaps are better able to withstand pressure and shear and can be particularly useful in osteomyelitis, by bringing highly vascularized muscle tissue into the area of infection. The decision to use a particular flap or type depends on the surgeons’ expertise and the size and location of the injury. It is important to approach issues that impair postoperative healing that include smoking, spasticity, nutritional concerns, and bacterial colonization (contamination from urine and feces). If there is a great deal of stool incontinence interfering with the wound, or suspected to interfere with postoperative healing of pressure injuries over the sacrum and ischial tuberosities, a temporary diverting colostomy may be considered, although most pressure injuries heal postoperatively without such procedures [157].

At the sacral area, the gluteus maximus muscle may be used entirely or in portions. At the ischium, a posterior thigh fasciocutaneous flap, inferior gluteus maximus myocutaneous flap, hamstring V-Y advancement flap, and tensor fascia lata fasciocutaneous flap can all be used to cover defects in this region. Prophylactic unilateral or bilateral ischiectomy is not recommended. At the greater trochanter, the tensor fascia lata fasciocutaneous flap is considered the flap of choice, although alternatives include the use of the vastus lateralis, inferior gluteus maximus, and rectus femoris muscles.

Postoperatively, strict bed rest is prescribed on a low-air-loss mattress or an air-fluidized bed, maintaining pressure off the surgical site as much as possible. For repairs of the sacrum or IT, the head of the bed should not be elevated greater than 15° since this position increases the risk of shear on the repaired ulcer site. There is no consensus in the literature on the necessary length of immobilization post-flap, which varies based on the size of the flap as well as the individual protocols and ranges from 2–6 weeks. Once healing occurs, passive range of motion (ROM) of the hips in preparation for sitting can be initiated. Once the hip ROM is at 90° without stress on the surgical site, sitting is initiated in short intervals, i.e., 15 min, and then with return to bed for evaluation of the surgical site. A progressive sitting program ensues, with an increase in sitting by 15 min once to twice per day. While institutional protocols vary, usually over a course of 2–3 weeks, the patient can progress to sitting up to 5 h/day completing the full protocol up to 8½ weeks [158]. Postoperative complications are common. In a recent study of post-flap complications, they found that the overall rate was 21 %, with suture dehiscence as the most common (31 %) followed by infection (25 %) [159].

Pressure injury recurrence is common and most frequently recurs at the ischial tuberosities. Smoking, diabetes mellitus, and cardiovascular disease are associated with the highest rates of recurrence.



18.5 Sexuality and Fertility in SCI


While men and women remain interested in sexual activity after SCI, their level of desire and frequency of activity decreases [160]. Regaining sexual function is extremely important and is an area of unmet need for persons with SCI [160162]. It is reported to be the highest priority among individuals with paraplegia and the second highest priority, after regaining arm and hand function, among individuals with tetraplegia [161]. As such, knowledge of this topic and discussion with patients at the appropriate time are extremely important.


18.5.1 Erectile Dysfunction in Men with SCI


The degree of dysfunction depends upon the level and severity of the SCI. A man with an upper motor neuron (UMN) lesion will typically have preserved reflexogenic erections, with minimal capacity for psychogenic erections. Greater than 90 % of men with complete and incomplete UMN lesions can achieve reflexogenic erections, while <10 % of men with complete UMN injuries and ~ 50 % of those with an incomplete UMN lesion may be able to achieve psychogenic erections [163]. While the majority of men with UMN lesions are able to obtain reflexogenic erections, these are often unreliable and poorly sustained and often are insufficiently rigid to achieve successful intercourse. For persons with a complete LMN lesion, ~ 12 % can achieve reflexogenic erections, with approximately 25 % being able to achieve psychogenic erections [163]. Approximately 90 % of patients with incomplete LMN injury can achieve an erection. It should be kept in mind that intrathecal baclofen, used to manage spasticity, may cause difficulties with erection and sexual function [164].

There are several treatment options available for erectile dysfunction and include oral phosphodiesterase PDE-5 inhibitors, penile implants, vacuum erection devices, vasoactive intracavernosal injections, and intraurethral alprostadil. Most commonly, men with SCI will have their erectile dysfunction treated or managed with a PDE-5 inhibitor [160].

The phosphodiesterase class of medications, most specifically the PDE-5 isoenzyme including sildenafil (Viagra) and vardenafil (Levitra) and tadalafil (Cialis), has been used with success in the SCI population with UMN lesions [165167]. These medications appear to have similar safety and efficacy profiles, although side effect profile may vary. Since the PDE-5 inhibitors operate on the nitric oxide-induced cyclic GMP system, they are less effective in men with LMN lesions where reflexogenic erections are rare. PDE-5 inhibitors do not initiate the erection (as do intracavernosal injections) but help maintain erections via maintenance of intracavernosal levels of cyclic GMP. PDE-5 inhibitors are contraindicated in patients taking nitrates (because of hypotension) for angina or coronary artery disease, and as such patients at risk for AD should be so cautioned. Men with tetraplegia or high-level paraplegia should be cautioned about the possibility of experiencing postural hypotension for several hours after use.

The penile prosthesis, surgically implanted into the erectile tissue, was the first significant treatment for erectile dysfunction for men with SCI, with satisfactory results in 60–80 % of cases. Different types exist including malleable (semirigid) and inflatable (hydraulic). Although complication rates have improved over the years, they still may occur in ~10 % in patients with inflatable penile prostheses [168, 169]. Penile prostheses may be effective for treatment of erectile dysfunction in men with SCI; however, it should generally be reserved for situations where all reversible erectile dysfunction treatments have failed [160].

Vacuum erection devices (pump with constriction band) can be an effective noninvasive method of managing erectile dysfunction in men with SCI [170]. Although fairly safe and effective, the device is not used frequently because of the process required for use.

Intracorporeal injections with prostaglandin E1 (Alprostadil) can induce an erection in those with UMN and LMN injuries, with a response rate of over 90 % [171]. Alprostadil injected intracavernosally works rapidly and is not dependent on the nitric oxide-PDE-5 system of maintaining high intracavernous levels of cyclic GMP (since PGE-1 stimulates higher levels of cyclic AMP, another potent vasodilator within the corpora cavernosa) [172]. Adverse effects include hypotension, bleeding, bruising, pain and fibrosis at the injection site, and priapism, especially if the dose is not carefully titrated. As with the vacuum pump, men with poor hand function may have difficulty administering the injections without help or may be dependent on a partner who is trained and willing to perform the injection. This should not be used in persons with sickle cell disease. Alprostadil has also been formulated as a small suppository (MUSE) that can be administered intraurethrally [173]. While less invasive, intraurethral preparations are not effective for treatment of erectile dysfunction in men with SCI [160].

To enhance orgasm in men with SCI, there are promising options that include microsurgery of the sensory nerves to the penis and sensory substitution training [174]. Further study is needed.


18.5.2 Fertility in Men with SCI


Most men with SCI have difficulty to father children without some assistance, with <10 % of couples achieving successful spontaneous pregnancies [175]. Erectile dysfunction, ejaculatory dysfunction, and semen abnormalities are the chief contributors to this condition. Despite this, men with SCI should maintain realistic expectations of becoming a biological father.

The majority of men with SCI are unable to ejaculate during sexual intercourse with successful ejaculations in approximately 5 % of men with complete UMN lesions and 18 % of those with LMN lesions [176]. The percentage is higher in those with incomplete injuries. Achieving ejaculation, however, does not ensure successful reproduction. Patients who experience infertility should be evaluated by a reproductive specialist soon after the decision to attempt pregnancy is made.

To obtain sperm in men who do not ejaculate, penile vibratory stimulation (PVS) and, if unsuccessful, electroejaculation (EEJ) can be attempted. PVS involves placing a vibrator on the dorsum or frenulum of the glans penis, and the mechanical stimulation produced by the vibrator recruits the ejaculatory reflex to induce ejaculation [177]. This method is more effective in men with a level of injury T10 or above (with an intact bulbocavernosus response) as compared to men with a level of injury T11 and below [178, 179]. Patients with untreated hypertension or cardiac disease should also avoid this treatment, as PVS may increase blood pressure and can induce AD. The majority of responders will ejaculate within 2 min of stimulation onset.

Electroejaculation (EEJ) may be used for individuals who do not respond to PVS and involves electric current delivered through a probe placed into the rectum that stimulates nerves that lead to emission of semen. EEJ is contraindicated for patients with inflammatory bowel disease involving the rectum and patients on anticoagulation therapy. Similar to PVS, EEJ can provoke AD and precautions should be taken.

If these methods are unsuccessful, there are a number of surgical techniques available to obtain sperm. These include testicular sperm extraction, testicular sperm aspiration, microsurgical epididymal sperm aspiration, percutaneous epididymal sperm aspiration, and aspiration of sperm from the vas deferens [163].

Once ejaculate is obtained from the male, determination of the total sperm count and quality is undertaken. Abnormal semen quality (low sperm motility and viability as opposed to low volume) contributes to infertility in men with SCI [180, 181]. Depending upon the sperm count and viability, there are various options for intravaginal insemination (IVI) and/or intrauterine insemination (IUI). When the total mobile sperm count is low, more advanced (and expensive) methods are recommended to attempt pregnancy. The method of in vitro fertilization (IVF) involves removing sperm from the male partner and eggs from the female partner.

In cases where there are not enough motile sperm to attempt fertilization by a conventional method of IVF, a more advanced form, intracytoplasmic sperm injection (ICSI), injection of a single sperm into a single egg, can be performed, and the inseminated eggs are placed in a laboratory dish, and resulting embryos are transferred into the woman’s uterus. Reasonable pregnancy rates by IVI or IUI have been obtained in couples with SCI male partners.


18.5.3 Sexual Dysfunction in Women with SCI


For women with SCI, there are a number of physical and psychological barriers to engaging in sexual activity. These include spasticity and method of bladder management with fear of incontinence, as well as low self-esteem (feeling unattractive), difficulty in meeting a partner, and a lack of confidence in sexual ability and ability to satisfy a partner [160, 182, 183]. Longer duration and lower level of injury are positive predictors of participation in sexual intercourse [184].

Genital arousal in women can be achieved via psychogenic or reflexogenic pathways and is diminished in ~25–50 % women with SCI [185]. Spared pinprick and sensory function in the T11–L2 dermatomes in women with SCI has been associated with the ability to have psychogenic genital vasocongestion (psychogenic arousal) and a greater degree of genital responsiveness than subjects with minimal or no sensory preservation in those dermatomes [186, 187]. Reflex genital arousal (manual genital stimulation) has been associated with intact reflex function in the S2–S4 dermatomes [188]. In women with complete SCI above T6, psychogenic arousal can occur in the absence of genital vasocongestion. Approximately 50 % of women report developing new areas of arousal above their level of injury, including the head, neck, and torso [189]. It is believed that the vagus nerve may serve as a genital sensory pathway that bypasses the spinal cord and conveys vaginocervical afferent activity that can lead to orgasm [190, 191].

Most women with SCI report the ability to have penetrative sexual intercourse, post-injury. Factors interfering with intercourse include injury level, pain, spasticity, and AD during sexual activity [189]. More than 50 % of women with SCI report frequent sexual activity, and almost half of all women with SCI are able to achieve orgasm, although time to orgasm is prolonged compared to women without SCI [192194]. Women with SCI report achieving orgasm primarily through stimulation of the genitalia and breasts [192]. The ability to achieve orgasm has been associated with presence of genital sensation and with spasticity. Women with intact bulbocavernosus and/or anal wink reflexes are usually able to experience orgasm, whereas women without S2–S5 sensation or absent bulbocavernosus and anal wink reflexes (LMN injuries) have significantly reduced ability.

Continent urinary diversion in women with tetraplegia may result in improved self-image, quality of life, and greater sexual satisfaction [160]. While one trial reported some improvement in sexual arousal with sildenafil 50 mg combined with manual stimulation and visual stimulation, overall sildenafil does not appear to result in clinically meaningful benefits in women who have sexual arousal disorder as a result of SCI [36, 160, 195].


18.5.4 Fertility in Women with SCI


SCI does not affect female fertility once menses returns. Immediately following SCI, amenorrhea occurs in 85 % of women with cervical and high thoracic injuries and 50–60 % of women overall. Within 6 months and 1 year post-injury, 50 and 90 % of women have return of menstruation. The completeness of injury does not appear to influence the menstrual cycle. Women with SCI experience menopause at similar ages to women without SCI. Once normal menstruation resumes, women with SCI can become pregnant with similar success rates as the general population. Methods of birth control should be discussed with the patient’s gynecologist taking into account risks (e.g., risk of thromboembolism) versus benefits of each option.

Pregnancy presents a unique set of potential problems including the development of pressure ulcers, recurrent UTIs, increased spasticity, or decreased pulmonary function. There is a slightly increased incidence of preterm labor in SCI women [196, 197]. AD may develop in susceptible women during labor. Preeclampsia can be difficult to distinguish from AD; however, once the diagnosis of AD has been made, epidural anesthesia is the treatment of choice and should continue at least 12 h after delivery or until the AD resolves. The SCI physician should follow the patients closely in cooperation with the obstetrician.

The rate of spontaneous vaginal delivery has been reported at ~ 37 %, with an additional 31 % of deliveries by assisted vaginal delivery; the remaining 32 % delivered by cesarean delivery (198). The rate of spontaneous vaginal delivery is probably higher in patients with a level of injury below T6, whereas patients with higher-level injuries are more likely to develop AD and require assisted deliveries.


Conclusion

The medical issues discussed in this chapter have a significant influence on the acute and chronic phases of the life of persons who have sustained a traumatic spinal cord injury (SCI). Although these consequences of SCI are gaining increasing recognition, diagnostic, preventive, and treatment approaches remain diverse, and further research is needed to help inform clinical practice guidelines and overall patient care.


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Aug 25, 2017 | Posted by in NEUROLOGY | Comments Off on Medical Complications of Spinal Cord Injury: Bone, Metabolic, Pressure Ulcers, and Sexuality and Fertility

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