Need for Appropriate Type and Level of Carein Quadriplegia

Craig H Lichtblau^1,2,3*, Scott Raffa⁴, Kaveh Asadi⁵, Christopher Warburton⁶, Gabrielle Meli⁶, Allyson Gorman⁷ 

¹Medical Director of The Osseointegration Program at The Paley Orthopedic and Spine Institute at St. ,West Palm Beach, FL, USA; ²Physical Medicine and Rehabilitation Consultant to The Paley Orthopedic and Spine Institute, St. Mary’s Medical Center, West Palm Beach, Florida, USA; ³Consultant to Children’s Medical Services for The State of Florida, District 9, St. Mary’s Medical Center, West Palm Beach, Florida 33407, United States; ⁴Neurosurgeon, Paley Orthopedic and Spine Institute at St. Mary’s Medical Center, West Palm Beach, FL, USA; ⁵Pediatric Neurosurgeon, Paley Orthopedic and Spine Institute at St. Mary’s Medical Center, West Palm Beach, FL, USA; ⁶University of Miami Miller School of Medicine, Miami, FL, USA; ⁷Medical College of Wisconsin, Wauwatosa, Wisconsin, USA

ABSTRACT

Spinal cord injury often leads to quadriplegia, where patients lose functioning in all four extremities. Those with quadriplegia are at an increased risk for several complications that enhance health-related costs, shorten life expectancy, and diminish quality of life. Here, we review issues in quadriplegia and how co improve outcomes in individual patients.
Keywords: Quadriplegia, Spinal Cord Injury (SC[}

INTRODUCTION

Spinal Cord Injury (SC[} has been documented as far back as 2,500 years B.C. and today occurs in up co half a million people each year [ 1,2). le occurs when pachophysiological processes in the spine lead co destruction through processes such as inflammation, apoprosis, ischemia, and oxidative stress, causing major dysfunction in motor, sensory, and autonomic systems [3). When discontinuity within the spinal cord occurs, conduction of impulses are disrupted, leading co functional alterations [4).

The condition now affects more than 2.5 million people across the world [4,5]. According co the National Spinal Corel Injury Statistical Center, approximately 18,000 cases occur in the U.S. alone each year [6,7). Roughly 14% of all SC!s result in complete quadriplegia, also known as tetraplegia, meaning there is a full loss of neurologic function below the site of injury [8]. In many cases, incomplete quadriplegia occurs, where some sensation and/or motor functioning is retained below that site [91.

Injuries from SCI may be transient or permanent, and in the latter cases, are extremely costly. In quadriplegia, the lifetime coses co adequately care for a patient are significantly increased because of the amount and level of aid and attendant care required [ 10). Because chose with quadriplegia face lifelong

dysfunction and increased risk for complications, providing the appropriate type and level of care is critical for minimizing pain and suffering, optimizing quality of life, and maximizing life expectancy. In attempting to make a determination of life expectancy in those with quadriplegia, one of the most helpful cools is the ‘acional Spinal Cord Injury Statistical Center at the University of Alabama [11).

Here, we review causes and outcomes related to quadriplegia, including relevant complications and the care required to adequately prevent or overcome those complications.

Quadriplegia often occurs due to preventable causes and risk depends on race, sex and age

Trauma to the cervical spinal cord anywhere between the cervical vertebrae (CI co C7) is the most common direct cause of quadriplegia [9). However, the condition can also occur as a result of non-traumatic causes, such as infectious, autoimmune, vascular, or cancerous conditions [ 12,13). In some cases, SCI may result from inflammation, metabolic disturbances, toxic exposures, or lack of blood flow [2]. Nonetheless, 90% of SCis are traumatic, and they tend co result from preventable causes such as motor vehicle accidents, violence, falls, and spores [2,14,15).

Correspondence to: Craig H Lichtblau, Medical Director of The Osseointegration Program at The Paley Orthopedic and Spine Institute, Sc. Mary’s Medical Center, West Palm Beach, Florida, USA, E-mail: [email protected]

Received: 13-Nov-2023, Manuscript No. JPMR-23-27988; Editor assigned: 15-‘.’Jov-2023. PreQC No. JPMR-23-27988 (PQ); Reviewed: 01-Dec-2023, QC No. JPMR-23-27988; Revised: 08-Dec-2023, Manuscript :–Jo. JPMR-23-27988 (R); Published: 18-Dec-2023, DOI: I0.35248/2329-9096.23.l l.705

Citation: Lichtblau CH, Raffa S, Assadi K, Warburton C, Meli G, Gorman A (2023) Need for Appropriate Type and Level of Care in Quadriplegia.

Inc J Phys Med Rehabil. I 1:705.

Copyright: © 2023 Lichtblau CH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Int J Phys Med Rchabil, Vol.I I lss.11 No, I000705

The data on SCI shows that about a quarter of SCis in the

U.S. occur in the black population and that males are more likely than females to endure SCI [6,7]. Since 2015, about 79% of SCI cases in the U.S. have occurred in males.

There is some inconsistency in the data on the age at which people are at highest risk for SCI, but lace adolescence and early adulthood appear to be the most likely times for SCI to occur [2,12]. Some of the inconsistency in age data may be due to the fact that men tend to endure SCI at younger ages, whereas women’s risk is bimodal, with peaks both early and lace in life [15].

Quadriple_gia patients suffer significant complications

Those who experience quadriplegia lose motor and sensory functioning in their arms, legs, trunk, and pelvic organs and are likely to suffer one or more of several potential complications.

Respiratory complications: In those with quadriplegia, the leading cause of both morbidity and mortality is respiratory complications [ 16,17]. In these cases, SCI causes weakness in respiratory muscles that impairs lung function and the ability to cough. Pneumonia is particularly likely to develop in those with poor inspiratory muscle strength. People with lesions above CJ cannot maintain spontaneous respiration, and those with high cervical cord lesions are often dependent on ventilators [9].

Urinary and bowel complications: Gastrointestinal tract (GI) dysfunction often presents lifelong challenges for SCI patients [ 18]. For this population, bowel dysfunction is the second most frequently reported complication and the fourth cause of rehospitalization [ 19]. In addition to the medical concerns these complications raise, they also have an adverse effect on quality of life, as they disrupt the ability to engage in normal daily activities and create social barriers.

Cardiovascular and metabolic complications: People with SC[ experience coronary heart disease earlier than the general population [20]. They also are more likely to suffer insulin resistance, diabetes mellitus, and lower serum HDL (“good cholesterol”) levels. Abnormal carbohydrate metabolism and lipid metabolism occur more frequently in this population than in mobile populations and are also associated with muscle atrophy and heightened adiposity.

Cognitive impairment: Those with SCI are 13 times more likely to suffer cognitive dysfunction than their healthy counterparts [ l2]. Research shows chat as many as 6 or 7 out of 10 of SCI patients will have some degree of cognitive impairment and chat chose with SC[ appear co be at a heightened risk for Alzheimer’s disease compared to those without SC!. One theory for the comorbidity of SC[ and cognitive impairment is che potential for Traumatic Brain Injury (TB[) to have co-occurred at the time of SCL

Psychological: Anxiety and depression frequently occur in those with SCI, which may be due co the substantial burden of SCI

and the mental stress it imposes. Critically, some research suggests that psychological factors may dictate prognosis.

Accordingly, successful psychological intervention in C4 dislocation patients has been shown to have a positive impact on quality of life as well as prognosis [2l[.

Skin breakdown: Skin breakdown, which may involve pressure injuries or burns, often occurs in SCL SCI patients who develop chronic wounds have an increased risk of infections, sepsis, and death [22].

In summary, complications associated with cervical SCl and immobility include but are not limited to: deep vein thromboses, pulmonary emboli, pneumonia, urinary tract infection, cellulicis, osteomyelitis, sepsis, chronic pain, hypotension, osteoporosis, bone fractures, and autonomic dysreflexia [21,23].

If SC! occurs below C7, upper extremity function and posture are often spared. Because the phrenic nerve from C3 to CS innervates the diaphragm, patients with injuries in chose levels must be assessed for respiratory deficiencies. ln these patients, upper and lower neuron injuries frequently coexist [10].

Because a greater extent of the body is affected, chose with quadriplegia are at a higher risk for complications than those whose SC!s have led to other conditions, such as paraplegia [24]. For example, cardiovascular and respiratory systems tend to be more compromised in quadriplegics than in paraplegics [25]. Because quadriplegic patients are less likely than paraplegia patients to be capable of mounting fever and tachycardia, they may suffer worse outcomes if they develop sepsis [26].

Quadriplegia is associated with poor outcomes

SC[ pathophysiology is complex, as are the biological changes that occur in response to the injury [ 15]. As a consequence, treatment is challenging, and though acute care has progressed in recent decades, long-term care has not [ 15,27]. Because there is no treatment chat fully restores the spinal cord following SCI, these injuries often lead to permanent disabiliry and severe morbidity [2].

With no solid interventions, the recovery process following SCI relies largely on the formation of neural pathways based on synaptic plasticity in the nervous system [41. Prognosis is thus quite poor, and SC! survivors experience a reduced life expectancy [12]. Overall, younger victims of SCI recover better than chose who endure SCI later in life [28].

Fewer than I% of patients fully recover functioning before being discharged from the hospital following their injury [21. However, che recovery of strength in the first month following the injury is predictive on long-term outcomes with respect to recovering normal functioning [9]. Unfortunately, only about 12% of SCI survivors can maintain a job, and less than half of those who are single at the time of injury get married [21.

Outcomes can be optimized by ensuring proper type and level of care

The complications and potential dysfunction in other organ systems that occur in quadriplegia place these patients at a high risk for morbidity in addition to reducing their quality of life [27). fu such, ongoing care and rapid interventions are critical to optimizing outcomes and life expectancy in this patient population.

Medical professionals with the relevant credentials can often identify complications char may arise in each quadriplegia patient because these complications are related to specific physical, psychological, and environmental factors [29). Experts suggest that though medical care can prevent SCI patients from dying from complications within the first few years following their injury, care is not currently properly deployed to optimize SCI outcomes [301. le is critical to fill this care gap to improve health outcomes and longevity and to reduce suffering and health-related costs.

Patients who do not suffer from chronic pain may require less attendant care. However, patients with chronic pain will require more aid and attendant care than is expected in regards to their level of injury.

Research into care for those with tetraplegia has shown chat only 14% of quadriplegic patients undergo surgical tendon transfer procedures despite up to 75% potentially benefiting from the surgery [311. Critically, when asked about which functions they most want restored, quadriplegic patients most frequently report the desire for hand function restoration [32). Thus, in addition co care associated with outcomes, there is also a gap in care chat is responsive co their needs and preferences.

CONCLUSION

Quadriplegia is a complex disorder chat is associated with long­ term disabilities and poor outcomes. le increases the risk for several complications, which are associated with further morbidity and mortality. In addition, the acute care related to these complications accounts for a large proportion of health costs associated with SCI [33]. Thus, preventing these complications or addressing chem before they require hospitalization can both improve outcomes and reduce costs.

There is evidence co show chat outcomes can be improve and coses can be minimized if proper care is deployed for quadriplegic patients. However, data also demonstrate that care is not meeting chis potential. Determining the specific needs of each quadriplegic patient and ensuring they have the right type and level of care is the best way to support these patients, their families, and the broader healthcare system.

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