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Paraplegia — Clinical Guidelines

Overview

Paraplegia refers to paralysis of the lower limbs and often involves varying degrees of trunk involvement, typically resulting from spinal cord injury. Long-term wheelchair use in paraplegic individuals can lead to musculoskeletal complications, particularly in the shoulders, including rotator cuff tears.

Diagnosis

Key Diagnostic Criteria: Presence of paralysis in lower extremities, often with sensory and motor deficits.

Recommended Tests:

- Radiographic Assessment: Lateral spine radiographs to assess spinopelvic alignment 1. - MRI of Shoulders: To detect rotator cuff tears and assess tear extent and severity 3.

Grading: Use classification systems like Kendall et al. and Roussouly et al. for spine alignment assessment 1.

Management

First-Line Treatments:

- Postural Training: To improve seated posture and reduce strain on shoulders 1. - Physical Therapy: Focus on shoulder stabilization and strengthening exercises 1 3.

Adjunctive Treatments:

- Surgical Intervention: For significant rotator cuff tears refractory to conservative management 3. - Pain Management: Analgesics and anti-inflammatory medications as needed for pain control 3.

Special Populations

Pregnancy:

- Major complications include urinary tract infections and anemia; obstetrical issues may involve preterm labor 4. - Tuberculous paraplegia during pregnancy can occur but does not preclude successful delivery and post-delivery surgical intervention 5.

Comorbidities:

- Increased risk of musculoskeletal issues like rotator cuff tears with prolonged wheelchair use 2 3. - Monitoring for complications such as scrotal fistulas due to urethro-vasal reflux in certain cases 6.

Key Recommendations

Regular MRI screening of shoulder joints in long-term wheelchair users to detect rotator cuff tears early (Evidence: Moderate 3).

Implement postural correction and physical therapy programs to mitigate musculoskeletal strain and prevent rotator cuff injuries (Evidence: Moderate 1 3).

Consider surgical repair for symptomatic bilateral rotator cuff tears in paraplegic patients (Evidence: Weak 3).

Monitor paraplegic pregnant women closely for urinary tract infections and anemia, with readiness for obstetric interventions (Evidence: Expert opinion 4 5).

References

1 Kentar Y, Brunner M, Bruckner T, Hug A, Raiss P, Zeifang F et al.. Impact of spine alignment on the rotator cuff in long-term wheelchair users. Journal of shoulder and elbow surgery 2018. link 2 Akbar M, Balean G, Brunner M, Seyler TM, Bruckner T, Munzinger J et al.. Prevalence of rotator cuff tear in paraplegic patients compared with controls. The Journal of bone and joint surgery. American volume 2010. link 3 Escobedo EM, Hunter JC, Hollister MC, Patten RM, Goldstein B. MR imaging of rotator cuff tears in individuals with paraplegia. AJR. American journal of roentgenology 1997. link 4 Kulkarni S, Morgan OS. Pregnancy outcome in paraplegic women. The West Indian medical journal 1992. link 5 Govender S, Moodley SC, Grootboom MJ. Tuberculous paraplegia during pregnancy. A report of 4 cases. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 1989. link 6 Ahn JH, Reiter R, Farcon E, Morales P. Scrotal fistula from urethro-vasal reflux in paraplegia. Urology 1989. link90448-2) 7 Thomas SE, Conway J, Ebling FJ, Harrington CI. Measurement of sebum excretion rate and skin temperature above and below the neurological lesion in paraplegic patients. The British journal of dermatology 1985. link 8 Asayama K, Nakamura Y, Ogata H, Morita H, Kodama S, Hatada K. Energy expenditure of paraplegic marathon runners measured during a wheelchair marathon. Journal of UOEH 1984. link 9 Zwiren LD, Bar-Or O. Responses to exercise of paraplegics who differ in conditioning level. Medicine and science in sports 1975. link

Paraplegia