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Author: Katherine Hartley, Medical Student, University of Nottingham, Nottingham, UK. Copy edited by Gus Mitchell. November 2020.
Paraplegia and tetraplegia are a loss of neurological function usually resulting from a spinal cord injury. In paraplegia only the lower body and limbs are affected following a spinal cord injury in the thoracic, lumbar, or sacral region. Tetraplegia also involves the upper limbs and upper body due to interruption in the cervical spine. Loss of function can be complete or incomplete, congenital or acquired, reduced or complete loss of sensation, paralysis or weakness.
Multiple body systems can be affected including the musculoskeletal, gastrointestinal, and genitourinary systems. It is important to consider the effects on mental health especially following an acute event.
Spinal cord injuries in the cervical and upper thoracic spine can result in an inability to maintain a constant core temperature.
Changes in sweat secretion are common after spinal cord injuries. Reduced or absent sweating may occur below the level of the injury, with a compensatory hyperhidrosis above it. Less often there may be reflex sweating below a cervical or high thoracic injury.
Pressure ulcers are a common complication of spinal cord injury, and the most common long-term complication. A pressure ulcer is defined as a soft tissue injury resulting from unrelieved pressure over a bony prominence resulting in ischaemia, cell death, and tissue necrosis. Pressure, moisture, shear forces, and friction are extrinsic factors contributing to the development of skin ischaemia and necrosis. Pressure ulcers usually develop below the level of spinal cord injury, with the most common sites being over the ischial tuberosity (from prolonged sitting), sacrum, trochanter, and heel.
Paraplegia and tetraplegia are particularly associated with pressure ulcer development due to reduced mobility, reduced skin sensation, and faecal/urinary incontinence.
Other factors contributing to increased risk include:
The European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) classification system is used to categorise pressure ulcers.
Careful daily examination of the skin is required to identify early signs of pressure at an easily reversible stage. Skin care should include:
Once skin ulceration has developed, treatment options may include:
Alterations to immune function following spinal cord injury are thought to increase the risk of skin infections.
Tinea is the most commonly reported infection associated with paraplegia and tetraplegia, almost always developing below the level of the spinal cord injury. Predisposing factors may include hyperhidrosis, humid environment (limited airing of the skin), occlusive clothing, maintaining adequate skin hygiene, and comorbidities. The most common presentations associated with paraplegia and tetraplegia are tinea cruris, tinea pedis, and onychomycosis.
Management is as usual for tinea: skin scapings or nail clippings for fungal microscopy and culture, topical or oral antifungal medications prescribed, and treatment of predisposing factors to reduce the risk of recurrence.
Post-operative wound infections are three times more common than in patients without a spinal cord injury. Secondary bacterial infection of surgical wounds, pressure ulcers, and eczema should be confirmed on swabs and treated appropriately, in addition to treatment of the underlying condition.
Asteatotic eczema develops in very dry skin, particularly on the lower limbs below the level of injury. It is reported to develop in the first 12 months after the spinal cord injury. Dry skin is commonly associated with paraplegia and tetraplegia and may be due to a number of factors including reduced skin blood flow, reduced sweating, and nutritional deficiencies. Treatment is with regular emollient use and topical corticosteroids when required.
Seborrhoeic dermatitis is often reported in patients following spinal cord injury. Studies on the effect of a spinal cord injury on sebaceous gland function have shown contradictory results. Seborrhoeic dermatitis affects the skin above the level of injury, and some authors suggest it results from inadequate hair and face washing in the initial acute period following injury.
Pressure ulcers can be complicated by secondary infection, which may not manifest as pain due to reduced or absent skin sensation.
Tinea pedis increases the risk of lower leg cellulitis by providing an entry point for bacteria through the skin between the toes.
Asteatotic eczema can generalise if severe, resulting in widespread, secondary disseminated eczema.
Skin complications of paraplegia and tetraplegia can be prevented in the following ways:
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