British Association of Spinal Cord Injury Specialists

MANAGEMENT OF INDIVIDUALS WITH SPINAL CORD INJURY

IN

GENERAL HOSPITALS

 GOOD PRACTICE GUIDE

BRITISH ASSOCIATION OF SPINAL CORD INJURY SPECIALISTS

A Report of the British Association of Spinal Cord Injuries Specialists

Complied by :

Mr G Ravichandran FRCS

Consultant in Spinal Injuries

Princess Royal Spinal Injuries Unit, Sheffield

Mr W S El Masri

Consultant Surgeon in Spinal Injuries FRCS Ed  

Senior Lecturer University Of Keele

Chairman  British Association of Spinal Injuries Specialists

RJ & AH Orthopaedic Hospital

Executive Summary

Survival of individuals with spinal cord injury has progressively improved as a result of advances in the acute and long term management of the paralysed.  Similar improvements in the care of poly-traumatised patients have resulted in the survival of paralysed patients with multiple other injuries/diseases.  Both the long-term survivors and individuals with acute traumatic spinal cord injury are inevitably referred to local District General Hospitals [DGH] where primary care is given.  Changing patterns of healthcare delivery, increasing public expectation, and the implementation of Clinical Governance have resulted in a significant escalation of litigations against General Hospitals by people with spinal cord injury.  Many of these litigation’s are settled out of court and do not usually attract the attention of the general public.  Specialist centres dealing exclusively with patients with spinal cord injury have been aware for sometime that in certain instances the application of simple and basic techniques in the management of paralysed patients would substantially improve the quality of care received by the paralysed in DGHs.  The British Association of Spinal Cord Injury Specialists [BASCIS] believes that failure to prevent avoidable complications in patients with spinal cord injury is the cause of increased morbidity and a significant increase in the total time spent in  hospital.  This Good Practice Guide is intended to improve healthcare given to people with spinal cord in non- specialist centres. 

The key objectives of Clinical Governance are:

i                      To provide reassurance to patients, managers and clinical staff alike that:

·   Quality of care drives decision making about provisions of services within each Trust

·   Care delivered within each service meets the required standards

·   Planning and delivery of services take full account of the prospective of patients

ii                    To support clinical staff in improving quality of care

iii        To ensure that poor performance is identified and dealt with.

iv        To help DGHs minimise litigation

BASCIS believes that the implementation of the guidelines contained in this document will improve those objectives.

1   Guidelines on the Management of Acute Traumatic Spinal Cord Injury in a General Hospital:

The potential for spinal column/spinal cord injury [SCI] should be suspected in all cases of high velocity road traffic accidents.  Unguarded falls, particularly of elderly individuals, diving injuries, and rugby accidents all have a potential to result in significant neurological deficit.  Hyperextension injuries to the cervical spine, particularly in the elderly can result in significant neurological deficit without clear evidence of a bony injury. 

i                       Neurological Syndromes:       Complete paralysis following a spinal cord injury results in loss of
                                                     sensation/muscle power over a clearly defined anatomical
                                                     dermatomes/myotomes.

                                                                 Incomplete spinal cord injury may present as one or more of the following
                                                    syndromes.

                                                                Anterior cord syndrome (Significant motor paralysis with some preservation
                                                    of touch and joint position sense).

                                                                Posterior cord syndrome (preservation of some voluntary power with loss of
                                                                proprioception.)

                                                                Central cord syndrome (resulting in dense sensory & motor loss in the upper
                                                                limbs compared to lower limbs).

                                                                Brown Sequard syndrome (where there is asymmetric preservation of
                                                                sensation and muscle power between the left and right half of the body
                                                                below the lesion.

ii          Recognition:                             In the conscious individual, a systematic neurological assessment should
                                                                identify the level of the injury and the extent of neurological disability.  It is
                                                                important to remember that sensory preservation over the manubrium sterni
                                                                may be due to C4 innervation (supra-clavicular nerves) rather than from the
                                                                intercostal nerves at T3/4. Sensory assessment should follow specific
                                                                well established landmarks which include the axilla (T2),the umbilicus (T10),
                                                                anterior superior iliac spine D12/L1).

                                                                In the unconscious individual, paralysis can be suspected by neurogenic 
                                                                paradoxical respiration with indrawing of the intercostals during inspiration
                                                                may be seen in patients with cervical spinal cord injury, the absence of
                                                                response to painful stimuli that might arise from movement of an injured
                                                                extremity and the presence of pseudo priapism in the male.
                                                                Hyperpathia in a dermatomal fashion in the upper extremity may also be
                                                                elicited.

            Caution:                                     Action of deltoid and/or biceps in a C5 tetraplegic could result in abduction
                                                                of the shoulder and flexion of the elbow with passive movements of the
                                                                wrist and fingers. If voluntary reproducible finger movements could not be
                                                                demonstrated, such incidental passive movements of fingers should not be
                                                                interpreted to indicate normal power. 

                                                                Involuntary twitching of the paralysed lower extremity may be seen in the
                                                                A & E Department soon after cord injury, for a varying period of time.
                                                                These do not indicate preservation of voluntary power in the lower
                                                                extremities.

                                                                The tone in the lower extremity may be partly preserved soon after the
                                                                accident. Plantar stimulation may result in reflex withdrawal of the lower
                                                                extremity.  Again these do not suggest preservation of function in the lower
                                                                extremities unless it is voluntary and reproducible.

                                                                Neurological charting such as “grade 1/5 in upper and lower limbs” is not
                                                                meaningful documentation but can result in unnecessary litigation against
                                                                Health Authorities, should these “neurological chartings” be assumed to
                                                                represent true function.  Medical documentation should clearly identify what
                                                                was actually observed during neurological assessment and whether it was
                                                                reproducible, in a conscious patient.

iii                    Patho-physiology:                  Individuals with cervical spinal cord injury often have physiological
                                                    bradycardia (pulse, 45-60 and Hypotension (80-90 systolic).  This is related
                                                    to loss of sympathetic tone and a relative increase in vagal activity on
                                                    the heart. 
                                                    In the absence of clearly established and significant blood loss, any fluid
                                                    replacement should be moderate and attempt should not be made to correct
                                                    the physiological hypovolaemia.  Indiscriminate administration of intravenous
                                                    fluid could result in precipitous respiratory embarrassment from pulmonary
                                                    congestion/oedema.

                                                                Extremities are often warm with a good volume pulse in tetraplegic patients
                                                                seen in the A & E Departments in spite of bradycardia and hypotension.

                                                                Previously fit tetraplegic patients usually maintain their oxygen saturation
                                                                unless the injury is above the level of C5.
                                                                Ventilatory difficulties however can occur during the acute phase due to
                                                                cord oedema/ bleed etc. Close monitoring of O2 saturation will be
                                                                essential.

                                                                Bowel sounds may be present during initial assessment in the A & E
                                                                Department but they usually disappear during the subsequent 4-8 hours
                                                                It is therefore advisable not to administer significant volumes of oral fluids
                                                                for the first 24-48 hours.

                                                                Paralysed skin over bony prominences cannot withstand sustained pressure.
                                                                Prolonged stay on a stretcher/hard objects
                                                                inevitably results in significant tissue damage that is often difficult to heal
                                                                and contributes to a considerable increase in hospital stay.

                                                                Tetraplegic patients are poikilo-thermic with a tendency to lose body heat
                                                                rapidly. Suitable shielding from the environment to reduce heat loss is
                                                                essential. Any attempt at warming should be gradual and should not include
                                                                placing warm bottles over insensate skin.

iv                   Investigations:                         Routine haematological and biochemical parameter  assessment could include
                                                    estimation of arterial blood gases and whenever possible vital capacity and
                                                    FEV1.

                                                                Radiological assessment initially should be restricted to an AP and lateral view
                                                                of the suspected area/s of injury/s.  These should be reviewed by a Senior
                                                                Medical Practitioner before additional views are obtained.

                                                                Better X rays of the cervico-thoracic junction could be obtained by supervised,
                                                                sustained and careful pulling of the shoulder.
                                                                Such a manoeuvre should not result in undue rotation or tilt of the skull/cervical
                                                                spine. Oblique views of the cervico-thoracic junction often give further details of
                                                                the facet joints.  Swimmers views may be of value in some instances.

                                                                Additional imaging including CT scans and MR scans where indicated should be
                                                                carried out provided spinal movement could be minimised and the
                                                                patient’s general condition allows .

Nursing:                                                It is difficult to under-estimate the important role played by informed nurses in
                supporting the multi-system needs of a paralysed individual.  Two excellent
                books published by the Spinal Injuries Association ^2,3 deal with the essential
                features of nursing a patient with acute traumatic spinal cord injury.  BASCIS
                would strongly recommend the acquisition of these books by every A &E
                Department, ITU and Acute Wards that may be called upon to deal with patients
                with spinal cord injury. In many instances admission to ITU/ HDU may be a
                 better way of organising the necessary level of nursing expertise.

       (a) Blood pressure, pulse, respiratory rate and temperature, should be recorded
       regularly, the frequency of such recording being determined by the clinical
       condition.

       (b) Neurological charting should include head injury observations (if needed) and
       a record of presence/absence of sensation/movements (voluntary) in the
       extremities.

       (c) If catheterised, record the time of catheterisation, urine drained and urine
       output-initially on an hourly basis.

       (d) Note and record if there is any faecal soiling during de-robing of the
       patient.

       (e) Record all externally visible signs of injury.

       (f) Comfort the patient.  Do not confirm the diagnosis even if it is strongly
       suspected.  Remember long term functional/neurological outcome following a
       spinal cord injury in patients who may have “complete lesion” in the A&E
       Department is difficult to predict soon after injury.

       (g) Learn safe and effective transfer of the paralysed patient from a spinal
       board on to bed/x-ray table/examining couch using appropriate manpower. 

       (h) Periodic log-rolling and in cervical spine injuries, pelvic twisting may be
       essential to avoid the development of pressure sores.

       (i) Maintain spinal alignment during all spinal procedures.  Remember that the
       patient may have pre-existing kyphosis/ankylosing spondylitis etc.  In these
       patients, spinal alignment means the return to their pre-injury normal contour
       of the spine and not supine.  Thus there may be a need to use pillows to support
       the neck of a patient with ankylosing spondylitis and paralysis.

       (j)Pain due to spinal cord injury is minimal, but pain due to a spinal column
       injury may be significant.  Associated anxiety and fear will clearly exacerbate
       perceived pain. 

       (k)The need to maintain “spinal column alignment” should not compromise
       access to other system injuries.  Informed compromises and repositioning of the
       patient will be needed in the A & E Department.

       (l) Maintain intake/output chart.  Avoid oral fluids, if at all possible during the
       first 24 hours or longer in patients with spinal cord injury.^1,2 See Page 16.

vi         Transport:                                  Patients with suspected spinal column injury/spinal cord   injury, should be
                                                   transported to various departments accompanied by an experienced nurse.  All
                                                   transfers between the spinal board or A & E trolley to examining surfaces/x-ray
                                                   tables should involve minimal movements of the spinal column.  Maintain normal
                                                   spinal alignment, normal to the patient before the injury.

                                                                               Unless there are major cardio-respiratory contraindications avoid inclining the
                                                                 patient on transport trolleys beyond 10°.

vii        Management of Multi-system Disability:

Cardio-vascular system:             In tetraplegic patients physiological bradycardia and hypotension is common.  In
                                                                the absence of clear evidence of blood loss due to other injuries, it is
                                                                recommended that the fluid replacement be limited to estimated fluid loss.  In
                                                                general a 70 kilogram male with no additional fluid loss is likely to need between
                                                                2.0 – 2.5 litres of fluid over a 24-hour period. NOTE: Urine output is usually low
                                                                during the first 24-48 hours. 

                                                                Central venous pressure is not likely to be a reliable guide to the state of
                                                                perfusion of a paralysed individual (due to autonomic disturbance).

                                                                Atropine 0.3 – 0.6mg should be administered if the pulse rate drops below 45 per
                                                                minute and repeated as needed.

                                                                Unless there are specific contraindications due to other systemic illness, all
                                                                patients with spinal cord injury should receive low monocular weight Heparin
                                                                and/or oral anticoagulants.  Liver function tests may be necessary.  INR of
                                                                between 2-3 is adequate in patients with spinal cord injury to prevent DVT/PE.

Respiratory system:

       Tetraplegic patients rely exclusively on their diaphragm for respiration.  It is
       therefore important to avoid respiratory infection by regular and period chest
       physiotherapy (deep breathing exercise, vibration, percussion and postural
       drainage).

        In these patients any co-existing rib fractures, haemothorax, pneumothorax will
        significantly reduce their respiratory function.

        It is advisable to document respiratory frequency, oxygen saturation, and vital
        capacity on a regular basis at least for the first 48-72 hours.

        Patients with spinal cord injury at C5 or above have the potential to develop a
        gradual deterioration of their respiratory function due to spinal cord oedema,
        intra-spinal haematoma etc. during the first 72 hours of injury.  In these
        patients regular monitoring of pH , pCO2 and  neurological level will help to
        determine the need for assisted ventilation.

        Placement of chest tubes either to drain a pneumothorax or a haemothorax
        should take into account the fact that the paralysed patient may be confined to
        bed for several weeks and nursing needs demand regular turns.  It is therefore
        essential to place chest drain tubes more anteriorly.

Gastro-intestinal tract:                              All patients with spinal cord injury are at risk of developing delayed paralytic
       ileus. It is therefore advisable to avoid oral fluids for 24-48 hours.  At the end of
       this period, commencement of oral fluids should be gradual and guided by    
       abdominal girth and bowel sounds. Paralytic ileus and abdominal distension
       could cause splinting of the diaphragm resulting in respiratory difficulties
       particularly in the tetraplegic patients

       Contemporary medical practise advocates the use of appropriate
       antacids/proton pump inhibitors such as Ranitidine to reduce the incidence of
       gastric bleed/stress ulcerations.

       A PR check after 48 hours followed by once a day insertion of a suppository
       (Glycerine/Bisacodyl) should be carried out until regular bowel evacuations
       occur.  This will avoid unexpected faecal soiling. 

       If prolonged paralytic ileus occurs (in ventilated patients, or patients who have
       undergone abdominal surgery) there may be an indication for parentral feeding.

Genito-Urinary tract:

Indwelling urethral catheter is by far the safest way of managing the urinary tract during the first 48hrs after injury and occasionally longer. Documentation of hourly urine output is essential. Urine output is expected to be initially reduced in the first 24-48 hours. Subsequently it may exceed intake for a few days or weeks in certain instances, during the acute phase of injury.

The team should ascertain that the catheter is introduced in to the bladder and not resting either in the prostatic urethra or in the bulbous urethra – in the absence of sensation the patient is unable to inform the observer of discomfort.

Timely early introduction of intermittent catheterisation, can prevent a number of lower urinary tract complications

Reflex erection can cause urethral damage if the indwelling urethral catheter is not appropriately strapped with a suitable catheter holding device.

During every turn, make sure the drainage system is not kinked.

Discussions concerning sexual dysfunction and storage of semen should be delayed until informed expert advice becomes available in a Spinal Injuries Unit.

Musculo-skeletal system:

In general extremity injuries should be immobilised by appropriate early surgical procedures – plating, nailing etc.  As far as possible external fixation of extremity fractures should be avoided since they often contribute to significant nursing problems.

Informed judgement on the need for bony realignment of extremity fractures should be made, taking into consideration the patient’s neurological deficit. Thus in general there is a greater need for expert reconstruction of upper extremity fractures; soft tissue injuries compared to lower extremity injuries. 

Surgical intervention to spinal column injuries is very unlikely to contribute to neurological recovery.

Most spinal column injuries, associated with spinal cord injury can be treated conservatively in a DGH, if the hospital has adequate and reliable nursing expertise. 

Patients with cervical spinal column/cord injuries will usually need skull traction with appropriate tongs   Patients with hyperextension injuries of the cervical spine with a resultant tetraparesis can often be treated without skull traction and the neck supported on a pillow to avoid extension, provided such an individual does not have head injury/cerebral irritation.

Attempts should be made to reduce dislocations of the cervical spine at the earliest opportunity by gradually increasing skull traction with or without gentle manipulation of the cervical spine  using appropriate radiological control . By avoiding a general anaesthetic the neurology can be assessed and monitored during the process

Inexpert application of either traction or manipulation is potentially dangerous.  Please liaise with your local Spinal Injuries Unit. 

Surgical stabilisation of cervical spinal column injuries in the presence of neurological deficit should be attempted only by surgeons with adequate expertise  supported by informed anaesthetists.  Inexpert and extensive anterior and/or posterior stabilisation not uncommonly results in the need for extended period of postoperative ventilation and other respiratory complications.  Such procedures do not necessarily contribute to neurological recovery nor reduction in hospital stay but can add significantly to the cost of care and the development of multiple complications.

Thoracic spinal column injuries, associated with complete paraplegia can often be managed conservatively.

Thoraco-lumbar spinal column injuries without neurological deficit can benefit from segmental instrumentation carried out by an orthopaedic team familiar with such procedures. Opinion is divided about the benefits of surgery in patients with neurological damage.

Spinal canal clearance by surgical decompression does not necessarily contribute to neurological recovery in the majority of patients with SCI.. Please liaise with your local spinal cord injuries centre

Central nervous system:

Neurological assessment is often difficult in patients who are under the influence of alcohol/drugs or who have a head injury.

Whenever possible sensory and motor assessment together with reflex changes should be documented.  Involuntary, reflex withdrawal of extremities to stimulus should be distinguished from voluntary, repeatedly reproducible movements of extremities.  Ill-defined observations such as “moving periphery”, “moving all four limbs” is inadequate to make a meaningful assessment of the extent of the neurological deficit.  If examination is difficult, documentation should reflect this.  If examination is incomplete, documentation should reflect this.

Sensory assessment particularly around the perineum has significant prognostic value and should always be performed. In the unconscious patient the presence of priapism may suggest neurological deficit due to SCI.  A proportion of patients seen soon after SCI in the A & E Department may exhibit involuntary fasciculation of lower extremity muscles and rarely in the upper extremity muscles.  These do not represent preservation of true motor function. 

The use of a sensory chart is strongly recommended (appendix A). 

The use of a spinal injury motor chart may be of value in certain centres (appendix B). 

Neurological assessment should be repeated at least once after transfer to an appropriate receiving ward during the first 24 hours.  Neurological assessment should be carried out following each increment of traction weight if a reduction is being attempted.  Daily neurological charting during the first week and weekly charting thereafter is strongly recommended.  Occasionally patients with thoraco-lumbar spinal column injury may suffer a gradual but progressive neurological deterioration over several hours or days.  This could be related to a spinal cord oedema or vascular insult to the spinal cord.

Physiotherapy:

Regular physiotherapy to improve respiratory function and avoid atelectasis is essential.

Once the patient is admitted to a reception ward daily physiotherapy should include passive range of movements of the extremities through full range, as far as possible.

Appropriate positioning of the extremities to prevent contractures at the elbow, wrist and shoulders is essential.  

Appropriate positioning of the lower extremities will reduce muscle tone and the development of excessive spasticity.

Psychological support:                       This devastating injury, not uncommonly results in anger, depression, denial and prolonged grieving before the paralysed individual accepts the true extent of the paralysis. Patients normally employ many denial techniques. It is counter productive to re-enforce the diagnosis before the patient is ready to accept his condition.  If the patient has pre-existing psychological /psychiatric disabilities, it may be appropriate to take suitable advice from a local psychologist/psychiatrist.  Discussions with the local Spinal Injuries Centre is likely to be advantageous to both the patient and the DGH.

Steroid therapy:                                    Highly publicised studies have suggested that high dose Methylprednisolone therapy is an essential treatment in most cases of spinal cord injury in spite of important related
clinical complications.  In common with clinicians in other countries BASCIS has carefully evaluated the information now available. The published evidence does not support the use of high dose Methyl prednisolone as a standard treatment in acute spinal cord injury. 

Key point:   Your local Spinal Injuries Centre will always be ready to give  advice and provide support concerning any matter related to the management of patients with spinal injuries. Please do not hesitate to pick up the telephone to discuss your patient prior to referral and/or transfer to your Regional Spinal Injuries Centre.

2  

Management of Acute Emergencies in Individuals

with

Established Spinal Cord Injury.

The following guidelines are not an exhaustive list and they merely highlight key areas of concern in managing paralysed patients in District General Hospitals.

i           Cardio-vascular system

Autonomic dysreflexia:         Tetraplegic patients and some high thoracic paraplegic patients can suffer autonomic
                                                dysreflexia. This is caused by an abnormal response to ‘would be’ painful stimuli by
                                                the isolated/decompensate autonomic systems.

                                                The condition presents with severe hypotension, bradycardia, pounding headache,
                                                flushed blotchy skin and occasionally with profuse sweating above the level of the
                                                injury.

                                                In the majority of the instances autonomic dysreflexia is precipitated by a distended
                                                bladder or  mal-positioned catheter in the urethra.  Other causes of dysreflexia
                                                include distended bowel (usually with severe constipation or impaction), ingrowing
                                                toenails, pressure sores, burns, sunburn, urinary tract infection, bladder spasm, renal
                                                calculi, bladder calculi, visceral pain due to appendicitis, cholecystitis etc, pregnancy,
                                                parturition, deep venous thrombosis, limb fractures etc.

                                                            Most tetraplegic patients or their carers can often identify the precipitating cause of
                                                            dysreflexia.

                                                           This is a medical emergency and needs prompt resolution of the precipitating
                                                           cause.  If the bladder is distended immediate catheterisation would be indicated.  If
                                                           the catheter has been inflated in the prostatic /bladder neck area, deflation of the
                                                           balloon and reintroduction would  reduce symptoms.

                                                           Medical management includes:

                                                           Sit the patient up
                                                           Sublingual Glycerol Tri-nitrate or Coro-nitro spray (200-400 micrograms) or
                                                           Nifedipine

                                                           Dysreflexia related to anal fissure causing severe anal sphincter spasm and
                                                           constipation could be reduced with the use of local Lignocaine /Xylocaine gel applied
                                                           before bowel evacuation.

ii         Respiratory system

                                                          Chest infections are not uncommon in tetraplegic patients.  Most patients and their
                                                          carers are well versed in active chest physiotherapy.  In addition to treating chest
                                                          infection with appropriate antibiotics, tetraplegic patients may need re-hydration,
                                                          application of humidified oxygen and informed chest physiotherapy. Rapid fluid
                                                          replacements can precipitate respiratory insufficiency in tetraplegic patients.
                                                          Estimation of arterial pH and PCO2 would assist the treating physician in establishing
                                                          the need for respiratory assistance/ventilation.  Clinical signs are often difficult to
                                                          elicit in tetraplegic patients.  A good quality x-ray is often necessary.

iii        GI tract

                                                          Constipation is not uncommon but patients are usually competent in managing their
                                                          bowel  function. Patients can present with profuse rectal bleeding due to piles
                                                          and/or rectal mucosal prolapse. Localising signs normally seen in conditions such as
                                                          appendicitis, cholecystitis, pancreatitis or twisted ovarian cysts are often difficult to
                                                          identify due to loss of sensation and paralysis. Appropriate investigations followed by
                                                          informed assessment by a Senior Medical/Surgical Practitioner is often necessary. 
                                                          Most surgical procedures including a laparotomy result in prolonged paralytic ileus in
                                                          these patients.  Contrast examination of the large bowel in paraplegic/tetraplegic
                                                          patients is often fraught with difficulties because of the tendency for reflex bowel
                                                          evacuation during the procedure. To achieve good bowel clearance patients usually
                                                          need 2 full days of hospital stay with appropriate medications.

iv       Genito-Urinary tract

                                                          Urinary tract infection presenting with septicaemia/haematuria is not uncommon. 
                                                          Bladder drainage with an indwelling urethral catheter and appropriate hydration of
                                                          the patient with intravenous fluids is essential.

                                                          Patients could present with severe dysreflexic symptoms due to orchitis.

                                               Renal tract calcification is well known.  Urological assessments often include
                                               intravenous urography and/or ultrasound examination of the kidneys.  Occasionally
                                               patients may have urinary tract infections associated with erosion of artificial
                                               urethral sphincter, implanted stent etc.   Priapism related to administration of
                                               intracorporeal vaso-active drugs can cause retention of urine and occasionally
                                               dysreflexia.  Aspiration of blood from the corpora together with injection of vaso-
                                               constrictors such as phenyl ephedrine would be of value.

v         Musculo-skeletal system

                                                Extremity fractures in the paralysed part of the body can usually be treated with a
                                                well padded, lightweight POP slab that can be removed easily for the inspection of
                                                underlying skin.  A full POP cast should be avoided.

                                                            Internal fixation of osteoporotic extremity fractures, on occasions may be an
                                                            advantage. 

                                                Treatment by external fixator often results in considerable hardship without material
                                                benefit to the patient.  Soft tissue injuries around the shoulders and elbows will need
                                                protracted period of informed rehabilitation, bed rest and recuperation.

                                                Contractures to the elbows/knees should not be treated by serial plasters.

vi       Central nervous system

            Autonomic dysreflexia – see above.

                                                A small proportion of patients with traumatic spinal cord injury develop
                                                syrinx/syringomyelia resulting in further ne