What is the management of a patient with quadriparesis (quadriplegia)?

Management of Quadriparesis (Quadriplegia)

The management of quadriparesis requires a comprehensive, multidisciplinary approach beginning with early spine immobilization and continuing through specialized rehabilitation to maximize functional outcomes and quality of life.

Initial Management

Immobilization and Assessment

• Early spine immobilization is strongly recommended for any trauma patient with suspected spinal cord injury to limit neurological deterioration 1
• For patients requiring intubation:
  • Use manual in-line stabilization
  • Remove anterior part of cervical collar during intubation
  • Perform rapid sequence induction with direct laryngoscopy
  • Use a gum elastic bougie to increase first-attempt success 1

Blood Pressure Management

• Maintain systolic blood pressure >110 mmHg before injury assessment 1
• For confirmed spinal cord injury, maintain mean arterial pressure (MAP) up to 70 mmHg during the first week 2
• Avoid hypotension as it is an independent factor for mortality 1

Imaging

• Cervical spine can be cleared clinically in alert, cooperative patients with: GCS 15, no intoxication, no neck pain/tenderness, and no distracting injuries 1
• For patients not meeting clinical clearance criteria:
  • Three-view cervical radiographs (lateral, anteroposterior, odontoid)
  • High-resolution CT of entire cervical spine with sagittal reconstructions
  • MRI for patients with neurological deficits 1

Surgical Management

• Emergency surgical decompression should be performed within 24 hours of neurological deficit to improve long-term neurological recovery 2
• Ultra-early surgery (<8 hours) may further reduce complications and increase chances of neurological recovery 2

Acute Hospital Care

Respiratory Management

• Implement a respiratory weaning bundle for patients with cervical cord injury:
  • Abdominal contention belt during spontaneous breathing
  • Active physiotherapy and mechanically-assisted insufflation/exsufflation for secretion removal
  • Aerosol therapy combining beta-2 mimetics and anticholinergics 2
• Consider tracheostomy within the first 7 days for upper level spinal cord injury (C2-C5) 2

Pain Management

• Implement multimodal analgesia combining:
  • Non-opioid analgesics
  • Antihyperalgesic drugs (ketamine)
  • Opioids during surgical management 2
• For neuropathic pain, introduce oral gabapentinoid treatment for >6 months
• Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 2

Pressure Ulcer Prevention

• Implement early preventive measures:
  • Early mobilization once spine is stabilized
  • Visual and tactile checks of all areas at risk at least once daily
  • Repositioning every 2-4 hours with pressure zone checks
  • Use pressure-relieving tools (cushions, foam, pillows)
  • Use high-level prevention supports (air-loss mattress, dynamic mattress) 2

Bladder Management

• Use intermittent urinary catheterization as the reference method for urine drainage
• Remove indwelling catheter as soon as the patient is medically stable
• Implement a micturition calendar to adapt frequency and schedule of catheterization 2

Rehabilitation Phase

Early Rehabilitation

• Begin rehabilitation as soon as the patient is medically stable 1
• Focus on:
  • Maintaining joint amplitudes
  • Preventing and treating spasticity
  • Strengthening existing musculature 2
• Perform stretching for at least 20 minutes per zone
• Use simple posture orthoses and proper bed/chair positioning to prevent deformities 2

Positioning

• Elevate bed at least 30° if patient is at risk of aspiration or airway obstruction
• Consider positioning on the paretic side to facilitate communication and prevent aspiration 2
• Keep neck straight and maintain airway patency 2

Functional Training

• Implement activity-based therapy during rehabilitation phase
• Focus on independence in activities of daily living:
  • Skin care
  • Bowel and bladder management
  • Nutrition
  • Mobility
  • Hygiene and dressing 3

Long-term Considerations

Recovery Timeline

• Majority of recovery occurs during the first 9-12 months
• Relative plateau is typically reached at 12-18 months after injury 1

Complication Prevention

• Monitor for and prevent:
  • Pressure ulcers (affecting up to 55% of patients)
  • Respiratory complications
  • Venous thromboembolism (7-100% in patients with tetraparesis)
  • Urinary tract infections 1

Transfer and Specialized Care

• Transfer to a Level 1 trauma center is associated with earlier surgical procedures, reduced ICU length of stay, and improved neurological outcomes 1
• Involve a multidisciplinary team including:
  • Neurosurgeons/orthopedic surgeons
  • Intensivists
  • Rehabilitation specialists
  • Physical and occupational therapists
  • Respiratory therapists
  • Nurses specialized in spinal cord injury care 2

By following this comprehensive management approach, healthcare providers can optimize outcomes for patients with quadriparesis, focusing on preventing complications, maximizing functional recovery, and improving quality of life.