What is the management of Beevor's sign in paraplegia?

Management of Beevor's Sign in Paraplegia

In patients with paraplegia, Beevor's sign should be recognized as a diagnostic indicator of spinal cord injury between T10-T12 levels, and management should focus on addressing the underlying neurological deficit and preventing complications rather than treating the sign itself. 1

Understanding Beevor's Sign

Beevor's sign is characterized by an upward movement of the umbilicus when a patient flexes their neck or attempts to sit up from a supine position. This occurs due to:

• Paralysis of the inferior portion of the rectus abdominis muscle
• Preserved function of the upper rectus abdominis fibers, which pull the umbilicus upward
• Typically indicates a spinal cord lesion between T10 and T12 segments 2, 3

Diagnostic Significance in Paraplegia

• Helps determine the neurological level of injury (NLI), which is crucial for establishing the level and completeness of spinal cord injury 1
• Indicates a complete upper motor neuron (UMN) lesion when reflexes are preserved below the injury level but voluntary movement is absent 1
• May persist throughout the disease course in patients with certain conditions like hereditary spastic paraplegia 1

Management Approach

1. Comprehensive Neurological Assessment

• Document the presence of Beevor's sign to help localize the level of spinal cord injury
• Assess for other signs of autonomic dysfunction, as hyperreflexia may be an early sign of autonomic dysreflexia in patients with injuries at T6 or above 1
• Evaluate the degree of hyperreflexia to guide spasticity management decisions 1

2. Functional Assessment and Rehabilitation

• Engage the patient in tasks that promote normal movement, good alignment, and even weight-bearing 4
• Consider joint sessions with physical therapy colleagues to complete tasks using the upper limbs while standing with the aid of a standing frame for patients with bilateral functional lower limb weakness 4
• Implement strategies that reduce muscle overactivity, pain, and fatigue 4

3. Prevention of Complications

Pressure Injury Prevention

• For patients with paraplegia showing Beevor's sign, consider diverting colostomy if they are incontinent of stool to prevent repetitive wound contamination of pressure injuries 4
• Be aware that aggressive debridement of one ischium is generally well tolerated, but bilateral aggressive debridement should be avoided as it transfers sitting pressure to the sacrum 4

Spasticity Management

• Address spasticity based on the degree of hyperreflexia 1
• Implement strategies to reduce muscle overactivity such as:
  • Muscle relaxation strategies
  • Supporting affected limbs when at rest
  • Using pillows or furniture to take the weight of limbs when sitting or lying down 4

Autonomic Dysfunction Management

• Monitor for signs of autonomic dysreflexia, particularly in patients with injuries at T6 or above 1
• Implement regular monitoring of heart rate, blood pressure, and bowel and bladder function 4

4. Multidisciplinary Care Approach

• Involve a team including physical therapists, occupational therapists, rehabilitation specialists, and nurses 4
• Address psychological aspects including anxiety, depression, and pain which are common in patients with paraplegia 4
• Consider early engagement of caregivers and legal guardians, especially in patients with communication barriers 4

Special Considerations

• In patients with paraplegia, Beevor's sign may be present throughout the disease course, unlike in conditions like facioscapulohumeral muscular dystrophy where it has diagnostic value 2, 5
• The presence of Beevor's sign in paraplegia can provide valuable information about the effect of abdominal weakness on motor and respiratory function 6
• Avoid splinting as it may prevent restoration of normal movement and function, potentially leading to muscle deconditioning and increased pain 4

By recognizing and properly interpreting Beevor's sign in patients with paraplegia, clinicians can better understand the neurological level of injury and implement appropriate management strategies to improve outcomes related to mobility, prevention of complications, and quality of life.