What is the approach to assessing a patient with paraplegia?

Comprehensive Assessment of Patients with Paraplegia

The assessment of a patient with paraplegia should include a thorough neurological examination, functional evaluation, and screening for common complications to optimize outcomes and quality of life.

Initial Neurological Assessment

• Determine the level and completeness of spinal cord injury using the American Spinal Injury Association (ASIA) Impairment Scale, which assesses motor and sensory function 1, 2
• Perform a comprehensive vascular examination including pulse palpation (femoral, popliteal, dorsalis pedis, and posterior tibial), auscultation for femoral bruits, and inspection of the legs and feet 1
• Assess motor function in all limbs, with particular attention to any preserved movement below the level of injury 3
• Evaluate sensory function including light touch, pinprick sensation, and proprioception to determine the sensory level 2
• Document reflexes, including deep tendon reflexes and pathological reflexes (e.g., Babinski sign) 4
• Assess for autonomic dysfunction, including blood pressure abnormalities, temperature dysregulation, and bowel/bladder function 2

Functional Assessment

• Evaluate independence in activities of daily living using the Spinal Cord Independence Measure III (SCIM III), which is the most frequently used functional assessment tool for patients with spinal cord injury 2
• Assess mobility status, including wheelchair skills, transfer abilities, and any preserved ambulatory function 5
• Evaluate upper extremity function thoroughly, as paraplegic patients rely almost exclusively on their upper extremities for weight-bearing activities such as transfers and wheelchair propulsion 5
• Consider using the "Get Up and Go Test" to assess mobility and balance in patients with incomplete paraplegia who retain some ambulatory function 1
• Document quality of life measures using validated tools such as VasculQoL-6 or other spinal cord injury-specific instruments 1

Screening for Complications

Vascular Assessment

• Measure blood pressure in both arms to identify potential subclavian artery stenosis (difference >15-20 mmHg between arms is abnormal) 1
• Calculate the ankle-brachial index (ABI) to screen for peripheral artery disease, with values ≤0.90 confirming PAD 1
• Inspect the lower extremities for signs of chronic limb-threatening ischemia, including nonhealing wounds, gangrene, or other ischemic skin changes 1

Pressure Injury Assessment

• Thoroughly examine all pressure points, especially the sacrum, ischial tuberosities, and trochanters 1
• Evaluate for signs of pelvic osteomyelitis in patients with sacral pressure injuries, which is a common complication in paraplegic patients 1
• Consider diverting colostomy in paraplegic patients with sacral pressure injuries who are incontinent of stool to prevent repetitive wound contamination 1

Upper Extremity Assessment

• Screen for shoulder pain and carpal tunnel syndrome, which affect up to 67.8% of paraplegic patients due to increased weight-bearing demands 5
• Assess for signs of overuse injuries in the upper extremities, as symptoms tend to increase with time from injury 5

Laboratory and Imaging Studies

• Obtain basic laboratory studies including complete blood count, renal function, electrolytes, and inflammatory markers (C-reactive protein, erythrocyte sedimentation rate) 1
• Consider additional laboratory tests as indicated, including HbA1c, lipid profile, and coagulation studies 1
• Order appropriate imaging studies based on clinical findings and suspected complications 6

Multidisciplinary Approach

• Coordinate care with an interdisciplinary team including physical medicine and rehabilitation specialists, physical therapists, occupational therapists, and other relevant specialists 1
• Address psychological aspects of paraplegia, including screening for depression which can impact functional outcomes 1
• Evaluate socioeconomic factors that may affect rehabilitation outcomes, including housing stability, caregiver support, and access to healthcare 1

Common Pitfalls to Avoid

• Failing to distinguish between paraplegia (complete loss of motor function) and paraparesis (partial preservation of motor function) 3
• Overlooking upper extremity complications that develop over time in paraplegic patients who rely on their arms for mobility 5
• Neglecting to perform regular skin assessments, which should be among the most frequently performed evaluations in paraplegic patients 2
• Missing peripheral artery disease, which may be masked by sensory deficits in paraplegic patients 1
• Underestimating the impact of depression and psychological factors on rehabilitation outcomes and quality of life 1