Musculoskeletal deterioration and hemicorporectomy after spinal cord injury

Abstract

Background and purpose: The long-term management following an hemicorporectomy (HCP) is not well documented in the scientific literature. The purpose of this case report is to describe the 25-year history of a man with a spinal cord injury who experienced severe musculoskeletal deterioration and hemicorporectomy.

Case description: The client sustained T10 complete paraplegia at age 18 years, developed severe decubitus ulcers, and required an HCP as a life-saving measure 13 years later. The authors describe the chronology of several rehabilitation and prosthetic strategies and speculate on factors that may have contributed to their successes and failures.

Outcomes: The client survived 12 years after the HCP and returned to independent mobility, self-care, and schooling despite complications with continued skin breakdown. Over the 12 years following discharge from the hospital after the spinal cord injury, he spent 749 days in the hospital. During the 12 years he lived after discharge from the hospital following the HCP, he was hospitalized 190 days.

Discussion: The authors discuss factors contributing to the client's musculoskeletal deterioration including chronic wounds, postural deviations, and incomplete adherence to pressure-relief recommendations and raise considerations for physical therapists who treat patients after HCP.

Figure 1

Mr P prior to 1996, lying prone. Note the distal scar at the hemicorporectomy terminus and the prominent L4 spinous process (arrow). The patient has an abrasion over the left lateral scapula; this was a frequent complication of wearing his prosthesis.

Figure 2

Mr P in an early version of his prosthesis, prior to the addition of the pyramid adaptor at the distal end (see Fig. 3). The plastic shell rested on a wooden platform (about 14 in square, indicated by lower arrow), which Mr P could rotate to face sideways by performing a wheelchair push-up. Note the openings for the ostomy sites on the abdominal portion of the prosthesis (indicated by upper arrow).

Figure 3

The prosthesis, viewed from the bottom. At center (arrow) is the pyramid (the innermost square), which was embedded into the distal prosthesis, and the pyramid adaptor ring (the circle and outermost square), which surrounded the pyramid. Four screws (visible between the circle and the innermost square) could be independently adjusted by prosthetists to correct deviations in Mr P’s seated tilt.

Figure 4

Mr P lying prone before 1996. Note the prominent L4 spinous process (arrow), which eventually required resection (along with L3) due to chronic skin breakdown and eventual osteomyelitis. Prosthetists routinely heat-relieved Mr P’s prosthesis over L4 to accommodate this bony prominence.

Figure 5

Mr P’s total days hospitalized between the time of his spinal cord injury (SCI) and his hemicorporectomy: (A) including days of acute SCI hospitalization and post-SCI rehabilitation stay and (B) excluding days of acute SCI hospitalization and post-SCI rehabilitation stay. Mr P’s total days hospitalized between the time of his hemicorporectomy and his death: (C) including the days hospitalized for the hemicorporectomy procedure and (D) excluding the days hospitalized for the hemicorporectomy procedure.