Clinical Case Report:

Nutrition Management for Tetraplegia and

Spinal Cord Injury
Dakkota Deem
ARAMARK Dietetic Internship
Williamsport Regional Medical Center
April 1, 2017
Description: Neurologic Disorders

Diseases of the brain, spine, and nerves that connect the

neurons.
Neurologic diseases are complex
Acute or Chronic
Genetics, trauma, secondary to disease, nutritional deficiency

Disorders:
Tetraplegia and Paraplegia due to spinal cord injury (SCI)
Wernicke-Korsakoff Syndrome, multiple sclerosis, Alzheimer's
Disease, peripheral neuropathy, ALS (amyotrophic lateral sclerosis or
Lou Gehrig's Disease), transient ischemic attacks

Nutritional considerations are integral to clinical

management
Description: Tetraplegia

Classified by the International Standards for Neurological

and Functional Classification of Spinal Cord Injury
(INSCSCI) using ASIA

Injury or neural defects resulting in paralysis or no

preservation of motor or sensory function more than
three segments below the level of injury.
Tetraplegia/Quadriplegia

Location of Injury
C1-C2: Functional phrenic nerves- no movement from the neck down
C-3: Likely will be ventilator dependent, shrug shoulders
C-4: Does not require vent past acute phase; deltoid control
C-5: shoulder and bicep control
C-6: Wrist control; no hand function
C-7: Have enhanced mobility; may propel a manual wheelchair; grip
Epidemiology: Spinal Cord Injury (SCI)
282,000 people living with SCIs in 2016
80% male

Average age: 47
Average length of stay: 11 days
Complete/Partial Tetraplegia 58.3%
Most prevalent cause of mortality: pneumonia and septicemia
Endocrine, metabolic, and nutrition-related diseases
Etiology: Tetraplegia

Injury to the spinal column C1-7

Tumor

Polio
Transverse myelitis
Spina bifida/other birth defects
Diagnostic: Tetraplegia

CT and MRI scan

Arterial blood gasses

Lactate
Hemoglobin
INSCSCI using ASIA
http://isncscialgorithm.azurewebsit
es.net

Progression-Trauma
Bleeding, contusion, gliosis,
fibrosis, liquifactive necrosis,
spinal fractures and ligament
instability
Comorbidies and Pathology

Obesity
Malnutrition
Paralytic Ileus/constipation
Diabetes
Cardiovascular Disease (CVD)/Atherogenesis
Osteoporosis and Osteopenia

Hyperlipidemia
Dysphagia
Risk for nutrient deficiency
Loss of sphincter control
Inability to self-feed
Evidenced-Based Recommendations: Nevin et. al
Systematic Review Recommendation:
Use indirect calorimetry
Predictive Equations in SCI (Harris Benedict, whenever possible
Quebbeman and Ausman) Acute:
Compared with measured REE Remove activity factor from
Harris Benedict to assess
Findings: needs (Stress: x1.2)
Harris-Benedict (remove activity factor)
Rehab (calories): EAL Guidelines
Overestimated needs by 30-90% 29 kcal/kg Ideal wt.
22.7 kcal/kg.- Ideal wt.
Up to 370 calories/day difference in SCI
Depending on trauma Add calories with more
function

Promising Findings: DEXA- Metabolic Map for Resting Energy

Expenditure (REE)
Evidenced-Based Recommendations: Lieberman et. al
Pilot Cross-Sectional Study Recommendation:
Conduct a food frequency
Diet quality of SCI vs. Able bodied questionnaire or food
CARDIA Questionnaire recall
Lower rates of CVD Assess compliance with
dietary guidelines
Findings: Assess access safe food
SCI average 2600 calories/day General healthful diet
Decreased energy expenditure education as needed
Assess at risk lab values
SCI consumed fewer than recommended:
Dairy, fruit, and whole grain.
Significantly lower intake of calcium, vitamin d, fiber

Limitation: Lacks generalizability- Convenience Population

EAL Recommendations : MNT for SCI

Indirect calorimetry is the most accurate.

Acute Phase: Estimated energy expenditure (EER): Harris-Benedict using admission
weight (wt.) and injury factor of 1.2 and activity factor of 1.1
Rehab Phase EER: 22.7 kcal/kg. for tetraplegia and 29 kcal/kg. for paraplegia
Protein Needs: 0.8-1 g./kg. is adequate (normal conditions)
Pressure Ulcers (PU): 1.2-1.5 g./kg for stage II PU, 1.5-2 g./kg. for stage III PU
30-40 kcal/kg. energy for pressure ulcers or Harris-Benedict with 1.2 stress factor for Stage II, and
1.5 for stage III and stage IV
30-40 ml./kg for fluids

Constipation: Recommend 40ml./kg of body weight +500 ml. of water and 14

grams fiber intake/day to improve gastric emptying
Micronutrients: Registered Dietitian should recommend a daily vitamin/mineral
supplement that meets no more than 100% RDA due to the changes in metabolic
demands.