eMedicine Specialties > Physical Medicine and Rehabilitation > Spinal Cord Injury

Prevention of Thromboembolism in Spinal Cord Injury: Differential Diagnoses & Workup

Author: Dana McKinney, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center
Coauthor(s): Susan V Garstang, MD, Assistant Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Attending Medical Staff, Director of Spinal Cord Injury Program, Department of Physical Medicine and Rehabilitation, University Hospital
Contributor Information and Disclosures

Updated: Jan 13, 2009

Differential Diagnoses

Achilles Tendon Injuries and Tendonitis
Bursitis
Cellulitis
Heterotopic Ossification
Lymphedema
Superficial Thrombophlebitis

Other Problems to Be Considered

Fracture
Muscle or soft tissue injury
Dependent edema
Ruptured Baker cyst
Hematoma

Workup

Laboratory Studies

  • D-dimer assays
    • Formed when crossed-linked fibrin contained in a thrombus is proteolyzed by plasmin
    • Useful adjunct to noninvasive testing for suggested deep vein thrombosis (DVT)
    • Highly sensitive
    • High negative predictive value - Rules out DVT if negative, but is less helpful if positive, especially in trauma patients

Imaging Studies

  • The accurate diagnosis of deep vein thrombosis (DVT) by clinical signs and symptoms alone is unreliable at best. Signs of unexplained fever, unilateral leg swelling (although swelling can be bilateral), or erythema should alert the clinician to the possibility of DVT. The sudden onset of chest pain, tachycardia, tachypnea, hypoxia, hypotension, or cardiac arrhythmia should suggest pulmonary embolism (PE). The following studies may be used in the diagnosis of thromboembolic disease:
    • Radiocontrast venography
      • The criterion standard for the diagnosis of DVT
      • Invasive procedure that may have adverse effects, including pain
      • Potential of contrast-mediated thrombosis and dye allergy
      • Costly procedure
  • Doppler ultrasonography
    • Noninvasive and sensitive (98-100%) method for the diagnosis of proximal DVT
    • Allows direct imaging of major veins and assessment of velocity of flow in these veins
    • Diagnostic accuracy compares favorably with that of venography
    • Dependent on operator expertise
    • Has become the preferred test in the diagnosis of DVT
  • 125 I fibrinogen scan
    • Greatest sensitivity for calf vein DVT
    • Rarely used in the clinical setting
    • Some disadvantages - These include cost, a 24-hour delay from injection to reading, failure to detect established thrombi, and the danger of viral transmission.
  • Impedance plethysmography (IPG)4
    • Noninvasive test
    • Generates no images, relying instead on unfamiliar technology
    • Less sensitive for detecting DVT of calf muscle
    • Less sensitivity and specificity than Doppler ultrasonography
    • Less sensitive to incomplete obstruction of vein by DVT
    • Extrinsic compression may give positive result.
  • Ventilation/perfusion lung scan
    • This scan is indicated as part of the diagnostic evaluation of PE.
    • A definitive diagnosis occurs if the results are normal or if there is a high probability, especially if clinical suspicion is confirmed by results.
    • Low or intermediate probability scan results require further evaluation (with, for example, lower extremity Doppler ultrasonography or pulmonary angiography).

Related eMedicine topic:
Bedside Ultrasonography, Deep Vein Thrombosis

More on Prevention of Thromboembolism in Spinal Cord Injury

Overview: Prevention of Thromboembolism in Spinal Cord Injury
Differential Diagnoses & Workup: Prevention of Thromboembolism in Spinal Cord Injury
Treatment & Medication: Prevention of Thromboembolism in Spinal Cord Injury
Follow-up: Prevention of Thromboembolism in Spinal Cord Injury
References
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References

  1. Yu HT, Dylan ML, Lin J, et al. Hospitals' compliance with prophylaxis guidelines for venous thromboembolism. Am J Health Syst Pharm. Jan 1 2007;64(1):69-76. [Medline].

  2. Powell M, Kirshblum S, O'Connor KC. Duplex ultrasound screening for deep vein thrombosis in spinal cord injured patients at rehabilitation admission. Arch Phys Med Rehabil. Sep 1999;80(9):1044-6. [Medline].

  3. Jones T, Ugalde V, Franks P, et al. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children. Arch Phys Med Rehabil. Dec 2005;86(12):2240-7. [Medline].

  4. Akers SM, Bartter T, Pratter MR. Impedance plethysmography. It's the clinical outcome that counts. Chest. Nov 1994;106(5):1317-8. [Medline]. [Full Text].

  5. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):381S-453S. [Medline].

  6. Green D. Prophylaxis of thromboembolism in spinal cord-injured patients. Chest. Dec 1992;102(6 Suppl):649S-651S. [Medline]. [Full Text].

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  9. Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med. Sep 5 1996;335(10):701-7. [Medline]. [Full Text].

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  11. Shackford SR, Cook A, Rogers FB, et al. The increasing use of vena cava filters in adult trauma victims: data from the American College of Surgeons National Trauma Data Bank. J Trauma. Oct 2007;63(4):764-9. [Medline].

  12. Burns SP, Nelson AL, Bosshart HT, et al. Implementation of clinical practice guidelines for prevention of thromboembolism in spinal cord injury. J Spinal Cord Med. 2005;28(1):33-42. [Medline].

  13. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Prevention of Thromboembolism in Spinal Cord Injury. 2nd ed. Washington, DC: Paralyzed Veterans of America; 1999.

  14. Hebbeler SL, Marciniak CM, Crandall S, et al. Daily vs twice daily enoxaparin in the prevention of venous thromboembolic disorders during rehabilitation following acute spinal cord injury. J Spinal Cord Med. 2004;27(3):236-40. [Medline].

  15. Slavik RS, Chan E, Gorman SK, et al. Dalteparin versus enoxaparin for venous thromboembolism prophylaxis in acute spinal cord injury and major orthopedic trauma patients: 'DETECT' trial. J Trauma. May 2007;62(5):1075-81; discussion 1081. [Medline].

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  17. Anand SS, Wells PS, Hunt D, et al. Does this patient have deep vein thrombosis?. JAMA. Apr 8 1998;279(14):1094-9. [Medline].

  18. Green D, Rossi EC, Yao JS, et al. Deep vein thrombosis in spinal cord injury: effect of prophylaxis with calf compression, aspirin, and dipyridamole. Paraplegia. Aug 1982;20(4):227-34. [Medline].

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Further Reading

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Keywords

deep venous thrombosis, embolism, DVT, pulmonary embolism, spinal cord injury, clot, blood clot, blood clots, paralysis, spinal cord, spinal, platelet, platelets, thromboembolism, vein thrombosis, deep vein thrombosis, venous thrombosis, anticoagulation, paraplegia, thromboembolic disease, vein thrombosis treatment, venous thrombosis treatment

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Contributor Information and Disclosures

Author

Dana McKinney, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center
Dana McKinney, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Paraplegia Society, and National Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Susan V Garstang, MD, Assistant Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Attending Medical Staff, Director of Spinal Cord Injury Program, Department of Physical Medicine and Rehabilitation, University Hospital
Susan V Garstang, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Medical Editor

Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General Hospital, and Ohio Valley General Hospital.
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds Novaritis; Novaritis  Novaritis; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

 
 
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