In March 2020, the Centers for Disease Control and Prevention (CDC) announced priority levels for testing patients with symptoms of COVID-19 and provided information on when to seek medical attention. At the same time, the agency provided almost no guidance for people with spinal cord injury (SCI), who may not present with typical symptoms due to physiological changes. In an article published in Nature in May 2020, Radha Korupolu, MD, MS, and her research team outlined important differences in how people with SCI may present differently with COVID-19.1
“As soon as the COVID-19 pandemic began, we recognized that patients with SCI would not fit into the screening criteria established by the CDC, and would present a diagnostic challenge,” says Dr. Korupolu, an assistant professor in the department of Physical Medicine and Rehabilitation at McGovern Medical School at UTHealth and an affiliated attending physician at TIRR Memorial Hermann. “Having a spinal cord injury may increase the risk of COVID-19 morbidity, and at the same time it may disguise the symptoms of acute respiratory illness. Last March we had very stringent criteria for COVID-19 testing, and many patients with SCI didn’t meet those criteria. As part of our review, we listed each symptom described by the CDC and explored how it could be very different in patients with spinal cord injury. We also noted that it was taking us longer to diagnose COVID-19 in people with SCI.”
Having a spinal cord injury may increase the risk of COVID-19 morbidity, and at the same time it may disguise symptoms of acute respiratory illness.
“Physiological changes associated with SCI include temperature dysregulation, impaired ability to cough, and abnormal sensations at or below the level of neurological injury, all of which hinder the presentation COVID-19 symptoms,” she says. “People with spinal cord injury may also develop other symptoms during infection, such as new or worsening spasticity, autonomic dysreflexia or fatigue inconsistent with the CDC guidelines.” In an international survey of 783 health care professionals who care for individuals with SCI, 10.3% reported their patients with COVID-19 had increased spasticity, 6.9% reported that their patients had rigors, and 6.0% reported that their patients had been asymptomatic.2
SCI patients with COVID-19 may not present with cough due to disruption of normal respiratory physiology. They also may not perceive the even more alarming presentations of COVID-19, including chest pain and pressure.
“This article was meant as a guide to help patients and families in the early days of the pandemic,” Dr. Korupolu says. “People with spinal cord injury were calling my office every day for information, and we wanted to provide help. We also wanted to bring global attention to the fact that there are atypical symptoms of COVID-19 among the SCI population, and that we need to have contingency plans available to ensure better outcomes for our patients with disabilities.”
1Korupolu R, Stampas A, Gibbons C, Hernandez Jimenez I, Skelton F, Verduzco-Gutierrez M. COVID-19: Screening and triage challenges in people with disability due to Spinal Cord Injury. Nature: Spinal Cord Series and Cases. 2020;6(35). https://doi.org/10.1038/s41394-020-0284-7.
2Stillman MD, Capron M, Alexander M, Di Giusto ML, Scivoletto G. COVID-19 and spinal cord injury and disease: results of an international survey. Spinal Cord Ser Cases. 2020;6:21. https://doi.org/10.1038/s41394-020-0275-8.