Showing papers in "Journal of Spinal Cord Medicine in 2011"

International standards for neurological classification of spinal cord injury (Revised 2011)

Abstract: This article represents the content of the booklet, International Standards for Neurological Classification of Spinal Cord Injury, revised 2011, published by the American Spinal Injury Association (ASIA). For further explanation of the clarifications and changes in this revision, see the accompanying article (Kirshblum S., et al. J Spinal Cord Med. 2011:doi 10.1179/107902611X13186000420242 The spinal cord is the major conduit through which motor and sensory information travels between the brain and body. The spinal cord contains longitudinally oriented spinal tracts (white matter) surrounding central areas (gray matter) where most spinal neuronal cell bodies are located. The gray matter is organized into segments comprising sensory and motor neurons. Axons from spinal sensory neurons enter and axons from motor neurons leave the spinal cord via segmental nerves or roots. In the cervical spine, there are 8 nerve roots. Cervical roots of C1-C7 are named according to the vertebra above which they exit (i.e. C1 exits above the C1 vertebra, just below the skull and C6 nerve roots pass between the C5 and C6 vertebrae) whereas C8 exists between the C7 and T1 vertebra; as there is no C8 vertebra. The C1 nerve root does not have a sensory component that is tested on the International Standards Examination. The thoracic spine has 12 distinct nerve roots and the lumbar spine consists of 5 distinct nerve roots that are each named accordingly as they exit below the level of the respective vertebrae. The sacrum consists of 5 embryonic sections that have fused into one bony structure with 5 distinct nerve roots that exit via the sacral foramina. The spinal cord itself ends at approximately the L1-2 vertebral level. The distal most part of the spinal cord is called the conus medullaris. The cauda equina is a cluster of paired (right and left) lumbosacral nerve roots that originate in the region of the conus medullaris and travel down through the thecal sac and exit via the intervertebral foramen below their respective vertebral levels. There may be 0, 1, or 2 coccygeal nerves but they do not have a role with the International Standards examination in accordance with the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Each root receives sensory information from skin areas called dermatomes. Similarly each root innervates a group of muscles called a myotome. While a dermatome usually represents a discrete and contiguous skin area, most roots innervate more than one muscle, and most muscles are innervated by more than one root. Spinal cord injury (SCI) affects conduction of sensory and motor signals across the site(s) of lesion(s), as well as the autonomic nervous system. By systematically examining the dermatomes and myotomes, as described within this booklet, one can determine the cord segments affected by the SCI. From the International Standards examination several measures of neurological damage are generated, e.g., Sensory and Motor Levels (on right and left sides), NLI, Sensory Scores (Pin Prick and Light Touch), Motor Scores (upper and lower limb), and ZPP. This booklet also describes the ASIA (American Spinal Injury Association) Impairment Scale (AIS) to classify the severity (i.e. completeness) of injury. This booklet begins with basic definitions of common terms used herein. The section that follows describes the recommended International Standards examination, including both sensory and motor components. Subsequent sections cover sensory and motor scores, the AIS classification, and clinical syndromes associated with SCI. For ease of reference, a worksheet (Appendix 1) of the recommended examination is included, with a summary of steps used to classify the injury (Appendix 2). A full-size version for photocopying and use in patient records has been included as an enclosure and may also be downloaded from the ASIA website (www.asia-spinalinjury.org). Additional details regarding the examination and e-Learning training materials can also be obtained from the website15.

Spinal tuberculosis: A review

Abstract: Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a ‘cold’ abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.

Reference for the 2011 revision of the international standards for neurological classification of spinal cord injury

Abstract: The latest revision of the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) was available in booklet format in June 2011, and is published in this issue of the Journal of Spinal Cord Medicine. The ISNCSCI were initially developed in 1982 to provide guidelines for the consistent classification of the neurological level and extent of the injury to achieve reliable data for clinical care and research studies. This revision was generated from the Standards Committee of the American Spinal Injury Association in collaboration with the International Spinal Cord Society's Education Committee. This article details and explains the updates and serves as a reference for these revisions and clarifications.

Comparison of training methods to improve walking in persons with chronic spinal cord injury: a randomized clinical trial

Abstract: ObjectiveTo compare two forms of device-specific training – body-weight-supported (BWS) ambulation on a fixed track (TRK) and BWS ambulation on a treadmill (TM) – to comprehensive physical therapy (PT) for improving walking speed in persons with chronic, motor-incomplete spinal cord injury (SCI).MethodsThirty-five adult subjects with a history of chronic SCI (>1 year; AIS ‘C’ or ‘D’) participated in a 13-week (1 hour/day; 3 days per week) training program. Subjects were randomized into one of the three training groups. Subjects in the two BWS groups trained without the benefit of additional input from a physical therapist or gait expert. For each training session, performance values and heart rate were monitored. Pre- and post-training maximal 10-m walking speed, balance, muscle strength, fitness, and quality of life were assessed in each subject.ResultsAll three training groups showed significant improvement in maximal walking speed, muscle strength, and psychological well-being. A significant im...

Inpatient treatment time across disciplines in spinal cord injury rehabilitation

Abstract: Background/objectiveLength of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs.MethodsSix hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and with...

Epidemiological profile of 239 traumatic spinal cord injury cases over a period of 12 years in Tianjin, China.

Abstract: Study design Hospital-based retrospective review. Objective To describe the epidemiological characteristics and trends of traumatic spinal cord injury in Tianjin, China. Setting Tianjin Medical University General Hospital. Methods Medical records of 239 patients with traumatic spinal cord injury admitted to a general hospital from 1998 to 2009 were reviewed. Variables included gender, age, marital status, occupation, etiology, time of injury, level, and severity of injury. Epidemiological characteristics of different countries were compared. Results Over this period, the mean age of patients with traumatic spinal cord injury was 45.4 ± 14.1 years, and the male/female ratio was 4.6:1. In all, 86.2% were married. The leading cause was fall (52.3%), followed by motor vehicle collision (36.4%). The most common injury site was the cervical spinal cord, accounting for 82.0%. Incomplete tetraplegia made up for 59.4%, followed by complete tetraplegia (22.6%). Eight patients died after operation, six of whom died ...

The SCIRehab project: treatment time spent in SCI rehabilitation. Psychology treatment time during inpatient spinal cord injury rehabilitation.

Abstract: Background: Rehabilitation psychologists are integral members of spinal cord injury (SCI) rehabilitation teams. Objective: To describe specific information regarding types and intensity of treatments delivered by rehabilitation psychologists to patients with various levels of SCI. Methods: Utilizing a taxonomy of psychological interventions as a framework, rehabilitation psychologists documented time spent on specific psychology interventions for each interaction they had with 600 patients with traumatic SCI at 6 inpatient SCI rehabilitation centers. Associations of patient and injury characteristics with time spent on various psychological interventions were examined using ordinary least squares stepwise regression models. Results: Psychologists focus the majority of the time they spend with patients with SCI on psychotherapeutic interventions of processing emotions, emotional adjustment, and family coping, while educational efforts focus mostly on coping and adjusting to the new injury. There was wide variation in the amount of time spent on psychotherapeutic and psychoeducational interventions; patient, injury, and clinician characteristics explained little of the variation in time spent. Conclusions: Variations observed in psychological treatment delivery mirror real-world human complexity and clinical experience; they are not explained well by patient and injury characteristics and set the stage for future analyses to associate treatments with outcomes.

Spinal cord injury in Manitoba: a provincial epidemiological study.

Abstract: Objective: To define the epidemiological trends and identify populations at risk of traumatic and non-traumatic spinal cord injury (NTSCI) for the province of Manitoba, Canada. Methods: We reviewed records retrospectively for subjects in three cohorts (1981–1985, 1998–2002, and 2003–2007). A total of 553 individuals with spinal cord injury (SCI) were studied for variables such as age, level of injury, severity of injury, First Nations (FN) status, and etiology of injury. Results: Incidence of overall SCI has increased from 22.0 to 46.5 per million (P< 0.001). Incidence of NTSCI increased from 3.12 per million to 16.7 per million (P < 0.001). Incidence of traumatic spinal cord injury (TSCI) has increased from the 17.1 per million to 25.6 per million (P < 0.001). There was a significant increase in the mean age at injury from 30.23 to 45.768 years of age (P < 0.0001). Female and NTSCI have a higher mean and median age at injury. There was a significant (P = 0.0008) increase in the proportion of females with a most recent male/female ratio of 3.4:1. A temporal increase in incomplete injuries was observed (P < 0.0001). Incomplete and thoracic level injuries are more common with NTSCI. Conclusion: The results demonstrate that there are significant differences between NTSCI and TSCI in Manitoba, and that Manitoba trends in SCI are in keeping with those seen on a national and an international level. There is a high risk of SCI in Manitoba FN, for which preventive strategies need to be put in place, and higher resource structure geared towards. Additionally, the trend of older age at injury has significant implications for structuring acute care and rehabilitation programs for these individuals, enhancing the need for treating older and more medically complicated individuals with SCI.

Effects of reduction in shoulder pain on quality of life and community activities among people living long-term with SCI paraplegia: a randomized control trial

Abstract: Objective/backgroundPeople with spinal cord injury (SCI) paraplegia can develop shoulder problems over time, which may also cause pain. Shoulder pain may complicate or interfere with a person's daily activities, social events, and their overall quality of life (QOL). The purpose of this study was to examine changes in social interaction and QOL after an exercise treatment for shoulder pain in people with SCI paraplegia.DesignFifty-eight participants with SCI paraplegia who were also experiencing shoulder pain were selected and randomized to either an exercise treatment or a control group. Participants in the treatment group participated in a 12-week, at-home, exercise and movement optimization program designed to strengthen shoulder muscles and modify movements related to upper extremity weight bearing.MethodsParticipants filled out self-report measures at baseline, 12 weeks later at the end of treatment, and at a 4-week follow-up.Outcome measuresThe Wheelchair User's Shoulder Pain Index (WUSPI), ...

Influence of motor complete spinal cord injury on visceral and subcutaneous adipose tissue measured by multi-axial magnetic resonance imaging

Abstract: Objective: Abdominal obesity conveys substantial health risks, in association with high levels of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and an increased proportion of VAT to SAT. The purposes were to determine the influence of spinal cord injury (SCI) on the associations between single axial cross-sectional area (CSA) slices and the average CSA or volumes of VAT and SAT across multi-axial slices of magnetic resonance imaging (MRI); and the relationships relative to the whole body composition and anthropometrics. Methods: Thirteen healthy male participants with traumatic motor complete SCI underwent fast spin-echo MRI to measure VAT and SAT across multi-axial slices, followed by dual-energy X-ray absorptiometry to measure whole body fat-free mass (FFM) and fat mass (FM). Waist circumference (WC) was also measured in the seated position. Results: The trunk CSAs of VAT and SAT were 99 ± 51 and 164 ± 69 cm2, respectively, and the ratio of VAT to SAT was 0.68 ± 0.33. The CSAs of VAT ...

Treatment of urinary tract infection in persons with spinal cord injury: guidelines, evidence, and clinical practice. A questionnaire-based survey and review of the literature.

Abstract: Objectives: To investigate current clinical practice in the treatment of urinary tract infections (UTIs) in persons with spinal cord injury (SCI) in SCI centers where German is spoken and to compare it with current guidelines and evidence-based standards evaluated by a literature review. Methods: A standardized questionnaire was mailed to 16 SCI rehabilitation centers. The results were compared with a literature review Results: Of the 16 centers, 13 responded. Indications for UTI treatment, medications, and treatment duration differed substantially among the individual centers and from the existing guidelines. Antibiotic treatment is regarded as the method of choice. Compared with the existing literature, patients in two center were undertreated, whereas they were overtreated in seven centers. Conclusion: Even in specialized centers, treatment of UTI in patients with SCI is based more on personal experience of the treating physicians than on published evidence. This may at least partly be due to the paucity of evidence-based data. The observed tendency toward overtreatment with antibiotics carries substantial future risks, as this strategy may well lead to the induction of multiresistant bacterial strains. Therefore, developing guidelines would be an important step toward a unification of the different treatment strategies, thus reducing unnecessary antibiotic treatment. Furthermore, evidence-based studies evaluating the success of antibiotic treatment as well as the usefulness of alternative strategies are urgently needed.

Evaluation of activity monitors in manual wheelchair users with paraplegia

Abstract: Objective: The aim of this study was to evaluate the performance of SenseWear® (SW) and RT3 activity monitors (AMs) in estimating energy expenditure (EE) in manual wheelchair users (MWUs) with paraplegia for a variety of physical activities.Methods: Twenty-four subjects completed four activities including resting, wheelchair propulsion, arm-ergometry exercise, and deskwork. The criterion EE was measured by a K4b2 portable metabolic cart. The EE estimated by the SW and RT3 were compared with the criterion EE by the absolute differences and absolute percentage errors. Intraclass correlations and the Bland and Altman plots were also used to assess the agreements between the two AMs and the metabolic cart. Correlations between the criterion EE and the estimated EE and sensors data from the AMs were evaluated.Results: The EE estimation errors for the AMs varied from 24.4 to 125.8% for the SW and from 22.0 to 52.8% for the RT3. The intraclass correlation coefficients (ICCs) between the criterion EE and ...

Effect of technique and timing of tracheostomy in patients with acute traumatic spinal cord injury undergoing mechanical ventilation

Abstract: Objective: To assess the effect of timing and techniques of tracheostomy on morbidity, mortality, and the burden of resources in patients with acute traumatic spinal cord injuries (SCIs) undergoing mechanical ventilation. Design: Review of a prospectively collected database. Setting: Intensive and intermediate care units of a monographic hospital for the treatment of SCI. Participants: Consecutive patients admitted to the intensive care unit (ICU) during their first inpatient rehabilitation for cervical and thoracic traumatic SCI. A total of 323 patients were included: 297 required mechanical ventilation and 215 underwent tracheostomy. Outcome measures: Demographic data, data relevant to the patients’ neurological injuries (level and grade of spinal cord damage), tracheostomy technique and timing, duration of mechanical ventilation, length of stay at ICU, incidence of pneumonia, incidence of perioperative and early postoperative complications, and mortality. Results: Early tracheostomy (<7 days after orotracheal intubation) tracheostomy was performed in 101 patients (47%) and late (≥7 days) in 114 (53%). Surgical tracheostomy was employed in 119 cases (55%) and percutaneous tracheostomy in 96 (45%). There were 61 complications in 53 patients related to all tracheostomy procedures. Two were qualified as serious (tracheoesophageal fistula and mediastinal abscess). Other complications were mild. Bleeding was moderate in one case (late, percutaneous tracheostomy). Postoperative infection rate was low. Mortality of all causes was also low. Conclusion: Early tracheostomy may have favorable effects in patients with acute traumatic SC. Both techniques, percutaneous and surgical tracheostomy, can be performed safely in the ICU.

Comparison of 24-hour cardiovascular and autonomic function in paraplegia, tetraplegia, and control groups: Implications for cardiovascular risk

Abstract: BackgroundFluctuations in 24-hour cardiovascular hemodynamics, specifically heart rate (HR) and blood pressure (BP), are thought to reflect autonomic nervous system (ANS) activity. Persons with spinal cord injury (SCI) represent a model of ANS dysfunction, which may affect 24-hour hemodynamics and predispose these individuals to increased cardiovascular disease risk.ObjectiveTo determine 24-hour cardiovascular and ANS function among individuals with tetraplegia (n = 20; TETRA: C4–C8), high paraplegia (n = 10; HP: T2–T5), low paraplegia (n = 9; LP: T7–T12), and non-SCI controls (n = 10). Twenty-four-hour ANS function was assessed by time domain parameters of heart rate variability (HRV); the standard deviation of the 5-minute average R–R intervals (SDANN; milliseconds/ms), and the root-mean square of the standard deviation of the R–R intervals (rMSSD; ms). Subjects wore 24-hour ambulatory monitors to record HR, HRV, and BP. Mixed analysis of variance (ANOVA) revealed significantly lower 24-hour BP ...

Mortality in patients with traumatic spinal cord injury: Descriptive analysis of 62 deceased subjects

Abstract: Study design Retrospective study. Objective To investigate the causes of death in patients who were ≤50 years at the time of traumatic spinal cord injury (tSCI). Setting Convenience sample of a tertiary rehabilitation center. Methods All deceased patients with tSCI who survived a minimum of 10 years post-injury, were included. In addition, causes of death were compared between subjects surviving <10 years and ≥10 years. Neurological assessments were performed according to the American Spinal Injury Association scale. Data on causes of death were analyzed using the ICD-10 classifications. Differences were calculated using the Mann–Whitney and chi-square tests. Results A total of 100 patients, with 38 and 62 surviving <10 and ≥10 years, respectively, were included. No significant differences in causes of death were identified between these two groups. In patients surviving ≥10 years, paraplegia was associated with a higher life expectancy compared with tetraplegia, 34 and 25 years (p = 0.008), respectively,...

Comparison of the effects of body-weight- supported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury

Abstract: Objective: Determine the effects of body-weight-supported treadmill training (BWSTT) and tilt-table standing (TTS) on clinically assessed and self-reported spasticity, motor neuron excitability, and related constructs in individuals with chronic spinal cord injury (SCI). Design: Random cross-over. Methods: Seven individuals with chronic SCI and spasticity performed thrice-weekly BWSTT for 4 weeks and thrice-weekly TTS for 4 weeks, separated by a 4-week wash-out. Clinical (Modified Ashworth Scale, Spinal Cord Assessment Tool for Spinal reflexes) and self-report (Spinal Cord Injury Spasticity Evaluation Tool, Penn Spasm Frequency Scale) assessments of spasticity, quality of life (Quality of Life Index Spinal Cord Injury Version – III), functional mobility (FIM Motor Subscale), plus soleus H-reflex were measured at baseline, after the first training session and within 2 days of completing each training condition. Results:In comparison with TTS, a single session of BWSTT had greater beneficial effects for muscle tone (effect size (ES) = 0.69), flexor spasms (ES= 0.57), and the H/M ratio (ES = 0.50). Similarly, flexor spasms (ES = 0.79), clonus (ES = 0.66), and self-reported mobility (ES= 1.27) tended to benefit more from 4 weeks of BWSTT than of TTS. Participation in BWSTT also appeared to be favorable for quality of life (ES = 0.50). In contrast, extensor spasms were reduced to a greater degree with TTS (ES = 0.68 for single session; ES = 1.32 after 4 weeks). Conclusion: While both BWSTT and TTS may provide specific benefits with respect to spasticity characteristics, data from this pilot study suggest that BWSTT may result in a broader range of positive outcomes.

Comparison of nutritional intake between individuals with acute and chronic spinal cord injury.

Abstract: ObjectiveTo compare the nutritional intake of patients with acute and chronic spinal cord injury (SCI).DesignCross-sectional, observational study.SettingSpinal cord unit.MethodsTwelve in-house patients of a spinal cord unit with acute SCI and paralysis duration of 5.3 ± 2.5 months (acute group) were compared with 12 subjects with chronic SCI (chronic group) with lesion duration of 55.5 ± 21.0 months. All subjects recorded their nutritional intake for 7 days, which was analyzed for intake of energy, proteins, fat, carbohydrates, vitamins, mineral nutrients, fluid, and dietary fiber. Resting energy expenditure (REE) and total body fat were also determined.ResultsThe chronic group showed a significantly higher total body fat content compared to the acute group (19.4 ± 3.8 vs. 15.7 ± 4.3%). All other parameters were not significantly different between groups. Both groups ingested excessive fat and insufficient amounts of carbohydrates compared with common nutritional recommendations. Low intakes of vi...

Weight gain following spinal cord injury: a pilot study.

Abstract: Study designRetrospective chart review.ObjectiveTo define the temporal course of weight gain in persons with new spinal cord injury (SCI), and to identify predictors of weight gain in this population.SettingA United States Department of Veterans Affairs (VA) SCI Unit.MethodsA retrospective chart review in a VA SCI Unit was conducted. Participants (n = 85) included all persons with new SCI completing initial rehabilitation at the center between 1998 and 2006. Outcome measures were mean change in body mass index (BMI) between rehabilitation admission and final follow-up, time of greatest BMI change, and distribution of participants by BMI classification. These measures were also examined relative to SCI level, American Spinal Injury Association Impairment Scale (AIS) grade, primary mode of mobility, and age at rehabilitation admission.ResultsMean BMI increased by 2.3 kg/m2 between rehabilitation admission (mean 45 days post-injury) and final follow-up (mean 5 years post-injury). The distribution of ...

Efficacy of cranial electrotherapy stimulation for neuropathic pain following spinal cord injury: a multi-site randomized controlled trial with a secondary 6-month open-label phase

Abstract: Background Chronic pain is a significant problem for many individuals following spinal cord injury (SCI). Unfortunately, SCI-related neuropathic pain has proven to be largely refractory to analgesic medications and other available treatments. Cranial electrotherapy stimulation (CES) has been effective in managing some types of pain. It involves the application of a small amount of current through the head via ear clip electrodes. Objective Explore the effectiveness of CES for neuropathic pain in persons with SCI and chronic pain. Study design Multi-site, double-blind, sham-controlled study. Participants Adults with SCI and chronic neuropathic pain at or below the level of injury were randomized to receive active or sham CES. Intervention Application of active CES or sham CES 1 hour daily for 21 days. Six-month open-label phase to assess ‘as-needed’ CES use. Outcome measures Change in pre- to post-session pain ratings as well as change in pain intensity, pain interference, pain quality, pain beliefs and co...

Treatment of pressure ulcers with autologous bone marrow nuclear cells in patients with spinal cord injury

Abstract: Context: Pressure ulcers are especially difficult to treat in patients with spinal cord injury (SCI) and recurrence rates are high Prompted by encouraging results obtained using bone marrow stem cells to treat several diseases including chronic wounds, this study examines the use of autologous stem cells from bone marrow to promote the healing of pressure ulcers in patients with SCI Objective: To obtain preliminary data on the use of bone marrow mononuclear cells (BM-MNCs) to treat pressure ulcers in terms of clinical outcome, procedure safety, and treatment time Participants: Twenty-two patients with SCI (19 men, 3 women; mean age 5641 years) with single type IV pressure ulcers of more than 4 months duration Interventions: By minimally invasive surgery, the ulcers were debrided and treated with BM-MNCs obtained by Ficoll density gradient separation of autologous bone marrow aspirates drawn from the iliac crest Results: In 19 patients (8636%), the pressure ulcers treated with BM-MNCs had fully healed after a mean time of 21 days The number of MNCs isolated was patient dependent, although similar clinical outcomes were observed in each case Compared to conventional surgical treatment, mean intra-hospital stay was reduced from 8516 to 4306 days Following treatment, 5 minutes of daily wound care was required per patient compared to 20 minutes for conventional surgery During a mean follow-up of 19 months, none of the resolved ulcers recurred Conclusions: Our data indicate that cell therapy using autologous BM-MNCs could be an option to treat type IV pressure ulcers in patients with SCI, avoiding major surgical intervention

Clinical assessment of obesity in persons with spinal cord injury: validity of waist circumference, body mass index, and anthropometric index.

Abstract: Objective: To study the relationship of waist circumference (WC) and bioelectrical impedance analysis (BIA) and degree of agreement between anthropometric index (AI) and BIA, using BIA as a reference or ‘gold standard’. The second objective isto study the relationship between body mass index (BMI) and BIA in subjects with spinal cord injury (SCI). Study design: Comparative cross-sectional study. Setting: Convenience sample at outpatient clinic of spinal cord center. Outcome measures: Estimation of obesity was made in 23 men with motor complete paraplegia (>1 year postinjury). Bland and Altman statistics were used to define level of agreement between AI and BIA, Pearson’s r to describe correlation between WC and BIA and BMI and BIA. Results: Good agreement between BIA and AI with a small systematic difference in fat mass (FM) (mean difference: −0.28%, Pearson’s r: 0.91) was found. The correlation between WC and the BIA (% FM) was very high (Pearson’sr: 0.83). The correlation between WC and BMI (% FM) was just over moderate (Pearson’sr: 0.51). Conclusion: AI seems to be a valid proxy measure to estimate obesity in males living with SCI. Measurement of obesity in persons with SCI based on WC is promising. BMI showed not to be valid to estimate obesity in persons with SCI.

Occupational therapy treatment time during inpatient spinal cord injury rehabilitation

Abstract: BackgroundOccupational therapy (OT) is a critical component of the rehabilitation process after spinal cord injury (SCI), the constitution of which has not been studied or documented in full detail...

Dysphagia in individuals with tetraplegia: incidence and risk factors

Abstract: Background/objective: Dysphagia following cervical spinal cord injury (SCI) can increase risk for pulmonary complications that may delay the rehabilitative process. The objective of this study was to identify risk factors for dysphagia after cervical SCI.Design: Prospective cohort study.Methods: Individuals with cervical SCI within 31 days of injury underwent a bedside swallow evaluation (BSE) followed by a videofluoroscopy swallow study (VFSS) within 72 hours of the BSE. Subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS.Results: Twenty-nine patients (7 female and 22 male) were enrolled. Of these, 21 (72%) had high cervical tetraplegia (C4 or higher) and 8 (38%) had lower cervical tetraplegia. A tracheostomy was present in 18 (62%) patients; 15 (52%) subjects were on ventilators. Dysphagia was diagnosed in 12 (41%) subjects. Dysphagia was noted in 62% of the subjects with tracheostomy and 53% of the subjects on the ventilator, but only tracheostomy res...

What's happening now! Telehealth management of spinal cord injury/disorders

Abstract: ContextSpinal cord injury and/or disorders (SCI/D) is a costly chronic condition. Impaired mobility, and lengthy travel distances to access specialty providers are barriers that can have adverse impact on expenses and quality of care. Although ample opportunities for use of telehealth technologies exist between medical facilities, and from clinical to home settings, field experience has largely been focused on home telehealth services to promote better patient self-management skills and improve clinical outcomes.FindingsThis paper provides an overview of published literature on use of telehealth technologies with the SCI/D population. Presentation of case studies describe telehealth as a potential strategy for addressing disparities in providing quality care, and explore comprehensive management of multiple health issues in individuals with SCI/D. Experiences of providers in both private sector health-care systems and VHA medical facilities are described. Development of telehealth clinical protoco...

Lumbar vertebral haemangioma causing pathological fracture, epidural haemorrhage, and cord compression: a case report and review of literature.

Abstract: Context Vertebral haemangiomas are recognized to be one of the commonest benign tumours of the vertebral column, occurring mostly in the thoracic spine. The vast majority of these are asymptomatic. Infrequently, these can turn symptomatic and cause neurological deficit (cord compression) through any of four reported mechanisms: (1) epidural extension; (2) expansion of the involved vertebra(e) causing spinal canal stenosis; (3) spontaneous epidural haemorrhage; (4) pathological burst fracture. Thoracic haemangiomas have been reported to be more likely to produce cord compression than lumbar haemangiomas. Findings A forty-nine year old male with acute onset spinal cord compression from a pathological fracture in a first lumbar vertebral haemangioma. An MRI delineated the haemangioma and extent of bleeding that caused the cord compression. These were confirmed during surgery and the haematoma was evacuated. The spine was instrumented from T12 to L2, and a cement vertebroplasty was performed intra-operatively...

A case report on the use of sustained release platelet-rich plasma for the treatment of chronic pressure ulcers

Abstract: Background/objectives: Chronic pressure ulcers affect patient health, emotional state, and quality of life, causing considerable morbidity and mortality in addition to contributing to significant health care costs from lengthy hospitalizations to advanced home care and surgical care costs. The conventional treatment of these wounds can be slow due to their chronic inflammatory state and the senescence of local reparative cells. Platelet-rich plasma (PRP) therapy has been growing as a viable treatment alternative for a number of clinical applications and has potential benefit for use in chronic wounds. The sustained release of large quantities of autologous growth factors, cytokines, and other mediators found in PRP plus the favorable mononuclear cell profile of PRP may help us to stimulate wound healing and resolve chronic inflammation. Methods: Three veterans with spinal cord injury (SCI), presenting with chronic stage IV pressure ulcers, were treated with a sustained release PRP therapy to stimulate wound healing. Results: PRP treatment consistently resulted in the formation of granulation tissue and improved vascularity for each of the three patients treated, while reducing the overall ulcer area and volume. Conclusion: The controlled release of growth factors from PRP demonstrated a positive stimulatory effect on the healing rate of chronic pressure ulcers in individuals with SCI.

Prehospital transport of patients with spinal cord injury in Nigeria

Abstract: Background: Awell-organized and efficient prehospital transport is associated with improved outcome in trauma patients. In Nigeria, there is paucity of information on prehospital transport of patients with spinal cord injury (SCI) and its relation to mortality. Objective: To determine if prehospital transportation is a predictor of mortality in patients with SCI in Nigeria. Design: Prospective cohort study Methods: Prehospital transport related conditions, injury arrival intervals and persons that brought patients with SCI to the casualty were noted. Data analyzed using descriptive statistics, the chi-square test and multiple logistic regressions. Main Outcome Measures: Mortality within 6 weeks on admission Results: 168 patients with SCI presented in the casualty during this review period. Majority (67.9%) presented after 24 hrs of the injury. Majority (58.3%) were conveyed into the casualty by their relatives. Salon car (54.2%) was the most common mode of transportation where majority (55.4%) laid on their back during the transfer. Majority (75%) of the patients had multiple hospital presentation before reporting in our casualty. The mortality observed was 16.7%. Multivariate analysis after adjusting for age, gender, and means of transportation revealed that age (OR= 63.41, 95% CI= 9.24-43.53), crouched position during transfer (OR= 23.52, 95% CI= 7.26-74.53), presentation after 24 hrs (OR=5.48, 95% CI=3.20-16.42) and multiple hospital presentation (OR= 7.94, 95% CI= 1.89-33.43) were associated with mortality within 6 weeks of admission. Conclusion: A well-organized and efficient prehospital transport would reduce mortality in spinal cord injured patients. Public enlightenment campaign on factors that could reduce road traffic injury would help reduce mortality.

Transmission of low-intensity vibration through the axial skeleton of persons with spinal cord injury as a potential intervention for preservation of bone quantity and quality.

Abstract: Background/objective: Persons with spinal cord injury (SCI) develop marked bone loss from paralysis and immobilization. Low-intensity vibration (LIV) has shown to be associated with improvement in bone mineral density in post-menopausal women and children with cerebral palsy. We investigated the transmissibility of LIV through the axial skeleton of persons with SCI as an initial approach to determine whether LIV may be used as a clinical modality to preserve skeletal integrity. Methods: Transmission of a plantar-based LIV signal (0.27 ± 0.11 g; 34 Hz) from the feet through the axial skeleton was evaluated as a function of tilt-table angle (15, 30, and 45°) in seven non-ambulatory subjects with SCI and ten able-bodied controls. Three SCI and five control subjects were also tested at 0.44± 0.18 g and 34 Hz. Transmission was measured using accelerometers affixed to a bite-bar to determine the percentage of LIV signal transmitted through the body. Results: The SCI group transmitted 25, 34, and 43% of the LIV signal, and the control group transmitted 28, 45, and 57% to the cranium at tilt angles of 15, 30, and 45°, respectively. No significant differences were noted between groups at any of the three angles of tilt. Conclusion: SCI and control groups demonstrated equivalent transmission of LIV, with greater signal transmission observed at steeper angles of tilt. This work supports the possibility of the utility of LIV as a means to deliver mechanical signals in a form of therapeutic intervention to prevent/reverse skeletal fragility in the SCI population.

Cervical spinal cord multiple sclerosis: evaluation with 2D multi-echo recombined gradient echo MR imaging

Abstract: Objective: The two-dimensional multi-echo recombined gradient echo (MERGE) technique automatically acquires and sums multiple gradient echoes at various echo times in cervical spine magnetic resonance (MR) imaging. This technique increases the grey–white matter contrast within the spinal cord and should also improve the depiction of cervical cord lesions. The aim of this study was to qualitatively and quantitatively evaluate MERGE imaging compared with T2-weighted fast spin-echo (T2WFSE) imaging for depicting multiple sclerosis (MS) lesions in the cervical cord. Methods: Nineteen consecutive patients (10 males and 9 females; age range 22–62 years, mean age 43.6 years) with clinically diagnosed MS were examined with cervical spinal cord MR imaging at 3 T including both MERGE and T2WFSE imaging. Qualitative evaluation for MS lesion conspicuity was performed. The quantitative criterion utilized to compare MERGE imaging with T2WFSE imaging was the lesion-to-background contrast-to-noise ratio (CNR). Results: M...

An effective oral vitamin D replacement therapy in persons with spinal cord injury

Abstract: Background/objective: Vitamin D deficiency is prevalent in chronic spinal cord injury (SCI). A 3-month course of oral vitamin D3 to ‘normalize’ serum vitamin D levels was investigated. Design: Prospective drug-intervention study. Setting: VA Medical Center; private rehabilitation facility. Methods: Seven individuals with chronic SCI and vitamin D deficiency completed 3 months of oral vitamin D3 (i.e. cholecalciferol) supplementation. At screening, baseline, and months 1 and 3, blood was collected for serum calcium, 25 hydroxyvitamin D [25(OH)D], intact parathyroid hormone (iPTH), and N-telopeptide (NTx); 24-hour urine for calcium, creatinine, and NTx was performed. Oral vitamin D3 (2000 IU daily) and elemental calcium (1.3 g daily) were prescribed for 90 days. The results are expressed as mean ± standard deviation (SD). Analysis of variance with a Fisher’s post-hoc analysis was performed to test for differences between study visits. Subjects were classified as deficient ( 30 ng/ml) in 25(OH)D. Results: Serum 25(OH)D levels were greater at months 1 and 3 than at baseline (26± 6 and 48± 17 vs. 14 ± 2n g/ml; P = 0.005). Six of seven subjects were no longer deficient [25(OH)D >30 ng/ml] by month 3. Serum iPTH levels were significantly decreased at month 1 and month 3; serum NTx levels were significantly lower at month 3 than at baseline. Serum and urinary calcium levels remained within the normal range. Conclusion: A daily prescription of 2000 IU of oral vitamin D3 for 3 months safely raised serum 25(OH)D levels into the normal range in persons with chronic SCI on calcium supplementation.