Late-Life Spinal Cord Injury and Aging with a Long Term Injury: Characteristics of Two Emerging Populations

Abstract

Modern care of patients with spinal cord injury is leading to greater numbers of individuals surviving into old age and the emergence of a cohort that has sustained injury at an advanced age. The clinical characteristics of either group of patients has not been well characterized. Analyses from the Aging with a Long-Term Disability Research Program database, which is enriched by the presence of a high quality Spinal Cord Injury Service, revealed a population of 510 recently assessed individuals with a mean age of 50 years, ranging from 16 to 84 years. Twenty-three percent of the patients were at least 65 years of age. Spinal cord injuries were usually the result of automobile accidents in individuals injured younger than 50 years of age and falls in individuals injured when older than 50 years of age. Patients surviving late life injury are much more likely to have incomplete injuries predominantly affecting the cervical spine. A number of conditions were found to be more prevalent in older patients. These included carpal tunnel syndrome, chronic obstructive pulmonary disease, myocardial infarction, diabetes, kidney stones, pressure ulcers and hypertension. The development of diabetes, kidney stones and perhaps pressure ulcers was directly related to aging with SCI, but not just to aging alone. The better functional outcomes in late life spinal cord injury may be secondary to selective survival. The excess morbidity associated with late life spinal cord injury has significance for future planning of healthcare needs for the spinal cord injured patient. (J Spinal Cord Med; 18:183–193)     

Maintenance Hemodialysis in End-Stage Renal Disease Associated with Spinal Cord Injury

Data on maintenance hemodialysis in end-stage renal disease (ESRD) associated with spinal cord injury (SCI) are lacking. Forty-three SCI-ESRD patients treated with hemodialysis in our unit were retrospectively studied. A control group of ESRD patients without SCI were included for comparison. Predialysis concentrations of Na, K, bicarbonate, creatinine, albumin, calcium, and phosphorus and anion gap were significantly lower in the SCI group than in the control group. In contrast, chloride concentration was significantly higher in the SCI patients. Hemodialysis was equally effective in providing azotemia control and acid-base, electrolyte, and fluid balance in both groups. Interdialytic weight gain in the SCI group was significantly less than that of the control group. Hypotensive episodes during dialysis were quite common in the SCI patients. Interestingly, hypertensive episodes during or shortly after dialysis were also noted with considerable frequency. The hypotensive episodes usually responded to blood flow reduction and/or fluid administration. Hypertensive episodes were usually mild to moderate and reversed with continued dialysis without requiring vigorous intervention. The leg cramps often seen in ambulatory patients due to rapid ultrafiltration and fluid shifts were uncommon among the SCI patients. However, diffuse painful muscle spasms caused by uninhibited spinal reflexes were observed with considerable frequency and presented a difficult therapeutic problem. Due to prolonged immobilization and other factors, SCI-ESRD patients appear to be at high risk of thromboembolic disorders. SCI-ESRD patients thus appear to differ from the ambulatory ESRD patients from both clinical and biochemical viewpoints. These specific feaures can be of significant value with respect to the dietary and therapeutic considerations.     

Animal Model for Investigation of Spinal Cord Injury Caused by Aortic Cross-Clamping

The objective of this experimental protocol was to design a large animal model that could simulte the ischemic condition caused by aortic cross-clamping during the operation for intrathoracic and thoraco-abdominal aneurysm. Domestic swine weighing 25 to 30 kg were used for this model. The thoracic cavity was opened through the fourth intercostal space. Cross-clamp was applied below the left subclavian artery. Duration of cross-clamp was 30 min and the reperfusion period was 24 h. Methods of assessment included Tarlov's criteria, histology transmission electron microscopy, and spinal cord perfusion with microspheres. This model is reproducible. The results of experimental protocols completed using this model are referenced. This article discusses the details of the experimental protocol with steps toward reproduction of the model and rationalization. This animal model can be used for the evaluation of the pathophysiology of spinal cord injury and sensory- and motor-evoked potentials, and most importantly it can also be used for the examination of pharmacological interventions for prevention and treatment of ischemia reperfusion injury caused by aortic cross-clamping.     

Refractory Spinal Cord Injury Induced Gastroparesis: Resolution with Erythromycin Lactobionate,a Case Report

Abstract

Erythromycin lactobionate (ERY), a macrolide antibiotic, has been the focus of investigation as a new gastrointestinal prokinetic agent. In individuals who are able-bodied (AB), ERY has shown promise in various forms of gastroparesis (GP). Recent evidence suggests that medications used to stimulate intestinal motility in individuals who are AB have had similar results in those individuals with spinal cord injury (SCI). Medications that have been used in the past for CP in SCI include metaclopramide, neostigmine, and bethanechol.

In this observation, a patient with T-6 paraplegia, who developed GP secondary to acute SCI, is presented. During his hospital stay, the patient was treated with gastric decompression, bowel rest, H2 blockers, intravenous metaclopramide, and eventually required parenteral nutritional support. ERY was started and symptoms abated. At this point, the nasogastric tube was removed and oral feeding was successfully started. This case report is the first to describe a patient with refractory SCI-induced GP who responded to intravenous ERY. Further study in this area is warranted.     

脊髓损伤大鼠脊髓组织的病理形态学观察

目的：研究脊髓损伤（SCI）用高压氧（HBO）处理后脊髓的病理学变化。方法：用SD大鼠复制SCI模型，0．1MPa和0．25MPaHBO处理后，取损伤脊髓作HE染色。结果：正常对照组脊髓结构完整，细胞形态正常，分布均匀，胞膜，胞核正常，组织间隙正常，单纯损伤组示组织出血，疏松水肿，细胞空泡变性，神经纤维溶解，消失；处理后，0．25MPaHBO组及0．25MPaHBO＋激素（L，M）组脊髓恢复最明显，组织水肿，细胞空泡变性减轻，细胞形态恢复，结构排列完整，结论：HBO治疗可明显阻止或减轻脊髓损伤的病理变化，有利于脊髓功能的恢复。     

脊柱外伤的MRI表现

本文报告了50例急、慢性脊柱外伤病人MRI的检查结果,描述了15例急性期脊髓损伤后水肿和出血的MRI信号改变和35例慢性期脊髓损伤后脊髓囊变、纤维化和脊髓萎缩的MR信号改变。探讨不同MR信号与预后的关系。     

Indications for a Home Standing Program for Individuals with Spinal Cord Injury

Abstract

Additional analyses were conducted on a recently published survey of persons with spinal cord injury (SCI) who used standing mobility devices. Frequency and duration of standing were examined in relation to outcomes using chi square analyses. Respondents (n = 99) who stood 30 minutes or more per day had significantly improved quality of life, fewer bed sores, fewer bladder infections, improved bowel regularity, and improved ability to straighten their legs compared with those who stood less time. Compliance with regular home standing (at least once per week) was high (74%). The data also suggest that individuals with SCI could benefit from standing even if they were to begin several years after injury. The observation of patient benefits and high compliance rates suggest that mobile standing devices should be more strongly considered as a major intervention for relief from secondary medical complications and improvement in overall quality of life of individuals with SCI.     

Spinal Cord Injury and Aging: Exploring the Unknown

ABSTRACT

We conducted a retrospective case-control study of falls over a four year period on a 30 bed neurorehabilitation unit at the Burke Rehabilitation Hospital to characterize the nature of falls and identify factors associated with falling. The most common diagnoses treated on the unit were traumatic spinal cord injury, brain injury, and multiple sclerosis; stroke patients are treated on another service. Falls represented 72 percent of all incident reports made to the Nursing Office during the study period. One hundred seventeen (117) falls occurred in 82 patients during a time when the unit census was 28,622 patient days, yielding a rate of 1,439 falls per 1,000 patient years. One hundred fourteen (114) patients admitted with no history of falling during the same period were selected randomly for comparison. Most falls were associated with no injury (n=96) or minor injury (n=18). The most significant injuries occurred in three cases with lacerations requiring sutures. Falls occurred with greatest frequency during the first and fourth quartiles of the hospital stay, during the evening and while bed transfers were being performed. No association between falling and patient age, sex, diagnosis, number of medications, use of sedating medications, presence of motor, visual or cognitive impairment or orthostatic hypotension was evident. An increased risk of falling was associated with physician orders for Posey restraints. The implication of these findings for falls prevention programs is discussed. (J Am Paraplegia Soc: 17; 179–182)     

Breathlessness and Exercise in Spinal Cord Injury

Abstract

Objective: To determine the impact of medical complications on adult outcomes of individuals with pediatric-onset spinal cord injury (SCI).

Method: Structured interview including standardized measures.

Participants: Individuals who sustained SCI at age 1 8 years or younger and were 24 years of age or older at interview.

Outcome Measures: A structured interview covering employment, independent living and driving, and marriage. Standardized measures include the Craig Handicap Assessment and Reporting Technique (CHART), the Short Form (SF-12), and the Satisfaction with Life Scale (SWLS).

Results: Two hundred sixteen individuals were interviewed, with a mean age at injury of 14 years and a mean age at follow-up of 29 years. Of all the complications, pressure ulcers, severe urinary tract infection (UTI), and spasticity had the greatest impact on adult outcomes. Pressure ulcers were statistically related to all main outcomes. Severe UTI was statistically associated with all the outcomes except for marriage. Spasticity was associated with all the measured outcomes, except for marriage and life satisfaction. Life satisfaction was most significantly associated with severe UTI, pressure ulcers, pain, and respiratory complications.

Conclusion: Medical complications significantly affect adult outcomes of individuals with pediatric-onset SCI.     

Menstruation and Pediatric Spinal Cord Injury

Abstract

Menstrual characteristics were studied in young women who sustained spinal cord injuries (SCI) prior to puberty or in early adolescence. Subjects were 37 females who were injured prior to age 16 years and who were at least 10 years old at the time of interview; 22 were injured prior to menarche and 15 after menarche. Average age of menarche for females injured before puberty was 12.3 years which is similar to their mothers (mean 12.6 years) and to patients injured after menarche (mean 12.0 years). Of 15 females injured after menarche, seven reported no interruption in menses while eight had interruptions ranging from one to seven months. No significant menstrual problems were noted in either group. This information about menstruation should be included in sexuality teaching of parents and patients when an SCI occurs to a child or adolescent. (J Spinal Cord Med 1997; 20:56-59)     

前外侧减压治疗胸腰段脊柱骨折并脊髓损伤

我们对陈旧性胸腰段骨折并脊髓损伤15例及新鲜脊髓损伤3例,采用脊髓前外侧减压术。18例中有12例功能改善,各病例因外伤情况不同其恢复程度不同,其中不完全性神经根和园锥损伤予后较好;有运动功能比仅有感觉残留的病例疗效显著。     

Autonomic Hyperreflexia With Spinal Cord Injury

ABSTRACT

Autonomic hyperreflexia occurs in up to 85 percent of individuals with spinal cord injuries above the major splanchnic sympathetic outflow. In such cases, paroxysmal reflex sympathetic activity develops in response to noxious stimuli below the level of the neurologic lesion. The clinical features of autonomic hyperreflexia are due largely to reflex sympathetic adrenergic and cholinergic discharges with dysfunctional supraspinal regulatory control. Cephalgia, diaphoresis, flushing, tachycardia or bradycardia, and paroxysmal hypertension are most commonly observed. Although a variety of stimuli can provoke autonomic responses of variable magnitudes, bladder and bowel distention continue to account for most episodes. Removal of the offending stimulus is important to restoring the autonomic nervous system to its baseline activity. Current understanding of the pathophysiology, clinical features, and medical management of this fascinating but potentially serious complication of spinal cord injury are reviewed.     

脊髓损伤与男性不育(英文)

脊髓损伤 (SCI)通常会对育龄男性造成一定的影响。脊髓受损后的男性大多会在以下方面发生问题 :如勃起和射精功能障碍 ,精子发生受损 ,精子存活力、活率及形态异常 ,泌尿生殖系统感染以及内分泌异常。本文将从病理生理、评价和治疗等方面对脊髓损伤引起的男性不育症进行论述。脊髓损伤可对精浆产生影响并加速精液氧化 ,从而使得SCI男性的精液质量下降。本文还将对用于SCI男性的精子复苏技术和辅助生育技术所取得的进展进行讨论。     

Urodynamic Monitoring After Spinal Cord Injury

Abstract

Urinary tract infection (UTI) continues to be a major cause of mortality in patients with neurogenic bladders. Even patients who void reflexly and have unobstructed voiding with external condom drainage have a high incidence of chronic recurrent bacteriuria. Our recent studies have described the difficulty of diagnosing and localizing UTI in patients with neurogenic bladders. Symptoms correlated poorly with significant bacteriuria (> 10⁵ colonies/ml) and the use of the Fairley washout test gave less than optimal results in our studied population. Breakdown of endogenous host defenses, development of drug resistant organisms, and external contamination from urinary drainage appliances and fecal incontinence should be considered in diagnosis and management of these patients. Adequate bladder drainage is the most effective prophylactic measure against recurrent urinary tract infections. Our methods of bladder drainage include use of alpha blockers, transurethral sphincterotomy, and in selected paraplegics, long-term intermittent self-catheterization. We stress decreasing pathogenic bacterial skin colonization through daily perineal washing with soap and water, and cleaning drainage appliances at least once daily with 0.06% sodium hypochlorite. We treat the symptomatic patients and patients with positive urine cultures with potential stone forming organisms. Antibiotic therapy in asymptomatic patients should be guided by an inflammatory response with white blood cell count of > 10⁴ colonies/ml in the urine and positive bacterial culture of > 10⁵ colonies/ml.     

Bowel Management in Children and Adolescents with Spinal Cord Injury

Abstract

There is little in the literature regarding bowel management in children and adolescents with spinal cord injuries (SCI). This study was undertaken to examine specific patterns of bowel care, individual levels of satisfaction with bowel management, the incidence of incontinence in this population, and effects on lifestyle because of time commitment and dependence in bowel management. Surveys were sent to all persons (n = 45) under age 19 with a diagnosis of SCI who had received care at our medical center since 1985. Thirty-one subjects (69 percent) returned the surveys. The average age at injury was 8.1 years, with an average follow-up period of 3.9 years. Fifty-five percent were individuals with tetraplegia and 77 percent had a complete injury (ASIA Class A). A bowel management program, including medications or manual manipulation, was required for 81 percent of the subjects; only two were independent in their bowel management. Over half of the subjects performed evening bowel care and over half performed their care daily. Digital stimulation tended to be used more commonly by younger children. Medications, either oral, rectal, or both, were used by 88 percent. Sixty percent of the subjects reported they were completely or very satisfied with their bowel management. About half the subjects had limited freedom because of their bowel programs, which caused some dissatisfaction. Sixty-eight percent reported occasional or frequent interference with school activities because of their bowel programs. No correlation was found between bowel accidents and satisfaction with bowel management, despite the fact that almost 84 percent of the children reported at least rare accidents. Lifestyle limitations, bowel accidents, dependence in bowel management, and subject and family dissatisfaction continue to be significant problems for children and adolescents with SCI. (/Spinal Cord Med 1998; 21:335-341)     

脊髓半切损伤模型的制备

目的：建立一种简便易行、稳定可靠的脊髓半切伤动物模型。方法：取大鼠C5-7颈髓阶段，T8—ll胸髓阶段直径1/2脊髓半切。术后不同时间观察脊髓组织学变化，并纪录脊髓神经功能综合评分(CBS)。结果：光镜下半切脊髓远端侧索和灰质神经变性坏死，术后24h、1周实验组CBS评分与假手术组有显著意义(P＜0．05)，且脊髓腹角运动神经元与假手术组比较明显变化，行为表现为大鼠运动和感觉功能障碍。结论：颈髓5—7半切模型死亡率低，安全可靠。