Urethral cultures in patients with spinal cord injury

STUDY DESIGN: Prospective analysis. OBJECTIVES: To investigate the colonization of the distal urethra and bladder during the initial stages of rehabilitation in acute spinal-cord injury (SCI) and to examine the association between bacteriuria and colonization of the distal urethra. SETTING: Selcuk University Meram Faculty of Medicine, Konya, Turkey. METHODS: A total of 27 patients with SCI (13 females and 14 males) and 40 controls without evidence of disease of the urinary tract were studied. Cultures were taken from the patients who applied clean intermittent catheterization and compared with normal subjects. RESULTS: Escherichia coli was predominantly isolated from the urine and urethral cultures of both female and male SCI patients. Colonization of other bacteria in the urine and urethral cultures was similar in both female and male patients, except for Pseudomonas, which was colonized in male patients. In all, 72% of patients who had E. coli positive urethral cultures also had E. coli colonization in their simultaneous urine cultures. There was concordance between urethra and urine cultures concerning the growth of E. coli (P=0.82). When urethral cultures collected 1 week before were evaluated in patients with E. coli positive urine cultures (n=24 cultures), 15 of these urethral cultures also had E. coli colonization. There was concordance between urethra and urine cultures concerning the growth of E. coli (P=0.66). CONCLUSIONS: Our study suggested that urethral flora was a significant source for the development of urinary infection in spinal cord-injured patients.     

Urinary tract complications in spinal cord injury patients

The characteristics of urinary tract complications in a series of 202 spinal cord injury patients are described. Repeated urinary infection was the most usual problem. Upper urinary tract changes were detected in 61 patients (30%). 56 patients (28%) underwent bladder outlet surgery for problems with voiding. Urinary diversion was done to 8 patients (4%), and 12 (6%) were treated with permanent indwelling catheter or self-catheterization. The high incidence of bladder stones (29%) and urethral complications (14%) was regarded as due to indwelling catheterization at the early stage post-injury. Despite the high urinary tract morbidity, only one patient has so far died of renal failure.     

Weight gain following spinal cord injury: a pilot study

Study design

Retrospective chart review.

Objective

To 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.

Setting

A United States Department of Veterans Affairs (VA) SCI Unit.

Methods

A 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.

Results

Mean 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 participants shifted from lower BMI classifications at rehabilitation admission to higher BMI classifications at final follow-up. For participants transitioning from normal to overweight or obese, the greatest increase occurred during the first year after acute rehabilitation. Neurological level, impairment category, primary mode of mobility, and age at rehabilitation admission did not significantly predict BMI change. BMI at rehabilitation admission correlated significantly with BMI at final follow-up (P < 0.0005).

Conclusions

These findings confirm a significant increase in BMI after new SCI and suggest that persons with new SCI are at greatest weight gain risk during the first year following acute rehabilitation.     

Carbon dioxide urethral pressure profilometry before and after external sphincterotomy in spinal cord injury patients

Seven spinal cord injury patients were studied before and after transurethral external sphincterotomy with combined electromyographic and gas urethral pressure profilometry. The technique was simple, rapid, accurate and reproducible in evaluating the completeness of external sphicterotomy. A significant reduction in maximum urethral closure pressure, as well as in the residual urine volume, was a consistent after spincterotomy. The electromyographic profile showed evidence of periurethral striated muscle activity preoperatively in 2 patients with lower motor neuron lesions in whom the bulbocavernosus reflex could not be elicited. Thus, absence of the bulbocavernosus reflex did not eliminate sphincter reflex activity.     

Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

This scoping review systematically reviewed relevant research to summarize the literature addressing the significance of monitoring spinal cord perfusion pressure (SCPP) in acute traumatic spinal cord injury (SCI). The objectives of the review were to (1) examine the nature of research in the field of SCPP monitoring in SCI, (2) summarize the key research findings in the field, and (3) identify research gaps in the existing literature and future research priorities.Primary literature searches were conducted using databases (Medline and Embase) and expanded searches were conducted by reviewing the references of eligible articles and searches of Scopus, Web of Science core collection, Google Scholar, and conference abstracts. Relevant data were extracted from the studies and synthesis of findings was guided by the identification of patterns across studies to identify key themes and research gaps within the literature.Following primary and expanded searches, a total of 883 articles were screened. Seventy-three articles met the review inclusion criteria, including 34 original research articles. Other articles were categorized as conference abstracts, literature reviews, systematic reviews, letters to the editor, perspective articles, and editorials. Key themes relevant to the research question that emerged from the review included the relationship between SCPP and neurological recovery, the safety of monitoring pressures within the intrathecal space, and methods of intervention to enhance SCPP in the setting of acute traumatic SCI.Original research that aims to enhance SCPP by targeting increases in mean arterial pressure or reducing pressure in the intrathecal space is reviewed. Further discussion regarding where pressure within the intrathecal space should be measured is provided. Finally, we highlight research gaps in the literature such as determining the feasibility of invasive monitoring at smaller centers, the need for a better understanding of cerebrospinal fluid physiology following SCI, and novel pharmacological interventions to enhance SCPP in the setting of acute traumatic SCI. Ultimately, despite a growing body of literature on the significance of SCPP monitoring following SCI, there are still a number of important knowledge gaps that will require further investigation.     

Penile urethral obstruction in a subject with spinal cord injury

STUDY DESIGN: Single case report. OBJECTIVE: To report a case of urethral obstruction because of calculus in a subject with spinal cord injury (SCI). SETTING: Bangalore, India. CASE REPORT: A 25-year-old man sustained complete SCI at C(6) level following a road traffic accident. After 14 months, while on self-intermittent catheterization he noticed difficulty in introducing catheter and acute retention of urine. X-ray examination revealed a calculus in the penile urethra at the level of the glans penis. CONCLUSION: Impaction of calculi in penile urethra, although rare, can manifest with acute painless urinary retention in patients with SCI.     

Urethral hypotonicity after suprasacral spinal cord injury.

Established suprasacral spinal cord injuries usually are associated with detrusor hyperreflexia and varying degrees of detrusor-sphincter dyssynergia. Occasionally, such injuries result in detrusor areflexia or urethral hypotonicity or both. The results of the urodynamic evaluation of 4 patients with suprasacral spinal cord injuries are described. Detrusor areflexia and urethral hypotonicity were demonstrated in 3 cases and urethral smooth muscular hypotonia but preserved reflex detrusor function in 1. It is shown that destruction of the thoracolumbar sympathetic outflow can cause the complete loss of urethral smooth muscular closing function and that resting urethral closure is totally independent of preganglionic cholinergic influences.     

Comparison of medical complications following nontraumatic and traumatic spinal cord injury

BACKGROUND: Nontraumatic spinal cord injury (NT/SCI) has been shown to represent a significant proportion of individuals admitted for SCI rehabilitation. Although medical complications of patients with traumatic SCI (T/SCI) have been well studied, there is a paucity of literature regarding those with nontraumatic SCI. Our objective was to compare the incidence of secondary SCI medical complications in patients with nontraumatic and traumatic SCI. DESIGN: A 2-year prospective data comparison of 117 patients with SCI admitted to a regional SCI rehabilitation unit and tertiary university medical center was undertaken. NT/SCI was defined as spinal stenosis, tumorous compression, vascular ischemia, and infectious etiologies. METHODS: Outcome measures included secondary SCI medical complications, injury characteristics, demographics, and rehabilitation outcomes. Statistical analyses were conducted between the 38 NT/SCI and 79 T/SCI who met admission criteria for acute inpatient rehabilitation. RESULTS: Statistically significant differences (P<.05) between nontraumatic and traumatic SCI were noted for deep venous thrombosis (7.9% vs 22.8%), pressure ulcers (21.1% vs 41.8%), autonomic dysreflexia (0% vs 24.1%), pneumonia (2.6% vs 26.6%), orthostatic hypotension (5.3% vs 36.7%), spasticity (21.1% vs 44.3%), and wound infections (16% vs 3%). Similar incidences were found for depression (23.7% vs 26.6%), urinary tract infections (52.6% vs 67.1%), heterotopic ossification (2.6% vs 7.6%), pain at admission (55.3% vs 62.0%), and gastrointestinal bleed (2.6% vs 2.5%). In addition, significant differences were noted between NT/SCI and T/SCI for age (55 years vs 39 years), rehabilitation length of stay (26.4 days vs 43.0 days), and neurologically complete injury (5.3% vs 45.6%). CONCLUSION: This study indicates that patients with NT/SCI present with different incidences of secondary SCI medical complications when compared with individuals with T/SCI. These data, along with differences in demographics, clinical presentation, and rehabilitation outcomes, have important implications for the medical, rehabilitation management, and long-term outcome of individuals with NT/SCI.     

Dermatological problems following spinal cord injury in Korean patients

Objective

To identify dermatological conditions following spinal cord injury (SCI) and analyze these conditions in relation to various characteristics of SCI.

Design

Retrospective chart review.

Setting

National Health Insurance Corporation Ilsan Hospital of Korea, Rehabilitation Center, Spinal Cord Unit.

Participants

Patients treated for SCI who were referred to dermatology for dermatological problems, 2000–2012.

Results

Of the 1408 SCI patients treated at the spinal cord unit, 253 patients with SCI were identified to have been referred to dermatology for skin problems and a total of 335 dermatological conditions were diagnosed. The most common dermatological finding was infectious (n = 123, 36.7%) followed by eczematous lesions (n = 109, 32.5%). Among the infectious lesions, fungal infection (n = 76, 61.8%) was the most common, followed by bacterial (n = 27, 21.9%) lesions. Seborrheic dermatitis (n = 59, 64.1%) was the most frequent eczematous lesion. Ingrown toenail occurred more frequently in tetraplegics whereas vascular skin lesions occurred more commonly in patients with paraplegia (P < 0.05). Xerotic dermatitis showed a higher occurrence within 12 months of injury rather than thereafter (P < 0.05). Of these, 72.4% of the infectious and 94.7% of the fungal skin lesions manifested below the neurological level of injury (NLI; P < 0.001) and 61.5% of the eczematous lesions and 94.9% of seborrheic dermatitis cases occurred above the NLI (P < 0.001). There was no significant difference in dermatological diagnoses between patients with neurologically complete and incomplete SCI.

Conclusion

The most common dermatological condition in patients with SCI among those referred to dermatology was fungal infection, followed by seborrheic dermatitis. Although dermatological problems after SCI are not critical in SCI outcome, they negatively affect the quality of life. Patients and caregivers should be educated about appropriate skin care and routine dermatological examinations.     

Long-term result of Memokath urethral sphincter stent in spinal cord injury patients

Background

Memokath urethral sphincter stents are used to facilitate bladder emptying in patients with spinal cord injury, but long term follow-up has not been reported.

Methods

Case series of ten men with spinal cord injury who underwent insertion of Memokath stents and were followed for up to nine years.

Results

Within four years, the stent had to be removed in nine out of ten patients because of: extensive mucosal proliferation causing obstruction to the lumen of the stent; stone around the proximal end of the stent, incomplete bladder emptying, and recurrent urinary infections; migration of the stent into the bladder related to digital evacuation of bowels; large residual urine; concretions within the stent causing obstruction to flow of urine, and partial blockage of the stent causing frequent episodes of autonomic dysreflexia. In one patient the stent continued to function satisfactorily after nine years.

Conclusions

The Memokath stent has a role as a temporary measure for treatment of detrusor-sphincter dyssynergia in selected SCI patients who do not get recurrent urinary infection and do not require manual evacuation of bowels.

     

Fertility following spinal cord injury: a systematic review

STUDY DESIGN: Systematic review.Objectives:To review systematically fertility of persons with spinal cord injuries (SCI) and their partners. METHODS: Reports from six databases (1966-2003), selected annual proceedings (1997-2002) and manufacturer's information were screened against eligibility criteria. Searches covered female obstetrical issues, and the efficacy of vibration and electroejaculation for males, as well as advanced fertility (AF) treatments for partners of SCI males. Data were pooled from case-series reports on SCI males' ejaculation, and pregnancies and live births for partners of SCI males. RESULTS: In all, 2,127 unique reports were evaluated, of which 66 reports were included. No studies investigated fertility in SCI females. Ejaculation interventions in the last decade resulted in response rates of 95% (95% confidence intervals (CI) 91%, 99%), with 100% response rate reported in several recent publications. A total of 13 studies (1993-2001) yielded pregnancy rates of 51% (95% CI 42%, 60%) in partners of SCI males. Of these, 11 studies (1993-2003) yielded live birth rates of 41% (95% CI 33%, 49%). CONCLUSIONS: Fertility of SCI males is extensively studied. Semen for fertility purposes can generally be obtained using vibration and electroejaculation. AF techniques are increasing pregnancy rates. Research is needed to improve sperm quality. Freezing of sperm is unlikely to significantly improve fertility rates. Fertility of SCI females is addressed only in case reports and opinion articles. The opinion that female fertility is unaffected by SCI should be further investigated using appropriate research methodology.     

Surgical management of patients following traumatic spinal cord injury: Identifying barriers to early surgery in a specialized spinal cord injury center

Context/Objective: Early surgery in individuals with traumatic spinal cord injury (T-SCI) can improve neurological recovery and reduce complications, costs and hospitalization. Patient-related and healthcare-related factors could influence surgical delay. This study aimed at determining factors contributing to surgical delay in individuals with T-SCI.

Design: Prospective cohort study.

Setting: Single Level I trauma center in Québec, Canada.

Participants: One hundred and forty-four patients who sustained a T-SCI.

Interventions: None.

Outcome measures: Socio-demographic and clinical administrative data were collected during the pre-operative period. The cohort was stratified in early surgery, or ES (<24 hours post-trauma) and late surgery, or LS (≥ 24 hours post-trauma) groups. A multivariate logistic regression analysis using patient- and healthcare-related factors was carried out to identify the main predictors of LS.

Results: 93 patients had ES (15.6?±?4.7 hours post-trauma), which is 31 hours earlier than the 51 patients in the LS group (46.9?±?30.9 hours; P??3). The transfer delay from trauma site to the SCI center was 8 hours shorter (5.0?±?3.0 hours vs 13.6?±?17.0; P??3) for the ES group, and the surgical plan was completed 17 hours faster (6.0?±?4.0 hours vs 23.3?±?23.6 hours; P??3) than for the LS group. The occurrence of LS was predicted by modifiable factors, such as the transfer delay to the SCI center, the delay before surgical plan completion, and the waiting time for the operating room.

Conclusions: A dedicated team for surgical treatment of individuals with T-SCI, involving direct transfer to the SCI center, faster surgery planning and access to the operating room in hospitals dealing with emergencies from all subspecialties could improve surgical delay and increase the rate of patients undergoing ES.     

Chronic complications of spinal cord injury

Spinal cord injury (SCI) is a serious medical condition that causes functional, psychological and socioeconomic disorder. Therefore, patients with SCI experience significant impairments in various aspects of their life. The goals of rehabilitation and other treatment approaches in SCI are to improve functional level, decrease secondary morbidity and enhance health-related quality of life. Acute and long-term secondary medical complications are common in patients with SCI. However, chronic complications especially further negatively impact on patients’ functional independence and quality of life. Therefore, prevention, early diagnosis and treatment of chronic secondary complications in patients with SCI is critical for limiting these complications, improving survival, community participation and health-related quality of life. The management of secondary chronic complications of SCI is also important for SCI specialists, families and caregivers as well as patients. In this paper, we review data about common secondary long-term complications after SCI, including respiratory complications, cardiovascular complications, urinary and bowel complications, spasticity, pain syndromes, pressure ulcers, osteoporosis and bone fractures. The purpose of this review is to provide an overview of risk factors, signs, symptoms, prevention and treatment approaches for secondary long-term complications in patients with SCI.     

Exploring the first pressure injury and characteristics of subsequent pressure injury accrual following spinal cord injury

Context/Objective: Clinicians have guidance on prevention and treatment of pressure injuries, but little is known regarding characteristics of patients who develop additional pressure injuries. Thus, our objective was to explore the first pressure injury and characteristics of individuals who develop subsequent pressure injuries during acute care and inpatient rehabilitation following spinal cord injury.Design: Secondary analysis of longitudinal data from a cohort of adults following initial traumatic spinal cord injury.Setting: Urban acute care hospital and inpatient rehabilitation facilities.Participants: A convenience sample of adults (n = 38) who developed at least one pressure injury during acute care and inpatient rehabilitation.Interventions: Not applicable.Outcome Measures: The primary outcomes were number of additional pressure injuries and stage of care during which they occurred, prior to community discharge.Results: A covariate-adjusted model revealed that participants with ASIA D injury had a 67% decrease in the rate of additional pressure injury incidence compared to participants with ASIA A injury (Rate Ratio = .33, 95% CI [0.13, 0.88]). The severity of the first pressure injury had no significant association with subsequent pressure injury incidence (P = .10).Conclusion: These findings indicated that individuals with greater sensory and motor loss had an increased risk of developing additional pressure injuries compared to individuals with less impairment. These results are meaningful for stakeholders interested in understanding factors associated with developing subsequent pressure injuries during the index rehabilitation stay and provide a foundation for future research in this area.     

Nutritional and immune status following spinal cord injury: a case controlled study

STUDY DESIGN: Case controlled study. OBJECTIVE: To compare nutritional status and immune response in a group of spinal cord injured (SCI) patients with age and gender matched non SCI control subjects. METHOD: Thirty past patients of the Burwood Hospital Spinal Injuries Unit living locally were enrolled in the study. Age and gender matched non SCI control subjects were selected volunteers from hospital staff. Nutritional status was assessed by generating a Nutritional Risk Score (NRS, Appendix 1) and drawing blood for full blood count, iron studies, red blood cell folate, vitamin B12, ferritin, magnesium, and zinc. Immune status was assessed by vaccination response index (VRI) to Pneumovax 23 vaccine. RESULTS: Full blood count, iron studies, and testing for red blood cell folate, albumin, prealbumin, vitamin B12, ferritin, magnesium and zinc were normal range for both groups. The SCI group had significantly different median values than controls (P < 0.01) for haemoglobin concentration, white blood cell count, albumin, prealbumin, serum iron and % saturation. Body Mass Index (weight kg/(height cm(2)) was 22.2 (range 15-30) for the SCI group, significantly less than the paired control group index of 26 (range 20-32, P = 0.0004). Median NRS for SCI patients was 2 (range 0-6), compared to 0 (range 2-4) for paired controls (P < 0.0001). Scores ranged from 0 to 2 for each of the five NRS components for the SCI patients and 0 to 3 for the control group. There was no significant difference in the pre- and post-vaccination ratio for IgG, IgA, and IgM response to Pneumovax 23 vaccine. CONCLUSION: We have not identified any nutritional or immune status abnormality in SCI patients, however the SCI patients have a lower value for certain nutritional parameters and BMI. SCI patients however are at only slight risk of nutritional problems given their NRS and their lower normal values for certain nutritional factors.