Unilateral hyperhidrosis from a contralateral source in an individual with C4 complete tetraplegia

Setting:

Outpatient clinic of a spinal cord injury rehabilitation center.

Design:

Case report.

Participant:

A 40-year-old man with a 20-year history of C4 complete tetraplegia complained of 5 years of excessive intermittent left-sided sweating. The sweating occurred only in the seated upright position. There was no associated headache, blurred vision, or blood pressure variability.

Findings:

When examined upright, the patient sweated excessively on the left face and body. When he was laid down, sweating ceased. Skin examination revealed intact ischial regions. Pressure applied to the right ischium for several minutes caused sweating to recur on the left forehead, but it then subsided with release of pressure. This phenomenon was repeatable. Local lidocaine injection in the subcutaneous tissues around the right ischium and subsequent use of lidocaine transdermal patches halted the contralateral sweating in the upright position. Pressure mapping analysis showed increased pressure in the region of the right ischial tuberosity. The patient''s gel cushion was replaced with an air-filled cushion, providing significant ongoing relief from the hyperhidrosis.

Conclusion/Clinical Relevance:

Unilateral hyperhidrosis can be caused by a contralateral source of irritation. Use of techniques that interrupt the afferent arm of the autonomic pathway may be effective in the management of hyperhidrosis in individuals with spinal cord injury.     

Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: a descriptive study

Context/objective

Pressure ulcers (PrUs) are a serious, costly and potentially life-long complication of spinal cord injury (SCI). Co-morbid conditions increase PrU risk, adding to the health behavior challenges faced by people with SCI. Little is known about medical co-morbidities, health beliefs, risk, protective behaviors, and readiness to improve skin care behaviors in people with SCI. This study describes the potentially modifiable medical and behavioral risk factors among veterans with SCI and severe (Stage III/IV) PrUs.

Design

Cross-sectional observational design.

Setting

6 VA SCI Centers.

Participants

Convenience sample from a larger intervention study of 148 veterans hospitalized for PrUs.

Interventions

Not applicable.

Outcome measures

Knowledge, PrU risk, skin protective behaviors, health beliefs, and practices, health locus of control, skin worsening.

Results

Most ulcers were stage IV (73%) and about half had 2+ PrUs. Participants reported a mean of 6.7 co-morbid conditions (respiratory, gastrointestinal, renal disease/urinary tract infection, autonomic dysreflexia, diabetes, bowel/bladder incontinence). Potential intervention opportunities include proactive assistance with management of multiple chronic conditions, substance abuse, nutrition, adherence to skin protective behaviors, readiness to change, and access to resources. Overall knowledge about PrUs was low, especially for how to prevent PrUs and what to do if skin breakdown occurs.

Conclusion

Future research should address whether comprehensive models that include patient self-management, decision support and health care system, and proactive behavior change assistance for patients help reduce PrU incidence and recurrence in persons with SCI.

Trial Registration

http://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00105859","term_id":"NCT00105859"}}NCT00105859     

Impact of annual urodynamic evaluations on guiding bladder management in individuals with spinal cord injuries

Study design

A single-center institutional review board-approved prospective cross-sectional observational study.

Context

Urodynamic studies are essential to accurately direct bladder management following spinal cord injury (SCI). There is no consensus on how often testing should be performed.

Objective

To determine the impact of annual urodynamic studies on guiding bladder management following SCI.

Methods

Individuals with traumatic SCI undergoing annual urological evaluations were enrolled in this study. They had to be injured for at least 2 years so that urodynamic changes could be compared with their previous annual urodynamic evaluation. Changes in the urodynamic parameters and autonomic dysreflexia were determined by comparing this study with the previous year''s study. All studies were done with the same physician and nursing staff. Demographic data, bladder management, urodynamic parameters, and the need and type of interventions based on the urodynamic study were obtained. The main outcome measure was whether or not there was a need for an intervention based on the urodynamics. Interventions were classified as urological intervention, non-urological intervention, or a combination of urological and non-urological intervention. The impact of the type of bladder management, length of injury, and level of injury was also evaluated.

Results

Ninety-six consecutive individuals with SCI undergoing annual urodynamic evaluations were enrolled over a 5-month period. Overall, 47.9% of individuals required at least one type of intervention based on urodynamic studies: 82.6% were urological interventions (medication changes were most common, comprising 54.3% of urological interventions); 13.0% were non-urological interventions; and 4.3% were a combination of non-urological and urological interventions. The need for interventions did not appear to be influenced by the type of bladder management, the length of time post-injury or level of injury.

Conclusion

Annual urodynamic evaluation plays an important role in guiding bladder management following SCI.     

Effects of Acute Nitric Oxide Synthase Inhibition on Lower Leg Vascular Function in Chronic Tetraplegia

Background/Objective:

To improve our understanding of the lower-leg vascular responses of nitric oxide synthase inhibition in persons with tetraplegia.

Participants:

Six people with chronic tetraplegia and 6 age-matched controls.

Methods:

Lower-leg relative vascular resistance and venous volume variation were obtained by venous occlusion plethysmography and blood pressure by auscultation at baseline. Postintravenous infusion of the nitric oxide synthase inhibitor N^G-nitro-l-arginine-methyl-ester (1 mg·kg⁻¹) or placebo on separate days.

Results:

At baseline in the group with tetraplegia compared with controls, mean arterial pressure and relative vascular resistance of the leg were significantly lower. After nitric oxide synthase inhibition, mean arterial pressure and lower leg vascular resistance were significantly elevated in both groups. There were no group or intervention differences in venous volume variation.

Conclusion:

These preliminary results suggest that nitric oxide synthase inhibition with 1 mg·kg⁻¹ N^G-nitro-l-arginine-methyl-ester normalizes seated blood pressure and lower leg vascular resistance to control group baseline levels.     

Autonomic Dysreflexia in a Man With Multiple Sclerosis

Background/Objective:

To report manifestation of autonomic dysreflexia (AD) in a man with multiple sclerosis (MS).

Design:

Case report.

Findings:

A young man presented with a history of several admissions to the emergency department with complaints of hypertensive attacks, palpitations, difficulty in breathing, headaches, and flushing. The attacks were attributed to a previously diagnosed anxiety disorder. Onset of numbness of the left leg numbness prompted a more thorough study, which showed evidence of MS. AD was suspected as the cause of his recurrent attacks of hypertension. Bladder distension was identified as the cause of AD, and his hypertensive attacks were controlled by management of neurogenic bladder.

Conclusions:

This report emphasizes that AD can occur in MS. Somatic symptoms warrant thorough investigation before attributing them to psychosomatic causes.     

Reproducibility and effect of posture on impulse oscillation parameters in persons with spinal cord injury

Background

The impulse oscillation system (IOS) offers significant value in the assessment of airway dynamics in persons with spinal cord injury (SCI) because of minimal patient effort but measurement reproducibility in SCI is unknown.

Objective

To evaluate between-day reproducibility and the effect of posture on airway resistance [respiratory resistances at 5 Hz (R5) and 20 Hz (R20)] in subjects with tetraplegia, paraplegia and able-bodied controls.

Methods

Ten subjects with tetraplegia, 10 subjects with paraplegia and 11 able-bodied individuals were evaluated using IOS. Three 30 second trials were obtained in each while in the seated and supine position on Day 1, and repeated on Day 2.

Results

The within-day coefficient of variation (CV%) for R5 and R20 were comparable in the 3 study groups in the seated and supine positions. Compared to controls, the between-day CV% for the combined data was higher in subjects with tetraplegia and paraplegia for R5 seated, and was higher in subjects with tetraplegia for R5 supine.

Conclusions

IOS has applicability to the study of within-day respiratory resistance in SCI. However, performing longer-term studies in subjects with tetraplegia and paraplegia may be problematic because of the greater variability for R5 when compared to able-bodied individuals.     

Palliative Laparoscopic End Colostomy in a Nonagenarian

Background:

Patients with advanced gynecologic malignancy often require fecal diversion as a sole procedure in cases of obstruction or fistula formation. This unique patient population has a frequent history of advanced age, prior abdominal surgery, pelvic radiation, poor nutritional status and medical comorbidities. The use of laparoscopic colostomy for palliative fecal diversion in this context has not been well described in the gynecologic oncology literature.

Case:

We present the first case of palliative laparoscopic end-colostomy in a nonagenarian as a sole procedure for fecal diversion in advanced gynecologic malignancy.

Conclusion:

Palliative laparoscopic end-colostomy is a safe, feasible, and effective method to optimize quality of life in select elderly women with advanced gynecologic malignancy.     

Time and Effort Required by Persons with Spinal Cord Injury to Learn to Use a Powered Exoskeleton for Assisted Walking

Background:

Powered exoskeletons have been demonstrated as being safe for persons with spinal cord injury (SCI), but little is known about how users learn to manage these devices.

Objective:

To quantify the time and effort required by persons with SCI to learn to use an exoskeleton for assisted walking.

Methods:

A convenience sample was enrolled to learn to use the first-generation Ekso powered exoskeleton to walk. Participants were given up to 24 weekly sessions of instruction. Data were collected on assistance level, walking distance and speed, heart rate, perceived exertion, and adverse events. Time and effort was quantified by the number of sessions required for participants to stand up, walk for 30 minutes, and sit down, initially with minimal and subsequently with contact guard assistance.

Results:

Of 22 enrolled participants, 9 screen-failed, and 7 had complete data. All of these 7 were men; 2 had tetraplegia and 5 had motor-complete injuries. Of these, 5 participants could stand, walk, and sit with contact guard or close supervision assistance, and 2 required minimal to moderate assistance. Walk times ranged from 28 to 94 minutes with average speeds ranging from 0.11 to 0.21 m/s. For all participants, heart rate changes and reported perceived exertion were consistent with light to moderate exercise.

Conclusion:

This study provides preliminary evidence that persons with neurological weakness due to SCI can learn to walk with little or no assistance and light to somewhat hard perceived exertion using a powered exoskeleton. Persons with different severities of injury, including those with motor complete C7 tetraplegia and motor incomplete C4 tetraplegia, may be able to learn to use this device.     

Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: A case report

Context

Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel.

Findings

Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved.

Conclusion/Clinical relevance

This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel.     

Psychosocial outcomes among youth with spinal cord injury by neurological impairment

Objective

Examine psychosocial outcomes of youth with spinal cord injury (SCI) as a function of neurological level (paraplegia/tetraplegia) and severity (American Spinal Injury Association (ASIA) Impairment Scale (AIS)).

Design

Survey research.

Setting

Three pediatric SCI specialty centers in the USA.

Participants

Youth with SCI ages 5–18 with neurological impairment classifications of: tetraplegia AIS ABC (tetraplegia ABC), paraplegia AIS ABC (paraplegia ABC), or AIS D.

Outcome Measures

Children''s Assessment of Participation and Enjoyment, Pediatric Quality of Life Inventory, Revised Children''s Manifest Anxiety Scale, and Children''s Depression Inventory.

Results

Three hundred and forty youth participated; 57% were male; 60% were Caucasian, 21% Hispanic, 7% African-American, 2% Native American, and 3% reported “other”. Their mean age was 8.15 years (standard deviation (SD) = 5.84) at injury and 13.18 years (SD = 3.87) at interview. Ninety-six youth (28%) had tetraplegia ABC injuries, 191 (56%) paraplegia ABC injuries, and 53 (16%) AIS D injuries. Neurological impairment was significantly related to participation and quality of life (QOL). Specifically, youth with paraplegia ABC and AIS D injuries participated in more activities than youth with tetraplegia ABC (P = 0.002; P = 0.018, respectively) and youth with paraplegia ABC participated more often than youth with tetraplegia ABC (P = 0.006). Youth with paraplegia ABC reported higher social QOL than youth with tetraplegia ABC (P = 0.001) and AIS D injuries (P = 0.002). Groups did not differ regarding mental health.

Conclusion

Interventions should target youth with tetraplegia ABC, as they may need support in terms of participation, and both youth with tetraplegia ABC and AIS D injuries in terms of social integration.     

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

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 from respiratory complications.

Conclusion

The results of this study are in accordance with that of most other developing countries; falls and motor vehicle collisions were the two leading causes, but the mean age was older. Percentage of the aged with traumatic spinal cord injury was increasing. The low-falls group tended to expand over this period. All these data indicated that the preventive programs should focus on the traffic accidents and falls, and more attention should be paid to the aged for the vulnerability to low fall.     

Life-threatening outcomes associated with autonomic dysreflexia: A clinical review

Context

Autonomic dysreflexia (AD) is a life-threatening complication of chronic traumatic spinal cord injury (SCI).

Objective

To document and provide insight into the life-threatening sequelae associated with AD.

Methods

A review was conducted to identify literature which documented cases of AD associated with life-threatening outcomes (and death). The search strategy comprised of a keyword search on the PubMed database as well as manual searches of retrieved articles. Outcomes were categorized into three main classes: central nervous system (CNS), cardiovascular (CV), and pulmonary.

Results

Thirty-two cases of death or life-threatening complications of AD were found. Twenty-three (72%) cases were CNS-related, seven (22%) cases were CV-related, and two (6%) cases were pulmonary-related. In total, seven (22%) deaths were noted as a direct result of complications following an AD attack.

Conclusion

AD is a well-known consequence of SCI among individuals with high thoracic and cervical injuries. Many of these individuals experience this condition on a daily basis. Medical personnel, care givers, and individuals with SCI should be aware of the importance of timely diagnosis and management of this life-threatening condition, which can result in a variety of significant complications including stroke, seizures, myocardial ischemia, and death.     

Safety and Efficacy of Medically Performed Tongue Piercing in People with Tetraplegia for Use with Tongue-Operated Assistive Technology

Background:

Individuals with high-level spinal cord injuries need effective ways to perform activities.

Objectives:

To develop and test a medically supervised tongue-piercing protocol and the wearing of a magnet-containing tongue barbell for use with the Tongue Drive System (TDS) in persons with tetraplegia.

Methods:

Volunteers with tetraplegia underwent initial screening sessions using a magnet glued on the tongue to activate and use the TDS. This was followed by tongue piercing, insertion of a standard barbell, a 4-week healing period, and an exchange of the standard barbell for a magnet-containing barbell. This was then used twice weekly for 6 to 8 weeks to perform computer tasks, drive a powered wheelchair, accomplish in-chair weight shifts, and dial a phone. Symptoms of intraoral dysfunction, change in tongue size following piercing, and subjective assessment of receiving and wearing a magnet-containing tongue barbell and its usability with the TDS were evaluated.

Results:

Twenty-one volunteers underwent initial trial sessions. Thirteen had their tongues pierced. One individual’s barbell dislodged during healing resulting in tongue-tract closure. Twelve had the barbell exchanged for a magnet-containing barbell. One subject withdrew for unrelated issues. Eleven completed the TDS testing sessions and were able to complete the assigned tasks. No serious adverse events occurred related to wearing or using a tongue barbell to operate the TDS.

Conclusions:

Using careful selection criteria and a medically supervised piercing protocol, no excess risk was associated with tongue piercing and wearing a tongue barbell in people with tetraplegia. Participants were able to operate the TDS.     

Specialized Respiratory Management for Acute Cervical Spinal Cord Injury:: A Retrospective Analysis

Background:

In individuals with cervical spinal cord injury (SCI), respiratory complications arise within hours to days of injury. Paralysis of the respiratory muscles predisposes the patient toward respiratory failure. Respiratory complications after cervical SCI include hypoventilation, hypercapnea, reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Ultimately, the patient must use increased work to breathe, which results in respiratory fatigue and may eventually require intubation for mechanical ventilation. Without specialized respiratory management for individuals with tetraplegia, recurrent pneumonias, bronchoscopies, and difficulty in maintaining a stable respiratory status will persist.

Objective:

This retrospective analysis examined the effectiveness of specialized respiratory management utilized in a regional SCI center.

Methods:

Individuals with C1-C4 SCI (N = 24) were the focus of this study as these neurological levels present with the most complicated respiratory status.

Results:

All of the study patients’ respiratory status improved with the specialized respiratory management administered in the SCI specialty unit. For a majority of these patients, respiratory improvements were noted within 1 week of admission to our SCI unit.

Conclusion:

Utilization of high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflation– exsufflation have demonstrated efficacy in stabilizing the respiratory status of these individuals. Optimizing respiratory status enables the patients to participate in rehabilitation therapies, allows for the opportunity to vocalize, and results in fewer days on mechanical ventilation for patients who are weanable.     

Resolution of Tracheostomy Complications by Decanulation and Conversion to Noninvasive Management for a Patient With High-Level Tetraplegia

Objectives:

To report conversion from tracheostomy (TIV) to noninvasive intermittent positive pressure ventilation (NIV) for a continuously ventilator-dependent patient with high-level spinal cord injury (SCI) with no measurable vital capacity (VC = 0 mL) to resolve tracheostomy-associated complications.

Methods:

A case report of a 38-year-old female in a chronic care facility in Japan with a 10-year history of ventilator-dependent tetraplegia (C1 ASIA-A) presented for increasing difficulty vocalizing. She had been using a fenestrated cuffed tracheostomy tube to produce speech with the cuff deflated. Speech was increasingly hypophonic, because of tracheostoma enlargement, tube migration, and tracheal granulation.

Results:

The NIV was provided via nasal and oral interfaces, the ostomy was surgically closed, and vocalization resumed. Airway secretions were expulsed using manually assisted coughing. The patient returned to the community.

Conclusion:

Conversion to NIV should be considered for ventilator-dependent patients with SCI who have adequate bulbar-innervated muscle function to permit effective speech and assisted coughing.     

Relationship of occupational therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project

Background/objective

Describe associations of occupational therapy (OT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and 1-year post-injury.

Methods

Occupational therapists at six inpatient rehabilitation centers documented detailed information about treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary for a 75% subset; models were validated with the remaining 25%. Functional outcomes for injury subgroups (motor complete low tetraplegia and motor complete paraplegia) also were examined.

Results

OT treatment variables explain a small amount of variation in Functional Independence Measure (FIM) outcomes for the full sample and significantly more in two functionally homogeneous subgroups. For patients with motor complete paraplegia, more time spent in clothing management and hygiene related to toileting was a strong predictor of higher scores on the lower body items of the self-care component of the discharge motor FIM. Among patients with motor complete low tetraplegia, higher scores for the FIM lower body self-care items were associated with more time spent on lower body dressing, manual wheelchair mobility training, and bathing training. Active patient participation during OT treatment sessions also was predictive of FIM and other outcomes.

Conclusion

OT treatments add to explained variance (in addition to patient characteristics) for multiple outcomes. The impact of OT treatment on functional outcomes is more evident when examining more homogeneous patient groupings and outcomes specific to the groupings.

Note

This is the third of nine articles in the SCIRehab series.     

Randomized controlled trial of pharmacological replacement of melatonin for sleep disruption in individuals with tetraplegia

Objective

To determine the effectiveness of a melatonin agonist for treating sleep disturbances in individuals with tetraplegia.

Design

Placebo-controlled, double-blind, crossover, randomized control trial.

Setting

At home.

Participants

Eight individuals with tetraplegia, having an absence of endogenous melatonin production and the presence of a sleep disorder.

Interventions

Three weeks of 8 mg of ramelteon (melatonin agonist) and 3 weeks of placebo (crossover, randomized order) with 2 weeks of baseline prior to and 2 weeks of washout between active conditions.

Outcome

Change in objective and subjective sleep.

Measures

Wrist actigraphy, post-sleep questionnaire, Stanford sleepiness scale, SF-36.

Results

We observed no consistent changes in either subjective or objective measures of sleep, including subjective sleep latency (P = 0.55, Friedman test), number of awakenings (P = 0.17, Friedman test), subjective total sleep time (P = 0.45, Friedman test), subjective morning alertness (P = 0.35, Friedman test), objective wake after sleep onset (P = 0.70, Friedman test), or objective sleep efficiency (P = 0.78, Friedman test). There were significant increases in both objective total sleep time (P < 0.05, Friedman test), subjective time in bed (P < 0.05, Friedman test), and subjective sleep quality (P < 0.05, Friedman test), although these occurred in both arms. There were no significant changes in any of the nine SF-36 subscale scores (Friedman test, Ps >Bonferroni adjusted α of 0.005).

Conclusion

In this pilot study, we were unable to show effectiveness of pharmacological replacement of melatonin for the treatment of self-reported sleep problems in individuals with tetraplegia.

Trial Registration

ClinicalTrials.gov # {"type":"clinical-trial","attrs":{"text":"NCT00507546","term_id":"NCT00507546"}}NCT00507546.     

Superior mesenteric artery syndrome – A rare presentation and challenge in spinal cord injury rehabilitation: A case report and literature review

Background

Obstruction of the third part of the duodenum (D3) is a very rare cause of gastric outflow obstruction. Rapid weight loss is the biggest risk factor. Patients seen in acute rehabilitation settings, not uncommonly, have a period of rapid weight loss. We report two cases of superior mesenteric artery (SMA) syndrome and review the literature.

Clinical details

The patients presented differently, one with repeated, refractory autonomic dysreflexia and severe spasticity and one with nausea, abdominal discomfort, and vomiting. CT abdomen with contrast identified dynamic duodenal (D3) obstruction against the posterior structures by narrow angled SMA, gastric distension and, in one case, dilation of the left renal vein. Both patients responded well to optimizing nutrition in different ways. Surgery was successfully avoided.

Discussion

SMA syndrome is an atypical cause of high intestinal obstruction, frequently occurring in patients who have had rapid weight loss during spinal cord injury (SCI) rehabilitation. It may co-exist with left renal vein dilation “nutcracker phenomena”. The associated neurogenic bowel dysfunction due to the nature of SCI could possibly contribute to delay in diagnosis.

Conclusion

Clinicians should consider the risk of SMA syndrome in patients with SCI with rapid weight loss. Early diagnosis is possible by doing a CT abdomen with contrast and angiography if there is a high index of suspicion. SMA syndrome can be successfully treated by aggressive nutritional management. This may include total parenteral nutrition or feeding by a nasojejunal tube. Duodenojejunostomy could be required in refractory cases.