Factors associated with upper extremity contractures after cervical spinal cord injury: A pilot study

Objective: To examine the prevalence of joint contractures in the upper limb and association with voluntary strength, innervation status, functional status, and demographics in a convenience sample of individuals with cervical spinal cord injury to inform future prospective studies.

Design: Cross-sectional convenience sampled pilot study.

Setting: Department of Veterans Affairs Research Laboratory.

Participants: Thirty-eight participants with cervical level spinal cord injury.

Interventions: Not applicable.

Main Outcome Measures: Contractures were measured with goniometric passive range of motion. Every joint in the upper extremity was evaluated bilaterally. Muscle strength was measured with manual muscle testing. Innervation status was determined clinically with surface electrical stimulation. Functional independence was measured with the Spinal Cord Independence Measure III (SCIM-III).

Results: Every participant tested had multiple joints with contractures and, on average, participants were unable to achieve the normative values of passive movement in 52% of the joints tested. Contractures were most common in the shoulder and hand. There was a weak negative relationship between percentage of contractures and time post-injury and a moderate positive relationship between percentage of contractures and age. There was a strong negative correlation between SCIM-III score and percentage of contractures.

Conclusions: Joint contractures were noted in over half of the joints tested. These joint contractures were associated with decreased functional ability as measured by the SCIM-III. This highlights the need the need for detailed evaluation of the arm and hand early after injury as well as continued monitoring of joint characteristics throughout the life course of the individual with tetraplegia.     

Percutaneous peripheral nerve stimulation for treatment of shoulder pain after spinal cord injury: A case report

Context: This describes the first person with spinal cord injury (SCI) treated with percutaneous peripheral nerve stimulation for chronic shoulder pain.

Findings: From baseline to one-week after treatment, the subject's worst pain in the last week, rated on a 0–10 numerical rating scale (BPI-SF3), decreased by 44%. Pain interference decreased and remained below baseline 12 weeks after the end of treatment. There was an associated improvement in the mental component of quality of life.

Conclusion: This case demonstrates the feasibility of treating shoulder pain in patients with SCI with percutaneous PNS. To demonstrate efficacy further studies are required.     

创伤性上升性脊髓缺血损伤

脊椎损伤后,脊髓损伤平面上升较为少见。作者报告了５例,其中Ｔ１０－１１骨折脱位２例：１例于伤后２周内,截竣平面上升至Ｃ２,呼吸麻痹死亡,１例上升至颈部脊髓,双上肢无力;另３例为Ｔ１２骨折２例,Ｌ３骨折１例：其中截竣平面上升至Ｔ９至１例,Ｔ８者２例。５例患者双下肢皆呈软竣,１例死亡患者尸检见脊髓完整,Ｔ９－１０段脊髓前后动静脉血栓,其向上至Ｃ３,向下至Ｓ１,脊髓前血管、中央血管、髓内小血管多处 栓,     

脊髓损伤患者62例前瞻性临床研究

目的:通过前瞻性研究设计,对影响脊髓损伤患者功能恢复的各种影响因素进行初步分析.方法:设计前瞻性队列研究方案,在不干涉临床治疗方案前提下,采集2006年12月至2007年12月收治的脊髓损伤患者资料,纳入标准定为:急性脊髓损伤(受伤时间在1周以内),男女不限,年龄限定在18～65岁,根据临床查体结合MRI或CT检查证实为美国脊髓损伤协会(ASIA)分级标准(2000年修订)的A级(完全性脊髓损伤,损伤平面下不存在任何运动和感觉功能)或者B级(不完全性脊髓损伤,损伤平面下不存在运动功能,但存在感觉功能).所有入选病例均获随访,并分别在受伤入院当时及第1次评估后1、3、6个月采用ASIA分级标准、功能独立性评测(FIM)评价脊髓损伤及恢复情况,分析影响脊髓损伤患者功能恢复的因素.结果:共入选62例患者,男性60例,女性2例;年龄18～41岁,平均24岁;A级损伤29例,B级损伤33例.A级损伤中,手术减压患者(手术组)和非手术减压患者(非手术组)的感觉、运动ASIA评分及FIM评分比值在术后各时间点上的差异无统计学意义(P>0.05),B级损伤中,手术组和非手术组在手术前后感觉、运动ASIA评分、FIM评分的比值在各个时间点上差异均具有统计学意义(P<0.05).在手术组患者中,减压手术在伤后8 h以内(≤8 h)进行者,术前和术后感觉、运动ASIA评分、FIM评分比值与在伤后8 h以外(>8 h)进行者相比差异具有统计学意义(P<0.05).结论:对于A级损伤,手术减压时间点的选择对损伤的脊髓功能恢复影响差别不大,考虑到护理的方便和维持脊柱稳定性的要求,可以选择减压内固定手术;对于B级损伤,应该尽早进行减压手术以最大程度地恢复损伤脊髓的功能.     

颈髓挥鞭样损伤的回顾性研究

目的通过对临床资料的回顾性分析,探讨颈髓挥鞭样损伤病例手术的必要性。方法根据治疗方式和损伤后MR I所示脊髓受压程度的不同,将2004年4月～2006年4月收治的36例过伸性颈椎损伤患者分成3组：非手术治疗组（8例）、受压不明显者手术组（10例）、受压明显者手术组（18例）;比较3组间治疗前后的ASIA评分及Frankel分级改变。结果所有患者获得12～24个月随访,神经功能行ASIA评分及Frankel分级,手术组均高于非手术治疗组（P〈0.05）。结论过伸性颈脊髓损伤尽早手术减压是最大限度恢复神经功能的关键。凡存在明显神经功能障碍、MR I提示有颈髓损伤,无论是否有明显脊髓受压者都应早期手术。手术可避免因颈椎管高压和颈椎不稳造成的继发性脊髓损伤,保证其远期疗效。     

无颈椎骨折脱位的急性颈髓损伤

目的探讨无颈椎骨折脱位的急性颈髓损伤的特征和机制.方法对33例无颈椎骨折脱位的急性颈髓损伤病例进行回顾性研究,分析其神经学、X线和MRI检查结果.结果颈髓完全性损伤者8例,不完全性损伤者25例;21例患者有颈椎变性改变(椎间盘间隙狭窄伴有骨赘形成者15例,后纵韧带骨化者6例),3例C5颈椎管Pavlov率小于0.8;30例可见颈髓受压,25例表现为椎旁软组织损伤.结论无颈椎骨折脱位的急性颈髓损伤的重要诱因为颈椎变性改变和发育性颈椎管狭窄,致病原因主要为颈髓受压;MRI检查有利于查明脊髓损伤的部位和机制.     

扩大半椎板切除术治疗颈脊髓损伤

OBJECTIVE: To treat cervical spinal cord injury (SCI) accompanied with narrowing spinal canal by expanded hemilaminectomy. METHODS: From 1995 January to 1998 April 51 patients of cervical SCI were treated by expanded hemilaminectomy. Spinal injury classified in to 3 types: no fracture-dislocation (39 patients) fracture dislocation at the lower cervical spine (11), and burst fracture (1). The types of SCI included central cord injury (18 patients) incomplete cord injury (19), and complete cord injury (14). MR imaging in 23 patients showed degenerative changes with normal intensity of the cord in 14 patients, multiple level hyperintensity in 3, cystic changes in 3, myelomalasia in 3, and cord brocken in 1. Expanded hemilaminectomy was performed in 24 hours in 3 patients, in 48 hours in 9, in one week in 2, after one week in 35, and after one year in 2. The left or right laminae were removed from C(7) to C(3) in 42 patients, C(3) - T(1) in 3, C(2) - C(7) in 2, C(3) - C(6) in 3 and C(4) - C(7) in 3. Hemilaminectomy was expanded lateral to the inner of apophyseal joint and medial to the inner lamina beneath the spinal process. RESULTS: Follow-up lasted for 1 year and 7 months. Six patients with complete cord injury had of the no recovery lower extremity but recovery of the brachialis and extensor radial longus. 12 patients of central cord injury had full recovery except intrinsic muscles of the hand (5). They operated were on 2 weeks after injury. 17 patients of incomplete cord injury recovered to Frankel IV. CONCLUSIONS: Expanded hemilaminectomy is indicated for patients of cervical SCI with narrowing spinal canal or without fracture dislocation. Best results can be obtained in patients of central cord injury, and incomplete cord injury. Even in complete cord injury, 1 - 2 forearm muscle may recover (24.8%), securing a pinch grip reconstruction.     

Changes of intracellular calcium and the correlation with functional damage of the spinal cord after spinal cord injury

OBJECTIVE: To observe dynamic changes of intracellular calcium ([Ca(2+)]i) after spinal cord injury, and to study the relationship between the changes of [Ca(2+)]i and the functional damage of the spinal cord. METHODS: The rats were subjected to a spinal cord contusion by using a modified Allen's method. The [Ca(2+)]i in the injured segment of the spinal cord was measured by the technique of La(3+) blockage and atomic absorption spectroscopy at 1, 4, 8, 24, 72, and 168 hours after injury. The motor function on the inclined plane was measured at the same time. RESULTS: The spinal cord [Ca(2+)]i increased significantly (P<0.05 or P<0.01) aft er spinal cord injury. There was a significant correlation (P<0.05) between the changes of [Ca(2+)]i and the motor function. CONCLUSIONS: [Ca(2+)]i overload may play an important role in the pathogenesis of spinal cord injury.     

脊髓损伤后的免疫抑制研究进展

脊髓损伤（SCI）致死率高、预后差,常导致患者终身瘫痪,可引起系统性神经源性免疫抑制综合征（SCI-IDS）^[1]。SCI后的免疫抑制会增加机体对病原体感染的易感性,导致患者并发症发生率及病死率增高。近年,国内外SCI的临床及动物模型研究证实,SCI可导致机体免疫细胞功能受损,免疫因子也发生一定程度的变化,从而引起免疫功能障碍^[2-3],但具体机制尚不明确。由于免疫系统可由中枢神经系统通过下丘脑-垂体-肾上腺轴（HPA）、交感神经系统（SNS）和副交感神经系统（PNS）进行调节,所以中枢神经系统的损伤可引起免疫相关的神经功能受损,进而引起免疫抑制,同时亦可造成内分泌功能障碍,间接引起免疫功能障碍^[4-5]。明确SCI导致机体防御系统受损的相关机制及脊髓平面、损伤程度等相关因素对发生SCI后免疫功能的影响,对治疗SCI、提高患者的生存质量至关重要。本文就HPA、SNS与SCI后的免疫抑制的可能关联、产生的适应性免疫抑制的相关机制及与其相关方向的治疗前景作如下综述。     

脊髓损伤的MR表现

研究脊髓损伤的MR表现。采用GESigna0．5T超导型磁共振检查机，用脊柱表面线圈，对55例脊柱创伤病人做MR检查。所有病例做轮位和矢状位检查，用自旋回波序列和快速自旋回波序列。脊髓损伤表现为脊髓水肿23例次（41．8％），髓内出血10例次（18．1％），脊髓不完全性和完全性断裂7例次（12．7％），椎间盘值22例次（364％），脊柱韧带断裂30例次（545％）。脊髓损伤多见于爆裂型和骨折脱位型脊柱骨折。MR是脊髓损伤最有效的检查方法，MR对发现和评估脊髓损伤优于CT扫描。     

神经毒素在脊髓损伤中的作用

目的 探讨神经毒素兴奋性氨基酸（ＥＡＡ）和神经肽在脊髓损伤的作用。方法 应用高效液相色谱法检测脊髓损伤后伤段组织中谷氨酸（Ｇｌｕ）天门冬氨酸（Ａｓｐ）两种ＥＡＡ的含量变化；应用放射免疫分析技术测定脊髓损伤段组织中神经肽之一强腓肽ＤｙｎＡ１－１３含量的变化；观察了蛛网膜下腔注射Ｇｌｕ，ＤｙａｎＡ１－１３兴奋性氨基酸受体拮抗剂３－（２－羧基哌嗪）丙基－１－磷酸（ＣＰＰ），ＤｙｎＡ１－１３抗血清（Ａｎ－     

Start-up propulsion biomechanics changes with fatiguing activity in persons with spinal cord injury

Objective: Shoulder pathology is a common condition in wheelchair users that can considerably impact quality of life. Shoulder muscles are prone to fatigue, but it is unclear how fatigue affects start-up propulsion biomechanics. This study determines acute changes in start-up wheelchair propulsion biomechanics at the end of a fatiguing propulsion protocol.

Design: Quasi-experimental one-group pretest-postest design.

Setting: Biomechanics laboratory. Participants: Twenty-six wheelchair users with spinal cord injury (age: 35.5?±?9.8 years, sex: 73% males and 73% with a paraplegia).

Interventions: Protocol of 15 min including maximum voluntary propulsion, right- and left turns, full stops, start-up propulsion, and rests.

Outcome measures: Maximum resultant force, maximum rate of rise of applied force, mean velocity, mean fraction of effective force, and mean contact time at the beginning and end of the protocol during start-up propulsion.

Results: There was a significant reduction in maximum resultant force (P?<?0.001) and mean velocity (P?<?0.001) at the end of the protocol. Also, contact time was reduced in the first stroke of start-up propulsion (P?<?0.001). Finally, propelling with a shorter contact time was associated with a greater reduction in performance (maximum velocity) at the end of the protocol.

Conclusion: There are clear changes in overground propulsion biomechanics at the end of a fatiguing propulsion protocol. While reduced forces could protect the shoulder, these reduced forces come with shorter contact times and lower velocity. Investigating changes in start-up propulsion biomechanics with fatigue could provide insight into injury risk.     

Neurological and functional recovery after thoracic spinal cord injury

Objective

To describe neurological and functional outcomes after traumatic paraplegia.

Design

Retrospective analysis of longitudinal database.

Setting

Spinal Cord Injury Model Systems.

Participants

Six hundred sixty-one subjects enrolled in the Spinal Cord Injury Model Systems database, injured between 2000 and 2011, with initial neurological level of injury from T2–12. Two hundred sixty-five subjects had second neurological exams and 400 subjects had Functional Independence Measure (FIM) scores ≥6 months after injury.

Outcome Measures

American Spinal Injury Association Impairment Scale (AIS) grade, sensory level (SL), lower extremity motor scores (LEMS), and FIM.

Results

At baseline, 73% of subjects were AIS A, and among them, 15.5% converted to motor incomplete. The mean SL increase for subjects with an AIS A grade was 0.33 ± 0.21; 86% remained within two levels of baseline. Subjects with low thoracic paraplegia (T10–12) demonstrated greater LEMS gain than high paraplegia (T2–9), and also had higher 1-year FIM scores, which had not been noted in earlier reports. Better FIM scores were also correlated with better AIS grades, younger age and increase in AIS grade. Ability to walk at 1 year was associated with low thoracic injury, higher initial LEMS, incomplete injury and increase in AIS grade.

Conclusion

Little neurological recovery is seen in persons with complete thoracic SCI, especially with levels above T10. Persons who are older at the time of injury have poorer functional recovery than younger persons. Conversion to a better AIS grade is associated with improvement in self-care and mobility at 1 year.     

序贯法药物治疗脊髓损伤后中枢性疼痛

目的：研究应用序贯法药物治疗脊髓损伤后中枢性疼痛及临床效果。方法：自1994年至2008年共收治脊髓损伤后中枢性疼痛28例,其中男23例,女5例;年龄25—59岁,平均42岁。应用三级序贯法药物治疗,根据患者对药物治疗的反应,逐步调整药物治疗级别,直至疼痛缓解。根据治疗前后的VAS评分情况,评估药物镇痛效果。第一级：应用COX-2抑制剂。第二级：应用三环类抗抑郁药物阿米替林＋COX-2抑制剂＋卡马西平。第三级：应用阿米替林三环类抗抑郁药物＋加巴喷丁＋神经妥乐平或COX-2抑制剂。结果：28例均有不同程度的疼痛缓解。第一级药物治疗VAS评分降低（23．3±1．2）分,第二级药物治疗VAS评分降低（54．5±3．8）分,第三级药物治疗VAS评分降低（65．8±5．1）分。结论：应用三级序贯法药物治疗脊髓损伤后中枢性疼痛,具有疗效优良、不良反应少的优点。     

钙调素拮抗剂对大鼠脊髓损伤的作用及意义

目的观察钙调素（ＣａＭ）特异性拮抗剂三氟啦嗪（ＴＦＰ）对脊髓损伤（ＳＣＩ）的影响,探讨ＣａＭ在ＳＣＩ病理机制中的作用。方法采用氢清除法、斜板试验和电生理技术,以６４只大鼠为实验对象观察ＴＦＰ对ＳＣＩ后脊髓血流量（ＳＣＢＦ）、运动功能和诱发电位（ＭＥＰ）的影响。结果在肾上腺素维持系统动脉压的条件下,ＴＦＰ可明显改善ＳＣＩ后ＳＣＢＦ、ＭＥＰ和运动功能。结论ＣａＭ拮抗剂对ＳＣＩ具有保护作用,ＣａＭ可能是参与ＳＣＩ病理机制的重要因素     

Post-traumatic growth following spinal cord injury

Context/objective

Examine the relationship of post-traumatic psychological growth (PTG), depression, and personal and injury characteristics in persons with spinal cord injury (SCI).

Design

Cross-sectional survey.

Setting

Community.

Participants

Eight hundred and twenty-four adults with SCI.

Interventions

None.

Outcome measures

Five items from the Post-traumatic Growth Inventory, reflecting positive change after injury in life priorities, closeness to others, new opportunities being available, stronger faith, and personal strength.

Results

Initial structural equation model testing of a conceptual model of personal and injury characteristics, violent etiology, depression, and PTG resulted in a poor fit. Model modifications resulted in an improved fit, but explained only 5% of the variance in PTG. Being female, younger, having less formal education, and less time since injury had significant relationships with PTG, whereas depression, violent etiology, and injury level/severity did not. In each PTG domain, between 54 and 79% of the sample reported at least some positive change after injury.

Conclusions

The results of this study, while promising, explained only a small portion of the variance in PTG. A majority of the sample experienced some positive change after injury, with the greatest change in discovering that they were stronger than they thought they were. Comparing means previously reported in a non-SCI sample of those who experienced trauma, positive change after injury was comparable for each PTG item except for new opportunities being available, which was significantly lower for those with SCI. Future directions of research include the development of theoretical models of PTG after SCI.     

无骨折脱位颈髓损伤的临床治疗

1996—2001年，我院在颈髓损伤的治疗中，收治无骨折脱位的颈髓损伤患者24例。由于此类患者X线检查无明显骨折脱位以及对该病的认识和经验不足，较易造成漏诊、误诊，治疗效果常不够理想。本文就对该病的临床诊断、治疗和发病机制作一探讨，报告如下。     

继发性脊髓损伤的细胞凋亡研究现状

细胞凋亡，又称程序性细胞死亡，在继发性脊髓损伤过程中起着关键作用。本文对继发性脊髓损伤细胞凋亡的作用、诱导因素和防治途径作一综述。     

Psychological factors and risk of mortality after spinal cord injury

Objective: Identify the association of personality and purpose in life with competing risks of multiple causes of death after spinal cord injury (SCI), using data from the SCI Longitudinal Health Study.

Design: Prospective cohort study with data collected in 1997–1998 and 2007–2009. Mortality status determined as of December 31, 2016.

Setting: Specialty hospital in the Southeastern United States.

Participants: 3070 adults with chronic (>1-year), traumatic SCI.

Interventions: N/A.

Outcome Measures: We examined 6 psychological factors (Purpose in Life and 5 scales of the Zuckerman-Kuhlman Personality Questionnaire) and risk of mortality due to 6 specific causes of death, building on published analyses of behavioral and health/clinical risk and protective factors.

Results: There were 803 deaths. Four of the 6 psychological factors were predictive of all-cause mortality. All except 1 personality scale were related to cause-specific mortality. Psychological factors were most predictive of unintentional injury deaths. Purpose in life was protective of death due to pneumonia; whereas, Activity was protective of death due to diseases of heart and blood vessels and to unintentional injury. Sociability, Impulsive-Sensation Seeking, and Neuroticism-Anxiety were risk factors for death due to unintentional injury. Neuroticism-Anxiety was related to death due to septicemia. There were no significant psychological predictors of cancer.

Conclusions: Rehabilitation professionals have a central role in promoting purpose in life as a means of increasing longevity. By assessing personality factors predictive of specific causes of mortality, those at risk may be targeted for cause-specific prevention strategies.