Weight change after spinal cord injury

Objectives: To study the patterns of weight change after spinal cord injury (SCI) and identify associated risk factors.

Study design: Cohort study.

Setting: Sixteen Spinal Cord Injury Model Systems (SCIMS), USA.

Participants: One thousand and ninety-four individuals with an SCI who were entered into the SCIMS and had a 1-year follow-up between October 2006 and November 2012.

Intervention: Not applicable.

Outcome measure: Change in body mass index (BMI) during the first year of injury. Height and weight were assessed during inpatient rehabilitation and 1 year after injury.

Results: Mean BMI decreased from 26.3 to 25.8?kg/m² during the first year after SCI (mean change: ?0.5?kg/m² (standard deviation: 3.58)). Weight loss was mainly observed among individuals classified as overweight or obese during rehabilitation (n = 576) with a BMI decrease of 1.4?kg/m², which varied significantly by sex, education, neurological level, and the presence of vertebral injury. Weight gain was noted among individuals classified as underweight or normal weight during rehabilitation (n?=?518) with a BMI increase of 0.5?kg/m², with the greatest increase among individuals of Hispanic origin (1.2?kg/m²), other marital status (1.2?kg/m²), age group 31–45 years (1.1?kg/m²), with less than high school education (1.1?kg/m²), without spinal surgery (0.9?kg/m²), and with motor functionally incomplete injury (0.8?kg/m²).

Conclusion: Our findings suggest that strategies for weight management should be addressed after a SCI to ameliorate the potential for unhealthful weight change, particularly among at-risk groups.     

脊髓损伤后血流改变

选用成年狗１０只，于胸９－０给以２０ｇ×２５ｃｍ打击量，应用氢清除法于伤后１５ｍｉｎ～４ｂ测定脊髓血流量（ＳＣＢＦ）。结果显示伤后不同时期灰质血流量均较白质血流量（ｗＳＣＢＦ）为高，近侧节较远侧节亦高，伤后２ｈ，ｗＳＣＢＦ稍升高，但４ｈ恢复正常。作者认为，伤后头几个小时为关键时刻，此时如能采用有效措施，对不全瘫还能逆转。本文结果与文献相比有些差异，可能与实验条件不同及观察时间较短有关。     

Management of obesity after spinal cord injury: a systematic review

Context: Individuals with chronic spinal cord injury (SCI) are susceptible to central and visceral obesity and it’s metabolic consequences; consensus based guidelines for obesity management after SCI have not yet been stablished.

Objectives: To identify and compare effective means of obesity management among SCI individuals.

Methods: This systematic review included English and non-English articles, published prior to April 2017 found in the PubMed/Medline, Embase, CINAHL Psychinfo and Cochrane databases. Studies evaluating any obesity management strategy, alone or in combination, including: diet therapy, voluntary and involuntary exercise such as neuro-muscular electric stimulation (NMES), pharmacotherapy, and surgery, among individuals with chronic SCI were included. Outcomes of interest were reductions in waist circumference, body weight (BW), body mass index (BMI) and total fat mass (TFM) and increases in total lean body mass (TLBM) from baseline. From 3,553 retrieved titles and abstracts, 34 articles underwent full text review and 23 articles were selected for data abstraction. Articles describing weight loss due to inflammation, cancer or B12 deficiency were excluded. The Downs and Black reported poor to moderate quality of the studies.

Results: Bariatric surgery produced the greatest permanent weight reduction and BMI correction followed by combinations of physical exercise and diet therapy. Generally, NMES and pharmacotherapy improved TLBM and reduced TFM but not weight.

Conclusions: The greatest weight reduction and BMI correction was produced by bariatric surgery, followed by a combination of physical exercise and diet therapy. NMES and pharmacologic treatment did not reduce weight or TFM but increased in TLBM.     

Electrically induced cycling and nutritional counseling for counteracting obesity after spinal cord injury: A pilot study

Objective: The purpose of this pilot study was to determine the preliminary efficacy of interval functional electrical stimulation (FES) cycling combined with nutritional counseling in obese adults with SCI.Setting: Community-based individuals with chronic SCI.Participants: Ten participants with chronic SCI.Interventions: Participants were divided into 2 groups (1) FES cycling and nutritional counseling (FES & Nutri) and (2) nutritional counseling only (Nutri Only). The FES & Nutri group performed high intensity interval FES cycling for 30 min 3 times per week for 8 weeks and received nutritional counseling for 30 min once per week for 8 weeks. The Nutri Only group received the nutritional counseling only.Outcome Measures: Body composition (fat mass, lean mass, body fat percentage), blood glucose levels.Results: Participants in the FES & Nutri group had a statistically significant greater decrease in body fat percentage (M = −1.14) compared to those in the Nutri Only group (M = +0.28) and gained more lean mass in their legs (M = +0.66 kg) compared to the Nutri Only group (M = –1.05 kg).Discussion/Conclusion: The statistically significant decrease in body fat percentage for the FES & Nutri group provides evidence that further study is merited. Future studies should include larger numbers of participants and the possible introduction of a preliminary strengthening program before initiating interval FES cycling. In addition, an increase in exercise volume and a greater role for nutritional counseling should be considered in order to optimize the treatment for obesity.     

Midodrine in patients with spinal cord injury and anejaculation: A double-blind randomized placebo-controlled pilot study

Objective

The objective of this study is to evaluate the efficacy of midodrine in the treatment of anejaculation in men with spinal cord injury (SCI).

Study design

Prospective, double-blind, randomized, placebo-controlled pilot study.

Method

Men with anejaculation associated with SCI (level of injury above T10) of more than 1 year in duration were approached. Those with no ejaculatory response to one penile vibratory stimulation (PVS) trial were assigned in a double-blind manner to one of the two following interventions once a week for a maximum of 3 weeks or until ejaculation occurred: oral administration of flexible midodrine (7.5–22.5 mg max) followed by PVS (group M), or oral administration of flexible sham-midodrine (placebo) followed by PVS (group P). Sociodemographic data, medical characteristics, and plasma desglymidodrine concentration were collected for all participants.

Outcome measure

Ejaculation success rate in each group.

Results

Among the 78 men approached, 23 participants (level of SCI: C4–T9) were randomized. Three participants abandoned the study and 20 completed the study; 10 were assigned to group M, 10 to group P. Ejaculation was reached for one participant of group M and for two participants of group P. Autonomic dysreflexia associated to PVS occurred in three patients.

Conclusion

In this small sample study, treatment of anejaculation after SCI with midodrine and PVS did not result in a better rate of antegrade ejaculation in 10 men than in 10 men treated with a placebo and PVS.     

Prevalence of metabolic syndrome in veterans with spinal cord injury

Context/Objective: Recent literature would suggest the prevalence of metabolic syndrome in persons with spinal cord injury (SCI) is higher than that of the general population, although no large cohorts have yet been reported. Part of the controversy relates to the differing definitions provided for metabolic syndrome and the characterization of obesity in persons with SCI.

Design/Participants: The current retrospective investigation represents a cross-sectional cohort of 473 veterans with SCI from a single center in the mid-Atlantic region of the United States for whom modified International Diabetes Federation (IDF) criterion variables for the metabolic syndrome were available in the computerized personal record system (CPRS).

Outcome Measures: These variables included a surrogate marker of obesity appropriate to SCI (Body Mass Index (BMI) ≥ 22?kg/m²), as well as indicators of diabetes, dyslipidemia and hypertension.

Results: Over 57% of the veterans assessed were determined to have metabolic syndrome by modified IDF criteria, including 76.7% with BMI ≥ 22?kg/m², 55.1% with or under treatment for hypertension, 49.7% with or previously diagnosed with diabetes mellitus, and 69.7% with or under treatment for high density lipoprotein (HDL) cholesterol under 40?mg/dl.

Conclusion: Metabolic syndrome and its constituent components appear to be more prevalent in veterans with SCI than in the general population, suggesting a greater need for identification and treatment interventions in this specialty population.     

Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry

Objective: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center.

Design: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year.

Setting: Dallas, TX, USA.

Participants: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591.

Outcome Measures: Data included demographic and clinical characteristics, charges, and healthcare utilization.

Results: Mean age was 46.1?years (±18.9?years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use.

Conclusion: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.     

脊柱脊髓损伤患者低钠血症的临床研究

目的：探讨脊柱脊髓损伤患者低钠血症的临床发病情况、发生机制及治疗措施。方法：回顾性分析543例急性脊柱脊髓损伤患者的临床资料。结果：543例患者中发生低钠者202例，占全部病例的37．2％。脊柱脊髓损伤患者低钠血症的发生率与患者脊髓损伤平面和程度有关。202例低钠者中13例出现神经精神症状。结论：脊柱脊髓损伤患者低钠血症的发生与钠盐摄入量减少、过量水负荷、脊髓损伤后肾脏排水保钠能力下降等原因有关。ASIA运动评分与脊柱脊髓损伤患者低钠血症的发生有相关性。     

脊髓损伤后并发肺损伤的实验研究

目的探讨脊髓损伤后并发肺损伤的机理、病理及治疗方法。方法家兔40只,通过改良Allen法制成脊髓损伤模型,截瘫按Talove分级为1～2级,分为治疗组(B)和对照组(A),治疗组于伤后3h开始自静脉给予常规剂量(0.35mg/kg)的地塞米松治疗,分别于不同的时相点处死家兔,观察动物肺脏的病理改变。结果家兔脊髓损伤后均发生了不同程度的肺脏损伤,肺出血(100%)。脊髓损伤所致的肺出血,治疗组明显轻于对照组(P<0.01)。结论脊髓损伤均并发不同程度的肺损伤。肺损伤的发生机理主要是神经-体液应急反应。应用常规剂量的地塞米松即可以有效地预防和治疗脊髓损伤并发的肺损伤。     

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。     

Examining health-care utilization in the first year following spinal cord injury

Abstract

Objective

To identify factors associated with health-care utilization during the first year after inpatient rehabilitation (IR) in individuals with traumatic spinal cord injury (SCI).

Design

Prospective cohort.

Methods

One hundred and sixty-eight patients were prospectively enrolled and followed over 1 year after discharge from an SCI Model System IR program. Telephone follow-up occurred at 3, 6, 9, and 12 months. Participants were grouped into four impairment levels (C1–4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A–C, C5–C8 AIS A–C, paraplegia AIS A–C, and all AIS D). Three domains of health-care utilization were examined: hospital care, outpatient provider visits, and home services.

Results

Health-care utilization in the first year following IR was high with 45% of subjects reporting re-hospitalization. Twenty percent of patients were initially discharged to a skilled nursing facility (SNF), and an additional 10% required SNF care during this first year. Overall, those with C1–4 AIS A–C used the most services. Participants discharged home used less health care compared to those discharged elsewhere. SCI due to falls (vs. vehicular crashes) was associated with fewer in-home service visits. Age, sex, race, and education were unrelated to higher use.

Conclusion

Those with greater neurological impairment or not discharged home after IR had higher health-care utilization, while age was not associated with utilization. Targeted efforts to reduce genitourinary and respiratory complications may reduce the need for hospital care in the first year after IR.     

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.     

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.     

Experimental spinal cord injury: Lumbar vertebra resection to shorten the gap between spinal cord stumps

Summary Experimental spinal cord transection injuries followed by spinal cord destruction and gentle resection of the destructed cord tissue necessarily lead to a gap between both of the cord stumps. For any attempts to reconstruct the cord or to bridge this gap by transplantation it may be useful to narrow or close the gap. This can be done by vertebral resection.The technique of upper lumbar vertebra resection in cats and rabbits with and without spinal cord lesion is presented. The spine is shortened by approximately 20 mm by spondylectomy. This length exceeds the 10–14 mm long gap in the spinal cord which is created by a spinal cord crush injury using haemostatic forceps and the subsequent destruction zone resection which is performed seven days later. The upper lumbar vertebra is resected by the posterior approach and the spinal cord is sufficiently exposed to perform spinal cord reconstruction experiments.     

大鼠脊髓横断性损伤后细胞周期蛋白D3的表达变化

目的 探讨细胞周期蛋白D3（Cyclin D3）在横断性脊髓损伤（tSCI）后的表达变化以及定位情况。方法 将48只成年SD大鼠随机分为8组：正常对照组，T9横断伤2、8h、1、3、5、7和14d组，每组6只。采用Western blot测定损伤后各时间段Cyclin D3蛋白水平在脊髓中的表达变化。采用免疫组织化学方法检测Cyclin D3在正常以及损伤后脊髓中的分布和定位。结果 West—emblot显示，Cyclin D3蛋白水平在tSCI后头、尾段均呈现先升高后下降的趋势，尾段明显：Cyclin D3的表达于损伤后8h开始逐渐升高，3d达到高峰，一直持续到第5天，之后逐渐下降。免疫组织化学表明Cyclin D3在正常脊髓中均匀分布，损伤后3d，Cyclin D3在脊髓白质和灰质中表达明显增强；免疫荧光双标记表明Cyclin D3与神经元的标记物neuronal nucleus（NeuN）、少突胶质细胞标记物cyclic nucleotide 3’phosphohydrolase（CNPase）有明显共定位，与星形胶质细胞标记物gtial fibrillary acidic protein（GFAP）和小胶质细胞标记物OX-42也存在部分共定位。结论脊髓损伤后Cyc—lin D3蛋白水平呈现明显的时相变化，并且与神经元、少突胶质细胞、星形胶质细胞和小胶质细胞存在共定位，提示Cyclin D3参与了脊髓损伤后的病理生理过程。     

内皮素与脊髓损伤后血脊屏障损害的关系

目的：阐明内皮素（ＥＴ）与脊髓损伤（ＳＣＩ）后血脊屏障损害的关系,为临床治疗ＳＣＩ提供指导。方法：ＳＤ大鼠２４只,分为４组,即生理盐水组、ＥＴ－１组、损伤＋生理盐水组和损伤＋ＰＤ１４５０６５组。实验一：无损伤组分别于鞘内注射生理盐８水或ＥＴ－１。实验二：压迫法致伤脊髓（５０ｇ,１ｍｉｎ）,分别于伤前１０ｍｉｎ鞘内注射生理盐水或非选择性ＥＴ受体拮抗ＰＤ１４５０６５。伊文思兰（ＥＢ）定量法评价血脊屏障     

Osteoporosis after spinal cord injury.

Dual-photon absorptiometry characterized bone loss in males aged less than 40 years after complete traumatic paraplegic and quadriplegic spinal cord injury. Total bone mass of various regions and bone mineral density (BMD) of the knee were measured in 55 subjects. Three different populations were partitioned into four groups: 10 controls (healthy, age matched); 25 acutely injured (114 days after injury), with 12 reexamined 16 months after injury; and 20 chronic (greater than 5 years after injury). Significant differences (p less than 0.0001) in bone mass mineral between groups at the arms, pelvis, legs, distal femur, and proximal tibia were found, with no differences for the head or trunk. Post hoc analyses indicated no differences between the acutely injured at 16 months and the chronically injured. Paraplegic and quadriplegic subjects were significantly different only at the arms and trunk, but were highly similar at the pelvis and below. In the acutely injured, a slight but statistically insignificant rebound was noted above the pelvis. Regression techniques demonstrated early, rapid, linear (p less than 0.0001) decline of bone below the pelvis. Bone mineral loss occurs throughout the entire skeleton, except the skull. Most bone loss occurs rapidly and below the pelvis. Homeostasis is reached by 16 months at two thirds of original bone mass, near fracture threshold.     

脊髓损伤后的高凝状态

目的:观察脊髓损伤患者凝血系统的变化。方法:以20例符合条件的脊髓损伤病人为研究对象,分别于伤后2~6h、伤后1、3、5d采集病人股静脉血,测定血浆凝血酶抗凝血酶Ⅲ复合物(TAT)、凝血酶原片段1 2(F1 2)和D-二聚体(D-dimer)浓度;同时测定20名健康献血员TAT、F1 2、D-dimer血浆浓度作为正常对照。结果:正常对照组TAT、F1 2和D-dimer血浆浓度分别为3.1±0.9ng/ml、0.9±0.2nmol/l和42.6±9.3ng/ml。20例脊髓损伤病人伤后2~6hTAT、F1 2、D-dimer血浆浓度即显著增高(P<0.05),分别达45.3±14.2ng/ml、4.1±0.7nmol/l和136.2±14.3ng/ml,伤后1、2d内仍明显高于对照组,伤后3、4d趋于正常。结论:脊髓损伤后可激活凝血系统,造成高凝状态,这种高凝状态于伤后数小时即可发生,且持续存在2~3d。