脊髓损伤患者股骨远端和胫骨近端骨密度的变化

目的 探讨脊髓损伤患者发病早期股骨远端及胫骨近端骨密度变化的规律。     

The relationship between basal metabolic rate and femur bone mineral density in men with traumatic spinal cord injury

OBJECTIVES: To investigate the relationship between basal metabolic rate (BMR) and hip bone mineral density (BMD) in people with spinal cord injury (SCI) and to determine whether neurologic factors contribute to this relationship. DESIGN: Cross-sectional study. SETTING: Inpatient SCI unit in a rehabilitation hospital. PARTICIPANTS: Thirty men with chronic (time since injury, >1 y) traumatic SCI with an American Spinal Injury Association Impairment Scale grade A or B. Subjects' mean age was 32 years (range, 20-45 y). INTERVENTIONS: All participants were evaluated with neurologic examination to define the level and severity of injury. BMR was determined by indirect calorimetry, and BMD was determined by dual-energy x-ray absorptiometry (DXA). Patients were allocated to osteoporotic, osteopenic, and normal bone density groups according to World Health Organization criteria. DXA was used also to estimate lean- and fat-tissue mass (in kilograms) by standard methods. DXA measurements were performed on the same day as BMR analysis. MAIN OUTCOME MEASURES: DXA and indirect calorimetry. RESULTS: BMR correlated significantly with BMD of the total femur, femur neck, trochanter, and shaft. However, there was no correlation between BMR and femur Ward's triangle. These correlations were stronger in patients with tetraplegia. There was a moderate correlation between BMR and lean tissue mass (r = .66, P < .001), although femur BMD values did not correlate with lean tissue mass in our study group (P > .05). CONCLUSIONS: BMR is closely associated with BMD in men with SCI.     

比较脊髓损伤及制动后大鼠骨密度与生物力学变化的差异

背景:脊髓损伤及制动均可导致骨质疏松的发生.目的:建立胸髓横断大鼠动物模型,建立大鼠失用性萎缩模型,观察及比较大鼠胸髓损伤大鼠和失用性骨质疏松大鼠的骨密度及生物力学改变.设计、时间及地点:随机对照动物实验,于2008-08/11在解放军第四军医大学骨科研究所实验室完成.材料:将48只4月龄雌性大鼠分为3组:对照组(假手术组)、制动组、脊髓损伤组.方法:脊髓损伤组及对照组大鼠麻醉后行T10椎板切除,脊髓损伤组用锐刀横切脊髓,对照组则仅进行椎板切除术而不干预脊髓,制动组大鼠左下肢用小夹板固定后绷带悬吊,室温下分笼饲养,标准大鼠饲料,自由饮水、摄食.主要观察指标:术后3,6周检测大鼠腰4椎体、肱骨近端、股骨远端、骨盆骨密度及生物力学变化.结果:与对照组比较,术后3周,脊髓损伤组大鼠股骨远端骨密度显著下降(P＜0.05):术后6周,股骨远端、骨盆骨密度显著F降(P＜0.01,P＜0.05),两组肱骨近端、腰椎骨密度无明显差异.与对照组比较,术后3周,制动组大鼠股骨远端、腰椎骨密度较对照组下降,差异无显著性意义;术后6周,股骨远端、腰椎骨密度降低(P＜0 05).制动组与对照组肱骨近端、骨盆骨密度差异无显著性意义.术后6周,脊髓损伤组骨盆、股骨远端骨密度低于制动组(P＜0.05),腰椎骨密度高于制动组(P＜0.05).术后3周,脊髓损伤组及制动组大鼠腰椎、肱骨近端及骨盆最大载荷、结构刚度与对照组差异无显著性意义.术后3,6周,脊髓损伤组股骨远端最大载荷、结构刚度均低于对照组(P＜0.05,P＜0.01),肱骨近端及腰椎差异无显著性意义.结论:脊髓损伤及制动均可导致骨质疏松的发生,但骨密度及生物力学变化不同,即两种骨质疏松所发生的部位不同,即使同一部位发生骨质疏松,发生的程度也不相同.     

脊髓损伤对大鼠股骨骨密度与生物力学特性的影响

目的探讨脊髓损伤(spinal cord injury, SCI)对大鼠股骨生物力学和骨密度(bone mineral density, BMD)的影响. 方法将40只3月龄大鼠随机分为SCI组和对照组,SCI组于T10椎体处完全切断脊髓,对照组仅行椎板切除术.于术后3,6周分2批处死动物进行股骨骨密度和生物力学测定. 结果术后3周时SCI组大鼠股骨远端BMD较对照组显著下降(P<0.05);术后6周时SCI组股骨近端BMD与对照组比较,下降差异显著(P<0.05);股骨远端BMD较对照组下降差异非常显著(P<0.01);股骨干BMD与对照组相比有降低趋势,但无统计学意义.术后3周时股骨颈最大载荷、最大变形、结构刚度及能量吸收在2组间差异均无统计学意义.术后6周时最大变形、结构刚度和能量吸收均低于对照组(P均<0.05),最大载荷低于对照组,差异具有极显著性意义(P<0.01). 结论脊髓损伤后松质骨骨密度和生物力学性能的降低先于密质骨.脊髓损伤后6周时SCI组股骨松质骨的骨密度及生物力学参数均显著低于对照组,脊髓损伤后6周的大鼠可作为骨质疏松动物模型.     

Bone mineral density after spinal cord injury: a reliable method for knee measurement

OBJECTIVES: To test the interrater reliability of a standardized method to analyze knee bone mineral density (BMD) using dual-energy x-ray absorptiometry (DXA); to compare spine, hip, and knee BMD of people with spinal cord injury (SCI) with able-bodied controls; and to determine the relation between hip BMD and knee BMD in SCI and able-bodied subjects. DESIGN: Criterion standard and masked comparison. SETTING: Primary care university hospital. PARTICIPANTS: A convenience sample of 11 subjects with complete SCI was age and sex matched with 11 able-bodied control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Four raters analyzed regions of interest according to operational definitions recently developed to standardize the analysis of BMD of the knee. Subjects with chronic SCI and matched controls underwent conventional DXA scans of the spine and hips and "less conventional" scans of the distal femurs and proximal tibias. The relation between hip and knee BMD was analyzed. RESULTS: The knee measurements were highly reliable (femur intraclass correlation coefficient model 2,1 [ICC(2,1)]=.98; tibia ICC(2,1)=.89). Subjects with SCI had lower BMD values than controls at all hip and knee sites (P<.05). Lumbar spine BMD did not differ between groups. Hip BMD was moderately predictive of distal femur BMD (R2=.67), but less correlated with the proximal tibia (R2=.38). CONCLUSIONS: Knee BMD can be reliably analyzed using DXA with this protocol. Subjects with SCI have diminished knee and hip BMD. Low hip BMD is associated with low distal femur BMD.     

大鼠脊髓急性损伤后血流动力学变化的光学监测

目的观察脊髓损伤后血流动力学的变化,探讨脊髓损伤的血流动力学机制。 方法雌性SD大鼠20只,分为对照组和损伤组,每组10只。Nystrom法制造大鼠脊髓（T10~11）中度压迫性损伤模型。利用激光散斑成像系统监测大鼠脊髓损伤后第10分钟、30分钟、1小时、2小时、3小时、6小时背部血管内的血流速度和血流量以及血管管径的变化。 结果对照组大鼠各时间点血管内的血流速度、血流量以及血管管径均较稳定,无明显波动。损伤组大鼠各项指标均低于对照组。 结论激光散斑成像技术可以用于监测脊髓血流动力学的变化;急性脊髓损伤后血流动力学的变化提示进行性的“创伤后缺血”,静脉回流受阻可能是引起创伤后缺血的一个重要因素。     

大鼠脊髓急性损伤后血流动力学变化的光学监测

目的 观察脊髓损伤后血流动力学的变化,探讨脊髓损伤的血流动力学机制.方法 雌性SD大鼠20只,分为对照组和损伤组,每组10只.Nystrom法制造大鼠脊髓(T10-11)中度压迫性损伤模型.利用激光散斑成像系统监测大鼠脊髓损伤后第10分钟、30分钟、1小时、2小时、3小时、6小时背部血管内的血流速度和血流量以及血管管径的变化.结果 对照组大鼠各时间点血管内的血流速度、血流量以及血管管径均较稳定,无明显波动.损伤组大鼠各项指标均低于对照组.结论 激光散斑成像技术可以用于监测脊髓血流动力学的变化;急性脊髓损伤后血流动力学的变化提示进行性的"创伤后缺血",静脉回流受阻可能是引起创伤后缺血的一个重要因素.     

H-reflex changes following spinal cord injury

Changes in both central synaptic excitability (CSE) and peripheral sensitivity of muscle spindle stretch receptors have been hypothesized to contribute to hyperactive stretch reflexes of spasticity. To assess CSE, the monosynaptic H-reflex to the triceps surae muscles was tested serially over the first six months after traumatic spinal cord injury (SCI). Six clinically complete SCI patients were compared to age-matched control subjects. As a measure of H-reflex excitability, H/M ratios were calculated by dividing maximum H-reflex by maximum M-response amplitude. Analysis of variance over the testing trials showed significant change in H/M ratios for SCI patients (p less than 0.01). T-tests comparing mean H/M ratios at different time periods after SCI revealed a significant increment after three months (p less than 0.01). H-reflex amplitude also increased significantly over this time period (p less than 0.04), but M-response amplitude did not change significantly. These increases in H/M ratio and H-reflex amplitude suggest that an increase in CSE may contribute to the appearance of hyperreflexia after SCI.     

Functional changes in persons aging with spinal cord injury

Declines in general physical function and the effect of these changes on activities of daily living and needs for assistance were assessed in 150 individuals with spinal cord injury (SCI). The sample consisted of outpatients returning for follow-up at the spinal cord injury clinic at Rancho Los Amigos National Rehabilitation Center in Downey, CA. The average duration of injury of the sample was 13 years (range 1-37), and average age was 38 years (range 18-64). Twenty-four percent of those sampled experienced a decline or change in their physical function within the last 5 years. Individuals experiencing declines were significantly older than those without changes, averaging 45 years versus 36 years. The group with change also had a longer duration of injury, averaging 18 years versus 11 years compared to the group reporting no declines. Fatigue was the most frequently reported problem, followed by pain and weakness. Over half of the group with changes required additional assistance with activities of daily living (ADLs). Family members were the primary helpers for both ADLs and instrumental activities of daily living (IADLs) for those persons experiencing changes. The use of assistive technology, primarily equipment for bathing, toileting, and low technology devices, increased with time. The increased vulnerability to loss of function in persons with advancing age and duration of injury in this population with SCI suggests the need for early preventative measures, routine assessments to detect changes, and access to health care and supportive services to alleviate or minimize the effect of these changes.     

骨髓间充质干细胞向脊髓损伤区的迁徙☆

背景:骨髓间充质干细胞移植到脊髓损伤区域后,如何观察其在体内的生存和转归情况,一直是让人困扰的问题。目的:观察骨髓间充质干细胞在大鼠脊髓损伤区内的迁徙情况。方法:36只Wistar大鼠随机分为2组,实验组制作脊髓损伤模型1周后,经尾静脉移植用DAPI标记的骨髓间充质干细胞(1×109L-1)1mL,连续注射2d。对照组未行脊髓损伤,与实验组同一时间同法行骨髓间充质干细胞移植。分别于移植后5,10,15d,制作损伤脊髓冰冻切片,在激光共聚焦显微镜下观察骨髓间充质干细胞的迁徙情况。结果与结论:实验组于移植后5d,在脊髓损伤组织血管内出现少量荧光标记的骨髓间充质干细胞,10d后有血管外弥散,15d后有广泛弥散。对照组均未见DAPI标记的骨髓间充质干细胞。结果表明骨髓间充质干细胞经大鼠尾静脉移植后,能透过血脊髓屏障向损伤脊髓组织迁徙。     

骨髓间充质干细胞与运动性脊髓损伤

背景:骨髓间充质干细胞移植对于运动性脊髓损伤是一种有效的治疗手段.但目前有关脊髓损伤的研究尚不充分,且缺乏对其机制及其良好治疗方法的探讨.目的:通过分析运动性脊髓损伤的病理特征、骨髓间充质干细胞的生理特性,及其运用于脊髓损伤的应用,为制定运动性脊髓损伤的康复治疗方案提供理论依据和科学支撑.方法:应用计算机检索Pubmed数据库(1991/2010),以"Mesenchymal stem cell,sports Knee injuries"为检索词;应用计算机检索维普数据库(1991/2010),以"骨髓间充质干细胞、运动性脊髓损伤"为检索词.结果与结论:共收集到85篇文献,排除发表时间较早、实验设计科学性较差的文献,共25篇文献符合标准被纳入.骨髓间充质干细胞能分化为神经元样细胞,反应性分泌各种营养因子及生长因子,以增强神经的保护作用和促进局部微血管再生,从而起到治疗脊髓损伤的作用.但运动性脊髓损伤后损伤部位的缺血、缺氧、运动性自由基的产生及兴奋性氨基酸等影响骨髓间充质干细胞分化及其结果的相关问题仍需要大量的实验研究予以一一证实.     

Metabolic and endocrine changes in persons aging with spinal cord injury

Persons with spinal cord injury (SCI) have secondary medical disabilities that impair their ability to function. With paralysis, dramatic deleterious changes in body composition occur acutely with further adverse changes ensuing with increasing duration of injury. Lean mass, composed of skeletal muscle and bone, is lost and adiposity is relatively increased. The body composition changes may be further exacerbated by associated reductions in anabolic hormones, testosterone, and growth hormone. Individuals with SCI also have decreased levels of activity. These body composition and activity changes are associated with insulin resistance, disorders in carbohydrate and lipid metabolism, and may be associated with premature cardiovascular disease. Although limited information is available, upper body exercise and cycle ergometry of the lower extremities by functional electrical stimulation (FES) have been reported to have a salutary effect on these body composition and metabolic sequelae of paralysis. Perhaps other innovative, externally mediated forms of active exercise of the paralyzed extremities will result in an increased functional capacity, metabolic improvement, and reduction of atherosclerotic vascular disease.     

Estimation of geometric properties of cortical bone in spinal cord injury

OBJECTIVE: To evaluate structural and geometrical properties of the tibia shaft in subjects with spinal cord injury (SCI) and subjects without SCI and to estimate the potential usefulness of a multimodal approach to diagnosing osteoporosis in SCI. DESIGN: A cross-sectional study of randomly selected SCI and non-SCI subjects. METHODS: Measurements of bone geometric indices by computed tomography, and calculated bending stiffness with a biomechanical testing method. SETTING: An SCI center hospital. SUBJECTS: Ten men without known orthopedic or neurologic impairments (controls), 10 men with SCI who had a history of lower extremity pathologic fracture since SCI, and 10 men with SCI who had never had lower extremity pathologic fracture. RESULTS: Analysis of geometric and structural indices of subjects' tibias found a significant difference in all geometric indices between controls and the SCI subjects with pathologic fracture history. Between the controls and the SCI subjects with no fracture history, however, differences were found only in cross-sectional area and calculated bending stiffness. CONCLUSION: Structural analysis of leg bone, combined with measurement of bone density, may improve the ability to assess fracture risk in patients with SCI.     

Metabolic changes in persons after spinal cord injury

Persons with chronic SCI have several metabolic disturbances. As a consequence of inactivity and the body compositional changes of decreased skeletal muscle with a relative increase in adiposity, a state of insulin resistance and hyperinsulinemia has been demonstrated to exist, associated with abnormalities in oral carbohydrate handling. Elevated plasma insulin levels in persons with SCI probably contribute to the cause of frequent dyslipidemia and hypertension. This constellation of metabolic changes represents an atherogenic pattern of CHD risk factors with many of the distinctive features of a cardiovascular dysmetabolic syndrome that is called syndrome X. Reduction in modifiable risk factors for CHD should decrease the occurrence of catastrophic cardiovascular events. There is evidence to suggest that endogenous anabolic hormone levels are depressed in a proportion of individuals with SCI. Depression of serum testosterone and growth hormone/IGF-I levels may exacerbate the adverse lipid and body compositional changes, reduce exercise tolerance, and have deleterious effects on quality of life. Because of immobilization, individuals with paraplegia have osteoporosis of the pelvis and lower extremities, and those with tetraplegia also have osteoporosis of the upper extremities. In addition, there is evidence to suggest that bone loss progresses with time in persons with chronic SCI. This may be caused by chronic immobilization per se or may be a consequence of adverse hormonal changes, including deficiency of anabolic hormones or deficiency of vitamin D and calcium with secondary hyperparathyroidism. Serum thyroid function abnormalities resembling the euthyroid sick "low T3 syndrome" have been reported in those with acute and chronic spinal cord injury. Depressed serum T3 and elevated rT3 in chronic SCI may be caused by associated illness. Current practice has been hesitant to treat abnormal serum thyroid chemistries associated with nonthyroidal illness. Recognition of metabolic abnormalities in individuals with SCI is vital as a first step in improving clinical care. The application of appropriate interventions to correct or ameliorate these abnormalities promises to improve longevity and quality of life in persons with SCI.     

脊髓损伤患者站立活动量与骨密度的变化

背景:脊髓损伤后的骨质疏松,可造成患者持重能力下降,严重影响其生活质量。目的:分析脊髓损伤后患者的活动情况与骨密度变化的情况。方法:根据脊髓损伤患者每天的站立活动情况,分为3组:充分活动组每天站立活动1h以上;限制活动组每天站立活动不足1h;无活动组无站立活动。结果与结论:通过双能X射线骨密度仪对患者腰椎及股骨部进行骨密度检查后显示,充分活动组与限制活动组的腰椎(L2~4)、股骨颈、股骨转子和Ward’s三角区骨密度水平高于无活动组(P<0.05),充分活动组的骨密度水平较限制活动组有显著提高(P<0.05)。结果证实,相对于脊髓损伤后的相对制动,适当的站立活动在一定程度上有助于减少患者的骨质丢失,缓解骨质疏松的发展,提高骨密度水平。     

Aging with spinal cord injury

The years after SCI may be associated with acceleration of the aging process because of diminished physiologic reserves and increased demands on functioning body systems. Clinicians with expertise in the treatment and prevention of SCI-specific secondary complications need to collaborate with gerontologists and primary care specialists and need to invest in the training of future physicians to ensure a continuum of accessible, cost-effective, and high-quality care that meets the changing needs of the SCI population. Managed care payers often do not adequately cover long-term disability needs to prevent secondary SCI-specific complications. In this era of increasing accountability, evidence-based clinical practice guidelines are needed to document scientific evidence and professional consensus to effectively diagnose, treat, and manage clinical conditions; to reduce unnecessary testing and procedures; and to improve patient outcomes. Longitudinal research is needed to minimize cohort effects that contribute to misinterpretation of cross-sectional findings as representative of long-term changes in health and functioning. However, longitudinal studies confound chronologic age, time since injury, and environmental change. Thus, time-sequential research, which controls for such confounding effects, is essential, as is research on the effects of gender,culture, and ethnicity. If we consider how much progress has been made over the past 50 years with respect to SCI mortality related to infectious disease, we can expect to achieve even greater progress against the effects of aging in the next 50 years. Recent developments in molecular biology regarding growth and neuro-trophic factors are bringing us closer to the goal of repairing the damaged spinal cord. The challenge remains for rehabilitation professionals to provide the most comprehensive and holistic approach to long-term follow-up, with an emphasis on health promotion and disease prevention, to postpone functional decline and enhance QOL.     

慢性脊髓损伤的病理学变化及其修复特点

目的:当前脊髓损伤慢性期患者的数量增多,慢性脊髓损伤修复治疗日益成为迫切的需要,回顾性分析慢性脊髓损伤病理学及研究的进展。资料来源:应用计算机检索Medline数据库1985-01/2005-10期间与慢性脊髓损伤有关的文章,检索词“spinalcordinjuries,chronicdisease”,并限定文章语言种类为英文,同时以相同检索词计算机检索CNKI数据库2000-01/2005-10期间的相关文章,限定文章语言种类为中文。资料选择:对资料进行初审,选择以慢性脊髓损伤修复为主要内容的文献。其中研究内容相似的,以近5年且发表在较权威杂志的优先选择。资料提炼:就检索到的400余篇文献进行筛选,以慢性脊髓损伤病理学和修复为主要内容的文献90多篇。最终选定40篇关于慢性脊髓损伤病理学和损伤修复的文献。资料综合:与急性脊髓损伤相比,由于慢性损伤期的神经纤维自身再生能力下降,损伤部位微环境不支持轴突的再生,许多能够促进急性脊髓损伤再生的治疗措施不能够诱发慢性脊髓损伤轴突的长距离再生。结论:由于慢性脊髓损伤的病理特点,其损伤修复有很大难度,当前能够实现慢性损伤脊髓纤维向损伤对侧长距离生长的方法还很少。     

慢性脊髓损伤的病理学变化及其修复特点

目的：当前脊髓损伤慢性期患者的数量增多，慢性脊髓损伤修复治疗日益成为迫切的需要，回顾性分析慢性脊髓损伤病理学及研究的进展。 资料来源：应用计算机检索Medline数据库1985～01／2005—10期间与慢性脊髓损伤有关的文章，检索词“spinal cord injuries，chronic disease”，并限定文章语言种类为英文，同时以相同检索词计算机检索CNKI数据库2000-01／2005—10期间的相关文章，限定文章语言种类为中文。 资料选择：对资料进行初审，选择以慢性脊髓损伤修复为主要内容的文献。其中研究内容相似的，以近5年且发表在较权威杂志的优先选择。 资料提炼：就检索到的400余篇文献进行筛选，以慢性脊髓损伤病理学和修复为主要内容的文献90多篇。最终选定40篇关于慢性脊髓损伤病理学和损伤修复的文献。 资料综合：与急性脊髓损伤相比，由于慢性损伤期的神经纤维自身再生能力下降，损伤部位微环境不支持轴突的再生，许多能够促进急性脊髓损伤再生的治疗措施不能够诱发慢性脊髓损伤轴突的长距离再生。结论：由于慢性脊髓损伤的病理特点，其损伤修复有很大难度，当前能够实现慢性损伤脊髓纤维向损伤对侧长距离生长的方法还很少。     

Psychosocial responses to spinal cord injury

Spinal cord injury (SCI) is devastating both physiologically and psychologically. The psychosocial responses to SCI are the focus of this article. The following nursing diagnoses as they relate to the acute SCI population are examined in detail: disturbance in self-concept (body image, self-esteem, and role performance); powerlessness; functional grieving; and alteration in family process. Each nursing diagnosis will be explored in depth.