Urological rehabilitation of spinal cord injury patients

The urological rehabilitation of spinal cord injury patients depends on an optimal urological treatment plan and good cooperation between the patient, general practitioner, urologist, and a centre that specialises in treating spinal cord injuries. Because of medical advancements in neuro-urology, one can assume that in cases of lifelong urological care, the individual's life expectancy will be almost normal. The recognition that nonphysiological bladder storage pressure results in restricted kidney function has led to various therapeutic strategies with complementary goals, such as protection of the upper urinary tract, urinary continence, individualized bladder management.     

Urological follow-up of 124 women following spinal cord injury

Summary A review of the urological status of 124 women with spinal cord injuries admitted over a 25-year period to the National Medical Rehabilitation Centre is presented. In all, 84 (68%) of these patients are currently catheter-free, 27 (22%) have permanent catheter drainage, 11 perform clean, intermittent self-catheterisation and 2 have undergone urinary diversions. There are many reports on the urological follow-up of patients with spinal cord injuries, but few of these have dealt with women. It is clear that whereas males may be kept dry with the aid of external urinals, women present a distinct problem. The experience at our centre clearly shows that women less frequently develop outlet obstruction and suffer less from incontinence. This study assesses the status of 124 women, with particular reference to continence and catheter independence.     

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.     

Respiratory management during the first five days after spinal cord injury

Respiratory complications are the most common cause of morbidity and mortality in acute spinal cord injury (SCI), with an incidence of 36% to 83%. Eighty percent of deaths in patients hospitalized with cervical SCI are secondary to pulmonary dysfunction, with pneumonia the cause in 50% of the cases. The number of respiratory complications during the acute hospital stay contributes significantly to the length of hospital stay and cost. Four factors (use of mechanical ventilation, pneumonia, the need for surgery, and use of tracheostomy) explain nearly 60% of hospital costs and may be as important a predictor of hospital cost as level of injury. Atelectasis (36.4%), pneumonia (31.4%), and ventilatory failure (22.6%) are the most common complications during the first 5 days after injury. Ventilatory failure occurs on average 4.5 days after injury. Transfer to an SCI center specializing in acute management of tetraplegia has been shown to significantly reduce the number of respiratory complications. This review concentrates on the first 5 days after injury, focusing on complications, predictive factors, prevention, and management of those complications.     

Spasticity after spinal cord injury

Symptoms of spasticity are often experienced by individuals with spinal cord injury (SCI) following a period of spinal shock and, in many cases, these symptoms negatively affect quality of life. Despite its prevalence, spasticity as a syndrome in the SCI population is not always managed effectively. This is likely due to the fact that the syndrome can have various presentations, each with their own specific etiology. This overview summarizes the symptoms and pathophysiology of the various presentations of spasticity in the SCI population and discusses the currently accepted management techniques. There is a need for a better understanding of the syndrome of spasticity as well as the development of a valid and reliable assessment tool.     

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。     

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.     

Functional electrical stimulation after spinal cord injury.

This article reviews work mainly from my own laboratory on the effects of electrical stimulation for therapy and function following spinal cord injury. One to two hours per day of intermittent stimulation can increase muscle strength and endurance and also reverse some of the osteoporosis in bones that are stressed by the stimulation. Stimulation during walking can also be used to improve speed and other parameters of the gait. Surface stimulation systems with 1-4 channels of stimulation were used in a multicenter study. Initial increases of almost 20% in walking speed were seen and overall increases of nearly 50% in subjects who continued to receive stimulation for a year on average. Some changes were due to improved strength and coordination with stimulation and additional walking, but a specific effect of stimulation persisted throughout the trial. Improved devices will soon be available commercially that were developed on the basis of feedback from users.     

Urological management of female spinal cord injury patients--clinical survey of 28 cases

Most of the literature about the urological management of spinal cord injury patients is on male patients, and the method of the urological treatment for male spinal cord injury patients is often not useful for female patients. A clinical survey was done on 28 female neurogenic bladder patients after spinal cord injury treated at our Hospital between January, 1980 and January, 1985. At discharge, 11 patients (39.3%) were catheter free, 3 (10.7%) were managed by clean intermittent self catheterization, 1 (3.6%) was managed by clean intermittent catheterization by a helper, and 13 (46.4%) were on indwelling catheters. One of the main reasons that prevents female spinal cord injury patients from becoming catheter free is that there are no effective external collecting devices or devices to prevent urinary incontinence for female neurogenic bladder patients. Another reason is that some female patients can not obtain a high enough ADL level for toilet activities by rehabilitation in spite of lower thoracic or lumbar lesions.     

Urological treatment of patients with spinal cord injury in the chronic stage

One hundred eighty patients with spinal cord injury were admitted to our hospital between January, 1980 and June, 1983. Eighty-five of them had cervical lesions, 54 had thoracic lesions and 41 had lumbar lesions. Most of the neurogenic bladders due to spinal cord injury treated in our clinic, could be classified into 3 major patterns: hypoactive detrusor-hypoactive sphincter, hypoactive detrusor-active sphincter, and hyperactive detrusor-hyperactive sphincter. To control the hyperactivity of the detrusor and the sphincter, we employed pharmacotherapy first and then we performed transurethral resection of the bladder neck and prostatectomy (TUR-Bn.P) and nerve block (sacral nerve block, pudendal nerve block, obturator nerve block and lumbar nerve block). In the case of a hypoactive detrusor, we employed TUR-Bn.P, open ileal flap fixation to the bladder and voiding training. Using these procedures, we could make 157 patients catheter-free.     

Worklife after traumatic spinal cord injury

OBJECTIVE: To develop predictive models to estimate worklife expectancy after spinal cord injury (SCI). DESIGN: Inception cohort study. SETTING: Model SCI Care Systems throughout the United States. PARTICIPANTS: 20,143 persons enrolled in the National Spinal Cord Injury Statistical Center database since 1973. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Postinjury employment rates and worklife expectancy. RESULTS: Using logistic regression, we found a greater likelihood of being employed in any given year to be significantly associated with younger age, white race, higher education level, being married, having a nonviolent cause of injury, paraplegia, ASIA D injury, longer time postinjury, being employed at injury and during the previous postinjury year, higher general population employment rate, lower level of Social Security Disability Insurance benefits, and calendar years after the passage of the Americans with Disabilities Act. CONCLUSIONS: The likelihood of postinjury employment varies substantially among persons with SCI. Given favorable patient characteristics, worklife should be considerably higher than previous estimates.     

Rehabilitative therapies after spinal cord injury

We review some basic and highly relevant concepts in the effort to develop improved rehabilitative interventions for subjects with spinal cord injury (SCI). Interventions that are likely to contribute to improved sensorimotor function include (1) practice of the specific motor task that needs to be improved; and (2) combining the training with one or more interventions--such as pharmacological modulation of the excitability of spinal neural networks, implantation of selected cell types such as olfactory ensheathing glia (OEG), and/or modulation of the excitability of the spinal cord via epidural stimulation. Upon improvement of the neural control of the musculature following SCI, it will always be prudent to maximize the torque output from these activation patterns by assuring that muscle mass is maintained. Therefore, it seems quite feasible that considerable improvement in locomotor performance can be achieved by improved coordination of motor pools, as well as effective recovery of muscle mass, which will assist in the potential generation of normal forces among agonistic and antagonistic muscle groups.     

脊髓损伤后骨代谢

脊髓损伤(spinal cord injury)使机体的骨代谢发生改变并产生严重的并发症，其中骨质疏松(osteoporosis)与异位骨化(heterotopic ossification或ectopic ossification)是脊髓损伤患者常见的并发症。骨质疏松使肢体骨折风险性加大，异位骨化通常发生于大关节的周围，使关节功能受限，严重影响其生活质量。笔者就脊髓损伤后骨代谢改变研究进展作一综述。