脊髓损伤伴神经源性肠功能障碍患者肠道管理最佳证据总结

目的 总结脊髓损伤伴神经源性肠功能障碍患者肠道管理的最佳证据,为改善患者肠道功能提供依据。方法 检索国内外相关循证资源网站及数据库中关于脊髓损伤肠道功能障碍患者肠道管理证据。对纳入文献进行方法学质量评价和证据提取。结果 共纳入17篇文献,其中指南7篇、专家共识5篇、系统评价3篇、随机对照试验2篇。总结了关于肠道功能评估方法、评估量表、健康教育、饮食干预、药物干预、行为干预及手术干预7个方面的26条证据。结论 脊髓损伤伴神经源性肠功能障碍患者最佳证据可为临床医护人员评估患者肠道功能及采取干预措施提供依据,实际应用中应结合临床实际情况和患者需求选择证据。     

A comparison of bowel care patterns in patients with spinal cord injury: upper motor neuron bowel vs lower motor neuron bowel.

STUDY DESIGN: A face-to-face interview survey. OBJECTIVE: To compare bowel care patterns in spinal cord injury (SCI) patients based on type of neurogenic bowel. SETTING: Department of Physical Medicine and Rehabilitation of a tertiary university hospital in Suwon, Korea. METHODS: Among chronic SCI patients, 22 patients with upper motor neuron bowel (UMNB) and 20 patients with lower motor neuron bowel (LMNB) participated in an interview survey for the evaluation of bowel care patterns. RESULTS: The patients with LMNB demonstrated increased frequency of defecation, increased frequency of fecal incontinence, increased use of oral medications for bowel care, increased required time for defecation and more diet modification than those with UMNB (P < 0.05). However, there was no significant difference in the subjective difficulty of bowel care. Among several available bowel care methods, suppositories were used most frequently by the UMNB group, whereas the Valsalva maneuver was the most frequently used method by the LMNB group. CONCLUSIONS: Patients with LMNB tend to suffer more difficulties in management of their neurogenic bowel than those with UMNB. Therefore, more intensive and aggressive bowel care programs should be provided for SCI patients with LMNB.     

Neuroimaging in traumatic spinal cord injury: an evidence-based review for clinical practice and research

OBJECTIVE: To perform an evidence-based review of the literature on neuroimaging techniques utilized in spinal cord injury clinical practice and research. METHODS: A search of the medical literature for articles on specific neuroimaging techniques used in SCI resulted in 2,302 published reports. Review at the abstract and full report level yielded 99 clinical and preclinical articles that were evaluated in detail. Sixty nine were clinical research studies subjected to quality of evidence grading. Twenty-three articles were drawn from the pre-clinical animal model literature and used for supportive evidence. Seven review articles were included to add an element of previous syntheses of current thinking on neuroimaging topics to the committee process (the review articles were not graded for quality of evidence). A list of clinical and research questions that might be answered on a variety of neuroimaging topics was created for use in article review. Recommendations on the use of neuroimaging in spinal cord injury treatment and research were made based on the quality of evidence. RESULTS: Of the 69 original clinical research articles covering a range of neuroimaging questions, only one was judged to provide Class I evidence, 22 provided Class II evidence, 17 Class III evidence, and 29 Class IV evidence. RECOMMENDATIONS: MRI should be used as the imaging modality of choice for evaluation of the spinal cord after injury. CT and plain radiography should be used to assess the bony anatomy of the spine in patients with SCI. MRI may be used to identify the location of spinal cord injury. MRI may be used to demonstrate the degree of spinal cord compression after SCI. MRI findings of parenchymal hemorrhage/ contusion, edema, and spinal cord disruption in acute and subacute SCI may contribute to the understanding of severity of injury and prognosis for neurological improvement. MRI-Diffusion Weighted Imaging may be useful in quantifying the extent of axonal loss after spinal cord injury. Functional MRI may be useful in measuring the anatomic functional/metabolic correlates of sensory-motor activities in persons with SCI. MR Spectroscopy may be used to measure the biochemical characteristics of the brain and spinal cord following SCI. Intraoperative Spinal Sonography may be used to identify spinal and spinal cord anatomy and gross pathology during surgical procedures. Further research in these areas is warranted to improve the strength of evidence supporting the use of neuroimaging modalities. Positron Emission Tomography may be used to assess metabolic activity of CNS tissue (brain and spinal cord) in patients with SCI.     

Intestinal diversion (colostomy or ileostomy) in patients with severe bowel dysfunction following spinal cord injury.

BACKGROUND: Spinal cord injury (SCI) affects motor and sensory nervous integrity resulting in paralysis of lower or both upper and lower extremities, as well as autonomic nervous system function resulting in neurogenic bowel. SCI leads to diminished or lost sensations of the need to defecate or inability to distinguish the presence of gas versus liquid versus solid stool in the rectal vault. Sensory loss, incomplete evacuation of stool from the rectal vault, immobility, and reduced anal sphincter tone increase the risk of fecal incontinence. Gastrointestinal symptoms are associated with depression, anxiety, and significant impairments in quality of life (QOL) in a significant portion of persons with SCI. OBJECTIVES: 1. To compare clinical, functional, or quality of life outcomes in spinal cord injured patients with gastrointestinal symptoms managed by conservative measures versus intestinal diversion (colostomy or ileostomy). 2. To identify complications associated with ostomy surgery in patients with bowel dysfunction and SCI. SEARCH STRATEGY: A systematic review of electronic databases MEDLINE and CINAHL (from January 1960 to November 2007) was undertaken using the following key words: (1) ostomy, (2) stoma, (3) colostomy, and (4) ileostomy. Boolean features of these databases were used to combine these terms with the key word "spinal cord injuries." Prospective and retrospective studies that directly compared clinical, functional, QOL outcomes or satisfaction among patients with intestinal diversions to patients managed by conservative means were included. RESULTS: Creation of an ostomy in selected patients provides equivocal or superior QOL outcomes when compared to conservative bowel management strategies. Both colostomy and ileostomy surgery significantly reduce the amount of time required for bowel management. Patients who undergo ostomy surgery tend to be satisfied with their surgery, and a significant portion report a desire to be counseled about this option earlier. There are no clear advantages when functional, clinical, or QOL outcomes associated with colostomy are compared to those seen in SCI patients undergoing ileostomy. IMPLICATIONS FOR PRACTICE: 1. The WOC nurse plays a pivotal role in both conservative bowel management and the decision to undergo ostomy surgery. 2. Preoperative stoma site marking is vital for the best surgical outcome. 3. The system best suited to an individual is based on a variety of factors including but not limited to stoma location, type of effluent, peristomal plane and contours, and the individual's capabilities and preferences. 4. Some individuals with a sigmoid or descending colostomy may benefit from colostomy irrigation as a management method. 5. Postoperatively, assessment of pressure points for signs of tissue breakdown, evaluation of treatment methods for existing pressure ulcers with suitable modification, and support surface assessment should be included in ongoing annual follow-up visits.     

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).

Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.

Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.

Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.     

Anorectal stimulation causes increased colonic motor activity in subjects with spinal cord injury

BACKGROUND: Difficulty with evacuation (DWE) is a major problem after spinal cord injury (SCI). Stimulation of the anal canal and lower rectum, accomplished using a gloved finger (so-called digital rectal stimulation or DRS) is often used as an adjunct to laxatives and enemas to facilitate bowel evacuation. However, the basis for the efficacy of DRS is not known. This study assessed the effect of DRS on colonic motility. METHODS: Six subjects with SCI were studied several hours after a bowel care session. Colonic motility was assessed using a manometric catheter (affixed endoscopically to the splenic flexure) at baseline, during DRS, and after DRS. In addition, evacuation of barium oatmeal paste (with the consistency of stool and introduced into the rectum and descending colon) was assessed simultaneously using fluoroscopic techniques. RESULTS: The mean number (+/- SEM) of peristaltic waves per minute increased from 0 at baseline to 1.9 (+/- 0.5/min) during DRS and 1.5 (+/- 0.3/min) during the period immediately after cessation of DRS (P < 0.05). The mean amplitude (+/- SEM) of the peristaltic contractions was 43.4 (+/- 2.2) mmHg. The frequency of contractions, as well as amplitude of contractions, during or immediately after DRS was not significantly different. These manometric changes in response to DRS were accompanied by expulsion of barium oatmeal paste in every subject by the fifth DRS. CONCLUSIONS: DRS causes left-sided colonic activity in subjects with SCI. At least in part, an anorectal colonic reflex that results in enhanced contractions of the descending colon and rectum may contribute to bowel evacuation in individuals with SCI.     

Virtual reality for the treatment of neuropathic pain in people with spinal cord injuries: A scoping review

Context: Virtual and augmented imagery are emerging technologies with potential to reduce the severity and impact of neuropathic pain in people with spinal cord injury (SCI).Objective: We aimed to identify and discuss studies using virtual and augmented reality applications for the management of neuropathic pain in people with spinal cord injury.Methods (data sources, data extraction): A systematic literature search was conducted using PRISMA scoping review guidelines. Articles were searched in PubMed, Embase and Web of Science databases using search terms relating to SCI, virtual and augmented reality and neuropathic pain. With no strong evidence for visual imagery in the treatment of pain in SCI patients, we selected exploratory, feasibility and more rigorous methodologies such as randomized controlled trials and case-control studies. We only selected studies evaluating the effects of visual imagery on neuropathic pain at or below the spinal cord injury level.Results: Of 60 articles located, we included nine articles involving 207 participants. All studies were exploratory using head-mounted devices or 3D and 2D screens with virtual walking or limb movement imagery. Outcomes included pain sensitivity, motor function and body ownership. Eight of the nine studies reported significant reductions in neuropathic pain intensity. However, given small sample sizes in all studies, results may be unreliable.Conclusion: Although the number of studies and individual sample sizes are small, these initial findings are promising. Given the limited options available for the effective treatment of neuropathic SCI pain and early evidence of efficacy, they provide valuable incentive for further research.     

Fournier gangrene in spinal cord injury: a case report

BACKGROUND: Fournier gangrene is a necrotizing fasciitis of the perineal and genital region resulting from polymicrobial infection in which infection spreads along fascial planes, causing soft-tissue necrosis. If surgical debridement and control of infection are delayed, the disease can progress and result in septic shock, multiorgan failure, and death. Initial symptoms are severe pain in the genital region followed by swelling and erythema. In patients with spinal cord injury (SCI), lack of pain sensation could cause delay in seeking medical attention. SCI patients are at higher risk for Fournier gangrene secondary to neurogenic bladder, neurogenic bowel, and impaired sensation. A literature search resulted in only 1 report of Fournier gangrene with localized necrosis of the scrotum in a patient with SCI. METHODS: Case report of a 47-year-old man with C4 tetraplegia. RESULTS: Patient presented with a necrotic ulceration on the ventral aspect of the penis and scrotum of 2 days duration and was diagnosed with fulminant Fournier gangrene. CONCLUSIONS: Patients with SCI are at higher risk for Fournier gangrene secondary to neurogenic bladder, neurogenic bowel, and impaired sensation. Mortality is high. Prevention and early diagnosis are essential. Prompt aggressive intervention is warranted to maximize outcomes.     

Provider adherence to implementation of clinical practice guidelines for neurogenic bowel in adults with spinal cord injury

BACKGROUND/OBJECTIVES: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the "Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine METHODS: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention. RESULTS: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1. CONCLUSIONS: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.     

Time is spine: What's over the horizon

The overarching theme in the early treatment of acute spinal cord injury (SCI) is to reduce the extent of secondary damage to facilitate early neurological and functional recovery. Although multiple studies have brought us innovative and potential new therapies to treat SCI, ameliorating neural damage remains a formidable challenge. Knowledge translation of clinical and basic research studies has shown that surgical intervention is a valuable treatment modality; however, the role, timing and optimal technique in surgery remains a topic of great controversy. While evidence to support the concept of ultra-early surgery for acute SCI continues to emerge, current protocols and international guidelines that encourage reducing time from trauma to surgery support the concept of “Time is Spine”. The present article provides a critical narrative review of the current best practice, with a particular focus on the timing of surgical intervention, which shapes our understanding of how time is of the essence in the management of acute SCI.     

A systematic review of the effects of pharmacological agents on walking function in people with spinal cord injury

Studies of spinalized animals indicate that some pharmacological agents may act on receptors in the spinal cord, helping to produce coordinated locomotor movement. Other drugs may help to ameliorate the neuropathological changes resulting from spinal cord injury (SCI), such as spasticity or demyelination, to improve walking. The purpose of this study was to systematically review the effects of pharmacological agents on gait in people with SCI. A keyword literature search of articles that evaluated the effects of drugs on walking after SCI was performed using the databases MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO, and hand searching. Two reviewers independently evaluated each study, using the Physiotherapy Evidence Database (PEDro) tool for randomized clinical trials (RCTs), and the modified Downs & Black scale for all other studies. Results were tabulated and levels of evidence were assigned. Eleven studies met the inclusion criteria. One RCT provided Level 1 evidence that GM-1 ganglioside in combination with physical therapy improved motor scores, walking velocity, and distance better than placebo and physical therapy in persons with incomplete SCI. Multiple studies (levels of evidence 1-5) showed that clonidine and cyproheptadine may improve locomotor function and walking speed in severely impaired individuals with incomplete SCI. Gains in walking speed associated with GM-1, cyproheptadine, and clonidine are low compared to those seen with locomotor training. There was also Level 1 evidence that 4-aminopyridine and L-dopa were no better than placebo in helping to improve gait. Two Level 5 studies showed that baclofen had little to no effect on improving walking in persons with incomplete SCI. There is limited evidence that pharmacological agents tested so far would facilitate the recovery of walking after SCI. More studies are needed to better understand the effects of drugs combined with gait training on walking outcomes in people with SCI.     

Chronic pain after spinal cord injury: a survey of practice in spinal injury units in the USA

OBJECTIVE: To determine the current practice regarding assessment and management of patients with chronic pain after spinal cord injury (SCI) in the United States of America (USA). METHODS: A postal questionnaire sent to the medical directors of 12 spinal injury units in the USA. RESULTS: A response was received from eight of the 12 units. Chronic pain was considered a significant problem amongst patients with SCI. There was inconsistency of opinion regarding prevalence estimates, investigation and management of chronic pain after SCI; but classification systems for pain were remarkably similar amongst units. Most felt that there was a need for further information, although only one unit said it was presently conducting research into the subject. CONCLUSION: Our survey has demonstrated the uncertainty that exists amongst USA specialists dealing with pain after SCI, and strengthens the case for more research into the subject with a view to developing guidelines for care.     

An overview of published research about the acute care and rehabilitation of traumatic brain injured and spinal cord injured patients

Knowledge of the breadth, nature, and volume of traumatic brain injury (TBI) and spinal cord injury (SCI) research can aid in research planning. This study aimed to provide an overview of existing TBI and SCI research to inform identification of knowledge translation (KT), systematic review (SR), and primary research opportunities. Topics and relevant articles from three large neurotrauma evidence resources were synthesized: the Global Evidence Mapping (GEM) Initiative (129 topics and 1644 articles), the Acquired Brain Injury Evidence-Based Review (ERABI; 152 topics and 732 articles), and the Spinal Cord Injury Rehabilitation Evidence (SCIRE) Project (297 topics and 1650 articles). A de-duplicated dataset of SRs, randomized controlled trials (RCTs), and other studies identified by these projects was created. In all, 145 topics were identified (66 TBI and 79 SCI), yielding 3466 research articles (1256 TBI and 2210 SCI). Topics with KT potential included cognitive therapies for TBI and prevention/management of urinary tract problems post-SCI, which accounted for 17% and 18%, respectively, of the TBI and SCI yield. Topics that may require SR included management of raised intracranial pressure in TBI, and ventilation and intermittent positive pressure interventions following SCI. Topics for which primary research may be needed included pharmacological therapies for neurological recovery post-TBI, and management of sleep-disordered breathing post-SCI. There was a larger volume of non-intervention (epidemiological) studies in SCI than in TBI. This comprehensive overview of TBI and SCI research can aid funding agencies, researchers, clinicians, and other stakeholders in prioritizing and planning TBI and SCI research.     

Chronic pain after spinal cord injury: a survey of practice in UK spinal injury units

OBJECTIVE: To determine current practice regarding assessment and management of patients with chronic pain after spinal cord injury (SCI) in the UK. METHODS: A postal questionnaire sent to the medical directors of the 12 spinal injury units in the UK. RESULTS: A response was received from nine of the 12 units. Chronic pain was felt to be a significant problem amongst patients with SCI, with inconsistent opinion between respondents regarding prevalence, aetiology and classification of chronic pain after spinal cord injury. Only one unit had established protocols for the investigation and management of pain, and most units felt that guidelines would be useful. Most felt that there was a need for further information on the subject. CONCLUSION: Our survey has demonstrated the uncertainty that exists amongst specialists dealing with pain after SCI, and emphasised the need for more research into the problem.     

A Web-based systematic review on traumatic spinal cord injury comparing the "citation classics" with the consumers' perspectives

Although the citation index of an article is not a direct measure of its quality or importance, it is a measure of recognition that may suggest its impact on the scientific community. This study was undertaken to examine the characteristics of the top 100 most frequently cited articles (so-called "citation classics") on traumatic spinal cord injury (SCI) that were published between 1986 and 2003, and to compare this selected professional literature with the consumers' perspective on the key issues in SCI research. The 100 top-cited articles on traumatic SCI were identified using the Internet database of the Science Citation Index Expanded and the Web of Science with the terms "spinal cord injury" and "spinal cord injuries." Meeting abstracts, letters, and editorials were excluded. No language restriction was applied. From a consumers' perspective, the areas of greatest interest for people with SCI as reported in two previous large-scale surveys include motor function, bowel and bladder control, sexual function, and pain. The final list of citation classics on traumatic SCI included 82 original articles and 18 article reviews, which were cited 146 times on average. Topics on basic science (63%) were more frequent than clinical studies (37%). The years of publication were distributed in a bell-shape curve with a peak between 1992 and 1994. North American and European centers (99%) led the list of the citation classics. Most of the top 100 most frequently cited articles on traumatic SCI (63%) explicitly focused on at least one of the topics of greatest interest to individuals with SCI. Motor function was the leading topic in the matching list between professional literature and consumers' perspective. This bibliometric analysis, for the first time, identifies the key features of the citation classics on traumatic SCI between 1986 and 2003, a period that represents one of an unprecedented increase in knowledge in this field. The 100 top-cited peer-reviewed articles have been predominantly focused on basic science SCI research indicating a need for greater bench-to-bedside translational studies in SCI research. Although the body of this top-cited professional literature mostly matches with the consumers' perspective, most of this research has been focused on motor function assessment and recovery following SCI.     

Bowel management in children and adolescents with spinal cord injury

There is little in the literature regarding bowel management in children and adolescents with spinal cord injuries (SCI). This study was undertaken to examine specific patterns of bowel care, individual levels of satisfaction with bowel management, the incidence of incontinence in this population, and effects on lifestyle because of time commitment and dependence in bowel management. Surveys were sent to all persons (n = 45) under age 19 with a diagnosis of SCI who had received care at our medical center since 1985. Thirty-one subjects (69 percent) returned the surveys. The average age at injury was 8.1 years, with an average follow-up period of 3.9 years. Fifty-five percent were individuals with tetraplegia and 77 percent had a complete injury (ASIA Class A). A bowel management program, including medications or manual manipulation, was required for 81 percent of the subjects; only two were independent in their bowel management. Over half of the subjects performed evening bowel care and over half performed their care daily. Digital stimulation tended to be used more commonly by younger children. Medications, either oral, rectal, or both, were used by 88 percent. Sixty percent of the subjects reported they were completely or very satisfied with their bowel management. About half the subjects had limited freedom because of their bowel programs, which caused some dissatisfaction. Sixty-eight percent reported occasional or frequent interference with school activities because of their bowel programs. No correlation was found between bowel accidents and satisfaction with bowel management, despite the fact that almost 84 percent of the children reported at least rare accidents. Lifestyle limitations, bowel accidents, dependence in bowel management, and subject and family dissatisfaction continue to be significant problems for children and adolescents with SCI.     

Civilian Gunshot Injuries of the Spinal Cord: A Systematic Review of the Current Literature

Background

The principles that guide management of spinal cord injury (SCI) derive from injury resulting from blunt trauma, not gunshot wounds. Civilian gunshot-induced spinal cord injury (CGSWSCI) is a common, potentially serious cause of neurological deficit; there is disagreement about whether the same approaches used for SCI caused by blunt-force trauma should apply to gunshot-induced SCI.

Questions/purposes

We reviewed the literature to answer the following questions regarding presentation and outcome of gunshot wound-induced SCI: (1) Are there differences in recovery prognosis between complete SCI and other patterns of SCI in CGSWSCI. (2) Does the use of steroids improve neurological recovery? (3) Does surgery to remove the bullet affect neurological recovery in CGSWSCI? (4) Does surgery result in an increased risk of complications of treatment?

Methods

We performed a systematic literature review of articles related to civilian gunshot injuries to the spine. Information relating to incidence, pattern of neurological injury, associated injuries, treatment, neurological outcome, and associated complications was extracted. Three independent reviewers assessed the strength of evidence present in the literature by examining quality, quantity, and consistency of results.

Results

A total of 15 articles met the predetermined inclusion criteria. Complete SCIs are associated with the worst functional recovery regardless of treatment. Steroids do not appear to have any added benefit in terms of restoring sensory and motor function. There appears to be some neurologic benefit to surgical decompression with intracanalicular bullet retrieval in patients with an incomplete lesion and a cauda equina syndrome. Complication rates are greater in operated patients.

Conclusions

These findings should be interpreted with caution because of considerable heterogeneity among the studies in the literature on gunshot-induced SCI and because of generally poor-quality study design and a high associated risk of selection bias. Supportive management should be the primary method of care, whereas surgery should be an option in case of radiographic evidence of a static compression on the spinal cord. Future studies are necessary to develop better treatment guidelines for patients with gunshot wound-associated SCI.     

Bowel Management in Children and Adolescents with Spinal Cord Injury

Abstract

There is little in the literature regarding bowel management in children and adolescents with spinal cord injuries (SCI). This study was undertaken to examine specific patterns of bowel care, individual levels of satisfaction with bowel management, the incidence of incontinence in this population, and effects on lifestyle because of time commitment and dependence in bowel management. Surveys were sent to all persons (n = 45) under age 19 with a diagnosis of SCI who had received care at our medical center since 1985. Thirty-one subjects (69 percent) returned the surveys. The average age at injury was 8.1 years, with an average follow-up period of 3.9 years. Fifty-five percent were individuals with tetraplegia and 77 percent had a complete injury (ASIA Class A). A bowel management program, including medications or manual manipulation, was required for 81 percent of the subjects; only two were independent in their bowel management. Over half of the subjects performed evening bowel care and over half performed their care daily. Digital stimulation tended to be used more commonly by younger children. Medications, either oral, rectal, or both, were used by 88 percent. Sixty percent of the subjects reported they were completely or very satisfied with their bowel management. About half the subjects had limited freedom because of their bowel programs, which caused some dissatisfaction. Sixty-eight percent reported occasional or frequent interference with school activities because of their bowel programs. No correlation was found between bowel accidents and satisfaction with bowel management, despite the fact that almost 84 percent of the children reported at least rare accidents. Lifestyle limitations, bowel accidents, dependence in bowel management, and subject and family dissatisfaction continue to be significant problems for children and adolescents with SCI. (/Spinal Cord Med 1998; 21:335-341)     

Current practices and goals for mean arterial pressure and spinal cord perfusion pressure in acute traumatic spinal cord injury: Defining the gaps in knowledge

Context: The mainstay of treatment for acute traumatic spinal cord injury (SCI) is to artificially elevate the patient’s mean arterial pressure (MAP) to >85 mmHg to increase blood flow to the injured spinal cord for 7 days. However, the literature supporting these recommendations are only Class III evidence. In fact, the critical time window in which to elevate MAP after SCI and the optimal vasopressor to use are largely unknown, as is whether cerebrospinal fluid diversion has a role, and this leads to variability among practitioners. Also undefined is whether manipulating these parameters improves neurological outcome.Objective: Our goal is to better delineate current clinical practice and identify gaps in knowledge surrounding the care of patients with traumatic SCI.Methods: We undertook a systematic review of the current literature identified from PubMed on MAP elevation and spinal cord parenchymal pressure in acute SCI.Results: The 8 articles (6 human; 2 porcine) that met our inclusion criteria were all published within the last 6 years. Four were prospective, 1 was retrospective, and 3 were review articles. Only one study was randomized. All of these studies involved small sample sizes and varying lengths of MAP elevation. Choice of vasopressor was variable as well.Conclusions: From our literature review, we posit that norepinephrine may be the vasopressor of choice, that spinal parenchymal pressure monitors can be safely placed at the injury site, and that the combination of MAP elevation and cerebrospinal fluid drainage may improve neurologic outcome more than either intervention alone.