Deep venous thrombosis in patients with chronic spinal cord injury

Context/Objective: Deep venous thrombosis (DVT) is a well-known complication of an acute spinal cord injury (SCI). However, the prevalence of DVT in patients with chronic SCI has only been reported in a limited number of studies. The aim of our study was to examine the prevalence of DVT in patients with SCI beyond three months after injury.

Design: Cross-sectional study.

Setting: Rehabilitation Department at the Bydgoszcz University Hospital in Poland.

Participants: Sixty-three patients with SCI that were more than 3 months post injury. The patients, ranging in age from 13 to 65 years, consisted of 15 women and 48 men; the mean age of the patients was 32.1 years. The time from injury varied from 4 to 124 months.

Outcome measures: Clinical assessment, D-dimer and venous duplex scan.

Results: The venous duplex scan revealed DVT in 5 of the 63 patients. The post-injury time in four of the patients varied between 4 and 5 months; one patient was 42 months post-injury.

Conclusion: DVT occurred in patients with chronic SCI, mainly by the 6th post injury month.     

Deep venous thrombosis and pulmonary embolism in patients with acute spinal cord injury: a comparison with nonparalyzed patients immobilized due to spinal fractures

The occurrence of deep venous thrombosis (DVT) was studied in the series of 23 consecutive patients with acute spinal cord injury and 14 immobilized patients with spinal fractures without paralysis. The incidence of DVT in paralyzed patients was 100% as detected by the 125I-labeled fibrinogen test and confirmed by contrast venography, and 64% as detected by repeated clinical examinations and confirmed by contrast venography. The respective incidence of DVT in nonparalyzed patients with spinal fractures was 0%. The diagnosis of DVT was reached earlier with the radiofibrinogen test than with the clinical followup (5 days vs. 25 days). Two of the 23 paralyzed patients (9%) developed nonfatal clinical pulmonary embolism (PE). There were no differences in the values of routine coagulation tests. The result justifies prophylactic anticoagulant therapy in all cases of spinal cord injury during the acute post-traumatic phase.     

Dysphagia in patients with acute cervical spinal cord injury

STUDY DESIGN: Longitudinal observational. OBJECTIVES: (a) To establish a reliable and feasible method to indicate the presence and severity of dysphagia and (b) to establish a course of treatment in individuals presenting with cervical spinal cord injury (CSCI). SETTING: Spinal Cord Injury Center, Werner Wicker Klinik, Bad Wildungen, Germany. PATIENTS AND METHODS: This is a cross-sectional study of 51 patients consecutively admitted to the Intensive Care Unit of the SCI in-patient service. They were subjected to neurological and fiberoptic endoscopic examination of swallowing (FEES). Data concerning artificial respiration, presence of tracheostomy, oral or non-oral feeding were obtained from the medical charts. Statistics were carried out by a calculation of a nonparametric correlation (Spearman). RESULTS: Five levels of dysphagia could be distinguished. At levels 1 and 2, patients presented with a severe impairment of swallowing, in level 3 aspiration was met by a powerful coughing reflex, level 4 comprised a laryngeal edema and/or a mild aspiration of fluids only and at level 5 laryngeal function was not compromised. On admission, 20 patients with CSCI presented with mild (level 4), eight with moderate (level 3) and 13 with severe dysphagia (levels 1 and 2). In 10 no signs of dysphagia could be detected. After treatment, level 1 was no longer detected, one patient showed level 2, two patients showed level 3, all other patients showed only mild or no signs of dysphagia any longer. CONCLUSIONS: Dysphagia of various severities was present in the majority of these patients with CSCI together with respiratory insufficiency. FEES allows for the detection and classification of dysphagia as well as for an evaluation of the therapeutic management. Under interdisciplinary treatment the prognosis of dysphagia is good.     

胸腰段脊柱骨折合并急性创伤性脊髓损伤患者术后深静脉血栓的危险因素分析

【摘要】 目的：探讨胸腰段脊柱骨折合并急性创伤性脊髓损伤患者术后深静脉血栓的危险因素。方法：选取2018年7月~2020年9月于我院进行手术治疗的T11～L2骨折合并急性创伤性脊髓损伤（spinal cord injury,SCI）患者136例。收集患者的统计患者的年龄、性别、体重指数、既往病史等一般资料,检测并收集患者总胆固醇（total cholesterol,TC）、甘油三酯（triacylglycerol,TG）、低密度脂蛋白胆固醇（low density lipoprotein cholesterol,LDL-C）、高密度脂蛋白（high density lipoprotein cholesterol, HDL-C）等实验室指标。收集患者术前、术后6个月内的下肢静脉彩超,根据是否出现DVT分为DVT组（n=64）和非DVT组（n=72）。比较两组患者的一般资料,通过单因素分析及多因素Logistic回归分析确定急性创伤性SCI患者术后发生DVT的独立影响因素。通过Spearman法和Pearson法分析各影响因素间的相关性。根据独立影响因素建立并验证列线图模型。结果：单因素分析结果显示,DVT组和非DVT组的体重指数（27.03±2.12kg/m2和24.03±3.32kg/m2）、吸烟人数占比（39.06%和20.83%）、输血人数占比（45.31%和27.78%）、肿瘤病史人数占比（46.89%和23.61%）、出血量＞600 mL人数占比（42.19%和22.22%）、ASIA分级A级人数占比（45.31%和18.06%）、肢体气压治疗及踝泵练习人数占比（18.75%和52.78%）、ASIA分级D级人数占比（14.06%和33.33%）、CRP（20.36±4.37和11.45±3.76）、FIB（6.49±1.31和4.51±1.26）以及D-二聚体（1.83±0.39和0.45±0.26）之间的差异均具有统计学意义（P＜0.05）。多因素Logistic回归分析显示,输血、ASIA分级A级、FIB>5g/L、D-二聚体>1.6mg/L以及未进行肢体气压治疗及踝泵练习是急性创伤性SCI患者术后DVT的独立危险因素（P＜0.05）,相关性分析显示,输血、ASIA分级A级、FIB、D-二聚体以及未进行肢体气压治疗及踝泵练习均呈明显的正相关关系（P＜0.05）。根据独立影响因素构建列线图预测模型,模型的ROC曲线下面积（area under curve,AUC）为0.837（95%CI：0.791~0.864）,具有较好的区分度,校准曲线评价结果提示模型具有较好的准确性。结论：输血、ASIA分级A级、FIB>5g/L、D-二聚体>1.6mg/L以及未进行肢体气压治疗及踝泵练习是急性创伤性SCI患者术后DVT形成的独立危险因素,各独立危险因素之间均存在密切联系。     

脊髓损伤患者静脉血栓形成的临床相关因素分析

目的 :分析脊髓损伤患者伴发静脉血栓的临床相关因素,以更好地防治脊髓损伤患者的静脉血栓。方法:回顾性分析2013年12月~2015年1月在我院康复医学科住院的165例脊髓损伤患者的病历资料,按有无静脉血栓(venous thrombosis,VT)分为VT组和非VT组,分别统计两组患者年龄、性别、发病原因、既往史、骨折情况(无骨折、单纯椎体骨折及多发骨折)、脊髓损伤程度(ASIA分级)及平面(C1~C7、T1~T12及L1~S5)、并发症、手术开展时间、康复介入时间等临床指标,并采用SPSS 17.0统计软件进行统计分析,计数资料行X列表的卡方检验,检验标准α=0.05,P0.05为有统计学差异。采用两分类Logistics回归分析对相关危险因素进行相关性分析,P0.05表示有统计学意义。结果:入组患者165例,VT组82例,非VT组83例,其年龄、既往史、性别、临床并发症等基线指标组间无统计学差异(P0.05)。手术开展时间单因素分析时两组间有统计学差异(χ2=8.682,P=0.034),但在回归分析中显示无统计学差异(OR=0.432,P=0.149);骨折情况(OR=2.526)、脊髓损伤程度(OR=-0.637)、康复介入时间(OR=-0.706)方面两组间有统计学差异(P0.05)。结论:损伤程度重、多发骨折的脊髓损伤患者发生静脉血栓的风险相对较高,早期康复介入并采用综合预防和管理措施有利于减少静脉血栓形成,更有利于后期功能康复。     

The neurological outcome in patients with acute cervical spinal cord injury]

Twenty-three patients (twenty males and three females) with acute cervical spinal cord injury were cared for within a defined protocol and followed for 14 to 589 days (mean. 133 days). We evaluated the relationship between neurological recovery and neurological examination, myelography (MLG), CT-myelography (CTM) on admission. All of them were admitted to Kitasato University Hospital within 24 hours after injury. Thirteen of the 23 patients had complete injury, and the others had incomplete injury. Result: Four factors were found to be related to neurological recovery. They included: 1) complete injury; 2) areflexia; 3) cord swelling on CTM; and 4) complete block on MLG. Fourteen of 15 patients who had at most two of the four factors improved. But, no patients with three or four factors improved. Conclusion: These four factors have been recognized as indicators of bad neurological outcome. However, our result indicates that by our result, improvement of neurological function can be expected in patients affected by only one or two of these four factors. In other words these four factors have prognostic value for predicting the neurological outcome after acute cervical spinal cord injury.     

D-dimer monitoring combined with ultrasonography improves screening for asymptomatic venous thromboembolism in acute spinal cord injury

Objective: We compared screening methods for asymptomatic venous thromboembolism (VTE) in patients with acute spine and spinal cord injuries (SCI). Patients were screened by D-dimer monitoring alone (DS group) or by D-dimer monitoring combined with ultrasonography (DUS group).

Design: Prospective cohort study.

Setting: One department of a university hospital in Japan.

Participants: 114 patients treated for acute SCI between 2011 and 2017.

Interventions: N/A.

Outcome Measures: D-dimers were measured upon admission and 1, 3, 5, 7, and 14 days thereafter. DUS-group patients also underwent an ultrasound 7 days after admission. If ultrasonography indicated deep venous thrombosis (DVT), or if D-dimer levels increased to ≥?10?µg/mL, the patient was assessed for VTE, including DVT or pulmonary embolism (PE), by contrast venography. We analyzed the incidence of VTE detected in the DS and DUS groups.

Results: In the DS group, D-dimers were elevated (≥?10?µg/mL) in 15 of 70 patients (21.4%), and 9 of the 15 had asymptomatic VTE (12.9%, DVT 11.4%, PE 5.7%). In the DUS group, one patient developed VTE on day 4, and D-dimers were elevated in 13 of 43 patients (30.2%), ultrasonography indicated DVT in 12 patients (27.9%), and asymptomatic VTE was diagnosed in 12 patients (27.9%, DVT 27.9%, PE 4.7%). The DUS group had a higher incidence of DVT (P?=?0.002) and VTE (P?=?0.042) than the DS group.

Conclusions: Combined D-dimer and ultrasound screening in patients with acute SCI improved the detection of VTE, including PE, compared with D-dimer screening alone.     

急性颈髓损伤后的低钠血症

[目的]探讨急性颈髓损伤后低钠血症的病因、发病机制、诊断和治疗。[方法]回顾性分析2004年-2006年收治的急性颈髓损伤后低钠血症患者15例的临床资料。[结果]全组患者入院24—72h内血钠低于130mmol／L，其中5例低于120mmol／L。14例尿钠40—68mmol／L，1例尿钠为148mmol／L；尿渗透压420～980mmol／L，12例患者经适当的补盐和限制水摄入量治疗，低钠症状2～3周内改善；2例发热患者因发热不能严格限制水摄入，其中1例2个月后恢复，另1例失访；1例患者补盐限水后病情加重，调整治疗方案后恢复。[结论]颈髓损伤越重，损伤后低钠血症发生率越高；颈髓损伤后低钠血症多由抗利尿激素分泌异常综合征引起；血钠浓度，血、尿渗透压等是诊断依据；适当补充钠盐和液体量是有效的治疗方法。     

外伤性颈髓损伤患者早期并发症与损伤程度的相关性

目的:调查不同程度颈脊髓损伤(CSCI)患者早期并发症的发生情况,探讨颈髓损伤严重程度与并发症发生的相关性。方法:2005年1月~2009年5月我院收治CSCI早期患者325例,除外20例因各种原因住院时间<7d的患者,共有305例患者入选。男249例,女56例;年龄14～83岁,平均45岁;伤后距来院就诊时间0.5h～20d,住院时间7～45d,平均为23d。高处坠落伤111例,车祸伤85例,摔伤75例,重物砸伤15例,原因不明损伤19例。按ASIA分级:A级132例,B级26例,C级89例,D级58例。按损伤程度将患者分为A(A级)、B(B级)、C(C级)、D(D级)4组,对4组患者早期并发症发生情况进行统计和分析。结果:305例患者共发生13种并发症,其中便秘229例次(75.08%),心率减慢144例次(47.21%),低钠血症137例次(44.92%),高热124例次(40.46%),呼吸功能障碍104例次(34.10%),血压下降94例次(30.82%),低蛋白血症83例次(27.21%),贫血72例次(23.61%),消化功能障碍70例次(22.95%),低钾血症45例次(14.75%),压疮38例次(12.46%),泌尿系感染28例次(9.18%),下肢深静脉血栓9例次(2.95%)。便秘、下肢深静脉血栓的发生率4组间无显著性差异(P>0.05),其余并发症的发生率4组间均有显著性差异(P<0.05);除便秘、压疮、泌尿系感染、下肢深静脉血栓外,并发症发生率均为A组>B组>C组>D组,且A、B组明显高于C、D组。结论:颈脊髓损伤患者早期并发症较多;除便秘、压疮、泌尿系感染、下肢深静脉血栓外,其余并发症的发生率随着损伤程度加重而增高,A-SIA分级A、B级患者的发生率明显高于C、D级患者。     

Tendon transfers in patients with cervical spinal cord injury

Between 1983 and 1988, 32 patients with cervical spinal cord injuries underwent 124 upper limb tendon transfers during 85 procedures. Of the numerous surgical procedures that have been recommended for treatment of this condition, my experience indicates that the most successful are posterior deltoid-to-triceps transfer, restoration of finger flexion, and restoration of thumb opposition. Longitudinal incisions prove to be quite cosmetic.     

颈椎骨折合并急性颈髓损伤的手术时机探讨

目的：探讨颈椎骨折合并急性颈髓损伤的手术时机。 方法：回顾性分析2000年1月~2011年1月我科治疗的颈髓损伤患者42例,其中急诊手术组（≤24h）18例,延期手术组（>24h）24例,对比分析手术前后神经功能变化、术后并发症和住院时间等临床资料,并进行统计学分析。 结果：急诊手术组感觉和运动功能改善明显,并发症发生率、重症监护时间和住院时间均低于延期手术组。 结论：颈椎骨折合并急性颈髓损伤的急诊手术减压是可行的,对神经功能的恢复有积极作用,并减少围手术期并发症。     

Spinal cord evoked injury potentials in patients with acute spinal cord injury

Six patients were examined in the acute stage of spinal cord injury, between 11 h and 12 days posttrauma. Quadripolar epidural electrodes were positioned either percutaneously using a Tuohy needle or directly into the epidural space during surgical intervention. These electrodes were combined with a common reference to obtain monopolar recordings of spinal cord evoked potentials resulting from either median nerve stimulation at the wrist or tibial nerve stimulation at the popliteal fossa. Spinal cord evoked injury potentials (SCEIPs), stationary potentials with positive polarity on the distal aspect of the lesion and negative polarity on the proximal aspect, were recorded in all cases. The average amplitude (n = 3) of the SCEIP resulting from tibial nerve stimulation as measured across the lesion was 13.5 microV with an average duration of 12.7 msec. For median nerve stimulation, the average amplitude (n = 3) of the SCEIP was 16.3 microV with an average duration of 6.7 msec. There was a change in polarity in all cases over a distance of less than 6 mm, the distance between the electrode contacts on the epidural electrode. In one case, recordings were performed initially at 11 h and repeated at 21 days posttrauma. In the latter recording, the SCEIP was still present but was five times smaller in amplitude. Coincidentally, the patient also showed clinical signs of improvement in sensory and motor spinal cord function. This study demonstrates the feasibility of recording the SCEIP in patients with acute spinal cord injury, describes the features of these SCEIPs, discusses their origins, and explores the utility of recording the SCEIP as an aid in determining the severity of the injury as well as a means of monitoring changes in spinal cord function.     

High incidence of venous thromboembolism after acute cervical spinal cord injury in patients with ossification of the posterior longitudinal ligament

Objective: To determine the incidence of venous thromboembolism (VTE) in patients with acute cervical spinal cord injury (SCI) and ossification of the posterior longitudinal ligament (OPLL).Design: Prospective cohort study.Setting: A department of a university hospital in Japan.Participants: This study included 57 patients (OPLL, n = 10; non-OPLL, n = 47) treated for acute cervical SCI between January 2011 and April 2017. Patients were classified according to motor complete paralysis (MC), motor incomplete paralysis (MIC), or normal motor function, based on American Spinal Injury Association (ASIA) Impairment Scale results.Interventions: N/A.Outcome Measures: All patients were screened for VTE by D-dimer monitoring, and some underwent ultrasonography. If ultrasonography indicated deep venous thrombosis (DVT) or if the D-dimers increased to ≥10 µg/mL, patients underwent contrast venography to detect VTE, including DVT or pulmonary embolism. We compared blood coagulability and VTE incidence in the OPLL and non-OPLL groups.Results: VTE occurred in 11 (19.3%) of 57 patients. The incidence of VTE was higher in the OPLL group than in the non-OPLL group (50% vs. 12.8%; P = 0.017) and higher in the MC group (57.1%) than in the MIC (8.3%; P = 0.002) or normal group (5.3%; P = 0.002). In the MC group, VTE occurred in 50% of OPLL patients and in 62.5% of non-OPLL patients (P = 0.529). In the MIC group, VTE occurred in 50% of OPLL patients and in none of the non-OPLL patients (P = 0.022).Conclusions: Patients with OPLL tended to develop VTE after SCI with motor complete and incomplete paralysis.     

Risk factors for laryngeal penetration-aspiration in patients with acute traumatic cervical spinal cord injury

Background Context

Laryngeal penetration-aspiration, the entry of material into the airways, is considered the most severe subtype of dysphagia and is common among patients with acute cervical spinal cord injury (SCI).

急性颈脊髓损伤的早期手术疗效

目的:探讨大剂量激素冲击并早期前、后路手术减压固定治疗急性颈脊髓损伤的疗效。方法:11例急性颈脊髓损伤患者,男7例,女4例;年龄23～63岁,平均37岁;受伤时间30min～6h。脊髓神经功能Frankel分级:A级2例,B级6例,C级2例,D级1例。早期大剂量激素冲击的同时,6例行前路减压植骨钢板内固定,3例行后路单开门椎板减压侧块钢板固定,2例先后路减压复位再前路减压植骨钢板固定。结果:跟踪随访3～22个月,平均13个月。脊髓神经功能的恢复按Frankel分级评定,平均提高2.1级,其中A→B1例,A→C1例,B→C2例,B→D3例,B→E1例,C→E2例,椎间融合率100%,无内固定松动发生。结论:早期大剂量激素冲击积极手术内固定可获得彻底地减压、有效防止脊髓继发损伤,植骨融合率高,稳定性好。     

Prevention of deep venous thrombosis in patients with acute spinal cord injuries: use of rotating treatment tables

A randomized clinical trial of 15 patients with acute spinal cord injuries was performed to test the hypothesis that rotating treatment tables prevent deep venous thrombosis in this population. Four of 5 control (nonrotated) patients developed distal and proximal thrombi, assessed by 125I fibrinogen leg scans and impedance plethysmography. In comparison, only 1 of 10 treated (rotated) patients developed both distal and proximal thrombosis (P = 0.007). These results suggest but do not prove that rotating treatment tables prevent the development of proximal deep venous thrombosis in spinal cord-injured patients. Larger clinical trials are needed to confirm this heretofore undocumented benefit of rotating treatment tables.     

急性颈脊髓损伤的最佳手术时机

<正>急性颈髓损伤常见于颈椎外伤,可造成严重后果甚至危及生命。据估计,在全世界范围内,每年每100万人口中约有750人遭受创伤性脊髓损伤[1];而1/3的创伤性脊髓损伤患者是由颈椎外伤造成的[2]。由此造成的患者严重残疾和经济负担已成为一个社会问题。脊髓组织极易受损伤,且其自我修复能力非常有限,其治疗至今仍是医学领域最大的挑战之一。目前学界普遍认可手术减压和固定重建稳定是治疗颈髓损伤的重要手段,但何时手术才是最佳的手术时机仍存在争议。     

完全性颈脊髓损伤患者的手术时机选择

<正>创伤性脊髓损伤(traumatic spinal cord injury,t SCI)是一种严重的致残性疾病。通过手术对损伤节段进行减压和固定是治疗颈脊髓损伤的重要方式之一。早在一个世纪以前,Burrell就认为损伤程度和手术时机是影响脊髓损伤预后的两个关键点[1]。然而到目前为止,包括系统分析在内的诸多文献依然对包括完全性颈脊髓损伤在内的脊髓损伤手术时机选择存在争议[2、3]。