颈髓损伤康复中呼吸功能训练效果分析

目的：观察呼吸功能训练对颈髓损伤患者肺功能的影响。方法：对85例颈髓损伤患者进行肺功能测定，然后对患者实施8周的呼吸功能训练，观察呼吸功能训练前后患者肺活量（VC）、最大通气量（MVV）、时间肺活量（FVC）、第一秒最大呼气量（FEV1）等肺功能指标的变化，并对结果进行分析。结果：所有患者呼吸功能训练前VC、MVV、FVC、FEV1均较正常值降低．经过8周的训练后，其肺功能指标均较训练前有不同程度改善（P〈0．05）。其中在颈髓损伤后8周内开展呼吸功能训练者的肺功能提高程度明显好于8周后开展呼吸功能训练的患者（P〈0．05）。结论：颈髓损伤后患者肺功能均有不同程度降低，呼吸功能训练可以改善患者肺功能，伤后开展呼吸功能训练的时间越早．其肺功能的改善越明显。     

The effect of duration of compression on lipid peroxidation after experimental spinal cord injury

The present study was performed to evaluate the effect of duration of acute spinal cord compression on tissue lipid peroxidation in rats. A clip compression method (1) was used to produce acute spinal cord injury. Rats were divided into 3 groups, each consisting of 10. At 1 hour after trauma all rats were sacrificed, and MDA content of the injured spinal cord segment was measured. The tissue MDA contents were 3.922 μmolMDA/gww in group 1 (control), 10.192 μmol MDA/gww in group 2 (30 seconds compression), and 12.147 μmolMDA/gww in group 3 (60 seconds compression). These results demonstrate that the length of duration of compression significantly enhances lipid peroxidation. Our study supported the view that persisting compression may cause progression of secondary mechanisms which may irreversibly eliminate any potential for recovery.     

Inpatient rehabilitation outcomes in neoplastic spinal cord compression vs. traumatic spinal cord injury

Objective: To compare neurological and functional outcomes, and complications of patients with neoplastic vs traumatic spinal cord injury (SCI) after in-patient rehabilitation.Design: This study is a retrospective analysis.Setting: In-patient rehabilitation unit of a tertiary research hospital.Participants: A total of 252 patients with a SCI were included; 43 with neoplastic SCI (mean age: 60.9 ± 15.7 years, 60.5% were males) and 209 with traumatic SCI (mean age: 43.1 ± 16.8 years, 71.3% were males).Outcome measures: Comparisons were made of demographic characteristics, etiology, American Spinal Injury Association (ASIA) impairment scale, functional independence measurement (FIM) and Functional Ambulation Categories (FAC) scores, length of stay (LOS), bladder independence, medical comorbidities and complications in both groups.Results: Patients with neoplastic SCI were significantly older than those with traumatic SCI (P < 0.01). No difference was present between the groups in terms of sex and lesion level (P > 0.05). Incomplete SCI was significantly higher in the neoplastic group when compared with the traumatic group (P < 0.01). The LOS was significantly shorter in the neoplastic group than traumatic group (34.8 ± 41.03 vs. 60.02 ± 53.1, P < 0.01). There were no differences in the admission FIM scores (69.3 ± 24.7 vs. 58.7 ± 18.9, P > 0.05), discharge FIM scores (82.1 ± 25.1 vs. 74.02 ± 23.3, P > 0.05) and FIM efficiencies (0.43 ± 0.72 vs. 0.36 ± 0.51, P > 0.05) for the neoplastic and traumatic groups, respectively. However, neoplastic SCI patients demonstrated lower FIM gains compared to traumatic patients (12.9 ± 11.9 vs. 15.4 ± 15.2, P < 0.05). During rehabilitation, urinary tract infection (48.4% vs. 69.4%) and decubitus ulcer (11.6% vs. 35.9%) were significantly more common in the traumatic group than the neoplastic group (P < 0.05).Conclusion: Neoplastic SCI patients who commonly present at rehabilitation units exhibit different characteristics from traumatic SCI patients but the rehabilitation results are similar. Similar functional development can be achieved in a shorter period of time with inpatient rehabilitation in the neoplastic SCI group.     

脊髓损伤中钙蛋白酶的作用

脊髓损伤后可发生不同程度的神经坏死和组织变性,导致脊髓神经功能障碍。脊髓继发性损伤过程中钙蛋白酶(calpain)在脊髓损伤中发挥重要作用。Calpain为一Ca2+依赖性半胱氨酸蛋白酶,该酶包括2种同分异构体μ-calpain和m-calpain,分别由微摩尔和毫摩尔浓度的Ca2+激活。细胞内calpain以非活性酶原形式存在,细胞内游离Ca2+浓度升高后,calpain酶原被活化,引起calpain活化后一系列分子生物化学的改变,在脊髓引起细胞凋亡或损伤。应用calpain的特异性抑制剂进行干预后,脊髓calpain的表达和活性受到抑制,脊髓的病理改变和细胞凋亡得到缓解,神经功能得以保护。该文将calpain在脊髓损伤发展过程中的作用作一综述。     

损伤前应用甲基强的松龙对脊髓的保护作用

目的探讨损伤前应用甲基强的松龙(MP)对脊髓损伤的影响。方法SD大鼠27只,随机分为A、B、C3组。A、B组分别于术前和术后3h给予MP30mg/kg静脉推注。维持剂量5·4mg/(kg·h)。C组术前3h给于相同剂量的生理盐水。以25g/cm致伤量直接打击脊髓致不完全损伤。分别于术后8、16、24h光镜观察受打击部位组织学变化。结果脊髓损伤后使用MP较不使用损伤反应轻;打击前使用MP组损伤较打击后处理组轻。结论脊髓损伤前使用MP对脊髓有保护作用。     

The prevention of iatrogenic spinal cord injury utilizing the evoked spinal cord potential

Summary The evoked spinal cord potential elicited by direct stimulation of the cord has been used clinically to monitor cord function in the course of operations on the spine. The technique used allows measurement of a relatively large amplitude of potential, which is fairly stable against anaesthetics and related drugs, by means of a simple recording system and is sensitive enough to indicate cord damage. Continuous monitoring can easily be carried out. We have encountered no complications when using this method on 99 patients.

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Résumé Le potentiel évoqué provoqué par la stimulation directe de la moelle épinière a été utilisé en clinique pour contrôler la fonction de la moelle lors des interventions sur le rachis. Cette technique permet de mesurer une assez grande amplitude de potentiel, qui est relativement stable à l'égard des anesthésiques et d'autres drogues de même type, grâce à un système simple d'enregistrement; il est suffisamment sensible pour détecter des altérations de la moelle. Une surveillance continue peut aisément être effectuée. Aucun incident n'a été rencontré chez 99 malades lors de l'utilisation de cette méthode.

     

GM-1预防大鼠急性脊髓损伤的研究

目的：探讨单唾液酸神经节苷脂（GM-1）对大鼠急性脊髓损伤的预防作用。方法：随机将126只大鼠分为3组，每组42只。A组（正常组）：行椎板切除术但不损伤脊髓；B组（对照组）：行椎板切除术，同时予脊髓损伤打击；C组（GM-1组）：术前应用GM-1，行椎板切除术，同时予脊髓损伤打击。脊髓损伤采用改良Allen’s打击法。术后24h、48h和72h采用胥少汀6级行为学评分及Rivlin斜板试验进行神经功能评价；1h和72h对大鼠脊髓损伤后运动诱发电位（MEP）潜伏期和波幅进行分析；8h、24h、48h和72h对损伤部位脊髓通过光镜和电镜进行病理学观察。结果：GM-1组与对照组相比，行为学评分障碍率及斜板障碍率较对照组低。神经功能评分提高；术后MEP潜伏期较对照组短，波幅下降较对照组小，MEP得到改善；光镜、电镜下见脊髓损伤轻。结论：预防性应用GM-1可能对减轻脊髓损伤有一定的作用。     

脊髓急性牵拉损伤动物模型机理研究

目的对犬脊髓(神经根)急性牵拉损伤的病理机制进行初步探讨。方法12只健康成年杂种犬，随机分为对照组和不同程度牵拉损伤组。前后路联合手术离断脊柱后施加纵向牵拉损伤，对牵拉应变率、体感诱发电位(SEP)、神经源性脊髓运动诱发电位(NMEP)、硬膜下压力(SP)、硬膜血流量(EBF)等进行持续观察。伤后取脊髓及神经根标本进行HE、髓鞘神经中丝(NF)及胶原纤维酸性蛋白(GFAP)抗体免疫组织化学染色及电镜超微结构观察。结果牵拉损伤涉及牵拉节段和其上下脊髓及神经根的损伤。牵拉后出现硬膜下压力的显著增高和硬膜血流的显著降低。SEP异常的出现较NMEP更早。结论牵拉后脊髓内压力的增加导致脊髓血流减少。以及直接的机械性牵拉损伤可能是脊髓牵拉损伤的重要机制。     

脊髓急性损伤后神经细胞凋亡的时相和空间分布特点

目的 研究脊髓急性损伤后神经细胞的凋亡及其时相和空间特点。方法 大鼠脊髓（T8,9）经中度压迫损伤后,分别在30min、2h、4h、8h、24h、48h、72h、7d、14d、和21d处死取材（n=4)。应用HE、Nissl染色及凋亡细胞原位末端标记法对脊髓组织进行标记。结果 损伤4h后,在损伤段及邻近段可见末端标记阳性神经细胞,损伤段灰质中阳性细胞数8h达高峰,24h白质中阳性胶质细胞数量达高峰。相邻节段阳性细胞数量在72h达高峰。阳性细胞以白质中胶质细胞为主,主要分布于相邻节段。结论 脊髓损伤后神经细胞凋亡是继发损伤期的重要病理变化,并有其时相和空间分布特点。     

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。     

苦参素对大鼠急性脊髓损伤后热休克蛋白47表达的影响

目的探讨苦参素治疗大鼠急性脊髓损伤(SCI)的机制。方法用30只Wistar大鼠制作钳夹型SCI模型,随机分成正常组、假手术组、SCI组、对照组和治疗组,在SCI后3d及每周评价BBB评分,并在第8周用免疫组化方法分析脊髓中热休克蛋白47(HSP47)的表达情况。结果正常组和假手术组Wistar大鼠脊髓组织低表达胶质细胞酸性蛋白(GFAP)和HSP47,高表达神经丝蛋白(NF),在SCI后GFAP和HSP47表达明显提高(P<0.05),NF表达明显降低(P<0.05)。苦参素治疗后,GFAP和HSP47表达降低(P<0.05),NF表达升高(P<0.05)。结论苦参素对Wistar大鼠SCI具有治疗作用,很可能通过抑制HSP47的表达发挥治疗作用。     

高血糖对急性脊髓损伤后果的影响

目的探讨给予高渗糖对急性脊髓损伤后神经学功能恢复的影响。方法将16只健康禁食的大白兔随机分为两组,采用Alien’s脊髓损伤模型,在脊髓损伤前一组动物接受50％高渗糖0．5g／kg体重（处理组）,另一组采用等容量生理盐水对照（对照组）,脊防损伤前后采股动脉血测定血糖并于损伤后3天进行神经学评分。结果处理组与对照组相比,血糖水平显著增高（P＜0．04）,72小时后的神经功能评分也明显不如对照组（P＜0．01）。结论急性脊髓损伤期间的高血糖可加重脊髓继发性损伤。     

采用预防性甲基强的松龙保护脊髓损伤的最佳时间和剂量

目的 研究预防性使用大剂量甲基强的松龙保护急性脊髓损伤大鼠神经功能的最佳时间和剂量.方法 96只SD大鼠按析因设计随机分为16组,甲基强的松龙的使用剂量分别为:15 mg/kg、30 mg/kg、60 mg/kg、120 mg/kg;使用时间分别在脊髓打击前:0 min、15 min、30 min、60 min.在脊髓损伤后72小时,进行Tarlov评分、Molt斜板功能评分和运动诱发电位检测.结果 在Tarlov评分障碍率上,预防性使用甲基强的松龙30 mg/kg组效果明显;在Molt斜板功能障碍率、运动诱发电位上,预防性使用甲基强的松龙30 mg/kg、60 mg/kg组均有效果,而预防性使用甲基强的松龙的使用时间则影响不大.综合以上指标,在15 min～30 min范围内使用较好.其中,又以提前30 min使用,效果最明显.结论 30 mg/kg、60 mg/kg的甲基强的松龙对脊髓损伤有神经保护作用,但以30 mg/kg效果更明显.在脊髓损伤前15 min～30 min范围内使用甲基强的松龙较好.其中,30 mg/kg体重的甲基强的松龙在脊髓损伤前30 min静脉推注对脊髓损伤大鼠神经功能的预防保护作用更好.     

Outcome of the acute abdomen in patients with previous spinal cord injury

Background : Patients with spinal cord injury (SCI) have always posed difficulties for the diagnosis of an acute abdomen. The aim of the present study was to define this problem retrospectively at Princess Alexandra Hospital and to assess the results of treatment for these patients. Methods : A retrospective review was conducted of 133 SCI patients admitted with an acute abdomen in the 16 years prior to this analysis at the Spinal Injuries Unit (SIU) of Princess Alexandra Hospital. There were 21 patients who conformed to the study criteria. All the patients had sustained traumatic SCI at or above the level of T11, more than 1 month prior to admission. Results : There were 13 male and eight female patients. The time lapse between SCI and the onset of an acute abdomen ranged from 1.5 months to 27 years. The age range was 26–79 years. The majority of patients had C6 injuries (six patients). There were 18 patients with injury levels above T6 and three patients with injuries below this level. The time taken to diagnose the cause of the acute abdomen ranged between 1 day and 3 months. Investigations were found to be useful in making the diagnoses in 61.9% of cases. There were 14 patients who had surgical interventions. Five patients had surgical complications and there were two deaths in the study. The length of follow up was 1–132 months. The mortality in the study was 9.5%. Conclusion : An aggressive approach to the diagnosis and treatment of the acute abdomen in SCI patients with suspicious symptoms is recommended. A high index of suspicion should be maintained in those patients with pre‐existing SCI who present with abdominal trauma.     

Surgery in incomplete spinal cord injury

A case of spinal cord injury treated surgically is reported; it is unusual in that it showed the classic indication for surgery—a documented progression of neurological impairment. The patient made a full recovery following anterior decompression of the spinal cord. We believe this case gives added evidence that surgery does have a valuable place in the management of certain selected spinal cord injuries. The literature is reviewed.     

The effect of intravesical electrical stimulation on bladder function and synaptic neurotransmission in the rat spinal cord after spinal cord injury

OBJECTIVE

To investigate the effects of intravesical electrical stimulation (IVES) on bladder function and synaptic neurotransmission in the lumbosacral spinal cord in the spinalized rat, as the clinical benefits of IVES in patients with increased residual urine or reduced bladder capacity have been reported but studies on the mechanism of IVES have mainly focused on bladder Aδ afferents in central nervous system‐intact rats.

MATERIALS AND METHODS

In all, 30 female Sprague‐Dawley rats were divided equally into three groups: normal control rats, sham‐stimulated spinalized rats and IVES‐treated spinalized rats. IVES was started 5 weeks after spinal cord injury (SCI) and was performed 20 min a day for 5 consecutive days. At 7 days after IVES, conscious filling cystometry was performed. Sections from the L6 and S1 spinal cord segments were examined for n ‐methyl‐d ‐aspartic acid receptor 1 (NMDAR1) subunit and γ‐aminobutyric acid (GABA) immunoactivity.

RESULTS

In IVES‐treated spinalized rats, the number and maximal pressure of nonvoiding detrusor contractions were significantly less than in sham‐stimulated spinalized rats. The mean maximal voiding pressure was also lower in IVES‐treated than in sham‐stimulated spinalized rats. IVES significantly reduced the interval between voiding contractions compared with the untreated spinalized rats. There was an overall increase in NMDAR1 immunoactivity after SCI, which was significantly lower in IVES‐treated spinalized rats. Immunoactivity of GABA after SCI was significantly lower than in the control group and was significantly higher in IVES‐treated spinalized rats.

CONCLUSION

Our results suggest that IVES might affect voiding contractions in addition to inhibiting C‐fibre activity and that IVES seems to have a more complex effect on the bladder control pathway. For synaptic neurotransmission in the spinal cord, IVES could possibly shift the balance between excitation and inhibition towards inhibition.     

The efficacy of erythropoietin on acute spinal cord injury. An experimental study on a rat model

Introduction  The accumulated knowledge of erythropoietin (EPO) interaction in neural injury has led to potentially novel therapeutic strategies. Previous experimental studies of recombinant human EPO (rhEPO) administration have shown favorable results after central and peripheral neural injury. In the present study we used the aneurysmal clip model to evaluate the efficacy of two different regimes of rhEPO administration on the functional outcome after severe acute spinal cord injury (ASCI). Materials and methods  Thirty rats were operated on with posterior laminectomy at thoracic 10th vertebra. Spinal cord trauma produced by extradural placement of the aneurysm clip, for 1 min. Animals were divided into three groups; the first group received a low total EPO dose (EPO-L), (2 doses of 1,000 IU each s.c.). The second group was administered the high total EPO dose (EPO-H), (14 doses of 1,000 IU each s.c.), and the third was the Control group, which received normal saline in the same time fashion with EPO-H group. Follow-up was for 6 weeks. Estimation of the functional progress of each rat was calculated using the locomotor rating scale of Basso et al, with a range from 0 to 21. Results  After surgery the animals suffered paraplegia with urinary disturbances. Rats that received EPO demonstrated statistically significant functional improvement compared to the Control group, throughout study interval. On the last follow-up at 6 weeks the EPO-L rats achieved a mean score 17.3 ± 1.15, the EPO-H 14.7 ± 1.82, and the control group 8.2 ± 0.78. Comparison between the two EPO groups reveals superior final outcome of the group treated with lower total dose. Conclusion  Our study supports current knowledge, that EPO administration has a positive effect on functional recovery after experimental ASCI. These data reflect the positive impact of EPO on the pathophysiologic cascade of secondary neural damage. However, we observed a dose-related effect on functional recovery. Interestingly, large doses do not seem to favor the neurological recovery as lower doses do.     

Venous thromboembolism in acute spinal cord injury patients

Background:

The western literature on deep vein thrombosis (DVT) and pulmonary embolism (PE) following spinal cord injury (SCI) report an alarmingly high incidence, necessitating thromboprophylaxis. The literature on incidence from the Asian subcontinent is scanty and from India is almost nonexistent.

Materials and Methods:

Seventy hospitalized acute SCI patients presenting within five days of the injury were included in the present analysis. Forty-two cases were subjected to color Doppler studies and 28 cases had to be subjected to venography due to lack of facility at some point of time. The clinical course of the patients was closely observed during the period of hospitalization. All except 14 were managed nonoperatively. Thromboprophylaxis was not given to any patient at any stage; however, treatment was instituted in those showing the features of DVT on investigations.

Results:

Twelve patients died during the period of hospitalization. Deep vein thrombosis could be detected in seven patients only, three in the proximal and four in the distal segment of the lower limb and of these three died. Based on the clinical course and positive investigation report in favor of DVT, we presumed that the cause of death in these three patients was pulmonary embolism. In the other nine, in the absence of an autopsy report, the cause of deaths was considered as pulmonary infection, asphyxia, diaphragmatic paralysis, hematemesis, cervicomedullary paralysis etc. Clinical features to diagnose DVT were of little help.

Conclusions:

There is a much lower incidence (10%) of DVT and PE following spinal cord injury (SCI) in India than what is reported from the western countries. Higher age group and quadriplegia were the only factors which could be correlated. Deep vein thrombosis extending proximal to the knee was significant. In the absence of autopsy and other screening tests like D-dimer test or 125I fibrogen uptake study, the true incidence of venous thromboembolism remains uncertain. Noninvasive screening of all patients for the detection of deep vein thrombosis in SCI patients is strongly recommended.     

Somatosensory spinal cord evoked potentials in the evaluation of the effect of dexamethasone in experimental spinal cord injury

We studied the effects of high-dose dexamethasone on amplitude and latency values of spinal cord evoked potentials. Thirty-three rabbits were divided into three equal groups. The first group served as the control group, the others received high-dose (2.5 mg/kg) dexamenthasone, the second group 1 hour prior to and the third group immediately after the induction of a spinal cord trauma in segment T12. The spinal cord evoked potentials were recorded epidurally from T12 segment 5 min before and 5, 30, 60, 90,120 and 150 min after trauma. Pretreatment with dexamethasone (group II) prevented the latency delay, and later treatment with dexemethasone (group III) prevented the latency delay partially.Our results suggest that when dexamethasone is given prophylactially it prevents latency alteration, while treatment with dexamethasone after lesioning prevents latency alteration partially. From our results we conclude that pre-treatment with dexamethasone may involve different mechanisms than were activated in the posttreatment group.     

急性颈髓损伤血浆NSE含量与损伤程度的相关性

目的探讨急性颈髓损伤后血浆神经元特异性烯醇化酶(NSE)含量的动态变化在评估病情严重程度的相关价值。方法从2010年3月至2012年3月,收集急性颈髓损伤60例,根据ASIA评分,分 A、B、C、D、E级。采集损伤后24小时内、48小时、72小时、7天的静脉血2ml,使用双抗体夹心型电化学发光法,测定血浆NSE的水平,并选择60例对照组比较,观察其动态变化。结果急性颈髓损伤患者血浆NSE 含量较对照组有升高(P0.05),主要表现在A、B级。约72小时时达高峰,随后下降,7天时恢复至正常水平。损伤评级高(越接近 A 级),血浆NSE 峰值越高。结论血NSE可作为急性颈髓损伤评估病情严重程度的监测指标。