Successful decannulation of patients with traumatic spinal cord injury: A scoping review

Context: Patients with spinal cord injury (SCI) often require tracheostomy as an immediate life-saving measure. Successful decannulation, or removal of the tracheostomy, improves patient quality of life, function, and physical appearance and is considered an important rehabilitative milestone for SCI patients.Objective: We sought to synthesize the existing published literature on SCI patients undergoing decannulation.Methods: Ovid MEDLINE, Embase, Web of Science, CINAHL, and Cochrane Central Register of Controlled Trials were systematically searched through July 2, 2019 using appropriate keywords and MeSH terms pertaining to tracheostomy and SCI. Searches were human-subject only without language restrictions. Published literature discussing the outcomes of SCI patients who underwent decannulation were screened using inclusion/exclusion criteria determined a priori and reviewed.Results: Twenty-six publications were eligible for review and synthesis out of 1,493 unique articles. Over half of the studies were retrospective case series or reports. The research was nearly all published within the fields of physical medicine and rehabilitation, neurology, and pulmonary/critical care. Three themes emerged from review: (1) interdisciplinary or multidisciplinary tracheostomy team management to optimize decannulation processes, (2) non-invasive intermittent positive-pressure ventilatory support instead of tracheostomy-based ventilator support, and (3) wide variation in the reporting of post-decannulation clinical outcomes.Conclusion: Published research lacks a consistent taxonomy for reporting post-decannulation outcomes in SCI patients. Non-invasive ventilation research could benefit many SCI patients but has been studied in depth primarily by a single authorship group. Further investigation into the socioeconomic and fiscal impact on tracheostomies on SCI patients is warranted.     

Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

This scoping review systematically reviewed relevant research to summarize the literature addressing the significance of monitoring spinal cord perfusion pressure (SCPP) in acute traumatic spinal cord injury (SCI). The objectives of the review were to (1) examine the nature of research in the field of SCPP monitoring in SCI, (2) summarize the key research findings in the field, and (3) identify research gaps in the existing literature and future research priorities.Primary literature searches were conducted using databases (Medline and Embase) and expanded searches were conducted by reviewing the references of eligible articles and searches of Scopus, Web of Science core collection, Google Scholar, and conference abstracts. Relevant data were extracted from the studies and synthesis of findings was guided by the identification of patterns across studies to identify key themes and research gaps within the literature.Following primary and expanded searches, a total of 883 articles were screened. Seventy-three articles met the review inclusion criteria, including 34 original research articles. Other articles were categorized as conference abstracts, literature reviews, systematic reviews, letters to the editor, perspective articles, and editorials. Key themes relevant to the research question that emerged from the review included the relationship between SCPP and neurological recovery, the safety of monitoring pressures within the intrathecal space, and methods of intervention to enhance SCPP in the setting of acute traumatic SCI.Original research that aims to enhance SCPP by targeting increases in mean arterial pressure or reducing pressure in the intrathecal space is reviewed. Further discussion regarding where pressure within the intrathecal space should be measured is provided. Finally, we highlight research gaps in the literature such as determining the feasibility of invasive monitoring at smaller centers, the need for a better understanding of cerebrospinal fluid physiology following SCI, and novel pharmacological interventions to enhance SCPP in the setting of acute traumatic SCI. Ultimately, despite a growing body of literature on the significance of SCPP monitoring following SCI, there are still a number of important knowledge gaps that will require further investigation.     

Self-management of pain and depression in adults with spinal cord injury: A scoping review

Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.

Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.

Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.

Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.

Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.     

Direct health care costs after traumatic spinal cord injury

BACKGROUND: The objective was to quantify direct health care costs attributable to traumatic spinal cord injury (SCI). METHODS: This population-based cohort study followed individuals with SCI from date of injury to 6 years postinjury. SCI cases were matched to a comparison group randomly selected from the general population. Administrative data from a Canadian province with a universal publicly funded health care system and centralized health databases were used. Costs included hospitalizations, physician services, home care, and long-term care. RESULTS: Attributable costs in the first year were $121,600 (2002 $CDN) per person with a complete SCI, and $42,100 per person with an incomplete injury. In the subsequent 5 years, annual costs were $5,400 and $2,800 for persons with complete and incomplete SCIs, respectively. CONCLUSION: Direct costs in the first year after SCI are substantial. In the subsequent 5 years, individuals with SCI will continue to accrue greater costs than the general public.     

Bone biomarkers in patients with chronic traumatic spinal cord injury

Background contextBone loss after spinal cord injury (SCI) occurs because of pathologic changes in osteoblastic and osteoclastic activities due to mechanical unloading. Some biochemical changes in bone metabolism after SCI are described before that were related to bone mineral loss.PurposeOur purpose was to determine bone markers' changes and related effective factors in patients with chronic traumatic SCI.Study designThis investigation was designed as an observational cross-sectional study.Patient sampleAll patients with chronic SCI who were referred to Brain and Spinal Injury Research Center and did not meet our exclusion criteria entered the study.Outcome measuresSelf-reporting measures including patient's demographic features and date of accident were obtained using a questionnaire and physiologic measures including spinal magnetic resonance imaging to determine the level of injury accompanied with physical examination along with dual-energy X-ray absorptiometry were performed. Blood samples were analyzed in the laboratory.MethodsDual-energy X-ray was used to determine bone mineral density in femoral and spinal vertebrae bone sites. Serum level of C-telopeptide cross-linked Type 1 collagen (CTX), parathyroid hormone, calcitonin, osteocalcin, and bone alkaline phosphatase (BALP) were measured.ResultsWe detected a negative association between CTX level and bone mineral density in femoral and spinal bone sites that confirms that CTX is a bone resorption marker. C-telopeptide cross-linked Type 1 collagen and BALP levels did not show any significant correlation with postduration injury. Patients with spinal injury at lumbar level had the highest calcitonin level (p<.04). C-telopeptide cross-linked Type 1 collagen was positively related with osteocalcin and BALP (p<.0001, r=0.51), and osteocalcin was positively related with BALP (p<.0001, r=0.44). Osteocalcin was related negatively only to femoral intertrochanteric zone bone mineral density.ConclusionsSome bone biomarkers undergo noticeable changes after SCI. C-telopeptide cross-linked Type 1 collagen was positively correlated with BALP and osteocalcin that shows the coincidental occurrence of osteoblastic and osteoclastic activities. Our data also support this fact that although bone reduction after 2 years is slower than acute phase after SCI, bone resorption rate is higher than bone formation. These bone markers also revealed different site of action as osteocalcin level only affected femoral intertrochanteric bone mineral density. Generally, it seems that the coincidental consideration of these factors that influence bone mineral density can lead to a better understanding of bone changes after SCI.     

Bladder deformity in traumatic spinal cord injury patients

Fifty-nine patients with traumatic spinal cord injury were subjected for the analysis of bladder deformity. Bladder deformity means bladder trabeculation and deformity of bladder shape such as pine tree shape. We classified bladder deformity into grade 0 (none), grade I (mild), grade II (moderate) and grade III (severe). Upper urinary tract deterioration was found in 0% of grade 0 (16 pts.), 32% of grade I (22 pts.), 80% of grade II (10 pts.) and 82% of grade III (11 pts.). We suggested that bladder deformity was one of the risk factors of upper urinary tract deterioration. High grade (greater than grade II) bladder deformity was found more frequently in complete injury than in incomplete injury. There was no differentiation between overactive bladder-overactive sphincter and underactive bladder-overactive sphincter. All patients with low compliance bladder had a high grade bladder deformity. There was a significant relationship between severity of urinary tract infection and severity of bladder deformity. Intermittent catheterization program was effective for preventing bladder deformity.     

Epidemiology of traumatic spinal cord injury in Asia: a systematic review

Study design

A systematic review.

Background

The number of traumatic spinal cord injury (TSCI) reports grows annually, especially in China and Korea. The epidemiological characteristics of TSCI in Asia differ from those in other countries. Thus, we compiled epidemiological factors from Asia to compare with those from other countries.

Method

We searched articles published in any language between January 1980 to December 2011 using the terms “spinal cord injury”, “traumatic spinal cord injury”, “epidemiology”, and “Asia”. The articles were reviewed for information regarding TSCI incidence, total cases, case criteria, case source, causes of injury, male/female ratio, mean age, prospective or retrospective, neurological level of injury, extent of injury, and America Spinal Injury Association Impairment Scale (AIS)/grade.

Results

Epidemiological data were extracted from 39 reports in the published literature that met the inclusion criteria. Only two studies reported prevalence rates. Incidence rates ranged from 12.06 to 61.6 per million. The average age ranged from 26.8 to 56.6 years old. Men were at higher risk than women. Motor vehicle collisions (MVCs) and falls were the main causes of TSCI. However, several countries reported war wounds as the major cause. The neurological level and extent of injury were mixed, and most patients were categorized as AIS/Frankel grade A.

Conclusion

TSCI is an important public health problem and a major cause of paralysis. We must understand the epidemiology to implement appropriate preventative measures. Asian epidemiology is different from that in other regions, so intervention measures must be established according to population-specific characteristics.     

Critical care and perioperative management in traumatic spinal cord injury

Traumatic spinal cord injury is frequently associated with brain injury and with alterations in respiratory and cardiovascular function that require critical care management. Complications include respiratory failure, atelectasis, pneumonia, neurogenic shock, autonomic dysreflexia, venous thromboembolism, and sepsis. While complications may be managed with supportive care, the goal of ameliorating neurologic outcome has proved elusive. Methylprednisolone, when instituted <8 hours after traumatic spinal cord injury, was associated in two clinical trials with statistically significant improvements in motor scores at 6 months and 1 year; however, critical reappraisal of these data raises questions about their validity and clinical relevance. Until more evidence of clinically effective therapies is available, acute management must be driven by pathophysiologic principles, with emphasis on interventions that attenuate secondary neurologic injury; these include the rational use of immobilization, cautious airway management, and promotion of cord perfusion and oxygenation with the appropriate level of hemodynamic and respiratory support. Clinical trials of pharmacologic neuroprotection have yielded disappointing results, but the ongoing elucidation of spinal cord repair and regenerative mechanisms suggests new therapeutic prospects.     

Impact of age on mortality in patients with acute traumatic spinal cord injury requiring intensive care

Objective

To evaluate the impact of age (< or ≥ 65 ans) on hospital mortality in traumatic spinal cord injury requiring intensive care.

Design

Retrospective, monocenter.

Patients and methods

A total of 131 patients greater or equal to 15 years (< 65 years, n = 109 and ≥ 65 years, n = 22) was analyzed (cervical, n = 71; thoracolumbar, n = 60), over a 10 years period (1998–2008). The hospital and long-term mortality were studied. The risks factors of death were searched by a uni- and multivariate analysis. Intensive care unit (ICU) discharge and long-term neurological recovery, and long-term functional independence measure (FIM) were assessed.

Results

Hospital mortality was increased in patients greater or equal to 65 years (41% vs 6%, P < 0.001) and long term mortality was not different between the two groups (31% vs 12%, P = 0.150). The risks factors of death were age (HR = 3.44; IC 95%: 1.53–7.72, P = 0.028), previous coronary disease (HR = 3.64; IC 95%: 1.25–10.65; P = 0.018) and fall injury (HR = 2.40; IC 95%: 1.15–5.00, P = 0.020). Among survivors, incompletes forms (Frankel B, C, D, E) were significantly more frequent in older patients at ICU discharge and long term follow up. At long term, FIM was similar in the two groups except a better sphincter control in patient greater or equal to 65 years.

Conclusion

Mortality rate of older people (≥ 65 years) were greater than those in younger people, mainly caused by an increased hospital mortality. Among survivors, the neurological recovery was better in patients’ greater or equal to 65 years, and was associated with a functional status at least comparable than in the youngest patients.     

Preventive care among primary care patients living with spinal cord injury

Objective: Context/Objective: Family physicians may lack the knowledge or resources to adequately support patients with spinal cord injury (SCI). Our objectives were to determine patterns of preventive care for patients with SCI in a primary care setting (i.e. cancer screening, influenza vaccinations, general physicals, bone mineral density tests), and determine physicians’ level of comfort with providing primary care to patients with SCI.

Design: i) Retrospective chart review, ii) Survey of physicians in the family practice.

Setting: Six primary care practice sites in Ontario, Canada.

Participants: All adult rostered patients of the family practice with SCI; All family physicians in the six sites.

Outcome Measures: Proportion of patients up-to-date on cancer screening, proportion of patients with influenza vaccinations, general physicals, bone mineral density tests; physicians’ level of comfort with providing care to patients with SCI.

Results: Sixty patients were included in analyses. Rates of cancer screening were generally poor. The highest uptake was seen for cervical cancer screening, where 50% of eligible women were up-to-date on Pap tests. Only 36.7% of patients were up-to-date on colorectal cancer screening. Only 14 (23.3%) patients had a documented general physical exam in their electronic record. There was a recorded flu vaccination for 55% of patients, and of those, there was a median of 19 months since last vaccination. Fifteen physicians (21.4%) responded to the survey. Ten physicians reported at least one patient with SCI, with the maximum being 20 patients. Comfort level in managing SCI-relevant conditions varied and was lowest for spasticity, respiratory issues and autonomic dysreflexia, where only 27.3% of respondents had some level of comfort.

Conclusion There are many opportunities to improve the preventive care of patients living with SCI.     

Participation following traumatic spinal cord injury: an evidence-based review for research

BACKGROUND/OBJECTIVE: To report an evidence-based review of participation instruments that have been used in spinal cord injury (SCI) clinical practice and research. METHODS: Rehabilitation literature was searched for instruments used by at least 2 independent SCI researchers since 2000. Each instrument was reviewed by 2 committee members. One person reviewed the scale and documented the level of use and psychometric properties. The second committee member verified the values and made suggestions for changes. RESULTS: Three instruments met the review criteria: Craig Handicap Assessment and Reporting Technique (CHART), Assessment of Life Habits (LIFE-H), and the Impact on Participation and Autonomy (IPA). Each instrument incorporates different perspectives in the measurement of participation. The LIFE-H uses a qualitative approach, whereas the CHART adopts a quantitative approach; both are based on societal norms of participation. In contrast, the IPA integrates individual choice and control in defining participation. CHART is the most widely used instrument, although its development predates the development of the ICF. The IPA is a relatively new instrument, and its psychometric properties have only recently published. CONCLUSIONS: Continuing research is needed to develop conceptually and psychometric valid measures of participation for use with people with SCI. Priorities include understanding the relationship between objective and subjective indicators of participation, describing the dimensions of participation, and identifying appropriate measurement models and psychometric approaches to evaluate the nonhierarchical character of participation. Researchers and clinicians should be aware of the strengths and limitations of existing measures to make informed decisions about appropriate instruments.     

Decreasing pressure injuries and acute care length of stay in patients with acute traumatic spinal cord injury

ObjectivesIdentifying factors associated with the occurrence of pressure injuries (PI) during acute care and with longer length of stay (LOS), focusing on modifiable factors that can be addressed and optimized by the acute rehabilitation team.DesignProspective cohort study.SettingA single Level-1 trauma center specialized in SCI care.ParticipantsA cohort of 301 patients with acute TSCI was studied.Outcome measuresThe primary outcome was the occurrence of PI during acute care stay. The secondary outcome was acute care LOS. Bivariate and multivariate logistic or linear regression analyses were performed to determine the association between non-modifiable factors and outcomes (PI of any stage and acute LOS), whereas bivariate and hierarchical multivariate logistic or linear regression analyses were used for modifiable factors.ResultsWhen controlling for the level and severity of the TSCI, the occurrence of pneumonia (OR = 2.1, CI = 1.1–4.1) was significantly associated with the occurrence of PI. When controlling for the level and severity of the TSCI, the occurrence of medical complications (PI, urinary tract infection and pneumonia) and lesser daily therapy resulted in significantly longer acute care LOS (P < .001).ConclusionsPrevention of PI occurrence and the optimization of the acute care LOS represent crucial challenges of the acute rehabilitation team, as they are significantly associated with higher functional outcomes. Patients who develop pneumonia may benefit from more aggressive prevention strategies to reduce PI occurrence. Systematic protocols for the prevention of complications as well as greater volume of therapy interventions should be considered to optimize the acute care LOS.     

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.     

Inconsistencies with screening for traumatic brain injury in spinal cord injury across the continuum of care

Objective: Explore how traumatic brain injury (TBI) is screened among spinal cord injury (SCI) patients across the continuum of care.

Design: Retrospective chart review

Setting: Emergency department, trauma, inpatient rehabilitation

Participants: 325 patients with SCI from inpatient rehabilitation facility (IRF) between March 1, 2011 and December 31, 2014 were screened. 49 eligible subjects had traumatic SCI and received care in adjoining acute care (AC) hospital.

Outcome Measures: Demographic characteristics and variables that capture diagnosis of TBI/SCI included documentation from ambulance, emergency department, AC, and IRF including ICD-9 codes, altered mental status, loss of consciousness (LOC), Glasgow Coma Score, Post Traumatic Amnesia (PTA), neuroimaging, and cognitive assessments.

Results: Participants were male (81%), white (55%), privately insured (49%), and aged 39.3±18.0 years with 51% paraplegic and 49% tetraplegic. Mechanisms of injury were gunshot wound (31%), fall (29%), and motor vehicle accident (20%). TBI occurred in 65% of SCI individuals, however documentation of identification of TBI, LOC, and CT imaging results varied in H&P, discharge notes, and ICD-9 codes across the continuum. Cognitive assessments were performed on 16% of subjects.

Conclusions: Documentation showed variability between AC and IRF and among disciplines. Imaging and GCS were more consistently documented than LOC and PTA. It is necessary to standardize screening processes between AC and IRF to identify dual diagnosis.     

Physical activity promotion to persons with spinal cord injury by health and exercise professionals: A scoping review

Objectives:Health and exercise professionals (HEPs) are ideal promoters and valued messengers of physical activity (PA) information among persons with spinal cord injury (SCI). However, little is known about what strategies used by HEPs increase PA behavior in persons with SCI, or what factors influence HEPs when promoting PA to persons with SCI. The purposes of this scoping review were to (1) ascertain the extent, range and nature of the literature, (2) identify strategies used by HEPs that are associated with an increase in PA behavior for persons with SCI, and (3) identify the facilitators and barriers to PA promotion by the HEPs.Methods:A comprehensive search was undertaken. Search terms were expanded surrounding three key terms: PA, promotion, and SCI.Results:Twenty-four articles representing 18 unique studies were identified. HEPs predominantly consisted of physiotherapists, occupational therapists, and leisure trainers/therapists. Most interventions were delivered by HEPs to persons with SCI in in-patient rehabilitation centres and community-based settings. Tailored exercise programs and on-going counseling support were considered essential for increasing PA behavior. HEPs’ common barriers to PA promotion were perceived lack of time, education, and training.Conclusion:A need to improve and sustain SCI-specific PA knowledge and education was identified if PA promotion is to become a structured and integral component of practice. This study provides valuable information for interventions to increase PA behavior among persons with SCI by improving PA promotion by HEPs.     

Mapping the continuum of care to surgery following traumatic spinal cord injury

BackgroundTraumatic spinal cord injury (SCI) is a devastating injury, frequently resulting in paralysis and a lifetime of medical and social problems. Reducing time to surgery may improve patient outcomes. A vital first step to reduce times is to map current pathways of care from injury to surgery, identify rapid care pathways and factors associated with rapid care pathway times.MethodsA retrospective review of the Alfred Trauma Service records was undertaken for all cases of spinal injury recorded in the Alfred Trauma Registry over a three year period. Patients with an Abbreviated Injury Scale (AIS) code matching 148 codes for spinal injury were included in the study. Information extracted from the Alfred Trauma Registry included demographic, clinical and key care timelines.ResultsOf the 342 cases identified, 119 had SCI. The average age of SCI patients was 52 years, with 84% male. The vast majority of SCI patients experienced multiple concurrent injuries (87%). Median time from injury to surgery was 17 h r 28 min for SCI patients in comparison to 28 h r 23 min for non-SCI patients. Three pathways to surgery were identified following Trauma Centre presentation- transfer to surgery direct from trauma unit (median time to surgery was 4 h 17 min.), via Intensive Care (median time to surgery was 24 h 33 min) and via the ward (median time to surgery 28 h r 35 min.) SCI was independently associated with the fastest pathway - direct transfer from trauma unit to surgery - with 41% of SCI cases transferred directly to surgery from the trauma unit.ConclusionNotwithstanding that the vast majority of SCI patients presented with other traumatic injuries, half of all SCI cases reached surgery within 18 h of injury, with 25% within 9 h. SCI was independently associated with direct transfer to surgery from the trauma unit. SCI patients achieve rapid times to surgery within a complex trauma service. Furthermore, the trauma system is well positioned to implement further time reductions to surgery for SCI patients.