Rapid progression of acute cervical syringomyelia: A case report of delayed complications following spinal cord injury

Context: Post-traumatic syringomyelia treatment usually focuses on restoring normal cerebrospinal fluid (CSF) flow. Herein, the first-reported case of delayed post-traumatic syringomyelia associated with an L2 compression fracture 30 years prior to syringomyelia symptoms that rapidly progressed to the brainstem within 5 months, leading to respiratory and circulatory impairments, is summarized. The improvement in symptoms and significant decrease in size of the syringomyelia/syringobulbia achieved in this patient suggest that the initial treatment of choice in such acute cases should be posterior fossa decompression (PFD). Intradural exploration in order to restore the normal CSF flow at the level of trauma can then be planned in a later time.Findings: A retrospective analysis of clinical manifestations and findings obtained from magnetic resonance (MR) imaging, including pre-operative and post-operative follow-up data acquired 6 months later, provided adequate comparisons of the neurological deficits and syrinx size. Interestingly, serial MR images showed that a cervical syrinx acutely progressed to the brainstem within 5 months. PFD and sectioning of the thick veil completely obstructing the foramen of Magendie resulted in partial resolution of the neurological deficits and syringomyelia regression after surgery.Conclusions: To our knowledge, this is the first case report to summarize the delayed complications of a spinal cord injury and acute syringomyelia progression to the brainstem in a short period. The symptoms were relieved by an emergency PFD, chosen due to the rapid progression of symptoms. An atypical treatment strategy is described for extremely rare cases, but with a good short-term prognosis.     

The impact of early spasticity on the intensive functional rehabilitation phase and community reintegration following traumatic spinal cord injury

Context/Objectives: To determine the impact of spasticity presenting during the acute care hospitalization on the rehabilitation outcomes following a traumatic spinal cord injury (TSCI).

Design: Retrospective cohort study.

Setting: A single Level 1 trauma center specialized in SCI care.

Participants: 150 individuals sustaining an acute TSCI.

Interventions: Not applicable.

Outcome Measures: The total inpatient functional rehabilitation length of stay. The occurrence of medical complications and the discharge destination from the inpatient functional rehabilitation facility were also considered.

Results: 63.3% of the cohort presented signs and/or symptoms of spasticity during acute care. Individuals with early spasticity developed medical complications during acute care and during intensive functional rehabilitation in a higher proportion. They were also hospitalized significantly longer and were less likely to return home after rehabilitation than individuals without early spasticity. Early spasticity was an independent factor associated with increased total inpatient rehabilitation length of stay.

Conclusion: The development of signs and symptoms of spasticity during acute care following a TSCI may impede functional rehabilitation outcomes. In view of its association with the occurrence of early spasticity, higher vigilance towards the prevention of medical complications is recommended. Early assessment of spasticity during acute care is recommended following TSCI.     

Prediction of functional recovery six months following traumatic spinal cord injury during acute care hospitalization

Objectives: To determine factors associated with functional status six months following a traumatic cervical and thoracic spinal cord injury (SCI), with a particular interest in factors related to the acute care hospitalization stay.

Design: This is a prospective cohort study. Sixteen potential predictive variables were studied. Univariate regression analyses were first performed to determine the strength of association of each variable independently with the total Spinal Cord Independence Measure (SCIM) score. Significant ones were then included in a General linear model in order to determine the most relevant predictive factors among them. Analyses were carried out separately for tetraplegia and paraplegia.

Setting: A single specialized Level I trauma center.

Participants: One hundred fifty-nine patients hospitalized for an acute traumatic SCI between January 2010 and February 2015.

Interventions: Not applicable.

Main outcome measure: The SCIM (version 3) functional score.

Results: Motor-complete SCI (AIS-A,B) was the main predictive factor associated with decreased total SCIM score in tetraplegia and paraplegia. Longer acute care length of stay and the occurrence of acute medical complications (either pneumonia, urinary tract infections or pressure ulcers) were predictors of decreased functional outcome following tetraplegia, while increased body mass index and higher trauma severity were predictive of decreased functional outcome following paraplegia.

Conclusions: This study supports previous work while adding information regarding the importance of optimizing acute care hospitalization as it may influence chronic functional status following traumatic SCI.     

颈髓损伤四肢瘫的手功能重建

目的　介绍重建颈髓损伤四肢瘫患者手功能的临床经验。方法　对 5例颈髓损伤伴手部功能障碍者 ,利用其残留的有功能的前臂肌肉进行肌腱转位术 ,重建拇指的侧捏和手指的抓握功能。结果　术后平均随访 1.5年 ,5例患者的手功能明显改善 ,提高了生活自理能力 ,并恢复了部分工作自立能力 ,如操作电脑 ,经营小杂货店等。结论　颈髓损伤伴手部功能障碍患者 ,后期施行手功能重建是有效的 ,是一个具有社会意义的举措     

脊髓损伤后急性期甲基强的松龙干预对脊髓神经细胞凋亡的影响

目的:观察脊髓损伤后即刻甲基强的松龙干预治疗对脊髓神经细胞凋亡的影响,探讨该药物促进脊髓神经功能修复的机制。方法:采用改良Allen′s法建立脊髓损伤(SCI)兔动物模型,实验动物随机分为假手术组(S组)36只,单纯损伤组(C组)与MP治疗组(T组)各36只,分别于损伤后8h、24h、72h、7d、14d和28d时随机取6只动物灌注固定取材,HE染色观察损伤区脊髓组织的病理改变,TUNEL法检测各组脊髓标本细胞凋亡情况;分别于损伤后1d、3d、7d、14d及28d观察各组动物运动神经功能情况,包括Rivlin斜板试验和BBB评分。结果:术后C组和T组斜板试验临界角度值和BBB评分值随时间点延长均逐渐升高,损伤7d及之后各时间点,T组均高于C组,但小于S组(P<0.05)。HE染色S组脊髓组织在各时间点未见明显异常;T组及C组损伤后8h、24h及72h时脊髓组织结构紊乱,可见不同程度出血、神经细胞水肿、坏死,灰质中空泡形成,炎症细胞浸润,两组无明显区别;损伤后7d、14d及28d,T组脊髓组织较C组恢复较好,整体损伤程度轻,血肿逐渐吸收,空泡减少,灰质和白质坏死吸收并胶原纤维组织增生,胶质细胞减少,可见较多神经细胞。TUNEL法检测凋亡细胞,S组未发现阳性细胞,C组及T组在损伤后8h可见阳性细胞,24h达到高峰,3d时仍较多,术后7d渐渐减少,14d及28d时阳性细胞数明显降低。两组对比,在损伤后8h、24h、3d及7d四个时间点,T组阳性细胞明显少于C组(P<0.05),14d及28d时两组比较无统计学意义(P>0.05)。结论:MP在脊髓损伤急性期干预治疗,有利于损伤的脊髓神经功能恢复,可能通过抗细胞凋亡机制产生作用。     

Dermatological problems following spinal cord injury in Korean patients

Objective

To identify dermatological conditions following spinal cord injury (SCI) and analyze these conditions in relation to various characteristics of SCI.

Design

Retrospective chart review.

Setting

National Health Insurance Corporation Ilsan Hospital of Korea, Rehabilitation Center, Spinal Cord Unit.

Participants

Patients treated for SCI who were referred to dermatology for dermatological problems, 2000–2012.

Results

Of the 1408 SCI patients treated at the spinal cord unit, 253 patients with SCI were identified to have been referred to dermatology for skin problems and a total of 335 dermatological conditions were diagnosed. The most common dermatological finding was infectious (n = 123, 36.7%) followed by eczematous lesions (n = 109, 32.5%). Among the infectious lesions, fungal infection (n = 76, 61.8%) was the most common, followed by bacterial (n = 27, 21.9%) lesions. Seborrheic dermatitis (n = 59, 64.1%) was the most frequent eczematous lesion. Ingrown toenail occurred more frequently in tetraplegics whereas vascular skin lesions occurred more commonly in patients with paraplegia (P < 0.05). Xerotic dermatitis showed a higher occurrence within 12 months of injury rather than thereafter (P < 0.05). Of these, 72.4% of the infectious and 94.7% of the fungal skin lesions manifested below the neurological level of injury (NLI; P < 0.001) and 61.5% of the eczematous lesions and 94.9% of seborrheic dermatitis cases occurred above the NLI (P < 0.001). There was no significant difference in dermatological diagnoses between patients with neurologically complete and incomplete SCI.

Conclusion

The most common dermatological condition in patients with SCI among those referred to dermatology was fungal infection, followed by seborrheic dermatitis. Although dermatological problems after SCI are not critical in SCI outcome, they negatively affect the quality of life. Patients and caregivers should be educated about appropriate skin care and routine dermatological examinations.     

脊髓损伤患者机构康复训练效果的影响因素分析

目的 :评价脊髓损伤患者机构康复训练效果并分析其影响因素。方法 :收集2013年1月~2016年12月在上海市养志康复医院(上海市阳光康复中心)进行康复训练的脊髓损伤患者的档案,采集人口学和损伤基本特征指标,训练前后15个基本技能指标(包括进食、梳洗修饰、洗澡、穿裤子、穿上衣、上厕所、床/椅/轮椅转移、入厕和浴室转移、行走、上下楼梯和使用轮椅、人际沟通能力、解决问题能力和情绪处理能力指标)、3个家庭应用能力评估指标(个人卫生、家务劳动和休闲娱乐)以及5个社会生活应用能力评估指标(轮椅使用、交通工具使用、到达目的地的活动、沟通能力和任务完成情况)的评估结果。共有383例康复训练患者纳入本研究,患者入院时年龄为9~71岁(中位数45岁),受伤年龄0~69岁(中位数31岁),从受伤到参加康复训练间隔0~61年(平均11年,中位数5年)。外伤303例(79.3%)。应用因子分析考察数据变量间的内在结构,提取5个公因子,分别为基本生活技能、心理认知、行走和上下楼梯、家庭和社会生活应用。采用多元线性回归分析从受伤到参加机构训练的间隔时间、性别、教育水平、婚姻状况、受伤水平和受伤原因对5个因子的影响。结果:在康复训练45d后,患者的所有评估指标得分均显著性提高(P0.01),提升最小的为进食(2.2%),最大的为轮椅实际使用(78.8%);5个因子中家庭应用能力提升最大(54.3%,P0.01),行走和上下楼梯提高幅度最小(10.5%,P0.01)。在基本生活技能方面,参加训练间隔时间越长,相对提高越少(β=-0.101,P0.1);与腰骶段损伤相比,颈段(β=0.273,P0.1)和胸段(β=0.23,P0.1)损伤的患者提高较多。在心理认知方面,大专及以上学历的患者比初中及以下患者提高相对更多(β=0.122,P0.1)。在家庭应用方面,训练间隔是负面影响因素(β=-0.147,P0.1),已婚比未婚康复效果更好(β=0.11,P0.1),外伤患者比非外伤患者改善效果差(β=-0.141,P0.1)。在社会应用方面,已婚和更早参加康复训练都是正面影响因素。结论:脊髓损伤患者短期参加机构康复训练可改善其日常生活自理能力和社会适应能力;康复效果与受伤到训练的间隔时间、损伤节段、学历、婚姻状况和教育背景有关。患者早期参加机构康复训练,关注患者的教育等多方面需求,有助于提升康复训练效果。     

颈髓急性损伤后的磁共振波谱评价

目的:探讨颈髓急性损伤后磁共振波谱(1H-MRS)的诊断价值。方法:对19例急性颈髓损伤患者根据神经功能分为完全性损伤及不全性损伤两组,选取创区与创区头侧远端颈髓行1H-MRS,半定量分析氮-乙酰门冬氨酸(NAA)、胆碱(Cho)、肌酸(Cr)和乳酸(Lac)含量的比值。结果:颈髓完全性损伤组中NAA/Cho、NAA/Cr显著减低,Lac/Cho显著增高,其创区头侧远端Lac/Cho含量也增高(P<0.05);不完全损伤组中仅Lac/Cho含量增加,头侧远端乳酸含量亦增高(P<0.05)。颈髓损伤不同程度组间NAA/Cho、NAA/Cr有显著性差异(P<0.05)。结论:1H-MRS所测NAA/Cho、NAA/Cr从代谢水平反映颈髓损伤的不同程度,创区头侧远端Lac/Cho比值增高提示颈髓隐匿损伤的存在。     

分阶段策略预防急性颈脊髓损伤呼吸系统并发症的回顾性研究

目的:探讨分阶段策略预防急性颈脊髓损伤(ACSCI)呼吸系统并发症的临床效果。方法:回顾性分析2008年9月至2013年5月手术治疗的91例ACSCI患者的临床资料,其中采用分阶段策略预防呼吸系统并发症42例(分阶段组),男30例,女12例,年龄28～76岁,平均50岁;未采取分阶段策略预防呼吸系统并发症的49例患者作为对照组,男38例,女11例,年龄30～77岁,平均47岁。两组患者均于伤后48 h收入院,且入院时无呼吸系统并发症。分阶段组分为术前、术中及术后3个阶段,并根据不同阶段采取不同措施预防呼吸系统并发症,而对照组无系统及全面措施预防呼吸系统并发症。对两组患者的呼吸系统并发症发生率、由呼吸系统并发症导致气管插管或切开率及病死率进行分析。结果:分阶段组中10例出现呼吸系统并发症(肺部感染7例,肺不张1例,呼吸衰竭2例),其中3例因呼吸系统并发症而行气管插管或切开;对照组中24例出现呼吸系统并发症(肺部感染15例,肺不张3例,呼吸衰竭6例),其中11例因呼吸系统并发症行气管插管或切开,两组比较差异有统计学意义(χ²= 6.12,4.07;P=0.013,0.044).因呼吸系统并发症导致死亡在分阶段组中1例,对照组中4例,两组比较差异无统计学意义(χ²=1.39,P=0.238).结论:分阶段策略可降低ACSCI呼吸系统并发症发生率及改善呼吸系统并发症的预后。     

脊髓损伤后血流改变

选用成年狗１０只，于胸９－０给以２０ｇ×２５ｃｍ打击量，应用氢清除法于伤后１５ｍｉｎ～４ｂ测定脊髓血流量（ＳＣＢＦ）。结果显示伤后不同时期灰质血流量均较白质血流量（ｗＳＣＢＦ）为高，近侧节较远侧节亦高，伤后２ｈ，ｗＳＣＢＦ稍升高，但４ｈ恢复正常。作者认为，伤后头几个小时为关键时刻，此时如能采用有效措施，对不全瘫还能逆转。本文结果与文献相比有些差异，可能与实验条件不同及观察时间较短有关。     

Surgical management of patients following traumatic spinal cord injury: Identifying barriers to early surgery in a specialized spinal cord injury center

Context/Objective: Early surgery in individuals with traumatic spinal cord injury (T-SCI) can improve neurological recovery and reduce complications, costs and hospitalization. Patient-related and healthcare-related factors could influence surgical delay. This study aimed at determining factors contributing to surgical delay in individuals with T-SCI.

Design: Prospective cohort study.

Setting: Single Level I trauma center in Québec, Canada.

Participants: One hundred and forty-four patients who sustained a T-SCI.

Interventions: None.

Outcome measures: Socio-demographic and clinical administrative data were collected during the pre-operative period. The cohort was stratified in early surgery, or ES (<24 hours post-trauma) and late surgery, or LS (≥ 24 hours post-trauma) groups. A multivariate logistic regression analysis using patient- and healthcare-related factors was carried out to identify the main predictors of LS.

Results: 93 patients had ES (15.6?±?4.7 hours post-trauma), which is 31 hours earlier than the 51 patients in the LS group (46.9?±?30.9 hours; P??3). The transfer delay from trauma site to the SCI center was 8 hours shorter (5.0?±?3.0 hours vs 13.6?±?17.0; P??3) for the ES group, and the surgical plan was completed 17 hours faster (6.0?±?4.0 hours vs 23.3?±?23.6 hours; P??3) than for the LS group. The occurrence of LS was predicted by modifiable factors, such as the transfer delay to the SCI center, the delay before surgical plan completion, and the waiting time for the operating room.

Conclusions: A dedicated team for surgical treatment of individuals with T-SCI, involving direct transfer to the SCI center, faster surgery planning and access to the operating room in hospitals dealing with emergencies from all subspecialties could improve surgical delay and increase the rate of patients undergoing ES.     

Traumatic vs non-traumatic spinal cord injury: A comparison of primary rehabilitation outcomes and complications during hospitalization

Objective: To compare outcome for patients with traumatic (TSCI) and non-traumatic spinal cord injuries (NTSCI) after primary rehabilitation regarding neurological improvement measured by the American Spinal Injury Association Impairment Scale (AIS), length of stay and complications.

Design: Retrospective comparative cohort study on patients with TSCI and NTSCI, hospitalized during a ten-year period at Haukeland University Hospital, Norway. Impairment, length of stay and complications during first in-patient rehabilitation period were analyzed. Uni- and multivariate analysis was performed.

Setting: Spinal Cord Rehabilitation Unit, Haukeland University Hospital, Norway

Participants: A total of 174 persons with a spinal cord injury (SCI) were included; 102 with TSCI and 72 with NTSCI.

Outcome measures: Neurological improvement measured by AIS from admission to discharge, number of weeks in the hospital, frequency and significance of complications were compared.

Results: Improvement in AIS after primary rehabilitation did not differ between TSCI and NTSCI. Length of stay was in average 3.4 weeks longer for TSCI. Urinary tract infections and pressure ulcers significantly influenced length of stay in both groups. Urinary tract infections were more frequent in TSCI (67%) vs NTSCI (42%). Pressure ulcers were more frequent among NTSCI (24%) vs TSCI (14%). Pneumonia and neuropathic pain did not depend on etiology and did not influence length of stay.

Conclusions: Patients with SCI have a rehabilitation potential regardless of etiology. Complications are frequent in both groups and often prolong hospitalization. Complication patterns differ in the two groups, and specific prevention and optimal treatment will shorten and optimize the length of primary rehabilitation.     

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。     

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。     

The impact of spine stability on cervical spinal cord injury with respect to demographics,management, and outcome: a prospective cohort from a national spinal cord injury registry

Background Context

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

颈髓挥鞭性损伤误诊分析

颈髓挥鞭性损伤,尤其是颈部症状不明显而又无放射影像异常者,常常易引起误诊。我院自1992年10月至2008年2月所遇初诊误诊患者18例,现对原因分析如下。     

Lower extremity hemorrhage in patients with spinal cord injury receiving enoxaparin therapy

Low-molecular-weight heparin is commonly favored over unfractionated heparin because of its predictable pharmacokinetic and pharmacodynamic properties. However, full-dose enoxaparin can cause major soft tissue bleeding that may lead to compartment syndrome and even limb amputation. In patients with spinal cord injury, range of motion exercises should be carefully performed if on full-dose enoxaparin. This vulnerable patient population is particularly susceptible to aggressive stretching, which could lead to bleeding, and compartment syndrome. Providers should also monitor weight fluctuations in patients receiving full-dose enoxaparin. Changes in weight without proper dose adjustment can cause over or under treatment. Attention to both these issues can improve patient care.     

Early complications of high-dose methylprednisolone in acute spinal cord injury patients

BACKGROUND: To evaluate the early complications and effect on neurological outcome of methylprednisolone (MP) treatment in spinal cord injury (SCI) patients during the acute phase. METHODS: We retrospectively reviewed the whole cohort of patients admitted to our ICU between January 1994 and December 2005 due to acute SCI. Patients were grouped according to the medical treatment received (MP group versus no-MP group). Patient data as age, gender, Glasgow coma score (GCS), APACHE II, injury severity score (ISS) and ICU stay were recorded. Outcome at ICU discharge and neurological function based on Frankel grade was recorded at ICU admission and at ICU discharge. Early complications were also noted. RESULTS: There were no differences between both groups in ICU mortality (OR=0.48; 95% CI: 0.08-3.64) nor neurological function at ICU discharge. (OR=1.09; 95% CI: 0.35-3.66). MP group presented an increase in respiratory tract infections (OR=8.19; 95% CI: 1.10-358.6) and in total infections (OR=4.90; 95% CI: 1.46-18.83) compared to no-MP group during the ICU stay. There was a significant increase in the incidence of hyperglycaemia in the MP group (OR=17.0; 95% CI: 4.52-66.3). CONCLUSIONS: The use of MP in patients with acute SCI is not associated with an improvement in outcome or neurological function at ICU discharge. Moreover, the use of MP is associated with an increased risk of infectious and metabolic complications during ICU stay.     

Lower extremity hemorrhage in patients with spinal cord injury receiving enoxaparin therapy

Abstract

Low-molecular-weight heparin is commonly favored over unfractionated heparin because of its predictable pharmacokinetic and pharmacodynamic properties. However, full-dose enoxaparin can cause major soft tissue bleeding that may lead to compartment syndrome and even limb amputation. In patients with spinal cord injury, range of motion exercises should be carefully performed if on full-dose enoxaparin. This vulnerable patient population is particularly susceptible to aggressive stretching, which could lead to bleeding, and compartment syndrome. Providers should also monitor weight fluctuations in patients receiving full-dose enoxaparin. Changes in weight without proper dose adjustment can cause over or under treatment. Attention to both these issues can improve patient care.     

Management of acute spinal cord injury: A summary of the evidence pertaining to the acute management,operative and non-operative management

Acute traumatic spinal cord injury is often a lifechanging and devastating event with considerable mortality and morbidity. Over half a million people suffer from traumatic spinal cord injury annually with the majority resulting from road traffic accidents or falls. The Individual, societal and economic costs are enormous. Initial recognition and treatment of acute traumatic spinal cord injury are crucial to limit secondary injury to the spinal cord and to provide patients with the best chance of some functional recovery. This article is an overview of the management of the acute traumatic spinal cord injury patient presenting to the emergency department. We review the initial assessment, criteria for imaging and clearing the spine, and evaluate the literature to determine the optimum timing of surgery and the role of non-surgical treatment in patients presenting with acute spinal cord injury.