Bisphosphonate Use in Acute and Chronic Spinal Cord Injury: A Systematic Review

Background/Objective:

Bone density loss occurs rapidly after traumatic spinal cord injury (SCI) and is associated with low-energy fractures below the level of injury, commonly occurring around the knee. Bisphosphonates have been tested as potential agents to prevent bone loss after SCI, but no guidelines exist for clinical use of bisphosphonates in these patients. The objective of this study was to systematically review and evaluate evidence quality in studies of bisphosphonate use in patients with post-treatment follow-up of sublesional bone mineral density.

Methods:

Literature search in MEDLINE/PubMed and ISI database using key words bisphosphonates, spinal cord injury, quadriplegia, paraplegia, and tetraplegia.

Results:

The search identified 6 experimental studies and 1 quasi-experimental study of bisphosphonate therapy in patients with acute and chronic SCI. The studies were small and of fair or poor quality, and none included fracture outcomes. Mild attenuation of bone density loss with acute administration of bisphosphonates after SCI was found at some measurement sites but was not always maintained during follow-up.

Conclusions:

Data were insufficient to recommend routine use of bisphosphonates for fracture prevention in these patients. Current studies are limited by heterogeneity of patient populations and outcome measures. Uniform bone density measurement sites with rigorous quality control and compliance monitoring are needed to improve reliability of outcomes. Future studies should address specific populations (acute or chronic SCI) and should assess fracture outcomes.     

Efficacy of Surgical Decompression in the Setting of Complete Thoracic Spinal Cord Injury

Abstract

Background/Objective: An assessment of neurological improvement after surgical intervention in the setting of traumatic thoracic spinal cord injury (SCI).

Methods: A retrospective evaluation of a nonconsecutive cohort of patients with a thoracic SCI from T2 to T11. The analysis included a total of 12 eligible patients. The neurologic and functional outcomes were recorded from the acute hospital admission to the most recent follow-up. Data included patient age, level of injury, neurologic examination according to the Frankel grading system, the performance of surgery, and the mechanism of the time-related SCI decompression.

Results: All patients had a complete thoracic SCI. The median interval from injury to surgery was 11 days (range, 1-36 days). Decompression, bone fusion, and instrumentation were the most common surgical procedures performed. The median length of follow-up was 18 months after surgery (range, 9-132 months). Motor functional improvement was seen in 1 patient (Frankel A to C).

Conclusion: Surgical decompression and fusion imparts no apparent benefit in terms of neurologic improvement (spinal cord) in the setting of a complete traumatic thoracic SCI. To better define the role of surgical decompression and stabilization in the setting of a complete SCI, randomized, controlled, prospective studies are necessary.     

False-Negative Triple-Phase Bone Scans in Spinal Cord Injury to Detect Clinically Suspect Heterotopic Ossification: A Case Series

Abstract

Background/Objective: Heterotopic ossification (HO) is a complication seen in patients after spinal cord injury (SCI). Triple-phase nuclear bone scanning is the most sensitive test for the detection of HO. This retrospective study assesses whether patients with clinically suspected HO but negative triple-phase nuclear bone scans develop delayed positive nuclear bone scans.

Methods: Case series: A cohort of patients with SCI and clinically suspected HO who underwent triple phase nuclear bone scans over a period of 2 years was identified from retrospective chart review of an acute inpatient SCI rehabilitation service. A subgroup of 7 patients with initially negative but subsequently positive triple-phase nuclear bone scans was identified, and the following data were collected: date, mechanism, admission level, and admission completeness of injury as well as date, number, and results of bone scans. Laboratory studies were also collected during the time of imaging.

Results: Over a 2-year period, 343 patients were admitted to the SCI rehabilitation service; 60 patients were suspected of having HO and underwent a total of 85 triple-phase nuclear bone scans. Seven patients were identified with initially negative but subsequently positive bone scans.

Conclusions: In patients with clinically suspicious HO but negative bone scans, follow-up scans are indicated to identify initial false-negative studies.     

Midsagittal tissue bridges are associated with walking ability in incomplete spinal cord injury: A magnetic resonance imaging case series

Context: Following spinal cord injury (SCI), early prediction of future walking ability is difficult, due to factors such as spinal shock, sedation, impending surgery, and secondary long bone fracture. Accurate, objective biomarkers used in the acute stage of SCI would inform individualized patient management and enhance both patient/family expectations and treatment outcomes. Using magnetic resonance imaging (MRI) and specifically a midsagittal T2-weighted image, the amount of tissue bridging (measured as spared spinal cord tissue) shows potential to serve as such a biomarker. Ten participants with incomplete SCI received MRI of the spinal cord. Using the midsagittal T2-weighted image, anterior and posterior tissue bridges were calculated as the distance from cerebrospinal fluid to the damage. Then, the midsagittal tissue bridge ratio was calculated as the sum of anterior and posterior tissue bridges divided by the spinal cord diameter. Each participant also performed a 6-minute walk test, where the total distance walked was measured within six minutes.

Findings: The midsagittal tissue bridge ratio measure demonstrated a high level of inter-rater reliability (ICC?=?0.90). Midsagittal tissue bridge ratios were significantly related to distance walked in six minutes (R?=?0.68, P?=?0.03).

Conclusion/clinical relevance: We uniquely demonstrated that midsagittal tissue bridge ratios were correlated walking ability. These preliminary findings suggest potential for this measure to be considered a prognostic biomarker of residual walking ability following SCI.     

Characterization of the Bone Mineral Density of Children with Spinal Cord Injury

ABSTRACT

The purpose of this study was to compare the bone mineral density in children with spinal cord injury (SCI) with age-and sex-matched controls in three anatomic areas of the proximal hip. In addition, post Ziocanalysis looked for differences in bone density between sub-groups considering several factors associated with spinal cord injury: the presence or absence of spasticity, the level of injury and the presence or absence of pathologic fractures. Fifty-one pediatric patients with spinal cord injury between the ages of 3 and 20 underwent bone density measurements using dual photon absorptiometry. Before pooling the data across age groups, all measurements were normalized to age-and sex-matched controls because of increasing bone density with growth and higher bone density in males. The results revealed lower bone densities in subjects with SCI as compared with their non-disabled peers, ranging from 56 percent to 65 percent of normal across the three anatomic regions. On the average, subjects who had a previous history of fractures had significantly lower bone density measurements than those without fractures. At the intertrochanteric region, a 10.6 percent difference was noted between subjects with tetraplegia versus those with paraplegia. At the femoral neck and Ward’s Triangle, an 8.5 percent difference was noted between subjects with and without spasticity. No conclusions could be drawn from the analyses at the other sites. Together these results begin to characterize bone density levels of the pediatric SCI population. (J Spinal Cord Med] 19:249–254)     

Spinal cord injury providers’ perspectives on managing sublesional osteoporosis

Objective: Persons with spinal cord injuries (SCI) experience rapid sublesional bone loss following injury (1, 3). Evidence on preventing/managing osteoporosis in SCI is lacking. This project examined how providers manage bone loss in SCI.

Design: Telephone interviews with SCI providers.

Setting: VA SCI centers and clinics.

Participants: Veterans Administration SCI centers and clinics were categorized on their average number of dual-energy X-ray absorptiometry (DXA) scans (FY2014-2016). Twelve SCI providers from high and low DXA-ordering sites were interviewed. Questions included osteoporosis screening/diagnosis, prevention/treatment strategies, secondary causes of osteoporosis, and osteoporotic fracture complications. Interviews were audio-recorded, transcribed, and analyzed.

Results: Providers described a lack of standardized guidelines for managing osteoporosis in SCI. They most often screened for osteoporosis using DXA when: (1) considering use of a new device or activity, (2) for patients with a history of fracture. Some providers assumed that non-ambulatory SCI patients already have osteoporosis so infrequently ordered DXAs. Assessment of secondary causes of osteoporosis was uncommon. Fracture prevention strategies identified included weight-bearing and engaging in activities like adaptive sports. Vitamin D and calcium were frequently prescribed as a result of deficiencies identified during lab testing. Providers seldom prescribed FDA-approved medications for osteoporosis. Post-fracture complications encountered included nonunion/malunion and compartment syndrome. Providers indicated that patients often experienced psychological stress, anxiety and depression following fractures.

Conclusion: Providers described a lack of evidence for screening and management of patients with SCI and osteoporosis. Future efforts should include developing evidence-informed guidelines to aid providers in osteoporosis management.     

Bone Loss and Muscle Atrophy in Spinal Cord Injury: Epidemiology,Fracture Prediction,and Rehabilitation Strategies

Abstract

Summary: Individuals with spinal cord injury (SCI) often experience bone loss and muscle atrophy. Muscle atrophy can result in reduced metabolic rate and increase the risk of metabolic disorders. Sublesional osteoporosis predisposes individuals with SCI to an increased risk of low-trauma fracture. Fractures in people with SCI have been reported during transfers from bed to chair, and while being turned in bed. The bone loss and muscle atrophy that occur after SCI are substantial and may be influenced by factors such as completeness of injury or time postinjury. A number of interventions, including standing, electrically stimulated cycling or resistance training, and walking exercises have been explored with the aim of reducing bone loss and/or increasing bone mass and muscle mass in individuals with SCI. Exercise with electrical stimulation appears to increase muscle mass and/or prevent atrophy, but studies investigating its effect on bone are conflicting. Several methodological limitations in exercise studies with individuals with SCI to date limit our ability to confirm the utility of exercise for improving skeletal status. The impact of standing or walking exercises on muscle and bone has not been well established. Future research should carefully consider the study design, skeletal measurement sites, and the measurement techniques used in order to facilitate sound conclusions.     

Perceived Quality of Care and Outcomes Following Spinal Cord Injury: Minority Status In The Context Of Multiple Predictors

Abstract

Objective: T o determine whether patients with spinal cord injury (SCI) who are members of minority groups experience a disadvantage with regard to quality of care, and investigate predictors of perceived quality of care and indicators of outcome.

Design: Correlational analysis of longitudinal data.

Sample: One hundred and forty-three individuals with SCI in the first year following injury (43.3 % tetraplegia, 56.7% paraplegia; 53.6% of total had complete injuries).

Setting: Hospital and post discharge (usually outpatient) care at 3 SCI model systems.

Main Outcome Measures: Perceived quality of acute, rehabilitative, and continuing care rated by patients according to standardformat. Objective indicators of amount of care (eg, length of stay [LOS], charges) and outcomes (eg, medical complications,Functional lndependence Measure [FIM] scores, a life satisfaction measure [the Diener Scale], and the Craig Handicap and Reporting Technique [CHART; a community participation scale]).

Results: Minorities did not report statistically significant differences in perceived quality of care or other indicators (eg, amount ofcare, medical complications, FIM gain, life satisfaction, and CHART scores) compared with other groups. Severity ofinjury affected LOS and activity outcomes. Satisfaction with medical care before the injury significantly predicted perceived quality of acute hospital care, inpatient rehabilitation, and continuing ca re (P < 0.03, 0.02, and 0.02, respectively) .

Conclusion: A number of factors may affect variations in perceived quality of care and outcomes, but ethnicity is not always the most important predictor. Asking patients about their satisfaction with previous care can assist in distinguishing satisfaction with currentcare from pre-existing biases.     

Measurement of Bone: Diagnosis of SCI-Induced Osteoporosis and Fracture Risk Prediction

Background:

Spinal cord injury (SCI) is associated with a rapid loss of bone mass, resulting in severe osteoporosis and a 5- to 23-fold increase in fracture risk. Despite the seriousness of fractures in SCI, there are multiple barriers to osteoporosis diagnosis and wide variations in treatment practices for SCI-induced osteoporosis.

Methods:

We review the biological and structural changes that are known to occur in bone after SCI in the context of promoting future research to prevent or reduce risk of fracture in this population. We also review the most commonly used methods for assessing bone after SCI and discuss the strengths, limitations, and clinical applications of each method.

Conclusions:

Although dual-energy x-ray absorptiometry assessments of bone mineral density may be used clinically to detect changes in bone after SCI, 3-dimensional methods such as quantitative CT analysis are recommended for research applications and are explained in detail.Key words: bone density, finite element analysis, fracture, osteoporosis, QCT, rehabilitation medicine, spinal cord injuryAcute spinal cord injury (SCI) is associated with rapid loss of bone mass, resulting in severe osteoporosis and eventual fracture in up to 50% of all affected individuals. Fractures after SCI are associated with high rates of complications, prolonged hospital stay, and diminished quality of life. Given the already high rate of secondary conditions in this population, preventing fractures is an important clinical goal. However, there is currently no standard of care for preventing or treating bone loss after SCI, and there are no validated fracture prediction tools available for assessing risk. This article will review the biological and structural changes that are known to occur in bone after SCI in the context of promoting future research to prevent or reduce risk of fracture in this population. We will also review the most commonly used methods for assessing bone after SCI and discuss the strengths, limitations, and clinical applications of each method.     

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.     

Traumatic spinal cord injury in West Virginia: Disparities by insurance and discharge disposition from an acute care hospital

Context: Medicaid has been linked to worse outcomes in a variety of diagnoses such as lung cancer, uterine cancer, and cardiac valve procedures. It has furthermore been linked to the reduced health-related quality of life outcomes after traumatic injuries when compared to other insurance groups. In spinal cord injury (SCI), the care provided in the subacute setting may vary based upon payor status, which may have implications on outcomes and cost of care.

Design: A retrospective review utilizing the institutional trauma databank was performed for all adult patients with spinal cord injury since 2009. Pediatric patients were excluded. Insurance type, race, length of stay, discharge status (alive/dead), discharge disposition, injury severity score (ISS), and hospital charges billed were recorded.

Results: Two hundred patients were identified. Overall 27.5% of patients with SCI during the period of our review were Medicaid beneficiaries. ISS was similar between Medicaid and non-Medicaid patients, but the Medicaid beneficiaries were younger (37 vs 50 years of age; P?<?.001). Medicaid beneficiaries had a significantly longer length of stay (20.9 days; P?<?.001) when compared to all other patients. They furthermore were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center. Inpatient charges billed for Medicaid beneficiaries were significantly higher than those of non-Medicaid patients (203,264 USD vs 140,114 USD; P?=?.015), likely reflecting the increased length of stay while awaiting appropriate disposition.

Conclusion: Medicaid patients with SCI in West Virginia had a longer hospital stay, higher charges billed, and were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center, when compared to non-Medicaid patients. The lack of availability of rehabilitation facilities for Medicaid beneficiaries likely explains this difference.     

Systematic review of melatonin levels in individuals with complete cervical spinal cord injury

Context: Pineal melatonin production is mediated by afferent signaling pathways that navigate through the cervicothoracic spinal cord. Melatonin profiles in individuals with complete cervical spinal cord injury (SCI) have not been systematically reviewed despite this proposed pathway.

Objectives: The primary objective was to understand melatonin profiles in individuals with complete cervical SCI, as compared to healthy controls and those with thoracolumbar and incomplete cervical SCI. Secondary objectives were to understand the impact of injury chronicity and melatonin supplementation on melatonin values in adults with complete cervical SCI.

Methods: This review (PROSPERO ID: CRD42017073767) searched several databases and gray literature sources from January 1978 to August 2017. Studies were eligible if they evaluated melatonin levels (blood, saliva or urinary metabolite measurements) in adults with complete cervical SCI. 390 studies were screened and 12 studies met final selection criteria. Given the heterogeneity in study designs, a narrative analysis was performed.

Results: There is evidence that adults with complete cervical SCI have absent diurnal melatonin rhythms as compared to healthy controls and individuals with thoracolumbar SCI below T3. There is limited evidence comparing levels in individuals with incomplete tetraplegia. There is insufficient evidence describing profiles immediately (<2 weeks) after cervical SCI. Based on a limited number of studies, melatonin supplementation does not appear to improve sleep outcomes in adults with long-standing complete cervical SCI.

Conclusions: Future research should explore melatonin levels acutely after cervical SCI and the impact of supplementation on non-sleep outcomes.     

Fatal Fever of Unknown Origin in Acute Cervical Spinal Cord Injury: Five Cases

Background/Objective: Patients with traumatic upper thoracic and cervical spinal cord injuries are at increased risk for the development of autonomic dysfunction, including thermodysregulation. Thermoregulation is identified as an autonomic function, although the exact mechanisms of thermodysregulation have not been completely recognized. Quad fever is a hyperthermic thermoregulatory disorder that occurs in people with acute cervical and upper thoracic spinal cord injuries. First described in 1982, it has not been widely discussed in the literature.

Methods: Case reports of 5 patients with cervical spinal cord injury (SCI).

Results: Five of 18 patients (28%) with acute cervical SCI who were admitted during a 1-year period had fatal complications caused by persistent hyperthermia of unknown origin.

Conclusions: Patients with acute traumatic cervical and upper thoracic SCI are at risk for thermoregulatory dysfunction. Changes in the hypothalamic axis may be implicated, especially in the light of modification in hypothalamic afferent nerves, but this hypothesis has not yet been explored. Thermodysregulation may be an early sign of autonomic dysfunction. A comprehensive guideline is needed for the management of elevated body temperature in critically ill patients with cervical SCI, because this condition may be fatal.     

Bone Loss at the Os Calcis Compared with Sone Loss at the Knee in Individuals with Spinal Cord Injury

Abstract

Background/Objective: The objective of this study was to document acute bone loss at the os calcis and compare it with bone lossat the knee following spinal cord injury (SCI) as a potential proxy for bone loss in individuals with SCI.

Methods: Bone mineral density (BMD) was measured by dual energy x-ray absorptiometry (DEXA) at the knee and os calcis, whichalso was assessed by ultrasound in 6 individuals-5 with complete SCI and 1 with incomplete SCI-at means of 33.5 and 523 daysfollowing injury.

Results: Bone mineralwas progressively greater as measured from proximal to distal sites. The net average BMD of the knee declined24% (P = 0.017). The distalfemurlost 27% (P = 0.03 8) and the proximal tibia lost 32% (P = 0 .015) , whereas the os calcis lost3 8% (P = 0.001) as measured by DEXA and 49% (P<0.001) as estimated from ultrasound. The mean loss of 24'7'o at the kneewas significantly different from the loss percentages at the os calcis as measured by both techniques: DEXA (P = 0.036) andultrasound (P = 0.043). Differences between annualized loss rates at the knee and the os calcis measured by both techniques alsowere significant: DEXA (P = 0.032) vs ultrasound (P = 0.038). However, annualized loss rates demonstrated the same trend fordifferentiallass at the sites examined in the 5 individuals with complete injuries but not for the 1 participant with an incomplete injury.The loss rates were similar for the complete and incomplete participants at the os calcis, but not at the knee.

Conclusion: The BMD of the os calcis declined 3 8% by DEXA and 49% by ultrasound compared with 24% at the knee whenmeasured 1 to 1.5 years after injury. BMD of the os calcis and distal femur measured by DEXA in persons with complete SCI werehighly correlated (r = 0.84, P < 0.0001 ).     

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.     

Flexion Model Simulating Spinal Cord Injury Without Radiographic Abnormality in Patients With Ossification of the Longitudinal Ligament: The Influence of Flexion Speed on the Cervical Spine

Abstract

Background/Objective: It is suspected that the speed of the motion of the spinal cord under static compression may be the cause of spinal cord injury (SCI). However, little is known about the relationship between the speed of the motion of the spinal cord and its stress distributions. The objective was to carry out a biomechanical study of SCI in patients with ossification of the longitudinal ligament without radiologic evidence of injury.

Methods: A 3-dimensional finite element spinal cord model was established. After the application of static compression, the model underwent anterior flexion to simulate SCI in ossification of the longitudinal ligament patients without radiologic abnormality. Flexion of the spine was assumed to occur at 1 motor segment. Flexion angle was 5°, and flexion speeds were 0.5°/s, 5°/s, and 50°/s. Stress distributions inside of the spinal cord were evaluated.

Results: Stresses on the spinal cord increased slightly after the application of 5° of flexion at a speed of 0.5°/s. Stresses became much higher at a speed of 5°/s and increased further at 50°s.

Conclusions: The stress distribution of the spinal cord under static compression increased with faster flexion speed of the spinal cord. High-speed motion of the spinal cord under static compression may be one of the causes of SCI in the absence of radiologic abnormality.     

Global meaning in people with spinal cord injury: Content and changes

Abstract

Background/Objective: To compare the t-scores of proximal femur and lumbar spine of patients with spinal cord injury (SCI) with different levels of weight bearing.

Methods: Cross-sectional study comparing 3 groups of patients with SCI: patients with daily standing times of more than 1 hour, patients with daily standing times of less than 1 hour, and nonstanding patients. Seventy-one patients with chronic SCI were recruited. They were assigned to 1 of 3 groups according to their reported daily standing time. The bone density of lumbar and proximal femoral regions was measured with dual-energy x-ray absorptiometry.

Results: The 3 groups were similar in terms of demographics and clinical variables. No significant difference was found among the mean t-scores of lumbar and proximal femoral regions of the groups. However, the patients in the group that stood more than 1 hour daily had a slight tendency to have higher t-scores than those in the control group.

Conclusions: There was no significant difference among the 3 groups. However, standing might be partially helpful in protecting the bone density in SCI by opposing the effects of immobilization.     

Sleep disordered breathing in spinal cord injury: A systematic review

Context: Spinal cord injury commonly results in neuromuscular weakness that impacts respiratory function. This would be expected to be associated with an increased likelihood of sleep-disordered breathing.

Objective: (1) Understand the incidence and prevalence of sleep disordered breathing in spinal cord injury. (2) Understand the relationship between injury and patient characteristics and the incidence of sleep disordered breathing in spinal cord injury. (3) Distinguish between obstructive sleep apnea and central sleep apnea incidence in spinal cord injury. (4) Clarify the relationship between sleep disordered breathing and stroke, myocardial infarction, metabolic dysfunction, injuries, autonomic dysreflexia and spasticity incidence in persons with spinal cord injury. (5) Understand treatment tolerance and outcome in persons with spinal cord injury and sleep disordered breathing.

Methods: Extensive database search including PubMed, Cochrane Library, CINAHL and Web of Science.

Results: Given the current literature limitations, sleep disordered breathing as currently defined is high in patients with spinal cord injury, approaching 60% in motor complete persons with tetraplegia. Central apnea is more common in patients with tetraplegia than in patients with paraplegia.

Conclusion: Early formal sleep study in patients with acute complete tetraplegia is recommended. In patients with incomplete tetraplegia and with paraplegia, the incidence of sleep-disordered breathing is significantly higher than the general population. With the lack of correlation between symptoms and SDB, formal study would be reasonable. There is insufficient evidence in the literature on the impact of treatment on morbidity, mortality and quality of life outcomes.     

Abstracts and Posters

Abstract

Context/objective

Radiation exposure from medical imaging is an important patient safety consideration; however, patient exposure guidelines and information on cumulative inpatient exposure are lacking.

Design/setting

Trauma patients undergo numerous imaging studies, and spinal imaging confers a high effective dose; therefore, we examined cumulative effective radiation dose in patients hospitalized with spinal trauma. We hypothesized that people with spinal cord injury (SCI) would have higher exposures than those with spine fractures due to injury severity.

Particpants/interventions

Retrospective data were compiled for all patients with spine injuries admitted to a level I trauma center over a 2-year period.

Outcome measures

Injury severity score (ISS) and cumulative radiation exposure were then determined for these patients, including 406 patients with spinal fractures and 59 patients with SCI.

Results

Cumulative effective dose was 45 millisieverts (mSv) in SCI patients, compared to 38 mSv in spinal fracture patients (P = 0.01). Exposure was higher in patients with an ISS over 16 (P = 0.001). Mean exposure in both groups far exceeded the European annual occupational exposure maximum of 20 mSv. More than one-third of patients with SCI exceeded the US occupational maximum of 50 mSv.

Conclusion

Patients with SCI had significantly higher radiation exposure and ISS than those with spine fracture, but the effective dose was globally high. Dose did not correlate with injury severity for patients with SCI. While the benefits of imaging are clear, radiation exposure does involve risk and we urge practitioners to consider cumulative exposure when ordering diagnostic tests.     

SCIRehab Project Series: The Speech Language Pathology Taxonomy

Introduction: Outcomes research for speech language pathology (SLP) interventions for acute traumatic spinal cord injury (SCI) rehabilitation in the US is difficult because of the lack of a treatment classification system (taxonomy).

Objective: To describe a taxonomy developed by speech language pathologists (SLPs) to examine the effects of SLP interventions on SCI rehabilitation outcomes.

Methods: The SCIRehab study uses practice-based evidence, a rigorous observational methodology that examines treatment processes without specifying or requiring specific therapeutic interventions. Speech language pathology lead clinicians and researchers at 6 US SCI centers developed a detailed SLP taxonomy documentation process that is comprehensive of SLP interventions for patients with SCI.

Results: The SLP taxonomy consists of 7 intervention categories that address deficits (speech production for patients with artificial airway, motor speech and voice, swallowing, cognitive-communication, and communication) and the associated exercises and tasks that patients perform. Time is recorded for each category, and supplementary information focuses on cueing needs and family involvement that helps to describe and guide intervention selection. The SCIRehab project is enrolling 1,500 patients with acute traumatic SCI at 6 inpatient rehabilitation facilities.

Conclusions: Speech language pathology taxonomy information is being captured for the SCIRehab patients who are referred for SLP services; this may be the first attempt to document the many details of the SLP rehabilitation process for patients with SCI in the US.