Duplex ultrasound surveillance for deep vein thrombosis after acute traumatic spinal cord injury at rehabilitation admission

Context/objective: To determine the prevalence of deep vein thrombosis (DVT) detected through routine duplex screening and factors associated with DVT in spinal cord injury (SCI) patients on admission to rehabilitation.

Design: Retrospective chart review of medical records.

Setting: Acute inpatient rehabilitation.

Participants: One hundred and eighty-nine individuals admitted to rehabilitation within 2 weeks of initial traumatic SCI who underwent routine surveillance with duplex scan for DVT.

Interventions: Duplex scan of lower extremities.

Outcome measures: The dependent variable was positive duplex screening for either any DVT (distal and/or proximal) or proximal DVT.

Results: Of the 189 patients, 31 patients (16.4%) had a positive scan for any (proximal and/or distal) DVT, with 9 (4.8%) positive for a proximal DVT and 22 (11.6%) positive for isolated distal DVT. Of those with isolated distal DVT, 31.8% later developed propagation with either proximal DVTs or pulmonary embolism (mean?=?22 days). Factors significantly associated with positive duplex scans for any (proximal and/or distal) DVT include more severe neurological injury (AIS A, B or C versus AIS D: χ²?=?7.1791, df?=?1, P?=?0.007) and older age (age ≥50 years old: χ²?=?14.9410, df?=?1, P?=?0.000).

Conclusion: In acute traumatic SCI, older age and more severe neurological impairment (AIS A, B, and C) are independent risk factors for positive duplex screening for any (proximal and/or distal) DVT detected on rehabilitation admission. Individuals with an acute distal DVT have a high likelihood for future thrombus progression. Routine surveillance for these patients may be warranted.     

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.     

Spinal stenosis vs traumatic spinal cord injury: a rehabilitation outcome comparison

OBJECTIVE: Nontraumatic spinal cord injury (NT/SCI), which can occur secondary to spinal stenosis, has been shown to represent a significant proportion of individuals admitted for SCI rehabilitation. The objective of this study was to compare demographics and outcomes of patients with spinal stenosis-induced SCI (SS/SCI) with those with traumatic spinal cord injury (T/SCI) following inpatient rehabilitation. DESIGN: This 7-year prospective review compared 81 patients with SS/SCI and 102 patients with T/SCI admitted to an SCI rehabilitation unit with similar levels and completeness of injury. Main outcome measures included rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, rehabilitation charges, and discharge rates to home. RESULTS: Results indicate that, when compared with the T/SCI, patients with SS/SCI had a significantly (P < .05) higher mean age (64.1 years vs 44.4 years), were more often female (39% vs 20%), and tended to present with paraplegia vs tetraplegia (69% vs 46%) and with motor incomplete SCI vs incomplete SCI (100% vs 49%). When comparing etiologies of SCI within tetraplegic and paraplegic groups, results showed that individuals with tetraplegic SS/SCI had a significantly (P < .05) shorter rehabilitation LOS (25.7 vs 35.9 days), and lower FIM change (24.5 vs 32.5) and FIM efficiency (1.0 vs 1.3); however, no statistical differences were noted for discharge FIM scores and discharge to home rates. Individuals with paraplegic SS/SCI also had significantly lower FIM change (20.2 vs 28.7); however no significant differences were noted for rehabilitation LOS, charges, FIM efficiency, or discharge-to-home rates. CONCLUSIONS: The findings indicate that patients with SS/SCI present with less severe clinical impairments (motor incomplete and paraplegia) in comparison with patients with T/SCI. Clinically similar SS/SCI groups were noted to achieve rates of functional gain and community discharge comparable with T/SCI patients. Although patients with T/SCI achieved greater overall functional improvement, patients with SS/SCI had shorter rehabilitation LOS and lower rehabilitation charges. These findings have important implications for the interdisciplinary rehabilitation process in the overall management and outcome of individuals with NT/SCI.     

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.     

Tracheostomy timing in traumatic spinal cord injury

The study conducted is the retrospective study and the main objective is to evaluate the benefits and safety of early versus late tracheostomy in traumatic spinal cord injury (SCI) patients requiring mechanical ventilation. Tracheostomy offers many advantages in critical patients who require prolonged mechanical ventilation. Despite the large amount of patients treated, there is still an open debate about advantages of early versus late tracheostomy. Early tracheostomy following the short orotracheal intubation is probably beneficial in appropriately selected patients. It is a retrospective clinical study and we evaluated clinical records of 152 consecutive trauma patients who required mechanical ventilation and who received tracheostomy. The results show that the early placement (before day 7 of mechanical ventilation) offers clear advantages for shortening of mechanical ventilation, reducing ICU stay and lowering rates of severe orotracheal intubation complication, such as tracheal granulomas and concentric tracheal stenosis. On the other hand, we could not demonstrate that early tracheostomy avoids neither risk of ventilator-associated pneumonia nor the mortality rate. In SCI patients, the early tracheostomy was associated with shorter duration of mechanical ventilation, shorter length of ICU stay and decreased laryngotracheal complications. We conclude by suggesting early tracheostomy in traumatic SCI patients who are likely to require prolonged mechanical ventilation.     

New rehabilitation interventions in spinal cord injury

Progress in the care of people with spinal cord injury (SCI) spans every aspect, from research in neuroregeneration to pharmacologic interventions. This article focuses on advances in rehabilitation interventions, which have employed bioengineering, computerization, and advanced therapeutic techniques. These interventions are being applied to functional deficits of the bladder, bowel, upper extremities, and respiratory system, as well as to improvements in ambulation and mobility. Functional electrical stimulation (FES) is being used to augment the function of the lower extremities, the upper extremities (Freehand System), and the bowel and bladder (Vocare System). Tendon transfer is a reconstructive technique used to improve upper extremity function; it is sometimes combined with FES. Body weight-supported treadmill training is being used to improve ambulation in people with incomplete SCI, and advances in wheelchair technology are expanding options for mobility. Cushion design and pressure mapping are modalities being used to reduce the high risk for pressure ulcers in the SCI population. Research on shoulder stressors is being applied to transfer techniques, exercise regimens, adaptive equipment and wheelchair mechanics to minimize shoulder pain, another common complication. The effectiveness of rehabilitation interventions needs to be documented by evidence-based research. Researchers are focusing on the identification of outcomes measures that will form the basis for established standards of care for individuals with SCI. Perhaps the combination of conventional and newer therapies may enhance neurological recovery. Well-designed studies are needed before we can make this determination.     

Determining priorities in functional rehabilitation related to quality of life one-year following a traumatic spinal cord injury

Context/Objective: To determine the relationship between the different functional aspects (as determined by the Spinal Cord Independence Measure) and quality of life (QOL) following a traumatic spinal cord injury (TSCI), considering clinical confounding factors.

Design: Retrospective review of a prospective cohort

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

Participants: One hundred and forty-two individuals sustaining an acute traumatic SCI

Interventions: Not applicable

Outcome measures: The four QOL domains as assessed by the WHOQoL-bref questionnaire 6–12 months following a TSCI.

Results: Mobility subscore was the only functional aspect significantly associated with all QOL domains (physical, psychological, social and environmental). Females present better chronic social and environmental QOL when compared to males. The level of injury may also influence environmental QOL.

Conclusion: Mobility training (mobility in bed, mobility with or without technical aids, transfers and stair management) should be an important part of the rehabilitation process in order to optimize chronic QOL following a TSCI.     

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.     

Sexual rehabilitation of women with a spinal cord injury

STUDY DESIGN: Literature review and a qualitative study. OBJECTIVE: This article reviews literature examining the sexual rehabilitation of women following spinal cord injury (SCI). It includes recommendations for improvements in initial clinical rehabilitation efforts and counselling services. SETTING: United Kingdom, Denmark and Sweden. METHODS: Articles concerning sexual rehabilitation following SCI from the last two decades have been reviewed and critiqued. Qualitative results from discussions with women with SCI in Denmark and Sweden are presented. RESULTS: The literature focuses on the effect of neurological change on women's ability to achieve sexual arousal and orgasm. Urinary and bowel incontinence, spasticity, vaginal lubrication and autonomic dysreflexia are the physical consequences of SCI that appear to have most impact on sexual activity. More recent studies have acknowledged that psychosocial factors such as age and partnership status may also affect the successful sexual rehabilitation. Discussions with women with SCI in Denmark and Sweden on their reactions to information and counselling offered during rehabilitation revealed an overwhelming need for the exchange of information and experience with other women with SCI, and a desire for opportunities for counselling after initial rehabilitation. CONCLUSION: Successful sexual rehabilitation of women with SCI demands a holistic approach that considers individual neurological, physical and psychosocial circumstances. Peer-counselling could make a significant contribution to the sexual rehabilitation of women with SCI.     

Antispasmodic medications may be associated with reduced recovery during inpatient rehabilitation after traumatic spinal cord injury

Objective: To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI).

Design/Methods: Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not.

Outcome measures: Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level.

Results: Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4–24.2). Total motor score averaged 39.2 (95% CI 37.8–40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P?=?0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics.

Conclusions: Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.     

Platelet aggregation in traumatic spinal cord injury.

Study design: Collagen-induced platelet aggregation and platelet count of ten paraplegic patients (four females, six males, aged 16 - 42 years) with traumatic spinal cord injury (SCI) (posttraumatic 12 - 48 weeks) and of ten age-matched healthy volunteers (control group; five females, five males, aged 18 - 37 years) were investigated. Objectives: Investigation of platelet aggregation in the whole blood of the patients with SCI. Setting: Ankara/Turkey. Methods: Platelet aggregation was evaluated by impedance technique using Chrono Log Model 560 WB aggregometer in whole blood. Platelet count was determined by Medonic Cell Analyser 610. Results: Maximal intensity of collagen-induced platelet aggregation of the patients was 18.50+/-8.28 ohm (mean+/-SD) and of the controls was 7.60+/-4.25 ohm. Maximal rate of collagen-induced aggregation of platelets from the patients was 3.98+/-1.59 ohm/min, maximal rate of aggregation of platelets from the controls was 1.57+/-1.01 ohm/min. Platelet counts of the patients and controls were 290 500+/-50 357/mm3 and 273 000+/-48 343/mm3 respectively. It was determined that both maximal rate (P<0.001) and maximal intensity (P<0.01) of collagen-induced platelet aggregation of the patients were significantly higher than those of the controls. There was no significant difference between the two groups in respect to platelet counts. Conclusion: Collagen-induced platelet aggregation of patients with traumatic SCI 12 - 48 weeks after the trauma was significantly higher than that of the controls. Our results indicate that increased tendency of platelet aggregation, which is probably induced by free radicals, may have a great impact on the late thromboembolic complications reported in patients with traumatic 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.     

Pain management after traumatic spinal cord injury

Pain is experienced by people suffering from spinal cord injury leading to disability and affecting the person's functional ability, independence, psychological well - being, ability to return to work and quality of life. Pain management in these patients is notoriously difficult due to multiple factors and varied mechanism leading to pain. Only few treatments have been assessed in randomized, controlled trials and management is based on different case reports. We are reporting our experience of managing 2 patients with neuropathic pain following traumatic spinal cord injury. Both the patients were refractory to conventional pain medications but there was significant reduction in pain following lignocaine infusion in the first patient and with ketamine in the second patient.     

Urodynamic patterns after traumatic spinal cord injury

Objectives

To study the correlation between neurological level of spinal injury and bladder functions as detected by urodynamic study.

Study design

Analytical study.

Setting and participants

Seventy individuals with traumatic spinal cord injury (SCI) admitted to the Department of Physical Medicine and Rehabilitation, S.M.S. Medical College and Hospital, Jaipur. Detailed clinical, neurological evaluation as per American Spinal Injury Association Classification and radiological assessment were done along with clinical examination of bladder and urodynamic study.

Results

Out of 65 patients with suprasacral injuries, 53 (81.5%) demonstrated hyperreflexia with or without detrusor sphincter dyssynergia, 6 (9.2%) detrusor areflexia, and 6 (9.2%) had normal bladders, 41 (59.4%) low compliance (<20 ml/cmH₂O), and 47 (72.30%) had high detrusor leak pint pressures (>40 cmH₂O). Of the five patients with sacral injuries, one (20%) showed detrusor hyperreflexia, four (80%) detrusor areflexia, and one (20%) had low bladder compliance; all five (100%) had high detrusor leak point pressures.

Conclusions

The correlation between somatic neurologic findings, spinal imaging studies, and urodynamic findings in patients with SCI is not exact. Therefore, bladder management should not completely rely only on clinical bladder evaluation or neurological examination alone, but should always include urodynamic studies.     

Urinary calculi following traumatic spinal cord injury

OBJECTIVE: To investigate the time aspect of the development of renal and bladder calculi in individuals with traumatic spinal cord injury (SCI) and a possible relation between the development of calculi and the bladder-emptying method. MATERIAL AND METHODS: The study comprised a retrospective data collection from medical records and a questionnaire follow-up at least 10 years after the SCI. RESULTS: A total of 236 individuals with SCI (82% male, 18% female; 47% tetraplegic, 53% paraplegic) who were injured between 1956 and 1990 participated in the study and the response rate was 84.6%. The mean age at the time of follow-up was 50.5 years (range 28-84 years). The mean duration from the time of SCI was 24.1 years (range 10-45 years). During follow-up 47 participants (20%) had at least one episode of renal calculi and 32 (14%) had at least one episode of bladder calculi. The risk of first renal and bladder calculus was highest within the first 6 months post-injury. The cumulative proportion of calculi-free participants 45 years post-injury was 62% for renal calculi and 85% for bladder calculi. For participants who did not develop renal calculi within the first 2 years post-injury, the risk of having a renal calculus within the next 43 years was 34%. For bladder calculi the corresponding risk of having a bladder calculus within the next 43 years was 5%. No significant differences were found regarding the bladder-emptying method and either renal or bladder calculi, only a non-significant trend that more participants with bladder calculi used indwelling catheters. Participants with renal or bladder calculi were not statistically significantly different from the remainder of the study group regarding gender, para- or tetraplegia or Frankel classification. CONCLUSIONS: The risk of developing renal and bladder calculi was higher in the SCI population compared to the normal population. Bladder calculi primarily occur early post-injury and renal calculi appear both early post-injury and years later. Therefore, it is important to follow individuals with SCI regularly by means of urological investigations from the time of the injury until death.     

Urological rehabilitation of spinal cord injury patients

The urological rehabilitation of spinal cord injury patients depends on an optimal urological treatment plan and good cooperation between the patient, general practitioner, urologist, and a centre that specialises in treating spinal cord injuries. Because of medical advancements in neuro-urology, one can assume that in cases of lifelong urological care, the individual's life expectancy will be almost normal. The recognition that nonphysiological bladder storage pressure results in restricted kidney function has led to various therapeutic strategies with complementary goals, such as protection of the upper urinary tract, urinary continence, individualized bladder management.