Epidemiology of spasticity following traumatic spinal cord injury

Two epidemiologic studies of spasticity at discharge and first annual follow-up in patients with traumatic spinal cord injury (SCI) are reported. Study 1 analyzed occurrence of spasticity and its severity for 96 subjects at one SCI center, with 67% of subjects developing spasticity by discharge and 37% receiving antispasticity medication. By follow-up, these figures were 78% and 49%, respectively. Incidence of spasticity was higher among cervical and upper thoracic than lower thoracic and lumbosacral levels of injury groups (p less than 0.001). Study 2 analyzed presence of spasticity severe enough to have warranted treatment on 466 subjects at 13 collaborating SCI centers, where 26% of subjects received treatment by discharge and 46% by follow-up. Probability of spasticity treatment was significantly related (p less than 0.05) to days from injury to discharge and level of injury group, whereas age, gender, and Frankel grade were not related. Among only cervical and upper thoracic subjects, Frankel grade was significantly related (p less than 0.01), with grades A (27%) and D (29%) being less frequently treated than grades B (50%) and C (52%). Importance of controlling the above significantly related factors is emphasized for future studies of methods to reduce incidence or severity of spasticity.     

Co-occurring traumatic brain injury and acute spinal cord injury rehabilitation outcomes

Macciocchi S, Seel RT, Warshowsky A, Thompson N, Barlow K. Co-occurring traumatic brain injury and acute spinal cord injury rehabilitation outcomes.ObjectiveTo determine the impact of co-occurring traumatic brain injury (TBI) on functional motor outcome and cognition during acute spinal cord injury (SCI) rehabilitation.DesignProspective, longitudinal cohort.SettingSingle-center National Institute of Disability and Rehabilitation Research SCI Model System.ParticipantsPersons aged 16 to 59 years (N=189) admitted for acute SCI rehabilitation during the 18-month recruitment window who met inclusion criteria.InterventionsNot applicable.Main Outcome MeasuresFIM Motor Scale (Rasch transformed) and acute rehabilitation length of stay (LOS).ResultsIn the tetraplegia sample, co-occurring TBI was not related to FIM Motor Scale scores or acute rehabilitation LOS despite having negative impacts on memory and problem solving. Persons with paraplegia who sustained co-occurring severe TBI had lower admission and discharge FIM Motor Scale scores and longer acute rehabilitation LOS than did persons with paraplegia and either no TBI or mild TBI. Persons with paraplegia and severe TBI had lower functional comprehension, problem solving, and memory and impairments on tests of processing speed compared with persons with paraplegia and no TBI, mild TBI, and moderate TBI. Persons with paraplegia and co-occurring mild and moderate TBI had equivalent acute rehabilitation motor outcomes and cognitive functioning compared with persons with paraplegia and no TBI.ConclusionsThis study provides evidence that persons aged 16 to 59 years with paraplegia and co-occurring severe TBI had worse motor outcomes and longer acute rehabilitation LOS than did persons with paraplegia and no TBI. Impairments in processing speed, comprehension, memory, and problem solving may explain suboptimal motor skill acquisition. Research with larger samples is required to determine whether mild and moderate TBI impact acute rehabilitation motor outcomes and LOS.     

急性创伤性脊髓损伤患者死亡原因分析

目的 分析创伤性脊髓损伤患者早期死亡原因,提出可预测患者死亡的临床指标。方法 对14例急性创伤性脊髓损伤患者的病例进行回顾性分析。结果 在426例急性创伤性脊髓损伤患者中,伤后4个月内有14例死亡,死亡原因包括气管过度刺激致心跳骤停,外科手术致病情恶化,肺炎,多器官衰竭,痰液堵塞及食物误吸致急性呼吸道梗阻等。结论 在本组病例中,创伤性脊髓损伤后4个月内死亡内为3．3％,主要原因是对气管过度刺激心跳呼吸骤停、外科手术致病情恶化和肺炎。颈5及以上3脊髓损伤或上肢肌力指数6分以下,痰多,咳嗽排痰无力,低血氧分压持续或进行性下降,出现神经恶化等可作为预测死亡的临床指标。     

Anemia after traumatic spinal cord injury

The incidence and natural history of anemia in patients with spinal cord injuries (SCI) were investigated in a prospective study of 68 patients consecutively admitted to a regional acute SCI unit. Fifty had SCI and 18 had spine injuries (SI) without neurologic deficit. Thirty-six of 41 males (88%) and six of nine females (67%) with SCI were anemic on at least one occasion. In the first two weeks after injury, in females and in males, there was no significant difference in mean hemoglobin level between SI and SCI patients. At six weeks, no male with SI was anemic, and males with SCI had significantly lower mean hemoglobin levels than those with SI (121.6 g/L vs 145.4 g/L, p less than .001). Identified early causes of anemia were blood loss due to bony soft tissue or visceral injury, gastrointestinal bleeding, and surgery. In the postacute phase (more than six weeks after injury), anemia occurred in 25 of 41 male and three of nine female SCI patients, and its occurrence was associated with the presence of an identified chronic disease, especially urinary tract infection.     

A comparison of independent living outcomes following traumatic brain injury and spinal cord injury

This study compares independent living outcomes in persons with traumatic brain injury (TBI) and spinal cord injury (SCI). Both injuries represent life-altering events that are known to have a negative impact on independent living and are predominantly experienced by members of the same demographic group. However, the types of resultant impairments and disabilities experienced by the two populations differ substantially. The TBI participants were recruited consecutively from Canada's largest tertiary care trauma centre and followed prospectively for four years. The SCI participants were recruited via a mailed survey to members of a provincial branch of the Canadian Paraplegic Association. Independent living outcomes were measured using DeJong and Hughes' (1982) classification system of productivity status, the Reintegration to Normal Living Index, and questions on assistance from environmental supports in the form of wheelchair use and paid/unpaid personal assistance. The TBI group was found to be significantly more productive, have higher levels of satisfaction with their current experience of community integration, and use fewer environmental supports than their SCI counterparts (P相似文献   

Pain following spinal cord injury

Pain is one of the most common, severe, and treatment-resistant complications that follows SCI. Recent years have seen a surge of research on methods for assessing and treating spinal cord injury pain. In this article, pain after SCI is reviewed in terms of nature, scope, assessment techniques, and treatment strategies.     

Dural tear following traumatic spinal cord injury. A delayed complication.

Dural tears with leakage of cerebral spinal fluid into surrounding soft tissues can occur after traumatic spinal cord injury. An unusual case presented in a patient with traumatic paraplegia where the onset was delayed and clinical features were suggestive of autonomic dysfunction. The clinical features, pathophysiology and treatment of this interesting complication following traumatic spinal cord injury are discussed.     

Closed head injury in acute traumatic spinal cord injury: incidence and risk factors

Investigators estimate that 15% to 50% of all patients with spinal cord injury (SCI) also incur a closed head injury (CHI), but studies have been hampered by design flaws, including retrospective assessment and inconsistent definition of CHI. We conducted a prospective study of combined CHI and SCI among 82 SCI patients consecutively admitted at two hospitals within 24 hours of injury. The purpose of the study was to determine the incidence and duration of loss of consciousness and posttraumatic amnesia (PTA), and to establish the risk factors for combined CHI and SCI. The overall incidence of CHI as defined by the presence of PTA of any duration was 49%. There was a significantly increased risk of CHI for patients involved in traffic accidents (risk ratio = 3.7; 95% confidence interval 1.8 to 7.2). There was no increased risk associated with level of injury (quadriplegic vs paraplegic; risk ratio = 1.2; 95% confidence interval = 0.8 to 1.8). All SCI patients, regardless of level of injury, deserve systematic evaluations for CHI in their acute care evaluations.     

创伤性脊髓损伤急性不稳定期的康复护理

总结45例创伤性脊髓损伤急性不稳定期患者的康复护理.根据患者损伤程度制定相应康复护理目标,早期介入体位护理、呼吸系统护理、膀胱和直肠功能护理、肢体功能训练指导,可有效预防和减少并发症的发生.45例患者中发生泌尿系感染5例、呼吸系统感染2例.     

Life satisfaction following spinal cord and traumatic brain injury: a comparative study

The current study was designed to examine the predictive validity of several factors that are common to spinal cord injury (SCI) and traumatic brain injury (TBI) populations to overall life satisfaction. We examined several demographic and functional predictors (1) within each group separately and (2) using both groups while controlling for unique predictors within groups. Participants included 190 and 57 individuals with SCI and TBI, respectively. To minimize the influence of injury duration, we assessed life satisfaction at 1-year postinjury in both groups. Functional disability (Functional Impairment Measure [FIM]) was the only common predictor within groups. For the TBI group, marital status was also a significant predictor of life satisfaction. None of the other predictors examined was significant among the SCI group. After functional disability and marital status were controlled, overall life satisfaction did not differ between groups. Total explained variance in life satisfaction was low in both groups, 9% and 25% in the SCI and TBI groups, respectively. Future directions are discussed.     

Determining impairment following spinal cord injury

Determining the level of impairment and disability of an individual with SCI is reasonably straightforward. An impairment rating may be determined by either analyzing the impact of the SCI on various bodily systems or by considering the injury as a more global diagnostic category. Functional abilities based on level of neurologic preservation are well recognized. Although secondary medical complications, which may affect both impairment and disability, can arise at any time after SCI, neurologic and functional abilities are overwhelmingly stabilized by 12 months postinjury. A comprehensive history and physical examination should allow even the inexperienced examiner to obtain a valid determination of impairment after SCI. Although a more functionally oriented and perhaps interdisciplinary evaluation is needed to assess disability, it is also fairly straightforward. On the other hand, an evaluation of handicap is a more challenging undertaking, requiring a more detailed knowledge of the field of vocational rehabilitation.     

Marital adjustment following spinal cord injury

The present study examined marital characteristics of couples who are coping successfully with spinal cord injury (SCI) versus those who are not and the relationship of positive marital adjustment in SCI couples as compared with positive adjustment among able-bodied (AB) couples. In a 2 X 2 factorial design the marital relations of 10 nondistressed and 10 distressed SCI couples and 14 nondistressed and 10 distressed AB couples were examined. Assessments were conducted in the couples' homes and included self-report measures of recreational-social activities and sexual relations, and observations of marital communication skills. Multivariate analyses revealed significant interaction effect with posthoc comparisons, indicating that spouses in distressed SCI marriages engaged in significantly fewer activities alone and with their spouse and requested the greatest degree of change in the marital relationship in comparison with the other groups. There was a significant main effect for marital satisfaction, with distressed couples expressing more dissatisfaction in sexual relations and more negative communications during conflict resolution tasks. Although the results do not indicate that substantive differences exist in quantitative and qualitative aspects of marital relations between SCI and AB couples, several trends were observed which suggest the need for further research.     

Immobilization hypercalcemia following spinal cord injury

Based on the author's experience with more than 20 cases of immobilization hypercalcemia following spinal cord injury, current concepts of this condition are presented. Symptoms may be mild or severe: laboratory findings are essential for differential diagnosis in older individuals, in whom preinjury Paget's disease and mild primary hyperparathyroidism must be ruled out. Most cases of immobilization hypercalcemia are seen in adolescent boys following recent spinal cord injury. Besides sex (male), risk factors include age (less than 21 years), complete neurologic injuries, high cervical levels of spinal cord injury, dehydration, and a prolonged period of immobilization. A preinjury history of large ingestion of milk and/or extreme exposure to sunshine may also be contributory factors. Therapy includes vigorous hydration, saline infusions and diuretics, calcitonin, and steroids. The clinical course, without treatment, may be prolonged to 14 months, but the condition is always self-limiting.     

H-reflex changes following spinal cord injury

Changes in both central synaptic excitability (CSE) and peripheral sensitivity of muscle spindle stretch receptors have been hypothesized to contribute to hyperactive stretch reflexes of spasticity. To assess CSE, the monosynaptic H-reflex to the triceps surae muscles was tested serially over the first six months after traumatic spinal cord injury (SCI). Six clinically complete SCI patients were compared to age-matched control subjects. As a measure of H-reflex excitability, H/M ratios were calculated by dividing maximum H-reflex by maximum M-response amplitude. Analysis of variance over the testing trials showed significant change in H/M ratios for SCI patients (p less than 0.01). T-tests comparing mean H/M ratios at different time periods after SCI revealed a significant increment after three months (p less than 0.01). H-reflex amplitude also increased significantly over this time period (p less than 0.04), but M-response amplitude did not change significantly. These increases in H/M ratio and H-reflex amplitude suggest that an increase in CSE may contribute to the appearance of hyperreflexia after SCI.     

创伤性脊髓损伤的早期康复效果

目的：确定创伤性脊髓损伤（SCI）的自然病程和早期康复的效果。设计：回顾性,多中心研究。环境：16所Rosai医院,1所医学院。参加者：123例SCI病人,其中男104例,女19例,平均年龄：(48.8±17.7）岁。干预：将病人分成早期康复组和延迟康复组。利用国际SCI分类表对差别进行测量。测量：利用美国脊髓损伤协会（ASIA）的分类标准将运动功能的康复率（MRR）表示为（出院时的ASIA运动分数－入院时的ASIA运动分数）/（100－入院时的ASIA运动分数）。利用MRR分期确定6个亚组（早期或晚期四肢瘫,中央脊损伤,偏瘫）的FIM和ASIA…     

Early rehabilitation effect for traumatic spinal cord injury

OBJECTIVE: To determine the natural course of traumatic spinal cord injury (SCI) and the effect of early rehabilitation on it. DESIGN: A retrospective, multicenter study. SETTING: Sixteen Rosai hospitals and 1 medical school. PARTICIPANTS: One hundred twenty-three SCI patients (104 men, 19 women; mean age, 48.8 +/- 17.7yr) enrolled. INTERVENTIONS: Dividing the subjects into an early rehabilitation group and a delayed group; differences were ensured by international classification of SCI. MAIN OUTCOME MEASURES: Using the American Spinal Injury Association (ASIA) classifications, the motor recovery rate (MRR) was defined as (ASIA motor score at discharge - ASIA motor score at admission)/(100 - ASIA motor score at admission). The regression lines for FIM instrument score and ASIA motor score were determined for 6 subgroups (early or delayed tetraplegia, central cord injury, paraplegia) by the MRR staging. The regression lines for physical or cognitive FIM score and ASIA motor score were also determined for 6 subgroups. RESULTS: Three stages were obtained: acute stage: 2 weeks postinjury; recovery stage: 2 weeks to 6 months postinjury; and chronic stage: more than 6 months postinjury. Regression lines showed that rehabilitation improved physical functional independence for ASIA motor score, especially in the early rehabilitation subgroups. There was no correlation between cognitive FIM score and ASIA motor score in 6 subgroups. CONCLUSION: Early SCI rehabilitation contributes to good physical activities of daily living for motor function.     

Late neurologic recovery after traumatic spinal cord injury

OBJECTIVE: To present Model Spinal Cord Injury System (MSCIS) data on late neurologic recovery after 1 year after spinal cord injury (SCI). DESIGN: Longitudinal study of neurologic status as determined by annual evaluations at 1 and 5 years postinjury. SETTING: MSCIS centers contributing data on people with traumatic SCI to the National Spinal Cord Injury Statistical Center database. PARTICIPANTS: People with traumatic SCI (N=987) admitted to an MSCIS between 1988 and 1997 with 1- and 5-year follow-up examinations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, motor index scores (MIS), motor level, and neurologic level of injury (NLI), measured and compared for changes over time. RESULTS: The majority of subjects (94.4%) who had a neurologically complete injury at 1 year remained complete at 5 years postinjury, with 3.5% improving to AIS grade B, and up to 1.05% each improving to AIS grades C and D. There was a statistically significant change noted for MIS. There were no significant changes for the motor level and NLI over 4 years; however, approximately 20% of subjects improved their motor level and NLI. People with complete and incomplete injuries had similar improvements in motor level, but subjects with an incomplete injury had a greater chance of improvement in NLI and MIS. CONCLUSIONS: There was a small degree of neurologic recovery (between 1 and 5 y postinjury) after a traumatic SCI. Late conversion, between 1 and 5 years, from a neurologically complete to an incomplete injury occurred in 5.6% of cases, but in only up to 2.1% was there a conversion from motor complete to motor incomplete status. Limitations of this study included changes in the ASIA classification during the study and in the intra- and interrater reliability typically seen in longitudinal studies of the ASIA standards. Functional changes were not studied. Knowledge of the degree of late recovery may help in analyzing newer interventions to enhance recovery.