Qualitative Investigation of Health Information Resources for Caregivers and Individuals Living With Spinal Cord Injury.

There are approximately 273 000 people living with traumatic spinal cord injury (SCI) in the USA,1 with as many as 1.275 million people in the US living with SCI-related paralysis.2 This represents a significant number of individuals who have SCI-related medical needs, and there is evidence that these are often being unmet.3 The importance of follow-up by specialized clinicians and primary care physicians has been previously reported for persons with SCI.3–6 The most common secondary complications presenting over time include bowel and/or bladder dysfunction, pain, skin, cardiac, and bone-related issues, depression, and sexual and reproductive health issues. Few primary care physicians have exposure to SCI-specific related medical issues in their training as well as exposure from within their practice; as each primary care physician has a limited SCI patient population. This commentary by Dr Michael Stillman presents important aspects regarding the need for and value of comprehensive primary care follow-up for persons with SCI.7 The program established at their center should be commended and represents a model that can be modified based upon the specifics of other healthcare centers, emphasizing collaboration between the primary care and SCI specialists. For decades, the issue of who should care for patients with SCI as they age has been examined. While many patients may prefer that their physiatrist or SCI physician assume primary care responsibilities,4,5 some physiatrists reportedly have not been willing or feel unable to assume the primary care role.6 Further study in this area is important. As we enter a new age of healthcare reform in terms of which services are covered, accountable care organizations being developed, and merging healthcare systems, it is critical that as professionals in the field of SCI we have the patient experience as our priority. Collaboration between primary care physicians and SCI specialists is critical. Physician offices need to be accessible; with a development and exchange of protocols for the commonest of medical complications post-SCI, sharing of information (e.g. electronic medical records), and open dialog between the clinicians. Hopefully, we will see this type of collaborative effort, as discussed in Dr Stillman's program, be advanced at other centers so that our patients' care will be optimized.

INTRODUCTION: Cervical spinal cord injury (SCI) results in devastating paralysis. Spinal column injury (i.e., traumatic SCI) may result in worse outcomes as compared to non-traumatic SCI. However, there remains a lack robust data determining the role of traumatic etiology in prognosticating outcomes after cervical SCI. METHODS: From prospective cohort of SCI model systems, we included adult patients >15 years with traumatic SCI, neurological-level C1-C8, ASIA impairment-scale (AIS) A-D, presented within 30-days of SCI. Traumatic SCI was defined as SCI resulting from spinal column injury and non-traumatic SCI was defined as SCI without any spinal column injury. The primary outcome was composite independence in eating, bladder-management, and transfers domains of functional independence measure at 1-year. Each domain ranges from 1-7; lower score indicating greater functional dependence. Composite independence was defined as score of >=6 in at least 2 domains. RESULTS: Between 1992-2016, 853 patients with cervical SCI and complete neurological/functional measures were included. At baseline, 86% (737) had traumatic SCI and 14% (116) had non-traumatic SCI. Patients with traumatic SCI had significantly larger rates of motor-complete SCI (AIS A-B); 71% versus 31% in non-traumatic SCI (p<0.001). At one-year follow-up, non-traumatic SCI had significantly larger recovery rates in FIM functions compared to traumatic SCI; 53% of non-traumatic cervical SCI patients gained composite independence in FIM functions vs. 39% in traumatic cervical SCI (p=0.007). In multivariable regression, after accounting for age, sex, symmetry-of-SCI, and SCI severity by AIS grade, traumatic SCI was not a significant predictor of functional outcome (p=0.47). CONCLUSIONS: Although patients with traumatic SCI present with worse injury severity as compared to non-traumatic SCI. However, both traumatic and non-traumatic cervical SCI have a similar recovery potential. Optimization of clinical pathways is needed to provide appropriate rehabilitation care for patients with cervical SCI.

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A concomitant traumatic brain injury is often seen in patients with acute traumatic spinal cord injury. Unfortunately, the exact epidemiology of concomitant traumatic brain injury-traumatic spinal cord injury remains unknown. Our objective was to determine the incidence of concomitant traumatic brain injury-traumatic spinal cord injury and identify clinical factors associated with its occurrence. A prospective cross-sectional study of 476 traumatic spinal cord injury patients was conducted. In all patients, baseline characteristics were routinely collected and the presence of a traumatic brain injury was sought prospectively by a specialized neurosurgeon using standardized diagnostic criteria based on clinical and radiological variables. Of the 476 included patients, 250 (53%) had isolated traumatic spinal cord injury and 226 (47%) had concomitant traumatic brain injury-traumatic spinal cord injury. Almost 85% of diagnosed traumatic brain injuries were mild. At the univariate level, patients with concomitant traumatic brain injury-traumatic spinal cord injury were more likely to present a history of drug/alcohol abuse ( P = 0.014), be involved in a motor vehicle accident ( P < 0.001), sustain a high energy mechanism ( P < 0.001), or present tetraplegia rather than paraplegia ( P = 0.021). These factors all remained significant at the multivariate level. A concomitant traumatic brain injury can be found in around 50% of traumatic spinal cord injury individuals. There are several clinical variables that should increase clinical suspicion of underlying traumatic brain injury and warrant further investigation to facilitate prompt identification and treatment of affected patients.

Monocenter case-control study. Effects of spinal surgical adverse events (SSAE) on clinical and functional outcome, length of stay, and treatment costs after traumatic cervical spinal cord injury (SCI). Traumatic SCI is a challenge for primary care centers because of the emergency setting and complex injury patterns. SSAE rates of up to 15% are reported for spine fractures without SCI. Little is known about SSAE after traumatic SCI and their outcome relevance. Acute traumatic cervical SCI patients were enrolled from 2011 to 2017. Cases with and without SSAE were compared regarding neurological recovery, functional outcome, secondary complications, mortality, length of stay, and treatment costs. Adjusted logistic regression and generalized estimating equation models were calculated for the endpoints ASIA impairment scale (AIS)-conversion and dysphagia. All analyses were run in the total and in a propensity score matched sample. At least one SSAE occurred in 37 of 165 patients (22.4%). Mechanical instability and insufficient spinal decompression were the most frequent SSAE with 13 (7.9%) or 11 (6.7%) cases, respectively. The regression models adjusted for demographic, injury, and surgery characteristics demonstrated a reduced probability for AIS-conversion related to SSAE (OR [95% CI] 0.14 [0.03-0.74]) and additionally to single-sided ventral or dorsal surgical approach (0.12 [0.02-0.69]) in the matched sample. Furthermore, SSAE were associated with higher risk for dysphagia in the matched (4.77 [1.31-17.38]) and the total sample (5.96 [2.07-17.18]). Primary care costs were higher in cases with SSAE (median (interquartile range) 97,300 [78,200-112,300]) EUR compared with cases without SSAE (52,300 [26,700-91,200]) EUR. SSAE are an important risk factor after acute traumatic cervical SCI with impact on neurological recovery, functional outcome, and healthcare costs. Reducing SSAE is a viable means to protect the limited intrinsic capacity for recovery from SCI.Level of Evidence: 4.

ObjectivesTo provide a methodological reference paper for the inception cohort of the Swiss Spinal Cord Injury Cohort Study (SwiSCI), by detailing its methodological features and reporting on participant characteristics, response rates and non-response bias.DesignProspective cohort study starting in 2013 in all 4 specialized rehabilitation centres in Switzerland.SubjectsIncluded are 655 newly diagnosed first rehabilitation patients aged ≥16 years with traumatic or non-traumatic spinal cord injury (TSCI, NTSCI).MethodsDescriptive statistics were used to depict participant characteristics and to compare characteristics of responders and non-responders. Logistic regressions were conducted to estimate non-response bias.RESULTSThe sample consisted of 69% males, with mean age 53.5 years, 57.9% TSCI, 60.7% paraplegia and 78.8% incomplete SCI. Males and younger persons more often sustained TSCI and more severe SCI, resulting in longer duration of rehabilitation. Complete lesions were more prevalent in TSCI compared to NTSCI. The response rate was 47.5% and study participation was less likely in females, older persons, persons with lower functional independence and those with NTSCI.ConclusionSwiSCI inception cohort data enable the estimation of epidemiological figures of SCI in Switzerland, and prognostic and trajectory modelling of outcomes after SCI to guide policy, service provision and clinical practice.LAY ABSTRACTThe inception cohort of the Swiss Spinal Cord Injury Cohort Study (SwiSCI) is a prospective study including newly diagnosed first rehabilitation patients aged over 16 years with traumatic or non-traumatic spinal cord injury (SCI) who received first rehabilitation in a specialized center in Switzerland. This paper describes the methods and the design of the SwiSCI inception cohort and reports on participant characteristics, response rates and differences between respondents and non-respondents. The response rate was 47.5% and 655 patients participated in the study. Of participants, 69.0% were male, mean age was 53.5 years, 57.9% had traumatic SCI, 60.7% paraplegia and 78.8% incomplete SCI. Male subjects and younger persons more often sustained traumatic SCI and more severe SCI, resulting in longer duration of rehabilitation. Complete lesions were more prevalent in traumatic SCI compared with non-traumatic SCI. Females, older persons, persons with lower functional independence and those with non-traumatic SCI were less likely to participate in the study.

Multi-centre prospective descriptive study. To establish a profile of the population affected with traumatic and non-traumatic spinal cord injury (SCI) admitted to rehabilitation centres in the Netherlands and Flanders (Belgium) and to describe determinants of length of stay (LOS) and functional outcome. Eleven rehabilitation centres in the Netherlands and Flanders. A total of 919 patients with traumatic and non-traumatic SCI on first admission to rehabilitation centres between 2002 and 2007. Information about LOS, functional outcome and personal and injury characteristics was derived from a joint data set developed for this project. A total of 54.7% of patients with SCI had a non-traumatic lesion. The group of patients with non-traumatic SCI showed a more even gender distribution, a more advanced age and less severe lesion characteristics than the group of patients with traumatic SCI. Linear regression models explained 32% of the variance of LOS and 42% of the variance of functional outcome. Functional status on admission was the strongest determinant of LOS and completeness of the lesion was the strongest determinant of functional outcome. Aetiology (traumatic versus non-traumatic) was a weak independent determinant of LOS but was not an independent determinant of functional outcome. Patients with non-traumatic SCI formed a majority in the Dutch and Flemish SCI population. Although the characteristics of patients with traumatic and non-traumatic SCI clearly differed, rehabilitation of patients with non-traumatic SCI appears at least as efficient as rehabilitation of patients with traumatic SCI.

Evidence-based medicine and clinical decision-making in spine surgery

Pressure ulcers (PUs) are common complications in patients with complete spinal cord injury (SCI) or incomplete SCI in which sensory function is spared. Most studies analyzing associated factors of PU and SCI have been performed in cases of traumatic SCI and in just a few cases of nontraumatic SCI. This study was designed to look specifically at the differences in causative factors of PU in cases of traumatic and nontraumatic SCIs. The authors performed a retrospective, cross-sectional study evaluating patients with complete and incomplete SCIs (American Spinal Injury Association Grades A and B) under the coverage of the financial, medicosocial, and rehabilitative support provided by the State Welfare Organization of Iran (SWOI). There were 3791 cases of traumatic SCI (63.2%) and 2110 cases of nontraumatic SCI (35.2%). For 94 patients (1.6%), sufficient data were not available. A PU was detected in 39.2% of all patients with an SCI (71.8% of those with traumatic SCI vs 28.2% of those with nontraumatic SCI). A univariate analysis showed a significant association between occupation, education, and the presence of PU in patients with a traumatic SCI (p < 0.05). This contrasted with nontraumatic SCI in which an association between PU and age was noted (p < 0.05). Using logistic regression, traumatic cause, older age, an interval less than 1 year since the onset of SCI, male sex, and single status were found to significantly increase the risk of PU in all patients with an SCI. However, a higher education level had a preventive effect on PU. This study revealed some risk factors for PU in the authors' setting. The authors' findings suggest a possible difference between the risk factors for PU in patients with both types of SCI. Further study on the pathoetiology of these differences is paramount in the future.

Neurogenic bowel dysfunction and neurogenic lower urinary tract dysfunction are often associated with spinal cord injury (SCI). In Brazil, studies and statistical data on these dysfunctions are scarce. To estimate the prevalence of neurogenic bowel dysfunction and neurogenic lower urinary tract dysfunction in Brazilians diagnosed with traumatic and nontraumatic SCI. In this retrospective cross-sectional study, a form was used to collect sociodemographic and clinical data from medical records. The Mann-Whitney statistical tests were used for 2 independent samples, Pearson's chi-square test for categorical variables, and the Kruskal-Wallis test for more than 2 independent samples for quantitative variables. A logistic regression model was used to understand the factors associated with neurogenic bowel dysfunction. The sample comprised 1056 participants from all regions of Brazil. Of this sample, 60.90% had traumatic SCI, and 69.03% were male. The prevalence of neurogenic bowel dysfunction in the sample was 88%, and the prevalence of neurogenic lower urinary tract dysfunction was 90.6%. Participants with traumatic SCI are more affected by neurogenic bowel and lower urinary tract dysfunction than those with nontraumatic SCI. Most people with SCI have neurogenic lower urinary tract and bowel alterations, especially those with traumatic SCI. Further studies are needed, and bowel and bladder reeducation programs should be provided in rehabilitation centers.

Based upon evidence that opioid antagonists improve neurological outcome following either traumatic or ischemic spinal cord injury, endogenous opioids have been implicated in the pathophysiology of these disorders. Naloxone improved both spinal cord perfusion and neurological function following traumatic spinal cord injury in cats, and was subsequently observed to improve neurological outcome following ischemic spinal cord injury in rabbits. Using several opioid antagonists with varied selectivities for different types of opioid receptors, it was suggested that kappa opioid receptors are involved in both these models of spinal cord injury. In addition, spinal cord trauma in rats is associated with increased concentrations of the endogenous kappa agonist dynorphin A, and increased kappa opioid receptor binding capacity localized to the injury site. Furthermore, dynorphin A induces hindlimb and tail flaccidity following intrathecal injection in rats. Thus, the pathophysiological effects of endogenous opioids in spinal cord injury have been proposed to involve dynorphin A interactions with kappa opioid receptors. However, disparities between the actions of intrathecally injected dynorphin A in rats and the presumed actions of endogenous dynorphin A in cat and rabbit spinal cord injury have been revealed in recent experiments. Paralysis resulting from intrathecal dynorphin A is not altered by opioid receptor antagonists or TRH, produced by non-opioid dynorphin A fragments but not by other selective kappa opioid agonists, and associated with non-opioid mediated reductions in spinal cord blood flow. Furthermore, despite reports of endogenous opioid changes following rat spinal cord trauma, in contrast to cats and rabbits, naloxone failed to improve neurological outcome following traumatic rat spinal cord injury. Thus, the specific endogenous opioids and opioid receptor types involved in spinal cord injury remain to be resolved, and do not appear to be universal among different models of spinal cord injury in different species. Additionally, dynorphin A may participate in spinal cord injury mechanisms in the rat through non-opioid actions.

Objective To evaluate the clinical value of susceptibility- weighted imaging(SWI) in detecting intramedullary hemorrhage of traumatic acute spinal cord injury. Methods From October 2012 to December 2014, 37 TSCI (traumatic spinal cord injuries) patients undergone the MRI scans including routine MRI and SWI were enrolled. Further according to ASIA classification standard, all patients were evaluated as ASIA A (n=4), ASIA B (n=4), ASIA C (n=19) and ASIA D (n=10). Referring to axial T2WI images at the same slice, the manifestations of hemorrhage in amplitude image, phase image and SWI were evaluated. At the slice with maximal size of hemorrhage area and its neighboring slices, the hemorrhage regions were manually drawn; and the total area was automatically calculated. The number of hemorrhage lesions was defined as the number of hemorrhage lesions at single slice × slice number. One-way ANOVA was used to compare the differences among different grading ASIA in terms of hemorrhage area and number. Meanwhile, the relations between hemorrhage area and ASIA grade; hemorrhage number and ASIA grade were evaluated by Spearman rank correlation. Results The hemorrhage was detected by SWI in 15 patients, including 4 ASIA A, 4 ASIA B, 7 ASIA C. Hemorrhage represents as isointense in T1WI and a slightly low signal intensity or isointense in the center companied by high intensity at circus in T2WI. In magnitude image and SWI hemorrhage appears as low signal intensity and low signal intensity in the center companied by high intensity at circus in phase image. In detecting the hemorrhage, SWI (98 lesions were detected) was 5.4 times of T2WI (19 lesion were detected). As for the number of hemorrhage, significant differences were found among ASIA grading A, B and C (grading A: 22.5±1.3, grading B: 19.5±1.3, grading C: 4.0±1.1; F= 38.720, P<0.01); Further the pairwise comparison showed statistical significance (P<0.05); besides, the number of hemorrhage lesions closely related with the ASIA grade (r=0.864, P<0.01). For the hemorrhage area, the calculated results of grading ASIA A, B and C were (23.5 ± 0.6), (21.8 ± 1.9), (3.9 ± 0.7) mm2, respectively; there were significant differences among the different ASIA grades (F=29.987, P<0.001); furthermore the hemorrhage area also showed closely relation with the ASIA grade (r=0.778, P<0.01). Conclusions SWI is more sensitive in detecting the hemorrhage in traumatic acute spinal cord injury. The more number and area of bleeding area suggest the more severe of the damage level. Key words: Spinal cord injuries; Magnetic resonance imaging; Hemorrhage

Interventional stereotactic radiation for traumatic spinal cord injury (SCI) in patients with confirmed paralysis

Incidence and Risk Factors for Venous Thromboembolism in Patients with Spinal Cord Injury: A Retrospective Study

Traumatic brain and spinal cord injuries are significant causes of permanent disability and death. In 2010, 823,000 traumatic brain injuries were reported in the United States alone; in fact, the actual number is likely considerably higher because mild traumatic brain injuries and concussions are underreported. The number of new traumatic spinal cord injuries has been estimated at 12,000 annually. Survival from these injuries has increased due to improvements in medical care. This review covers mild traumatic brain injury and concussion, moderate to severe traumatic brain injury, and traumatic spinal cord injury. Figures include computed tomography scans showing a frontal contusion, diffuse cerebral edema and intracranial air from a gunshot wound, a subdural hematoma, an epidural hematoma, a skull fracture with epidural hematoma, and a spinal fracture from a gunshot wound. Tables list requirements for players with concussion, key guidelines for prehospital management of moderate to severe traumatic brain injury, key guidelines for management of moderate to severe traumatic brain injury, brain herniation brain code, key clinical practice guidelines for managing cervical spine and spinal cord injury, and the American Spinal Injury Association’s neurologic classification of spinal cord injury. This review contains 6 highly rendered figures, 12 tables, and 55 references.