Cervical Cord Injury Research Articles

Abstract TP252: Stroke Risk After Blunt Cerebrovascular Injury With Dissection

INTRODUCTION: Blunt cerebrovascular injuries (BCVI) are common in trauma. The natural history of stroke in patients with traumatic dissection has not been well investigated. The goal of this study was to evaluate the risk of stroke with BCVI related dissection in the internal carotid (ICA) or vertebral artery (VA) territory. METHODS: We instituted a protocol in 2007 for CTA of the head and neck in BCVI patients to look for dissection. Criteria for CTA were patients with skull base fractures, cervical spine injury, neurological deficit, or infarction on head CT. Patients with a dissection were followed clinically for development of stroke by the trauma and neurointerventional teams. A follow-up phone call was prospectively obtained at the time of data analysis for patients with confirmed dissection for interim stroke evaluation. IRB approval was obtained. RESULTS: 51 patients were identified with an abnormal CTA for BCVI. Patients were excluded due to dissection in the external carotid (n=1), vasospasm(n=12), <1 month follow-up due to death (n=7). Of the remaining 31 patients with dissection in the analysis, the injury mechanism was: 18 MVAs, 11 falls, and 2 altercations. Location of injury was VA (n=24), ICA (n=8), and PICA (n=1). Two patients had lesions in the VA and ICA. There were 4 pseudoaneurysms (12.9%). Patients were treated with aspirin (n=27, mean 223 days); or anticoagulants (n=7, mean 114 days). Most patients (22/31, 71%) were treated with antithrombotics within 3 days of injury. One patient had a carotid stent for progressive stenosis. Mean follow-up (clinical/imaging) was 18.5+6.6 months (range 1-53 months); 19/31 (61%) patients had > 6 months follow-up. Six patients had neurological symptoms of which 3 were attributed to cervical cord injury, 1 to stroke after bypass surgery (for carotid artery avulsion), and 1 with diffuse axonal injury. One patient developed ataxia 3 days after MVC and had a cerebellar stroke. The cumulative incidence of stroke was therefore 1/31 (3.2%). CONCLUSION: The incidence of stroke after carotid or vertebral artery dissection related to BCVI is low with good prognosis. Larger prospective studies are of interest to better define stroke risk in this population.

A Pilot Study on the Effect of Pelvic Exercise on Standing Balance in Patients with Incomplete Cervical Spinal

The purpose of this study was to evaluate the effect of pelvic exercise on standing balance in patients with incomplete cervical spinal cord injury for healthy rehabilitation. 11 patients (8 men and 3 women) with levels of incomplete injury between cervical 3 and cervical 6 who were participated in a study measuring the standing balance using an interactive balance system (IBS) before and after pelvic exercise. The index of standing balance after pelvic exercise was significantly lower than before exercise in patients with incomplete cervical cord injury. The greatest improvements were observed in incomplete cervical spinal cord injury with neurologic levels of cervical 3 and 4 with Brown-Sequard syndrome. These results suggest that the pelvic exercise for rehabilitation significantly improved in part standing balance in patients with incomplete cervical spinal cord injury.

Hypertensive Intracerebral Hemorrhage Due to Autonomic Dysreflexia in a Young Man with Cervical Cord Injury

The author reports the case of a 36 year old man with cervical cord injury in whom autonomic dysreflexia developed into intracerebral hemorrhage during inpatient rehabilitation. This patient showed complete quadriplegia (motor below C6 and sensory below C7) due to fracture of the 6th cervical vertebra. An indwelling urethral catheter had been inserted into the bladder for 3 months, diminishing bladder expansiveness. Bladder capacity decreased to 200 ml and the patient frequently experienced headaches whenever his bladder was full.To obtain smoother urine flow, a supra-pubic cystostomy was performed. The headaches were temporarily cured, but soon relapsed with extreme increases in blood pressure, representing typical symptoms of autonomic dysreflexia. However, no potential triggers were identified or removed, and lack of blood pressure management led to left putaminal hemorrhage. Despite operative treatment, the right upper extremity showed progressive increases in muscle tonus and finally formed a frozen shoulder with elbow flexion contracture. Two factors contributed to this serious complication: first, autonomic dysreflexia triggered by minor malfunction and/or irritation from the cystostomy catheter; and second, the medical staff lacked sufficient experience in and knowledge about the management of autonomic dysreflexia.It is of the utmost importance for medical staff engaging in rehabilitation of spinal patients to share information regarding triggers of autonomic dysreflexia and to be thorough in ensuring proper medical management.

Pentax-AWS video laryngoscope for tracheal intubation in a patient with Klippel-Feil syndrome

Pentax-AWS video laryngoscope for tracheal intubation in a patient with Klippel-Feil syndrome

Comparison of Functional Recovery of Manual Dexterity after Unilateral Spinal Cord Lesion or Motor Cortex Lesion in Adult Macaque Monkeys

In relation to mechanisms involved in functional recovery of manual dexterity from cervical cord injury or from motor cortical injury, our goal was to determine whether the movements that characterize post-lesion functional recovery are comparable to original movement patterns or do monkeys adopt distinct strategies to compensate the deficits depending on the type of lesion? To this aim, data derived from earlier studies, using a skilled finger task (the modified Brinkman board from which pellets are retrieved from vertical or horizontal slots), in spinal cord and motor cortex injured monkeys were analyzed and compared. Twelve adult macaque monkeys were subjected to a hemi-section of the cervical cord (n = 6) or to a unilateral excitotoxic lesion of the hand representation in the primary motor cortex (n = 6). In addition, in each subgroup, one half of monkeys (n = 3) were treated for 30 days with a function blocking antibody against the neurite growth inhibitory protein Nogo-A, while the other half (n = 3) represented control animals. The motor deficits, and the extent and time course of functional recovery were assessed. For some of the parameters investigated (wrist angle for horizontal slots and movement types distribution for vertical slots after cervical injury; movement types distribution for horizontal slots after motor cortex lesion), post-lesion restoration of the original movement patterns (“true” recovery) led to a quantitatively better functional recovery. In the motor cortex lesion groups, pharmacological reversible inactivation experiments showed that the peri-lesion territory of the primary motor cortex or re-arranged, spared domain of the lesion zone, played a major role in the functional recovery, together with the ipsilesional intact premotor cortex.

Charcot Arthropathy of the Lumbosacral Spine Mimicking a Vertebral Tumor after Spinal Cord Injury

Charcot spinal arthropathy is a rare, progressive type of vertebral joint degeneration that occurs in the setting of any preexisting condition characterized by decreased afferent innervation to the extent that normal protective joint sensation in the vertebral column is impaired. The authors report on a case of Charcot arthropathy of the lower lumbar spine mimicking a spinal tumor following cervical cord injury.

106 C5レベル頸髄損傷者を対象とした車いす操作支援ロボットの開発(OS1-2 人を支援するメカトロニクス(2),OS1 人を支援するメカトロニクス)

106 C5レベル頸髄損傷者を対象とした車いす操作支援ロボットの開発(OS1-2 人を支援するメカトロニクス(2),OS1 人を支援するメカトロニクス)

The Selection of the Appropriate Computer Interface Device for Patients With High Cervical Cord Injury

In order to determine the most suitable computer interfaces for patients with high cervical cord injury, we report three cases of applications of special input devices. The first was a 49-year-old patient with neurological level of injury (NLI) C4, American Spinal Injury Association Impairment Scale (ASIA)-A. He could move the cursor by using a webcam-based Camera Mouse. Moreover, clicking the mouse could only be performed by pronation of the forearm on the modified Micro Light Switch. The second case was a 41-year-old patient with NLI C3, ASIA-A. The SmartNav 4AT which responds according to head movements could provide stable performance in clicking and dragging. The third was a 13-year-old patient with NLI C1, ASIA-B. The IntegraMouse enabling clicking and dragging with fine movements of the lips. Selecting the appropriate interface device for patients with high cervical cord injury could be considered an important part of rehabilitation. We expect the standard proposed in this study will be helpful.

2A2-C03 C4レベル頸髄損傷者の残存機能を利用した上肢動作支援システムの開発(福祉ロボティクス・メカトロニクス(2))

2A2-C03 C4レベル頸髄損傷者の残存機能を利用した上肢動作支援システムの開発(福祉ロボティクス・メカトロニクス(2))

RETRACTED: <i>A rare presentation of silent gastric perforation in quadriplegic patient</i>

Traumatic cervical spinal cord lesions are highly susceptibility to produce life threatening complications like respiratory failure, cardiac failure and gastrointestinal complications. We are presenting a case of traumatic cervical cord injury with quadriplegia, presented with chief complaints of constipation with abdominal distention and altered sensorium. After detailed examination and history, patient diagnosed as case of post traumatic cervical spine with incidental finding of gastric perforation and managed surgically in emergency.

Laminoplasty for Cervical Cord Injury without Bone Injury

Laminoplasty for Cervical Cord Injury without Bone Injury

Urinary tract management in patients with incomplete cervical cord injury during the recovery phase

For patients with incomplete cervical cord injuries, appropriate urinary management based on an assessment of voiding and storage function of the bladder is necessary for a better prognosis, especially during the recovery phase. In our review of medical records of such patients, we identified factors related to recovery of bladder function and parameters for predicting prognosis. In this study, we included 234 patients with incomplete cervical cord injuries admitted to Kanagawa Rehabilitation Hospital. Their medical records were retrospectively reviewed for various parameters related to final urinary management measures at discharge. Parameters included age, severity of paralysis, bladder function over time, urinary sensation and cystometry results. Patients were managed using urethral catheterization, suprapubic cystostomy, clean intermittent catheterization (CIC) by oneself or care givers, CIC with occasional spontaneous voiding, or spontaneous voiding alone. Bladder function improved in majority of the patients during hospitalization. The severity of paralysis and urinary sensation are predictive parameters for improvement in voiding function. In patients who were admitted with catheterization but were discharged with spontaneous voiding, the period for recovery was 85.2 days on average (range 16-142 days). Selection of urinary management measures for patients with incomplete cervical cord injuries can be performed adequately by considering the severity of paralysis and urinary sensation.

Clinical and magnetic resonance imaging features of neuromyelitis optics with positive anti-nuclear antibody serum

To analyze the clinical features and brain, spinal cord magnetic resonance imaging (MRI) features of neuromyelitis optical (NMO) patients with positive anti-nuclear antibody serum (ANAs). The clinical data of expanded disability status scale (EDSS) score, duration of the first relieving phase and first year recurrence-positive rate and MRI features of 34 NMO patients at our hospital during the period of 2006-2011 were retrospectively reviewed and divided into two groups according to the outcome of antibodies test:ANAs positive group (n=14) and ANAs negative group (n=20). (1) In the ANAs-positive group, the EDSS score of first NMO attack was (2.8±1.1), first remission continued to (9±9) months and the first year recurrence-positive rate was 71.0%; in the ANAs-negative group, the EDSS score of first NMO attack was 2.3±0.8, first remission continued to (31±39) months and the first year recurrence-positive rate was 30.0%. The differences in the first attack EDSS score, duration of first remission and first recurrence rate between two groups were statistically significant (P<0.05). (2) Brain damage-positive rate in the ANAs-positive group on prompt MRI was 35.71% (5/14) and it was higher than that in ANAs-negative group (5/20). But no significant difference existed between two groups. The spinal cord lesions were predominantly located in cervical and thoracic spinal cords simultaneously in both groups (about 50% respectively). And, in the ANAs-positive group, the cervical lesions involved were much more common than the thoracic counterparts (6/14 vs 1/14). However, in the ANAs-negative group, thoracic segments were usually involved (6/20 vs 4/20). With severe neurological deficits in the first clinical attack and a short remission, ANAs-positive NMO patients are more prone to relapse in the first year, brain damage and cervical cord injury.

Cough - another important factor in extubation readiness in critically ill patients

Ling Liu and colleagues [1] found that critically ill patients who fail weaning have impaired ability to convert neuromuscular activity into tidal ventilation, highlighting the eff ect of diaphragm weakness on weaning and extubation from mechanical ventilation. However, it is noteworthy that the insuffi cient cough strength greatly contributes to failed extubation in clinical practice as well, particularly in patients with acute cervical cord injury, or who have undergone major thoracic or abdominal surgery. Some intubated patients with inadequate cough strength can successfully pass the spontaneous breathing trial, but nevertheless might still experience extubation failure afterwards. It is diffi cult for them to clear secretions in airways due to the inability to cough, which leads to increased risk of atelectasis and respiratory infection. Weak cough can be attributable to expiratory muscle dysfunction, inspiratory muscle weakness, and so on; however, expiratory muscle function is crucial for eff ective cough [2]. Th e major expiratory muscles include the muscles of the anterolateral wall of the abdomen, the expiratory intercostal muscle, and the triangularis sterni [3]. Th e neuro-ventilatory effi ciency of these muscles, however, cannot be assessed by diaphragm electrical activity. Expiratory muscle strength became a focus of interest for estimating cough strength. Cough peak expiratory fl ow was used to evaluate cough refl ex, which was considered an indicator for predicting successful extubation of

Diffusion tensor imaging and tractography in brown-sequard syndrome

Case report. To demonstrate the utility of diffusion tensor imaging and tractography in two patients with Brown-Sequard syndrome after penetrating cervical cord injury. Milwaukee, WI, USA. Two patients, who presented with features of Brown-Sequard syndrome after sustaining stab wounds to the neck, underwent DTI and tractography of the cervical cord within a week of the injury. DTI metrics were measured within the left and right hemicord around the level of injury. Diffusion tensor tractography was performed to visualize the site of injury and injured fiber tracts. Axial fractional anisotropy maps at the site of injury showed unilateral damage to the cord structure, and FA was significantly reduced within the injured hemicord in both patients. Tractography allowed for visualization of the injured fiber tracts around the level of injury. Both DTI metrics and tractography showed an asymmetry that corresponded to the neurological deficits exhibited by the patients. This report illustrates the utility of DTI and DTT in delineating regions of cord injury in two patients with traumatic Brown-Sequard syndrome. Our results indicate that DTI provides clinically relevant information that supplements conventional MR imaging for patients with acute SCI.

Efficacy of Spinal Pia Mater Incision and Laminoplasty Combined with Internal Fixation for Old Spinal Cord Injury

To evaluate the clinical efficacy of incising spinal pia mater to relieve pressure and unilateral open-door laminoplasty with internal screw fixation for treatment of the dated spinal cord injury. From March, 2009 to July, 2010, 16 cases with chronic cervical cord injury underwent spinal dura mater incision and unilateral open-door laminoplasty with internal screw fixation. Nerve functions of pre- and postoperation were evaluated by Frankel classification and the Japanese Orthopaedic Association (JOA) scale.The improvement rate of JOA score at the indicated time was recorded. Postoperative Frankel classification rating of 16 patients improved obviously.JOA scores at the 1st month, 3rd month, 6th month, and 12th month after surgery were 7.9 ± 2.3, 8.5 ± 1.6, 8.9 ± 2.1, and 12.4 ± 2.5, respectively, and significantly increased compared with that prior to surgery (5.5 ± 0.6). At the end of follow-up period, JOA score was significantly higher than that of pre-treatment (P<0.05). The recovery was relatively rapid during the first 3 months following the surgery, then entered a platform period. It is effective for patients with dated spinal cord injury to undergo spinal decompression and laminoplasty.

Tetraplegia or paraplegia with brachial diparesis? What is the most appropriate designation for the motor deficit in patients with lower cervical spinal cord injury?

The authors seek to clarify the nomenclature used to describe cervical spinal cord injuries, particularly the use of the terms "tetraplegia", "quadriplegia", "quadriparesis", "tetraparesis", "incomplete quadriplegia" or "incomplete tetraplegia" when applied to patients with lower cervical cord injuries. A review of the origin of the terms and nomenclature used currently to describe the neurological status of patients with SCI in the literature was performed. The terms "tetraplegia", "quadriplegia", "quadriparesis", "tetraparesis", "incomplete quadriplegia" or "incomplete tetraplegia" have been used very often to describe patients with complete lower cervical SCI despite the fact that the clinical scenario is all the same for most of these patients. Most of these patients have total loss of the motor voluntary movements of their lower trunk and inferior limbs, and partial impairment of movement of their superior limbs, preserving many motor functions of the proximal muscles of their arms (superior limbs). A potentially better descriptive term may be "paraplegia with brachial diparesis". In using the most appropriate terminology, the patients with lower cervical SCI currently referred as presenting with "tetraplegia", "quadriplegia", "quadriparesis", "tetraparesis", "incomplete quadriplegia" or "incomplete tetraplegia", might be better described as having "paraplegia with brachial diparesis".

Severe neurologic manifestations from cervical spine instability in spondylo‐megaepiphyseal‐metaphyseal dysplasia

Spondylo-megaepiphyseal-metaphyseal dysplasia (SMMD; OMIM 613330) is a dysostosis/dysplasia caused by recessive mutations in the homeobox-containing gene, NKX3-2 (formerly known as BAPX1). Because of the rarity of the condition, its diagnostic features and natural course are not well known. We describe clinical and radiographic findings in six patients (five of which with homozygous mutations in the NKX3-2 gene) and highlight the unusual and severe changes in the cervical spine and the neurologic complications. In individuals with SMMD, the trunk and the neck are short, while the limbs, fingers and toes are disproportionately long. Radiographs show a severe ossification delay of the vertebral bodies with sagittal and coronal clefts, missing ossification of the pubic bones, large round "balloon-like" epiphyses of the long bones, and presence of multiple pseudoepiphyses at all metacarpals and phalanges. Reduced or absent ossification of the cervical vertebrae leads to cervical instability with anterior or posterior kinking of the cervical spine (swan neck-like deformity, kyknodysostosis). As a result of the cervical spine instability or deformation, five of six patients in our series suffered cervical cord injury that manifested clinically as limb spasticity. Although the number of individuals observed is small, the high incidence of cervical spine deformation in SMMD is unique among skeletal dysplasias. Early diagnosis of SMMD by recognition of the radiographic pattern might prevent of the neurologic complications via prophylactic cervical spine stabilization.

Rehabilitation Starts in the Intensive Care Unit

Each year between 10 000 and 12 000 spinal cord injuries occur in the United States. Once injured, many of these patients will receive a portion of their care in an intensive care unit (ICU), where their treatment will begin. Harborview Medical Center in Seattle, Washington, provides comprehensive care to approximately 60 to 70 cervical spinal cord injuries each year. Because of many factors such as hemodynamic instability, pulmonary complications, and risk of infection, patients with cervical spinal cord injuries can spend up to 2 or more weeks in the ICU before they transfer to a rehabilitation unit. To achieve optimal outcomes, it is imperative that members of the interdisciplinary team work together in a consistent, goal-oriented, collaborative manner. This team includes physicians, nurses, respiratory therapists, physical and occupational therapists, speech pathologists, dieticians, and rehabilitation psychologists. An individual plan is developed for each patient and rehabilitation starts in the ICU as soon as the patient is medically stable. This article will highlight the management strategies used in the neuroscience ICU at Harborview Medical Center and will include a case study as an example of the typical experience for our patients with high cervical cord injury.

One-Year Evolution of Ulnar Somatosensory Potentials after Trauma in 365 Tetraplegic Patients: Early Prediction of Potential Upper Limb Function

Early prediction of hand function is crucial for efficient rehabilitation of cervical spinal cord injury (cSCI). This study investigated correlations between ulnar somatosensory evoked potentials (ulnar SSEPs) and functional outcome of hand function following acute traumatic cervical cord injury. Neurological assessment of sensory scores and hand function were compared with five ulnar SSEP categories of similar persistence and quality in 365 patients throughout the first year after cSCI. Of the 365 patients, 218 (68%) exhibited ulnar SSEP potentials at any one stage during the year, and in 147 patients (40.3%) ulnar SSEPs were obtainable at every assessment stage. While ulnar SSEP latency and amplitude assessments remained largely unchanged over time in the majority of patients, hand function improved remarkably during the first year following cSCI. One year outcome of hand function was predetermined by ulnar SSEP category due to distinct differences in the ulnar SSEP parameters. Additionally, an early prognostic group allocation by ulnar SSEP criteria at the first assessment stage within 4 weeks after spinal trauma allowed reliable prediction of hand function outcome after 1 year. We conclude that early assessment of ulnar SSEP as a non-invasive and objective neurophysiological test is a valuable marker of prospective hand function and independence 1 year after cSCI. This could be most relevant for planning neurorehabilitation, and in prospective clinical SCI trials.