Cervical Cord Injury Research Articles

Evidence-based respiratory management strategies required to prevent complications and improve outcome in acute spinal cord injury patients

Spinal injuries without neurological damage have little effects on respiratory function unless associated with injury to the chest wall. Early verticalisation or mobilisation of these patients is safe and likely to improve vital capacity. Spinal injury with cord damage has a profound effect on the mechanics of respiration and on respiratory function particularly in cervical cord injuries. Around 40% of spinal cord injuries occur in the cervical spine, a trend that is steadily increasing, with respiratory causes being responsible for death in over 20% of individuals. Loss of lung volumes and relative hypoxemia contribute to global hypoxaemia, exacerbating cord ischaemia in the acute period. Respiratory compromise results in the loss of muscle strength generation capacity and reduced lung volumes and in particular vital capacity, of up to 70%, ineffective cough and secretion clearance abilities; reductions in both lung and chest wall compliance and an additional oxygen cost of breathing due to changes in respiratory mechanics, with obstructive sleep apnoea evident in over 50% of acute tetraplegics. While some countries have specialist spinal centres to manage such catastrophic trauma with a demonstrable improvement in health outcomes attributed to their contribution, many individuals are initially admitted to local hospitals where healthcare professionals are less likely to fully appreciate the significant and continued vulnerabilities of such individuals. This article aims to provide a basic understanding of the causes and identification of the main principles of the respiratory management strategies required to maintain pulmonary health for cervical spinal cord injury patients during the initial and early post trauma phase.

Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients

Background. Paralysis of the upper limbs from spinal cord injury results in an enormous loss of independence in an individual’s daily life. Meaningful improvement in hand function is rare after 1 year of tetraparesis. Therapeutic developments that result in even modest gains in hand volitional function will significantly affect the quality of life for patients afflicted with high cervical injury. The ability to neuromodulate the lumbosacral spinal circuitry via epidural stimulation in regaining postural function and volitional control of the legs has been recently shown. A key question is whether a similar neuromodulatory strategy can be used to improve volitional motor control of the upper limbs, that is, performance of motor tasks considered to be less “automatic” than posture and locomotion. In this study, the effects of cervical epidural stimulation on hand function are characterized in subjects with chronic cervical cord injury. Objective. Herein we show that epidural stimulation can be applied to the chronic injured human cervical spinal cord to promote volitional hand function. Methods and Results. Two subjects implanted with a cervical epidural electrode array demonstrated improved hand strength (approximately 3-fold) and volitional hand control in the presence of epidural stimulation. Conclusions. The present data are sufficient to suggest that hand motor function in individuals with chronic tetraplegia can be improved with cervical cord neuromodulation and thus should be comprehensively explored as a possible clinical intervention.

Intubation biomechanics: laryngoscope force and cervical spine motion during intubation in cadavers-effect of severe distractive-flexion injury on C3-4 motion.

OBJECTIVE With application of the forces of intubation, injured (unstable) cervical segments may move more than they normally do, which can result in spinal cord injury. The authors tested whether, during endotracheal intubation, intervertebral motion of an injured C3-4 cervical segment 1) is greater than that in the intact (stable) state and 2) differs when a high- or low-force laryngoscope is used. METHODS Fourteen cadavers underwent 3 intubations using force-sensing laryngoscopes while simultaneous cervical spine motion was recorded with lateral fluoroscopy. The first intubation was performed with an intact cervical spine and a conventional high-force line-of-sight Macintosh laryngoscope. After creation of a severe C3-4 distractive-flexion injury, 2 additional intubations were performed, one with the Macintosh laryngoscope and the other with a low-force indirect video laryngoscope (Airtraq), used in random order. RESULTS During Macintosh intubations, between the intact and the injured conditions, C3-4 extension (0.3° ± 3.0° vs 0.4° ± 2.7°, respectively; p = 0.9515) and anterior-posterior subluxation (-0.1 ± 0.4 mm vs -0.3 ± 0.6 mm, respectively; p = 0.2754) did not differ. During Macintosh and Airtraq intubations with an injured C3-4 segment, despite a large difference in applied force between the 2 laryngoscopes, segmental extension (0.4° ± 2.7° vs 0.3° ± 3.3°, respectively; p = 0.8077) and anterior-posterior subluxation (0.3 ± 0.6 mm vs 0.0 ± 0.7 mm, respectively; p = 0.3203) did not differ. CONCLUSIONS The authors' hypotheses regarding the relationship between laryngoscope force and the motion of an injured cervical segment were not confirmed. Motion-force relationships (biomechanics) of injured cervical intervertebral segments during endotracheal intubation in cadavers are not predicted by the in vitro biomechanical behavior of isolated cervical segments. With the limitations inherent to cadaveric studies, the results of this study suggest that not all forms of cervical spine injury are at risk for pathological motion and cervical cord injury during conventional high-force line-of-sight intubation.

Characteristics of patients who fell into open drains: a report from a single emergency center in East Shizuoka: Epidemiology of patients who fell into open drains in East Shizuoka.

To clarify the characteristics of injuries caused by falling into an open drain. A medical chart review was retrospectively carried out of all patients in East Shizuoka, Japan, who were injured due to falling into an open drain, and who were subsequently transported to hospital by ambulance or a physician-staffed helicopter, between January 2013 and December 2014. The patients were divided into two groups, those treated as outpatients and those who were admitted to hospital. During the investigation period, there were 33 patients who had accidentally fallen into an open drain. The ages of the subjects ranged from 10 to 90 years, with an average age of 58.8 years. The average age of the subjects, the ratio of female patients, and the average injury severity score in the admission group were higher than that of the outpatient group. One patient in the admission group who had cardiac arrest due to a cervical cord injury eventually died. Falls into open drains are especially frequent in elderly people and female patients, and older patients tend to more frequently require admission due to severe injury. To prevent injuries of this type, some measures are required to improve the safety of open drains.

Disaster anxiety and self-assistance behaviours among persons with cervical cord injury in Japan: a qualitative study

ObjectivesPersons with disabilities, especially those with a severe disability, have a vague anxiety about future disasters; however, the measures of self-assistance for disaster preparedness have not been standardised. The present...

Biomechanics and Physiology for Propelling Wheelchair Uphill Slope.

A vertical slope of sidewalks significantly inhibits to the mobility of manual wheelchair users in their daily life. International guidelines of the vertical slope are specified approximately 4% or 5% (1:20) gradient or less as preferred, and allow 8.3% (1:12) as its maximum when it is impossible. Relevant research of the physical strain for wheelchair users with pushing on slopes, and the validity assessment of slope guidelines have been investigated. However, the analysis for the effect of a slope distance and their transient performance are still remained. The purpose of this study is to clarify the physiological and biomechanical characteristics of manual wheelchair users that propelling a wheelchair on an uphill slope. We measured these data by a metabolic analysis system, a heart rate monitor system and an instrumented wheelchair wheel. Sixteen unimpaired subjects (non-wheelchair users) were examined to investigate the effect of a long slope with 120m distance and 8% gradient. And five wheelchair users with cervical cord injury were examined to evaluate the influence of different gradients (5%, 6.7%, 8.3%, 10% and 12.5%) with 3m length in laboratory. Our experimental results of the long slope showed that wheelchair propulsion velocity and power increased considerably at the beginning of the slope where the peak mean value of them were 0.96 m/s and 70.8W and they decreased linearly to 0.55m/s and 33.6W at final interval. A mean oxygen uptake and heart rate were increased as the distance increased and their results indicated the extremely high exercise intensity at a final interval that were 1.2liter /min and 152bpm. While wheelchair pushing cadence reduced after an initial interval, mean of strokes per10m increased to compensate the decrease of upper limb's power. The results of different gradients indicated that the normalized power of subjects with cervical cord injury was significant difference between each subject in the ability to climb a slope. Mean normalized power were 0.23W/kg on a 5% slope, 0.24W/kg on 6.7%, and 0.26W/kg on 8.3% respectively. Based on these findings, we examined the relationship between the theoretical normalized power and the lowest velocity to climb a slope, and we might indicate the ability to push on an uphill slope for the persons with manual wheelchair user.

Recovery patterns of spinal cord injury after traumatic cervical cord injury in a developing country

Background: Traumatic cervical cord injury (CCI) management requires extended acute care and lifelong chronic care. Aims: The present study was aimed to find out that after traumatic CCI, if neurological recovery takes place, how early it starts, how long it continues, and after how many weeks we can safely prognosticate that no more recovery will take place. Materials and Methods: Different epidemiological factors, radiological evidence of trauma, types of injury, cause, mechanism of injury, and level were recorded. The patients were examined every week to record any neurological recovery, either as per Frankel's or ASIA grading. These recordings were done till 6 weeks of admission. Cervical fractures were usually treated by continuous skull traction either by Crutchfield tong traction or by head halter traction giving adequate weight according to the level of vertebral fracture. At the end of 2 years, we followed the recovery pattern in 126 CCI patients. Results: 20.00% of patients showed signs of recovery and 56.36% patients did not show any sign of recovery in complete lesion. 69.01% of patients showed sign of recovery and 25.35% patients did not show any sign of recovery in incomplete lesion. 53.84% of patients showed the first sign of neurological recovery within 1 st week, 32.30% in 2 nd week, 9.23% in 3 rd week, and 4.61% in 4 th week. In upper cervical spine lesion, 22.22% of patients showed first sign of neurological recovery within 1 st week, 55.55% in 2 nd week, 16.11% in 3 rd week, and 5.55% in 4 th week. In lower cervical spine lesion, 65.95% of patients showed the first sign of neurological recovery within 1 st week, 23.40% in 2 nd week, 8.51% in 3 rd week, and 2.12% in 4 th week. Conclusions: In traumatic CCI, patients' level of lesion, type of injury, and nature of injury may be helpful in the early prediction of recovery pattern of patients and careful monitoring of these patients may reduce the social burden in developing countries and reduce morbidity and mortality of these patients.

Sensitivity of Pyramidal Signs in Patients with Cervical Spondylotic Myelopathy.

Study DesignThis was a retrospective study.PurposeThe purpose of this study was to study the relationship between prevalence of pyramidal signs and the severity of cervical myelopathy. The study is focused on patients having increased signal intensity in T2-weighted magnetic resonance imaging.Overview of LiteratureCervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in elderly population. It is the consequence of spondylotic changes leading to cervical cord injury with resulting clinical deficits. Diagnosis in such patients is made based on clinical and radiographic features. A patient must have both symptoms and signs consistent with cervical cord injury as well as radiographic evidence of damage to spondylotic cord.MethodsForty-six patients with complaint of cervical spondylotic myelopathy with increased signal intensity in T2-weighted magnetic resonance imaging were included in the study. The neurological finding of the patients was reviewed for the presence of pyramidal signs. The prevalence of each pyramidal sign was calculated and correlated to severity of cervical myelopathy. The motor function scores of the upper and lower extremities for cervical myelopathy set by the Japanese Orthopedic Association (motor Japanese Orthopaedic Association score, m-JOA) scores were used to assess severity of myelopathy.ResultsThe most prevalent signs were hyperreflexia (89.1%), Hoffmann reflex (80.4%), Babiniski sign (56.5%), and ankle clonus (39.1%). Babiniski sign, ankle clonus, and Hoffmann reflex showed significant association with the lower m-JOA score.ConclusionsIn patients with cervical myelopathy, hyperreflexia exhibited highest sensitivity whereas ankle clonus demonstrated lowest sensitivity. The prevalence of the pyramidal signs is correlated with increasing severity of myelopathy.

Critical Path for Cervical Cord Injuries Considering the Psychological Status of Patients

Critical Path for Cervical Cord Injuries Considering the Psychological Status of Patients

Missed or Delayed Cervical Spine or Spinal Cord Injuries Treated at a Tertiary Referral Hospital in Rwanda

This study was aimed at 1) reporting cases of missed cervical spine injuries treated at a tertiary-level hospital, King Faisal Hospital, Rwanda (KFH-R), and 2) identifying the causes of delaying the diagnosis. We prospectively collected data from patients with a missed or delayed cervical spine and/or cord injury treated at King Faisal Hospital, Kigali for a 12-month period (January 2012 to December 2012). The total number of cervical spine injury patients treated at our center was retrieved from the hospital admission registry. Forty-two patients with cervical spine or spinal cord injuries were treated at KFH-R in 2012, and 4 of them had a missed or delayed diagnosis. Clinical and radiologic findings of all 4 patients are presented, and the reasons for delaying diagnosis are identified. This study found that the cervical spine injuries were missed in 9.5% of the cervical spine trauma patients and resulted in a longer hospital stay for all 4 patients and severe disability in 1 patient (25%). The reasons for missed diagnoses in this study were 1) lack of cervical spine radiographic evaluation, 2) inadequate cervical spine radiographs to show the level of injury, 3) poor sensitivity of cervical spine plain radiography, 4) poor physical examination, 5) the presence of a distracting injury, and 6) poor sensitivity of radiographs and computed tomography scans for soft tissue injuries.

Hyperglycemia During Acute Spinal Cord Injury Is a Detrimental Factor That Impairs Functional Improvement in Acute C3-C4 Cervical Cord Injury Patients Without Any Bony Damages

Spinal cord injury (SCI) is a major public health problem and a devastating event for individuals. Because the central nervous system has a limited capacity for endogenous regeneration and repair, it is necessary to identify factors that exacerbate SCI to prevent any further deterioration of neurological function and improve the outcomes of injuries[1]. We previously demonstrated that transient hyperglycemia during acute SCI is a detrimental factor that impairs functional improvement in mice and human patients after acute SCI[2]. Although we performed not only Pearson x2 analysis but also a multiple linear regression analysis in the previous study, neurological function is difficult to be assessed for the patients with multiple injury levels. It is more ideal to estimate neurological recovery after SCI to match the injury level.

Can anatomic level of injury on MRI predict neurological level in acute cervical spinal cord injury?

Background. Determining neurological level of injury (NLI) is of paramount importance after spinal cord injury (SCI), although its accuracy depends upon the reliability of the neurologic examination. Here, we determine if anatomic location of cervical cord injury by MRI (MRI level of injury) can predict NLI in the acute traumatic setting. Methods. A retrospective review was undertaken of SCI patients with macroscopic evidence of cervical cord injury from non-penetrating trauma, all of whom had undergone cervical spine MRI and complete neurologic testing. The recorded MRI information included cord lesion type (intra-axial edema, hemorrhage) and MRI locations of upper and lower lesion boundary, as well as lesion epicenter. Pearson correlation and Bland–Altman analyses were used to assess the relationship between MRI levels of injury and NLI. Results. All five MRI parameters, namely (1) upper and (2) lower boundaries of cord edema, (3) lesion epicenter, and (4) upper and (5) lower boundaries of cord hemorrhage demonstrated statistically significant, positive correlations with NLI. The MRI locations of upper and lower boundary of hemorrhage were found to have the strongest correlation with NLI (r = 0.72 and 0.61, respectively; p < 0.01). A weaker (low to moderate) correlation existed between lower boundary of cord edema and NLI (r = 0.30; p < 0.01). Upper boundary of cord hemorrhage on MRI demonstrated the best agreement with NLI (mean difference 0.03 ± 0.73; p < 0.01) by Bland–Altman analysis. Conclusions. MRI level of injury has the potential to serve as a surrogate for NLI in instances where the neurologic examination is either unavailable or unreliable.

Simulation study of nasotracheal and orotracheal fiberoptic intubation with the Aintree Intubation Catheter.

Fiber-optic tracheal intubation is an essential technique to secure the airway for difficult airway and cervical cord injury victims. However, there is an anxiety about the vocal cord passage of tracheal tubes because of the potential of collision with the surroundings of the vocal cords. This study aimed to examine the utility of the Aintree Intubation Catheter in nasotracheal and orotracheal intubation. Participants were 21 anesthesiologists with more than 2 years of experience in clinical anesthesia. Participants attempted fiber-optic tracheal intubation through the oral or nasal cavity with or without the Aintree Intubation Catheter in random order. The success rate of tracheal intubation, intubation time, and collision with the glottis were recorded. Participants also evaluated the subjective difficulty of the entire intubation process and passing the tracheal tube through the glottis using a Visual Analogue Scale. There were no significant differences in intubation time or Visual Analogue Scale scores for passing the tracheal tube through the glottis between nasal and oral intubation, regardless of the use of the Aintree Intubation Catheter. However, the catheter significantly reduced the number of collisions with the glottis in both routes (nasal, P = 0.026; oral, P = 0.017). Our findings that the Aintree Intubation Catheter is effective in reducing collisions with the glottis during nasal and oral fiber-optic intubation suggest that Aintree Intubation Catheter use may reduce the risk of mechanical injury related to airway obstruction.

Prognostic factors for surgical outcome in spinal cord injury associated with ossification of the posterior longitudinal ligament (OPLL).

BackgroundOssification of the posterior longitudinal ligament (OPLL) may increase the risk of spinal cord injury (SCI) with various neurological deficits after minor trauma. However, few studies have investigated the influence of OPLL on neurological outcome after acute cord injury. We examined whether severe spinal canal stenosis caused by OPLL affects neurological outcome after SCI based on intramedullary signal intensity (SI) changes on magnetic resonance imaging (MRI).MethodsFrom June 2006 to July 2013, we treated 246 patients with cervical cord injury. Fifty-one (20.7 %) patients had ventral cord compression due to OPLL without any bony fractures. Among them, 38 patients (34 men, mean age 62.7 years) underwent cervical laminoplasty (8) and cervical decompression and fixation (30). The neurologic assessments were performed in patients who had 1-year follow-up, and the mean follow-up period was 42.2 months. OPLL type, cause of injury, cervical sagittal angle, cervical spine stenosis, cord compression ratio (space available for the spinal cord (SAC)), and grade of intramedullary SI (grade 0, none; grade 1, light; grade 2, intense T2WI) were assessed.ResultsMean American Spinal Injury Association (ASIA) motor score at admission was 38.4 ± 21.9 (range, 2–70) and improved to 67.7 ± 19.1 (range, 8–94) at last follow-up (p < 0.05). Mean recovery rate of the motor score was 55.8 ± 19.9 %. Five patients had SI grade 0, 20 patients had SI grade 1, and 13 patients had SI grade 2. Among the variables tested, age, initial ASIA motor grade, intramedullary SI grade, and SAC were significantly related to neurological outcome. However, initial cervical alignment, canal diameter, length of SI, time interval between injury and operation, and OPLL type had no significant effect on neurological outcome.ConclusionsPreoperative neurological status, cord compression ratio, and SI grade are related to neurological outcome in patients with SCI associated with OPLL. The better the preoperative neurological status, the more favorable the neurological outcome after surgery. A higher SI grade on preoperative T2WI was negatively related to neurological outcome. Therefore, the severity of SI change, cord compression ratio, and preoperative neurological status can be regarded as significant prognostic factors in patients with SCI associated with OPLL.

Invitation lecture and practice trial by person with history of disease instructors (third report)

Background: Various educational methods simulating actual clinical scenes are introduced in physical therapist training course classrooms, but it is still difficult for students to grasp the reality of patients’ image and to experience a real feeling of strain and a sense of the reality of actual clinical scenes. In order to reduce such difficulties, we invited people with history of diseases as special lecturers. Purpose: The purpose of this study was to clarify whether repeated lectures bypeoplewith history of diseases contribute to the reduction of these difficulties. Methods:Twoneurological physical therapy lessonswere allocated to the lecture for students with very limited clinical training, where they only observed most of the time. The lectures took place during the second semester of their 2nd year and the first semester of their 3rd year. Two weeks before the lectures, the students were notified of the lessons, where “a personwith history of disease” will be invited. Then the teacher provided a preparatory lecture concerning cervical cord injury or cerebral stroke complemented with visual materials and assigned physical therapy assessment items. On the day of the lecture, the people with history of disease were invited to talk about their experiences and feelings from the patients’ viewpoint in a lecture form. Following the talk, students conducted the practice for physical therapy evaluation. After the lecture, A questionnaire survey of students (19 items, four-point scale evaluation) was conducted to compare the results obtained from the second semester of the 2nd year and first semester of the 3rd year. Results: Lectures by outsiders with experience of disease were helpful for students in understanding patients’ image, experiencing a feeling of strain and a sense of the reality of the actual clinical situation, and comprehending the importance of acquiring clinical knowledge and skills. Also, compared to the second semester in the 2ndyear, the result of questionnaire conducted in the first semester of the 3rd year saw increase in positive opinions concerning the relationship with patients, acquisition of clinical skills, and reflections on their learning attitude with an awareness of their future practice. Conclusion(s): Lectures, where people with history of diseases were invited as lecturers, successfully helped students to understand the patients’ image, experience a feeling of strain and a sense of the reality of the actual clinical situation, and become aware of the importance of acquiring clinical knowledge and skills. Also, the repetition of lectures by people with history of disease were found to increase skill practice lessons and provide students with a more fulfilling learning experience, which seems attributable to the effect of repetition. Implications: It was suggested that repeated lectures by people with history of diseases contribute to the acquisition of basic knowledge and skills of physical therapy regardless of the type of disease.

The clinical effects of atlantoaxial pedicle screw combined with unilateral axial spinous process and lamina screws for atlantoaxial instability

Objective To investigate the clinical effects of the posterior atlantoaxial pedicle screw fixation combined with unilateral axial spinous process and lamina screws and allogeneic bone graft for atlantoaxial instability. Methods From March 2010 to April 2014, data of 10 patients with atlantoaxial instability who had undergone atlanto-axial vertebral pedicle fixation and interbody fusion combined with posterior atlanto-axial spines lamina nails were retrospectively analyzed. There were 6 males and 4 females with an average age of 39 (range, 16-62) years old. The inclusion criteria was atlantoaxial instability together with unilateral vertebral artery segment high cross deformity (7 patients) or atlantoaxial joint break bad involving unilateral pedicle (7 patients). 3 patients have spinal cord disease symptoms and physical signs, both suffered limited neck mobility and pain. The VAS scores were 1-8, with an average of 3.70±2.11. Preoperative X-ray, CT three-dimensional reconstruction and MRI were collected. X-ray and CT examination were performed 7 d and 1, 3, 6, 12 months after operation to evaluate the internal fixation and bone grafting fusion. Results There's no occurrence of cervical spinal cord and vertebral artery injury. Screws were successfully implanted. 1 case's incision occurred infiltration liquid 3 days after operation. For allograft rejection consideration, we changed the plan, and the infiltrating stopped 5 days later. Other incisions were all primary healing. VAS scores were 1.01±0.89 after operation, which was significantly reduced. X-ray showed good recovery of cervical sequence after the operation, and CT revealed 1 patient with atlas pedicle screw in the medial cortex damage. Spinal canal was without infringing, and the other screw positions were normal. 6 months after operation, X-ray or CT examination both showed bony fusion. Conclusion Atlantoaxial pedicle screw fixation combined with unilateral axial spinous process and lamina screws and allograft bone graft fusion for the treatment of atlantoaxial instability can observe good clinical effects. Key words: Cervical atlas; Axis; Joint instability; Internal fixators

Significance of T2 Hyperintensity on Magnetic Resonance Imaging After Cervical Cord Injury and Return to Play in Professional Athletes.

Cervical cord magnetic resonance imaging (MRI) T2 hyperintensity is used as evidence of cord trauma in the evaluation and management of athletes in contact sports. The long-term pathophysiologic and prognostic value of this finding is poorly understood, especially in return to play (RTP). To examine the significance of T2 hyperintensity in the cervical spinal cord of professional athletes. Retrospective review of MRI T2 hyperintensity findings between 2007 and 2014 in 5 professional athletes. Pertinent examination and demographics, including mechanism of injury, surgical intervention, radiographs, MRI studies, long-term outcomes, and RTP recommendations were collected. Four National Football League players and 1 professional wrestler had prior traumatic neurapraxia that at the time of initial consultation had resolved. MRIs showed congenitally small cervical canal (1) and multilevel spondylosis/stenosis/disc herniation (4) along with focal cord T2 hyperintensity (5). The signal abnormalities were at C3/C4 (3), C4 mid-vertebral body (1), and C5/C6 (1). Four athletes had single-level anterior cervical discectomy and fusion, and 1 was nonoperative. Serial MRI imaging at 3 months after surgery showed hyperintensity partially resolved (4) and unchanged (1), and at 9-months 3 of the 5 completely resolved. Based on the author's RTP criteria, 4 of 5 were released to return to their sport. Clearance for RTP preceded complete resolution of MRI T2 hyperintensity in 3 of 4 athletes. The 2 athletes that have returned to profession sport have not had any additional episodes of neurapraxia or any cervical spine-related complications. MRI T2 hyperintensity in contact sport athletes who are symptom-free with normal examination and no evidence of spinal instability may not be a contraindication to RTP. Additional observations are needed to confirm this observation.

The effect of virtual visual feedback on supernumerary phantom limb pain in a patient with high cervical cord injury: a single-case design study

We characterized the effect of virtual visual feedback (VVF) on supernumerary phantom limb pain (SPLP) in a patient with high cervical cord injury. The subject was a 22-year-old man diagnosed with complete spinal cord injury (level C2) approximately 5 years ago. We applied the ABA′B′ single-case design and set phases B and B′ as intervention phases for comparison. SPLP significantly improved in comparison of phase A with phase B and phase A with phase B′. We suggest that VVF reduces SPLP and the effect lasts after VVF.

Management of acute traumatic spinal cord injury.

Spinal cord injury (SCI) causes significant morbidity and mortality. Clinical management in the acute setting needs to occur in the intensive care unit in order to identify, prevent, and treat secondary insults from local ischemia, hypotension, hypoxia, and inflammation. Maintenance of adequate perfusion and oxygenation is quintessential and a mean arterial pressure >85-90mm Hg should be kept for at least 1week. A cervical collar and full spinal precautions (log-roll, flat, holding C-spine) should be maintained until the spinal column has been fully evaluated by a spine surgeon. In patients with SCI, there is a high incidence of other bodily injuries, and there should be a low threshold to assess for visceral, pelvic, and long bone injuries. Computed tomography of the spine is superior to plain films, as the former rarely misses fractures, though caution needs to be exerted as occipitocervical dislocation can still be missed. To reliably assess the spinal neural elements, soft tissues, and ligamentous structures, magnetic resonance imaging is indicated and should be obtained within 48-72h from the time of injury. All patients should be graded daily using the American Spinal Injury Association classification, with the first prognostic score at 72h postinjury. Patients with high cervical cord (C4 or higher) injury should be intubated immediately, and those with lower cord injuries should be evaluated on a case-by-case basis. However, in the acute setting, respiratory mechanics will be disrupted with any spinal cord lesion above T11. Steroids have become extremely controversial, and the professional societies for neurosurgery in the United States have given a level 1 statement against their use in all patients. We, therefore, do not advocate for them at this time. With every SCI, a spine surgeon must be consulted to discuss operative vs nonoperative management strategies. Indications for surgery include a partial or progressive neurologic deficit, instability of the spine not allowing for mobilization, correction of a deformity, and prevention of potential neurologic compromise. Measures to prevent pulmonary emboli from deep venous thromboembolisms are necessary: IVC filters are recommended in bedbound patients and low-molecular weight heparins are superior to unfractionated heparin. Robust prevention of pressure ulcers as well as nutritional support should be a mainstay of treatment. Lastly, it is important to note that neurologic recovery is a several-year process. The most recovery occurs in the first year following injury, and therefore aggressive rehabilitation is crucial.

C5レベル頸髄損傷者を対象とした装着型車いす操作支援ロボットの開発

Cervical Cord Injury(CCI) causes a upper limb dysfunction. In an individual with C5-level CCI, which is the most frequent of all eight types of CCI, flexion force can be exerted by the biceps brachii, while extension force cannot be exerted by the paralyzed triceps brachii. Without the ability of the triceps brachii to exert this force, individuals with a C5-level CCI cannot operate a wheelchair along a carpet or sloping road. In this study, we developed an exoskeletal wheelchair operational assistance robot. We first developed a upper limb motion assistance robot. We then analyzed the difference between the wheelchair operations of a healthy person and a C5-level CCI. We designed a control model that included a user and a wheelchair. The wearer's arm was modeled as a two-link manipulator, and the extension force and hand position were estimated using the equation of motion. The estimated extension force was compared with the driving force required to operate a wheelchair with the target velocity defined at the time of flexion of an arm. We then applied the proposed method via an exoskeletal robot. The effectiveness of the proposed method is demonstrated by the experiment of wheelchair operation with C5-level CCI.