Complete SCI Research Articles

Effects of lower limb electrical stimulation on trunk stability in persons with SCI during walking: a case series.

The purpose of the present case series was to investigate whether three lower limb rehabilitation training approaches have any effects on trunk stability of persons with motor complete SCI during a 10-minute assisted walk. These trainings included electrical stimulation (ES), standing retraining (SRT), and a novel multi-modality approach that combined ES with SRT. We observed that multi-muscle ES directed at the lower limbs had a prominent, indirect effect on the upper and lower muscles of the trunk. More specifically, trunk muscle activations of the ES+SRT subject increased after training for the more distal muscles of the trunk. This study provides preliminary evidence that combining lower limb ES with SRT may provide beneficial effects in improving trunk control and stability.

Impacts of Ultra-early Hyperbaric Oxygen Therapy on Bone Mass of Rats With Complete Spinal Cord Transection.

Seventy-five SD rats were randomly assigned to four groups: sham-operated group (Sham, n = 15), complete spinal cord transection (CSCT, n = 20) group, hyperbaric oxygenation group 1 (HBO1, n = 20), and hyperbaric oxygenation group 2 (HBO2, n = 20). The aim of this study was to analyze the impacts of ultra-early hyperbaric oxygen therapy on bone mass of rats with CSCT. Treatment of patients with complete SCI is still an unresolved medical issue and needs to be further investigated. Studies on changes in bone mass as well as osteoporosis prevention after SCI have important clinical significance. Rats in the sham group only underwent T10 laminectomy, without damaging the spinal cord. Rats in CSCT, HBO1, and HBO2 groups underwent T10 laminectomy and spinal cord transection at T10 level. Rats in HBO1 and HBO2 groups received three courses of hyperbaric oxygen therapy with 10 days per course starting at 3 and 12 hours after spinal cord injury, respectively. The femoral biomechanical characteristics, the bone calcium, and the bone hydroxyproline (B-HYP) contents were determined. Morphology of the femur bone trabecula and the bone collagen were observed by HE staining and by masson triad color staining, respectively. After 6 weeks of treatment, rats in the CSCT group showed significant decreases in femur structural and material mechanics parameters, calcium and B-HYP contents, (P < 0.01), as well as sparse, fractured, malaligned trabecular bone and collagen compared with rats in the sham group. After treatments, compared with rats in the CSCT and HBO2 groups, rats in HBO1 group showed enhancement in femur structural and material mechanics parameters, calcium and B-HYP contents, (P < 0.05), as well as trabecular bone and collagen with better continuity and neater arrangement. Ultra-early HBO therapy can significantly improve bone mass in CSCT rats. N/A.

New approach based on biomarkers in acute traumatic spinal cord injury

Abstract Spinal cord injury (SCI) is one of the most devastating traumas for an individual because the complete traumatic spinal cord injury leads to paraplegia or tetraplegia. The mechanical injuries directly cause axonal destruction in fiber tracts, destruction of the neurons and of the glial cells, and their destruction releases substances whose presence, quantity and dynamics can be lesional biomarkers. The reactions of partially injured cells simultaneously start and the occurring substances and their quantity may be reaction biomarkers. The lesional biomarkers appear immediately postinjury and after several hours there are both lesional biomarkers and reaction biomarkers. The most important lesional biomarkers are the phosphorylated neurofilament subunits resulting from the axonal neurofilament destruction. The heavy phosphorylated neurofilament subunit (pNF-H) is a predictive lesional biomarker because its values pattern can show the reducing or stopping of the secondary lesions and the favorable outcome. The complete SCI patients with a favorable development had a specific pattern of daily values of pNF-H: a sudden increase up to a maximum value then a progressive decrease to normal. The patients with unfavorable outcome or neurological stabilisation had two patterns: an increase to a plateau of pNF-H values or a progressive increase up to a peak followed by a progressive decrease to quasi-normal values.

Longitudinal changes in body composition and metabolic profile between exercise clinical trials in men with chronic spinal cord injury

Study design: Longitudinal design.Objectives: The study was undertaken to determine the effects of cessation of exercise interventions on body composition and metabolic profiles in men with chronic SCI.Settings: Clinical trials within a Medical Center.Methods: Eleven men with motor complete SCI were followed on average over a period of 2.5 years. Six men were involved in two different exercise interventions (functional electrical stimulation cycling versus arm cycling ergometer), 5 days/week for 16 weeks (exercise group), and five men served as a control (control group). Anthropometrics and dual energy X-ray absorptiometry (DXA) were captured to measure changes in lean mass (LM), fat mass (FM), percentage FM before, immediately after exercise, and after a period of 2.5 years. Basal metabolic rate (BMR) and lipid panel were also measured.Results: Thigh circumference increased by 8.5% following exercise (P = 0.042) and remained 6.4% greater than baseline measurements (P = 0.012). Leg LM increased by 9% following the exercise intervention (P = 0.03) and decreased by 16% in the follow-up visit (P = 0.02). Percentage trunk and total body FM increased by 4.5% (P = 0.008) and 3.5% (P = 0.019) in the follow-up visit, respectively, and whole body LM increased by 8.4% and decreased back by 5.4% following a 2.5 year-period. BMR significantly decreased by 15.5% following the exercise (P = 0.029) interventions.Conclusion: Exercise training is accompanied with positive changes in body composition as well as compensatory decrease in BMR, that regressed back following 2.5 years of exercise cessation. Participation in an exercise trial is unlikely to confound the measurements of a follow-up trial.

Identification of Factors on Recovery and Quality of Life in Spinal Cord Injury

Objective: To identify factors related to recovery and quality of life in spinal cord injury. Research design: Non-experimental. Setting: SVNIRTAR and Regional Spinal Injury Centre (RSIC), Cuttack. Participants: 150 SCI subjects. Outcome measures: Questionnaire based on history, WHOQOL-BREF scale, Perceived stress scale (PSS), the satisfaction with life scale (TSWLS). Results and conclusion: Subjects with better functional recovery included those who underwent surgical treatment, spent less time at injury site, and had not lost consciousness and no neurological deterioration at site of injury. Also, QOL domains, perceives stress, satisfaction with life are not related. QOL and life satisfaction with complete and incomplete SCI are different. Similarly, satisfaction with life among married and unmarried subject is different.

Effects of erythropoietin in improving function of spinal cord injury

Introduction: Acute Spinal Cord Injury (ASCI) is one of the most common and important disorders in the field of neurosurgery. Progress achieved in relation to the care provided to repair spinal cord injuries have been taken from ancient times to the present day. Recently Neuroprotective therapies have attracted a lot of staff to approach the patient. Research scientists have shown that there is a possibility of recovery after spinal cord injury. Many pharmacological agents, Erythropoietin, in this field are used to reduce secondary damage after the primary insult and try to preserve nerve tissue. The aim of this study was to investigate the effect of Erythropoietin on sensory and motor status of patients with acute spinal cord injury. Materials and Methods: In this clinical trial, 60 patients with acute spinal cord injury in the Frankel classification, the category A to C, and the selection of matched Frankel class into two groups A and B (each group consisted of 30 patients) was done. Group A underwent conventional treatment received methylprednisolone, were used erythropoietin and were compared after 4days,6-months intervals in terms of complete and incomplete cord injury status with group B (that underwent only conventional treatment such as methylprednisolone). Results: In our study of two groups there were 16 patients with complete spinal cord injury and 44 patients were had incomplete SCI. In the period of 4 days after the onset of the study, patients with complete SCI in case and control group did not recover. In Patients with incomplete spinal cord injury in case group 13 of 21 patients (62%) and 2 of 23 patients (9%) in the control group were cured. In the period of 6 months after the study, 2 of 8 patients (25%) in case group with complete cord had recovery. In the control group of patients with complete spinal cord injury didn't have any recovery. Also in incomplete SCI 12 of 19 patients (63%) in case group and 5 of 21 patients (23%) in the control group were cured. Conclusion: Based on the results obtained improvement in muscle strength and sensory classified according to Frankel in patients receiving erythropoietin in period between 4 days and 6 months can be seen that the difference significant with the control group (P<0.0001). So Frankel class B, C to C- D- E Frankel grade was reached after recovery. Keywords: Acute spinal cord injury; Classification Frankel; Erythropoietin; Methylprednisolone

Metabolic Responses to Endurance Electrical Stimulation Training in Persons with Spinal Cord Injury

Persons with spinal cord injuries are at high risk for metabolic and cardiovascular disease due to reductions in physical activity. Improvements in metabolic health may be possible in this population with the use of electrical stimulation exercise. PURPOSE: Measure metabolic changes in response to 4 months of home-based electrical stimulation endurance training of the quadriceps muscles. METHODS: Oral glucose tolerance test (OGTT), lipid panel, and NIRS-measured mitochondrial capacity assessments were performed before and after electrical stimulation training in 14 persons with motor complete SCI, ranging from C4-T9. RESULTS: Baseline homeostatic model assessment-insulin resistance (HOMA-IR) was 4.3 ± 2.5. On average, glucose and insulin responses to OGTT did not improve after electrical stimulation exercise, p > 0.05. Glucose at 120 min pre: 123.1 ± 34.5 mg/dL vs. post 126.3 ± 36.7 mg/dL and insulin at 120 min pre: 221.1 ± 205 vs. post 195.4 ± 263.3 IU/L. On average, mitochondrial capacity in the vastus lateralis improved by 120% (range: -14 to 387%, p = 0.019). CONCLUSION: Endurance electrical stimulation training of the vastus lateralis muscles was not sufficient to elicit whole-body changes in glucose metabolism, although muscle specific changes in mitochondrial capacity occurred. Future studies should consider training additional muscles, as well as incorporating nutritional interventions. Supported by NIH RO1HD039676.

Development and validation of a risk prediction model for tracheostomy in acute traumatic cervical spinal cord injury patients

Tracheostomy may become indispensable for patients with acute traumatic cervical spinal cord injuries. However, the early prediction of a tracheostomy is often difficult. Previous prediction models using the pulmonary function test (PFT) have limitations because some severely injured patients could not provide acceptable PFT results. We aim to develop an alternative model for predicting tracheostomy using accessible data obtained from the bedside. Clinical, neurological and radiological data from 345 consecutive patients with acute tetraplegia were retrospectively reviewed. We applied multiple logistic regression analysis (MLRA) and classification and regression tree (CART) analysis to develop the prediction model for tracheostomy. By train-test cross-validation, we used the sensitivity, specificity, area under the receiver operating characteristics curve (AUC) and correction rate to evaluate the performance of these models. According to the American Spinal Injury Association (ASIA) standards, an admission ASIA motor score (AAMS) ≤ 22, ASIA grade A and presence of respiratory complications were identified as independent predictors of tracheostomy by both models. The model derived by CART suggested that the highest signal change (HSC) in the spinal cord on magnetic resonance imaging (MRI) also affected a patient's requirement for a tracheostomy, while MLRA demonstrated that tracheostomy was also influenced by the presence of an ASIA grade B injury. The CART model had a sensitivity of 73.7%, specificity of 89.7%, AUC of 0.909 and overall correction rate of 87.3%. The sensitivity, specificity, AUC and correction rate of the MLRA model were 81.8, 86.4, 0.889 and 85.7%, respectively. We suggest using the CART model in clinical applications. Patients with AAMS ≤ 1 exhibit an increased likelihood of requiring a tracheostomy. For patients with an AAMS in the range of 2-22, surgeons should consider giving these patients a tracheostomy once respiratory complications occur. Surgeons should be cautious to give a tracheostomy to patients with an AAMS ≥ 23, if the patient experiences an incomplete spinal cord injury and the HSC in the spinal cord is at C3 level or lower based on MRI. For other patients, close observation is necessary; generally, patients with complete SCI might require a tracheostomy more frequently.

Neurological and functional recovery after thoracic spinal cord injury

Objective: To describe neurological and functional outcomes after traumatic paraplegia.Design: Retrospective analysis of longitudinal database.Setting: Spinal Cord Injury Model Systems.Participants: Six hundred sixty-one subjects enrolled in the Spinal Cord Injury Model Systems database, injured between 2000 and 2011, with initial neurological level of injury from T2–12. Two hundred sixty-five subjects had second neurological exams and 400 subjects had Functional Independence Measure (FIM) scores ≥6 months after injury.Outcome Measures: American Spinal Injury Association Impairment Scale (AIS) grade, sensory level (SL), lower extremity motor scores (LEMS), and FIM.Results: At baseline, 73% of subjects were AIS A, and among them, 15.5% converted to motor incomplete. The mean SL increase for subjects with an AIS A grade was 0.33 ± 0.21; 86% remained within two levels of baseline. Subjects with low thoracic paraplegia (T10–12) demonstrated greater LEMS gain than high paraplegia (T2–9), and also had higher 1-year FIM scores, which had not been noted in earlier reports. Better FIM scores were also correlated with better AIS grades, younger age and increase in AIS grade. Ability to walk at 1 year was associated with low thoracic injury, higher initial LEMS, incomplete injury and increase in AIS grade.Conclusion: Little neurological recovery is seen in persons with complete thoracic SCI, especially with levels above T10. Persons who are older at the time of injury have poorer functional recovery than younger persons. Conversion to a better AIS grade is associated with improvement in self-care and mobility at 1 year.

SAT0478 Effect of Complete Spinal Cord Injury on Bone Turnover and Bone Mineral Density (BMD) Evolution. A One Year Follow-Up Study

BackgroundSpinal cord injury (SCI) has been associated with marked bone loss and an increased risk of fractures under the SCI level.ObjectivesTo analyze the effect of recent complete SCI on bone...

A short-term arm-crank exercise program improved testosterone deficiency in adults with chronic spinal cord injury.

To determine the influence of arm-crank exercise in reproductive hormone levels in adults with chronic SCI. Further objectives were to assess the influence of arm-crank exercise on muscle strength and body composition. Seventeen male adults with complete SCI at or below the 5th thoracic level (T5) volunteered for this study. Participants were randomly allocated to the intervention (n = 9) or control group (n = 8) using a concealed method. The participants in the intervention group performed a 12-week arm-crank exercise program, 3 sessions/week, consisting of warming-up (10-15 min) followed by a main part in arm-crank (20-30 min [increasing 2 min and 30 seconds each three weeks]) at a moderate work intensity of 50-65% of heart rate reserve (HRR) (starting at 50% and increasing 5% each three weeks) and by a cooling-down period (5-10 min). Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone and estradiol were determined by ELISA. Muscle strength (handgrip) and body composition (waist circumference [WC]) were assessed. After the completion of the training program, testosterone level was significantly increased (p = 0.0166;d = 1.14). Furthermore, maximal handgrip and WC were significantly improved. Lastly, a significant inverse correlation was found between WC and testosterone (r =- 0.35; p = 0.0377). The arm-crank exercise improved reproductive hormone profile by increasing testosterone levels in adults with chronic SCI. A secondary finding was that it also significantly improved muscle strength and body composition in this group.

Transplanting neural progenitors to build a neuronal relay across the injured spinal cord.

Cellular transplantation for repair of spinal cord injury is a promising therapeutic strategy that includes the use of a variety of neural and non-neural cells isolated or derived from embryonic and adult tissue as well as embryonic stem cells and induced pluripotent stem cells. In particular, transplants of neural progenitor cells (NPCs) have been shown to limit secondary injury and scar formation and create a permissive environment in the injured spinal cord through the provision of neurotrophic molecules and growth supporting matrices that promote growth of injured host axons. Importantly, transplants of NPC are unique in their potential to replace lost neural cells – including neurons, astrocytes, and oligodendrocytes – critical for reconstruction of the normal microenvironment of the spinal cord and restoration of connectivity and function. Different NPC preparations have been used for transplantation experiments in multiple, diverse models of SCI, ranging from the classical work with fetal spinal cord (FSC) that defined the optimal age for donor tissue and its capacity to generate neural cells (Reier et al., 1983; Reier et al., 1986), to studies that demonstrated the formation of a neuronal relay by NPC transplants across the injured spinal cord to reconnect the interrupted sensory system (Bonner et al., 2011). At the developmental stage of embryonic day (E)13.5–14 the FSC is composed primarily of neuronal restricted progenitors (NRP) and glial restricted progenitors (GRP), but also contains a small number of immature neural stem cells, neurons, endothelial cells and fibroblasts (Kalyani et al., 1998; Cai et al., 2002; Lepore and Fischer, 2005; Medalha et al., 2014). While grafts of acutely isolated FSC contain all of these cell subpopulations, the process of isolating and culturing of NRP and GRP from FSC, particularly by adherent, sub-confluent culture on a poly-L-lysine/laminin substrate generates pure, defined, and reproducible populations of progenitors (Cai et al., 2002) for cryopreservation or transplantation experiments. NRP and GRP, in contrast to multipotent NSC have a capacity for self-renewal and a restricted differentiation potential, as they are committed to neuronal and glial phenotypes, respectively (Han et al., 2002; Lepore and Fischer, 2005). The injured spinal cord, however, presents a variety of impediments not only to the regeneration of injured host axons in the form of chondroitin sulfated proteoglycans (CSPG) and myelin-associated byproducts, but also significantly limits the survival and differentiation of graft-derived neurons (Cao et al., 2002; Lepore and Fischer, 2005).

Implanted functional electrical stimulation: case report of a paraplegic patient with complete SCI after 9 years

BackgroundsExperience of an implanted functional electrical stimulation neuroprosthesis (FES) associating 8-channel epimysial and 4-channel neural stimulations. The primary objective consisted in presenting clinical and technological experiences based on a 9-year follow-up of one patient implanted with this FES device. The secondary objective consisted in assessing resulting functional benefits.MethodsOne patient recruited in 1996 within the European Stand Up and Walk Project benefited from a 9-year follow-up with clinical and technological evaluations.ResultsThe patient was still using the system nine years later making this a unique case, even when compared to other similar studies. The analysis of muscular response to FES underlined the great variability of stimulation thresholds evolution (−26% to +360%, mean +110%) and quality of the induced contraction. Three muscles out of five scored at least 4/5 on the Medical Research Council scale, all stimulated via neural pathways. The patient used the system once a week for 6 years, up to 2006, due to lack of use, the FES-induced muscular response worsened even though the implant was properly functioning, leading to significant decline in gait performances (best 3.45 m/s on 2.9 m), due to muscle fatigue and loss of muscle mass.ConclusionTwo major issues arise: first the importance of muscle fatigue, underlining the relevance of muscle strength training, and second technological hurdles raising up the question of neural vs. epimysial FES. This advanced technology proves the concept of restoring lower limb motor functions in patients with spinal cord injury. The main features of the stimulation device remain stable even after long periods of inactivity, yet there is a real need for close clinical and technological monitoring.

Predictors of mortality in veterans with traumatic spinal cord injury

Retrospective. To determine the predictors of mortality in veterans with traumatic spinal cord injury (tSCI). Tertiary clinic in the state of Oklahoma. One hundred and forty-seven patients with tSCI who were enrolled in our Spinal Cord Injury program from 1 January 2000 to 31 December 2011 were retrospectively studied. The study sample was divided into two groups, based on the survival status by 31 December 2011. In this sample of 147 patients with tSCI, survival at the end of the 12-year study period was 60%. There were three major causes of death: infection-related, such as pneumonia (21%), urinary infection (14%), and infection of the pressure ulcers (11%); cardiovascular-related, such as congestive heart failure (16%), coronary arterial disease (13%), and atrial fibrillation (2%); and cancer-related (16%). In veterans with complete SCI, deaths were mainly infection-related and occurred in the hospital (51%), while deaths in veterans with incomplete SCI were primarily cardiovascular and cancer-related and occurred in the community. A Cox regression analysis showed the age at the time of injury to be the main predictor of SCI-related mortality. This study suggests that an older age at the time of injury is a significant predictor of mortality following tSCI with patients more likely to die from cardiovascular deaths than the general population. These findings support the need for preventative strategies, including a focus on cardiovascular risk factor management, in order to decrease long-term mortality.

AB0614 Role of wnt antagonists (sclerostin and dkk-1) on bone turnover markers and bone mass, in patients with complete spinal cord injury. preliminary results

BackgroundSpinal cord injury (SCI) has been associated with a marked increase in bone loss.ObjectivesTo analyse the effect of Wnt signalling antagonists (sclerostin and DKK-1) and their relationship with bone turnover...

Spinal cord injuries related to cervical spine fractures in elderly patients: factors affecting mortality

Background contextSpinal cord injuries (SCIs) related to cervical spine (C-spine) fractures can cause significant morbidity and mortality. Aggressive treatment often required to manage instability associated with C-spine fractures is complicated and hazardous in the elderly population. PurposeTo determine the mortality rate of elderly patients with SCIs related to C-spine fractures and identify factors that contribute toward a higher risk for negative outcomes. Study design/settingRetrospective cohort study at two Level 1 trauma centers. Patient sampleThirty-seven consecutive patients aged 60 years and older who had SCIs related to C-spine fractures. Outcome measuresLevel of injury, injury severity, preinjury medical comorbidities, treatment (operative vs. nonoperative), and cause of death. MethodsHospital medical records were reviewed independently. Baseline radiographs and computed tomography or magnetic resonance imaging scans were examined to permit categorization according to the mechanistic classification by Allen and Ferguson of subaxial C-spine injuries. Univariate logistic regression analyses were performed to identify factors related to in-hospital mortality and ambulation at discharge. There were no funding sources or potential conflicts of interest to disclose. ResultsThe in-hospital mortality rate was 38%. Respiratory failure was the leading cause of death. Preinjury medical comorbidities, age, and operative versus nonoperative treatment did not affect mortality. Injury level at or above C4 was associated with a 7.1 times higher risk of mortality compared with injuries below C4 (p=.01). Complete SCI was associated with a 5.1 times higher risk of mortality compared with incomplete SCI (p=.03). Neurological recovery was uncommon. Apart from severity of initial SCI, no other factor was related to ambulatory disposition at discharge. ConclusionsIn this elderly population, neurological recovery was poor and the in-hospital mortality rate was high. The strongest risk factors for mortality were injury level and severity of SCI. Although each case of SCI related to C-spine fractures is different, physicians may be able to use these findings to help better determine the prognosis and guide subsequent treatment.

Safety and Feasibility of using the EksoTM Bionic Exoskeleton to Aid Ambulation after Spinal Cord Injury

Objective: Evaluate feasibility and safety of EksoTM to aid ambulation in individuals with SCI. Design: Prospective pilot study. Setting: SCI Rehabilitation Center Outpatient Gym. Participants: Eight individuals, at least 18 years of age, with complete T1 SCI or below, within 2 years of injury, completed initial inpatient rehabilitation. All participants signed informed consent, had been cleared from requiring spinal orthoses, met inclusion criteria, and were pre-screened based on device requirements and medical stability. Intervention: Six weekly sessions with graduated time and less assistance in the EksoTM device. Outcome Measures: Skin evaluation, blood pressure, pain level, spasticity, time and level of assistance needed to transfer into and donn device; time ambulating; time up in device; assistive devices used during ambulation; step length; distance walked; level of assistance during use; and level of assistance needed to doff and transfer out of device. Results: No major skin effects, minimal pain reports, no known fractures, swelling, or other adverse events. Level of assistance ranged from dependent to moderate independent, average set up time was 18.13 minutes, loss of balance and falls were infrequent. Conclusions: Bionic exoskeletons such as EksoTM are safe for those with complete thoracic SCI in a controlled environment, in the presence of experts, and may eventually enhance mobility in those without volitional lower extremity function. There appears to be a training effect in the device but further trials are needed. Future studies of bionic exoskeletons as gait training devices are warranted. Future studies of bionic exoskeletons as a clinical tool to alleviate secondary complications should be considered.

Medical complication in adults with spina bifida

SettingCohort study. IntroductionSpina bifida (SB) is a congenital malformation affecting the central nervous system (CNS) and is one of the most prevalent CNS disorders in children. Hydrocephalus (HC) is present in 80% of newborns with SB. The aim of the present study was to analyze the medical complications and to relate the complications to age at examination, the level of injury, AIS grade and presence of HC in adults with SB. Materials and methodsSB patients were recruited from the Spinalis out-patient clinic at the Karolinska University Hospital at their annual follow-up. The patients underwent a thorough general and neurological examination and background data including medical complications were retrieved from the medical files. Results127 of 157 (82%) SB patients (114 with MMC and 13 SB occulta) with a mean age of 34 years were included. Half of the patients had a complete SCI and a lumbar level was most common. Nearly 60% of the patients had HC. 88 patients (69%) suffered from at least one medical complication. Urinary tract infection (UTI), scoliosis and pain were the most common complications found in 46%, 30% and 28% of the patients, respectively. Less common complications were epilepsy, pressure ulcers (PU) and spasticity. DiscussionSB gives a disability including motor, sensory dysfunctions and the patients suffer from a high frequency of medical complications like UTI, scoliosis, pain, and epilepsy. Data gives basis for adequate routines for medical examination at the follow-up.

Predicting the need for tracheostomy in patients with cervical spinal cord injury

Approximately 75% of hospitalized patients with a cervical spinal cord injury (CSCI) will require intubation and mechanical ventilation (MV) because of compromised respiratory function. It is difficult to predict those CSCI patients who will require prolonged ventilation and therefore will most benefit from early tracheostomy. This study intended to show the benefits of tracheostomy, particularly early, and to identify predictors of prolonged MV after CSCI. A retrospective review of patients aged 16 years and older with acute CSCI admitted to London Health Science Center from 1991 to 2010 was performed. Demographic data and clinical parameters were extracted from medical records and the trauma registry. Regression analysis was used to identify predictors of prolonged MV. There were 66 eligible patients of which 42 (62%) had a tracheostomy performed. Five patients (7.6%) remained ventilator dependent and seven (10.6%) died more than 7 days after injury secondary to sepsis. After adjusting for the number of ventilator days after injury, patients who had a tracheostomy had fewer pulmonary complications than those who did not have a tracheostomy (p = 0.001). Early tracheostomy resulted in fewer days on the ventilator and a shorter hospital stay. Clinical parameters that predicted MV to be required longer than 7 days were Injury Severity Score > 32, complete SCI, and a PAO2/FIO2 ratio < 300 3 days after MV was initiated. We recommend early tracheostomy if the Injury Severity Score is >32, the patient has a complete SCI, and the PAO2/FIO2 ratio is <300 3 days after MV was initiated. Prognostic study, level III.

Plasticity of the Injured Human Spinal Cord: Insights Revealed by Spinal Cord Functional MRI

IntroductionWhile numerous studies have documented evidence for plasticity of the human brain there is little evidence that the human spinal cord can change after injury. Here, we employ a novel spinal fMRI design where we stimulate normal and abnormal sensory dermatomes in persons with traumatic spinal cord injury and perform a connectivity analysis to understand how spinal networks process information.MethodsSpinal fMRI data was collected at 3 Tesla at two institutions from 38 individuals using the standard SEEP functional MR imaging techniques. Thermal stimulation was applied to four dermatomes in an interleaved timing pattern during each fMRI acquisition. SCI patients were stimulated in dermatomes both above (normal sensation) and below the level of their injury. Sub-group analysis was performed on healthy controls (n = 20), complete SCI (n = 3), incomplete SCI (n = 9) and SCI patients who recovered full function (n = 6).ResultsPatients with chronic incomplete SCI, when stimulated in a dermatome of normal sensation, showed an increased number of active voxels relative to controls (p = 0.025). There was an inverse relationship between the degree of sensory impairment and the number of active voxels in the region of the spinal cord corresponding to that dermatome of abnormal sensation (R2 = 0.93, p<0.001). Lastly, a connectivity analysis demonstrated a significantly increased number of intraspinal connections in incomplete SCI patients relative to controls suggesting altered processing of afferent sensory signals.ConclusionsIn this work we demonstrate the use of spinal fMRI to investigate changes in spinal processing of somatosensory information in the human spinal cord. We provide evidence for plasticity of the human spinal cord after traumatic injury based on an increase in the average number of active voxels in dermatomes of normal sensation in chronic SCI patients and an increased number of intraspinal connections in incomplete SCI patients relative to healthy controls.