Regional Spinal Cord Injury Center Research Articles

Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department.

Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

Twenty Years of a Veterans' Spinal Cord Injury Colorectal Clinic: Flexible Sigmoidoscopy and Multiple Hemorrhoid Ligation.

Colorectal and anal problems arise in chronic spinal cord injury care. We review 20 years of experience in a colorectal clinic at a veterans medical center treating mostly male veterans who have spinal cord injury. We aim to show the results of colorectal interventions in a population with chronic spinal cord injury. This study is a retrospective records review. This study was conducted at a Department of Veterans Affairs regional spinal cord injury center. Six hundred forty-one individuals (625 males) made 1208 visits. Mean age was 56 ± 13 years; ages ranged from 21 to 90 years. Flexible sigmoidoscopy was done for diagnosis and screening, and hemorrhoid ligation was performed for symptomatic hemorrhoids. The primary outcomes measured were the frequency, timing, and results of procedures. Five hundred forty-eight people had 781 flexible sigmoidoscopies. At first examination, mean age was 65 ± 12 and the duration of injury was 19 ± 15 years. Sixty examinations (7.7%) displayed poor preparation. The interval between adequate-prepared examinations was 5.7 ± 2.0 years. The adenoma detection rate was 4.7%. Two hundred fifteen people had 406 hemorrhoid ligations. At first banding, the mean age was 52 ± 13 and the duration of injury was 20 ± 15 years. Mean number of ligations per procedure was 4.9 ± 2.0; a range of 1 to 20. Nine hemorrhoid operations were done in this period. Regarding the futility of procedures, 250 people died, with a mean age at death of 69 ± 11. The median time between any procedure and death was 4.4 years. Seventeen procedures were done within 6 months of death; these deaths were either unexpected or because of conditions identified at or after the procedure. This was a retrospective review of a single institution, it involved a mostly male population, and it used a subjective assessment of bowel preparation. In a spinal cord injury colorectal clinic, sigmoidoscopy can keep screening current, with an acceptable level of poor preparation. The adenoma detection rate may or may not be adequate. Hemorrhoid ligation can be expanded beyond its limits in the non-spinal cord-injured population, including multiple and external banding, taking the place of an operation in most cases. These procedures are well tolerated and rarely futile.

Early outcome and predictors of early outcome in patients treated surgically for central cord syndrome.

The purpose of this study was to characterize changes in American Spinal Injury Association motor score (AMS) in the 1st week after traumatic central cord syndrome (CCS) to identify predictors of improved early outcome in patients treated with early versus delayed surgical intervention. All patients presenting to a regional spinal cord injury center between January 2004 and June 2009 were queried for those with a diagnosis of CCS. Patients treated conservatively were excluded. A prospectively maintained spinal cord injury database was used to track AMS throughout each patient's hospitalization. Hospital records provided information regarding demographics, presenting neurological examination, imaging findings, comorbidities, timing and nature of surgical procedures, and length of stay (LOS) in the hospital and intensive care unit (ICU). Patients were separated into those who underwent early surgery, within 1 day of presentation (early group), and those who underwent surgery on a delayed basis (delayed group). Differences between groups were analyzed using the Student t-test and chi-square test. Predictors of outcome were identified using correlation analysis and multiple linear regression. Of 426 patients in the database, 80 (18.8%) were diagnosed as having CCS, and 68 of them ultimately underwent surgical decompression. Nineteen (28%) of 68 patients underwent surgery within 1 day of presentation (early group) while the remaining 49 patients (72%) underwent surgery on a delayed basis (delayed group). The mean age in the early group was significantly younger than that of the delayed group (52 vs 59 years, p = 0.049). Other characteristics were similar between groups including sex, proportion of patients with cord edema on MRI (44% early vs 55% delayed, p = 0.47), and proportion of patients with cervical fracture (26% early vs 28% delayed, p = 0.98). Patients in the early group presented with an AMS of 62.5 versus 70.0 for the delayed group (p = 0.36). No difference in the change in AMS was seen at 7 days between the early group (-2.9 points) and the delayed group (-4.2 points) (p = 0.34). Additionally, the number of patients who had early improvement was similar between the early and delayed groups (50% vs. 48%, respectively, p = 0.94). Neither time in the ICU (3.4 vs. 3.4 days, p = 0.84) nor the overall LOS (10.5 vs 12.5 days, p = 0.59) was different in the early versus delayed groups, respectively. Correlation analysis and multiple linear regression demonstrated early surgery was not associated with change in AMS or AMS at Day 7. Age was identified as the only significant predictor of change in AMS and had a negative effect (coefficient = -0.34, p = 0.025). Early treatment of patients with CCS remains controversial. Although some long-term neurological recovery is expected in patients with a CCS, surgeons and patients should not expect early neurological improvement with or without early operative intervention.

The effect of preexisting hypertension on early neurologic results of patients with an acute spinal cord injury.

Retrospective case-control. To characterize changes in American Spinal Injury Association Motor Score (AMS) in patients treated with relative hypertension (HTN) (mean arterial pressure (MAP) > 85 mm Hg for 5 days) with and without preexisting HTN. A regional spinal cord injury (SCI) center in Pennsylvania, United States. All patients with an acute SCI who were treated with induced HTN (MAP goal above 85) in the intensive care unit (ICU) for at least 5 days were identified. Patients were stratified based on the presence of preexisting HTN, and the change in the AMS between admission and day 5 was determined. Predictors of outcome were identified using correlation analysis and multiple linear regression. Ninety-two patients met inclusion criteria of which 22 had a previous history of HTN. HTN was a predictor of poor early outcome. Patients with HTN had an average decline in their AMS of 7.6, compared with an average decrease of only 0.6 in the AMS of patients without HTN (P=0.04). HTN had no effect (P>0.05) on other in-hospital variables including length of stay, length of stay in the ICU, complications or mortality. Additionally, multiple linear regression analysis demonstrated that diabetes, coronary artery disease and pulmonary disease had no effect on the change in AMS. Chronic HTN is an independent risk factor for poor early neurologic recovery in patients treated with relative HTN for an acute SCI. This is independent of age and other comorbidities.

Increased mean arterial pressure goals after spinal cord injury and functional outcome

Introduction:Acute spinal cord injury (SCI) is often treated with induced hypertension to enhance spinal cord perfusion. The optimal mean arterial pressure (MAP) likely varies between patients. Arbitrary goals are often set, frequently requiring vasopressors to achieve, with no clear evidence supporting this practice. We hypothesize that increased MAP goals and episodes of relative hypotension do not affect hospital outcome.Materials and Methods:All cervical and thoracic SCI patients treated at a level one trauma and regional SCI center over at 2.5-year period were retrospectively reviewed. Lowest and average hourly MAP was recorded for the first 72 h of hospitalization, allowing for quantification of mean MAP and the total number of episodic relative hypotensive events. These data were further compared to daily American spinal injury association motor score (AMS), which was used to determine the severity of SCI and improvement/decline during hospitalization. Patient's data were finally analyzed at theoretic MAP set points.Results:One hundred and five patients had complete data during the study period. At higher theoretic MAP set points (85 and 90), increased number of relative hypotensive episodes correlated with lower admission AMS (85 mmHg: <10 episodes, AMS 66.2; >50 episodes, 22.0; P < 0.001) and the need for vasopressors (P < 0.03) but showed no statistical change in AMS by hospital discharge. The need for vasopressors correlated with the number of hypotensive episodes and inversely related to admission AMS at all theoretic MAP goal set points but was not correlated with the change in AMS during the hospitalization.Conclusions:The frequency of relative hypotension and the need for vasopressors are progressively related to more severe SCI, as denoted by lower admission AMS. However, episodes of hypotension and the need for vasopressors did not affect the change in AMS during the acute hospitalization, regardless of theoretic MAP goal set-point. Arbitrarily elevated MAP goals may not be efficacious.

The Mortality Inflection Point for Age and Acute Cervical Spinal Cord Injury

Acute cervical spinal cord injury (cSCI) is associated with significant morbidity and mortality. Vertebral level and American Spinal Injury Association (ASIA) score influence both hospital course and ultimate outcome. While controlling for these variables, we describe the effect of age on cSCI-related pneumonia and mortality. All patients treated at our regional spinal cord injury center with an acute cSCI during a 5-year period (2005-2009) were reviewed retrospectively. Patient demographics, injury level, ASIA score, length of stay (LOS), radiologic, laboratory, and microbiology data were reviewed. Pneumonia was defined as an infiltrate on chest X-ray along with two of the following: leukocytosis, fever greater than 101°F, or positive bronchial alveolar lavage cultures; all occurring within the same 24-hour period. There were 244 cSCI during the study period. In-hospital mortality was significantly higher for those older than 75 years (40.5% vs. 4.0%, p < 0.0001). Pneumonia rates were not significantly different between age groups. In all age groups, high ASIA scores (A and B) were associated with increased pneumonia (61.9% vs. 17.4%, p < 0.0001) and mortality (16.7% vs. 3.5%, p = 0.002). Similarly, patients with higher cervical injury levels (C4 and above) had a higher incidence of pneumonia (39.5% vs. 25.9%, p < 0.05) and a trend toward higher mortality. Age was associated with an increase in mortality among patients with an acute cSCI. Injury level and ASIA score contributed significantly to overall pneumonia rate and mortality at all ages; however, pneumonia did not correlate directly with mortality in this population. Other factors play a role in the mortality associated with geriatric spinal cord-injured patients, including end-of-life decision making; these need to be investigated further in future studies.

Trends in Epidemiology and Management of Type II Odontoid Fractures

A retrospective cohort study of consecutive type II Odontoid fractures presenting to a Level 1 Regional Model Systems Spinal Cord Injury Center between June 1985 and July 2006. To assess trends in management of type II Odontoid fractures presenting to a Level 1 Model Systems Regional Spinal Cord Injury Center over a 20-year period. Type II Odontoid fracture management is controversial, and a majority of studies have had relatively small cohorts. There is no consensus regarding definitive treatment, particularly in older patients. Medical records of 263 consecutive type II Odontoid fractures from June 1985 to July 2006 were retrospectively reviewed. Patients were excluded if they had neurologic deficits, nonacute fracture, or ambiguous fracture classification. A cohort of 192 neurologically intact, acute type II odontoid fractures were identified. Admission records were reviewed for age, date of injury, date of admission, date of discharge, mechanism of injury, associated injuries, medical comorbidities, and radiologic findings. There was a statistically significant increase in the rate of presentation of type II odontoid fractures with time. The average age and medical comorbidities of the patient did not change over time. The probability of operative management markedly increased over time, corresponding to a statistically significant increase in length of hospital stay for patients undergoing surgery. The discharge disposition correlated significantly to both age of the patient and associated injuries. The number and frequency of type II odontoid fractures compared with other spine injuries seems to be increasing over the last 2 decades, which may be correlated with the increasing number of elderly persons in the population, given that referral patterns have been unchanged at our institution. Prospective outcomes data are needed to better elucidate optimal treatment algorithms from both, an outcomes and cost-efficacy perspective.

Congenital absence of the internal carotid artery in a patient with spinal cord injury: case report

Case report. To describe a rare case of congenital absence of the internal carotid artery (ICA) in the setting of acute spinal cord injury and review the existing literature. Regional Spinal Cord Injury Center of the Delaware Valley, Philadelphia, PA, USA. We report on a 47-year-old male who presented as a T2 ASIA A spinal cord injury with a T2-T3 fracture dislocation injury after a 25-feet fall from a tree. Magnetic resonance angiography imaging of the neck carried out as per routine spinal trauma protocol suggested an acute traumatic injury to the carotid artery. Therefore, computed tomographic angiography imaging of the neck was performed, which revealed absence of the left ICA and a diminutive left carotid canal at the skull base, suggesting congenital absence. Follow-up magnetic resonance imaging of the brain to evaluate for acute infarct showed no diffusion restriction contributing to the evidence that this was a congenital anomaly and not traumatic occlusion of the artery. Congenital absence or hypoplasia of the ICA is a rare anomaly. It should be considered in the differential in patients who have absent or diminished carotid arteries on radiologic imaging in the setting of trauma.

Trends in Surgical Management for Type II Odontoid Fracture: 20 Years of Experience at a Regional Spinal Cord Injury Center

This study reviewed surgical treatment methods in patients with type II odontoid fracture who were admitted to a level 1 spinal cord injury center during a 20-year period. Of the 186 patients who met inclusion criteria, 75 were treated operatively. The rate of surgical intervention increased during the study period. Length of hospital stay was not related to treatment. Estimated blood loss was significantly higher for posterior techniques. The Brooks technique and anterior odontoid screw fixation declined in frequency, whereas the Magerl technique has been used at a consistent rate since its introduction. The C1 lateral mass and C2 pedicle/isthmus screw technique has increased significantly since its description. Pneumonia, vocal cord, and swallowing problems occurred more often with anterior approaches.

Spinal Injuries in Pedestrians Struck by Motor Vehicles

Retrospective study of consecutive patients that were struck by motor vehicles and sustained spinal injuries over a 6-year period from 1997 to 2003. To determine spinal injury patterns and associated injuries in pedestrians struck by motor vehicles. Motor vehicle accidents involving pedestrians are associated with high morbidity and mortality rates. All injured patients admitted to Level I Trauma and Regional Spinal Cord Injury Center were reviewed retrospectively to identify those who were struck by motor vehicles and sustained injury to the spinal column. Before 2001, clearance of the thoracolumbar (TL) spine was performed by plain radiographs. Beginning in 2001, such clearance was performed by helical truncal computed tomography of the chest/abdomen/pelvis (CT/CAP) that was performed to evaluate potential visceral injuries. Of the 1672 patients who were struck by motor vehicles, 135 patients (8%) were found to have spinal injuries. Cervical injuries were found in 35%, thoracic in 19%, lumbar in 37%, and sacral injuries in 27%. Associated injuries were present in 99% of the patients. By relative risk analyses, there were no regional associations between injuries of the TL spine and injuries to the chest and abdomen. Patients frequently had combinations of injuries in distant locations, presumably from a "double-impact" injury mechanism. Before initiation of the CT/CAP protocol to clear the TL spine, 7% of patients had injuries initially missed by TL radiographs. Spinal injuries in pedestrians struck by motor vehicles are more evenly distributed throughout the spinal column and more often coexist with injuries to remote organs compared with car occupants and motorcyclists where regional tendencies and isolated spinal injuries are more frequent. A systematic approach to both diagnosis and treatment is, therefore, necessary. Helical truncal CT, performed to evaluate visceral injury, effectively screens for TL fractures.

Point of View

From the Regional Spinal Cord Injury Center of Delaware Valley, Thomas Jefferson University, Philadelphia, PA. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to John F. Ditunno, Jr, MD, Regional Spinal Cord Injury Center of Delaware Valley, Thomas Jefferson University, 132 S. 10th Street, Suite 375, Philadelphia, PA 19107; E-mail: [email protected]

Evidence-Based Practice: Pressure Ulcer Management Guidelines for Spinal Cord Injury

Evelyn M. Phillips, MS, RD, LDN, is Clinical Nutrition Manager and Researcher, Magee Rehabilitation Hospital/Jefferson Health System, Regional SCI Center of the Delaware Valley, Philadelphia, Pennsylvania. ndividuals with spinal cord injury (SCI) have the highest prevalence of pressure ulcers in the United States (15.2%–30% I from 1990 to 2000) and an incidence range (7.5%–23.7%) similar to long-term care residents (7%–23.9%). Malnutrition is a major risk factor for the development of pressure ulcers in both acute and chronic spinal injury populations. As a federally designated Regional SCI Center, Magee Rehabilitation Hospital provides acute rehabilitation after initial SCI (approximately 330 admissions per year) as well as lifetime follow-up care for approximately 2,500 individuals with chronic SCI – the majority of whom either have or will develop a pressure ulcer at some point in their lifetimes. Development of Pressure Ulcer Management Guidelines

Poster 193: The effect of hand dominance on motor recovery in incomplete cervical spinal cord injury.

Objective: To determine the relationship between hand dominance and motor recovery in incomplete cervical spinal cord injury (SCI). Design: Retrospective analysis using neurologic assessment at admission and 1 year or later postinjury. Hand dominance prior to injury was obtained via telephone. Setting: Regional SCI center affiliated with a university hospital. Participants: 58 subjects (51 right handed, 7 left handed) with incomplete cervical SCI. Interventions: Traditional medical and rehabilitation care. Main Outcome Measures: Motor point recovery per extremity and percentage recovery per extremity. Percentage recovery was defined as actual motor point recovery per extremity divided by maximum possible motor point recovery per extremity. Outcome measures were analyzed for statistical significance using Wilcoxon test for P values, the Hodges-Lehmann estimates for median differences, and 95% confidence intervals (CIs). Results: The average motor point recovery for upper extremities was 7.84 for the dominant side and 8.97 for the nondominant side. Corresponding values for the lower extremities were 7.19 for the dominant side and 7.66 for the nondominant side. The percentage recovery for the upper extremities was 50% for the dominant side and 51% for the nondominant side; for the lower extremities, 38% for the dominant side and 36% for the nondominant side. The median difference between dominant and nondominant motor point recovery for the upper extremities was −1.0 point (95% CI, −3.0 to 0.5) and −0.5 points (95% CI, −3.5 to 2.5) in the lower extremities. The median difference between dominant and nondominant percentage of motor recovery was −4% (95% CI, −13% to 5%) in the upper extremities and −2% (95% CI, −12% to 12%) in the lower extremities. P values failed to reach statistical significance ( P<.05). Conclusions: Hand dominance does not influence motor recovery in incomplete cervical SCI.

Aging, spinal cord injury, and quality of life: structural relationships

McColl MA, Arnold R, Charlifue S, Glass C, Savic G, Frankel H. Aging, spinal cord injury, and quality of life: structural relationships. Arch Phys Med Rehabil 2003;84:1137–44. Objective: To quantify relationships among 3 sets of factors: demographic factors, health and disability factors, and quality of life (QOL). Design: Part of a program of longitudinal research on aging and spinal cord injury (SCI) involving 3 populations: American, British, and Canadian. The present analysis uses data from the 1999 interval. Setting: The Canadian sample was derived from the member database of the Ontario and Manitoba divisions of the Canadian Paraplegic Association. The British sample was recruited from a national and a regional SCI center in England. The American sample was recruited through a hospital in Colorado. Participants: A sample of 352 participants was assembled from 4 large, well-established databases. The sample included individuals who had incurred an SCI at least 20 years earlier, were admitted to rehabilitation within 1 year of injury, and were between the ages of 15 and 55 at the time of injury. Interventions: Not applicable. Main Outcome Measures: A combination of self-completed questionnaires and interviews. Data included demographics, injury-related variables, health and disability-related factors, QOL, and perceptions about aging. Results: Using linear structural relationships modeling, we found that QOL was affected both directly and indirectly by age, health and disability problems, and perceptions of aging. Two surprising findings were as follows: those who experienced fewer disability-related problems were more likely to report a qualitative disadvantage in aging, and the younger members of the sample were more likely to report fatigue. Conclusions: Fatigue is a concern because of the relationship of fatigue with perceived temporal disadvantage in aging, health problems, and disability problems. This finding highlights the need for clinical vigilance among those just beginning to experience the effects of aging.

Spine infections: variations in incidence during the academic year.

A prospective analysis of variations in monthly spinal infection rates at a spinal cord injury center with resident and fellow involvement in surgical care. To analyze the association between resident and fellow participation in spinal surgery and the incidence of perioperative wound infection over the academic year. It has been hypothesized that resident and fellow participation in surgical procedures may account for increased wound complications. Previous spinal infection studies have not addressed variations in the incidence of perioperative wound infections over the academic year. All cases of postoperative spinal infections at a spinal cord injury center from January 1994 through December 1997 were analyzed to determine whether monthly variations reflect the changes in surgical house officer experience through the academic year. A statistically significant (P < 0.027) increase in the incidence of spinal infection was demonstrated for the month of January. No other significant variations in the monthly incidence of spinal infection existed. No significant differences were found when the data were analyzed: year-to-year (P < 0.727), season-to-season (P < 0.204), 4-month resident rotation (P < 0.061), and 6-month fellow rotation (P < 0.075). A significantly higher incidence of spinal infection (10.5%) was observed for the month of January. Because January does not represent the start of a new resident or fellow rotation, there appears to be no association between the incidence of perioperative spinal wound infections and the level of experience of the surgical house officers in a regional spinal cord injury center.

Acute respiratory compromise associated with flexed cervical traction after C2 fractures.

Acute respiratory compromise is occasionally observed in a subgroup of patients with upper spinal injuries involving the C2 vertebrae. A retrospective review was performed to identify fracture types and risk factors for early respiratory deterioration following injury to the upper cervical spine. To examine the frequency of respiratory complications encountered following traction manipulation of specific upper cervical spinal injuries involving the C2 vertebrae. Major complications related to cervical skeletal traction are uncommon. Respiratory compromise with occasional mortality has been observed. Risk factors for acute respiratory failure are unknown. The medical records of 166 consecutive patients with fractures of the C2 vertebrae admitted between January 1994 and July 1998 to a regional spinal cord injury center were examined. Demographic data, injury subtype, fracture displacement, respiratory status, treatment method, and outcome at discharge were examined. Patients with comorbidities compromising respiratory function were excluded. One hundred fifty-five patients met the inclusion criteria of this study. Sixty-one patients had Type II odontoid fractures of which 53 were displaced (32 posteriorly and 21 anteriorly). In addition, there were 21 patients with Type III odontoid fractures, 33 with axis C2 body fractures, 32 with Hangman's fractures, and eight patients with an os odontoideum. Thirteen of 32 patients with posteriorly displaced odontoid fractures experienced acute respiratory compromise following reduction with cervical skeletal traction and immobilization, while only three of the remaining 123 patients had respiratory difficulties. Respiratory distress as a consequence of cervical spine fractures resulted in three deaths. Two of these patients had posteriorly displaced Type II odontoid fractures whose airway could not be emergently intubated. Frequent respiratory deterioration (40% of patients) during acute management of posteriorly displaced Type II odontoid fractures after reduction was observed. Physicians must be aware that cervical flexion in the treatment of posteriorly displaced odontoid fractures may significantly increase the risk of airway obstruction due to the presence of acute retropharyngeal swelling. This may be avoided with elective nasotracheal intubation in this upper cervical spine fracture subtype.

Epidemiolgy of spinal cord injury after acute odontoid fractures

Cervical spinal cord injury (SCI) after odontoid fracture is unusual. To identify predisposing factors, the authors evaluated a consecutive series of patients who sustained SCI from odontoid fractures. A consecutive series of 5096 admissions to the Delaware Valley Regional Spinal Cord Injury Center were reviewed, and 126 patients with neurological impairment at the C1-3 levels were identified. Seventeen patients had acute closed odontoid fractures with neurological deficit. Various parameters including demographics, mechanisms of injury, associated injuries, fracture types/displacements, and radiographic cervical canal dimensions were compared between "complete" and "incomplete" spinal cord injured-patients as well as with neurologically intact patients who had suffered odontoid fractures. There were similar demographics, mechanisms of injury, associated injuries, fracture type/displacement, and canal dimensions in patients with complete and incomplete SCIs. However, only patients with complete injury were ventilator dependent. In comparison with patients with intact spinal cords, spinal cord-injured patients were more commonly males (p = 0.011) who had sustained higher velocity injuries (p = 0.027). The computerized tomography scans of 11 of 17 neurologically impaired patients were compared with those of a random sample of 11 patients with intact spinal cords. Although the anteroposterior diameter (p = 0.028) and cross-sectional area (p = 0.0004) of the cervical spinal canal at the C-2 level were smaller in impaired patients, the displacement of the fragment was not different. Odontoid fractures are an infrequent cause of SCI. Patients with these injuries typically are males who have smaller spinal canals and have sustained high velocity injuries.

Return to school after spinal cord injury

Objective:To determine the typical time elapsed between discharge from an inpatient spinal cord injury (SCI) rehabilitation program and the physical return to school, and to identify barriers faced by patients attempting to return to school. Study Design: A retrospective review of all patients ages 18 years or younger who sustained SCI between 1989 and 1995, with resultant paraplegia or tetraplegia, and who attended either primary or secondary school, completed their inpatient rehabilitation at our regional SCI center, and were using a wheelchair when discharged from the hospital. Results: Fifteen of 16 eligible patients agreed to participate. The median time for subjects with paraplegia to return to school after hospital discharge was 10 days; subjects with tetraplegia required a median of 62 days. Architectural and transportation barriers that patients encountered were identified. Conclusion: Individuals with SCI return to school relatively soon after discharge from the hospital. Barriers do not prohibit a return to school, but they are problematic.

The pattern of reflex recovery during spinal shock.

A prospective descriptive study of the course of recovery of reflexes following acute spinal cord injury (SCI). The purpose of the study was to observe the pattern of reflex recovery following acute SCI in order to determine the prognostic significance of reflexes for ambulation and their relationship to spinal shock. A regional spinal cord injury center in Philadelphia, Pennsylvania, USA. Fifty subjects admitted consecutively over a 9 month period and on the day of injury were observed for the following reflexes; bulbo-cavernosis (BC), delayed plantar response (DPR), cremasteric (CRM), ankle jerk (AJ), knee jerk (KJ), and normal plantar response for 5 7 days a week and 6-8 weeks duration. The 50 subjects were assessed for ambulation of 200 feet at time of discharge. MRI studies were reviewed on 13/28 complete (ASIA A) injuries. Thirty-five subjects (28 ASIA A, 4 ASIA B, 3 ASIA C) had a DPR of 2 days or longer duration and these subjects were not ambulatory. The fourteen subjects (12 ASIA D and 2 ASIA C), who were ambulatory, either had no DPR (11/14) or had a DPR of only 1 days duration (3/14). One subject (ASIA B) was not ambulatory and had a DRP of 1 days duration. The DPR was the first reflex to recover most often, followed by the BC, CRM in the first few days and later followed by the deep tendon reflexes (AJ & KJ) by 1-2 weeks respectively. Less than 8% of subjects had no reflexes on the day of injury and the reflexes did not follow a caudal-rostral pattern of recovery. Prognosis for ambulation based on reflexes early after SCI should not be linked to current descriptions of spinal shock. In fact, the view of spinal shock, based on the absence of reflexes and the recovery of reflexes in a caudal to rostral sequence, is of limited clinical utility and should be discarded. The evolution of reflexes over several days following injury may be more relevant to prognosis than the use of the term spinal shock and the presence or absence of reflexes on the day of injury.