Regional Spinal Injuries Centre Research Articles

Cannabis use by individuals with spinal cord injury in the UK: a call for improved patient education and physician awareness for pain and spasticity management

Study designProspective observational qualitative study.ObjectiveCannabis is used by patients for the treatment of chronic pain, spasticity, sleep issues or mood disorders such as anxiety and depression. Since 2018, it has been authorised in the United Kingdom for medical use as an unlicensed medicine. This study aims to determine if patients are using cannabis for the management of symptoms related to spinal cord injury, and if so, whether they are using medical or illicit cannabis.MethodsSpinal cord injury patients from the Yorkshire Regional Spinal Injuries Centre and SPINE Community in the United Kingdom were surveyed. Participants were sent a 7-point electronic survey. All results were anonymous, and confidentiality was maintained throughout the process.ResultsIn total, 223 patients completed the survey. Not all patients answered every question. Of those who responded 65.35% (n = 132) were paraplegic and 34.65% (n = 70) were tetraplegic. Patients were suffering from chronic pain (longer than 3 months), spasticity, loss of/difficulty in sleeping or anxiety/depression. Almost 15% (14.93%, n = 33 out of 221) used cannabis to manage their symptoms, out of those the majority used street cannabis (79.41%, n = 27 out of 34) were using street cannabis.ConclusionThis study demonstrates that there are spinal cord injury patients in the UK using cannabis to treat their symptoms. A majority appear to be using illicit cannabis. Given that cannabis can interact with other medications, and that the quality and content of illicit cannabis can be highly variable and at times dangerous, it is important for physicians to discuss cannabis use with their patients. This can inform prescribing and allow them to educate patients on the dangers of medical cannabis and potential alternatives.

Clinical Venous Thromboembolism in Spinal Trauma with and Without Spinal Cord Injury: A 3-Year Experience of Midlands Centre for Spinal Injuries, Oswestry, UK

Background and Aims: This study aimed to determine the incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE) among patients admitted acutely to a regional spinal injury center, following spinal trauma; to compare its occurrence between those with spinal cord injury (SCI) and those without; and to assess the effect of various factors such as age, gender, neurological impairment, and duration of prophylaxis on the incidence observed. Patients and Methods: We retrospectively reviewed the charts of 374 consecutive patients who sustained traumatic spinal injury and were admitted acutely to the Midlands Centre for Spinal Injuries, Oswestry (UK), over a 3-year period. A total of 159 patients had spinal trauma with SCI and 215 were neurologically intact. The majority of these patients were treated nonsurgically and received the same thromboprophylactic regimen started within a median of 2 days postinjury. The incidence of clinical VTE (DVT and PE) was determined and some risk factors were assessed. Ethical approval was obtained through the Audit Office Committee of the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. Results: Among the neurologically intact group, one patient developed clinical PE (0.5%). Out of 159 patients with SCI, 23 developed clinically evident VTE (14.5%), 15 had DVT (11.9%), 4 had PE (5%), and 4 had both DVT and PE. There was no fatality. Complete SCI lesions were associated with higher incidence of VTE compared to incomplete lesions, 17.6% and 11%, respectively (P < 0.001). There were two peaks of thromboembolic episodes: the first during the first 2 weeks after injury (30% of cases) and the second was after the 8th week postinjury (38% of cases). A higher incidence of VTE was recorded in males than females (14.3% and 7.9%, respectively). Aso, the incidence of VTE is slightly higher in the age group between 40 and 60 years, but these differences were not statistically significant. Conclusions: SCI is associated with high risk of venous thromboembolism, and the risk increases with the severity of cord insult. While spinal column injury is shown to be associated with much lower risk. The risk is reduced with strict adherence to thromboprophylactic regimen which we suggest to continue for at least 12 weeks for SCI patients.

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.

Urinary retention and acute kidney injury in a tetraplegic patient using condom catheter after partying: a preventable complication

BackgroundSpinal cord injury patients, who manage their bladder using a condom catheter, are at risk of developing urine retention when they consume large volumes of alcoholic drinks within a short period of time.Case presentationA male tetraplegic patient had been managing satisfactorily penile sheath drainage for 8 years. He went out socializing during which he consumed large volumes of alcohol but did not take any recreational drugs. The following morning, he noticed distension of the lower abdomen and passed urine in dribbles. He then developed a temperature and became unwell. He was seen by district nurses and a doctor, who prescribed antibiotics. He continued to feel unwell. After 8 days, he referred himself to a spinal unit at Regional Spinal Injuries Centre, Southport. The blood test results showed the following: blood urea: 19.8 mmol/L; creatinine: 172 μmol/L; and C-reactive protein: 336.4 mg/L. Urethral catheterization led to immediate drainage of 1,400 mL of urine. A computed tomography scan revealed an enlarged, swollen left kidney, indicating acute bacterial nephritis. He was prescribed intravenous fluids and Meropenem. Creatinine decreased to 46 μmol/L.ConclusionSpinal cord injury patients using condom catheters should be made aware of the risk of urine retention when they consume large amounts of alcoholic drinks in a short period of time. Patients and caregivers should be informed to consider intermittent catheterizations for 24–48 hours or insert indwelling urethral catheter when planning for an evening out.

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.

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.

Atrial fibrilation in a tetraplegic paralympic athlete

BackgroundIndividuals with Spinal Cord Injury (SCI) experience various types of cardiovascular dysregulation depending on the level of their cord lesion. The recognition and management of cardiovascular dysfunction following SCI represent...

Barriers to Implementing Intermittent Catheterisation in Spinal Cord Injury Patients in Northwest Regional Spinal Injuries Centre, Southport, U.K.

Intermittent catheterisation is the preferred method of managing the neurogenic bladder in patients with spinal cord injury. However, spinal cord physicians experienced problems when trying to implement an intermittent catheterisation regime in some spinal cord injury patients in the northwest of England. We present illustrative cases to describe practical difficulties encountered by patients while trying to adopt an intermittent catheterisation regime. Barriers to intermittent catheterisation are (1) caregivers or nurses are not available to carry out five or six catheterisations a day; (2) lack of time to perform intermittent catheterisations; (3) unavailability of suitable toilet facilities in public places, including restaurants and offices; (4) redundant prepuce in a male patient, which prevents ready access to urethral meatus; (5) urethral false passage; (6) urethral sphincter spasm requiring the use of flexible-tip catheters and α-drenoceptor–blocking drugs; (7) reluctance to perform intermittent catheterisation in patients >60 years by some health professionals; and (8) difficulty in accessing the urethral meatus for catheterisation while the patient is sitting up, especially in female patients. These cases demonstrate the urgent need for provision of trained caregivers who can perform intermittent catheterisation, and improvement in public facilities that are suitable for performing catheterisation in spinal cord injury patients. Further, vigilance should be exercised during each catheterisation in order to prevent complications, such as urethral trauma and consequent false passages. Health professionals should make additional efforts to implement intermittent catheterisation in female spinal cord injury patients and in those >60 years.

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.

Survival after short- or long-term ventilation after acute spinal cord injury: a single-centre 25-year retrospective study

A retrospective review of acute spinal cord injury patients having assisted ventilation on or after admission between 1981 and 2005. To assess survival after acute ventilatory support. Northwest Regional Spinal Injuries Centre, Southport, England. Causes of death were ascertained from the Office of National Statistics. Kaplan-Meier analysis of survival was calculated according to ventilator-wean status at discharge. Risk factors were obtained by Cox regression analysis. Over 50% of deaths in weaned and ventilated patients were respiratory in origin. The mean survival of weaned patients in the age group 31-45 was 19.3 compared with 10.5 years for ventilated patients (P=0.047). Those under 30 survived a further 22.1 and 18.4 years (P=0.31), while those over 45 lived for 11.0 and 8.3 years (P=0.50), values for weaned and ventilated patients, respectively. The survival advantage for weaned patients in the middle age group was less evident when the 1-year survivors were compared. The mean survival time of younger patients with diaphragm pacing was 1.8 years longer than those on mechanical ventilation (P=0.142). The variables with significant hazard ratios were any comorbidity (3.07); mechanical ventilation on discharge (2.26); and older age at injury, (3.1). The survival time for patients with high tetraplegia on long-term ventilation compares with other datasets and older patients have a proportionately greater loss in life expectancy. Self-ventilating patients with tetraplegia remain at considerable risk from respiratory death and consideration needs to be given to more effective preventative measures.

Analysis of tetraplegic reaching in their 3D workspace following posterior deltoid-triceps tendon transfer

Cross-sectional study. To quantify three-dimensional (3D) reachable workspace in different groups of tetraplegic participants and to assess their reaching performance within this workspace. Northwest Regional Spinal Injuries Centre, UK. The 3D reachable workspace of three groups of tetraplegics (NON-OP, operated group (OP) and tetraplegic control group (CON(Tetraplegic)) with varying levels of triceps function together with a healthy control group (CON(Healthy))) was defined by reaching to five target positions (anterior, medial, lateral, superior and inferior) located on the periphery of their workspace. Joint angles and inter-joint co-ordination were analysed after a 3D reconstruction of the thorax, humerus and forearm. The performance related variables of movement time, peak velocity, time-to-peak velocity and curvature index were also examined. The reachable volumes covered were consistent with the level of triceps function as CON(Healthy) covered a significantly greater volume than the tetraplegic groups and in turn the OP covered a larger workspace volume than NON-OP. The reduced workspace of tetraplegics was identified as being due to restrictions in workspace above shoulder height and across the body. Co-ordination data identified some differences in movement patterns but when reaching to targets on the workspace there were no significant differences between the OP and NON-OP groups. This study provided a detailed assessment of reachable workspace and target reaching. Tetraplegic participants found the superior and medial parts of the workspace were the most challenging directions. Standardised biomechanical analysis of tetraplegic upper-limb function is required for objective assessment.

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.

Utilization, access and satisfaction with primary care among people with spinal cord injuries: a comparison of three countries

Cross-sectional; survey. To describe the utilization, accessibility and satisfaction of primary and preventive health-care services to individuals with long-term spinal cord injuries, and compare results among three countries: the United States, Canada and the United Kingdom. The Canadian sample was obtained from the Canadian Paraplegic Association-Ontario and Manitoba Divisions. The British sample was recruited from the Northwest Regional Spinal Injuries Centre in Southport and National Spinal Injuries Centre at Stoke Mandeville Hospital in Aylesbury. The American sample was recruited through Craig Hospital in Englewood, CO, USA. A total sample of 373 individuals aging with a spinal cord injury participated in a mailed survey. The Health Care Questionnaire was used to measure utilization, access and satisfaction with primary care and preventive services. In total, 93% of individuals reported having a family doctor, 63% had a spinal injuries specialist and 56% had both a family doctor and spinal injuries specialist. Considerable duplication of services occurred for general medical and preventive services, although lifestyle and emotional issues were not addressed for over 75% of the participants. Significant differences were found in utilization among Canada, US and UK, with Canadians most likely to receive health care from family physicians and Americans most likely to receive care from specialists. Access to and satisfaction with health services was not significantly different among countries. People with long-standing spinal cord injuries develop complex maps by which they seek out appropriate primary health-care and preventive services. Given the differences among countries, it is clear that the health delivery model plays an important role in how and where individuals receive health services.

Two case reports of cervical spinal cord injury in football (soccer) players

Two case reports of male football players who sustained injury to cervical spinal cord as a direct result of the sport. To raise the awareness that playing football (soccer), a very popular sport, may cause injury to the cervical spinal cord with dire consequences, albeit rarely. North West Regional Spinal Injuries Centre, Southport, UK. We report two male football players, who sustained injury to the cervical spine and developed tetraplegia as a direct result of the sport. Case 1: A 21-year-old football player was tackled from behind while running with the football, he lost his balance and landed on his head resulting in burst fracture dislocation of C5/C6 associated with immediate onset of complete tetraplegia (ASIA-A). Case 2: A 24-year-old football player collided, head first, with his own team goalkeeper, causing a hyperextension of neck. He developed motor complete tetraplegia at C5 level, with some sensation sparing below the level of injury (ASIA-B). Injury to the cervical spinal cord is known to occur in some team contact sports such as rugby and American football. Over time the laws and the preparation of the athletes for these games have been changed in order to minimize the neck injuries. What might not be appreciated is that playing football (soccer), a very popular sport worldwide, may cause injury to cervical spinal cord with dire consequences.

Bedside assessment of sympathetic skin response after spinal cord injury: a brief report comparing inspiratory gasp and visual stimulus

A case control study in five controls, and 20 tetraplegic and paraplegic patients, complete and incomplete. The aim was to assess the feasibility of a simple test for sympathetic system preservation after spinal cord damage in a pain-free manner and which could be undertaken worldwide without specialist equipment or manpower. Patients were attending the Southport Regional Spinal Injuries Centre, England, either as outpatients or as in-patients during rehabilitation. The sympathetic skin response (SSR) was recorded on a single-channel ECG recorder from the right hand and right foot in turn after inspiratory gasp (IG) or visual stimulation. Unlike the visually evoked SSR, the gasp-evoked SSR was reliable, albeit of variable amplitude, and there was little difference between the hand and foot. Paraplegics had similar SSRs in the hands as the controls. There was minor insignificant habituation of response for the gasp reflex. There was occasional unexpected SSR distally in patients with complete lesions, and in patients with incomplete lesions the responses could not have been predicted from the sensory motor pattern. Trained IG induces an SSR which is sufficient to elucidate sympathetic loss following spinal cord injury. It is superior to visual stimulation in this respect. Habituation is not a problem with at least 1 min between tests, and high doses of anticholinergics agents may impair the response.