Spinal Cord Injury Care Research Articles

Current Topics in the Management of Acute Traumatic Spinal Cord Injury.

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Promoting Long-Term Health among People with Spinal Cord Injury: What's New?

A key ingredient to successful health promotion is a primary care provider who can offer an informed first response to lifestyle issues, emerging problems and chronic challenges. This article aims to assist family physicians to play their role in promoting the health of people with SCI, by summarizing the latest evidence in the management of spinal cord injury in primary care. This study used a scoping review methodology to survey peer-reviewed journal articles and clinical guidelines published between January 2012 to June 2016. This search strategy identified 153 articles across 20 topics. A prevention framework is used to identify five primary, nine secondary, four tertiary, and two quaternary prevention issues about which family physicians require current information. Major changes in the management of SCI in primary care were noted for 8 of the 20 topics, specifically in the areas of pharmacological management of neuropathic pain and urinary tract infection; screening for bowel and bladder cancer; improvements in wound care; and clarification of dietary fibre recommendations. All of these changes are represented in the 3rd edition of Actionable Nuggets—an innovative tool to assist family physicians to be aware of the best practices in primary care for spinal cord injury.

Involvement of poly(ADP-ribose) polymerase-1 in development of spinal cord injury in Chinese individuals: a Chinese clinical study.

ObjectiveWe aimed to evaluate whether the polymorphism of poly(ADP-ribose) polymerase-1 (PARP-1) is involved as potential risk factor in the development of spinal cord injury (SCI) among Chinese individuals.Patients and methodsPatients with a confirmed diagnosis of SCI (other than traumatic injury) and healthy individuals with no clinical symptoms of SCI were enrolled at Spinal Cord Injury Care Center, The Third People’s Hospital of Dalian, China. Genetic polymorphisms were studied in plasma samples by polymerase chain reaction-restriction fragment length polymorphism assay.ResultsA total of 130 Chinese patients with SCI and 130 healthy Chinese individuals were included. We found that patients with the GG genotype (odds ratio [OR]: 4.09, 95% confidence interval [CI] 2.42–6.90, P<0.001) and carriers of the G allele (OR 3.96, 95% CI 2.33–6.74, P<0.0001) were at high risk of developing SCI. A del/ins polymorphism of the NF-κB1 gene (OR 3.32, 95% CI 1.96–5.61, P<0.001) was also found to be associated with SCI.ConclusionOur study suggests that PARP-1 polymorphisms are involved in the development of SCI in Chinese individuals. Thus, PARP-1 polymorphisms can be considered as one of the potential risk factors for developing SCI.

The impact of a specialized spinal cord injury center as compared with non-specialized centers on the acute respiratory management of patients with complete tetraplegia: an observational study.

Retrospective cohort study. To compare the proportion of tracheostomy placement and duration of mechanical ventilation (MV) in patients with a complete cervical spinal cord injury (SCI) that were managed early or lately in a specialized acute SCI-center. The second objective was to determine the impact of the timing of admission to the SCI-center on the MV support duration. A single Level-1 trauma center specialized in SCI care in Quebec (Canada). A cohort of 81 individuals with complete tetraplegia over a 6-years period was included. Group 1 (N = 57- early group-) was admitted before surgical management in one specialized acute SCI-center, whereas Group 2 (N = 24 -late group-) was surgically managed in a non-specialized center and transferred to the SCI-center for post-operative management only. The proportion of tracheostomy placement and MV duration were compared. Multivariate regression analysis was used to assess the impact of the timing of admission to the SCI-center on the MV duration during the SCI-center stay. Patients in Group 2 had a higher proportion of tracheostomy (70.8 vs. 35.1%, p = 0.004) and a higher mean duration of MV support (68.0 ± 64.2 days vs. 21.8 ± 29.7 days, p = 0.006) despite similar age, trauma severity (ISS), neurological level of injury and proportion of pneumonia. Later transfer to the specialized acute SCI-center was the main predictive factor of longer MV duration, with a strong impact factor (s = 946.7, p < 0.001). Early admission to a specialized acute SCI-center for surgical and peri-operative management after a complete tetraplegia is associated with lower occurrence of tracheostomy and shorter mechanical ventilation duration support. MENTOR Program of the Canadian Institute of Health Research and US Department of Defense Spinal Cord Injury Research Program.

Update on critical care for acute spinal cord injury in the setting of polytrauma.

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

Optimizing Clinical Decision Making in Acute Traumatic Spinal Cord Injury

Spinal cord injury (SCI) is a devastating event causing lifelong disability that results in a significant decrease in quality of life and immense cost to the health care system, individuals and their families. Providing specialized and timely care can improve recovery and reduce costs, but to make this a reality requires understanding of the current care delivery processes and the care journey. The objective of this focus issue is to examine the current state of health care delivery and discover opportunities to improve access and timing to specialized care for individuals with tSCI. This issue provides an overview of care throughout the SCI continuum and its impact on individuals with tSCI using pan-Canadian data. The issue also presents findings from the RHI Access to Care and Timing (ACT) Project, a multi-center research study involving a multi-disciplinary team of Canadian researchers and clinicians. The initial articles describe the current state of the tSCI care journey including a comparison of environmental barriers, health status, and quality-of-life outcomes between patients living in rural and urban settings. The issue concludes with an article describing the national knowledge translation efforts of using the evidence from the articles published here to inform practice and policy change. Overall, this focus issue will be an excellent reference to guide and optimize evidence informed decision-making in the care of those with tSCI. The evidence can be transferred to care in non-traumatic SCI and other conditions that benefit from timely access to specialized care such as stroke and traumatic brain injury.

Forecasting Financial Resources for Future Traumatic Spinal Cord Injury Care Using Simulation Modeling.

Survivors of traumatic spinal cord injury (tSCI) have intense healthcare needs during acute and rehabilitation care and often through the rest of life. To prepare for a growing and aging population, simulation modeling was used to forecast the change in healthcare financial resources and long-term patient outcomes between 2012 and 2032. The model was developed with data from acute and rehabilitation care facilities across Canada participating in the Access to Care and Timing project. Future population and tSCI incidence for 2012 and 2032 were predicted with data from Statistics Canada and the Canadian Institute for Health Information. The projected tSCI incidence for 2012 was validated with actual data from the Rick Hansen SCI Registry of the participating facilities. Using a medium growth scenario, in 2032, the projected median age of persons with tSCI is 57 and persons 61 and older will account for 46% of injuries. Admissions to acute and rehabilitation facilities in 2032 were projected to increase by 31% and 25%, respectively. Because of the demographic shift to an older population, an increase in total population life expectancy with tSCI of 13% was observed despite a 22% increase in total life years lost to tSCI between 2012 and 2032. Care cost increased 54%, and rest of life cost increased 37% in 2032, translating to an additional CAD $16.4 million. With the demographics and management of tSCI changing with an aging population, accurate projections for the increased demand on resources will be critical for decision makers when planning the delivery of healthcare after tSCI.

Methodology of the Access to Care and Timing Simulation Model for Traumatic Spinal Cord Injury Care.

Despite the relatively low incidence of traumatic spinal cord injury (tSCI), the management and care of persons with tSCI can be resource intensive and complex, spanning multiple phases of care and disciplines. Using a simulation model built with a system level view of the healthcare system allows for prediction of the impact of interventions on patient and system outcomes from injury through to community reintegration after tSCI. As has been previously described, the Access to Care and Timing (ACT) project developed a simulation model for tSCI care using techniques from operations research. The objective of this article is to briefly describe the methodology and the application of the ACT Model, as it was used in several of the articles in this focus issue. The approaches employed in this model provide a framework to look into the complexity of interactions both within and among the different SCI programs, sites, and phases of care.

Traumatic Spinal Cord Injury Care in Canada: A Survey of Canadian Centers.

Specialized centers of care for persons sustaining a traumatic spinal cord injury (tSCI) have been established in many countries, but the ideal system of care has not been defined. The objective of this study was to describe care delivery, with a focus on structures and services, for persons with tSCI in Canada. A survey was sent to 26 facilities (12 acute, 11 rehabilitation, and three integrated) from eight provinces participating in the Access to Care and Timing project. The survey included questions about: 1) care provision; 2) structural attributes and; 3) service availability. Survey completion rate was 100%. Data sources used to complete the survey were the Rick Hansen Spinal Cord Injury Registry, other hospital databases, clinical protocols, and subject matter experts. Acute and rehabilitation care provided by integrated facilities were described separately, resulting in data from 15 acute and 14 rehabilitation facilities. The number of admissions for tSCI over a 12-month period between 2009–2011 ranged from 17 to 104 (median 39), and 11 to 96 (median 32), for acute and rehabilitation facilities, respectively. Grouping of patients was reported by 8/15 acute and 10/14 rehabilitation facilities. Criteria for admission to the inpatient rehabilitation facilities varied among facilities (25 different criteria reported). Results from the survey revealed similarities in the basic structure and the provision of general services, but also some differences in the degree of specialization of care for persons with tSCI. Continued work on the impact of specialized care for both the patient and healthcare system is needed.

Social support and its association with depression, gender and socioeconomic indicators in individuals with spinal cord injury in Iran.

Descriptive cross-sectional study. To investigate the relationship between perceived social support and depression and to evaluate the role of family, friends and other caregivers in the perception of social support in Iranian individuals with spinal cord injury (SCI). Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran. Social support was evaluated using the Multidimensional Scale of Perceived Social Support questionnaire, which gauges perceptions of support from family, friends and 'important persons'. The presence and severity of depression were assessed with the Beck Depression Inventory (BDI-II-PERSIAN)-a 21-item multiple-choice questionnaire. A total of 140 individuals with SCI were enrolled in the study. The average age of the participants was 29.4±7.9 years; the mean duration of injury was 46.3±46.5 months and most patients were male (72%). Social support and all subscales of social support were numerically greater in males; however, this difference was not statistically significant. The subcategory of friends' support in men was 17.9±7.9 compared to 14.6±8.0 in women (P=0.04). The self-reported social support score (r=-0.387, P<0.001) and subscales of social support, including family (r=-0.174, P=0.045), friends (r=-0.356, P<0.001) and important persons (r=-0.373, P<0.001), were all negatively correlated with depression. Higher self-reported perception of social support appears to be associated with lower levels of depression in individuals with SCI. SCI care providers should consider the relationship between social support and depression in their continuing care.

Nanomaterials for stimulating nerve growth.

Flexible nanomaterials may recruit neurons or create artificial bridges to restore connectivity

Characteristics and outcomes of gunshot-acquired spinal cord injury in South Africa.

Spinal cord injuries (SCIs) caused by assault present a unique challenge facing the healthcare system, in that very little is known about how these injuries manifest compared with other causes of injury. Understanding the nuances of gunshot SCIs could contribute towards better care provision. To determine the characteristics of gunshot SCI and compare both injury characteristics and outcomes between gunshot SCI and all other traumatic causes taken together. The gunshot SCI sub-cohort was derived from a 1-year prospective, population-based study, including both tertiary-level hospitals providing SCI care in the Cape Metropolitan area of South Africa (SA). All consenting 145 survivors, after a window period of 7days, were included, and their demographic and injury characteristics were captured according to the International SCI Core Basic Data Set. Further, selected secondary medical complications (outcomes) were prospectively and routinely assessed throughout acute care. Both descriptive and inferential statistics were used to describe and compare characteristics and outcomes, respectively. Of the 145 survivors of traumatic SCIs, 45 (31%) injuries were caused by gunshots. The gunshot SCI group consisted mainly of males (n=43, 96%), and the average age of injury onset was 26 years. Most survivors of the gunshot SCI group were paraplegic (69%), had complete lesions (69%) and vertebral injuries (96%), and presented with significant associated injuries (84%). When comparing gunshot SCI with all other traumatic causes, significant differences were found in relation to demographic and injury characteristics and adverse outcomes, indicating that those survivors with gunshot SCI were typically younger males with complete paraplegia, had more frequent secondary medical complications, and a longer hospital stay. This study contributes to the knowledge base of survivors with gunshot SCIs in a region of SA. Efforts should be made to reduce the occurrence of all gunshot SCIs, since those injuries affect survivors negatively in terms of injury characteristics and adverse outcomes.

Superficial swab versus deep-tissue biopsy for the microbiological diagnosis of local infection in advanced-stage pressure ulcers of spinal-cord-injured patients: a prospective study

ObjectiveTo assess the predictive value of superficial ulcer swab culture to make a microbiological diagnosis of deep wound infections in spinal cord injury (SCI) patients with advanced-stage pressure ulcers. MethodsFrom July 2011 to February 2014, we performed a prospective, single-centre study on adult SCI patients undergoing scheduled surgical debridement and reconstruction for advanced-stage pressure ulcers, at Montecatone Rehabilitation Institute, a 150-bed hospital dedicated to SCI care. Three superficial ulcer swabs were preoperatively collected using the Levine technique, then sent for culture. In surgery, multiple bone and soft-tissue specimens were taken and sent for culture and histological examination. No antibiotics were administered before surgery. The results of swabs and intraoperative specimens were compared. ResultsIn all, 116 patients were included, median age 49 years; a majority were males with post-traumatic paraplegia. According to intraoperative specimen cultures, the most common micro-organisms were Staphylococcus aureus, Proteus mirabilis, and Pseudomonas aeruginosa, found in 31, 27, and 16 cases, respectively. Concordance between superficial swabs and intraoperative specimen culture was found in only in 25 out of 116 cases (22%). The main reason for non-concordance was the yielding of different micro-organisms (41 out of 116); false negatives (swab negative/intraoperative positive) accounted for 31 out of 116 and false positives (swab positive/intraoperative negative) for 19 out of 116. When compared with intraoperative specimens, sensitivity and specificity of the swab culture were 80% and 54%, respectively. ConclusionsOur results confirm that in patients with advanced-stage pressure ulcers, the cultures of a superficial ulcer swab are not useful in either the diagnosis of a superinfection or the prediction of the role of involved micro-organisms.

Experiences of hospital readmission and receiving formal carer services following spinal cord injury: a qualitative study to identify needs

Purpose: The purpose of this study is to explore the needs of people living with spinal cord injury, receiving formal carer and hospital services.Materials and methods: This exploratory qualitative study was undertaken with people living with spinal cord injury in metropolitan or regional Victoria. Participants were recruited through the Australian Quadriplegic Association. Twenty-two in-depth interviews were conducted between September and October 2015. Participants were purposely selected based on their age, gender, level of injury, and compensation status. A thematic analysis was undertaken using a framework approach.Results and conclusions: With respect to hospitalization, the findings highlighted the need for improved access to spinal cord injury specialist care and greater personalization of care delivery for people with spinal cord injury. When receiving formal care services, participants reported the need for carers to be educated in preventing and managing secondary conditions, and for information about managing carers in their life and home. A more reliable and accessible supply of carers was also required to reduce the anxiety associated with an actual or potential absence of their assistance. To improve the independence and quality of care and life for people living with spinal cord injury, more responsive and individualized care is needed in the hospital, rehabilitation, and community settings.Implications for rehabilitationUnderstanding the individualized needs of people living with spinal cord injury and their families with respect to carer management is necessary to provide tailored rehabilitation education and ensure appropriate community supports are in place.The development of individualized plans by rehabilitation health professionals for obtaining spinal cord injury specialist care post-discharge could reduce anxiety and improve safety and quality of care.Integrating peer support into rehabilitation processes could offer benefits in managing carer issues.Greater family involvement in the rehabilitation process and follow-up psychological support could assist with adjustment and quality of life post-discharge.

Prehospital Care of Spinal Cord Injuries in India

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The development of an outcome measures toolkit for spinal cord injury rehabilitation.

Spinal cord injury (SCI) is a complex medical condition that can be difficult to monitor. This study aimed to establish a common set of validated outcome measures specifically for SCI clinical practice. In a three-round online Delphi process, experts in SCI care across Canada suggested and ranked outcome measures for clinical practice. The facilitators provided feedback between rounds and determined if consensus (at least 75% agreement) was reached on a single outcome measure per clinical area. One hundred and forty-eight outcome measures were initially considered for inclusion. After three rounds, consensus was reached for 23 out of 30 clinical areas. In the remaining seven, more than one outcome measure was recommended. The final toolkit comprises 33 outcome measures with sufficient measurement properties for use with a SCI population. An outcome measures toolkit validated specifically for SCI should lead to improved identification of best practice and enable clinicians to monitor client progress effectively.

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.

The evolution of national care pathways in spinal cord injury management

Spinal cord injury service delivery in the UK has improved over the years. The modern concept of Spinal Cord Injury care commenced after the Second World War. Patients started to live longer after the improvement in the medical and nursing care which was delivered in Spinal Cord Injury Centres across the country. In the last five years, spinal cord injury care has seen major advances. The Spinal Cord Injury Strategy Board was established in 2010 which led to the development of the Spinal Injury Pathway, the Spinal Injury National database and the creation of the clinical reference group for Spinal Cord Injury. This led to improvement in the care of evidence-based management.

Spinal cord injuries: overcoming barriers to seamless care for patients.

Patients with spinal cord injuries (SCIs) often have complex needs that require multidisciplinary support in specialist centres. Optimal management depends on seamless transitions between service providers. Delays at any point potentially compromise clinical outcomes and efficient resource utilisation. The Spinal Advisory Working Group aims to develop and implement practical initiatives to improve SCI care, initially focusing on admission and discharge. A literature review identified few relevant papers. In addition, the generalisability of the findings of these papers to SCI centres in the UK is unclear. Therefore, further research is needed to, for example: establish best practice in the UK; quantify the associations between admission criteria and clinical and economic outcomes from a UK perspective; and determine the extent and impact of barriers that influence the transition of SCI patients between NHS care providers. Such research would enable the development of evidence-based strategies to overcome or minimise these barriers. In the meantime, pragmatic consensus guidelines would help standardise management, aid service optimisation, overcome inequities and, potentially, reduce bed blocking. The working group agreed that the robust inclusion and exclusion criteria developed by the Welsh Spinal Cord Injury Rehabilitation Centre could form the basis of a consensus guideline, to be piloted across the five SCI centres represented by members of the group.

Mental disorder prevalence among U.S. Department of Veterans Affairs outpatients with spinal cord injuries

Objectives: Depression and other mental disorders are more prevalent among individuals living with spinal cord injury (SCI) than in the community at large, and have a strong association with quality of life. Yet little is known about the prevalence and predictors of mental disorders among U.S. military Veterans living with SCI. The primary aim of this study was to present an estimate of mental disorder point prevalence in this population. The secondary aim was to examine the relationship of mental disorders to demographics, injury characteristics, and other clinically relevant features such as impairment from mental health problems and life satisfaction.Design: Cross-sectional.Setting: A SCI & Disorders Center at a U.S. Veterans Affairs Medical Center.Participants/Methods: Administrative and medical records of 280 Veterans who attended annual comprehensive SCI evaluations were evaluated. Demographics, injury characteristics, self-reported mental and emotional functioning (i.e. SF-8 Health Survey), and clinician-determined mental disorder diagnoses were attained.Results: Overall, 40% of patients received at least one mental disorder diagnosis, most commonly depressive disorders (19%), posttraumatic stress disorder (12%), and substance or alcohol use disorders (11%). Several patient characteristics predicted mental disorders, including age, racial minority identity, non-traumatic SCI etiology, and incomplete (i.e. AIS D) vs. complete injury. Mental disorders were associated with greater impairment from health and mental health-related problems and less satisfaction with life.Conclusions: Mental disorders are common among outpatients receiving VA specialty care for SCI. These findings highlight the importance of having adequate and effective available mental health services available for Veterans with SCI.