Traumatic Spinal Cord Lesion Research Articles

Macrophage polarization in vitro and in vivo modified by contact with fragmented chitosan hydrogel.

We have previously shown that implantation of a fragmented chitosan hydrogel suspension (chitosan-FPHS) into a traumatic spinal cord lesion in adult rats led to significant axon regrowth and functional recovery, which was associated to a modulation of inflammation. Using an in vitro culture system, we show here that polarization of bone marrow-derived macrophages is indeed modified by direct contact with chitosan-FPHS. Reducing the degree of acetylation (DA) and raising the concentration of chitosan (Cp, from 1.5% to 3%), favors macrophage polarization toward anti-inflammatory subtypes. These latter also migrate and adhere efficiently on low, but not high DA chitosan-FPHS, both in vitro and in vivo, while inflammatory macrophages rarely invade a chitosan-FPHS implant in vivo, no matter the DA. Our in vitro model setup should prove a valuable tool for screening diverse biomaterial formulations and combinations thereof for their inflammatory potential prior to implantation in vivo.

Exclusive Image Gallery on Human Spinal Cord Regeneration-Clinical Image-9

Classifi cation scheme for human peripheral nerve fi bers. Conduction velocities (V) and nerve fi ber diameters (Ø) of afferent and efferent nerve fi ber groups in normal humans and in patients with a traumatic spinal cord lesion for 0.5 to 6 years.

Major destructive asymptomatic lumbar Charcot lesion treated with three column resection and short segment reconstruction. Case report, treatment strategy and review of literature.

Charcot's spine is a long-term complication of spinal cord injury. The lesion is often localized at the caudal end of long fusion constructs and distal to the level of paraplegia. However, cases are rare and the literature relevant to the management of Charcot's arthropathy is limited. This paper reviews the clinical features, diagnosis, and surgical management of post-traumatic spinal neuroarthropathy in the current literature. We present a rare case of adjacent level Charcot's lesion of the lumbar spine in a paraplegic patient, primarily treated for traumatic spinal cord lesion 39 years before current surgery. We have performed end-to-end apposition of bone after 3 column resection of the lesion, 3D correction of the deformity, and posterior instrumentation using a four-rod construct. Although the natural course of the disease remains unclear, surgery is always favorable and remains the primary treatment modality. Posterior long-segment spinal fusion with a four-rod construct is the mainstay of treatment to prevent further morbidity. Our technique eliminated the need for more extensive anterior surgery while preserving distal motion

"Relationship between Modified Ashworth Scale and Alpha Motoneuron Excitabilityin Spinal Cord Lesions"

Background: Spasticity is one of the major neurological complications occurring in people with Spinal Cord Lesions due to loss of supra-spinal and spinal control over alpha motor neuron activity. Its accurate assessment is necessary for tailoring patient specific rehabilitation program. Clinical assessment is commonly done through Modified Ashworth Scale where in the examiner subjectively judges resistance to passive range of motion whereas, electrophysiological quantification of spasticity can be done through Hoffman’s Reflex which is an estimate of alpha motor neuron activity.Methods: This co-relational study establishes an association between MAS and H reflex in a sample of both traumatic and non-traumatic Spinal Cord lesion patients. A sample of 22 patients was obtained who were rated for MAS grades 0,1,1+,2 and 3 in bilateral gastro soleus and consequent H reflex elicitation was done.Results: Karl Pearson Correlation coefficient was calculated between MAS and H amplitude (r = 0.342, p<0.05); MAS and h latency (r = 0.013, p>0.05) ; MAS and H/M ratio (r=0.190 ,p>0.05).Conclusion: It was concluded that there exists a weak but significant correlation between MAS and H amplitude but non-significant relationship between MAS and H latency; MAS and H/M ratio.

Multiple sclerosis following a spinal cord injury: a rare and unfortunate case

This is a case report and review of literature with the objective report of the case of a young man with physical disability following a traumatic spinal cord injury (SCI) who was later newly diagnosed with multiple sclerosis (MS) in an inpatient SCI rehabilitation center. (Barcelona, Spain). A 24-year-old male sustained a traumatic spinal cord lesion (T9 AIS A) as the result of a motorcycle accident. He completed his rehabilitation process without complications and returned to the community having adjusted to his new disability. Two and a half years after his initial injury, he attended the clinic after experiencing 2 months of paresthesias in his left hand, progressing to his right upper limb, and difficulty with fine hand movements. An magnetic resonance imaging (MRI) was arranged and although post-traumatic syringomyelia was ruled out, demyelinating areas in the cervical spinal cord were found. A brain MRI revealed multiple demyelinating lesions suggestive of MS. The diagnosis of MS was confirmed by a neurologist and treatment was started with daily doses of glatiramer acetate. At this time the patient was still independent in transfers, activities of daily living and wheelchair management. In young patients with SCI, adequate follow-up is important to detect subsequent complications that may lead to clinical and functional deterioration with a view to uncommon causes such as MS.

Antispastic therapy with botulinum toxin type A in patients with traumatic spinal cord lesion.

Objectives: The purpose of this study was to determine the effect of botulinum toxin injections for the treatment of spasticity after traumatic spinal cord injury. Methods: 9 patients were included in this prospective designed study, with a follow-up of at least 2 years. All patients suffered from a massive spasticity after traumatic spinal cord lesion. Conservative treatment options did not show satisfying results. All patients were injected a maximal dose of 2,000 units of botulinum toxin A in no more than 6 skeletal muscle groups. Clinical control examinations were performed after 2 weeks and after at least 2 years. Results: 6 patients reported a good or very good result. One patient offered increasing difficulty in walking for a short time after injection. 2 patients showed no beneficial effects. One patient experienced a modest temporary general weakness for 3 days. After 2 years, 3 patients showed improved function with persistent reduction of spasticity. In the other cases, the beneficial effect lasted for an average of 9 months. Conclusion: Botulinum toxin A injection seems to be an effective complementary therapy option in the treatment of spasticity of paraplegic patients with complete deficit of their motor function (ASIA A and B) and a spastic distribution pattern, effecting only a limited number of muscle groups. Caution has to be recommended for incomplete paretic patients, who are able to walk.

Time course of arterial remodelling in diameter and wall thickness above and below the lesion after a spinal cord injury

Physical inactivity in response to a spinal cord injury (SCI) represents a potent stimulus for conduit artery remodelling. Changes in conduit artery characteristics may be induced by the local effects of denervation (and consequent extreme inactivity below the level of the lesion), and also by systemic adaptations due to whole body inactivity. Therefore, we assessed the time course of carotid (i.e. above lesion) and common femoral artery (i.e. below lesion) lumen diameter and wall thickness across the first 24 weeks after an SCI. Eight male subjects (mean age 35 ± 14 years) with a traumatic motor complete spinal cord lesion between T5 and L1 (i.e. paraplegia) were included. Four subjects were measured across the first 6 weeks after SCI, whilst another four subjects were measured from 8 until 24 weeks after SCI. Ultrasound was used to examine the diameter and wall thickness from the carotid and common femoral arteries. Carotid artery diameter did not change across 24 weeks, whilst femoral artery diameter stabilised after the rapid initial decrease during the first 3 weeks after the SCI. Carotid and femoral artery wall thickness showed no change during the first few weeks, but increased both between 6 and 24 weeks (P < 0.05). In conclusion, SCI leads to a rapid and localised decrease in conduit artery diameter which is isolated to the denervated and paralyzed region, whilst wall thickness gradually increases both above and below the lesion. This distinct time course of change in conduit arterial diameter and wall thickness suggests that distinct mechanisms may contribute to these adaptations.

Functional outcome of patients 12 and 48 weeks after acute traumatic tetraplegia and paraplegia: data analysis from 2004–2009

During the first rehabilitation of patients with traumatic spinal cord injuries (SCIs), professional skills are learned, which can be objectified in an independent measurement score. The aims of this study were to record the skills of patients 12 and 48 weeks after acute trauma and perform an analysis of the data to identify provisions of importance. All patients from 2004 to 2009 who experienced traumatic SCI were included in this investigation. Data recording were accomplished by the European Multi-Centre Study about Spinal Cord Injury (EMSCI) databank. Patients were divided into tetraplegia and paraplegia groups. Parameters were age at injury, the American Spinal Injury Association-Score, level of lesion and spinal cord independence measure (SCIM-Score) 12 and 48 weeks after traumatic spinal cord lesion. A questionnaire was also added to help clarify where deficiencies were prevalent. Data analysis of 103 tetraplegic and 110 paraplegic patients showed no correlation between the ASIA score, level of lesion, age and SCIM score. On average, tetraplegic patients had a SCIM score of 43 points 12 weeks after treatment, with 81% showing an increase to 58 points after 48 weeks. Paraplegic patients showed an average SCIM score of 60 points after 12 weeks, with 71% experiencing an increase to 71 points after 48 weeks. In all, 9% of tetraplegic patients and 19% of paraplegic patients experienced a decrease of SCIM points after 48 weeks, which occurred mainly in the bladder and intestinal control subgroups. Results of the questionnaire were not helpful for clarifying the location of the deficiencies. Most of the patients experienced an increase of SCIM points 48 weeks after traumatic SCI. However, data also showed that, especially in paraplegic patients, special attention must be given to bladder and intestinal management to avoid negative late-term consequences.

Predictors of the Length of Stay of Inpatients in Rehabilitation Setting After Traumatic Spinal Cord Injury

Predictors of the Length of Stay of Inpatients in Rehabilitation Setting After Traumatic Spinal Cord Injury

Assessment of Gadolinium Leakage Into Traumatic Spinal Cord Lesion Using Magnet Resonance Imaging

Exploratory study in patients with acute spinal cord trauma using magnetic resonance imaging (MRI). The aim of this study was to assess the leakage of Gd-DTPA into traumatic lesions of the human spinal cord using MRI. While MRI of acute spinal cord trauma is a routine type of clinical investigation, the time course of Gd-DTPA enhancement in traumatic spinal cord injury is not known. In early stage after spinal cord injury (<24 hours) and at follow-up on day 4, 7, 14, 21, 28, and 84, the accumulation of Gd-DTPA within 30 minutes after bolus injection was investigated in sagittal and axial T2-weighted images and T1-weighted images. In 4 men aged between 23 and 55 years with severe paraparesis, the traumatic spinal cord lesion had a maximum of spatial extent after 7 days. Gd-enhancement was first detected on day 4 in T1-weighted images, was most pronounced between day 7 and 28 but absent on day 84. The Gd-enhancement progressively increased in intensity after intravenous injection between 5 and 10 minutes when a maximum was reached, which remained stable for up to 30 minutes. We used MRI to study the dynamics of post-traumatic Gd-DTPA leakage into the injured spinal cord. This appears as a promising approach for monitoring the local secondary lesion changes.

Processing in prefrontal cortex underlies tactile direction discrimination: An fMRI study of a patient with a traumatic spinal cord lesion

We have investigated cortical processing of tactile direction discrimination (TDD) in a patient with unilateral tactile disturbance due to spinal cord lesion. The patient R.A. (male, 45 years old), suffers from a traumatic dorsal column lesion at the level of Th XI–XII on the right side. He was instructed to report the direction of 2 mm long skin pull stimulations applied in a proximal or distal direction on his right or left lower legs during functional magnetic resonance imaging (fMRI). Although R.A. considered himself to have nearly normal tactile sensibility, testing showed severely disturbed TDD on his right leg whereas results were within the range of healthy subjects on his left leg. For both legs TDD activated an extensive cortical network that included opercular parietal area 1 (OP1) of the second somatosensory cortex (S2), as has previously been observed in healthy subjects. However, dorsolateral prefrontal cortex (DLPFC) and anterior insular cortex (AIC) were only activated for the unaffected (left) leg where TDD was normal. A revisit of previously published data showed that healthy subjects consistently had TDD-related activations in DLPFC and AIC. However, in several healthy subjects AIC, but not DLPFC, was also activated for skin pull stimulations per se without the TDD task. Thus, the patient's data, in conjunction with the previous results from healthy subjects, suggest that DLPFC processing is important for tactile decision making based on proper tactile input.

Traumatic and non-traumatic spinal cord lesions: an Italian comparison of neurological and functional outcomes

Retrospective study. To compare the rehabilitation outcomes of non-traumatic and traumatic spinal cord injury patients. Spinal cord unit of a rehabilitation hospital in Italy. In total, 380 patients at first rehabilitation stay after the lesion (144 traumatic patients and 236 non-traumatic patients; 244 men and 136 women; mean age 46.1±19.9 years; mean lesion to admission time 49.6±39.8 days). Not applicable. American Spinal Injury Association standards; Barthel index (BI), Rivermead mobility index and walking index for spinal cord injury. Poisson regression models with relative risks and 95% confidence intervals adjusted for the following confounders: age, sex, lesion level and Asia impairment. Models were stratified by age because a strong interaction between different variables and age was found. Traumatic and non-traumatic populations showed several significant differences with regard to age, level and severity of lesion. When adjusted for these factors patients with traumatic injuries showed a significantly lower BI score at admission and significantly better improvement in the BI score by discharge. The two populations were discharged with similar functional outcome. No significant differences were found with regard to the others outcomes. In clinically stable patients, spinal cord injury etiology does not seem to affect the rehabilitative prognosis. At admission, traumatic patients show lower autonomy in daily life activities, probably because of the associated lesions that these patients often have. At discharge, traumatic and non-traumatic spinal cord lesion patients achieved similar results with regard to neurological and functional improvement.

Botulinum toxin type A in the healing of a chronic buttock ulcer in a patient with spastic paraplegia after spinal cord injury

Pressure sores are a significant secondary complication in spinal cord injured patients. A new indication for botulinum toxin type A is described here, in treatment of recurrent muscular spasms that had hampered the healing of a chronic buttock ulcer in a subject with severe spastic paraplegia. A 27-year-old man with spastic paraplegia following traumatic spinal cord lesion at the thoracic level had developed recurrent severe muscular spasms, particularly involving the buttock region, with an Ashworth scale score of 3-4 and a Spasm Frequency Scale of grade 4. The patient had a pressure ulcer in the left gluteal region (grade IV according to the European Pressure Ulcer Advisory Panel (EPUAP). Several treatments were administered without success, and all efforts at healing the ulcer by topical medication were hampered by recurrent spasms involving the buttock muscles and ulcer region. The left gluteus maximus muscle was treated with 2 infiltrations of 660 IU botulinum toxin type A. The use of botulinum toxin type A allowed better care of the pressure ulcer, which had healed by 6 months after the initial infiltration. The use of botulinum toxin type A may be an important adjunctive therapy for treatment of pathological conditions involving recalcitrant involuntary muscle contraction.

Hospital Care of Postacute Spinal Cord Lesion Patients in Italy

To define the clinical characteristics of hospital readmissions of subjects with spinal cord lesion. Prospective, multicenter, 2-yr survey in 32 spinal cord lesion centers in Italy. Readmitted traumatic or nontraumatic spinal cord lesion patients were included. Main outcome measures were number of readmissions, their causes, complications on admission, and length of stay. Out of 2070 total admissions of patients with spinal cord lesion, 1056 (51.0%) were readmissions. The median period between the onset of disease and readmission was 3.4 yrs. A program of functional gain was the main cause of readmission (33%). A pressure sore was reported in 20.6% of cases on readmission. Readmission for a program of functional gain was correlated to nontraumatic and incomplete lesions. Readmission necessary for clinical complications was correlated to traumatic spinal cord lesion and completeness of the lesion. A longer length of stay correlated with cause of readmission, admission to rehabilitation centers, and nontraumatic origin. Readmissions account for more than half of total admissions to centers for spinal cord lesion in Italy. The main burden is represented by a program of functional gain, pressure sores, and urological complications.

Traumatic vs non-traumatic spinal cord lesions: comparison of neurological and functional outcome after in-patient rehabilitation

Retrospective comparative study of 2 years duration. To compare neurological and functional outcome and length of stay of persons with traumatic vs non-traumatic spinal cord lesion (SCL) after in-patient rehabilitation. Neurological rehabilitation department of a tertiary research center in Bangalore, Karnataka, India. Seventy-six in-patients with spinal cord lesion: traumatic (38 patients, M/F=34:4) and non-traumatic (38 patients, M/F=16:22) were admitted for in-patient multidisciplinary neurorehabilitation. ASIA impairment scale, duration of stay (DOS), and admission and discharge--Barthel Index scores in both the groups were recorded, compared and analyzed. ASIA impairment scale scores were significantly higher in non-traumatic group both at admission and discharge (P=0.020 and 0.017), respectively, showing lesser impairment in non-traumatic group. DOS for rehabilitation was higher for traumatic group as compared to non-traumatic group (65.97+/-47.66 vs 60.68+/-45.69 days), although statistically not significant (P>0.05). Barthel Index scores were 28.68+/-17.15 vs 27.63+/-14.96 at admission and 54.21+/-25.10 vs 51.44+/-19.86 at discharge in traumatic and non-traumatic groups, respectively. All patients (n=76) showed significant improvement in Barthel Index (P=0.000), but no statistically significant difference (P>0.05) was recorded between the two groups, both at admission and at discharge. Orthoses was required significantly more frequently (P=0.043) in traumatic SCL group. The study showed that despite more impairment in persons with traumatic spinal cord lesion, there was statistically no significant difference in the length of stay and the functional outcome between persons with traumatic and non-traumatic spinal cord lesion after in-patient rehabilitation.

Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions

Objective. To investigate the relationship between lesion severity and other clinical factors and bladder function recovery.Patients and methods. The charts of 269 patients with traumatic and non traumatic spinal cord lesion (SCL) were reviewed and the following information was recorded: lesion to admission time, injury variables, length of stay and neurological status. At five months, urological outcome was assessed by voiding modalities, and urodynamics according to International Continence Society.Statistics. Logistic approach with univariate and multivariate analysis.Results. Both ASIA impairment at admission and age were significantly correlated with bladder function outcome. None of the patients with ASIA A impairment at admission reached volitional voiding at five months. ASIA B patients had a 90% lower probability of achieving good bladder control and ASIA C ones a 65% lower than ASIA D patients (p < 0.05). Older patients had a significant lower probability (60%) of achieving volitional voiding than younger ones (p < 0.05). Of the 121 patients with ASIA D impairment at discharge only 78 voided spontaneously and showed a higher frequency of cervical lesions and a lower frequency of detrusor-external sphincter dyssynergia.Discussion and conclusion. Bladder recovery in patients with complete SCL is limited. ASIA B patients showed a better neurological recovery and, concurrently, better bladder function recovery than ASIA A patients, thus demonstrating the importance of sensation preservation for recovery. Younger patients show better bladder recovery than older ones, probably because of different efficiency of spinal cord plasticity. Finally, patients with good neurological recovery may not achieve volitional voiding. Patients with bladder function recovery show a higher frequency of central cord and Brown-Sequard syndromes (with better prognosis) and a lower frequency of detrusor-sphincter dyssynergia.

Sexual activity and satisfaction in men with traumatic spinal cord lesion

To estimate sexual activity and sexual satisfaction in men with spinal cord lesion. Cross-sectional study. All adult citizens in Helsinki with traumatic spinal cord lesion were identified. The final study group comprised 92 male subjects, corresponding to a participation rate of 79%. A structured questionnaire was sent to all subjects and they were invited for a clinical visit. Clinical examination was based on the manual of the American Spinal Injury Association (ASIA). Examinations were performed on all subjects by the same experienced physician and physiotherapist. In total, 86% of the subjects experienced sexual desire and 68% had been sexually active during the last 12 months. A total of 65% of subjects reported experiencing orgasm since the injury, but most subjects rated it as weaker than before the injury. There were no statistically significant differences between the ASIA Impairment Scale groups. Men with paraplegia reported a more satisfactory sex life (p = 0.05) than those with tetraplegia. This study confirms the earlier findings that the ability to reach orgasm is deficient in men with spinal cord lesion. The completeness of the lesion had no effect. The more severe locomotory disability might adversely affect the sex life of persons with tetraplegia compared with those with paraplegia.

Health-related quality of life in persons with traumatic spinal cord lesion in Helsinki

To estimate the health-related quality of life (HRQoL) of persons with spinal cord lesion. The study design was cross-sectional. All adult citizens in Helsinki with traumatic spinal cord lesion were identified. The final study group comprised 117 subjects, corresponding to a participation rate of 77%. HRQoL was assessed by a generic 15-dimensional self-administered instrument (15D). Clinical examination was based on the manual of the American Spinal Injury Association. Examinations were performed on all subjects by the same experienced physician and physiotherapist. The average 15D score of the study group was significantly lower (p<0.001) than that measured in the age-matched general population sample. Subjects with spinal cord lesion had significantly more problems due to the neurological lesion but also on the dimensions of sleeping, discomfort and symptoms and vitality. In regression analysis of the study group the only variable explaining HRQoL was the neurological level of the lesion. Spinal cord lesion caused more depression and distress in persons with motor incomplete lesion than those with motor complete lesion. Persons with spinal cord lesion had lower HRQoL than the population in general. The results indicate that spinal cord lesion may cause problems in the areas of sleeping, discomfort and symptoms or vitality, in particular. More attention should be paid to finding ways of improving the situation of persons with motor incomplete lesion, especially in terms of psychological function.

Treatment of Spinal Fractures in Children and Adolescents

The authors examined a case series of patients younger than 16 years who had sustained a traumatic spine injury. To evaluate clinical and radiologic findings and the effectiveness of conservative versus surgical treatment at long-term follow-up. Although injuries to children have received increasing coverage in the literature over the last several years, few reports have focused on the long-term results of conservative versus surgical treatment. Forty-four patients who had sustained a traumatic spine injury at the average age of 14 years (range 3-16 years) were clinically and radiographically reviewed. The fractures were separated into three groups: stable (n = 20) and unstable (n = 13) injuries without cord lesion and fractures with spinal cord lesion (n = 11). Mean follow-up was 18 years (range 9-23 years). Conservative treatment was successful in all stable fractures, whereas it failed in the unstable injuries. The surgical treatment stabilized without significant deformity in five of the seven unstable fractures. Of 11 with spinal cord injuries, the 4 children conservatively treated developed a severely progressive, paralytic scoliosis. Only three of the seven surgically treated patients were stabilized without any deformity at follow-up. In children and adolescents, conservative treatment is an available option for stable fractures without neurologic lesion. Early surgical treatment (instrumentation and fusion) is mandatory for unstable fractures and injuries associated with spinal cord lesion. In children, a traumatic spinal cord lesion may develop a deformity that is mainly scoliotic, kyphotic, or lordotic in >90% of the cases.

Recovery of neurologic function after spinal cord injury in Israel.

A retrospective cohort study was conducted. To assess neurologic recovery and the manner in which it is affected by the severity of the neurologic damage after spinal cord injury. Studies from various countries, but not from Israel, have shown considerable potential for recovery of the damaged human spinal cord. The study sample included 250 patients with a traumatic spinal cord lesion treated between 1962 and 1992 at the major referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from the hospital charts. The degree of neurologic recovery in each patient was determined by comparing the Frankel grade of neurologic deficit at first admission for rehabilitation with the grade at discharge from that hospitalization. There was median delay of 36 days between injury and admission for rehabilitation. During rehabilitation, full or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred in 27% of all the patients who were Grade A, B, or C on admission, and in 54% of those who were Grade C. The neurologic recovery was negatively associated with severity of the neurologic deficit. The outcome findings are similar to those reported from spinal rehabilitation units in other countries. The study is a further demonstration of the considerable potential for neurologic recovery after spinal cord injury, when posttraumatic or postsurgical management is focused on prevention of complications and maximal use of functional ability.