Spinal Cord Injury Update
Spring 2003
Literature Review
The articles previewed below were selected from a monthly screening of the National Library of Medicine database for articles on spinal cord injury. In the judgment of the editors, they include potentially useful information on the diagnosis or management of spinal cord injury. A request to your local medical library is the fastest and least expensive method to obtain copies of the complete articles. Articles can also be obtained from UW Health Sciences Library Document Delivery Service (call 206-543-3436 for fee schedule).
Contents
Acute Care
Impact of respiratory complications on length of stay and hospital costs in acute cervical spine injury.
A retrospective analysis of 413 patients admitted with acute traumatic cervical spinal injury (exclusive of concurrent thoracic injuries) and discharged alive, found that both mean length of stay (LOS) and total hospital costs increased with the number of respiratory complications experienced, and that four variables-use of mechanical ventilation, occurrence of pneumonia, need for surgery, and use of tracheostomy-explain nearly 60% of the variance in both LOS and hospital costs. The authors conclude that the number of respiratory complications experienced during the initial acute-care hospitalization for CSI is a more important determinant of LOS and hospital costs than is level of injury.
Winslow C, Bode RK, Felton D, et al.
Chest 2002 May;121(5):1548-54
Complications
Efficacy of amitriptyline for relief of pain in spinal cord injury: results of a randomized controlled trial.
Eighty-four participants with SCI and chronic pain were randomized to a 6-week double-blind trial of amitriptyline or an active placebo, benztropine mesylate. Results indicate that amitriptyline was not efficacious in reducing chronic pain or disability or improving quality of life in persons with SCI and chronic pain. However, amitriptyline was found helpful by a small proportion of subjects (18%) who chose to continue on the drug after unblinding.
Cardenas DD, Warms CA, Turner JA, et al.
Pain 2002 Apr;96(3):365-73
Gabapentin for neuropathic pain following spinal cord injury.
In a retrospective review of 38 patients with SCI who received gabapentin, 76% reported a reduction in neuropathic pain, which was assessed before and during treatment at 1, 3 and 6 months with a 10 cm visual analogue scale ranging from 0 (`no pain') to 10 (`worst pain imaginable'), or by verbal descriptors of pain. In those patients with data at all four measurement points, the mean pretreatment score was 8.86; the score dropped to 5.23, 4.59 and 4.13 at 1, 3 and 6 months after treatment, respectively. Gabapentin may offer an effective therapeutic alternative for the alleviation of neuropathic pain following SCI.
To TP, Lim TC, Hill ST, et al.
Spinal Cord 2002 Jun;40(6):282-5
Upper-extremity deep vein thrombosis associated with peripherally inserted central catheters in acute spinal cord injury: a report of 2 cases.
Catheter-associated upper-extremity deep vein thrombosis (DVT) carries a 12% to 36% risk of pulmonary embolism (PE). Acute SCI is a thrombophilic state resulting from altered fibrinolytic and platelet function and abnormal concentrations of clotting factors. Patients with SCI are frequently burdened with the classic risk factors of Virchow's triad including stasis, hypercoagulability, and intimal trauma. Two patients with acute cervical SCI developed insidious venous thrombosis of the upper extremity associated with peripherally inserted central catheters, and 1 patient developed a large PE. A high index of suspicion is necessary to make the diagnosis, and prompt aggressive anticoagulation is warranted absent contraindications.
Hyman GS, Cardenas DD.
Arch Phys Med Rehabil 2002 Sep;83(9):1313-6
Treatments for chronic pain associated with spinal cord injuries: many are tried, few are helpful.
A postal survey assessed pain treatments and helpfulness and the Chronic Pain Grade questionnaire answers in two groups of adults with SCI and pain in the community (n=308 and n=163). Respondents reported multiple pain treatments, most commonly oral medications and physical therapy. Medications most commonly reported were nonsteroidal anti-inflammatory drugs, acetaminophen and opioids, whereas the most helpful treatments were opioids, physical therapy, and diazepam, and least helpful were spinal cord stimulation, counseling or psychotherapy, acetaminophen and amitriptyline. Alternative treatments reported as most helpful were massage therapy and marijuana. Acupuncture was tried by many but rated only moderately helpful.
Warms CA, Turner JA, Marshall HM, Cardenas DD.
Clin J Pain 2002 May-Jun;18(3):154-63
Catastrophizing is associated with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain after spinal cord injury.
In this study, 174 community residents with SCI and chronic pain completed a mailed questionnaire that included the SF-36 Mental Health scale, Coping Strategies Questionnaire (CSQ), and Graded Chronic Pain Scale. The pain coping and catastrophizing measures explained 29% of the variance in pain intensity, 30% of the variance in psychological distress and 11% of the variance in pain-related disability. Catastrophizing was the only CSQ scale associated significantly and independently with the outcome measures. Potentially, the assessment and treatment of catastrophizing may reduce psychological distress and pain-related disability among individuals with chronic pain and SCI.
Turner JA, Jensen MP, Warms CA, Cardenas DD.
Pain 2002 Jul;98(1-2):127-34
Medical Rehabilitation Care
A comparison of heparin/warfarin and enoxaparin thromboprophylaxis in spinal cord injury: the Sheffield experience.
In a retrospective review of two cohorts of patients with acute SCI, one group received heparin/warfarin in combination with antiembolism stockings and mechanical measures for thromboprophylaxis; the second group received enoxaparin in combination with the other measures. Four of the 101 patients on heparin/warfarin developed symptoms of venous thromboembolism compared to 13 of the 72 who were on enoxaparin. Of the 13, three had been on 40 mg of enoxaparin daily and 10 on 20 mg. This study suggests that the traditional protocol of warfarin/heparin for thromboprophylaxis remains a safer option than enoxaparin for patients with SCI.
Thumbikat P, Poonnoose PM, Balasubrahmaniam P, et al.
Spinal Cord 2002 Aug;40(8):416-20
Outcome
Late recovery following spinal cord injury. Case report and review of the literature.
A man with C-2 tetraplegia, ASIA A, had no substantial recovery in the first 5 years after SCI from an equestrian accident and was unable to breathe without assisted ventilation. Five years after injury, the subject began an "activity-based recovery" program. After 3 years the patient's condition improved from ASIA A to ASIA C; motor scores improved from 0/100 to 20/100; and sensory scores rose from 5-7/112 to 58-77/112. Recovery also included reversal of osteoporosis; increase in muscle mass; and decrease in spasticity, medical complications, infections and use of antibiotics. The role of patterned neural activity in regeneration and recovery of function after SCI is a fruitful area for future investigation.
McDonald JW, Becker D, Sadowsky CL, et al.
J Neurosurg 2002 Sep;97(2 Suppl):252-65
Rehabilitation Therapies
Intensive exercise may preserve bone mass of the upper limbs in spinal cord injured males but does not retard demineralisation of the lower body.
This cross-sectional study compared 17 active males with SCI to active able-bodied male controls matched for age, height, and weight. All had physical activity levels in excess of 60 minutes per week over and above that required for rehabilitation. Dual energy X-ray absorptiometry scanning was used to determine bone mass. Bone mineral density (BMD) values of the total body, hip region and leg were significantly lower in the SCI group than in their controls, and bone mineral content (BMC) of the leg was also significantly lower in the SCI group. By contrast, lumbar spine BMD and arm BMD and BMC did not differ between the SCI and control groups.
Jones LM, Legge M, Goulding A.
Spinal Cord 2002 May;40(5):230-5
Functional electric stimulation-assisted rowing: Increasing cardiovascular fitness through functional electric stimulation rowing training in persons with spinal cord injury.
Six persons with level C7-T12 SCI (ASIA A-C) participated in a 36-session, progressive functional electric stimulation (FES) rowing hybrid training program consisting of three 30-minute sessions per week for 12 weeks at 70%-75% of pretest peak functional aerobic power during FES rowing on an open loop control, FES-assisted rowing machine. After training (22-36 sessions), rowing distance increased significantly by 25%, peak oxygen consumption by 11.2%, and peak oxygen pulse by 11.4%. Heart rate response to hybrid training did not change at the end of training, although peak heart rate with FES lower-extremity exercise increased significantly from pre- to post-training. FES-assisted rowing is an effective, safe, and well-tolerated training system for persons with SCI.
Wheeler GD, Andrews B, Lederer R, et al.
Arch Phys Med Rehabil 2002 Aug;83(8):1093-9
Knee cartilage of spinal cord-injured patients displays progressive thinning in the absence of normal joint loading and movement.
Morphologic parameters of the knee cartilage (mean and maximum thickness as well as surface area) were computed from magnetic resonance imaging (MRI) data in patients with complete SCI (C2-L1) at 6 (n=9), 12 (n=11), and 24 months (n=6) after injury, and compared with 9 healthy volunteers. Six months after injury, the mean articular-cartilage thickness was significantly less in the patella and medial tibia (decrease of 10% and 16%, respectively) but not in the lateral tibia (decrease of 10%), compared with healthy volunteers. Twelve and 24 months after injury, the differences amounted to, respectively, a reduction of 21% and 23% in the patella, 24% and 25% in the medial tibia, and 16% and 19% in the lateral tibia. These data show, for the first time, that atrophy of human cartilage occurs in the absence of normal joint loading and movement.
Vanwanseele B, Eckstein F, Knecht H, et al.
Arthritis Rheum 2002 Aug;46(8):2073-8
Urology
Does fluid amount and choice influence urinary stone formation in persons with spinal cord injury?
Forty-one patients with SCI who were diagnosed with urinary stones between 1992 and 1998 and 171 age- and duration-matched controls were interviewed by telephone. Stone cases were more likely than controls to be white, current smokers, users of indwelling catheterization, and to have a lower body mass index (kg/m(2)), worse renal function, and higher urine specific gravity (P<.10). A greater consumption of juice (>207mL/d) was associated with a 70% decreased risk in stone formation after adjusting for other risk factors. An interesting, but not significant (P=.15), increased risk for coffee consumption was observed. There was no association for total fluid intake
Chen Y, Roseman JM, Devivo MJ, et al.
Arch Phys Med Rehabil 2002 Jul;83(7):1002-8
Recurrent kidney stone: a 25-year follow-up study in persons with spinal cord injury.
In a consecutive sample of 77 patients with SCI and initial kidney stones followed up on a yearly basis between 1973 and 1999, there were 19 patients with recurrence, 15 with residual stones, and 43 who were stone-free over an average of 7 years (range 1 to 21). It was estimated that approximately 34% of the patients with an initial stone would develop a second stone episode within 5 years. This figure did not significantly change during the past 25 years. Stone recurrence was two or more times greater for men than for women, for whites than for blacks, and for tetraplegics than for paraplegics, but differences were not statistically significant. Renal function did not significantly decline over time for any of the post-treatment outcomes of the initial stones. Despite marked improvement in urologic rehabilitation, little progress has been made during the past 25 years in reducing stone recurrence in persons with SCI.
Chen Y, DeVivo MJ, Stover SL, et al.
Urology 2002 Aug;60(2):228-32