Spinal Cord Injury Update
Summer 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
BOWEL MANAGEMENT
Silent autonomic dysreflexia during a routine bowel program in persons with traumatic spinal cord injury: a preliminary study.
Ten subjects with chronic, complete SCI with a neurologic level of injury above T6, stable bowel program, and no known history of autonomic dysreflexia (AD) were fitted with an automated vital sign-recording device that monitored systolic (SBP) and diastolic (DBP) blood pressures and heart rate during a routine bowel program. The mean resting blood pressure for the subject group was 104/65 mmHg. During the bowel program, no subject reported any of the classic symptoms of AD. The mean maximum blood pressure recorded during the bowel program was 160/90 mmHg. All of the patients had an increase in SBP greater than 20 mmHg above baseline; 70% had an increase in SBP greater than 40 mmHg above baseline; 60% had an increase in SBP greater than 150 mmHg; and 40% reached an SBP greater than 170 mmHg at least once during their bowel program. Silent AD occurs frequently in SCI during bowel programs.
Kirshblum SC, House JG, O'connor KC.
Arch Phys Med Rehabil 2002 Dec;83(12):1774-6
Decreased colonic motility in persons with chronic spinal cord injury.
Colonoscopy was performed on 8 subjects with SCI (4 with paraplegia and 4 with tetraplegia) and 6 age-matched spinally intact (SI) controls with the proximal end of a solid state pressure transducer catheter (four sensors each separated by 10 cm) tethered to the splenic flexure using endoclips. Baseline colonic activity of the SCI group was significantly less than in SI subjects. During meals, the motility index, mean amplitude of the waves, percent activity, and number of waves was significantly less in the SCI group. In both groups, a postprandial colonic response was observed. However, in the SCI group, the response was seen only in the descending colon and not in the rectosigmoid region.
Fajardo NR, Pasiliao RV, Modeste-Duncan R, et al.
Am J Gastroenterol 2003 Jan;98(1):128-34
The effects of colostomy on the quality of life in patients with spinal cord injury: a retrospective analysis.
A quality of life (QOL) questionnaire was given to 27 persons with SCI who had undergone colostomies for chronic bowel dysfunction. All 27 patients were "satisfied" and 16 (59%) were "very satisfied" with colostomy; 19 (70%) would have preferred colostomy earlier and 3 (11%) wished it reversed. Colostomy reduced the number of hospitalizations caused by chronic bowel dysfunction by 70.4% and reduced the average time spent on bowel care from 117.0 min/day to 12.8 min/day. Stoma prolapse and wound dehiscence were the most common complications of stomal surgery. Colostomy is a safe, effective and well-accepted treatment for chronic bowel dysfunction in patients with SCI and significantly improves QOL and bowel management procedures.
Rosito O, Nino-Murcia M, Wolfe VA, et al.
J Spinal Cord Med 2002 Fall;25(3):174-83
COMPLICATIONS
Shoulder biomechanics and muscle plasticity: implications in spinal cord injury.
Overall, 51% of persons with spinal cord injury have shoulder problems. These begin with muscle imbalance that can lead to glenohumeral instability, impingement disease, rotator cuff tears and subsequent degenerative joint disease, and can be attributed to functional demands such as overhead activities, wheelchair use and transfers. Despite preventive exercises, shoulder problems in persons with SCI remain a significant problem, causing pain and functional limitations. This article reviews the biomechanics of the shoulder resulting from changes in muscle plasticity, and addresses the effects of scapular protraction that can result from muscle imbalance, the age-dependent properties of the anterior band of the inferior glenohumeral ligament, and the influence of the dynamic restraints around the shoulder.
Lee TQ, McMahon PJ.
Clin Orthop 2002 Oct;(403 Suppl):S26-36
Posttraumatic syringomyelia: predisposing factors.
Analysis of all symptomatic posttraumatic syringomyelia (PTS) patients (n = 58) treated at the Univ. of Toronto over 30 years found that 28 patients had cervical and 30 had thoracic and lumbar SCI; 40 (69%) had complete injuries (compared with 43% complete injuries in the general SCI population). Onset of PTS was earlier with increasing age, cervical and thoracic levels of injury (compared with lumbar injuries), and dislocated fractures and spinal instrumentation without decompression. Mean time to onset of PTS has decreased in recent years. PTS follows complete SCI more often than incomplete and is frequently associated with arachnoiditis..
Vannemreddy SS, Rowed DW, Bharatwal N.
Br J Neurosurg 2002 Jun;16(3):276-83
Quantitative ultrasound assessment of acute bone loss following spinal cord injury: a longitudinal pilot study.
This longitudinal pilot study assessed bone changes in 15 males with SCI over a 6-week period using quantitative ultrasound (QUS) and dual-energy X-ray absorptiometry (DXA). Mean time since SCI was 110.3 days. DXA assessment showed decreases in bone mineral density of the calcaneus and proximal tibia by 7.5% and 5.3%, respectively. QUS was sensitive to these changes. Calcaneal broadband ultrasound attenuation decreased by 8.5%, and speed of sound decreased by 1.5%. Overall, this study confirmed the rapid onset of bone loss following SCI and showed QUS to be a useful portable measure of acute bone changes soon after injury, a period when traditional axial DXA assessment is limited by practical constraints.
Warden SJ, Bennell KL, Matthews B, et al.
Osteoporos Int 2002 Jul;13(7):586-92
Interface pressure characteristics of alternating air cell mattresses in persons with spinal cord injury.
A force-sensing array system was used to examine interface pressure characteristics of two alternating air cell mattresses used for pressure ulcer prevention and treatment in the SCI population. Analyses were performed on 15 subjects with SCI in the supine and 45-degree upright positions for both mattresses. The sacrum was chosen as the area of interest. Maximum and average interface pressures and interface pressure ranges were significantly higher, whereas minimum interface pressures were significantly lower on the Pegasus Airwave Mattress vs the Dynamic Flotation System (DFS) mattress. For either mattress, the 45-degree position resulted in significantly greater interface pressures. Twelve subjects preferred the DFS, 2 preferred the Pegasus, and 1 had no preference. The most clinically relevant interface pressure characteristic remains undetermined. Avoidance of the 45-degree sitting position is recommended.
Goetz LL, Brown GS, Priebe MM.
J Spinal Cord Med 2002 Fall;25(3):167-73
GENITOURINARY
The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up.
Twelve men with tetraplegia underwent external striated sphincter stenting with the UroLume wallstent instead of external sphincterotomy for detrusor external sphincter dyssynergia (DESD). Urodynamic follow-up of the seven patients who completed 12-year follow-up showed a significantly sustained reduction in maximum detrusor pressure and duration of detrusor contraction. Five patients developed bladder neck dyssynergia and were successfully treated with bladder neck incision. There were no problems with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. Permanent urethral stenting using the UroLume wallstent is effective in managing DESD and provides an acceptable long-term alternative to sphincterotomy. The procedure is also reversible, minimally invasive and requires a shorter hospital stay.
Hamid R, Arya M, Patel HR, Shah PJ.
BJU Int 2003 Jan;91(1):51-3
Efficacy and safety of sildenafil citrate (Viagra) in men with erectile dysfunction and spinal cord injury: a review.
A literature search identified 2 randomized controlled trials and 4 prospective case series that evaluated sildenafil treatment for erectile dysfunction from SCI. For general efficacy, the proportion of patients who reported improved erections and ability to have intercourse was as high as 94%. Up to 72% of intercourse attempts were successful. For measures of erectile function, 5 of the 6 studies showed statistically significant improvements among sildenafil-treated versus placebo-treated patients. Erectile response rates were generally higher in patients with incomplete versus complete SCI and in patients with upper versus lower motor neuron lesions. Sildenafil was well tolerated; no symptoms of autonomic dysreflexia were reported.
Derry F, Hultling C, Seftel AD, Sipski ML.
Urology 2002;60(Suppl 2B):49-57
OTHER
Military gunshot wound-induced spinal cord injuries.
Data were prospectively reviewed on 105 consecutive male patients with military gunshot-caused SCI admitted to the rehabilitation unit of a military medical school in Turkey over a two-year period. Military gunshot wounds are made by high-velocity weapons and have a greater wounding capacity than low-velocity, civilian weapons. As compared with Model Systems data on civilian gunshot-caused SCIs, the subjects in this study had a higher percentage of complete injuries and a higher rate of spinal surgery. Contrary to expectations, high-velocity gunshot wounds did not have more SCI-related medical complications than low-velocity wounds, and only bladder calculi had a higher incidence.
Alaca R, Yilmaz B, Goktepe AS, Yazicioglu K, Gunduz S.
Mil Med 2002 Nov;167(11):926-8
Gabapentin effect on neuropathic pain compared among patients with spinal cord injury and different durations of symptoms.
Thirty-one patients with neuropathic pain and SCI or cauda equina syndrome were divided into two groups: 13 with less than 6 months pain duration (Group 1) and 18 with more than 6 months (Group 2). Pain in these patients was refractory to conventional analgesics. In this study, conventional analgesics were continued at a therapeutic level, and gabapentin was administrated for an 18-day titration period followed by a 5-week maintenance period at a dosage of 1800 mg/day (up to 3600mg/day as tolerated). The efficacy of gabapentin administration was gauged by a pain score and a sleep interference score every 2 weeks using a visual analogue scale. A significant reduction in mean pain and sleep interference scores occurred in both groups (with the largest reduction in Group 1) after 2 weeks, and a further reduction after 4 weeks that continued at that level to 8 weeks. Some mild or moderate adverse effects were noted.
Ahn SH, Park HW, Lee BS, et al.
Spine 2003 Feb 15;28(4):341-6; discussion 346-7
Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being.
Thirty-four men and women (aged 19-65 years) with SCI (C4-L1; ASIA A-D) of 1-24 years duration were randomized into exercise (EX; n=21) and control (CON; n=13) groups. Subjects were assessed for one repetition maximum (1RM) strength, arm ergometry performance, and several indices of quality of life (QOL) and psychological well-being at baseline, 3, 6 and 9 months. At baseline, there were no significant differences between groups in age, submaximal arm ergometry performance, muscle strength, or psychological well-being. Following progressive exercise training twice-weekly for 9 months, the EX group had significant increases in submaximal arm ergometry power output (81%), and upper body muscle strength (19-34%). No significant changes occurred in the CON group, which received bi-monthly education sessions about exercise. Participants in the EX group reported significantly less pain, stress and depression after training, and scored higher than CON in indices of satisfaction with physical function, level of perceived health and overall QOL.
Hicks AL, Martin KA, Ditor DS, et al.
Spinal Cord 2003 Jan;41(1):34-43