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Spinal Cord Injury Update

Winter 2007: Volume 16, Number 1

 

Literature Review

Respiratory

Outcomes of outpatient visits for acute respiratory illness in veterans with spinal cord injuries and disorders.
Respiratory complications are a leading cause of death in persons with spinal cord injuries and disorders (SCI&D). This retrospective study examined the rates of hospitalization and death in a national population of veterans with SCI&D. Between October 1997 and September 2002, 4,597 veterans made a total of 8,775 clinic visits due to acute respiratory illness (ARI), which included upper respiratory infections (URI), acute bronchitis, and pneumonia and influenza (P&I). Approximately half (49%) of all ARI visits were for URI, 28% for pneumonia, 21% for acute bronchitis, and 2% for influenza. Over 30% of visits resulted in hospitalization within 60 days, most of them due to respiratory causes, and almost half of all P&I diagnoses resulted in hospitalization on the same day as the visit. Death within 60 days of the clinic visit was 2.9% overall, but 7.9% for pneumonia. Compared to the general population, veterans with SCI&D are at greater risk for hospitalization and death in cases of ARI. Continued vigilance and use of preventive strategies are warranted.
Weaver FM, Smith B, Evans CT , et al.
Am J Phys Med Rehabil. 2006 Sep;85(9):718-26.

New CDC recommendations: annual influenza vaccination recommended for individuals with spinal cord injuries.
Respiratory complications are common in persons with SCI, and as a result, this population has a higher death rate from influenza than the general population. The Centers for Disease Control (CDC) recommends vaccine for certain high-risk groups, including people with chronic illnesses. Yet influenza vaccination rates are well below national targets for both the general population and high-risk groups. Vaccination rates in persons with SCI are unknown but thought to be low, especially in younger individuals, because persons with SCI often receive care only from specialists, who rarely recommend or give vaccinations, and because generalists who see this population may not know about the risks of respiratory complications in SCI and are less likely to recommend immunization to younger persons with SCI. Given the enormous benefits and relatively small risks of influenza vaccines for the SCI population, new education and information campaigns for providers and consumers are needed.
Goldstein B, Weaver FM, Hammond MC.
J Spinal Cord Med. 2005;28(5):383-4.

Bowel Management

A comparison of patient outcomes and quality of life in persons with neurogenic bowel: standard bowel care program vs colostomy.
A national survey that included questions about neurogenic bowel management was sent to 1,503 veterans with SCI; 58.4% responded, and of these 74 had colostomies and 296 used a standard bowel care program. There were no significant differences in satisfaction or quality of life between the veterans with colostomies and those with traditional bowel care programs. Respondents in both groups indicated that they experienced relatively few complications and their quality of life related to bowel care was generally good. Nevertheless, a large number (55.7% with colostomies; 41.7% without) reported dissatisfaction with their bowel care program, indicating that this is a major problem for veterans with SCI.
Luther SL, Nelson AL , Harrow JJ, et al.
J Spinal Cord Med. 2005;28(5):387-93.

Surgery for Obesity

Gastric bypass surgery in a paraplegic morbidly obese patient.
Persons with SCI who are also obese have complex medical and socioeconomic problems. While bariatric (gastric bypass) surgery has been successful in reducing the serious medical problems associated with obesity, this option has not been routinely offered to obese patients with SCI. This article describes the first case of a morbidly obese male with a SCI who underwent a successful Roux-en-Y gastric bypass.
Alaedeen DI, Jasper J.
Obes Surg. 2006 Aug;16(8):1107-8.

Urology

Botulinum toxin-type A in the treatment of drug-resistant neurogenic detrusor overactivity secondary to traumatic spinal cord injury.
Botulinum toxin-type A (BTX-A) was injected into the detrusor (bladder) muscle of 37 patients with SCI and neurogenic detrusor overactivity (NDO, also known as "overactive bladder") that was not controlled adequately with anticholinergic drugs. After BTX-A injection, 25 (86%) of the 29 patients who used anticholinergics were able to stop the drug or reduce their daily dosage. There was also an overall significant increase in bladder capacity and decrease in bladder pressure. Incontinence and NDO were eliminated in 82% and 76% of patients, respectively. Symptoms improved for an average of 9 months.. Scores on Quality of Life questionnaires also improved. BTX-A injection has few side-effects or complications and is an effective treatment for drug-resistant NDO in patients with SCI.
Patki PS, Hamid R, Arumugam K, et al.
BJU Int. 2006 Jul;98(1):77-82.

Intermittent catheterization in the rehabilitation setting: a comparison of clean and sterile technique.
Thirty-six inpatients with cervical SCI requiring intermittent catheterization were randomized to either clean (16 subjects) or sterile (20 subjects) intermittent catheterization. Of these, six in the clean group and nine in the sterile group developed symptomatic urinary tract infections (UTIs), suggesting that clean intermittent catheterization is safe in the rehabilitation setting, has significant cost and time saving benefits, and enhances transition for the patient from rehabilitation to the community.
Moore KN, Burt J, Voaklander DC.
Clin Rehabil. 2006 Jun;20(6):461-8.

Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder.
Eighty-nine subjects with neurogenic bladder were randomized to irrigate their bladders twice daily for 8 weeks with 30 mL of either (a) sterile saline, (b) acetic acid, or (c) neomycin-polymyxin solution. Urinalysis, cultures, and antimicrobial susceptibility tests were performed at baseline and weeks 2, 4, and 8 to see whether the solutions affected numbers and types of bacteria, urinary pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. None of the 3 irrigants had a detectable effect on the degree of bacteriuria or pyuria in 52 persons who completed the study protocol. Bladder irrigation was generally well tolerated. No advantages were detected for neomycin-polymyxin or acetic acid over saline, and the researchers conclude that bladder irrigation does not reduce bacteriuria in persons with neurogenic bladder.
Waites KB, Canupp KC, Roper JF, et al.
J Spinal Cord Med. 2006;29(3):217-26.

Pain

A comprehensive pain management programme comprising educational, cognitive and behavioural interventions for neuropathic pain following spinal cord injury.
Twenty-seven outpatients with SCI and neuropathic pain participated in a 10-week, twice-weekly pain management program consisting of educational sessions, cognitive behavioral therapy, relaxation, stretching, light exercise and body awareness training. A control group of 11 patients with SCI and neuropathic pain was selected for comparison. Participants completed questionnaires measuring pain, sleep quality, mood, quality of life and life satisfaction at baseline, 10 weeks, and 3, 6 and 12 months. In the treatment group, anxiety and depression decreased significantly between baseline and 12 months, and depression improved compared to the control group. This study suggests that a multidimensional pain management program can be a valuable complement in the treatment of SCI patients with neuropathic pain.
Norrbrink Budh C, Kowalski J, Lundeberg T.
J Rehabil Med. 2006 May;38(3):172-80.

Low Testosterone in SCI

Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation.
Total serum testosterone level, prealbumin, albumin, hematocrit and aspartate aminotransferase were measured in 92 men with SCI who had been injured 15 years or less. Low testosterone levels (<241 ng/dl) were present in 83% of men with acute injuries (<4 months), but only 7% of men with subacute SCI (4-12 months) and 10% of chronic SCI (>12 months). The median testosterone level for men who sustained injuries <4 months earlier was 160 ng/dl. Age, time since injury, and hematocrit levels were significant predictors of low testosterone. Low testosterone is high among men with acute SCI, suggesting a need for routine screening for low testosterone in this group and consideration given to testosterone replacement therapy.
Schopp LH, Clark M, Mazurek MO , et al.
Am J Phys Med Rehabil. 2006 Aug;85(8):678-84; quiz 685-7.

Neural Repair

Neurological aspects of spinal-cord repair: promises and challenges.
This review article explains the main challenges of translating spinal repair methods that have been successful in animals into human studies. Artificial transection of the spinal cord in animals does not cause the same damage as the contusion injuries typical in human SCI, which usually affects both central and peripheral nerves and causes large cysts and scar formation. There are significant differences between rats and humans in the mode of locomotion (quadrupedal vs. bipedal) and autonomic system functions, which is more complex and important in humans. The extensive damage of motor neurons and roots associated with spinal-cord contusion is not addressed in current animal studies and has direct implications for rehabilitation strategies and functional outcome. Problems associated with chronic complete SCI, such as degradation of neuronal function below the level of the lesion, further complicate regeneration-inducing treatment.
Dietz V, Curt A.
Lancet Neurol. 2006 Aug;5(8):688-94.

Therapeutic interventions after spinal cord injury.
The authors review the cellular and molecular strategies for spinal cord repair that are supported by more than one peer-reviewed animal experiment and that result in functional improvements after SCI, including transplantation of cells (peripheral nerve, Schwann, olfactory, embryonic and adult stem/progenitor), tissues (embryonic CNS), and macrophages; use of neuroprotective therapies (growth factors, myelin inhibitors); and locomotive training (treadmill, robotic, FES-assisted). Many of these strategies have reached, or are approaching, clinical trial. The authors emphasize a need for reproducible evidence of safety and efficacy in all trials, and recommend that preclinical studies be reproduced by independent laboratories. Individual therapies are unlikely to emerge as a cure for SCI. Rather, the authors predict that tailored combinations of strategies will lead to cumulative improvements in outcome after different types of SCI.
Thuret S, Moon LD, Gage FH.
Nat Rev Neurosci. 2006 Aug;7(8):628-43.

Recovery of Walking

Spinal and brain control of human walking: implications for retraining of walking.
The authors review the evidence for both spinal and brain regulation of walking in humans. They describe the sensory control of walking in young babies and spinal-cord-injured adults, two models with weak descending input from the brain, suggesting that subcortical structures are important in shaping walking behavior. The primitive pattern of walking seen in babies forms the base upon which additional features are added by supraspinal input as independent walking develops. Increasing evidence suggests the motor cortex is important in the control of level-ground walking in adults, in contrast to quadrupedal animals. This brain input seems particularly important for distal flexors in the leg. Recovery of walking after incomplete SCI may depend on the presence of descending input from the motor cortex and our ability to strengthen that input, implying that training methods for improving walking after injury to the nervous system must promote the involvement of both spinal and brain circuits.
Yang JF, Gorassini M.
Neuroscientist. 2006 Oct;12(5):379-89.