Literature Review
The articles previewed below were selected from a recent 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. You may obtain copies of the complete articles through your local medical library or from UW Health Sciences Library Document Delivery Service (call 206-543-3436 for fee schedule).
Contents:
Bone Loss | Pain | Other complications | Miscellaneous
BONE LOSS
Fracture threshold in the femur and tibia of people with spinal cord injury as determined by peripheral quantitative computed tomography.
Peripheral quantitative computed tomography (pQCT) measurements of the tibia and femur were completed and post- SCI fracture history was obtained in 99 subjects with motor complete ( ASIA A and B) SCI . Twenty-seven subjects had sustained a fracture of the lower extremities, of which 18 were to either the tibia or fibula. Trabecular (spongy) bone mineral density (BMD) of the femur and tibia distal epiphyses was the most sensitive parameter for distinguishing SCI subjects with and without fractures and can only be determined by pQCT (and not by dual-energy x-ray absorptiometry). Fractures occurred in subjects with trabecular BMD of less than 114 mg/cm 3 and less than 72 mg/cm 3 for the femoral and tibial distal epiphysis, respectively. Approximately 50% of the subjects with chronic SCI (longer than 5 years for femur data and 7 years for tibia) had trabecular BMD values above the fracture threshold in the femur and about one third above the fracture threshold in the tibia. pQCT may help identify subjects who are at risk of fracture through minor trauma.
Eser P, Frotzler A, Zehnder Y, Denoth J.
Arch Phys Med Rehabil. 2005 Mar;86(3):498-504.
Trabecular bone is more deteriorated in spinal cord injured versus estrogen-free postmenopausal women.
Osteoporosis is common in postmenopausal women and individuals with SCI . In this study, the effects of estrogen loss (due to menopause) and unloading (non-weight-bearing) on the trabecular (spongy) bone of the knee were assessed in 17 pre- and postmenopausal ambulatory women and in 20 pre- and postmenopausal women with SCI . High-resolution magnetic resonance imaging was used to compare groups on measures of trabecular bone density in the distal femur and proximal tibia, which is the most common fracture site in the SCI population. Trabecular bone of the knee was deteriorated in women with SCI compared to ambulatory women, and premenopausal women with SCI had more bone loss than postmenopausal ambulatory women, suggesting that unloading has a greater influence on bone density than estrogen loss.
Slade JM, Bickel CS, Modlesky CM, et al.
Osteoporos Int. 2005 Mar;16(3):263-72. Epub 2004 Aug 28.
Effect of alendronate on bone mineral density in spinal cord injury patients: a pilot study.
Nineteen subjects with SCI longer than 6 months and classified as ASIA A, B or C were randomly assigned to a control or experimental group. Controls received 1000 mg of calcium daily, and the experimental group received 1000 mg of calcium plus 10 mg of alendronate daily. Bone density parameters were analyzed using whole-body dual-energy X-ray absorptiometry at baseline and after 6 months. The experimental group showed improvements in 9 of the 12 bone density parameters measured, although changes were significant in only two parameters. In the control group, an increase in bone density was observed in only one parameter, and the remaining 11 presented either no change or a decrease. Alendronate had a positive effect on bone mineral density in SCI patients and therefore represents a potential tool for prevention and treatment of osteoporosis in this population.
Moran de Brito CM, Battistella LR, et al.
Spinal Cord. 2005 Jun;43(6):341-8.
PAIN
Intravenous lidocaine relieves spinal cord injury pain: a randomized controlled trial.
Twenty-four SCI patients with neuropathic pain at or below the level of injury completed a double-blind crossover trial of the sodium channel blocker lidocaine versus placebo infused over 30 minutes. Subjects were assigned to two groups: those with and those without evoked pain (pain due to a normally non-painful stimulus), and then randomized to receive either lidocaine or placebo. Pain was assessed using a visual analog scale and quantitative sensory testing. Lidocaine significantly reduced pain in all patients and in each of the two groups with and without evoked pain. Also, more patients were responders (defined as those who experienced a 33% reduction in pain) to lidocaine (11 subjects) than to placebo (2 subjects). Agents (such as anticonvulsants or antiarrhythmics) with sodium channel-blocking properties may be a treatment option for SCI pain.
Finnerup NB, Biering-Sorensen F, Johannesen IL, et al.
Anesthesiology. 2005 May;102(5):1023-30.
Pain following spinal cord injury: the impact on community reintegration.
To examine the relationship between pain and community integration, subjects from 66 consecutive admissions to an inpatient SCI center were followed prospectively. Standardized pain assessments were performed on admission, discharge and 6 months of community living and correlated with assessments of community reintegration using the Reintegration to Normal Living Index. In all, 86% of individuals with SCI reported pain at six months postdischarge, and 27% of these persons had pain that negatively affected activities. Pain intensity alone had the largest single effect on community integration. The results of this study highlight the need to address pain during both the rehabilitation phase of treatment and the early transition into the community.
Donnelly C, Eng JJ.
Spinal Cord. 2005 May;43(5):278-82.
Quality of sleep in individuals with spinal cord injury: a comparison between patients with and without pain.
Mailed questionnaires about pain, mood and sleep quality were completed by 191 persons with SCI . Respondents were divided into three groups according to whether they reported: (1) no pain (50 respondents), (2) intermittent pain (42), or (3) continuous pain (99). Patients reporting continuous pain rated pain intensity and unpleasantness significantly higher than those with intermittent or no pain, and had the poorest quality of sleep and the highest ratings of anxiety and depression. Anxiety, together with pain intensity and depression, were the main predictors for poor sleep quality. Melatonin-a neuromodulator involved in regulating anxiety, depression, pain and sleep-is decreased in persons with SCI , and as such is an important avenue for further research.
Norrbrink Budh C, Hultling C, Lundeberg T.
Spinal Cord. 2005 Feb;43(2):85-95.
OTHER COMPLICATIONS
A longitudinal evaluation of sleep and breathing in the first year after cervical spinal cord injury.
To examine the incidence of sleep disordered breathing (SDB) after acute tetraplegia and to determine the relation between the Apnea-Hypopnea Index score and selected SDB predictors (benzodiazepine use; measures of respiratory function; neck and abdominal circumference) in tetraplegia, full polysomnography (sleep studies) was performed, and spirometry, maximum inspiratory and expiratory pressures, medication usage, and neck and abdominal girth were assessed in 20 subjects immediately after acute tetraplegia and at 2, 4, 13, 26, and 52 weeks postinjury. Preinjury SDB was estimated using the multivariate apnea prediction equation. Thirteen subjects completed 12 months of follow-up. Three subjects had probable SDB before injury. In the first 48 hours after injury, no subject had SDB. At 2 weeks, 60% had SDB; at 4 weeks, 62%; at 13 weeks, 83%; at 26 weeks, 68%; and at 52 weeks, 62%. While SDB is common in acute SCI and peaks around three months, no relation was found between the SDB predictors and presence of SDB.
Berlowitz DJ, Brown DJ, Campbell DA, Pierce RJ.
Arch Phys Med Rehabil. 2005 Jun;86(6):1193-9.
Evolving risk for thromboembolism in spinal cord injury (SPIRATE Study).
Two groups of patients admitted to the SCI unit of a rehabilitation hospital during different time periods and tested for venous thromboembolism (VTE) were compared on rates of VTE. The recent group, seen during 1999-2003, consisted of 76 patients, and the previous group, seen during 1992-95, of 243 patients. Analysis variables included level and completeness of SCI , concomitant injuries, surgical procedures, complications, preexisting illnesses, and use of antithrombotic medications. Six (7.9%) subjects in the recent group had VTE, which was a significant decrease from the previous group, in which 21% had VTE. The major differences between the recent and previous patient samples were a decrease in the use of unfractionated heparin (15.8% vs. 56.8%) and an increase in the use of low molecular weight heparin (LMWH) (81.6% vs. 59.7%). This study confirms that the recent switch from unfractionated heparin to LMWH for the prevention of VTE has coincided with a decrease in the frequency of this complication.
Green D, Sullivan S, Simpson J, et al..
Am J Phys Med Rehabil. 2005 Jun;84(6):420-2.
Pressure ulcer prevalence in people with spinal cord injury: age-period-duration effects.
This was a multicenter cohort study of 3,361 individuals with SCI from 9 Model SCI Systems who were injured between 1986 and 1995 and followed up annually through 2002. At follow-up, 33% were found to have a physician-confirmed pressure ulcer of stage II or greater. Data analysis showed a significant trend toward increasing pressure ulcer prevalence in the recent years (1994-2002 vs 1984-1993) not explained by aging, years since injury, or demographic and clinical factors, but possibly due to shortened length of hospital stay. The risk of pressure ulcers was steady during the first 10 years postinjury and increased after 15 years. Pressure ulcers were more common among the elderly, men, African Americans, singles, subjects with education less than high school, unemployed, subjects with complete injury, and subjects with history of pressure ulcers, rehospitalization, nursing home stay, and certain medical conditions. Injury cause and level had no significant effect.
Chen Y, Devivo MJ, Jackson AB.
Arch Phys Med Rehabil. 2005 Jun;86(6):1208-13.
MISCELLANEOUS
Psychogenic and pharmacologic induction of the let-down reflex can facilitate breast-feeding by tetraplegic women: a report of 3 cases.
A functional let-down reflex is required to provide adequate milk to a nursing infant. Infant suckling activates tactile receptors in the breast, and this signal is carried via afferent nerves in the T4-6 dorsal roots to the spinal cord and then to neurons in the hypothalamus, which release oxytocin into the bloodstream. Oxytocin triggers milk ejection from the breast (the let-down reflex). Although suckling-induced afferent stimuli are absent in women with SCI above T4 and are reduced if the injury is between T4 and T6, three women in this report (C8, ASIA B; C8, incomplete; C6-7, ASIA A) maintained breast-feeding for 12-54 weeks after delivery using active mental imaging and relaxation techniques or oxytocin nasal spray to induce let-down.
Cowley KC.
Arch Phys Med Rehabil. 2005 Jun;86(6):1261-4.
Measuring energy expenditure using heart rate to assess the effects of wheelchair tire pressure.
Three women and 11 men with SCI between T4 and L1 participated in four trials of wheelchair propulsion with tires inflated at four different pressures (100, 75, 50 and 25 psi). Each subject wheeled at a constant self-selected velocity for 8 minutes, with 10-minute rests between trials. Oxygen consumption, heart rate and distance traveled were recorded during each trial. Tire pressure was found to affect the amount of energy required for propulsion, but only when tires are substantially deflated (50% or less than maximum recommended value). Tire pressures below 50% inflation add an additional 25% increase in energy expenditure during wheeling. Heart rate correlated well with oxygen consumption in persons at T5 and below and could be used to assess energy expenditure under different conditions of tire pressure when oxygen consumption analysis is not available. Above T5 the relationship between heart rate and oxygen consumption was weaker. Heart rate has limitations and should only be used to measure within-subject differences.
Sawatzky BJ, Miller WC, Denison I.
Clin Rehabil. 2005 Mar;19(2):182-7.
Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI : effects on functional walking ability and measures of subjective well-being.
Thirteen individuals with chronic (mean 7.4 years) incomplete SCI (levels L1 - C4; ASIA B & C) completed thrice-weekly sessions of body-weight-supported treadmill training (BWSTT) for approximately 12 months (144 sessions). At the outset of the study, all were wheelchair-dependent and 11 had no standing or walking capability. All subjects improved in treadmill walking ability and six improved their capacity to walk over ground. Satisfaction with life and with physical function improved significantly. Subjects were assessed again 8 months after completing the 12-month training. There was a slight decline in treadmill walking performance, and over-ground walking scores remained relatively stable. Results suggest that BWSTT has benefits that extend beyond improvements in functional walking and may be appropriate for persons with SCI who do not have residual motor function.
Hicks AL, Adams MM, Martin Ginis K, et al.
Spinal Cord. 2005 May;43(5):291-8.