Spinal Cord Injury Update

Winter 2005: Volume 14, Number 1

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 judgement 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).

Loss of sympathetic coordination appears to delay gastrointestinal transit in patients with spinal cord injury.
Using a noninvasive hydrogen breath test, orocecal transit time (OCTT) was evaluated in 36 SCI patients and 12 age- and sex-matched healthy volunteers in order to study rate of passage through the gastrointestinal (GI) tract. Electrocardiogram was performed for all subjects and spectral analysis of heart rate variability (HRV) was obtained to assess their sympathovagal balance. SCI patients had higher occurrences of GI symptoms (nausea/vomiting, belching/hiccup, and constipation) and delayed OCTT compared to controls. The OCTTs of SCI patients were negatively correlated with their low frequencies of HRV, and OCTT was more delayed in patients with quadriplegia than paraplegia. OCTT was not related to SCI etiology, time since injury, or high frequency of HRV. Delayed GI transit in SCI patients is probably due to loss of sympathetic activity, which is one of the essential components in the coordination of GI peristalsis.
Chen CY, Chuang TY, Tsai YA, et al.
Dig Dis Sci. 2004 May;49(5):738-43.
The analgesic effect of intravenous ketamine and lidocaine on pain after spinal cord injury.
Ten patients with SCI (1 complete; 9 incomplete) of at least two-years' duration and neuropathic pain below the level of injury participated in this randomized, double-blind, placebo-controlled, crossover design comparing the analgesic effect of ketamine, lidocaine, and placebo (saline) delivered intravenously over 40 minutes. Blood concentrations of drugs; pain ratings (measured by a visual analog scale-VAS); and sensitivity to touch and temperature were assessed before and during drug administration. Response to treatment, defined as a 50% reduction in VAS score, was recorded in 5 subjects while receiving ketamine, 1 receiving lidocaine, and none receiving placebo. Side-effects were common after both ketamine and lidocaine. Ketamine but not lidocaine showed a significant analgesic effect in this patient population, and pain relief was not associated with altered temperature thresholds or other changes of sensory function.
Kvarnstrom A, Karlsten R, Quiding H, Gordh T.
Acta Anaesthesiol Scand. 2004 Apr;48(4):498-506.
Management of community-acquired pneumonia in persons with spinal cord injury.
Charts were reviewed on 41 patients with chronic SCI seen at three VA SCI centers for treatment of community-acquired pneumonia (CAP) between Oct. 1998 and Sept. 2000. Signs and symptoms of CAP and short-term mortality were similar to the general population, but hospitalization was more common, length of stay longer, and long-term mortality (2-4 years later) was higher in the SCI group. Antibiotics met current guidelines for most outpatients but only half the inpatients. The authors urge clinicians treating this high-risk population to promote preventive measures (pneumococcal and influenza vaccines), to consider inpatient management if diagnosis is unclear, and to closely follow patients managed as outpatients.
Burns SP, Weaver FM, Parada JP, et al.
Spinal Cord. 2004 Jan;42(2):450-458.
Antispastic effect of penile vibration in men with spinal cord lesion.
Nine men with SCI (C2 to T8; six complete; 4 months to 50 years since injury) participated in this unblinded crossover study, each subject serving as his own control and randomized into a treatment or no-treatment group. Twenty-four hours of electromyographic recordings (to measure spasticity) from four leg muscles were taken, followed by either penile vibratory stimulation (PVS) with a vibrating plastic disk or no treatment, followed by another 24 hours of recordings. Spasticity was evaluated by the Modified Ashworth Scale. This sequence was repeated after at least one week, except that the subjects this time received the treatment (PVS vs. no treatment) other than the one they received the first time. Stimulation was applied until ejaculation occurred or for a maximum of 5 minutes. In 8 subjects (recordings failed in one subject) PVS significantly reduced the mean number of electromyographic events up to three hours after PVS and significantly decreased muscle tone immediately after PVS. This suggests that PVS may be useful as an antispastic therapy without the side effects of spasmolytics, and unlike electroejaculation, PVS can be easily applied by the subject at home.
Laessoe L, Nielsen JB, Biering-Sorensen F, Sonksen J.
Arch Phys Med Rehabil. 2004 Jun;85(6):919-24.

Genitourinary:

Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury.
Forty-eight persons with SCI participated in this randomized, double-blind, placebo-controlled study. Subjects were at least one year post-injury; managed neurogenic bladder by intermittent catheterization or external collection device; and had a bacterial count of 104 colonies per milliliter. Participants ingested 2 g of concentrated cranberry juice or placebo in capsule form daily for six months, and urine was collected and analyzed monthly. There were no differences detected between the 26 subjects who received cranberry extract and the 22 controls with respect to number of urine specimens with bacterial counts of at least 104 colonies per milliliter, types and numbers of different bacterial species, numbers of urinary leukocytes, urinary pH, or episodes of symptomatic urinary tract infection. Cranberry extract taken in capsule form did not reduce bacteriuria and pyuria in persons with SCI and cannot be recommended as a means to treat these conditions.
Waites KB, Canupp KC, Armstrong S, DeVivo MJ
J Spinal Cord Med. 2004;27(1):35-40.
Prostate cancer diagnosed in spinal cord-injured patients is more commonly advanced stage than in able-bodied patients.
Of 636 SCI patients identified from a multi-center database, 11 (1.7%) had been diagnosed with prostate cancer since their injury. In contrast, 919 (4.4%) of the 20,949 non-injured men in the database had prostate cancer. Of the patients with SCI and prostate cancer, 7 (63.6%) had locally advanced (Stage T3) or metastatic prostate cancer compared with 267 (29.1%) in the non-injured population. Although there was a larger percentage of prostate cancer in the able-bodied group, the prostate cancer detected in the SCI group tended to be a more advanced stage and grade, and the difference was likely due to decreased screening in this population. The low cancer detection rate, increased rate of advanced disease, poor response to hormonal therapy, and good tolerance to local therapies for prostate cancer in the SCI population suggest that early detection and intervention could benefit these individuals.
Scott PA Sr, Perkash I, Mode D, et al.
Urology. 2004 Mar;63(3):509-12.

Musculoskeletal:

Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal cord injury.
Nine subjects (8 males) with incomplete (ASIA C) SCI (range C4 - T12) of at least two years' duration participated in body weight-supported treadmill (BWST) training three times weekly for six months. Pre- and post-training evaluations revealed that as a result of training, subjects were able to support more of their own weight while on the equipment and to increase walking velocity and duration. Muscle biopsies showed improved muscle quantity and quality, i.e., increases in type I and IIa fibers; reduction in type IIax/IIx fibers; and a decrease in IIX myosin heavy chain. Training resulted in increased maximal citrate synthase and 3-hydroxy-acyl-CoA dehydrogenase activity and in reduced plasma total (-11%) and low-density lipoprotein (-13%) cholesterol. The study suggests that BWST training can induce an increase in muscle fiber size and in muscle oxidative capacity and improve ambulatory capacity and blood lipid profile.
Stewart BG, Tarnopolsky MA, Hicks AL, et al.
Muscle Nerve. 2004 Jul;30(1):61-8.
Treatment of myofascial shoulder pain in the spinal cord injured population using static magnetic fields: a case series.
Eight individuals with SCI (3 women; mean age 45; mean injury duration 12.3 years) and myofascial shoulder pain participated in this study. Treatment consisted of placement of a commercially available magnet with a static magnetic field of 500 gauss on the affected shoulder for 1 hour. Pain intensity was assessed before and after treatment using a pain questionnaire. Analysis of scores demonstrated a significant decrease in present pain intensity and in the intensity of the sensory descriptors stabbing, sharp, and tender. Static magnetic fields may decrease the sensory dimensions and intensity of myofascial shoulder pain from overuse injuries in persons with SCI.
Panagos A, Jensen M, Cardenas DD.
J Spinal Cord Med. 2004;27(2):138-42.
Factors influencing body composition in persons with spinal cord injury: a cross-sectional study.
In this cross-sectional comparative study, body composition of 133 men with chronic SCI (66 with tetraplegia, 67 with paraplegia) were compared with 100 age-, height-, and ethnicity-matched able-bodied male controls. Measurements were taken using two different dual-energy X-ray absorptiometry densitometers. Total body and regional lean mass were lower and fat mass was higher in persons with SCI compared with controls. The SCI group was 13% fatter per unit of body mass index compared with the control group. Advancing age was strongly associated with less lean mass and greater adiposity in those with SCI, but only mildly related in controls. Persons with incomplete lesions showed greater sparing of absolute lean and bone tissues in both SCI subgroups. Bone mineral content was lower in the paralyzed regions in those with SCI. The adverse soft tissue body composition changes may increase the risk of macrovascular disease.
Spungen AM, Adkins RH, Stewart CA, et al.
J Appl Physiol. 2003 Dec;95(6):2398-407. Epub 2003 Aug 08

Outcome:

Magnetic brain stimulation can improve clinical outcome in incomplete spinal cord injured patients.
Four stable incomplete SCI patients (3 males injured 7-8 years; 1 female injured 15 months) received 5 days of 1-hour sessions of repetitive transcranial magnetic stimulation (rTMS) over the occipital cortex (sham treatment), followed by 5 days of rTMS over the motor cortex (real treatment). Patients were assessed using electrophysiological, clinical and functional measures before treatment, during sham treatment, during the therapeutic treatment and during a 3-week follow-up period. Cortical inhibition was reduced during the treatment week. Perceptual threshold to electrical stimulation of the skin, ASIA clinical measures of motor and sensory function and time to complete a pegboard improved and remained improved into the follow-up period. This preliminary trial showed that rTMS altered cortical inhibition in SCI and improved clinical and functional outcome, making rTMS a strong candidate for further development as a rehabilitation tool for SCI.
Belci M, Catley M, Husain M, et al.
Spinal Cord. 2004 Jul;42(7):417-9.
Work-related tetraplegia: cause of injury and annual medical costs.
Review of a U.S. workers' compensation (WC) claims database found 62 individuals who sustained work-related cervical SCI between 1989-99. Most (92%) were male; 26% were in the construction industry; 15% each were in transportation and retail; 13% in manufacturing; and 11% in agriculture and utility. Most injuries were due to falls (36%) and vehicular accidents (34%). The mean first year cost was $560,524 for those with C2-4 ASIA A-C injuries; $431,033 for C5-8 ASIA A-C injuries; and $178,041 for those with ASIA D tetraplegia. The mean cost of years 2-5 was, $130,992; $129,250; and $34,352, respectively. Comparing these results with previous SCI cost studies found that persons with work-related tetraplegia may receive more injury-related paid medical benefits after the first year postinjury than non-WC-supported individuals with SCI.
Webster B, Giunti G, Young A, et al..
Spinal Cord. 2004 Apr;42(4):240-7.
Repair of the injured spinal cord and the potential of embryonic stem cell transplantation.
Recent advances in neural injury and repair, and progress towards development of neuroprotective and regenerative interventions have generated increased optimism in the treatment of SCI. This review article describes current concepts of the pathophysiology, repair, and restoration of function in the damaged spinal cord, and presents an overview of how neural stem cells, particularly embryonic stem (ES) cells, fit into the picture as important scientific tools and therapeutic targets. Unique features of ES cells, including indefinite replication, pluripotency, and genetic flexibility, provide strong tools to address questions of neural repair. Selective marker expression in transplanted ES cell-derived neural cells is providing new insights into transplantation and repair not possible previously. These features of ES cells will produce a predictable and explosive growth in scientific tools that will translate into discoveries and rapid progress in neural repair.
McDonald JW, Becker D, Holekamp TF, et al.
J Neurotrauma. 2004 Apr;21(4):383-93.