GENERAL SESSION 1
Management of Medical Complications (Section 1)

Corrective Surgery in post-traumatic Deformities of the Spine in the Paralysed
Patrick J. Kluger, MD.; Jan Borremans, MD.; Balraj Singhal, MD.
National Spinal Injuries Centre, Stokemandeville Hospital
Buckinghamshire Hospitals NHS Trust
Aylesbury, Bucks. HP21 8AL, UK

Objective: To assess indication, methods, and timing for corrective procedures in dissatisfactory results from earlier treatment of vertebral lesions with neural damage

Design: Prospective survey of consecutive patients in a 5-Years period

Participants/methods: 72 Patients underwent post-acute corrective spinal interventions from 1st February 2000 to 31st January 2005. The reasons were, numerous in some subjects:
· Complications of earlier treatment (implant-related: 31, pseudo-arthrosis: 17, chronic infection: 3)
· Unnecessary multi-segmental fixations restricting rehabilitation and daily activities (24)
· Symptomatic misalignment (42)
· Predictable loss of correction due to persisting voids in anterior column (10)

Results: The surgical morbidity in late corrections was found significantly higher, than seen in acute treatment (30-Days mortality 2, 1 intra-operative death). 7 patients required re-interventions (infection 2, loss of correction 2, pseudo-arthrosis 3). However, the underlying indications were successfully treated in 95% of the cases, and the patients’ satisfaction rate reached 87% at 1 Year follow-up.

Conclusion:
1. Corrective surgery of dissatisfactory results from earlier treatment should be done at early onset of symptoms or at early detection of predicting factors. The procedures become more invasive and the complication rate increases with the time elapsed.
2. A comprehensive institution for the treatment of Spinal Cord Injury requires access to a highly skilled and well trained service in spinal surgery

Support: No funding to be reported, no conflict of interests

Objective: The incidence of paralytic scoliosis subsequent to acquired spinal cord injury (SCI) has been reported to range from 46% to 97% in patients injured prior to the adolescent growth spurt. The purpose of this report is to review early bracing of children with SCI as a means of preventing or delaying surgical fusion to allow for growth of the spine.

Design: Retrospective review.

Participants / methods: Patient records from January 1996 to December 2001 were retrospectively reviewed. 123 patients met the inclusion criteria of cervical or thoracic SCI with neurologic deficit and a minimum of 2 years follow-up. Patients were divided into five groups based on their radiographic curve severity at presentation. Each of these groups was subdivided into a group that was initially managed with bracing and a group that was not braced. End-points included completion of bracing regimen, surgery, or cessation of growth. Univariate and multivariate analyses were performed.

Results: The average age at time of injury was 4 years (range, 15 days to 12 years), with average age at presentation of 6.5 years (range, 1 year to 11 years). Follow-up was 7 years (range, 2 to 13 years). 42 patients presented with a curve less than 10°, 29 of whom were managed with a brace and 13 without. Of the braced group, 13 went on to surgery while 10 of the non-braced had surgical correction (p=0.03). Of the patients who were initially braced, the average time to surgery was 8.5 years, while time to surgery for the non-braced group was 4.2 years (p=0.002). Similarly, of the 18 braced children in the 10 to 20° group, 9 had subsequent surgery 6.8 years after presentation, while 6 of the 7 patients in the non-braced group had surgery 3.7 years after presentation (p<0 .001). There was no significant difference between time to surgery for the braced and non-braced patient groups at higher initial curve presentations (>20°).

Conclusion: Bracing of children with SCI prior to significant curve formation (< 20°) delays the time to surgical correction of the deformity as it progresses. At smaller curves (< 20°), bracing may even prevent the need for surgery. As curve size increases, bracing plays a limited role, as it does not appear to prevent surgery or delay time to surgical correction.

Objective: To determine whether an intensive exercise intervention utilizing neuromuscular electrical stimulation (NMS) prevents bone mineral density (BMD) loss after acute spinal cord injury (SCI)

Design: Randomized-controlled trial

Participants/Method: 16 subjects with C5 to T10 ASIA Impairment Scale A or B injuries within 2-12 weeks post injury participated in this study. The control group received usual inpatient rehabilitative care. The intervention group received 1 hour of NMS to the quadriceps 5 days per week for 6 weeks. Primary outcome measures included BMD obtained by dual x-ray absorptiometry, expressed as Z-scores at the spine, hip, distal femur and proximal tibia. Additionally, biomarkers of bone turnover (bone and urine), and were obtained at entry into study, at 6 weeks, and at 5 months after entry.

Results: 9 subjects were randomized to the NMS group and 7 to the control group. Average age was 29.8 and 31.8 years in the NMS and control groups, respectively. BMD of the lumbar spine was not significantly different between the groups, nor did it change significantly over the 3 time periods. Subjects in both groups had lost bone by the baseline exam (mean 28.3 and 33.3 days post-SCI for the NMS and control groups; tibial Z-score -1.83 for both groups). Tibial Z-scores were not significantly different immediately post-intervention (NMS -2.18 vs. Control -2.12; P-value=.34). Delayed exam revealed an improvement in the NMS group at -1.68 while the Control group continued to decline at -4.06 (P-value-=.02). There were no significant differences in the biochemical markers of bone resorption, with the exception of osteocalcin, which was lower immediately post-intervention in the NMS group (12.14 vs 23.8; P-value=.004).

Conclusions: Preliminary results indicate that bone mineral density loss occurring after SCI can be prevented with an intensive neuromuscular stimulation intervention.

Support: This project is funded by NIDRR grant #H133B031114, the Rehabilitation Research and Training Center on SCI: Promoting Health and Preventing Complications through Exercise.

Objectives: Recent evidence supports direct pathological activity of blood-borne C-reactive protein (CRP) on vascular cells and monocytes/macrophages. This study examined the prevalence of elevated CRP elevation and its cardiovascular disease risk (CVD) distribution in persons with chronic SCI.

Design: Cross-sectional study.

Participants/Methods: Participants were 76 apparently healthy individuals (56 males, 20 females) aged 39.1 ± 11.5 years with chronic paraplegia and tetraplegia (ASIA A/B). Fasting blood samples were assayed for CRP by a high-sensitivity nephelometric assay on a BN-100 analyzer (Dade-Behring, Deerfield, Illinois). Subjects were stratified by American Heart Association (AHA) – Centers for Disease Control and Prevention (CDC) cutpoints of low risk (<1.0 mg/L), average risk (1.0 to 3.0 mg/L), and high risk (>3.0 mg/L), which correspond to approximate tertiles of CRP in the adult population.

Results: The study population average for CRP was 7.51 ± 11.9 mg/L, 50% above reference range tissue inflammation. Seventeen individuals (22.3%) exceeded AHA-CDC criteria for non-cardiovascular causes of inflammation. Assignment of CVD risk using AHA-CDC guidelines showed 25% of subjects (n=19) at low risk, 18% (n=14) at average risk, and 57% (n= 43) at high risk. AHA-CDC consensus finds that persons stratified for CRP in the high-risk tertile have a 2-fold increase in relative CVD risk compared with the low-risk tertile.

Conclusions: As current evidence endorses CRP as an independent predictor and potential trigger of increased coronary disease, these data support previous findings of significantly heightened CVD risk in this population. The role of elevated CRP as an inflammatory marker and/or CVD instigator in persons with SCI requires additional study.

Support: This study was supported by NIDRR grant #H133B031114; the Rehabilitation Research and Training Center on SCI: Promoting Health, and Preventing Complications through Exercise, and by the Miami Project to Cure Paralysis.

Objective: Assess prevalence and the determinants of medical complications during and after inpatient rehabilitation in persons with a spinal cord injury (SCI).

Design: Longitudinal multi-centre study determining complications at start of inpatient rehabilitation (t1), three months later (t2), at discharge (t3) and one year after discharge, (t4).

Participants/methods: 212 wheelchair-dependent persons with a SCI were assessed on the prevalence of pressure sores, urinary tract infections, musculoskeletal complaints, (degree of) pain and spasticity. Patterns and potential risk-factors (age, gender, smoking status, cause, level and completeness of injury) were determined with random coefficient analyses.

Results: At t1 36% of the subjects reported pressure sores; its prevalence decreased during inpatient rehabilitation. Urinary tract infections (in 47 % of the subjects at t1), pain (82% at t1) and complaints of the musculoskeletal system (21% at t1) also decreased during inpatient rehabilitation. After discharge the prevalence of pressure sores increased, and there was a trend towards an increase in urinary tract infections and musculoskeletal complaints. The prevalence of spasticity (67% at t1) did not change during the study-period. Elderly, women, and subjects with a tetraplegia were more at risk for complications. Subjects with a complete lesion reported more pressure sores and urinary tract infections, but less pain and spasticity.

Conclusion: Attention needs to focus on prevention and treatment of complications after inpatient rehabilitation and in subgroups of persons with a SCI.

Support: Health Research and Development Council, The Netherlands (grant no. 1435.0003; 1435.0025).

Objective:
Because most cervical spine injuries in those 65 and older are treated non-operatively, this study expands upon a recent review of operative outcomes in the elderly undertaken at our institution. Short term outcomes of a large group of cervical spine injuries in patients 65 and older are compared to those of similarly injured younger patients.

Design:
A retrospective review of 12 years of consecutive patients with cervical spine injuries at one institution. Both operatively and non-operatively treated patients were included.

Participants/methods:
959 consecutive patients with cervical spine injuries treated over 12 years at one tertiary spine center were reviewed, and divided into two groups by age (65 or over, and younger than 65). Groups were compared in areas of: mortality, neurologic sequela, injury type – 45 categories, injury mechanism – 17 categories, comorbidities – 37 categories, and complications – 48 types.

Results:
Elderly patients were significantly more likely (p<.05) to have fallen, to have pre-existing arthritis, hypertension, and ankylosing spondylitis, to sustain anterior arch and Type 2 odontoid fractures, and to develop arrhythmias and respiratory failure after injury. Younger patients were significantly more likely to have abused drugs, alcohol, and tobacco, to have been injured in a collision, shooting, or altercation, and to sustain subaxial burst injuries. Short term mortality rates were 14.1% in the elderly, and 4.0% in the young (p<.05).

Conclusions:
An earlier investigation reported very favorable short term post-operative mortality rates in elderly patients with cervical injuries. This broader study affirms that regardless of injury type or operative or non-operative treatment, short term mortality rates for elderly patients with cervical spine injuries are quite small relative to published data.

Objective: To determine the evidence base for self care in the prevention of pressure ulcers in people with spinal cord injury

Design: Systematic Literature Review

Participants/method: The review question was: Are self care-promoting interventions for adults with spinal cord injury effective in reducing the occurrence of pressure ulcers?

We searched the following databases: MEDLINE, EMBASE, CINAHL, DARE, BIDs, PsycInfo, the Cochrane Library, Where possible, we used previously established search strings (e.g. Cochrane injury and wound study group) and modified them for our purposes to identify relevant information. In addition, we performed Internet searches using Google, AltaVista and Yahoo to identify grey literature. We limited our search to literature reports to the time interval October 1995 – October 2005. Evidence of effectiveness of self-care was based on reviewing controlled trials comparing a self-care intervention was compared with a control group and non-controlled studies. The quality of the literature was appraised by two independent reviewers using an established checklist (Oxman, Cook & Guyatt, 1994).

Results: Few studies have systematically examined self care interventions in the prevention of pressure ulcers and few met strict RCT criteria and quality appraisal standards. Studies were classified according the UK’s Medical Research Council’s Evaluation Framework as pre-clinical, modelling or exploratory studies. Number of study participants was generally small. Studies were grouped by design, intervention mode, and outcome.

Conclusions: While self care and self management interventions have been examined for other conditions, there is scarce evidence of such programs in the prevention of pressure ulcers after SCI.

Support: This project is funded by NIDRR grant #H133B031114, the Rehabilitation Research and Training Center on SCI: Promoting Health and Preventing Complications through Exercise.

Paraplegic person have an important stasis in lower limbs. Former studies showed that passive cycling movement can increase central cardiac flow by enhancing venous return.

Objective: The purpose of this study is to determine the acute peripheral hemodynamic response of paraplegic subject during a passive leg cycle exercise.

Design: Prospective study

Participants/Methods: 15 individuals with traumatic paraplegia (age 47±8; 19±8 years after trauma) performed a 10 minutes passive leg cycle exercise (P_LCE), directly from a wheelchair. The exercise was performed at 40 rotations per minute. Cardiac frequency (Fc), maximal (Vmax) and minimal (Vmin) femoral blood flow velocity were measured at rest and immediately after the passive exercise using quantitative duplex Doppler ultrasound. Mean blood flow velocity (Vmean) and velocity index (VI), used as vascular resistance indicator (VI=(Vmax -Vmin)/ Vmax) were calculated for each condition.

Results: Vmax and Vmean increased significantly (from 80±18cm/min to 96±24cm/min, p<0.01 and respectively, from 8.6±2cm/min to 10.9±4cm/min, p<0.01) after 10 min of P_LCE. Fc did not differ. VI descreased significantly from 1.23± 0.1 to 1.16± 0.21(p=0.038).

Conclusion: The results of the present study suggest that acute P_LCE increase vascular blood flow velocity of the paralysed legs in individuals with paraplegia. This exercise could have clinical implication for immobilized persons.

Support: This study was funded by Britanny Regional Council through the CRITT health project, ref: I691200356PEDALAGE

Objective: Assess factors associated with perception of overweight / obesity among
adults with spinal cord injury (SCI).

Design: Prospective survey with multi-method design

Participants/methods: The Virginia Spinal Cord Injury (SCI) Needs Assessment Survey was sent to the know population of individuals with SCI living in Virginia, resulting in a valid sample to 1,600. 553 individuals with SCI completed the surveys, yielding a response rate of 34%. The survey included items that asked if respondents considered themselves overweight, if they were trying to lose weight, and if they wanted or had access to fitness centers.
Results: 38% of respondents considered themselves to be overweight (n=204). Females and non-Hispanic Whites were significantly more likely to identify themselves as overweight; no differences were found based on level or completeness of injury. However, individuals who reported themselves to be overweight also reported a greater number of medical problems. Among those who indicated they were overweight, 87% were currently trying to lose weight, 47% indicated that they would like to participate in a program to lose weight, and 46% reported wanting access to a fitness center or gym. Results were similar for wheelchair users and non-wheelchair users.

Conclusion: Given that approximately 60% of adults in the United States are
overweight or obese, results from this study suggest that many individuals with SCI
may not aware of their weight status and associated increased risk for secondary
conditions. These findings suggest the need for increased education, assessment, and
programming related to weight and weight management for this population.

Support: This project was funded by Grant # 03-212 from the Commonwealth
Neurotrauma Initiative (CNI) Trust Fund.

Objective: Segmental delays in colonic transit are present and evacuation is incomplete in SCI patients. Our aim was to evaluate if a new method for colonic washout (Peristeen® by Coloplast – Denmark) was able to induce evacuation of the retained radioopaque markers in SCI patients with severe slow intestinal transit time.

Design: A single abdominal X-ray film was obtained after daily ingestion of 10 radioopaque pellets for six days, during which number of bowel motions was evaluated by a diary. Then, trans anal irrigation (TAI) was performed by a device equipped with a enema continence catheter fit for an 800 ml infusion of tap water in 8 minutes allowed by a constant positive pressure inside the system. A second X-ray was performed immediately after patient evacuation.

Participants/methods: 12 patients with difficult evacuation (8 males, 4 tetraplegic and 8 paraplegic, mean age 36±13 years, range: 26-64 years) all with ASIA score A save 2 paraplegic, underwent to the Intestinal Transit Study and TAI procedure. Radioopaque markers which were present in the right, in the left and in the rectosigmoid tract were numbered before and after the unique session of colonic washout. Intestinal Transit Time was calculated according to the Abrahamsson’s method [Scand J Gastroenterol 1988; 152: 72-80].

Results (mean±SD): the average Total Intestinal Transit Time was 5.2±1.1 days (range 3.5-6.5 days) in relationship to 2.3±1.1 evacuations (range: 1-4) which occurred during the study period; 13.6±9.3 markers, 10.6±7 and 22.8±16 markers were in the right, left and recto-sigmoid tract respectively. After TAI-induced defecation 10.5±10.3 markers, 1.5±1.6 and 5±3.5 markers were still located in the three colonic segments respectively. Comparison shows a statistical significant (T-test for paired data) decrease in the left and the rectosigmoid tract (p<.03).

Conclusion: This study confirms that constipation in SCI patients is related to a very slow colonic transit; 2) in these patients, defecation is incomplete since there is a discrepancy between markers retained number and bowel motion frequency; 3) retrograde colonic irrigation by means of Peristeen® is effective for inducing a complete emptying of the left colon and rectosigmoid tract.

Objective: Bowel dysfunction in spinal cord injury patients often causes constipation, fecal incontinence or a combination of both with a high impact on quality of life. However, controlled trials of different bowel management regimes are lacking. This study aims to compare transanal irrigation using Peristeen Anal Irrigation (Coloplast A/S, Denmark) with conservative bowel management (best supportive bowel care without irrigation).

Design: Prospective, randomized, controlled, multicenter trial involving five specialized European spinal cord injury centers.

Participants/methods: 87 spinal cord injury patients with neurogenic bowel dysfunction were randomly assigned to either transanal irrigation (42 patients) or conservative bowel management (45 patients) for a ten-week trial period. At baseline and at termination bowel function was assessed using the Cleveland Clinic Constipation Scoring System (0-30, 30 = severe symptoms), St. Mark’s Fecal Incontinence Grading System (0-24, 24 = severe symptoms), and the Neurogenic Bowel Dysfunction Score (0-47, 47 = severe symptoms). Symptom-related quality of life was assessed using a modification of the American Society of Colorectal Surgeon Fecal Incontinence Score (for each domain, 0-4, 4 = high quality of life).

Results: Comparing transanal irrigation vs. conservative bowel management at termination (means, SD) the Cleveland Clinic Constipation Scoring System was 9.7 (4.2) vs. 13.2 (3.4) (p=0.0002), the St. Mark’s Fecal Incontinence Grading System was 4.1 (4.2) vs. 7.1 (3.4) (p=0.00016), and the Neurogenic Bowel Dysfunction score was 9.7 (7.0) vs. 13 (6.3) (p=0.034). The modified American Society of Colorectal Surgeon Fecal Incontinence Score was: lifestyle 3.0 (0.6) vs. 2.6 (0.8) (p=0.03), coping/behavior 3.0 (0.6) vs. 2.4 (0.7) (p=0.00006), depression/self perception 3.1 (0.8) vs. 2.7 (0.8) (p=0.037), and for embarrassment 3.4 (0.7) vs. 2.8 (0.9) (p=0.0053).

Conclusions: Transanal irrigation in spinal cord injured patients with neurogenic bowel dysfunction improves constipation, fecal incontinence and symptom-related quality of life.

Support: This project was funded by Coloplast A/S, Denmark.

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