I ORAL PRESENTATIONS

Topic 6: Acute Management
Chair: Rainer Abel, Peter Wing


Introduction Lecture:
MANAGEMENT OF ACUTE SCI – EARLY REHABILITATION. FACT OR FANTASY?
Rainer Abel
Abstract not available

39/6 Arriving in the theatre in the middle of the night: how safe is it?
A review of early complications of spinal surgery on emergency lists.

Jariwala A, Borremans J, Kluger P
NSIC Stoke Mandeville Hospital, Mandeville Road, Aylesbury, HP21 8AL , UK

Many reviews state that operating out of working hours poses a substational risk to the
patient’s health and safety. Therefore, there is a move towards operating non lifesaving
emergency cases on designated elective lists.

In a two-year retrospective study, the incidence of early complications in emergency
operations for spinal cord injured (SCI) patients was compared to an equal number of
patients operated on elective lists. A single surgeon performed all operations.

Demographics, injury patterns, time relapse to admission and theatre were compared.
Furthermore the surgical procedure, its duration, the postoperative results and early
complications were considered.

Each group consisted of 22 patients. The majority were young males sustaining a
complete thoracic SCI after a road traffic accident. None, except two, received steroids.
The average admission time was 3 days. Surgery occurred within 48h. The mean
theatre time was 2.8h for the emergency group and 3.4h for the elective cases. Early
postoperative complications were chest infections, urinary tract infections, wound
infections, thrombosis and PE. The incidence of complications was higher in cervical
injuries, polytrauma, complicated procedures and individuals requiring intensive care.
No significant differences were noted in either of the groups.

Operating non life-saving emergency cases on elective list constitutes a good clinical
practice. Although, until designated trauma lists are in place it is probably not safe to
reject such cases on presumption of increased complication rates. This study
reemphasizes that complications rather relate to the injury level, associated injuries
and the procedure itself than the timing of surgery.

40/6 Audit on the use of a structured transfer guidelines for inter-hospital
transfer of patients with spinal injuries
G Joseph, MV Jigajinni, D Philip, AN McLean, MH Fraser, DB Allan, RA
Johnston
Queen Elizabeth national spinal injuries unit, Glasgow, United Kingdom

Aim: To describe use of written guidelines for inter-hospital transfer of spinal injury
patients from peripheral trauma units to the national spinal unit.

Background: We recognised that patients with spinal injuries were vulnerable to early
complications or secondary spinal cord injuries before and during transfer.

Materials and Methods: We designed transfer guidelines following concerns raised in
a pilot study of the transfer of 16 patients. We then examined the effectiveness of the
guidelines in 100 consecutive patients and completed the audit cycle by re-auditing a
further 254 consecutive admissions after incorporating changes from the initial audit.

Results: The transfer guidelines addressed ten areas of clinical concern. We recorded
a 50% improvement in monitoring and management of the airway and breathing. There
was also improvement in anti-ulcer therapy and thrombo-prophylaxis (from 50% to
96%). We saw a 50% improvement in the use of appropriate support staff during the
transfer.

The re-audit showed that initial improvements were maintained and further
improvements were noted in the transfer of relevant documentation and investigations.

Conclusion: The use of transfer guidelines improved patient care by ensuring that
common problems had been addressed before and during transfer. This system
reduced the risk of preventable complications during inter-hospital transfer.

41/6 Endogenous risk factors of Deep Vein Thrombosis in spinal cord lesions

Aito S. , Abbate R., Ricci L., Marcucci R.
Spinal Unit, Careggi University Hospital, Florence, Italy
Aim of the study: investigate the presence of additional endogenous risk factors of DVT.

Methods: 46 spinal injured patients with history of DVT (group A) were
comprehensively evaluated and tested for blood concentration of: Antitrombin III,
Protein C, Protein S, Leiden V factor, gene 200210A polymorphism, anti-cardiolipin
antibodies, omocysteine, folic acid and Vitamin B12, Inhibitor of plasminogen activator
1 ( PAI-1) and Lipoprotein A, all connected to the risk of DVT. Control group ( group B,
no history of DVT): 43 patients homogeneous to group A for sex, age, neurological
status and prophylactic treatment in acute stage. Statistical analysis: Mann-Whitney
and Fisher Exact tests.

Results: group A: 54% had no endogenous risk factor and 46% had at least 1; group
B: 14% had no risk factor and 86% had at least one. No patient had a deficit of
coagulation inhibitors (antitrombin III, protein C and S); lipoprotein A level was
equivalent in the two groups. Omocistein and PAI-1 were significantly higher in group B.

Conclusions: Increase of plasma omocistein and PAI-1 result to be independent risk
factors of DVT. Our next study will prospectively investigate the levels of Omocistein
and PAI-1 to all admitted patients in order to better define such risk factors and verify
the efficacy of an additional prophylactic therapy.

42/6 Prevention of pressure ulcers in Thai paraplegic persons: was the
patient education programme effective?

Apichana Kovindha, Narin Wilekha
Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai
University, Chiang Mai 50200, Thailand

Background: Patient education on pressure ulcer prevention has been stressed to
spinal cord injured (SCI) persons.

Objective: To study the outcome of patient education on pressure ulcer prevention.

Design: A cross-sectional study

Patient and Method: Ninety-five paraplegic wheelchair-users completed the
questionnaire.

Results: There were 72 males and 23 females: 68% complete paraplegic and 32%
sensation spare only. Average age at onset was 26 years and average duration of
being paraplegia was 10 years. During admission, 91 percent received patient
education on pressure ulcer prevention. Only 15% has had no pressure ulcers since
injury, 62% had ulcers in the past, 5% has current ulcers and 18% has had recurrent
ulcers; and 58% has ulcers twice or more. Regarding demographic data, none were
related to ulcers. Seventy-one percent thought that sitting or lying for a longer period
was a major cause. Sixty one percent and 17 percent thought that weight-relief
techniques and cushions helped prevent ulcers respectively. However those with ulcers
pushed themselves up every half an hour (average) to relieve weight while sitting.
Concerning protective means, behaviours and risk factors, they were no significant
relations to ulcers. Only smoking showed relation to ulcers (p =0.047) when compared
between those with and those without ulcers.

Discussion: Pressure ulcers did occur at least once in long-term Thai paraplegic
persons and 23% have ulcers at the time of study that was no difference to the result
found in past 10 years. This reflected either inadequacy or failure of the patient
education programme on pressure ulcers prevention. Therefore it should be revised
and more emphasized to ensure that every SCI paraplegic not only has adequate
knowledge, equipment and protective skills but also has positive behaviours and
attitude towards good health and risk factors management. Further study after
implementation of the revised programme should be conducted to prove its
effectiveness.

43/6 The Metabolic Syndrome in Patients with Spinal Cord Injury

Perkash I, Punj V, Haze M, Lee M V and Madan S
SCI Service, VA Palo Alto Health Care System and Stanford University

Introduction: Metabolic syndrome is a pre runner for type 2 Diabetes. The syndrome
is a constellation of disorders resulting from insulin resistance which leads to
endothelial dysfunction and atherosclerotic cardiovascular disease.. Patients with SCI
have a high prevalence of insulin resistance and type 2 Diabetes, Denervation of
skeletal muscle with loss of contractility leads to marked impairment of insulin-mediated
glucose disposal. Visceral obesity and inactivity are also major contributing factors.
We present an overview of the syndrome and its management.

Methods and Materials: We started an SCI-Diabetes/Heart clinic about 4 years ago to
focus on screening for diagnosis and management of these patients. Follow up results
are presented.

Results: In a review of 177 SCI patients 39 were pre-diabetics, 77 were diabetics, and
61 were dyslipidemics. In one of our epidemiological study,22% of patients with SCI
were found to be diabetic as compared to only 6% of the general population, The
mean HbA1c on their first visit was 6.95 + 1.27 and on the last visit it was 5.87 +
p<0.001. In addition mean HbA1c levels were overall lower for individuals of all SCI
patients.

Conclusions: In spinal cord injury patients a high prevalence rate of metabolic
syndrome and type 2 Diabetes impacts far more seriously than the general population.
Early recognition and aggressive medical management with poly medical therapy are
therefore warranted.

44/6 Zoledronate reduces early acute bone loss at the hip following
spinal cord injury

JS Bubbear, A Gall, FRI Middleton, M Ferguson-Pell, RW Keen
Royal National Orthopaedic Hospital, Stanmore, UK

All patients aged =18 with acute spinal cord injury (complete or incomplete injuries),
who were =3 months of injury were invited to participate in this randomised open-label
study. Active treatment was a single infusion of 4mg IV Zoledronate. All patients
received standard care. Bone mineral density (BMD) was measured at baseline and at
three months by dual energy xray absorbitometry at the lumbar spine and hip.
12 patients (5 controls and 7 zoledronate) were recruited and randomised. The groups
were well matched for baseline characteristics such as age, sex distribution, baseline
BMD and duration since injury.

There were no significant differences either within or between groups at the lumbar
spine. There were significant losses at both hip sites (-7.38% total hip, -6.14% femoral
neck) in the control group and at the total hip(-1.49%) in the zoledronate group
(p=0.025). Total hip BMD at three months was significantly lower in the control group
than the active treatment group (p<0.0001). 5 of the 7 actively treated patients
experienced an acute phase reaction, but no long-term complications.

These data confirm BMD is rapidly lost following SCI at the hip sites. They suggest a
single infusion of zoledronate reduces this bone loss at the hip.

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