Spinal Cord Injury Rehabilitation Key Reference Articles
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The following are recommended as key reference articles on Spinal
Cord Medicine by David Chen, MD. Click on the articles to view their abstracts.
Spinal instability as defined by the three-column spine
concept in acute spinal trauma.
Denis F - Clin Orthop - 1984 Oct; (189): 65-76
Full Source Title: Clinical Orthopaedics and Related Research
Authors: Denis F
Abstract: This article is a presentation of the concept of the
three-column spine. The concept evolved from a retrospective review of 412
thoracolumbar spine injuries and observations on spinal instability. The
posterior column consists of what Holdsworth described as the posterior
ligamentous complex. The middle column includes the posterior longitudinal
ligament, posterior annulus fibrosus, and posterior wall of the vertebral body.
The anterior column consists of the anterior vertebral body, anterior annulus
fibrosus, and anterior longitudinal ligament. Major spinal injuries are
classified into four different categories, all definable in terms of the degree
of involvement of each of the three columns. Each type is defined also in terms
of its pathomechanics, roentgenograms, and computerized axial tomograms, as
well as in terms of its particular stability. The compression fracture is
basically stress failure of the anterior column with an intact middle column.
The burst fracture indicates failure under compression of both the anterior and
middle columns. The seat-belt-type spinal fracture is the result of failure of
the posterior and middle columns under tension with an intact anterior hinge.
In fracture-dislocations, the structure of all three columns fails from forces
acting to various degrees from one or another direction.
Traumatic central cord syndrome: clinical features and functional
outcomes.
Roth EJ - Arch Phys Med Rehabil - 1990 Jan; 71(1): 18-23
Full Source Title: Archives of Physical Medicine and
Rehabilitation
Author Affiliation: Department of Rehabilitation Medicine,
Northwestern University Medical
School, Chicago, IL.
Authors: Roth EJ; Lawler MH; Yarkony GM
Abstract:
This retrospective study examined clinical features of 81
rehabilitated patients with traumatic central cord syndrome and identified
factors which predicted more favorable rehabilitation outcomes. The sample had
two age peaks and a mean age of 46 years. Most injuries were caused by
vehicular accidents, but falls were more common among older persons.
Predominant upper extremity weakness was proximal in 4%, distal in 36%, and
generalized in the remainder. Forty-one percent also had significant lower limb
weakness. More than 90% of the patients experienced neurologic recovery of
upper and/or lower limb strength. After an average acute hospitalization of 30
days and a mean rehabilitation stay of 70 days, most patients performed each of
14 functional skills independently, 84% had bladder continence, and 89% were
discharged home. Statistically significant improvements were noted for mean
Modified Barthel Index scores between rehabilitation admission and discharge.
Favorable rehabilitation outcomes were associated most frequently with younger
age, preinjury employment, absence of lower extremity impairment on admission,
and documented upper or lower extremity strength recovery during
rehabilitation. Central cord syndrome generally has a good prognosis for
neurologic and functional improvement during rehabilitation.
[published erratum appears in N Engl J Med 1991 Dec
5;325(23):1659-60] [see comments]
Geisler FH - N Engl J Med - 1991 Jun 27; 324(26): 1829-38
Comment: N Engl J Med 1991 Jun 27;324(26):1885-7; N Engl J Med
1992 Feb 13;326(7):493; discussion 494; N Engl J Med 1992 Sep 3;327(10):735-6
Full Source Title: New England Journal of Medicine
Author Affiliation: Shock Trauma Center, Maryland Institute for
Emergency Medical Services
Systems, Baltimore.
Authors: Geisler FH; Dorsey FC; Coleman WP
Abstract: BACKGROUND. Spinal-cord injury is devastating; until
recently, there was no medical treatment to improve recovery of the initial
neurologic deficit. Studies in animals have shown that
monosialotetrahexosylganglioside (GM-1) ganglioside enhances the functional recovery
of damaged neurons. METHODS. A prospective, randomized, placebo-controlled,
double-blind trial of GM-1 ganglioside was conducted in patients with
spinal-cord injuries. Of 37 patients entered into the study, 34 (23 with
cervical injuries and 11 with thoracic injuries) completed the test-drug
protocol (100 mg of GM-1 sodium salt or placebo intravenously per day for 18 to
32 doses, with the first dose taken within 72 hours of the injury) and a
one-year follow-up period. Neurologic recovery was assessed with the Frankel
scale (comprising five categories) and the American Spinal Injury Association
(ASIA) motor score (a scale of scores from 0 to 100, derived from strength
tests of 20 specific muscles, each scored from 0 to 5). RESULTS. There was a
significant difference between groups in the distribution of improvement of
Frankel grades from base line to the one-year follow-up (improvement of 0, 1,
2, and 3 grades in 13, 4, 1, and 0 patients, respectively, in the placebo group
and 8, 1, 6, and 1 patients, respectively, in the GM-1 group; P = 0.034 by the
Cochran-Mantel-Haenszel chi-square test). The GM-1-treated patients also had a
significantly greater mean improvement in ASIA motor score from base line to
the one-year follow-up than the placebo-treated patients (36.9 vs. 21.6 points;
P = 0.047 by analysis of covariance with the base-line ASIA motor score as the
covariate). An analysis of individual muscle recoveries revealed that the
increased recovery in the GM-1 group was attributable to initially paralyzed
muscles that regained useful motor strength rather than to strengthening of
paretic muscles. CONCLUSIONS. This small study provides evidence that GM-1
enhances the recovery of neurologic function after one year. A larger study
must be conducted, however, before GM-1 is considered efficacious and safe in
treating spinal-cord injury.
Bracken MB - N Engl J Med - 1990 May 17; 322(20): 1405-11
Comment: N Engl J Med 1990 May 17;322(20):1459-61; N Engl J Med
1990 Oct 25;323(17):1207-9
Full Source Title: New England Journal of Medicine
Author Affiliation: Department of Epidemiology and Public Health,
Yale University School of
Medicine, New Haven, CT 06510.
Authors: Bracken MB; Shepard MJ; Collins WF; Holford TR; Young W;
Baskin DS;
Eisenberg HM; Flamm E; Leo-Summers L; Maroon J; et al
Abstract: Studies in animals indicate that methylprednisolone and
naloxone are both potentially beneficial in acute spinal-cord injury, but
whether any treatment is clinically effective remains uncertain. We evaluated
the efficacy and safety of methylprednisolone and naloxone in a multicenter
randomized, double-blind, placebo-controlled trial in patients with acute
spinal-cord injury, 95 percent of whom were treated within 14 hours of injury.
Methylprednisolone was given to 162 patients as a bolus of 30 mg per kilogram
of body weight, followed by infusion at 5.4 mg per kilogram per hour for 23
hours. Naloxone was given to 154 patients as a bolus of 5.4 mg per kilogram,
followed by infusion at 4.0 mg per kilogram per hour for 23 hours. Placebos
were given to 171 patients by bolus and infusion. Motor and sensory functions
were assessed by systematic neurological examination on admission and six weeks
and six months after injury. After six months the patients who were treated
with methylprednisolone within eight hours of their injury had significant
improvement as compared with those given placebo in motor function (neurologic
change scores of 16.0 and 11.2, respectively; P = 0.03) and sensation to
pinprick (change scores of 11.4 and 6.6; P = 0.02) and touch (change scores,
8.9 and 4.3; P = 0.03). Benefit from methylprednisolone was seen in patients
whose injuries were initially evaluated as neurologically complete, as well as
in those believed to have incomplete lesions. The patients treated with
naloxone, or with methylprednisolone more than eight hours after their injury,
did not differ in their neurologic outcomes from those given placebo. Mortality
and major morbidity were similar in all three groups. We conclude that in
patients with acute spinal-cord injury, treatment with methylprednisolone in
the dose used in this study improves neurologic recovery when the medication is
given in the first eight hours. We also conclude that treatment with naloxone
in the dose used in this study does not improve neurologic recovery after acute
spinal-cord injury.
New approaches in the rehabilitation of the traumatic high
level quadriplegic.
Bach JR - Am J Phys Med Rehabil - 1991 Feb; 70(1): 13-9
Full Source Title: American Journal of Physical Medicine and
Rehabilitation
Author Affiliation: Department of Physical Medicine and
Rehabilitation Medicine, New Jersey
Medical School-UMDNJ, Newark.
Authors: Bach JR
Abstract: The use of noninvasive alternatives to tracheostomy for
ventilatory support have been described in the patient management of various
neuromuscular disorders. The use of these techniques for patients with
traumatic high level quadriplegia, however, is hampered by the resort to
tracheostomy in the acute hospital setting. Twenty traumatic high level
quadriplegic patients on intermittent positive pressure ventilation (IPPV) via
tracheostomy with little or no ability for unassisted breathing were converted
to noninvasive ventilatory support methods and had their tracheostomy sites
closed. Four additional patients were ventilated by noninvasive methods without
tracheostomy. These methods included the use of body ventilators and the
noninvasive intermittent positive airway pressure alternatives of IPPV via the
mouth, nose, or custom acrylic strapless oral-nasal interface (SONI). Overnight
end-tidal pCO2 studies and monitoring of oxyhemoglobin saturation (SaO2) were
used to adjust ventilator volumes and to document effective ventilation during
sleep. No significant complications have resulted from the use of these methods
over a period of 45 patient-years. Elimination of the tracheostomy permitted
significant free time by glossopharyngeal breathing for four patients, two of
whom had no measurable vital capacity. We conclude that noninvasive ventilatory
support alternatives can be effective and deserve further study in this patient
population.
Autonomic hyperreflexia: pathophysiology and medical
management.
Erickson RP - Arch Phys Med Rehabil - 1980 Oct; 61(10): 431-40
Full Source Title: Archives of Physical Medicine and
Rehabilitation
Authors: Erickson RP
Abstract: Integral to the successful rehabilitation of patients
with myelopathies is the prompt and proper management of autonomic hyperreflexia.
More than 80% of tetraplegic and high paraplegic patients experience this
syndrome of disordered autonomic homeostasis during their rehabilitation.
Successful prevention and management require a clear understanding of the
pathophysiology, aided in particular by recent clarification of catecholamine
activity in spinal man. Prevention is accomplished through optimal general
medical care, as well as proper bladder, bowel and skin management. Treatment
of the acute episode requires prompt identification and removal of the
offending stimulus, and occasionally the administration of a potent direct
vasodilator (diazoxide, nitroprusside). Recurrent episodes are approached
through definitive management of the primary problem provoking the stimulus,
accompanied by symptomatic prevention of the syndrome (mecamylamine,
phenoxybenzamine).
Etiology, incidence, and prevention of deep vein thrombosis
in acute spinal cord injury.
Merli GJ - Arch Phys Med Rehabil - 1993 Nov; 74(11): 1199-205
Full Source Title: Archives of Physical Medicine and
Rehabilitation
Author Affiliation: Department of Medicine, Thomas Jefferson
University Hospital, Philadelphia,
PA 19107.
Authors: Merli GJ; Crabbe S; Paluzzi RG; Fritz D
Abstract: This article provides a critical review of the
literature on the etiology, incidence, and prevention of deep-vein thrombosis
in acute spinal cord injured patients. Stasis and hypercoagulability are the
two major factors contributing to the development of thrombosis in this patient
population. This has been supported by studies that demonstrate an impaired
venous return from the lower extremities and abnormal coagulation factors,
which predispose to thrombogenesis. The incidence of deep vein thrombosis
secondary to the above etiologies varies from 49% to 100% in the first 12 weeks
with the first 2 weeks having the highest rate following acute injury. This
high rate of complication has led to numerous studies to identify the most
effective regimens of prophylaxis. Studies using noninvasive testing and
venography in acute spinal cord injury have supported two approaches for
preventing deep-vein thrombosis. Single agent pharmacologic therapy with
adjusted dose heparin is effective but does carry some risk of bleeding. Combination
therapy with external pneumatic compression sleeves plus either
aspirin/dipyridamole or low-dose heparin and electrical stimulation plus
low-dose heparin have significantly reduced the incidence of deep vein
thrombosis. The duration of prophylaxis with the above modalities has varied
between 8 and 12 weeks following acute injury. Further large scale studies are
required in this high-risk population to better delineate the incidence of deep
vein thrombosis and pulmonary embolism, to identify the best modalities, and to
define the duration of treatment for the prevention of these complications.
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