Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis

OBJECTIVES

To examine the frequency and reasons for rehospitalization in persons with acute traumatic spinal cord injury (SCI) during follow-up years and to examine the association between rehospitalization and demographics, neurologic category, payer sources, length of stay (LOS), discharge motor FIM instrument score, and discharge residence.

DESIGN

Survey design with analysis of cross-sectional data.

SETTING

Model Spinal Cord Injury Systems (MSCIS) centers.

PARTICIPANTS

Data for 8668 persons with SCI from 16 MSCIS centers entered in the National Spinal Cord Injury Statistical Center database between 1995 and 2002.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

MSCIS Forms I and II were used to identify the annual incidence, medical complications, and etiologies of rehospitalizations reported at 1-, 5-, 10-, 15-, and 20-year follow-ups.

RESULTS

The leading cause of rehospitalization was diseases of the genitourinary system, including urinary tract infections (UTIs). Diseases of the respiratory system tended to be more likely in patients with tetraplegia (C1-8 American Spinal Injury Association [ASIA] grades A, B, C); whereas patients with paraplegia (T1-S5 ASIA grades A, B, C) were more likely to be rehospitalized for pressure ulcers. The rate of rehospitalization was significantly higher at year 1, 5, and 20 for those who were discharged to a skilled nursing facility after acute rehabilitation. Lower motor score using the FIM was predictive of rehospitalization (P=.000). The average LOS per rehospitalization at the year-5 follow-up was approximately 12 days, which is lower than in past MSCIS reports.

CONCLUSIONS

Despite improvements in SCI medical management, rehospitalization rates remain high, with an increased incidence in conditions associated with the genitourinary system (including UTIs), respiratory complications (including pneumonia), and diseases of the skin (including pressure ulcers). Acutely injured patients need close follow-up to reduce morbidity and rehospitalizations.

Updates for the International Standards for Neurological Classification of Spinal Cord Injury

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most widely used classification in the field of spinal cord injury medicine. Since its first publication in 1982, multiple revisions refining the recommended examination, scaling, and classification have taken place to improve communication, consistency, and clarity. This article describes a brief historical perspective on the development and changes over the years leading to the current ISNCSCI, detailing the most recent updates of 2011 and the worksheet 2013 as well as issues facing the ISNCSCI for the future.

Late neurologic recovery after traumatic spinal cord injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To present Model Spinal Cord Injury System (MSCIS) data on late neurologic recovery after 1 year after spinal cord injury (SCI).

DESIGN

Longitudinal study of neurologic status as determined by annual evaluations at 1 and 5 years postinjury.

SETTING

MSCIS centers contributing data on people with traumatic SCI to the National Spinal Cord Injury Statistical Center database.

PARTICIPANTS

People with traumatic SCI (N=987) admitted to an MSCIS between 1988 and 1997 with 1- and 5-year follow-up examinations.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, motor index scores (MIS), motor level, and neurologic level of injury (NLI), measured and compared for changes over time.

RESULTS

The majority of subjects (94.4%) who had a neurologically complete injury at 1 year remained complete at 5 years postinjury, with 3.5% improving to AIS grade B, and up to 1.05% each improving to AIS grades C and D. There was a statistically significant change noted for MIS. There were no significant changes for the motor level and NLI over 4 years; however, approximately 20% of subjects improved their motor level and NLI. People with complete and incomplete injuries had similar improvements in motor level, but subjects with an incomplete injury had a greater chance of improvement in NLI and MIS.

CONCLUSIONS

There was a small degree of neurologic recovery (between 1 and 5 y postinjury) after a traumatic SCI. Late conversion, between 1 and 5 years, from a neurologically complete to an incomplete injury occurred in 5.6% of cases, but in only up to 2.1% was there a conversion from motor complete to motor incomplete status. Limitations of this study included changes in the ASIA classification during the study and in the intra- and interrater reliability typically seen in longitudinal studies of the ASIA standards. Functional changes were not studied. Knowledge of the degree of late recovery may help in analyzing newer interventions to enhance recovery.

_ 2009 review and revisions of the international standards for the neurological classification of spinal cord injury

The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) were recently reviewed by the ASIA's Education and Standards Committees, in collaboration with the International Spinal Cord Society's Education Committee. Available educational materials for the ISNCSCI were also reviewed. The last citable reference for the ISNCSCI's methodology is the ISNCSCI Reference Manual, published in 2003 by ASIA. The Standards Committee recommended that the numerous items that were revised should be published and a precedent established for a routine published review of the ISNCSCI. The Standards Committee also noted that, although the 2008 reprint pocket booklet is current, the reference manual should be revised after proposals to modify/revise the ASIA Impairment Scale (AIS as modified from Frankel) are considered. In addition, the Standards Committee adopted a process for thorough and transparent review of requests to revise the ISNCSCI.

Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury

OBJECTIVE

To compare neurologic, medical, and functional outcomes of patients with acute spinal cord injury (SCI) undergoing early (<24 h and 24-72 h) and late (>72 h) surgical spine intervention versus those treated nonsurgically.

DESIGN

Retrospective case series comparing outcomes by surgical and nonsurgical groups during acute care, rehabilitation, and at 1-year follow-up.

SETTING

Multicenter National Spinal Cord Injury Database.

PARTICIPANTS

Consecutive patients with acute, nonpenetrating, traumatic SCI from 1995 to 2000, admitted in the first 24 hours after injury. Surgical spinal intervention was likely secondary to nature of injury and the need for spinal stabilization. Interventions Not applicable.

MAIN OUTCOME MEASURES

Changes in neurologic outcomes (motor and sensory levels, motor index score, American Spinal Injury Association [ASIA] Impairment Scale [AIS]), medical complications (pneumonia and atelectasis, deep vein thrombosis and pulmonary embolism, pressure ulcers, autonomic dysreflexia, rehospitalization), and functional outcomes (acute and rehabilitation length of stay [LOS], hospital charges, FIM instrument score, FIM motor efficiency scores).

RESULTS

Subjects in the early surgery group were more likely ( P <.05) to be women, have paraplegia, and have SCI caused by motor vehicle collisions. The nonsurgical group was more likely ( P <.05) to have an older mean age and more incomplete injuries. ASIA motor index improvements (from admission to 1-y follow-up) were more likely ( P <.05) in the nonsurgical groups, as compared with the surgical groups. Those with late surgery had significantly ( P <.05) increased acute care and total LOS and hospital charges along with higher incidence of pneumonia and atelectasis. No differences between groups were found for changes in neurologic levels, AIS grade, or FIM motor efficiency.

CONCLUSIONS

ASIA motor index improvements were noted in the nonsurgery group, though likely related to increased incompleteness of injuries within this group. Early versus late spinal surgery was associated with shorter LOS and reduced pulmonary complications, however, no differences in neurologic or functional improvements were noted between early or late surgical groups.

International standards to document remaining autonomic function after spinal cord injury

This is the first guideline describing the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI). This guideline should be used as an adjunct to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) including the ASIA Impairment Scale (AIS), which documents the neurological examination of individuals with SCI. The Autonomic Standards Assessment Form is recommended to be completed during the evaluation of individuals with SCI, but is not a part of the ISNCSCI. A web-based training course (Autonomic Standards Training E Program (ASTeP)) is available to assist clinicians with understanding autonomic dysfunctions following SCI and with completion of the Autonomic Standards Assessment Form (www.ASIAlearningcenter.com).

Characterizing Natural Recovery after Traumatic Spinal Cord Injury

The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6-9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.

Gabapentin in the treatment of neuropathic pain after spinal cord injury: a prospective, randomized, double-blind, crossover trial

BACKGROUND

Neuropathic pain is a common complaint after traumatic spinal cord injury (SCI). Gabapentin, a synthetic structural analogue of GABA, has been shown to have beneficial effects in the treatment of neuropathic pain in other diagnostic groups; however, no standardized clinical trial has been performed to evaluate its efficacy after SCI.

DESIGN

A 10-week, prospective, randomized, double-blind, crossover, and placebo-controlled clinical trial.

OBJECTIVE

To determine the efficacy of gabapentin in the treatment of SCI-related neuropathic pain.

METHODS

Seven subjects with neuropathic pain, who were more than 30 days post-SCI, completed the study. Two groups received a 4-week course of gabapentin and placebo in a randomized crossover design with a 2-week washout period. The Neuropathic Pain Scale was used to record daily pain levels. Data were analyzed using the Wilcoxon signed rank test.

RESULTS

Gabapentin has some beneficial effects on certain types of neuropathic pain. There was a significant decrease of "unpleasant feeling" and a trend toward a decrease in both the "pain intensity" and "burning sensation" at the fourth week of gabapentin treatment compared with those on the placebo. No significant difference was found among other pain descriptors during the gabapentin and placebo treatment, although this may have been limited by the small sample size and low maximum dosage of gabapentin.

CONCLUSIONS

Gabapentin reduces certain types of neuropathic pain in the SCI population. Future studies with larger sample sizes, higher dosages, and quicker titration will help further determine the efficacy of gabapentin in the treatment of SCI-related neuropathic pain.

Electromyogram-triggered neuromuscular stimulation for improving the arm function of acute stroke survivors: a randomized pilot study

OBJECTIVE

To assess the efficacy of electromyogram (EMG)-triggered neuromuscular stimulation (EMG-stim) in enhancing upper extremity motor and functional recovery of acute stroke survivors.

DESIGN

A pilot randomized, single-blinded clinical trial.

SETTING

Freestanding inpatient rehabilitation facility.

PATIENTS

Nine subjects who were within 6 weeks of their first unifocal, nonhemorrhagic stroke were randomly assigned to either the EMG-stim (n = 4) or control (n = 5) group. All subjects had a detectable EMG signal (>5 microV) from the surface of the paretic extensor carpi radialis and voluntary wrist extension in synergy or in isolation with muscle grade of <3/5.

INTERVENTION

All subjects received two 30-minute sessions per day of wrist strengthening exercises with EMG-stim (experimental) or without (control) for the duration of their rehabilitation stay.

MAIN OUTCOME MEASURES

Upper extremity Fugl-Meyer motor assessment and the feeding, grooming, and upper body dressing items of the Functional Independence Measure (FIM) were assessed at study entry and at discharge.

RESULTS

Subjects treated with EMG-stim exhibited significantly greater gains in Fugl-Meyer (27.0 vs 10.4; p = .05), and FIM (6.0 vs 3.4; p = .02) scores compared with controls.

CONCLUSION

Data suggest that EMG-stim enhances the arm function of acute stroke survivors.

Reliability and repeatability of the motor and sensory examination of the international standards for neurological classification of spinal cord injury

OBJECTIVE

To determine the reliability and repeatability of the motor and sensory examination of the International Standards for Classification of Spinal Cord Injury (SCI) in trained examiners.

PARTICIPANTS/METHODS

Sixteen examiners (8 physicians, 8 physical therapists) with clinical SCI experience and 16 patients participated in a reliability study in preparation for a clinical trial involving individuals with acute SCI. After a training session on the standards, each examiner evaluated 3 patients for motor, light touch (LT), and pin prick (PP). The following day, 15 examiners reevaluated one patient. Interrater reliability was determined using intraclass correlation coefficients (1-way, random effects model). Intrarater reliability was determined using a 2-way random effects model. Repeatability was determined using the method of Bland and Altman.

RESULTS

Patients were classified as complete tetraplegia (n = 5), incomplete tetraplegia (n = 5), complete paraplegia (n = 5), and incomplete paraplegia (n = 1). Overall, inter-rater reliability was high: motor = 0.97, LT = 0.96, PP = 0.88. Repeatability values were small in patients with complete SCI (motor < 2 points, sensory < 7 points) but large for patients with incomplete SCI. Intra-rater reliability values were > or = 0.98 for patients with complete SCI.

CONCLUSIONS

The summed scores for motor, LT, and PP in subjects with complete SCI have high inter-rater reliability and small repeatability values. These measures are appropriately reliable for use in clinical trials involving serial neurological examinations with multiple examiners. Further research in subjects with incomplete SCI is needed to determine whether repeatability is acceptably small.

Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the national spinal cord injury database

OBJECTIVE

To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS).

DESIGN

Longitudinal cohort; follow-up to 1 year.

SETTING

U.S. SCIMS.

PARTICIPANTS

Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in AIS, UEMS, LEMS, and motor levels.

RESULTS

From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination (P=.54) or initial neurologic level (P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2-3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2-7.8; P<.001).

CONCLUSIONS

More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.

Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study

OBJECTIVE

To determine the effectiveness of cranberry supplement at preventing urinary tract infections (UTIs) in persons with spinal cord injury (SCI).

DESIGN

A prospective, double-blinded, placebo-controlled, crossover study.

PARTICIPANTS

21 individuals with neurogenic bladders secondary to SCI.

MAIN OUTCOME MEASURES

Favorable or unfavorable response of cranberry supplement vs placebo on urinary bacterial counts and white blood cell (WBC) counts and the combination of bacterial and WBC counts.

METHODS

Individuals with neurogenic bladders due to SCI were recruited and randomly assigned to standardized 400-mg cranberry tablets or placebo 3 times a day for 4 weeks. After 4 weeks and an additional 1-week "washout period," participants were crossed over to the other group. Participants were seen weekly, during which a urine analysis was obtained. UTI was defined as significant bacterial or yeast colony counts in the urine and elevated WBC counts (WBC count > or = 10 per high power field) in centrifuged urine. Participants with symptomatic infections were treated with appropriate antibiotics for 7 days and restarted on the cranberry tablet/ placebo after a 7-day washout period. Urinary pH between the cranberry and placebo groups was compared weekly. Data were analyzed using the Ezzet and Whitehead's random effect approach.

RESULTS

There was no statistically significant treatment (favorable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination. Urinary pH did not differ between the placebo and cranberry groups.

CONCLUSION

Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTIs in individuals with neurogenic bladders. Further long-term studies evaluating specific types of bladder management and UTIs will help to determine whether there is any role for the use of cranberries in individuals with neurogenic bladders.

Predictors of dysphagia after spinal cord injury

OBJECTIVE

To quantify the incidence of swallowing deficits (dysphagia) and to identify factors that predict risk for dysphagia in the rehabilitation setting following acute traumatic spinal cord injury.

DESIGN

Retrospective case-control study.

SETTING

Freestanding rehabilitation hospital.

PATIENTS

Data were collected on 187 patients with acute traumatic spinal cord injury admitted for rehabilitation over a 4-year period who underwent a swallowing screen, in which 42 underwent a videofluoroscopic swallowing study (VFSS).

MAIN OUTCOME MEASURES

VFSS was performed on patients with suspected swallowing problems. Possible antecedents of dysphagia were recorded from the medical record including previous history of spine surgery, surgical approach and technique, tracheostomy and ventilator status, neurologic level of injury, ASIA Impairment Classification, orthosis, etiology of injury, age, and gender.

RESULTS

On admission to rehabilitation 22.5% (n = 42) of spinal cord injury patients had symptoms suggesting dysphagia. In 73.8% (n = 31) of these cases, testing confirmed dysphagia (aspiration or requiring a modified diet), while VFSS ruled out dysphagia in 26.2% (n = 11) cases. Logistic regression and other analyses revealed three significant predictors of risk for dysphagia: age (p < .028), tracheostomy and mechanical ventilation (p < .001), and spinal surgery via an anterior cervical approach (p < .016). Other variables analyzed had no relation or at best a slight relation to dysphagia. Tracheostomy at admission was the strongest predictor of dysphagia. The combination of tracheostomy at rehabilitation admission and anterior surgical approach had an extremely high rate of dysphagia (48%).

CONCLUSION

Swallowing abnormalities are present in a significant percentage of patients presenting to rehabilitation with acute traumatic cervical spinal cord injury. Patients with a tracheostomy appear to have a substantially increased risk of development of dysphagia, although other factors are also relevant. Risk of dysphagia should be evaluated to decrease the potential for morbidity related to swallowing abnormalities.

Clinical Trials in Traumatic Spinal Cord Injury

Traumatic spinal cord injury (SCI) results in impaired neurologic function that for many individuals is permanent and significantly impacts health, function, quality of life, and life expectancy. Many efforts have been taken to develop effective treatments for SCI; nevertheless, proven therapies targeting neurologic regeneration and functional recovery have been limited. Existing therapeutic approaches, including early surgery, strict blood pressure control, and consideration of treatment with steroids, remain debated and largely focus on mitigating secondary injury after the primary trauma has occurred. Today, there is more research being performed in SCI than ever before. Current clinical trials are exploring pharmacologic, cell-based, physiologic, and rehabilitation approaches to reduce secondary injury and also overcome barriers to neurorecovery. In the future, it is likely that tailored treatments combining many of these strategies will offer significant benefits for persons with SCI. This article aims to review key past, current and emerging neurologic and rehabilitation therapeutic approaches for adults with traumatic SCI.

Rehabilitation of persons with central nervous system tumors

A tumor that affects the central nervous system can have a dramatic impact on the individual affected, as well as his or her family and friends. The tumor, regardless of extent or location, may affect the physical, social, vocational, and emotional capabilities of the individual. Basic aspects of rehabilitation for patients with tumors affecting the brain and spinal cord are reviewed in this article. The authors have found that the same principles of neurorehabilitation applied to persons with traumatic brain injury, stroke, and traumatic spinal cord injury are equally appropriate for persons with brain and spinal cord tumors. These principles include the prevention of medical complications; the treatment of medical problems such as pain, spasticity, and neuropathic bowel and bladder; and the improvement of patients' mobility and activities of daily living. Rehabilitation specialists can help prevent complications, maximize function, and improve the quality of life for patients with central nervous system tumors.

Spinal cord injury-functional index: item banks to measure physical functioning in individuals with spinal cord injury

OBJECTIVES

To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning.

DESIGN

Cross-sectional.

SETTING

Inpatient and community.

PARTICIPANTS

Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Spinal Cord Injury-Functional Index (SCI-FI) measurement system.

RESULTS

Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models.

CONCLUSIONS

Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning.

Electrodiagnostic changes of the lower limbs in subjects with chronic complete cervical spinal cord injury

OBJECTIVE

To assess the electrodiagnostic changes in the lower limbs as measured by nerve conduction studies (NCSs) and electromyography in individuals with chronic complete tetraplegia.

DESIGN

Prospective testing of NCS and electromyography.

SETTING

Model spinal cord injury rehabilitation center.

PARTICIPANTS

Twenty-five individuals with chronic complete tetraplegia without risk factors for peripheral neuropathy or other lower motoneuron disorders.

INTERVENTIONS

Nerve conduction parameters recorded from the peroneal, tibial, and sural nerves, and compared with normal values. The presence of spontaneous activity (SA), including fibrillation and positive sharp waves, recorded in 5 muscle groups-2 proximal (vastus medialis, iliopsoas), 2 distal (tibialis anterior, medial gastrocnemius), and L4 lumbar paraspinals. Analysis to see if the presence of SA correlated with the distance of the muscle from the spinal cord or with spasticity (measured by the modified Ashworth scale).

MAIN OUTCOME MEASURES

Nerve conduction latencies and velocities; motor and sensory conduction latencies; compound muscle action potential (CMAP) and sensory nerve action potential amplitudes; spontaneous potentials: fibrillation and positive sharp waves; and spasticity.

RESULTS

NCS responses were obtained at a decreased frequency relative to able-bodied subjects. Statistically significant results in comparison to normal means included a diminished sural amplitude, and diminished peroneal and tibial CMAP and nerve conduction velocity (p <.0001). SA was recorded in at least 1 of the muscles tested in 92% of subjects, with 72% having SA in more than 1 of the muscles tested affected. A significant difference was seen for SA in the medial gastrocnemius as compared with the iliopsoas (p =.039). No correlation was noted in terms of SA with degree of spasticity.

CONCLUSION

A statistically significant difference in NCS responses in the lower limbs in chronic tetraplegia was found relative to normal control values. However, only the frequency of responses elicited and the decreased CMAP of the peroneal nerve are clinically significant. SA was present in many of the lower extremity muscles in the subjects. Predominantly axonal changes were evident in individuals with chronic complete tetraplegia.

Treatment alternatives for spinal cord injury related spasticity

Spasticity is a disorder of the motor system that occurs after injury to the central nervous system, which may increase the disability of an individual with spinal cord injury (SCI). Treatment options detailed in this review include rehabilitation techniques and modalities, pharmacological options, injection techniques, intrathecal baclofen, and surgery. This review will hopefully help health professionals to be aware of the treatment alternatives available for patients with SCI related spasticity.

Effect of pamidronate administration on bone in patients with acute spinal cord injury

Eleven subjects participated in a prospective placebo-controlled trial to address the efficacy of pamidronate in reducing bone loss in persons with acute spinal cord injury (SCI). We administered pamidronate (treatment) or normal saline (placebo) intravenously at baseline (22 to 65 days after injury) and sequentially over 12 months, with follow-up at 18 and 24 months. Regional bone mineral density (BMD) was lost over time, regardless of group. In the treatment group compared with the placebo group, we noted a mild early reduction in loss of total leg BMD. Significant bone loss from baseline occurred earlier in the placebo group at the regional sites than in the treatment group. However, by the end of the treatment and follow-up phases, both groups demonstrated a similar percent bone loss from baseline. Despite an early reduction in bone loss, pamidronate failed to prevent major, long-term bone loss in persons with acute neurologically complete SCI.

High-dose methylprednisolone may do more harm for spinal cord injury

Because of the National Acute Spinal Cord Injury Studies (NASCIS), high-dose methylprednisolone became the standard of care for the acute spinal cord injury. In the NASCIS, there was no mention regarding the possibility of acute corticosteroid myopathy that high-dose methylprednisolone may cause. The dosage of methylprednisolone recommended by the NASCIS 3 is the highest dose of steroids ever being used during a 2-day period for any clinical condition. We hypothesize that it may cause some damage to the muscle of spinal cord injury patients. Further, steroid myopathy recovers naturally and the neurological improvement shown in the NASCIS may be just a recording of this natural motor recovery from the steroid myopathy, instead of any protection that methylprednisolone offers to the spinal cord injury. To our knowledge, this is the first discussion considering the possibility that the methylprednisolone recommended by NASCIS may cause acute corticosteroid myopathy.