Persistent hypercoagulation associated with heterotopic ossification in patients with spinal cord injury long after injury has occurred

Effects of Four-Week Rehabilitation Program on Hemostasis Disorders in Patients with Spinal Cord Injury

Background: Patients with spinal cord injury (SCI) exhibit hemostasis disorders. This study aims at assessing the effects of a 4-week rehabilitation program on hemostasis disorders in patients with SCI. Methods: Seventy-eight in-patients undergoing a 4-week rehabilitation were divided into three groups based on time elapsed since SCI: I (3 weeks–3 months), II (3–6 months), and III (>6 months). Tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombin–antithrombin complex (TAT) and D-dimer levels, antithrombin activity (AT), and platelet count (PLT) were measured on admission and after rehabilitation. Results: Rehabilitation resulted in an increase in TF in group III (p < 0.050), and decrease in TFPI (p < 0.022) and PLT (p < 0.042) in group II as well as AT in group I (p < 0.009). Compared to control group without SCI, TF, TFPI, and TAT were significantly higher in all SCI groups both before and after rehabilitation. All SCI groups had elevated D-dimer, which decreased after rehabilitation in the whole study group (p < 0.001) and group I (p < 0.001). Conclusion: No decrease in activation of TF-dependent coagulation was observed after a 4-week rehabilitation regardless of time elapsed since SCI. However, D-dimer levels decreased significantly, which may indicate reduction of high fibrinolytic potential, especially when rehabilitation was done <3 months after SCI.

Association of α2-HS Glycoprotein with Neurogenic Heterotopic Ossification in Patients with Spinal Cord Injury

Background

The aim of this study was to explore the relationship between the α₂-HS glycoprotein concentrations in serum and the occurrence of neurogenic heterotopic ossification (NHO) in patients with spinal cord injury (SCI).

Material/Methods

During the period between January 2011 and January 2012, 75 patients (67 male) with paraplegia caused by spinal cord injury were enrolled. The patients were divided into 2 groups in accordance with the occurrence of heterotopic ossification based on the results high-frequency ultrasound on the bilateral hip joint. The levels of α₂-HS glycoprotein, C-reactive protein (CRP), D-dimer, and bone morphogenetic protein (BMP) were detected by ELISA.

Results

We found a significant decrease of α₂-HS glycoprotein in SCI patients with NHO compared to SCI patients without NHO. In contrast, a significant elevation of serum calcium, D-dimer, BMP, and CRP was observed in SCI patients with NHO. The degree of maturity of NHO did not influence the level of α₂-HS glycoprotein. Multivariate liner regression analysis showed that the level of serum α₂-HS glycoprotein was correlated with CRP and spasticity.

Conclusions

The decreased level of α₂-HS glycoprotein may be related to the formation of neurogenic heterotopic ossification in patients with spinal cord injury. Our results suggest that α₂-HS glycoprotein might be a risk factor for NHO in patients with SCI.

Perioperative complications associated with spine surgery in patients with established spinal cord injury

BACKGROUND CONTEXT

Only a small percentage of patients with spinal cord injury (SCI) require consideration for reconstructive surgery after their initial injury. For those who do, perioperative complications can be frequent and significant. There has been very little published literature examining treatment of these patients and essentially nothing to guide the surgeon in perioperative decision making and management.

PURPOSE

To identify some of the common challenges associated with surgery in this patient population and review the literature to highlight the perioperative concerns in patients with chronic SCI.

STUDY DESIGN

Review article.

METHODS

A primary PubMed literature search was performed and reviewed for patients with chronic SCI with emphasis on the complications and difficulties encountered during surgical treatment of patients with chronic SCI.

RESULTS

For those who do proceed with surgery in this patient population, preoperative nutrition, bone density, and skin should be evaluated and optimized. Preoperative inferior vena cava filters should be considered. The integrity of the reconstruction will be extensively challenged. In addition, augmented fixation and bracing should be contemplated.

CONCLUSIONS

Patients with chronic SCI who require spinal reconstruction provide many unique challenges. Indications for surgery must be strong as perioperative complications can be frequent and long-term outcomes unpredictable. Close monitoring for postoperative complications is essential.

Development of heterotopic ossifications, blood markers and outcome after radiation therapy in spinal cord injured patients

STUDY DESIGN

Retrospective study.

OBJECTIVES

This study was implemented to detect risk factors for the developing of heterotopic ossifications (HOs) in spinal cord injury (SCI) patients.

SETTING

This study was conducted in Murnau, Germany.

METHODS

All patients from 2008-2012 with acute SCI were routinely examined by ultrasound of the hips every 2 weeks. The sub group of SCI patients suffering of HO of the hips were extracted and the incidence of developing an HO was calculated. Parameters like age, level of injury, ASIA Impairment Scale (AIS), duration time of accident until diagnosis of HO, Brooker stage, localization of HO (magnetic resonance imaging (MRI)) and symptoms like thrombosis, emboli, decrease of range of motion (ROM), dermal symptoms, swelling, increase in D-Dimere level, were evaluated. Also accompanying injuries of the brain, lung and extremities were recorded.

RESULTS

From January 2008 until January 2012, 575 patients with an acute and traumatic SCI were treated in our Department. During this period 32 HOs were detected in the muscles surrounding the hip. In 10 cases a single side and in 22 cases both sides were affected. A total of 26 patients were detected showing up a Brooker 0, two patients Brooker 1, and five patients a Brooker stage >2. The adductor muscles showed an edema in 19 cases and the quadriceps muscles were affected in 15 cases. 26% of all SCI patients showed AIS A status, but in patients who developed HO, 64% have had an AIS A status. 19% of patients with a HO were AIS B and 9.5% showed an AIS C and D. Regarding the level of injury the distribution of patients suffering of HO was comparable to the distribution of SCI patients without HO. In mean HO were detected 9 weeks after SCI and no new HO were found after the 22nd (n=1) week of injury. Clinical symptoms such as swelling, pain, redness or decrease in ROM or increase in D-Dimere levels were seen in 24 cases. Accompanying injuries like brain injury and lung contusions were found in 83% of patients developing HO. The incidence of thrombosis was comparable to SCI patients without HO. One patient with no accompanying injuries or clinical symptoms was detected by routinely performed ultrasound.

CONCLUSIONS

The risk of developing HO in patients with traumatic SCI is 5.5% but increases when accompanying injuries of the brain and lung occur. Patients with a neurological status of AIS A must also be quoted as risk patients. When considering the described risk factors and clinical symptoms, 96% of all HO can be detected.

Incidence of deep vein thrombosis after spinal cord injury in Korean patients at acute rehabilitation unit

Deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) remain significant causes of morbidity, mortality in patients with spinal cord injury (SCI). Since incidence of DVT after SCI in Korean population has not been much studied, we retrospectively analyzed the medical records of 185 SCI patients admitted for acute rehabilitation unit to investigate the incidence of DVT. Color Doppler ultrasonography was performed to screen for the occurrence of DVT at the time of initial presentation to acute rehabilitation unit. Primary study outcome was the incidence of DVT. Possible risk factors for DVT including the epidemiologic characteristics, completeness of motor paralysis, cause of injury, spasticity, surgery, and active cancer were analyzed. The incidence of DVT after SCI was 27.6%. In multiple logistic regression analysis, absence of spasticity was a significant independent risk factor (P<0.05) for occurrence of DVT. Symptomatic pulmonary embolism was evident in 7 patients without an episode of sudden death. Therefore, it is concluded that the incidence of DVT after SCI in Korean patients is comparable with that in Western populations. This result suggests that pharmacologic thromboprophylaxis should be considered in Korean patients with SCI.

Thromboprophylaxis in patients with acute spinal injuries: an evidence-based analysis

BACKGROUND

The increased risk for venous thromboembolic events following spinal trauma is well established. The purpose of the present study was to examine the literature in order to determine the optimum thromboprophylaxis regimen for patients with acute spinal injuries with or without spinal cord injury.

METHODS

EMBASE, MEDLINE, and Cochrane databases were searched from the earliest available date to April 2008 for clinical trials comparing different methods of thromboprophylaxis in adult patients following acute spinal injuries (with or without spinal cord injury). Outcome measures included the prevalences of deep-vein thrombosis and pulmonary embolism and treatment-related adverse events.

RESULTS

The search yielded 489 studies, but only twenty-one of them fulfilled the inclusion criteria. The prevalence of deep-vein thrombosis was significantly lower in patients without spinal cord injury as compared with patients with spinal cord injury (odds ratio = 6.0; 95% confidence interval = 2.9 to 12.7). Patients with an acute spinal cord injury who were receiving oral anticoagulants had significantly fewer episodes of pulmonary embolism (odds ratio = 0.1; 95% confidence interval = 0.01 to 0.63) than those who were not receiving oral anticoagulants (either untreated controls or patients managed with low-molecular-weight heparin). The start of thromboprophylaxis within the first two weeks after the injury resulted in significantly fewer deep-vein-thrombosis events than delayed initiation did (odds ratio = 0.2; 95% confidence interval = 0.1 to 0.4). With regard to heparin-based pharmacoprophylaxis in patients with spinal trauma, low-molecular-weight heparin significantly reduced the rates of deep-vein thrombosis and bleeding episodes in comparison with the findings in patients who received unfractionated heparin, with odds ratios of 2.6 (95% confidence interval = 1.2 to 5.6) and 7.5 (95% confidence interval = 1.0 to 58.4) for deep-vein thrombosis and bleeding, respectively.

CONCLUSIONS

The prevalence of deep-vein thrombosis following a spine injury is higher among patients who have a spinal cord injury than among those who do not have a spinal cord injury. Therefore, thromboprophylaxis in these patients should start as early as possible once it is deemed safe in terms of potential bleeding complications. Within this population, low-molecular-weight heparin is more effective for the prevention of deep-vein thrombosis, with fewer bleeding complications, than unfractionated heparin is. The use of vitamin K antagonists appeared to be effective for the prevention of pulmonary embolism.

Coagulation profile in persons with long-standing spinal cord injury

Acute spinal cord injury (SCI) is associated with a marked propensity to thromboembolism and a variety of coagulation abnormalities. However, data on blood coagulation profiles in patients with uncomplicated long-standing SCI are limited. These data were studied here. Eight men with uncomplicated chronic SCI and nine able-bodied normal men were studied. Plasma activities and/or antigen concentrations of high molecular weight kininogen (HMWK) and of factors XII, XI, IX, VIII, VII, X, V, II and XIII as well as von Willebrand factor (vWF), fibrinogen and fibronectin were measured by appropriate functional and or immunological assays. The SCI group exhibited normal values for factors XII, IX, VIII, vWF, VII, X and V as well as HMWK, vWF and fibronectin concentration. However, they showed slight reductions in plasma factor XI activity, factor XIII antigen concentration and modest increases in fibrinogen and factor II concentrations. No correlation was found between the parameters studied and either the duration or the level of injury. In conclusion, in contrast to acute SCI, the coagulation profile in uncomplicated chronic SCI is noted to be largely normal with only a few minor alterations of questionable clinical significance.