Demographic profile of traumatic spinal cord injuries admitted at Indian Spinal Injuries Centre with special emphasis on mode of injury: a retrospective study

Cortical intermittent theta burst stimulation on gait pathomechanics and urinary tract dysfunction in incomplete spinal cord injury patients: Protocol for a randomized controlled trial

Gait impairment and neurogenic bladder are co-existing common findings in incomplete spinal cord injury (iSCI). Repetitive transcranial magnetic stimulation (rTMS), evident to be a promising strategy adjunct to physical rehabilitation to regain normal ambulation in SCI. However, there is a need to evaluate the role of Intermittent theta burst stimulation (iTBS), a type of patterned rTMS in restoring gait and neurogenic bladder in SCI patients. The aim of the present study is to quantify the effect of iTBS on spatiotemporal, kinetic, and kinematic parameters of gait and neurogenic bladder dyssynergia in iSCI. After maturing all exclusion and inclusion criteria, thirty iSCI patients will be randomly divided into three groups: Group-A (sham), Group-B (active rTMS) and Group-C (active iTBS). Each group will receive stimulation adjunct to physical rehabilitation for 2 weeks. All patients will undergo gait analysis, as well assessment of bladder, electrophysiological, neurological, functional, and psychosocial parameters. All parameters will be assessed at baseline and 6th week (1st follow-up). Parameters except urodynamics and gait analysis will also be assessed after the end of the 2 weeks of the intervention (post-intervention) and at 12th week (2nd follow-up). Appropriate statistical analysis will be done using various parametric and non-parametric tests based on results.

Spinal cord injury etiology, severity, and care in East Asia: a cross-sectional analysis of the International Spinal Cord Society Database Project

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To evaluate etiologic factors associated with spinal cord injury (SCI) severity and to identify predictive factors of reduction in SCI severity in six countries.

SETTING

SCI centers in Bangladesh, India, Malaysia, Nepal, Sri Lanka, and Thailand.

METHODS

Data from centers collected between October 2015 and February 2021 were analyzed using descriptive statistics and logistic regression.

RESULTS

Among 2634 individuals, the leading cause of SCIs was falls (n = 1410, 54%); most occurred from ≥1 meter (n = 1078). Most single-level neurological injuries occurred in the thoracic region (n = 977, 39%). Greater than half of SCIs (n = 1423, 54%) were graded American Spinal Injury Association Impairment Scale (AIS) A. Thoracic SCIs accounted for 53% (n = 757) of all one-level AIS A SCIs. The percentage of thoracic SCIs graded AIS A (78%) was significantly higher than high cervical (52%), low cervical (48%), lumbar (24%), and sacral (31%) SCIs (p < 0.001). Regression analyses isolated predictive factors both of SCI severity and inpatient improvement. Four factors predicted severity: age, neurological level, etiology, and country of residence. Four factors predicted improvement: age, neurological level, AIS grade on intake, and country of residence.

CONCLUSIONS

Findings can be used by healthcare providers and public health agencies in these countries to inform the public of the risk of SCI due to falls. Future studies should examine the social and occupational milieux of falls. Country-to-country comparisons of prehospital and inpatient care are also justified. Fall prevention policies can encourage the use of safety equipment when performing tasks at heights ≥1 meter.

Challenges and strategies in the surgical management of traumatic spinal cord injuries in the Democratic Republic of the Congo

BACKGROUND

Significant progress has been made in the management of traumatic spinal cord injuries. However, deep disparities persist in developing countries. This work aims to describe the different challenges in the surgical management of traumatic spinal cord injuries at the Kinshasa University Teaching Hospital and some strategies implemented to overcome them.

METHODS

This is a cross-sectional study of 105 patients from January 2016 to June 2023. The variables of interest included: gender, age, cause, levels of lesion, hospital admission modalities, time to admission, time to surgery, AIS score at admission and on discharge, treatment, pre, peri- and post-operative complications and outcome.

RESULTS

We admitted 105 patients. Only 16 % of them were taken to hospital in an ambulance. The average admission time was 49.9 ± 81.79 days. Seventy-two patients (68.6 %) were operated. The average time to surgery was 62.43 ± 85.20 days. No patient was stabilized at the trauma site. Osteosynthesis was performed with appropriate implants in 63.2 % and with improvised elements in 26.8 %. Four patients were operated without an image intensifier. Short-segmental fixation was performed in 8 patients. Twenty-one patients developed pressure ulcers. At discharge, 24 patients recovered their neurological function. Neurological status remained stationary in 43 patients. Five patients died. Seventeen patients went to rehabilitation center. There was no significant difference between the improvised strategies implemented and conventional procedures on functional recovery upon discharge from hospital or rehabilitation centre (p-value : 0.838 and 0.468 respectively).

CONCLUSION

Our establishment faces many challenges in TSCI surgery: lack of pre-hospital emergency services and mutual health insurance, delay in admission, lack of surgical implants and image intensifier, the poverty of the population. Some strategies have been implemented to overcome some of them.

Epidemiology of Traumatic Spinal Cord Injury in the Himalayan Range and Sub-Himalayan region: A Retrospective Hospital Data-Based Study

OBJECTIVE

To compile epidemiological characteristics of traumatic spinal cord injury (TSCI) in the Northern Indian Himalayan regions and Sub-Himalayan planes.

METHODS

The present study is a retrospective, cross-sectional descriptive analysis based on hospital data conducted at the Department of Physical Medicine and Rehabilitation and Spine Unit of Trauma Centre in a tertiary care hospital in Uttarakhand, India. People hospitalized at the tertiary care center between August 2018 and November 2021 are included in the study sample. A prestructured proforma was employed for the evaluation, including demographic and epidemiological characteristics.

RESULTS

TSCI was found in 167 out of 3,120 trauma patients. The mean age of people with TSCI was 33.5±13.3, with a male-to-female ratio of 2.4:1. Eighty-three participants (49.7%) were from the plains, while the hilly region accounts for 50.3%. People from the plains had a 2.9:1 rural-to-urban ratio, whereas the hilly region had a 6:1 ratio. The overall most prevalent cause was Falls (59.3%), followed by road traffic accidents (RTAs) (35.9%). RTAs (57.2%) were the most common cause of TSCI in the plains' urban regions, while Falls (58.1%) were more common in rural plains. In both urban (66.6%) and rural (65.3%) parts of the hilly region, falls were the most common cause.

CONCLUSION

TSCI is more common in young males, especially in rural hilly areas. Falls rather than RTAs are the major cause.

Epidemiological characteristics of 1,806 patients with traumatic spinal cord injury: A retrospective study

Background

Traumatic spinal cord injury (TSCI) is a type of highly disabling central nervous system trauma. In this study, we investigated the epidemiological characteristics of 1,806 TSCI patients and compared the characteristics of patients with traumatic cervical spinal cord injury (TCSCI) caused by cervical fracture/dislocation and disc herniation/bulging.

Methods

We retrospectively reviewed the hospital records of 1,806 TSCI patients. The detailed information included gender, marital status, occupation, age, neurological level of injury, etiology, American Spinal Injury Association (ASIA) grade, combined injuries, complications, treatment, the interval between admission and surgery, intubation/tracheostomy requirement, and the length of hospital stay.

Results

Cervical spinal cord injury (CSCI) was the most common injury. Compared to non-CSCI cases, patients with TCSCI were older, and more likely to suffer from tetraplegia and require intubation/tracheostomy, but had fewer other injuries or complications and a shorter length of hospital stay. Compared to patients with cervical fracture/dislocation, those with TCSCI caused by disc herniation/bulging were older and more likely to suffer from paraplegia, but required intubation/tracheostomy less frequently, exhibited fewer other injuries and complications, and required shorter hospitalization.

Conclusions

Men, married individuals, manual laborers, and individuals aged 31-75 years had the highest risk of TSCI. Patients with TCSCI tended to have a shorter length of hospital stay than patients with non-CSCI. More attention should be paid to the other injuries and complications of non-CSCI patients, which may increase the length of hospital stay and delay rehabilitation. Compared to patients with cervical disc herniation, the patients with fracture/dislocation tended to be younger, but prognosis was severely compromised by tetraplegia, a greater need for intubation/tracheostomy, additional injuries, and complications.

Thermo-sensitive hydrogel combined with SHH expressed RMSCs for rat spinal cord regeneration

Purpose: Spinal cord injury (SCI) has a damaging impact on patients, amid being a worldwide problem with no effective treatment. Herein, we reported a method for functional therapy of SCI in rats, wherein we combined thermo-sensitive hydrogel with Sonic Hedgehog (SHH) expressed in rat bone-marrow derived mesenchymal stem cells (RMSCs).

Methods: Bone marrow-derived mesenchymal stem cells (BMSCs) were isolated from Sprague-Dawley (SD) female rats. The SHH was optimized and transferred into RMSCs via cationic liposomes, while thermo-sensitive hydrogel was reformed with hyaluronate (HA) and Pluronic F127. Then, a rat model with SCI was established accordingly by male SD rats and randomized into sham, model, RMSCs with hydrogel and SHH-RMSCs with hydrogel. The evaluation of SCI repair based on Basso, Beattie Bresnahanlocomotor rating scale (BBB scale) and inclined plate score. Immunofluorescence, immunohistochemistry and hematoxylin-eosin were utilized to explore the expression of protein (GFAP, GAP43, NF200 and MBP) and histopathology.

Results: It was demonstrated that transfection of SHH with cationic liposomes exhibited more effect in RMSCs than lipofectamine 2000. As shown in SEM, 3.5% HA-F127 demonstrated porous structure. In the MTT and dead/live assay, 3.5% HA-F127 showed good biocompatibility for RMSCs. Both RMSCs and SHH-RMSCs groups could significantly promote BBB and inclined plate scores (p < 0.01) compared with the model. Furthermore, the SHH-RMSC group was significantly improved than RMSC with the expression of related proteins, where NF200, MBP, and GAP43 were principally enhanced with the GFAP expression being virtually down-regulated.

Conclusion: All in all, the results suggested that transplantation of RMSCs with SHH could improve the function of SCI and promote nerve regeneration.

Hindi translation and reliability testing of the international spinal cord injury quality of life basic data set version 1.0

STUDY DESIGN

Methodological study design: translation and test-retest reliability testing.

OBJECTIVES

To translate International Spinal Cord Injury Quality of Life Basic Data Set (ISCIQoLBDS) Version 1.0 into Hindi language and conduct reliability testing of Hindi ISCIQoLBDS (hISCIQoLBDS).

SETTING

The study was conducted at Indian Spinal Injuries Centre, New Delhi, India.

METHODS

The study was done in two phases-translation of ISCIQoLBDS Version 1.0 into Hindi language and reliability testing of hISCIQoLBDS. In the translation phase, the data set was forward translated by two independent professional translators. Then backward translation was done by another pair of professional translators to ensure the essence of the data set. For their feedback, field testing of hISCIQoLBDS was done on ten individuals with Spinal Cord Injury (SCI). After this, an expert panel reviewed their recommendations, and the final hISCIQoLBDS was administered on 50 participants with SCI for test-retest reliability of the data set.

RESULTS

hISCIQoLBDS was found to be equivalent to ISCIQoLBDS Version 1.0 on back-translation. It showed high test-retest reliability for each item in the data set. Intraclass Correlation Coefficient (95% CI) for items of hISCIQoLBDS was within the range of (0.91-0.98).

CONCLUSION

The hISCIQoLBDS is a stepwise systematic Hindi translation of the ISCIQoLBDS Version 1.0 for the Hindi literate population with high test-retest reliability. It can facilitate international data exchange on the quality of life (QoL) of Hindi literate individuals with SCI.

Cervical Spinal Lesion, Completeness of Injury, Stress, and Depression Reduce the Efficiency of Mental Imagery in People With Spinal Cord Injury

OBJECTIVES

The aims of this study were to assess the relationships of (1) clinical variables (age, level of injury, time since injury [TSI], and completeness of injury) and (2) psychological variables (stress and depression) with mental imagery ability in individuals with spinal cord injury.

STUDY DESIGN

This was a cross-sectional study. Participants with spinal cord injury (N = 130) were requested to fill the Kinesthetic and Visual Imagery Questionnaire and Vividness of Motor Imagery Questionnaire. They also completed the Perceived Stress Scale and Patient Health Questionnaire 9 for the assessment of stress and depression, respectively.

RESULTS

Mental imagery scores were found to be significantly low in cervical injuries (P < 0.001) as compared with thoracic injuries (P < 0.001). Furthermore, higher levels of spinal injuries resulted in lower mental imagery scores. Completeness of injury (according to Asia Impairment Scale) also had a significant relationship (P < 0.001) with the mental imagery ability among spinal cord injury participants. Presence of stress (P < 0.001) and depression (P < 0.001) also associated with reduced efficiency of mental imagery in these individuals.

CONCLUSIONS

Injury type and psychological factors were associated with mental imagery in SCI patients. Imagery-based interventions should be designed after consideration of identified factors yielding effect on their outcomes.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the impact of clinical variables such as level of injury, completeness and chronicity of injury on mental imagery ability in spinal cord injury; (2) Discuss the role of stress and depression on mental imagery ability in spinal cord injury; and (3) Describe the various dimensions of mental imagery ability and its variability among individuals who have spinal cord injury.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Epidemiology of Traumatic Spinal Cord Injury in Developing Countries from 2009 to 2020: a Systematic Review and Meta-analysis

INTRODUCTION

Traumatic spinal cord injury (TSCI) is a catastrophic event with a considerable health and economic burden on individuals and countries. This study was performed to update an earlier systematic review and meta-analysis on epidemiological properties of TSCI in developing countries published in 2013.

METHODS

Various search methods including online searching in database of EMBASE and PubMed, and hand searching were performed (2012 to May 2020). The keywords 'Spinal cord injury', 'epidemiology', 'incidence' and 'prevalence' were used. Based on definition of developing countries by International Monetary Fund, studies related to developing countries included. Data selection was according to PRISMA guidelines. The quality of included studies was evaluated by Joanna Briggs Institute Critical Appraisal Tools. Results of meta-analysis were presented as pooled frequency, and forest, funnel and drapery plots.

RESULTS

we identified 47 studies from 23 developing countries. The pooled incidence of TSCI in developing countries was 22.55/million/year (95% CI: 13.52; 37.62/million/year). Males comprised 80.09% (95% CI: 78.29%; 81.83%) of TSCIs, and under 30 years patients were the most affected age group. Two leading etiologies of TSCIs were motor vehicle crashes (43.18% (95% CI: 37.80%; 48.63%)), and falls (34.24% (95% CI: 29.08%; 39.59%)), respectively. The difference among the frequency of complete injury (49.47% (95% CI: 43.11%; 55.84%)), and incomplete injury (50.53% (95% CI: 44.16%; 56.89%)) was insignificant. The difference among frequency of tetraplegia (46.25% (95% CI: 37.78%; 54.83%)) and paraplegia (53.75% (95% CI: 45.17%; 62.22%)) was not statistically significant. The most prevalent level of TSCI was cervical injury (43.42% (95% CI: 37.38%; 49.55%).

CONCLUSION

In developing countries, TSCIs are more common in young adults and males. Motor vehicle crashes and falls are the main etiologies. Understanding epidemiological characteristics of TSCIs could lead to implant appropriate cost-effective preventive strategies to decrease TSCIs incidence and burden.

In-hospital mortality in people with complete acute traumatic spinal cord injury at a tertiary care center in India-a retrospective analysis

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI).

SETTING

The study was performed at the Indian Spinal Injuries Centre, New Delhi.

METHODS

Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression.

RESULTS

Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14-85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p < 0.001). Greater age (OR (multivariable models) = 1.03, 95% CI = 1.01-1.06), associated injuries (OR = 2.42, 95% CI = 1.11-5.27), high tetraplegia (OR = 5.09, 95% CI = 2.21-11.72), low tetraplegia (OR = 4.84, 95% CI = 1.29-18.09), need for ventilator support (OR = 31.32, 95% CI = 14.92-65.35), septicemia (OR = 4.60, 95% CI = 1.05-20.07), respiratory complications (OR = 3.46, 95% CI = 1.63-7.33), and cardiovascular causes (OR = 39.03, 95% CI = 8.29-183.89) were significant risk factors associated with mortality.

CONCLUSION

Respiratory complications, septicemia, and cardiovascular causes were the commonest causes of in-hospital mortality in people with complete ATSCI. Greater age, presence of associated injuries, tetraplegia, and ventilator support were risk factors significantly associated with mortality. To reduce morbidity and mortality in the acute phase, there is a need to focus on respiratory management and prevention of infections, especially in tetraplegics.

Epidemiological profile of 338 traumatic spinal cord injury cases in Shandong province, China

STUDY DESIGN

Hospital-based retrospective review.

OBJECTIVE

To describe the epidemiological characteristics of traumatic spinal cord injury (TSCI) in Liaocheng, China.

SETTING

Liaocheng People's Hospital.

METHODS

Medical records of 338 persons with TSCI admitted to Liaocheng People's Hospital from 2013 to 2017 were reviewed. The detailed information included gender, age, marital status, occupation, time, etiology, level of injury, ASIA grade, spinal stenosis, concomitant injury, treatment, length of stay.

RESULTS

Over this period, the mean age (SD) of persons with TSCI was 50.1 (14.1) years, and the male/female ratio was 3.1:1. 96.4% of all were married. The leading cause was fall, followed by motor vehicle accident (MVA). The most common level of injury was the cervical cord. ASIA grade D and A injuries were the most common, accounting for 48.5 and 29.3% respectively. Among the concomitant injuries, spinal fractures were the most common. Within 24 h, 91.1% of individuals with TSCI arrived hospital, 63.3% of all accepted surgery.

CONCLUSION

The results showed that fall and MVA were the two main causes, so we should focused on preventing fall and reducing MVA. Cervical spinal stenosis can increase the risk of TSCI, so education should be provided to this population to raise their risk awareness. In addition, timely treatment was critical for TSCI, but the data showed that rescue process was not standard, so it was necessary for medical staff to popularize professional knowledge.

Better late than never: Clinical outcomes of delayed fixation in thoracolumbar spinal trauma

PURPOSE

To analyse factors influencing functional outcome and neurological recovery in patients undergoing delayed surgery for traumatic spinal cord injury (SCI) involving thoracolumbar spine.

METHODS

Retrospective analysis of 33 patients with thoracolumbar SCI who underwent delayed surgery (≥ 72hrs post-trauma) with a minimum follow-up of 1 year (average:32.55 months) was done. The parameters studied included age, sex, co-morbidities, mode of trauma, associated trauma, level and number of vertebrae involved, fracture morphology, thoracolumbar injury classification and severity score (TLICS), maximal spinal cord compression (MSCC), signal changes in the cord, neurological deficit as per the American Spinal Injury Association (ASIA) scale, lower extremity motor score (LEMS), bowel bladder involvement, time interval between trauma and surgery.

RESULTS

Mean time interval from injury to spine surgery was 24.45 days. At the end of 1-year follow-up, 17(51.5%), 12(36.36%), and 3(9.1%) patients had ≥ 1, ≥ 2, and ≥ 3-grade ASIA improvement, respectively. The mean LEMS rose to 33.86 from 17.09 (P < 0.001). 8 out of 20 patients with bladder involvement showed improvement. 4 patients succumbed, 22 were ambulatory, and 7 remained non-ambulatory. On comparing various parameters, pre-operative LEMS score (P-value: < 0.001), cord signal changes (P-value:0.002), and presence of cord transection (P-value:0.007) differed significantly in the above-mentioned three groups, while age (P-value:0.442), average TLICS (P-value:0.872), time from injury to surgery (P-value:0.386) did not differ significantly.

CONCLUSION

This study highlights that there is still a significant scope for neurological improvement even after delayed surgery in patients with thoracolumbar SCI. The lower the LEMS score at the time of presentation, signal changes in the cord and presence of cord transection have a significant influence on unfavourable clinical outcomes at the end of 1-year post-surgery.

Surgical Outcome in Spinal Operation in Patients Aged 70 Years and Above

Introduction

The world is seeing a growth of the aging population and the number of surgical treatments in this age group which is also true for spinal conditions. The greatest increase in spinal fusion surgery has been observed in patients aged 65 years and above. Only a few works of literature were available on the issue, especially in India.

Materials and Methods

An observational study in which 70 patients aged 70 years and above who underwent spinal surgery for degenerative and traumatic spinal injury, from January 2013 to July 2017 in the neurosurgery department of a single institute, were reviewed. Around 53 patients were assessed for disability/functional outcome and their health-related quality of life (HRQOL) using the Oswestry disability index (ODI) and RAND 36-item health survey 1.0 scoring method (SF-36) comparing the preoperative and postoperative status.

Result

The mean age was 74.19 years (range 70-91 years). Laminectomy-19 (27.14%) was the most common surgical procedure performed. Overall there were nine (12.85%) major complications with mortality of five (7.14%) patients. There was a significant reduction of crippled patients (14-9, P = 0.009) in the ODI score. SF-36: There was significant improvement in degenerative patient (P = 0.000 to P = 0.012). In traumatic patient, only pain had significant improvement (P = 0.045).

Conclusion

This study showed that the age of the patient should not be the limiting factor for the surgical management of a patient with a degenerative or a traumatic spinal condition.

Pattern of spine fracture in Sub-Himalayan region: A prospective study

BACKGROUND

Though spine trauma contributes to great functional, psychological, and economic loss, research regarding the demographic profile of patients according to different regions of our country are lacking.This study aims to identify the demographic pattern and clinical profile of patients with spinal fracture in the Sub-Himalayan region.

METHOD

Patients with acute or subacute spine trauma presenting within 8weeks and involving fracture of cervical, dorsal, or lumbar vertebra, from July 2017 to December 2019 were included prospectively. Patients with osteoporotic or metastatic collapse, isolated transverse or spinous process fracture, penetrating trauma or ballistic injuries were excluded.

RESULTS

Out of 280 enrolled patients, 180 were males and 100 were females. The maximum number of spine trauma patients was in 16-30 years age group. The most common mechanism of injury was fall from height (FFH, 42.5%)> road traffic accident (RTA, 38.6%). RTA was more common among males and FFH among females (p < 0.0001). Most common location of injury was at thoracolumbar junction (D10-L2) (37.5%) followed by cervical spine (25.3%). 58.2% of patients had AO type A facture morphology followed by AO types C (36.1%) and AO type B (5.7%). Spinal Cord Injury (SCI) was seen in 82.1% spine trauma patients with statistically significant association with male gender (p- 0.045). Complete paralysis was seen maximum in patients with cervical spine injury (67.3%, p < 0.0001). Complete neurological deficit (ASIA grade A) was seen maximum in AO type C fracture morphology (74.25%, p < 0.001) followed by AO type A4 (29.6%). Seasonal distribution showed increased incidence during summer and monsoon season.

CONCLUSION

Young aged males in age group of 16-30 yrs were most commonly affected with fall from height as the most common mechanism of trauma. Association was found between gender and mechanism of injury (RTA in males and FFH in females). Most common vertebral injury level was thoracolumbar junction. AO type A was the most common fracture morphology. SCI seen in 82.1% of spine trauma. Statistically significant association was found between Complete SCI with Location of Injury (Cervical) and Fracture morphology (AO type C).

Impact of Patient Counseling and Socioeconomic Factors on Initiation of Rehabilitation Program in Spinal Cord Injury Patients Presenting to a Tertiary Spine Unit in India

Study Design

Prospective case series.

Purpose

This study aimed to investigate the impact of education, financial income, occupation, and patient counseling on the timing of enrolment in a spinal cord injury (SCI) rehabilitation program.

Overview of Literature

A rehabilitation program following SCI is essential to improve functional outcomes. Socioeconomic factors can affect the timing of enrolment to a rehabilitation program. Literature on the effects of socioeconomic factors among patients with SCI in the Indian scenario is limited.

Methods

A prospective, consecutive analysis of patients with SCI was performed with 1-year follow-up. Assessment of the timing of enrolment to a rehabilitation program was performed using the modified Kuppuswamy socioeconomic scores (MKSS). Patients admitted to the SCI unit (group A), underwent intensive individual, group, and family counseling sessions to encourage early enrolment into a rehabilitation program. Patients presenting directly for rehabilitation (group B) were analyzed for comparison.

Results

A total of 153 patients were recruited. Group A was composed of 122 patients who started the rehabilitation program after a mean of 28 days, compared with a mean of 149 days for 31 patients in group B. In group A, 104 patients (85%; mean MKSS, 14.02) and 18 patients (15%; mean MKSS, 15.61) enrolled for rehabilitation <6 weeks and ≥6 weeks, respectively. In group B, 12 patients (39%; mean MKSS, 13.69) and 19 patients (61%; mean MKSS, 12.10) enrolled for rehabilitation <6 weeks and ≥6 weeks, respectively. The total MKSS and scores for education, income, and occupation did not show a significant difference between the two both groups (p>0.05).

Conclusions

Early patient counseling in the acute care unit helps in the early enrolment of patients with poor socioeconomic demographic profile to a rehabilitation program.

Clinical and sociodemographic profiles of persons with spinal cord injury

AIM

To collect and correlate the sociodemographic and clinical details of persons with spinal cord injury who were admitted to the Department of Neurological Rehabilitation.

OBJECTIVES

To assess the sociodemographic characteristics and collect the clinical profiles of persons with spinal cord injury and to correlate their sociodemographic and clinical details.

MATERIALS AND METHODS

A retrospective file review was done over a period of 2 years from January 2017 to December 2018 to study patients with spinal cord injury who were admitted to the Neurological Rehabilitation ward of NIMHANS, Bengaluru, Karnataka, India.

RESULTS

A total of 60 patients were admitted with spinal cord injury. The mean age was 32.39 years and majority of the patients were young married males. Most of them belong to the low socioeconomic status and are housewives and daily wage laborers. Falls and road traffic accidents are the causes for the injury. Anxiety and depression are high among traumatic spinal cord injury patients.

CONCLUSION

This information may contribute to prevent SCI and to improve the quality of life of patients with SCI. It has implications for the primary care physicians who are at first contact to identify and refer them for specialized super speciality district hospitals for further treatment as they pose a great threat to public health and their proportions are increasing. It is imperative that trauma care is included in graduate medical training as well to facilitate early intervention after initial screening.

Bone marrow mesenchymal stem cells improve spinal function of spinal cord injury in rats via TGF-β/Smads signaling pathway

Bone marrow mesenchymal stem cells (BMSCs) on the repair of spinal cord injury (SCI) in rats as well as the role of transforming growth factor-β (TGF-β)/Smads signaling pathway in the repair were investigated. Rat BMSCs and astrocyte-spinal cords (ASCs) were isolated and cultured in vitro, and the cell purity was detected by flow cytometry. ASCs were co-cultured with TGF-β1, BMSCs and BMSCs + TGF-β1, respectively, and grouped accordingly, and ASCs cultured conventionally were included into control group. 3-(4,5)-Dimethylthiahiazo(-z-y1)-3,5-diphenyltetrazoliumbromide (MTT) assay was conducted to detect the proliferation ability of ASCs in each group. Western blotting (WB) was utilized to examine the expression of TGF-β/Smads signaling pathway-related proteins [TGF-β1, Smad2 and phosphorylated (p)-Smad2] in ASCs and ASCs co-cultured with BMSCs. A rat model of SCI was established, and BMSCs were injected locally. Then (BBB) score was used to evaluate spinal cord repair, and WB was adopted to detect the expression of TGF-β1, Smad2 and p-Smad2 at the injured site. BMSCs and ASCs isolated in vitro grew well. According to MTT assay results, TGF-β1 significantly promoted the proliferation of ASCs (P<0.05), and co-culture of ASCs and BMSCs remarkably reduced the proliferation of ASCs (P<0.05). The detection of protein expression at the SCI site via WB demonstrated that the expression of TGF-β1, Smad2 and p-Smad2 in SCI group were obviously upregulated compared with those in Sham group at 1 week (P<0.05), and the injection of BMSCs could markedly downregulate the expression (P<0.05). After 3 week, there were no significant differences in the expression of TGF-β1, Smad2 and p-Smad2 among groups (P>0.05). The transplantation of BMSCs can improve the spinal function of SCI rats probably by inhibiting the TGF-β/Smads signaling pathway and reducing the proliferation of ASCs.

Recommendations for standards of physiotherapy care following complete traumatic paraplegia in India

STUDY DESIGN

Qualitative study.

OBJECTIVES

To formulate recommendations for standards of physiotherapy care for people with complete traumatic paraplegia in India using a Delphi methodology.

SETTING

India.

METHODS

Twenty-three physiotherapy experts were invited to participate in an online consensus process. Fourteen (n = 14) of 23 physiotherapy experts from India accepted an invitation to participate in an online consensus development exercise (Response rate-60.86%). Four rounds of consensus meetings were conducted which involved posting the quotations from a previous study on expectations of people with paraplegia to obtain perceptions of physiotherapy experts in round 1, retrieving codes/code groups from round 1, posting these code groups in rounds 2 and 3 for experts' agreement/disagreement, the preparation of the draft of recommendations, and posting it in round 4 for experts' opinion. Data were analyzed using descriptive statistics and ATLASti software for qualitative data analysis.

RESULT

Recommendations for physiotherapy care for persons with complete traumatic paraplegia in India are presented.

CONCLUSIONS

Education to patients and/or caregivers regarding care post injury is one of the important recommendations by physiotherapy experts. It is emphasized that the subjective assessment of the patients, including their needs and preferences, is equally important as that of their objective assessment. Physiotherapy students and practicing physiotherapists must also enhance their knowledge to provide optimal physiotherapy care to people with paraplegia.

Loss of work-related income impoverishes people with SCI and their families in Bangladesh

Study design

Cross-sectional study.

Objectives

To determine the degree of impoverishment of people with spinal cord injury (SCI) and their families in Bangladesh caused by loss of work-related income following injury.

Setting

Spinal cord injury centre, Bangladesh.

Methods

A total of 410 wheelchair-dependent people with recent SCI about to be discharged from a hospital in Bangladesh were interviewed to determine the size of their families, their incomes from paid work prior to injury and the incomes of their family members. These data were used to calculate income per family unit and per family member prior to and immediately after injury.

Results

Ninety percent of the participants were men, 98% were from rural areas of Bangladesh and 58% were manual labours prior to injury. Median (interquartile range, IQR) family size was 5 (4–6) people. Prior to injury, 74% of participants were the main income earners for their families and 50% provided the only source of income for their families. Participants’ median (IQR) monthly income prior to injury was US$106 (US$60–US$180) per person and family members’ income was US$30 (US$19–US$48) per person. After injury, the median income (IQR) of each family member dropped to US$0 (US$0–US$18) placing 91% of families below the extreme poverty line of US$37.50 per person per month (equivalent to US$1.25 per day).

Conclusion

In Bangladesh, SCI have profound financial implications for individuals and their families and causes extreme poverty. This is because those most often injured are young and the main income earners for their families.

International Spinal Cord Society (ISCoS) database: Asian Spinal Cord Network (ASCoN) Pilot Project [IDAPP]

Study design

Global mapping project of ISCoS for traumatic spinal cord injury (T-SCI) highlighted paucity of data from low and middle income countries (LMICs). Recognizing this gap, IDAPP study of one year duration was proposed as the first step to develop an International SCI database.

Objectives

Primary objective was to assess database variables, processes involved and web platform for their suitability with a view to provide guidance for a large scale global project. Secondary objective was to capture demographic and selected injury/safety data on patients with T-SCI with a view to formulate prevention strategies.

Setting

Nine centers from Asia.

Methods

All patients with T-SCI admitted for first time were included. International SCI Core Data Set and especially compiled Minimal Safety Data Set were used as data elements. Questionnaire was used for feedback from centers.

Results

Results showed relevance and appropriateness of processes, data variables and web platform of the study. Ease of entering and retrieval of data from web platform was confirmed. Cost of one year IDAPP study was USD 7780. 975 patients were enrolled. 790 (81%) were males. High falls (n = 513, 52%) as a cause and complete injuries (n = 547, 56%) were more common. There was a higher percentage of thoracic and lumbar injuries (n = 516, 53%).

Conclusions

The study confirms that establishing the SCI database is possible using the variables, processes and web platform of the pilot study. It also provides a low cost solution. Expansion to other centers/regions and including non-traumatic SCI would be the next step forward.

The Burden of Spine Fractures in India: A Prospective Multicenter Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the association between patient or injury characteristics and outcomes after spinal trauma.

METHODS

In affiliation with the ongoing INternational ORthopaedic MUlticentre Study (INORMUS), 192 patients with spinal injuries were recruited during an 8-week period (November 2011 to June 2012) from 14 hospitals in India and followed for 30-days. The primary outcome was a composite of mortality, complications, and reoperation. This was regressed on a set of 13 predictors in a multiple logistic regression model.

RESULTS

Most patients were middle-aged (mean age = 51.0 years; median age = 55.5 years; range = 18.0 to 72.0 years), male (60.4%), injured from falls (72.4%), and treated in a private setting (59.9%). Fractures in the lumbar region (51.0%) were most common, followed by thoracic (30.7%) and cervical (18.2%). More than 1 in 5 (21.6%) patients experienced a treatment delay greater than 24 hours, and 36.5% arrived by ambulance. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR = 11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications.

CONCLUSIONS

Treatment in the public health care system, increased severity of injury, and surgical intervention were associated with increased risk of major complications following spinal trauma. The need for a large-scale, prospective, multicenter study taking into account spinal stability and neurologic status is feasible and warranted.

Epidemiology of road traffic injury patients presenting to a tertiary hospital in Hyderabad, India

BACKGROUND

Road traffic injuries kill more people in India than in any other country in the world, and these numbers are rising with increasing population density and motorization. Official statistics regarding road traffic injuries are likely subject to underreporting. This study presents results of a surveillance program based at a public tertiary hospital in Hyderabad, India.

METHODS

All consenting patients who presented to the casualty ward after a road traffic injury over a 9-month period were enrolled. Interviews were performed and data abstracted from clinical records by trained research assistants. Data included demographics, injury characteristics, risk factors, safety behaviors, and outcomes.

RESULTS

A total of 5,298 patients were enrolled; their mean age was 32.4 years (standard deviation 13.8) and 87.3% were men; 58.2% of patients were injured while riding a motorcycle or scooter, 22.5% were pedestrians, and 9.2% used motorized rickshaws. The most frequent collision type was skid or rollover (40.9%). Male victims were younger than female victims and were overrepresented among motorized 2-wheeler users. Patients were most frequently injured from 1600 to 2400. A total of 27.3% of patients were admitted. Hospital mortality was 5.3%, and 48.2% of deaths were among motorized 2-wheeler users.

CONCLUSION

This is one of the few prospective, hospital-based studies of road traffic injury epidemiology in India. The patient population in this study was similar to prior hospital-based studies. When compared to government surveillance systems, this study showed motorized 2-wheeler users to be more frequently represented among the overall population and among fatalities. Further research should be done to develop interventions to decrease mortality associated with 2-wheeled vehicles in India.

Neglected Thoraco Lumbar Traumatic Spine Injuries

STUDY DESIGN

Retrospective study.

PURPOSE

To outline the etiology, complications and management difficulties encountered in the management of neglected thoracolumbar spine injuries.

OVERVIEW OF LITERATURE

The English literature describes overlooked diagnosis as the most common cause of neglected spine injuries. However, the reasons differ in developing or under-developed nations. Moreover, there is scarcity of literature about the neglected spinal injuries.

METHODS

Patients presenting with thoracolumbar traumatic injuries who had not received any form of treatment for more than three weeks were included in the study. The demographic details, operative procedure performed and complications encountered, along with American Spinal Injury Association grade and spinal cord independence measure score recorded on the history sheets were noted. The data were analyzed.

RESULTS

Forty patients were included in the study. Inadequate treatment at the first contact hospital (45%) followed by late presentation (38%) and missed injury (17%) were the major etiological factors for the neglected traumatic injuries in the thoracolumbar spine. The most common complications seen in the management of these cases were pressure sores (58%), back pain (57%), urinary tract infection (42%) and residual kyphotic deformity (42%).

CONCLUSIONS

Management of neglected thoracolumbar injuries is challenging. The delay in presentation should not prevent spine surgeon in proceeding with operative intervention as good results can be expected.

Hindi translation and evaluation of psychometric properties of Craig Hospital Inventory of Environmental Factors instrument in spinal cord injury subjects

INTRODUCTION

The Craig Hospital Inventory of Environmental Factors instrument (CHIEF) is one of the few tools to assess the environmental barriers. The purpose of this study was to translate long and short CHIEF into Hindi language, and to determine its validity and reliability.

DESIGN AND SETTING

The study design was observational case series with repeated measures. It was carried out at Indian Spinal Injuries Centre New Delhi, a specialized center for rehabilitation for spinal cord injury.

METHODS

The CHIEF instrument was translated from English to Hindi based on the Beaton guidelines for the cross-cultural adaptation of health status measures. The Hindi version of the CHIEF instrument was then administered on a convenience sample of 30 spinal cord injured subjects. Its content validity, internal consistency, test-rest reliability (intraclass correlation coefficient [ICC] 2,1), standard error of measurement (SEM), and minimum detectable change (MDC) were determined for both the longer and shorter version.

RESULTS

The mean ± SD of total of Hindi-CHIEF instrument, longer version was 1.44 ± 0.82 and total score of the shorter version was 1.07 ± 0.66. The content validity determined by the content validity ratio was found to be 1 for all the items except item number 5, 11, and 12. The content validity index was 0.97 for the longer version and for the shorter version it was 0.98. Internal consistency, Cronbach's α value was found to be 0.92 and test-retest value (ICC 2,1) was 0.80 (P < 0.001). The MDC was found to be 0.99 and SEM was 0.36 for the longer version. The Cronbach's α was 0.731, ICC 2,1 was 0.63 (P < 0.001), SEM was 0.24, and MDC was 0.66 for the shorter version.

CONCLUSION

The Hindi translated version of the CHIEF scale has acceptable content validity and reliability. It can be used to assess environmental barriers perceived by spinal cord injury patients.

Stem cell therapy in spinal trauma: Does it have scientific validity?

Stem cell-based interventions aim to use special regenerative cells (stem cells) to facilitate neuronal function beyond the site of the injury. Many studies involving animal models of spinal cord injury (SCI) suggest that certain stem cell-based therapies may restore function after SCI. Currently, in case of spinal cord injuries, new discoveries with clinical implications have been continuously made in basic stem cell research, and stem cell-based approaches are advancing rapidly toward application in patients. There is a huge base of preclinical evidence in vitro and in animal models which suggests the safety and clinical efficacy of cellular therapies after SCI. Despite this, data from clinical studies is not very encouraging and at times confounding. Here, we have attempted to cover preclinical and clinical evidence base dealing with safety, feasibility and efficacy of cell based interventions after SCI. The limitations of preclinical data and the reasons underlying its failure to translate in a clinical setting are also discussed. Based on the evidence base, it is suggested that a multifactorial approach is required to address this situation. Need for standardized, stringently designed multi-centric clinical trials for obtaining validated proof of evidence is also highlighted.

Retrospective analysis of spinal trauma in patients with ankylosing spondylitis: a descriptive study in Indian population

OBJECTIVE

This study aims to understand the demographics, mode of trauma, hospital stay, complications, neurological improvement, mortality and expenditure incurred by Indian patients with spinal trauma and ankylosing spondylitis (AS).

METHODS

Retrospective analysis of the patient data admitted to a tertiary referral hospital from 2008 to 2013 with the diagnosis of AS and spinal trauma was carried out. The variables studied were demographics, mode of trauma, neurological status, neurological improvement, involved vertebral level, duration of hospital stay, comorbid factors, expenditure and complications during the stay.

RESULTS

Forty-six patients with diagnosis of AS with spine trauma were admitted over the last 5 years with a total of 52 fractures. All were male patients; 58.6% had injury because of trivial trauma and 78.2% patients presented with neurological injury. C5 C6, C6 C7, C7 D1 and D12 were the most common injured level. Fractures through intervertebral disc were most common in cervical spine. Of the patients, 52.7% had shown neurological improvement of at least grade 1(AIS). Mean expenditure of patient admitted with spinal cord injury (SCI) with AS is 7957 USD (United States dollar), which is around five times the per capita income in India (as per year 2013).

CONCLUSION

Males with AS are much more prone to spinal fractures than females and its incidence may be higher than previously reported. Domestic falls are the most common mechanism of spinal trauma in this population. High velocity injuries are associated with complete SCI. The study reinforces the need for development of subsidized spinal care services for SCI management.