Acute spinal cord injury

Spinal cord injury and degenerative cervical myelopathy

Spinal cord injury (SCI) often results in impaired respiratory function. Paresis or paralysis of inspiratory and expiratory muscles can lead to respiratory dysfunction depending on the level and severity of the injury, which can affect the management and care of SCI patients. Respiratory dysfunction after SCI is more severe in high cervical injuries, with vital capacity (VC) being an essential indicator of overall respiratory health. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Respiratory management includes mechanical ventilation and tracheostomy in high cervical SCI, while noninvasive ventilation is more common in patients with lower cervical and thoracic injuries. Mechanical ventilation can negatively impact the function of the diaphragm and weaning should start as soon as possible. Patients can sometimes be weaned from mechanical ventilation with assistance of electrical stimulation of the phrenic nerve or the diaphragm. Respiratory muscle training regimens may also improve patients' inspiratory function following SCI. Despite the critical advances in preventing, diagnosing, and treating respiratory complications, they continue to significantly affect persons living with SCI. Additional studies of interventions to reduce respiratory complications are likely to further decrease the morbidity and mortality associated with these injuries.

Impact of voice and communication deficits for individuals with cervical spinal cord injury living in the community

BACKGROUND

Post-spinal cord injury (SCI), individuals may exhibit mild to moderate impairments in aspects of speech influenced by impaired respiratory support. However, limited research has been conducted into the impact of these impairments on activity and participation when living in the community.

AIMS

To examine the nature and extent of voice and communication function in a group of individuals with cervical SCI living in the community, and to explore participant perceptions of the impact of these deficits on levels of activity and participation.

METHODS & PROCEDURES

Participants included 14 individuals who had sustained a SCI above C8 level and had returned to living in the community. All completed a series of speech and voice assessments, the Voice Handicap Index, the Australian Therapy Outcome Measures Voice scale, four voice perception questions, and the General Short Form of the Communicative Participation Item Bank.

OUTCOMES & RESULTS

As a group, participants were found to have reduced vocal intensity and phonatory duration. Vocal quality was mildly altered in 93% and pitch control, breath support for speech, speech rate and phrase length impacted in one-quarter or more of the group. All reported impacts, though three individuals reported that their impairments had more extensive impact on communication in daily life.

CONCLUSIONS & IMPLICATIONS

Individuals post-SCI experience mild speech and voice deficits that can have negative impacts on functional communication. The monitoring of communication function may help to identify those individuals who could benefit from additional support and intervention on return to community life.

Complete traumatic dislocation of the cervical spine at C2–C3

Traumatic dislocation of the cervical spine is a relatively rare injury, but the ramifications of a missed injury are severe and life-long. The imaging findings related to traumatic dislocation are commonly mentioned in the literature although actual images of this pathophysiology are rare. In this particular case, three-dimensional computed tomography demonstrates the large amount of cervical spine distraction and associated damage. Epidemiology and management of acute cervical spine injuries in regard to this injury are discussed.

Electric ventilation: indications for and technical aspects of diaphragm pacing stimulation surgical implantation

OBJECTIVE

Patients with high cervical spinal cord injury are usually dependent on mechanical ventilation support, which, albeit life saving, is associated with complications and decreased life expectancy because of respiratory infections. Diaphragm pacing stimulation (DPS), sometimes referred to as electric ventilation, induces inhalation by stimulating the inspiratory muscles. Our objective was to highlight the indications for and some aspects of the surgical technique employed in the laparoscopic insertion of the DPS electrodes, as well as to describe five cases of tetraplegic patients submitted to the technique.

METHODS

Patient selection involved transcutaneous phrenic nerve studies in order to determine whether the phrenic nerves were preserved. The surgical approach was traditional laparoscopy, with four ports. The initial step was electrical mapping in order to locate the "motor points" (the points at which stimulation would cause maximal contraction of the diaphragm). If the diaphragm mapping was successful, four electrodes were implanted into the abdominal surface of the diaphragm, two on each side, to stimulate the branches of the phrenic nerve.

RESULTS

Of the five patients, three could breathe using DPS alone for more than 24 h, one could do so for more than 6 h, and one could not do so at all.

CONCLUSIONS

Although a longer follow-up period is needed in order to reach definitive conclusions, the initial results have been promising. At this writing, most of our patients have been able to remain ventilator-free for long periods of time.

Anaesthetic Aspects of Implanting Diaphragmatic Pacing in Patients with Spinal Cord Injury

Some patients with high cervical spinal cord injury are largely or completely dependent on mechanical ventilator support. Diaphragmatic phrenic nerve pacing is a new technique that offers some patients greater independence from mechanical ventilation. In selected patients, electrodes are placed on the abdominal side of the diaphragm via laparoscopy. An external pacing box provides the pacing stimulus. We report our experience with four patients with spinal cord injury in a pilot project, presenting for laparoscopic insertion of diaphragmatic phrenic nerve pacing leads inserted. The surgery took about two hours and diaphragmatic mapping precluded muscle relaxants. We used desflurane with remifentanil for maintenance. Apart from transferring the patients to and from their usual ventilators, other anaesthesia issues were difficult venous and arterial access for lines and long-term tracheostomies with no cuff or cuffs filled with water. While hypotension was a frequent problem, one patient also developed intraoperative hypertension secondary to autonomic dysreflexia. Preoperative testing predicted pacing outcome with three of the four patients having successful pacing with tidal volumes of up to 10 ml/kg at the end of surgery. This initial Australian experience may lead to greater use of the technique.