Faecal microbiota transplantation for multidrug-resistant organism decolonization in spinal cord injury patients: a case series.

Introduction: The increase of multidrug-resistant (MDR) bacteria in healthcare settings is a worldwide concern. Isolation precautions must be implemented to control the significant risk of transmitting these pathogens among patients. Antibiotic decolonization is not recommended because of the threat of increasing antibiotic resistance. However, restoring gut microflora through faecal microbiota transplantation (FMT) is a hopeful solution. Patients and method: In 2019-2022, FMT was indicated in seven patients of the Spinal Cord Unit at University Hospital Motol who were colonized with MDR bacterial strains. Five patients tested positive for carriage of carbapenemase-producing Enterobacteriaceae, and two were carriers of vancomycin-resistant enterococci. Isolation measures were implemented in all patients. Donor faeces were obtained from healthy, young, screened volunteers. According to local protocol, 200-300 ml of suspension was applied through a nasoduodenal tube. Results: The mean age of the patients was 43 years. The mean length of previous hospital stay was 93.2 days. All patients were treated with broad-spectrum antibiotics for infectious complications before detecting colonisation with MDR bacteria. MDR organism decolonization was achieved in five patients, and consequently, isolation measures could be removed. Colonization persisted in two patients, one of whom remained colonized even after a third FMT. No adverse events were reported after FMT. Conclusion: FMT is a safe and effective strategy to eradicate MDR bacteria, even in spinal cord injured patients. FMT can allow relaxation of isolation facilitates, the participation of patients in a complete rehabilitation program, their social integration, and transfer to follow-up rehabilitation centres.

Epidural spinal cord stimulation can facilitate ejaculatory response in spinal cord injury individuals: a report of two cases.

BACKGROUND: The recovery of autonomic functions and the ability to reproduce in particular is of the highest priority to individuals with spinal cord injury (SCI). The potential of epidural spinal cord stimulation (ESCS) for promoting recovery of sensorimotor functions in the chronic phase of SCI has long been studied. In recent years, several studies have emerged confirming the positive effect of ESCS also on the cardiovascular system and neurogenic bladder and bowel. However, the potential of ESCS in restoring sexual function, especially ejaculation, has not yet been addressed. CASE REPORT: Two cases of people with chronic sensorimotor complete SCI in the 4th thoracic spinal segment are presented. Both men were also diagnosed with severe erectile dysfunction and anejaculation. Thanks to ESCS, Participant 1 successfully restored the ejaculatory reflex using PVS in his home environment. His outcome was subsequently verified under clinical conditions. During ESCS, Participant 1 was also able to achieve ejaculation by masturbation; moreover, he conceived a child naturally without the need for IVF. In Participant 2, we then demonstrated the same effect of ESCS on the restoration of the ejaculatory reflex when targeting the stimulation to the same spinal segment. CONCLUSION: This is the first report on the potential of ESCS for restoring the ability to ejaculate in individuals with complete SCI. Confirmation of these results could significantly reduce the need for assisted reproduction and improve the quality of life of men after SCI in the future.

Walking Outcome After Traumatic Paraplegic Spinal Cord Injury: The Function of Which Myotomes Makes a Difference?

BACKGROUND: Accurate prediction of walking function after a traumatic spinal cord injury (SCI) is crucial for an appropriate tailoring and application of therapeutical interventions. Long-term outcome of ambulation is strongly related to residual muscle function acutely after injury and its recovery potential. The identification of the underlying determinants of ambulation, however, remains a challenging task in SCI, a neurological disorder presented with heterogeneous clinical manifestations and recovery trajectories. OBJECTIVES: Stratification of walking function and determination of its most relevant underlying muscle functions based on stratified homogeneous patient subgroups. METHODS: Data from individuals with paraplegic SCI were used to develop a prediction-based stratification model, applying unbiased recursive partitioning conditional inference tree (URP-CTREE). The primary outcome was the 6-minute walk test at 6 months after injury. Standardized neurological assessments ≤15 days after injury were chosen as predictors. Resulting subgroups were incorporated into a subsequent node-specific analysis to attribute the role of individual lower extremity myotomes for the prognosis of walking function. RESULTS: Using URP-CTREE, the study group of 361 SCI patients was divided into 8 homogeneous subgroups. The node specific analysis uncovered that proximal myotomes L2 and L3 were driving factors for the differentiation between walkers and non-walkers. Distal myotomes L4-S1 were revealed to be responsible for the prognostic distinction of indoor and outdoor walkers (with and without aids). CONCLUSION: Stratification of a heterogeneous population with paraplegic SCI into more homogeneous subgroups, combined with the identification of underlying muscle functions prospectively determining the walking outcome, enable potential benefit for application in clinical trials and practice.

Implementation of multilingual support of the European Multicenter Study about Spinal Cord Injury (EMSCI) ISNCSCI calculator.

OBJECTIVES: Since their introduction, electronic International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) calculators have evolved to powerful tools providing error-free ISNCSCI classifications in education, research and clinical practice. For increased accessibility and dissemination, a multilingual support is mandatory. The aim of this work was to setup a general multilingual framework for the freely available ISNCSCI calculator ( https://ais.emsci.org ) of the European Multicenter Study about Spinal Cord Injury (EMSCI). METHODS: The graphical user interface (GUI) and PDF export of the ISNCSCI worksheet were adapted for multilingual implementations. Their language-dependent content was identified. These two steps called internationalization have to be performed by a programmer in preparation of the translations of the English terms into the target language. This step following the internationalization is called localization and needs input by a bi-lingual clinical expert. Two EMSCI partners provided Standard Mandarin Chinese and Czech translations. Finally, the translations are made available in the application. RESULTS: The GUI and PDF export of the ISNCSCI worksheet were internationalized. The default language of the calculator is set according to the user's preferences with the additional possibility for manual language selection. The Chinese as well as a Czech translation were provided freely to the SCI community. CONCLUSIONS: The possibility of multilingual implementations independent from software developers opens the use of ISNCSCI computer algorithms as an efficient training tool on a larger scale.

Causes of death after spinal cord injury in the Czech Republic.

STUDY DESIGN: A retrospective cohort study OBJECTIVES: To determine the causes of death in people with spinal cord injury (SCI) admitted to the Spinal Cord Unit (SCU) of the University Hospital Motol from 2004 to 2018. SETTING: University Hospital Motol, Prague METHODS: From a cohort of people admitted to the SCU between 2004 and 2018, all deaths were identified based on the database of health insurance companies. The causes of death (ICD-10) were obtained from the Institute of Health Information and Statistics. The standardized mortality ratio (SMR) was calculated for most frequent causes of death. RESULTS: During the study period, 990 patients with acute SCI were admitted to the SCU, out of which 183 (18.5%) died. Thirty-five people who had SCI due to cancer were excluded from the study. The leading cause of death in the remaining 148 people was pneumonia, followed by cardiac complications, pulmonary embolism, suicide, and urinary tract infection (UTI). In the group of the individuals who died within 1 year after SCI (N = 41), the main causes of death were pneumonia and pulmonary embolism (17.1% each). Among individuals who survived up to1 year after SCI (N = 107), the most common causes of death were pneumonia (14%) and pressure injuries (12.1%). The cause-specific SMRs were significantly increased for UTI, embolism, pneumonia, and suicide. CONCLUSION: The frequent causes of death in our study group were pressure injuries and suicides. These findings are fundamental to the development and implementation of preventive programs to reduce mortality and increase life expectancy.

Can Exercise Targeting Mid-Thoracic Spine Segmental Movement Reduce Back Pain and Improve Sensory Perception in Cross-Country Skiers?

OBJECTIVE: To assess the role of exercise targeting proper trunk stabilization and segmental spinal movement in back pain and sensory perception among cross-country skiers. DESIGN: Randomized, controlled trial with blinded outcome assessors. SETTING: University Hospital, Department of Rehabilitation and Sports Medicine. PARTICIPANTS: Twenty elite cross-country skiers aged 17 to 27 years. INTERVENTIONS: Ten cross-country skiers integrated 3 types of exercise targeting segmental motion in mid-thoracic spine into their routine training practice for 2 months. The 10 controls performed routine athletic training. MAIN OUTCOME MEASURES: The Young Spine Questionnaire to measure intensity and frequency of back pain was completed at the start and end of study. Tactile sensory perception using 10-g Semmes-Weinstein monofilament, thermic perception using TIP THERM device, graphesthesia assessed by a touch monitor pencil, 2-point discrimination assessed by a digital caliper, and vibration perception assessed by a 128-Hz tuning fork measured in mid-thoracic spine 5 times. RESULTS: No significant group differences in pain and sensory perception were identified at baseline. Over the 2-month study interval, repeated-measures analysis of variance revealed that the experimental group improved significantly relative to the control group on pain intensity (P = 0.005 for cervical, P = 0.004 for thoracic, and P = 0.014 for lumbar) and frequency of pain in the thoracic area only (P = 0.011). Improvements were also observed in the experimental relative to control group on graphesthesia (P < 0.001), vibration perception (P = 0.002), and 2-point discrimination (P < 0.001). CONCLUSIONS: Exercise targeting the mid-thoracic spine may decrease back pain and improve sensory perception in cross-country skiers. LEVEL OF EVIDENCE: Original research, level I.

Hemicorporectomy - the ultimate solution of terminal pelvic sepsis.

Hemicorporectomy is the amputation of the lower body - pelvis and lower limbs. It requires transection of the spine and dural sac at the level of aortic bifurcation and inferior lower vein, and permanent urinary and stool derivation. Performance indications are tumour trauma and terminal pelvic osteomyelitis. So far about 60 cases have been published; only 11 operations were performed for terminal osteomyelitis. We have successfully performed hemicorporectomy in a patient with chronic sepsis from terminal pelvic osteomyelitis after exhausting all other treatment options. The experience gained and the important moments of the procedure are given in the case report.

Recovery after traumatic thoracic- and lumbar spinal cord injury: the neurological level of injury matters.

STUDY DESIGN: Multicenter prospective cohort. OBJECTIVE: To discern neurological- and functional recovery in patients with a traumatic thoracic spinal cord injury (TSCI), conus medullaris syndrome (CMS), and cauda equina syndrome (CES). SETTING: Specialized spinal cord injury centers in Europe. METHOD: Lower extremity motor score (LEMS) and spinal cord independent measure (SCIM) scores from patients with traumatic TSCI, CMS, and CES were extracted from the EMSCI database. Scores from admittance and during rehabilitation at 1, 3, 6, and 12 months were compared. Linear mixed models were used to statistically analyse differences in outcome, which were corrected for the ASIA Impairment Scale (AIS) in the acute phase. RESULTS: Data from 1573 individuals were analysed. Except for the LEMS in patients with a CES AIS A, LEMS, and SCIM significantly improved over time for patients with a TSCI, CMS, and CES. Irrespectively of the AIS score, recovery in 12 months after trauma as measured by the LEMS showed a statistically significant difference between patients with a TSCI, CMS, and CES. Analysis of SCIM score showed no difference between patients with TSCI, CMS, or CES. CONCLUSION: Difference in recovery between patients with a traumatic paraplegia is based on neurological (motor) recovery. Regardless the ceiling effect in CES patients, patients with a mixed upper and lower motor neuron syndrome (CMS) showed a better recovery compared with patients with a upper motor neuron syndrome (TSCI). These findings enable stratifications of patients with paraplegia according to the level and severity of SCI.

Diastasis of rectus abdominis muscles in low back pain patients.

BACKGROUND: Abdominal muscles are important spinal stabilizers and its poor coordination, as seen in diastasis of rectus abdominis (DRA), may contribute to chronic low back pain (LBP). However, this has not yet been studied directly. OBJECTIVES: To conduct a pilot study to examine the association between DRA and LBP. METHODS: Using a digital caliper, standard clinical DRA measurement was performed in 55 participants with and 54 without chronic LBP. RESULTS: Participants were on average 55 years old, 69 (63%) were women. Among the 16 participants with DRA, 11 (69%) had chronic LBP; among the 93 participants without DRA, 44 (47%) had LBP. Among men, 7 of 9 (77%) with DRA had LBP and 14 of 31 (45%) without DRA had LBP. Among women, 4 of 7 (57%) with DRA had LBP and 30 of 62 (48%) without DRA had LBP. BMI was the strongest correlate of DRA and may explain the relation between DRA and chronic LBP. CONCLUSIONS: DRA and LBP may be interrelated, especially among men. This may be a function of greater BMI in individuals with chronic LBP. Understanding the association between DRA, LBP, and BMI may have important implications for treatment of LBP and for intervention.

Women's Sex Life After Spinal Cord Injury.

INTRODUCTION: After spinal cord injury (SCI), individuals are typically considered by the general public to be asexual. Handicapped women have more problems with socio-sexual adaptation, stemming from low self-confidence, low self-esteem, and the absence of spontaneity. AIMS: To determine changes in the sexual lives of women after SCI. METHODS: A self-constructed questionnaire was used to map sexual function after SCI. We retrospectively compared sexual function in 30 women with SCI with that in 30 without SCI who led an active sexual life. Descriptive and inductive statistics were applied using the Student paired and non-paired t-tests and the Levene test. MAIN OUTCOME MEASURES: The main variables were presence vs absence of sexual dysfunction in a group of women after SCI and a comparison of the incidence of sexual dysfunctions in women after SCI with that of a control group. RESULTS: A significant difference was ascertained in women with SCI in sexual desire (P < .001), lubrication (P < .001), and reaching orgasm before and after injury (P = .030). A comparison of the two groups showed a significant difference in the realization of coital sexual activity (P < .001), erotogenous zones of the mouth (P = .016), nipples (P = .022), and genitals (P < .001), and in the ability to reach orgasm (P = .033). The negative impact of incontinence on the sexual life of women with SCI proved significant (P < .001). Negative factors for sexual activity in women with SCI were lower sensitivity in 16 (53%), spasms and mobility problems in 12 (40%), lower desire in 11 (36%), pain in 4 (13%), and a less accommodating partner in 3 (10%). CONCLUSION: Intercourse was the preferred sexual activity in women with SCI. Compared with the period before injury, there was significant lowering of sexual desire, impaired lubrication, and orgasmic ability after SCI. A comparison of the two groups showed a difference in erotogenous zones and in reaching orgasm. Sramkova T, Skrivanova K, Dolan I, et al. Women's Sex Life After Spinal Cord Injury. Sex Med 2017;5:e255-e259.

Pulmonary dysfunction in patients after cervical spinal cord injury: serial follow-up measurement within the first year post-injury.

OBJECTIVES: Respiratory complications are most common cause of morbidity/mortality in patients with cervical spinal cord injury (cSCI) due to respiratory muscle weakness and lower diaphragm position resulting in limited availability of inspiration, reduced thorax mobility and limited forced expiration. Differences in respiratory dysfunctions (RDs) in patients with motor complete versus incomplete cSCI were assessed. DESIGN: Prospective longitudinal study, serial measurement. SETTING: University hospital and ambulatory departments. METHODS: Twenty two patients with acute cSCI were recruited. Neurological level of injury and severity according to ISNCSCI were used as criteria for recruitment. Patients were divided into two groups - motor complete and incomplete. Standardized pulmonary function tests (PFT) were used - spirometry and respiratory muscle strength (RMS) measurement. Motor score of key muscles assessments for upper (UEMS) and lower (LEMS) limbs were used. Tests were performed in 5 measurement sessions starting on (medians) 14.5 days (M1), then 6.7 weeks, 3.2 months, 6.3 months and 1.0 year (M5). RESULTS: Significant differences in measurement sessions M2-M5 between groups in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), expiratory reserve volume (ERV), maximal static inspiratory/expiratory pressures (MIP, MEP) and UEMS were proved. Consequently, prominent differences in courses of particular parameters were found. No intergroup changes in UEMS were found during study. CONCLUSIONS: Obvious differences in parameters of spirometry, respiratory muscles and limb muscles strength between motor complete and incomplete group were found. Carefull monitoring of RDs by functional assessments (i.e., PFT and UEMS/LEMS tests) within one year after SCI seems to be clinically important.

Cardiovascular response to peak voluntary exercise in males with cervical spinal cord injury.

CONTEXT/OBJECTIVE: Traumatic damage to the cervical spinal cord is usually associated with a disruption of the autonomic nervous system (ANS) and impaired cardiovascular control both during and following exercise. The magnitude of the cardiovascular dysfunction remains unclear. The aim of the current study was to compare cardiovascular responses to peak voluntary exercise in individuals with tetraplegia and able-bodied participants. DESIGN: A case-control study. SUBJECTS: Twenty males with cervical spinal cord injury (SCI) as the Tetra group and 27 able-bodied males as the Control group were included in the study. OUTCOME MEASURES: Blood pressure (BP) response one minute after the peak exercise, peak heart rate (HRpeak), and peak oxygen consumption (VO2peak) on an arm crank ergometer were measured. In the second part of the study, 17 individuals of the Control group completed the Tetra group's workload protocol with the same parameters recorded. RESULTS: There was no increase in BP in response to the exercise in the Tetra group. Able-bodied individuals exhibited significantly increased post-exercise systolic BP after the maximal graded exercise test (123±16%) and after completion of the Tetra group's workload protocol (114±11%) as compared to pre-exercise. The Tetra group VO2peak was 59% and the HRpeak was 73% of the Control group VO2peak and HRpeak, respectively. CONCLUSIONS: BP did not increase following maximal arm crank exercise in males with a cervical SCI unlike the increases observed in the Control group. Some males in the Tetra group appeared to be at risk of severe hypotension following high intensity exercise, which can limit the ability to progressive increase and maintain high intensity exercise.

Clostridium difficile ribotype 078 cultured from post-surgical non-healing wound in a patient carrying ribotype 014 in the intestinal tract.

Extra-intestinal infections caused by Clostridium difficile are rare. The risk of extra-intestinal infections associated with C. difficile may be particularly relevant in environments contaminated with C. difficile spores. This paper describes the case of a non-diarrheic patient colonized with C. difficile ribotype 014 in the intestinal tract who developed a post-surgical wound infection by C. difficile ribotype 078. The infection responded to metronidazole administered first intravenously and then orally. This case indicates that C. difficile may not only be related to diarrheic diseases, but also to infections of non-healing wounds, especially in situations when C. difficile is the only isolated pathogen.

Delayed diagnosis of an unsuspected pelvic fracture in a patient with tetraplegia.

STUDY DESIGN: Case report. CONTEXT: In patients with a complete spinal cord injury (SCI) above T6 level, autonomic dysreflexia (AD) can be the only alerting sign of complications below the level of injury. A case report is presented of a patient with tetraplegia who progressively developed an AD syndrome after falling from a wheelchair. Initially, he was treated for symptomatic urinary tract infection and only later an unstable pelvic fracture was detected. FINDINGS: A patient with chronic tetraplegia fell from his wheelchair while intoxicated. After the fall, he showed no signs of injury. Two days later, AD symptoms appeared while lying on his side or sitting. He presented to his community-based physician and received antibiotics for concomitant urinary tract infection. Because of persisting complaints, the patient was referred to the Spinal Cord Unit. Once the history of falling from the wheelchair was made known, symptoms of AD were suggestive of an internal injury. Radiography showed pelvic fracture and conservative treatment was administered. The fractures healed in 3 months, the therapeutic bed rest regimen was relaxed without trigerring AD symptoms. CONCLUSION: AD symptoms can suggest complications below the SCI level. Awareness and recognition of these symptoms are of utmost importance. However, etiology may be misleading. The role of a community-based general physician is to recognize the right moment when the need of a specialized assessment in a Spinal Cord Unit arises. In addition, patients should also be well informed about the most common possible complications from specialized SCI centers.

Primary motor cortex inhibition in spinal cord injuries.

OBJECTIVES AND METHODS: Excitability changes in the primary motor cortex in 17 spinal-cord injured (SCI) patients and 10 controls were studied with paired-pulse transcranial magnetic stimulation. The paired pulses were applied at inter-stimulus intervals (ISI) of 2 ms and 15 ms while motor evoked potentials (MEP) were recorded in the biceps brachii (Bic), the abductor pollicis brevis (APB) and the tibialis anterior (TA) muscles. RESULTS: The study revealed a significant decrease in cortical motor excitability in the first weeks after SCI concerning the representation of both the affected muscles innervated from spinal segments below the lesion, and the spared muscles rostral to the lesion. In the patients with motor-incomplete injury, but not in those with motor-complete injury, the initial cortical inhibition of affected muscles was temporarily reduced 2-3 months following injury. The degree of inhibition in cortical areas representing the spared muscles was observed to be smaller in patients with no voluntary TA activity compared to patients with some activity remaining in the TA. Surprisingly, motor-cortical inhibition was observed not only at ISI 2 ms but also at ISI 15 ms. The inhibition persisted in patients who returned for a follow-up measurement 2-3 years later. CONCLUSION: The present data showed different evaluation of cortical excitability between patients with complete and incomplete spinal cord lesion. Our results provide more insight into the pathophysiology of SCI and contribute to the ongoing discussion about the recovery process and therapy of SCI patients.