Changing demographics of spinal cord injury over a 20-year period: a longitudinal population-based study in Scotland.

STUDY DESIGN: A retrospective cohort study. OBJECTIVES: To review demographic trends in traumatic spinal cord injury (TSCI) and non-traumatic spinal cord injury (NTSCI). SETTING: The Queen Elizabeth National Spinal Injuries Unit (QENSIU), sole provider of treatment for TSCI in Scotland; a devolved region of the UK National Health Service. METHODS: A retrospective review of the QENSIU database was performed between 1994 and 2013. This database includes demographic and clinical data from all new TSCI patients in Scotland, as well as patients with severe NTSCI. RESULTS: Over this 20-year period there were 1638 new cases of TSCI in Scotland; 75.2% occurring in males. TSCI incidence increased non-significantly (13.3 per million population to 17.0), while there were significant increases in mean age at time of TSCI (44.1-52.6 years), the proportion of TSCIs caused by falls (41-60%), the proportion of TSCIs resulting in an American Spinal Injury Association Impairment Scale score of C and D on admission (19.7-28.6% and 34.5-39.5%, respectively) and the proportion of cervical TSCIs (58.4-66.3%). The increase in cervical TSCI was specifically due to an increase in C1-C4 lesions (21.7-31.2%). NTSCI patients (n=292) were 5 years older at injury, more likely to be female (68.1% male) and had a range of diagnoses. CONCLUSION: This study supports the suggestion that demographic profiles in SCI are subject to change. In this population, of particular concern is the increasing number of older patients and those with high level tetraplegia, due to their increased care needs. Prevention programmes, treatment pathways and service provision need to be adjusted for optimum impact, improved outcome and long-term care for their target population.

Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis.

Patients with ankylosing spondylitis (AS) are vulnerable to cervical spine fractures. Long-standing pain may mask the symptoms of the fracture. Radiological imaging of the cervical spine may fail to identify the fracture due to the distorted anatomy, ossified ligaments and artefacts leading to delay in diagnosis and increased risk of neurological complications. The objectives are to identify the incidence and risk factors for delay in presentation of cervical spine fractures in patients with AS. Retrospective case series study of all patients with AS and cervical spine fracture admitted over a 12-year period at Queen Elizabeth National Spinal Injuries Unit, Scotland. Results show that total of 32 patients reviewed with AS and cervical spine fractures. In 19 patients (59.4%), a fracture was not identified on plain radiographs. Only five patients (15.6%) presented immediately after the injury. Of the 15 patients (46.9%) who were initially neurologically intact, three patients had neurological deterioration before admission. Cervical spine fractures in patients with long-standing AS are common and usually under evaluated. Early diagnosis with appropriate radiological investigations may prevent the possible long-term neurological cord damage.

Functional outcome and discharge destination in elderly patients with spinal cord injuries.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To describe functional outcome and discharge destination of elderly patients with traumatic spinal cord injuries. SETTING: National Spinal Injuries Unit, Glasgow, UK. METHODS: We collected data for 5 years on all patients >65 years old with a traumatic spinal cord injury treated at the National Spinal Injuries Unit. RESULTS: We identified 39 patients. Of these, nine patients died during admission; all had cervical spine injuries. The mean age of the 30 survivors was 73 years (range 65-88). The most common cause of injury was a fall: 26 patients (87%). In addition, 21 (70%) sustained injury to cervical cord, 3 (10%) had thoracic and 6 (20%) had lumbar spine fractures. In all, 23 patients (77%) were treated by orthosis and 7 (23%) underwent surgical intervention. Twelve (40%) patients showed an improvement in American Spinal Injury Association impairment scale. The median hospital stay was 136 days. Thus, 11 patients (37%), all with incomplete injuries, were discharged home, 10 (33%) were transferred to nursing homes/community hospitals and 9 patients (30%) were discharged back to the referring hospital, while they were awaiting adjustments at home. Patients who were discharged home had significantly higher Functional Independence Measure scores, both at the onset of rehabilitation and at discharge, than those who were discharged to a nursing home or other hospitals (P<0.01 and <0.001, respectively). DISCUSSION AND CONCLUSION: Although the elderly patients may benefit from the services of a dedicated spinal injuries centre, they should be carefully selected. The patient, relatives as well as the referring doctors should be alerted to the likely long-term outcomes early in the course of the injury. Elderly patients with complete lesions of the spinal cord will almost certainly remain institutionalized. Early endeavour should be made to find alternate rehabilitation settings with a lower-intensity treatment.

Hydrocephalus complicating a cervical spine fracture in a patient with ankylosing spondylitis.

We present a case of obstructive hydrocephalus secondary to ascending spinal cord oedema, sustained after cervical spine fracture in a patient with ankylosing spondylitis. To our knowledge, this is the first report of ascending oedema from a cervical cord injury causing obstructive hydrocephalus.

Arm-cranking exercise assisted by Functional Electrical Stimulation in C6 tetraplegia: a pilot study.

Tetraplegic volunteers undertook progressive exercise training, using novel systems for arm-cranking exercise assisted by Functional Electrical Stimulation (FES). The main aim was to determine potential training effects of FES-assisted arm-crank ergometry (FES-ACE) on upper limb strength and cardiopulmonary (fitness) in tetraplegia. Surface FES was applied to the biceps and triceps during exercise on an instrumented ergometer. Two tetraplegic volunteers with C6 Spinal Cord Injury (SCI) went through muscle strengthening, baseline exercise testing and three months of progressive FES-ACE training. Repeat exercise tests were carried out every four weeks during training, and post-training, to monitor upper-limb strength and cardiopulmonary fitness. At each test point, an incremental test was carried out to determine peak work rate, peak oxygen uptake, gas exchange threshold and oxygen uptake-work rate relationship during FES-ACE. Peak oxygen uptake for Subject A increased from 0.7 l/min to 1.1 l/min, and peak power output increased from 7 W to 38 W after FES-ACE training. For Subject B, peak oxygen uptake was unchanged, but peak power output increased from 3 W to 8 W. These case studies illustrate potential benefits of FES-ACE in tetraplegia, but also the differences in exercise responses between individuals.

Automatic electrical stimulation of abdominal wall muscles increases tidal volume and cough peak flow in tetraplegia.

Paralysis of the respiratory muscles in people with tetraplegia affects their ability to breathe and contributes to respiratory complications. Surface functional electrical stimulation (FES) of abdominal wall muscles can be used to increase tidal volume (V_{T}) and improve cough peak flow (CPF) in tetraplegic subjects who are able to breathe spontaneously. This study aims to evaluate the feasibility and effectiveness of a novel abdominal FES system which generates stimulation automatically, synchronised with the subjects' voluntary breathing activity. Four subjects with complete tetraplegia (C4-C6), breathing spontaneously, were recruited. The automatic stimulation system ensured that consistent stimulation was achieved. We compared spirometry during unassisted and FES-assisted quiet breathing and coughing, and measured the effect of stimulation on end-tidal CO_2 (EtCO_2) during quiet breathing. The system dependably recognised spontaneous respiratory effort, stimulating appropriately, and was well tolerated by patients. Significant increases in V_T during quiet breathing (range 0.05-0.23 L) and in CPF (range 0.04-0.49 L/s) were observed. Respiratory rate during quiet breathing decreased in all subjects when stimulated, whereas minute ventilation increased by 1.05-2.07 L/min. The changes in EtCO_2 were inconclusive. The automatic stimulation system augmented spontaneous breathing and coughing in tetraplegic patients and may provide a potential means of respiratory support for tetraplegic patients with reduced respiratory capacity.

A control system for automatic electrical stimulation of abdominal muscles to assist respiratory function in tetraplegia.

People with tetraplegia have poor respiratory function leading to limited tidal volume (V(T)) and reduced cough peak flow (CPF). These problems may cause respiratory failure during the initial admission or subsequent intercurrent illness. Electrical stimulation of the abdominal muscles during expiration can improve respiratory function by increasing V(T) and CPF. We developed a novel control system to automatically trigger muscle stimulation, synchronised with the subject's voluntary respiratory activity. The system was tested in four subjects with a functionally complete lesion at level C4 to C6, aged between 16 and 46 years, 3 months to 5 years post injury, who were breathing spontaneously. The algorithm delivered automatic stimulation patterns, detecting cough and quiet breathing while suppressing stimulation during other activities such as speaking. Marked increases in V(T) (between 9% and 71% of baseline) and CPF (between 31% and 54% of baseline) were observed, suggesting that the technique may have potential use in both acute and established tetraplegia to increase minute ventilation and to improve cough clearance of secretions.

Comparison of stimulation patterns for FES-cycling using measures of oxygen cost and stimulation cost.

AIM: The energy efficiency of FES-cycling in spinal cord injured subjects is very much lower than that of normal cycling, and efficiency is dependent upon the parameters of muscle stimulation. We investigated measures which can be used to evaluate the effect on cycling performance of changes in stimulation parameters, and which might therefore be used to optimise them. We aimed to determine whether oxygen cost and stimulation cost measurements are sensitive enough to allow discrimination between the efficacy of different activation ranges for stimulation of each muscle group during constant-power cycling. METHODS: We employed a custom FES-cycling ergometer system, with accurate control of cadence and stimulated exercise workrate. Two sets of muscle activation angles ("stimulation patterns"), denoted "P1" and "P2", were applied repeatedly (eight times each) during constant-power cycling, in a repeated measures design with a single paraplegic subject. Pulmonary oxygen uptake was measured in real time and used to determine the oxygen cost of the exercise. A new measure of stimulation cost of the exercise is proposed, which represents the total rate of stimulation charge applied to the stimulated muscle groups during cycling. A number of energy-efficiency measures were also estimated. RESULTS: Average oxygen cost and stimulation cost of P1 were found to be significantly lower than those for P2 (paired t-test, p<0.05): oxygen costs were 0.56+/-0.03l min-1 and 0.61+/-0.04l min-1 (mean+/-S.D.), respectively; stimulation costs were 74.91+/-12.15 mC min-1 and 100.30+/-14.78 mC min-1 (mean+/-S.D.), respectively. Correspondingly, all efficiency estimates for P1 were greater than those for P2. CONCLUSION: Oxygen cost and stimulation cost measures both allow discrimination between the efficacy of different muscle activation patterns during constant-power FES-cycling. However, stimulation cost is more easily determined in real time, and responds more rapidly and with greatly improved signal-to-noise properties than the ventilatory oxygen uptake measurements required for estimation of oxygen cost. These measures may find utility in the adjustment of stimulation patterns for achievement of optimal cycling performance.

The protein metabolic response to short-term starvation in man.

Plasma protein concentrations, in particular the serum albumin concentration, are often quoted as indicators of nutritional state in surgical patients. Injury also affects the circulating concentrations of these proteins. Twenty students were subjected to a 3-day total fast and the concentration of plasma proteins, generally affected by trauma, determined before and after the fast. The only protein to show any negative response was retinal binding protein which fell by 16% during the starvation period (p < 0.001). Albumin, the protein often used as a nutritional index, demonstrated a significant (p < 0.001) increase during this period. This was not related to changes in the hydration state of the subjects.

Outcome of halo immobilisation of 104 cases of cervical spine injury.

STUDY DESIGN: Retrospective review. OBJECTIVES: To present and discuss the outcome of halo jacket immobilisation of cervical spine injuries. SETTING: National Spinal Injuries Unit in a Scottish University teaching Hospital. METHODS: Retrospective review of case-notes and radiographs of all patients treated with halo jacket both as primary means of immobilisation or as adjunct to surgical stabilisation between 1992-1999 and followed up at a weekly halo clinic. RESULTS: Out of a total one hundred and four patients with cervical spine injury, eighty-six were treated with Halo jacket as primary means of cervical immobilisation. Halo was used as adjunct to surgical stabilisation for the rest. There were nine cases of true failure. This is a failure rate of 10% for primary halo immobilisation. Of the nine patients who had failure of bony healing, four had fibrous healing, three had surgery to stabilise spine, two were subsequently lost to follow-up. The highest incidence of recurrence of subluxation occurred in patients with fracture/subluxation with a healing rate of 85%. Patients with ankylosing spondylitis did well. Odontoid fractures had 18% failure rate. The commonest complication was loss of reduction, followed by pin-site infection. CONCLUSION: Halo is an effective non-surgical treatment for the injured cervical spine at both upper and lower levels.

Delayed hydrocephalus as an unusual complication of a stab injury to the spine.

STUDY DESIGN: Case report. OBJECTIVE: To report a rare complication following a stab injury to the upper cervical spine and cord. SETTING: National spinal injury unit in a Scottish university teaching hospital. CASE REPORT: A 19-year-old male sustained a stab injury to his upper cervical spine, with a partial cord transection. After 5 months of rehabilitation, his condition deteriorated. CT scans showed hydrocephalus, which was treated by shunting. After shunting, the patient's condition improved but he remained tetraplegic requiring ventilatory support at night. CONCLUSION: Hydrocephalus as a late complication of a cervical spine injury is rare but should be considered if the condition of the patient with an upper cervical spine injury deteriorates. The likely mechanism of the hydrocephalus development is also discussed.

Assistive technology in the rehabilitation of patients with high spinal cord lesions.

The functional requirements for daily living at home are the same for a ventilator dependent quadriplegic person as they are for anyone, whether less severely disabled or able bodied. In persons with high spinal cord lesions, the necessary presence of a carer near to hand should not deter the use of assistive technology to increase independence. Maximised independence is desirable to free the carer from minute by minute tasks such as turning pages, switching lights, TV etc. This not only frees the carer for other tasks, making the caring task more bearable (and thus easier to recruit carers) but also vastly improves the morale of the disabled person. Some assistive devices, especially those concerned with mobility and transfer can avoid the need for multiple carers at times such as toiletting and going on car journeys. Whichever devices are required by the quadriplegic person, they all clearly need to be worked by a common, carefully selected input interface device matched to his or her preferences and physical abilities for switching. It is vital to ensure a technical integration of the four generic areas of device functionality: those of mobility (wheelchairs, cars), manipulation (page-turners, robotic arms), communication (keyboard emulators, voice processors, artificial speech) and control of the environment. In most countries this integration is poorly addressed owing to the different agencies involved in the provision of devices relating to each of these generic areas--despite the technology being available today.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of insufflation leaks upon ventilation. A quantified comparison of ventilators.

Some ventilator-dependent patients use uncuffed tracheostomy tubes, resulting in fluctuations in the minute volume of ventilation. Bedside measurement of ventilation is difficult because of the insufflation and exsufflation leaks. This laboratory study of five different ventilators measured the tidal volumes achieved with three insufflation leaks introduced in an increasing order of magnitude and at three levels of compliance. The largest leak reduced the peak inflation pressure from 26 to 14 cmH2O in two pressure-limited ventilators with a 35% loss of the initial tidal volume of 800 ml. The turbine-driven pressure-limited ventilator retained a peak pressure of 20.5 cmH2O and lost only 14% of the volume, whereas the volume ventilators lost 65% of the tidal volume. The loss of volume was 3% for every cmH2O decrease in airway pressure due to a leak, regardless of the ventilator or compliance. Using the Friedman test, the differences between the volume ventilators and the pressure ventilators were significant whilst the three pressure-limited ventilators did not perform significantly differently from each other.

The effect of insufflation leaks in long-term ventilation. Waking and sleeping transcutaneous gas tensions in ventilator-dependent patients with an uncuffed tracheostomy tube.

Transcutaneous blood gases were recorded for 60 min when awake and asleep in 10 ventilator-dependent patients with high tetraplegia who used a pressure-limited ventilator and uncuffed tracheostomy tube. The mean arterial oxygen tension awake was 16.0 kPa compared with 15.2 kPa when asleep; the mean arterial carbon dioxide tension awake was 3.2 kPa, compared with 3.9 kPa when asleep. The oxygen tensions in each patient during the awake and sleep states were not significantly different between the two states, but during sleep the carbon dioxide tension was significantly greater.

Total i.v. anaesthesia for transcranial magnetic evoked potential spinal cord monitoring.

Continuous intraoperative monitoring of transcranial magnetic motor evoked potentials (TcMMEP) can warn the surgeon of motor tract damage more effectively than somatosensory evoked potentials. As a non-invasive technique it is especially useful during post-traumatic internal fixation and is applicable whatever the level of the spinal cord at risk. Inhalation and many i.v. anaesthetics block the single pulse TcMMEP but a total i.v. anaesthetic regimen based on methohexitone, alfentanil and ketamine was effective in seven patients undergoing post-traumatic internal fixation. Consistent TcMMEP of 100-1000 mcV were obtained in all patients, with a latency change of only 2 ms above preoperative values. Good cardiovascular stability was maintained during operation.

Delayed presentation of post-traumatic aneurysm of the posterior inferior cerebellar artery in a patient with spinal cord injury.

STUDY DESIGN: A case report. OBJECTIVE: To present and discuss the case of a patient with serious head and spinal injuries who suffered delayed haemorrhage from a post-traumatic aneurysm of the right posterior inferior cerebellar artery following surgical treatment of vertebral fracture and hydrocephalus. SETTING: National Spinal Injuries Unit and Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland, UK. METHODS: Clinical and radiological follow-up of the patient. RESULTS: The aneurysm was treated by coil occlusion of the right vertebral artery. Post-operative films showed that the aneurysm had been successfully obliterated. CONCLUSION: Post-traumatic cerebral aneurysms are very rare. Neurosurgical and rehabilitation teams need to be aware of this late treatable sequela of head injury.

Rupture of tuberculous spinal abscess resulting in tuberculous empyema and chylothorax.

STUDY DESIGN: Case report with a review of scientific literature. OBJECTIVE: To describe the course of tuberculous spinal disease (Pott's disease) complicated by pyogenic and tuberculous empyema, and chylothorax as there has been an increase in the numbers of notified cases of tuberculosis in the UK(1). To the best of our knowledge, a similar case has not been reported previously in the UK, although there has been a report of bilateral chylothorax associated with Pott's disease. SETTING: A national spinal injuries unit in a Scottish university teaching hospital. METHODS: Review of literature on the chemotherapy of spinal tuberculosis and the role of streptokinase in the treatment of empyema and the relation between spinal tuberculosis, empyema and chylothorax. RESULTS: Although spinal tuberculosis was recognised and treated appropriately with chemotherapy, the patient sustained pleural involvement with later development of both empyema and chylothorax. CONCLUSION: The case highlights the difficulties in the treatment of tuberculosis of the spine inspite of the presence of fully sensitive organisms and early institution of appropriate chemotherapy. In the absence of surgical debridement, the duration and dosage of chemotherapy as practised in the initial period may have to be prolonged into the continuation phase. The thoracic duct can be damaged either because of extension of the tuberculosis itself or because of instillation of intrapleural streptokinase for treatment of pleural empyema leading to chylothorax. There is a need for randomised trials of intrapleural streptokinase treatment in tuberculous empyema.

Spinal cord infarction due to a self-inflicted needle stick injury.

STUDY DESIGN: Case report. OBJECTIVE: To report a case of spinal cord infarction after a self-inflicted needle stick injury, following an injection of heroin into the cord. SETTING: National spinal injury unit in a Scottish University teaching hospital, Glasgow, UK. CASE REPORT: A 20-year-old male, injected street heroin accidentally into the cord through the left side of the neck, leading to sudden loss of power to all four limbs. Initial magnetic resonance imaging scans showed extensive cord oedema and follow-up scans showed signal changes within the anterior horns of the spinal cord in keeping with a cord infarct. CONCLUSION: Self-inflicted spinal cord injury with a small needle is difficult, but not impossible. Cord infarct as a result of a self-inflicted injury has not been previously reported. The mechanism of the injury resulting in cord infarction is explained by the vascular anatomy of the spinal cord circulation, and this may also explain the residual neurological status of the patient.

Acute hypotension associated with terbutaline nebuliser therapy in a traumatic tetraplegic patient during the spinal shock phase. Case report.

Acute hypotension was observed during the spinal shock stage of a 35-year-old C3 complete tetraplegic patient after receiving nebulised terbutaline for respiratory therapy. Nine weeks later, when he had recovered from spinal shock, he again received nebulised terbutaline but there was no significant fall in arterial blood pressure. This case illustrates the possibility of a serious degree of hypotension occurring in such patients with this drug.

Unusual complications of intermittent self-catheterisation in spinal cord injury patients.

Three unusual complications of intermittent self-catheterisation in spinal cord injury patients observed over a period of 30 months are described. (1) Two patients performing intermittent catheterisation with a PVC catheter requiring the use of lignocaine gel to numb the urethra, developed allergic reaction in the form of swelling and erythematous lesions around the external urethral meatus. This rare complication was overcome by switching over to the use of a Lofric catheter instead of a PVC catheter for intermittent catheterisation. (2) Urethral bleeding was observed on three occasions in male paraplegic patients performing intermittent self-catheterisation who had allowed the bladder to become over-distended. Bladder emptying therefore, took nearly 10 min, by which time the Lofric catheter became too sticky in the urethra and required undue force for withdrawal, resulting in trauma to the adherent urethral mucosa and urethral bleeding. By adopting the policy of catheterisation at regular intervals and not allowing the bladder to become distended beyond 450 ml of urine, this complication was never seen again either in these three patients or in any other patient using Lofric catheter for intermittent urethral catheterisation. (3) Failure to drain urine after urethral catheterisation resulting in a panic reaction was observed in a 45 year old woman practising intermittent catheterisation. This unique complication happened because there were no eye holes on the Nelaton catheter.