Exploration of surgical blood pressure management and expected motor recovery in individuals with traumatic spinal cord injury.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To assess the impact of mean arterial blood pressure (MAP) during surgical intervention for spinal cord injury (SCI) on motor recovery. SETTING: Level-one Trauma Hospital and Acute Rehabilitation Hospital in San Jose, CA, USA. METHODS: Twenty-five individuals with traumatic SCI who received surgical and acute rehabilitation care at a level-one trauma center were included in this study. The Surgical Information System captured intraoperative MAPs on a minute-by-minute basis and exposure was quantified at sequential thresholds from 50 to 104 mmHg. Change in International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor score was calculated based on physiatry evaluations at the earliest postoperative time and at discharge from acute rehabilitation. Linear regression models were used to estimate the rate of recovery across the entire MAP range. RESULTS: An exploratory analysis revealed that increased time within an intraoperative MAP range (70-94 mmHg) was associated with ISNCSCI motor score improvement. A significant regression equation was found for the MAP range 70-94 mmHg (F[1, 23] = 5.07, r2 = 0.181, p = 0.034). ISNCSCI motor scores increased 0.039 for each minute of exposure to the MAP range 70-94 mmHg during the operative procedure; this represents a significant correlation between intraoperative time with MAP 70-94 and subsequent motor recovery. Blood pressure exposures above or below this range did not display a positive association with motor recovery. CONCLUSIONS: Hypertension as well as hypotension during surgery may impact the trajectory of recovery in individuals with SCI, and there may be a direct relationship between intraoperative MAP and motor recovery.

Do appreciable changes in the upper extremity motor capability to perform clean intermittent catheterization come about with time after traumatic spinal cord injury?

INTRODUCTION: Bladder dysfunction after spinal cord injury (SCI) often requires clean intermittent catheterization (CIC) or other management strategies. A common dilemma in those desiring to perform CIC independently but lacking the appropriate upper extremity (UE) motor function is the timing of reconstructive surgery. METHODS: We assessed the National Spinal Cord Injury Data Set for the years 2000-2016. Our cohort consisted of persons with cervical SCI, who underwent complete motor examination upon discharge from rehabilitation and at 1-year follow-up. Using a previously published algorithm, UE motor scores were transformed to predict a patient's ability to independently perform CIC. Improvements in the predicted ability to self-catheterize were evaluated. RESULTS: Of the 1428 individuals meeting the inclusion criteria, improvements in the predicted UE motor function necessary to independently self-catheterize were observed in 39%, 42%, and 38% of those deemed possibly able, only able with surgical assistance, or unable to self-catheterize at rehabilitation discharge, respectively. On multivariate analysis, only increasing Association Impairment Scale (AIS) classification and AIS classification improvement over the first year were associated with an increased odds of improving predicted CIC ability (odds ratio [OR] = 1.44 for AIS C and 1.97 for AIS D compared with AIS A, and OR = 1.90 for AIS classification improvement versus stable AIS classification, P < 0.05 for each). CONCLUSION: Improvements in UE motor function to independently perform CIC occur in approximately 40% of persons with cervical SCI in the first year after rehabilitation discharge. Those with incomplete injuries are more likely to improve. These findings should enhance patient bladder management counseling and guide surgeons in determining an appropriate timeline for offering reconstruction.

Mechanical insufflation-exsufflation device prescription for outpatients with tetraplegia.

BACKGROUND: Mechanical insufflation-exsufflation (MIE) is an option for secretion mobilization in outpatients with spinal cord injury (SCI) who lack an effective cough and are at high risk for developing pneumonia. OBJECTIVE: To describe characteristics of persons with SCI who received MIE devices for outpatient use and compare respiratory hospitalizations before and after MIE prescription. DESIGN: Retrospective cohort study of all persons who were prescribed MIE devices for outpatient use during 2000 to 2006 by a Veterans Affairs SCI service. RESULTS: We identified 40 patients with tetraplegia (4.5% of population followed by the SCI service) who were prescribed MIE devices. Of these, 30 (75%) had neurologic levels of C5 or rostral, and 33 (83%) had motor-complete injuries. For chronically injured patients who were prescribed MIE for home use, there was a nonsignificant reduction in respiratory hospitalization rates by 34% (0.314/y before MIE vs 0.208/y after MIE; P = 0.21). A posthoc subgroup analysis showed a significant decline in respiratory hospitalizations for patients with significant tobacco smoking histories. CONCLUSIONS: Mechanical insufflation-exsufflation was typically prescribed for people with motor-complete tetraplegia. Outpatient MIE usage may reduce respiratory hospitalizations in smokers with SCI. Further research of this alternative, noninvasive method is warranted in the outpatient SCI population.