Single kidney outcome and management in persons with spinal cord injury.

This case study examined the outcomes of persons with spinal cord injury (SCI) who had a single kidney. A Urologic Database, including 1655 persons with SCI between 1969 and 1997, was examined and 22 persons were identified with single kidneys. Twenty persons had adequate follow-up. Renal function was measured by total and individual kidney effective renal plasma flow (ERPF). Of 11 persons who had a single kidney prior to injury or as a result of an associated injury, all maintained a normal ERPF for an average of 8.6 years. Of 9 persons who had removal of a kidney following their injury for other diseases or urinary complications, 3 were deceased, but 2 had a normal ERPF in the remaining kidney prior to death. One with vesicoureteral reflux had decreased renal function in the remaining kidney. Recurrent renal calculi in a single kidney carries risks for decreasing renal function, urosepsis, and death.

History, implementation, and current status of the National Spinal Cord Injury Database.

OBJECTIVE: To summarize a 25-year history of the Model Spinal Cord Injury Program and the coexistent National Spinal Cord Injury Database and provide the status of the Database with a discussion of the strengths and weaknesses. DESIGN: Inception cohort. SETTING: Model spinal cord injury systems throughout the United States. RESULTS: As of September 1998, the National Spinal Cord Injury Database included abbreviated registry records on 6,085 new patients, more complete initial injury and hospitalization records on 18,969 new patients, and 78,627 annual follow up records on those persons. Although stability and continuity of the Database has been a priority since it was started, some changes were needed to meet the changes in health care, health care policy, and new technology. CONCLUSION: This large database can now provide a wealth of information about short- and long-term outcomes, provide data on which future health care policies can be evaluated, and act as a source for answers to future research questions.

Comparison of long-term renal function after spinal cord injury using different urinary management methods.

OBJECTIVE: To determine the effect of different bladder management methods on long-term renal function in persons with spinal cord injury (SCI). DESIGN: Cohort study. SETTING: Model SCI care system within a large teaching hospital. PATIENTS: Consecutive sample of 1,114 persons with SCI who were injured between 1969 and 1994. MAIN OUTCOME MEASURE: Total and individual kidney effective renal plasma flow (ERPF). RESULTS: ERPF was generally lower in persons with cervical injuries or kidneys that had a renal stone, older persons, and women. Overall, there was very little change in renal function as time postinjury increased, and there were no clinically meaningful differences in the change in renal function over time among persons using different bladder management methods. CONCLUSION: Renal function was adequately preserved in the great majority of persons and did not appear to be influenced to any great extent by method of bladder management.

Skin complications other than pressure ulcers following spinal cord injury.

This study identifies skin and nail complications other than pressure ulcers after spinal cord injury and correlate these complications to the level of injury. A prospective study was performed at the time of 679 annual spinal cord injury clinic visits from 1988 to 1991 at which time the skin and nails were examined for changes or other lesions. Clinical skin thickening and nail hypertrophy were the most frequent findings. Skin thickening occurred in 57.9% of cervical injuries, 31.6% of higher thoracic injuries, 23.6% of lower thoracic injuries, and 16.0% of thoracolumbar injuries, p < .0001. Skin thickening was also seen more commonly with increasing time after injury, 20.3% at 1 year and 51.2% at 5 years, p < .0001. Nail hypertrophy occurred in the lower extremities and was not correlated with the level of injury. Denervation and autonomic dysfunction may be implicated in these changes.

Clinical skin thickening following spinal cord injury studied by histopathology.

Dermatohistopathologic studies were performed in persons with spinal cord injury to evaluate the clinical observation of skin thickening. Twenty subjects were included in a prospective acute study and 59 subjects in a chronic study. Skin biopsies of the lower lateral thigh were studied by routine histopathology. The most common histopathologic findings included dermal fibrosis and perivascular inflammatory infiltrate. Dermal fibrosis was already identified within two months after injury in the acute study. In chronic patients, dermal fibrosis was found in 65 percent of persons with tetraplegia compared to 25 percent with paraplegia (p = .0038). Perivascular inflammatory infiltrate was less frequent and its presence was not associated with the level of injury. Histopathologic findings were generally not as prominent as the clinical picture. This disparity may be explained by a combination of edema and dermal fibrosis. Loss of autonomic nervous system control or other neuroendocrine dysfunction is suspected as a causative factor in the pathogenesis of these findings.

Spinal cord injury model systems of care: the legacy and the promise.

The Spinal Cord Injury Model Systems of Care have served a unique role in the provision of integrated and coordinated care for persons with spinal cord injuries (SCI), and in collaborative research efforts to advance available technologies. Although the basic mission of the model systems remains viable, contemporary issues and trends indicate that the model systems concept ought to be expanded in terms of roles and functions to meet current needs.

Causes of death during the first 12 years after spinal cord injury.

A study of 9,135 persons injured between 1973 and 1984 and treated at any of 13 regional spinal cord injury care systems was conducted to compare their age-, sex-, race-, and cause-specific mortality rates with those of the general population. All subjects survived at least 24 hours. Follow-up was terminated in December, 1985 when 854 persons (9.3%) had died. Although many persons had multiple causes of death, the leading primary causes were pneumonia, nonischemic heart disease, septicemia, symptoms and ill-defined conditions, pulmonary emboli, and ischemic heart disease. During the study period, spinal cord injured persons were 82.2 times more likely to die of septicemia, 46.9 times more likely to die of pulmonary emboli, and 37.1 times more likely to die of pneumonia than comparable individuals from the general population. Though some cause-specific mortality rates for spinal cord injured persons have declined dramatically, many remain substantially above normal. Before life expectancies increase further, improved methods for preventing and managing these fatal complications must be developed.

A cross-sectional study of the relationship between age and current health status for persons with spinal cord injuries.

As life expectancies of persons with spinal cord injuries increase, this population is aging rapidly. This trend requires that increasing attention be given to the healthcare needs of older persons with spinal cord injury. Follow up data on 11,117 persons injured since 1973 were analyzed by current age at 15-year intervals. Mean time postinjury was 4.7 years. Several trends were observed when comparing persons currently in the 16-30 year age group with persons in the oldest age group (age 76+). The percentage of persons independent in selfcare decreased from 61.9% to 29.1%. Ventilator use increased from 1.7% to 4.3%. Nursing home residence increased from 1.4% to 22.2%. The percentage of persons rehospitalized during the most recent year increased from 26.5% to 33.7%. Age was an important predictor of health status, but time postinjury was less important, perhaps due to the study's short postinjury time frame. While few differences in health status were observed in individuals between 16 and 60 years of age, persons in the oldest two age groups demonstrated lower levels of health status than younger individuals.

Motor recovery of the upper extremities in traumatic quadriplegia: a multicenter study.

Clinicians need to know recovery of neurologic function in the upper extremities after traumatic quadriplegia to prognosticate function in self-care, to determine the effectiveness of various interventions, and to develop a comprehensive rehabilitation plan. This study was undertaken to determine the extent of recovery of key muscles of the arms in motor complete quadriplegic subjects. The hypothesis stated that patients with some motor power (grades 1.0 to 2.5/5) in muscles in the zone of partial preservation would recover at an earlier time and to a greater extent than those with no motor power (grade 0/5). One hundred fifty subjects, C4, C5, and C6 motor complete, were entered in the study within one week of injury from four centers. Serial muscle examinations of the biceps, wrist extensors, and triceps on the right and left sides were performed up to 24 months after spinal cord injury. The pattern of recovery in the key muscles of the 67 subjects with some motor power in the zone of partial preservation to grade 3/5 was significantly greater than the 83 subjects with no motor power (68% to 82% vs 14% to 36%, p less than .001) at three to six months postinjury. The plateau of the median manual muscle test score determined the extent of recovery and reached grade 4/5 in subjects with some motor power at three to six months. The pattern of recovery revealed more subjects with some motor power improved to grade 3/5 at all intervals earlier than those with no motor power (p less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Trends in spinal cord injury demographics and treatment outcomes between 1973 and 1986.

A study of the National Spinal Cord Injury Statistical Center database on 6,563 persons treated at Spinal Cord Injury Care Systems was conducted to detect demographic and treatment outcome trends over time. Data from the initial hospitalization and first two years postinjury were divided into four time periods based on injury year (1973 to 1977, 1978 to 1980, 1981 to 1983, 1984 to 1986). Between 1973 and 1986, mean age at injury increased, as did the percentage of nonwhites and the percentage of persons with quadriplegia, while the percentage of neurologically complete lesions decreased. There was an increase in long-term use of intermittent catheterization. Ventilator use during hospitalization also increased. Mean lengths of stay for acute care and rehabilitation decreased, although mean inflation-adjusted hospital charges increased. The percentage of persons rehospitalized during the second postinjury year decreased substantially. From 1973 to 1986, for persons admitted to the model system within 24 hours of injury, there was a 66% decrease in the risk of dying within the first two years postinjury. Overall, these data document changing demographics and treatment practices as well as an improved prognosis for persons with spinal cord injuries.

Prognostic factors for 12-year survival after spinal cord injury.

A study of 9,135 persons injured between 1973 and 1984 and treated at any of 13 model regional spinal cord injury care systems was conducted to determine both overall survival and the effects of prognostic factors. All subjects survived at least 24 hours, and followup ended December 31, 1985. Cumulative 12-year survival was 85.1% (88.2% of normal). Survival ranged from almost 95% (more than 96% of normal) for persons who were younger than 25 years at time of injury and who had neurologically incomplete lesions, to 18.1% (26.9% of normal) for persons who were at least 50 years old at time of injury and who had neurologically complete quadriplegia. Spinal cord injury mortality rates ranged from 1.68 to 15.98 times higher than corresponding rates for non-spinal-injured persons. Although mortality rates for many persons with spinal cord injuries have declined dramatically during the past few decades, these data confirm the continued poor prognosis for older persons with neurologically complete quadriplegia.

Suicide following spinal cord injury.

A study of 9135 persons injured between 1973 and 1984 and treated at any of 13 model regional spinal cord injury (SCI) care systems was conducted. Follow-up ended December 31, 1985, by which time 50 persons had committed suicide (6.3% of deaths). Based on age-sex-race-specific rates for the general population, 10.2 suicides were expected to occur. Therefore, the standardized mortality ratio (SMR) for suicide was 4.9. The highest SMR occurred 1 to 5 years after injury. The SMR was also elevated for the first post-injury year, but was not significantly elevated after the fifth year. The SMR was significantly elevated for all neurological groups, but was highest for persons with complete paraplegia. The SMR was highest for persons aged 25 to 54 years, but was also elevated for persons aged less than 25 years. Suicide was the leading cause of death for persons with complete paraplegia and the second leading cause of death for persons with incomplete paraplegia. The most common means of committing suicide was by gunshot. These figures demonstrate the need for increased staff, patient and family awareness of this problem, and improved follow-up assessment and psychosocial support programmes.

Neurogenic urinary tract infection.

Even though renal failure secondary to the urologic complications of chronic or recurrent urinary tract infection has decreased markedly due to advances in diagnostic, preventive, and therapeutic measures, infection and its sequelae continue to be major problems in patients with spinal cord injury regardless of the bladder emptying method employed. Although lower urinary tract complications have decreased with intermittent catheterization, the effects of increased intravesicular pressure, inflammation, and chronic bacterial colonization or invasion of the urinary tract on long-term renal function are still undetermined. Thorough evaluation of the urologic status on a regular basis in all patients with spinal cord injury is encouraged. Treatment of urinary tract infection should be guided by scientific data and drug susceptibilities of etiologic bacteria. The general consensus is that the presence of asymptomatic bacteriuria, particularly in the absence of pyuria, usually does not warrant antibiotic treatment, and that prophylaxis or suppression of infection with systemic antibiotics is not effective for any considerable length of time. Preservation of renal function is the ultimate goal of all bladder management strategies.

Spinal cord injury. Rehabilitation adds life to years.

The National Spinal Cord Injury Statistical Center data base contains information collected prospectively on 13,763 persons injured since 1973 and treated at model systems of care throughout the United States. These data clearly demonstrate improved neurologic status and independent function in activities of daily living following acute care and rehabilitation for most persons with spinal cord injuries. Decreased lengths of initial and subsequent hospital stays and increased survival rates are also documented. Most persons are discharged to a private residence in the community and remain there. Many complete their educations and return to gainful employment after injury. Spinal cord injury has only a short-term effect on marriage and divorce rates, which appears to dissipate within a few years after injury. Overall, these figures demonstrate the dramatic improvements in length and quality of life achieved by most persons with spinal cord injuries during the past two decades.

Experience with surgical resection of heterotopic bone in spinal cord injury patients.

Extensive heterotopic ossification may occur after a spinal cord injury. Surgical removal of the heterotopic bone is considered only in patients who develop limitations of function or related skin pressure areas. In a prospective study of 21 patients, a total of 43 surgical procedures were performed to resect heterotopic bone. Long-term follow-up study was available for 18 patients who had 38 surgical procedures. This was a descriptive study since preoperative, surgical, and postoperative care varied slightly over time and were dependent on newer advances in surgical techniques and therapeutic agents. Primary complications included excessive bleeding, infection, fractures, and recurrence of the heterotopic ossification. Procedures are outlined that may reduce the incidence of postoperative infection. Fractures are related to the degree of regional osteoporosis. Recurrence is still a common problem, and any or all therapeutic agents that may reduce the extent of postoperative recurrence should be considered before surgical excision is planned.

Benefits of early admission to an organised spinal cord injury care system.

Patients admitted to the University of Alabama Hospital between 1973 and 1985 were studied to determine the benefits, if any, of early admission to an organised, multidisciplinary spinal cord injury (SCI) care system. Patients admitted within 1 day of injury who received all subsequent care within the system were compared with patients who received their acute care services elsewhere and who were admitted to the system solely for rehabilitation. Both patient groups were comparable with respect to age, neurologic level and extent of spinal cord lesion, pre-existing major medical conditions, associated injuries, ventilator dependency and acute surgical procedure experience. Findings included statistically significant reductions in acute care and total lengths of stay coupled with a highly significant reduction in the incidence of pressure ulcers for patients admitted within 1 day of injury. Moreover, for patients admitted within 1 day of injury, mortality rates were lower than reported previously for patients not admitted to an organised SCI care system.

Effect of bullet removal on subsequent pain in persons with spinal cord injury secondary to gunshot wound.

The prevention or minimization of future pain is often cited as a reason for removal of the bullet from patients who have incurred a spinal cord injury secondary to a gunshot wound. In an attempt to examine this assumption, multimodal pain ratings were recorded for 14 patients with spinal cord injury due to a gunshot wound in whom the bullet was still present, 14 neurologically matched patients with spinal cord injury due to a gunshot wound in whom the bullet was removed, and 28 control patients with spinal cord injury unrelated to a gunshot wound who were neurologically matched to the first two groups. The results suggest that persons who sustain a spinal cord injury secondary to gunshot wounds report more pain than those injured in other ways. In addition, there was no indication that surgical removal of the bullet was helpful in reducing subsequent pain either early in the rehabilitation process or at 1 year postinjury. The location of the bullet and the type of pain that subsequently developed were not correlated with the initial decision to surgically remove the bullet. Implications for further study and clinical practice are discussed.