Evolución neurológica en la lesión medular traumática en función del tamaño de la hemorragia intraparenquimatosa / Neurological evolution in traumatic spinal cord injury according to the size of the intraparenchymal hemorrhage

Introducción y objetivos: La presencia de hemorragia medular es considerada como un factor de mal pronóstico evolutivo en el estudio de la lesión medular traumática (LMT). No obstante, se ha sugerido en trabajos publicados que el pronóstico de los sangrados de menor tamaño no es tan negativo. El objetivo del presente trabajo es valorar la evolución neurológica en individuos con hemorragia intraparenquimatosa en función del tamaño de la misma. Material y métodos: Estudio observacional retrospectivo. Recopilados los pacientes ingresados por LMT aguda con estudio de resonancia, que objetivase una hemorragia medular entre los años 2010 y 2018. Se establecieron 2 grupos en función del tamaño del sangrado: microhemorragias (menor de 4mm) y macrohemorragias (superior a 4mm). Se comparó la exploración neurológica al ingreso y al alta atendiendo al grado AIS y el índice motor (IM). Resultados: Recogidos 46 casos, 17 microhemorragias y 29 macrohemorragias. El 70,6% de las primeras eran AIS A mientras que entre las macrohemorragias el porcentaje era del 89,6%. Al momento del alta se apreció una mejoría del grado AIS en el 40,0% de las microhemorragias por un 4,0% de las macrohemorragias (p=0,008). El IM inicial fue muy similar, 45,2±22,2 en las microhemorragias y 40,9±20,4 en las mayores (p=0,459), pero al alta era superior en el primer grupo: 60,4±20,5 por 42,7±22,8 (p=0,033). Ocho pacientes (17,4%) fallecieron durante el ingreso. Conclusiones: Existe relación entre el tamaño de la hemorragia intraparenquimatosa y el pronóstico neurológico de la LMT, presentando una mejor evolución las hemorragias menores de 4mm.(AU)

Introduction and objectives: The presence of spinal cord hemorrhage is considered as a poor prognostic factor in traumatic spinal cord injury (SCI). However, it has been suggested in published works that the prognosis of small hemorrhages is not so negative. The aim of this paper is to assess the neurological evolution in individuals with intraparenchymal hemorrhage according to its size. Material and methods: Retrospective observational study. Selected all the patients admitted for acute traumatic SCI between 2010 and 2018 with early magnetic resonance study and spinal cord hemorrhage. Two groups were established depending on the size of the bleeding: microhemorrhages (less than 4mm) and macrohemorrhages (greater than 4mm). The neurological examination at admission and discharge was compared according to the AIS grade and the motor score (MS). Results: Forty-six cases collected, 17 microhemorrhages and 29 macrohemorrhages. 70.6% of the microhemorrhages were AIS A while among macrohemorrhages the percentage was 89.6%. At the time of discharge, an improvement in the AIS grade was observed in 40.0% of the microhemorrhages compared to 4.0% of the macrohemorrhages (P=.008). Initial MS was similar, 45.2±22.2 in the microhemorrhages and 40.9±20.4 in the macrohemorrhages (P=.459), but at discharge it was higher in the first group: 60.4±20.5 for 42.7±22.8 (P=.033). Eight patients (17.4%) died during admission. Conclusions: There is a relationship between the size of the intraparenchymal hemorrhage and the neurological prognosis of SCI, with hemorrhages smaller than 4mm presenting a better evolution.(AU)

[Neurological evolution in traumatic spinal cord injury according to the size of the intraparenchymal hemorrhage]. / Evolución neurológica en la lesión medular traumática en función del tamaño de la hemorragia intraparenquimatosa.

INTRODUCTION AND OBJECTIVES: The presence of spinal cord hemorrhage is considered as a poor prognostic factor in traumatic spinal cord injury (SCI). However, it has been suggested in published works that the prognosis of small hemorrhages is not so negative. The aim of this paper is to assess the neurological evolution in individuals with intraparenchymal hemorrhage according to its size. MATERIAL AND METHODS: Retrospective observational study. Selected all the patients admitted for acute traumatic SCI between 2010 and 2018 with early magnetic resonance study and spinal cord hemorrhage. Two groups were established depending on the size of the bleeding: microhemorrhages (less than 4mm) and macrohemorrhages (greater than 4mm). The neurological examination at admission and discharge was compared according to the AIS grade and the motor score (MS). RESULTS: Forty-six cases collected, 17 microhemorrhages and 29 macrohemorrhages. 70.6% of the microhemorrhages were AIS A while among macrohemorrhages the percentage was 89.6%. At the time of discharge, an improvement in the AIS grade was observed in 40.0% of the microhemorrhages compared to 4.0% of the macrohemorrhages (P=.008). Initial MS was similar, 45.2±22.2 in the microhemorrhages and 40.9±20.4 in the macrohemorrhages (P=.459), but at discharge it was higher in the first group: 60.4±20.5 for 42.7±22.8 (P=.033). Eight patients (17.4%) died during admission. CONCLUSIONS: There is a relationship between the size of the intraparenchymal hemorrhage and the neurological prognosis of SCI, with hemorrhages smaller than 4mm presenting a better evolution.

Valor pronóstico de la resonancia magnética precoz en la morbilidad y mortalidad de la lesión medular traumática / Prognostic value of early magnetic resonance imaging in the morbidity and mortality of traumatic spinal cord injury

Objetivo Valorar en individuos con lesión medular traumática (LMT) la relación en re la mortalidad y la necesidad de UCI y las alteraciones objetivadas mediante resonancia magnética (RM) precoz, analizando alteraciones parenquimatosas, disrupción de ligamentos vertebrales (DLV) y compresión del cordón medular (CCM). Diseño Estudio retrospectivo. Ámbito Hospital de tercer nivel, unidad de lesionados medulares y UCI. Pacientes Individuos con LMT aguda entre los años 2010 y 2019. Intervenciones Análisis de RM realizada en las primeras 72horas. Variables de interés Ingreso en UCI y mortalidad. Resultados Recogidos 269 casos. El patrón que se asoció a una mayor mortalidad fue la hemorragia (16,7%) por 12,5% de los edemas a un nivel y 6,5% de los edemas a múltiples niveles (p=0,125). Lo mismo aconteció con los ingresos en UCI: 69,0% en hemorragia por 60,2% en edema múltiple y 46,3% en edemas cortos (p=0,018). Con respecto a la CCM, la mortalidad fue del 13,4% con 59,2% de ingresos en UCI por 2,2% y 42,2% de quienes no presentaban compresión (p=0,020 y p=0,003). Las cifras de éxitus e ingreso en UCI en los individuos con DLV fueron del 15,0% y el 67,3%, respectivamente, por un 6,2% y 44,4% de los individuos sin DLV (p<0,001 y p=0,013). Conclusiones La presencia de hemorragia medular, CCM y DLV se asoció a una mayor necesidad de UCI. Existe un significativo aumento de la mortalidad en los casos con CCM y DLV (AU)

Objective To assess in individuals with traumatic spinal cord injury (TSCI) the relationship between mortality and need for ICU and early magnetic resonance imaging (MRI), analyzing spinal parenchymal alterations, disruption of vertebral ligaments (DVL) and spinal cord compression (SCC). Design Retrospective study. Setting Third-level hospital, Spinal Cord Injury Unit and ICU. Patients Individuals with acute TSCI between 2010 and 2019. Interventio Analysis of MRI performed in the first 72h. Variables of interest Admission to ICU and mortality. Results 269 cases collected. The pattern that demonstrated higher mortality was cord hemorrhage (16.7%) for 12.5% of single-level edema and 6.5% of multilevel edema (p=0.125). The same happened with ICU admissions: 69.0% in hemorrhage, 60.2% in multilevel edema and 46.3% in short edema (p=0.018). Analyzing CCM, mortality was 13.4% with 59.2% of ICU admissions, for 2.2% and 42.2% of individuals without cord compression (p=0.020 and p=0.003). The figures of death and ICU admission among cord injuries with DVL were 15.0% and 67.3%, for 6.2% and 44.4% of the individuals without DLV (p<0.001 and p=0.013). Conclusions The presence of spinal cord hemorrhage, SCC and DVL was associated with a higher admission in ICU. A significant increase in mortality was observed in cases with SCC and DVL (AU)

Epidemiology of traumatic spinal cord injury in childhood and adolescence in Galicia, Spain: report of the last 26-years.

OBJECTIVE: To analyze the characteristics of traumatic spinal cord injury in children of Galicia (Spain). DESIGN: Descriptive and retrospective study. METHODS: Data extracted from the internal registry of the Spinal Cord Injury Unit and the patient's medical records, between March 1988 and December 2014. Inclusion criteria: patients aged ≤ 17 years with a traumatic spinal cord injury.Outcome measures: Total patients, percentages, incidence, ASIA scale results and improvement. RESULTS: A total of 68 patients were included. The incidence was 5.6 cases/1,000,000 inhabitants/year. The mean age was 14.4 years (median: 16). Only 25% were younger than 15. Male patients accounted for 73.5% of the total. The main cause were traffic accidents (60.3%; n = 41), being higher (77.8%) in children ≤ 10 years. Other etiologies included falls (19.1%), diving accidents (16.2%) and other causes (4.4%). Eleven patients (16.2%) had injuries classified as SCIWORA, 8 (72.7%) of them aged ≤ 10 years. The mean age of the SCIWORA group was 7.5 years versus 15.7 years in the non-SCIWORA group (P < 0.001). Half (50%) of these patients had a complete spinal cord injury and, of these, 64.6% were paraplegic. CONCLUSIONS: Traumatic spinal cord injuries are rare in children, and most cases occur between 15 and 17 years. Unlike in adults, SCIs in children mostly involve the thoracic spine. Most patients aged ≤ 10 years have SCIWORA. The most common etiology continues to be traffic accidents, although sports accidents prevail among adolescent patients.

Actualización en lesión medular aguda postraumática. Parte 2 / Update on traumatic acute spinal cord injury. Part 2

El objetivo en el tratamiento de la lesión medular aguda traumática es preservar la función neurológica residual, evitar el daño secundario, y restaurar la alineación y la estabilidad de la columna. En esta segunda parte proporcionaremos un enfoque en el tratamiento de la lesión medular en cuestiones relativas al manejo respiratorio a corto plazo, donde es prioritaria la preservación de la función diafragmática, así como la posibilidad de predecir la duración de la ventilación mecánica y la necesidad de traqueostomía. Abordaremos la valoración quirúrgica de las lesiones de columna en función de unos criterios de tratamiento actualizados, teniendo en cuenta que, aunque el tipo de intervención depende del equipo quirúrgico, en el momento actual el tratamiento implica descompresión y estabilización precoz. En el tratamiento integral del paciente con lesión medular es fundamental identificar y tratar adecuadamente el dolor asociado a la lesión medular, así como la ansiedad, al igual que prevenir y diagnosticar precozmente complicaciones secundarias a la afectación que la lesión medular ocasiona en todos los sistemas del organismo (enfermedad tromboembólica, alteraciones gastrointestinales, afectación del sistema urinario, úlceras por presión) (AU)

The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers) (AU)

Efectividad de programas de terapia ocupacional en personas con daño cerebral adquirido en el ámbito domiciliario y ambulatorio: una revisión sistemática / Effectiveness of occupational therapy programmes in the home and ambulatory setting for people with an acquired brain injury: a systematic review

Introducción. Los programas de rehabilitación domiciliaria y ambulatoria son fundamentales en la recuperación funcional en personas con daño cerebral adquirido. El objetivo de esta revisión es comprobar la efectividad de programas de terapia ocupacional domiciliaria y atención primaria, sobre el nivel de independencia de las actividades de la vida diaria, en personas adultas con daño cerebral adquirido. Metodología. Se realizó una búsqueda bibliográfica, en bases de datos especializadas en revisiones sistemáticas (CRD Database) y de estudios originales (Pubmed, Scopus, Web of Science y OTseeker). Se analizaron las siguientes variables: funcionalidad en las actividades de la vida diaria, n.° de días de estancia hospitalaria, intensidad de las sesiones de rehabilitación realizadas, tiempo de espera desde el alta hospitalaria al inicio del proceso de rehabilitación y n.° de reingresos. Resultados. Se seleccionaron una revisión sistemática y cuatro estudios originales. Tres de los cuatro estudios fueron ensayos clínicos aleatorizados, el estudio restante fue un ensayo clínico no controlado. Conclusiones. La evidencia es limitada para afirmar con rotundidad la efectividad de los programas de terapia ocupacional en rehabilitación domiciliaria y ambulatoria, en personas con daño cerebral adquirido. Se produjeron algunas diferencias significativas sobre los niveles de independencia en actividades de la vida diaria, fruto de intervenciones muy heterogéneas entre sí (AU)

Introduction. Home and outpatient rehabilitation programmes are crucial in the functional recovery of people with an acquired brain injury. The objective of this review was to determine the effectiveness of home occupational therapy programmes and primary care in increasing independence for activities of daily living in adults with an acquired brain injury. Methodology. A literature search was conducted in databases specialised in systematic reviews (CRD Database) and in original articles (Pubmed, Scopus, Web of Science and OTseeker). The following variables were analysed: activities of daily living functionality, length hospital stay, the intensity of the rehabilitation sessions carried out, waiting time from hospital discharge to the start of the rehabilitation process, and number of readmissions. Results. A systematic review and four original studies that met the inclusion criteria were retrieved. Three of the four studies were randomised controlled trials and the remaining study was a non-controlled clinical trial. Conclusions. The evidence is too limited to allow definitive conclusions to be drawn on the effectiveness of occupational therapy programmes in the home or ambulatory setting in people with an acquired brain injury. There were some significant differences in levels of independence in activities of daily living, but these were the result of widely heterogeneous interventions (AU)

Actualización en lesión medular aguda postraumática. Parte 1 / Update on traumatic acute spinal cord injury. Part 1

La lesión medular traumática precisa una acción multidisciplinar, tanto para el tratamiento especializado de la fase aguda como para las complicaciones secundarias. La sospecha y/o el diagnóstico de una lesión medular es el primer paso para establecer un tratamiento correcto. En esta revisión se aborda el manejo en la fase prehospitalaria y los aspectos característicos de la fase aguda. La monitorización respiratoria para una intubación selectiva precoz, la identificación y el tratamiento correcto del shock neurogénico son fundamentales para la prevención del daño medular secundario. En la actualidad el uso de esteroides no es un estándar en el tratamiento neuroprotector, siendo el control hemodinámico y la descompresión quirúrgica precoz pilares fundamentales. La lesión medular traumática generalmente se presenta en el contexto de un politraumatismo que puede dificultar el diagnóstico. El examen neurológico y la selección adecuada de pruebas radiológicas evitan que pase desapercibida la lesión medular y otras lesiones asociadas, y ayudan a establecer el pronóstico

Traumatic spinal cord injury requires a multidisciplinary approach both for specialized treatment of the acute phase and for dealing with the secondary complications. A suspicion or diagnosis of spinal cord injury is the first step for a correct management. A review is made of the prehospital management and characteristics of the acute phase of spinal cord injury. Respiratory monitoring for early selective intubation, proper identification and treatment of neurogenic shock are essential for the prevention of secondary spinal cord injury. The use of corticosteroids is currently not a standard practice in neuroprotective treatment, and hemodynamic monitoring and early surgical decompression constitute the cornerstones of adequate management. Traumatic spinal cord injury usually occurs as part of multiple trauma, and this can make diagnosis difficult. Neurological examination and correct selection of radiological exams prevent delayed diagnosis of spinal cord injuries, and help to establish the prognosis

Update on traumatic acute spinal cord injury. Part 1. / Actualización en lesión medular aguda postraumática. Parte 1.

Traumatic spinal cord injury requires a multidisciplinary approach both for specialized treatment of the acute phase and for dealing with the secondary complications. A suspicion or diagnosis of spinal cord injury is the first step for a correct management. A review is made of the prehospital management and characteristics of the acute phase of spinal cord injury. Respiratory monitoring for early selective intubation, proper identification and treatment of neurogenic shock are essential for the prevention of secondary spinal cord injury. The use of corticosteroids is currently not a standard practice in neuroprotective treatment, and hemodynamic monitoring and early surgical decompression constitute the cornerstones of adequate management. Traumatic spinal cord injury usually occurs as part of multiple trauma, and this can make diagnosis difficult. Neurological examination and correct selection of radiological exams prevent delayed diagnosis of spinal cord injuries, and help to establish the prognosis.

Update on traumatic acute spinal cord injury. Part 2. / Actualización en lesión medular aguda postraumática. Parte 2.

The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers).

Epidemiology of traumatic spinal cord injury in Galicia, Spain: trends over a 20-year period.

STUDY DESIGN: Observational study with prospective and retrospective monitoring. OBJECTIVE: To describe the epidemiological and demographic characteristics of traumatic spinal cord injury (TSCI), and to analyze its epidemiological changes. SETTING: Unidad de Lesionados Medulares, Complejo Hospitalario Universitario A Coruña, in Galicia (Spain). METHODS: The study included patients with TSCI who had been hospitalized between January 1995 and December 2014. Relevant data were extracted from the admissions registry and electronic health record. RESULTS: A total of 1195 patients with TSCI were admitted over the specified period of time; 76.4% male and 23.6% female. Mean patient age at injury was 50.20 years. Causes of injury were falls (54.2%), traffic accidents (37%), sports/leisure-related accidents (3.5%) and other traumatic causes (5.3%). Mean patient age increased significantly over time (from 46.40 to 56.54 years), and the number of cases of TSCI related to traffic accidents decreased (from 44.5% to 23.7%), whereas those linked to falls increased (from 46.9% to 65.6%). The most commonly affected neurological level was the cervical level (54.9%), increasing in the case of levels C1-C4 over time, and the most frequent ASIA (American Spinal Injury Association) grade was A (44.3%). The crude annual incidence rate was 2.17/100 000 inhabitants, decreasing significantly over time at an annual percentage rate change of -1.4%. CONCLUSIONS: The incidence rate of TSCI tends to decline progressively. Mean patient age has increased over time and cervical levels C1-C4 are currently the most commonly affected ones. These epidemiological changes will eventually result in adjustments in the standard model of care for TSCI.

Consenso sobre la profilaxis y tratamiento de la enfermedad tromboembólica venosa en la lesión medular y en el daño cerebral adquirido / Prevention and treatment of venous thromboembolism in spinal cord injury and acquired brain injury

La enfermedad tromboembólica venosa es un proceso patológico que abarca tanto la trombosis venosa profunda como el tromboembolismo pulmonar. Son muchos los estudios que recogen la alta incidencia de esta enfermedad en pacientes afectos de lesiones neurológicas como la lesión medular, el traumatismo craneoencefálico o el ictus, todos ellos pacientes susceptibles de ingreso en centros de rehabilitación. En la literatura publicada existe controversia acerca de la necesidad de screening de enfermedad tromboembólica venosa en estos pacientes, el tiempo de mantenimiento de la profilaxis o los fármacos a utilizar tanto en la profilaxis como una vez se establece la sospecha o el diagnóstico definitivo de dicha enfermedad. Con esta revisión de la literatura pretendemos hacer un consenso para intentar aclarar dudas y establecer unas directrices de sospecha, diagnóstico y tratamiento que nos ayuden en la práctica clínica diaria

Venous thromboembolism is a disease that includes both deep vein thrombosis and pulmonary embolism. Many studies reflect the high incidence of this disease in patients with neurological injuries such as, spinal cord injury, traumatic brain injury, or stroke, and all these patients are candidates for admission to rehabilitation centres. There is controversy in the published literature on the need for screening of deep vein thrombosis in these patients, time on prophylaxis drug maintenance or the drugs to use for prophylaxis once suspected or when the definite diagnosis of this disease is established. A review of the literature is presented in order to attempt to clarify these doubts and establish guidelines for suspicion, diagnosis and treatment to help us in daily clinical practice

Sexual satisfaction in women with spinal cord injuries.

STUDY DESIGN: Structured interview based on a predesigned survey. OBJECTIVE: To examine the factors that affect the degree of sexual satisfaction in a sample of women with spinal cord injury (SCI). SETTING: The study participants were women with SCIs, from the area of the SCI Unit of A Coruña, a reference unit for the Community of Galicia in the northwest of Spain. All study participants were selected consecutively in the outpatient clinic in 2013. METHODS: The study included women with the American Spinal Injury Association (ASIA) A-D spinal injuries, between the ages of 18 and 65 years, who completed rehabilitation therapy and live in the community. A total of 32 women formed the final study group. RESULTS: When comparing the group of women who were sexually active with those who were not, variables such as age, neurological level, time since the SCI, ASIA or Spinal Cord Independence Measure score, urinary incontinence, chronic pain and spasticity were not related to sexual activity. The only factors that we found to be related to sexual activity were not having a stable partner (P=0.017) and a lack of sensation in the genital area (P=0.039). CONCLUSION: The only variables related to sexual activity were not having a partner and a lack of sensation in the genital area. Improving sexual satisfaction, information and specific programs during rehabilitation can help women with SCI explore and investigate new erotic possibilities, thereby improving their self-esteem and social relationships.

Trombosis venosa profunda en la lesión medular traumática aguda / Deep vein thrombosis in acute traumatic spinal cord injury

Objetivo. Describir y analizar los aspectos epidemiológicos de la trombosis venosa profunda (TVP) en pacientes con lesión medular traumática aguda. Material y métodos. Estudio descriptivo retrospectivo donde se incluyeron los pacientes ingresados en nuestra unidad, durante el período comprendido entre los años 1999 y 2010. Los datos recogidos se trataron mediante el análisis informático SPSS®. Resultados. De un total de 751 pacientes, 45 presentaron TVP con una incidencia del 6%. Veinticuatro pacientes presentaron tromboembolismo pulmonar (TEP) asociado (53,3%). El 69,8% presentaban lesión medular (LM) completa y el 57,2% eran parapléjicos. El tiempo de evolución medio desde la lesión hasta el diagnóstico de TVP fue de 48 días. La estancia media fue de 189 días frente a 135 de los que no desarrollaron TVP (p<0,001). No habían iniciado sedestación el 64,4%. El 15,6% presentaron concomitantemente osificación paraarticular (OPA). El 60% presentaban algún factor de riesgo sobreañadido para desarrollar TVP, siendo los más frecuentes: fracturas de miembros inferiores (MMII) (26,7%), traumatismo craneoencefálico (TCE) (24,4%) e hipertensión (HTA) (22,2%). Las únicas variables que encontramos asociadas con aparición de TVP son la presencia de OPA (p<0,005; RR:4) y el grado ASIA (p=0,001; RR:2,7). Conclusiones. La incidencia de TVP se mantiene constante a lo largo del período estudiado. La TVP aumenta la mortalidad y significativamente la estancia media. La probabilidad de desarrollar TVP se correlaciona con la presencia de OPA y el ASIA; aumentando en los pacientes con OPA y disminuyendo en las lesiones incompletas (AU)

Objective. Describe and analyze the epidemiology of deep vein thrombosis (DVT) in patients with acute traumatic spinal cord injury. Material and methods. Retrospective study of patients admitted in our unit during the period between 1999 and 2010. The data collected were processed with SPSS 16.0 analysis. Results. Of a total of 751 patients, 45 had DVT, with an incidence of 6%. Twenty-four had associated pulmonary embolism (53.3%). 69.8% had complete spinal cord injury (SCI), 57.2% were paraplegics. The average time of evolution from injury to diagnosis of DVT was 48 days. The average stay was 189 days compared to 135 in those who do not develop DVT (P<0.001). They had begun sitting on 64.4%. The 15.6% had concomitant OPA. The 60% had superimposed a risk factor for developing DVT, the most common: lower limbs fractures (26.7%), traumatic brain injury (24.4%) and hypertension (22.2%). The only variables that are associated with development of DVT include the presence of para-articular ossification (PAO) (P<0.005; RR:4) and ASIA grade (P=0.001; RR:2.7). Conclusions. The incidence of DVT remains constant throughout the study period. The DVT increase mortality and significantly the average stay. The probability of developing DVT correlates with the presence of PAO and ASIA grade, increasing in patients with OPA and decreasing it in incomplete injuries (AU)

Sarcoma de Ewing axial. A propósito de un caso / Axial Ewing's sarcoma. A case report

El sarcoma de Ewing (SE) axial es un tumor óseo y de tejidos blandos maligno, raro, con una tríada clínica característica de dolor, déficit neurológico y masa palpable. Típicamente presenta la translocación cromosómica t(11;22)(q24;q12). El tratamiento habitual del SE combina cirugía, radioterapia y quimioterapia. Se presenta el caso de una paciente de 40 años con clínica de lumbalgia aguda y paraparesia progresiva, que en el estudio radiológico realizado se objetiva una tumoración con morfología de reloj de arena, de localización primaria vertebral y sin metástasis, por lo que fue intervenida quirúrgicamente, y posteriormente realizó tratamiento quimioterápico y rehabilitador. Destacamos la importancia del caso clínico por la rareza de su edad de presentación y la localización vertebral primaria (AU)

Axial Ewing's sarcoma (ES) is a rare and malignant bone and soft tissue tumor, with a characteristic clinical triad of pain, neurological deficit and palpable mass. It typically presents the chromosome translocation t(11;22)(q24;q12). Its usual treatment combines surgery, radiotherapy and chemotherapy. A case report is presented of a 40-year old female patient with symptoms of acute low back pain and progressive paraparesis. The MRI study showed lumbar tumor with hourglass morphology, having a primary spinal location without metastases. The patient was operated on, after which chemotherapy and rehabilitation treatment were performed. We emphasize the importance of the clinical case due to its rarity of age of presentation and the primary spinal location (AU)

Artropatía vertebral de Charcot en lesionados medulares: problema diagnóstico / Vertebral osteoarthropathy or Charcot’s disease of the spine in spinal cord lesions: a diagnostic challenge

La artropatía neuropática de Charcot fue descrita en 1868 en pacientes afectos de tabes dorsal, y unos años después se describió su localización en articulaciones intervertebrales. Actualmente es una entidad reconocida entre las secuelas de lesiones medulares crónicas. Sin embargo, su diagnóstico y tratamiento siguen sujetos a discusión, y diversas publicaciones hacen referencia al problema del diagnóstico diferencial con artropatías de origen infeccioso afectando a la columna. Se exponen dos casos de pacientes afectos de lesiones medulares de larga evolución y que presentaron hallazgos compatibles con articulaciones neuropáticas de columna, pero que dieron lugar a un problema de diagnóstico diferencial con artritis infecciosa. El diagnóstico es complejo en pacientes lesionados medulares que presentan clínica de infección, pudiendo incluso superponerse ambos procesos

Neuropathic osteoarthropathy, or Charcot joint disease, was first described in 1868 in patients affected by tabes dorsalis, and it is currently a recognized entity among the sequelae of chronic spinal cord lesions. However, its diagnosis and treatment are still under discussion, and various publications make reference to the difficulties of differential diagnosis in cases of osteoarthropathies of infectious origin affecting the spine. The diagnosis is complex in patients with spinal cord lesions that have symptoms and signs of infection, and the two processes can even overlap. We describe two cases of patients with long-standing spinal cord lesions that presented findings compatible with neuropathic spinal articulations but that gave rise to a problem in the differential diagnosis with infectious arthritis. A surgical approach enabled histological and microbiological studies, confirming Charcot's disease and ruling out infection of the intervertebral space in the second case. Conclusion. In patients presenting febrile syndromes of unknown origin and a generally declining state of health whose laboratory findings indicate infection, the differential diagnosis can be hindered when it is difficult to differentiate Charcot's disease from pyogenic discitis or Pott's disease on imaging studies. The possibility of superinfection of a Charcot joint must be taken into account, and the surgical approach is usually necessary

Síndrome de Ogilvie y lesión medular. A propósito de un caso / Ogilvie’s syndrome and spinal cord injury. A case report

Introducción. Presentamos un caso de pseudo-obstrucción (síndrome de Ogilvie) en un paciente con lesión medular. Caso clínico. Se trata de un paciente varón de 50 años que sufrió politraumatismo con fractura-luxación D12-L1 y afectación medular secundaria. Tras 8 meses de evolución desarrolló un cuadro de dolor, distensión abdominal, náuseas y vómitos. La radiografía simple reveló dilatación del colon, diagnosticándose de pseudo-obstrucción colónica aguda. La tomografía axial computarizada confirmó el diagnóstico y descartó la obstrucción mecánica. A pesar de las medidas de soporte, el cuadro clínico empeoró y se realizó una intervención quirúrgica urgente. El paciente falleció durante la cirugía, a las 24 horas de evolución del cuadro. Discusión. El reconocimiento clínico está interferido por la lesión medular. Este síndrome debería tenerse en cuenta en pacientes con lesión medular que desarrollan íleo después de la fase aguda de la lesión, ya que un diagnóstico precoz y un manejo adecuado pueden disminuir la morbimortalidad

Introduction. To report a case of acute colonic pseudo-obstruction (Ogilvie's syndrome) in a patient with spinal cord injury (SCI). Case report. A 50-year-old man suffered a high-energy fall, resulting in: luxation-fracture of the thoracolumbar spine between T12 and L1 with spinal cord injury. After 8 months of evolution, he developed abdominal distension, nausea, vomiting and pain. Simple ƒ rays revealed colonic dilation and a diagnosis of acute colonic pseudo-obstruction was made. Computerized tomography scan confirmed the diagnosis and excluded mechanical obstruction. Despite supportive measures, his symptoms progressed over the following hours, and emergency surgery was performed. He died during surgery 24 hours after the initiation of the problem. Discussion. SCI may interfere with the accurate assessment of the abdomen. This syndrome should be borne in mind in patients with SCI who develop ileus after the acute damage phase, because early diagnosis and appropriate treatment would reduce morbidity and mortality

Long-term follow-up study of intraurethral stents in spinal cord injured patients with detrusor-sphincter dyssynergia.

STUDY DESIGN: Retrospective study. OBJECTIVES: To assess in the long-term clinical and urodynamic results of intraurethral stents in a group of patients with spinal cord injury. SETTING: Spinal Cord Injury Unit, Juan Canalejo Hospital, A Coruña, Spain. METHODS: Forty-seven consecutive male patients were studied from 1993 to 2002. All of them suffered from hyperreflexia with detrusor-sphincter dyssynergia (DSD) owing to spinal cord injury, and were treated by means of the placement of an intraurethral stent at the external sphincter. RESULTS: After surgery, significant decreases in all the parameters studied were observed. The number of patients with symptoms of urinary tract infection decreased by 25% (P<0.031). Post-void residual urine volume experienced an average decrease of 224.3 cm(3) (P=0.001). Episodes of dysreflexia decreased from 35.1 to 16.2% (P=0.039). The urodynamic study showed an average reduction of 44.36 cm H(2)O in the maximum detrusor pressure (P<0.0001). Complications in the upper urinary tract descended from 46.8 to 23.4% after placing the stent (P=0.013). The most frequent stent complication was displacement, followed by stenosis, lithiasis and intraprosthetic calcification. In all, 8.5% required the stent removal. CONCLUSIONS: Intraurethral stent is a good choice for the long-term management of DSD in spinal cord-injured patients, even in those who had been previously submitted to prior sphincterotomy. It has the advantage of being a potentially reversible procedure, so patients prefer it to more invasive therapies such as sphincterotomy.

Sexual issues in a sample of women with spinal cord injury.

STUDY DESIGN: Semistructured interview. OBJECTIVES: To assess the degree of participation in sexual intercourse of a sample of women with spinal cord injury (SCI) in our community, to establish to what extent their sexual lives have been affected in comparison to before the injury, and to search for those factors that may have a major influence on both aspects. SETTING: Spinal Cord Injuries Unit, A Coruna, Spain. PARTICIPANTS: A total of 37 women, average age 40 years, time since onset average 10 years. RESULTS: In all, 62% claimed regular sexual activity after the injury. The women who suffered the injury before reaching the age of 18 years run a higher risk of not having physical relationships than those who were above that age when they incurred the SCI (P=0.04, OR 4.75). We discovered a significant drop in the frequency of intercourse (P=0.003) and the ability to reach an orgasm (P=0.008), after the injury. Of these women, 69% were satisfied with their current sexual activity and 77.4% considered the information they received from their doctors on the changes the SCI would cause in their sexuality to be either insufficient or nonexistent. CONCLUSIONS: There is a noticeable decrease in the frequency of intercourse as well as a significant reduction in the capability of reaching orgasm. Despite these changes and problems that ensue during intercourse as a result, most show satisfaction with their current sexual lives. On the other hand, the occurrence of the injury before the age of 18 years may imply a greater risk of not having an active sex life in adult years. We consider it is essential to provide the appropriate sexual information during the process of rehabilitation, aimed at helping women with SCI to adapt to their new situation.

Dolor crónico después de la lesión medular: prevalencia, características y factores relacionados / Chronic pain after spinal cord injury. Prevalence, characteristics and associated factors

Introducción. El objetivo de este trabajo es analizar la prevalencia del dolor crónico en pacientes con lesión medular, investigar qué factores influyen en su desarrollo o intensidad, y en qué medida el dolor crónico afecta a las actividades diarias. Pacientes y métodos. Se ha realizado un estudio observacional basado en una entrevista personal. Se registraron datos demográficos, características de la lesión medular, grado de ansiedad y depresión, presencia de dolor crónico y características de éste. Resultados. Se incluyeron 114 pacientes. El 54,4 por ciento presentaban dolor crónico y el 26,2 por ciento lo calificaron como grave. El dolor neuropático por debajo de la lesión fue el más frecuente. Se encontró relación del dolor con la edad en el momento de la lesión (p = 0,009) y con la edad en el momento de la entrevista (p = 0,022). Se observó una asociación entre la intensidad del dolor y la interferencia en las actividades de la vida diaria (p = 0,033). Los niveles de ansiedad y depresión fueron mayores en el grupo de pacientes con dolor respecto al grupo control (p = 0,045). Se realizó una regresión logística indicando que únicamente la edad en el momento de la lesión modifica significativamente la probabilidad de sufrir dolor crónico (odds ratio, 1,03; intervalo de confianza del 95 por ciento, 1,00-1,06; p = 0,042). Conclusiones. Se confirma una alta prevalencia e intensidad del dolor crónico en la población de lesionados medulares, así como su inicio precoz tras la lesión. La única variable que hemos encontrado relacionada con su desarrollo es la edad (AU)

Spinal cord infarction: prognosis and recovery in a series of 36 patients.

OBJECTIVE: To study the clinical evolution and the functional outcome of patients suffering from spinal cord infarction who were treated at the Spinal Cord Injuries Unit. To try to determine the factors that could have influence in their functional outcome. SETTING: In a Spinal Cord Injuries Unit, regionally-based, and which forms part of a general hospital with a high level of specialization. METHOD: Retrospective study of the medical records of patients suffering from vascular spinal cord ischemia, as acute anterior spinal artery syndrome or associated with aortic surgery or rupture. Cases that were due to compressive, tumoral or inflammatory pathologies were excluded. Assessment of the neurological syndrome followed the ASIA/IMSOP criteria. Age, sex, history and magnetic resonance imaging (MRI) findings were analyzed. Assessment of functional outcome was made regarding ambulatory ability or wheelchair use, and bladder/sphincter control. RESULTS: Thirty-six cases were selected, the commonest group being spinal cord ischemia due to idiopathic causes (36.1%). Following these, there were cases associated with aortic surgery (25%), systemic arteriosclerosis (19.4%) and acute deficit of perfusion (11.1%). The average age of the patients was 59.3 years, with a mortality of 22.2% during the hospital stay. Regarding the functional outcomes at the moment of discharge, it must be pointed out that 57.1% of the patients were wheelchair users, 25% were ambulatory, using technical aids, and 17.9% were fully ambulatory. The group who could perform some kind of walking was significantly younger than the group of wheelchair users (48.17 vs 61.38 years). Additionally, it became evident that those patients who did not show voluntary muscle contraction at the time of admission (ASIA groups A and B) presented a higher risk of being wheelchair users. CONCLUSION: Acute spinal cord ischemia syndrome has a severe prognosis with permanent and disabling sequelae. Initial neurological assessment following ASIA/IMSOP classification proves to be the best predictor of prognosis, and the patient's advanced age constitutes a negative factor for functional recovery.