Alan N. McLean

Prophylaxis of thromboembolism in spinal injuries--results of enoxaparin used in 276 patients.

Objective: To evaluate the results of thromboembolic prophylaxis using enoxaparin in acute spinal injury patients.Background: Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in patients with acute spinal injuries. A wide range of thromboprophylactic measures have been proposed. The present study describes the outcome of a regime of enoxaparin and antithromboembolic stockings in acute spinal injuries irrespective of neurological damage.Setting: Scotland, UK.Methods: Eighteen-month retrospective review of acute spinal injury patients admitted to a national spinal injuries unit. A thromboembolic prophylactic regimen of early mobilisation, use of antithromboembolic stockings, and subcutaneous administration of enoxaparin 40 mg once a day until patients could be mobilised for more than 4 h per day, was used. Patients with clinical suspicion of deep venous thrombosis or pulmonary embolism were investigated as appropriate.Results: Out of 146 (53% of total) patients with spinal injuries with no neurological deficit only one patient (0.4%) developed clinical evidence of pulmonary embolism and out of 130 (47% of total) with spinal cord injury two (0.7%) developed clinical evidence of deep venous thrombosis while still on enoxaparin. Four patients (1.5%) developed deep venous thrombosis and one (0.4%) pulmonary embolism after discontinuing enoxaparin. There were no fatal pulmonary emboli and one suspected intraspinal bleeding.Conclusions: The present study suggests that, in addition to physical and mechanical measures, low molecular weight heparin in the form of enoxaparin 40 mg administered once daily compares favourably with previous studies for thromboprophylaxis in acute spinal injuries.Spinal Cord (2001) 39, 88–91.

Role of peripheral quantitative computed tomography in identifying disuse osteoporosis in paraplegia

ObjectiveDisuse osteoporosis is a major long-term health consequence of spinal cord injury (SCI) that still needs to be addressed. Its management in SCI should begin with accurate diagnosis, followed by targeted treatments in the most vulnerable subgroups. We present data quantifying disuse osteoporosis in a cross-section of the Scottish paraplegic population to identify subgroups with lowest bone mineral density (BMD).Materials and methodsForty-seven people with chronic SCI at levels T2-L2 were scanned using peripheral quantitative computed tomography at four tibial sites and two femoral sites, at the Queen Elizabeth National Spinal Injuries Unit, Glasgow (UK). At the distal epiphyses, trabecular BMD (BMDtrab), total BMD, total bone cross-sectional area (CSA) and bone mineral content (BMC) were determined. In the diaphyses, cortical BMD, total bone CSA, cortical CSA and BMC were calculated. Bone, muscle and fat CSAs were estimated in the lower leg and thigh.ResultsBMDtrab decreased exponentially with time since injury at different rates in the tibia and femur. At most sites, female paraplegics had significantly lower BMC, total bone CSA and muscle CSA than male paraplegics. Subjects with lumbar SCI tended to have lower bone values and smaller muscle CSAs than in thoracic SCI.ConclusionAt the distal epiphyses of the tibia and femur, there is generally a rapid and extensive reduction in BMDtrab after SCI. Female subjects, and those with lumbar SCI, tend to have lower bone values than males or those with thoracic SCI, respectively.

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.

Decreases in bone mineral density at cortical and trabecular sites in the tibia and femur during the first year of spinal cord injury.

BACKGROUND Disuse osteoporosis occurs in response to long-term immobilization. Spinal cord injury (SCI) leads to a form of disuse osteoporosis that only affects the paralyzed limbs. High rates of bone resorption after injury are evident from decreases in bone mineral content (BMC), which in the past have been attributed in the main to loss of trabecular bone in the epiphyses and cortical thinning in the shaft through endocortical resorption. METHODS Patients with motor-complete SCI recruited from the Queen Elizabeth National Spinal Injuries Unit (Glasgow, UK) were scanned within 5weeks of injury (baseline) using peripheral Quantitative Computed Tomography (pQCT). Unilateral scans of the tibia, femur and radius provided separate estimates of trabecular and cortical bone parameters in the epiphyses and diaphyses, respectively. Using repeat pQCT scans at 4, 8 and 12months post-injury, changes in BMC, bone mineral density (BMD) and cross-sectional area (CSA) of the bone were quantified. RESULTS Twenty-six subjects (5 female, 21 male) with SCI (12 paraplegic, 14 tetraplegic), ranging from 16 to 76years old, were enrolled onto the study. Repeated-measures analyses showed a significant effect of time since injury on key bone parameters at the epiphyses of the tibia and femur (BMC, total BMD, trabecular BMD) and their diaphyses (BMC, cortical BMD, cortical CSA). There was no significant effect of gender or age on key outcome measures, but there was a tendency for the female subjects to experience greater decreases in cortical BMD. The decreases in cortical BMD in the tibia and femur were found to be statistically significant in both men and women. CONCLUSIONS By carrying out repeat pQCT scans at four-monthly intervals, this study provides a uniquely detailed description of the cortical bone changes that occur alongside trabecular bone changes in the first year of complete SCI. Significant decreases in BMD were recorded in both the cortical and trabecular bone compartments of the tibia and femur throughout the first year of injury. This study provides evidence for the need for targeted early intervention to preserve bone mass within this patient group.

Spinal Injuries in Scottish Mountaineers

Abstract Objective.—To identify the frequency and pattern of spinal injury sustained in mountaineering accidents. Methods.—All patients with spinal injuries sustained while mountaineering who were treated at the Queen Elizabeth National Spinal Injuries Unit from 1992 to 2001 were studied. Information was obtained from hospital notes, and each patient completed a questionnaire. Results.—Twenty-one patients with spinal injuries sustained in mountaineering accidents were identified. Fourteen patients (67.7%) were experienced mountaineers. Four (19.0%) were rock climbing, 6 (28.6%) were winter climbing, 6 (28.6%) were hill walking, and 5 (23.8%) were winter walking. Ten patients (47.6%) sustained cervical injuries, 5 (23.8%) sustained thoracic injuries, 5 (23.8%) sustained lumbar injuries, and 1 (4.8%) sustained cervical and lumbar injuries. Nineteen patients (90.5%) sustained fractures, 1 (4.8%) sustained a dislocation, and 1 (4.8%) sustained a fracture dislocation. Seventeen patients (81.0%) were neurologically intact, 2 (9.5%) sustained complete cord injury, and 2 (9.5%) sustained incomplete cauda equina lesions. Ten patients (47.6%) required internal fixation of their fractures. Fourteen patients (57.1%) sustained other significant injuries. Conclusions.—This is the first study specifically aimed to describe patterns of spinal injuries and their outcomes in mountaineers. The group we studied had sustained fractures at differing spinal levels with no specific injury pattern. The incidence of cord injury was lower than in other spinal injury patient groups. The majority had also sustained other significant and potentially distracting injuries. Prehospital care providers should maintain a high suspicion of spinal injury in this group.

Abdominal stimulation for respiratory support in tetraplegia: a tutorial review

Neuromuscular stimulation of the abdominal wall muscles can provide respiratory support in tetraplegia, where the main expiratory muscles are affected by paralysis. Stimulation may be applied by simple surface stimulation, resulting in a uniform muscle contraction which can help to improve expiratory function for coughing and breathing. In this review, an overview of methods and approaches available for abdominal muscle stimulation is given. Studies are discussed which show that this technique can lead to improvements in expiratory flow and tidal volume, resulting in enhanced cough and breathing functions. Approaches are introduced which aim to integrate abdominal stimulation with the subjects own voluntary breathing functions. These are illustrated with experimental results from the evalu- ation of automatic stimulation methods in tetraplegic patients. Clinical significance and applications are discussed and future developments are outlined. Index Terms—Electrical stimulation, Pulmonary function, Tetraplegia, Abdominal muscle function

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 patients 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.

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 (Potts 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 UK1. 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 Potts 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.

Changes in pulmonary function measures following a passive abdominal functional electrical stimulation training program.

Abstract Objective To demonstrate the effect of a passive abdominal functional electrical stimulation (AFES) training program on unassisted respiratory measures in tetraplegia. Design Longitudinal feasibility study. Setting National spinal injuries unit in a university teaching hospital. Participants Twelve patients with tetraplegic spinal cord injury, who could breathe independently, with reduced vital capacity and no visible abdominal movement. Intervention Three weeks of abdominal muscle conditioning using transcutaneous AFES. Main outcome measures Forced vital capacity (FVC), forced exhaled volume in 1 second (FEV1), peak expiratory flow rate (PEF), and maximum exhaled pressure (MEP). Results Mean (SD) FVC increased by 0.36 l (0.23) during training (P = 0.0027). Mean (SD) FEV1 and PEF tended to increase by 0.18 l (0.16) and 0.39 l/seconds (0.35), respectively, but this was not significant. No significant change was found in the outcome measures during a 1-week pre-training control phase and during a 3-week post-training phase. Conclusions The increase in FVC over the training period and the absence of change before or after training suggest that passive abdominal FES training can be used for respiratory rehabilitation in tetraplegia.

Predicting patient-specific rates of bone loss at fracture-prone sites after spinal cord injury

Purpose: People with spinal cord injury (SCI) experience bone loss and have an elevated rate of fracture in the paralysed limbs. The literature suggests an exponential time course of bone loss after SCI, but true rates may vary between patients. We propose systematic evaluation of bone status in the early stages of SCI to identify fast bone losers. Method: A case series of six patients with complete SCI were scanned using peripheral quantitative computed tomography within 5 weeks and at 4, 8 and 12 months post-injury. Bone mineral density (BMD) and bone mineral content (BMC) were measured at fracture-prone sites in the tibia and femur. Patient-specific-predictions (PSP) of expected rates of bone loss were produced by individualising published model equations according to each patient’s measured values at baseline. Wilcoxon Signed-Rank tests were used to identify changes between time-points; chi-squared tests for differences between measured and PSP values. Results: In the lower limbs, mean values decreased significantly between baseline and 8 months post-injury, by 19–31% for trabecular BMD, 21–32% for total BMD, and 9–29% for BMC. Most subjects showed no significant differences between PSP and measured values, but individuals with significantly faster rates of bone loss than predicted should be investigated further. Conclusions: There was considerable intersubject variability in rates of bone loss after SCI. Patients showing the fastest bone loss could benefit from continued follow-up and possibly treatment. Implications for Rehabilitation Spinal cord injury (SCI) leads to extensive muscle paralysis, and is often accompanied by significant bone loss and increased fracture risk. Repeat bone scans within months of injury can be used to “red-flag” patients who are losing bone faster than predicted. A patient-specific approach to osteoporosis management will facilitate targeted treatment aimed at those who need it most, in SCI and other patient groups.