Alberto Martinez-Arizala

Pain Symptom Profiles in Persons with Spinal Cord Injury

OBJECTIVE Persistent pain is a common consequence of spinal cord injury. A patient-specific assessment that combines both the identification of pain symptoms and psychosocial factors is needed for a tailored treatment approach. The aim of the study was to define pain symptom profiles and to determine their relationship with psychosocial factors in persons with spinal cord injury. DESIGN Face-to-face interview and examination. SETTING VA Medical Center and Miami Project to Cure Paralysis, Miami, Florida. PATIENTS Persons with spinal cord injury (135 men and 21 women) provided detailed descriptions of 330 neuropathic pains. OUTCOME MEASURES The American Spinal Injury Impairment Scale, pain history and measures of pain interference, life satisfaction, locus of control, social support and depression. RESULTS The exploratory factor analyses and regression analyses revealed three distinct symptom profiles: 1) aching, throbbing pain, aggravated by cold weather and constipation predicted by a combination of chance locus of control and lower levels of life satisfaction; 2) stabbing, penetrating, and constant pain of high intensity predicted by a combination of pain interference, localized pain, powerful others locus of control and depressed mood; and 3) burning, electric, and stinging pain aggravated by touch and muscle spasms predicted by pain interference. CONCLUSIONS Although these results need to be replicated in other spinal cord injury samples, our findings suggest that pain symptom profiles may be a useful way to further characterize pain in a comprehensive assessment strategy.

Hypothermia in Patients With Chronic Spinal Cord Injury

Abstract Design: Retrospective analysis of medical records. Background/Objectives: To determine frequency and degree of hypothermic episodes in patients with chronic spinal cord injury (SCI). Setting: Veterans Administration Medical Center. Methods: Research involved analysis of body temperature records of 50 chronic patients with tetraplegia. All patients were men with a length of injury of 19 ± 6 years. Mean age was 53 ± 15 (SD) years. Data were derived from the computerized patient record database system of the Veterans Administration Medical Center. Results were classified into 3 groups: (a) hypothermia (<95°F), (b) subnormal temperature (<97.7°F), and normal temperatures (97.7°F to 98.4°F). Body temperature was recorded during hospitalization (minimum duration of 30 days) using an oral probe twice a day. Ambient temperature was controlled by a central air-conditioning system and maintained at 72°F to 74°F. Results: A total of 867 measurements of body temperature were evaluated; normal temperature was recorded 298 times (35%), subnormal temperature was recorded 544 times (63%), and hypothermia was recorded 25 times (3%). There were 15 patients with 30 hypothermic episodes; subnormal temperature was found in all 50 patients from 1 to 47 times. Regression analysis of age and duration of SCI showed a nonsignificant relationship with body temperature. Conclusions: Our data suggest that patients with tetraplegia after SCI have significant dysfunction of thermoregulation associated with frequent episodes of subnormal body temperature in a normal ambient environment. Further studies are needed to evaluate possible consequences of low temperatures on the general health of patients and to develop preventive interventions.

Decreased Spinothalamic and Dorsal Column Medial Lemniscus-Mediated Function Is Associated with Neuropathic Pain after Spinal Cord Injury

Neuropathic pain (NP) after spinal cord injury (SCI) can significantly and negatively affect quality of life and is often refractory to currently available treatments. In order to find more effective therapeutic avenues, it would be helpful to identify the primary underlying pathophysiological mechanisms in each individual. The aim of the present study was to assess the relationship between the presence and severity of NP after SCI and measures of somatosensory function mediated via the dorsal column medial lemniscal (DCML) pathway and the spinothalamic tract (STT). Vibratory, mechanical, thermal, and pain thresholds measured in areas at and below the neurological level of injury (LOI) in persons with SCI and NP (SCI-NP, n=47) and in persons with SCI without NP (SCI-noNP, n=18) were normalized to data obtained from able-bodied pain-free control subjects (A-B, n=30). STT-mediated function at and below the LOI was significantly impaired in both SCI groups compared with A-B controls (p<0.001), but not significantly different between the two SCI groups (NP vs. no-NP). In contrast, the SCI-NP group had significantly greater impairment of DCML-mediated function at the LOI, as reflected by greater vibratory detection deficits (z=-3.89±0.5), compared with the SCI-noNP group (z=-1.95±0.7, p=0.034). Within the SCI-NP group, NP severity was significantly associated with increased thermal sensitivity below the LOI (r=0.50, p=0.038). Our results suggest that both impaired STT and DCML-mediated function are necessary for the development of NP after SCI. However, within the SCI-NP group, greater NP severity was associated with greater sensitivity to thermal stimuli below the LOI. This finding concurs with other studies suggesting that STT damage with some sparing is associated with NP.

Deep Brain Stimulation Improves the Symptoms and Sensory Signs of Persistent Central Neuropathic Pain from Spinal Cord Injury: A Case Report

Central neuropathic pain (CNP) is a significant problem after spinal cord injury (SCI). Pharmacological and non-pharmacological approaches may reduce the severity, but relief is rarely substantial. While deep brain stimulation (DBS) has been used to treat various chronic pain types, the technique has rarely been used to attenuate CNP after SCI. Here we present the case of a 54-year-old female with incomplete paraplegia who had severe CNP in the lower limbs and buttock areas since her injury 30 years prior. She was treated with bilateral DBS of the midbrain periaqueductal gray (PAG). The effects of this stimulation on CNP characteristics, severity and pain-related sensory function were evaluated using the International SCI Pain Basic Data Set (ISCIPBDS), Neuropathic Pain Symptom Inventory (NPSI), Multidimensional Pain Inventory and Quantitative Sensory Testing before and periodically after initiation of DBS. After starting DBS treatment, weekly CNP severity ratings rapidly decreased from severe to minimal, paralleled by a substantial reduction in size of the painful area, reduced pain impact and reversal of pain-related neurological abnormalities, i.e., dynamic-mechanical and cold allodynia. She discontinued pain medication on study week 24. The improvement has been consistent. The present study expands on previous findings by providing in-depth assessments of symptoms and signs associated with CNP. The results of this study suggest that activation of endogenous pain inhibitory systems linked to the PAG can eliminate CNP in some people with SCI. More research is needed to better-select appropriate candidates for this type of therapy. We discuss the implications of these findings for understanding the brainstem’s control of chronic pain and for future progress in using analgesic DBS in the central gray.

Dorsal Column Dysfunction Following Revision of Spinal Cord Stimulator

conduction studies. Imaging modalities such as MRI are infrequently utilized, but can assist in the diagnosis when cauda equina enhancement is present. Conclusions: The diagnosis of TM was unmasked as GBS in this patient after the changes in physical exam during rehabilitation triggered the need for further work-up. This case highlights the importance of an initial EMG, repeat MRI and lumbar puncture in the presence of progressive neurological deficits.

Poster 509 Some Characteristics of Bone Fractures after Spinal Cord Injury

restrictive lung disease was being treated for pneumonia on an inpatient spinal cord injury unit when he sustained a cardiac arrest requiring intubation, aggressive fluid resuscitation, and an intensive care unit (ICU) stay of several days. While in the ICU, the patient developed a 6 x 6.5 cm unstageable deep tissue injury to his left ischial area. Initial attempts to promote wound healing included diuresis, offloading, moisture management, nutritional support, ultrasonic mist therapy, chemical debridement, and, subsequently, three bedside surgical debridements. Despite these interventions, significant necrotic tissue persisted in the wound bed. Further surgical procedures were not possible due to the patient’s poor medical condition, and the decision was made to pursue biological debridement. The patient underwent three cycles of maggot therapy each lasting 2-3 days utilizing 250-500 Lucilia sericata larvae covered with a custom dressing. Setting: Inpatient spinal cord injury unit. Results or Clinical Course: Following biodebridment, the wound base consisted of healthy granulation tissue. The patient was discharged home with subsequent successful wound healing. Discussion: Decubitus ulcers are a major source of morbidity and mortality in patients with spinal cord injuries (SCIs). Annual incidence in this group has been estimated to range from 20% to 31%, resulting in yearly health care costs in the United States exceeding one billion dollars. There is extensive literature on the successful use of biodebridement in wound care; however, few reports focus specifically on the SCI population. When placed in the wound bed, Lucilia sericata larvae selectively dissolve necrotic tissue and secrete antibacterial substances that assist in wound disinfection. Maggot therapy is inexpensive, relatively simple to implement, and may be superior to surgical alternatives in patients with significant medical comorbidities and/or a high risk of autonomic dysreflexia. Conclusions: Decubitus ulcers are a common and potentially life-threatening problem in patients with spinal cord injuries, and healthcare providers should be aware of biodebridement with medical maggots as a safe and effective means of non-surgical management.