Douglas J Brown

A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention

Study design:Literature review.Objectives:To map traumatic spinal cord injury (TSCI) globally and provide a framework for an ongoing repository of data for prevention.Setting:An initiative of the ISCoS Prevention Committee.Methods:The results obtained from the search of Medline/Embase using search phrases: TSCI incidence, aetiology, prevalence and survival were analysed. Stratification of data into green/yellow/red quality ‘zones’ allowed comparison between data.Results:Reported global prevalence of TSCI is insufficient (236–1009 per million). Incidence data was comparable only for regions in North America (39 per million), Western Europe (15 per million) and Australia (16 per million). The major cause of TSCI in these regions involves four-wheeled motor vehicles, in contrast to South-east Asia where two-wheeled (and non-standard) road transport predominates. Southern Asia and Oceania have falls from rooftops and trees as the primary cause. High-fall rates are also seen in developed regions with aged populations (Japan/Western Europe). Violence/self-harm (mainly firearm-related) was higher in North America (15%) than either Western Europe (6%) or Australia (2%). Sub-Saharan Africa has the highest reported violence-related TSCI in the world (38%). Rates are also high in north Africa/Middle East (24%) and Latin America (22%). Developed countries have significantly improved TSCI survival compared with developing countries, particularly for tetraplegia. Developing countries have the highest 1-year mortality rates and in some countries in sub-Saharan Africa the occurrence of a spinal injury is likely to be a fatal condition within a year.Conclusion:Missing prevalence and insufficient incidence data is a recurrent feature of this review. The piecemeal approach to epidemiological reporting of TSCI, particularly failing to include sound regional denominators has exhausted its utility. Minimum data collection standards are required.

A survey of pain during rehabilitation after acute spinal cord injury

There has been little research on pain in the acute phase of spinal cord injury (SCI) rehabilitation. This study surveyed the pain experience and management strategies in such patients. The subjects consisted of inpatients who were undergoing rehabilitation following their acute injury, and were assessed regarding the presence and type of any pain upon admission to the rehabilitation ward, and reviewed weekly during their stay. They were reassessed on reporting any new pain. Pain intensity was recorded on a Visual Analogue Scale. The maximum intensity of pain during admission was compared to that at discharge. All interventions directed at pain management were documented. Patients were reviewed one year after discharge regarding current pain experience. Almost all of the patients (n=23; 96%) experienced pain at some stage during their inpatient rehabilitation. Overall pain intensity for those patients with pain during inpatient admission decreased by the time of discharge. At the one year review however, pain intensity tended towards that seen on admission. The reasons for pain tending to increase after discharge were not apparent. Neuropathic and Myofascial Pain Syndrome (MPS) were the most common types of pain experienced. A combination of pharmacological, interventional, physical and psychological approaches were used in pain management. At one year review, neuropathic pain remained common while MPS and orthopaedic pain had decreased. Pain is a common and significant problem for many SCI patients and is a challenge for the treating team to manage.

Gabapentin for neuropathic pain following spinal cord injury

Study design: Retrospective review of patient data.Objective: To present two years of experience in the use of gabapentin for the alleviation of neuropathic pain in spinal cord injury patients.Setting: Supra-regional Spinal Cord Service, Melbourne, Australia.Method: Data were retrieved from the medical records of all spinal cord injury patients prescribed gabapentin for neuropathic pain. Pain was assessed prior to and during treatment at 1, 3 and 6 months with a 10 cm visual analogue scale which ranged from 0 (‘no pain’) to 10 (‘worst pain imaginable’), or by the documentation of a verbal description of pain.Results: Seventy-six per cent of patients receiving gabapentin reported a reduction in neuropathic pain. In those patients with data at all four measurement points, the mean pretreatment score was 8.86. Following treatment with gabapentin the score dropped to 5.23, 4.59 and 4.13 at 1, 3 and 6 months, respectively. Where only a verbal description of pain was documented, the trend was that the pretreatment report of ‘unbearable’ was replaced by ‘liveable’ during treatment.Conclusion: Our experience suggests that gabapentin offers an effective therapeutic alternative for the alleviation of neuropathic pain following spinal cord injury. Controlled clinical trials are now required to confirm these observations.

Collection of semen from men in acute phase of spinal cord injury.

In chronic spinal cord injury, semen obtained by assisted ejaculation is usually abnormal. We have assessed electroejaculation early after injury in seven patients. There were no adverse effects. Initial samples contained few or no spermatozoa but as patients emerged from spinal shock, semen improved and five had specimens cryopreserved. Thereafter sperm motility and viability decreased towards the pattern of chronic spinal cord injury by day 16. Cryopreservation was not possible in one patient with many medical complications and another who started electroejaculation 15 days after injury. Semen storage within the first 2 weeks after spinal cord injury is recommended for future fertility treatment.

Vocational achievements following spinal cord injury in Australia.

This study describes the vocational achievements in a sample (n = 139) of Australian persons with spinal cord injuries. The post-accident and employment achievements (February-March 1993) were represented by significant diversity in outcomes. Around one-third of subjects went on to obtain further qualifications since their injury, and around 31% were employed full-time or part-time. The majority of subjects utilized informal means of returning to work. Around two-thirds of those employed indicated that they were in a preferred occupation and their median length of employment was 108 months. The hours of work varied greatly but were centred around a median of 38 hours (i.e. a full-time job). A model of diverse employment outcomes and achievement following spinal cord injury is proposed.

Pressor dose responses and baroreflex sensitivity in quadriplegic spinal cord injury patients.

Objective: To assess the relative contribution of impaired baroreceptor reflexes and enhanced cardiovascular reactivity to the exaggerated blood pressure rises which occur in quadriplegic spinal cord injury patients with automatic hyperreflexia. Design: Pressor dose responsiveness was evaluated by determining the steady-state dose of phenylephrine, α-methylnoradrenaline and angiotensin II required to achieve a blood pressure rise of 20mmHg and the steady-state dose of isoprenaline required to increase heart rate by 20 beats/min in eight quadriplegic spinal cord injury patients and eight control subjects. Results: The dose of phenylephrine α -methylnoradrenaline and angiotensin II to achieve a rise in blood pressure of 20mmHg was significantly reduced in the spinal cord injury group, whilst the dose of isoprenaline required to raise heart rate by 20 beats/min did not differ significantly from the control group. Baroreceptor sensitivity, assessed by straight line regression of change in heart period with change in blood pressure during steady-state infusions of phenylephrine, did not differ statistically between the two groups, but the results could not exclude some evidence of impairment in the spinal cord injury patients. Baroreceptor sensitivity was much less variable in spinal cord injury patients than in controls. Conclusions: These findings suggest that quadriplegic patients with spinal cord injury have exaggerated pressor responses with significantly less variability in baroreflex sensitivity. The former probably contributes to the autonomic hyperreflexia seen in these patients. The latter provides some support to the suggestion that centrally mediated psychogenic responses contribute to the variability in baroreceptor sensitivity seen in normal subjects.

Labour force participation and employment among a sample of Australian patients with a spinal cord injury

This study examined the employment achievements of 219 spinal cord injured people and attempted to identify predictors which, individually and in combination, (a) discriminated between those who were in the labour force or not, and (b) correlated with the amount of time in employment post injury. Results indicated that at the time of the survey 26% were in full-time work, 11% were in part-time work, 4% were unemployed and 59% were not actively seeking work. Multivariate analyses identified three variables (impairment type, study since injury, level of pre-injury secondary schooling) which were related to both labour force participation and the amount of work undertaken post-injury. These results are discussed with reference to post-injury services that could be offered to spinal cord injured people who wish to return to work or gain employment.

A study of the alpha-1 adrenoceptor blocker prazosin in the prophylactic management of autonomic dysreflexia in high spinal cord injury patients

The ability of the alpha-1 adrenoceptor antagonist, prazosin, to reduce the severity and duration of episodes of autonomic dysreflexia was studied in cervical and high thoracic spinal cord injury patients with documented episodes of autonomic dysreflexia. Sixteen patients participated in a double blind parallel group study comparing prazosin 3 mg b.d. with placebo given for 2 weeks. Both groups were matched for age, sex and baseline severity of autonomic dysreflexia episodes. Prazosin was well tolerated and did not produce a significant lowering of resting blood pressure. Compared to baseline measurements, patients allocated to prazosin therapy were found to have fewer severe episodes of autonomic dysreflexia and during these episodes to have significant reductions in average rise in systolic and diastolic blood pressure, symptom duration and requirement for acute antihypertensive medication. The severity of headache during individual autonomic dysreflexia episodes was also diminished with prazosin therapy. No symptom parameter was significantly altered by placebo therapy. It is concluded that prazosin is superior to placebo in the prophylactic management of autonomic dysreflexia and that these findings are consistent with suggestions that alpha-1 adrenoceptors play an important role in the pathogenesis of this syndrome.

Depression following acute spinal cord injury

Nine patients meeting the DSM-111 criteria for major depressive episode were identified among 84 consecutive admissions to the Spinal Injuries Unit of the Austin Hospital. All were successfully treated with antidepressants. The means of recognition of depression, the differentiation of a depressive illness from grief and the implications for rehabilitation are discussed.

Depression, disease and disability: application to patients with traumatic spinal cord injury

Depressive symptoms are common in medically ill patients. Methodological difficulties of many of the studies demonstrating this do not allow differentiation of depressive symptoms from depressive illness. This paper examines representative samples of studies in the medically ill to highlight these problems. Data from a study of patients with traumatic spinal cord injury are used to demonstrate (1) ways of overcoming some of these difficulties and (2) the means of differentiating depressive symptoms and depressive illness. Difficulties of detection and diagnosis of depression in the medically ill are discussed.