Frederick Maynard

International standards for neurological and functional classification of spinal cord injury

International Standards for Neurological and Functional Classification of Spinal Cord Injury

Urinary Infection and Complications During Clean Intermittent Catheterization Following Spinal Cord Injury

A total of 50 patients with recent spinal cord injury secondary to trauma participated in a prospective study of urinary complications during an interval of clean intermittent catheterization at initial hospitalization in a spinal cord injury unit. Patients were assigned randomly to groups receiving or not receiving a prophylactic antibacterial preparation. Both groups were divided further into subgroups in which laboratory infections (bacteriuria more than 100,000 organisms per ml.) were treated with definitive antibiotics or in which antibiotic treatment was given only for clinical infections (fever more than 100F or urethral discharge and bacteriuria). Antibacterial prophylaxis significantly reduced the probability of laboratory infection but not the probability of clinical infection, although a trend was noted toward fewer clinical infections. No significant reduction was noted in the probability of clinical infection in subgroups treated promptly for laboratory infection.

A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury

This study was designed to test the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. One hundred and six professionals in the field of spinal cord injury attending an instructional course at the 1994 ASIA Meeting participated in the test. Participants completed a pretest and posttest in which they classified two patients who had a spinal cord injury (one with complete tetraplegia and one with incomplete paraplegia) by sensory and motor levels, zone of partial preservation (ZPP), ASIA Impairment Scale and completeness of injury. Between tests, three members of the ASIA Standards Executive Committee gave presentations on the neurological assessment, scoring, scaling and classification of spinal cord injury and a video of the actual examinations of the two cases was viewed. Percent ‘correct’ (as defined by the ASIA Standards Committee) was calculated for sensory and motor levels, ZPP, ASIA Impairment and completeness. Overall, the analyses showed that participants had very little difficulty in correctly classifying the patient with complete tetraplegia. Pretests scores ranged from 72% (left motor level) to 96% (complete injury), posttest scores from 73% (left motor level) to 100% correct (complete injury). For the patient with incomplete paraplegia (Case 2), scores were considerably lower. Pretest scores ranged from 16% (right motor level) to 95% correct (incomplete injury); posttest scores from 21% (right motor level) to 97% correct (incomplete injury). The results showed that further revisions of the 1992 Standards and more training is needed to ensure accurate classification of spinal cord injury.

Clean Intermittent Catheterization for Spinal Cord Injury Patients

Charts were reviewed retrospectively for 65 patients with traumatic spinal cord injury discharged from the hospital between 1972 and 1977 on clean intermittent catheterization for management of neurogenic bladders. While 54 patients were still using clean intermittent catheterization 9 had discontinued its use and 2 were lost to followup. Complete urologic followup records were available for 28 long-term clean intermittent catheterization users, with an average followup of 3.7 years. Complications seen in this group included nephrolithiasis-3 cases, cystolithiasis--3, epididymitis--4 and urinary tract infection--12. No patient had hydronephrosis or radiographic pyelonephritis. Clean intermittent catheterization appears to be a safe and satisfactory alternative for long-term management of the neurogenic bladder of selected spinal cord injury patients, since the incidence of serious renal complications is low. Factors that should be considered before long-term clean intermittent catheterization is recommended include type of neurogenic bladder, prognosis for recovery, incontinence despite medication, history of urethral trauma, host resistance, physical independence in self-catheterization, compliance and patient preference.

Shoulder pain in acute traumatic quadriplegia

Fifty two patients with traumatic quadriplegia admitted to a spinal cord injury program within 6 months of injury were studied retrospectively. Seventy five per cent had shoulder pain documented in their medical records during initial rehabilitation, and 60% had shoulder pain for 2 weeks or more. When shoulder pain was documented it was bilateral in 61% of the cases. Age greater than 50 years, decreased shoulder range of motion, and not receiving shoulder exercise during the first 2 weeks after injury were positive risk factors associated with the onset of shoulder pain. At discharge 42% of the patients with shoulder pain were pain-free, 35% were noted to have improvement of their pain, and 23% had the same or worse shoulder pain. Study results demonstrate the high incidence of shoulder pain during initial rehabilitation of patients with traumatic quadriplegia and the importance of starting shoulder exercises during early acute care.

Management of the neuropathic bladder by clean intermittent catheterisation: 5 year outcomes

Based on a telephone interview and medical record review of the urological outcomes among 40 spinal cord injury patients with a neuropathic bladder at discharge who were an average of 60 months post-injury and who were all initially managed by chronic clean intermittent catheterisation (CCIC), the following conclusions were made: Over 80% of patients using CCIC at discharge continued to use it, suggesting low morbidity and high patient acceptance; Urological complications in patients using CCIC were more frequent in the lower urinary tract than in the upper urinary tract, were more frequent in men than women, and had a low morbidity; Urological complications and hospitalisations were more frequent among the 41% of patients using CCIC who had frequent SxUTIs; SxUTIs were common in patients using CCIC but rates may be comparable with other methods; Although 44% of CCIC patients were hospitalised at least once in 5 years for urological complications, this is comparable to reported multi-centre outcomes in the U.S.A. (Young, 1982).

Stabilization of Spinal Injury for Early Transfer

We have reviewed the means of transport and type of stabilization used for all patients with acute spinal cord injuries (SCI) transferred to our center since 1985 to determine what effect these variables may have had on change in level of impairment and probability of neurologic improvement after arrival. Sixty-one patients were reviewed, 47 males and 14 females, with a mean age of 34 years. Twenty-five patients (41%) were transported by ground ambulance, 33 (54%) by helicopter, three (5%) by fixed-wing aircraft. Forty-three patients (70.5%) had cervical spine injuries, 11 (18%), thoracic spine injuries, and seven (11.5%), lumbar spine injuries. Fifty-one patients (84%) were transferred within 24 hours of injury. A variety of standard methods of stabilization were used during transport. No patient suffered ascending level of injury as a result of early transfer. Level of function improved before discharge in 26 of 61 patients (43%); patients transported within 24 hours were more likely to show improvement (25/51) than those transported after 24 hours (1/10). There was no significant difference in the probability of improvement between ground (8/25) or air (18/36) transport. Skeletal traction was used before transfer in only four of 43 patients with cervical spine injuries, and was maintained as a method of long-term stabilization in two patients. We conclude that acute SCI patients can be safely transported by air or ground using standard precautions. Distance and extent of associated injury are the best determinants of mode of transport. Skeletal traction does not appear to be a prerequisite for safe, early transfer of SCI patients.

Prevalence and Associated Features of Depression and Psychological Distress in Polio Survivors

This cross-sectional study examines the prevalence of psychological distress and depression among 116 polio survivors. It investigates demographic, medical, and coping differences between subjects with (n = 17) and without (n = 99) these symptoms. Subjects were administered the Brief Symptom Inventory (BSI), the Coping with Disability Inventory (CDI), and a questionnaire about their polio histories. The BSI provided measures of psychological distress and depression that defined the subgroups. The CDI assessed coping behaviors. BSI scores for the overall sample were within the normal range indicating no major distress, depression, nor elevated somatic complaints. Several significant differences were found between the two subgroups. On average, depressed/distressed subjects reported an increase in pain (p < .01) and further deterioration of their medical status since the time of their physical best subsequent to the onset of polio (p < .01). They consistently rated their health as poorer than did nondepressed/nondistressed subjects (p < .001). They also reported less satisfaction with life and their occupational status (p < .001) and displayed poorer coping behaviors combined (p < .001). Selected variables such as life satisfaction, pain, decrease in activity, and current living situation accounted for 51% of the variance when predicting distress and depression among this group of polio survivors.

The reflex sympathetic dystrophy syndrome associated with traumatic myelopathy: report of 5 cases

&NA; Pain is a frequent problem following recent traumatic spinal cord injury (SCI). Of specific concern in the rehabilitation setting is function‐limiting hand pain which prevents optimal participation in therapy and limits independence. A treatable etiology of function‐limiting hand pain in SCI is the reflex sympathetic dystrophy syndrome (RSDS). The presentation of RSDS in patients with recent SCI can be easily confused with that of dysesthetic (central origin) or radicular pain. Previous reports of RSDS associated with recent traumatic SCI have not been based on specific clinical criteria outlined in recent literature, and treatment has not been evaluated by objective outcome measures. This report describes 5 cases of RSDS associated with recent traumatic SCI that are identified by specific clinical criteria and are confirmed by a 3 phase bone scan. It is suggested that aggressive early intervention is necessary to obtain optimal functional outcome and minimize length of hospital‐based rehabilitation.

Early clinical experience with clonidine in spinal spasticity

The centrally active, alpha-2 adrenergic receptor agonist Clonidine was given to 12 spinal cord injury patients with problematic spasticity not adequately controlled by recognized spasmolytic drug therapy. Five patients had an excellent reduction and 2 patients had some reduction in clinical spasticity (average dose 0.39 mg daily). Four of the 7 responders discontinued Clonidine because of adverse reactions after an average of ten weeks of therapy. Three responders have continued to tolerate the drug well with excellent control of spasticity for 18 to 34 months. Five patients had no change in clinical spasticity (average dose of 0.24 mg daily). Three of the non-responders discontinued Clonidine because of adverse reactions after an average of three weeks of therapy. Significant associated adverse reactions included syncopal seizures (3), cerebrovascular accident (1), deep vein thrombosis (1), autonomic hyperreflexia (3), lethargy/drowsiness (3), and nausea/vomiting (1). Possible mechanisms of action for Clonidine to affect spasticity and the unstable cardiovascular system of quadriplegics is discussed. While spinal cord injured patients with severe spasticity may benefit from Clonidine, great caution is recommended during its use until further study establishes safe parameters of administration and efficacy is confirmed on controlled studies.