Gary M. Yarkony

A Randomized, Controlled Trial of Methylprednisolone or Naloxone in the Treatment of Acute Spinal-Cord Injury

Abstract Studies in animals indicate that methylprednisolone and naloxone are both potentially beneficial in acute spinal-cord injury, but whether any treatment is clinically effective remains uncertain. We evaluated the efficacy and safety of methylprednisolone and naloxone in a multicenter randomized, double-blind, placebo-controlled trial in patients with acute spinal-cord injury, 95 percent of whom were treated within 14 hours of injury. Methylprednisolone was given to 162 patients as a bolus of 30 mg per kilogram of body weight, followed by infusion at 5.4 mg per kilogram per hour for 23 hours. Naloxone was given to 154 patients as a bolus of 5.4 mg per kilogram, followed by infusion at 4.0 mg per kilogram per hour for 23 hours. Placebos were given to 171 patients by bolus and infusion. Motor and sensory functions were assessed by systematic neurologic examination on admission and six weeks and six months after injury. After six months the patients who were treated with methylprednisolone within eigh...

Prevention of Thromboembolism after Spinal Cord Injury Using Low-Molecular-Weight Heparin

OBJECTIVE To examine the safety and effectiveness of a low-molecular-weight heparin in the prevention of thromboembolism in patients with recent spinal cord injury and complete motor paralysis. DESIGN Randomized evaluation of two heparin regimens in 41 consecutive patients meeting eligibility requirements for anticoagulant prophylaxis. Daily bedside examinations were supplemented by serial venous flow studies; suspicious or positive tests were confirmed by venography. INTERVENTION Standard heparin, 5000 units subcutaneously three times a day; low-molecular-weight heparin 3500 anti-Xa units subcutaneously once daily. MEASUREMENTS AND MAIN RESULTS Five patients in the standard heparin group had thrombotic events, including two patients with fatal pulmonary embolism; two other patients had bleeding severe enough to necessitate withdrawing the heparin. The cumulative event rate was 34.7% (95% CI, 13.7% to 55.2%). None of the patients treated with low-molecular-weight heparin had thrombosis or bleeding (CI, 0% to 14%). The difference between the two groups was significant (P = 0.006, log-rank test). CONCLUSIONS Low-molecular-weight heparin is safe and effective in the prevention of thromboembolism in selected patients with spinal cord injury and complete motor paralysis, and is superior to standard heparin in fixed doses of 5000 units three times a day.

Function-limiting dysesthetic pain syndrome among traumatic spinal cord injury patients: a cross-sectional study

&NA; Diffuse burning dysesthetic sensations distal to the level of spinal injury are the most common and disabling painful sequelae of traumatic spinal cord injury (SCI). In a cross‐sectional study of 19 SCI patients, clinical characteristics and results of 3 validated pain measurement instruments (McGill Pain Questionnaire, Stembach Pain Intensity and Zung Pain and Distress Scale) were used to develop a profile of function‐limiting dysesthetic pain sydrome (DPS). Compared to a cohort of 147 patients admitted to the Midwest Regional Spinal Cord Injury Care System during the time period of the study, subjects were more likely to have paraplegia, incomplete sensory myelopathy, gunshot wounds to the spine and non‐surgical spinal stabilization. Most patients described the pain as ‘cutting,’ &bgr;urning,’ ‘piercing,’ ‘radiating’ and ‘tight.’ The majority of patients located the pain internally and in the lower extremities. Values obtained from 6 McGill Pain Questionnaire subscales, 2 Sternbach Pain Intensity ratings and the Zung Pain and Distress index equalled or exceeded those reported for other pain syndromes. Use of these validated pain measures resulted in a systematic comprehensive assessment of function‐limiting DPS following SCI.

Pressure ulcers: A review

This article reviews the etiology, pathology, description, risk factors, prevention, medical and surgical management, and complications of pressure ulcers. Pressure ulcers, which develop primarily from pressure and shear, are also known as decubitus ulcers, bed sores, and pressure sores. They continue to occur in hospitals, nursing homes, and among disabled persons in the community. Estimates of the prevalence of pressure ulcers in hospitalized patients range from 3% to 14% and up to 25% in nursing homes. Persons with spinal cord injury and the elderly are two groups at high risk. The most common sites of development are the sacrum, ischium, trochanters, and about the ankles and heels. Areas of ongoing research such as electrical stimulation and growth factors are discussed.

Trazodone hydrochloride in the treatment of dysesthetic pain in traumatic myelopathy: a randomized, double-blind, placebo-controlled study

&NA; Dysesthetic pain following traumatic myelopathy is characterized by diffuse burning and tingling sensations distal to the level of spinal injury. The dysesthetic pain syndrome (DPS) can compromise performance of functional abilities and inhibit participation in rehabilitation programs. Recent laboratory evidence suggests that antidepressant medications with selective inhibition of serotonin reuptake in the brain may be associated with superior analgesic effect compared to such non‐selective agents as amitriptyline. Trazodone hydrochloride is a potent presynaptic serotonin reuptake blocker with few anticholinergic and cardiovascular side effects. This study was a randomized, double‐blind, placebocontrolled trial of trazodone hydrochloride for the treatment of DPS. Following a 2‐week placebo lead‐in period, patients were randomized to a 6‐week course of 150 mg trazodone hydrochloride/day or placebo. Evaluations of pain quality and intensity were performed at 2‐week intervals, utilizing the McGill Pain Questionnaire, Sternbach Pain Intensity Scale, and Zung Pain and Distress Index. Neurologic examination and assessment of side effects were performed at each evaluation session. No significant changes were noted in reported pain measures between patients allocated to the active drug group and those given placebo during the course of the protocol. However, significantly more patients randomized to trazodone complained of side effects and prematurely terminated their participation in the study. The results of this investigation are consistent with those of other earlier trials which indicate that such antidepressant medications as trazodone hydrochloride which selectively inhibit presynaptic reuptake of serotonin, may not be effective in the control of certain pain syndromes. These results do not preclude the possible utility of these agents in the treatment of other pain syndromes or at higher doses than previously studied.

Cough in spinal cord injured patients: comparison of three methods to produce cough.

Pulmonary complications are the major causes of morbidity and mortality for persons with cervical spinal cord injury. Diminished ability to cough constitutes a major contribution to the high incidence of pulmonary morbidity in this population. This article reports preliminary results for a new technique for providing assisted cough in this population. In this study, efficacy of cough (as measured by peak expiratory flow rate) was measured under three conditions: volitionally with no assistance, with manual assist of a therapist, and with electrical stimulation of abdominal muscles. Coughs produced by electrical stimulation were approximately as effective as manually assisted coughs. The results suggest this technique is worthy of more detailed study and may be a potentially effective new modality for assisting spinal cord injured persons to clear their airways.

SPINAL CORD INJURY REHABILITATION OUTCOME: THE IMPACT OF AGE

The effect of age on self-care and mobility skill performance after spinal cord injury was studied using a 15-task modified Barthel Index (MBI) to score functional abilities for 708 patients aged 6 through 88 years. Analysis of covariance showed no relationship between age and discharge MBI score; however, patients with paraplegia, incomplete lesions, and greater admission functional ratings had greater discharge functional scores than did those with quadriplegia, complete lesions, and lower admission scores, respectively. Advancing age was associated with increased dependence in only seven functional skills (bathing, upper and lower body dressing, stair climbing, and transfers to chair, toilet and bath) and only for patients with complete paraplegia. Other MBI component tasks and patients with complete quadriplegia, incomplete paraplegia and incomplete quadriplegia demonstrated no relationship between age and skill performance. Results of this study support the practice of providing comprehensive rehabilitation services to all patients following spinal cord injury regardless of age.

A controlled study of neuropsychological deficits in acute spinal cord injury patients.

According to a number of studies, between 40% and 60% of acute traumatic spinal cord injury (SCI) patients demonstrate cognitive dysfunction resulting from various forms of cerebral damage, including concurrent or premorbid closed head injury, chronic alcohol or substance abuse, and other causes. However, applicability of findings from these reports has been limited due to the use of inadequate neuropsychological testing techniques and the lack of control data. In a collaborative investigation, 81 acute SCI patients and 61 non-injured control subjects between 18 and 55 years of age completed a comprehensive motor-free neuropsychological test battery, including: Halstead Category Test (HCT), Vocabulary Subtest (VOCAB) of the Wechsler Adult Intelligence Scale - Revised; Mental Control (MC) Subtest, and Initial and Recall trials of Logical Memory (LM) and Paired Associates (PA) Subtests of the Wechsler Memory Scale; and the 8 trials of the Rey Auditory Verbal Learning Test (RAVLT). Percentages of retained information on the LM and PA were also calculated. Impairment levels for each test were defined as values which exceeded two standard deviations (one-tailed) from the control mean. Based on this definition, the prevalence of neuropsychological abnormality on each test ranged between 10% and 40%. Mean performance levels of patients were significantly more impaired than those of control subjects for all tests except for the Interference trial of the RAVLT and for the percentages of retained information on the LM and PA subtests. Comparison of test results of SCI patients with those of control subjects demonstrates that poor attention span and limited initial learning ability are frequent problems among SCI patients. Other common neuropsychological deficits among these patients include poor concentration ability, impaired memory function, and altered problem solving ability. These deficits may interfere with rehabilitation following SCI.

The older adult with a spinal cord injury

Sixty-two consecutive acute spinal cord injury (SCI) patients who were aged 55 years or older were studied and compared to 296 SCI patients of age less than 55 years. Compared to younger patients, the older group had significantly more females (29%), preexisting medical conditions (87%), associated injuries (55%), incomplete quadriplegic patients (63%), and persons whose injuries resulted from falls (53%). There were no differences between groups in frequency of ventilator use, occurrence of medical complications, or acute length of stay, but older patients tended to have fewer surgical spinal fusions (40%), shorter rehabilitation stays (66.5 days), more indwelling urethral cathteters (31%), and more nursing home discharges (19%). With other factors being controlled, advancing age was predictive only of nursing home discharge, and not of acute or rehabilitation lengths of stay. Among older SCI patients, those with complete injuries were nearly 3 times as likely to have been discharged to nursing homes in our series compared to older patients with incomplete lesions. Although many aspects of the presentation, course, and care of older SCI individuals are similar to those of younger patients, there are several unique features of older adults with a SCI.

Rehabilitation outcomes in complete C5 quadriplegia

Establishment of rehabilitation goals for spinal cord injury patients generally has been based on the degree of residual motor function. Despite extensive clinical experience with spinal cord injury rehabilitation, there have been no reports of the ability of C5 quadriplegic patients to perform self-care and mobility skills before and after rehabilitation. This study was designed to examine the rehabilitation outcomes of 63 patients with C5 complete quadriplegia, who completed an interdisciplinary inpatient rehabilitation program, using the 100-point modified Barthel Index as a means of rating functional status. There were statistically significant increases in the mean modified Barthel index scores from 7.1 on admission to 28.9 on discharge for the entire group of patients. The self-care subscore increased significantly from 6.5 on admission to 20.0 on discharge and the mobility subscore increased significantly from 0.5 on admission to 8.9 on discharge. Ability to perform self-care and mobility subscore tasks is described. This study documented significant improvements in function during comprehensive rehabilitation among patients with C5 spinal cord injury