Joseph J. Biundo

Risk factors for early occurring pressure ulcers following spinal cord injury.

We carried out a prospective study to determine the association between immobilization in the immediate postinjury period and the development of pressure ulcers in spinal cord-injured patients following their admission to Charity Hospital, New Orleans. Of 39 patients consecutively admitted to the hospital, 23 (59%) developed a grade one ulcer within 30 days, mostly in the sacral region (57%), the peak time of onset being day 4 postinjury (6/23 cases). In partial support of an earlier retrospective study (Linares HA, Mawson AR, Suarez E, Biundo JJ Jr: Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987;10:571-573), duration of unrelieved pressure prior to ward admission was significantly associated with ulcers developing within the first eight days of injury (P=0.04), but not with ulcers developing during the entire 30-day observation period (P=0.09). Time on the spinal board was also significantly associated with ulcers developing within 8 days (P=0.01), but not with ulcers developing within 30 days (P=0.09). An unexpected finding was the significant inverse association between systolic blood pressure and the development of ulcers both within 8 days (P=0.03) and within 30 days (P=0.02), suggesting that reduced tissue perfusion increases the spinal cord-injured patients susceptibility to pressure ulcers.

Association between pressure sores and immobilization in the immediate post-injury period

Pressure sores are a frequent complication of spinal cord injury (SCI) and are assumed to result from insufficient rotation following admission to the acute care unit. The likelihood of pressure sores occurring before admission to the nursing unit is not usually recognized. This study attempts to determine whether pressure sores are associated with prolonged immobilization in the early post-injury period, before admission to the acute care ward, and to identify other etiological factors relating to evacuation, transportation, and emergency room treatment. Thirty-two SCI patients were studied, 16 of whom developed sores in the hospital, and 16 who did not. Excluding five patients who failed to recall their immediate post-injury care, none of the remaining 14 patients with sores recalled being turned within two hours of injury; all 13 patients without sores said that they were rotated within two hours. Almost all patients said they were first turned on the hospital ward by a nurse. Whereas most of those without sores took less than two hours to reach the ward, most of those who later developed sores took three hours or longer.

Sacral transcutaneous oxygen tension levels in the spinal cord injured: risk factors for pressure ulcers?

Evidence is mounting that susceptibility to pressure ulcers in the spinal cord injured is due to the interactive effects of prolonged immobilization and injury-related autonomic dysfunction associated with reduced tissue perfusion. To determine whether tissue oxygenation at the sacrum is reduced in spinal cord injury, we compared transcutaneous oxygen tension (PtcO2) levels in 21 subjects with spinal cord injury and 11 able-bodied controls lying prone and supine on egg-crate mattresses. Spinal cord injured subjects above and below the median supine PtcO2 value were also compared in terms of the presence or absence of pressure ulcers. The PtcO2 level of the spinal cord injured (mean +/- SD) was lower than that of the controls in the prone position (65.3 +/- 16mmHg vs 76.4 +/- 13mmHg; F = 3.9, df = 1, p = .053), and markedly lower in the supine position (49.1 +/- 26mmHg versus 74.2 +/- 10mmHg; F = 9.7, df = 1, p = .004). Examination of mean PtcO2 levels over time showed that those of the controls fell slightly following supination but returned to the previous level within 15 minutes. In contrast, those of the spinal cord injured fell rapidly by 18mmHg and stabilized after 15 minutes at a level 27mmHg below that of the controls. Five of the 10 (50%) spinal cord injured subjects with PtcO2 levels below the median supine PtcO2 level had a pressure ulcer compared to one among the 11 (9%) spinal cord injured subjects with PtcO2 levels above the median (p = .055, by Fishers exact test). These results suggest the need for further studies on the role of reduced tissue oxygenation in the etiology of pressure ulcers.

Effect of high voltage pulsed galvanic stimulation on sacral transcutaneous oxygen tension levels in the spinal cord injured

Evidence is mounting that spinal cord injured (SCI) persons may be at increased risk of pressure ulcers due to prolonged immobilization together with the injury-induced loss of sympathetic tone and decreased vascular resistance. With a view to developing a new method of preventing pressure ulcers, the objective of this study was to determine whether high voltage pulsed galvanic stimulation (HVPGS) could increase sacral transcutaneous oxygen tension (PtcO2) in SCI persons lying prone and supine. In experiment 1, HVPGS applied to the back at spinal level T6 led to a sustained, dose-related increase in sacral PtcO2 in 3 subjects lying prone. In experiment 2, carried out on 29 subjects lying supine on egg-crate mattresses, HVPGS (75 volts, 10 Hz) produced a 35% increase in sacral PtcO2, from a baseline level (Mean ± SD) of 49 ± 21 mmHg to 66 ± 18 mmHg after 30 minutes of stimulation (F = 39.4, p < .00001). In experiment 3, simulated HVPGS was found to have no effect on sacral PtcO2 in 5 subjects lying supine. In experiment 4, HVPGS was repeated on 10 subjects and its effects found to be highly reproducible. It is hypothesized that HVPGS restores sympathetic tone and vascular resistance below the level of the spinal cord lesion, thereby increasing the perfusion pressure gradient in the capillary beds. Randomized controlled trials are now indicated to determine the efficacy of HVPGS for preventing pressure ulcers.

Rehabilitation of orthopedic and rheumatologic disorders. 4. Musculoskeletal disorders

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with orthopedic and musculoskeletal disorders. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses new advances in such topics as idiopathic scoliosis, nontraumatic shoulder pain, rotator cuff tendinitis, and Dupuytrens disease.

Costovertebral joint erosion in ankylosing spondylitis.

We describe a patient with ankylosing spondylitis who had severe pain in the thoracic spine area owing to a destructive arthropathy of a costovertebral joint. A computed tomographic scan revealed severe osteolysis of the head of the right eleventh rib, with hypertrophic sclerotic arthropathy of the joint as the source of the patients pain. Costovertebral arthropathy should be considered in ankylosing spondylitis patients with severe thoracic pain.

Paraplegia in a patient with Marfan's syndrome as a result of a thoraco-abdominal aortic aneurysm repair

Marfans syndrome is a hereditary disorder involving a deficit in connective tissue collagen. Physical findings include musculoskeletal, ocular, and cardiovascular abnormalities. A 29-year-old man with a history of Marfans syndrome was admitted to the hospital with back and chest pain secondary to a dissecting aortic aneurysm. He later underwent surgical aortic bypass graft surgery. Postoperatively, he was paraplegic. Our impression was anterior spinal artery syndrome due to prolonged cross-clamping of the aorta during surgical repair. This paper shows the risk of paralysis resulting from surgical repair of an aortic aneurysm as a poorly documented complication of Marfans syndrome.

Detection of anti-DNA antibodies by counterimmunoelectrophoresis

Abstract The technique of counterimmunoelectrophoresis (CIE) has been adapted for the purpose of detecting and quantitating serum anti-DNA precipitating antibody. Ionagar No. 2 and Tris-HCl buffer were employed. Conditions for electrophoresis were 5.4 V per linear cm of agar, 20.0 mA per slide, and a 20 min migration interval. Pyronin staining was used to facilitate the presence of DNA in precipitin bands. Clear-cut, dense DNA anti-DNA precipitin bands were detectable by CIE using selected reference human sera from patients with systemic lupus erythematosus. Precipitin activity was absorbable with DNA and with a goat anti-IgG immunosorbent. Precipitins were also detected in ammonium sulfate-precipitated serum fractions and in IgG-rich fractions obtained by DEAE-cellulose chromatography. CIE would seem to offer advantages of simplicity and rapid reproducibility in screening large numbers of serum samples for anti-DNA precipitating antibody.