M Belci

Resolution of SPAM following cordectomy: implications for understanding pathophysiology

Study design:Case report.Objective:To describe the clinical benefit of a spinal cordectomy with the aim of limiting neurological deterioration related to the development of a subacute posttraumatic ascending myelopathy (SPAM) supporting previously described mechanism for SPAM formation.Setting:National Spinal Injuries Centre, Stoke Mandeville Hospital, UK.Method and results:A 38-year old patient presented 6 months after spinal cord injury substantial neurological deterioration expanding from the initial T4-injury level through C4. Magnetic resonance imaging revealed intra-medullary haemorrhage at the site of injury and subsequent-ascending cord oedema. A cordectomy was performed leading to neurological stabilisation and complete resolution of SPAM.Conclusion:Cordectomy can be an effective intervention in case of rapid progressive neurological deterioration.

MRI in acute and subacute post-traumatic spinal cord injury: pictorial review

Study design:Pictorial review.Objectives:To illustrate MRI signs of acute and subacute injury with emphasis on evidence-based links to clinical outcome and implications for treatment.Methods:Description of important aspects of MRI techniques and illustration of critical MRI signs important in the assessment of spinal cord injury following trauma, in the acute and subacute stages.Conclusions:Familiarity with cord MRI appearances has an important impact on planning the management of the acutely spinal cord injured patient and also identifying complications in the subacute phase particularly in the presence of neurological deterioration.

Incidence of pulmonary embolism after the first 3 months of spinal cord injury

Background:Pulmonary embolism (PE) is a significant cause of morbidity and mortality in patients with spinal cord injury (SCI). Prophylactic anticoagulation is associated with a reduction in mortality rates, but there is limited evidence regarding the incidence rate of PE following cessation of anticoagulation after the first 3 months of injury.Study design:Single-centre retrospective study.Objective:To estimate the incidence rate of PE after 90 days of SCI.Setting:The National Spinal Injuries Centre at Stoke Mandeville Hospital, Aylesbury, UK.Methods:The study includes 640 new-onset SCI patients. All computer tomography pulmonary angiograms (CTPAs) or ventilation-perfusion lung scans between 2008 and 2013 were identified. Medical notes and scans were reviewed and clinical outcomes and radiological findings were recorded.Results:A total of 91 patients with a new-onset SCI had a CTPA or a perfusion lung scan. PE was detected in a total of 8 patients. The incidence of PE was 1.25%; 95% confidence interval (0.39–2.11) over a 6-year period. The duration of injury at the time of PE was 7 months.Conclusion:The incidence rate of PE post 3 months of SCI remains significant, though much lower than immediately post injury.

Knowledge, attitudes and practices of medical staff towards obesity management in patients with spinal cord injuries: an International survey of four western European countries

Objective:To (1) examine the opinions of medical staff working in spinal cord injury (SCI) centres (SCICs); (2) evaluate their knowledge, attitudes and practices towards obesity prevention and management; (3) report the number of beds and dietitians available at each SCIC.Methods:A 37-item questionnaire was sent to 23 SCICs in the UK, the Netherlands, Belgium and the Republic of Ireland between September 2012 and January 2013.Results:Eighteen SCICs returned the questionnaires for analysis. All respondents stated that they had an interest in obesity treatment but only 2.3% of the respondents received training in obesity management. Sixty-one percent of staff did not consider body mass index (BMI) to be appropriate for use in SCI patients and subsequently less than half of the respondents use BMI routinely. The majority of respondents reported that they are confident in dealing with overweight (74.5%) and obese (66.1%) SCI adults, less than half (44.1%) are confident in treating overweight and obese SCI children. Respondents also indicated the need for nationally adopted guidelines and a lack of physical activity provision. There were 17.5 whole-time equivalent (WTE) dietitians recorded in 22 SCICs, equivalent to 47.8 beds per WTE dietitians (range 10–420). Non-UK SCIC dietitians are significantly better resourced than in UK SCICs (beds per WTE dietitian: 36 vs 124, P=0.035).Conclusion:Medical staff expressed the need to participate in obesity prevention and management. Appropriate training should be considered for all medical staff and the development of specific weight management guidelines and dietetic provision should be considered.

Outcomes of whole-body computed tomography in spinal cord-injured patients with sepsis.

Study design:Retrospective case series.Objectives:To evaluate the efficacy of body computed tomography (CT) in spinal cord injury (SCI) patients with sepsis.Setting:Specialist acute care and rehabilitation SCI centre in United Kingdom.Methods:Patients with SCI and suspected or known sepsis, who had CT of the chest, abdomen and pelvis, over a 4-year period, were identified. Only patients who fulfilled the definition of sepsis or severe sepsis were included. Their medical notes and CT scans were reviewed and clinical outcomes and radiological findings recorded.Results:Twenty-two patients with sepsis were identified including seven categorised as having severe sepsis. A specific radiological diagnosis was found in three patients (14%) and non-specific findings were found in 15 patients (68%).Conclusion:Although in the majority of cases, the findings were non-specific, a small number of patients had significant pathology identified by CT, which influenced their management significantly.

Thromboembolism in the Sub-Acute Phase of Spinal Cord Injury: A Systematic Review of the Literature

To review the evidence of thromboembolism incidence and prophylaxis in the sub-acute phase of spinal cord injury (SCI) 3–6 months post injury. All observational and experimental studies with any length of follow-up and no limitations on language or publication status published up to March 2015 were included. Two review authors independently selected trials for inclusion and extracted data. Outcomes studied were incidence of pulmonary embolism (PE) and deep vein thrombosis (DVT) in the sub-acute phase of SCI. The secondary outcome was type of thromboprophylaxis. Our search identified 4305 references and seven articles that met the inclusion criteria. Five papers reported PE events and three papers reported DVT events in the sub-acute phase of SCI. Studies were heterogeneous in populations, design and outcome reporting, therefore a meta-analysis was not performed. The included studies report a PE incidence of 0.5%–6.0% and DVT incidence of 2.0%–8.0% in the sub-acute phase of SCI. Thromboprophylaxis was poorly reported. Spinal patients continue to have a significant risk of PE and DVT after the acute period of their injury. Clinicians are advised to have a low threshold for suspecting venous thromboembolism in the sub-acute phase of SCI and to continue prophylactic anticoagulation therapy for a longer period of time.

Effects of Transcranial Direct Current Stimulation (tDCS) on Chronic Pain in Spinal Cord Injured Patients

Introduction: Pain following spinal cord injury (SCI) is notoriously difficult to manage and often refractory to treatment. Novel approaches, such as non-invasive brain stimulation, targeting central mechanisms associated with chronic pain, have shown early promise as a safe treatment in various patient groups, including spinal cord injury. To date the number of small clinical trials using non-invasive brain stimulation to treat chronic pain in SCI has produced mixed results. We report here the findings of a UK based trial examining the effects of anodal transcranial direct current stimulation (TdCs) administration on pain in spinal injury patients. Methods: Sixteen spinal injury patients from the National Spinal Injury Centre, Stoke Mandeville Hospital, Aylesbury, UK participated in a single centre, double blind randomized control trial. Patients were randomly allocated to either the active (n=8) or sham (n=8) treatment groups. tDCS was administered by electrodes with anode placement over the dominant M1 and the cathode electrode over the contralateral supraorbit scalp area. Subjects received either active (2 mA anodal current) or sham tDCS for 20 min daily treatment for 5 consecutive days with the dose based on previously reported chronic pain studies in spinal cord injury patients. A mixed ANOVA was used to evaluate both tDCS treatment and time effects on validated assessment measures for pain and depression up to 2 weeks following treatment intervention. Results: No adverse effects of the treatment were observed in this study, nor were there any significant differences between groups in rating perception of stimulation. While treatment appeared to have reduced group pain scores on a visual analogue scale [VAS], there were no statistically significant differences between active and sham treatment groups when re-examined in the 2 week follow up. Conclusion: There were some reductions in self-assessed VAS pain score in our small group of SCI patients during treatment in both the sham and active tDCS and at two weeks’ post treatment. However, our study appears to indicate only a placebo-like effect of tDCS on chronic pain in SCI, and not one attributed to the active, anodal stimulation over motor cortex. We also did not observe any significant effects over time or treatment for an assessment of neuropathic pain. We observed some trends of non-significant reduction in some of selfassessed pain scores measures, however, these are inconclusive. Studies of clinical efficacy of pain treatment by tDCS in spinal cord injury should therefore be conducted on a larger scale, and with a longer follow up period to address the limited evidence available.

Posterior circulation infarction in patients with traumatic cervical spinal cord injury and its relationship to vertebral artery injury

Study design:Prospective study.Objective:To ascertain the prevalence of posterior circulation stroke in traumatic chronic spinal cord injured (SCI) patients and associated traumatic vertebral artery injuries (VAI).Methods:All adult patients with cervical SCI and American Spinal Injury Association Impairment Scale (AIS) grade A or B referred for follow-up magnetic resonance imaging of their spinal cord were invited to take part in the study between January 2010 and December 2012 at the National Spinal Injury Centre. Two additional sequences were added to the existing imaging protocol to evaluate the brain and vertebral arteries.Results:Ninety-eight patients were recruited. All imaging were analysed independently by three consultant radiologists. Posterior circulation infarcts were noted in seven (7%) patients. Significant VAI was noted in 13 patients (13%) with 10 occlusions and 3 with high-grade stenosis. However, only one patient had co-existent posterior circulation infarct and significant VAI.Conclusion:There is an increased prevalence of posterior circulation infarction in SCI patients. The relationship with associated traumatic VAI requires further investigation.

Review: indications for interventional radiology in the management of patients with spinal cord injuries.

OBJECTIVES To outline a range of minimally invasive image-guided procedures that benefit spinal cord-injured patients and may expedite clinical care. STUDY DESIGN Pictorial review. RESULTS/CONCLUSIONS Image-guided procedures have made a significant impact in medical management in many specialties. These techniques continue to evolve rapidly and afford opportunities to reduce patient morbidity and in-patient length of stay.