Rodney H. Adkins

Motor and Sensory Recovery Following Incomplete Paraplegia

Fifty-four individuals admitted for rehabilitation with a diagnosis of incomplete paraplegia due to trauma underwent serial prospective examinations to quantify motor and sensory recovery. Motor and sensory scoring guidelines recommended by the American Spinal Injury Association were used to assess changes. Lower extremity motor scores (LEMS) differed significantly (p < .03) between groups of patients partitioned by category of initial neurologic level of injury (NLI) with the following averages at 1 month after injury: 6.8 +/- 11.3 above T12, 15.0 +/- 8.2 at T12 and 18.3 +/- 11.4 below T12. However, the amount of motor recovery was independent of the NLI with the differences between the NLI groups remaining essentially constant from 1 month to 2 years. While the LEMS increased significantly (p < .001) an average of 11.9 +/- 8.7 points between 1 month and 1 year, the annualized rate of motor recovery rapidly declined in the first 6 months and then subsequently plateaued. All patients having a 1-month LEMS greater than 10 points (28 cases) with hip flexion or knee extension strength > or = 2/5 were able to ambulate in the community with a reciprocal gait pattern using crutches and orthoses at 1-year follow-up.

Carpal tunnel syndrome in paraplegic patients.

Thirty-eight (49 per cent) of seventy-seven paraplegic patients whose level of injury was at or caudad to the second thoracic vertebra were found to have signs and symptoms of carpal tunnel syndrome. The prevalence of carpal tunnel syndrome was found to increase with the length of time after the injury. In the eighteen patients in whom manometric studies were done, the carpal tunnel pressures when the wrist was in the neutral position were higher than those that have been reported in non-paraplegic patients who did not have carpal tunnel syndrome but were lower than the values in non-paraplegic patients who did have the syndrome. When the wrist was in flexion, the pressures were similar to the values that have been reported for non-paraplegic patients. However, in the paraplegic patients, regardless of whether or not they had carpal tunnel syndrome, the pressures that developed when the wrist was in extension were significantly higher than those in non-paraplegic patients, regardless of whether or not they had carpal tunnel syndrome. Most of the activities of daily living of paraplegic patients, including the maneuver to relieve ischial pressure that consists of arising from the seated position using the extended arms, are performed with the wrists locked in maximum extension. The pressure that develops in the carpal canal during this forced extension of the wrist, probably combined with the repetitive trauma to the volar aspect of the extended wrist while propelling a wheelchair, contributes to the high frequency with which carpal tunnel syndrome is found in paraplegic patients.

Pulmonary function in chronic spinal cord injury: A cross-sectional survey of 222 Southern California adult outpatients☆☆☆★★★♢♢♢

OBJECTIVES To evaluate risk factors for respiratory morbidity in chronic spinal cord injury (SCI). SETTING Model SCI care system based at an urban public rehabilitation medical center. DESIGN Case series with evaluation of pulmonary function by conventional spirometric testing. PARTICIPANTS Two hundred twenty-two adults with SCI of more than 1-year duration who were not chronically dependent on mechanical ventilation, including 98 with tetraplegia (62 with complete and 26 with incomplete motor lesions) and 124 with paraplegia (87 with complete and 37 with incomplete motor lesions). MAIN OUTCOME MEASURES Forced vital capacity (FVC), forced expired volume in 1 second (FEV1), and peak expiratory flow rate (PEFR), all measured in the supine and erect seated positions and compared with predicted normal values for industrial workers. RESULTS FVC and FEV1 were normal in persons with low-level paraplegia who had never smoked, but both decreased similarly with rising SCI level, more markedly in those with tetraplegia. PEFR decreased with rising SCI level. Incomplete lesions mitigated function loss in those with tetraplegia. In middle-aged individuals with tetraplegia, longer duration of injury was associated with greater function loss, independent of age. Current smokers showed excess function loss, except for those with high tetraplegia. Most people with complete tetraplegia showed FVC and FEV1 increases in the supine position relative to the erect position. CONCLUSIONS Pulmonary function is compromised by most lesions of the spinal cord, even in those with paraplegia, and is affected relative to the level of lesion. Efforts to help SCI patients minimize respiratory complications-in particular, assistance in smoking cessation-should be given high priority.

The effects of removal of bullet fragments retained in the spinal canal : a collaborative study by the national spinal cord injury model systems

Serial motor and sensory examinations were conducted on 90 patients with bullet fragments lodged in the spinal canal. Annual follow-up examinations were completed on 66 patients. Despite the fact that approximately 20% of the bullets had perforated the alimentary canal, no cases of infection were noted. Statistical analyses indicated that removal of the bullet fragments made no significant difference with regard to reducing pain or improving the recovery of sensation. However, bullet removal did have an effect on motor recovery, depending on the level at which the lesion occurred. Among those patients with lesions between vertebral levels T12 and L4, there was significantly greater (P < 0.001) motor recovery in those patients from whom the bullet was removed from than in patients not having bullet removal. Bullet removal from the canal between T1 and T11 had no significant effect on motor recovery.

Regional Osteoporosis in Women Who Have a Complete Spinal Cord Injury

Background: Regional bone loss in patients who have a spinal cord injury has been evaluated in males. In addition, there have been reports on groups of patients of both genders who had an acute or chronic complete or incomplete spinal cord injury. Regional bone loss in females who have a complete spinal cord injury has not been reported, to our knowledge. Methods: In a study of thirty-one women who had a chronic, complete spinal cord injury, we assessed bone mineral density in relation to age, weight, and time since the injury. The results were compared with the bone mineral density in seventeen healthy, able-bodied women who had been age-matched by group (thirty years old and less, thirty-one to fifty years old, and more than fifty years old). Dual-energy x-ray absorptiometry was used to measure the bone mineral density of the lumbar spine, hip, and knee; Z-scores for the hip and spine were calculated. Results: The mean bone mineral density in the spine in the youngest, middle, and oldest spinal-cord-injury groups was 98%, 108%, and 115% of the densities in the respective age-matched control groups (p < 0.0001), and the mean bone mineral density in the oldest spinal-cord-injury group was equal to that in the youngest control group. This gain in bone mineral density in the spine was reflected by the spine Z-scores, as the mean score in the oldest injured group averaged more than one standard deviation above both the norm and the mean score in the control group. The mean loss of bone mineral density in the knee in the youngest, middle, and oldest spinal-cord-injury groups was 38%, 41%, and 47% compared with the densities in the corresponding control age-groups (p < 0.0001). Furthermore, the oldest injured group had a mean reduction of knee bone mineral density of 54% compared with the youngest control group. The mean loss of bone mineral density in the hips of the injured patients was 18%, 25%, and 25% compared with the densities in the control subjects in the respective age-groups (p < 0.0001). Conclusions: The bone mineral density in the spine either was maintained or was increased in relation to the time since the injury. This finding is unlike that seen in healthy women, in whom bone mineral density decreases with age. The bone mineral density in the hips of the injured patients initially decreased approximately 25%; thereafter, the rate of loss was similar to that in the control group. The bone mineral density in the knees of the injured patients rapidly decreased 40% to 45% and then further decreased only minimally. Clinical Relevance: The results provide a partial explanation of the fracture patterns seen after spinal cord injuries. Vertebral fractures rarely occur, whereas the knee is at risk for fracture soon after the spinal cord injury. The potential for fracture of the hip also occurs soon after the spinal cord injury. This risk increases with age and the amount of time since the spinal cord injury.

Is immobilization associated with an abnormal lipoprotein profile? Observations from a diverse cohort.

Objective: The potential effects of ethnicity, gender, and adiposity on the serum lipid profile in persons with spinal cord injury (SCI) were determined. Subjects: Subjects with SCI were recruited during their annual physical examination from Rancho Los Amigos Medical Center, Downey, California. Sedentary able-bodied controls were Bridge and Tunnel Officers of the Triboro Bridge and Tunnel Authority of the New York City metropolitan area. Methods: Serum lipid profiles were investigated in 320 subjects with SCI and compared to those obtained from 303 relatively sedentary able-bodied controls. Serum lipid studies were obtained in the fasting state. Data were collected between 1993 and 1996. All lipid determinations were performed by the same commercial laboratory. Main outcome measures: The dependent variables were the values from the lipid profile analysis. The independent variables consisted of study group, gender, ethnic group, age, duration of injury, and anthropometric measurements. Results: The serum high-density lipoprotein cholesterol (HDL-c) level was reduced in the SCI compared with the control group (mean±SEM) (42±0.79 vs 47±0.67 mg/dl, P<0.0005). The serum HDL-c level was significantly lower in males with SCI than males in the control group (39±0.83 vs 45±0.70 mg/dl, P<0.0001), but not for females (51±1.54 vs 54±1.52 mg/dl, n.s.). Within the subgroups for whites and Latinos, HDL-c values were also lower in subjects with SCI than in controls (whites: 41±1.02 vs 46±0.86 mg/dl, P<0.0001; Latinos: 37±1.53 vs 42±1.59 mg/dl, P<0.05), but not for African Americans (49±1.56 vs 51±1.27 mg/dl, n.s.). African Americans had higher HDL-c values than whites or Latinos (SCI: 49±1.56 vs 41±1.02 or 37±1.53 mg/dl, P<0.0001; controls: 51±1.27 vs 46±0.86 mg/dl, P<0.01 or 42±1.59 mg/dl, P<0.0005). In persons with SCI, the serum HDL-c values were inversely related to body mass index and estimated per cent body fat (r=0.27, P<0.0001). Conclusion: In white and Latino males, but not in females or African Americans, immobilization from SCI appears to be associated with lower HDL-c values than in controls.

The effect of residual neurological deficit on serum lipoproteins in individuals with chronic spinal cord injury

Subjects with spinal cord injury (SCI) have been shown to have an adverse lipid profile. Prior studies performed with smaller numbers of subjects have not been able to demonstrate any relationship between the level and degree of the neurological deficit and plasma lipid levels. Over a 2 year period we investigated the lipid profiles in 541 subjects from Rancho Los Amigos Medical Center, Downey, California. Subjects were grouped by tetraplegia (Tetra; n=247) or paraplegia (Para; n=294) and by subgroup for degree of neurological deficit: complete Tetra (n=156), incomplete Tetra (n=91), complete Para (n=206) and incomplete Para (n=88). The serum high-density lipoprotein (HDL) cholesterol level was lower in the Tetra than in the Para group (38±0.7 vs 45±0.8, P<0.01). The group with Tetra had a higher percentage of subjects with serum HDL cholesterol values <35 mg/dL [an independent risk factor for coronary heart disase (CHD)] than those with Para (38% vs 21%, P<0.0001). A significant inverse relationship was found for degree of neurological deficit and mean serum HDL cholesterol level (r=0.19, P<0.001), with the greater the deficit, the lower the serum HDL cholesterol level. Serum total cholesterol levels were higher in the Para group than in the Tetra group (198±2.6 vs 184±2.6, P<0.01). However, the ratio of total cholesterol to HDL cholesterol (a discriminator of risk for CHD) was significantly lower in the Para group than the Tetra group (4.8 vs 5.2%, P<0.01). Thus, in persons with SCI a spectrum of depressed serum HDL cholesterol levels and increased cardiovascular risk occur, with the most adverse lipid changes correlating with the severity of neurological deficit.

Metabolic and Endocrine Changes in Persons Aging with Spinal Cord Injury

Persons with spinal cord injury (SCI) have secondary medical disabilities that impair their ability to function. With paralysis, dramatic deleterious changes in body composition occur acutely with further adverse changes ensuing with increasing duration of injury. Lean mass, composed of skeletal muscle and bone, is lost and adiposity is relatively increased. The body composition changes may be further exacerbated by associated reductions in anabolic hormones, testosterone, and growth hormone. Individuals with SCI also have decreased levels of activity. These body composition and activity changes are associated with insulin resistance, disorders in carbohydrate and lipid metabolism, and may be associated with premature cardiovascular disease. Although limited information is available, upper body exercise and cycle ergometry of the lower extremities by functional electrical stimulation (FES) have been reported to have a salutary effect on these body composition and metabolic sequelae of paralysis. Perhaps other innovative, externally mediated forms of active exercise of the paralyzed extremities will result in an increased functional capacity, metabolic improvement, and reduction of atherosclerotic vascular disease.

Emergency cervical-spine immobilization

STUDY OBJECTIVE To determine the effectiveness of a cervical-spine immobilization using a rigid cervical extrication collar and an Ammerman halo orthosis with and without spine boards. DESIGN A mixed model multivariate design with one within factor (device type) and one between factor (spine board application). SETTING Radiology suite. TYPE OF PARTICIPANTS Twenty normal men with a mean age of 29.6. INTERVENTIONS Unrestrained cervical motion was compared with motion in a cervical extrication collar and an Ammerman halo orthosis with and without a spine board. MEASUREMENTS Photographic measurement of head and neck motion during maximal flexion-extension, lateral bending, and rotation. Radiologic measurement of maximal intervertebral flexion-extension. MAIN RESULTS Both cervical extrication collar and Ammerman halo orthosis significantly reduced motion in all planes (P less than .001) with the Ammerman halo orthosis reducing these motions significantly more (P less than .001). With the use of a spine board these motions were restricted even more (P less than .001). The Ammerman halo orthosis with a spine board provided the greatest immobilization, equivalent to that provided by an halo-vest. CONCLUSION A rigid cervical collar and a spine board provide significantly better immobilization than the collar alone. Further immobilization is provided by an Ammerman halo orthosis.

Emergency, acute, and surgical management of spine trauma

OBJECTIVES To assess trends in emergency, acute, and surgical management of spinal cord injury (SCI), and evaluate the relations between surgery and the occurrence of specific complications. SETTING Model SCI Care Systems. DESIGN Case series. PARTICIPANTS Consecutive samples of 3,756 acute spinal injuries admitted to the Midwest Regional Spinal Cord Injury Care System between 1990 and 1999, 2,204 individuals admitted to a Model SCI System within 24 hours of injury before 1995, and 941 individuals who were injured between December 1995 and August 1998 and were admitted to a Model System within 24 hours of injury. MAIN OUTCOME MEASURES Frequencies of injury types, nonoperative treatment and types of spine surgeries, and time sequence associated complications including postoperative wound infections, pressure ulcers, deep vein thrombophlebitis, pulmonary embolism, and pneumonia or atelectasis. RESULTS Eighty-eight percent of cases entering a Model System through acute care were admitted within 72 hours of injury, 85% were admitted within 24 hours. Comparing 1990 with 1998, the number of persons admitted to Model Systems within 72 hours of injury declined 11%. Operative treatment within the Model Systems increased 5% (p < .01), with increases due to decompression surgeries. Complication rates of nonoperative and surgical cases were not different. CONCLUSIONS The reduction in 72-hour admissions suggests an increasing percentage of admissions are directly to rehabilitation at a Model System after receiving acute care elsewhere. The increase in the use of surgical procedures involving surgical decompression of the spine is probably due to advances in surgical technology and increased experience and confidence in spine surgery. Surgery does not influence complication development beyond the usual expectations for those who sustain SCI.