Vadim Bluvshtein

Recovery of Neurologic Function Following Nontraumatic Spinal Cord Lesions in Israel

Study Design. Retrospective cohort study. Objective. To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs). Summary of Background Data. NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce. Method. The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patients Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs). Results. Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs. Conclusions. The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs.

Survival, neurological recovery and morbidity after spinal cord injuries following road accidents in Israel

Design:A retrospective cohort study.Objective:Assess outcomes in patients with spinal cord injuries (SCI) following road accidents, and factors that affect them.Setting:Loewenstein Rehabilitation Hospital, Raanana, Israel.Subjects:A total of 143 patients admitted for rehabilitation between 1962 and 2004.Methods:Survival rates were estimated using the product limit (Kaplan–Meyer) method and their association with risk factors was analyzed with the Cox model. Neurological recovery was determined by comparing the Frankel grade at admission to rehabilitation and at discharge. The relation between recovery and various factors was tested with logistic regression.Results:The risk of SCI in road accidents is higher among car drivers and motorcycle or bicycle riders. Median survival was 43 years. Survival was negatively associated with age at injury (P<0.0002) and with diagnosis of pressure sores (P=0.0065). Recovery of at least one Frankel grade occurred in 29.1% of patients. Useful recovery (upgrade to Frankel grade D or E) occurred in 23.1% of all patients. Neurological recovery was negatively associated with the severity of neurological deficit (P<0.001) and with thoracic injuries (P=0.046). The most common complications were pressure sores and those of the urinary and respiratory systems.Conclusions:In SCI following road accidents, survival rates were higher and recovery rates lower than in mixed types of trauma. This may be related to better compensation followed by better nursing for road accident victims in Israel, which may prevent life-shortening complications, and to more severe injuries caused by road accidents.Sponsorship:The Israeli Union of Insurance Companies.

Hemodynamic responses to head-up tilt after spinal cord injury support a role for the mid-thoracic spinal cord in cardiovascular regulation

Background:Data showing a role for the mid-thoracic spinal cord (SC) in the control of hemodynamic changes is scarce despite existing evidence for its involvement in autonomic regulation.Study design:On the basis of the open label prospective series comparing three groups.Objective:To determine whether the mid-thoracic SC has a role in hemodynamic regulation during head-up tilt (HUT).Setting:Spinal Research Laboratory, Loewenstein Rehabilitation Hospital.Methods:A total of 13 healthy control subjects, 10 patients with T4–T6 paraplegia and 11 with C4–C7 tetraplegia were examined during supine rest and during HUT. Heart rate (HR), blood pressure (BP), HR spectral components (lower frequency fluctuation (LF), higher frequency fluctuations (HF) and LF/HF) and cerebral blood flow velocity (CBFV) were continuously measured or calculated.Results:BP response to HUT differed among these groups (P<0.02). During HUT, BP decreased markedly in the tetraplegia group (from a mean value of 81.65 to 67.69 mm Hg), and increased in the control groups (from 92.89 to 95.44 mm Hg) and in the T4–T6 paraplegia group (from 96.24 to 97.86 mm Hg). Significant correlation was found in the control and tetraplegia groups between increases in HR LF/HF and HR at HUT (r>0.7; P<0.01). No such correlation was found in the paraplegia group. HUT effect on HR and CBFV was significant in all groups (P<0.001), but group differences were statistically non-significant.Conclusion:Findings were generally compatible with those of comparable previously published studies, but they also support a role for the mid-thoracic SC in hemodynamic regulation, which should be considered in clinical setting and in research.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

Purpose. To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel. Method. This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA. Results. Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay. Conclusions. Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

An International Age- and Gender-Controlled Model for the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI)

Background. A quadratic formula of the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI) has previously been published. This formula was based on a model of Spinal Cord Independence Measure (SCIM95), the 95th percentile of the SCIM III values, which correspond with the American Spinal Injury Association Motor Scores (AMS) of SCI patients. Objective. To further develop the original formula. Setting. Spinal cord injury centers from 6 countries and the Statistical Laboratory, Tel-Aviv University, Israel. Methods. SCIM95 of 661 SCI patients was modeled, using a quantile regression with or without adjustment for age and gender, to calculate SCI-ARMI values. SCI-ARMI gain during rehabilitation and its correlations were examined. Results. A new quadratic SCIM95 model was created. This resembled the previously published model, which yielded similar SCIM95 values in all the countries, after adjustment for age and gender. Without this adjustment, however, only 86% of the non-Israeli SCIM III observations were lower than those SCIM95 values (P < .0001). Adding the variables age and gender to the new model affected the SCIM95 value significantly (P < .04). Adding country information did not add a significant effect (P > .1). SCI-ARMI gain was positive (38.8 ± 22 points, P < .0001) and correlated weakly with admission age and AMS. Conclusions. The original quadratic SCI-ARMI formula is valid for an international population after adjustment for age and gender. The new formula considers more factors that affect functional ability following SCI.

Insulin resistance in tetraplegia but not in mid-thoracic paraplegia: is the mid-thoracic spinal cord involved in glucose regulation?

Study design:Controlled experimental human study.Objectives:To assess insulin resistance (IR) in tetraplegia and paraplegia, and the role of the spinal cord (SC) in glucose regulation.Setting:Laboratory of Spinal Research, Loewenstein Rehabilitation Hospital.Methods:Glucose and insulin levels and the heart rate variation spectral components LF (low frequency), HF (high frequency) and LF/HF were studied at supine rest, head-up tilt and after a standard meal in three groups: 13 healthy subjects, 7 patients with T4–T6 paraplegia and 11 patients with C4–C7 tetraplegia.Results:Glucose and insulin increased significantly after the meal in all groups (P<0.001). Glucose increased significantly more in the tetraplegia than in the other groups (P<0.01). Increases in insulin level tended to accompany increases in LF/HF after the meal in the tetraplegia and control groups but not in the paraplegia group.Conclusion:Post-prandial IR appears in C4–C7 but not in T4–T6 SC injury. The results of the study, combined with previously published findings, are consistent with the hypotheses that IR is related to activation of the sympathetic nervous system, and that below T4 the mid-thoracic SC is involved in the regulation of glucose and insulin levels.

Using a Sniff Controller to Self-Trigger Abdominal Functional Electrical Stimulation for Assisted Coughing Following Cervical Spinal Cord Lesions

Individuals with cervical spinal cord lesions (SCLs) typically depend on caregivers to manually assist in coughing by pressing against their abdominal wall. Coughing can also be assisted by functional electric stimulation (FES) applied to abdominal muscles via surface electrodes. Efficacy of FES, however, depends on precise temporal synchronization. The sniff controller is a trigger that enables paralyzed individuals to precisely control external devices through alterations in nasal airflow. We hypothesized that FES self-triggering by sniff controller may allow for effective cough timing. After optimizing parameters in 16 able-bodied subjects, we measured peak expiratory flow (PEF) in 14 subjects with SCL who coughed with or without assistance. Assistance was either manual assistance of a caregiver, caregiver activated FES, button self-activated FES (for SCL participants who could press a button), or sniff-controlled self-activated FES. We found that all assisted methods provided equally effective improvements, increasing PEF on average by 25 ± 27%

Reply to comment on coronary artery disease and hypertension in a non-selected spinal cord injury patient population (letter to the Editor)

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A new instrument for outcome assessment in rehabilitation medicine: Spinal cord injury ability realization measurement index.

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Survival after nontraumatic spinal cord lesions in Israel.

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