Spinal injuries. Part 1.
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Spinal Cord Injuries↗
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History of the treatment of spinal injuries.
Injury of the spinal cord has been known since antiquity. There is no cure for the injury and until modern times patients died rapidly from a combination of pressure sores and urinary tract infection. Treatment consists of preventing complications until the spine has stabilised and the patient can be rehabilitated to an independent life. This article explores how this treatment developed in the ancient world, the middle ages, in Europe, Great Britain, and latterly in the United States. It describes how these principles of treatment were recognised particularly in Germany, the United States, and Great Britain and evaluates the relative contributions made by the different pioneers.
Europe↗
Motor unit firing during and after voluntary contractions of human thenar muscles weakened by spinal cord injury.
Spinal cord injury may change both the distribution and the strength of the synaptic input within a motoneuron pool and therefore alter force gradation. Here, we have studied the relative contributions of motor unit recruitment and rate modulation to force gradation during voluntary contractions of thenar muscles performed by five individuals with chronic (>1 yr) cervical spinal cord injury. Mean +/- SD thenar unit firing rates were low during both steady-level 25% (8.3 +/- 2.2 Hz, n = 27 units) and 100% maximal voluntary contractions (MVCs, 9.2 +/- 3.1 Hz, n = 23 units). Thus modest rate modulation, or a lack of it in some units, was seen despite an average fourfold increase in integrated surface electromyographic activity and force. During ramp contractions, units were recruited at 5.7 +/- 2.5 Hz, but still only reached maximal firing rates of 12.8 +/- 4.9 Hz. Motor units were recruited up to 85% of the maximal force achieved (14.6 +/- 5.6 N). In contrast, unit recruitment in control hand muscles is largely complete by 30% MVC. Thus, during voluntary contractions of thenar muscles weakened by cervical spinal cord injury, motor unit rate modulation was limited and recruitment occurred over a wider than usual force range. Those motor units that were stopped voluntarily had significantly lower derecruitment versus recruitment thresholds. However, 8 units (24%) continued to fire long after the signal to end the voluntary contraction at a mean frequency of 5.9 +/- 0.8 Hz. The forces generated by this prolonged unit activity ranged from 0.3 to 7.2% maximum. Subjects were unable to stop this involuntary unit activity even with the help of feedback. The mechanisms that underlie this prolonged motor unit firing need to be explored further.
Adult↗
Mechanisms controlling normal defecation and the potential effects of spinal cord injury.
Spinal cord injury frequently leads to bowel dysfunction with the result that emptying the bowel can occupy a significant part of the day and reduce the quality of life. This chapter contains an overview of the function and morphology of the normal distal gut in the human, and of gut behaviour in normal defecation. In humans, this can be monitored and is described, but knowledge of the mechanisms controlling it is limited. Work on animals has shown that the intrinsic activity of the smooth muscles and their interactions with the enteric nervous system can program the activity that is necessary to expel waste material, but the external anal sphincter is controlled through somatic nerves. The gut however also receives input from the central nervous system through autonomic nerves, and a spinal reflex centre exists. Voluntary effort to induce defecation can influence all the control mechanisms, but the precise importance of each is not understood. The behaviour and properties of the individual muscles in the normal human rectum and anal canal are described, including their responses to intrinsic nerve stimulation and adrenergic and cholinergic agonists. The effects of established spinal cord injury are then considered. For convenience, supraconal and conal/cauda equina lesions are considered as two categories. Prolongation of transit times and disordered defecation are common problems. Supraconal lesions result in reduced resting anal pressures and increased risk of fecal incontinence. The acute effects of spinal cord injury are described, with injury causing ileus (prolonged total gastrointestinal transit times), constipation (prolonged colonic transit times) and fecal incontinence (passive leakage).
Cholinergic Agonists↗
Prospective study of omental transposition in patients with chronic spinal injury.
OBJECTIVES: This prospective study was designed to assess the effects of omental transposition in patients with a chronic spinal injury. METHODS: Neurological status was established to be stable and multiple baseline across patient studies were done preoperatively and repeated postoperatively. Assessments included activities of daily living (ADL), functional ability, degree of spasticity, motor power, sensation, pain perception, urodynamic studies, electromyography, sensory evoked potentials (SEPs), and infrared thermography to measure peripheral and general skin vascular responses. Each patient had MRI. Assessments were done at 3, 6, and 12 months after omental transposition in 17 patients. RESULTS: The detailed assessments failed to show significant improvement, although some patients showed minor objective and subjective change in some categories. Neurological deterioration occurred in one patient. There were 20 surgical complications including urinary tract infection, deep vein thrombosis, wound infection, and incisional hernia. CONCLUSIONS: Omental transposition has not been shown to improve neurological function in 17 patients with chronic spinal cord injury, and continued use of this operation in this situation is not supported by this study. Further advances in spinal cord repair may utilise the pedicled omental graft to provide an alternative vascular supply, but its current use should be limited to experimental models.
Activities of Daily Living↗
Contact dermatitis in a spinal injuries centre.
A routine patch testing survey carried out on 122 patients in the National Spinal Injuries Centre at Stoke Mandeville Hospital showed that 40.1% of the patients studied gave positive patch test results to medicaments and other topical applications. The incidence of positive results was higher in patients with a history of pressure sores (45.1%) than in those who had never had sores (33.3%). The significance of these results is discussed.
Adolescent↗
[Current surgical methods for the management of spinal injuries. Experience of the 1st International Postgraduate Course of Spinal Surgery of the Orthopedic Association (Davos, 6-11 January 1985)].
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Bone Plates↗
The nursing management of spinal injuries.
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Spinal Injuries↗
Differential affinities of TRH analogs at the mammalian spinal cord TRH receptor: implications for therapy in spinal injuries.
The equilibrium receptor binding properties and the pharmacological specificity of the spinal receptors for thyrotropin-releasing hormone (TRH) were determined. [3H]MeTRH bound to a single class of high-affinity (dissociation constant, KdS = 5.0; 6.0 and 5.5 nM), saturable (Bmax = 21.5, 32.6 and 130.7 fmol/mg protein) binding sites for TRH in homogenates of the rat, guinea pig and rabbit spinal cord respectively. [3H]MeTRH receptor binding was competitively but differentially inhibited by TRH analogs. The inhibition constants (Kis) in the three spinal cord preparations were: MeTRH (4.2-5.9 nM); TRH (14.2-33.9 nM); RX77368 (113-122 nM); CG3703 (117-142 nM); MK-771 (122-140 nM); CG3509 (10-32 microM); NVal2-TRH (32-56 microM) and TRH free acid (37-73 microM). These data have shown that the parent tripeptide. TRH, and its methylated analog. MeTRH, are the most potent displacers of [3H]MeTRH receptor binding, and that N-terminus modifications (as in CG3703, CG3509). C-terminus modifications (as in RX77368, TRH free acid) and both N- and C-terminus modifications (as in MK-771) of TRH result in markedly reduced affinity for the TRH receptor. Although, CG3703 and CG3509 have been previously found to be almost equally effective in the treatment of spinal cord injury, we have found that CG3703 has a significantly higher (70- to 283-fold) affinity than CG3509 for spinal TRH receptors. Interestingly, although RX77368 and MK-771 appear to have similar TRH receptor affinities to CG3703, the former analogs have shown less beneficial effects in animal models of spinal injury.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
The effects of melatonin on the antioxidant systems in experimental spinal injury.
Melatonin has been recently shown by various in-vivo and in-vitro studies to exert potent neutralising effects on hydroxyl radicals, stimulate glutathione peroxidase (GSH-Px) activity, and protect catalase (CAT) from the destructive activity of hydroxyl radicals in neural tissue. We aimed to investigate the possible effects of pharmacological dose of melatonin on some of the antioxidant defence systems in an in-vivo study of experimental spinal injury. Seven groups of adult male Sprague Dawley rats were used in the following scheme: Group I: Naive (n = 6), Group II: Lesion (n = 8), Group III: Melatonin (n = 5), Group IV: Melatonin + Lesion (n = 8), Group V: Placebo + Lesion (n = 5), Group VI: Sham operation (n = 5), and Group VII: Placebo (n = 5). Experimental spinal injury was induced at level T7-T8 by 5 sec compression of the total cord with an aneurysm clip on anaesthetised and laminectomized animals. The total 10 mg/kg dose of melatonin (Sigma) dissolved in alcohol-water was administered i.p. four times in 2.5 mg/kg doses, at 20 min pre-, at the time of and at 1 h and 2h post-compression. At 24 +/- 2h post-injury, the rats were euthanized and the lesioned segments of cord were dissected and homogenised with special care taken to distribute equal amount of injured tissue in each sample for analysis of reduced glutathione (GSH), oxidised glutathione (GSSG), superoxide dismutase (SOD), and CAT activity. Compression injury decreased GSH/GSSG ratio significantly (p < .0001). Melatonin, by itself, significantly decreased GSSG content (p < .05) and increased CAT activity (p < .05) in the naïve rats. Melatonin treatment decreased GSSG activity, thus elevating GSH/GSSG ratio, and also increased SOD and CAT activity without reaching statistical significance in the lesioned animals. In conclusion, pharmacological dose of systemically applied melatonin seemed to support some features of the antioxidant defence systems in our hands.
Animals↗
[Treatment of neurological complications of spinal injuries].
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Humans↗
Pediatric spinal injury: the very young.
Maturity of the spine and spine-supporting structures is an important variable distinguishing spinal cord injuries in children from those in adults. Clinical data are presented from 71 children aged 12 years or younger who constituted 2.7% of 2598 spinal cord-injured patients admitted to the authors' institutions from June, 1972, to June, 1986. The 47 children with traumatic spinal cord injury averaged 6.9 years of age and included 20 girls (43%). The etiology of the pediatric injuries differed from that of adult injuries in that falls were the most common causative factor (38%) followed by automobile-related injuries (20%). Ten children (21.3%) had spinal cord injury without radiographic abnormality (SCIWORA), whereas 27 (57%) had evidence of neurological injury. Complete neurological injury was seen in 19% of all traumatic pediatric spinal cord injuries and in 40% of those with SCIWORA. The most frequent level of spinal injury was C-2 (27%, 15 cases) followed by T-10 (13%, seven cases). Upon statistical examination of the data, a subpopulation of children aged 3 years or younger emerged. These very young children had a significant difference in level of injury, requirement for surgical stability, and sex distribution compared to 4- to 12-year-old children.
Age Factors↗
Spinal injuries due to hockey.
Although many types of sports and recreational activities have been identified as common causes of acute spinal cord injury, hockey has been a rare cause of acute cord injury in Canada or elsewhere. For example, from 1948 to 1973 there were no patients with cord injuries due to hockey in a series of 55 patients with acute cord injuries due to sports or other recreational activities admitted to two Toronto hospitals. In contrast, between 1974 and 1981, the Acute Spinal Cord Injury Unit, Sunnybrook Medical Centre treated six patients with cervical spinal injury due to hockey, five of whom were seen during a 13 month period from September, 1980 to October, 1981. Five of the six sustained a severe acute cervical spinal cord injury, and one a cervical root injury. The cord injury was complete in two cases, while three had complete motor loss but incomplete sensory loss below the level of the lesion. All were males aged 15 to 26 years. Of the players with cord injury, four struck the boards with the neck flexed, and one struck another player with the neck flexed. The one player without cord injury struck the boards with his neck extended. The commonest bony injury was a burst fracture of C5 or C6. One of the patients with a complete cord injury died three months later of a pulmonary embolus, and the other patients with cord injury showed some recovery of root function, but little or no cord recovery. The reasons for the increase in spinal injuries in hockey are unknown.
Adolescent↗
Blockade of sodium channels by phenytoin protects ultrastructure and attenuates lipid peroxidation in experimental spinal cord injury.
Spinal cord injury (SCI) involves a series of pathological events. Abnormal sodium influx has been implicated as one of the key events in the pathophysiology of the SCI. Pharmacological blockade of sodium channels can reduce secondary injury and increase recovery from trauma. The aim of the present study was to show the neuroprotective effect of phenytoin, a sodium channel blocker, after experimental SCI. Control and laminectomy-only groups were not injured. 50 g-cm weight drop injury was produced in the trauma group. In the treatment groups, methylprednisolone (30 mg/kg) and phenytoin (1 mg/kg, 10 mg/kg, or 30 mg/kg) were given intraperitoneally immediately after injury. Malondialdehyde (MDA) levels in the spinal cord samples were examined for lipid peroxidation. Spinal cord ultrastructure was evaluated and grading system was used for quantitative evaluation. Trauma increased tissue MDA levels. Treatment with methylprednisolone and phenytoin decreased MDA levels compared to trauma in all doses. Significant ultrastructural neuroprotection was observed with 30 mg/kg of phenytoin treatment according to general neural score. This ultrastructural neuroprotection of phenytoin was not different from methylprednisolone. Phenytoin appears to protect spinal cord against injury by decreasing lipid peroxidation and lessening neuronal damage associated with SCI in rats.
Animals↗
Patient education in practice: an international survey of spinal injury units.
A survey of the use of patient education programmes in spinal injury units was undertaken between 1982-1983. The aim of the survey was to find out the extent and use of educational materials and methods as well as the perceived areas of need. From over 100 units contacted, 52 have responded. The results were consistent across units in the developed world in their use of methods, areas taught and in perceived needs. One conclusion is that a dialogue between units about educational practice, problems and resources might well be of great values.
Evaluation Studies as Topic↗
Acute management of the patient with spinal cord injury.
Spinal cord injuries are not as common as many other types of injuries. The victims are often young, the injury debilitating, and the effects devastating and incalculable. The acute management of patients with spinal cord injury can significantly affect the patient's eventual neurologic and functional outcome and ultimately their quality of life. Early interventions are aimed at reestablishing physiologic homeostasis, lessening the amount of secondary injury, and preserving neurologic function.
Autonomic Dysreflexia↗
[A comparison of plain film, axial CT, 2D and 3D reconstructions in unstable spinal injuries following surgery].
During a period of 18 months about 70 patients suffering from an unstable spinal injury were operated in the surgical department of our clinic. In 50 of these patients it was possible to correlate the results of preoperative radiography and CT with the operative findings. Several cases of distraction instability in the dorsal column had not been recognised in the preoperative radiologic evaluation. Therefore the rationale of this study was the question as to whether modern CT technology can help to avoid such wrong diagnoses. For that purpose radiographs, axial CT-scans of 2 mm thickness or less, sagittal and coronal 2D and (in 35 cases) 3D reconstructions were re-evaluated step by step by a specifically trained radiologist without knowing the operative findings. 15 additional lesions out of 28 were demonstrated and specifically classified as distraction instabilities of the dorsal column using the improved CT technology.
Adult↗