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PubMed2001

Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings.

BACKGROUND: The true importance of blunt cardiac trauma (BCT) is related to the cardiac complications arising from it. Diagnostic tests that can predict accurately if such complications will develop or not may allow early and aggressive monitoring or early discharge. We investigated the role of two simple and convenient tests, serum cardiac troponin I (cTnI) and electrocardiogram (ECG), when used to identify patients at risk of cardiac complications after BCT. METHODS: Over a 10-month period, 115 patients with evidence of significant blunt thoracic trauma were prospectively followed to identify the presence of clinically significant BCT (Sig-BCT), defined as cardiogenic shock, arrhythmias requiring treatment, or structural cardiac abnormalities directly related to the cardiac trauma. An ECG was obtained at admission and at 8 hours. Cardiac troponin I was measured at admission, at 4 hours, and at 8 hours. Transthoracic echocardiography was performed when clinically indicated. The sensitivity, specificity, and positive and negative predictive values of ECG and cTnI to identify Sig-BCT were calculated. Clinical risk factors for Sig-BCT were examined by univariate and multivariate analysis. RESULTS: Nineteen patients (16.5%) were diagnosed with Sig-BCT and, in 18 of them, symptoms presented within 24 hours of admission. Abnormal electrocardiographic findings were detected in 58 patients (50%) and elevated cTnI levels in 27 (23.5%). Electrocardiography and cTnI had positive predictive values of 28% and 48% and negative predictive values of 95% and 93%, respectively. However, when both tests were abnormal (positive) or normal (negative), the positive and negative predictive values increased to 62% and 100%, respectively. Other independent risk factors for Sig-BCT were head injury, spinal injury, history of preexisting cardiac disease, and a chest Abbreviated Injury Score greater than 2. CONCLUSION: The combination of ECG and cTnI identifies reliably the presence or absence of Sig-BCT. Patients with an abnormal ECG and cTnI need close monitoring for at least 24 hours. Patients with a normal admission ECG and cTnI can be safely discharged in the absence of other injuries.

Electrocardiography↗
PubMed2001

Long-term follow-up of prophylactic greenfield filters in multisystem trauma patients.

PURPOSE: The efficacy of prophylactic Greenfield filter (PGF) placement in multisystem trauma patients at high risk for venous thromboembolism has been established. The objective of this study is to demonstrate the long-term safety and durability of PGFs placed in young, active trauma patients. METHODS: Starting January 1992, all trauma patients at high risk for development of venous thromboembolism were identified for placement of PGFs. These included patients with ISS > 9 and severe closed head injury, spinal injury, pelvic fracture, multiple long bone fracture, or direct iliofemoral venous injury. Four patients with PGFs placed before the study protocol in 1992 were also included. Follow-up was attempted in all patients with at least 5 years' duration since placement of PGF using physical examination, duplex ultrasound (US), and plain abdominal radiograph. RESULTS: There were 108 patients who had a PGF placement during the period of January 1992 to June 1994 that were eligible for the study. Eighteen of these 108 (17%) patients died. Twelve of them (67%) had autopsies and medical records available to determine the cause of death, none from a pulmonary embolism. The average time of death was 2.7 months after injury. The remaining 90 patients and the 4 patients with PGFs placed before 1992 were sought for follow-up, but only 36 patients could be contacted, 33 of which returned for evaluation (35%). The mean time of follow-up from the time of injury to the time of examination was 67.7 months, and the mean age at follow-up was 38.1 years. Although six patients had mild to moderate lower extremity edema on physical examination, none of them had a deep venous thrombosis by US. Radiographs obtained in 19 of the 33 patients showed no migration or breakdown of the Greenfield filters in place. CONCLUSION: Prophylactic Greenfield filters in high-risk trauma patients are safe and durable. There appears to be no significant consequence in over 5 years of follow-up.

Adult↗
PubMed2003

Effects of insulin-like growth factor-1/binding protein-3 complex on muscle atrophy in rats.

Muscle atrophy and wasting is a serious problem that occurs in patients with prolonged debilitating illness, burn injury, spinal injury, as well as with space flight. Current treatment for such atrophy, which often relies on nutritional supplementation and physical therapy, is of limited value in preventing the muscle wasting that occurs. Considerable recent attention has focused on the use of anabolic growth factors such as insulin-like growth factor (IGF-1) in preventing muscle atrophy during limb disuse or with various catabolic conditions. However, potential side effects such as hypoglycemia appear to be limiting factors in the usefulness of IGF-1 for clinical treatment of muscle wasting conditions. The formulation of IGF-1 used in this study (IGF-1/BP3) is already bound to its endogenous-binding protein (BP3) and, as a result, has a greater specificity of action and significantly less hypoglycemic effect. Using a rat model of hind limb suspension (HLS) for 10 days, we induced marked muscle atrophy that was accompanied by enhanced muscle proteolysis and reduced muscle protein content. When HLS rats were treated with IGF-1/BP3 (50 mg/kg, b.i.d.), they retained greater body and muscle mass. Muscle protein degradation was significantly reduced and muscle protein content was preserved. The rate of protein synthesis, although somewhat reduced in HLS muscle, was not significantly elevated by IGF-1/BP3 treatment. Volume density of HLS-treated muscles were increased compared to untreated HLS rats and the actual number of fibers per area of muscle was likewise increased. The results of the current study suggest that IGF-1/BP3 might be useful for inhibiting muscle proteolysis in catabolic conditions and thus preserving muscle protein content and mass.

Animals↗
PubMed1997

[Identification of macrophage migration inhibitory factor (MIF) in rat spinal cord and its kinetics on experimental spinal cord injury].

BACKGROUND: Among spinal cord injuries, secondary injury is considered to be a "reversible" process and seems to be a key target for the treatment of spinal cord injury. Recently, macrophage migration inhibitory factor (MIF) has been reevaluated as being one of the most important cytokines which act during wound healing, proliferation and differentiation of cells. However, the expression of MIF in the spinal cord has not been investigated yet. PURPOSE: The purpose of this paper is to demonstrate the MIF expression in normal rat spinal cord and to evaluate the kinetics of MIF after spinal cord injury. MATERIALS & METHODS: Female Wistar (280-320 g) rats were studied. Spinal cord injury was made by the clip compression method at the level of C7/Th1 (56 g, For 1 min.). The expression of MIF was examined by immunohistochemistry and northern blot analysis. MIF content in the cerebrospinal fluid (CSF) was measured by enzyme-linked immunosorbent assays (ELISA). Furthermore, to examine the MIF function on neuronal cell, cell proliferation assay (MTS assay) was carried out using PC12, pheochromocytoma cell line, and LN444, glioblastoma cell line, in the presence of anti-MIF monoclonal antibody. RESULTS: MIF stain was positive in normal rat spinal cord white matter. The expression of MIF decreased between 1 hour and 6 hours after injury. It was found to have re-appeared 24 hours after injury. The kinetics of MIF mRNA expression showed reverse-correlation with those of the MIF positive stain. MIF content in CSF was found to be elevated soon after injury. MTS assay suggested that MIF had some proliferative function on neuronal cells. CONCLUSION: MIF exists in the rat white matter. And it's immediately released into the CSF and then re-synthesized 24-hr after injury. MIF shows a cell proliferative function on neuronal cells. These results suggest that MIF plays an important role for secondary spinal cord injury.

Animals↗
PubMed2005

Can direct spinal cord injury occur without paresthesia? A report of delayed spinal cord injury after epidural placement in an awake patient.

UNLABELLED: We discuss the etiology of a delayed spinal cord injury after epidural anesthesia without paresthesia. The description of such a case in an awake, adult patient who underwent a Whipple resection is provided. An epidural was performed at approximately the T8-9 interspace with the patient in the sitting position after 1 mg of midazolam was administered. On the first attempt, a dural puncture occurred. The patient did not report any paresthesia or pain. The needle was withdrawn and a second attempt was made one interspace lower. At this level, the epidural catheter was advanced into the epidural space uneventfully. Postoperatively, the patient suffered decreased motor function in the right leg. Magnetic resonance imaging revealed high signal intensity within the spinal cord, indicating cord edema compatible with direct needle trauma. An extradural fluid collection consistent with a hematoma was also noted. Although it may be impossible to confirm if the spinal cord injury was a result of direct needle trauma, hematoma, or a combination of needle trauma and hematoma, these events clearly raise the important question of whether an awake patient will always report paresthesia secondary to spinal cord trauma. IMPLICATIONS: This case reminds anesthesiologists that we should not simply assume paresthesia will always occur and be reported if a needle encroaches on the spinal cord even in an awake patient.

Aged↗
PubMed2004

[Cervical spine trauma and spinal cord injury: the deaths caused by spinal cord swelling].

OBJECTIVE: To investigate clinical status features of the patient's who died from spinal cord and brain swelling. MATERIAL AND METHODS: Retrospectively collected data on 67 persons with severe spinal cord injury. These patients were treated and died in Kaunas University of Medicine Hospital between 1995 and 2003. The death reasons were determined after autopsy. The study included 2 (3%) females and 65 (97%) males. The age range was 16-82 years, mean age was 49.6 years. Cervical spine injuries in all patients were visualized at computed tomography and radiography. The cervical spine injury patterns were determined using Ferguson-Allen's classification. Motor and sensory evaluation after admission to hospital was conducted using the guidelines established by the American Spinal Cord Injury Association. From this group of patients, 48 cases were selected with spinal cord swelling as the reason of death. We divided these patients into two groups; 21 patients with C4-C5 neurological level were in the first group and 27 persons with C6-Th1 neurological level were in the second group. RESULT: . We compared the patients from the first and the second groups and did not find any difference between their age, the patterns of the accidents, the patterns of the cervical spine injuries (p>0.05), clinical status after admission to hospital and six hours before patient's death (p>0.05). Patients, who died from spinal cord swelling, had alterations in cardiopulmonary function before their death. The patients from the first group died on average in 80 hours after the accident; the patients from the second group died on average in 146 hours after the trauma (p<0.05). CONCLUSIONS: Patients, who died from spinal cord swelling, had distinct respiratory failure before their death. Alterations of the clinical status of patients with C4-C5 neurological level were faster.

Adolescent↗
PubMed2003

[Bioenergetic characteristics of the diaphragm after spinal cord injury].

INTRODUCTION: C2 spinal cord hemisection interrupts descending bulbospinal respiratory axons coursing through the cervical spinal cord. One consequence of this type of spinal cord injury is the partial deafferentation of the ipsilateral phrenic nucleus, which renders the hemidiaphragm paralysed. The biochemical properties of the intact or denervated locomotor skeletal muscles have been studied extensively, whereas the biochemical properties of the diaphragm after a cervical spinal cord injury received relatively little attention. This seems unfortunate, given that the diaphragm is the most important mammalian respiratory muscle and is the only skeletal muscle considered essential for survival. Therefore, the purpose of this work was to analyse the bioenergetic characteristics of the diaphragm following a cervical spinal cord injury. METHODS: Segments of the crural diaphragm from rat were homogenised to determine the activities of a glycolytic enzyme, lactate dehydrogenase (LDH), and a Krebs cycle enzyme, citrate synthase (CS). RESULTS: Data show a significant decrease of the CS activity on the ipsilateral hemidiaphragm to the cervical hemisection. No change in the LDH is observed between the animal without or with a cervical spinal cord injury. CONCLUSIONS: These data suggested that the CS activity could be dependent of the nervous influx from the central respiratory rhythm generator and that LDH activity could be maintained by a peripheral respiratory activity or by the cross phrenic phenomenon activation. Biochemical data should be considered in subjects presenting respiratory deficiency induced by a cervical spinal cord injury. Furthermore, the diaphragmatic muscle metabolic activity could be used to evaluate the functional respiratory recovery observed spontaneously or experimentally after using repair strategies of the spinal cord.

Animals↗
PubMedDate not supplied

[Spinal cord injuries in children].

Spinal cord injuries are rare in children, in face of their higher mobility comparing to adults. The high cervical and the thoracic segments of the spine are more frequently affected. In the last 10 years we had 90 cases of spinal injuries in our service being 12 with neurologic deficient (8 male and 4 female) and four of them without radiographic abnormality, even in the dynamics studies. The authors emphasise the possibility of occurrence of neurologic deficit in children after trauma, even without any radiographic abnormality.

Child↗
PubMed1998

Fetal spinal cord transplants support the development of target reaching and coordinated postural adjustments after neonatal cervical spinal cord injury.

Neonatal midthoracic spinal cord injury disrupts the development of postural reflexes and hindlimb locomotion. The recovery of rhythmical alternating movements, such as locomotion, is enhanced in injured animals receiving fetal spinal cord transplants. Neonatal cervical spinal cord injury disrupts not only locomotion but also skilled forelimb movement. The aims of this study were to determine the consequences of cervical spinal cord injury on forelimb motor function and to determine whether transplants of fetal spinal cord support normal development of skilled forelimb use after this injury. Three-day-old rats received a cervical spinal cord lesion at C3, with or without a transplant of fetal cervical spinal cord (embryonic day 14); unoperated pups served as controls. Animals were examined daily during the first month of life using a behavioral protocol that assessed reflexes, postural reactions, and forelimb motor skills. They also were trained and tested as adults to assess performance in goal-directed reaching tasks. The onset of postural reflexes was delayed in the lesion-only group, and goal-directed reaching and associated postural adjustments failed to develop. The transplant group developed reflex responses and skilled forelimb activity that resembled normal movement patterns. Transplant animals developed both target reaching and accompanying postural adjustments. Target reaching requires integration of segmental, intersegmental, and supraspinal input to propriospinal and motor neurons over many spinal cord levels. Transplants may support the reestablishment of input onto these neurons, permitting the development of skilled forelimb activity after neonatal cervical spinal cord injury. The neuroanatomical reorganization of descending and propriospinal input was examined in the companion paper (Diener and Bregman, 1998).

Animals↗
PubMed2006

Orthostatic hypotension and autonomic pathways after spinal cord injury.

Individuals with spinal cord injury (SCI) are prone to orthostatic hypotension (OH). We aimed to develop a simple bedside test to evaluate autonomic control following chronic SCI, and to identify those most at risk of OH and cardiovascular dysfunction. We studied 14 subjects with cervical SCI, 11 with thoracic SCI, and 17 able-bodied controls. We continuously recorded heart rate (HR; ECG) and beat-to-beat systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures (Finometer) while supine, and following the passive assumption of an upright seated position. Stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were calculated. Plasma catecholamines were determined. Motor and sensory loss was assessed using the American Spinal Injury Association (ASIA) impairment scale. Autonomic pathways were assessed from sympathetic skin responses (SSR). Cervical SCI subjects had lower supine HR, SAP, and noradrenaline levels than thoracic SCI and controls (p < 0.05), and lower DAP and MAP than controls (p < 0.05). When upright, HR increased in all groups (p < 0.05); SAP, DAP, and MAP increased (p < 0.01) in thoracic SCI and controls, but not in cervical SCI. Cervical SCI had larger postural falls in SV (p < 0.05) and CO, with smaller increases in TPR than the other two groups. Upright catecholamine levels were lower in cervical SCI (p < 0.05) than thoracic SCI and controls. Completeness of SCI assessed by ASIA scale did not necessarily correlate with autonomic completeness assessed by SSR. Cardiovascular control during orthostasis was impaired and OH was common in cervical SCI, but not thoracic SCI. SSR may identify those at greatest risk of orthostatic hypotension and impaired cardiovascular control. We advocate that assessments of autonomic function be included in the neurological evaluation of SCI, in addition to the ASIA assessment.

Adult↗
PubMed1999

Employment after spinal cord injury: an analysis of cases from the Model Spinal Cord Injury Systems.

OBJECTIVE: To describe the relationship of multiple biographic, injury-related, and educational factors with employment outcomes after spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Data were collected through 18 model SCI systems, a nationwide network of hospitals that treat approximately 14% of all SCIs in the United States. PARTICIPANTS: A total of 3,756 persons with traumatic SCI who completed the Form II data collection during their annual follow-up at years 1, 2, 5, 10, 15, 20, or 25 years (the most recent Form II was accepted). MAIN OUTCOME MEASURES: The Model Systems Forms I and II were used to identify biographic, injury-related status, employment at injury, and productivity status upon follow-up (Form I is used to elicit basic demographic and discharge information, whereas Form II is used to track multiple outcomes during annual follow-ups). The Craig Handicap Assessment Reporting Technique (CHART) was used to assess hours spent in gainful employment and other productive activities. RESULTS: CHART data revealed only a modestly higher Employment rate (24.8%) than that of the traditional single Form II item (22%). Being Caucasian, younger at injury, having lived more years with SCI, having a less severe injury, and having more years of education were all predictive of being employed. Violence at injury was associated with lower employment rates (only 12.9% employed), especially among Caucasians (only 24% employed). Being employed at injury was associated with a greater probability of postinjury employment, but only in the first few years after injury. Among employed participants, women and those who had been injured fewer years averaged fewer hours spent at work. CONCLUSIONS: Findings were consistent with those in previous studies. Interventions to improve employability should focus on education and the needs of individuals from minority backgrounds.

Adolescent↗
PubMed2005

Gunshot injuries of the spine--a review of 49 cases managed at the Groote Schuur Acute Spinal Cord Injury Unit.

UNLABELLED: The Acute Spinal Injury Unit, relocated from Conradie Hospital to Groote Schuur Hospital in mid-2003, admitted 162 patients in the first year of its existence. A large number of these injuries were the result of interpersonal violence, particularly gunshot wounds. AIM: To review patients with gunshot injuries to the spine, with reference to neurological injury, associated injuries, need for surgery and complications. METHODS: A comprehensive database is maintained to collect data on all spinal injury admissions. These data, as well as case notes and X-rays, were reviewed for all gunshot spine patients admitted to the Acute Spinal Injury Unit over a year. Forty-nine patients were identified. Thirty-eight were male and 11 female with an average age of 27.5 years (range 15-51 +/- 8.53). The average stay in the acute unit was 30 (4-109 +/- 28) days. RESULTS: The spinal injury was complete in 38 and incomplete in 8, with 3 having no neurological deficit. The level was cervical in 13, thoracic in 24 and lumbar in 12. Only 9 patients improved neurologically. The spine was considered stable in 43 cases. Stabilisation was performed in the 6 unstable cases. The bullets were removed in 11 cases as they were in the canal. There were 55 significant associated injuries, viz. 14 haemo-pneumothoraces, 16 abdominal visceral injuries, 3 vascular injuries, 4 injuries of the brachial plexus and 3 of the oesophagus, 2 tracheal injuries, 1 soft palate injury and 11 non-spinal fractures. Complications included 3 deaths and discitis in 3 cases, pneumonia in 6 and pressure sores in 6. CONCLUSION: Gunshot injuries of the spine are a prevalent and resource-intensive cause of paralysis. There is a high incidence of permanent severe neurological deficit, but usually the spine remains mechanically stable. Most of the management revolves around the associated injuries and consequences of the neurological deficit.

Cervical Vertebrae↗
PubMed1993

Acute neurologic management of the patient with spinal cord injury.

Early and effective spinal immobilization, physiological support, precise radiographic analysis, and surgical intervention tailored to the specific anatomic pathology form the basis for appropriate management of spinal injury. Despite improvements in each of these areas, however, the neurologic outcome in patients with severe deficits remains problematic. Research into the prevention of adverse metabolic changes that occur in the acutely injured spinal cord may offer hope for improved outcomes.

Acute Disease↗
PubMed1991

[Local spinal cord glucose utilization and extracellular potassium activity changes after spinal cord injury in rats].

Spinal microenvironment and metabolic alterations after experimental contusional injury of the spinal cord were evaluated in the same Wistar rats. Severe spinal cord injury was made under light GOF anesthesia with a 10 g weight drop onto the exposed Th-8 spinal cord from a 10 cm height and then halothane was ceased. The author studied extracellular potassium activity ([K+]e) and DC potential for 2 hours after paraplegic spinal cord injury in conscious rats. Furthermore, at 2 hours after cord injury, local spinal cord glucose utilization (1-SCGU) was measured with quantitative autoradiographic 2-[14C] deoxy-glucose method (Sokoloff et al.). [K+]e in injured spinal cords was 59 +/- 5 (mean +/- S.E.M.) mEq at 10 min after injury and was cleared with an exponential half-life of 1 hour. At 2 hours after injury [K+]e was still high with a value of 16 +/- 1 mEq compared with 4 mEq of control animals. DC potential changes was a mirror image of that of [K+]e. DC potential changed by a mean of 10.7 mV positively from 10 min. to 2 hours after injury. 1-SCGU at the impact site was extremely low in both white and gray matters. At 6mm rostral from the impact center 1-SCGU was remarkably reduced in the gray matter, and in the lateral white matter. But at 3 mm rostral 1-SCGU was well preserved. And at 20 mm rostral there was no difference in 1-SCGU with control animals. Massive potassium efflux from the injured spinal cord to the adjacent spinal segment was clarified at this experiment.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2000

A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury.

From the beginning, the reporting of the results of National Acute Spinal Cord Injury Studies (NASCIS) II and III has been incomplete, leaving clinicians in the spinal cord injury (SCI) community to use or avoid using methylprednisolone in acute SCI on the basis of faith rather than a publicly developed scientific consensus. NASCIS II was initially reported by National Institutes of Health announcements, National Institutes of Health facsimiles to emergency room physicians, and the news media. The subsequent report in the New England Journal of Medicine implied that there was a positive result in the primary efficacy analysis for the entire 487 patient sample. However, this analysis was in fact negative, and the positive result was found only in a secondary analysis of the subgroup of patients who received treatment within 8 hours. In addition, that subgroup apparently had only 62 patients taking methylprednisolone and 67 receiving placebo. The NASCIS II and III reports embody specific choices of statistical methods that have strongly shaped the reporting of results but have not been adequately challenged or or even explained. These studies show statistical artifacts that call their results into question. In NASCIS II, the placebo group treated before 8 hours did poorly, not only when compared with the methylprednisolone group treated before 8 hours but even when compared with the placebo group treated after 8 hours. Thus, the positive result may have been caused by a weakness in the control group rather than any strength of methylprednisolone. In NASCIS III, a randomization imbalance occurred that allocated a disproportionate number of patients with no motor deficit (and therefore no chance for recovery) to the lower dose control group. When this imbalance is controlled for, much of the superiority of the higher dose group seems to disappear. The NASCIS group's decision to admit persons with minor SCIs with minimal or no motor deficit not only enables statistical artifacts it complicates the interpretation of results from the population actually sampled. Perhaps one half of the NASCIS III sample may have had at most a minor deficit. Thus, we do not know whether the results of these studies reflect the severely injured population to which they have been applied. The numbers, tables, and figures in the published reports are scant and are inconsistently defined, making it impossible even for professional statisticians to duplicate the analyses, to guess the effect of changes in assumptions, or to supply the missing parts of the picture. Nonetheless, even 9 years after NASCIS II, the primary data have not been made public. The reporting of the NASCIS studies has fallen far short of the guidelines of the ICH/FDA and of the Evidence-based Medicine Group. Despite the lucrative "off label" markets for methylprednisolone in SCI, no Food and Drug Association indication has been obtained. There has been no public process of validation. These shortcomings have denied physicians the chance to use confidently a drug that many were enthusiastic about and has left them in an intolerably ambiguous position in their therapeutic choices, in their legal exposure, and in their ability to perform further research to help their patients.

Acute Disease↗
PubMed1994

Collection of semen from men in acute phase of spinal cord injury.

In chronic spinal cord injury, semen obtained by assisted ejaculation is usually abnormal. We have assessed electroejaculation early after injury in seven patients. There were no adverse effects. Initial samples contained few or no spermatozoa but as patients emerged from spinal shock, semen improved and five had specimens cryopreserved. Thereafter sperm motility and viability decreased towards the pattern of chronic spinal cord injury by day 16. Cryopreservation was not possible in one patient with many medical complications and another who started electroejaculation 15 days after injury. Semen storage within the first 2 weeks after spinal cord injury is recommended for future fertility treatment.

Acute Disease↗