Efficacy of Surgery and Rehabilitation for Cervical Cord Injury with Concomitant Heterotopic Ossification around the Hip Joint on the Acquisition of Transferable Movements / The Japanese Journal of Rehabilitation Medicine

Heterotopic ossification (HO) is one of the complications of a cervical cord injury that results in limited range of motion, which can interfere with basic movements and activities of daily living. We encountered a case of a cervical cord injury patient with limited range of motion and mobility due to HO of the hip joint who experienced improvement in both as a result of early surgery and rehabilitation. A 17-year-old boy was diagnosed with a cervical cord injury due to an anterior fracture of the sixth cervical vertebrae following a fall into a pool. It was classified as bilateral C6BII according to the Zancolli's classification for cervical cord injury. The patient presented with limited range of motion in his left hip and was diagnosed with HO four months after the injury. Eight months after the injury, his hip range of motion deteriorated further；consequently, he required continuous transfer assistance. Therefore, surgical HO removal was performed during this period of convalescent rehabilitation. The patient underwent constant post-operative rehabilitation, and the range of motion in his left hip joint improved；thus, he became independent in transfer activities. A concomitant HO after a cervical cord injury can lead to functional impairment in convalescent rehabilitation. In addition, no practice guidelines have been developed that include recommendations on when to perform surgical procedures for HO. Treatment of HO with a combination of immediate surgery and aggressive rehabilitation can be expected to restore function and maximize activity and participation in patients with cervical cord injury with concomitant HO.

Efficacy of Surgery and Rehabilitation for Cervical Cord Injury with Concomitant Heterotopic Ossification around the Hip Joint on the Acquisition of Transferable Movements / The Japanese Journal of Rehabilitation Medicine

Heterotopic ossification (HO) is one of the complications of a cervical cord injury that results in limited range of motion, which can interfere with basic movements and activities of daily living. We encountered a case of a cervical cord injury patient with limited range of motion and mobility due to HO of the hip joint who experienced improvement in both as a result of early surgery and rehabilitation. A 17-year-old boy was diagnosed with a cervical cord injury due to an anterior fracture of the sixth cervical vertebrae following a fall into a pool. It was classified as bilateral C6BII according to the Zancolli's classification for cervical cord injury. The patient presented with limited range of motion in his left hip and was diagnosed with HO four months after the injury. Eight months after the injury, his hip range of motion deteriorated further；consequently, he required continuous transfer assistance. Therefore, surgical HO removal was performed during this period of convalescent rehabilitation. The patient underwent constant post-operative rehabilitation, and the range of motion in his left hip joint improved；thus, he became independent in transfer activities. A concomitant HO after a cervical cord injury can lead to functional impairment in convalescent rehabilitation. In addition, no practice guidelines have been developed that include recommendations on when to perform surgical procedures for HO. Treatment of HO with a combination of immediate surgery and aggressive rehabilitation can be expected to restore function and maximize activity and participation in patients with cervical cord injury with concomitant HO.

The Need for Early Tracheostomy in Patients with Traumatic Cervical Cord Injury

BACKGROUND: In patients who need sustained endotracheal intubation and mechanical ventilation due to respiratory failure after traumatic cervical spinal cord injury, tracheostomy can be performed to reduce the duration of mechanical ventilation and respiratory complications. The purpose of this study was to determine criteria and timing of tracheostomy in patients with severe traumatic cervical spinal cord injury accompanied by motor weakness. METHODS: We reviewed 22 patients who underwent tracheostomy (study group) and 27 patients who did not (control group) from January 2005 to March 2016. We assessed the American Spinal Injury Association (ASIA) impairment scale score and investigated accompanying thoracic injury, paradoxical respiration, postoperative endotracheal intubation and other clinical parameters. The study group was also subdivided into the early tracheostomy group and late tracheostomy group depending on whether the tracheostomy was performed within or later than 7 days after surgery. RESULTS: Twenty-two patients in the study group had a mean ASIA impairment scale score of 14.1 points, which was lower than the control group's 23.4 points. Paradoxical respiration was observed in 77% of the patients in the study group compared to 18% in the control group. Postoperative intubation was maintained in 68% in the study group; 32% underwent endotracheal intubation due to respiratory failure within 4 days after surgery and had a tracheostomy. In the control group, postoperative intubation was maintained in 22%, and all of them were weaned off intubation within 4 days after surgery. The duration of intensive care unit hospitalization was 11.4 days for the early tracheostomy group, which was shorter than the late tracheostomy group's 19.7 days. CONCLUSIONS: In patients with severe traumatic cervical spinal cord injury, tracheostomy may be needed when the motor grade of the ASIA scale is low, above the C4 segment is injured, or paradoxical respiration occurs after injuries. In addition, if endotracheal extubation is not feasible within 4 days after surgery, an early tracheostomy should be considered.

Comparison of the Using Ability Between a Smartphone and a Conventional Mobile Phone in People With Cervical Cord Injury

OBJECTIVE: To investigate the ability of spinal cord injury (SCI) patients in the use mobile cellular devices, especially the smartphone. METHODS: Seventeen people with motor complete cervical SCI participated in the study. The assist-devices deemed most fitting were introduced to the patients: a mouth stick, multifunctional splint, activities of daily living (ADL) splint, universal cuff or none of the above. To determine the effective devices, a Multi-Directional Click Test (MDCT), Phone Number Test (PNT), and individual satisfaction inquiry were used. The most appropriate assist device was selected by MDCT. Subsequently PNT and individual satisfaction inquiry were performed with the conventional model and compared. RESULTS: Those with C4 cord injury chose mouth stick. Those with C5 cord injury chose multifunctional splint (3 people) and ADL splint (2 people). Those with C6 cord injury chose universal cuff (3 people) or bare hands only. Those with C7 cord injury chose universal cuff (3 people). With a smartphone, all participants were able to complete the PNT. With a conventional model, only twelve participants (71%) were able to complete the same test. While it took 26.8+/-6.8 seconds with a conventional model to complete PNT, the same test took 18.8+/-10.9 seconds to complete with a smartphone (p<0.05). Overall, participants expressed higher satisfaction when using a smartphone. CONCLUSION: The results offer a practical insight into the appropriate assist devices for SCI patients who wish to use mobile cellular devices, particularly smartphones. When the SCI patients are given the use of a smartphone with the appropriate assist devices, the SCI patients are expected to access mobile cellular device faster and with more satisfaction.

Comparison of the Using Ability Between a Smartphone and a Conventional Mobile Phone in People With Cervical Cord Injury

OBJECTIVE: To investigate the ability of spinal cord injury (SCI) patients in the use mobile cellular devices, especially the smartphone. METHODS: Seventeen people with motor complete cervical SCI participated in the study. The assist-devices deemed most fitting were introduced to the patients: a mouth stick, multifunctional splint, activities of daily living (ADL) splint, universal cuff or none of the above. To determine the effective devices, a Multi-Directional Click Test (MDCT), Phone Number Test (PNT), and individual satisfaction inquiry were used. The most appropriate assist device was selected by MDCT. Subsequently PNT and individual satisfaction inquiry were performed with the conventional model and compared. RESULTS: Those with C4 cord injury chose mouth stick. Those with C5 cord injury chose multifunctional splint (3 people) and ADL splint (2 people). Those with C6 cord injury chose universal cuff (3 people) or bare hands only. Those with C7 cord injury chose universal cuff (3 people). With a smartphone, all participants were able to complete the PNT. With a conventional model, only twelve participants (71%) were able to complete the same test. While it took 26.8+/-6.8 seconds with a conventional model to complete PNT, the same test took 18.8+/-10.9 seconds to complete with a smartphone (p<0.05). Overall, participants expressed higher satisfaction when using a smartphone. CONCLUSION: The results offer a practical insight into the appropriate assist devices for SCI patients who wish to use mobile cellular devices, particularly smartphones. When the SCI patients are given the use of a smartphone with the appropriate assist devices, the SCI patients are expected to access mobile cellular device faster and with more satisfaction.

The Selection of the Appropriate Computer Interface Device for Patients With High Cervical Cord Injury

In order to determine the most suitable computer interfaces for patients with high cervical cord injury, we report three cases of applications of special input devices. The first was a 49-year-old patient with neurological level of injury (NLI) C4, American Spinal Injury Association Impairment Scale (ASIA)-A. He could move the cursor by using a webcam-based Camera Mouse. Moreover, clicking the mouse could only be performed by pronation of the forearm on the modified Micro Light Switch. The second case was a 41-year-old patient with NLI C3, ASIA-A. The SmartNav 4AT which responds according to head movements could provide stable performance in clicking and dragging. The third was a 13-year-old patient with NLI C1, ASIA-B. The IntegraMouse enabling clicking and dragging with fine movements of the lips. Selecting the appropriate interface device for patients with high cervical cord injury could be considered an important part of rehabilitation. We expect the standard proposed in this study will be helpful.

Diagnosis and Prognosis of Adult Post-traumatic Cervical Cord Injury Without Radiographic Evidence of Trauma Using Magnetic Resonance Imaging / 대한척추외과학회지

STUDY DESIGN: This is a retrospective review of 10 consecutive patients with spinal cord injury without radiographic evidence of abnormalities (SCIWORA) and 17 spinal cord injury patients without radiographic evidence of trauma (SCIWORET). OBJECTIVES: We wanted to assess the MRI and clinical findings, the prognosis and effect of anterior decompression of the spinal cord in SCIWORET patients. SUMMARY OF THE LITERATURE REVIEW: SCIWORET is not uncommon among middle-age and elderly people. It is less reported in adults as compared with children. There are no studies on the method for the treatment or the effectiveness of anterior decompression of the spinal cord. MATERIALS AND METHODS: From February 1994 to December 2005, this study included 27 patients who had cervical spinal cord injury without radiographic evidence of trauma on the plain roentgenography and MRI. Ten patients had no spinal cord compression (SCIWORA patients, group 1) and 17 had their spinal cord compressed from the anterior (SCIWORET patients, group 2), We conservatively treated the group 1 patients and 10 of the group 2 patients, and anterior decompression and fusion were done for 7 of the group 2 patients. Neurological evaluation was performed initial and at last follow up using an ASIA motor score and the Frankel grade. RESULTS: The patients who had spinal cord edema on MRI had a better prognosis than those who had contusion (p=0.06). There is no statistical difference between the two groups for the neurologic changes at the initial period and the last follow up period (p=0.06, 0.61). Decompression of the spinal cord anteriorly was not effective for the neurologic recovery (p=0.25) and the involved segments were not related to the neurologic changes (p=0.34, 0.25). CONCLUSIONS: It was presumed that patients with edema of the spinal cord had a better prognosis than those with contusion of the spinal cord. There was no difference between the SCIWORA and SCIWORET groups for the neurologic changes and anterior decompression was not effective for the recovery of neurologic symptoms. This study was limited by its retrospective nature and the small number of patients, so a multi-center study is needed.

The Effect of Midodrine on Exercise-induced Hypotension in Cervical Cord Injury Patients

OBJECTIVE: To evaluate the effect of midodrine, an alpha(1) agonist, on symptom and hemodynamic response during standing and arm bicycle ergometer exercise in patients with cervical cord injury. METHOD: Twelve cervical spinal cord injury patients with orthostatic hypotension symptoms and post-exercise hypo- tension were enrolled. They were positioned on a 90degrees standing frame for 3 minutes. After 15 minutes of resting on supine position, 5 minutes of arm bicycle ergometer exercise was done. These tests were done without midodrine initially, but, with 5 mg midodrine on the next day. Heart rate, self-perceived presyncope score (PPS), systolic and diastolic blood pressure were measured before, during and after the exercise. RESULTS: With 5 mg midodrine, the decrease of systolic and diastolic blood pressures after 3 minutes' standing was significantly smaller than without midodrine (p<0.05). PPS was also significantly decreased with midodrine on standing frame test. Arm ergometer exercise induced less systolic blood pressure decrease and better PPS on immediate and 5 minutes after exercise with midodrine (p<0.05). The change of diastolic blood pressure and heart rate was not significant after the exercise with midodrine. CONCLUSION: In cervical spinal cord injury patients with orthostatic and post-exercise hypotension, 5 mg midodrine significantly improved the symptoms and the systolic blood pressures.

The Force and Endurance of Wheelchair Propulsion in Persons with Cervical Cord Injuries

OBJECTIVE: This study was carried out to help the comprehensive rehabilitation of cervical cord injuries by measuring propulsion force and endurance on their wheelchair hand- rims, predicting the differences between neurological levels and analysing the factors which contributed to maintain the wheelchair propulsion force. METHOD: The BTE work simulator was used on 17 cervical cord injuries to test the force and endurance during wheel chair propulsion. The 141 large wheel of BTE work simulator and standard wheelchair which was removed handrims was used for simulating wheelchair propulsion. Wilcoxon rank sum test was used to compare force and endurance among the groups. RESULTS: The wheelchair propulsion force and endurance showed significant differences between neurological levels and types of the life style. The lower the level, the higher the strength and endurance (p<0.001). The wheelchair propulsion force of cervical cord injuries showed statistically significant differences between those with and without jobs (p<0.05). The outdoor wheelchair users and wheelchair propulsion exercise group showed significantly high maximum isometric strengths compared to the indoor users and the only ROM exercise group, respectively (p<0.05). CONCLUSION: During the rehabilitation period cervical cord injured persons need the wheelchair propulsion exercise using BTE work simulator to improve the quality of life.

Midodrine for the Treatment of Hypotension in a Tetraplegic Patient with Cervical Cord Injury in ICU: A case report / 대한구급학회지

Cervical spinal cord injury results in significant dysfunction of the sympathetic nervous system. Reduced sympathetic activity below the level of spinal cord injury is associated with low resting blood pressure,orthostatic hypotension,and reflex bradycardia.Hypotension can be treated with vasoactive agents,such as dopamine,epinephrine,norepinephrine, and phenylephine .Orally administered midodrine is an alpha adrenergic receptor agonist that increases blood pressure with vasoconstriction.Its action is fast and effective in treating hypotension in patients with spinal cord injury,and it has less severe side effects.A 70-year-old tetraplegic patient with fracture and dislocation of C6-7 after a motor vehicle accident was admitted to ICU and underwent anterior cervical intervertebral body fusion.Symptomatic hypotension following postural changes was treated with intravenous infusion of dopamine,but it was difficult to reduce the dose of dopamine without causing severe hypotension.Midodrine was prescribed and the patient was well tolerated without any adverse effect.With adequately maintained blood pressure,intravenous infusion of dopamine was successfully switched to the oral midodrine.This case suggests that the midodrine is effective for the treatment of hypotension in tetraplegic patients with spinal cord injury and enables patients to participate in early rehabilitation therapies.

Effect of Decompressive Surgery on Neurological Outcome Following Incomplete Cord Injury of the Mid and Lower Cervical Spines

To determine the effects of decompressive surgery on neurological outcome following incomplete cord injury of the mid and lower cervical spines, 44 patients(decompression and stabilization group: stabilization or conservative treatment group=21:23) who underwent operations between 1993 and 1995 were retrospectively reviewed. We compared neurological outcome by Frankel's grade, Prolo economic and functional rating scale, and final ambulatory status between two groups. Also, we analysed MRI findings related to neurologic outcome in these cervical cord injured patients. With regard to upgrading scale by Frankel's grade, decompressive surgery group was more improved(98% vs 78%). With regard to Prolo's scale, decompressive surgery group were excellent in 24%, good in 52%, and fair in 24%. Stabilization only or conservative treatment group were as follows: excellent(22%), good(39%), fair(30%), and poor (9%). In the viewpoint of walking status, the result of decompressive surgery group was better(90% vs 74%). Initial MRI findings and neurological assesment correlated with neurological recovery. In conclusion, decompressive surgery may be more effective in patients with incomplete cord injury on mid or lower cervical spines when there are cord compressive lesions such as traumatic disc herniation, spondylotic spur, bony impingement in the spinal canal, and irreducible spinal malalignment unless major intramedullary hemorrhage is present.

Reflex Sympathetic Dystrophy in Cervical Cord Injured Patients

OBJECTIVE: Reflex sympathetic dystrophy (RSD) is a syndrome of post-traumatic neuropathic pain in association with dystrophic changes and signs of sympathetic overactivity. Pain following spinal cord injury occurs frequently, but RSD is not usually considered as one of the common sources of pain. There have only been a few reports of RSD in spinal cord injured patients, although this condition is well-known in the painful upper extremity of hemiplegia due to stroke. The purpose of this study was to investigate the rate of occurrence, characteristic clinical features and more objective evaluation tools for the diagnosis of RSD in cervical cord injured patients. METHOD: Thirty-two cervical cord injured patients were evaluated for hand pain, swelling, vasomotor changes and dystrophic skin or nail changes. The patients were evaluated with studies such as three phase bone scintigrathy, digital infrared thermographic imaging (DITI) and plain roentgenograms of the hands. RESULTS: Eighteen patients (56.3%) were diagnosed as RSD based on the clinical symptoms and findings of three phase bone scintigraphy. Characteristic symptoms were hand pain, edema and dystrophic skin or nail changes, in the order of frequency. In patients with spasticity of the upper extremity, the incidence of RSD was higher than in patients without spasticity. CONCLUSION: We should consider RSD as a cause of upper extremity pain in cervical cord injured patients. This will lead to early diagnosis and treatment of the condition and it will be helpful in preventing various complications.

The Relation between Nocturnal Polyuria and Diurnal Variation of the ADH in Patients with Cervical Cord Injury

OBJECTIVE: It was reported that nocturnal polyuria in cervical cord injured patients may be due to attenuation of diurnal variation of antidiuretic hormone (ADH) level. However, it has been unclear whether the attenuation of diurnal variation of ADH level caused nocturnal polyuria and bladder overdistension. To improve the management of neurogenic bladder with overdistension during the night, we investigated whether the attenuation of diurnal variation of ADH level is the cause of nocturnal polyuria or bladder overdistens-ion in patients with cervical cord injury. METHOD: The subjects consisted of 17 patients with cervical cord injury. The age distribution ranged from 31 to 63 years with an average of 41.5 years. The duration of illness ranged from 5 months to 4 years. Oral intake was restricted below 2,000 ml per day. We measured urine volume and urine osmolarity during the day (8 AM~8 PM) and night period (8 PM~8 AM) and the level of plasma ADH and serum osmolarity at 2 PM and 2 AM. RESULTS: Plasma ADH level was 0.81+/-0.51 pg/ml during the day and 1.04+/-0.65 pg/ml during the night (p=0.17). Urine volume was 1050+/-410 ml during the day and 970+/-550 ml during the night (p=0.92). The average of urine osmolarity was 450.4+/-182.8 mosm during the day and 558.4+/-359 mosm during the night (p=0.25). The average of serum osmolarity was 292.4+/-14.5 mosm during the day and 290.4+/-9.3 mosm during the night (p=0.53). CONCLUSION: This study showed that there was no significant difference in each parameter for two periods and urine volume was not increased in spite of attenuation of diurnal variation of ADH level. Therefore this indicated that attenuation of diurnal varia-tion of ADH was less likely responsible for nocturnal polyuria in patients with cervical cord injury.

Locked Facet Syndrome of the Cervical Spine

Between 1984 and 1995, sixty-one patients were treated for facet interlocking of the cervical spine. The most common level of dislocation was C6/7; unilateral facet locking was observed in 27 patients, and bilateral locking in 34. Immediate traction with increasing weight reduced the dislocation in 51 patients, but ten required surgery, and of the 51 patients whose dislocations were successfully reduced with traction, 36 underwent surgery due to spinal instability.In all 46 patients who were operated on, spinal stability was achieved without major complications. On discharge, neurological improvement was observed in 18 patients. These findings suggest that even in neurologically compromised patients, prompt reduction and internal stabilization can facilitate recovery.

Cervical Cord Injury Associated with Osteochondroma Involving Cervical Lamina: Case Report

Osteochondroma of long bone are common lesions : however spinal involvement may occur in 2.5% to 7% of all, and usually occurs from the neural arch of spinous process. Neurological complications are rare, occurring in less than 1% of patients of them. The authors report a solitary osteochondroma occurring in the lamina of C5, causing spinal cord compression.