An interval of clinically silent gastrointestinal bleed in dysautonomic spinal cord injury: a case report.

BACKGROUND: Gastrointestinal bleed (GIB) has high incidence in traumatic spinal cord injured (tSCI) patients and can frequently be life-threatening, especially early post-injury. Several risk factors often compound bleeding risk, some are unique to this patient population. Normally, clinical suspicion for GIB arises from symptoms like coffee-ground emesis, hematemesis, melena or even hematochezia. A hemoglobin drop may be a late sign. Due to tSCI, however, patients often experience neurogenic bowels and dysautonomia, which may delay symptom presentation and complicate timely diagnosis of GIB. We report a case of an almost clinically silent GI bleed in the context of acute cervical tSCI. CASE PRESENTATION: A 21-year-old female presented with cervical cord transection at C-7 in the setting of motor vehicle rollover, for which surgical decompression was performed. During the acute injury phase, she also received a 10-day course of dexamethasone for symptomatic COVID-19 pneumonia. Two weeks after injury, she underwent percutaneous endoscopic gastrostomy (PEG) placement which demonstrated normal gastric and duodenal anatomy. One week later, a large spike (10x) in blood urea nitrogen: creatinine (BUN: Cr) ratio raised concern for GIB, but hemoglobin remained stable, and stool color remained unchanged. The following day, a gastroenterology consult was requested under increased suspicion of GIB from a sudden 3.5 g/dL hemoglobin drop. The patient received blood transfusion and pantoprazole. An upper endoscopy was performed, revealing three small duodenal ulcers. Melanotic stool ensued afterwards. CONCLUSIONS: Due to dysautonomia, clinical presentation of GIB can be significantly delayed in the tSCI patient population, leaving them vulnerable to succumb to illness. This case illustrates the possibility of an interval in which the patient was bleeding, with the sole indicator being an elevated BUN. Our case calls for closer monitoring of and vigilance for tSCI patients, and possibly employment of different strategies to reduce the incidence and enhance early detection of GIB in tSCI patients to subsequently decrease the morbidity and mortality associated with it.

IncobotulinumtoxinA versus onabotulinumtoxinA intradetrusor injections in patients with neurogenic detrusor overactivity incontinence: a double-blind, randomized, non-inferiority trial.

BACKGROUND: A randomized, double-blind, non-inferiority clinical study was performed on the efficacy and tolerability of IncobotulinumtoxinA (Incobot/A) vs. OnabotulinumtoxinA (OnabotA) intradetrusor injections in patients with refractory neurogenic detrusor overactivity incontinence performing intermittent catheterization. METHODS: Sixty-four patients with spinal cord injury (SCI) or multiple sclerosis were randomized to receive 30 intradetrusor injections of Incobot/A or OnabotA 200 U; 28 patients in incobotulinumtoxinA group and 29 in onabotulinumtoxinA group completed the study. Primary outcome measure was the non-inferior variation from baseline in daily urinary incontinence episodes (week 12), with a non-inferiority margin of one episode/day. Secondary outcomes measures were changes in Incontinence- Quality of Life questionnaire, Visual Analog Scale Score (bother of symptoms on Quality of Life), urodynamic parameters, occurrence of adverse effects and related costs (week 12). RESULTS: At week 12, mean value of difference in urinary incontinence episodes/day between the two groups was -0.2 (95% two-sided CI: -1; 0.7); the difference in incontinence episodes/day between the two groups was -0.4 with a higher limit of one-sided 95% CI of 0.2 episodes/day which was much lower than the non-inferiority margin of one episode/day. Total score and subscores of Incontinence- Quality of Life questionnaire, Visual Analog Scale scores and urodynamics did not show differences between the two groups. Adverse effects were similar for both treatments, with urinary tract infection being the most frequent, localised effect. Minor costs were observed following Incobot/A. CONCLUSIONS: In patients with refractory neurogenic incontinence due to SCI or multiple sclerosis, incobotulinumtoxinA was not inferior to onabotulinumtoxinA in improving clinical and urodynamic findings in the short-term follow-up, with comparable adverse effects but minor costs.

Spasticity following brain and spinal cord injury: assessment and treatment.

PURPOSE OF REVIEW: Spasticity is a common sequela of brain and spinal cord injury and contributes to disability, reduces quality of life, and increases economic burden. Spasticity is still incompletely recognized and undertreated. We will provide an overview of recent published data on the definition, assessment, and prediction, therapeutic advances, with a focus on promising new approaches, and telemedicine applications for spasticity. RECENT FINDINGS: Two new definitions of spasticity have been recently proposed, but operational criteria should be developed, and test-retest and inter-rater reliability should be explored. Cannabinoids proved to be effective in spasticity in multiple sclerosis, but evidence in other types of spasticity is lacking. Botulinum neurotoxin injection is the first-line therapy for focal spasticity, and recent literature focused on optimizing its efficacy. Several pharmacological, interventional, and nonpharmacological therapeutic approaches for spasticity have been explored but low-quality evidence impedes solid conclusions on their efficacy. The recent COVID-19 pandemic yielded guidelines/recommendations for the use of telemedicine in spasticity. SUMMARY: Despite the frequency of spasticity, robust diagnostic criteria and reliable assessment scales are required. High-quality studies are needed to support the efficacy of current treatments for spasticity. Future studies should explore telemedicine tools for spasticity assessment and treatment.

Early insights of the COVID-19 pandemic in the Veterans' Affairs spinal cord injury and disorders population.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The primary outcome of the study was to identify patient characteristics associated with a positive COVID-19 test. The secondary outcome was to identify patient characteristics associated with mortality from COVID-19. SETTING: Veterans Health Administration (VHA) National Spinal Cord Injury and Disorders (SCI) Registry, created by the National Spinal Cord Injury and Disorders SCI Program Office in March 2020. METHODS: Data was analyzed in the form of descriptive statistics and then subsequent regression analysis was performed. RESULTS: A total of 4,562 persons with SCI were tested for COVID-19 between March and July 2020, and 290 were positive. The study found that African Americans had increased odds of testing positive for COVID-19 (OR 1.53 (1.18-2.00), p < 0.01). Increased age correlated with increased odds of mortality after testing positive for COVID-19 (1.046 (1.003-1.090)). Non-smokers had lower odds of mortality following positive COVID-19 test (0.15 (0.04-0.52)). No association was found between neurologic level of injury (NLI) and positive COVID-19 test or increased mortality. Increased Body Mass Index (BMI) did correlate with positive COVID-19 test but not increased mortality. The case fatality rate for persons with SCI and a positive test for COVID-19 was 12%. CONCLUSIONS: It is important to define the risk factors for patients with SCI to elucidate and mitigate individual and population risks. These risk factors also can play a role in determining the allocation of critical healthcare resources.

Living with spinal cord injury during COVID-19: a qualitative study of impacts of the pandemic in Nepal.

STUDY DESIGN: A qualitative study using focus group discussion. OBJECTIVE: To explore the impacts of COVID-19 on multiple aspects of the lives of individuals living with spinal cord injury (SCI) in Nepal. SETTING: Community settings in Nepal. METHODS: A qualitative phenomenological study was conducted using two virtual focus group discussions. Fourteen individuals with SCI residing in different parts of Nepal participated. A thematic analysis approach was used to analyze and interpret the participants' responses. RESULTS: The four key themes for the impacts of COVID-19 on individuals with SCI were: (1) physical health with subthemes of (a) difficulty due to the presence of COVID-19 symptoms and (b) deterioration in secondary conditions; (2) mental health with subthemes of (c) constant fear of COVID-19 and (d) psychological distress; (3) social life with subthemes of (e) social stigma and (f) social isolation, and (4) economic problems with subthemes of (g) financial burden and (i) inadequate resources. CONCLUSIONS: The pandemic has tremendously impacted the physical, mental, social, and economic aspects of the lives of individuals with SCI. These, in turn, could impede the functioning and well-being of this population. The utilization of telehealth to provide education, psychosocial support, social awareness programs, and the provision of essential medical supplies appear necessary to maintain and improve the well-being of individuals with SCI during this pandemic. Future studies using an in-depth interview approach and psychosocial interventions are recommended.

Pulmonary Embolism After Acute Spinal Cord Injury and COVID-19.

The coronavirus virus disease 2019 is best known for its pulmonary sequelae. Understanding of the disease process is rapidly growing, and the medical community already appreciates a hypercoagulable state associated with coronavirus virus disease 2019. Acute spinal cord injury has an inherent increased risk for venous thromboembolism. In this case report, the patient presented with bilateral lower limb weakness and sensory loss secondary to thoracic disc herniation. Incidentally, at the same time as the initial presentation, the patient was also found to have coronavirus virus disease 2019 without significant respiratory symptoms. During hospitalization, the patient developed extensive bilateral lower limb deep vein thrombosis despite chemoprophylaxis. Therapeutic anticoagulation was initiated, yet several days later, he developed pleuritic chest pain. Computed tomography angiography revealed bilateral pulmonary emboli. This case highlights the need for clinicians to have elevated vigilance with regard to screening and treatment for venous thromboembolism in high-risk patients, such as spinal cord injury with a concurrent diagnosis of coronavirus virus disease 2019.

A case for inspiratory muscle training in SCI: potential role as a preventative tool in infectious respiratory diseases like COVID-19.

INTRODUCTION: Respiratory complications (RC) are a leading cause of death after spinal cord injury (SCI) due to compromised immune function and respiratory muscle weakness. Thus, individuals with SCI are at high risk of developing COVID-19 related RC. Results of a SCI clinical trial showed a supervised respiratory muscle training (RMT) program decreased risk of developing RC. The feasibility of conducting unsupervised RMT is not well documented. Four publications (n = 117) were identified in which unsupervised RMT was performed. Significant improvements in respiratory outcomes were reported in two studies: Maximal Inspiratory and Expiratory Pressure (MIP40% and MEP25%, respectively), Peak Expiratory Flow (PEF9%), seated and supine Forced Vital Capacity (FVC23% and 26%, respectively), and Peak Cough Flow (28%). This review and case report will attempt to show that an inspiratory muscle training (IMT) home exercise program (HEP) is feasible and may prepare the respiratory system for RC associated with COVID-19 in patients with SCI. CASE PRESENTATION: A 23-year-old with tetraplegia (P1), history of mechanical ventilation, and hospitalization for RC, completed 27 IMT HEP sessions in one month. MIP and sustained MIP (SMIP) increased from baseline by 28% and 26.5%, respectively. Expiratory volumes and rates also improved (FVC, FEV1, and PEF: 11.7%, 8.3%, and 14.2%, respectively). DISCUSSION: The effects of COVID-19 on patients with SCI remains inconclusive, but recent literature and the results of this case suggest that unsupervised IMT is feasible and may limit the severity of RC in patients with SCI who contract COVID-19.

Clinical features and prognosis of COVID-19 in people with spinal cord injury: a case-control study.

STUDY DESIGN: Observational case-control study. OBJECTIVE: Individuals with spinal cord injury (SCI) develop systemic physiological changes that could increase the risk of severe evolution of coronavirus disease 2019 (COVID-19) and result in atypical clinical features of COVID-19 with possible delay in both diagnosis and treatment. We evaluated differences in clinical features and evolution of COVID-19 between people with SCI and able-bodied individuals. SETTING: The study was conducted in an Italian inpatient rehabilitation referral center for individuals with SCI during the lockdown for the COVID-19 pandemic. METHODS: We compared clinical information between patients with SCI and able-bodied healthcare workers of the same center who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasopharyngeal swab polymerase chain reaction. RESULTS: Overall, 15 out of the 25 SCI patients admitted to the center and 17 out of the 69 healthcare workers tested positive for SARS-CoV-2. Patients with SCI exhibited a significantly more advanced age and a higher prevalence of comorbidities. Nevertheless, no significant differences in clinical expression of COVID-19 and treatment strategies were observed between the two groups. All hospitalized subjects were treated in nonintensive care units and no deaths occurred in either group. CONCLUSIONS: This study does not support the supposed notion that COVID-19 could exhibit atypical clinical features or a worse evolution in the frail population of people with SCI.

A Patient With Acute Cervical Cord Injury and COVID-19: A First Case Report.

During the pandemic of coronavirus disease 2019, it is possible for rehabilitation physicians and personnel to take care of patients with concurrent spinal cord injury and coronavirus disease 2019. Here, we describe a case of acute cervical spinal cord injury resulting in complete tetraplegia C5 American Spinal Injury Association Impairment Scale A with unrecognized, severe acute respiratory syndrome coronavirus 2 infection. This resulted in large-scale quarantines of related surgical and rehabilitation staff, and the unexpected death of the patient despite receiving the treatments according to the standard guideline. Rehabilitation personnel who take care of acute spinal cord injury patients with coronavirus disease 2019 should consider the effect of spinal cord injury on the course of coronavirus disease 2019, the effect of coronavirus disease 2019 and its treatments on the course of spinal cord injury, and risks of severe acute respiratory syndrome coronavirus 2 transmission between patients and rehabilitation staff, to continue providing safe and effective rehabilitation programs.