Young spinal cord injured patients in nursing homes: rehospitalization issues and outcomes.

Most spinal cord injured (SCI) patients are discharged to their homes and families after they complete their initial rehabilitation program. Nursing homes, however, were the discharge destinations for 3.9% of all SCI patients nationally. When a nursing home is the only discharge option for a young SCI adult, certain economic, medical and psychosocial incongruencies make this placement potentially stressful for both the nursing home staff and the young patient. This study of the rehospitalization of 12 SCI patients under the age of 50 who were discharged to nursing homes explores the issues of cost, care and outcome during their first year following nursing home admission. Nine of the 12 patients were rehospitalized a total of 21 times, mainly for urinary tract infections and decubiti. Charges for 18 of these 21 rehospitalizations amounted to over $423,110 for 599 days of care. Four of these 9 patients died before the end of the first year. Although this is a retrospective study of the medical records and follow up data for a small key group of SCI patients, it calls attention to the need for continued investigation into the outcomes of a minimally visible population that lacks advocacy for change.

Clonidine transdermal system for treatment of spasticity in spinal cord injury.

Clonidine tablets have been used in the past for treatment of spasticity with some success. The use of clonidine, however, has been limited by adverse effects, mainly hypotension. Over a two-year period, 17 patients were started on clonidine transdermal delivery system. They were followed for up to 18 months. Twelve of the 17 patients had a beneficial response and have continued on the patch. In ten of these 12 patients, other antispasticity drugs were either reduced or discontinued. In another three of the 17 patients, the response was good, but the patch was discontinued. No patient demonstrated persistent problematic hypotension. Clonidine Transdermal Patch appears to be an effective treatment for spasticity after a spinal cord injury. Adverse effects appear to be minimized using this mode of delivery.

Non-granulomatous spinal epidural abscess: a rehabilitation perspective.

Spinal epidural abscess (SEA) as a cause of back pain, fever, and neurological deficits has been recognised. Reports of this entity have increased in recent years, possibly likely secondary to increasing intravenous drug abuse. Most patients recover without neurological sequelae. Recent reports in fact indicate that those with persistent deficit have a much poorer prognosis for survival. As a result, few patients with SEA are seen in spinal injury rehabilitation programmes. Our 5 years experience with SEA was reviewed. Thirteen patients were admitted with residual neurological deficits following a course of prolonged antibiotic therapy. Of these most had progressive neurological improvement with only 3 of 4 remaining Frankel class A and 3 of 7 Frankel class C. The only mortalities (2) were secondary to the underlying medical problems. Most patients were discharged home.

Targeting teenagers in a spinal cord injury prevention program.

The problem of teenage spinal cord injury (SCI) secondary to gunshot wounds was observed in a model SCI system. By identifying one factor, 'risk taking', in which the system could intervene, a SCI prevention program was developed that has had major community attention. Hopefully, it will also meet the needs of other communities experiencing interpersonal violence among adolescents.

Falls resulting in spinal cord injury: patterns and outcomes in an older population.

Falls are the major cause of spinal cord injuries in older people. The pattern of injury seen most frequently is that of a central cord syndrome due to cervical hyperextension. The medical records of 58 patients over 50 years of age who sustained a spinal cord injury in a fall were reviewed for circumstances of onset, length of stay and outcomes of rehabilitation. The study identified elderly single or widowed men, and those who use alcohol, as high risk groups.

Victims of gun shootings. A retrospective study of 36 spinal cord injured adolescents.

Interpersonal violence with a handgun is the primary cause of spinal cord injuries (SCI) among teenagers in the population served by the Southeastern Michigan Spinal Cord Injury System (SEMSCIS). As part of a community-wide effort to reduce the injury and death rate from acts of violence, SEMSCIS selected the victim, rather than the perpetrator or the sociocultural environment, as its segment of a prevention program. A retrospective study of demographic data, causal statements, medical information from the medical records of 36 injured adolescents, and telephone conversations with the victims identified "risk taking" as the pre-event behavior that had made them vulnerable to violence. This study led to the production of a powerful video, "Wasted Dreams," in which disabled teenagers tell their peers about their injury and how to avoid becoming a victim.

A new approach to catastrophic injury: spinal cord injury patients.

Catastrophic injuries and illnesses create great financial strains on patients who require lifetime care. Families, health care providers and insurers recognise that individual patient care needs require a closer look at the prudent allocation of health care benefit dollars. Blue Cross Blue Shield of Michigan has initiated an approach to this problem called 'case management'. Two ventilator dependent quadriplegics were discharged home utilising the case management concept. This system provides many advantages for patients. However, the health care team needs to be aware of the drawbacks of the system.

Independent dressing after spinal cord injury: a functional time evaluation.

Functional skill independence is generally defined as the ability to perform a functional task. The time required for completion, however, is usually not a major consideration. Postdischarge follow-up interviews indicated that patients do not always continue to perform all reacquired functional skills that were considered important rehabilitation goals. A pilot study was done to look at the skill of dressing independently to determine if time was a factor in the decision to retain, modify, or completely delegate this activity. Ten patients with C6-level quadriplegia, who were capable of self-dressing at discharge, participated in the study. They were timed for dressing at home. Although all ten patients were capable of dressing independently within one hour, none did so routinely. "Too much time and too much work" were the reasons stated. The implication is that a functional skill must be accomplished within the individual's concept of an appropriate time and/or energy framework in order to be considered truly functional.

Posterior central cord syndrome following a hyperextension injury: case report.

Throughout the spinal cord literature, a posterior central cord syndrome has been noted to be a rare occurrence. Furthermore, it has never been correlated with a specific type of injury. A patient with clinical signs consistent with a posterior central cord syndrome is discussed, and hyperextension is suggested as a possible mechanism for this type of injury.

Fever and thromboembolic disease in acute spinal cord injury.

Thromboembolic Disease (T.E.D.) is a major cause of morbidity and mortality in the first few months following spinal cord injury. The purpose of this three year retrospective study is to delineate the previously poorly described role of fever as both a common component of T.E.D. manifestation and, on occasion, the sole presenting sign of an otherwise occult T.E.D. process. We reviewed 148 consecutive admissions to the Southeastern Michigan Spinal Cord Injury System (1982-1985). Ten patients with documented T.E.D. were found and extensively reviewed; 3 had inadequate documentation of clinical manifestations and 1 patient was found from venography to have a non-acute thrombosis. Of the remaining 6 cases, all had fever as a sign, and 4 of these patients had fever as the sole presenting sign. Full fever work-ups were performed in each case and no other source for fever could be found. Fever spikes occurred most commonly at night, with a maximum temperature of 100.2 degrees F (oral) to a high in one case of 103.0 degrees F (oral). All fevers resolved within the first week of adequate anticoagulation therapy. These findings indicate that fever may be the earliest and, possibly, only clinical sign of an otherwise occult T.E.D. process.

Thromboembolic disease presenting as fever in spinal cord injury.

A 45-year-old man had complete C5 quadriplegia after sustaining a C6-7 fracture dislocation in a motor vehicle accident. Twenty-six days after injury the patient spiked nightly temperatures of 100.5F to 102.5F. Before a full fever workup could be completed, the patient developed shortness of breath. Thromboembolism was confirmed via venography and Ventilation/Perfusion scan. Other clinical signs of asymmetric swelling or warmth were notably absent throughout the course of the thromboembolic event. The patient became afebrile on the third day of anticoagulant therapy and remained afebrile. This case indicates that thromboembolic disease can present with fever only and the disease should be included in the differential diagnosis for fever in any patient with acute spinal cord injury.

Spasmodic torticollis as a cause of ulnar nerve entrapment.

Spasmodic torticollis is thought to be a central nervous system disorder with no peripheral nervous system component. Several consecutive patients with spastic torticollis were found to have ulnar nerve compromise at the elbow on the side ipsilateral to the direction of chin turning. This article describes three such patients in detail. It is postulated that the cause is the stereotypical posture assumed by these patients in using their hand to maintain a neutral head position. The chronic leaning and elbow flexion place the ulnar nerve at risk for the development of pressure neuropathy.

Functional paralysis mimicking spinal cord injury resulting in admission to a spinal cord injury center.

From 1978 through 1982, five patients with final diagnoses of nonorganic functional paraplegia or quadriplegia were seen and treated at the Northern California Regional Spinal Cord Injury Center. The patients ranged in age from 13 to 26 years and four were males. All had normal bowel and bladder function with otherwise complete motor and sensory paralysis, shifting sensory findings, and normal deep tendon reflexes early after injury. In each patient, a retrospective analysis demonstrated that structural anatomic lesion could be ruled out by a neurologic examination. Clinical and investigatory studies are discussed with respect to the diagnostic process.

Paraplegia following aortic surgery.

It has long been recognised that paraplegia may occur after various surgical procedures on the heart and the aorta. Paraplegia occurring following traumatic rupture of the aorta has not been commonly reported due to the dismal prognosis of such rupture. Over the past 3 years, we have encountered five patients who survived traumatic rupture of the aorta and developed paraplegia, and three patients who had chronic dissecting aneurysms of the aorta who also developed paraplegia. These patients continued to show neurological and functional improvement over the years. We are presenting these cases to illustrate their neurological improvement and to show that the prognosis for these patients may not be as dismal as previously reported once they survive the acute episode.

Heterotopic ossification in the hand of a patient with spinal cord injury.

Heterotopic ossification (HO), reported to occur in 20% to 40% of spinal cord injured patients, has been described in the hips, knees, shoulders and elbows, but not in the hands or around the phalangeal joints. This report is believed to be the first of HO of the hand after spinal cord injury. Nine weeks after injury, a diving accident, a 27-year-old man having C6 quadriplegia, motor complete, sensory incomplete, developed acute swelling and loss of range of motion in both hands. Serum alkaline phosphatase showed no significant rise. Bone scan demonstrated increased uptake in many joints of the left hand with x-rays remaining normal. Repeat films three weeks later demonstrated calcific densities adjacent to the midshaft of the proximal phalanx of the left finger. Twice daily range of motion of the hand resulted in improved range of motion. the etiology of HO in spinal cord injured patients remains unknown, and we have no explanation of its occurrence in the hands of this patient.

Electromyographic abnormalities following myelography.

Electromyographic (EMG) abnormalities were found in 13 of 32 patients with previously normal studies following myelography. These abnormalities usually developed by the first day after myelography and resolved by the fourth day. The changes were evenly divided between those restricted to a single paraspinal muscle level, thus mimicking the frequent findings in radioculopathy, and those present bilaterally and at multiple levels. We were unable to correlate these EMG changes with the clinical status of the patient or with events occurring at myelography. Thus, the performance of EMG within four days following myelography can lead to false-positive results if paraspinal muscle EMG abnormalities are used as the diagnostic criteria.

Effect of tourniquet time on postoperative quadriceps function.

Postoperative weakness of quadriceps function following knee arthrotomy has often been attributed to pain inhibition or lack of motivation. However, the delayed recovery may be the result of a slowly resolving axonal compression syndrome caused by the pneumatic tourniquet. Forty-eight patients who underwent knee arthrotomy were evaluated including postoperative electromyographic testing and clinical follow-up. Thirty of these patients (62.5%) developed postoperative EMG changes. Abnormalities were noted in various muscle groups but most commonly involved the quadriceps alone or quadriceps and gastrocnemius. An effort was made in 20 patients to substantially decrease the duration of tourniquet compression by limiting tourniquet inflation to intracapsular portions of the procedures. Fewer EMG changes and more rapid clinical recovery were noted in patients with decreased tourniquet times, suggesting that it is beneficial to minimize the duration of tourniquet compression. In all patients who returned for serial testing, the EMG abnormalities eventually resolved.