The importance of the anal exam in neurologic classification of spinal cord injury.

The examination of the sensation of the anal orifice and the contraction of the external anal sphincter, either voluntarily or reflexly, has always been an integral part of the International Standards for Neurologic Classification of Spinal Cord Injury (ISNCSCI). Yet the importance of this component has been defended and challenged. This paper compares these two points of view as expressed by Previnaire and Marino, respectively. Both authors make important points but as the papers do not address the same aspect of the anal exam, room for further refinement of ISNCSCI both regarding the details of the exam and the use of components of the exam for prognostication of neurologic recovery is apparent.

Multicenter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder.

OBJECTIVES: To compare the effectiveness of bacterial interference versus placebo in preventing urinary tract infection (UTI). METHODS: The main outcome measure was the numbers of episodes of UTI/patient-year. Randomization was computer generated, with allocation concealment by visibly indistinguishable products distributed from a core facility. The healthcare providers and those assessing the outcomes were unaware of the group allocation. Adult patients (n = 65) with neurogenic bladder after spinal cord injury and a history of recurrent UTI were randomized in a 3:1 ratio to receive either Escherichia coli HU2117 or sterile saline. Urine cultures were obtained weekly during the first month and then monthly for 1 year. The patients were evaluable if they remained colonized with E. coli HU2117 for >4 weeks (experimental group). The trial is closed to follow-up. RESULTS: Of the 59 patients who received bladder inoculations, 27 were evaluable (17 in the experimental group and 10 in the placebo group). The 2 study groups had comparable clinical characteristics. Of 17 patients colonized with E. coli HU2117 and the 10 control patients, 5 (29%, 95% confidence interval 0.11-0.56) and 7 (70%, 95% confidence interval 0.35-0.92) developed >1 episode of UTI (P = .049; 1-sided Fisher's exact test), respectively. The average number of episodes of UTI/patient-year was also lower (P = .02, Wilcoxon rank sum test) in the experimental (0.50) than in the control group (1.68). E. coli HU2117 did not cause symptomatic UTI. CONCLUSIONS: Bladder colonization with E. coli HU2117 safely reduces the risk of symptomatic UTI in patients with spinal cord injury. Effective, but less complex, methods for achieving bladder colonization with E. coli HU2117 are under investigation.

Mechanical ventilation, health, and quality of life following spinal cord injury.

OBJECTIVE: To examine differences in perceived quality of life (QOL) at 1 year postinjury between people with tetraplegia who required mechanical ventilation assistance at discharge from rehabilitation and those who did not. DESIGN: Prospective cross-sectional examination of people with spinal cord injury (SCI) drawn from the SCI Model Systems National Database. SETTING: Community. PARTICIPANTS: People with tetraplegia (N=1635) who sustained traumatic SCI between January 1, 1994, and September 30, 2008, who completed a 1-year follow-up interview, including 79 people who required at least some use of a ventilator at discharge from rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Satisfaction With Life Scale (SWLS); Craig Handicap Assessment and Reporting Technique (CHART)-Short Form Physical Independence, Mobility, Social Integration, and Occupation subscales; Patient Health Questionnaire-9 (PHQ-9), Medical Outcomes Study 36-Item Short-Form Health Survey self-perceived health status. RESULTS: Significant differences were found between the ventilator-user (VU) group and non-ventilator-user (NVU) group for cause of trauma, proportion with complete injury, neurologic impairment level, and number of rehospitalizations. The NVU group had significantly higher SWLS and CHART Social Integration scores than the VU group after controlling for selected covariates. The NVU group also had more positive perceived health status compared with a year previously and a lower incidence of depression assessed by using the PHQ-9 than the VU group. There were no significant differences between groups for perceived current health status. CONCLUSIONS: People in this study who did not require mechanical ventilation at discharge from rehabilitation post-SCI reported generally better health and improved QOL compared with those who required ventilator assistance at 1 year postinjury. Nonetheless, the literature suggests that perceptions of QOL improve as people live in the community for longer periods.

Outcome measures for gait and ambulation in the spinal cord injury population.

BACKGROUND: At the 2006 National Institute on Disability and Rehabilitation Research (NIDRR) sponsored pre-conference on spinal cord injury (SCI) outcomes, several gait and ambulation measures were evaluated for utility in clinical practice, validity, and reliability as research measurement tools. The Conference Subcommittee on Gait and Ambulation chose to review the Walking Index for Spinal Cord Injury II (WISCI II), 50-Foot Walk Test (50FTWT), 6-Minute Walk Test (6MWT), 10-Meter Walk Test (10MWT), and Functional Independence Measure-Locomotor (FIM-L). METHODS: A subcommittee of international experts evaluated each instrument for test construct, administration, population applicability, reliability, sensitivity to change, and validity. Evaluations for each outcome measure were compiled, distributed to the whole committee, and then further reviewed with addition of comments and recommendations for consensus. An audience of experts voted on the validity and usefulness of each measure. RESULTS: WISCI II and 10MWT were found to be the most valid and clinically useful tests to measure improvement in gait for patients with SCI. FIM-L had little utility and validity for research in SCI. 6MWT and 50FTWT were found to be useful but in need of further validation or changes for the SCI population. CONCLUSION: A combination of the 10MWT and WISCI II would provide the most valid measure of improvement in gait and ambulation in as much as objective changes of speed, and functional capacity allow for interval measurement. To provide the most comprehensive battery, however, it will be important to include a measure of endurance such as the 6MWT. Further validation and study should be devoted to WISCI II, 10MWT, and 6MWT as primary outcome measures for gait in SCI.

Development of spontaneous intracranial hypotension concurrent with grade IV mobilization of the cervical and thoracic spine: a case report.

Spontaneous intracranial hypotension (SIH) has been clinically defined as the development of severe orthostatic headaches caused by an acute cerebrospinal fluid (CSF) leak. Typically, intracranial hypotension occurs as a complication of lumbar puncture, but recent reports have identified cases caused by minor trauma. We report a case of SIH secondary to a dural tear caused by a cervical and thoracic spine mobilization. A 32-year-old woman with SIH presented with severe positional headaches with associated hearing loss and C6-8 nerve root distribution weakness. CSF opening pressure was less than 5cmH(2)O and showed no abnormalities in white blood cell count. Cranial, cervical, and thoracic magnetic resonance imaging revealed epidural and subdural collections of CSF with associated meningeal enhancement. Repeated computed tomography myelograms localized the leak to multiple levels of the lower cervical and upper thoracic spine. A conservative management approach of bedrest and increased caffeine intake had no effect on the dural tear. The headache, hearing loss, and arm symptoms resolved completely after 2 epidural blood patches were performed. Practitioners performing manual therapy should be aware of this rare, yet potential complication of spinal mobilizations and manipulations.

Donald Munro Lecture. Spinal cord injury--past, present, and future.

This special report traces the path of spinal cord injury (SCI) from ancient times through the present and provides an optimistic overview of promising clinical trials and avenues of basic research. The spinal cord injuries of Lord Admiral Sir Horatio Nelson, President James A. Garfield, and General George Patton provide an interesting perspective on the evolution of the standard of care for SCI. The author details the contributions of a wide spectrum of professionals in the United States, Europe, and Australia, as well as the roles of various government and professional organizations, legislation, and overall advances in surgery, anesthesia, trauma care, imaging, pharmacology, and infection control, in the advancement of care for the individual with SCI.

Construct validity and dimensional structure of the ASIA motor scale.

BACKGROUND/OBJECTIVE: The use of the American Spinal Injury Association (ASIA) motor score as an outcome measure requires metrological study. This paper tests the hypothesis that a more accurate representation of motor function is obtained using separate upper and lower extremity scales rather than combining all 20 key muscle ratings into a single ASIA motor score. METHODS: We analyzed archived data from 6116 ASIA motor scale records extracted from the National Spinal Cord Injury Statistical Center Database. RESULTS: The hypothesis that separate scales more accurately represent motor function than a single motor scale was supported (chi2(difference) = 2596; df=1; P < 0.0001). Two scales account for 87% of the variance, whereas a single scale accounts for only 82%. Lower extremity function is well represented in both solutions; however, upper extremity function is accurately represented only with the use of 2 separate scales. CONCLUSIONS: The use of components of the ASIA standards for other than classification of spinal cord injury needs study. Several lines of study converge to provide strong support for the existence of 2 distinctive dimensions underlying the ASIA motor scale. The use of a single motor score in spinal cord injury research should be questioned and justified to the extent possible. The use of upper and lower extremity scales will lead to a reduction in measurement error when the motor score is used as an outcome measure. The confirmation of 2 separate dimensions underlying the ASIA motor score will enable more accurate representation of motor function in spinal cord injury research.

Bacterial interference for prevention of urinary tract infection: a prospective, randomized, placebo-controlled, double-blind pilot trial.

This prospective, randomized, placebo-controlled, double-blind pilot trial examined the efficacy of bacterial interference in preventing urinary tract infection (UTI) in 27 patients with spinal cord injury. Patients whose bladders became colonized with Escherichia coli 83972 were half as likely (P=.01) than noncolonized patients to develop UTI during the subsequent year.

Comparison of dalteparin and enoxaparin for deep venous thrombosis prophylaxis in patients with spinal cord injury.

OBJECTIVE: To determine differences between dalteparin and enoxaparin in patients with spinal cord injury. DESIGN: This prospective, randomized, open-label study was performed as a multiple hospital trial in a large urban setting. A total of 100 patients with acute (<3 mo) spinal cord injury were recruited. A total of 95 patients met all inclusion criteria. Fifty received enoxaparin, and 45 received dalteparin. Main outcome measures included deep venous thrombosis, bleeding, compliance, Short Form-12 Health Status Survey, satisfaction, and medication/labor costs. Patients were randomized to receive 30 mg of enoxaparin subcutaneously every 12 hr or 5000 IU of dalteparin subcutaneously once daily. Prophylaxis was continued for 3 mo for motor-complete and 2 mo for motor-incomplete patients. RESULTS: Six percent of the patients developed deep venous thrombosis while receiving enoxaparin and 4% while receiving dalteparin (chi2 = 0.44, df = 1, P = 0.51). Four percent developed bleeding while receiving dalteparin and 2% while receiving enoxaparin (chi2 = 0.13, df = 1, P = 0.72). No differences were noted in compliance, health status, or most of the satisfaction measures. It was, however, noted that after being discharged home, the patients receiving enoxaparin rated the shots significantly more inconvenient (two injections per day) compared with taking three pills per day, than those receiving dalteparin (one injection per day, P < 0.05). The cost of the medication was 1101 US dollars/mo for enoxaparin (two injections per day) and 750 US dollars/mo for dalteparin (one injection per day). CONCLUSION: Similar compliance, health status, deep venous thrombosis, and bleeding rates were found between dalteparin and enoxaparin.

A view of the future Model Spinal Cord Injury System through the prism of past achievements and current challenges.

OBJECTIVE: To examine the contributions of the Model Spinal Cord Injury System (MSCIS) program to the evaluation and care of individuals with spinal cord injury (SCI) and to acknowledge today's challenges to chart the future course of the MSCIS. METHODS: Retrospective review of the literature and prospective development of consensus by task force members and consultants. Integration of recent reported findings from panel presentations and publications regarding the MSCIS 2000 through 2005. FINDINGS: Significant strides have been made toward the improvement of care for individuals with SCI, which can be attributed to the quality of clinical investigation and education. This has been achieved through the leadership of MSCIS directors in partnership with members from national and international voluntary organizations. These efforts include more than 2,000 peer-reviewed publications from the MSCIS, which have served as a basis for practice guidelines in the field. Although much has been accomplished with regard to reducing medical and behavioral complications, mortality, and length of stay in the hospital and increasing successful return to the community, more is needed. CONCLUSION: The MSCIS has a unique opportunity to provide solutions because of its world-renowned database and center, outcome measures, and infrastructure for trials. To maximize this opportunity, the MSCIS must continue to address the appropriate investigational and service issues by defining the best approach to data collection, rigorous clinical studies, and behavioral strategies in the next decade.

Role of type 1 fimbria- and P fimbria-specific adherence in colonization of the neurogenic human bladder by Escherichia coli.

Recent clinical studies suggest that the deliberate colonization of the human bladder with a prototypic asymptomatic bacteriuria-associated bacterium, Escherichia coli 83972, may reduce the frequency of urinary tract infection in individuals with spinal cord injuries. However, the mechanism by which E. coli 83972 colonizes the bladder is unknown. We examined the role in bladder colonization of the E. coli 83972 genes papG and fimH, which respectively encode P and type 1 receptor-specific fimbrial adhesins. E. coli 83972 and isogenic papGDelta and papGDelta fimHDelta mutants of E. coli 83972 were compared for their capacities to colonize the neurogenic human bladder. Both strains were capable of stable colonization of the bladder. The results indicated that type 1 class-specific adherence and P class-specific adherence, while implicated as significant colonization factors in experiments that employed various animal model systems, were not required for colonization of the neurogenic bladder in human beings. The implications of these results with regard to the selection of potential vaccine antigens for the prevention of urinary tract infection are discussed.