"Doctor, how long will it take?" Results from an historical cohort on surgical pressure ulcer healing delay and related factors in persons with spinal cord injury.

BACKGROUND: Flap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors. METHODS: This observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Hérault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure. RESULTS: 85 patients were included. Median healing time was 48 days (R: 20-406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02). CONCLUSION: After primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.

Rotator cuff surgery in persons with spinal cord injury: relevance of a multidisciplinary approach.

BACKGROUND: This article is a prospective review of patients with spinal cord injury who underwent multidisciplinary consultation from January 2005 to September 2013 for pain in one or both shoulders. METHODS: We performed clinical, functional, and lesion evaluations of 38 patients with paraplegia and quadriplegia presenting with rotator cuff pathologies. RESULTS: Surgery was indicated and performed on 38 shoulders in 28 patients. The lesion assessment during surgery showed injuries that were more severe than one would have thought based on imaging data. The mean pain intensity rating in the operative and nonoperative groups was 0 and 1.6, respectively, at rest and 2 and 4.9, respectively, during paroxysmal peaks. On average, for patients who had surgery, the Functional Independence Measure score decreased by 2.3. The mean satisfaction index in operated patients was 8.5 of 10. CONCLUSIONS: When the surgical indication was based on a multidisciplinary decision, no negative results were reported that could have challenged the validity of this decision. Pain relief was the primary benefit reported after surgery. The functional status was modified because of the technical aids needed to prevent shoulder overuse. There are several arguments in favor of rotator cuff surgery for wheelchair-bound patients with spinal cord injury. Because of their functional impairments, wheelchair-bound patients will continue to overburden their shoulders after rotator cuff surgery. A multidisciplinary approach emerges as the solution to inform and educate patients to limit the risk of recurrence.

Osteoporosis in persons with spinal cord injury: the need for a targeted therapeutic education.

OBJECTIVES: To identify circumstances surrounding the onset of fracture and common risk factors in persons with spinal cord injury (SCI) and to suggest an alternative or complement to the pharmacologic approach by evaluating the need for a prospective study based on the impact of a targeted therapeutic education on risk management of fractures in this population. DESIGN: Retrospective study. SETTING: Hospital and Rehabilitation Center Setting. PARTICIPANTS: Women (n=7) and men (n=25; N=32; with ≥1 fracture after the initial SCI that occurred at home or in a hospital setting; mean ± SD age, 53±12y at the time of clinical review) with bone mineral density (BMD) measurements. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographics, main circumstances of onset, and complications of fractures, as well as transversal bone mineral density evaluation. RESULTS: Nine patients had more than 1 fracture and 23 patients had only 1 fracture (total, 43 fractures; mean age at onset of fracture, 49±12y; median time since injury, 13.9y; mean delay in diagnosis, 6.5±15d). Fractures occurred mostly in the lower limbs. The circumstances of onset of these fractures were different and very stereotyped. In 3 cases, no trauma was reported. The most frequent mechanisms identified were forced maneuvers by the patient or a third party and falls. In 10 cases, the fracture occurred during a wheelchair transfer with forced maneuver or a fall from the wheelchair. Twenty-five patients were confined to bed after the fracture (mean duration of bed confinement, 18±28d; range, 0-120d). Postfracture follow-up showed that for 43 cases of fractures, 19 had at least 1 orthopedic complication, 15 had local complications, and 23 had general complications. Patients (23 of 32) benefited from dual-energy X-ray absorptiometry to assess BMD a few months or years after the fracture (mean femoral neck BMD, 0.574±0.197g/cm²; mean femoral neck T score, -3.8±1.5). CONCLUSION: With this retrospective analysis of common risk factors and circumstances of onset of secondary fractures, there is a clear future for a prospective study to evaluate the impact of targeted therapeutic education on risk factors for secondary fractures in patients with SCI.

Metastatic paraplegia and functional outcomes: perspectives and limitations for rehabilitation care. Part 2.

OBJECTIVE: To identify functional outcomes that could justify the need for a rehabilitation care program for patients with metastatic epidural spinal cord compression (MESCC) and paraplegia. DATA SOURCES: Publications from 1950 to January 2010 selected from 3 databases. STUDY SELECTION: Original articles dealing with outcome data for functional status, pain, and bladder dysfunction. DATA EXTRACTION: Standardized reading grid. DATA SYNTHESIS: The data are dominated by retrospective studies for even functional-related data, and studies from rehabilitation teams are rare. They report a functional evolution similar to a population with traumatic spinal cord injury for the first 3 months. Patients who were ambulatory before treatment retained their ability to walk, and patients who were nonambulatory before treatment could regain gait abilities. Data also showed a positive impact on pain and bladder and/or bowel dysfunction. CONCLUSIONS: By restricting physical medicine and rehabilitation therapeutic care to a short time (1-2mo), the progression margin is possible in the short term and implies a voluntary and active therapeutic care approach for patients with paraplegia after MESCC on the basis of a codified and standardized program with clinical indicators, as well as patients' comfort indicators.