Upper extremity neuropathies in patients with spinal cord injuries

Case-Control Study of Ultrasound Evaluation of Acute Median Nerve Response to Upper Extremity Circuit Training in Spinal Cord Injury

OBJECTIVE

Individuals with spinal cord injury (SCI) often present signs and symptoms of median nerve (MN) pathology. Preclinical signs identification of MN pathology might facilitate early intervention to prevent or delay carpal tunnel syndrome in SCI. We assessed if ultrasound parameters changed in response to upper extremity (UE) circuit training exercise in individuals with paraplegia and able-bodied individuals.

DESIGN

Case-control study.

PARTICIPANTS

Adults (N=32) with paraplegia (n=16) and age- and sex-matched able-bodied controls (n=16).

INTERVENTION

Circuit training exercise.

MAIN OUTCOME MEASURES

MN ultrasound evaluation at the pisiform and radius before and after UE exercise. Ultrasound parameters included cross-sectional area (CSA), and gray scale (GS). Data presented as mean ± SD.

RESULTS

Pre-exercise CSAs were larger in SCI at the radius (12.0±2.9 vs 9.0±2.1; P=.003), but not the pisiform (9.8±3.1 vs 9.1±1.7; P=.431). There were no statistical differences in MN response to exercise between groups (all P≥.293). Across participants, CSA changes were inversely associated with their pre-exercise values at the pisiform (r=-0.648; P<.001) and the radius (r=-0.366; P=.043). Participants with pre-exercise CSA values ≥10.00 mm² at the pisiform responded to exercise with decreases in CSA (mean change ± SD, -2.0±1.5; P=.002) and GS (-2.8±6.2; P=.029). Participants with pre-exercise CSA ≤9.99 mm² at the pisiform responded to exercise with no change in CSA (mean change ± SD, 0.7±2.5; P=.002) and increased GS (3.2±7.2; P=.029).

CONCLUSIONS

CSA exercise response was more strongly related to pre-exercise MN values than presence or absence of SCI.

Longitudinal changes in medical complications in adults with pediatric-onset spinal cord injury

OBJECTIVES

To determine longitudinal changes in the occurrence of medical complications in adults with pediatric-onset spinal cord injury (SCI).

DESIGN

Longitudinal study of long-term outcomes.

SETTING

Community.

PARTICIPANTS

Individuals who had sustained an SCI before age 19, were 23 years of age or older at initial interview, and followed annually between 1996 and 2011. They were classified into four American Spinal Injury Association (ASIA) Impairment Scale (AIS) severity groups: C1-4 AIS ABC, C5-8 AIS ABC, T1-S5 AIS ABC, AIS D.

OUTCOME MEASURES

Generalized estimating equation (GEE) models were formulated to obtain the odds ratio (OR) of having a medical complication over time.

RESULTS

A total of 1793 interviews were conducted among 226 men and 125 women (86% Caucasian; age at baseline, 26.7 ± 3.6 years; time since injury at baseline, 12.9 ± 5.2 years). Odds of complication occurrence over time varied among severity groups, with increased ORs of severe urinary tract infection (1.05, confidence interval (CI) 1.02-1.09), autonomic dysreflexia (AD) (1.09, CI 1.05-1.14), spasticity (1.06, CI 1.01-1.11), pneumonia/respiratory failure (1.09, CI 1.03-1.16), and hypertension/cardiac disease (1.07, CI 1.01-1.15) in the C1-4 ABC group; AD (1.08, CI 1.04-1.13) and pneumonia/respiratory failure (1.09, CI 1.02-1.16) in the C5-8 ABC group; and hypertension/cardiac disease (1.08, CI 1.02-1.14) in the T1-S5 ABC group. Upper extremity joint pain had increased odds of occurrence in all injury severity groups.

CONCLUSION

The significantly increased odds of having medical complications over time warrants awareness of risk factors and implementation of preventive measures to avoid adverse consequences of complications and to maintain independence in individuals with pediatric-onset SCI.

Advances in the rehabilitation management of acute spinal cord injury

Aggressive assessment and management of the secondary complications in the hours and days following spinal cord injury (SCI) leads to restoration of function in patients through intervention by a team of rehabilitation professionals. The recent certification of SCI physicians, newly validated assessments of impairment and function measures, and international databases agreed upon by SCI experts should lead to documentation of improved rehabilitation care. This chapter highlights recent advances in assessment and treatment based on evidence-based classification of literature reviews and expert opinion in the acute phase of SCI. A number of these reviews are the product of the Consortium for Spinal Cord Medicine, which offers clinical practice guidelines for healthcare professionals. Recognition of and early intervention for problems such as bradycardia, orthostatic hypotension, deep vein thrombosis/pulmonary embolism, and early ventilatory failure will be addressed although other chapters may discuss some issues in greater detail. Early assessment and intervention for neurogenic bladder and bowel function has proven effective in the prevention of renal failure and uncontrolled incontinence. Attention to overuse and disuse with training and advanced technology such as functional electrical stimulation have reduced pain and disability associated with upper extremity deterioration and improved physical fitness. Topics such as chronic pain, spasticity, sexual dysfunction, and pressure sores will be covered in more detail in additional chapters. However, the comprehensive and integrated rehabilitation by specialized SCI teams of physicians, nurses, therapists, social workers, and psychologists immediately following SCI has become the standard of care throughout the world.

Is carpal tunnel release under-utilized in veterans with spinal cord injury?

OBJECTIVE

Carpal tunnel syndrome (CTS) is a common disorder among individuals with spinal cord injury (SCI). Although carpal tunnel release is highly effective, the procedure may be under-utilized in this population. This study attempts to identify if CTS is under-treated in Veterans with SCI.

DESIGN

The Veterans Affairs (VA) National Patient Care Database was used for data compilation within fiscal years 2007 and 2008. Using ICD-9-CM diagnoses codes, individuals with SCIs were identified, including those diagnosed with CTS. Current procedural terminology (CPT) codes further showed those who had undergone surgical intervention including open and endoscopic release of the transverse carpal ligament. The VA SCI cohort was compared to the general VA population with regard to demographics, diagnosis, surgical intervention, and treatment location.

RESULTS

A total of 19 296 veterans with SCI were identified within the 2-year period. The prevalence of CTS within this cohort was 3.5%, compared to 2.1% in the general VA population. The rate of transverse carpal ligament release was similar between the VA SCI cohort and general population (0.24 and 0.17%, respectively). The majority of surgical treatment (89%) occurred within the VA 'hub-and-spoke' system of SCI care.

CONCLUSION

CTS appears to be under-diagnosed and under-treated in veterans with SCI.

Myotonic dystrophy presenting as new-onset hand weakness and recurrent pneumonia in a patient with paraplegia: A case reportaaNo commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

We describe a previously independent T11 paraplegic patient who had delayed-onset hand weakness and recurrent pneumonia caused by myotonic dystrophy. A man in his late thirties suffered a thoracic spinal cord injury (SCI) from a gunshot wound at the age of 17 years, with resultant T11 American Spinal Injury Association class A paraplegia. He lived independently until the age of 36 years when he was hospitalized multiple times for pneumonia. During a rehabilitation stay after one of the acute hospitalizations, the patient's hand weakness and diffuse muscular atrophy were noted. Electrodiagnostic testing was performed, which showed myotonic discharges. Genetic testing was consistent with myotonic dystrophy. This case shows the importance of considering causes of weakness that affect the population as a whole when evaluating a patient with SCI who presents with delayed-onset weakness.

Comparison of three different models to represent the wrist during wheelchair propulsion

Due to the high incidence of secondary wrist injury among manual wheelchair users, recent emphasis has been placed on the investigation of wheelchair propulsion biomechanics. Accurate representation of wrist activity during wheelchair propulsion may help to elucidate the mechanisms contributing to the development of wrist injuries. Unfortunately, no consensual wrist biomechanical model has been established. In order to determine if different methodologies obtain similar results, this investigation created and compared three different wrist models: 1) a fixed joint center placed between the styloids (midstyloid joint center); 2) a joint center with 2 degrees of freedom computed from de Leva's joint center data; and 3) a floating joint center. Results indicate that wrist flexion and extension angles are highly consistent between models, however, radial and ulnar deviation angles vary considerably. Mean maximum right flexion angles were found to be 3.5 degrees, 2.2 degrees, and 5.0 degrees for the midstyloid, de Leva, and floating joint center models, respectively. Extension angles were 22.3 degrees, 23.6 degrees, and 23.6 degrees, respectively. Mean maximum right radial deviation angles for the midstyloid, de Leva, and floating joint center models were 26.0 degrees, 26.9 degrees, and 45.1 degrees, respectively, and ulnar deviation angles were found to be 30.5 degrees, 38.8 degrees, and 10.2 degrees, respectively. This information is useful when comparing kinematic studies and further supports the need for consensual methodology.

Electrodiagnosis in spinal cord injured persons with new weakness or sensory loss: central and peripheral etiologies

OBJECTIVE

To assess the prevalence and causes of late neurologic decline of persons with spinal cord injury (SCI).

DESIGN

Retrospective review of persons with SCI over a 9-year period. Those with complaints of new weakness or sensory loss were grouped into three categories based on clinical examination, electrodiagnosis, and imaging: (1) central pathology (ie, brain, spinal cord, or nerve root); (2) peripheral pathology (plexus or peripheral nerve); or (3) no identifiable etiology. The specific diagnoses of late neurologic decline were identified.

SETTING

Regional Veterans Affairs Spinal Cord Injury Service.

PATIENTS

Five hundred two inpatient and outpatient adults with SCI.

RESULTS

Nineteen percent of the study population complained of new weakness and/or sensory loss. Neurologic abnormalities were noted in 13.5%, 7.2% with central and 6.4% with peripheral causes. The most common pathologies were posttraumatic syringomyelia (2.4%) and cervical (1.6%) and lumbosacral (1.2%) myelopathy/radiculopathy. A specific etiology was not determined in 6 cases (1.6%). Peripheral involvement was mostly from ulnar nerve entrapment (3.4%) and carpal tunnel syndrome (3.0%).

CONCLUSIONS

Late-onset neurologic decline is common after SCI and can result from central or peripheral pathology. Regular neurologic monitoring of SCI patients is recommended, since many with neurologic decline respond favorably if diagnosed and treated early.