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1.  Dysphagia and Respiratory Care in Individuals with Tetraplegia: Incidence, Associated Factors, and Preventable Complications 
Dysphagia occurs in a significant number of individuals with spinal cord injury (SCI) presenting to acute care and inpatient rehabilitation. This prospective study has found dysphagia in nearly 40% of individuals with tetraplegia. Tracheostomy, mechanical ventilation, nasogastric tube, and age are significant risk factors. The detrimental complications of dysphagia in SCI can cause significant morbidity and delays in rehabilitation. Thus, early and accurate diagnosis of dysphagia is imperative to reduce the risk of developing life-threatening complications. Incidence and risk factors of dysphagia and the use of the bedside swallow evaluation (BSE) and videofluoroscopy swallow study (VFSS) to diagnose dysphagia are presented. The often underappreciated role of respiratory therapists, including assist cough, high tidal volume ventilation, and the use of Passy-Muir valve, in the care of individuals with SCI who have dysphagia is discussed. Improved secretion management and respiratory stabilization enable the individuals with dysphagia to be evaluated sooner and safely by a speech pathologist. Early evaluation and intervention could improve upon morbidity and delayed rehabilitation, thus improving overall clinical outcomes.
PMCID: PMC3584748  PMID: 23459783
aspiration; dysphagia; intubation; mechanical ventilation; pneumonia; spinal cord injury; swallowing; tetraplegia; tracheostomy
2.  Specialized Respiratory Management for Acute Cervical Spinal Cord Injury: 
In individuals with cervical spinal cord injury (SCI), respiratory complications arise within hours to days of injury. Paralysis of the respiratory muscles predisposes the patient toward respiratory failure. Respiratory complications after cervical SCI include hypoventilation, hypercapnea, reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Ultimately, the patient must use increased work to breathe, which results in respiratory fatigue and may eventually require intubation for mechanical ventilation. Without specialized respiratory management for individuals with tetraplegia, recurrent pneumonias, bronchoscopies, and difficulty in maintaining a stable respiratory status will persist.
This retrospective analysis examined the effectiveness of specialized respiratory management utilized in a regional SCI center.
Individuals with C1-C4 SCI (N = 24) were the focus of this study as these neurological levels present with the most complicated respiratory status.
All of the study patients’ respiratory status improved with the specialized respiratory management administered in the SCI specialty unit. For a majority of these patients, respiratory improvements were noted within 1 week of admission to our SCI unit.
Utilization of high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflation– exsufflation have demonstrated efficacy in stabilizing the respiratory status of these individuals. Optimizing respiratory status enables the patients to participate in rehabilitation therapies, allows for the opportunity to vocalize, and results in fewer days on mechanical ventilation for patients who are weanable.
PMCID: PMC3584785  PMID: 23459555
atelectasis; mechanical ventilation; pneumonia; respiratory complications; respiratory therapy; spinal cord injury; tetraplegia
3.  Dysphagia and Associated Respiratory Considerations in Cervical Spinal Cord Injury 
Dysphagia is a relatively common secondary complication that occurs after acute cervical spinal cord injury (SCI). The detrimental consequences of dysphagia in SCI include transient hypoxemia, chemical pneumonitis, atelectasis, bronchospasm, and pneumonia. The expedient diagnosis of dysphagia is imperative to reduce the risk of the development of life-threatening complications.
The objective of this study was to identify risk factors for dysphagia after SCI and associated respiratory considerations in acute cervical SCI.
Bedside swallow evaluation (BSE) was conducted in 68 individuals with acute cervical SCI who were admitted to an SCI specialty unit. Videofluroscopy swallow study was conducted within 72 hours of BSE when possible.
This prospective study found dysphagia in 30.9% (21 out of 68) of individuals with acute cervical SCI. Tracheostomy (P = .028), ventilator use (P = .012), and nasogastric tube (P = .049) were found to be significant associated factors for dysphagia. Furthermore, individuals with dysphagia had statistically higher occurrences of pneumonia when compared with persons without dysphagia (P < .001). There was also a trend for individuals with dysphagia to have longer length of stay (P = .087).
The role of respiratory care practitioners in the care of individuals with SCI who have dysphagia needs to be recognized. Aggressive respiratory care enables individuals with potential dysphagia to be evaluated by a speech pathologist in a timely manner. Early evaluation and intervention for dysphagia could decrease morbidity and improve overall clinical outcomes.
PMCID: PMC3584789  PMID: 23459678
dysphagia; respiratory complications; spinal cord injuries; tetraplegia
4.  Dysphagia in individuals with tetraplegia: incidence and risk factors 
Dysphagia following cervical spinal cord injury (SCI) can increase risk for pulmonary complications that may delay the rehabilitative process. The objective of this study was to identify risk factors for dysphagia after cervical SCI.
Prospective cohort study.
Individuals with cervical SCI within 31 days of injury underwent a bedside swallow evaluation (BSE) followed by a videofluoroscopy swallow study (VFSS) within 72 hours of the BSE. Subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS.
Twenty-nine patients (7 female and 22 male) were enrolled. Of these, 21 (72%) had high cervical tetraplegia (C4 or higher) and 8 (38%) had lower cervical tetraplegia. A tracheostomy was present in 18 (62%) patients; 15 (52%) subjects were on ventilators. Dysphagia was diagnosed in 12 (41%) subjects. Dysphagia was noted in 62% of the subjects with tracheostomy and 53% of the subjects on the ventilator, but only tracheostomy resulted in a statistically significant association with dysphagia (P = 0.047). All three subjects who had nasogastric tubes were diagnosed with dysphagia (P = 0.029). The relationships between dysphagia and gender, high versus low tetraplegia, presence of halo or collar, head injury, and ventilator use were not statistically significant, but age was a significant risk factor (P = 0.028).
Dysphagia is present in about 41% of individuals with acute tetraplegia. Only age, tracheostomy, and nasogastric tubes were identified as significant risk factors for dysphagia for individuals with tetraplegia. No relationship between dysphagia and level of SCI, spine surgery, collar, and ventilator use was found to exist.
PMCID: PMC3066491  PMID: 21528631
Spinal cord injuries; Tetraplegia; Rehabilitation; Physical; Dysphagia; Bedside swallow evaluation; Videofluoroscopy swallow study; Tracheostomy
5.  Phlegmasia Cerulea Dolens: Rare Complication of Vena Cava Filter Placement in Man With Paraplegia 
To describe a complication of placement of an inferior vena cava (IVC) filter in a man with paraplegia.
Case report.
A 48-year-old man with T11 paraplegia secondary to an L1 burst fracture underwent thoracic spinal fusion. The postoperative course was complicated by deep vein thrombosis (DVT) of the right common femoral vein, which was treated with warfarin.
During rehabilitation, the hematocrit declined, and fluctuance was noted along the surgical site. Computed tomographic scan suggested a hematoma in the paraspinal and latissimus dorsi muscles. Warfarin was discontinued, and an IVC filter was placed. He subsequently developed severe leg pain, followed by hypotension, acute renal failure, and compartment syndrome in bilateral lower extremities requiring fasciotomies. Ultrasound and computed tomographic angiogram showed extensive bilateral lower extremity DVTs and pulmonary emboli. The diagnosis of cerulea dolens was made. Mechanical and pharmacological thrombectomy was aborted secondary to bleeding complications and hypotension. The patient died shortly after care was withdrawn at the family's request. The autopsy revealed multiple thrombi in IVC, bilateral pelvic and femoral veins, and left pulmonary artery embolus, consistent with phlegmasia cerulea dolens.
Inferior vena cava filters may prevent pulmonary embolism but do not affect the underlying thrombotic process. An IVC filter should be recognized as a possible thrombogenic nidus in patients with spinal cord injury who have known DVT.
PMCID: PMC2582430  PMID: 18959358
Phlegmasia cerulea dolens; Venous thrombosis; Spinal cord injuries; Vena cava filters; Pulmonary embolism; Paraplegia
6.  Respiratory Management During the First Five Days After Spinal Cord Injury 
Respiratory complications are the most common cause of morbidity and mortality in acute spinal cord injury (SCI), with an incidence of 36% to 83%. Eighty percent of deaths in patients hospitalized with cervical SCI are secondary to pulmonary dysfunction, with pneumonia the cause in 50% of the cases. The number of respiratory complications during the acute hospital stay contributes significantly to the length of hospital stay and cost. Four factors (use of mechanical ventilation, pneumonia, the need for surgery, and use of tracheostomy) explain nearly 60% of hospital costs and may be as important a predictor of hospital cost as level of injury. Atelectasis (36.4%), pneumonia (31.4%), and ventilatory failure (22.6%) are the most common complications during the first 5 days after injury. Ventilatory failure occurs on average 4.5 days after injury. Transfer to an SCI center specializing in acute management of tetraplegia has been shown to significantly reduce the number of respiratory complications. This review concentrates on the first 5 days after injury, focusing on complications, predictive factors, prevention, and management of those complications.
PMCID: PMC2031940  PMID: 17853652
Spinal cord injuries; Acute; Respiratory complication; Ventilator dependence; Pneumonia; Bronchospasm; Pulmonary edema; Atelectasis; Tracheostomy; Tetraplegia; Paraplegia
7.  Neuroarthropathy of the Wrist in Paraplegia: A Case Report 
Neuroarthropathy, also known as Charcot joint, is most commonly seen in the spine and other weight-bearing joints in individuals with spinal cord injury (SCI). It is rarely seen in the joints of the upper extremities because the pathophysiology of the neuroarthropathy is thought to be significant repetitive trauma such as with weight bearing in an insensate joint.
Case report of neuroarthropathy in the wrist of a 46-year-old man with a 30-year history of T4 paraplegia caused by ependymoma.
The patient recently developed a nonpainful swelling in the left wrist, which had decreased sensation since the time of his initial SCI. Radiological evaluation showed marked degenerative changes consistent with neuroarthropathy. A magnetic resonance image of the spine showed spinal cord atrophy at the cervicothoracic junction.
This case shows an unusual presentation of a neuroarthropathy in a wrist in an individual with functional paraplegia. Because the treatment options for neuroarthropathy in the upper extremity in individuals with SCI are limited, early diagnosis is crucial to implement conservative management before significant destruction of the joint occurs.
PMCID: PMC1864861  PMID: 17044396
Neuroarthropathy; Charcot joint; Spinal cord injuries; Wrist; Paraplegia; Ependymoma
8.  Late Complications of Displaced Thoracolumbar Fusion Instrumentation Presenting as New Pain in Individuals With Spinal Cord Injury 
Harrington rods and more modern thoracolumbar posterior fusion with segmental instrumentation have been used successfully for decades in individuals with scoliosis or spinal cord injury (SCI). However, late complications of these instrumentations specifically presenting as new, localized pain in individuals with SCI have not been previously reported. Displacement of the hooks and the rods can cause significant back pain that may require hardware removal.
Two case reports illustrate thoracolumbar fusion rod removal because of displaced hooks with protruding rods and associated pain.
Both of the individuals experienced back pain caused by proximal hook displacement. There was no neurologic deterioration. The proximal portions of the rods were sawed off and the displaced hooks and the rods were removed.
These cases illustrate the importance of clarifying different types of pain experienced by individuals with SCI and the importance of diagnosing the cause of pain accurately.
PMCID: PMC1864899  PMID: 16396383
Spinal cord injuries; Harrington rods; Spinal fixation; Low back pain; Complications

Results 1-8 (8)