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1.  The Impact of Sacral Sensory Sparing in Motor Complete Spinal Cord Injury 
Objective
To determine the effect of sensory sparing in motor complete persons with spinal cord injury (SCI) on completion of rehabilitation on neurologic, functional, and social outcomes reported at 1 year.
Design
Secondary analysis of longitudinal data collected by using prospective survey-based methods.
Setting
Data submitted to the National SCI Statistical Center Database.
Participants
Of persons (N=4106) enrolled in the model system with a motor complete injury (American Spinal Injury Association Impairment Scale [AIS] grade A or B) at the time of discharge between 1997 and 2007, a total of 2331 (56.8%) completed a 1-year follow-up interview (Form II) and 1284 (31.3%) had complete data for neurologic (eg, AIS grade, injury level) variables at 1 year.
Interventions
Not applicable.
Main Outcome Measures
AIS grade (A vs B) at 1 year, bladder management, hospitalizations, perceived health status, motor FIM items, Satisfaction With Life Scale, depressive symptoms, and social participation.
Results
Compared with persons with AIS grade A at discharge, persons with AIS grade B were less likely to require indwelling catheterization and be hospitalized and more likely to perceive better health, report greater functional independence (ie, self-care, sphincter control, mobility, locomotion), and report social participation in the first year postinjury. A greater portion of individuals with AIS grade B at discharge had improved neurologic recovery at 1 year postinjury than those with AIS grade A. Significant AIS group differences in 1-year outcomes related to physical health were maintained after excluding persons who improved to motor incomplete status for only bladder management and change in perceived health status. This recognition of differences between persons with motor complete injuries (AIS grade A vs B) has important ramifications for the field of SCI rehabilitation and research.
doi:10.1016/j.apmr.2010.07.242
PMCID: PMC3698852  PMID: 21353822
Outcome assessment (health care); Paraplegia; Rehabilitation; Spinal cord injuries
2.  Intrathecal baclofen for the treatment of spinal myoclonus: a case series 
Context/objective
To demonstrate the utility of intrathecal baclofen in the treatment of secondary myoclonus of spinal origin.
Design
Case series.
Setting
University medical center.
Participants
Two patients with spinal myoclonus who required the use of an assistive device because of difficulty walking resulting in falls.
Interventions
Intrathecal baclofen management.
Outcome measures
Symptom management and mobility function.
Results
Both experienced resolution of their spinal myoclonus and became community-level ambulators without the need of an assistive device.
Conclusion
Intrathecal baclofen is an effective treatment of secondary myoclonus of spinal origin.
doi:10.1179/2045772311Y.0000000006
PMCID: PMC3240919  PMID: 22330193
Spinal myoclonus; Assistive devices; Intrathecal baclofen; Spinal cord injuries; Stiff person syndrome; Transverse myelitis
3.  Association of Daily Stressors and Salivary Cortisol in Spinal Cord Injury 
Rehabilitation psychology  2009;54(3):288-298.
Objective
Examine the diurnal variation of salivary cortisol in adults with spinal cord injury (SCI) and the effect of stressors on cortisol and mood.
Method
Ecological momentary assessment (EMA) to capture cortisol, stress and mood from 25 persons with SCI and 26 without SCI. Data were analyzed using linear mixed models.
Results
There were no systematic differences between groups on missing data. Diurnal variation of cortisol of participants with SCI reflected an expected pattern. No significant group differences for cortisol diurnal pattern, stress or mood; when group interactions were significant, results indicated lower cortisol reactivity to stress in participants with SCI. Stress had a significant impact on positive, negative and agitated moods.
Conclusions
Stress in daily life and its association with cortisol and mood were largely similar between persons with and without SCI. A key methodological contribution is the demonstration of using EMA to collect biological and behavioral data in the field from participants with SCI. The use of EMA in rehabilitation psychology research has great potential to advance our understanding of the dynamics of daily life with disability.
doi:10.1037/a0016614
PMCID: PMC2924200  PMID: 19702427
spinal cord injuries; stress, psychological; hydrocortisone; ecological momentary assessment
4.  Intrathecal Baclofen for Spasticity Management: A Comparative Analysis of Spasticity of Spinal vs Cortical Origin 
Background/Objective:
To examine the differences in intrathecal baclofen management of individuals with spasticity of cortical vs spinal etiologies.
Design:
Retrospective chart review of 57 individuals with the diagnoses of severe cortical and spinal spasticity requiring an intrathecal baclofen pump.
Methods:
Parameters evaluated included daily dosage of medication required, flex vs simple continuous delivery modes, dosing changes, need for other local spasticity treatment, and catheter complications.
Results:
There were no statistically significant differences between individuals with cortical spasticity and spinal spasticity when comparing daily dosage, number of contacts, and mode of delivery. At 6 months, there was a statistically significant difference in dosing between individuals with multiple sclerosis and those without. Within groups, there was a significant difference in average daily dosing over 3 years. A significant difference was found comparing the use of botulinum toxin type A for upper extremity spasticity within the cortical group. Nine individuals had catheter complications.
Conclusions:
Cortical and spinal spasticity appear to parallel each other with no significant differences in daily dosing, dosing changes, and mode of delivery of intrathecal baclofen. This did not hold true at all time points for the multiple sclerosis subgroup. The significant difference noted within groups for daily dosing over the first 3 years challenges the notion of stable dosing over time. Focal injections of Botox/phenol in the upper extremities are an important adjunct therapy for patients with cortical spasticity, even after the placement of an intrathecal baclofen pump. Our complication rate was slightly lower than that reported in the literature.
PMCID: PMC2853324  PMID: 20397440
Spinal cord injuries; Multiple sclerosis; Cerebral palsy; Stroke; Brain injury, traumatic; Baclofen, intrathecal; Botulinum toxin type A; Phenol; Spasticity, cortical, spinal; Intrathecal pump
5.  Relationship of Spasticity to Soft Tissue Body Composition and the Metabolic Profile in Persons With Chronic Motor Complete Spinal Cord Injury 
Background/Objective:
To determine the effects of spasticity on anthropometrics, body composition (fat mass [FM] and fat-free mass [FFM]), and metabolic profile (energy expenditure, plasma glucose, insulin concentration, and lipid panel) in individuals with motor complete spinal cord injury (SCI).
Methods:
Ten individuals with chronic motor complete SCI (age, 33 ± 7 years; BMI, 24 ± 4 kg/m2; level of injury, C6–T11; American Spinal Injury Association A and B) underwent waist and abdominal circumferences to measure trunk adiposity. After the first visit, the participants were admitted to the general clinical research center for body composition (FFM and FM) assessment using dual energy x-ray absorptiometry. After overnight fasting, resting metabolic rate (RMR) and metabolic profile (plasma glucose, insulin, and lipid profile) were measured. Spasticity of the hip, knee, and ankle flexors and extensors was measured at 6 time points over 24 hours using the Modified Ashworth Scale.
Results:
Knee extensor spasticity was negatively correlated to abdominal circumferences (r  =  −0.66, P  =  0.038). After accounting for leg or total FFM, spasticity was negatively related to abdominal circumference (r  =  −0.67, P  =  0.03). Knee extensor spasticity was associated with greater total %FFM (r  =  0.64; P  =  0.048), lower %FM (r  =  −0.66; P  =  0.03), and lower FM to FFM ratio. Increased FFM (kg) was associated with higher RMR (r  =  0.89; P  =  0.0001). Finally, spasticity may indirectly influence glucose homeostasis and lipid profile by maintaining FFM (r  =  −0.5 to −0.8, P < 0.001).
Conclusion:
Significant relationships were noted between spasticity and variables of body composition and metabolic profile in persons with chronic motor complete SCI, suggesting that spasticity may play a role in the defense against deterioration in these variables years after injury. The exact mechanism is yet to be determined.
PMCID: PMC2853330  PMID: 20397439
Spasticity; Body composition; Resting energy expenditure; Metabolism; Spinal cord injuries; Paraplegia; Tetraplegia; Cardiovascular disease
6.  A prospective, masked 18 month minimum follow-up on neurophysiologic changes in persons with spinal stenosis, low back pain, and no symptoms 
Objective
To describe neurophysiological changes over time in persons with and without spinal complaints, and to assess whether paraspinal denervation predicts change in stenosis on MRI and clinical course.
Design
Prospective, controlled, masked trial.
Setting
University spine program.
Participants
Persons aged 55–80, screened for polyneuropathy and determined on clinical examination to have spinal stenosis, mechanical low back pain, or no spinal symptoms.
Interventions
Subjects underwent comprehensive codified history and physical examination, ambulation testing, masked electrodiagnostic testing including paraspinal mapping, and MRI; repeated at >18 months. This publication presents detailed technical information and additional analyses not reported previously.
Main Outcome Measurements
Change in electrodiagnostic findings. Among persons with clinical stenosis, relationship of change in paraspinal mapping scores to MRI findings and clinical changes.
Results
Of 149 initial subjects, 83 (79.3% of eligible subjects) repeated testing at 20 +/− 2 s.d.) months. No significant change in limb muscle spontaneous activity or motor unit pathology was noted in any group. In 23 persons with initial diagnosis of stenosis, paraspinal mapping EMG related to change in diagnosis over time (ANOVA F=3.77, p=0.037), but not to most initial MRI measurements or to change in spinal canal diameter.
Conclusions
Clinical spinal stenosis is neurophysiologically stable in most persons. Paraspinal EMG changes reflect large changes in clinical course, but neither neurophysiological nor clinical changes relate to change in spinal geometry over 20 months.
doi:10.1016/j.pmrj.2008.10.007
PMCID: PMC2735230  PMID: 19627886
Spinal Stenosis; Back pain; Electrodiagnosis; Erector spinae; Disk Degeneration; Radiculopathy; Magnetic Resonance Imaging
7.  Effect of Intrathecal Baclofen Concentration on Spasticity Control: Case Series 
Background/Objective:
Intrathecal baclofen (ITB) has been shown to be an effective treatment for severe spasticity of spinal or cerebral origin. Although most patients respond well to an ITB trial, there are often difficulties in achieving and/or maintaining such effectiveness with ITB pump treatment. There are few published guidelines for dosing efficacy and no studies looking at the effect of concentration of ITB on spasticity management.
Methods:
Case series of 3 adults with severe spasticity treated with ITB pump: a 44-year-old man with C7 tetraplegia using a 40-mL Medtronic SynchroMed II pump with 500-μg/mL concentration; a 35-year-old woman with traumatic brain injury with right spastic hemiplegia using a 18-mL Medtronic SynchroMed EL pump with 2,000-μg/mL concentration; and a 43-year-old woman with spastic diplegic cerebral palsy using a 40-mL Medtronic SynchroMed II pump with 2,000-μg/mL concentration.
Results:
After reducing ITB concentrations in the pump, either as part of a standard protocol for dye study to assess the integrity of pump and catheter system or secondary to plateau in therapeutic efficacy, patients experienced temporary, significant reduction in spasticity based on range of motion, Modified Ashworth scores, and verbal feedback.
Conclusions:
Decreasing the concentration of ITB seems to affect spasticity control. Further research in this area is needed for those patients with refractory spasticity to optimize efficacy of ITB therapy.
PMCID: PMC2582431  PMID: 18959357
Spasticity; Baclofen; Intrathecal; Tetraplegia; Hemiplegia; Cerebral palsy; Traumatic brain injury
8.  Sexual Dysfunction Associated With Intrathecal Baclofen Use: A Report of Two Cases 
Background/Objective:
Intrathecal baclofen is considered standard treatment for severe spasticity of spinal cord and cerebral origin. Recognized side effects include fatigue and constipation. There are few reported findings of sexual dysfunction in men and none in women.
Methods:
Two case reports.
Results:
A male and a female patient with spasticity treated with intrathecal baclofen were recognized to have sexual dysfunction side effects from treatment. On reduction of the intrathecal baclofen dose, complete return to baseline sexual function was achieved for both subjects.
Conclusions:
Intrathecal baclofen can impair sexual function and ejaculation in some patients. Clinicians should be aware of this risk and ask about it during routine clinic follow-up for spasticity. Dosing adjustments need to be considered in these patients.
PMCID: PMC2435028  PMID: 18533420
Baclofen; Intrathecal; Spinal cord injuries; Cerebral palsy; Sexual dysfunction; Spasticity; Gamma-aminobutyric acid-B receptors
9.  Predictors of Ventilator Weaning in Individuals With High Cervical Spinal Cord Injury 
Background/Objective:
To evaluate which tests best predict the ability of patients with ventilator-dependent tetraplegia to wean from the ventilator.
Methods:
Retrospective review of patients.
Participants:
Twenty-six ventilator-dependent patients with tetraplegia admitted to a university inpatient spinal cord–injury rehabilitation unit with American Spinal Injury Association (ASIA) injury levels C2 to C6, A or B.
Results:
Failure to wean off the ventilator completely was predicted by absence of motor unit recruitment of one hemidiaphragm or at least moderate decreased recruitment with needle electromyography (EMG) in both hemidiaphragms. Phrenic nerve conduction studies would have predicted that all patients who weaned off the ventilator would have failed. Fluoroscopic examination of the diaphragm and bedside spirometry were not as good predictors of ability to wean, failing to predict accurately in 44% and 19% of cases, respectively. ASIA examination was also not entirely predictive, and any outliers that may have been expected to wean based on ASIA examination (ie, C4 or lower neurological levels) were predicted not to wean by needle electromyography.
Conclusions:
Negative inspiration force diaphragm needle EMG best predicted the ability to wean from the ventilator. Bedside spirometry (negative inspiratory force and forced vital capacity) is an accurate bedside measure of a patient's readiness to wean. Fluoroscopic examination of the diaphragm and phrenic nerve conduction studies were not helpful in determining weaning potential in ventilator-dependent patients with cervical spine injury.
PMCID: PMC2435030  PMID: 18533415
Spinal cord injuries, cervical; Tetraplegia; Mechanical ventilation; Ventilator dependence; Ventilator weaning; Electromyography
10.  Spinal Cord Injury Caused by Epidural B-Cell Lymphoma: Report of Two Cases 
Background/Objective:
Spinal cord injury (SCI) caused by cancer is increasing in incidence as the mean age of our patient population increases. Understanding the prognosis and functional outcome requires knowledge of diseases of the spinal column. This paper presents the unusual presentation of epidural B-cell lymphoma.
Methods:
Case reports.
Results:
Two patients presented with an unusual cause of SCI, namely B-cell lymphoma. Both patients presented with sensory deficits greater than motor deficits and gait disorder. Both achieved functional independence at the community ambulation level and tumor remission with chemotherapy and radiation therapy.
Conclusions:
B-cell epidural tumors are an uncommon cause of SCI. Functional outcome can be quite good, as can tumor outcome. Residual sensory deficits greater than motor deficits are not uncommon.
PMCID: PMC2032008  PMID: 17385273
B-cell lymphoma; Spinal cord injuries, nontraumatic; Paraplegia; Epidural tumor
11.  Pain Management With Interventional Spine Therapy in Patients With Spinal Cord Injury: A Case Series 
Background/Objective:
Chronic pain is common in patients with spinal cord injury (SCI). Any new strategy that is effective in treating this problem would be welcomed by this patient population.
Methods:
A case series is presented of SCI with neuropathic pain. In these 3 cases, interventional spine therapy is used as a diagnostic and/or therapeutic tool in the management of pain.
Results:
In the cases presented, interventional spine therapy proved useful in identifying the patient's pain generator. In most cases, the intervention was effective in reducing pain for a long enough period to serve as an effective pain management strategy. Other associated problems, such as spasticity, were similarly reduced.
Conclusion:
Interventional spine therapy should be considered as a tool in the armamentarium of any SCI physician managing their patient's chronic pain.
PMCID: PMC1864898  PMID: 16396386
Spinal cord injuries; Neuropathic pain; Epidural injection; Pain management

Results 1-11 (11)