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Concept: Spinal cord injury


Cervical spondylotic myelopathy (CSM) is a common disorder involving chronic progressive compression of the cervical spinal cord due to degenerative disc disease, spondylosis, or other degenerative pathology. CSM is the most common form of spinal cord impairment and causes functional decline leading to reduced independence and quality of life. Despite a sound understanding of the disease process, clinical presentation and management, a universal definition of CSM and a standardized index of severity are not currently used universally. Work is required to develop a definition and establish clinical predictors of progression to improve management of CSM. Despite advances in decompressive and reconstructive surgery, patients are often left with residual disability. Gaps in knowledge of the pathobiology of CSM have limited therapeutic advances to complement surgery. Although the histopathologic and pathophysiologic similarities between CSM and traumatic spinal cord injury have long been acknowledged, the unique pathomechanisms of CSM remain unexplored. Increased efforts to elucidate CSM pathobiology could lead to the discovery of novel therapeutic targets for human CSM and other spinal cord diseases. Here, the natural history of CSM, epidemiology, clinical presentation, and current methods of clinical management are reported, along with the current state of basic scientific research in the field.

Concepts: Medicine, Spinal cord, Epidemiology, Disease, Pathology, Degenerative disc disease, Spinal cord injury, Myelopathy


Spinal cord ischemia is a potentially devastating complication after thoracic endovascular aorta repair (TEVAR). Patients with spinal cord ischemia after TEVAR often develop paraplegia, which is considered irreversible, and have significant increased postoperative morbidity and mortality. We report the case of a patient with unusual late complete neurologic recovery of acute-onset paraplegia after TEVAR for an infected thoracic aortic aneurysm.

Concepts: Central nervous system, Hospital, Aortic aneurysm, Aortic dissection, Aorta, Spinal cord injury, Aneurysm of sinus of Valsalva, Lumbar puncture


Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.

Concepts: Spinal cord, Infant, Stroke, Report, Pediatrics, Spinal cord injury, Nucleus pulposus


Spinal cord injuries disrupt bidirectional communication between the patient’s brain and body. Here, we demonstrate a new approach for reproducing lower limb somatosensory feedback in paraplegics by remapping missing leg/foot tactile sensations onto the skin of patients' forearms. A portable haptic display was tested in eight patients in a setup where the lower limbs were simulated using immersive virtual reality (VR). For six out of eight patients, the haptic display induced the realistic illusion of walking on three different types of floor surfaces: beach sand, a paved street or grass. Additionally, patients experienced the movements of the virtual legs during the swing phase or the sensation of the foot rolling on the floor while walking. Relying solely on this tactile feedback, patients reported the position of the avatar leg during virtual walking. Crossmodal interference between vision of the virtual legs and tactile feedback revealed that patients assimilated the virtual lower limbs as if they were their own legs. We propose that the addition of tactile feedback to neuroprosthetic devices is essential to restore a full lower limb perceptual experience in spinal cord injury (SCI) patients, and will ultimately, lead to a higher rate of prosthetic acceptance/use and a better level of motor proficiency.

Concepts: Skin, Sense, Somatosensory system, Spinal cord injury, Virtual reality, Proprioception, Human leg, Paraplegia


Context Spinal cord injury (SCI) causes disruption of the efferent input to and afferent input from respiratory muscles, which impairs respiratory motor and sensory functions, respectively. This disturbs the injured individual’s ability to respond to ventilatory loads and may alter the respiratory perceptual sensitivity of applied loads. Acute intermittent hypoxia with elevated CO2 (AIH treatment) has been shown to induce ventilatory long-term facilitation in individuals with chronic SCI. This study evaluated the effect of ten days of AIH treatment on ventilatory load compensation and respiratory perceptual sensitivity to inspiratory resistive loads (IRL), in an individual with chronic, incomplete cervical SCI. Methods Case report and literature review. Findings We report a case of a 55-year-old female with a C4 chronic, incomplete SCI (American Spinal Injury Association Impairment Scale D). The subject underwent evaluation at four time-points: Baseline, Post Sham, AIH Day 1 and AIH Day 10. Significant improvements in airflow generated in response to applied IRL were found after AIH treatment compared to Baseline. There were no significant changes in the respiratory perceptual sensitivity to applied IRL after AIH treatment. Clinical relevance Rehabilitative interventions after SCI demand restoration of the respiratory motor function. However, they must also ensure that the respiratory perceptual sensitivity of the injured individual does not hinder their capability to compensate to ventilatory challenges.

Concepts: Spinal cord, Carbon dioxide, Medical terms, Sense, Spinal cord injury, Motor skill, Physical trauma, Compensation


We characterized the effect of virtual visual feedback (VVF) on supernumerary phantom limb pain (SPLP) in a patient with high cervical cord injury. The subject was a 22-year-old man diagnosed with complete spinal cord injury (level C2) approximately 5 years ago. We applied the ABA'B' single-case design and set phases B and B' as intervention phases for comparison. SPLP significantly improved in comparison of phase A with phase B and phase A with phase B'. We suggest that VVF reduces SPLP and the effect lasts after VVF.

Concepts: Spinal cord, Amputation, Spinal cord injury, Proprioception, Audio feedback, Phantom limb, Phantom pain, Mirror box


Background Most spinal cord infarctions are due to aortic pathologies and aortic surgeries. Fibrocartilaginous Embolism (FCE) has been reported to represent 5.5% of spinal cord infarctions. Some believe that FCE is more common than presumed and is rather under-diagnosed due to vagueness surrounding its clinical presentation. Method A literature search was conducted for case reports of FCE published before August 2014. PubMed, the Cochrane Central Register and Google Scholar were searched for different combinations of the key words “fibrocartilaginous, "nucleus pulposus”, “embolism”, “spinal cord”, “inter-vertebral disc”, “infarction”, “stroke”, “paraplegia”, “quadriplegia”, “myelopathy”. Result Fifty-five case articles were reviewed, ten of which were translated from foreign languages. A total of 67 cases of FCE were found, 41 tissue-confirmed and 26 clinically suspected. A comprehensive summary of the clinical anatomy, patho-physiologic mechanisms, epidemiology, diagnosis and treatment of FCE is described, along with the conflicting opinions on its incidence and relevance after reviewing all of the related literature. The 41 tissue proven cases are summarized and a schematic approach to the clinical diagnosis of FCE, deducted from their clinical findings, is presented. Conclusion FCE of the spinal cord, often mis-diagnosed as transverse myelitis, may be more common than presumed. Future research into FCE, including the development of a chondrolytic therapy that can be given empirically upon its clinical suspicion to acutely reverse its symptoms, may be of value.

Concepts: Epidemiology, Diagnosis, Stroke, Medical diagnosis, Case, Spinal cord injury, Clinical death


This study aimed to investigate the effects of whole-body vibration (WBV) training on ankle spasticity, balance, and walking ability in patients with incomplete spinal cord injury (iSCI) at cervical level.

Concepts: Spinal cord, Spinal cord injury


Older people are at increased risk of traumatic spinal cord injury from falls. We evaluated the impact of older age (= 70 yr) on treatment decisions and outcomes.

Concepts: Spinal cord, Gerontology, Old age, Ageing, Spinal cord injury


Autonomic dysfunction is common in individuals with spinal cord injury (SCI) and leads to numerous abnormalities, including profound cardiovascular and bowel dysfunction. In those with high level lesions, bowel management is a common trigger for autonomic dysreflexia (AD, hypertension provoked by sensory stimuli below the level of injury). Improving bowel care is integral for enhancing quality of life (QoL). We aimed to describe the relationships between bowel care, AD, and QoL in individuals with SCI. We performed an online community survey of individuals living with SCI (n=287; injury levels C1-sacral). Individuals with injury levels at T7 or higher were considered at risk for AD (n=163). Survey completion rate was 74% (n=211). Average time since injury was 17.1±12.9 years. Bowel management was a problem for 78% of respondents: it interfered with personal relationships (60%), and prevented staying (62%), and working (41%) away from home. The typical bowel care duration was >60 mins in 24%; 33% reported bowel incontinence at least monthly. The most common management technique was digital rectal stimulation (59%). Of those at risk for AD, 74% had symptoms of AD during bowel care; 32% described palpitations. AD interfered with activities of daily living in 50%. Longer durations of bowel care (p<0.001), and more severe AD (p=0.04) were associated with lower QoL. Bowel management is a key concern for individuals with SCI and is commonly associated with symptoms of AD. Further studies should explore ways to manage bowel dysfunction, increase self-efficacy, and ameliorate the impact of AD to improve QoL.

Concepts: Quality, Quality of life, Spinal cord injury, Defecation, Autonomic dysreflexia