Despite promising advances in basic spinal cord repair research, no effective therapy resulting in major neurological or functional recovery after traumatic spinal cord injury (tSCI) is available to date. The neurological examination according to the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients (International Standards) has become the cornerstone in the assessment of the severity and level of the injury. Based on parameters from the International Standards, physicians are able to inform patients about the predicted long-term outcomes, including the ability to walk, with high accuracy. In those patients who cannot participate in a reliable physical neurological examination, magnetic resonance imaging and electrophysiological examinations may provide useful diagnostic and prognostic information. As clinical research on this topic continues, the prognostic value of the reviewed diagnostic assessments will become more accurate in the near future. These advances will provide useful information for physicians to counsel tSCI patients and their families during the catastrophic initial phase after the injury.
Early decompression may improve neurological outcome after spinal cord injury (SCI), but is often difficult to achieve because of logistical issues. The aims of this study were to 1) determine the time to decompression in cases of isolated cervical SCI in Australia and New Zealand and 2) determine where substantial delays occur as patients move from the accident scene to surgery. Data were extracted from medical records of patients aged 15-70 years with C3-T1 traumatic SCI between 2010 and 2013. A total of 192 patients were included. The median time from accident scene to decompression was 21 h, with the fastest times associated with closed reduction (6 h). A significant decrease in the time to decompression occurred from 2010 (31 h) to 2013 (19 h, p = 0.008). Patients undergoing direct surgical hospital admission had a significantly lower time to decompression, compared with patients undergoing pre-surgical hospital admission (12 h vs. 26 h, p < 0.0001). Medical stabilization and radiological investigation appeared not to influence the timing of surgery. The time taken to organize the operating theater following surgical hospital admission was a further factor delaying decompression (12.5 h). There was a relationship between the timing of decompression and the proportion of patients demonstrating substantial recovery (2-3 American Spinal Injury Association Impairment Scale grades). In conclusion, the time of cervical spine decompression markedly improved over the study period. Neurological recovery appeared to be promoted by rapid decompression. Direct surgical hospital admission, rapid organization of theater, and where possible, use of closed reduction, are likely to be effective strategies to reduce the time to decompression.
We describe the systemic white blood cell (WBC) response to human spinal cord injury (SCI) and demonstrate how this is influenced by overall trauma severity, lesion level, and neurological grade on admission. We identify acute neutrophilia as a negative predictor for patient outcomes, the occurrence of which reduces the likelihood of American Spinal Injury Association Impairment Scale (AIS) grade conversion. We further show that lymphopenia during the first week of SCI is typically associated with better recovery, but that higher neutrophil to lymphocyte ratios early after SCI are associated with infection presentation in at-risk patients. Collectively, the multi-factorial models described in this work allow for better patient stratification and more accurate prediction of their outcomes.
This study investigated use of electronic medical records (eMRs) in a spinal cord injury rehabilitation unit and the implications for person-centred care. This exploratory mixed-methods study conducted 17.5hours of observations of practitioner-patient encounters, 50 patient-experience surveys and 10 focus groups with 53 practitioners. Descriptive statistics and qualitative analysis were integrated into key themes. Practitioners in this specialised setting were reconciling the emergent challenges of eMR in practice with the advantages of improved accessibility and documentation legibility. eMR increased task complexity and information retrieval, particularly for nurses. Some documentation was an uneasy fit with the specialised setting, disrupting informal communications and aspects of person-centred care. Technological change closely aligned with frontline practice brought expected and unexpected challenges that may resolve over time. Practitioners' persistence and adaptability demonstrated their commitment to person-centred care in the digital environment. The impact of this less visible work of professional discretion seemed to vary, primarily by discipline-specific roles, with nurses experiencing the greatest pressure. Integrated electronic medical records (eMRs) bring benefits but challenge person-centred care. These first insights regarding frontline implementation of eMR in spinal injury rehabilitation suggest nursing challenges when seeking to fit specialised work into the generic eMR. However, most patients reported receiving person-centred care. Commitment to person-centred care appears to strengthen practitioners' perseverance with the eMR implementation challenges.
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