A longitudinal cohort study of 100 people with traumatic spinal cord injury (SCI) was performed to determine the prevalence and severity of different types of pain (musculoskeletal, visceral, neuropathic at-level, neuropathic below-level) at 5 years following SCI. Prospective data on the characteristics of pain up to 6 months following injury had been collected previously and allowed comparisons between the presence of pain at different time points. In addition, we sought to determine the relationship between the presence of pain and physical factors related to the injury such as level of lesion, completeness and clinical SCI syndrome. We also obtained information regarding mood, global self-rated health and the impact of pain on function. Of the 100 subjects in the original cohort, 73 were available for follow up. When all types of pain were included, 59 of the 73 subjects (81%) reported the presence of pain. Musculoskeletal pain was the most common type of pain experienced and was present in 43 subjects (59%), at-level neuropathic pain was present in 30 subjects (41%), below-level neuropathic pain was present in 25 subjects (34%) and visceral pain was present in four subjects (5%). Overall, 58% reported their pain as severe or excruciating and those with visceral pain were most likely to rate their pain in these categories. There was no relationship between the presence of pain overall and level or completeness of lesion, or type of injury. However, tetraplegics were more likely to report below-level neuropathic pain. This study prospectively demonstrates the differing time courses of different types of pain over the first 5 years following SCI. There was a strong correlation between the presence of both types of neuropathic pain at 5 years and earlier time points but both visceral pain and musculoskeletal pain demonstrated a poor correlation between time points. Chronic visceral pain occurs in a small percentage of patients and does not correlate with the presence of visceral pain early following injury. Those with neuropathic pain early following their injury are likely to continue to experience ongoing pain and the pain is likely to be severe. In contrast, chronic musculoskeletal pain is more common but less likely to be severe and cannot be predicted by the presence of pain in the first 6 months following injury.

A prospective, longitudinal study of 100 people with traumatic spinal cord injury (SCI) was performed to determine the time of onset. prevalence and severity of different types of pain (musculoskeletal, visceral, neuropathic at level, neuropathic below level) at 2, 4, 8, 13 and 26 weeks following SCI. In addition, we sought to determine the relationship between physical factors such as level of lesion, completeness and clinical SCI syndrome and the presence of pain. At 6 months following SCI, 40% of people had musculoskeletal pain, none had visceral pain, 36% had neuropathic at level pain and 19% had neuropathic below level pain. When all types of pain were included, at 6 months following injury, 64% of people in the study had pain, and 21% of people had pain that was rated as severe. Those with neuropathic below level pain were most likely to report their pain as severe or excruciating. There was no relationship between the presence of pain overall and level or completeness of lesion, or type of injury. Significant differences were found, however, when specific types of pain were examined. Musculoskeletal pain was more common in people with thoracic level injuries. Neuropathic pain associated with allodynia was more common in people who had incomplete spinal cord lesions, cervical rather than thoracic spinal cord lesions, and central cord syndrome. Therefore, this study suggests that most people continue to experience pain 6 months following spinal cord injury and 21% of people continue to experience severe pain. While the presence or absence of pain overall does not appear to be related to physical factors following SCI, there does appear to be a relationship between physical factors and pain when the pain is classified into specific types.

Survival related strongly to extent of neurological impairment. Future research should focus on identifying contextual factors, personal or environmental, that may contribute to the reduced life expectancy after SCI.

Study design: Longitudinal, descriptive design. Objectives: The aim of this study was to investigate the frequency, cause and duration of rehospitalisations in individuals with spinal cord injury (SCI) living in the community. Setting: Australian spinal cord injury unit in collaboration with State Health Department. Methods: A data set was created by linking records from the NSW Department of Health Inpatient Statistics Collection between 1989-1990 and 1999-2000 with data from the Royal North Shore Hospital (RNSH) Spinal Cord Injuries Database using probabilistic record linkage techniques. Records excluded were nontraumatic injuries, age o16 years, spinal column injury without neurological deficit, full recovery (ASIA Grade E) and index admission not at RNSH. Descriptive statistics and time to readmission using survival analysis, stratified by ASIA impairment grade, were calculated. Results: Over the 10-year period, 253 persons (58.6%) required one or more spinal-related readmissions, accounting for 977 rehospitalisations and 15,127 bed-days (average length of stay (ALOS) 15.5 days; median 5 days). The most frequent causes for rehospitalisation were genitourinary (24.1% of readmissions), gastrointestinal (11.0%), further rehabilitation (11.0%), skin-related (8.9%), musculoskeletal (8.6%) and psychiatric disorders (6.8%). Pressure sores accounted for only 6.6% of all readmissions, however, contributed a disproportionate number of bed-days (27.9%), with an ALOS of 65.9 (median 49) days and over 50% of readmissions (33 out of 64) occurred in only nine individuals aged under 30 years. Age, level and completeness of neurological impairment, all influenced differential rates of readmission depending on the type of complication. Overall rehospitalisation rates were high in the first 4 years after initial treatment episode, averaging 0.64 readmissions (12.6 bed-days) per person at risk in the first year and fluctuating between 0.52 and 0.61 readmissions (5.1-8.3 bed-days) per person at risk per year between the second to fourth years, before trending downwards to reach 0.35 readmissions (2.0 bed-days) as 10th year approaches. Time to readmission was influenced by degree of impairment, with significantly fewer people readmitted for ASIA D (43.2%) versus ASIA A, B and C (55.2-67.0%) impairments (Po0.0001). The mean duration to first readmission was 46 months overall, however, differed significantly between persons with ASIA A-C impairments (26-36 months) and ASIA D impairment (60 months). Conclusion: Identifying rates, causes and patterns of morbidity is important for future resource allocation and targeting preventative measures. For instance, the late complication of pressure sores in a small subgroup of young males, consuming disproportionately large resources, warrants further research to better understand the complex psychosocial and environmental factors involved and to develop effective countermeasures.

We performed a double-blinded, randomized, controlled trial in 15 patients to determine the efficacy of intrathecal morphine or clonidine, alone or combined, in the treatment of neuropathic pain after spinal cord injury. The combination of morphine and clonidine produced significantly more pain relief than placebo 4 h after administration; either morphine or clonidine alone did not produce as much pain relief. In addition, lumbar and cervical cerebrospinal fluid (CSF) concentrations, sampled at these levels at different times after administration were examined for a relationship between pain relief and CSF drug concentration. Lumbar CSF drug concentrations were initially several orders of magnitude larger than those in cervical CSF. After 1-2 h, the concentrations of morphine in cervical CSF markedly exceeded those of clonidine. The concentration of morphine in the cervical CSF and the degree of pain relief correlated significantly. We conclude that intrathecal administration of a mixture of clonidine and morphine is more effective than either drug administered alone and is related to the CSF-borne drug concentration above the level of spinal cord injury. If there is pathology that may restrict CSF flow, consideration should be given to intrathecal administration above the level of spinal cord damage to provide an adequate drug concentration in this region.

This study analyzed the mortality in 1453 spinal cord injured patients admitted early after injury to a specialised Spinal Injuries Unit within a University teaching hospital over a 40-year period. The cohort comprised 55.3% patients with cervical lesions and 44.7% patients with thoracic/lumbar lesions. Those patients who died within 18 months of the spinal injury (132) were excluded from the ®nal analysis. Standardised Mortality Ratios, survival rates and life expectancy ratios were calculated for speci®c ranges of current attained age and duration since injury with reference to level and degree of spinal cord injury. The projected mean life expectancy of spinal cord injured people compared to that of the whole population was then estimated to approach 70% of normal for individuals with complete tetraplegia and 84% of normal for complete paraplegia (Frankel grade A). Patients with an incomplete lesion and motor functional capabilities (Frankel grade D) are projected to have a life expectancy of at least 92% of the normal population.

Study Design: Cross-sectional study with repeated measurements. Objectives: To examine the patient's perspective of the impact of spinal cord injury (SCI) on physical, cognitive, emotional function, and quality of life (QOL). Setting: Australia. Methods: A sample of 63 patients with SCI, 32 of whom had recent injuries, and 31 with established injuries were administered the Ruff Neurobehavioral Inventory to examine patients' subjective evaluation of pre-and post-injury functioning. Current happiness levels were also evaluated using the Subjective Happiness Scale. A follow up assessment was performed 6 months later to examine changes over time. Results: A significant difference was found between perception of pre-and postmorbid function on composite Cognitive (t ¼ 5.99, df ¼ 62, Po0.001), Physical (t ¼ 11.56, df ¼ 62, Po0.001), and QOL (t ¼ 7.16, df ¼ 62, Po0.001) scales and on several of the Emotional subscales including anxiety, paranoia and suspicion, and substance abuse (Po0.001). A series of hierarchical regression analyses indicate that post-SCI pain was a significant predictor of: cognitive (R 2 ¼ 0.20, Po0.001); emotional (R 2 ¼ 0.13, Po0.004); and of QOL (R 2 ¼ 0.22, Po0.001) functioning. With the exception of a decrease in happiness (Po0.01), there were no significant changes in any measures over the 6 month time period. Conclusions: There are significant changes in patients' perceptions of physical and cognitive functioning, and of QOL before and after SCI and some aspects of emotional functioning. Pain has a significant adverse effect on functioning. Happiness decreased slightly in the 6 months between surveys.

Objective: To determine whether Methenamine Hippurate (MH) or cranberry tablets prevent urinary tract infections (UTI) in people with neuropathic bladder following spinal cord injury (SCI). Study design: Double-blind factorial-design randomized controlled trial (RCT) with 2 year recruitment period from November 2000 and 6 month follow-up. Setting: In total, 543 eligible predominantly community dwelling patients were invited to participate in the study, of whom 305 (56%) agreed. Methods: Eligible participants were people with SCI with neurogenic bladder and stable bladder management. All regimens were indistinguishable in appearance and taste. The dose of MH used was 1 g twice-daily. The dose of cranberry used was 800 mg twice-daily. The main outcome measure was the time to occurrence of a symptomatic UTI. Results: Multivariate analysis revealed that patients randomized to MH did not have a significantly longer UTI-free period compared to placebo (HR 0.96, 95% CI: 0.68-1.35, P ¼ 0.75). Patients randomized to cranberry likewise did not have significantly longer UTI-free period compared to placebo (HR 0.93, 95% CI: 0.67-1.31, P ¼ 0.70). Conclusion: There is no benefit in the prevention of UTI from the addition of MH or cranberry tablets to the usual regimen of patients with neuropathic bladder following SCI.