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Patients with acute spinal cord injury (SCI) have a high risk of venous thromboembolism (VTE) despite receiving thromboprophylaxis. The current standard of care recommended by guidelines is to use low-molecular-weight heparin (LMWH) for thromboprophylaxis for 90 days. This entails once- or twice-daily subcutaneous injections of LMWH for this duration, which is inconvenient for the patients and only partially effective. There are uncertainties about risk factors and the true incidence of SCI-associated VTE, the optimal time to commence thromboprophylaxis, and the optimal duration of thromboprophylaxis. Furthermore, there are currently no studies on the use of direct oral anticoagulants (DOACs) for thromboprophylaxis in patients with SCI. The use of DOACs for prophylaxis in this group can eliminate the inconvenience associated with daily subcutaneous injections for 3 months. To examine the incidence and risk factors of SCI-associated VTE, we performed a retrospective chart review of consecutive adult patients with acute SCI admitted to Hamilton General hospital from 2009 to 2015. The incidence of symptomatic VTE despite the use of thromboprophylaxis was 11% within 90 days of acute SCI; age and presence of other sites of injuries (such as lower limb fractures or pelvic fractures) along with SCI were independent risk factors for symptomatic VTE. To determine the opinion of Canadian spine surgeons about the optimal timing of starting LMWH after acute SCI, a short 5-question electronic survey was sent to the Canadian Spine Society. Data from our survey showed that the understanding about thromboprophylaxis after acute SCI was variable and that most spine surgeons were comfortable with starting LMWH after consultation with the surgeon. Future studies should focus on educational strategies to improve the knowledge base in this area. We will perform a pilot study at the Hamilton General Hospital comparing apixaban versus LMWH for thromboprophylaxis in patients with acute SCI. The use of apixaban for this indication can contribute to cost savings for the healthcare system and increased convenience for the patient. The protocol for the pilot study as well as steps towards a multi-center randomized controlled trial will be detailed in this thesis. / Thesis / Master of Science (MSc)

The internal vertebral venous plexus (IVVP) is an extensive vascular network recently implicated in various human and canine spinal disorders. Nevertheless, little recent information is available regarding normal anatomy of canine IVVP and its role in acute spinal injuries. The objectives of the study were; (1) to describe the normal IVVP morphology in the canine cervical region using transverse anatomy sections and computed tomography (CT), (2) to develop a technique for CT examination of the IVVP in vivo, (3) to analyze the quantitative characteristics of the IVVP, and (4) to assess the effect of acute experimental spinal cord compression on IVVP morphology. In the first experiment, CT of the cervical vertebral canal was performed in 6, normal, adult mixed-breed dogs. After dogs were euthanized, a gelatin and iothalamate mixture was injected into the right external jugular vein. Cadavers were then frozen to â 8°C, sliced into transverse sections, and compared with CT images. Vascular components such as the IVVP, interarcuate veins, intervertebral veins, and vertebral veins were accurately depicted on CT images. In the second experiment, CT venography was performed using a biphasic IV injection of iodinated contrast medium. Dimensions of the IVVP and other vertebral canal components were calculated for the C3-C7 vertebral region. Sagittal diameters of the IVVP ranged from 0.6 mm to 3.2 mm. The IVVP area occupied 30.61% of the cervical vertebral epidural space area. When C3-C7 segments were considered as a group, IVVP area dimensions were significantly correlated (r > 0.7, p < 0.0001) with vertebral canal area and dural sac area. In the last experiment, acute spinal cord compression (ASCC) was induced and maintained for 10 minutes using an angioplasty balloon catheter device over the C3/4 vertebral region in 6 dogs. Dogs were evaluated prior to, during, and after compression using digital subtraction venography (DSV) and CT venography. Results showed that ASCC produced a significant change in diameter of the IVVP at the site of compression. This effect persisted during the post-compression period. In conclusion, findings indicate that CT venography and DSV accurately depict the IVVP in dogs, and that significant changes of the IVVP morphology occur under ASCC conditions. / Ph. D.

published_or_final_version / Orthopaedics and Traumatology / Master / Master of Philosophy

Research has begun to explore the presence and role of health-related injustice perceptions in samples of individuals who experience chronic pain associated with traumatic injury. Existing studies indicate that higher level of injustice perception is associated with poorer physical and psychosocial outcomes. However, to date, few clinical populations have been addressed. The aim of the current study was to explore injustice perceptions in a sample of individuals who have sustained a spinal cord injury (SCI), as research suggests that such individuals are likely to experience cognitive elements characteristic of injustice perception (e.g., perceptions of irreparable loss, blame, and unfairness). The study explored the relationship between participants’ level of perceived injustice and several variables associated with outcomes following SCI (depression, pain, and disability) at initial admission to a rehabilitation unit and at three months following discharge. The Injustice Experience Questionnaire was used to measure injustice perceptions. IEQ was found to significantly contribute to depression and anger at baseline. IEQ significantly contributed to depression, present pain intensity, and anger at follow-up. The implication of these preliminary findings may be beneficial for development of future interventions, as many individuals in the United States experience the lifelong physical and psychological consequences of SCI at a high personal and public cost.

Advances in health care science are enabling greater numbers of spinal cord injured persons to live to old age. As these persons grow older, there may be additional problems in coping due to stressors such as decreasing health and income and loss of significant others. The purpose of this study was to determine those factors that contribute to the well-being of middle-aged and elderly community-residing spinal cord injured persons. One hundred spinal cord injured persons ranging in age from 40 to 73 were interviewed. Extensive data were collected in order to investigate the relationship among social support, types of social comparisons made, perceived control, health status and psychological well-being and life satisfaction. In general, respondents reported a degree of well-being that was slightly lower than that reported in studies of nondisabled populations on the same measures of psychological well-being, life satisfaction, and depression. Pearson correlations and multiple linear regressions showed that persons reporting high levels of well-being made favorable social comparisons, reported high levels of perceived control over their lives, had high levels of social support, and judged their health status to be good. They also viewed their disability more favorably and tended to have higher incomes, more education, to be employed, and to be more religious than those indicating lower levels of well-being. The severity of the spinal cord injury was not correlated highly with subjective well-being, although there was a tendency for persons with greater disabilities to report lower levels of well-being. Persons who were younger and who incurred their disability at a younger age also tended to report higher levels of well-being. A model of well-being is proposed. This model suggests that social support fosters the perception of control and the making of favorable social comparisons which, in turn, foster a sense of well-being and satisfaction with life. This model provides direction for future research and has valuable implications for clinical application.