Bakgrund: I Sverige lever cirka 5000 personer med spinalskada. Där spinalskadan lett till nedsatt blåsfunktion är ren intermittent kateterisering (RIK) den metod som rekommenderas i första hand. Syfte: Att undersöka hur personer med traumatisk spinalskada som använder ren intermittent kateterisering (RIK) upplever detta. Syftet var även att ta reda på vilka hanteringsstrategier som finns för att underlätta det dagliga livet. Metod: En kvalitativ metod med semistrukturerade intervjuer användes där fem personer med traumatisk spinalskada som använder RIK intervjuades. Resultat: Att behöva tillägna sig metoden väckte blandade känslor. Män upplevde det lättare att RIKa jämfört med kvinnor. Den egna kompetensen och kunnandet om metoden RIK ökade med tiden och de hittade nya hanteringsstrategier för att underlätta vardagen. Informanterna var medvetna om vikten av god hygien för att undvika urinvägsinfektioner. Däremot framgick det inte om informanterna var medvetna om kopplingen mellan vikten av regelbunden RIKning, residualurin i blåsan och uppkomsten av urinvägsinfektioner. Slutsats: Personer som använder RIK upplever det som nödvändigt och avgörande för att kunna leva ett normalt liv. Hanteringsstrategier är planering och anpassande av metoden efter fysisk förmåga och den egna vardagen. Behovet av stöd hos personer med spinalskada som använder RIK är individuellt och varierar. Adekvat stöd och utbildning underlättar och hjälper personer med nedsatt blåsfunktion som använder RIK att ta kontroll över utövandet och främjar följsamheten och långsiktig hälsa avseende urinvägarna. / Background: About 5,000 people in Sweden live with a spinal injury. Where the spinal injury leads to impaired bladder function, clean intermittent catheterization (CIC) is the method recommended in the first place. Aim: To examine  how individuals  with traumatic  spinal injury  using clean  intermittent catheterization experience the method. The aim was also to find out coping strategies available to facilitate daily life. Methods: A qualitative approach with semi-structured interviews was used where five people with traumatic spinal injury were interviewed. Results: The need to use CIC brought about mixed feelings among informants. Men felt that it was easier for them to use clean intermittent catheterization compared to women. Their expertise and knowledge increased with time and they found new coping strategies to facilitate everyday life. The informants were aware of the importance of good hygiene to prevent urinary tract infections. However, it was not clear if the informants were aware of the connection between the importance of using clean intermittent catheterization regularly, residual urine in the bladder and the occurrence of  urinary  tract  infections. Conclusion: People who use CIC experience it as essential and vital in order to live a normal life. The need for support of people with spinal injury who use CIC is individual and varies. Adequate support and training for people with impaired bladder function using CIC facilitates and helps them to take control initially and promotes an ongoing adherence and long-term health regarding urinary tract.

Bakgrund: Trauma förekommer över hela världen och olyckor står för den främsta dödsorsaken hos personer under 45 år, både internationellt och nationellt. Trauma är en av de vanligaste orsakerna till akuta skador i halskotpelaren och halsryggmärgen. Varje år drabbas cirka 4000 patienter i Sverige av frakturer i hals, bröst och ländrygg. För patienten kan spinal skada beskrivas som det mest livsomvälvande ögonblicket i patientens liv. Ambulanssjuksköterskans förmåga att omhänderta patienten gällande spinal rörelsebegränsning (SRB) har betydelse för vården av den drabbade patienten. Syfte: Syftet var att beskriva ambulanssjuksköterskans upplevelse av omhändertagandet vid misstänkt traumatisk spinal skada.  Metod: En kvalitativ metod med deskriptiv design och induktiv ansats har använts. Tretton semistrukturerade intervjuer gjordes. Manifest innehållsanalys inspirerad av Graneheim och Lundman (2004) utfördes. Resultat: Två kategorier framkom ur analysen: yrkesrollen och bemötande. Yrkesrollen innebar att ambulanssjuksköterskornas upplevelse var att det fanns teoretisk kunskap kring SRB. Däremot upplevdes vissa situationer oklara där beslut om SRB skulle tas. Ambulanssjuksköterskorna upplevde då en viss osäkerhet och tog det säkra före det osäkra. Ambulanssjuksköterskan upplevde ett stort ansvar samt att fokus för omhändertagandet var den fysiska skadan. I bemötandet upplevde ambulanssjuksköterskorna betydelsen av att vara och att inge lugn. Information och kommunikation upplevdes vara viktig i omhändertagandet med patienten vid misstänkt spinala skada. Teamet kring ambulanssjuksköterskan, både kollegan i samma ambulans och andra aktörer samt patienten själv upplevdes som viktigt. Slutsats: Ambulanssjuksköterskorna upplevde osäkerhet i omhändertagandet av patienter med misstänkt traumatisk spinal skada. Av studiens resultat behövs mer träning och övning i klinisk verksamhet. / Background: Trauma occurs all over the world and accidents are the leading cause of death in people under the age of 45, both internationally and nationally. Trauma is one of the most common causes of acute injuries to the cervical spine. Every year, about 4,000 patients in Sweden suffer fractures in the neck, chest and lumbar spine. For the patient, spinal injury can be described as the most life-changing moment in the patient's life. The ambulance nurse's ability to care for the patient regarding spinal movement restriction is crucial for the care of the affected patient.  Aim: The purpose was to describe the ambulance nurse's experience of care in case of suspected traumatic spinal injury. Method: A qualitative method with descriptive design and inductive approach has been used. Thirteen semi-structured interviews were conducted. Manifest content analysis inspired by Graneheim and Lundman (2004) was performed. Result: Two categories emerged: the professional role and approach. The professional role was described as the ambulance nurses' experience that there is a theoretical knowledge about spinal immobilization. However, some situations were perceived as unclear where decisions about the spinal immobilization should be taken and the situation made the ambulance nurses feel uncertain about a decision. The ambulance nurse felt a huge responsibility where focus was the physical injury. In the approach with the patient the ambulance nurses emphasized the importance of being calm. Information and communication were perceived as important in the care of the patient in case of suspected traumatic spinal injury. The team around the ambulance nurse, both the colleague in the same ambulance and other actors as well as the patient, were perceived as important. Conclusion: Ambulance nurses’ experienced uncertainty in the care of patients with suspected traumatic spinal injuries. As a results of the study, more training and practice is needed.

L’objectif de la thèse était d’étudier l’influence de facteurs anatomiques et biomécaniques tels que la présence d’ostéophytes vertébraux, le taux de chargement et le profil sagittal rachidien (défini par l’orientation et la forme de la colonne vertébrale dans le plan sagittal) sur les traumatismes de la colonne vertébrale thoracique et lombaire. Pour ce faire, des essais expérimentaux sur spécimens cadavériques rachidiens ont été réalisés et un modèle biomécanique détaillé du rachis T1-sacrum a été raffiné, validé expérimentalement et exploité. Les résultats ont démontré que les segments ostéophytiques présentaient des fractures de moindre sévérité localisées au niveau de la vertèbre proximale, contrairement aux segments sans ostéophytes, qui présentaient des fractures sévères (souvent comminutives) au niveau de la vertèbre médiane. Ils ont également confirmé que le taux de déformation jouait un rôle-clé dans l’initiation du traumatisme et que le profil sagittal avait une influence significative sur les caractéristiques des fractures osseuses lors d’accidents impliquant un mécanisme principalement en compression. En revanche, le profil sagittal n’exercerait qu’une influence limitée sur la nature des traumatismes lors d’un accident impliquant un mécanisme de flexion-distraction. / The objective of this thesis was to study the influence of anatomical and biomechanical factors such as the presence of vertebral osteophytes, the loading rate and the sagittal profile of the spine (defined by the orientation and shape of the spine in the sagittal plane) on spinal injuries at the thoracic and lumbar levels. To fulfill this objective, experiments on human cadaveric spines were performed and a detailed biomechanical model of the spine was refined, validated against experimental data, and exploited. Results showed that the presence of large osteophytes significantly influenced the location, pattern and type of fracture, and provided to the underlying vertebra a protective mechanism against severe compression fractures (e.g. burst fractures). They also showed that the loading rate played a key-role on the onset of spinal trauma and that the sagittal profile of the spine had a significant influence on the bone fracture in accidents that involve compression mechanisms. On the other hand, the sagittal profile of the spine had a limited influence on the nature of spinal injuries in accidents that involved flexion-distraction mechanisms.

Intraoperative neurophysiologic monitoring is an integral part of spinal surgeries and involves the recording of somatosensory evoked potentials (SSEP). However, clinical application of IONM still requires anywhere between 200 to 2000 trials to obtain an SSEP signal, which is excessive and introduces a significant delay during surgery to detect a possible neurological damage. The aim of this study is to develop a means to obtain the SSEP using a much less, twelve number of recordings. The preliminary step involved was to distinguish the SSEP with the ongoing brain activity. We first establish that the brain activity is indeed quasi-stationary whereas an SSEP is expected to be identical every time a trial is recorded. An algorithm was developed using Chebychev time windowing for preconditioning of SSEP trials to retain the morphological characteristics of somatosensory evoked potentials (SSEP). This preconditioning was followed by the application of a principal component analysis (PCA)-based algorithm utilizing quasi-stationarity of EEG on 12 preconditioned trials. A unique Walsh transform operation was then used to identify the position of the SSEP event. An alarm is raised when there is a 10% time in latency deviation and/or 50% peak-to-peak amplitude deviation, as per the clinical requirements. The algorithm shows consistency in the results in monitoring SSEP in up to 6-hour surgical procedures even under this significantly reduced number of trials. In this study, the analysis was performed on the data recorded in 29 patients undergoing surgery during which the posterior tibial nerve was stimulated and SSEP response was recorded from scalp. This method is shown empirically to be more clinically viable than present day approaches. In all 29 cases, the algorithm takes 4sec to extract an SSEP signal, as compared to conventional methods, which take several minutes. The monitoring process using the algorithm was successful and proved conclusive under the clinical constraints throughout the different surgical procedures with an accuracy of 91.5%. Higher accuracy and faster execution time, observed in the present study, in determining the SSEP signals provide a much improved and effective neurophysiological monitoring process.