Table 1.
Results of the Literature Search
| Authors | Title | Study type | Downs and Black score | Methods | Outcome | Notes |
|---|---|---|---|---|---|---|
| Rodriguez et al., 1991 | Obligatory negative nitrogen balance following SCI | Experimental non-randomized controlled trial | 14 | Cervical and thoracic level SCI. Nutritional needs calculated: PEE = BEE × 1.2 (activity factor) × 1.6 (stress factor for trauma). Protein based on 2 g protein/kg ideal body weight. Total nutritional support instituted within 72 h of admission. Changes in nutrient delivery were based on nitrogen balances and metabolic cart measurements. | No SCI patient was able to achieve and maintain positive NB during the 7-week period following injury. Two SCI patients had positive NB in the early post-injury period (+3 on day 4 post-injury); both showed severely negative NB at weeks 2 and 3. Increases in caloric and protein intakes above needs were attempted in all 10 patients to ensure that negative NB was not due to unaccounted-for hypermetabolic states. After the third week, NB became progressively less negative, until positive (average) NB was achieved at 2 months post-injury. Positive NB was reached in the control group by week 3 in 17/20 patients. | Case report within article: 22 year old with traumatic brain injury (TBI), blunt rupture thoracic aorta, and lumbar spine fracture (no neurological deficit). Aggressive nutritional support and positive NB. Suffered SCI during surgery to stabilize lumbar spine; developed negative NB in spite of increases in previously adequate amounts of protein and calories. |
| Frost et al., 1995 | The role of percutaneous endoscopic gastrostomy in spinal cord injured patients | Observational | 24 | PEG inserted, complication rates determined. | No serious complications. Gastrostomy occasionally became blocked and required flushing with water. One patient aspirated and required a jejunal tube. Another patient needed jejunal tube due to poor absorption. No inflammation at PEG site (checked daily). Two patients died; cause of death unrelated to gastrostomy. Median time of PEG feeding was 11.5 weeks. Median time PEG in situ 15.6 weeks. | |
| Kuric et al., 1989 | Nutritional support: A prophylaxis against stress bleeding after spinal cord injury | Observational | 25 | Paraplegic and tetraplegic SCI. Group 1 (first 15 months of study): started on oral diet “when clinically ready.” Group 2 (subsequent months): nutrition protocol if unable to tolerate oral diet by hospital day 4, central line inserted. TPN started on day 5: 25% glucose, 4.25% amino acid @ 50 mL/h up to 125 mL/h within 24–48 h, intralipid 20% 3 times per week. If oral or NG could not be instituted by day 17, or patient required surgery for other reasons and appeared unable to tolerate feeding in the near future, jejunostomy was placed. Both groups: cimetidine, NG suction, hourly pH with gastric acid neutralization if pH < 5.0. Calories = BEE × activity factor (not specified) × 1.35 (skeletal trauma factor). | 5/66 patients in group 1 developed severe acute ulceration versus 2/100 group 2 patients (p < 0.05). All 7 who developed severe acute ulceration had cervical injury with major neurological deficit. Group 1 reached total energy requirements (TER) at 15.5 ± 11.48 days; group 2 reached TER at 4.6 ± 5.6 days. Group 1 was on cimetidine 14.0 ± 8.83 days; group 2 for 11.0 ± 10.00 days. Group 1 needed antacid therapy 16.0 ± 10.63 days; group 2 needed antacid 6.0 ± 3.96 days (p < 0.05). Group 1 needed NG suction 13.4 ± 8.6 days; group 2 needed NG suction 3.3 ± 4.00 days (p < 0.05). | |
| Laven et al., 1989 | Nutritional status during the acute stage of SCI | Observational | 23 | Nutritional status of acute tetraplegic and paraplegic SCI patients examined using anthropometric measures, nutritional assays (energy and protein intake), biochemical assays (vitamin and nutrient levels), grip strength, and incidence of secondary medical complications. | 57% report poor appetite 2 weeks after injury; declined to 29% after 8 weeks. 14% report dysgeusia and 22% report dysosmia 2 weeks after injury. Significant weight loss (–4.37 ± 9.45; p < 0.05) occurred between 2 and 4 weeks. Weight loss also occurred between 4 and 8 weeks post-injury but was not significant (−0.86 ± 4.42; p > 0.05). Mean values for plasma albumin, carotene, folate, and ascorbate, as well as erythrocyte folate, were lowest 2 weeks after injury and improved thereafter. Vitamin B12 was unusually high at 2 weeks but declined substantially thereafter. Other nutrient levels remained constant over time. Complications in the first 2 weeks: bacteriuria (35%), pleurisy (10%), pneumonia (6%), post-operative wound infections (6%), septicemia (4%), and decubitus ulcers (2%). Complications between 2 and 4 weeks: bacteriuria (54%), pneumonia (8%), pleurisy (4%), post-operative wound infections (4%), septicemia (4%), decubitus ulcers (4%), pleurisy (2%), and septicemia (2%). Between 4 and 8 weeks 4% developed pneumonia. No consistent associations between incidence of specific secondary complications and measures of nutritional status. Low plasma folate associated with less hand grip strength (36.3 ± 10.1 kg versus 48.9 ± 8.8 kg; p = 0.027). Plasma folate level not associated with maximal inspiratory pressure or maximal expiratory pressure. Creatinine levels not correlated with estimates of protein intake. | Study suggests 1500 kcal/d may be sufficient to prevent nutrition-related complications. |
| Dvorak et al., 2004 | Early versus late enteral feeding in patients with acute cervical SCI | Randomized controlled trial | 37 | Tetraplegic (C2 to T1 level). Early group: NG feeding initiated within first 72 h post-injury; late group NG feeding initiated more than 120 h after injury. For both groups energy requirements were calculated using the Harris-Benedict equation. Dietitian estimated stress factor based on patient's condition; varied up to 1.5. Protein requirements estimated and varied from 1.0–1.3 g/kg protein. | Early group: mean 2.4 ± 1.5 infections; late group 1.7 ± 1.1 infections. Most were pulmonary infections (10 per group). Transferrin level was mean 137 ± 44 mg/dL in early group, 145 ± 38 mg/dL in late group on day 5. Day 14 transferrin level 178 ± 28 mg/dL in early group; 175 ± 48 mg/dL in late group. 39 feeding complications early group, 59 late group. Duration of ventilation in early group was 762.8 ± 846.3 h; in late group was 502.1 ± 347.3 h. Length of stay in early group was 53.0 ± 34.4 days; in late group was 37.9 ± 14.6 days. | |
| Rodriguez et al., 1997 | The metabolic response to SCI | Experimental non-randomized controlled trial | 22 | Tetraplegic and paraplegic patients. Nutritional support: 2 g protein/kg ideal body weight. Calories PEE = BEE × 1.2 (bedrest) × 1.6 (trauma); instituted within 48 h of admission; TPN converted to tube feeding as early as patient gut function allowed. | First week 5 patients had negative NB; 4 had positive NB; 1 had balance of 0.0. Second week: 7 had negative NB; 1 had positive NB. Third week: 9 had negative NB; 0 had positive NB. Fourth week: 2 had negative NB; 1 had positive NB. During weeks 1 and 2, the measured energy expenditure was lower than the PEE in the majority of patients. A single patient with motor complete myelopathy demonstrated similar metabolic response to trauma as did those with complete myelopathies. Patient with motor incomplete myelopathy manifested a “quite different” metabolic response (positive NB except for week 3). | |
| Kaufman et al., 1985 | General metabolism in patients with acute paraplegia and quadriplegia | Observational | 19 | Nutritional assessment carried out within 4 days of admission and within 4 days from 10th day after admission: NB, anthropomorphic measurements (weight, skin triceps fold, arm muscle circumference); lab tests: serum albumin, serum transferrin, creatinine height index, total lymphocyte count, skin antigen testing. Patients graded as mildly depleted if any test abnormal; graded as moderately to severely depleted if tests within pre-defined range. Length of stay on respirator, infection rates measured. | Average daily calorie intake was 848 kcal (38% of expected needs). NB was negative to a greater extent than expected and persisted for 10 days. Initial assessment (within 4 days of admission): 1 normal, 3 mild depletion, 2 moderate depletion, 2 severe depletion. Second assessment (within 4 days from 10th day of admission): 1 had mild, 3 had moderate, 3 had severe depletion. 3 patients did not change categories between assessments, 2 declined 1 category, and 2 declined 2 categories. Albumin, transferrin, and creatinine height index declined between assessments (3.4 ± 0.5 to 2.9 ± 0.4, 229 ± 37 to 190 ± 71, 106 ± 19 to 95 ± 24, respectively); total lymphocyte count rose (1096 ± 474 to 1533 ± 856). | |
| Rowan, et al., 2004 | Is early enteral feeding safe in patients who have suffered SCI? | Retrospective chart review | 27 | Data collected regarding enteral feeding and reasons for interrupting feeding for all patients admitted to the intensive care unit (ICU) with spinal cord transection resulting in paraplegia or tetraplegia. | 82% were commenced on enteral feeding; enteral feeding was commenced on day 2 (median), and patients were fed a median of 7.7 days during their ICU stay; 25 were commenced on NG and 2 were later converted to NJ; 2 were commenced on NJ due to high gastric aspirate. 23/27 were transferred from ICU on enteral feeding. 6 patients were not started on enteral feeds: 4 on oral, 1 had ileus, and 1 transferred to another hospital. Feeds were interrupted a median of twice (range 0–20 times): most frequently for high aspirates, followed by attempts at oral diet and diagnostic procedures. 1 patient's feeding was interrupted due to ileus and failure to absorb the feeding. This patients was switched to NJ 4 days after ileus onset, and there were no further interruptions. Another patient was unable to absorb the feeding, was switched to NJ 1.5 days after NG feeding started, and similarly had no further complications. 10 (37%) of patients did not have their feeding interrupted for high gastric aspirate; 10 (37%) were interrupted only once or twice. Only 3 patients had their feeding interrupted >4 times for high aspirate. | |
| Wolf et al., 2003 | Dysphagia in patients with acute cervical spine injury | Experimental non-randomized controlled trial | 31 | Performed fiberoptic endoscopic examination of swallowing (FEES) on patients with cervical SCI. 5 levels of respiratory/feeding treatment, depending on level of dysphagia. | On admission, 21/51 had severe dysphagia (levels 1–3), 20 had mild dysphagia, 10 had none detected. One patients had subglottic stenosis of the trachea with fixed vocal cords, one had post-operative unilateral vocal cord palsy, two had luxations of arytenoid cartilage. 27/51 had repeated FEES at 4- to 6-week intervals (either because initial dysphagia level 1–3, or because proven aspiration in patient with initial dysphagia level 4). Only 3 patients retained severe dysphagia with danger of substantial aspiration (one of whom had cranial nerve palsy secondary to a brainstem lesion). No significant relationship between level of SCI and level of dysphagia at admission. At outcome, small but highly significant relationship between SCI level and dysphagia level. Age not significantly associated with level of dysphagia. On admission, 40/51 were fed exclusively via NG or PEG. At outcome, 40/48 had exclusively oral diet, 8 had a PEG. 1 was exclusively fed via PEG, while 7 of those with PEG were partly fed orally (2 due to level 3 dysphagia; 5 had no dysphagia but oral diet had to be supplemented.) 40 patients fed exclusively via NG or PEG on admission; after therapy, 40 completely on oral diet, 8 had PEG but only 1 was completely dependent with level 2 dysphagia (remaining 7 had partly oral diet; 2 had level 3 dysphagia, 5 had no dysphagia but oral diet had to be supplemented). | |
| Abel et al., 2004 | Dysphagia in patients with acute SCI | Observational | 29 | Dysphagia screening done with questionnaires and tests on tetraplegic and quadriplegic patients with clinically complete cord transection; those with suspected dysphagia followed by speech therapist and underwent dye tests (if tracheal tube) or swallowing studies. Patients were classified according to severity, phase of impaired swallowing, and dietary restrictions. Adequacy of deglutition at discharge noted. Incidence of pneumonia and duration of orotracheal intubation determined. | Dysphagia suspected clinically in 32 cases: 3 severe, 8 moderate, and 15 minimal; in 6 cases further investigation did not confirm dysphagia. 8 had oral and pharyngeal impairment; 17 had pharyngeal impairment alone. One had swallowing problems in esophageal phase of deglutition due to loose hardware, which resolved after surgical removal of screw. No association between dysphagia and age in either subgroup. Pts with higher level of injury more likely to have dysphagia (Pearson χ2 = 16.2, df = 7; p < 0.05). Patients with complete (American Spinal Injury Association A) lesion more likely to have dysphagia than incomplete (Pearson χ2 = 9.9, df = 1; p < 0.01). Incidence of dysphagia was not higher among those with an associated traumatic brain injury (χ2 = 0.097; p > 0.75). Median ICU stay and median duration of respiratory dependency were both 24 days (inter-quartile range 40 and 31.5, respectively). Tracheostomy was strongly associated with dysphagia (Pearson χ2 = 14.56; p = 0.00014). Patients with dysphagia required significantly longer duration of respirator support (mean 100.1 versus 24.1 days; p < 0.01). | Duration of oral intubation significantly shorter than nasal intubation (mean 5.7 versus 14.4 days; p = 0.015). Duration of orotracheal intubation prior to tracheal tube placement: 10.0 days for patients without dysphagia, 16.9 days for patients with dysphagia (p > 0.05). Duration of orotracheal intubation for patients not being tracheostomized: 3.9 days for patients without dysphagia, 8.3 days for patients with dysphagia (p > 0.05). Tracheostomy closure was median 88 days (inter-quartile range 81) after tracheostomy, and median 67 days (inter-quartile range 86) after stopping mechanical ventilation. Of 33 patients with tracheostomy, 3 died, 4 remained respirator-dependent, and 1 had recurrent pulmonary aspiration requiring prolonged endotracheal suctioning. Mean time between end of mechanical ventilation and tracheostomy closure significantly longer in patients with dysphagia (106.4 days versus 188.5 days; p < 0.05). Anterior approach to cervical spine surgery not significantly correlated with dysphagia (Pearson χ2 = 0.67; p = 0.42). However, there was no patient with dysphagia who had neither a tracheostomy nor anterior approach to surgery, and a forward stepwise logistical regression model suggested that the combination may increase the risk for dysphagia. Halo fixation was not associated with dysphagia. 3/4 patients with ankylosing spondylitis with rigid cervical spine needed a tracheostomy and had severe dysphagia. 31/73 patients had no pneumonia symptoms; 24/73 had one episode (22 early, 6 late); 6 had one early and one late episode; 11 had early plus multiple late episodes of pneumonia. Incidence of late or multiple episodes of pneumonia 58% for those with dysphagia versus 9% for those without (Pearson χ2 = 24.5, df = 4; p < 0.01). Dysphagia necessitated dietary restrictions in the texture of foods or solid food for 18 of 26 patients with swallowing pathology. Oral phase problems required dietary modifications more often than pharyngeal alone (p = 0.044). 10 pts needed PEG. 4 died, 2 due to recurrent pneumonia. At time of discharge 9/22 had resolved (all oral phase problems). 7 had persistent problems, 5 with pharyngeal phase problem and 2 with combined oral + pharyngeal; none on dietary restrictions (hypervigilant while swallowing). 6 had persistent dysphagia and discharged with PEG. |
| Kearns et al., 1992 | Nutritional and metabolic response to acute spinal cord injury | Observational | 25 | C4–T10 SCI. Initial assessment including Abbreviated Injury Scale. Weekly nutritional exams including weight were done for 4 weeks or until the flaccid phase of acute SCI began to resolve (as evidenced by return of patellar reflex); 72-h calorie intake calculated weekly; biochemical analyses done including albumin and calcium. | Serum albumin increased over the course of the study from 31 ± 1 to 34 1 g/dL (p < 0.05), despite negative NB. Serum calcium increased from 2.12 ± 0.1 to 2.36 ± 0.14 mEq/L (p < 0.01). Cumulative weight loss was 7.0 ± 0.6 kg. Basal energy expenditure 1683 ± 65 kcal/d. Resting energy expenditure 1523 ± 109, did not change significantly over course of study. Negative fluid balance first 2 weeks of study. Urinary calcium:creatinine ratio = upper limits of normal at baseline, but by week 3, 8 of 10 patients had hypercalciuric ratios, in spite of increases in creatinine excretion. Ratio significantly higher in quadriplegics than tetraplegics. Urinary 3-methylhistidine significantly elevated at baseline and remained elevated at week 4. Total nitrogen excretion was highest at baseline, and remained elevated throughout the study, but fell significantly (p < 0.05 versus week 0) at week 3. NB remained negative throughout. | |
| Barco et al., 2002 | Energy expenditure assessment and validation after spinal cord injury | Experimental non-randomized controlled trial | 23 | Ventilator-dependent SCI patients with isolated SCI evaluated. PEE determined using Harris-Benedict equation with 1.1 activity factor and 1.2 injury factor. Patients fed either enterally or parenterally; nutritional support adjusted based on indirect calorimetry measure expenditure. Urinary urea nitrogen, NB, nutrient intake, respiratory quotient, and pre-albumin levels were measured. | Mean measured energy expenditure was 95–100% of PEE. Predicted and measured energy expenditure were significantly correlated at each data point (r = 0.74–0.79; p < 0.05). NB was negative over all 4 study weeks. Pre-albumin improved significantly over the study period (p < 0.001). Mean body weight decreased by 9% over the study period (predictive equation not adjusted). | |
| Kolpek et al., 1989 | Comparison of urinary urea nitrogen excretion and measured energy expenditure in spinal cord injury and nonsteroid-treated severe head trauma patients | Observational | 25 | SCI pts receiving enteral or parenteral nutrition studied; prospectively studied; matched with TBI for sex, age, and weight. Indirect calorimetry performed biweekly where possible. Daily protein and caloric intake measured, 24-h urinary urea nitrogen collected, and NB determined. PEE was determined using the Harris-Benedict equation without an activity factor (not specified whether stress factor was used). | Although SCI pts were fed less than TBI pts (mean 0.8 ± 0.07 g/kg/d protein and 18.5 ± 1.3 non-protein kcal/kg/d, and mean 1.1 ± 0.07 g/kg/d protein and 26.7 ± 1.4 non-protein kcal/kg/d, respectively), they achieved total caloric balance (177 ± 969 kcal), while the TBI pts had a negative overall caloric balance (−358 ± 1222 kcal). Measured energy expenditure for SCI patients was 56% of PEE in week 1. Over the course of the 3-week study period, measured energy expenditure was 94% of PEE for SCI, but was 48% higher than PEE for TBI. Both SCI and TBI had higher-than-normal nitrogen excretion, and both were in negative NB over the study period. |
BEE, basal energy expenditure; PEE, predicted energy expenditure; SCI, spinal cord injury; NB, nitrogen balance; PEG, percutaneous endoscopic gastrostomy; TPN, total parenteral nutrition; NG, nasogastric; NJ, nasojejunal; PEDro, Physiotherapy Evidence Database (de Morton, 2009).