40 years of experience in functional surgery of the tetraplegic upper limb.

The author relates his 40 years of experience in the field of functional surgery of the tetraplegic upper limb (FSTUL). After having introduced and developed this specialty in France, he disseminated it to various countries where he saw a large number of patients and acquired extensive experience. He presents his personal progression and discusses the recent therapies in this field. FSTUL is a personalize surgery, with each case being unique. It must, first and foremost, take into consideration the real wishes of a motivated and well-informed patient and consider the type of spinal cord injury (not only the upper level of the lesional segment but also the extent of the sub-lesional segment). The surgical indication and rehabilitation are very important factors in the outcome. The main goal of FSTUL is rapid social reintegration of the patient; in some cases, this could involve fewer surgical procedures and shorter stays in rehabilitation centers. FSTUL is in constant evolution and can be improved; it is a useful but not well-known surgery.

Are Body Composition, Strength, and Functional Independence Similarities Between Spinal Cord Injury Classifications? A Discriminant Analysis.

CONTEXT: There seems to be no consensus on which aspects better distinguish the different levels of spinal cord injury regarding body composition, strength, and functional independence. OBJECTIVE: The study aimed to determine which variables better differentiate tetraplegia (TP) from paraplegia and high paraplegia (HP) from low paraplegia (LP). DESIGN: Cross-sectional study. SETTING: Rehabilitation hospital network. PATIENTS: Forty-five men with spinal cord injury, n = 15 for each level (TP, HP, and LP) causing complete motor impairment (American Spinal Injury Association Impairment Scale: A or B) were enrolled in the study. MAIN OUTCOME MEASURES: The 1-maximum repetition test, functional independence measure, spinal cord independence measure, and body composition (skinfold sum, body fat percentage, and body mass index) were assessed. Discriminant analysis was carried out using the Wilks lambda method to identify which strength and functional variables can significantly discriminate subjects for injury classification (TP, HP, and LP). RESULTS: The discriminant variable for TP versus HP was body mass index and for TP versus LP was 1-maximum repetition (P ≤ .05). There were no variables that discriminated HP versus LP. CONCLUSIONS: The discriminant variables for TP versus HP and TP versus LP were body mass index and 1-maximum repetition, respectively. The results showed that HP and LP are similar for strength and functional variables.

Combining nerve and tendon transfers in tetraplegia: a proposal of a new surgical strategy based on literature review.

Spinal cord injury (SCI) is very common, most frequently resulting from motor vehicle accidents and falling from a height. Often, SCI occurs at the cervical level, resulting in tetraplegia, which consists of loss of effective arm and/or hand function. For these patients, hand function is considered the most desired function, above bowel, bladder and sexual function. Fortunately, understanding about nerve and tendon transfers is steadily growing, providing new surgical solutions for functional restoration in tetraplegia patients. The primary aim of this systematic review of the literature is to assess all the various ways to improve upper-limb function, using both nerve transfers and classical tendon transfers in patients suffering from tetraplegia. Surgical indications, optimum timing and contraindications were reviewed. In accordance with the International Classification for Surgery of the Hand in Tetraplegia, ten subgroups of tetraplegic patients were analysed and a proposal for treatment combining nerve and tendon transfers formulated for each subgroup, seeking alternatives to classical surgical strategies. We also sought to propose strategies that, in instances of failure, still would allow for the use of some classical surgical approach. Starting with traditional management, we proposed new strategies using tenodesis and tendon transfers in association with nerve surgery. We believe that the suggestions described in the current paper could both improve and complete current surgical strategies and contribute to ensuring that more patients benefit from these options in future.

Motor exam of patients with spinal cord injury: a terminological imbroglio.

The description of the motor deficit of patients with spinal cord injury (SCI) varies significantly, leading to confusion within the neurological terminology. This paper proposes a concise and easy to use terminology to describe the motor deficit of patients with SCI. A broad review of the origin of the nomenclature used to describe the motor deficit of patients with SCI was performed and discussed. The prefix: "hemi" should be used to describe paralysis of one half of the body; "mono" for one limb; "para" for lower limbs, di" for two symmetrical segments and/or parts in both sides of the body; "tri" for three limbs, or two limbs and one side of the face; and "tetra" for four limbs. The suffix: "plegia" should be used for total paralysis of a limb or part of the body, and "paresis" for partial paralysis. The term "brachial" refers to the upper limbs; and "podal" to the lower limbs. According to the spinal cord origin of the main key muscles for the limbs, patients with complete injury affecting spinal cord segments C1-5 usually presents with "tetraplegia"; C6-T1 presents with "paraplegia and brachial diparesis"; T2-L2 with "paraplegia"; and L3-S1 with "paraparesis".

Validation of Duruöz Hand Index in patients with tetraplegia.

STUDY DESIGN: Cross-sectional, clinical measurement. PURPOSE: To investigate the validity of the Duruöz Hand Index (DHI) in the assessment of hand function in patients with tetraplegia. METHODS: A total of 40 patients with tetraplegia participated. Patients' upper extremities were assessed on the level of 'body function and structure' [The American Spinal Cord Injury Association (ASIA) Impairment Scale (AIS) 2000 revised criteria, upper extremity motor score (UEMS), neurologic level of injury and visual analogue scale of hand function (VAS-HF)], 'activity' [DHI and Quadriplegia index of function-short form (QIF-SF)] and 'body function and structure, activity and participation' [Health Survey Short Form-36 (SF-36)] according to International Classification of Function. RESULTS: The DHI showed significant correlations with UEMS, AIS, QIF-SF, VAS-HF, physical functioning and physical compound summary scores of SF-36. CONCLUSIONS: The DHI was found a valid method in the assessment of hand functions in patients with tetraplegia. LEVEL OF EVIDENCE: Diagnostic III.

Reliability and Validity of the Sensory Component of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI): A Systematic Review.

BACKGROUND: Since 1982, the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) has been used to classify sensation of spinal cord injury (SCI) through pinprick and light touch scores. The absence of proprioception, pain, and temperature within this scale creates questions about its validity and accuracy. OBJECTIVE: To assess whether the sensory component of the ISNCSCI represents a reliable and valid measure of classification of SCI. METHODS: A systematic review of studies examining the reliability and validity of the sensory component of the ISNCSCI published between 1982 and February 2013 was conducted. The electronic databases MEDLINE via Ovid, CINAHL, PEDro, and Scopus were searched for relevant articles. A secondary search of reference lists was also completed. Chosen articles were assessed according to the Oxford Centre for Evidence-Based Medicine hierarchy of evidence and critically appraised using the McMasters Critical Review Form. A statistical analysis was conducted to investigate the variability of the results given by reliability studies. RESULTS: Twelve studies were identified: 9 reviewed reliability and 3 reviewed validity. All studies demonstrated low levels of evidence and moderate critical appraisal scores. The majority of the articles (~67%; 6/9) assessing the reliability suggested that training was positively associated with better posttest results. The results of the 3 studies that assessed the validity of the ISNCSCI scale were confounding. CONCLUSIONS: Due to the low to moderate quality of the current literature, the sensory component of the ISNCSCI requires further revision and investigation if it is to be a useful tool in clinical trials.

Impact of pressure ulcers on individuals living with a spinal cord injury.

OBJECTIVE: To describe the impact of pressure ulcers on the ability to participate in daily and community activities, health care utilization, and overall quality of life in individuals living with spinal cord injury (SCI). DESIGN: Cross-sectional study. SETTING: Nationwide survey. PARTICIPANTS: Participants (N=1137) with traumatic SCI who were >1 year postinjury and living in the community were recruited. Of these, 381 (33.5%, 95% confidence interval, 30.8%-36.3%) had a pressure ulcer over the last 12 months. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measures developed for the Rick Hansen Spinal Cord Injury Registry Community Follow-up Survey Version 2.0. RESULTS: Of the 381 individuals with pressure ulcers, 65.3% reported that their pressure ulcer reduced their activity to some extent or more. Pressure ulcers reduced the ability of individuals with SCI to participate in 19 of 26 community and daily activities. Individuals with 1 or 2 pressure ulcers were more dissatisfied with their ability to participate in their main activity than those without pressure ulcers (P=.0077). Pressure ulcers were also associated with a significantly higher number of consultations with family doctors, nurses, occupational therapists, and wound care nurses/specialists (P<.05). CONCLUSIONS: Pressure ulcers have a significant impact on the daily life of individuals with SCI. Our findings highlight the importance of implementing pressure ulcer prevention and management programs for this high-risk population and require the attention of all SCI-related health care professionals.

Tetraplegia or paraplegia with brachial diparesis? What is the most appropriate designation for the motor deficit in patients with lower cervical spinal cord injury?

The authors seek to clarify the nomenclature used to describe cervical spinal cord injuries, particularly the use of the terms "tetraplegia", "quadriplegia", "quadriparesis", "tetraparesis", "incomplete quadriplegia" or "incomplete tetraplegia" when applied to patients with lower cervical cord injuries. A review of the origin of the terms and nomenclature used currently to describe the neurological status of patients with SCI in the literature was performed. The terms "tetraplegia", "quadriplegia", "quadriparesis", "tetraparesis", "incomplete quadriplegia" or "incomplete tetraplegia" have been used very often to describe patients with complete lower cervical SCI despite the fact that the clinical scenario is all the same for most of these patients. Most of these patients have total loss of the motor voluntary movements of their lower trunk and inferior limbs, and partial impairment of movement of their superior limbs, preserving many motor functions of the proximal muscles of their arms (superior limbs). A potentially better descriptive term may be "paraplegia with brachial diparesis". In using the most appropriate terminology, the patients with lower cervical SCI currently referred as presenting with "tetraplegia", "quadriplegia", "quadriparesis", "tetraparesis", "incomplete quadriplegia" or "incomplete tetraplegia", might be better described as having "paraplegia with brachial diparesis".

Functional outcome of patients 12 and 48 weeks after acute traumatic tetraplegia and paraplegia: data analysis from 2004-2009.

OBJECTIVES: During the first rehabilitation of patients with traumatic spinal cord injuries (SCIs), professional skills are learned, which can be objectified in an independent measurement score. The aims of this study were to record the skills of patients 12 and 48 weeks after acute trauma and perform an analysis of the data to identify provisions of importance. METHODS: All patients from 2004 to 2009 who experienced traumatic SCI were included in this investigation. Data recording were accomplished by the European Multi-Centre Study about Spinal Cord Injury (EMSCI) databank. Patients were divided into tetraplegia and paraplegia groups. Parameters were age at injury, the American Spinal Injury Association-Score, level of lesion and spinal cord independence measure (SCIM-Score) 12 and 48 weeks after traumatic spinal cord lesion. A questionnaire was also added to help clarify where deficiencies were prevalent. RESULTS: Data analysis of 103 tetraplegic and 110 paraplegic patients showed no correlation between the ASIA score, level of lesion, age and SCIM score. On average, tetraplegic patients had a SCIM score of 43 points 12 weeks after treatment, with 81% showing an increase to 58 points after 48 weeks. Paraplegic patients showed an average SCIM score of 60 points after 12 weeks, with 71% experiencing an increase to 71 points after 48 weeks. In all, 9% of tetraplegic patients and 19% of paraplegic patients experienced a decrease of SCIM points after 48 weeks, which occurred mainly in the bladder and intestinal control subgroups. Results of the questionnaire were not helpful for clarifying the location of the deficiencies. CONCLUSION: Most of the patients experienced an increase of SCIM points 48 weeks after traumatic SCI. However, data also showed that, especially in paraplegic patients, special attention must be given to bladder and intestinal management to avoid negative late-term consequences.

Is there a cartesian renaissance of the mind or is it time for a new taxonomy for low responsive states?

The mass media have recently pointed out the likelihood of diagnostic errors in post-coma patients. Late recoveries of consciousness, even after 20 years, might indicate hidden misdiagnoses that are not corrected over a long period of time. The rate of misdiagnoses of patients in a vegetative state is very high when based on behavioral assessment strategies alone. An extremely restrictive motor repertoire, as occurs in locked-in patients, seems to be the major factor responsible for diagnostic confusion. Functional neuroimaging techniques are regarded as promising tools in unearthing covert awareness in behaviorally unresponsive patients who are unable to produce any motor output. However, unless we believe that these patients persistently live in an unconvincing Cartesian-like state, in which thinking and acting are mutually dissociated, we have to admit that a new taxonomy for low responsive states is called for. This taxonomy should take into account the possible syndromic overlap between disorders of consciousness and locked-in syndrome. We should suspect a "locked-in state" in behaviorally unresponsive patients unless we reach strong evidence that such is not the case; this is the only way to avoid dramatic misdiagnoses.

Classification of topographical pattern of spasticity in cerebral palsy: a registry perspective.

This study used data from a population-based cerebral palsy (CP) registry and systematic review to assess the amount of heterogeneity between registries in topographical patterns when dichotomised into unilateral (USCP) and bilateral spastic CP (BSCP), and whether the terms diplegia and quadriplegia provide useful additional epidemiological information. From the Victorian CP Register, 2956 individuals (1658 males, 1298 females), born 1970-2003, with spastic CP were identified. The proportions with each topographical pattern were analysed overall and by gestational age. Binary logistic regression analysis was used to assess temporal trends. For the review, data were systematically collected on topographical patterns from 27 registries. Estimates of heterogeneity were obtained, overall and by region, reporting period and definition of quadriplegia. Among individuals born <32 weeks, 48% had diplegia, whereas the proportion for children born ≥ 32 weeks was 24% (p < 0.001). Evidence was weak for a temporal trend in the relative proportions of USCP and BSCP (p = 0.038), but much clearer for an increase in the proportion of spastic diplegia relative to quadriplegia (p < 0.001). The review revealed wide variations across studies in the proportion of diplegia (range 34-90%) and BSCP (range 51-86%). These findings argue against a topographical classification based solely on laterality.

[Comorbidities in patients with cerebral palsy and their relationship with neurologic subtypes and Gross Motor Function Classification System levels].

OBJECTIVE: To analyze the comorbidities in patients with cerebral palsy (CP) from two perspectives as neurologic subtype and gross motor functions, and find their correlations. METHODS: Children with cerebral palsy treated in the rehabilitation center from January 2007 to June 2009 received the following examinations: intelligence capacity test, ophthalmologic consultation, language-speech test, brainstem auditory evoked potential and electroencephalogram. They were stratified according to both neurologic subtype and gross motor functions to detect the occurrence of comorbidities. RESULTS: Of all the 354 cases, 166 (46.89%) had mental retardation, 15 (4.24%) auditory limitations, 138 (38.98%) visual disorder, 216 (61.02%) language-speech disorder and 82 (23.16%) epilepsy. The frequency of individual comorbidities were distributed disproportionately between the different neurologic subtypes. Correlation analysis showed that there was a significant correlation between the spastic diplegia and the visual disorder (correlation coefficient = 0.26), between spastic hemiplegia and epilepsy (correlation coefficient = 0.17), between spastic quadriplegia and epilepsy and mental retardation (the correlation coefficient was 0.38 and 0.11, respectively) and between both dyskinetic and mixed children and language-speech disorder (the correlation coefficient was 0.24 and 0.27, respectively). The frequency of individual comorbidities was distributed disproportionately between the different neurologic subtypes and between the different GMFCS levels (P < 0.05), except for the frequency of visual disorders (chi(2) = 1.90, P > 0.05); and with the increase of the GMFCS levels, the burden of the comorbidities were more heavy and the incidence of the comorbidities was higher. Multi-comorbidities were relatively infrequently encountered in those with spastic hemiplegic or spastic diplegic children or patients whose GMFCS levels were I-III, while these entities occurred at a frequent level for those with spastic quadriplegic, dyskinetic, or mixed or children whose GMFCS levels were IV and V, and the differences were significant (P < 0.05). The mean GMFCS levels of children with spastic quadriplegic, dyskinetic or mixed CP were higher than level III, most of them had no ability of ambulation;while the mean GMFCS levels of spastic hemiplegic or spastic diplegic children were below level III, most of them could walk independently. CONCLUSIONS: There are correlations between the occurrence of the comorbidities such as mental retardation, auditory or visual impairments, language-speech disorders, epilepsy and the cerebral palsy subtype and the gross motor function levels. Clinicians should have a full recognition of these comorbidities, and we should have a cooperation between the different subjects to have an overall evaluation and rehabilitation and to improve the prognosis.

Neuropsychologic assessment and cognitive rehabilitation in a patient with locked-in syndrome and left neglect.

We describe a patient affected by severe incomplete locked-in syndrome (LIS) and left neglect caused by a combination of vascular lesions. Our patient's neglect prevented the use of augmentative communication devices based on a computerized eye-tracker system. For this reason, we adapted a visual scanning training for neglect rehabilitation. At the end of the rehabilitative training, the patient had regained full exploration of the monitor and could use the eye-tracker system for communicative purposes. This case report shows that specific rehabilitative approaches can be devised in severely disabled LIS patients with additional brain lesions and specific cognitive defects.

[Ethical aspects of dealing with coma patients]. / Ethische Aspekte im Umgang mit Komapatienten.

The number of patients who survive severe brain injury increased due to progress in neurosurgery and intensive care. To establish a proper prognosis on the coma stage and the possible potential of remission is difficult in many cases. The treatment of patients in chronic coma leads to economic and ethical problems. Progress in functional radiology may help to obtain a proper prognosis in future. While numerous issues deal with ethical aspects in case of brain death only few do so with treatment decisions in chronic coma patients.

Intra-rater agreement of the anorectal exam and classification of injury severity in children with spinal cord injury.

STUDY DESIGN: Intra-rater reliability study, cross-sectional design. OBJECTIVES: To report on the intra-rater agreement of the anorectal examinations and classification of injury severity in children with spinal cord injury (SCI). SETTING: Two, non-profit children's hospitals specializing in pediatric SCI. METHODS: 180 subjects had at least two trials of the anorectal examinations as defined by the International Standards for Neurological Classification of Spinal Cord Injury. Intraclass correlation coefficients (ICC) and 95% confidence intervals (CI) were used to evaluate the agreement. ICC>0.90=high agreement; ICC between 0.75-0.89=moderate agreement; ICC<0.75=poor agreement. RESULTS: When evaluated for the entire sample, agreement was moderate-high for anal sensation and contraction and injury classification. When evaluated as a function of age at examination and type of injury, agreement for anal sensation was poor for subjects with tetraplegia in the 12-15-year age group (ICC=0.56) and 16-21-year age group (ICC=0.70) and for subjects with paraplegia in the 6-11-year age group (ICC=0.69). Agreement for anal contraction was moderate for subjects with tetraplegia in the 16-21-year age group (ICC=0.81) and subjects with paraplegia in the 12-15-year age group (ICC=0.78) and poor for subjects with paraplegia in the 6-11-year age group (ICC=0.67). Agreement for injury classification was poor for subjects with tetraplegia in the 12-15-year group (ICC=0.56) and 16-21-year group (ICC=0.74) and paraplegia in the 6-11-year group (ICC=0.11) and 12-15-year group (ICC=0.63). Anorectal responses had high agreement in subjects with tetraplegia in the 6-11-year group and moderate to high agreement in subjects with paraplegia in the 16-21-year group. CONCLUSION: The data do not fully support the use of anorectal examination in children. Further work is warranted to establish the validity of anorectal examination.

The term diplegia should be enhanced. Part II: contribution to validation of the new rehabilitation oriented classification.

Recent proposals of classification for cerebral palsy (CP), mainly revised for epidemiological purposes, suggest to abandon the use of the term diplegia. Conversely, in this paper data are presented to support the proposal to maintain the distinction between spastic tetraplegia and diplegia, and to subdivide this latter according to four main clinical patterns of walking observable in these children. This proposal of classification was validated by testing a group of 467 subjects with CP, of whom 213 with diplegia and 115 with tetraplegia, consecutively admitted between January 2005 and December 2006 to two national reference centers for this disability. The results were compared with findings obtained by other methods of classifying gross and fine motor function and associated disorders. The subjects with tetraplegia strongly differ from those of diplegia, both for motor functions and for other disabilities. The four main walking patterns of spastic diplegia were easily recognizable and observers were able to assign most of the subjects to one form of the classification. Significant correlations between walking forms of diplegia and distribution of Gross Motor Function Classification System (GMFCS) levels were found. Some of the forms significantly differ also for fine motor and mental disability. These findings suggest that in clinical practice the category of diplegia not only can be kept as a separate form of CP, but it may be enhanced, through the identification of different subcategories of children, divided according to their walking patterns.

The Capacity Profile: a method to classify additional care needs in children with neurodevelopmental disabilities.

The aim of this study was to determine the interrater reliability and stability over time of the Capacity Profile (CAP). The CAP is a standardized method for classifying additional care needs indicated by current impairments in five domains of body functions: physical health, neuromusculoskeletal and movement-related, sensory, mental, and voice and speech, in children from 3 to 18 years of age. The intensity of care in each domain is defined from 0 (no need for additional care) to 5 (needs help with every activity). The intensity of additional care in each of the five separate domains indicates the CAP for the individual child. We developed the CAP to inform the parents and other caregivers of children with non-progressive, permanent neurodevelopmental disabilities, such as cerebral palsy and myelomeningocele, about the consequences of these conditions. To determine interrater agreement and stability over time, the CAPs of 67 children (39 males, 28 females) with a neurodevelopmental disability (mean age 18y [SD 1.2y]; range 14-22y) were assessed based on a semi-structured interview. In addition, the CAPs of the same individuals at the age of 3 years were determined based on a chart review. Interrater agreement of the CAP at the age of 3 was good to very good (weighted kappa 0.64-0.92). Agreement between the CAP at the age of 18 and the CAP at the age of 3 (providing evidence for stability over time) was also good (weighted kappa 0.68-0.77), except for the domain 'physical health functions', about which agreement was relatively poor (0.47). We conclude that the CAP is a reliable instrument for classifying the additional needs of a child with a non-progressive, permanent neurodevelopmental disability. The preliminary evidence for the stability over time of such needs according to the CAP should be validated in a prospective study.

Hip displacement in cerebral palsy.

BACKGROUND: Hip displacement is considered to be common in children with cerebral palsy but the reported incidence and the proposed risk factors vary widely. Knowledge regarding its overall incidence and associated risk factors can facilitate treatment of these children. METHODS: An inception cohort was generated from the Victorian Cerebral Palsy Register for the birth years 1990 through 1992, inclusive, and multiple data sources pertaining to the cohort were reviewed during 2004. Gross motor function was assessed for each child and was graded according to the Gross Motor Function Classification System (GMFCS), which is a valid, reliable, five-level ordinal grading system. Hip displacement, defined as a migration percentage of >30%, was measured on an anteroposterior radiograph of the pelvis with use of a reliable technique. RESULTS: A full data set was obtained for 323 (86%) of 374 children in the Register for the birth years 1990 through 1992. The mean duration of follow-up was eleven years and eight months. The incidence of hip displacement for the entire birth cohort was 35%, and it showed a linear relationship with the level of gross motor function. The incidence of hip displacement was 0% for children with GMFCS level I and 90% for those with GMFCS level V. Compared with children with GMFCS level II, those with levels III, IV, and V had significantly higher relative risks of hip displacement (2.7, 4.6, and 5.9, respectively). CONCLUSIONS: Hip displacement is common in children with cerebral palsy, with an overall incidence of 35% found in this study. The risk of hip displacement is directly related to gross motor function as graded with the Gross Motor Function Classification System. This information may be important when assessing the risk of hip displacement for an individual child who has cerebral palsy, for counseling parents, and in the design of screening programs and resource allocation.