Vertebrobasilar ischemia after cervical spine manipulation: a case report.

INTRODUCTION: The most serious accidents after cervical spine manipulation are vertebrobasilar ischemia. Their incidence is underestimated. Their risk of apparition is lower if the contraindications are respected and if they are realised according to suitable practice. CASE REPORT: Mrs B, 39 years old, was an active smoker and had migraine for 10 years ago. One day, she presented an unusual headache associated with neck pain that was treated by a cervical spine manipulation. Seven hours after, she developed an alternate syndrome with a right sensory motor defect, a cerebellar syndrome, a pyramidal syndrome and a left defect of cranial nerves. The arteriography showed a thrombosis of the basilar trunk and a dissection of the left vertebral artery. A thrombolysis "in situ" was realized six hours and a half after the onset of the neurological defects. After eight months of rehabilitation, there were still a paralysis of the right upper limb, of the cranial nerves and a cerebellar syndrome but the patient was able to walk with two crutches and can eat by herself. DISCUSSION: Several risk factors were present in this case and there was also a major contraindication to manipulations: unusual acute occipital headache. Given the long period between the onset of neurological symptoms and the confirmation of the diagnosis, intravenous thrombolysis could not be done. Unfortunately, after eight months, important neurological sequels persisted. In order to avoid this type of accident after cervical manipulations, it is necessary to realize a strict medical examination and to implement the recommendations from the French society of manual and orthopaedic osteopathic medicine (Société française de médecine manuelle orthopédique et ostéopathique [SOFMMOO]).

[Comparison between the terminal motor pudendal nerve terminal motor latency, the localization of the perineal neuralgia and the result of infiltrations. Analysis of 53 patients]. / Comparaison entre la latence distale motrice du nerf pudendal, la topographie de la douleur périnéale et le résultat d'infiltrations. Analyse pour 53 patients.

AIM: The aim is to study the value of the pudendal nerve terminal motor latency (PNTML) testing, in respect to the painful side in patients with pudenda neuralgia, and to determine whether a possible increased latency in the painful side is predictive of a good result with the infiltration. METHOD: This retrospective study included 53 outpatients (42 women, mean age 62) with suffering from pudendal neuralgia, who were seen between 2000 and 2004. The mean duration of the pain was 30+/-47 months. The PNTMPNL was measured by the Saint-Mark hospital technique, by the same operator. The following criteria have been were defined: significant increased latency greater than above 6 ms, significant difference of 2 ms in latency between 2 sides from 2 ms, and side of the infiltration corresponding to the side of the neuralgia. The infiltrations were performed either by perineal (30 cases) or transgluteal (8 cases) way. The results on pain were have been considered as good when a substantial reduction of the pain was observed for 6 months or more. Statistical analysis involved was done by the exact Fischer's test to seek for a possible relation between variables. RESULTS: Of 53 patients (42 women, 11 men, mean age 62) suffered from a with perineal neuralgia. The duration of the neuralgia was 30+/-47 months. It was bilateral in 10 cases and unilateral in 43 cases. In 43 patients with When the pain was unilateral pain, PNTML we find that the MDLPN was increased in both sides in 39.5% of the population, in the painful side in 14% and in the side opposite side of the to pain in 11%. In 10 patients with the neuralgia was bilateral pain, in 10 patients. Among then, 4 had a bilateral increase of the latency, one patient had an increase only on the right side, and another one an increase only on the left side. We did not find any correlation between the increased of the PNTML TMPNL and, either neither the duration of the neuralgia nor the result of the infiltrations, whatever the method way of the infiltration. CONCLUSION: The PNTML can be increased whether it corresponds or not to an entrapment of the pudendal nerve. Thus, the management of perineal pain is based mainly, from us, on clinical findings.

[Assessment of chronic pain as a disability in patients with spinal cord injuries]. / Evaluation fonctionnelle de la douleur chronique chez le patient blessé médullaire.

OBJECTIVES: To evaluate pain and its impact on daily life activities in patients with spinal cord injuries. METHODS: Patients with chronic pain associated with spinal cord injuries were mailed 2 questionnaires: the multidimensional pain inventory for spinal cord injury, which includes a visual numeric scale for pain; and the quality of life questionnaire SF-36. RESULTS: Twenty-two of the 28 patients (women 9, men 19) who were mailed the questionnaires responded. The location of pain was, in decreasing order: lower limbs, upper limbs, trunk. The clinical type of pain was usually neuropathic, and the mean pain intensity was 7.2+/-2.16. Eleven patients experienced sleep disturbances. In 17 patients, daily activities were limited because of pain (not counting 2 patients who were unable to answer because of hospitalization). Among 6 working patients (of 22), 5 experienced limitations in their job because of pain. SF-36 scores, which reflect psychological and physical health, were well below those of the general population. DISCUSSION-CONCLUSION: Despite the small size of our population and lack of a French-language validation of the questionnaire, these preliminary results point out the important interference of chronic pain in functional autonomy and quality of life in patients with spinal cord injuries.

Fatigue and respiratory disorders.

OBJECTIVES: To analyze the factors at the origin of fatigue in respiratory disorders. To assess fatigue and its functional impact on patients affected from respiratory diseases. To evaluate the results of comprehensive care on fatigue and functional capacity. MATERIALS AND METHODS: We systematically reviewed the literature in Medline and the Cochrane Library, using the following keywords: fatigue, respiratory disorders, questionnaire, evaluation, assessment, randomized controlled trial, meta-analysis. RESULTS: Fatigue is a high frequency symptom (90%) and takes an important place, as much as dyspnea, in the genesis of the respiratory induced handicap. Its assessment is varied, according to the studies. It originates from multiple causes, as shown from clinical and experimental studies. The main treatment consists in rehabilitation, using physical exercises. Its efficacy is demonstrated on physical endurance, but is not clear in terms of general fatigue. CONCLUSION: Although fatigue is very frequent complaint, along with a major disabling condition, the comprehensive assessment of fatigue, in respiratory disorders, including its physical and cognitive components, is not still really codified. Rehabilitation is the main treatment. Its efficiency has been demonstrated on the physical and functional components of fatigue. Its results on perceived fatigue remains to be evaluated.

[Treatment of heterotopic ossification by extracorporeal shock wave: 26 patients]. / Traitement des paraostéoarthropathies par ondes de choc. Etude sur 26 patients.

OBJECTIVES: To evaluate the effects of extracorporeal shockwave therapy (ESWT) on heterotopic ossification leading to functional limitations in the short and medium term. METHODS: Twenty-six patients with heterotopic ossification received sessions of ESTW (4000 shocks, 3/s), with an energy ranging from 0.54 to 1.06 mJ/mm2, once a week for 4 consecutive weeks. Intermediary assessments performed 1 month after the last session related to pain (on a visual analog scale [VAS]), range of motion, functional independence (FIM), walking distance (whenever possible), radiology, and blood calcium and alkaline phosphatase levels. Eighteen patients with total hip arthroplasty (THA) were followed up by quiz, at 11 months, on average. RESULTS: Heterotopic ossification was neurogenic in 5 patients and nonneurogenic in 21. The length of evolution of ossification was 32+/-21 months. The measurements showing significant improvement in the short term were pain, with a mean decrease of 4.32 to 1.14 on a VAS; joint flexion, with an mean increase of 8.18+/-11.9 degrees; and walking distance, with a mean increase from 1126 to 2776 m. The treatment was tolerated for the most part. THA cases showed a decline in factors initially shown to be improved. However, the long-term results were superior to clinical status before treatment. CONCLUSION: ESWT might be an interesting treatment for heterotopic ossification and can be a complement to usual medical treatment, physiotherapy, and before surgery.

Clinical experience with functional electrical stimulation-assisted gait with Parastep in spinal cord-injured patients.

STUDY DESIGN: Clinical evaluation of the Parastep method, a six-channel transcutaneous functional electrical stimulation device, in spinal cord-injured patients. OBJECTIVES: To investigate the motor performances of this new technique regarding energy expenditure and to evaluate its advantages and limitations, especially in social activities involving ambulation. METHODS: This study was conducted in 15 thoracic spine-injured patients. The lesion was complete except in two patients. The gait ability and the functional use were judged clinically. Energy cost was evaluated from heart rate, peak oxygen uptake, and lactatemia. RESULTS: Thirteen patients completed the training (mean: 20 sessions) and achieved independent ambulation with a walker. The mean walking distance, without rest, was 52.8 +/- 69 m, and the mean speed was 0.15 +/- 0.14 m/sec. One patient with incomplete lesion, who had been nonambulatory for 8 months after the injury, became able to walk without functional electrical stimulation after five sessions. The follow-up was 40 +/- 11 months. Five patients pursued using functional electrical stimulation-assisted gait as a means of physical exercise but not for ambulation in social activities. The patients experienced marked psychological benefits, with positive changes in their way of life. In three subjects, a comparison of physiologic responses to exercise between a progressive arm ergometer test and a walking test with the Parastep (Sigmedics, Inc., Northfield, IL) at a speed of 0.1 m/sec was performed, showing that the heart rate, the peak oxygen uptake, and lactatemia during gait were close to those obtained at the end of the maximal test on the ergometer. CONCLUSIONS: In spite of its ease of operation and good cosmetic acceptance, the Parastep approach has very limited applications for mobility in daily life, because of its modest performance associated with high metabolic cost and cardiovascular strain. However, it can be proposed as a resource to keep physical and psychological fitness in patients with spinal cord injury.

[Heterotopic ossification in Guillain-Barré syndrome]. / Paraostéoarthropathies dans le syndrome de Guillain-Barré

INTRODUCTION: Heterotopic ossification are frequent in central nervous disease, on the opposite just a few cases have been described in peripheral disorders. PURPOSE: To describe three cases of Guillain-Barré syndrome complicated by heterotopic ossification. METHODS: From the detailed case reports and a review of the literature. RESULTS: The authors report three cases of heterotopic ossification in Guillain-Barré syndrome. Each of them had serious symptom and had to go in intensive care. Two of them had encephalopathy. A patient had compression of ulnar nerve as complication of heterotopic ossification. In all cases the consequence of the heterotopic ossifications lead to a great functional handicap. DISCUSSION: Heterotopic ossification is a frequent complication in central neurologic lesions such spinal cord injury or brain injury. Just a few cases following peripheral nerve disorders have been reported. Serious neurologic deficit and encephalopathy may influence the apparition of heterotopic ossifications in patients suffering from Guillain-Barre syndrome. This possibility of complication must be known by the clinicians who should have a special attention to such patients.

[Urodynamics in functional rehabilitation]. / Urodynamique en réadaptation fonctionnelle.

Urodynamics is used as an help to aid the diagnosis of sphincter or bladder dysfunction mechanisms and as an evaluation tool of drugs (tests) or retraining (biofeedback). The following are used: uroflowmetry sphincterometry cystometry, electrodiagnosis. These data are recorded simultaneously. In rehabilitation medicine, a special place is given to the active patient's participation during the examination. This allows a good approach to voluntary control and micturition reflex.

[Heterotopic ossification and vascular compression]. / Paraostéoarthropathies et compressions vasculaires.

Heterotopic ossification is common in patients with spinal cord or brain injury. Whereas the articular complications of heterotopic ossification have been well documented, the vascular complications are less well known. We report three cases with vascular compression and discuss the diagnosis and treatment in the light of a review of the literature.

The stop-flow technique: a way to measure detrusor strength.

Maximum intravesical isometric pressure, obtained by stopping the urinary flow in progress, measures detrusor strength and allows an accurate evaluation of bladder contraction. Micturition studies were performed on 7 normal subjects and 48 patients with urinary obstruction, enuresis, neurogenic vesical dysfunction or stress incontinence. In the case of obstruction maximum isometric pressure appears to relate to the degree of detrusor compensation and allows a prognosis as to the future of detrusor function after the obstruction is removed. An unexpected large proportion of patients with enuresis were found to have high maximum isometric pressure usually associated with elevated urethral resistance, suggesting that urinary obstruction may not uncommon as an etiological factor of enuresis.

The reflex sympathetic dystrophy syndrome in patients who have had a spinal cord injury.

Patients suffering from a spinal cord injury often present with a pain syndrome. Although the reflex sympathetic syndrome is a common diagnosis in some forms of neurological disease such as patients with a stroke, it is less frequent in those with a spinal lesion. The authors report eight patients with reflex sympathetic dystrophy who had a spinal cord injury. The diagnosis and treatment are discussed along with a review of literature.

Restoration of gait by functional electrical stimulation for spinal cord injured patients.

In this clinical study, we report the results of functional electrical stimulation for the ambulation of paraplegic patients without long leg braces (LLB), according to the Parastep approach. Of 13 SCI patients with complete neurological lesions included in this trial, 12 progressed to independent ambulation with the aid of the Parastep. The average walking distance was 76 m, with a maximum of 350 m, and the mean speed 0.2 m s-1. Compared to the situation with long leg braces, which in fact are given up by most paraplegic patients, long term home use seems to be much more important. Tolerance of this method is satisfactory. The psychological benefits of the device are remarkable. From this experience, it is concluded that this method is valuable for the restoration of standing and walking in the long term management of spinal cord injury patients.

Influence of urinary management on urologic complications in a cohort of spinal cord injury patients.

OBJECTIVE: To study urologic complications in patients with spinal cord injury (SCI) in relation to their bladder management. DESIGN AND SETTING: A cohort study of patients with SCI in a rehabilitation center. PARTICIPANTS: One hundred eighty-two patients were studied; demographic data, disease characteristics, and urologic history were obtained for each. INTERVENTION: Patients responding to a questionnaire were given a clinical exam. Their medical records were reviewed, with particular attention given to the following urologic complications: lithiasis, urinary infections, orchiepididymitis, urethral trauma, vesicorenal reflux, and renal failure. RESULTS: Results are reported for 123 patients. Time since SCI was 8 years. Intermittent catheterization was the main method of bladder management. Only 32 patients had changed their method of vesical voiding. Urinary complications had developed in 75% of patients. The most common complication was urinary infection. Vesicoureteral reflux occurred in 26% of patients using percussion. Trauma related to catheterization was the main problem with intermittent catheterization, responsible for a high rate of orchiepididymitis. CONCLUSION: Intermittent catheterization is the most-used method of bladder management, but with a nonnegligible rate of urethral trauma in men. Percussion and Credé maneuver appear to be acceptable techniques of bladder management if the patient is closely monitored.

[Shy and Drager syndrome. Physiopathological and pharmacological approach based upon one case (author's transl)]. / Syndrome de Shy et Drager. Approche physiopathologique et pharmacologique à propos d'un cas.

The authors report a new case of Shy and Drager syndrome characterized by the severity of the extrapyramidal signs as well as that of orthostatic hypotension and urinary dysfunction. Peripheral adrenergic disturbance was proven, associated with an abnormality of the renin-angiotensin system. The authors describe the various drugs tried experimentally in treatment of the three main symptoms of the disease. A combination of Trihexyphenidyl and Dibenzepine finally appeared to be the most effective. Six months later, there remained a marked improvement in extrapyramidal signs and orthostatic hypotension. By contrast there was no improvement in urological symptoms.

[Urinary disorders in multiple sclerosis. Apropos of 47 cases]. / Les troubles urinaires dans la sclérose en plaques. A propos de 47 cas.

The authors report a series of 47 patients suffering from disseminated sclerosis who required neuro-urological management because of micturition disturbances. They were in general young (mean age 43 years) and had been suffering from disseminated sclerosis for 10 years (on average). The neurological disease was in general severe since it was progressive in 32 cases and pure remittent in 13 only. Two-thirds of the patients were autonomous from a locomotor standpoint. Micturition disturbances developed in the first five years of the disease in 2/ 3rds of the patients and became really troublesome only after disseminated sclerosis had been progressive for five years. Dysuria, frequency and incontinence with urgency were the commonest symptoms. Persistent or transient retention of urine remained relatively common. Nocturnal urine loss was rarer. Sphincter incompetence was marked in half of the patients but this did not necessarily go hand in hand with locomotor incapacity. Symptoms and signs were grouped as irritative, obstructive and mixed syndromes. From a urodynamic standpoint, the detrusor was sometimes normal but more often behaved pathologically, being either hyperactive or hypoactive. Hypoactivity of the detrusor was accompanied in 9 cases out of 10 by spasticity of the striate sphincter. Spasticity of the striate sphincter was the commonest type of behaviour, although normal striate sphincter electromyography was possible and; rarely, results were of peripheral neurogenic type. There was no evidence of any correlation between the type of micturition syndrome, detrusor function and striate sphincter function. Similarly, no correlation could be established between the type of detrusor dysfunction and the period for which disseminated sclerosis had been present.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of detrusor sphincter dyssynergia by transperineal injection of botulinum toxin.

Detrusor-sphincter dyssynergia is an involuntary contraction of the external urethral sphincter during the detrusor contraction. It causes voiding dysfunction and can lead to urologic complications such as hydroureteronephrosis and renal failure. Patients with spinal cord injuries are particularly vulnerable. Botulinum toxin has been used via cystoscopy to decrease the activity of the external urethral sphincter. This report describes the treatment of 5 tetraplegic patients by single transperineal injections of botulinum toxin for detrusor-sphincter dyssynergia, proved by a urodynamic study with electromyography. A total of 15 injections was given, resulting in improved bladder function in all patients. Urodynamic assessment after treatment showed an increase of the functional detrusor capacity and a decrease of the maximal detrusor pressure during voiding. These results confirm the consideration of botulinum toxin as a treatment for detrusor sphincter dyssynergia. A single transperineal injection is a valuable, less invasive treatment using a cystoscopic technique.