Bowel function in adults who have sustained spinal cord injury in childhood.

The impact of neuropathic bowel dysfunction on bowel habits was studied in 35 adult spinal cord injury (SCI) patients, who had sustained their injury in childhood. The methods used in the study were clinical interview and examination, quantitative scoring of bowel function (BCS) and estimation of bowel transit time with radiopaque markers. Thirty five healthy subjects without previous anorectal disease or surgery and with similar age and sex distribution as the patients served as controls. Most of the SCI patients were content with their bowel function. Nine (26%) out of 35 of the SCI patients were completely satisfied with their bowel function and reported no limitations in social life. The majority (69%) of the patients considered their bowel function to be significantly altered, causing only mild problems in their social life. Two of the patients had major problems of bowel function, which caused severe limitations in their social life. The majority (77%) of the patients declared that they had a low frequency of bowel evacuation. Eight out of 35 patients were using laxatives to promote bowel emptying. The quantitative BCS of the patients was significantly lower than that of the controls (P < 0.001). Moreover, there was a significant difference between the scores of patients with complete high (C2-T6) and complete low (T7-S4-5) lesions. The difference between the BCS and overall satisfaction with bowel function can be explained by good habilitation to SCI and by the prolonged transit times which enables relatively rare and controlled bowel movements and firm consistency of stools.

Later health-related quality of life in adults who have sustained spinal cord injury in childhood.

The outcome in terms of health-related quality of life (HRQL) in pediatric spinal cord injury (SCI) was studied in 36 adults who had sustained an SCI in childhood. The patients were interviewed and clinically examined. HRQL was assessed with the 15D, a generic fifteen-dimensional self-administered HRQL instrument. The 15 multiple-level dimensions are moving, seeing, hearing, breathing, sleeping, eating, communicating, urinary continence, working, social participation, mental functioning, pain, depression, distress and perceived health. The respondents choose, for each dimension, the level that best describe their health status. In the 15D valuation system the respondents first assign a relative importance weight to each dimension and then a relative value to the levels on each dimension. To derive the 15D HRQL score on a 0-1 scale the level values and importance weights are multiplied and combined with the levels chosen. The average HRQL score of this SCI group was significantly lower than that measured in the population sample. The average importance weights assigned by the SCI group differed significantly (P < 0.05) from those assigned by the general population on several dimensions. The weights assigned by the SCI group were higher for the dimensions of mental functioning, communicating, social participation and seeing and lower for moving, working, sleeping and eating. These differences in valuing the dimensions of HRQL can influence behaviour and should therefore be taken into consideration in rehabilitation.

Psychological defenses and psychiatric symptoms in adults with pediatric spinal cord injuries.

The psychological defenses and psychiatric morbidity of 30 adults with pediatric spinal cord injury and of 235 community controls were compared several years after the occurence of the injury. The patient group did not report more symptoms when measured with the Symptom Checklist-90 than the control group, but there were some characteristic features in their use of defenses as measured with the Defense Style Questionnaire. The adaptation process seems to follow a pattern: the greater the length of time since the injury, the less likely were the immature defenses omnipotence-devaluation and regression and the higher were the scores on the mature defense anticipation. It appears that the same result-symptom free adaptation-is first achieved by more immature means but as the adaptation process evolves, the psychological equilibrium can be maintained by mature defenses which do not distort reality. Furthermore, the results that patients with pediatric spinal cord injury scored higher on fantasy (daydreaming) and passive aggression (silent resistance) suggest that being injured very young may leave some faint, yet permanent psychodynamic traces.

Management of infected fractures of the tibia with associated soft tissue loss: experience with external fixation, bone grafting and soft tissue reconstruction using pedicle muscle flaps or microvascular composite tissue grafts.

The aim of this study was to assess the results of treatment given by a team of orthopaedic and plastic surgeons in a series of infected unhealed fractures of the tibia associated with loss of adjacent soft tissues. Twenty-five lower leg fractures, treated during a 10 year period, entered the study and were grouped according to the principles of treatment followed. In the earlier Group A (nine patients), the osteosynthesis implants were retained or changed to more stable internal fixation devices, the soft tissue defects were closed by conventional muscle or musculocutaneous flaps and bone grafting procedures were performed late in the treatment scheme. In the later Group B (16 patients) the implants were removed and the fracture stabilised by external fixation; the defects were covered with pedicle muscle flaps or with microvascular composite tissue grafts and cancellous bone grafting was performed at the same operation. Twenty-three fractures healed. One fracture developed non-union and in one patient infection necessitated below-knee amputation. The time of union after surgical reconstruction was significantly shorter in Group B (24 +/- 3 weeks) than in Group A (47 +/- 11 weeks). The results suggested that: in severe infected fractures of the tibia surgical implants used previously for fracture treatment should be removed and replaced with an external frame using firm axial compression, microvascular composite grafts seem to improve greatly the rate of healing, early bone grafting should be included in the reconstruction and late infections can be largely avoided even after extensive one-stage reconstructive procedures.

External transpedicular fixation test of the lumbar spine correlates with the outcome of subsequent lumbar fusion.

External transpedicular fixation was applied to the lower lumbar spine in a prospective study on 42 patients with chronic low back pain combined with suspected instability of the lumbar segments; the diagnosis was failed disk surgery, spondylolisthesis, and degenerative disk disease. The aim was to realign the involved segments, to restore disk height, and to record changes in pain and performance during the external fixation test. Pain was recorded on a visual analog scale, and performance was assessed using the Oswestry disability score. As independent observer assessed the test and treatment results. Twenty-nine patients experienced relief of pain and performed better in the fixator; they were subjected to anterior interbody fusion, the external frame being kept as a stabilizing device for an additional four months. Twenty-two patients have had follow-up evaluations for two years. One and two years after successful lumbar fusion, significantly (p < 0.02) better pain and performance scores were recorded; the results of lumbar fusion corresponded to the preoperative fixation test. A temporary external fixation test may be a useful procedure in patients considered for subsequent spondylodesis.

Bone mineral status after pediatric spinal cord injury.

The impact of spinal cord injury (SCI) on later bone mineral status was studied in 35 adults who had sustained their injury in childhood. The median age of the patients was 31 years, the median age at injury 12.9 years and the median time period from injury was 19 years. The methods used in the study were clinical interview and examination, measurement of bone mineral density (BMD) of the lumbar spine and the proximal femur with dual energy X-ray absorptiometry (DEXA) and estimation of bone turnover with biochemical markers. The densitometric examination revealed that the BMD at the lumbar spine was within the normal range but grossly decreased in the femoral region. Moreover, there was a significant difference in BMD between patients with high (C2-T6) and low (below T6) lesions in the lumbar spine as well as in the femoral region. Patients with lower lesions had higher BMD values. The markers of bone turnover which were studied were serum and urinary calcium and phosphate serum alkaline phosphatase and its isoenzymes, osteocalcin, carboxyterminal propeptide of human type I procollagen (PICP), carboxyterminal telopeptide of type I collagen (ICTP) and urinary deoxypyridinoline. These markers of bone metabolism showed no signs of ongoing accelerated bone formation or resorption. The present study suggests that caution should be observed in weight bearing training or mobilisation of patients with pediatric SCI or perhaps with long standing SCI because of increased fracture risk. The prevention of dissociated osteoporosis should be investigated further in order to avoid fractures of weakened bones. The modes of prevention might be found in the use of modern pharmacotherapy of osteoporosis and from correctly dosage physical training.

Comparison of health-related quality of life in three subgroups of spinal cord injury patients.

Health-related quality of life (HRQL) was evaluated in three subgroups of spinal cord injury (SCI) patients: (1) persons who had sustained a pediatric SCI (mean time from injury 20 years, age at injury 11.3 years, n = 36), (2) newly injured patients at the beginning of acute rehabilitation (mean age 35.3 years, n = 31), and (3) patients with a chronic SCI (mean time from injury 4.8 years, mean age at injury 35.2 years, n = 34). All the patients were clinically examined and structurally interviewed with a list of questions dealing with details of anamnestic information about injury, its treatment, possible complications and persons past and present psycho-social condition. HRQL was assessed by a generic fifteen-dimensional self-administered instrument (15D). The relative importance of the 15D dimensions and an overall judgement of health status were measured by a 0-100 visual analogue scale. Average importance weights of the dimensions of moving and working differed significantly in the three subgroups. Patients with pediatric SCI assigned the lowest importance for moving. The newly injured patients highly valued working capability. The HRQL scores of the patients who had sustained their injury in childhood were significantly higher than those of the newly injured patients or chronic patients. The tetraplegic patients estimated their HRQL significantly lower than patients with incomplete paraplegia. Of the three subgroups studied, those with pediatric SCI were well adjusted on the basis of anamnestic information and scored high on HRQL when compared with the other two subgroups. Patients injured in adulthood rated their overall HRQL lower and were often unable to return to work. Patients injured in childhood expressed better performance in physical functions than patients who had sustained their injury in adulthood. The subgroups did not differ in psychological functions.