sCD95L in serum after spinal cord injury.

STUDY DESIGN: A prospective observational study reporting correlation between sCD95L (serum cluster of differentiation 95 ligand) serum levels and remission after traumatic spinal cord injury (SCI). OBJECTIVES: To describe the correlation between sCD95L serum levels and remission after traumatic SCI in a human protocol compared with animal studies. SETTING: Rhineland-Palatinate (Rheinland-Pfalz), Germany. METHODS: We included 45 patients with traumatic SCI. According to their neurological outcome, patients were divided into two groups, patients with (G1, n=26) and without (G2, n=19) remission. Blood was collected on post-admission and according to a fixed scheme, that is, after 4, 9, 12 h, 1, 3 days and 1, 2, 4, 8, 12 weeks. RESULTS: By comparing G1 with G2, we found a correlation between neurological remission and sCD95L serum concentrations. Consistently elevated levels of sCD95L in G1 between 9 h and 1 month after injury show significantly differing values 7 days after injury. This indicates a correlation between patients with clinically documented neurological remission and elevated sCD95L serum concentrations. CONCLUSIONS: In opposite to animal studies, our patients with neurological remission show on average higher levels of sCD95L compared with patients without. Therefore, spinal cord-injured patients would probably not profit from neutralizing CD95L. Our results present that the transfer of findings from animal studies to humans must always be considered critically. We were able to show that peripheral serum cytokine expression is suitable to state processes after SCI in humans.

Preoperative scoring and limits of prognostication: functional outcome after surgical decompression in metastatic spinal cord compression.

OBJECTIVE: To determine whether preoperative parameters correlate with the postoperative functional outcome in para- and tetraplegic patients with lung, kidney, breast and prostate cancer and metastatic spinal cord compression (MSCC). METHODS: Information on 43 patients undergoing decompressive surgery and rehabilitation for MSCC was reviewed, including primary tumor, age, pre- and postoperative ambulation status, mobility subcategory of the Spinal Cord Injury Measure (mSCIM) and the Tokuhashi score. Differences between groups were analyzed by the nonparametric χ(2) test, and correlation coefficients (Spearman's rho) were computed. RESULTS: Preoperative ambulation (p < 0.001), the American Spinal Injury Association Impairment Scale (p < 0.001) and the type of operation (p = 0.02) influenced the postoperative functional outcome. Any positive change in the mSCIM was influenced by preoperative ambulation (p < 0.001). Patients with breast carcinoma showed significantly more positive changes in the mSCIM compared with other tumors (p = 0.002). No correlation was found between the treatment categories of the Tokuhashi score and the preoperative ambulatory status (p = 0.13) or the change in ambulation status (p = 0.29). CONCLUSION: The postoperative functional outcome of MSCC patients shows a linear association between the categories of the Tokuhashi score and the change in ambulation status. We recommend surgical decompression even in a palliative situation (Tokuhashi score 0-8) with the aim of optimizing the short-term rehabilitation outcome.

A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients.

STUDY DESIGN: A retrospective study reporting specific complications of certain skin flaps for treating pressure ulcers. OBJECTIVES: To describe the rate and type of complications after pressure ulcer surgery in patients with spinal cord injury. SETTING: Germany, Rheinland Pfalz. METHODS: We collected data from 352 patients treated with 421 skin flaps to determine the rate and type of complications of each skin flap used. RESULTS: In this study, we analyzed the results of 421 skin flaps in 352 patients with a total of 657 pressure ulcers from January 2006 to December 2010. Our patients had ischial, pelvic, sacral, trochanteric and lower extremity ulcers. Ischial ulcers were most common, followed by sacral and trochanteric ulcers. There were 87 complications in 421 flaps, which was an overall rate of 21%. Suture line dehiscence was the most common complication with 27 cases (31%), followed by 22 cases of infection (25.2%), 17 cases of hematoma (19.5%), 12 cases of partial necrosis (13.7%) and 9 cases of total flap necrosis (10.3%). CONCLUSION: Pressure ulcers in spinal cord-injured patients are very common and difficult and expensive to treat. The high rate of complications and the associated costs suggest the importance of evaluating the efficacy of treatment options. Conservative procedures have been standardized, but there still has been limited success in establishing guidelines on how to manage complications arising from flap surgery. Our extensive documentation of flap plastics will be useful managing complications after the surgical treatment of pressure ulcers in spinal cord-injured patients.

Autonomic dysreflexia: a possible trigger for the development of heterotopic ossifications after traumatic spinal cord injury? : A clinical longitudinal study.

PURPOSE: The aim of this study was to investigate the influence of the initial American Spinal Injury Association Impairment Scale (AIS) category and the conversion rate in acute traumatic tetraplegic patients on the development of heterotopic ossifications (HO). The second objective was to prove the hypothesis that tetraplegic patients with autonomic dysreflexia (AD) develop HO more often than patients without AD. METHODS: A retrospective analysis from 2002 to 2009 of 330 patients with spinal cord injuries was performed and led to the inclusion of 77 traumatic tetraplegic patients. Clinical data was reviewed to determine the appearance of HO (n = 8) and its possible coincidence with AD during urodynamics. Spearman's correlation coefficient was calculated to test the relationship between HO and initial AIS category or the change in AIS category within 6 weeks. A matched pair (age, neurological level of injury) analysis of two samples (n = 8 with/without appearance of HO; total n = 16) was performed. RESULTS: The appearance of HO was significantly correlated with an initial AIS A compared to incomplete tetraplegia at baseline (p < 0.017). The conversion of AIS A into incomplete tetraplegia was highly correlated with the incidence of HO (p < 0.003). AD showed a positive correlation with HO (r = 0.97, p = 0.001). CONCLUSIONS: An initial AIS A that converts early into an incomplete tetraplegia constitutes a risk factor for the development of HO. Additionally, AD constitutes an important trigger in the development of HO in acute traumatic tetraplegic patients.

Increase in soluble CD95L during subacute phases after human spinal cord injury: a potential therapeutic target.

STUDY DESIGN: A pilot study measuring the levels of serum-soluble CD95 ligand (CD95L) in eight spinal cord-injured patients. OBJECTIVES: To determine the soluble concentration of CD95L in spinal cord injury (SCI) patients after trauma. METHODS: We collected blood samples from eight patients with acute traumatic SCI. Soluble CD95L serum levels were determined using an enzyme-linked immunosorbent assay. American Spinal Injury Association (ASIA) was determined according to ASIA classification. The patients were monitored, and venous blood was drawn after arrival at the hospital on the 1st and 3rd day and during the 1st, 2nd, 4th, 8th and 12th weeks after trauma. RESULTS: The average patient age was 48.1 years (18-86 years). Three patients were paraplegic (two incomplete, one complete), five were quadriplegic (one complete, four incomplete). The serum concentration of soluble CD95L (sCD95L) decreased during the 1st week (41 ng(- l)) and increased after the 2nd week in all eight patients. It peaked during the 4th week (68.5 ng (- l)) and reached a plateau during the 12th week (76.2 ng (- l)). There are many possible explanations for not being able to detect a statistical significance, one of course being the small sample size. CONCLUSION: Promising results for anti-CD95L therapy have already been documented in lab studies with rodents. Anti-CD95L blocks the pro-apoptotic and proinflammatory activity of membrane-bound CD95L during the acute phase of SCI. We observed that sCD95L levels are elevated during the subacute and intermediate phases of SCI. It would be of great interest to study a larger group of patients to determine whether higher sCD95 levels are correlated with improved or impaired neurological outcome or with increasing levels of autoimmune components in peripheral blood.

The effect of early surgical treatment on recovery in patients with metastatic compression of the spinal cord.

We analysed the influence of the timing of surgery (< 48 hours, group 1, 21 patients vs > 48 hours, group 2, 14 patients) on the neurological outcome and restoration of mobility in 35 incomplete tetra- and paraplegic patients with metastatic spinal-cord compression. Pain and neurological symptoms were assessed using the American Spinal Injury Association impairment scale. More improvement was found in group 1 than in group 2 when comparing the pre-operative findings with those both immediately post-operatively (p = 0.021) and those at follow-up at four to six weeks (p = 0.010). In group 1 the number of pre-operatively mobile patients increased from 17 (81%) to 19 patients (90%) whereas the number of mobile patients in group 2 changed from nine (64%) to ten (71%). These results suggest that early surgical treatment in patients with metastatic spinal-cord compression gives a better neurological outcome even in a palliative situation.

Progressive spastic paraplegia: the combination of Scheuermann's disease, a short-segmented kyphosis and dysplastic thoracic spinous processes.

STUDY DESIGN: Case report. OBJECTIVE: To describe a rare case of paraplegia in a patient with Scheuermann's disease and dysplastic thoracic spinous processes. SETTING: Spinal Cord Injury Center, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany. CLINICAL PRESENTATION: The authors report on a 15-year-old boy with progressive incomplete spastic paraplegia presenting segmental dysplastic thoracic spinous processes and Scheuermann's disease. The magnetic resonance imaging showed a kyphotic angulation at T 5/6 and signs of myelopathy. Hypoplastic thoracic processes and hypoplastic paraspinal muscles in the upper thoracic spine were observed intraoperatively. In this case, dorsoventral stabilization from T 4-7 was performed and the neurological outcome improved at follow-up (6 months). CONCLUSION: Paraplegia can be accelerated in patients with Scheuermann's disease, severe kyphotic angulation and dysplastic posterior elements. After operative treatment, neurological recovery and a normal walking pattern were shown.

Neurogenic bladder dysfunction in patients with neoplastic spinal cord compression: adaptation of the bladder management strategy to the underlying disease.

OBJECTIVES: To study the outcome of different bladder management strategies in patients with neoplastic spinal cord compression. METHODS: 22 patients with neoplastic spinal cord compression underwent urodynamic examination. According to the urodynamic data and the underlying disease different bladder management strategies were recommended. In patients with curatively treated disease a full bladder rehabilitation program was arranged. In patients with metastatic malignant disease, voluntary voiding was continued if possible or a suprapubic catheter was placed. RESULTS: Eight patients were treated with curative intention. Of those, 2 patients were able to void during urodynamics continued normal voluntary voiding. Six patients were taught intermittent catheterisation, with three additionally received oral anticholinergic treatment because of UMN lesion. At follow-up, all patients had successfully finished bladder rehabilitation program and at follow up, all patients were continuing their previously recommended bladder rehabilitation program. Fourteen patients had malignant disease and were treated palliatively. In 2 patients with UMN lesion, voluntary control of micturition was maintained and both continued voluntary voiding. In 12 patients a suprapubic catheter was inserted. At follow-up, 9 out of 14 had died (mean 8 month after primary visit), the remaining 5 continued treatment with suprapubic catheters. CONCLUSION: Underlying disease and life expectancy should be considered for the selection of bladder management in patients with neoplastic spinal cord compression. In patients with curatively treated disease, a full bladder rehabilitation program is recommended while in patients with malignant disease and palliative care, a suprapubic catheter might be the treatment of choice.

[Functional electrical stimulation instead of surgery? Improvement of grasping function with FES in a patient with C5 tetraplegia]. / Funktionelle Elektrostimulation anstatt Operation? Verbesserung der Greiffunktion mittels FES bei einem Patienten mit Tetraplegie C5.

The aim of this study was to restore the grasp function of a tetraplegic patient with a C5 spinal cord injury (SCI) by means of functional electrical stimulation (FES). Using three pairs of surface electrodes and orthotic wrist stabilisation a simple palmar grasp was realised. The FES was controlled with a switch mounted on a wheelchair or-for the first time-with an EEG-based brain-computer interface (BCI). Application of this stimulation system enabled the patient to drink for the first time after the accident from a glass without any additional help.

Neuroprosthetics of the upper extremity--clinical application in spinal cord injury and future perspectives.

Within the last couple of years, partial restoration of lost motor functions in a larger number of spinal cord injured patients has become possible by the introduction of neuroprostheses into the clinical environment. The Freehand system in particular is the first implantable neuroprosthesis from which a certain group of tetraplegic patients with stable shoulder function, but missing or weak grasp and hold function of the hand do benefit. The system is based on the combination of electrical stimulation and operative tendon transfers and thus represents a multicomponent concept for long-term restoration of the grasp function. The crucial prerequisites for successful use of an implantable neuroprosthesis are the right indication, careful preoperative muscle stimulation, differentiated planning of the surgery and functional training adopted to the individual residual functions. After successful completion of an extensive rehabilitation program, patients are able to use the system for activities of daily living without the need for special additional aids, which enhances their quality of life and independency. In order to extend the group of potential users of neuroprostheses in the future, new technological developments will have to take into account that nowadays the majority of spinal cord injured patients suffer from an incomplete lesion of the spinal cord. For these particular patients who still possess residual functions, modular, "naturally" controllable systems for supporting these functions are needed rather than complex systems to substitute them.

Destructive osteoblastoma of the cervical spine with complete neurologic recovery.

STUDY DESIGN: Case report. OBJECTIVE: To describe a patient with a large tumor lesion of the 6th vertebrae affecting surrounding soft tissue, and symptoms of cord compression. Histologic diagnosis indicated a destructive osteoblastoma following dorsal and anterior resection and internal fixation. SETTING: University Hospital, Germany. METHODS: A 23-year old male patient was admitted with a 2-month history of increasing upper extremity weakness and pain. X-ray and MRI indicated massive involvement of the anterior and posterior elements of the 6th vertebrae with a large soft tissue mass. Following emergency decompression and dorsal stabilization, the pathologic investigation revealed a destructive osteoblastoma. Subsequent dorsal and anterior resection with internal fixation were performed. RESULTS: The patient initially presented with symptoms of beginning paraplegia of C6/7. According to the neurologic classification of spinal cord injury, motor function score was 56 and sensory function score 83. After emergency dorsal decompression and internal fixation with Luque-Instrumentation he showed increasing neurological recovery. Complete neurological recovery was achieved at 2 and 12-months postoperatively, following secondary dorsal and anterior resection of the tumor and internal fixation with bone cement (PalacosR) and Harms-cage. Radiologic signs of local recurrence were identified 1 year postoperatively. CONCLUSION: Osteoblastoma of the cervical spine is rare. Patients often present with severe neurological symptoms due to significant tumor mass. Complete resection is necessary to regain full recovery, to prevent recurrence and, in some cases, malignant transformation.

Tissue and serum concentrations of levofloxacin in orthopaedic patients.

The level of levofloxacin was determined in serum, bone and several tissues after a single dose of 500 mg i.v. Twenty-one patients (mean age: 56.8 years) undergoing bone surgery (nine patients) or surgical debridement of a decubitus ulcer (12 patients) who received levofloxacin as perioperative prophylaxis were included in the study. During surgery, blood and tissue samples were obtained approximately 1.5 h (range 40-210 min) postdosing. Levofloxacin concentrations in 87 specimens including 21 serum samples were determined using high-performance liquid chromatography (HPLC). The mean serum concentration at 1.5 h was 8.6+/-2.3 microg/ml. Concentrations above the MIC of common pathogens were reached in all tissues during the collection period with a maximum in skin samples (19.9+/-9.9 microg/g) followed by wound tissue and granulation tissue with 17.3+/-6.5 and 13.7+/-6.4 microg/g respectively. In muscle and fatty tissue mean levofloxacin concentrations of 8.0+/-0.9 and 4.0+/-2.2 microg/g were attained. Mean levels in cancellous bone were 6.6+/-3.6 microg/g, lowest levels were measured in cortical bone (2.8+/-1.1 microg/g). Twenty-two different pathogens were cultivated from the lesions of 11 of 12 patients with pressure ulcers. MIC values for levofloxacin were determined and compared with the corresponding tissue concentrations. Levofloxacin may be useful for perioperative prophylaxis and treatment in orthopaedic patients due to its good tissue penetration.

Osteoporosis in patients with paralysis after spinal cord injury. A cross sectional study in 46 male patients with dual-energy X-ray absorptiometry.

In a cross-sectional study, 46 male patients with paralysis after spinal cord injury (average age 32 years; injuries sustained from 1 to 26 years ago; 33 Frankel A, 13 Frankel B, C, D) were examined clinically and by dual-energy X-ray absorptiometry (DEXA). Their bone mineral density (BMD) values were compared with age-related controls and correlated to clinical parameters. BMD was reduced in the proximal femur (p < 0.05) and the distal forearm (p < 0.05), but not in the lumbar spine. Demineralisation was influenced in the proximal femur (Z-score -2.95) by immobilisation after surgical treatment. Patients suffering from complete lesions had significantly lower BMD in the lumbar spine (-1.47) compared with patients with incomplete lesions (+0.02). BMD was not significantly influenced by the level of the lesion and the ambulatory status. Long-term monitoring showed significant demineralisation in the proximal femur (r = -0.36) and the distal forearm (r = -0.4), but not in the lumbar spine (r = -0.21). By correlating BMD with clinical parameters, it can be deduced that, firstly, immobilisation after surgical treatment should be reduced to a minimum; secondly, that every effort must be expended to prevent turning an incomplete into a complete lesion; and finally, that rehabilitation treatment should be lifelong.

Long-term efficacy of subureteral collagen injection for endoscopic treatment of vesicoureteral reflux in neurogenic bladder cases.

PURPOSE: We evaluated the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injection (GAX 35) for endoscopic treatment of vesicoureteral reflux in patients with neurogenic bladder dysfunction due to meningomyelocele. MATERIALS AND METHODS: We prospectively studied 12 women and 8 men (26 ureteral renal units) with a median age of 8 years (range 1 to 51) who had neurogenic bladder due to meningomyelocele. Reflux into single collecting systems was treated with subureteral collagen injection (GAX 35). Followup with video urodynamics included voiding cystography. RESULTS: All patients performed intermittent catheterization to control the bladder. During the study all bladders were areflexic with normal compliance. Preoperative reflux according to the International Reflux Study Classification was grade I in 1, II in 9, III in 10, IV in 4 and V in 2 ureteral renal units. All patients were treated with subureteral collagen injection (mean volume 1.9 ml., range 0.7 to 3.5). Reflux resolved initially in all but 2 cases. Mean followup was 16 months (range 1 to 71). Reflux was still absent in only 15% of treated units after 24 months. CONCLUSIONS: Our data suggest that endoscopic subureteral collagen injection in neurogenic bladder cases is not effective with long-term followup. New biocompatible and biodegradable materials should be tested to control vesicoureteral reflux.

Ascending myelopathy in the early stage of spinal cord injury.

A 30-year-old healthy woman was involved in a road traffic accident. She sustained a fracture dislocation of T11/12 with a complete Frankel A paraplegia below T11. She had no associated injuries. High Dose Methylprednisolone was administered according to the NASCIS III protocol (48 h) together with low molecular weight Heparin and gastroprotected medication. Complete transection of the spinal cord and an anterior haematoma from T11 to T12 were confirmed on X rays, CT's and MRI scans. Posterior surgical stabilisation was performed using Isola instrumentation, starting 8 h post injury. Her post surgical period was uneventful except for some episodes of low blood pressure (85/60 mmHg) from which she had no symptoms. On the 12th post operative day, while in the physiotherapy department, she complained of right scapular pain. This occurred every time she was sat up and was associated with paraesthesia of both upper limbs. Two days later she deteriorated neurologically and her level ascended initially to T8 and then to T3. MRI of the spine with and without gadolinium showed spinal cord oedema between C3 and T1. There was no evidence of haemorrhage or syringomyelia. The authors discussed this case making different hypotheses. They are mainly the following: (1) Gradually ascending ischaemia due to a vascular disorder; (2) Double spinal trauma; (3) Ischaemia related to repeated hypotensive episodes; (4) Low grade intramedullary tumour; and (5) Thrombus of the Radicularis Magna artery. The case has been recognised as being very rare and interesting. In the conclusions, the presenting author stresses the importance of adopting MRI-compatible instrumentation for the surgical stabilisation of the spine, and careful monitoring of blood pressure during the acute phase of spinal cord injury. Dr Aito agrees with Mr El Masry about the opportunity of forming a group of clinicians in order to discuss protocols to cope with this devastating complication.

Residual deformity of the spinal canal in patients with traumatic paraplegia and secondary changes of the spinal cord.

INTRODUCTION: The effect of spinal deformity with posttraumatic kyphosis and stenosis of the spinal canal in producing secondary changes of the spinal cord has been discussed for quite some time. Since the advent of magnetic resonance imaging (MRI), 20-40% of patients with posttraumatic paraplegia are found to develop hydromyelia. PURPOSE OF OUR STUDY: To evaluate the influence of residual spinal deformity, defined by the extent of the posttraumatic kyphosis and stenosis, in the development of posttraumatic hydromyelia. MATERIAL AND METHODS: Two hundred and seven cases of traumatic paraplegia with MRI follow-up were reviewed retrospectively. A minimum of 3 years duration between trauma and MRI study was required (mean 10.6 years [3.2-38.3]). For statistical analysis two groups of patients were formed: with hydromyelia and without hydromyelia. After healing of the fracture, the extent of the kyphosis and stenosis, as well as the characteristics of the paraplegia were noted. RESULTS: We found that 53 patients had hydromyelia. A highly significant correlation was found for the extent of spinal stenosis and the amount of kyphosis. Cluster analysis indicated that patients with more than 15 degrees of posttraumatic kyphosis and more than 25% of stenosis were twice as likely to develop hydromyelia. The level of the lesion and the remaining neurological function was not proven to have any influence towards the development of hydromyelia. CONCLUSIONS: These results support the idea that chronic mechanical stress to the spinal cord increases the risk for the development of hydromyelia. Surgical reconstruction should be considered for all patients to prevent secondary changes of the spinal cord.

Complete paraplegia due to multiple intracerebral and spinal cavernomas.

We report on a 29-year-old male patient with multiple intracerebral and spinal cavernomas. Bleeding in the thoracic cord at admission and additional bleeding which occurred 12 days later in the cervical cord resulted in complete paraplegia below thoracic level 4 (Th4). Four years earlier multiple cerebral cavernomas had been diagnosed by magnetic resonance imaging (MRI). Based upon reported cases in the literature multiple intracerebral and spinal cavernomas are exceptional. Additionally, the clinical presentation in our case is uncommon.

Resection of heterotopic ossification of the hip in spinal cord injured patients.

Twenty nine spinal cord injury patients were treated by resection of heterotopic ossification in 41 hips. The average follow-up period after surgery was 4.2 years. The mean time to surgery after injury was 82.1 months. The indications for surgery were seating problems, loss of function, pressure sores and pain. The average preoperative motion in flexion and extension was 21.95 degrees, the average intraoperative motion was 94.51 degrees. The average motion at follow-up evaluation was 82.68 degrees. Clinical relevant recurrence occurred in three patients. Complications excluding recurrence occurred in 10 hips, including deep and superficial wound infections, fracture, aneurysm and pressure ulcer. The operation was followed by a specific regime of physiotherapy and radiation therapy.

[Results of extensive cervical laminectomy]. / Folgen der langstreckigen zervikalen Laminektomie.

39 patients were studied for late effects of cervical laminectomy. With a mean follow-up of 51 months and mean extent of laminectomy of 4.15 levels, analysis of pre- and postoperative radiographs showed changes in cervical spine curvature type in 72% and in 44% extreme spinal deformity. In addition, postoperative effects on pain and neurological symptoms are evaluated. Close follow-up during rehabilitation in essential for the prevention of clinical deterioration after laminectomy.