Motor and sensitive axonal regrowth after multiple intercosto-lumbar neurotizations in a sheep model.

STUDY DESIGN: Experimental animal study. OBJECTIVE: To evaluate motor and sensitive axonal regrowth after multiple intercosto-lumbar neurotizations in a sheep model. SETTING: France. METHODS: Fifteen sheep were separated into three groups. Five sheep had multiple intercosto-lumbar neurotizations and a spinal cord lesion, five sheep were neurotized without any spinal cord lesion and five sheep had a spinal cord lesion without any neurotizations. Six months after the initial surgery, histological study of the neurotized roots was performed. RESULTS: The length of the three rerouted intercostal nerves was sufficient in the 10 sheep to perform an intercosto-lumbar neurotization in good conditions. Eight sheep out of the 15 had postoperative complications responsible for the animal's death in five cases. Histological cross-sections of all the neurotized L2, L3 and L4 roots showed numerous myelinated regenerated axons. Dorsal root ganglions of neurotized roots showed both large and small neurons with normal nucleus and cytoplasm. The fluorescent retrograde labeling of 18 roots revealed labeled motor neurons in five cases. CONCLUSIONS: This study demonstrates the technical feasibility of intercosto-lumbar neurotizations in a big mammalian model. Intercostal nerve harvesting and rerouting was successfully performed in all the cases. Our histological results proved, in all the animals studied, the ability of motor and sensitive neurons to regenerate through the neurotization area. In the context of the future clinical application of strategies aimed at promoting axonal regeneration after severe spinal cord injury, the present data suggest that multiple intercosto-lumbar neurotization could be helpful to promote lower limb muscular strength recovery after spinal cord injuries.

Diffusion tensor imaging characteristics of the corpus callosum in mild, moderate, and severe traumatic brain injury.

BACKGROUND AND PURPOSE: The corpus callosum is an important predilection site for traumatic axonal injury but may be unevenly affected in head trauma. We hypothesized that there were local differences in axonal injury within the corpus callosum as investigated with diffusion tensor imaging (DTI), varying among patients with differing severity of traumatic brain injury (TBI). MATERIALS AND METHODS: Ethics committee approval and informed consent were obtained. Ten control subjects (7 men, 3 women; mean age, 37 +/- 9 years) and 39 patients with TBI (27 men, 12 women; 34 +/- 12 years) were investigated, of whom 24 had mild; 9, moderate; and 6, severe TBI. Regions of interest were selected in the callosal genu, body, and splenium to calculate fractional anisotropy (FA), apparent diffusion coefficient (ADC), and the number of fibers passing through. Statistical comparison was made through analysis of variance with the Scheffé post hoc analysis. RESULTS: Compared with controls, patients with mild TBI investigated <3 months posttrauma (n = 12) had reduced FA (P < .01) and increased ADC (P < .05) in the genu, whereas patients with mild TBI investigated > or =3 months posttrauma (n = 12) showed no significant differences. Patients with moderate and severe TBI, all investigated <3 months posttrauma, had reduced FA (P < .001) and increased ADC (P < .01) in the genu compared with controls and reduced FA in the splenium (P < .001) without significant ADC change. CONCLUSION: Mild TBI is associated with DTI abnormalities in the genu <3 months posttrauma. In more severe TBI, both the genu and splenium are affected. DTI suggests a larger contribution of vasogenic edema in the genu than in the splenium in TBI.

[Craniocerebral gunshot wounds: a study of outcome predictors]. / Les plaies crâniocérébrales d'origine balistique: recherche d'arguments pronostiques.

BACKGROUND AND PURPOSE: A retrospective study about craniocerebral gunshot wounds was done to better identify outcome predictors. METHODS: We reported and analyzed the clinical and radiological data of 18 patients admitted to Le Kremlin-Bicêtre institute for a craniocerebral gunshot wound between January 2000 and December 2005. The Glasgow Outcome Scale (GOS) was used to analyze patient outcome. RESULTS: There were 17 men and one woman, mean age 43 years (range 17-84). Fifteen patients died, two had a GOS equal to 2 and one GOS equal to 3. There were 16 suicides and two murders. All patients with areactive bilateral mydriasis and all patients with Glasgow Coma Scale (GCS) less than seven died except one. The 10 patients with intraventricular hemorrhage died. The bullet crossed the midline for 13 patients and all of them died. None of the patients underwent emergency surgery for the treatment of craniocerebral gunshot wounds because of low Glasgow Coma Scale. CONCLUSIONS: This study shows some interesting prognosis patterns: bilateral areactive mydriasis, GCS less or equal to 7 and bullet trajectory (if crossing the midline) are the most important factors predicting a fatal outcome.

[Endoscope-assisted biopsy for the diagnosis of neurosarcoidosis]. / Biopsie endoscopique diagnostique d'un cas de neurosarcoïdose.

A 56-year-old woman was followed in the neurological department for febrile mental confusion. The diagnosis of sarcoidosis was suggested on the ground of associated abdominal lymphadenopathy, elevated serum angiotensin-converting enzyme level, aseptic meningitis and intracranial hypothalamic lesion. Nevertheless, radiological, biological and histological analyses could not assert the diagnosis of systemic sarcoidosis. Six months later, cerebral MRI showed a recent enhanced nodule, located near the right choroid plexus, inducing a dilatation of the right temporal ventricular horn. A surgical endoscope-assisted biopsy of that lesion was decided. The endoscope was introduced in the right trapped temporal ventricle. The limits between normal and pathological tissues were clearly identified. The biopsy was thus accurately performed. Histological analysis definitely confirmed the diagnosis of neurosarcoidosis. No postoperative complication was noted. We report a case of neurosarcoidosis which was diagnosed by ventricular endoscope-assisted biopsy. The discussion stresses the potential advantages of endoscopy for the diagnosis of small periventricular lesions when ventricular dilatation is associated.

Multimodal cerebral monitoring and decompressive surgery for the treatment of severe bacterial meningitis with increased intracranial pressure.

Bacterial meningitis is still associated with a high mortality, mainly because of cerebral herniation as a result of increased intracranial pressure. Published data stress the necessity of an early diagnosis and immediate start of antibiotic therapy. Nevertheless, there are only few reports in which therapeutic strategy was based on the monitoring and the reduction of intracranial pressure (ICP). We report one case of bacterial meningitis caused by Neisseria meningitidis with an initial ICP value of 60 mmHg, which was treated by large hemicraniectomy and ventriculostomy, leading to a favorable neurological long-term result. The surgical decision was accelerated by an accurate ICP evaluation based on cerebral monitoring [transcranial Doppler ultrasonography (TCD) and intracranial ICP-device]. In selected patients with bacterial meningitis and clinical and radiological evidence of elevated ICP, cerebral monitoring and aggressive reduction of ICP may be crucial to improve survival and neurological outcome. When maximal medical ICP treatment fails to reduce severe intracranial hypertension, decompressive craniectomy should be rapidly proposed.

Diaphragm recovery by laryngeal innervation after bilateral phrenicotomy or complete C2 spinal section in rats.

This study aimed to highlight the functional aspects of diaphragm reinnervation by laryngeal motoneurons after bilateral phrenicotomy or complete cervical transection. The left recurrent laryngeal nerve was connected to the left phrenic nerve in 14 rats. Five months later, all bridged rats presented a substantial ipsilateral diaphragm recovery (74.2 +/- 10% of contralateral activity) whereas the diaphragm remained paralysed in non-bridged rats (n = 5/5). After additional right phrenicotomy, functional breathing persisted in bridged rats whereas all non-bridged died. After complete C2 spinal transection, diaphragm respiratory discharges persisted in bridged rats. The reinnnervation by laryngeal motoneurons was confirmed by retrograde labeling, stimulus-elicited diaphragm response by vagal stimulation and diaphragm inactivation after vagotomy. In conclusion, the recurrent-phrenic nerve anastomosis induces a reliable functional diaphragm outcome even after contralateral diaphragm denervation or complete high cervical spinal cord injury, and could be considered as a clinical repair strategy for re-establishing diaphragm autonomy following spinal cord trauma.

A new model of upper cervical spinal contusion inducing a persistent unilateral diaphragmatic deficit in the adult rat.

Research on spinal cord trauma requires models reflecting the contusion mechanisms encountered in clinical situation. The aim of this study was to develop in the adult rat a reproducible model of upper cervical spinal cord contusion inducing persistent unilateral diaphragm deficit. After dura and pia matter removal, weight drop and compression were targeted at the ventro-lateral funiculi which contain the bulbospinal descending respiratory pathways that command the phrenic motoneurons innervating the diaphragm. At 7 days post-injury, the left diaphragm activity recorded in contused rats (27.4 +/- 5.1% of the contralateral activity) was significantly lower than in the sham group (97.6 +/- 1.2%). This respiratory deficit still persisted 1 month later. Histology showed a reproducible left C2-lateralized lesion that involved both white and gray matter including the ventro-lateral funiculi. This C2 contusion model provides a basis for testing both regenerative and neuroprotective strategies aimed at improving functional respiratory recovery after spinal cord trauma.

MR diffusion tensor imaging and fiber tracking in 5 spinal cord astrocytomas.

Spinal cord astrocytomas are rare neoplasms that can result in alteration of the spinal cord structural integrity, which can be assessed by using diffusion tensor imaging methods. Our objective was to visualize the deformation of the posterior spinal cord lemniscal and corticospinal tracts in 5 patients with low-grade astrocytomas compared with 10 healthy volunteers by using 3D fiber-tracking reconstructions.

Multiple lumbar plexus neurotizations of the ninth, tenth, and eleventh intercostal nerves.

The topographic anatomy of the lower intercostal nerves is less known than the upper ones except for the twelfth intercostal nerve. It is possible to use the lower intercostal nerves to carry out a neurotization of the lumbar roots. We studied the anatomy of the ninth, tenth, and eleventh intercostal nerves in order to specify the data of descriptive and topographic anatomy allowing to carry out their harvesting under good conditions. Ninth, tenth, and eleventh intercostal nerves of 50 cadavers were dissected. The proximal part of the nerve in the posterior intercostal space was exposed through a posterior approach. The lateral intercostal space was exposed through a lateral approach, under the latissimus dorsi, which made it possible to harvest the intercostals nerve. The proximal course of the nerve in posterior intercostals space was the same in all the cases. The nerve moves obliquely towards the outside to reach the lower border of the rib. The exit of posterior intercostal space is a fibrous strait that marks the entry of a channel between two muscular layers. We describe an aponevrotic channel in which the nerve and the vessels are, immediately at the lower border of the cranial rib. The mean total length of intercostal nerve harvested by our technique was 17.96 cm for the ninth intercostal nerve, 17.14 cm for the tenth intercostal nerve, and 15.94 cm for the eleventh intercostal nerve. The bifurcation of the intercostal nerve in a deep branch and the ramus cutaneus lateralis was found in the majority of the cases, from 9.5 to 21 cm of the emergence of the intercostal nerve in posterior intercostal space. This anatomical study of the ninth, tenth, and eleventh intercostal nerves in posterior intercostal space and lateral intercostal space appears to us to allow the realization of a reliable surgical harvesting.

[Endoscope-assisted microsurgery for invasive endo- and suprasellar pituitary macroadenomas: a consecutive retrospective study with 13 patients]. / Endoscopie et traitement chirurgical des macroadénomes hypophysaires endo- et suprasellaires invasifs. Une série consécutive rétrospective de 13 patients.

BACKGROUND AND PURPOSE: Surgery of invasive endo- and suprasellar pituitary macroadenomas remains difficult. The records of 13 consecutive patients who underwent transsphenoidal surgery were analyzed in order to evaluate advantages and limitations of endoscopy for surgery of invasive pituitary macroadenomas. METHODS: A transseptal transsphenoidal intersepto-columellar approach was performed with a nasal 0-degree endoscope. Removal of the macroadenoma was performed under the control of a microscope. When the tumor seemed to be completely removed with microscope, a rigid 30-degree endoscope was inserted in the intrasellar and suprasellar regions in order to detect residual adenoma tissue. These residues were removed when technically possible. RESULTS: No rhinologic complication was noted. In 7 patients, the intra- and suprasellar endoscopic view detected a tumor residue which could be removed in each case. Two cases of cerebrospinal fluid leakage occurred during the complementary tumor resection. Two cases of diabetes insipidus and two of rhinorrhea were reported postoperatively. The analysis of the postoperative MRIs showed a complete removal in 23% of the patients (3/13), 75 to 100% removal in 54% of the patients (7/13), 50 to 75% removal in 8% of the patients (1/13) and 50% removal in 15% of the patients (2/13). More than 75% removal was thus achieved in 77% of the patients (10/13). The mean follow-up was 27.2 months. CONCLUSIONS: Rhinologic morbidity was reduced with the endoscopic endonasal approach. Endoscopy complemented with a microscope offered an optimal view of the intra- and suprasellar regions. Endoscopy also improved tumor resection of the invasive endo- and suprasellar pituitary macroadenomas by visualizing hidden suprasellar tumor residues. However, endoscopy was associated with a higher rate of postoperative rhinorrhea.

Cross-neurotization of the caudal brachial plexus with the contralateral C-8 ventral nerve branch in the cat. Potential surgical applications, effects of graft collection on the healthy donor limb and results.

Contralateral transfer of the right, eighth ventral nerve branch (C8) (C8 cross-transfer - C8CT) was performed in 6 adult cats, in which the caudal part of the left brachial plexus (C8 and T1) had been severed, in order to mimic nerve root avulsion. Clinical and electrophysiological parameters, muscle contraction force measurements and histology were used to evaluate the effects of the surgery in a 14- to 36-month follow-up. The right forelimb (donor side) was clinically normal (no lameness) in all the cats at the end of the study. Electromyography performed 14 days after surgery revealed denervation fibrillation potentials in both forelimbs. Fibrillation potentials disappeared in all the cats at the end of the study. Direct stimulation of the right C8 ventral branch induced motor and sensory evoked potentials in the left limb muscles in all the cats. The left to right contraction ratio of the extensor carpi radialis muscle was approximately 1. This experimental study demonstrates that C8CT enables re-innervation of the contralateral brachial plexus and allows the establishment of new functional neuromuscular units. This can in turn enable the restoration of function, and could potentially lead to partial recovery after caudal brachial plexus avulsion in the cat.

[Temporary vessel occlusion]. / Clampage vasculaire temporaire.

UNLABELLED: In many situations, temporary artery occlusion is an integral component of aneurysm surgery. The use of temporary clip may allow safer and easier aneurysmal dissection and clipping. Several points, concerning the duration and overall risks of temporary occlusion and the method of choice for cerebral function monitoring have to be discussed. MATERIAL AND METHODS: Non exhaustive review of neurosurgical literature. DISCUSSION: Temporary clip application decreases the risk of intraoperative aneurysmal rupture. The analysis of data published in the literature showed that several questions remain open concerning the optimal method of neuroprotection and cerebral function monitoring, as well as the limit of occlusion duration. Other clinical trials are needed to assess the efficacy and safety of this technique.

The thoracoabdominal intercostal nerves: an anatomical study for their use in neurotization.

The topographic anatomy of the lower intercostal nerves is less known than that of the upper ones, except for the subcostal nerve (twelfth intercostal nerve). It is possible to use the lower intercostal nerves to neurotize the lumbar roots. We studied the anatomy of the ninth, tenth and eleventh intercostal nerves in order to specify the descriptive and topographical anatomical data that will allow their harvest in good condition. The ninth, tenth and eleventh intercostal nerves of 30 cadavers were dissected. The proximal part of the nerves in the posterior intercostal space was exposed through a posterior approach. The lateral intercostal space was exposed through a lateral approach, deep to the latissimus dorsi, that made it possible to harvest the intercostal nerve. The proximal course of the nerves in the posterior intercostal space was the same in all cases. The nerves move obliquely towards the outside to reach the lower border of the rib. The exit of the posterior intercostal space is a fibrous strait, which marks the entry of a channel between two muscular layers. We describe an aponeurotic channel in which the nerve and vessels run, immediately at the lower border of the cranial rib. The mean total length of intercostal nerve harvested by our technique was 17.86 cm for the ninth intercostal nerve, 16.95 cm for the tenth and 15.75 cm for the eleventh. Bifurcation of the intercostal nerve into a deep branch and the lateral cutaneous branch was found in the majority of the cases, 9.5-21 cm from the emergence of the intercostal nerve in the posterior intercostal space. This anatomical study of the ninth, tenth and eleventh intercostal nerves in the posterior intercostal and lateral intercostal spaces appears to us to allow reliable surgical harvesting.

Neuroprotective effect of gacyclidine. A multicenter double-blind pilot trial in patients with acute traumatic brain injury.

The aim of this study was to assess the safety and efficacy of intravenous (IV) injections of gacyclidine, a novel NMDA receptor antagonist, for neurological and functional recovery following acute traumatic brain injury. This multicenter, prospective, randomized, placebo-controlled, double-blind study compared four parallel groups. Two IV doses were administrated (placebo, 2x0.005mg/kg, 2x0.001mg/kg, 2x0.02mg/kg): the first dose was given within 2 hours following the trauma, and the second dose 4 hours after the first. Fifty-one patients were enrolled and 48 studied between March 1995 and June 1997 in France. Evaluation criteria for safety were physical examination, cardiovascular parameters, blood chemistry, hematology, ECG, and neuropsychological changes monitored after medication. Primary evaluation criteria for efficacy was the Glasgow coma scale complemented by the initial CT-scan and Glasgow outcome scale, motor deficiencies, neuropsychological changes, and functional indenpendence at D90 and D365 or endpoint. Intracranial pressure (ICP) monitoring was not taken into account because all the clinical centers participating in this study did not use this technique in daily practice during the inclusion period. Twelve patients died during the follow-up period, none of these deaths being related to the drug. Serious adverse events (181) were reported by most of the patients with no significant differences between groups. Only 10 of these adverse events were considered to be drug-related. Safety-related laboratory tests did not show any relevant changes. Concerning efficacy, the predefined prognostic factors (initial CT-scan score, initial Glasgow Coma Scale and occurrence of low systolic blood pressure during the first 24 hours) largely determinated the patient's outcome. When the prognostic factors were taken into account together with the dose level in a logistic regression model, gacyclidine showed a beneficial long-term effect and a best dose-result in the 0.04mg/kg treated group. Data obtained in this clinical trial appeared sufficient to warrant a European multicenter study on gacyclidine using the same evaluation criteria and ICP monitoring.

Effects of surgery on the sensory deficits of syringomyelia and predictors of outcome: a long term prospective study.

OBJECTIVE: To quantify the effects of surgery on the thermal deficits of syringomyelia and assess the predictors for such effects. METHODS: The subjects were 16 consecutive patients (12 men, 4 women; mean (SD) duration of sensory symptoms, 5.1 (4.5) years) presenting with the typical symptoms of syringomyelia related to Chiari I malformation or trauma, and requiring surgical treatment. They were evaluated before surgery, then at six months and two years. Sensory evaluation included determination of the extent of thermal deficits and quantitative assessment of thermal, mechanical, vibration detection, and pain thresholds. Neuropathic pain intensity was evaluated on visual analogue scales. Magnetic resonance imaging was done before and after surgery to measure syrinx dimensions. RESULTS: The magnitude and extent of thermal deficits improved in a subgroup of patients and this was best predicted by the duration of sensory symptoms: patients operated on less than two years after the onset of their symptoms tended to improve, while those operated on later were stabilised or deteriorated slightly. The effect of surgery on thermal deficits was correlated with the duration of sensory symptoms. Surgery also affected vibration deficits in patients with the Chiari malformation, neuropathic pain on effort, and syrinx dimensions. CONCLUSIONS: The duration of sensory deficits is the best predictive factor of the efficacy of surgery for the thermal symptoms of syringomyelia. Early surgery is required if these deficits are to be minimised.

Angio-architecture of spinal cord arteriovenous shunts at presentation. Clinical correlations in adults and children. The Bicêtre experience on 155 consecutive patients seen between 1981-1999.

OBJECTIVE: To analyse possible relationships between the symptoms and signs created by intradural spinal cord arteriovenous shunts (SCAVSs) and their angio-architecture. METHODS: The clinical and radiological files of 155 patients, both adults and children, seen between 1981 and 1999 with a SCAVS were retrospectively reviewed. SCAVSs were divided into nidus type (small superficial or large intramedullary), and fistulas (micro (mAVFs)- or macrofistulas (MAVFs)). The angio-architectural points studied were arterial stenosis, proximal arterial aneurysm, distal arterial aneurysm, arteriovenous fistulas, pial venous drainage and/or reflux, venous ectasias, venous stenosis, venous thrombosis, false aneurysms. Correlations between architecture, location, age groups and symptoms and signs were made. FINDINGS: A male predominance was noted in both adults and children. Most of the lesions were located at the thoracic level, but hemorrhage occurred as the presenting event predominantly in cervical localizations. 30 patients (20 AVMs; 4 mAVFs, 6 MAVFs) were children. 5 of the 6 MAVFs found in children were associated with Hereditary Hemorrhagic Telengiectasia (HHT1). Twenty one children (70%) had bled. Spontaneous total or subtotal recovery was the rule in 15 of those who had bled (72%) but early recurrent hemorrhages occurred in 2. Among 125 adults 56 presented with hemorrhage (45%). The proportions of those who recovered spontaneously (71%) or rebled (3,6%) in the same year after the initial episode were very similar to children. All other adults presented with acute or progressive non-hemorrhagic episodes. There was no significant difference in the angio-architecture between hemorrhagic and non hemorrhagic SCAVS, except for that occurrence of pseudo-aneurysms. Hemorrhage in SCAVSs may not be exclusively due to haemodynamic factors. Venous congestion was responsible for progressive symptoms. Acute deficits unrelated to bleeds were due to intralesional thrombosis or hemodynamic changes. INTERPRETATION: The short term prognosis of hemorrhagic SCAVSs is good, and there is no need for emergency treatment. MRI delineates the cord and makes the diagnosis of the lesion but angiography remains the gold standard for analysis of the vasculature. The angio-architecture reflects the ageing of the lesion but there is not a precise correlation between angio-architecture and clinical symptoms, except for pseudoaneurysms which relate to the hemorrhagic portion of the lesion.

Experimental bypass surgery between the spinal cord and caudal nerve roots for spinal cord injuries.

Spinal cord injuries often cause permanent neurological deficits and are still considered as inaccessible to efficient therapy. Injured spinal cord axons are unable to spontaneously regenerate in adult mammalians. Re-establishing functional activity especially in the lower limbs by reinnervating the caudal infra-lesional territories could represent an attractive therapeutic strategy. For several years, we have studied and developed surgical bypasses using peripheral nerve grafts bridging the supra-lesional rostral spinal cord to the caudal infra-lesional lumbar roots. Main objectives were: 1- to overcome the spinal cord lesion and the consecutive glial barrier blocking the axonal regeneration; 2- to find and bring an alternative source of regenerating axons; 3- to guide those axons toward precisely definite targets (for example, lower limb muscles). We report here the results of our experimental research, which led us from animal experimental models (rodents, primates) to the first human experimentation. Limitations of the method (especially technical pitfalls) are numerous. However, we have obtained encouraging results in our attempts to "repair" the motor pathway. Functional recovery with strong evidence of centrifugal axonal regeneration from the spinal cord to the periphery has been observed. Regarding the sensory pathway, we have found evidence of centripetal axonal regeneration from the periphery toward the spinal cord. Further studies are obviously advocated, but our experimental model of spinal cord - nerve roots bypasses may be integrated in future "repair" strategies of both motor and sensory pathways following spinal cord injury.

Late spinal dislocation after treatment of spinal arteriovenous malformation. A case of Charcot spinal arthropathy.

Neuropathic arthropathy of the spine is a destructive condition of the spine which is secondary to a loss of the protective proprioceptive reflexes. In the majority of cases, it occurs in patients who have suffered from traumatic medullary lesions and is responsible for destruction of the vertebral bodies and considerable spinal deformity. We report a case of neurogenic lumbar arthropathy in a patient with a spinal arteriovenous malformation. This vascular lesion caused considerable disturbances of proprioception. The course was favorable with regard to the deformity after correction and fusion by posterior approach.

Partial return of motor function in paralyzed legs after surgical bypass of the lesion site by nerve autografts three years after spinal cord injury.

Spinal cord injuries often result in irreversible loss of motor and somatosensory functions below the lesion level. Treatment is limited to physiotherapy aimed at compensating disability. We previously showed that re-establishment of tissue continuity can be achieved in animal models through nerve autografts implanted between the rostral spinal ventral horn and the caudal ventral roots. Rostral motor neuron axons could thus reach peripheral targets, leading to some return of motor function. We used a similar approach in a paraplegic patient with stabilized clinical states three years after spinal cord traumatic damage at the T9 level. Three segments from autologous sural nerves were implanted into the right and left antero-lateral quadrant of the cord at T7-8 levels, then connected to homolateral L2-4 lumbar ventral roots, respectively. Eight months after surgery, voluntary contractions of bilateral adductors and of the left quadriceps were observed. Muscular activity was confirmed by motor unit potentials in response to attempted muscle contraction. Motor-evoked potentials from these muscles were recorded by transcranial magnetic stimulation. These data support the hypothesis that muscles have been re-connected to supra-spinal centers through motor neurons located in the rostral stump of the damaged cord. They suggest that delayed surgical reconstruction of motor pathways may contribute to partial functional recovery.