Hartshill rectangle: failure of spinal stabilisation in acute spinal cord injury.

A high rate of failure of the internal fixation of unstable spinal fractures in complete cord injured patients was noted in patients referred to the Salisbury Spinal Centre who had been stabilised with a Hartshill rectangle. This prompted a review of the operative notes, radiographs and clinical outcomes of all patients referred to the centre with a Hartshill rectangle in situ. All patients identified with a complete spinal cord injury and Hartshill rectangle were identified. Forty-three such patients referred from 13 different centres were found. Pre- and postoperative radiographs were assessed for fracture pattern and for spinal correction. Operative outcome in terms of pain and complications relating to surgery were identified. The most recent radiographs were assessed for signs of loss of reduction or stabilisation. Follow-up averaged 84 months (range 36-132 months). Of the 43 identified patients, 19 were found to have unsatisfactory stabilisation. Persistent pain, broken implants and worsening kyphosis were the main complications. The failure to use bone graft at the time of stabilisation was significantly (P < 0.001) related to risk of failure. The application and use of the Hartshill is not a technically challenging procedure; however, if the system is to be used, it must be used correctly. Failure to correctly apply the rectangle and to use bone graft will lead to an unacceptably high rate of failure.

The role of intestinal stoma in patients with spinal cord injury.

In the long term following spinal cord injury, bowel dysfunction causes major physical and psychological problems. A retrospective review of intestinal stomas performed in patients with spinal cord injury over a 10 year period was performed to investigate their role in alleviating these problems. Twelve patients underwent left iliac fossa end colostomy and two patients right iliac fossa end ileostomy. The mean age of patients at operation was 54.8 years (20-65), and the mean time from injury to stoma formation was 15 years (2-37). The mean period of unsatisfactory bowel management before stoma formation was 5.4 years (1.5-2.5). Following colostomy the mean time spent on bowel care per week fell from 8.8 h (0.6-12.2) to 1.4 h (0.3-3.5) and independence in bowel care rose from 50 to 92%. All patients stated that their bowel care was easier and 83% said their independence had increased. Ninety-two per cent wished colostomy had been offered earlier and no patient undergoing colostomy wanted it reversed. The most common complication following colostomy was exclusion colitis. The mean time of follow-up post colostomy formation was 38 months (7-130). Formation of an intestinal stoma is a safe, effective and well accepted treatment for selected patients with intractable problems of bowel management following spinal cord injury.

The use of the BiPAP biphasic positive airway pressure system in acute spinal cord injury.

In recent years there has been increasing demand on our Intensive Care Unit (ICU) facilities, mainly due to improved resuscitation techniques in the pre-hospital management of spinal cord injury (SCI). This has resulted in an increasing number of high tetraplegic and paraplegic patients with respiratory problems who have survived the initial injury, but have subsequently required ventilatory support, often for several weeks. In view of the continuing pressure on ICU beds and a consequent need for alternative means of providing ventilatory support within the spinal centre rather than within the ICU setting, there was a requirement to provide a simple means of ventilatory support suitable for use within the ward setting. Ventilatory assistance using BiPAP appeared to fulfil these criteria, enabling patients to be managed at reduced cost. We present our experience using this system in 28 acute SCI patients over a 4 year period.

Suprapubic catheterisation with urethral closure (the Feneley procedure) in spinal cord injured men.

Three male spinal cord injured patients who underwent suprapubic catheterisation with urethral closure are reported. Although the procedure is well established in women, and has been mainly used in patients with multiple sclerosis, this simple procedure is also possible in men, and worth considering in difficult situations where continence has been impossible to achieve by more conventional means.

A comparison of two methods of sterile urethral catheterisation in spinal cord injured adults.

The purpose of this study was to compare the incidence of urinary infection following sterile catheterisation after either (1) a handwash of 30 s and double gloving, (the shorter sterile technique) or (2) after a 3 minute wash from fingertips to elbows and the wearing of a sterile gown and one pair of gloves, (the longer sterile technique). Forty-six patients were randomly assigned to the two groups. No significant difference in urinary infection rates was found and as a result the more complicated technique has been discontinued.

Direct erosion of lumbar spine by an abdominal aortic aneurysm, resulting in paraparesis: unusual presentation. Case report.

Abdominal aortic aneurysm is a condition affecting nearly 4% of the elderly population. It has a potential for producing a wide range of symptoms, including abdominal pain and back pain. The latter is particularly difficult to interpret in patients with chronic rheumatological conditions, and delayed diagnosis may be associated with a poor outcome. We present a patient with rheumatoid arthritis and chronic low back pain, who developed bilateral leg weakness and hesitancy of micturition, due to an abdominal aortic aneurysm invading the spine.

The role of percutaneous endoscopic gastrostomy in spinal cord injured patients.

Our experience with percutaneous endoscopic gastrostomy (PEG) in spinal cord injured patients is described. We have shown it to be a safe, comfortable and easily managed method of providing an adequate nutritional and fluid intake in patients requiring long-term tube feeding. It avoids the risks of intravenous feeding and the serious complications of oesophageal ulceration and stricture, which may occur with prolonged nasogastric intubation.

Complications of spinal surgery in acute spinal cord injury.

Despite an increasing realisation that patients with acute spinal cord injuries require a multidisciplinary approach for their management, which can only be satisfactorily provided in spinal injuries units, these units are still not being used to their full potential in the United Kingdom. Not surprisingly, the initial admission of patients to other hospitals has inevitably led to delays in transfer to such units, with a high incidence of complications. The results of spinal surgery were studied in 420 consecutive patients with spinal cord injury admitted to the Duke of Cornwall Spinal Treatment Centre, Salisbury. Complications were more frequent in patients undergoing spinal surgery before transfer to the centre. Furthermore, the longer the delay in transfer, the higher the incidence of pressure sores. Suggestions are made as to how complications can be avoided in future.

Cranial nerve palsies in cervical injuries.

The occurrence of cranial nerve palsies in cervical injuries is described in eight patients. The clinical features were dramatic and usually presented soon after injury, the most common picture being that of a bulbar palsy, with acute respiratory distress and dysphagia. Neurologic recovery, both from cranial nerve palsies and motor and sensory deficits, was substantial in all instances, suggesting that brain-stem ischaemia due to vertebral artery spasm or compression had been a factor in their causation. Alternatively, differential movement between the base of the skull and the upper part of the cervical spine at the time of injury could have caused an extracranial injury to the lower cranial nerves.

Major amputation in paraplegic and tetraplegic patients.

In the 1940s major amputation in paraplegic and tetraplegic patients was performed mainly for the complications of pressure sores. With the increased understanding of paraplegia, life expectancy has greatly improved, with the consequence that the chief indication for amputation is now gangrene due to atherosclerosis. The special problems of the spinal-cord-paralysed amputee are reviewed.

Skull traction and its complications.

The complications of skull traction seen in a Spinal Injuries Unit over a 7-year period are reviewed. The application of skull calipers, generally thought to be a minor procedure in the initial treatment of cervical spine injuries, led to complications in 37.3 per cent of patients. The complication rate was lowest using the Cone caliper, which when inserted as described, had a complication rate of 6.25 per cent. Attention to detail in the application of skull calipers is essential, and the procedure must not be considered trivial. The Cone caliper is recommended for the initial treatment of traumatic tetraplegia.

Amputation for peripheral vascular disease in the paraplegic and tetraplegic.

The occurrence of lower limb gangrene due to atherosclerosis is reported in 14 spinal cord paralysed patients. A further three patients became paraplegic and developed lower limb gangrene following aortic surgery for atherosclerotic complications. The clinical features are described and the difficulty in diagnosing ischaemia in the paralysed limb is emphasised. The incidence and prognosis following amputation are similar to those in the general population and there is no evidence from this series that paraplegia and tetraplegia predispose to atherosclerosis.

A comparison of fine-bore suprapubic and an intermittent urethral catheterisation regime after spinal cord injury.

A prospective trial, comparing fine-bore suprapubic catheterisation and intermittent urethral catheterisation as methods of bladder drainage in the acute stage following spinal cord injury, was conducted. The results showed no important difference in either method of bladder management. Fine-bore suprapubic catheterisation is particularly suitable for young female patients, who find repeated urethral catheterisation distasteful; in other patients it is an acceptable alternative to intermittent urethral catheterisation, particularly where economic considerations are paramount.

Combined brachial plexus and spinal cord trauma.

The clinical features of combined injuries of the brachial plexus and spinal cord in 31 patients are described. Diagnosis of the brachial plexus lesion was delayed in 17 instances, and the reasons for this are discussed. Early diagnosis is important so that definitive treatment and long-term plans can be instituted without delay. This dual lesion constitutes a very severe disability; as a direct result of their brachial plexus paralysis, 9 paraplegics did not achieve their predicted level of independence. Possible mechanisms of injury are suggested. Motorcycle accidents are particularly likely to cause these injuries, and a plea is made for further legislation to reduce the risks of injuries to young motorcyclists.

The occurrence of acute renal failure in patients with neuropathic bladders.

A group of patients with neuropathic bladders, who developed acute renal failure, is described. In each instance, sepsis from the urinary tract, its consequences or its treatment was implicated in the aetiology of the renal failure. Aggressive management of acute renal failure in the patients in our study showed their survival and functional renal recovery to be no worse than for similar patients without paraplegia. This illustrates that these patients presenting with a rare and serious complication of paraplegia should not be abandoned, since aggressive treatment along conventional lines in consultation with renal physicians and urologists was successful in four out of five of our patients.

Problems in the management of combined brachial plexus and spinal cord injuries.

Despite the fact that spinal cord injury is rarely seen without other injuries, the association with brachial plexus lesions has been very infrequently reported. Eleven cases of such injuries are reported, six as a result of motorcycle accidents. The brachial plexus lesion is often overlooked because clinical attention is naturally directed to the spinal cord. The patient often is unable to give a coherent history due to head injury, and the paralysis may be thought to be due to the spinal cord lesion or the head injury. The brachial plexus lesion greatly complicates rehabilitation and requires attention to detail at all stages, preferably by rehabilitation teams experienced in this field.