Rehabilitation of acquired brain injuries: a multicentric prospective survey.

BACKGROUND: The rehabilitation of the persons with Severe Acquired Brain Injury (ABI) is an important concern to be approached with a comprehensive program aimed to improve the recovery of patients.The efficacy of an early and intensive rehabilitation program has been shown in large number of studies. Few studies focused on the prevalence of TBI and the data are often extrapolated in indirect ways. AIM: An analysis of the demographic characteristics of the population included in the GISCAR (Gruppo Italiano per lo Studio delle Gravi Cerebrolesioni Acquisite e Riabilitazione- Italian Group for the Study of the severe ABI) database, type and conditions associated to the index event; the treatment administered during hospitalization; and the prognosis according to outcome measures. DESIGN: The study was an observational prospective survey looking at management of ABI (both traumatic and non-traumatic). SETTING: In hospital rehabilitation. POPULATION: Patients consecutively admitted in each of the 52 GISCAR centres. METHODS: Every centre included a consecutive cohort and recorded demographic data and index event characteristics. RESULTS: In the study population were included 2626 subjects suffering of a severe ABI. The difference of length of stay (LOS) was significantly different with 67.5 days for traumatic patients compared to the 80 days of non traumatic ones. In the study population the probability of discharge at home is significantly greater for the traumatic condition (odds ratio 0,4587; CI 0.3671-0.5731). The overall benefit of the rehabilitative treatment was encountered in a net gain in all disability scores taken into account: LCF classes; DRS as well as GOS scores. At discharge the main destination for severe ABI patients was home (67.2%). CONCLUSIONS: A large number of patients admitted in Italian rehabilitative facilities for a severe ABI suffered from a TBI, more often these subjects were young male victims of road accident. The majority of subjects during the rehabilitative hospitalization demonstrated a significant recovery. CLINICAL REHABILITATION IMPACT: Considering the evidence of an early treatment benefit the delay ofthe rehabilitation program start is far from being satisfactory. The high frequency of the home discharge indicate a good compliance of national family network.

[Idiopathic spinal epidural hematoma in patients with sudden paraplegia: a case report]. / Hematoma epidural espinal idiopático en pacientes con paraplejía súbita: a propósito de un caso.

INTRODUCTION: Spontaneous spinal epidural hematoma (SEH) represents 0.3-0.9% of spinal epidural space-occupying lesions, and most surgeons advocate aggressive and early surgical intervention. In this paper we describe a patient with SEH with sudden paraplegia. CASE REPORT: This 30-year-old man had experienced one prior episode of sudden dorsal pain two days before the current admission and while he waited medical attendance, his legs suddenly became weak, and immediately afterwards, he became completely paraplegic in minutes. The patient had complete paraplegia, analgesia below the T4 level and urinary retention. He had no anticoagulant agent and no coagulopathic disease. He was submitted to computerized tomography that demonstrated a dorsally located epidural hematoma extending from the T3 to the T6 level with spinal cord compression. A laminectomy from T3 to T7 was performed four hours after the onset of the symptom. In postoperative time the patient presented the partial sensorial recovery and motor force grade II. The patient was directed to a neurorehabilitation program and in the last medical evaluation he presented recovery for motor grade III-IV, without pain. CONCLUSION: The SHE is rare, with severe neurological consequences for patients and early surgical treatment persist as essential for motor recovery.

A systematic review of physical and rehabilitation medicine topics as developed by the Cochrane Collaboration.

The aim of this paper is to give an overview of the Cochrane Collaboration, its development over the years, and its usefulness for physical and rehabilitation medicine specialists. After introducing the Cochrane Collaboration, we systematically analyzed all titles of the reviews in each of the 50 review groups. For ''Rehabilitation,'' we included not only exercise and physical therapy, but also all of the educational and pharmacological interventions aimed at supporting rehabilitation. The search was performed using Issue 2, 2007 of the Cochrane Library. We retrieved 138 completed reviews that dealt with rehabilitation interventions performed by 20 review groups. No umbrella reviews could be found at present. The most prolific groups in the rehabilitation field were: musculoskeletal (28 reviews), stroke (20), back (18), and the movement disorder group (13). The most discussed intervention was exercise (37 reviews), dealing with physical medicine (20) and pharmacological intervention (11). Six other reviews dealt with multidisciplinary rehabilitation. Low back pain treatment and stroke were the most investigated topics. The Cochrane Collaboration serves today as a main step in increasing an evidence-based approach to medicine and rehabilitation. Europa Medicophysica is continuously increasing its importance and presence in the world of physical and rehabilitation medicine, and part of its mission is to increase and strengthen an evidence-based approach to this field. We will continue to look at the contents of the Cochrane database and regularly report on its updates concerning topics of interest for physical and rehabilitation medicine.

Pharmacological interventions for spasticity following spinal cord injury: results of a Cochrane systematic review.

UNLABELLED: The aim of this paper was to assess the effectiveness and safety of baclofen, dantrolene, tizanidine and any other drugs for the treatment of long-term spasticity in spinal cord injury (SCI) patients, as well as the effectiveness and safety of different routes of administration of baclofen. A systematic review of randomised controlled trials (RCTs), within the Cochrane Collaboration Injuries Group, was carried out. The Cochrane Injuries Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL were searched up to July 2006 without language restriction. Drug companies and experts active in the area were also contacted to find other relevant studies. Two investigators independently identified relevant studies, extracted data and assessed methodological quality of studies resolving disagreement by consensus. Nine out of 55 studies met the inclusion criteria. The heterogeneity among studies did not allow quantitative combination of RESULTS: Study designs were: 8 crossover, 1 parallel-group trial. Two studies (14 SCI patients) showed a significant effect of intrathecal baclofen in reducing spasticity (Ashworth score and activities of daily living [ADL] performances), compared to placebo, without any adverse effect. The study comparing tizanidine to placebo (118 SCI patients) showed a significant effect of tizanidine in improving Ashworth score but not in ADL performances. The tizanidine group reported significant rates of adverse effects (drowsiness, xerostomia). For the other drugs (gabapentine, clonidine, diazepam, amytal and oral baclofen) the results do not provide evidence for a clinical significant effectiveness. This systematic review indicates that there is insufficient evidence to assist clinicians in a rational approach to antispastic treatment for SCI. Further research is urgently needed to improve the scientific basis of patient care.

Phrenic paresis and respiratory insufficiency associated with cervical spondylotic myelopathy.

Cervical spondylotic myelopathy is a common disease caused by chronic segmental compression of the spinal cord. Despite the fact that the columns of the nuclei of the phrenic nerve are located between the 3rd and 5th cervical nerve segments, phrenic nerve paresis is not usually clinically significant. We present one case of cervical spondylotic myelopathy with bilateral phrenic paresis in whom magnetic resonance imaging and surgical findings confirmed intrinsic cord disease as being the cause of this syndrome. This case report suggests that one pathophysiology of clinical phrenic nerve paresis may be segmental damage to the anterior horns caused by cervical spondylosis.

Spinal cord lesion management in Italy: a 2-year survey.

DESIGN: Prospective 2-year survey from 1 February 1997 to 31 January 1999. OBJECTIVES: To compare the route from injury to rehabilitation, and the outcome of care in a large sample of traumatic (T) and nontraumatic (NT) spinal cord lesion (SCL) patients at their 'first admission'. SETTING: T and NT SCI patients consecutively admitted to 37 SCL centres in Italy. METHOD: Data were recorded on simple, computerised, closed-question forms, which were Centrally collected and analysed. Descriptive and inferential analysis was conducted to define the characteristics and compare the T and NT populations, and to identify correlations among the variables examined: time from the event to admission (TEA); pressure sores (PS) on admission; length of stay (LoS) and destination on discharge. RESULTS: A total of 1014 SCL patients, 67.5% with a lesion of T and 32.5% of NT aetiology were analysed. The subjects in the T group were younger (median 34 versus 58 years), with higher probability of cervical involvement (OR 2.47, CI 1.8-3.4) and completeness of the lesion (OR 3.0, CI 2.3-4.0), shorter median TEA (37 versus 64 days, P<0.0001) and less frequent admission from home (3.6 versus 17.4%) compared to the NT group. TEA and PS on admission were analysed as indicators of the efficacy of the courses from injury to rehabilitation. Longer TEA was reported for people with NT aetiology, admitted to rehabilitation centre (RC), not locally resident, transferred from certain wards and to a lesser degree female subjects and those with complications on admission. PS were associated to completeness of lesion, longer TEA, admission to RC, nonlocal residence and coming from general intensive care units, or general surgery wards. Median LoS was 99 days (mean 116 and range 0-672), and was statistically shorter in the NT group (122 versus 57 median, P<0.00001). Upon discharge, bladder and bowel autonomy were, respectively, obtained in 68.1 and 64.5% of the whole population without significant difference between the T and NT groups. A total of 80.2% of patients were discharged home and the following factors: not living alone, being discharged after longer LoS, having sphincterial autonomy and no PS, were all independent predictors of outcome. CONCLUSION: There are important obstacles in the admission route to rehabilitation facilities, greater for NT, as longer TEA and more complications on admission testify. Moreover, the LoS is shorter for NT population. Our findings suggest that rehabilitation outcome could be improved through an early multidisciplinary approach and better continuity between acute and rehabilitation care, especially for the 'neglected' NT SCL patients.

Sensory stimulation for brain injured individuals in coma or vegetative state.

BACKGROUND: Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. OBJECTIVES: To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. SEARCH STRATEGY: We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. SELECTION CRITERIA: Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. DATA COLLECTION AND ANALYSIS: Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. MAIN RESULTS: Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. REVIEWER'S CONCLUSIONS: This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state.

[Constrictive arachnoiditis after pantopaque myelography causing syringomyelia and paraparesis: case report]. / Aracnoidite constritiva causada por pantopaque resultando em siringomielia e paraparesia: relato de caso.

We present an unusual case of thoracic constrictive arachnoiditis after pantopaque myelography, used 10 years before in the diagnosis of intradural arachnoid cyst.

Functional status in patients with spinal cord injury: a new standardized measurement scale. Gruppo Interdisciplinare Valutazione Interventi Riabilitativi.

OBJECTIVE: To report on the validation process of a new functional assessment scale (Valutazione Funzionale Mielolesi [VFM]) for patients with spinal cord injury (SCI). DESIGN: Prospective study testing for the VFM in a sample of patients with SCI to evaluate the scale characteristics in terms of psychometric and clinical validity. SETTING: Eight SCI units located in northern Italy. PATIENTS: One hundred patients were recruited and followed up for 18 months. Seventy-seven subjects were men, subjects' mean age was 37 years, 67 were paraplegic, and for 81 their SCI was of traumatic etiology. MAIN OUTCOME MEASURES: VFM's characteristics are described using estimates of construct and criterion validity (estimates of the strength and direction of associations between different VFM tasks and between VFM and other medical and nonmedical variables). The Barthel index was used as concurrent and independent measure. RESULTS: VFM met all psychometric criteria usually recommended and, at least in the current sample, was found to be strongly correlated with independent clinical variables (diagnosis and lesion level) and with the Barthel index. Moreover, most of the domains were able to document large and significant changes over time. CONCLUSIONS: VFM is a reliable and valid tool that can be used confidently in the rehabilitation setting for patients with SCI to screen for functional problems and monitor changes in patients' functional status and impact of rehabilitation.

[Approach to the patient in vegetative state. Part II: differential diagnosis]. / Approccio al paziente in stato vegetativo. Parte II: La diagnosi differenziale.

A prerequisite to the diagnosis of vegetative state is the exclusion of apparently similar syndromes, in which the patient retains the consciousness partially or even completely. Some syndromes are not separate nosological entities and should be abandoned: the apallic state, the neocortical death, the decerebrate and decorticate state, the alpha-coma, the vigil or prolonged or irreversible coma are among them. Three conditions deserve special consideration. The term locked-in syndrome describes a patient completely paralysed and mute, but fully conscious, and is usually caused by ischemic lesions of the pons. Several variants do exist, either in the causes and site of lesion. Some patients may become paralysed and mute, but conscious because of polyneuropathies, that is in the absence of any lesions of the central nervous system. The akinetic mutism is a rare condition characterised by loss of speech and nearly absent bodily movements. Painful stimulation may cause appropriate withdrawing, and wakefulness and self-awareness may be preserved, but cognitive impairment is usually present. It must be emphasised that this condition can be due to potentially treatable lesions, such as hydrocephalus and craniopharyngioma. The term "minimally responsive" or "minimally conscious" describes severely disabled patients in whom meaningful responses can be demonstrated, although inconstantly. This condition, the true diagnostic challenge, often represents a transition phase of vegetative patients recovering consciousness. Physicians, physiotherapists and patient's relatives should work all together to reach a correct diagnosis, by using current available methods to monitorize the recovery of consciousness.

[Approach to the patient in vegetative state. Part III: prognosis]. / Approccio al paziente in stato vegetativo. Parte III: La prognosi.

To define a vegetative state (VS) as permanent is to declare its irreversibility. In 1994 a North-American multidisciplinary task force, by extensively analysing the literature, concluded that the recovery of consciousness from a post-traumatic or non-traumatic VS is unlikely after 12 and 3 months respectively. These conclusions did not obtain unanimous consent. The term permanent was in fact inappropriately used to define either the loss of consciousness or of function. Furthermore, patients with traumatic brain injury have been shown to recover the consciousness in a substantial greater percentage (6-7%) than previously appreciated (1.6%). This is hardly compatible with the peremptoriness of the term permanent, which should be used only in case of certainty. Ancillary tests are important in defining the prognosis. Patients in deep coma after an anoxic brain injury can be predicted as having a poor prognosis (death or permanent VS) with 100% specificity within one week of the insult. Magnetic resonance of the brain can predict patients at high risk of permanent VS within 6-8 weeks of a traumatic brain injury. In conclusion, the available evidence does not permit to define with certainty the patients who have irremediably lost their consciousness after a devasting brain insult. However, it seems possible to reliably define the risk of severe disability. Whether or not this knowledge might or should be used to titrate the intensity of therapeutic approach is to be defined. In this respect, it is central the definition of what an "acceptable outcome" is, certainly not an exclusive medical attribution.

Pharmacological interventions for spasticity following spinal cord injury.

BACKGROUND: Spasticity is a major health problem for patients with a spinal cord injury (SCI) that limits patients' mobility and affects independence in activities of daily living and work. Spasticity may also cause pain, loss of range of motion, contractures, sleep disorders and impair ambulation in patients with an incomplete lesion. The effectiveness of available drugs is still uncertain and they may cause adverse effects. Assessing what works in this area is complicated by the lack of valid and reliable measurement tools. The aim of this systematic review is to critically appraise and summarise existing information of the effectiveness of available treatments and to identify areas where further research is needed. OBJECTIVES: To assess the effectiveness and safety of Baclofen, Dantrolene, Tizanidine and any other drugs for the treatment of long term spasticity in SCI patients as well as the effectiveness and safety of different routes of administration of Baclofen. SEARCH STRATEGY: We searched the Injuries Group specialised register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINHALH up to 1998. Drug companies and experts active in the area were also contacted. SELECTION CRITERIA: All parallel and crossover RCTs including spinal cord injury patients complaining of "severe spasticity". Studies where less than 50% of patients had a spinal cord injury were excluded. DATA COLLECTION AND ANALYSIS: Methodological quality of studies (allocation concealment, blinding, patients characteristics, inclusion and exclusion criteria; interventions; outcomes; lost to follow up) was independently assessed by two investigators. The heterogeneity among studies did not allow quantitative combination of results. MAIN RESULTS: Nine out of 53 studies met the inclusion criteria. Study design was: 8 cross over, 1 parallel-group trial. Two studies (14 SCI patients), showed a significant effect of intrathecal baclofen in reducing spasticity (Ashworth Score and ADL performances), compared to placebo, without any side effect. The study comparing tizanidine to placebo (118 SCI patients) showed a significant effect of tizanidine in improving Ashworth Score but not in ADL performances. Tizanidine group reported significant rates of adverse effects (drowsiness, xerostomia). For the other drugs (Gabapentine, Clonidine, Diazepam, Amytal and oral Baclofen ) the results do not provide evidence for a clinical significant effectiveness. REVIEWER'S CONCLUSIONS: There is insufficient evidence to assist clinicians in a rational approach to antispastic treatment for SCI. Further research is urgently needed to improve the scientific basis of patient care.

Paroxysmal atrial fibrillation and insidious neck pain.

Paroxysmal atrial fibrillation (AF) is an arrhythmia usually secondary to autonomic imbalance, and it may occur in the absence of any structural heart disease. The case of a patient with paroxysmal AF, in whom the arrhythmia may have been a presenting symptom of a later diagnosed cervical schwannoma, is reported.

Intravascular papillary endothelial hyperplasia causing cauda equina compression: case report.

OBJECTIVE AND IMPORTANCE: Intravascular papillary endothelial hyperplasia (Masson's vegetant hemangioendothelioma) is a rare condition affecting the neuraxis. In the literature, only one case of this lesion involving the vertebral canal with spinal cord compression has been reported. We present a case of cauda equina compression due to this abnormality. CLINICAL PRESENTATION: A 17-year-old boy was admitted at our hospital with pain, numbness, paresis of the left lower extremity, and bladder dysfunction of approximately 1 month's duration. Computed tomography and magnetic resonance imaging of the spine revealed a tumor within the spinal canal at the T12-L1 level. INTERVENTION: The patient underwent a T12-L1 laminectomy. An epidural red nodular tumor was visualized and totally resected. The findings of the pathological examination were compatible with intravascular papillary endothelial hyperplasia. At follow-up examination 1 month after the operation, the patient had complete resolution of the pain, and the motor deficit and bladder dysfunction had improved significantly. CONCLUSION: This rare benign vascular lesion may be clinically and histopathologically mistaken for an angiosarcoma. Because the intravascular papillary endothelial hyperplasia can be cured by complete surgical resection, it is important to distinguish between these two lesions to avoid inappropriate aggressive treatment.

Hereditary multiple exostoses and cervical ventral protuberance causing dysphagia. A case report.

STUDY DESIGN: A case report of a patient with hereditary multiple exostosis and who presented with cervical ventral protuberance causing dysphagia. OBJECTIVES: To present this rare situation and to discuss the treatment and the result obtained. SUMMARY OF BACKGROUND DATA: We found in the literature only one case of exostosis of the cervical spine causing dysphagia. METHODS: The patient, a 16-year-old girl, was affected by hereditary multiple exostosis, as was her father. The diagnosis was confirmed by radiograph, computed tomography, and magnetic resonance imaging, which showed a tumor in the anterior arch of the atlas. The patient was submitted to a transoral approach, and the tumor was excised. RESULTS: The patient had a good evolution 2 years after the surgery without sign of recurrence. CONCLUSIONS: This was a very rare situation, and the result validated the treatment used.

[Cerebellar abscess by Nocardia: a case report]. / Abscesso cerebelar por Nocardia: relato de caso.

The authors describe a case of cerebellar abscess by Nocardia in a patient with the acquired immunodeficiency syndrome (AIDS) that was submitted to a posterior fossa craniectomy for diagnosis and treatment. Pathological and neuroimage findings are discussed as well as the surgical approach taking into account literature data on the subject.

Corpectomy and anterior plating in cervical spine fractures with tetraplegia.

Between 1980 and 1989, 68 tetraplegic patients (69 males and 8 females) with cervical spine fractures were treated with corpectomy, iliac bone grafting and anterior plating. The average age was 27 years (15-58 years). The resected vertebrae was C4 in 4 cases, C5 in 24, C6 in 32 and C7 in 8. The injuries were classified according to Allen et al. in: compressive flexion in 47 cases, vertical compression in 20 and distractive flexion in 1. The neurologic deficit was complete in 30 patients and incomplete in 38 patients. The surgery was performed 7 days (average) (1-28 days) after the trauma. The mean follow-up was 2.8 years (1-9 years). In the postoperative period early mobilization was permitted with a plastic collar. There were 6 deaths that were not related to the technique in the first 4 weeks; the results of the remaining 62 patients are presented hereafter. In the final follow-up we observed that 56 patients had no complications related to the procedure and the spine was stabilized. The following complications were observed in the remaining patients: 5 partial loosening of the plate, but the patients were asymptomatic and 1 complete loosening that was reoperated after 2 weeks. The motor indices improved from 12.4 points initially to 23.7 in the complete tetraplegics and from 30.2 points to 72.5 in the incomplete tetraplegics. We conclude that the anterior plate fixation after anterior decompression for cervical spine fractures avoids the extrusion of the graft and provides immediate stabilization of the spine, permitting early mobilization of the patients.