Long-term follow-up study of outcomes of bladder management in spinal cord injury patients under the care of the Midlands Centre for Spinal Injuries in Oswestry.

STUDY DESIGN: Retrospective longitudinal study of short- and long-term urinary complications in chronic spinal cord injury (SCI) patients managed at the Midlands Centre for Spinal Injuries (MCSI). SETTING: MCSI, Oswestry, UK. METHOD: A total of 185 SCI patients were admitted to the MCSI between 1984 and 1989. Only 119 patients who met the following criteria were included: traumatic SCI, Frankel grade A-D, admission within 6 weeks post injury, regular annual follow-up or alternate year at MCSI, follow-up longer than 8 years. Follow-up ranged between 8 and 21 years with a mean of 17.7 (s.d.=1.98). The method of bladder drainage varied from the time of injury. Drainage was by indwelling urethral catheterisation (IndUC) before admission to the MCSI. Within 24 h of admission, assisted clean intermittent catheterisation (ACIC) by the nursing staff was commenced. This was followed by clean intermittent self catheterisation (CISC) once the patient was mobilised in the wheel chair and trained in the procedure. When detrusor reflex activity develops, patients with good hand function were given a choice between CISC and reflex voiding (RV). Patients with poor hand function are given the choice between RV, suprapubic catheters or ACIC during hospitalisation and after discharge. Only a minority of these patients choose ACIC following discharge. RV was supplemented occasionally by sphincterotomy. There were 99 males and 20 females (5:1). The age at the time of injury was 16-63 years with a mean of 29 (s.d.=12). Instead of a single method, a pattern of bladder management was analysed in the context of three continuous phases: Phase1 preadmission to MCSI. Phase2 during first hospitalisation at MCSI. Phase3 post discharge. In each phase, the patients were divided into those with and without complications. The complications were analysed in relation to the management and other relevant factors. RESULTS: The total complication rate at all stages was 62%. Complications of the upper urinary tract accounted for 22.6%. These results compared favourably with published material. CONCLUSION: The sequential system of supervised bladder management commencing with brief IndUC followed by IntC and/or RV remains effective in keeping the complication rate relatively low in SCI patients, who undergo regular surveillance and timely intervention. SPONSORSHIP: The project was supported by SPIRIT, a charitable not for profit trust that supports teaching, training, clinical research and dissemination of knowledge about all aspects of spinal paralysis in the UK.

The isolated sympathetic spinal cord: Cardiovascular and sudomotor assessment in spinal cord injury patients: A literature survey.

OBJECTIVES: To present a comprehensive approach to the assessment of the severity of the autonomic lesion in spinal cord injury (SCI) patients, with regard to the level of lesion. To discuss how to assess an isolated sympathetic spinal cord that has lost supraspinal control (sympathetically complete lesion). METHOD: PubMed was searched for articles related to cardiovascular (mainly cold pressor test, respiratory and postural challenges) and sudomotor (sympathetic skin responses) tests that have been used. The results of these evaluations are analysed with regard to the site of stimulation (above or below the lesion) according to three types of SCI that offer typical autonomic reactions (tetraplegics, paraplegics at T6 and at T10). RESULTS: Non-invasive cardiovascular and sudomotor testing allows the assessment of the isolated sympathetic spinal cord in SCI patients. Typical responses are found in relation with the level of the sympathetic lesion. Its definition would allow comparison with the somatic motor and sensory level of lesion of SCI patients and provide additional aid to the classification of those patients. CONCLUSION: For research purposes on the integrity of the spinal sympathetic pathways, a battery of test approach is probably needed, using a combination of stimuli above and below the lesion, evaluating both cardiovascular and sudomotor pathways.

A review of published reports on neuroprotection in spinal cord injury.

STUDY DESIGN: Literature review. OBJECTIVES: To review the main published current neuroprotection research trends and results in spinal cord injury (SCI). SETTING: This paper is the result of a collaboration between a group of European scientists. METHODS: Recent studies, especially in genetic, immune, histochemical and bio (nano)-technological fields, have provided new insight into the cellular and molecular mechanisms occurring within the central nervous system (NS), including SCIs. As a consequence, a new spectrum of therapies aiming to antagonize the 'secondary injury' pathways (that is, to provide neuroprotection) and also to repair such classically irreparable structures is emerging. We reviewed the most significant published works related to such novel, but not yet entirely validated, clinical practice therapies. RESULTS: There have been identified many molecules, primarily expressed by heterogenous glial and neural subpopulations of cells, which are directly or indirectly critical for tissue damaging/sparing/re-growth inhibiting, angiogenesis and neural plasticity, and also various substances/energy vectors with regenerative properties, such as MAG (myelin-associated glycoprotein), Omgp (oligodendrocyte myelin glycoprotein), KDI (synthetic: Lysine-Asparagine-Isoleucine 'gamma-1 of Laminin Kainat Domain'), Nogo (Neurite outgrowth inhibitor), NgR (Nogo protein Receptor), the Rho signaling pathway (superfamily of 'Rho-dopsin gene-including neurotransmitter-receptors'), EphA4 (Ephrine), GFAP (Glial Fibrillary Acidic Protein), different subtypes of serotonergic and glutamatergic receptors, antigens, antibodies, immune modulators, adhesion molecules, scavengers, neurotrophic factors, enzymes, hormones, collagen scar inhibitors, remyelinating agents and neurogenetic/plasticity inducers, all aiming to preserve/re-establish the morphology and functional connections across the lesion site. Accordingly, modern research and experimental SCI therapies focus on several intricate, rather overlapping, therapeutic objectives and means, such as neuroprotective, neurotrophic, neurorestorative, neuroreparative, neuroregenerative, neuro(re)constructive and neurogenetic interventions. CONCLUSION: The first three of these therapeutical directions are generically assimilated as neuroprotective, and are synthetically presented and commented in this paper in an attempt to conceptually systematize them; thus, the aim of this article is, by emphasizing the state-of-the art in the domain, to optimize theoretical support in selecting the most effective pharmacological and physical interventions for preventing, as much as possible, paralysis, and for maximizing recovery chances after SCI.

Assessment of the sympathetic level of lesion in patients with spinal cord injury.

STUDY DESIGN: To study the vasomotor responses (skin axon-reflex vasodilatation (SkARV) to stimulation of the skin in spinal cord injury (SCI) patients. OBJECTIVE: To assess the completeness of the sympathetic injury and to define the sympathetic level of lesion in paraplegic and tetraplegic patients. SETTING: Centre Calve, Fondation Hopale and Centre Bouffard-Vercelli, France. SUBJECTS: A total of 81 SCI patients ranging from C2 to L2. METHOD: A mechanical stimulation was applied to the skin on both sides of the trunk, using a blunt instrument. The presence of an abnormal response below the lesion helped define the sympathetic level. RESULTS: Above the lesion, SkARV was observed in all patients. In patients with a complete sympathetic injury, the response below the lesion was either a vasoconstrictor response in upper motor neuron lesions, or total absence of SkARV in lower motor neuron lesions. There was excellent correspondence between complete somatic (American Spinal Injury Association (ASIA) A) and complete sympathetic lesions (100% of paraplegic and 94% of tetraplegic patients), whereas an incomplete somatic (ASIA B-D) lesion was often associated with a complete sympathetic lesion. In 34% of complete ASIA A patients, a sympathetic zone of partial preservation was found, extending below the lesion on sensory denervated dermatomes. CONCLUSION: SkARV is a simple bedside test that allows the assessment of sympathetic completeness of injury across the lesion as well as the excitability of the isolated spinal cord. We suggest that the definition of sympathetic level should be part of the classification of complete thoracic SCI.

[Gesture apraxia disclosing carbon monoxide poisoning]. / Apraxie gestuelle révélant une intoxication oxycarbonée.

A seventy year old right handed woman presented progressive limb apraxia and headache due to carbon monoxide poisoning. Thereafter, when in hospital for one week, she developed akinetic mutism, coma and died. Limb apraxia has been rather uncommonly reported in carbon monoxide poisoning. The akinetic mutism observed after the patient had been removed from intoxication could be analysed as a delayed encephalopathy related to a chronic carbon monoxide poisoning.

Fractures of the scapula associated with traumatic paralysis: a pathomechanical indicator.

In this study, 25 cases of fracture of the scapula associated with traumatic paralysis were reviewed. The vast majority of the patients were young males, victims of high-speed traffic accidents. Of the vertebral injuries in this population, 76 per cent occurred in the thoracic region, 20 per cent in the lower cervical region and only one in the lumbar region. Complete paralysis was documented in 84 per cent of the patients. The characteristics of spinal column failure are determined by the anatomical configuration and the direction and energy of the impact. Important information about the latter can be extrapolated from careful analysis of the associated fractures.

Multilevel spinal injuries. Incidence, distribution and neurological patterns.

Spinal injury at more than one level is not uncommon. Awareness of multilevel injury of the spine and associated neurological patterns is important for the proper initial management of the patient. This study presents the incidence, pattern of signs and the neurological consequences of multilevel spinal injury. A review of 935 patients with spinal injuries revealed that lesions occurred in multiple levels in 9.7%; in over half of the cases, neurological lesions were incomplete. Multiple level non-contiguous lesions at more than two levels had the worst prognosis with 70% of patients suffering complete paraplegia.

Minitracheotomy in the early respiratory management of patients with spinal injuries.

Minitracheotomy is a new technique of tracheal suction by the introduction under local anaesthetic of a small bore tube into the trachea through the cricothyroid membrane. The use of minitracheotomy in the early management of respiratory problems in patients with spinal injuries is described with a few illustrative cases. This technique is an adjunct to good physiotherapy in clearing secretions from the trachea. Its advantages and disadvantages are discussed.

Spinal cord injury: prognostic indicators.

A retrospective analysis of 70 patients with closed traumatic incomplete injuries of the spinal cord was performed. Of those presenting with motor sparing, as minimal as muscle flicker, 86 per cent recovered useful motor function. Of those presenting with spinothalamic sensory sparing, as minimal as unilateral sacral sparing, 71 per cent recovered to a similar functional level. While the patients presenting with preservation of only posterior column sensory sparing had the worst prognosis, some still showed important improvement. Meticulous neurological assessment within 72 h of the injury can localize the tract spared and can help with the prognosis in those patients with incomplete lesions.

Pharmacodynamics and pharmacokinetics of the oral antispastic agent tizanidine in patients with spinal cord injury.

The efficiency and duration of action of a single oral dose (8 mg) of tizanidine in patients with spinal cord injuries were determined by studying its antispastic, cardiovascular and sedative effects along with its pharmacokinetic profile in five tetraplegic and five paraplegic patients. After the administration of tizanidine, there was a reduction in spasticity in both groups within half an hour, with the effects lasting for 3 to 4 hours. There was no rebound increase in blood pressure. There was a greater increase in sedation in the tetraplegics than in the paraplegics. Plasma tizanidine levels rose within half an hour after dosing and peaked at one hour. The levels had fallen to 15 percent by 6 hours. The plasma half-life was 2.7 +/- 0.06 hours. We conclude that oral tizanidine has antispastic effects in patients with spinal cord injuries without affecting the power of non-involved muscle groups. It has minimal effects on blood pressure and it lowers heart rate. Side effects include sedation and dryness of mouth.

A clinical review of the adult hip guidance orthosis (Para Walker) in traumatic paraplegics.

Twenty Adult traumatic paraplegics with neurologically complete lesions between C8 and T12 have ambulated using a ParaWalker (adult hip guidance orthosis), for a minimum of 6 months at home. At follow up, on average 20 months from the date of issue of the orthosis, 17 patients (85%) were still regularly using their ParaWalker. Patients achieved independent use of the orthosis and low energy ambulation both indoors and outdoors on a variety of surfaces. A new classification of adult paraplegic ambulation using an orthosis is described.

Augmentation of the Oswestry Parawalker orthosis by means of surface electrical stimulation: gait analysis of three patients.

The Oswestry 'Parawalker' orthosis has been supplied to 15 adult thoracic level complete paraplegic patients enabling them to achieve a reciprocal gait with an inherent low energy demand. In order to further off-load the work demands on the upper limb girdle musculature during ambulation, three of these patients have undergone electrical stimulation of the gluteal muscles in stance phase. This was shown to increase the stability of the adduction and also provided forward propulsion by driving the stance-leg into extension. Bilateral stimulation of the quadriceps muscles has been shown to facilitate standing and sitting in the orthosis. Using a Kistler force platform, the crutch impulse can be seen to be reduced by as much as 36%. We speculate that this leads to a similar order of reduction in the work done by the upper limbs in these patients.

Prevertebral soft tissue shadow widening--an important sign of cervical spinal injury.

Injury to the cervical spine may first be diagnosed by recognizing the increase in prevertebral soft tissue seen on a radiograph. Seven such patients are reviewed. Failure to recognize this important sign led to delay in diagnosis of the cervical spinal injury in one patient and resulted in tetraplegia. A large prevertebral swelling should be considered as an indication of a severe and unstable injury to the cervical spine and requires careful handling of the patient.

Fractures of the sternum associated with spinal injury.

Twelve cases of sternal injury associated with spinal fractures have been reviewed. The sternum is regularly buckled or fractured in patients with high thoracic spinal fractures. Our review suggests that sternal injuries may also be associated with spinal fractures outside this region, and with types of fracture other than crushing of vertebral bodies. Injury to the sternum, when due to indirect violence, is almost always associated with a severe spinal column injury. A displaced fracture of the thoracic spine, with or without an associated sternal fracture, can produce significant widening of the mediastinal shadow on a chest radiograph. This is caused by a paravertebral haematoma, and can be difficult to differentiate from widening due to an aortic rupture.

Tracheostomy in intensive care setting.

A detailed analysis of early complications resulting from tracheostomy in 50 consecutive patients, admitted to the Intensive Care Unit, who had required ototracheal intubation, is presented. The very low incidence of complications seen in this study supports the contention that a carefully performed tracheostomy is a safe procedure in the management of these critically ill patients. In view of this and the greater incidence of laryngeal and tracheal stenosis associated with longer periods of orotracheal intubation followed by tracheostomy, early tracheostomy should be considered in patients intubated for five days in whom further prolonged respiratory assistance is anticipated.