A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury.

This study was designed to test the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. One hundred and six professionals in the field of spinal cord injury attending an instructional course at the 1994 ASIA Meeting participated in the test. Participants completed a pretest and posttest in which they classified two patients who had a spinal cord injury (one with complete tetraplegia and one with incomplete paraplegia) by sensory and motor levels, zone of partial preservation (ZPP), ASIA Impairment Scale and completeness of injury. Between tests, three members of the ASIA Standards Executive Committee gave presentations on the neurological assessment, scoring, scaling and classification of spinal cord injury and a video of the actual examinations of the two cases was viewed. Percent 'correct' (as defined by the ASIA Standards Committee) was calculated for sensory and motor levels, ZPP, ASIA Impairment and completeness. Overall, the analyses showed that participants had very little difficulty in correctly classifying the patient with complete tetraplegia. Pretests scores ranged from 72% (left motor level) to 96% (complete injury), posttest scores from 73% (left motor level) to 100% correct (complete injury). For the patient with incomplete paraplegia (Case 2), scores were considerably lower. Pretest scores ranged from 16% (right motor level) to 95% correct (incomplete injury); posttest scores from 21% (right motor level) to 97% correct (incomplete injury). The results showed that further revisions of the 1992 Standards and more training is needed to ensure accurate classification of spinal cord injury.

Evaluation, treatment, and follow-up results of post polio patients with dysphagia.

Twenty consecutive patients were evaluated for reports of dysphagia from post-polio clinics. Only half the patients reported a history of swallowing problems at the time of their acute poliomyelitis. Each patient received a videofluorographic evaluation of the oral and pharyngeal phases of swallowing, and then was provided with recommendations to improve swallowing skills. A follow-up questionnaire was sent to all patients. The respondents had an average interval of 12 months since the initial evaluation. Of the 18 patients responding to the questionnaire, 14 (77%) reported regular use of the swallowing suggestions. Comparison of pre-evaluation results to followup of the 18 respondents yielded a statistically significant decline in the frequency of choking (p = 0.0156) and food sticking in the throat (p = 0.0195). We conclude that a dysphagia program can result in significant improvement of the swallowing symptoms reported with the post-polio population.

Shoulder pain in acute traumatic quadriplegia.

Fifty two patients with traumatic quadriplegia admitted to a spinal cord injury program within 6 months of injury were studied retrospectively. Seventy five per cent had shoulder pain documented in their medical records during initial rehabilitation, and 60% had shoulder pain for 2 weeks or more. When shoulder pain was documented it was bilateral in 61% of the cases. Age greater than 50 years, decreased shoulder range of motion, and not receiving shoulder exercise during the first 2 weeks after injury were positive risk factors associated with the onset of shoulder pain. At discharge 42% of the patients with shoulder pain were pain-free, 35% were noted to have improvement of their pain, and 23% had the same or worse shoulder pain. Study results demonstrate the high incidence of shoulder pain during initial rehabilitation of patients with traumatic quadriplegia and the importance of starting shoulder exercises during early acute care.

Epidemiology of spasticity following traumatic spinal cord injury.

Two epidemiologic studies of spasticity at discharge and first annual follow-up in patients with traumatic spinal cord injury (SCI) are reported. Study 1 analyzed occurrence of spasticity and its severity for 96 subjects at one SCI center, with 67% of subjects developing spasticity by discharge and 37% receiving antispasticity medication. By follow-up, these figures were 78% and 49%, respectively. Incidence of spasticity was higher among cervical and upper thoracic than lower thoracic and lumbosacral levels of injury groups (p less than 0.001). Study 2 analyzed presence of spasticity severe enough to have warranted treatment on 466 subjects at 13 collaborating SCI centers, where 26% of subjects received treatment by discharge and 46% by follow-up. Probability of spasticity treatment was significantly related (p less than 0.05) to days from injury to discharge and level of injury group, whereas age, gender, and Frankel grade were not related. Among only cervical and upper thoracic subjects, Frankel grade was significantly related (p less than 0.01), with grades A (27%) and D (29%) being less frequently treated than grades B (50%) and C (52%). Importance of controlling the above significantly related factors is emphasized for future studies of methods to reduce incidence or severity of spasticity.

Stabilization of spinal injury for early transfer.

We have reviewed the means of transport and type of stabilization used for all patients with acute spinal cord injuries (SCI) transferred to our center since 1985 to determine what effect these variables may have had on change in level of impairment and probability of neurologic improvement after arrival. Sixty-one patients were reviewed, 47 males and 14 females, with a mean age of 34 years. Twenty-five patients (41%) were transported by ground ambulance, 33 (54%) by helicopter, three (5%) by fixed-wing aircraft. Forty-three patients (70.5%) had cervical spine injuries, 11 (18%), thoracic spine injuries, and seven (11.5%), lumbar spine injuries. Fifty-one patients (84%) were transferred within 24 hours of injury. A variety of standard methods of stabilization were used during transport. No patient suffered ascending level of injury as a result of early transfer. Level of function improved before discharge in 26 of 61 patients (43%); patients transported within 24 hours were more likely to show improvement (25/51) than those transported after 24 hours (1/10). There was no significant difference in the probability of improvement between ground (8/25) or air (18/36) transport. Skeletal traction was used before transfer in only four of 43 patients with cervical spine injuries, and was maintained as a method of long-term stabilization in two patients. We conclude that acute SCI patients can be safely transported by air or ground using standard precautions. Distance and extent of associated injury are the best determinants of mode of transport. Skeletal traction does not appear to be a prerequisite for safe, early transfer of SCI patients.

Analysis of recreational off-road vehicle accidents resulting in spinal cord injury.

Twelve cases of spinal cord injury (SCI) resulting from recreational off-road vehicle (ORV) accidents seen during a three-year period at a spinal cord injury center were analyzed using structured interviews and record reviews. Seven accidents involved three-wheel all-terrain vehicles (ATVs), one involved a four-wheel ATV, and four involved two-wheel trailbikes. The analysis of accident victim characteristics showed that all age groups are at risk, and that most victims were young adult men vehicle drivers with experience and wearing helmets. Spinal injury levels were cervical, three; thoracic, three; and thoracolumbar, six. Categorized accident hazard patterns were loss of control, six; tipover, four; and hidden obstacle, two. Contributing causative factors to the accident occurrence were poor driver judgment, seven, and vehicle instability, eight. Speeding was the most frequent primary cause of ORV accidents. We discuss vehicle and driver performance characteristics as they relate to risk of accident occurrence. The frequency of ORV accidents as an etiology of traumatic SCI at our center was 8%, compared to 8% for diving accidents and 11% for motorcycle accidents. We recommend, in view of the high risk of severe injury, widespread public education about ORV accident prevention.

The choice to end life as a ventilator-dependent quadriplegic.

A 17-year-old male sustained a C5/6 fracture dislocation and complete C5 quadriplegia in a diving accident. Three days later sensory and motor function deteriorated and he required mechanical ventilation. Surgical exploration found no cause and a fusion was done. Neurologic function stabilized after three weeks with a C1 sensory level, no neck movement, and slight weakness of the tongue. Patient and family were followed closely by the spinal cord injury rehabilitation team from onset of injury. The patient was transferred to the ventilator-dependent pediatric rehabilitation program after ten weeks. Bowel, bladder, skin, and nutritional management were stabilized and taught to his parents who remained with him constantly. Communication was achieved with a "talking tracheostomy." He learned to use "Sip-n-Puff" control for driving an electric wheelchair and for Morse code input to a computer. He was passive but cooperative during hospitalization. Eight months after injury he was discharged to his home, which had been modified to meet his needs. A computer word processor, environmental control unit, and modified van were obtained; nursing care was provided around the clock. The patient enrolled in a community college course. Soon after discharge he contacted an attorney to explore legal actions for ending his life, which he considered intolerable. After obtaining medical and psychiatric reports, a court order was issued, which established his legal competence and directed people taking care of him to follow his directions. A few weeks later, 25 months after his injury, he privately said goodbye to his family, asked to be disconnected from the ventilator, and died. Medical and legal issues raised by this case are discussed.

Management of the neuropathic bladder by clean intermittent catheterisation: 5 year outcomes.

Based on a telephone interview and medical record review of the urological outcomes among 40 spinal cord injury patients with a neuropathic bladder at discharge who were an average of 60 months post-injury and who were all initially managed by chronic clean intermittent catheterisation (CCIC), the following conclusions were made: Over 80% of patients using CCIC at discharge continued to use it, suggesting low morbidity and high patient acceptance; Urological complications in patients using CCIC were more frequent in the lower urinary tract than in the upper urinary tract, were more frequent in men than women, and had a low morbidity; Urological complications and hospitalisations were more frequent among the 41% of patients using CCIC who had frequent SxUTIs; SxUTIs were common in patients using CCIC but rates may be comparable with other methods; Although 44% of CCIC patients were hospitalised at least once in 5 years for urological complications, this is comparable to reported multi-centre outcomes in the U.S.A. (Young, 1982).

Early clinical experience with clonidine in spinal spasticity.

The centrally active, alpha-2 adrenergic receptor agonist clonidine was given to 12 spinal cord injury patients with problematic spasticity not adequately controlled by recognized spasmolytic drug therapy. Five patients had an excellent reduction and 2 patients had some reduction in clinical spasticity (average dose 0.39 mg daily). Four of the 7 responders discontinued clonidine because of adverse reactions after an average of ten weeks of therapy. Three responders have continued to tolerate the drug well with excellent control of spasticity for 18 to 34 months. Five patients had no change in clinical spasticity (average dose of 0.24 mg daily). Three of the non-responders discontinued clonidine because of adverse reactions after an average of three weeks of therapy. Significant associated adverse reactions included syncopal seizures (3), cerebrovascular accident (1), deep vein thrombosis (1), autonomic hyperreflexia (3), lethargy/drowsiness (3), and nausea/vomiting (1). Possible mechanisms of action for clonidine to affect spasticity and the unstable cardiovascular system of quadriplegics is discussed. While spinal cord injured patients with severe spasticity may benefit from clonidine, great caution is recommended during its use until further study establishes safe parameters of administration and efficacy is confirmed on controlled studies.

Immobilization hypercalcemia following spinal cord injury.

Based on the author's experience with more than 20 cases of immobilization hypercalcemia following spinal cord injury, current concepts of this condition are presented. Symptoms may be mild or severe: laboratory findings are essential for differential diagnosis in older individuals, in whom preinjury Paget's disease and mild primary hyperparathyroidism must be ruled out. Most cases of immobilization hypercalcemia are seen in adolescent boys following recent spinal cord injury. Besides sex (male), risk factors include age (less than 21 years), complete neurologic injuries, high cervical levels of spinal cord injury, dehydration, and a prolonged period of immobilization. A preinjury history of large ingestion of milk and/or extreme exposure to sunshine may also be contributory factors. Therapy includes vigorous hydration, saline infusions and diuretics, calcitonin, and steroids. The clinical course, without treatment, may be prolonged to 14 months, but the condition is always self-limiting.

Post-polio sequelae--differential diagnosis and management.

Forty-two patients with a past history of poliomyelitis were evaluated at a post-polio clinic for new problems or impairments. Evaluation included a complete history, neurological and biomechanical examination and electrodiagnostic studies. Based on this evaluation patients were placed into three groups: 23 patients were considered to have or likely to have Progressive Post-Polio Muscular Atrophy (PPPMA); 17 patients were considered to have other post-polio sequelae; and two patients had problems unrelated to a past history of polio but mistaken for post-polio sequelae. Musculoskeletal pain was a common complaint among all groups of patients. Twenty-two of the 40 patients with post-polio sequelae were advised to alter their method of ambulation and/or decrease their activity pattern in order to decrease strain and/or excessive exertion of involved muscles. The role of chronic overuse and exercise in producing PPPMA or musculoskeletal pain problems is discussed. Characteristic clinical problems and useful management plans are described.

Urinary infection and complications during clean intermittent catheterization following spinal cord injury.

A total of 50 patients with recent spinal cord injury secondary to trauma participated in a prospective study of urinary complications during an interval of clean intermittent catheterization at initial hospitalization in a spinal cord injury unit. Patients were assigned randomly to groups receiving or not receiving a prophylactic antibacterial preparation. Both groups were divided further into subgroups in which laboratory infections (bacteriuria more than 100,000 organisms per ml.) were treated with definitive antibiotics or in which antibiotic treatment was given only for clinical infections (fever more than 100F or urethral discharge and bacteriuria). Antibacterial prophylaxis significantly reduced the probability of laboratory infection but not the probability of clinical infection, although a trend was noted toward fewer clinical infections. No significant reduction was noted in the probability of clinical infection in subgroups treated promptly for laboratory infection.

Posttraumatic cystic myelopathy in motor incomplete quadriplegia presenting as progressive orthostasis.

A 20-year-old man sustained a C7 burst fracture in a motor vehicle accident. Initial neurologic examination showed sensory incomplete C7 quadriplegia. Seventeen days postinjury anterior C7 body excision with bony fusion was performed. Postoperatively, his sensation improved. He first voluntarily moved the lower extremities at seven weeks. Eight months postinjury he could ambulate independently with forearm crutches for 500 feet. Eleven months postinjury he complained of headache and fatigability. Examination demonstrated orthostatic hypotension which became severe after walking 40 feet. In spite of salt loading, ephedrine, fludrocortisone, and compression garments, he became increasingly disabled by fatigability and orthostatic hypotension. Consequently, he could not ambulate regularly. Twenty-two months postinjury metrizamide myelogram showed widening of the spinal cord at C7. Following the myelogram CT showed a small cyst filled with contrast material. The patient underwent surgical decompression of the spinal cord cyst with placement of a drain from the cyst to the subarachnoid space. Postoperatively, he noted improvement of fatigability and was able to ambulate 500 feet without symptomatic orthostasis. Posttraumatic cystic myelopathy is increasingly recognized as a late complication of traumatic spinal cord injury. Presenting symptoms are usually pain and neurologic deterioration. Progressive loss of sympathetic nervous system function with severely symptomatic orthostatic hypotension should also alert physicians to consider this diagnosis.

Vestibular stimulation for supranuclear gaze palsy: case report.

Gaze palsies following severe destruction or irritative lesions of the cerebral hemispheres are rare. This report describes a patient with supranuclear ophthalmoplegia secondary to stroke which was rapidly resolved by cold caloric vestibular stimulation. The patient had a severe infarction of the right cerebral hemisphere and had a fixed deviated gaze to the right 3 months after onset. Cold caloric vestibular stimulation was used in an attempt to evaluate brain stem integrity. Following three successive injections of cold water at OC-5C into the external auditory canal, the patient regained full voluntary extraocular eye movements. The improvement continued for more than 12 months after the last treatment. A literature review of the neuroanatomy and neurophysiology of voluntary and reflex ocular movements is presented. A possible explanation for the improvement in this case is that vestibular input inhibits the tonic phase of antagonistic extraocular muscles while facilitating agonistic extraocular muscles.

Clean intermittent catheterization for spinal cord injury patients.

Charts were reviewed retrospectively for 65 patients with traumatic spinal cord injury discharged from the hospital between 1972 and 1977 on clean intermittent catheterization for management of neurogenic bladders. While 54 patients were still using clean intermittent catheterization 9 had discontinued its use and 2 were lost to followup. Complete urologic followup records were available for 28 long-term clean intermittent catheterization users, with an average followup of 3.7 years. Complications seen in this group included nephrolithiasis-3 cases, cystolithiasis--3, epididymitis--4 and urinary tract infection--12. No patient had hydronephrosis or radiographic pyelonephritis. Clean intermittent catheterization appears to be a safe and satisfactory alternative for long-term management of the neurogenic bladder of selected spinal cord injury patients, since the incidence of serious renal complications is low. Factors that should be considered before long-term clean intermittent catheterization is recommended include type of neurogenic bladder, prognosis for recovery, incontinence despite medication, history of urethral trauma, host resistance, physical independence in self-catheterization, compliance and patient preference.