Femoral nerve palsy as a complication due to COVID-19 coagulopathy and iliopsoas muscle hematoma - case report.

BACKGROUND: COVID-19 (Coronavirus disease 2019) pandemic is the main medical problem around the world from the end of 2019. We found until now many symptoms of this disease, but one of the most problematic was thrombosis. Wide recommendation on COVID-19 treatment was pharmacological thromboprophylaxis. In some papers we found that clinicians face the problem of bleeding in those patients. Is still unknown that coronavirus could led to the coagulopathy. CASE PRESENTATION: We described case report of patient who with COVID-19 disease present femoral nerve palsy caused by the iliopsoas hematoma. There were no deviations in coaguology parameters, patient got standard thromboprophylaxis, besides above probably COVID-19 was risk factor of hematoma formation. Non-operative treatment was applied, thrombophylaxis was discontinued. In the follow up in the radiological exam we saw reduction of the haematoma and patient report decrease of symptoms. CONCLUSIONS: We should assess individually patient with COVID-19 according to thrombosis risk factors. Probably we should be more careful in ordering thrombophylaxis medications in COVID-19 patients.

The diagnostic utility of inspiratory-expiratory radiography for the assessment of phrenic nerve palsy associated with brachial plexus injury.

BACKGROUND: The phrenic nerve is commonly injured with trauma to the brachial plexus. Hemi-diaphragmatic paralysis may be well-compensated in healthy individuals at rest but can be associated with persistent exercise intolerance in some patients. This study aims to determine the diagnostic value of inspiratory-expiratory chest radiography compared to intraoperative stimulation of the phrenic nerve for assessing phrenic nerve injury associated with brachial plexus injury. METHODS: Over a 21-year period, the diagnostic utility of three-view inspiratory-expiratory chest radiography for identification of phrenic nerve injury was determined by comparison to intraoperative phrenic nerve stimulation. Multivariate regression analysis was used to identify independent predictors of phrenic nerve injury and having an incorrect radiographic diagnosis. RESULTS: A total of 237 patients with inspiratory-expiratory chest radiography underwent intraoperative testing of phrenic nerve function. Phrenic nerve injury was present in approximately one-fourth of cases. Preoperative chest radiography had a sensitivity of 56%, specificity of 93%, positive predictive negative of 75%, and negative predictive value of 86% for identification of a phrenic nerve palsy. Only C5 avulsion was found to be a predictor of having an incorrect diagnosis of phrenic nerve injury on radiography. CONCLUSION: While inspiratory-expiratory chest radiography has good specificity for detecting phrenic nerve injuries, a high number of false negatives suggest that it should not be relied upon for routine screening of dysfunction after traumatic brachial plexus injury. This is likely multifactorial and relates to variation in diaphragm shape and position, as well as limitations regarding static image interpretation of a dynamic process.

Neurological severity evaluation using magnetic resonance imaging in acute spontaneous spinal epidural haematomas.

PURPOSE: This study aimed to elucidate the severity of neurological deficits in a large series of patients with acute spontaneous spinal epidural haematoma (SSEH) using magnetic resonance imaging (MRI). METHODS: We included 57 patients treated for acute SSEH at 11 institutions and retrospectively analysed their demographic and MRI data upon admission. We investigated MRI findings, such as the haematoma length and canal occupation ratio (COR). The neurological severity of SSEH was assessed based on the American Spinal Injury Association score on admission. RESULTS: Of the 57 patients, 35 (61%) presented with severe paralysis. The MRI analysis showed that SSEH was often located in the cervical spine, dorsal to the spinal cord, and spread over more than three vertebrae. No differences in age, sex, and aetiology were found between patients with and without severe paralysis. The hypo-intensity layer encircling the haematoma, intra-haematoma heterogeneity, and increased CORs were observed more frequently in the severe paralysis group. Furthermore, pathological examination of a dissected haematoma from one patient with a hypo-intensity layer revealed a collagen layer around the haematoma, and patients with intra-haematoma heterogeneity were more likely to have a bleeding predisposition. CONCLUSIONS: In this large series of patients with SSEH, we identified some MRI features associated with severe paralysis, such as the hypo-intensity layer, intra-haematoma heterogeneity, and increased COR. Accordingly, patients with these MRI characteristics should be considered for early surgical intervention.

Does Margin Convergence Reverse Pseudoparalysis in Patients with Irreparable Rotator Cuff Tears?

BACKGROUND: Margin convergence has been shown to restore muscle tension in a cadaveric model of a rotator cuff tear. However, the clinical utility of this technique remains uncertain for patients with pseudoparalysis caused by an irreparable rotator cuff tear. QUESTIONS/PURPOSES: (1) For patients with massive irreparable rotator cuff tears, in what proportion of patients does margin convergence reverse pseudoparalysis? (2) In patients with massive irreparable rotator cuff tears, does margin convergence improve American Shoulder and Elbow Surgeons (ASES) scores? (3) What is the survivorship free from MRI evidence of retear after margin convergence? METHODS: Between 2000 and 2015, we treated 203 patients for pseudoparalysis with a rotator cuff tear. Pseudoparalysis was defined as active elevation less than 90° with no stiffness, which a physical therapist evaluated in the sitting position using a goniometer after subacromial injection of 10 cc lidocaine to eliminate pain. Of those, we considered patients who underwent at least 3 weeks of unsuccessful nonoperative treatment in our hospital as potentially eligible. Twenty-one percent (43 of 203) who either improved or were lost to follow-up within 3 weeks of nonoperative treatment were excluded. A further 12% (25 of 203) were excluded because of cervical palsy, axillary nerve palsy after dislocation or subluxation, and development of severe shoulder stiffness (passive shoulder elevation < 90°). Repair was the first-line treatment, but if tears were considered irreparable with the torn tendon unable to reach the original footprint after mobilizing the cuff during surgery, margin convergence was used. When margin convergence failed, the procedure was converted to hemiarthroplasty using a small humeral head to help complete the repair. Therefore, 21% (42 of 203) of patients treated with regular repair (18% [36 of 203]) or hemiarthroplasty (3% [6 of 203]) were excluded. That left 93 patients eligible for consideration. Of those, 13 patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, and 86% (80 of 93) were analyzed (49 men and 31 women; mean age 68 ± 9 years; mean follow-up 26 ± 4 months). Seventy-six percent (61 of 80) were not evaluated in the last 5 years. We considered reversal of pseudoparalysis as our primary study outcome of interest; we defined this as greater than 90° active forward elevation; physical therapists in care measured this in the sitting position by using goniometers. Clinical outcomes were evaluated based on the ASES score from chart review, active ROM in the shoulder measured by the physical therapists, and the 8-month Kaplan-Meier survivorship free from MRI evidence of retear graded by the first author. RESULTS: Pseudoparalysis was reversed in 93% (74 of 80) patients, and improvement in ASES scores was observed at the final follow-up (preoperative 22 ± 10 to postoperative 62 ± 21, mean difference 40 [95% CI 35 to 45]; p < 0.01). The 8-month Kaplan-Meier survivorship free from MRI evidence of retear after surgery was 72% (95% CI 63% to 81%). There were no differences in clinical scores between patients with and without retears (intact ASES 64 ± 24, re-tear ASES 59 ± 10, mean difference 6 [95% CI -5 to 16]; p = 0.27). CONCLUSION: Margin convergence can be a good option for treating patients with pseudoparalysis and irreparable rotator cuff tears despite the relatively high retear rates. The proportion of pseudoparalysis reversal was lower in patients with three-tendon involvement. Further studies will be needed to define the appropriate procedure in this group. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Monitoring diffuse injury during disease progression in experimental autoimmune encephalomyelitis with on resonance variable delay multiple pulse (onVDMP) CEST MRI.

Multiple sclerosis (MS) is an autoimmune disorder that targets myelin proteins and results in extensive damage in the central nervous system in the form of focal lesions as well as diffuse molecular changes. Lesions are currently detected using T1-weighted, T2-weighted, and gadolinium-enhanced magnetic resonance imaging (MRI); however, monitoring such lesions has been shown to be a poor predictor of disease progression. Chemical exchange saturation transfer (CEST) MRI is sensitive to many of the biomolecules in the central nervous system altered in MS that cannot be detected using conventional MRI. We monitored disease progression in an experimental autoimmune encephalomyelitis (EAE) model of MS using on resonance variable delay multiple pulse (onVDMP) CEST MRI. Alterations in onVDMP signal were observed in regions responsible for hindlimb function throughout the central nervous system. Histological analysis revealed glial activation in areas highlighted in onVDMP CEST MRI. onVDMP signal changes in the 3rd ventricle preceded paralysis onset that could not be observed with conventional MRI techniques. Hence, the onVDMP CEST MRI signal has potential as a novel imaging biomarker and predictor of disease progression in MS.

MRI evaluation of motor function recovery by rTMS and intensive occupational therapy and changes in the activity of motor cortex.

Purpose/aim: An intervention that combines low-frequency repetitive transcranial magnetic stimulation and intensive occupational therapy can improve brain function in post-stroke patients with motor paralysis. The purpose of the present study is examined motor function recovery by repetitive transcranial magnetic stimulation and intensive occupational therapy and changes in the activity of motor cortex based on magnetic resonance imaging data.Materials and methods: In total, we assessed 30 patients with post-stroke upper extremity paralysis who were hospitalized for 12 sessions of low-frequency repetitive transcranial magnetic stimulation over the lesion-free hemisphere plus daily occupational therapy for 15 days. Imaging analysis was performed using 3-dimensional T1-weighted image and functional magnetic resonance imaging. Hemispheric dominance was assessed by functional magnetic resonance imaging using the laterality index. In addition, Seed-based functional connectivity analysis was used to evaluate functional connectivity between the precentral gyrus of the affected side and other areas.Results: A positive correlation was found between laterality index before intervention and the Brunnstrom recovery stage for hand/fingers (p < 0.05). The intervention resulted in significantly higher functional connectivity between the precentral gyrus of the affected side and that of the healthy side (false discovery rate corrected p < 0.05).Conclusions: We clarified that the recovery of motor function by intervention with low-frequency repetitive transcranial magnetic stimulation and occupational therapy and the increase of functional connectivity between the precentral gyrus on the affected side and the healthy side are related. These results facilitate prognostic predictions and evidence-based medical care.

Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury.

BACKGROUND: Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI. METHODS: This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as ΦST and ΦCL, respectively. The differences in the ΦST and ΦCL values due to the presence or absence of LTN palsy were examined, the cutoff values of ΦST and ΦCL for the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated. RESULTS: Both ΦST and ΦCL were significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for ΦST and 0.833 and 0.840 for ΦCL, respectively, when the cutoff value was set as ΦST = 15° and ΦCL ≤ 24°. CONCLUSION: Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.

Spectrum of clinical features and neuroimaging findings in acute cerebral infarction patients with unusual ipsilateral motor impairment- a series of 22 cases.

BACKGROUND: Cerebral infarction occurs when the arteries to brain are obstructed, and motor impairment contralateral to responsible lesion is commonly recognized. Few studies have profiled the characteristics of cases with ipsilateral motor impairment. We sought to characterize clinical features of patients with motor dysfunction caused by ipsilateral ischemic stroke. METHODS: We retrieved and analyzed the medical data for patients with ipsilateral cerebral infarction. Patients were regarded as having ipsilateral cerebral infarction if motor impairment is ipsilateral to recent stroke lesions. RESULTS: Only 22 patients with unusual ipsilateral cerebral infarction were included in this study. Ipsilateral limb paralysis was observed in all cases, and one case showed central facioplegia. Majority of patients with limb paralysis (90.9%, 20/22) presented with mild muscle strength deficits (MRC grading of 4 or more). Most of the patients (72.7%, 16/22) had a past history of stroke, and previous strokes were contralateral to the side of the recent stroke in 14 out of 16 patients (87.5%). No history of stroke or cerebral injury was identified in seven patients. With aspect of MRI findings, recent infarct lesions of all cases were located along the corticospinal tract. CONCLUSIONS: History of stroke plays an important role in the pathogenesis of ipsilateral motor impairment, and cortical reorganization in the unaffected hemisphere may contribute to the compensation of motor function after stroke. Besides that, some cases with first stroke may be due to impairment of ipsilateral uncrossed corticospinal fibers.

Unilateral winged scapula: Clinical and electrodiagnostic experience with 128 cases, with special attention to long thoracic nerve palsy.

INTRODUCTION: In this study we report a large series of patients with unilateral winged scapula (WS), with special attention to long thoracic nerve (LTN) palsy. METHODS: Clinical and electrodiagnostic data were collected from 128 patients over a 25-year period. RESULTS: Causes of unilateral WS were LTN palsy (n = 70), spinal accessory nerve (SAN) palsy (n = 39), both LTN and SAN palsy (n = 5), facioscapulohumeral dystrophy (FSH) (n = 5), orthopedic causes (n = 11), voluntary WS (n = 6), and no definite cause (n = 2). LTN palsy was related to neuralgic amyotrophy (NA) in 61 patients and involved the right side in 62 patients. DISCUSSION: Clinical data allow for identifying 2 main clinical patterns for LTN and SAN palsy. Electrodiagnostic examination should consider bilateral nerve conduction studies of the LTN and SAN, and needle electromyography of their target muscles. LTN palsy is the most frequent cause of unilateral WS and is usually related to NA. Voluntary WS and FSH must be considered in young patients. Muscle Nerve 57: 913-920, 2018.

Different nerve ultrasound patterns in charcot-marie-tooth types and hereditary neuropathy with liability to pressure palsies.

INTRODUCTION: Nerve ultrasound in Charcot-Marie-Tooth (CMT) disease has focused mostly on the upper limbs. We performed an evaluation of a large cohort of CMT patients in which we sonographically characterized nerve abnormalities in different disease types, ages, and nerves. METHODS: Seventy patients affected by different CMT types and hereditary neuropathy with liability to pressure palsies (HNPP) were evaluated, assessing median, ulnar, fibular, tibial, and sural nerves bilaterally. Data were correlated with age. RESULTS: Nerve dimensions were correlated with CMT type, age, and nerve site. Nerves were larger in demyelinating than in axonal neuropathies. Nerve involvement was symmetric. DISCUSSION: CMT1 patients had larger nerves than did patients with other CMT types. Patients with HNPP showed enlargement at entrapment sites. Our study confirms the general symmetry of ultrasound nerve patterns in CMT. When compared with ultrasound studies of nerves of the upper limbs, evaluation of the lower limbs did not provide additional information. Muscle Nerve 57: E18-E23, 2018.

Action Observation Treatment Improves Upper Limb Motor Functions in Children with Cerebral Palsy: A Combined Clinical and Brain Imaging Study.

The aim of the present study was to assess the role of action observation treatment (AOT) in the rehabilitation of upper limb motor functions in children with cerebral palsy. We carried out a two-group, parallel randomized controlled trial. Eighteen children (aged 5-11 yr) entered the study: 11 were treated children, and 7 served as controls. Outcome measures were scores on two functional scales: Melbourne Assessment of Unilateral Upper Limb Function Scale (MUUL) and the Assisting Hand Assessment (AHA). We collected functional scores before treatment (T1), at the end of treatment (T2), and at two months of follow-up (T3). As compared to controls, treated children improved significantly in both scales at T2 and this improvement persisted at T3. AOT has therefore the potential to become a routine rehabilitation practice in children with CP. Twelve out of 18 enrolled children also underwent a functional magnetic resonance study at T1 and T2. As compared to controls, at T2, treated children showed stronger activation in a parieto-premotor circuit for hand-object interactions. These findings support the notion that AOT contributes to reorganize brain circuits subserving the impaired function rather than activating supplementary or vicariating ones.

Acute flaccid myelitis: A clinical review of US cases 2012-2015.

This review highlights clinical features of the increasing cases of acute flaccid paralysis associated with anterior myelitis noted in the United States from 2012 to 2015. Acute flaccid myelitis refers to acute flaccid limb weakness with spinal cord gray matter lesions on imaging or evidence of spinal cord motor neuron injury on electrodiagnostic testing. Although some individuals demonstrated improvement in motor weakness and functional deficits, most have residual weakness a year or more after onset. Epidemiological evidence and biological plausibility support an association between enterovirus D68 and the recent increase in acute flaccid myelitis cases in the United States. Ann Neurol 2016;80:326-338.

Acute flaccid myelitis in childhood: a retrospective cohort study.

BACKGROUND AND PURPOSE: Clusters of acute limb weakness in paediatric patients have been linked to outbreaks of non-polio enteroviruses, termed acute flaccid myelitis (AFM). Outside these clusters, in countries where polio is not endemic, this poliomyelitic-like illness is rare in childhood and its natural history is not well defined. We describe presenting features, investigation findings and long-term outcome of a series of children with AFM. METHODS: This was a retrospective cohort study. RESULTS: Eight children (six females) aged 3 months to 8 years (median age 5 years) met case criteria. Initial symptoms were pain (n = 7) followed by limb weakness with hypotonia (n = 8). Flaccid paralysis occurred in only three patients. Two had cranial nerve dysfunction. Magnetic resonance imaging of the spinal cord demonstrated grey matter involvement particularly affecting the anterior cord, with longitudinally extensive changes in three children. Cerebrospinal fluid examination showed pleocytosis in six children with raised cerebrospinal fluid protein in five. Nerve conduction and electromyography findings were consistent with a motor neuronopathy. Residual deficits were common, with moderate to severe weakness seen in five patients. Median follow-up was 28 months (range 17-108 months, 30.4 patient years in total). CONCLUSIONS: Acute flaccid myelitis is an uncommon condition in childhood with a high rate of significant long-term morbidity. AFM should be considered in children presenting with acute limb pain and weakness.

Factors associated with postoperative C5 palsy after expansive open-door laminoplasty: retrospective cohort study using multivariable analysis.

PURPOSE: The aim of the present study was to investigate the factors associated with C5 palsy by focusing on radiological parameters using multivariable analysis. METHODS: The authors retrospectively assessed 190 patients with cervical spondylotic myelopathy treated by open-door laminoplasty. Four radiographic parameters-the number of expanded lamina, C3-C7 angle, lamina open angle and space anterior to the spinal cord-were evaluated to clarify the factors associated with C5 palsy. RESULTS: Of the 190 patients, 11 developed C5 palsy, giving an overall incidence of 5.8%. Although the number of expanded lamina, lamina open angle and space anterior to the spinal cord were significantly larger in C5 palsy group than those in non-palsy group, a multiple logistic regression analysis revealed that only the space anterior to the spinal cord (odds ratio 2.60) was a significant independent factor associated with C5 palsy. A multiple linear regression analysis indicated that the lamina open angle was associated with the space anterior to the spinal cord and the analysis identified the following equation: space anterior to the spinal cord (mm) = 1.54 + 0.09 × lamina open angle (degree). A cut-off value of 53.5° for the lamina open angle predicted the development of C5 palsy with a sensitivity of 72.7% and a specificity of 83.2%. CONCLUSIONS: The larger postoperative space anterior to the spinal cord, which was associated with the lamina open angle, was positively correlated with the higher incidence of C5 palsy.

C4/5 foraminal stenosis predicts C5 palsy after expansive open-door laminoplasty.

INTRODUCTION: Laminoplasty is frequently performed in cervical myelopathy patients, but can lead to unexpected postoperative C5 palsy. Although several studies have examined the pathogenesis and prevention of postoperative C5 palsy, many controversies remain and some radiological findings identified as risk factors were not correlated with our outcomes. PURPOSE: This study sought reliable radiological findings that predict C5 palsy after laminoplasty and examined why the predictors of C5 palsy did not apply in our series. METHODS: This study reviewed 116 patients who underwent open-door laminoplasty for cervical spondylotic myelopathy between January 2014 and April 2016, retrospectively. C5 palsy was defined as weakness of the deltoid muscle. We evaluated the incidence of C5 palsy, the preoperative C2-7 Cobb's angle, and Pavlov ratio at the C4/C5 level using simple cervical lateral radiographs. We also evaluated the existence of an ossified posterior longitudinal ligament, the transverse diameter of the C4/5 foramen, and increases in the anteroposterior diameter of the spinal canal at the C4/5 levels after surgery. Furthermore, a high signal intensity on T2-weighted images of the cervical spinal cord preoperatively was noted. RESULTS: Of the 116 patients, 16 cases were excluded and 100 cases were analyzed; postoperative C5 palsy occurred in 8 patients (8%). There were no significant differences between the two groups except the average diameter of the C4/5 foramen. A diameter of the C4/5 foramen of less than 2 mm was significantly related to C5 palsy in the binary logistic regression test. CONCLUSIONS: A smaller diameter of the C4/5 foramen was the only factor significantly correlated with C5 palsy after laminoplasty. The results suggest that C4/5 foraminal stenosis is one of the best predictors of C5 palsy, which might be related to ischemic/reperfusion injury of the C5 root nerve after laminoplasty.

Cervical laminectomy of limited width prevents postoperative C5 palsy: a multivariate analysis of 263 muscle-preserving posterior decompression cases.

PURPOSE: Between 2006 and 2010, we performed wide laminectomy (wide LAM) alone, with decompression performed between the bilateral medial margin of the zygapophyseal joints, or double-door laminoplasty (DL) combined with wide LAM for cervical compressive myelopathy (CCM). From 2010, instead of wide LAM and DL, we began to perform narrow LAM, where the laminectomy width was no more than 2-3 mm wider than the spinal cord width (SW). This study aimed to elucidate the risk factors for C5 palsy by reviewing surgical outcomes. METHODS: The clinical features and radiological findings of 263 CCM patients with or without C5 palsy were compared. Risk factors for C5 palsy were assessed using logistic regression analysis. The decompression width (DW) was defined as the laminectomy width or the width between the bilateral medial margins of the bony gutters in DL. RESULTS: Narrow LAM reduced the incidence of C5 palsy from 9.2 to 1.2%. DL was performed more frequently in the C5 palsy group. The difference between the DW and the SW (DW - SW) was significantly greater in the C5 palsy group. Posterior spinal cord shift, aging, and the number of consecutive laminae surgically treated were significantly higher in the C5 palsy group. The diameter of the foramen (DF) at C4/5 was significantly smaller in the C5 palsy patients. The logistic regression analysis revealed that DL, DW - SW, DF, and aging were risk factors for C5 palsy. CONCLUSIONS: Cervical laminectomy of limited width prevented postoperative C5 palsy without compromising the functional recovery.

Isolated Medial Rectus Palsy: Rare Presentation of Mesencephalon Infarction.

Isolated medial rectus palsy due to mesencephalon lesion is extremely rare. We here describe a patient of midbrain infarction involving the medial rectus subnuclei presenting as isolated medial rectus palsy. Axial diffusion-weighted and coronal T2-weighted magnetic resonance imaging showed acute ischemic lesion in mesencephalon.

Prospective study of deep vein thrombosis in patients with spinal cord injury not receiving anticoagulant therapy.

STUDY DESIGN: Prospective cross-sectional study. OBJECTIVES: To investigate the timing of deep vein thrombosis (DVT) onset secondary to spinal cord injury without anticoagulant therapies. SETTING: Spinal Cord Injury Center in Hokkaido, Japan. METHODS: Between November 2012 and June 2013, patients with spinal cord injury who were admitted to our hospital within 1 day after the injury and treated surgically within 24 h underwent a neurological examination, leg vein ultrasonography and D-dimer test 1, 3, 7, 14 and 28 days after surgery. All patients received treatment with intermittent pneumatic compression and elastic stockings, but without any anticoagulant. RESULTS: DVT developed in 12 patients (11 men and 1 women), with a mean age of 62.2 years (range, 41-80 years; mean age of total sample, 63.2 years (range, 25-78 years)), all distal to the popliteal vein. DVT occurred more often with a more severe paralysis (66.3%, AIS A and B). The median (± standard error) length of time from the operation to DVT detection was 7.5±2.2 days. The mean D-dimer level upon DVT detection was 14.6±11.8 µg ml(-1), with no significant differences between those who developed DVT and those who did not at any of the time points. CONCLUSION: These results suggest that DVT can develop at the very-acute stage of spinal cord injury and the incidence increases with a more severe paralysis. DVT detection was more reliable with ultrasonography, which should be used with DVT-preventive measures, beginning immediately after the injury, for the management of patients with spinal cord injury.