Spontaneous cervical epidural hemorrhage, anterior cord syndrome, and familial vascular malformation: case report.

Complete motor tetraplegia with incomplete sensory loss was caused by spontaneous epidural bleeding from an arteriovenous malformation in the cervical region. There was a family and personal history of cutaneous hemangioma.

Two spinal cord lesions in a patient with ankylosing spondylitis and cervical spine injury.

A patient with ankylosing spondylitis sustained C3-C4 vertebral subluxation and C4-C5 myelopathy after a hyperextension trauma. Autopsy showed that several segments below the main cervical cord lesion at the fractured site, there was a second spinal cord lesion at the T1 vertebral level with no corresponding local bony or ligamentous damage. The thoracic cord lesion was probably secondary to traction of the upper thoracic cord, where the blood supply is poor, in a narrow and rigid spinal canal at the moment of extreme hyperextension.

5-microtransducer catheter in evaluation of neurogenic bladder function.

Recent use of the multiple microtransducer catheter in the evaluation of neurogenic bladder due to spinal-cord injuries leads us to believe that the use of the inferior edge of the symphysis pubis as the zero point for resting bladder pressure is more accurate than its superior edge, changes in resting bladder pressure at various volumes are influenced more by body position than by intravesical position of the sensor, back-to-back microtransducers indicate significant pressure difference at the external sphincter zone, and detrusor bladder neck dyssynergia during autonomic dysreflexia in patients with spinal cord injury is more likely of skeletal than of smooth muscle origin.

Synchronous cystosphincterometry in patients with spinal cord injury. Studies with continuous bladder and urethral infusions and physical factors influencing interpretation.

A technique of synchronous study for monitoring the bladder activity and simultaneous urethral sphincteric responses is described. This study was made possible by using a 12 F trilumen catheter with which intravesical infusion and independent bladder pressure recording were conducted. Constant urethral infusion with intrasphincteric pressure recording was arranged through the third lumen of the trilumen catheter. This radiologic aided study was used for functional evaluation of the bladder and its outlet. The bulit-in artefacts of the technique were assessed. The physical factors, such as urethral infusion flow rate and the compliance of infusion catheter hydraulic system governing interpretation of the study during nonvoiding states, are described. With an experience of 100 studies on 75 patients with spinal cord injury and 5 normal subjects, this method has been found to be a useful clinical urodynamic technique well suited even to a nonambulatory patients with spinal cord injury.

Dual pressure transducer catheter for evaluating vesicourethral function: experiences in patients with neurogenic bladder.

Preliminary experiences with a dual pressure transducer catheter (7 F) for the functional vesicourethral evaluation are described. Synchronous cystosphincterometric recording, urethral pressure profile with simultaneous intravesical pressure, and pressure gradient across urethral sphincter were obtained. Comparison of the studies with those conducted with catheter infusion technique revealed that minimal artefacts were encountered with the former although the pressure events displayed by the two methods were grossly similar.

Radiography of posttraumatic syringomyelia.

Posttraumatic syringomyelia was studied in 15 patients. Gas myelography in 12 patients showed a definite spinal cord swelling in 10 and a probable cord enlargement in two. Plain spinal computed tomography (CT) in four patients demonstrated intramedullary radiolucent zones in three. After intrathecal injection of metrizamide in 10 patients, cysts were opacified in eight. Postoperative CT in two patients demonstrated collapse of the cyst in one. Gas myelography shows the extent and site of maximal dilatation of the cyst where a shunt can be placed. CT is less invasive and provides a definitive diagnosis.

Post-traumatic spinal epidural hematoma.

Five patients with vertebral fracture and spinal epidural hematoma (SEH) are described. Another 58-year-old man developed a post-traumatic SEH without bony damage. From the literature, 38 patients (31 male, 4 female, and 3 unknown) were collected. Ankylosing spondylitis or rheumatoid arthritis was noted in 9 of 12 subjects between 50 and 75 years of age. Two groups of patients were identified: Group 1--16 patients with spinal fracture (aged 23 to 63 years), and Group 2--22 patients without spinal fracture (the age was less than 18 years in 12 subjects). In Group 2, a coagulation defect or spinal epidural vascular malformation resulted in a SEH in 6 patients. The preoperative myelopathy was complete in 3 patients each from Group 1 (23.1%) and Group 2 (16.7%). Of the 31 patients operated upon, 9 of the 13 from Group 1 (69.3%) and 6 of the 18 from Group 2 (33.3%) underwent laminectomy within 1 week after the onset of symptoms. Postoperative neurological return was observed in 38.5% (5 of 13) and 88.9% (16 of 18) of these two groups of patients, respectively. Post-traumatic SEHs, predominant in the male population, are often associated with vertebral disease in elderly patients. In the very young patient, there is usually no fracture/dislocation of the spine. A predisposing lesion may be present when spinal fracture is not evident. The prognosis after surgical intervention is better in patients without spinal fracture than in those with vertebral damage, probably because of less contusion to the spinal cord and the presence of very young subjects in the former group of patients.

Value of gas myelography in early management of acute cervical spinal cord injuries.

Gas myelography was carried out in 22 patients with acute cervical spinal cord injuries in whom oily contrast media seemed contraindicated. The authors believe this technique makes a valuable contribution to the basic decision regarding the surgical versus medical treatment of a specific patient with a cervical cord injury. They emphasize the importance of visualizing cord compression due to disc herniation in these cases and conclude that gases are the optimal contrast agents for visualization of the entire circumference of the spinal cord.

Delayed paralysis after cervical fracture-dislocation. Case report.

The authors describe the late development of ascending damage to the spinal cord after a cervicothoracic fracture-dislocation that produced no evidence of cord or nerve injury other than transient mild paresthesia in the arms. After 16 years, progressive quadriplegia developed with subsequent ascending dissociated sensory loss in the upper cervical dermatomes. The presence of a central syrinx was verified at operation 18 years after the injury.

The treatment of spinal fractures with Harrington compression rods and segmental sublaminar wiring. A dangerous combination.

The increasing use of more rigid internal fixation constructs for spinal fractures, especially in association with spinal cord injury, has led surgeons to combine sublaminar segmental wiring with Harrington instrumentation systems. Two clinical cases whose neurologic condition deteriorated postoperatively were shown to have sustained direct cord injury by the combination of Harrington compression rods with segmental sublaminar wiring. Myelographic and surgical evidence of hook protrusion into the spinal canal with direct cord injury is presented. Laboratory spine simulations duplicating the clinical situation did demonstrate that sublaminar wiring of the Harrington compression rod system caused the standard hooks to protrude dangerously into the spinal canal. Caution should be exercised not to combine Harrington compression rods with segmental sublaminar wiring.

Forces in the halo-vest apparatus.

A previous study by Koch and Nickel (1978) determined the changes in the distraction forces in the halo-vest during different activities. The present study determined the variations of forces in different directions between the halo and the vest also during different activities. Clip-on strain gauges were used to measure the strains in the bars, while an on-line computer system was used to compute the forces. Anterior-posterior forces were found to be comparable with vertical ones. These forces and the changes during a particular activity were caused by gravity forces of the head in activities involving a change in attitude; and vest distortion from changes in body shape, direct pushing from the lower abdomen, the arms and shoulders, or from supporting surfaces. Activities producing the highest force changes included bending forwards from a seated position and reaching over sideways while lying. Medial-lateral forces were small in comparison with vertical and anterior-posterior forces. Implications of the study were that pin-skull forces were multidirectional, and that certain improvements in design could be effected by accounting for the factors causing high forces and consequently cervical motion.

Preoperative neurological status in predicting surgical outcome of spinal epidural hematomas.

The postoperative progress of 3 patients with spinal epidural hemorrhage, but without spinal fracture or dislocation, is presented. From the literature, 158 cases were collected of spontaneous spinal epidural hematoma treated surgically. Postoperative return of motor function was noted in 95.3%, 87%, and 45.3% of the patients with incomplete sensorimotor, incomplete sensory but complete motor, and complete sensorimotor lesions, respectively. Complete sensorimotor recovery occurred in 41.9%, 26.1%, and 11.3% of these 3 groups of patients, respectively. Recovery following surgical treatment depends on the severity of neurological deficits before treatment. However, the absence of motor or sensorimotor functions preoperatively does not necessarily indicate a poor prognosis.

Posttraumatic anterior spinal cord syndrome: pathological studies of two patients.

Two patients sustained acute anterior spinal cord injury associated with a posteriorly displaced bone fragment and herniated cervical disc. Postmortem examination of both spinal cords showed extensive destruction of the cord at the site of injury with sparing of the posterior portion of the dorsal columns; the anterior spinal artery was patent. We conclude that posttraumatic anterior spinal cord syndrome can be caused by damage to the anterior part of the cord without involvement of the anterior spinal artery.

Anterior fibular interbody fusion in the treatment of cervical spinal cord injuries.

A series of six patients with cervical spine fracture and spinal cord injury treated by removal of the fractured vertebral body and fibular strut graft is presented. There was no immediate mortality or major complication associated with the procedure. The stabilization achieved allowed early mobilization. Solid fusion was achieved in three months in all patients. Postmortem examination in one case showed union at the ends of the graft and bridging of the injured area by new bone. In selected patients interbody fusion is an important adjunct in the treatment of the fractured cervical spine.

Carcinoma in chronic pressure sores: a fulminant disease process.

Four cases of squamous cell carcinoma arising from chronic pressure sores in paraplegic and tetraplegic patients are presented and the literature reviewed. These pressure-sore carcinomas are characterized by a shorter latency period and a fulminant clinical course with a very high metastatic rate. Very aggressive treatment including even hemicorporectomy must be considered if a cure is to be achieved.

Sports medicine and the physiology of wheelchair marathon racing.

In the past three decades, wheelchair sports have become an international reality. Disabled athletes are exercising their right to accept the challenges and risks taken by able-bodied athletes. Marathon racing over a 26-mile, 385-yard course is the latest and most strenuous of the wheelchair athletic events. The small amount of available research data on wheelchair sports has been summarized, as well as some relevant data from exercise physiology studies on able-bodied subjects. Physicians and other health professionals who work with disabled people should be knowledgeable about the risks and benefits of wheelchair sports. Much more basic research is needed to improve the safety, training techniques, and performance of wheelchair athletes.