Intramedullary spinal cord and filum tumours-long-term outcome: single institution case series.

BACKGROUND: Intramedullary spinal cord tumours are rare and account for about 2-4% of primary CNS tumours. Ependymomas and astrocytomas are most frequent. The aim of this study was to evaluate the long-term neurological outcome, quality of life (QoL), survival, need for additional treatment and frequency of neuropathic pain in a patient group treated at a tertiary university hospital. METHOD: Retrospective descriptive study of 52 long-term survivors with intramedullary or filum tumours consenting to participate in this study. Fifty-six operations were performed in 48 patients. Clinical and radiological follow-up period was 113 and 117 months, respectively. RESULTS: Good neurological outcome (ASIA score D or E, modified McCormick grade 1 or 2) was achieved in 88%. We found two negative prognostic factors in regards of severe disability which were large craniocaudal tumour size (p = 0.004) and histologic verified astrocytomas (p = 0.002). SF-36 results showed significantly lower results on all five subdomains concerning physical function, whereas scores for mental health and role emotional showed no significant differences compared to Norwegian norms. Ten patients including all astrocytoma patients, one primitive neuroectodermal tumour and three recurrent tumours of filum terminale had adjuvant therapy. None of the patients with intramedullary ependymoma had adjuvant therapy. Neuropathic pain was present in 54% of patients at the last follow-up. CONCLUSION: This series shows that good results can be obtained with surgery for intramedullary tumours, even without perioperative neurophysiological monitoring. Multicentre studies are needed for further evaluation of negative and positive prognostic factors to further improve outcome.

Non-traumatic spinal cord injury in Norway 2012-2016: analysis from a national registry and comparison with traumatic spinal cord injury.

STUDY DESIGN: Registry-based cross-sectional study. OBJECTIVES: To describe and analyze epidemiological and demographic characteristics of non-traumatic spinal cord injury (NTSCI) and to compare persons with NTSCI and traumatic spinal cord injury (TSCI). SETTING: A total of 225 non-traumatic and 349 traumatic SCI patients were admitted for primary rehabilitation at one of the three specialized SCI departments in Norway (located in Bergen, Trondheim, and Oslo) from 2012 to 2016. Patients who consented to registration in the Norwegian Spinal Cord Injury Registry (NorSCIR) were included. METHODS: Data were collected using the International SCI Core Data Set, as recommended by the International Spinal Cord Society (ISCoS). Demographics and injury characteristics were analyzed descriptively. The NTSCI and TSCI groups were compared using a Mann-Whitney U test and chi-square test. RESULTS: The mean age of the NTSCI patients was 55 years, and 59% were male. The incidence of NTSCI was 7.7-10.4 per million person-years, which is lower than the incidence of TSCI. NTSCI individuals were older, less severely injured, and their length of stay at the hospital was shorter than the TSCI individuals. The results may be influenced by the inclusion criterion in the registry. This makes the analyzed sample for NTSCI less complete. However, the majority of patients with nonprogressive NTSCI are included in the NorSCIR. CONCLUSION: For the first time, we are able to provide the national epidemiological status on NTSCI based on available data from the national registry. Further studies are required to improve the capture of NTSCI for future incidence studies.

Epidemiology of traumatic spinal cord injury in Norway in 2012-2016: a registry-based cross-sectional study.

STUDY DESIGN: A registry-based cross-sectional study. OBJECTIVES: To analyse the epidemiological and demographic characteristics of persons with traumatic spinal cord injury (TSCI) in Norway. SETTING: TSCI patients admitted for primary rehabilitation to one of the three specialised spinal cord injury (SCI) departments (located in Bergen, Trondheim, and Oslo) and consented to the Norwegian Spinal Cord Injury Registry (NorSCIR). METHODS: Analysis of data from NorSCIR during a 5-year period (2012-2016) was performed. Data were collected by using the International SCI Core Data Set as recommended by the International Spinal Cord Society (ISCoS). RESULTS: The lowest incidence of TSCI was 11.4/million (2012), and the highest incidence was 15.9/million (2014). In the study period, 349 individuals were registered with TSCI. In total, 76% were male, and the mean age was 47 (SD ± 19) years. We observed dominance in the 60-74 years age group. The distribution between tetraplegia and paraplegia was 48%/42%. For those initially classified as American Spinal Cord Injury Association Impairment Scale (AIS) grade A (complete injury), 77% remained grade A at discharge. Considerable changes during primary rehabilitation after incomplete lesions were observed. Most patients (68%) were discharged home after primary rehabilitation. Falls were the main cause of TSCI (47%) and occurred more often during the weekend. CONCLUSION: Through a National Medical Quality Registry based on internationally provided data sets, we are able to present systematic and updated data from Norway.

Telehealth for people with spinal cord injury: a narrative review.

STUDY DESIGN: Narrative review. OBJECTIVES: To find and discuss what has been published about the use of telehealth, on people with spinal cord injury (teleSCI). SETTING: International. METHOD: Cochrane Library, Ovid Medline, EMBASE and CINAHL, from 1996 till June 2017 have been searched. Searches in  PsycINFO, from 1996 till September 2017, were included afterwards. Extracted data include studies in English language, containing information about spinal cord injury and disorders, and telehealth. Literature reviews, systematic reviews, and studies containing other types of neurological disorders, were excluded. Studies were grouped based on how and to whom telehealth was offered. RESULTS: Twenty nine studies were included in the review. They were categorized according to the way teleSCI was provided, and to what modality was used. Some studies utilized more than one modality. TeleSCI seems to be favorable concerning treatment and follow-up, as well as favorable socioeconomically and environmentally. The studies spanned across several aims and outcomes. There was also heterogeneity in number of participants, the differences in modalities, and in the level of evidence. Thus  it was challenging to compare studies  and make future recommendations. CONCLUSIONS: TeleSCI can be used for examination and guiding purposes. Further research is warranted to evaluate optimal utilization, methodology and efficacy. SPONSORSHIP: The first author has received funding from the Norwegian Extra Foundation.

Impact of fatal cases on the epidemiology of traumatic spinal cord injury in Estonia.

BACKGROUND AND PURPOSE: Most epidemiological studies on traumatic spinal cord injury (TSCI) have not included patients who die before hospitalization. The aim of the research was to study the incidence of TSCI by including the individuals who die at the scene of the accident in addition to data retrieved from all hospitals in Estonia. METHODS: Medical records of patients with TSCI from all hospitals in Estonia from 2005 to 2007 were studied. With collaboration from the Estonian Forensic Science Institute the data of the victims of TSCI who died before hospitalization were included. RESULTS: From 2005 to 2007, 391 TSCI cases were identified: 183 patients were found retrospectively from medical records and 208 cases were detected from autopsy reports. Fifty-three per cent of patients died before hospitalization. The annual incidence rate was 97.0 per million population (95% confidence interval 87.4-106.6). The mean age at injury was 44.4 ± 18.7 years. Motor vehicle accidents were the leading cause of TSCI amongst the individuals who died before hospitalization (75%). Falls accounted for the highest number of TSCIs (43%) amongst the patients who reached hospital. CONCLUSIONS: Our study shows that, when the cases that die at the scene of the accident are included, the incidence of TSCI in Estonia rises from 39.7 to 97.0 per million population.

Long-term outcome after spinal cord infarctions.

OBJECTIVES: To investigate long-term outcome in patients with spontaneous spinal cord infarctions and secondly to compare outcome with that of patients with cerebral infarction. MATERIAL AND METHODS: The study includes 30 patients with spinal cord infarction discharged between 1995 and 2010. Surviving patients were contacted by telephone and sent a questionnaire. Data on employment, function, depression, fatigue, pain, and quality of life were obtained and compared to similar data obtained from a group of patients with cerebral infarction. RESULTS: Seven patients with spinal cord infarction had died after a mean follow-up of 7.1 years. Mortality was associated with poor functioning in the acute phase. Thirteen of 20 responding patients were able to walk. Compared to patients with cerebral infarction, patients with spinal cord infarction had significantly lower mortality, poorer functioning, higher re-employment rate, and more pain. CONCLUSION: Many patients with spinal cord infarction experience significant improvement. Even though functional outcome is worse, the mortality rate is lower and the frequency of re-employment higher among patients with spinal cord infarction compared to patients with cerebral infarction.

Traumatic spinal cord injury in two European countries: why the differences?

BACKGROUND AND PURPOSE: The aim of the study was to compare the incidence, causes, severity and mortality of traumatic spinal cord injury (TSCI) in Western Norway and Estonia from 1997 to 2001. METHODS: The patients were identified from hospital records. All patients were followed until death or 14 October 2011. Analysed data included demographic data, causes of injury, neurological level, American Spinal Injury Association Impairment Scale and mortality. RESULTS: A total of 71 patients in Western Norway and 244 in Estonia were included. The standardized incidence rate per million was 24.9 (CI 95%, 19.4-31.7) for Western Norway and 37.4 (CI 95%, 32.8-42.5) for Estonia. Falls was the most frequent cause of TSCI in both countries. The incidence of TSCI was highest among men in their 20s in Estonia and men in their 70s in Western Norway. The median survival time among the deceased was 4.0 (95% CI, 1.50-6.50) years in Norway and 2.8 (95% CI, 1.54-4.04) in Estonia. The mean standardized mortality ratio (SMR) was 5.00 (95% CI, 4.00-6.20) in Estonia and 1.89 (95% CI, 1.23-2.77) in Western Norway. CONCLUSION: Although the two cohorts had similar demographic, injury and clinical characteristics, the age profile of the victims was different. The incidence rate was 1.5 times higher and SMR was 2.7 times higher in Estonia. Probable explanations for the different outcomes of the two European countries are socioeconomic differences, lower physical activity level, lower life expectancy and insufficient injury prevention programmes in Estonia.

Factors influencing optimal seating pressure after spinal cord injury.

STUDY DESIGN: Retrospective, cross-sectional design. OBJECTIVES: To identify factors that predict unsatisfactory seating pressure in spinal cord-injured (SCI) individuals. SETTING: Seating Clinic at the University Hospital, Norway. METHODS: All wheelchair users with traumatic SCI hospitalized between 1 January 2007 and 31 December 2010 were included. Individual assessment by a team was performed. To measure seating pressure, a computerized seating pad with sensing points 40 × 40 cm was used. Primary end points were defined as satisfactory or unsatisfactory seating position based on measured pressure (more or less 100 mm Hg), clinical findings and physical activity level. To explore possible risk factors for high seating pressure, both univariate and multivariate regression analysis were performed. RESULTS: A total of 75 persons with SCI were assessed, 39 (52%) with unsatisfactory result. Statistical analysis revealed that use of manual wheelchair (odds ratio (OR)=6.86, confidence interval (CI) 1.77-26.63) and history of pressure ulcer (OR=8.47, CI 2.46-29.13) significantly increase the risk of unsatisfactory seating pressure. Paraplegia caused significantly higher risk (OR=2.5, CI 0.99-6.34) in the univariate model, probably because the SCI with tetraplegia do prefer electrically powered wheelchairs. CONCLUSIONS: Use of manually driven wheelchairs and persons with previous pressure ulcer are at significant risk of high seating pressure and consequently developing new pressure ulcers. The patients from these subcategories need close follow-up regarding seating position and prevention of pressure ulcers.

High incidence of traumatic spinal cord injury in Estonia.

STUDY DESIGN: Retrospective population-based cohort study. OBJECTIVES: To provide national data on epidemiology of traumatic spinal cord injury (TSCI) among the population of Estonia from 1997 to 2007. SETTING: All Estonian hospitals. METHODS: Medical records of patients with TSCI from all regional, central, general and rehabilitation hospitals in Estonia were retrospectively reviewed. Epidemiological characteristics, etiology, neurological level and severity of injury, concomitant injuries were analyzed. RESULTS: A total of 595 patients with TSCI from 1 January 1997 to 31 December 2007 were identified. The male to female ratio was 5.5:1. The mean age at injury was 39.0 years. The crude incidence rate was 39.7 (95% confidence interval: 36.6-43.0) per million population. The most frequent cause of TSCI was falls (41%), followed by traffic accidents (29%). Alcohol consumption preceded 43% of injuries. The lesion level was cervical in 59.4%, thoracic in 18.3% and lumbar/sacral in 22.3%. CONCLUSION: Compared to recent studies from Europe, where the incidence of TSCI is between 15 and 30 per million population, the incidence of TSCI in Estonia is among the highest. The rates are significantly higher in men compared with women and especially among the youngest men. The leading cause of TSCI is falls. A significant proportion of injuries are related to alcohol consumption before trauma in Estonia.

A 50-year follow-up of the incidence of traumatic spinal cord injuries in Western Norway.

STUDY DESIGN: Retrospective population-based epidemiological study. OBJECTIVE: To assess the prevalence and temporal trends in the incidence of traumatic spinal cord injuries (TSCI), and demographic and clinical characteristics of an unselected, geographically defined cohort in the period 1952-2001. METHODS: The patients were identified from hospital records. Crude rates and age-adjusted rates were calculated for each year. The multivariate relationship between cause of injury, age at injury, decade of injury and gender was examined using a Poisson regression model. RESULTS: Of 336 patients, 199 patients were alive on 1 January 2002, giving a total prevalence of 36.5 per 100,000 inhabitants. The average annual incidence increased from 5.9 per million in the first decade to 21.2 per million in the last. Mean age at injury was 42.9 years and the male to female ratio 4.7:1. Fall was the most common cause of injury (45.5%), followed by motor vehicle accidents (MVA) (34.2%). The incidence of MVA-related injuries increased during the observation period, especially among men <30 years. The lesion level was cervical in 52.4%, thoracic in 29.5% and lumbar/sacral in 18.2%. The lesion was clinically incomplete in 58.6% and complete in 41.4%. The incidence of fall-related injuries and the proportion of incomplete cervical lesions increased during the observation period, especially among men >60 years. CONCLUSIONS: The incidence of TSCI has increased during the past 50 years. Falls and MVA are potentially preventable causes. The increasing proportion of older patients with cervical lesions poses a challenge to the health system.

Post-polio syndrome patients treated with intravenous immunoglobulin: a double-blinded randomized controlled pilot study.

Post-polio syndrome (PPS) is characterized by new muscle weakness, atrophy, fatigue and pain developing several years after the acute polio. Some studies suggest an ongoing inflammation in the spinal cord in these patients. From this perspective, intravenous immunoglobulin (IvIg) could be a therapeutic option. We performed a double-blinded randomized controlled pilot study with 20 patients to investigate the possible clinical effects of IvIg in PPS. Twenty patients were randomized to either IvIg 2 g/kg body weight or placebo. Primary endpoints were changes in pain, fatigue and muscle strength 3 months after treatment. Surrogate endpoints were changes in cerebrospinal fluid (CSF) cytokine levels. Secondary endpoints were pain, fatigue and isometric muscle strength after 6 months. Patients receiving IvIg reported a significant improvement in pain during the first 3 months, but no change was noted for subjective fatigue and muscle strength. CSF levels of tumour necrosis factor-alpha (TNF-alpha) were increased compared with patients with non-inflammatory neurological disorders. In conclusion, in this small pilot study no effect was seen with IvIg treatment on muscle strength and fatigue, however IvIg treated PPS patients reported significantly less pain 3 months after treatment. TNF-alpha was increased in the CSF from PPS patients. The results are promising, but not conclusive because of the low number of patients studied.

GM1 antibodies in post-polio syndrome and previous paralytic polio.

We studied the relationship between post-polio syndrome (PPS) and GM1 antibodies, since such antibodies have been associated with PPS and motor neuron disorders. Sera from 144 patients with previous poliomyelitis (105 paralytic, 22 nonparalytic and 17 PPS), 60 with previous Guillain-Barré syndrome, 44 with amyotrophic lateral sclerosis (ALS) and 22 healthy blood donors were analyzed with ELISA for GM1 IgM, IgG and IgA antibodies. GM1 antibodies were present in 14% of the PPS patients, but the prevalence did not differ significantly from that of the other groups. Our study does not support the hypothesis that GM1 antibodies are involved in the pathogenesis of PPS.

Polio survivors--well educated and hard working.

243 patients were diagnosed with acute poliomyelitis (polio) in Western Norway between 1950 and 1954; 186 were paralytic and 57 non-paralytic. This study examines how polio influenced their education, employment, profession, annual income, marital status and energy for leisure activities. 149 of the patients identified were alive and 98 of the matched controls responded to a questionnaire. Education length did not differ between acute paralytic polio patients, acute non-paralytic polio patients and controls. Fifty percent of the patients with residual weakness and 77 % of the patients with normal muscle power were employed, against 73 % of the controls (P=0.014). A higher proportion of patients without motor deficits had manual work than those with weakness or controls (P=0.002). There was no significant association between severity of weakness and education, employment and profession. Physical ability had been an important factor for the choice of education and profession for all the polio patients, but not for controls (P < 0.001). Annual income did not differ significantly between patients and controls. Residual weakness increased the chance of being single (P=0.023), although as many as 79% had married. 53 % of the patients with weakness claimed that fatigue prevented hobbies, compared wich 31% of the other patients and only 16% of the controls (P < 0.001). There was no significant association between severity of weakness and fatigue. In conclusion, the polio patients are generally well educated, provide their own income and marry. However, their polio has influenced choice of education and profession, and polio patients with persisting weakness differ from controls and polio patients without motor deficits regarding employment and marital status.

Long term outcome after poliomyelitis in different health and social conditions.

OBJECTIVE: To examine and compare the long term outcome after polio in an east European and a west European country with different access to rehabilitation and with different medical and social conditions. DESIGN AND SETTING: The patients who were acutely hospitalised for polio 1950-54 in the University Hospital in Bergen, Norway and 1958 in the University Hospital in Tartu, Estonia received the mailed questionnaire in the period between January 1998 and December 1998. PATIENTS: Patient files concerning 334 patients hospitalised in Tartu and 243 patients hospitalised in Bergen were obtained; of these 128 Estonian and 148 Norwegian patients were re-examined. MAIN RESULTS: Despite more pronounced disability in the acute stage, significantly more Norwegian patients were working full time and part time in 1998 (p<0.0001) and also through the period 1958-1998. In both countries, 30% of patients had manual work and 18% changed profession during their career. Low income (below 50% of national average) was reported by 73% of Estonian and 35% of Norwegian patients (p<0.0001). Except for the odds ratio for muscular pain of 1.89 (95%CI =1.14 to 3.14) for Norwegian patients, new symptoms indicating late progression did not differ. Norwegian patients were more independent with significantly less need for assistance in housekeeping (p=0.02), whereas the use of orthopaedic devices did not differ. CONCLUSIONS: The long term outcome after polio is different in eastern and western Europe. Access to continuous rehabilitation seems to maintain physical independence in polio patients, improves their ability to earn their own income, and lessens the need for disability pensions.

[Pharmacodynamic action of cavinton on regional volume blood flow, central hemodynamics and the bioelectric activity of the brain in the acute stage of a cerebral infarct]. / Farmakologicheskoe deistvie kavintona na regionarnyi ob''emnyi mozgovoi krovotok, tsentral'nuiu gemodinamiku i bioélektricheskuiu aktivnost' golovnogo mozga v ostroi stadii tserebral'nogo infarkta.

Forty-two patients with acute cerebral infarction were studied for the regional volumetric cerebral blood flow (rVCBF) and central hemodynamics (by integral rheography of the body) before and after the intravenous administration of 10 or 20 mg of cavinton (vinpocetine). It was found that in the absence of changes in the central hemodynamics an increase in the cerebral blood flow was the predominant characteristic, but parodoxical reactions were occasionally observed in the acute period of an extensive hemispherical infarct. The findings of quantitative frequency analysis of the EEG conducted in 40 patients correlated with the results of the study of the blood flow and indicated a more favourable prognosis in brain stem infarction or mild cortical infarction. Treatment of extensive cortical infarction was associated with cases of parodoxical deterioration of brain function which should be taken into account in prescribing cavinton to patients during the acute stage of cerebral infarction.

[Effect of calcium antagonists of the verapamil type on regional cerebral blood flow and bioelectric activity of the brain in patients with cerebral infarction]. / Deistvie antagonistov kal'tsiia tipa verapamila na regionarnyi ob"emnyi mozgovoi krovotok i bioélektricheskuiu aktivnost' golovnogo mozga u bol'nykh tserebral'nym infarktom.

The authors have studied the regional volume cerebral blood flow (RVCBF) in 25 patients with acute cerebral infarction before and after the intravenous administration of 5-7.5 mg of isoptin and carried out quantitative frequency analysis of the EEG in 20 patients prior to and following the administration of 5 mg of finoptin. It has been revealed that isoptin augments the RVCBF in the infarcted zone, particularly when patients with extensive infarction, edema and atrophy of the cerebral tissue (according to findings of computer-aided tomography) have low baseline levels of the RVCF and somewhat decreases the blood flow in intact zones. The administration of finoptin tended to normalize the EEG, particularly in the infarcted area in patients with a severe clinical picture of infarction. Calcium antagonists of the verapamil type exert a favourable effect on perfusion and bioelectrical activity of the brain; as a result their use is indicated in the patients with acute cerebral infarction.

Cardiovascular and urological dysfunction in spinal cord injury.

OBJECTIVE: A spinal cord injury (SCI) above the sixth thoracic vertebra interrupts the supraspinal control of the sympathetic nervous system causing an imbalance between the sympathetic and the parasympathetic nervous system. This article focuses on the symptoms, treatment and examination of autonomic disturbances of the cardiovascular and the urinary system after a SCI. METHODS: A non-systematic literature search in the PubMed database. RESULTS: Frequent complications in the acute phase of cervical and high thoracic SCI are bradyarrhythmias, hypotension, hypothermia/hyperthermia, increased neurogenic shock, vagovagal reflex, supraventricular/ventricular ectopic beats, vasodilatation and congestion. Serious complications in the chronic phase of SCI are orthostatic hypotension, impaired cardiovascular reflexes, autonomic dysreflexia (AD), reduced sensation of cardiac pain, loss of reflex cardiac acceleration, quadriplegic cardiac atrophy due to loss of left ventricular mass and pseudo-myocardial infarction. AD is associated with a sudden, uncontrolled sympathetic response, triggered by stimuli below the injury. It may cause mild symptoms like skin rash or slight headache, but also severe hypertension, cerebral haemorrhage and death. Early recognition and prompt treatment are important. Urinary autonomic dysfunctions include hyperreflexia or areflexia of detrusor and/or sphincter of the bladder. CONCLUSIONS: Patients with SCI have a high risk of cardiovascular complications, AD and urinary autonomic dysfunction both in the acute phase and later, affecting their prognosis and quality of life. Knowledge of cardiovascular and urological complications after SCI is important for proper diagnosis and treatment.

Clinical assessment and management of spasticity: a review.

Spasticity is a sign of upper motor neurone lesion, which can be located in the cerebrum or the spinal cord, and be caused by stroke, multiple sclerosis, spinal cord injury, brain injury, cerebral paresis, or other neurological conditions. Management is dependent on clinical assessment. Positive and negative effects of spasticity should be considered. Ashworth score and the modified Ashworth score are the most used scales for assessment of spasticity. These and other spasticity scales are based on assessment of resistance during passive movement. The main goal of management is functional improvement. A novel 100-point score to assess disability, function related to spasticity (Rekand disability and spasticity score) is proposed. Management of spasticity should be multimodal and should always include physiotherapy or exercise. Oral medications such as baclofen and tizanidine have limited efficacy and considerable side effects, but are easiest to use. Botulinum toxin combined with physiotherapy and/or orthopaedic surgery is effective treatment of localized spasticity. Treatment with intrathecal baclofen via programmable implanted pump is effective in generalized spasticity, particularly in the lower extremities. Neurosurgical and orthopaedic procedures may be considered in intractable cases.

Traumatic spinal cord injury and concomitant brain injury: a cohort study.

OBJECTIVE: To assess the temporal trends in the incidence and demographic characteristics of traumatic spinal cord injury (TSCI) with clinical concomitant traumatic brain injury (TBI), in an unselected, geographically defined cohort, 1952-2001. MATERIAL AND METHODS: The patients were identified from hospital records. TBI was classified as none, mild, moderate, and severe. RESULTS: Of 336 patients, 157 (46.7%) patients had a clinical concomitant TBI. Clinical TBI was classified as mild in 30.1%, moderate in 11.0% and severe in 5.7%. The average annual incidence increased from 3.3 per million in the first decade to 10.7 per million in the last. Alcohol was the strongest risk factor of clinical TBI (OR = 3.69) followed by completeness of TSCI (OR = 2.18). CONCLUSIONS: The incidence of TSCI with concomitant TBI has increased during the last 50 years. Alcohol and completeness of injury are strong risk factors. Increased awareness of dual diagnoses is necessary.