■ January 2004, Volume 42, Number 1
| Providing the clinical basis for new interventional therapies: refined diagnosis and assessment of recovery after spinal cord injury |
| A Curt1, M E Schwab2 and V Dietz1 |
Today, there is accumulating evidence from animal experiments that axonal regeneration and an enhanced level of functional repair can be induced after a spinal cord injury (SCI). Consequently, in the near future, new therapeutic approaches will be developed for the treatment of patients with SCI. The aim of the project presented here is to provide the required clinical basis for the implementation of novel interventional therapies. Refined and combined clinical and neurophysiological measures are needed for a precise qualitative and quantitative assessment of spinal cord function in patients with SCI at an early stage. This represents a basic requirement to recognise any improvement in the recovery of function and to monitor any significant effect of a new treatment. To this aim, five European Spinal Cord Injury Centres involved in the rehabilitation of acute SCI patients have built up a close clinical collaboration to develop a standardised protocol for the assessment of the outcome after SCI and the extent of recovery achieved by actually applied therapies in a larger population of SCI patients. The project's aim is to establish objective, refined tools as a basis for monitoring the effects of new treatment strategies.
| Calculus anuria in a spina bifida patient, who had solitary functioning kidney and recurrent renal calculi |
| S Vaidyanathan1, B M Soni1, J-J Wyndaele2, A Z Buczynski3, E Iwatsubo4, M Stoehrer5, H Madersbacher6, R Peschel6, G Singh1, J W H Watt1, P L Hughes7 and P Sett1 |
Study design: Clinical case report with comments by colleagues from Austria, Belgium, Germany, Japan, and Poland.
Objectives: To discuss challenges in the management of spinal bifida patients, who have marked kyphoscoliosis and no vascular access.
Setting: Regional Spinal Injuries Centre, Southport, UK.
Methods: A female patient, who was born with spina bifida, paraplegia and solitary right kidney, had undergone ileal loop urinary diversion. Renal calculi were noted in 1986. Percutaneous nephrostolithotomy was performed in 1989 and there was no residual stone fragment. However, she developed recurrence of calculi in the lower pole of the right kidney in 1991. Intravenous urography, performed in 1995, revealed right staghorn calculus and hydronephrosis. Chest X-ray showed markedly restricted lung volume due to severe kyphoscoliosis. In 2000, she was declared unsuitable for anaesthesia due to a lack of venous access and a high likelihood of difficulty in weaning off the ventilator in the postoperative period. In June 2002, she developed anuria (urine output=18 ml/24 h) due to ball-valve-type obstruction by a renal stone at the ureteropelvic junction. Urea: 14.4 mmol/l; creatinine: 236 l
l. Ultrasound showed right hydronephrosis. Percutaneous nephrostomy was
performed.Results:Following relief of urinary tract obstruction, there was postobstructive diuresis (3765 ml/24 h). However, the patient expired 19 days later due to progressive respiratory failure.
Conclusion: In this spina bifida patient, who had reached the age of 35 years, severe kyphoscoliosis and lack of vascular access presented insurmountable challenges to implement the desired surgical procedure for removal of stones from a solitary kidney.
| Muscle activation during unilateral stepping occurs in the nonstepping limb of humans with clinically complete spinal cord injury |
| D P Ferris1,3, K E Gordon1,3, J A Beres-Jones1 and S J Harkema1,2 |
Study design:Comparison of different kinematic and loading conditions on muscle activation in clinically complete spinal cord-injured subjects stepping unilaterally with manual assistance.
Objective:To determine if rhythmic lower limb loading or movement could produce rhythmic muscle activation in the nonstepping limb of subjects with clinically complete spinal cord injury (SCI).
Setting:Human Locomotion Research Center, Department of Neurology, University of California, Los Angeles, USA.
Methods:We recorded electromyography, joint kinematics, and vertical ground reaction forces as four subjects with clinically complete SCI stepped with manual assistance and partial bodyweight support. For all trials, one limb continuously stepped while the other limb underwent different conditions, including rhythmic lower limb loading in an extended position without limb movement, rhythmic lower limb movement similar to stepping without limb loading, and no lower limb loading or movement with the leg in an extended or flexed position.
Results:Three subjects displayed rhythmic muscle activity in the nonstepping limb for trials with rhythmic limb loading, but no limb movement. One subject displayed rhythmic muscle activity in the nonstepping limb for trials without ipsilateral limb loading or movement. The rhythmic muscle activity in the nonstepping limb was similar to the rhythmic muscle activity during bilateral stepping.
Conclusions:The human spinal cord can use sensory information about ipsilateral limb loading to increase muscle activation even when there is no limb movement. The results also indicate that movement and loading in one limb can produce rhythmic muscle activity in the other limb even when it is stationary and unloaded. These findings emphasize the importance of optimizing load-related and contralateral sensory input during gait rehabilitation after SCI.
| Fat oxidation at different intensities in wheelchair racing |
| B Knechtle1, G Muller1, F Willmann1, P Eser2 and H Knecht2 |
Study design: Determination of fat oxidation at three different intensities in trained wheelchair athletes on the treadmill.
Objective: The aim of the study was to assess the level and highest rate of fat oxidation in endurance-trained wheelchair athletes for recommendation on endurance training.
Setting: Institute of Sports Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland.
Methods: Nine (seven men and two women) endurance-trained wheelchair athletes (VO2peak 40.2±6.7 ml/kg/min) were studied over 20 min at 55, 65 and 75% VO2peak on a treadmill in their own racing wheelchairs in order to find the exercise intensity with the highest absolute fat oxidation.
Results: As presumed, total energy expenditure for wheelchair racing was highest at 75% VO2peak, while absolute fat oxidation was statistically not significantly different at the three tested intensities. Percentage of energy expenditure from fat oxidation decreased with increasing intensity from 31.4% at 55% VO2peak to 20.9% at 75% VO2peak, while percentage from carbohydrate oxidation increased from 68.6% at 55% VO2peak to 79.1% at 75% VO2peak.
Conclusion: For wheelchair athletes, we recommend training of fat metabolism for endurance exercise at an intensity of 55% VO2peak, because absolute fat metabolism is not higher at higher intensities but less carbohydrates are used at lower intensity levels. At lower intensities, exercise can be performed over a longer time before the emptied glycogen stores will limit exercise duration. This may apply especially to paraplegic subjects whose active muscle mass is limited in contrast to able-bodied athletes.
| Post-traumatic moderate systemic hypothermia reduces TUNEL positive cells following spinal cord injury in rat |
| S Shibuya1, O Miyamoto2, N A Janjua2, T Itano2, S Mori1 and H Norimatsu1 |
Study design:A standardized animal model of contusive spinal cord injury (SCI) with incomplete paraplegia was used to test the hypothesis that moderate systemic hypothermia reduces neural cell death. Terminal deoxynucleotidyl transferase [TdT]-mediated deoxyuridine triphosphate [dUTP] nick-end labeling (TUNEL) staining was used as a marker of apoptosis or cell damage.
Objective:To determine whether or not moderate hypothermia could have a neuroprotective effect in neural cell death following spinal cord injury in rats.
Setting:Kagawa Medical University, Japan.
Methods:Male Sprague-Dawley (SD) rats (n=39) weighing on average 300 g (280-320 g) were used to prepare SCI models. After receiving contusive injury at T11/12, rats were killed at 24 h, 72 h, or 7 days after injury. The spinal cord was removed en bloc and of examined at five segments: 5 and 10 mm rostral to the center of injury, center of injury, and 5 and 10 mm caudal to the center of injury. Rats that received hypothermia (32°C/4 h) were killed at the same time points as those that received normothermia (37°C/3 h). The specimens were stained with hematoxylin and eosin, and subjected to in situ nick-end labeling (TUNEL), a specific method for visualizing cell death in the spinal cord.
Results:At 24 h postinjury, TUNEL positive cells (TPC) decreased significantly 10 mm rostral to center of injury in hypothermic animals compared to the normothermia group. At 72 h post-SCI, TPC also decreased significantly at 5 mm rostral, and 5 and 10 mm caudal to the lesion center compared to normothermic animals. At 7 days postinjury, a significant decrease of TPC was observed at the 5 mm rostral and 5 mm caudal sites compared to normothermic animals.
Conclusion:These results indicate that systemic hypothermia has a neuroprotective effect following SCI by attenuating post-traumatic TPC.
| Gross quantitative measurements of spinal cord segments in human |
| H-Y Ko1, J H Park1, Y B Shin1 and S Y Baek2 |
Study design: Anatomical measurement.
Objective: To obtain quantitative anatomical data on each spinal cord segment in human, and determine the presence of correlations between the measures.
Setting: Department of Rehabilitation Medicine, Pusan National University Hospital, Pusan, Korea.
Methods: A total of 15 embalmed Korean adult human cadavers (13 males, two females; mean age 57.3 years) were used. The length of each cord segment was defined as the root attachment length plus the upper inter-root length. After performing a total vertebrectomy, a transverse cut was made at the approximate proximal and distal point of each segment from segment C3 to S5. Sagittal and transverse diameters at the proximal end of each segment, and cross-sectional area, height, and volume of the segment were measured.
Results: The transverse diameter was largest at segment C5, and decreased progressively to segment T8. However, the sagittal diameter of each segment did not change distinctly with the segment. The cervical and lumbar enlargements were determined by the transverse diameters of the segments. Segment C5 had the largest cross-sectional area, at 75.0 mm2. Segment T6 was the longest, averaging 22.4 mm in length. The longest segment in the cervical spinal cord was segment C5, at 15.5 mm, and segment L1 in the lumbar spinal cord. The volume was largest at segment C5, with a value of 1173.9 mm3.
Conclusions: We found characteristic quantitative differences in the values of the parameters measured in the thoracic spinal cord compared to those measured in the cervical and lumbar or lumbosacral spinal cords. These measurements of spinal cord segments appear to provide valuable and practical standard quantitative features and may provide basic data for understanding the morphometric characteristics relevant to pathophysiologic conditions of the spinal cord.
| Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users |
| K A M Samuelsson1, H Tropp2 and B Gerdle1 |
Study design: Cross-sectional.
Objectives: To describe the consequences of shoulder pain on activity and participation in spinal cord-injured paraplegic wheelchair users. To describe the prevalence and type of shoulder pain.
Setting: Two spinal cord injury (SCI) centres in Sweden.
Methods: All subjects with paraplegia due to an SCI of more than 1 year living in the counties of Uppsala and Linkoping, Sweden were contacted by mail and asked to fill in a questionnaire (89 subjects). Those of the responding 56 subjects with current shoulder pain were asked to participate in further examination and interviews. A physiotherapist examined 13 subjects with shoulder pain in order to describe type and site of impairment. To describe consequences of shoulder pain on activity and participation, the Constant Murley Scale (CMS), the Wheelchair Users Shoulder Pain Index (WUSPI) the Klein & Bell adl-index and the Canadian Occupational Performance Measure (COPM) were used.
Results: Out of all respondents, 21 had shoulder pain (37.5%). Data from 13 of those subjects were used in the description of type and consequences of shoulder pain. Findings of muscular atrophy, pain, impingement and tendinits were described. We found no difference in ADL-performance with, respectively without, shoulder pain (P=0.08) using the Klein & Bell adl-index. No correlation was found between the various descriptions of impairment, activity limitations and participation restriction (P>0.08). All together 52 problems with occupational performance due to shoulder pain were identified using the COPM. Of these, 54% were related to self-care activities.
Conclusion: The consequences of shoulder pain in paraplegic wheelchair users are mostly related to wheelchair activities. Since the wheelchair use itself presumably cause shoulder problems, this will become a vicious circle. More research is needed in order to reduce shoulder problems in wheelchair users.
| Does the neuronal plasticity exist in elderly patients? report of an unusual clinical case |
| G Gambardella1, O Gervasio1 and C Zaccone1 |
Study design: Case report.
Objective: To report complete recovery after paraplegia in an elderly patient after removal of meningioma at C7-T1 level.
Setting: Department of Neurosurgery, Reggio Calabria, Italy.
Methods: An 82-year-old lady with 48 months of progressive weakness and numbness was admitted with complete paraplegia lasting 15 days. Investigations (magnetic resonance imaging (MRI)) demonstrated a meningioma at C7-T1. The tumour compressed the extremely thinned spinal cord. MRI after surgery showed no evidence of residual tumour and the spinal cord was of normal dimensions. The patient recovered fully and locomotion was restored.
Conclusion: Surgical decompression gave an excellent result. The result raises the possibility of neuronal plasticity.
| Efficacy of intrathecal morphine in the treatment of baclofen tolerance in a patient on intrathecal baclofen therapy (ITB) |
| J Vidal1, P Gregori1, D Guevara1, E Portell1 and M Valles1 |
Study design: Case report.
Objectives: A case report of tolerance to intrathecal baclofen therapy (ITB) treated with intrathecal morphine ('baclofen holiday').
Setting: Institut Guttmann, Neurorehabilitation Hospital of Barcelona, Spain.
Case Report: A 30-year-old female patient is described with incomplete paraplegia below T6 on the left side and below T8 on the right side, ASIA B, caused by trauma occurring 12 years previously, in whom an intrathecal system had been implanted for baclofen infusion 10 years ago. The patient showed tolerance to baclofen therapy and was treated with intrathecal morphine infusion for 2 weeks. Baclofen infusion resulted in adequate control of spasticity.
| Intradural disc mimicking: a spinal tumor lesion |
| M V Aydin1, S Ozel2, O Sen1, B Erdogan1 and T Yildirim3 |
Study design: A case report of intradural disc hernia mimicking an intradural extramedullary spinal tumor lesion in radiological evaluation.
Objective: To describe a lumbar intradural disc herniation with atypical radiological appearance and point out the role of contrast magnetic resonance imaging (MRI) of the lumbar spine.
Setting: Turkey.
Case report: A 58-year-old man with suspected lumbar intradural mass and neurological involvement received L5 total laminectomy. L5 total laminectomy was performed, and on inspection dura was swollen and immobile. A longitudinal incision was made in the dura and an intradural-free disc fragment was removed. The patient's postoperative period was uneventful and he had full recovery in 3 months.
Conclusions: Lumbar intradural disc rupture must be considered in the differential diagnosis of mass lesions causing nerve root or cauda equina syndromes. Contrast-enhanced MRI scans are useful to differentiate a herniated disc from a disc space infection or tumor. This case demonstrates the role and the importance of contrast MRI in the diagnosis of intradural disc herniation.
| Professor Heinrich Sebastian Frenkel: a forgotten founder of Rehabilitation Medicine |
| M Zwecker1, G Zeilig1 and A Ohry2 |
Professor Heinrich Sebastian Frenkel:
A forgotten founder of Rehabilitation Medicine. Frenkel was born and later on practiced medicine in Heiden, Swizerland. This small town became, by his vigilant and innovative work, a place of pilgrimage for neurologists. He was the first to introduce the concept of exercise to restore dexterity and to improve ambulation and so pioneered the specialty of physical medicine and rehabilitation. Frenkel's method and philosophy became the foundation of treatment for many chronic neurological disabling diseases. His personality and work influenced many famous neurologists, worldwide.
| Milk of calcium in urethral diverticulum in a male patient with paraplegia and suprapubic urinary drainage |
| S Vaidyanathan1, P L Hughes2, B M Soni1, G Singh1, P Mansour3 and P Sett1 |