| Spinal Cord 2004 Abstracts （www.nature.com/sc ） （Jan-June 2004） |
■ April 2004, Volume 42, Number 4
1Emeritus Consultant in Spinal Injury, James Cook University Hospital, Middlesborough, UK
Measurement in spinal cord injury P Edmond1
1The Spinal Care Unit, Meir General Hospital, Kfar Saba, Israel 2Lewinstein Hospital, Raanana, Israel 3Hillel Yafe Hospital, Hedera, Israel 4Department of Spine Neurosurgery, Moscow, Russia
Reinnervation of the neurogenic bladder in the late period of the spinal cord trauma A Livshits1, A Catz2, Y Folman3, M Witz1, V Livshits1, A Baskov4 and R Gepstein1
Study design: Intercostal nerve to spinal nerve root anastomosis in chronic spine-injured patients.
Objectives: To analyze the effectiveness of neurogenic bladder reinnervation in spinal cord-injured patients through artificial creation of sprouting (intercostal nerve to spinal nerve root anastomosis).
Setting: Center of Neurosurgery, Moscow, Russia. Operations were performed by Professor A Livshits. (At present, Professor A Livshits is working at the Spinal Care Unit, Meir General Hospital, Kfar Saba, Israel.)
Methods: A total of 11 patients with spinal cord injury of the L1 level were operated on in the late (chronic) stage. The neurological status and urodynamics were investigated before and 12 months after operation. A laminectomy from T11 to L3 was performed. Next, a neurolysis of the 11th and 12th intercostal nerves was carried out, at a distance of 20-21 cm, and transferred to the vertebral canal. The S2-S3 roots were then cut in their proximal portion and anastomosed end-to-end to the intercostal nerves. The results of urodynamic studies were calculated by the Wilcoxon signed rank test for comparison before and 12 months after operation.
Results of urodynamic studies: Bladder capacity (ml) before operation - 489±79, after operation - 350±39, urine volume (ml) before - 18.2±17, after - 306.4±39.8, residual urine (ml) before - 459±99.4, after - 50±11.8. Detrusor tone (rel. units) before - 0.6±1.5, after 1.2±0.2; voiding pressure (cmH2O) before - 4.4±5.2, after - 30.5±4.9. Force of detrusor contraction before - 5±5.8, after - 32.8±5.5. Sphincter resistance (cmH2O) before - 6.5±3.8, after - 21.1±4.2. Significant improvements in bladder function were observed during the 10th to 12th postoperative months. Restoration of reflex voiding occurred in all patients; in eight of the 11 paresthesic in the groin and scrotum and reappearance of the bulbocavernous, anal and cremasteric reflexes were noted.
Conclusion: These results suggest that a restitutive process occurs in the bladder under novel conditions of its nerve supply provided by the intercostal nerve and by new connections established between it and the bladder nerves. Spinal cord lesions that might benefit from nerve crossover surgery would be located at the conus, so functional intercostal nerves could be connected to sacral roots to bypass the injury in an attempt to restore central connections to the bladder.
1Department of Psychobiology, UNIFESP, Sao Paulo, Brazil
Comparison between dopaminergic agents and physical exercise as treatment for periodic limb movements in patients with spinal cord injury M T de Mello1, A M Esteves1 and S Tufik1
Study design: Randomized controlled trial of physical exercise and dopaminergic agonist in persons with spinal cord injury and periodic leg movement (PLM).
Objective: The objective of the present study was to compare the effectiveness of physical exercise and of a dopaminergic agonist in reducing the frequency of PLM.
Setting: Centro de Estudos em Psicobiologia e Exercicio. Universidade Federal de Sao Paulo, Brazil.
Methods: A total of 13 volunteers (mean age: 31.6±8.3 years) received L-DOPA (200 mg) and benserazide (50 mg) 1 h before sleeping time for 30 days and were then submitted to a physical exercise program on a manual bicycle ergometer for 45 days (3 times a week).
Results: Both L-DOPA administration (35.11±19.87 PLM/h, P<0.03) and physical exercise (35.11±18.53 PLM/h, P<0.012) significantly reduced PLM; however, no significant difference was observed between the two types of treatment.
Conclusions: The two types of treatment were found to be effective in the reduction of PLM; however, physical exercise is indicated as the first treatment approach, while dopaminergic agonists or other drugs should only be recommended for patients who do not respond to this type of treatment.
1Laboratoire 'Sport Performance Santise', Faculte des Sciences du Sport et de l'Education Physique, Universite Montpellier, Montpellier, France 2Clinique La Pinede, Route de Peyrestorpes, St Esteve, France 3Federation Francaise Handisport, Paris, France
Isokinetic shoulder rotator muscles in wheelchair athletes P L Bernard1, P Codine2 and J Minier3
Objectives: To assess the influence of wheelchair propulsion and neurological level on isokinetic shoulder rotational strength.
Setting: University of Montpellier, France
Methods: Data were evaluated in three groups of subjects as follows: 12 nonathletes, 15 tennis players and 21 wheelchair athletes. We then compared 12 high paraplegic athletes (HPA) and nine low paraplegic athletes (LPA) within the group of 21 wheelchair athletes: The isokinetic tests were performed in the seated 45° abducted test position in the scapular plane at 60, 180 and 300° s-1 for both shoulders. Peak torque and mean power values were gathered and, from these values, the internal?external rotation ratios were calculated.
Results: Intergroup comparison showed an influence of lesion and sport on peak torque at 180 and 300° s-1 for the internal rotators and significantly higher values of the internal?external ratios in the wheelchair athlete group. For mean power, we observed significant differences under all test conditions and significant differences for ratio only on the dominant side at 180° s-1 and on the dominant side at 300° s-1. Comparison of the two groups of paraplegic athletes showed significantly higher values of peak torque and mean power of the external rotators in the LPA for all test conditions.
Conclusions: Neurological level of lesion does not systematically influence the development of internal rotator muscles; in contrast, the participation of the external rotators appears strongly correlated to neurological level. The comparison of the two sides in the two paraplegic groups showed that in two-thirds of the cases the values of the external rotators were significantly higher than those of the internal rotators on the nondominant side for peak torque and mean power. Ratios on the dominant side were systematically higher than on the nondominant side, with significant differences also noted in two-thirds of the cases. These results raise questions about the influence of neurological level and wheelchair propulsion on the muscular adaptations of the shoulder in wheelchair athletes.
Bacteriological investigation of infected pressure ulcers in spinal cord-injured patients and impact on antibiotic therapy B Heym, F Rimareix, A Lortat-Jacob and M-H Nicolas-Chanoine
Study design: Retrospective.
Objectives: To improve the use of bacteriological results for treating spinal cord-injured patients with infected pressure ulcers.
Setting: Microbiology and Orthopaedics Department, Ambroise Pare University Hospital, Boulogne-Billancourt, France.
Methods: Tissue specimens, sampled at the end of the surgical intervention from unbridled and cleaned ulcers were analysed. Drainage liquids were cultured at day 1 (D1) and day 5 (D5) postsurgery. For part of the patients, a presurgery superficial sample was analysed and compared with the surgical and postsurgical samples.
Results: In all, 168 surgical samples from 101 patients, 183 D1 and 104 D5 wound drainage liquids were included in this study. Out of the 168 surgical samples 17 (10%) had a negative culture, whereas 151 (90%) had a positive culture. For drainage liquids, the culture was negative in 48% and 56% of the samples at D1 and D5, respectively. The most frequently isolated species were enterobacteria, followed by staphylococci and streptococci.
Conclusion: Culturing deep tissue specimens sampled from the surgically cleaned and unbridled ulcers allows for the isolation of the bacterial species that are really involved in the ulcer infection. As the identification of these bacteria and their antibiotic susceptibility are available, when the culture results of the D1 postsurgical drainage liquid is also available, it is easier to choose targeted antibiotic treatment.
1Rehabilitation Center Amsterdam, Overtoom 283, 1054 HW, Amsterdam, The Netherlands 2Department of Rehabilitation Medicine, VU Medical Center, De Boeleiaan 1117, 1081 HV, Amsterdam, The Netherlands
Epidural metastatic spinal cord compression: functional outcome and survival after inpatient rehabilitation I E Eriks1, E L D Angenot1 and G J Lankhorst2
Study design: Retrospective descriptive study.
Objectives: (1) To obtain an overall appraisal of patients with epidural metastatic spinal cord compression (SCC) admitted to nine Dutch spinal cord units (SCUs) between 01-01-1990 and 01-01-2000. (2) To identify factors that predict survival >1 year after in-patient rehabilitation of patients with epidural metastatic SCC.
Setting: Dutch SCUs. Rehabilitation Center Amsterdam, Amsterdam. Rehabilitation Center Heliomare, Wijk aan Zee. Rehabilitation Center De Hoogstraat, Utrecht. Rehabilitation Center Rijndam, Rotterdam. Rehabilitation Center Sophia Stichting, Den Haag. Rehabilitation Center Beatrixoord, Haren. Rehabilitation Center Het Roessingh, Enschede. Rehabilitation Center Sint Maartenskliniek, Nijmegen. Rehabilitation Center SRL Hoensbroeck, Hoensbroek.
Methods: (1) Clinical records were reviewed and demographic, clinical and functional data were collected according to a protocol. The date of admittance to the SCU, rehabilitation goals, date of discharge and date of death were recorded. (2) The odds ratio (OR) was calculated for all determinants on admittance to the SCU in order to find indicators that predict survival >1 year after discharge from the SCU. An OR 2 was considered to be clinically significant.
Results: In total, 131 patients with epidural metastatic SCC were admitted. In all, 117 clinical records were retrieved and 97 clinical records provided complete data. The average age on admittance was 58 years. Among the patients 53% were male. The average Barthel score on admittance was 7.2/20 points. The average length of stay in the SCU was 104 days (3-336). Overall, 66% of the patients were discharged. The average Barthel score on discharge was 12.0 points. The average survival after discharge was 808 (0-3669) days. During their stay on the SCU, seven patients died. At 1 year after discharge, 52% of the patients were still alive. These patients suffered less complications, had been admitted less often to a hospital during rehabilitation, had made better functional progress and had been discharged home more often. A survival >1 year after discharge is related to ASIA D (OR 4.3), MRC 4 and 5 (OR 5.4), tumour in remission (OR 3.8) and independence or partial independence on the Barthel items: dressing (OR 4.3) and making transfers (OR 5.0).
Conclusions: Patients with epidural metastatic SCC may benefit from in-patient rehabilitation.
1Liberty Mutual Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA 2Boston Medical Center, Department of Rehabilitation Medicine, Boston, MA, USA 3School of Biomedical Sciences, University of Buffalo, Erie County Medical Center, Buffalo, NY, USA 4Address when study was initiated: Boston Medical Center, Department of Rehabilitation Medicine, Preston Family Bldg., 732 Harrison Ave., Boston, MA 02118-2392, USA 5Current address: School of Biomedical Sciences, University of Buffalo, G219, Erie County, Medical Center, 462 Grider St., Buffalo, NY 14214, USA
Work-related tetraplegia: cause of injury and annual medical costs B Webster1, G Giunti2, A Young1, G Pransky1 and S Nesathurai2,3,4,5
Study design: Descriptive study.
Objective: To describe the demographics, cause of injury, and annual-paid medical costs for the 5 years following injury for cases of work-related tetraplegia.
Setting: A single United States workers' compensation (WC) claims database.
Methods: Tetraplegia cases with initial date of injury from 1 January 1989 to 31 December 1999 were selected by cross-referencing word search terms pertaining to body part injured and nature of injury. The main outcome measures were injury causes and annual-paid medical payments (adjusted to year 2000 medical consumer price index) of work-related tetraplegia by injury group for each year postinjury over a 5-year time period.
Results: A total of 62 claimants with work-related tetraplegia injured between 1 January 1989 and 31 December 1999. The vast majority of those identified were male claimants (92%) and more than a quarter worked in the construction industry (26%). Other highly represented industries included transportation and retail (15% each), manufacturing (13%), and agriculture and utility (11% each). The majority of injuries were the result of falls (36%) and vehicular accidents (34%). The mean Year 1 cost was $560 524 for those with a high-level tetraplegia (C2-4 ASIA A-C), $431 033 for a low-level injury (C5-8 ASIA A-C), and $178 041 for those with an ASIA D tetraplegia injury. The mean cost of subsequent years (Years 2-5) was $130 992 for a high-level, $129 250 for a low-level, and $34 352 for an ASIA D tetraplegia injury.
Conclusions: Mean costs for Year 1 postinjury in WC cases are similar to previously published estimates. Comparing the current results with those of previous spinal cord injury cost studies suggests that those with work-related tetraplegia may receive more injury-related paid medical benefits after the first year postinjury than cases who do not receive WC-supported benefits.
Sponsorship: Supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research (NIDDR) (Grant # H133N00024).
1Liberty Mutual Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA USA 2Boston Medical Center, Department of Rehabilitation Medicine, Boston, MA, USA 3Current address: Medical Rehabilitation Associates, 7 Bates Street, Lewiston, ME 04240, USA 4Current address: School of Biomedical Sciences, University of Buffalo, G219, Erie County Medical Center, 462 Grider St., Buffalo, NY 14214 USA
Services provided following compensable work-related tetraplegia A E Young1, B Webster1, G Giunti2,3, G Pransky1 and S Nesathurai2,4
Design: Descriptive study.
Objective: To describe and compare the medical services provided following work-related tetraplegic spinal cord injury (SCI).
Setting: Workers' compensation claims database.
Methods: The administrative database of a workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In total, 62 cases were identified and grouped by impairment category. Medical payment data were extracted and assigned to service categories.
Results: Although the level of services was directly related to the severity of impairment, patterns were similar across categories; for example, the largest proportions of payments were associated with durable medical equipment (DME) and attendant care in each impairment category. DME, readmissions and attendant care services varied considerably from year to year and within impairment category. Payments for physician care and medications?supplies showed the least variation within impairment categories. Workers' compensation payments were similar to National Spinal Cord Injury Database (NSCID) payments for the first year following injury; however, in subsequent years, workers' compensation figures were much higher.
Conclusions: Differences in annual medical payment and services by impairment category appear to be primarily due to variations in DME, attendant care and readmission. Payment differences in relation to National SCI figures may be related to better capture of payments by the workers' compensation administrative database. In addition, results suggest broader coverage by workers' compensation for medical services and items related to independent living.
1Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA 2Peninsula Neurosurgical Associates, Salisbury, MD 21801, USA
Venous hypertensive myelopathy as a potential mimic of transverse myelitis C Krishnan1, J M Malik2 and D A Kerr1
Study design: Case report.
Objective: We describe a patient who developed a myelopathy associated with a noncompressive herniated cervical intervertebral disc at the same level. We provide clinical and radiological evidence that reveals that even though the disc herniation did not compress the spinal cord, it diminished venous blood flow out of the spinal cord, possibly resulting in a venous hypertensive myelopathy (VHM).
Setting: Baltimore, MD, USA.
Clinical presentation: A 29-year-old woman developed a cervical radiculopathy, followed by a slowly progressive cervical myelopathy associated with a herniated C5?C6 disc. Magnetic resonance imaging showed a noncompressive disc herniation, a swollen spinal cord with increased T2 signal most prominent at the site of the herniated disc, extending several levels above and below the disc. The patient was diagnosed with acute transverse myelitis (ATM) and was started on IV steroids. However, unlike most cases of transverse myelitis, spinal fluid analysis was noninflammatory. In contrast, several features suggested that the patient instead had VHM. We suggest that the disc herniation resulted in impaired drainage of blood from the spinal cord through compression of the venous plexus near the intervertebral foramen.
Intervention: Although the patient did not recover function following high-dose steroid administration, she recovered completely following C5-C6 discectomy and fusion.
Conclusion: To our knowledge, this is the first report of likely VHM in the absence of a spinal arteriovenous malformation. We suggest that some patients diagnosed with ATM in the setting of extrinsic spinal column abnormalities may actually have a noninflammatory myelopathy associated with impaired spinal venous drainage.