| Spinal Cord 2004 Abstracts （www.nature.com/sc ） （Jan-June 2004） |
■ May 2004, Volume 42, Number 5
1Neuro-Urology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
Intravesical therapy options for neurogenic detrusor overactivity A Reitz & B Schurch
Study design: Review article.
Setting: Neuro-Urology, Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.
Objectives: This review considers intravesical treatment options of neurogenic detrusor overactivity and discusses the underlying mechanism of action, clinical safety and efficacy, and the future trends.
Methods: The available literature was reviewed using medline services.
Results: Oral anticholinergic drugs are widely used to treat detrusor overactivity, but they are ineffective in some patients or cause systemic side effects such as blurred vision or dry mouth. As an alternative, topical therapy strategies have been suggested to achieve a profound inhibition of the overactive detrusor and to avoid high systemic drug levels. Currently available intravesical treatment options either act on the afferent arc of the reflex such as local anaesthetics or vanilloids or on the efferent cholinergic transmission to the detrusor muscle such as intravesical oxybutynin or botulinum toxin. Although an established and effective therapy, intravesical oxybutynin is not widely used. Evidence for clinical significance of intravesical atropine and local anaesthetic is missing. Intravesical capsaicin has been shown to improve clinical and urodynamic parameters, but cause pain in some patients. The intravesical instillation of resiniferatoxin and the injection of botulinum-A toxin into the detrusor muscle are promising new options; however, randomised placebo-controlled studies to prove their safety and efficacy are still missing.
Conclusion: Intravesical treatment strategies in patients with neurogenic detrusor overactivity may provide alternatives to established therapies such as oral anticholinergics. The selectivity of the intravesical treatment and the reduction or even the absence of side effects are major advantages of this topical approach.
1International Spinal Research Trust, Bramley Business Centre, Bramley, Guildford, Surrey, UK
International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP): another step forward for spinal cord injury research M Adams1 and J F R Cavanagh1
For over 20 years, charitable organizations have worked to promote research that will cure the paralysis associated with spinal cord injury (SCI). When they began this quest, the consequences of SCI were thought to be permanent; that once damaged, the spinal cord could not be repaired. Today, the same organizations are credited with funding research that has realized many significant advances, brought new optimism and changed the outlook of researchers, clinicians and injured individuals alike. Progress in understanding the basic biology of spinal cord repair means that it is now a case of how soon useful treatments will be available, rather than if there will ever be anything to offer. With this in mind, many of the organizations that promote spinal cord research have formed an alliance to determine the ways in which their collaboration can hasten progress. The mission and objectives of this alliance, termed the International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP), are described here.
1Department of Physical Medicine and Rehabilitation 2Faculty of Physical Therapy, National Yang Ming University, Taiwan 3Department of Physical Medicine and Rehabilitation, Chang-Hua Christian Hospital, Taiwan 4Department of Experimental Surgery 5Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan 6Department of Neurosurgery, School of Medicine, Taipei Medical University, Taiwan
Temporal differences in relative phasing of gait initiation and first step length in patients with cervical and lumbosacral spinal cord injuries H A Chang1, T Y Chuang1, S J Lee2, S F Liao3, H C Lee4, Y H Shih5,6 and H Cheng5
Study design: Comparison group design.
Objective: To compare the temporal distance factors during gait initiation between patients with incomplete cervical spinal cord injury, incomplete lumbosacral spinal lesion, and unimpaired control adults.
Setting: Human performance and movement analysis laboratory, Taiwan.
Participants: Five patients with an incomplete cervical spinal cord injury (Group 1), five patients with an incomplete lumbosacral spinal lesion (Group 2) and nine unimpaired control adults (Group 3).
Methods: Subjects underwent a three-dimensional gait analysis. The total gait initiation period, reaction time, each relative phasing of gait initiation and the length of the first step were identified by using the kinematic measurement system.
Main outcome measures: The total gait initiation period (start of the auditory cue for gait initiation to heel-strike of the first swing leg); each relative phasing of gait initiation indicated that the duration of the preparatory phase (start of auditory cue for gait initiation to heel-off of the first swing leg), the duration of the push-up phase (heel-off to toe-off of the first swing leg), and the duration of the single-stance phase (toe-off to heel-strike of the first swing leg) established by the total gait initiation period; and the length of the first step.
Results: The gait initiation period was greater in Groups 1 and 2 than that of Group 3 (P<0.05). Each relative phasing including the duration of the preparatory phase, the push-up phase, and the swing phase relative to the total gait initiation period, did not differ among Groups 1−3 (P>0.05). The length of the first step, measured while the nonpreferred leg stepped first in Groups 1 and 2, was shorter than that of Group 3 (P<0.05).
Conclusions: Patients with incomplete cervical spinal cord injuries or lumbosacral spinal lesions took more time in gait initiation than unimpaired control adults. The first step length also reduced in these patients while the nonpreferred leg stepped first, as compared to unimpaired control adults. The data indicated that centrally programmed gait initiation might be preserved in ASIA-D spinal patients who, in this study, executed gait initiation with varying temporal distance strategies to compensate for peripheral impairments, as compared to unimpaired control adults.
1Spinal Cord Injury and Medical Services, Department of Veterans Affairs Medical Center, West Roxbury, MA, USA 2Harvard Medical School, Boston, MA, USA
Microvascular instability in tetraplegic patients: preliminary observations J H Frisbie1
Study design: Case control.
Objectives: To describe the effect of spinal cord injury on microvascular stability.
Setting: Veterans Administration Medical Center, West Roxbury, MA, USA.
Methods: A total of 19 tetraplegic patients, aged 63±12 years, were surveyed for microvascular instability. Photoelectric pulse sensors were applied to the skin surface of the neck on both sides and to the distal pads of the left and right fourth fingers of subjects in the sitting position. All pulses during the survey periods were recorded by a polygraph system. The unstable fraction of pulsatile cutaneous blood flow (UFCF) was calculated by the sum of the periods during which pulses at any site were either half or twice the baseline amplitude divided by the survey time. Simultaneous UFCF, which was pulsatile flow change in the same direction at the same time in two leads, was also measured. Flow changes in patients with motor and sensory complete lesions were compared with incomplete lesions.
Results: Survey times were 7017±670 s. Tetraplegic complete UFCF and simultaneous UFCF were 0.25±0.12 and 0.07±0.07, respectively. Tetraplegic incomplete UFCF and simultaneous UFCF were 0.0.13±0.9 and 0.02±0.04, respectively. The differences between the groups were significant for UFCF (P=0.04), but not for simultaneous UFCF (P=0.14).
Conclusions: Tetraplegic subjects demonstrate an instability of cutaneous microvascular blood flow that is related to the severity of paralysis.
1Department of Rehabilitation Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands 2Department of Psychology and Psychotherapy, NIHES, Erasmus MC, Rotterdam, The Netherlands 3Rijndam Rehabilitationcenter, Rotterdam, The Netherlands
Tetraplegia Hand Activity Questionnaire (THAQ): the development,assessment of arm-hand function-related activities in tetraplegic patients with a spinal cord injury N E Land1, E Odding1, H J Duivenvoorden2, M P Bergen3 and H J Stam1
Study design: Development of Tetraplegia Hand Activity Questionnaire (THAQ).
Setting: Patients and spinal cord injury (SCI) professionals from five rehabilitation centres in the Netherlands and Belgium.
Objective: To construct a disease-specific questionnaire to evaluate interventions to the arm−hand of tetraplegics in terms of gained and lost activities relevant to the patient.
Methods: All arm−hand function-related activities were inventoried by examining existing scales and interviewing spinal cord injury patients and professionals in the field. Subsequently, item reduction was achieved; first, in the technical construction by incorporating all activities in an item list, then reducing the list by selecting the items most likely to be sensitive to change after surgical or functional electro stimulation interventions on the arm−hand as judged by an expert panel, using a Delphi method.
Results: The arm−hand-related activity inventory comprised 652 activities. The technical construction of the items and the Delphi procedure resulted in a questionnaire with 153 items. The experts considered many of the 'new' activities more relevant for the evaluation of hand function interventions than those found in scales studied in the literature. This is reflected in a relatively large proportion of new activities (69%) for the item list of the THAQ, and even more in the domains work/admin/telecom (88%) and leisure (100%).
Conclusion: The questionnaire constructed to assess hand function-related activities contains relevant activities to evaluate arm−hand function-related interventions for tetraplegic SCI patients.
1Rehabilitation Research Laboratory, GF Strong Rehab Centre, Vancouver, BC, Canada 2School of Rehabilitation Sciences, University of British Columbia, Vancouver, BC, Canada 3Spinal Cord Injury Program, GF Strong Rehab Centre, Vancouver, BC, Canada 4International Collaboration on Repair Discoveries, Vancouver, BC, Canada
Client-centred assessment and the identification of meaningful treatment goals for individuals with a spinal cord injury C Donnelly1,2, J J Eng1,2,4, J Hall3, L Alford3, R Giachino3, K Norton3 and D S Kerr3
Study design: Retrospective analysis.
Objectives: (1) Describe the self-care, productivity and leisure problems identified by individuals with a spinal cord injury (SCI) during rehabilitation, (2) describe the perceived level of satisfaction and performance with self-care, productivity and leisure activities following an SCI, (3) quantify the relationship between the Canadian occupational performance measure (COPM), a client-centred, individualized measure of function, and the functional independence measure (FIM).
Setting: Tertiary rehabilitation centre, spinal cord injury unit, GF Strong Rehabilitation Centre, Vancouver, Canada.
Methods: Health records from 41 individuals with an SCI admitted between 2000 and 2002 were reviewed. Information was obtained from assessments performed on admission and discharge. Self-care, productivity and leisure problems identified by individuals with an SCI were described and their perceived level of performance and satisfaction was calculated. The relationship between the COPM and the FIM was measured by the Pearson product correlation.
Results: Self-care goals were identified most frequently (79%) followed by productivity (12%) and leisure (9%) goals. The top three problems identified by individuals with an SCI were functional mobility (including transfers and wheelchair use), dressing and grooming. A fair relationship was found between the COPM and the FIM (r between 0.351 and 0.514, P<0.05).
Conclusions: The results highlight the importance of including a client-centred outcome measure in the assessment of individuals with an SCI. Initial support is provided for use of the COPM in individuals with an SCI.
1Regional Spinal Injuries Centre, District General Hospital, Southport PR8 6PN, UK
Pseudo-tumours of the urinary tract in patients with spinal cord injury/spina bifida S Vaidyanathan1, P L Hughes2, P Mansour3, B M Soni1, Gurpreet Singh1, J W H Watt1, T Oo1 and P Sett1
2Department of Radiology, District General Hospital, Southport PR8 6PN, UK
3Department of Cellular Pathology, District General Hospital, Southport PR8 6PN, UK
Objective: To raise awareness of pseudo-tumours of urinary tract, as pseudo-tumours represent benign mass lesions simulating malignant neoplasms. Accurate diagnosis helps to avoid unnecessary surgery in spinal cord injury patients.
Setting: Regional Spinal Injuries Centre, Southport, UK
Case reports: Pseudo-tumour of kidney: A 58-year-old man with tetraplegia developed a right perirenal haematoma while taking warfarin; ultrasound and CT scanning showed no evidence of tumour in the right kidney. The haematoma was drained percutaneously. After 8 months, during investigation of a urine infection, ultrasound and CT scan revealed a space-occupying lesion in the mid-pole of the right kidney. CT-guided biopsy showed features suggestive of an organising haematoma; the lesion decreased in size over the next 13 months, thus supporting the diagnosis. Pseudo-tumour of urinary bladder: A frail, 34-year-old woman, who had spina bifida, marked spinal curvature and pelvic tilt, had been managing her neuropathic bladder with pads. She had recurrent vesical calculi and renal calculi. CT scan was performed, as CT would be the better means of evaluating the urinary tract in this patient with severe spinal deformity. CT scan showed a filling defect in the base of the bladder, and ultrasound revealed a sessile space-occupying lesion arising from the left bladder wall posteriorly. Flexible and, later, rigid cystoscopy and biopsy demonstrated necrotic slough and debris but no tumour. Ultrasound scan after 2 weeks showed a similar lesion, but ultrasound-guided biopsy was normal with nothing to explain the ultrasound appearances. A follow-up ultrasound scan about 7 weeks later again showed an echogenic mass, but the echogenic mass was seen to move from the left to the right side of the bladder on turning the patient, always maintaining a dependent position. The echogenic bladder mass thus represented a collection of debris, which had accumulated as a result of chronic retention of urine and physical immobility.
Conclusion: Recognising the true, non-neoplastic nature of these lesions enabled us to avoid unnecessary surgical procedures in these patients, who were at high risk of surgical complications because of severely compromised cardiac and respiratory function.
1Department of Neurological Sciences, Neurosurgery, University of Rome 'La Sapienza', Italy 2Department of Neurosurgery-INM Neuromed IRCCS, Pozzilli (Is), Italy
Lumbar spinal angiolipomas: report of two cases and review of the literature G Rocchi1, E Caroli1, A Frati2, M Cimatti1 and M Savlati2
Study design: Case report and review of the literature.
Objectives: To describe two patients with angiolipoma in the ventral aspect of the lumbar epidural space, to discuss the clinical, radiologic, and surgical features of these lesions, and to review previously reported cases.
Setting: Rome, Italy.
Methods: Two cases, a 60-year-old man and a 54-year-old woman presented with lumbar?sciatic pain but with no abnormal neurological signs. Investigation (CT and MRI) demonstrated lumbar tumours.
Results: Laminectomy and excision of the tumors were performed, and symptoms improved immediately.
Conclusions: Magnetic resonance imaging with suppression fat sequences allows the recognition of these lesions. The prognosis after surgical removal of spinal angiolipoma is favorable.
1Service de Medecine Physique et de Readaptation, Hopital Bellevue, CHU de Saint-Etienne, Saint-Etienne, France 2Centre Medico-Chirurgical de Readaptation des Massues, 92 rue Edmond Locard, Lyon, France
Dantrolene and pleural effusion: case report and review of literature B Le-Quang1, P Calmels1, E Valayer-Chaleat1,2, I Fayolle-Minon1 and V Gautheron1
Study design: Single-subject case (a quadriplegic female, 56 years).
Objectives: To describe a new case of eosinophilic pleural effusion induced by dantrolene chronic administration.
Setting: Physical medicine and rehabilitation unit in a teaching hospital, France.
Methods: Diagnosis of an eosinophilic pleural effusion induced by dantrolene without any respiratory symptoms, except a decrease of breath sounds on the right lung base.
Results: Chest radiograph revealed a right-sided pleural effusion, and blood cell count a significant peripheral eosinophilia. Thoracenthesis contained 85% of eosinophils. The other explorations eliminated other causes of pleural effusion. The diagnosis of drug-induced effusion was almost sure and led us to discontinue the dantrolene. After 3 months, she had completely recovered. These characteristics, similar to the eight other cases described in the literature, are essential for the diagnosis of pleural effusion induced by dantrolene.
Conclusion: Dantrolene, a long-acting skeletal muscle relaxant, is well known to induce liver side effects but it can also induce pleural pericarditis. The pathogenesis is still not clearly identified, but similarities of chemical structures of dantrolene and nitrofurantoine make us think that it could be the same mechanism. The association between dantrolene and nitrofurantoine may have contributed to the expression of the pleural effusion.
1Department of Physical Medicine and Rehabilitation, School of Medicine, Ankara University, Turkey 2Department of Neurology, School of Medicine, Ankara University, Turkey
Brucellar spondylitis: a rare cause of spinal cord compression B Sonel Tur1, N Suldur1, S Ataman1, E A Ozturk1, A Bingol2 and M B Atay1
Study design: A case report.
Objectives: To present and discuss some of the difficulties in the diagnosis of brucellar spondylitis.
Setting: Ankara University, Ibni Sina Hospital, Turkey.
Methods: We report a patient with paraplegia, misdiagnosed as having a malignancy or tuberculosis who actually suffered from brucellar spondylitis. Diagnosis was established by her history and a compatible clinical picture together with a standard tube agglutination (Wright test) titer of 1/160 of antibodies for brucellosis. The patient was treated with oral doxycycline, rifampicin, and ciprofloxacin combination.
Results: At the end of the treatment, the blood Brucella Wright and anti-human globulin T titer levels decreased. Her lower limb weakness improved. She could walk, and climb stairs with the help of a cane. Urinary retention and fecal incontinence also resolved.
Conclusion: Brucellosis is a systemic infection involving the musculoskeletal and nervous systems. Spondylitis frequently occurs in elderly patients. An early diagnosis of brucellar spondylitis can often be difficult. In endemic regions, as in the case of our country, brucellar spondylitis should always be considered in the differential diagnosis of older patients with back pain and constitutional symptoms. An early diagnosis will help to prevent the development of more severe complications such as spinal cord compression.