| Spinal Cord 2004 Abstracts （www.nature.com/sc ） （Jan-June 2004） |
■ June 2004, Volume 42, Number 6
1Division of Neuroscience and Psychological Medicine, Imperial College, London; UK
Towards improved clinical and physiological assessments of recovery in spinal cord injury: a clinical initiative P H Ellaway1, P Anand1, E M K Bergstrom2, M Catley1, N J Davey1, H L Frankel2, A Jamous2, C Mathias1, A Nicotra1, G Savic2, D Short3 and S Theodorou1
2National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
3Midlands Centre for Spinal Injuries, Oswestry, UK
Clinical practice and scientific research may soon lead to treatments designed to repair spinal cord injury. Repair is likely to be partial in the first trials, extending only one or two segments below the original injury. Furthermore, treatments that are becoming available are likely to be applied to the thoracic spinal cord to minimise loss of function resulting from damage to surviving connections. These provisos have prompted research into the improvement of clinical and physiological tests designed (1) to determine the level and density of a spinal cord injury, (2) to provide reliable monitoring of recovery over one or two spinal cord segments, and (3) to provide indices of function provided by thoracic spinal root innervation, presently largely ignored in assessment of spinal cord injury. This article reviews progress of the Clinical Initiative, sponsored by the International Spinal Research Trust, to advance the clinical and physiological tests of sensory, motor and autonomic function needed to achieve these aims.
1Neuro-Urology, Swiss Paraplegic Center, Balgrist University Hospital, Zurich, Switzerland
Electromotive drug administration of lidocaine to anesthetize the bladder before botulinum-A toxin injections into the detrusor B Schurch, A Reitz & G Tenti
2Department of Urology, University Hospital, Zurich, Switzerland
Study design: Prospective, open label, cross-over-designed clinical study.
Objective: To evaluate the effectiveness of an instillation of lidocaine into the bladder with versus without electromotive drug administration (EMDA) to anesthetize the bladder before botulinum-A toxin injections.
Setting: Neurourology, Swiss Paraplegic Center, Balgrist University Hospital, Zurich, Switzerland.
Methods: In all, 28 patients with severe neurogenic detrusor overactivity but preserved bladder sensibility were treated with botulinum-A toxin injections into the detrusor muscle. A measure of 300 u of botulinum-A toxin (Botox R)) was injected at 30 sites sparing the trigone. Prior to the injection, the bladder was anesthesized with conventional lidocaine instillation in a group of 10 patients and with lidocaine instillation enhanced by EMDA in 28 patients. The patients scored the injection pain on a 10-point rating scale. Pain rating scores with versus without EMDA enhancement of the lidocaine instillation were analyzed and the costs of the EMDA procedure were compared to general/spinal anesthesia.
Results: The mean pain score of the 10 patients who underwent the injections of Botox R)) after conventional lidocaine instillation was 4.0 (SD 1.6). Following EMDA enhanced lidocaine instillation slight even or no pain occurred during the injections of Botox R)), and the mean pain score was 0.5 (SD 0.2). Compared to spinal or general anesthesia, the local anesthesia saved around 15% of the costs.
Conclusions: EMDA enhanced instillation of lidocaine enables a sufficient anesthesia of the bladder wall that ensures a painless application of the botulinum-A toxin injections into the detrusor muscle. This method may avoid general or spinal anesthesia in patients with preserved bladder sensibility. It ensures considerable cost reduction, avoids anesthesia-related risks and complications and enables the procedure on an outpatient basis.
1Department of Neurology, National Neuroscience Institute 2Department of Neurology
Intra-operative monitoring in scoliosis surgery with multi-pulse cortical stimuli and desflurane anesthesia Y L Lo, Y F Dan, Y E Tan, S Nurjannah, S B Tan, C T Tan & S Raman
3Department of Orthopedic Surgery 4Department of Anesthesia and Surgical Intensive Care, Singapore General Hospital, Singapore
Study design: Prospective, observational study.
Setting: Country General Hospital, Singapore.
Objective: Intraoperative monitoring (IOM) with motor-evoked potentials (MEPs) assesses the integrity of cortical spinal tracts during scoliosis surgery. MEPs are sensitive to the effects of inhalational anesthetic agents. We evaluate the use of desflurane in combination with multipulse cortical stimulation in this study.
Methods: In all, 10 consecutive neurologically normal subjects underwent scoliosis surgery with desflurane anesthesia (0.5 maximum alveolar concentration) and five pulse cortical stimulation (250 Hz) from two stimulators in parallel configuration, delivering a maximum intensity of 160 mA.
Results: Consistent MEPs were obtained from the abductor hallucis and tibialis anterior in nine of ten and five of five of subjects, respectively. Baseline coefficients of variations were below 16% for both muscles.
Conclusion: This combination of anesthetic and stimulation protocols is efficacious for IOM during spinal cord surgery. Our findings support the use of desflurane for successful acquisition of MEPs during scoliois surgery as an alternative anesthetic regime.
1Klinik Berlin, Department of Neurological Rehabilitation, Free University Berlin, Germany
Electromechanical gait training with functional electrical stimulation: case studies in spinal cord injury S Hesse, C Werner & A Bardeleben
Study design: Single case studies.
Objectives: To describe the technique of intensive locomotor training on an electromechanical gait trainer (GT) combined with functional electrical stimulation (FES).
Setting: Neurological Rehabilitation Clinic, Berlin, Germany.
Methods: Four spinal cord-injured (SCI) patients, one tetraparetic, two paraparetic, and one patient with an incomplete cauda syndrome, more than 3 months postinjury, who were unable to walk at all, or with two therapists. They received 25 min of locomotor training on the GT plus FES daily for 5 weeks in addition to the regular therapy.
Results: The patients tolerated the programme well, and therapists rated the programme less strenuous compared to manually assisted treadmill training. Gait ability improved in all four patients; three patients could walk independently on the floor with the help of technical aids, and one required the help of one therapist after therapy; gait speed and endurance more than doubled, and the gastrocnemius activity increased in the patients with a central paresis.
Conclusion: This combined technique allows intensive locomotor therapy in SCI subjects with reduced effort from the therapists. The patients' improved walking ability confirmed the potential of locomotor therapy in SCI subjects.
1Loewenstein Rehabilitation Hospital, Raanana, Israel 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 3Tel Aviv Medical Center, Tel Aviv, Israel 4The Statistical Laboratory, School of Mathematics, Tel Aviv University, Tel Aviv, Israel 5Sapir Medical Center, Kfar Sava, Israel
Length of stay in hospital following spinal cord lesions in Israel J Ronen, M Itzkovich, V Bluvshtein, M Thaleisnik, D Goldin, I Gelernter, R David, R Gepstein & A Catz
Study Design: Retrospective cohort study.
Objective: To monitor length of stay (LOS) in a specialist spinal cord lesion (SCL) department in Israel, evaluate factors that affect it, and assess its association with other outcome measures.
Setting: Loewenstein Rehabilitation Hospital, Raanana, Israel.
Methods: In all, 1367 SCL patients treated between 1962 and 2000, and a group of 44 patients admitted between 1996 and 2002 were recruited. LOS, factors that affect it, and Spinal Cord Independence Measure second version (SCIM-II) gain and efficiency were measured. Data were collected from hospital charts and from the Population Registry of the Israel Ministry of Internal Affairs. LOS associations were analyzed with ANOVA, ANCOVA, Pearson'sχ2 test, Pearson's correlation, and Cox proportional hazard model.
Results: The mean LOS was 239 days for traumatic SCL (SD=168) and 106 days for non-traumatic SCL (SD=137). SCL etiology, SCL severity, and decade of admission to rehabilitation, were associated with the LOS (P<0.001). SCIM II gain correlated with LOS in the first 70 days after admission (r=0.81−0.82; P<0.001). In some patients, longer LOS was associated with a considerable increase in ability, through 5−8 months from admission.
Conclusions: LOS of patients with SCL in Israel is within the customary LOS range in Europe. Longer LOS in a specialist SCL department may be positively associated with improved rehabilitation outcome. Further study is required to determine the LOS that allows optimal achievements.
1Rehabilitation Studies Unit, Faculty of Medicine, The University of Sydney & Moorong Spinal Unit, Royal Rehabilitation Centre, Sydney, Australia 2Centre for Epidemiology & Research, NSW Health Department, Sydney, Australia 3Spinal Injuries Unit, Royal North Shore Hospital, Sydney, Australia
Patterns of morbidity and rehospitalisation following spinal cord injury J W Middleton, K Lim, L Taylor, R Soden & S Rutkowski
Study design: Longitudinal, descriptive design.
Objectives: The aim of this study was to investigate the frequency, cause and duration of rehospitalisations in individuals with spinal cord injury (SCI) living in the community.
Setting: Australian spinal cord injury unit in collaboration with State Health Department.
Methods: A data set was created by linking records from the NSW Department of Health Inpatient Statistics Collection between 1989−1990 and 1999−2000 with data from the Royal North Shore Hospital (RNSH) Spinal Cord Injuries Database using probabilistic record linkage techniques. Records excluded were nontraumatic injuries, age <16 years, spinal column injury without neurological deficit, full recovery (ASIA Grade E) and index admission not at RNSH. Descriptive statistics and time to readmission using survival analysis, stratified by ASIA impairment grade, were calculated.
Results: Over the 10-year period, 253 persons (58.6%) required one or more spinal-related readmissions, accounting for 977 rehospitalisations and 15,127 bed-days (average length of stay (ALOS) 15.5 days; median 5 days). The most frequent causes for rehospitalisation were genitourinary (24.1% of readmissions), gastrointestinal (11.0%), further rehabilitation (11.0%), skin-related (8.9%), musculoskeletal (8.6%) and psychiatric disorders (6.8%). Pressure sores accounted for only 6.6% of all readmissions, however, contributed a disproportionate number of bed-days (27.9%), with an ALOS of 65.9 (median 49) days and over 50% of readmissions (33 out of 64) occurred in only nine individuals aged under 30 years. Age, level and completeness of neurological impairment, all influenced differential rates of readmission depending on the type of complication. Overall rehospitalisation rates were high in the first 4 years after initial treatment episode, averaging 0.64 readmissions (12.6 bed-days) per person at risk in the first year and fluctuating between 0.52 and 0.61 readmissions (5.1−8.3 bed-days) per person at risk per year between the second to fourth years, before trending downwards to reach 0.35 readmissions (2.0 bed-days) as 10th year approaches. Time to readmission was influenced by degree of impairment, with significantly fewer people readmitted for ASIA D (43.2%) versus ASIA A, B and C (55.2−67.0%) impairments (P<0.0001). The mean duration to first readmission was 46 months overall, however, differed significantly between persons with ASIA A/C impairments (26−36 months) and ASIA D impairment (60 months).
Conclusion: Identifying rates, causes and patterns of morbidity is important for future resource allocation and targeting preventative measures. For instance, the late complication of pressure sores in a small subgroup of young males, consuming disproportionately large resources, warrants further research to better understand the complex psychosocial and environmental factors involved and to develop effective countermeasures.
1Department of Orthopaedic Surgery, Nagoya University School of Medicine, Japan 2Department of Orthopaedic Surgery, Chubu Rosai Hospital, Japan 3Department of Orthopaedic Surgery, Toyohashi Municipal Hospital, Japan
Three-dimensional images for surgical plan of giant sacral schwannoma K Satake, Y Matsuyama, H Yoshihara, M Yanase & Y Miura
Objective: Documentation of three-dimensional (3D) images of a giant sacral schwannoma with intrapelvic expansion.
Setting: Nagoya University, Nagoya, Japan.
Results: 3D computed tomography (3D CT) showed a destructed bony region clearly. 3D CT angiography clarified the positional relationship between tumor and iliac arteries. Resection procedure was safely completed based on these 3D evaluations.
Conclusion: 3D images were helpful to make a surgical plan and to complete this complicated resection combined with sacroiliac reconstruction.
1Rehabilitation Clinic, Department of Clinical Neuroscience, University Hospital of Geneva, Geneva, Switzerland
Neurological improvement and rehabilitation potential following toxic myelopathy due to intrathecal injection of doxorubicin B Jordan, Y Pasquier & A Schnider
Study design: Case report of a 31-year-old woman who presented with toxic myelopathy due to intrathecal administration of doxorubicin.
Objective: To describe the pathology and the rehabilitation of an uncommon complication of intrathecal drug administration during the oncologic treatment of acute lymphoma.
Setting: Spinal cord rehabilitation center, University Hospital.
Method: Clinical and radiological observations during a rehabilitation program.
Results: Evidence of neurological improvement and rehabilitation potential after severe myelopathy due to intrathecal injection of doxorubicin.
Conclusion: This is, to our knowledge, the first report of severe myelopathy following accidental intrathecal administration of doxorubicin. Despite early complete paraplegia, some neurological and functional recovery was observed.
1Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Firat University, Elazig, Turkey 2Department of Neurology, Faculty of Medicine, Firat University, Elazig, Turkey 3Department of Radiology, Faculty of Medicine, Firat University, Elazig, Turkey
Spinal epidural hematoma associated with streptokinase treatment for myocardial infarction S Ozgocmen, T Yoldas, E Kocakoc, F Ozkurt-Zengin & O Ardicoglu
Study Design: Case Report.
Objective: Thrombolytic therapy has become a routine and valuable care for selected patients with acute myocardial infarction (AMI) and rarely complicates with spinal epidural hemorrhage causing cord compression.
Setting: Elazig, Turkey
Case report: A 72-year-old woman developed spinal epidural hemorrhage following streptokinase and heparin administration for AMI. Back pain and lower extremity neurologic deficits ensued secondary to spinal cord compression by epidural hematoma. Diagnosis of spinal epidural hematoma, extending through T11 to L2 vertebra levels, could be accurately made by magnetic resonance imaging (MRI). Careful follow-up by neurologic examination, reversal of anticoagulant effects, anti-edema treatment with steroids and a low-intensity rehabilitation program maintained a full recovery. Follow-up MRI, 3 months after the accident, revealed complete resolution of the hematoma.
Conclusion: Physicians should be aware of this rare complication secondary to thrombolytic therapy. A high index of suspicion for hemorrhagic complications is necessary, particularly in elderly patients under thrombolytic treatment regardless of spinal pain, and the patient's lethargic or confused status should be taken into account. MRI is a valuable imaging option that gives information on both localization and extent of lesion and recovery.
1Department of Neurosurgery, Baskent University Faculty of Medicine, Ankara, Turkey
Spontaneous corynebacterium discitis in a patient with chronic renal failure B Atalay, F Ergin, M Teksam, H Caner & N Altinors
2Department of Infectious Disease, Baskent University Faculty of Medicine, Ankara, Turkey
3Department of Radiology, Baskent University Faculty of Medicine, Ankara, Turkey
Study design: Case report describing spontaneous Corynebacterium diptheria discitis in a patient with chronic renal failure.
Objectives: To describe this very rare form of discitis and the results of surgical and antibiotic therapy.
Setting: University Department of Neurosurgery, Turkey.
Case report: A 55-year-old man with chronic renal failure presented with acute low-back pain. Lumbar magnetic resonance imaging (MRI) suggested discitis and osteomyelitis at the L5−S1 level. The L5−S1 disc was operated upon and the discectomy material was sent for pathological and microbiological analysis.
Results: Pathological examination revealed infection and bacterial culture grew C. diptheria. The patient was prescribed combination antibiotic therapy with vancomycin, a third-generation cephalosporin, and rifampicin. Clinical status improved after 8 weeks of therapy. Lumbar MRI revealed remission of the discitis and osteomyelitis after 10 months of follow-up.
Conclusion: Chronic renal failure patients with low-back pain should be investigated for spinal infection. These individuals are prone to low-grade infection in the form of discitis or osteomyelitis. Corynebacterium subspecies rarely cause spontaneous discitis. This case is interesting because of the unusual causal organism and the occurrence of discitis in the setting of chronic renal failure. ■