Earlier studies have shown that the diaphragm might have a postural function that could interfere with its respiratory function during arm cycling in patients with cervical cord injuries with impaired elbow extension. The purpose of this study was to evaluate the effect of trunk support on working performance in such patients. Ten patients with low-cervical-cord injuries performed an arm ergometer test without and with trunk support with at least one week between the tests. The work load averaged 30 (20-50) Watt. Oxygen uptake at steady state averaged 0.71 +/- 0.09 l/min without trunk support and 0.64 +/- 0.10 l/min with trunk support, P < 0.05. There was no difference in blood lactate without or with trunk support. Maximum performance time averaged 8.3 +/- 4.3 min without trunk support and 19.5 +/- 8.8 min with trunk support, P < 0.01. Oxygen saturation tended to decrease during work and returned to resting values after termination. This study showed that trunk support during arm ergometry in cervical-cord-injury patients with impaired elbow extension decreased the energy cost during sub-maximal work and increased the time to perform work. The results indicate that trunk stabilisation might improve performance of activities of daily living and that it should also be considered during exercise affecting the postural balance of these patients.

In a series of articles from the Stockholm Spinal Cord Injury Study (SSCIS), the health status of a near-total regional SCI population comprising 353 subjects has been investigated. The present study describes the psycho-social and financial consequences of SCI in this group. It is based on a level-of-living survey that has been used annually on 8000-14,000 Swedes since 1974. The health-focused version of this survey was used for data collection in the subset of 326 subjects in the SSCIS that were residents of the Greater Stockholm area. The normative material consisted of 1978 interviews of residents of the same area, provided by the Swedish Bureau of Statistics. The results show that SCI subjects, although provided with basic material commodities up to par with the general population, have less financial reserves and more frequently express worry about their finances. Less than half of the subjects are gainfully employed, when part-time jobs are also included. Social activities are more restricted, and more centered on the core social network. Several items in the survey point to a preoccupation with personal rather than public matters. We feel that these factors, at least to some degree, are consequential to separation from the workplace, with resulting disadvantageous financial and social effects. Intensified vocational rehabilitation efforts might thus be justified from both an economic and a psycho-social point of view.

Intravesical administration of drugs has been used commonly in spinal cord injury patients to suppress detrusor hyperreflexia (eg oxybutynin, verapamil, terodiline) or, to initiate a micturition reflex (eg 15S 15-methyl prostaglandin F2 alpha, protaglandin E2); however, the response has been variable and sometimes, unpredictable. This prompted us to study the presence of nerve fibres in the vesical urothelium and submucosa in mucosal biopsies taken from the dome and trigone (obtained prior to performing a therapeutic procedure eg, vesical lithotripsy, or a diagnostic cystoscopy) in 47 consecutive, unselected paraplegic/tetraplegic patients with a neuropathic urinary bladder. Nerve fibres were demonstrated by routine immunohistochemical technique using commercially available monoclonal and polyvalent antibodies against S-100 (DAKO A/S, Glostrup, Denmark) and Neurofilament (MILAB, Malmo, Sweden). Biopsy specimens were graded for the presence of nerve fibres on a 0-3 scale for urothelium, and superficial/deep submucosa separately in a blind and randomised manner. Virtually no fibre presence was found in one paraplegic patient and no superficial or single fibres were noted in a tetraplegic patient. Absence of C-fibre hyperplasia (Grade 0) was found in nine cases (paraplegic: 4; tetraplegic: 5); Grade 1 hyperplasia was observed in 17 cases (paraplegic: 4; tetraplegic: 13); Grade 2 hyperplasia was seen in 11 cases (paraplegic: 7; tetraplegic 4); and Grade 3 hyperplasia was noticed in eight cases (paraplegic 3: tetraplegic: 5). The magnitude of C-fibre hyperplasia was not significantly different between paraplegic and tetraplegic patients (chi(2) = 4.64; P = 0.3262). The relationship, if any, between the degree of C-fibre hyperplasia and duration of paralysis was studied by categorising patients as < 5 years, and > 5 years of paralysis. No evidence of single fibre or fibre bundle hyperplasia (Grade 0) was seen in five and six cases, grade 1 hyperplasia in six and 11 cases, grade 2 hyperplasia in two and nine cases, and grade 3 hyperplasia in three and five cases respectively in these two categories of patients. (chi(2) = 1.92; P = 0.58). The possible relationship between C-fibre hyperplasia in the vesical mucosa/submucosa and (i) the vesical response to intravesical drug administration; (ii) the vesical urothelial proliferation arrest; (iii) the electrical stimulation of urinary bladder by implanted electrodes (sacral anterior root stimulator); and (iv) long-term indwelling urethral Foley catheter drainage, are discussed with illustrative case reports. In conclusion, mucosal biopsy and study of nerve fibres in urothelium and submucosa of neuropathic bladder has helped to generate hypotheses on the association between C-fibre hyperplasia and response to intravesical pharmacotherapy and the predictive value of such a study in identifying those patients who are likely to respond to intravesical pharmacotherapy.

In order to assess some of the variables associated with neurological recovery after traumatic spinal cord injury with vertebral fracture, a randomised sample of 100 patients (50 without neurological recovery, and 50 with several degrees of recovery) were selected out of 245 patients admitted to our hospital. Both groups were homogeneous with respect to time lapse to admission, hospitalization time and level of lesion. Of the variables considered, the intensity of the lesion (incomplete) and vertebral displacement (under 30%) were statistically associated with neurological recovery. An age under 30 years at the moment of the injury was also associated with neurological recovery but only in those patients with an incomplete lesion. No correlation was found between the other variables studied such as the degree of vertebral wedging, type of fracture (compression, flexion-rotation) and management (conservative, surgical) and the neurological evolution.

The medical literature is replete with case reports of the syndrome known as autonomic dysreflexia. Although the majority of cases are known to be induced by either bladder or bowel distention. there does exist a small number of cases in which the inciting stimulus is more obscure. In such cases, a comprehensive medical evaluation is necessary to ensure proper identification of the source of irritation and the appropriate medical management of the patient. We present a patient with a heretofore unreported suspected etiology of autonomic dysreflexia, axial loading of a sacral stress fracture.

Disturbed motor control due to a spinal cord lesion is generally considered to be the cause of unusual standing utilized by those people suffering from spinal cord injury (SCI). Electromyographic (EMG) leg muscle activity during quiet standing was analyzed in four functional groups of SCI subjects and compared to the data of healthy people. A rating system for visual assessment of the stripchart recording was developed and its adequacy was confirmed by comparison of the rating system with computerized integrated EMG values of some of the recordings. The division of 47 subjects into functional groups was based on their ambulatory capabilities ie a non-support group, crutches, cane and walker user groups. Mean total muscle EMG activity was the highest in the group of subjects standing without support and it was significantly higher when compared to the other groups including the control group. Comparison between more and less active legs within each group showed significant differences in the non-support and crutches groups, whereas cane, walker and control groups showed nearly symmetric EMG patterns during standing. Analysis of the contribution of single muscles to the asymmetry of standing showed significantly higher activity in hamstring and triceps surae muscles than in other muscles in the non-support group. No significant differences in the activity of single muscles compared to their contralateral pair between more and less active leg were obtained in the remaining groups. It is evident, however, that different support devices used by SCI subjects greatly influence EMG patterns of postural muscles. The present findings suggest that disturbed conduction in the spinal cord is related to altered motor strategies employed by SCI subjects in attempts to perform the same volitional act as before the injury.

The existence of the central pattern generator (CPG) for locomotion in lower mammals has been clearly demonstrated by Brown I who showed that rhythmic stepping like activity observed in the acute spinal cat was not due to a succession of reflexes since it persisted after peripheral deafferentation of the distal stump of the spinal cord. The physiology of the CPG has been reappraised by Lundberg's group2,3 and then exten­ sively described in lower mammals.4,5 Spinal locomotor activity was mainly observed in acute spinal prepara­ tions after injection of cathecolaminergic drugs.2,4 Spinal locomotor activity was also observed in the chronic �inal cat but only if the cat was spinalized as a kitten or if the spinal section was immediately followed by daily training on a treadmill. 7 In the chronic trained adult spinal cat, clonidine (which is a cathecolaminergic drug) is not necessary to induce rhythmic activity but it improves its amplitude and its regularity.8 Similarly, spinal locomotor activity can be obtained in chronic spinal rats after transplanting embryonic cathecolaminer�ic cells below the level of the spinal transection.9,1 In the chronic spinal monkey, the existence of this CPG was first denied. I I This assertion has been rediscussed by the same group and has led to less clear cut interpretations of the results. 12 The presence of a CPG in man is still debated and the recent paper by Illisl3 asserts that it has not been unequivocally demonstrated, following complete trans­ ection in man. Usually, patients with a clinically complete spinal cord section clearly do not recover rhythmic alternating locomotor activity as expected, although encouraging results have been obtained recently by Dietz et al14 and Wernig et al15 and described in the review by Barbeau and Rossignol.16 In addition, our group brought out two significant arguments favouring the presence of a CPG in patients with clinically complete paraplegia. First, we demon­ strated that flexor reflexes in paraplegic patients are always related to the CPG network. 17 -19 Secondly we observed rhythmic spinal activity in a patient with a clinically complete spinal cord section (spinal myoclo­ nus)?O

Vertebral osteomyelitis is a difficult problem in the spinal cord injured patient. We present three such cases treated with extensive debridement followed by grafting and stabilization with external fixation. In all three patients the infection resolved. We feel this is a viable option for treating this condition.

Three male spinal cord injured patients who underwent suprapubic catheterisation with urethral closure are reported. Although the procedure is well established in women, and has been mainly used in patients with multiple sclerosis, this simple procedure is also possible in men, and worth considering in difficult situations where continence has been impossible to achieve by more conventional means.

Sarcoidosis is a multi-system, non-caseating granulomatous disease of unknown etiology. Although spinal cord involvement is rare, it may cause severe neurological complications. We report the case of a 52-year-old woman who developed low back pain and a progressive flaccid paraparesis whose investigations revealed pulmonary and spinal sarcoidosis. To our knowledge, this is the first reported case of sarcoidosis of the conus medullaris and cauda equina diagnosed by an unusual enhancement pattern observed on magnetic resonance imaging with gadolinium. Biopsy of the lumbar nerve roots and of the lung revealed a non-caseating granuloma. Treatment with steroids and intensive rehabilitation resulted in remarkable functional improvement. Although rare, sarcoidosis of the conus medullaris and cauda equina should be considered in the differential diagnosis of flaccid paraparesis, particularly in patients with non-diagnostic evaluations.