Complete Cord Lesions Research Articles

Etiology and Factors Related Outcomes of Longitudinally Extensive Transverse Myelitis in Thailand

Objective This study aimed to evaluate the clinical features, etiology, and prognosis of longitudinally extensive transverse myelitis (LETM) patients in Thailand. Background LETM has various etiology and is different in each region. Proper investigations are essential to reduce misdiagnosis and delay in treatments, which affect clinical recovery and prognosis. In Thailand, there is no clinical study on the etiology of LETM. Therefore, our study aimed to evaluate the clinical features, etiology, and prognosis of LETM patients in Thailand. Design/Methods Patients diagnosed with LETM at University Hospital between January 2015 and October 2021 were included. Patient demographics, clinical presentations, Expanded Disability Status Scale (EDSS), imagings, laboratory testing, cerebrospinal fluid profiles, final diagnosis, and treatments were recorded. Factors related to outcomes of LETM were analyzed. Results A total of 40 patients, there were 21 females (52.5%), the mean age of onset was 48.4 years (SD = 15.8). NMOSD was the most common etiology of LETM (n = 15), followed by infection (n = 5), SLE (n = 5), idiopathic causes (n = 4), CIS (n = 3), MS (n = 1), spinal dural AVF (n = 2), ADEM (n = 2), either 1 had spinal cord infarction, schwannoma, and vitamin B12 deficiency. Most patients in this study had severe LETM (n = 31). Complete cord had significantly poorer outcome (p-value = 0.003), while dorsolateral and anterior cord had better outcome (p-value = 0.046, 0.046). Conclusions NMOSD was the most common etiology of LETM, and a history of prior attacks led to the diagnosis of NMOSD. Complete cord lesion on axial spinal cord MRI was sensitive to NMOSD but not specifically. Factors related to the prognosis of LETM included completed cord lesions on MRI axial view trended to have a poor outcome, and dorsolateral and anterior cord lesions had a better prognosis.

Socio-demographic Characteristics and Mode of Traumatic Thoraco-Lumbar Spine Injuries at a Referral Tertiary Care Hospital in Bangladesh

Background: Traumatic thoraco-lumbar spine injuries occur in different ways during working.Objectives: The purpose of the present study was to find out the-demographic Characteristics and Mode of Traumatic Thoraco-Lumbar Spine Injuries.Methodology: This cross-sectional study was conducted at the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh from July 2004 to June 2006 for a period of 2(two) years. Patients with diagnosed cases of traumatic thoraco-lumbar spinal injury with complete or incomplete cord lesion irrespective of sex were selected as study population. An elaborate history of the selected patient was taken with an emphasis of mechanism, time of injury, past history of illness.Result: A total number of 17 patients with thoracolumbar spine injury were recruited. Out of 17 patients, 7(41.2%) patients were in the age group of 21-30 years that is very younger age group. The mean age was 29.29 years. The male and female ratio was 4.7:1. In this series most affected people are farmer (47.05%). Most affected groups are injured by fall from height (70.58%) especially from tree and from roof of the buildings.Conclusion: Young age group male workers are most commonly affected in traumatic thoraco-lumbar spine injuries.Journal of National Institute of Neurosciences Bangladesh, 2018;4(1): 51-53

Spinal cord injury—incidence, prognosis, and outcome: an analysis of the TraumaRegister DGU

Background contextLittle is known about the incidence of spinal cord injury (SCI) in polytrauma patients. PurposeThe purpose of this study was to analyze incidence, prognosis, and outcome of SCI in polytrauma patients. Study design/settingThis is a retrospective multicenter cohort study. Patient sampleA total of 57,310 patients of TraumaRegister DGU (2002–2012) of the German Trauma Society were included. Aim of this large multicentre database is a standardized documentation of severely injured patients. Outcome measuresOutcome measures were mortality and Glasgow Outcome 4Scale. MethodsInclusion criteria were adult blunt trauma patients (age greater than 16 years) and injury severity score (ISS) greater than 16. The severity of SCI was based on the Abbreviated Injury Scale (AIS), and the outcome of patients was assessed with the Glasgow Outcome Scale (GOS). Factors with an impact on the outcome were analyzed with a logistic regression model. ResultsFour thousand two hundred eighty five (7.5%) of 57,310 patients sustained SCI. Mean age was 48.9±20.7 years, ISS 28.0±12, and 72.7% were men. Two thousand two hundred twenty two (3.9%) SCIs involved the cervical, 1,388 (2.4%) the thoracic, and 791 (1.4%) the lumbar spine. One hundred fifty-nine (7.2%) cervical spine injuries were associated with transient neurologic deficit (TND) (AIS 3), 612 (27.5%) with an incomplete paraplegia (AIS 4), 1,101 (49.6%) with a complete paraplegia (AIS 5), and 350 (15.8%) with a complete lesion above C3 (AIS 6). Lesions of the thoracic spine showed in 93 (6.7%) of the 1,388 lesions a TND (AIS 3), in 332 (23.9%) an incomplete paraplegia (AIS 4), and in 963 (69.4%) a complete lesion (AIS 5). In the lumbar region, lesions were distributed as follows: TND (AIS 3) 145 (18.3%), incomplete paraplegia (AIS 4) 305 (38.6%), and complete lesion 341 (43.1%). Sepsis and multiorgan failure were found more often in patients with AIS 5/6 lesions (p<.001). The hospital length of stay in SCIs was significantly longer. Most of the patients (85.8%) with SCI were treated in Level I trauma centers. Spinal cord injuries had a minor impact in the mortality. Only AIS 6 injuries resulted in a significantly higher mortality (64.6%). Adjusted logistic regression analysis (target variable: GOS 4 or 5, good outcome) showed that the following factors were significantly associated with an unfavorable outcome (p≤.02): AIS greater than or equal to 4, age greater than or equal to 60 years, resuscitation, severe head injury, shock on scene, and severity of injury (ISS per point). ConclusionsSpinal cord injury with a neurologic deficit could be found in every 13th patient with polytrauma. Over half of the patients with SCI suffer from complete cord lesion. In polytrauma patients, SCI only has a limited influence on the mortality, with exception of AIS 6 lesions. Complications such as multiorgan failure or sepsis and extended hospital length of stay are more frequent in SCI.

Segmental Spine Instrumentation in Thoracolumbar and Lumbar Fractures—12 Years Experience

Introduction Thoracolumbar and lumbar fractures are serious lesions associated commonly with neurological deficits. Posterior stabilization by internal fixation is actually a frequent procedure for the treatment of unstable fractures. The objective of this study is to retrospectively analyze the functional outcome of segmental spine instrumentation of unstable thoracolumbar and lumbar fractures, and the association with neurological impairment. Materials and Methods This retrospective study included 70 patients (49 men and 21 women) with acute unstable thoracolumbar and lumbar fractures, between January 1996 and December 2007 treated with segmental instrumentation (61 with transpedicular fixation and 9 sublaminar wiring fixation). The medium age was 38.22 years (15 to 70 years) and the medium time of follow-up was 75.60 months (20 to 150 months). The fractures were in 14 cases D12, 26 L1, and 30 in other locations. The evaluation included location, mechanism, and type of fractures and associated injuries, neurological symptoms pre- and postsurgery, complications, and radiograph evaluation of the degree of reduction. The injuries were evaluated with the thoraco-lumbar injury classification and severity score (TLICS) and the patients with the Oswestry Disability Index (ODI) and visual pain analogical scale. Results The lesion resulted from a fall from height in 71.6%, from a car accident in 20%, and from another cause in 8.6%. In 56 cases 1 vertebra was affected, in 12 two vertebras and in 2 multi-level injuries. The angle of kyphosis was on average 22.1. Vertebral body was completely restored in 48 cases and incompletely in 22 (up to 5 deficit). TLICS was 5 in 25.7%, 6 in 21.4%, 7 in 11.4%, 8 in 11.4%, and 9 in 8.6%. 55.7% of the patients had no neurologic lesions; 7.1% nerve root, 14.3% incomplete and 20% complete cord lesion and 2,9% with cauda equina. 71.4% returned to work: 57.1% to the same and 14.3% to a lighter job; and the rest didn't work at all. According to the ODI, 36 patients had &lt;20% disability, 21&gt;20 to 40%, 7&gt;40 to 60% and 6&gt;80%. Conclusion Work status correlated directly with neurological impairment but not with injury level or mechanism. Although the important trauma experienced by these patients is return to work and results in the ODI were good. The group with complete neurological lesion had elevated disability scores associated with functional impairment. With adequate and early treatment of spine fractures, we can prevent further neurological deficits. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Krbec M, StulikJ. Treatment of thoracolumbar spinal fractures using internal fixators (evaluationof120 cases) Acta ChirOrthopTraumatolCech 2001;68(2):77–84 Avanzi O, landin E., Meves R. Fractura thoracolumbar por explosion: correlacionen tre el comprometimientodelcanal vertebral y resultados deltratamento conservador. Coluna 2009;8(1):49–56

Spinal cord injury

About 10% of blunt polytrauma cases have an underlying overt or occult spinal cord injury. All multiply injured patients should be managed expectantly and aggressively until injury is ruled out and normal physiological parameters are restored. The ability to assess these patients accurately is often limited by an associated head injury or by the absence of sensation below a complete cord injury. A high index of suspicion along with detailed clinical and radiological examination is required to detect any underlying injuries. The possibility of spinal shock should not be considered until hypovolaemia has been excluded. Intensive care management of acute spinal cord injury includes meticulous attention to fluid management, nutrition, thromboprophylaxis, early protective lung ventilation and measures to reduce ventilator-associated pneumonia. These measures have helped provide a steady improvement in long term survival of these patients over the last 20 years. There has been recent controversy about ‘clearing’ the spine in unconscious patients. Accurate clearance requires a painless examination in an alert, orientated patient with no distracting injury. Many ICU patients never fulfil these criteria and a risk benefit calculation has to be made. The consequences of converting a neurologically intact undiagnosed, unstable injury into a complete cord lesion are colossal. However, there is significant morbidity and mortality associated with treating all unconscious blunt trauma patients with universal spinal precautions. Many centres are now ‘clearing’ the c-spine of unconscious patients using a combination of cervical CT scans and plain radiological views.

Spinales Trauma

Every year, approximately 55,000 patients suffering from spinal trauma require hospital care in Germany. About 20% of these patients have symptoms of a spinal cord injury. It is important to know that vertebral column injury may be associated with spinal cord injury or not and that spinal cord injury may even occur without a lesion of the vertebral column. Pain and malposture are signs of vertebral column injury while a spinal cord lesion causes neuro-deficits, usually presenting as complete or incomplete transverse cord lesion. First aid calls for stabilization of blood pressure and pulmonary function. Additional damage to the cord should be avoided by immobilization. The application of steroids (methyl-prednisolone) is recommended according to the presently available evidence. The patient should be transferred to a center, in which all diagnostic and therapeutic facilities required for the management of spinal trauma are available. Currently, there are no evidence-based data favoring any treatment option. The outcome seems to be independent of surgical or non-surgical management. However, the advantage of surgical treatment is the early mobilization of the patient due to the immediate stabilization and a reduction of late complications.

Assessments of chronodispersion and tacheodispersion of F waves in patients with spinal cord injury.

To evaluate the chronodispersion and tacheodispersion of F waves in patients with spinal cord injury and to determine whether these parameters are more sensitive than those of standard F waves. F chronodispersion and F tacheodispersion as well as F wave latencies, amplitude, and persistence were measured in tibial nerves of 23 male patients with different scales of spinal cord injury and 23 normal subjects. Spasticity was measured and correlated with F chronodispersion in spinal cord injury patients. F chronodispersion of 6.4 +/- 1.9 msec (mean +/- SD) obtained in spinal cord injury patients was found to be significantly greater than the results of 3.9 +/- 1.6 msec in normal controls (P < 0.05). F chronodispersion was greater in spinal cord injury patients with complete cord lesion. A positive correlation was found between F chronodispersion and Ashworth Scores in spinal cord injury patients. There were no significant differences in minimal latency, amplitude, persistence of F waves, and F tacheodispersion between spinal cord injury patients and normal subjects. Measurement of F chronodispersion may provide a useful and sensitive electrophysiologic assessment in evaluation of spinal cord injury and serve as an evident tool for differentiating pathologic from normal state motoneuron excitability in spinal cord lesion.

Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center

Purpose: Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries. Methods: A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9½-year period (January 1991 through August 2000) was performed. Results: The mean age was 10.3 ± 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle-related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA. Conclusions: Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C-spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse. J Pediatr Surg 36:1107-1114. Copyright © 2001 by W.B. Saunders Company.

Characteristics of pediatric cervical spine injuries

The objective of this study was to assess the mechanisms and patterns of injury and outcome in children with cervical (C) spine trauma. We reviewed the National Pediatric Trauma Registry between April 1994 and March 1999 and identified (by ICD-9 criteria) all cases of blunt trauma victims with cervical fractures, dislocations, and spinal cord injuries without radiographic abnormality (SCIWORA). Data are shown as mean +/- SEM. During the 5-year period, the incidence of blunt C-spine injury was 1.6% (n = 408 of 24,740 total entries). Mean age was 10.5+/-0.3 (1 to 20) years, and 59% were boys. Leading mechanisms were motor vehicle accidents (n = 179; 44%), sports (n = 66; 16%), and pedestrian injuries (n = 57, 14%). Younger (< or =10 years) children more often sustained high (C1 to C4) vs low (C5 to C7) injuries (85% v 57%; P<.01) and also had a higher incidence of dislocations (31% v 20%; P<.01) and cord injuries (26% v 14%; P<.01), whereas older children had more C-spine fractures (66% v 43%; P<0.01). Mortality rates (overall, 17%) were higher in younger children (n = 180) when compared with older children (n = 228; 30% v 7%; P<.01). Overall, the majority of deaths (93%) were associated with brain injuries. No children with cervical dislocations had neurologic sequelae. The preponderance of children with fractures (83%) also were without neurologic injury, whereas those associated with SCIWORA usually were (80%) partial. Overall, complete cord lesions were infrequent (4%). These data, representing the largest series to date, confirm that blunt C-spine injuries in children are rare. Patterns of injury vary significantly according to child age. Major neurologic sequelae in survivors is uncommon, does not correlate well with cord level, and rarely is complete.

Vertebral artery occlusion after acute cervical spine trauma.

A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution. To determine the clinical and radiologic features of vertebral artery injury. Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine. Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury. The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage. Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.

The impact of contemporary bladder management techniques on struvite calculi associated with spinal cord injury

To evaluate the incidence, risk factors and complications of upper tract struvite calculi, often associated with spinal cord injury (SCI), as such patients have a high incidence of urinary infection complicating their neurogenic voiding dysfunction, by reviewing a large population of patients with SCI in whom modern techniques of bladder management were used. Between 1982 and 1996, 1669 patients with SCI were admitted to our institution; 1359 of these patients sustained their injuries during the study period. During this time, their bladder management was based on urodynamic and imaging criteria, using techniques such as early intermittent catheterization, sphincterotomy and bladder augmentation where possible to create a catheter-free, low-pressure reservoir. All instances of upper tract struvite calculi in this population were documented. Risk factors for stone development, presentation and complications, management and recurrence rates were assessed. Over the 15 years, 58 patients (3.5% of the SCI population) were treated for a total of 144 episodes of struvite calculi. The incidence of stones in those injured since 1982 was 1. 5%; 67% of these patients had complete spinal cord lesions, 54% had lesions of the cervical cord and 53% developed their first stone >10 years after injury. Only 22% presented within 2 years of injury. The group of patients developing stones had a significantly higher incidence of indwelling catheters (49%), bladder stones (52%) and vesico-ureteric reflux (28%) than those who were stone-free. The development of recurrent urinary tract infections was the most common mode of presentation. The stone-free rate after treatment was 87%. Normal renal function was preserved in 72% of patients. In a large population of patients with SCI managed using contemporary bladder techniques the incidence of upper tract calculi was 3.5%; 30% of these stones were complete or partial staghorns. Those patients with complete cord lesions, permanent indwelling catheters and vesico-ureteric reflux were at the highest risk. Stone clearance was 87% and recurrent stones occurred in 69% of patients. Struvite renal calculi continue to be a significant problem in the spinal cord injury population.

Spinal cord injuries in Australian footballers: 1986–1996

In the years 1896-1996, 82 Australian footballers were admitted to the Spinal Cord Injuries Units in Australia, there being two in New South Wales and one in each of the other States excluding Tasmania. All codes of football were encompassed by the retrospective review. On admission, 37 players had complete cord lesions and 45 incomplete ones. The information sought was identical to that presented in a previous study covering the years 1960-851 .

The Tetrafigap Survey on the long-term outcome of tetraplegic spinal cord injured individuals: Part I. Protocol and methodology.

The Tetrafigap Survey, a multicentre epidemiological survey on the outcome of tetraplegic spinal cord injured (TSCI) people from their first admission to a Rehabilitation Department or Centre is currently being undertaken in France. The general objective of this survey is to evaluate the situation of the TSCI people and their conditions of life in its medical, psychological and social aspects. This first article is aimed at presenting the protocol and the methodology of this survey. In a second part, yet to be submitted for publication, the preliminary results will be presented. It was first necessary to create a database of the population of TSCI people known to the centres and medical rehabilitation services, removing double entries. The criteria used for inclusion in the study were: a complete or incomplete traumatic cervical cord lesion, including post-surgical complications; age 16 or over at the time of the accident which must have occurred before December 31, 1992. The enquiry consisted of a self-administered questionnaire carried out with surviving tetraplegic people who had given their informed consent for their participation. The questionnaire consecutively covered the following topics: the situation at the time of the accident, the medical evolution between the accident and the end of stay in a rehabilitation unit, their evolution after discharge and the current situation (medical, social, professional and personal). During this first phase, 6082 TSCI people were identified by the collaborating centres. The 603 files of those who had died and 769 double entries were removed. Thus, 4710 questionnaires were sent out. The results of the participation show that 2251 people gave their consent and received questionnaires (340 additional deaths were acknowledged at this step). 163 refused, 869 were lost for follow-up, and 67 were excluded. There was no reply from 1020 people. We received 1830 questionnaires of which 1669 fulfilled all the necessary criteria for data exploitation. Home interviews with people who gave their consent will be carried out in a second phase as well as a study of deaths. A 5-year longitudinal follow-up is scheduled.

Anterior decompression and plate fixation in fracture dislocations of the lower cervical spine

Surgical treatment of unstable traumatic injuries of the cervical spine can be carried out by a posterior or anterior approach, with different advantages and disadvantages. Twenty patients were treated with anterior decompression, interbody fusion with autogenous iliac bone graft, and osteosynthesis with a Louis anterior plate. The screws were inserted in the vertebral body without reaching the posterior vertebral wall. There were 18 male and 2 female patients, aged between 18 and 66 years (average 36 years). The osteoarticular lesion was in 8 cases a tear-drop fracture and in 12 a fracture-dislocation. The mechanisms of injury were flexion-compression, flexion-rotation, hyperflexion, and hyperextension. A complete spinal cord lesion was present in 10 cases, central cord syndrome in 5, isolated radiculopathy in 3, and anterior cord syndrome in 1; one patient had normal neurological function. At long-term followup fusion of the graft was observed in all cases without evidence of spinal malalignment, breakage of the implant, or aseptic hardware loosening. Neurological deterioration was not observed in any case. In one case, complicated by late infection, healing was uneventful after plate removal, surgical debridement, and antibiotic therapy. A fistula of the hypopharynx due to perforation of the piriform recess appeared following repeated bronchoscopy 12 months after surgery. There were no signs of implant loosening and the lesion was surgically repaired. From a neurological point of view the 10 patients with complete cord lesion remained unchanged; those with incomplete cord lesions improved by 1 or 2 degrees on the Frankel scale; those with isolated radiculopathies recovered fully; and the neurologically intact patient remained unchanged. The present study and the data reported in the literature prove that anterior surgery with plate fixation in cervical spine injuries allows the achievement of complete neural decompression by direct visual examination. On the other hand, posterior surgery can result in incomplete decompression and associated neurological deterioration. Anterior plate instrumentation has proved itself mechanically adequate, even if it is less stable than posterior constructs. The advantages of anterior surgery compared to those of posterior surgery are such that several specific risks are acceptable. Posterior surgery is nevertheless indicated if the lesion cannot be reduced preoperatively under closed conditions.

The value of an aseptic intermittent catheterization program in the early management of spinal cord injury patients

From 1979 to 1989, 269 patients with spinal cord injury were managed by an aseptic intermittent catheterization program during the acute phase of their injuries at the Spinal Injuries Center. One hundred fifty one patients with incomplete cord lesion and 36 males with complete tetraplegia were managed by program I, which protects the shocked bladder from overdistention. In contrast, 82 patients with complete cord lesion excluding male tetraplegia were managed by program II, which allows overdistention of the bladder. Of the 187 patients managed by program I, 137 (73.3%) achieved trigger voiding function, 61.3% of whom were completely dry. Of the 82 patients managed by program II, 62 (75.6%) were put to self- or assisted catheterization, 67.7% of whom were dry. The incidence of a grade I, which means normal bladder configuration, was 88.0% for program I and 87.3% for program II during the follow up course. Upper urinary tract deterioration occurred in only one case. Surgical treatment for urinary tract complications was performed in 14 cases (5.2%). These results suggest that the patients with incomplete cord lesion managed by non-distension regimen of the bladder (program I) and those, especially female, with complete cord lesion managed by overdistention regimen of the bladder (program II) achieve urinary continence with excellent urinary prognosis.

Electromyographic registration of diaphragmatic fatigue during sustained trunk flexion in cervical cord injured patients.

When performing forward trunk flexion, cervical cord injured (CCI) patients exhibit continuous and high EMG activity in the diaphragm and elevated abdominal pressures. This study addressed the question whether the trunk flexion manoeuvres cause such a high force development in the diaphragm that this muscle shows EMG signs of fatigue. Six patients with complete cervical cord lesions were tested sitting in their own wheelchairs. The tension-time indices obtained when patients were sitting in a relaxed position were moderately to markedly higher than in normal subjects. The force developed during trunk flexion averaged 30% of the maximal transdiaphragmatic pressure and was accompanied by clear EMG findings of diaphragmatic fatigue in all patients except one. The acute diaphragmatic load in certain CCI patients may well produce ischaemia and increase the risk of tissue impairment. Therefore, there appears to be a need for differing strategies in the short and in the long term treatment of CCI patients; longitudinal evaluation of main diaphragmatic function may be useful for an adequate amount of respiratory muscle training.

Short-latency somatosensory evoked potentials (SSEPs) of the tibial nerves in spinal cord injuries.

Stimulations of the tibial nerves of 76 spinal cord injured patients revealed short-latency somatosensory evoked potentials (SSEPs) especially P37 recorded from the scalp. The SSEPs findings can be classified by degrees of impairment into 5 different types as follows: Type 1: Absence of P37. This was found in all patients with complete cord lesions as well as patients with loss of joint sense. Type 2: Decreased amplitude and prolonged latency. This was elicited in patients with moderate to severe central cord lesions. Type 3: Prolonged latency only. Type 4: Decreased amplitude only. Type 5: Normal P37, which was mostly seen in patients with mild central cord lesion. The study demonstrated that SSEPs of the tibial nerves are related to joint sense and seem to relate to the extent of cord damage, especially of central cord and complete cord lesions. It can be done as early as during the first week post injury, particularly in an uncooperative patient suspected of having spinal cord injury, in which case the clinical assessment may be difficult and unreliable.

Urinary Tract Infections in Spinal Cord Injury Patients Undergoing Intermittent Catheterization Procedures

A prospective study was organized to assess whether feeding back infection rates to staff performing intermittent catheterization in spinal cord-injured patients would produce a fall in urinary tract infection rates. Over a 12 month period, infection rates for such procedures were reported to unit staff: reporting was combined with educational programs emphasizing aseptic catheterization techniques and the importance ofhandwashing. Overall infection rates for the 12 month period were 13.3 per 1000 days of intermittent catheterization - unchanged from the preceding six months (15.1 per 1000 days) by retrospective chart review. Likewise, there was no statistically significant downward trend during the prospective phase of the study. A wide variety of infecting organisms were found, of whichKlebsiellaspecies (39%),Escherichia coli(18%) andEnterobacterspecies (17%) were most common: most infections were asymptomatic. Patients with complete cord lesions at or above the sixth thoracic spinal cord segment (T6) had a much higher incidence of infection (73%) than those with incomplete lesions below T6 (33%).

非骨傷性頚髄損傷の臨床的検討

The pathogenesis, prognosis and proper treatment of the cervical spinal cord injury have not yet been resolved. In order to make these problems clear, we analysed our 22 cases.These consisted of 20 males and 2 females with the average of 54.1 years old. The types of injury contained 1 case of complete cord lesion, 7 cases of anterior cord injury, 11 cases of central cord injury and 3 cases of Brown-Sequard syndrome. More than half of the cases suffered from hyperextension injury, and especially, most of the central cord injury cases suffered from it.As to the treatment, 17 cases were treated conservatively, while 5 cases underwent operative treatment. Anterior decompression and fusion by Cloward's method was performed in 2 cases of traumatic disc herniation, and laminectomy and/or laminoplasty was done in 3 cases of having OPLL.As for the prognosis, 1 case of complete cord lesion died. In the 21 cases of imcomplete cord lesion, two-step improvement on Frankel's classificarion was seen in 2 cases, both of which belonged to central cord injury, one-step improvement in 17 cases, and no improvement in 2 cases. There was no significant prognostic difference between conservative therapy and operative treatment.

Myelotomy for Acute Cervical Cord Injury

Four cases of acute cervical cord injury treated by posterior midline myelotomy are described. The initial neurological examinations of these four patients indicated complete cord lesions. On plain neck X-rays, two exhibited anterior dislocation and two showed no bony injury other than ossification of the posterior longitudinal ligament. Myelography via C1/2 lateral puncture showed complete block of the subarachnoid space in two cases, and incomplete block in the other two. Computed tomographic myelography revealed cord swelling in all cases. Posterior midline myelotomy was performed after administration of a steroid and mannitol, or reduction of spinal dislocation. The time from injury to myelotomy ranged from 5 to 21 hours. No patient developed new deficits postoperatively. During long-term follow-up, which ranged from 10 to 19 months, all patients showed improvement in motor function of the upper extremities. Sensory disturbances also diminished to some degree. However, in one patient, who underwent myelotomy 18 hours after injury and had shown progressive neurological deterioration before surgery, the improvement in motor function was only slight. In this case, earlier myelotomy may have been more beneficial. These results support the indication for myelotomy in cases of acute cervical cord injury with cord swelling. Particularly if performed early, this procedure is effective in preventing secondary neurological damage.