Complete Paraplegia Research Articles

Perioperative complications and risk factors of one-stage posterior vertebral column resection for severe spinal deformity

Objective To investigate the perioperative complications and risk factors of one-stage posterior vertebral column resection (VCR) for severe spinal deformity.Methods From September 2004 to July 2012,39 patients with severe and fixed spinal deformity underwent one-stage posterior VCR,including 15 males and 24 females,aged from 3 to 53 years (average,16.9 years).There were 24 cases of kyphoscoliosis (mean coronal Cobb angle:85.1°,mean sagittal Cobb angle:92.9°),7 cases of scoliosis (mean coronal Cobb angle:81.1°),and 8 cases of kyphosis (mean sagittal Cobb angle:94.4°).Eleven patients had neurological compromise.The perioperative complications and related risk factors of 39 patients were retrospectively analyzed.Results All patients were followed up for 3 to 72 months (average,29.4 months).There were 15cases (13 patients) of perioperative complications.Neurological complications occurred in 6 patients (15.4％),among whom one patient presented complete paraplegia after surgery and 5 patients presented transient paresthesia or muscle weakness.Adults had a significantly higher incidence of neurological complications than teenagers.The incidence rate of neurological complications was 36.4％ in patients with preoperative neurological compromise,while 7.1％ in patients without preoperative neurological compromise.All patients with postoperative neurological complications had kyphosis before operation,and the incidence of neurological complications increased significantly in patients with severe kyphosis (Cobb angle ≥90°).Prolonged respiratory support was conducted in 4 cases.Rupture of the parietal pleura occurred in 3 cases (7.7％),cerebrospinal fluid leak in 1 case (2.6％),and pulmonary infection in 1 case (2.6％).Conclusion One-stage posterior VCR is effective in the treatment of severe and rigid spinal deformity.However,the perioperative complications,especially the neurological complications are common.The risk factors of neurological complications include preoperative neurological compromise,degree of kyphosis and the age of patients. Key words: Scoliosis; Kyphosis; Intraoperative complications; Risk factors

Delayed paraplegia due to “surgiceloma” following thoracotomy for a Pancoast tumor

Dear Editor, Oxidized regenerated cellulose (ORC, Surgicel®, Ethicon Inc.) is widely used as a hemostatic fleece. The manufacturer recommends removing as much ORC as possible before closure. As one of the possible complications of its use, postoperative neurological compression symptoms caused by so-called “surgiceloma” have been described in the spine [1] and brain [2, 4]. Since this entity regularly occurs despite better knowledge, we would like to share our experience with a catastrophic complication following the inappropriate use of ORC in spinal surgery. A 54-year-old male underwent posterolateral thoracotomy for a Pancoast tumor T4N0M0 of the right upper pulmonary lobe with infiltration of the vertebral body of Th2 at another institution. The patient awoke from surgery without neurological deficits. On postoperative day 1, he fell asleep in the afternoon and woke up with paraplegia and complete sensory loss in his right leg. An emergencyMRI showed a mass lesion within the spinal canal at the Th2 level (Fig. 1a) whereupon the patient was transferred to our department for neurosurgical treatment. After a Th2-Th3 laminectomy (Fig. 1b), we found ORC material compressing the spinal cord from the right side and penetrating the dura, creating a cerebrospinal fluid (CSF) leak. A postoperative MRI showed the sequelae of the compression as an intramedullary hyperintense signal on T2-weighted imaging at the Th2-Th3 level (Fig. 1c). The patient was sent to rehabilitation with some recovery in the left leg. He died 1 year later because of the progression of the underlying oncological disease. We found 17 (N=17) reports of delayed neural compression due to ORC after a comprehensive MEDLINE search, and we would like to summarize the most salient features. Almost half of the described procedures (8/17=47 %) were thoracotomies at vertebral levels Th3 to Th8 for resection of neoplasms in adults. Three pediatric cases of thoracic surgery that resulted in neural compression syndromes due to ORC were also reported. Median time to symptom discovery was at 30 h postoperatively. The delayed occurrence of symptoms indicates that neurological deficits were not due to inadequate application of pressure on neural structures, but due to delayed swelling of the hemostatic material that was left in place and subsequent migration of material into the spinal canal via the neuroforamen. Eleven out of 17 patients (64 %) already had complete paraplegia at the time of reoperation. This indicates that by the time of symptom onset, the damage to the spinal cord is almost irreversible and decompression—if at all—only partly attenuates the damage. Hemostatic agents can be hypointense on T1and T2weighted imaging and may therefore be indistinguishable from (1) epidural hematoma or (2) a herniated disc on MRI [3]. In most of the literature, the “surgiceloma” was described as an extradural mass. While careful hemostasis during spinal and thoracic procedures is mandatory, it is also necessary to remain mindful of the amount of hemostatic materials we leave in situ. Removal of hemostatic fabric after successful hemostasis can prevent debilitating complications.

Hybrid procedures for thoracoabdominal aortic aneurysms and dissections

Background Hybrid procedures including debranching of visceral and renal arteries followed by endovascular exclusion of the thoracoabdominal aortic aneurysm (TAAA) have recently been proposed as a less invasive alternative to conventional TAAA surgery. This study aimed to evaluate the immediate and long-term outcomes of hybrid procedures for TAAA in high-risk patients. Methods Between September 1998 and May 2012, 32 high-risk TAAA patients (five females, median age 61.5 years) underwent hybrid procedures at a single institution. Simultaneous approach and staged approach were performed on the basis of patients' conditions. Follow-up computed tomography angiography (CTA) was routinely performed before discharge and at 6, 12 months and annually thereafter. Results Procedural success was achieved in all cases. The median hospital stay was (21.5P2.3) days, and the median procedure time was (420231) minutes. Blood loss averaged (21003261) ml. A total of 124 visceral artery bypasses was performed. Two patients (6.3%) died within 30 days. One patient exhibited complete paraplegia (3.1%). The visceral graft patency was 96.1% at 3 years. All-cause survival rates were 93.8%, 87.5%, 81.3% and 53.1% at 1, 2, 3 and 5 years, respectively. No patient died due to aortic events. The freedom rates from aortic events were 96.9%, 93.6%, 87.5%, 68.8% at 1, 2, 3 and 5 years, respectively. Conclusions The results of visceral hybrid repair for high-risk patients with complex TAAAs are encouraging. However, the procedure is still a significant physiological insult to patients. Until branched and fenestrated endovascular repair become more common, hybrid procedure will continue to have a role in high-risk patients.

Glycogen synthase kinase-3β inhibitor (TDZD-8) promotes axonal regeneration and functional recovery of hind limbs after spinal cord injury in rats

Objective To explore the effect of glycogen synthase kinase-3β(GSK-3β) inhibitor (TDZD-8) on axonal regeneration and functional recovery of hind limbs after spinal cord injury (SCI) in rats.Methods Animal models of complete paraplegia at T9 level were nade in 108 adult female Sprague-Dawley rats which were subjected to weight-drop impact before they were randonly divided into even 3 groups.(Group A was treated with 1 mg/(kg · d) TDZD-8,group B with 60 μL/d PBS and group C was set as blank controls.All agents were respectively injected through subarachnoid catheters implanted via L4 at one hour after SCI and the injections lasted for 3 weeks.The expressions of GAP-43 were measured respectively by SP immunohistochemical staining on 7.14 and 28 days after injection.The expressions of neuronal apoptosis were observed respectively by TUNEL staining at 2,4,8,24 hours and 7 days after injeetion.The motor function of hind limbs in each group was evaluated bv Basso-Beattie-Bresnahan (BBB) scores at 1.2,3,6,8 and 12 weeks respectively after injection.Axonal regeneration was evaluated by immunofluorescence staining at 8 weeks respectively after iujection.Results The expressions of neuronal apoptosis were detected at 2 hours after SCI,and rose to the peak at 8 hours before they gradually decreased.The apoptotic cells in group A were significantly lower than in groups B and C (P ＜ 0.05) at all time points.The expressions of GAP-43 were increased gradually after SCI and rose to the peak on the 14 days before they gradually decreased.The GAP-43 expressions in group A were significantly higher than in groups B and C at all time points (P ＜ 0.05).The BBB scores in group A were significantly higher than in groups B and C from 3 weeks after injection (P ＜O.05).More regeneration neurofibers extended through the lesion area in group A while few neurofibers did in groups B and C.At 8 weeks after injection,the positive fiber area of corticospinal tracts was significantly larger in group A than in the other 2 groups (P ＜ 0.05).Conclusion TDZD-8 may inhibit neuronal apoptosis,reduce secondary spinal cord injury,up-regulate the expression of GAP-43,promote axonal regeneration and ameliorate function recovery of hind limbs in rats. Key words: Spinal cord injuries; Enzyme inhibitors; Apoptosis; Recovery of function

Involuntary muscle spasm expressed as motor evoked potential after olfactory mucosa autograft in patients with chronic spinal cord injury and complete paraplegia

Object: The efficacy of olfactory mucosa autograft (OMA) for chronic spinal cord injury has been reported. New activity in response to voluntary effort has been documented by electromyography (EMG), but the emergence of motor evoked potential (MEP) reflecting electrophysiological conductivity in the central nervous system, including the corticospinal pathway, after OMA, and the best indications for OMA, have not been clarified. Here, we report the emergence of MEPs after OMA and offer recom-mendations for appropriate indications based on the presence of involuntary muscle spasm (IMS). We used analysis of MEP to examine the efficacy of OMA for patients with complete paraplegia due to chronic spinal cord injury. To clarify the indications for OMA, we investigated the association of IMS and efficacy of OMA. Methods: Four patients, 3 men and 1 woman, were enrolled. The mean age of the cases was 30.3 ± 9.5 years (range, 19 to 40 years). All 4 cases were American Spinal Injury Association (ASISA) grade A. The mean duration from injury to OMA was 95.8 ± 68.2 months (range, 17 to 300 months). Samples of olfactory mucosa were removed, cut into smaller pieces, and grafted into the sites of spinal cord lesions after laminectomy. Postoperative subcutaneous fluid collection, postoperative meningitis, postoperative nosebleed, postoperative infection in the nasal cavity, impaired olfaction, neoplastic tissue overgrowth at the autograft site, new sensory disturbance, and involuntary muscle spasm were investigated as safety issues. Improvements in ASIA grade, variations in ASIA scores, EMG, SSEP, and improved urological function were evaluated as efficacy indicators. Results: There were no serious adverse events in this series. In 2 of the 4 cases, an improvement in motor function below the level of injury was recognized. In one, the motor score was 50 until 16 weeks after surgery, and it increased to 52 from 20 weeks after surgery. In the other, the motor score was 50 until 20 weeks after surgery, and it increased to 52 at 24 weeks after surgery with a further increase to 54 at 48 weeks after surgery. The emergence of MEP was recognized in the latter case at 96 weeks after surgery. The other 2 cases had no improvement in ASIA motor score. Both of these cases who showed improvements in the ASIA motor scores exhibited relative IMS compared with those who had no ASIA motor score recovery. Conclusions: We recognized the emergence of MEPs in a case with complete paraplegia due to chronic spinal cord injury after OMA. IMS might be a candidate of indication of OMA.

Emergency Closed Reduction of a C4/5 Fracture Dislocation with Complete Paraplegia Resulting in Profound Neurologic Recovery

Introduction. Cervical spinal cord injuries due to traumatic fractures are associated with persistent neurological deficits. Although clinical evidence is weak, early decompression, defined as <24–72 h, has been frequently proposed. Animal studies show better outcomes after early decompression within one hour or less, which can hardly ever be achieved in clinical practice. Case Presentation. A 37-year-old patient was hospitalized after being hit by a shying horse. After diagnosis of C4/5 fracture dislocation and complete paraplegia, she was intubated and sedated with deep relaxation. Emergency reduction was performed at approximately 120 minutes after trauma. Subsequently, a standard anterior decompression, discectomy, and fusion were carried out. She was then transferred to a specialized rehabilitation hospital. Her neurologic function improved from AIS grade A on admission to grade B postoperatively and grade D after four months of rehabilitation. One year after the accident, she was ambulatory without walking aids and restarted horse riding. Discussion and Conclusion. Rarely in clinical practice, decompression of the spine canal can be performed as early as in this case. This case highlights the potential benefit of utmost early reduction in cervical fracture dislocations with compression of the spinal cord.

Comparison of Arm-Trunk Movement between Complete Paraplegic and Able- Bodied Subjects during Circle Drawing

Abstract Study design : This study was a cross sectional, controlled trial. Objectives: To examine the performance of repetitive circle drawing on dynamic sitting balance between subject with spinal cord injury (SCI) and age-matched able-bodied (AB) adults. Summary of background data : Previous studies showed that the dynamic sitting balance is impaired in SCI. However, the arm-trunk coordinated movement for different directions in seated SCI has not been examined yet. Methods: Twelve subjects with complete T7-T12 thoracic cord injury (mean age: 36.3 ± 3.0 years) and 12 age- matched AB adults were recruited. Subjects performed 10 repetitive circle drawing at seated position. The three- dimensional motion system (Vicon) was used to measure shoulder, trunk and pelvic angles at sitting position. Results : The SCI group displayed an arm-trunk movement with a significantly larger shoulder adduction/ abduction angle (p<0.001), but less trunk flexion/extension, pelvic anterior/posteriortilt and pelvic rotation angles than AB controls (p<0.05, p<0.001, and p<0.001, respectively). Conclusions: The small circle drawing is feasible to detect the compensatory movement of shoulder for the impairment of trunk and pelvic control in thoracic SCI. Furthermore, the assistance and guidance of trunk and pelvic movements is important for the arm-trunk coordinated movement in thoracic SCI.

Rehabilitation Outcomes of Persons with Complete Paraplegia at a Private Rehabilitation Hospital

In order to overcome activity limitations, prevent secondarycomplications and early death and achieve community integration comprehensiverehabilitation post spinal cord injury (SCI), is essential. The aim ofthe study was to evaluate outcomes of patients with complete paraplegia whoreceived rehabilitation at a private rehabilitation hospital.A quantitative, descriptive methodology was implemented. All patientswith complete, traumatic, thoracic spinal cord injuries, admitted to the studyhospital in the study period, were consecutively sampled. Thirty five patientswere identified of whom16 adhered to the inclusion criteria. The FunctionalIndependence Measure (FIM ) and Needs Assessment Checklist (NAC) wereused as measuring instruments.The mean length of stay was 95 days. Discharge FIM motor scores ranged from 72 to 83 with a mean of 79.3. Themean gain in FIM motor score was 55 and varied from 45 to 61. Discharge NAC scores ranged from 264 to 340 with amean of 300 out of a possible 347. A correlation between length of stay and discharge FIM scores (p = 0.05) were found.Both NAC and FIM scores indicated high levels of physical independence. According to NAC scores patients wereeducated on the prevention of secondary complications and received psychological counselling. Discharge planningand community integration scored lower with means of 80% and 61% respectively. Community based completionof rehabilitation programmes, the incorporation of the NAC, or another participation outcome measure and implementationof on-going programme monitoring and assessment strategies is recommended.

Motor Recovery after Spinal Cord Injury Enhanced by Strengthening Corticospinal Synaptic Transmission

The corticospinal tract is an important target for motor recovery after spinal cord injury (SCI) in animals and humans. Voluntary motor output depends on the efficacy of synapses between corticospinal axons and spinal motoneurons, which can be modulated by the precise timing of neuronal spikes. Using noninvasive techniques, we developed tailored protocols for precise timing of the arrival of descending and peripheral volleys at corticospinal-motoneuronal synapses of an intrinsic finger muscle in humans with chronic incomplete SCI. We found that arrival of presynaptic volleys prior to motoneuron discharge enhanced corticospinal transmission and hand voluntary motor output. The reverse order of volley arrival and sham stimulation did not affect or decreased voluntary motor output and electrophysiological outcomes. These findings are the first demonstration that spike timing-dependent plasticity of residual corticospinal-motoneuronal synapses provides a mechanism to improve motor function after SCI. Modulation of residual corticospinal-motoneuronal synapses may present a novel therapeutic target for enhancing voluntary motor output in motor disorders affecting the corticospinal tract.

Spinal Artery Thrombosis: An Unrecognized Severe Complication in Thalassemia and Sickle Disorders

AbstractAbstract 1155 Introduction.Anterior spinal artery thrombosis (AST) results in sudden, often irreversible sensory and motor loss, with partial or complete paraplegia. This is recognized as a complication of: prothrombotic states; right to left shunting; trauma and spinal surgery. Both venous and arterial thrombosis, including the central nervous system, are well-recognized risks in sickle cell disease (SCD) but AST has not been described. In thalassemia disorders (Thal), cerebral infarction, often silent, is increasingly recognized (Mussalam et al, Thromb Res, Aug 2012). However AST is not a recognized complication. Here we describe four cases of acute onset AST in adults (3 Thal major, 1 SCD), leading to severe neurological irreversible or partially reversible deficits. Patients and Methods.Patients described were attending outpatients for monitoring drawn from two large adults clinics in the UK (UCLH, Whittington, over 1500 hemoglobinopathy patients) and Italy (Ospedale Maggiore Policlinico, Milan, 400 patients). All events occurred within a 3 year period. Results.Presenting symptoms and Magnetic Resonance Imaging (MRI) findings are shown in the Table. All cases presented acutely with a sensory level on examination and with bladder dysfunction. Three presented with motor weakness of both lower limbs (1 case initially in one limb). Case 3 presented with a sensory deficit affecting the sacral region but no motor deficit. Partial reversibility occurred in cases 1 and 3. In Thal cases, no prodromal syndrome and no prior history of thrombosis were seen. MRI showed changes consistent with acute cord ischemia (delayed in case 4 until 5 days). Extra-medullary hematopoiesis was demonstrated by MRI only in case 2, but was not sufficient to cause cord compression. Cerebrospinal fluid analysis was normal in all cases. Concomitant risk factors such as autoimmune markers, active hepatitis, trauma, or demonstrable prothrombotic markers other than those expected in SCD or Thal were not detected. In none of the Thal cases was a thrombotic history elicited but the SCD patient had a history of retinal artery and renal artery thrombosis (1 year previously). Discussion.A case series of this serious complication has not been previously reported. The known prothrombotic tendency in SCD and Thal is the most likely risk factor as other risk factors were absent. Thal cases were transfusion dependent, where thrombosis risk is generally about a quarter of that in non transfusion dependent Thal (Cappellini, Blood Reviews, 265, 2012, S20–23). In the SCD case, the prior history of arterial thrombosis, consistent with an embolic etiology, led us to examine whether a patent foramen ovale (PFO) was present, which was confirmed by bubble jet studies. This was subsequently closed. In patients with a history of embolic thrombosis, the presence of PFO should be sought and closure considered. Two cases were treated with Methylprednisolone soon after presentation. Two cases were commenced on Aspirin 75mg once a day to limit extension and as secondary prevention. The use of thrombolytic agents such as tissue thromboplastin activator have not been described in AST. In conclusion, spinal cord ischemia should be considered when facing a Thal or SCD patient with acute neurological symptoms affecting legs or bladder. This may be more common in hemoglobin disorders than is apparent from the literature.TableCase 1Case 2Case 3Case 4Age at presentation24373227GenderMaleMaleFemaleFemaleDiagnosisSCDThal MajorThal MajorThal MajorPresentation symptomsBilateral leg weakness ParaparesisParaplegia Urine retentionSacral paraesthesia Urine retentionLower limb pain paraesthesia, & weakness Urine retentionMRI findingsFusiform cord swelling (T9, T10) Secondary to ischemiaHigh T2 signal (T6 to conus) Swollen cord from T9Low cord signal(T11 - T12) Intramedullary syrinx (T4/5 - T7/8)1stScan: normal Repeat: High T2 posterior dorsal signal to T9 Conus medullary edemaExtramedullary haematopoiesisNoYes but no cord compressionNoNoHb (g/L)8013211389Plt (× 109/L)451191474438WBC (× 109/L)12.75.112.77.7NRBCs (%)0.39NDND0.5TransfusionNoYesYesYesLast transfusionNone− 2 days− 19 days− 20 daysSplenectomyNoNoYesNoPrior thrombosisYesNoNoNoOther risk factors*NoNoNoNoND = not detected.*Autoimmune markers, active hepatitis C, prothrombotic screen - non contributory. Disclosures:Cappellini:Novartis Pharmaceuticals: Research Funding.

There is no evidence for an association between the serotonin receptor 3A gene C178T polymorphism and tardive dyskinesia in Korean schizophrenia patients

Background: Tardive dyskinesia (TD) is a potential adverse effect of long-term treatment with antipsychotics. Previous studies have suggested a link between brain serotonergic systems and TD vulnerability. A recent report described that a serotonin 3 receptor (5-HTR3) agonist induced rhythmic movements in mice with complete paraplegia. Furthermore, it has been reported that the 5-HTR3 antagonist ondansetron is efficacious in the treatment of Gilles de la Tourette syndrome (GTS). Aim: The aim of the present study was to determine whether the 5-HTR3A gene C178T polymorphism is associated with antipsychotic-induced TD in Korean schizophrenia patients. Methods: We investigated 280 Korean schizophrenia patients. Subjects with TD (n = 105) and without TD (n = 175) were matched for antipsychotic drug exposure and other relevant variables. Results: The distributions of genotypic (chi-squared = 3.55, p = 0.169) and allelic (chi-squared = 0.40, p = 0.528) frequencies did not differ between patients with and without TD. The total score on the Abnormal Involuntary Movement Scale also did not differ between the two genotype groups (F = 0.94, p = 0.391). Conclusions: The findings of the present study do not support the involvement of the 5-HTR3A gene C178T polymorphism in TD in Korean schizophrenia subjects.

Relationship of occupational therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project

Background/objectiveDescribe associations of occupational therapy (OT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and 1-year post-injury.MethodsOccupational therapists at six inpatient rehabilitation centers documented detailed information about treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary for a 75% subset; models were validated with the remaining 25%. Functional outcomes for injury subgroups (motor complete low tetraplegia and motor complete paraplegia) also were examined.ResultsOT treatment variables explain a small amount of variation in Functional Independence Measure (FIM) outcomes for the full sample and significantly more in two functionally homogeneous subgroups. For patients with motor complete paraplegia, more time spent in clothing management and hygiene related to toileting was a strong predictor of higher scores on the lower body items of the self-care component of the discharge motor FIM. Among patients with motor complete low tetraplegia, higher scores for the FIM lower body self-care items were associated with more time spent on lower body dressing, manual wheelchair mobility training, and bathing training. Active patient participation during OT treatment sessions also was predictive of FIM and other outcomes.ConclusionOT treatments add to explained variance (in addition to patient characteristics) for multiple outcomes. The impact of OT treatment on functional outcomes is more evident when examining more homogeneous patient groupings and outcomes specific to the groupings.NoteThis is the third of nine articles in the SCIRehab series.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Background/objectiveExamine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury.MethodsPhysical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia.ResultsPT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of “walk” or “both (walk and wheelchair)” on the discharge motor FIM for patients with AIS D injuries.ConclusionInjury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings.NoteThis is the second of nine articles in the SCIRehab series.

PAINLESS AORTIC DISSECTION WITH INITIAL SYMPTOMS OF PARAPLEGIA AND ACUTE RENAL FAILURE: A CASE REPORT

PAINLESS AORTIC DISSECTION WITH INITIAL SYMPTOMS OF PARAPLEGIA AND ACUTE RENAL FAILURE: A CASE REPORT

Autotransplanting of Bone Marrow-Derived Mononuclear Cells for Complete Cases of Canine Paraplegia and Loss of Pain Perception, Secondary to Intervertebral Disc Herniation

Severe intervertebral disc herniation causes complete paraplegia and loss of pain sensation in canines. The prognosis is poor, even when decompression surgery is performed immediately after onset. Studies suggest that bone marrow-derived mononuclear cells will regenerate the injured spinal cord and restore neurologic function. This study was conducted to assess the clinical efficacy of bone marrow-derived mononuclear cell autotransplanting in severe cases of canine intervertebral disc herniation. Eighty-two dogs (miniature dachshunds) with severe thoracolumbar intervertebral disc herniation were used. All had intervertebral disc herniation accompanied by paraplegia and loss of pain perception. In 36 dogs, bone marrow-derived mononuclear cells were autotransplanted to the lesioned spinal cord immediately after decompression surgery. Bone marrow was collected from the proximal humerus and subjected to density gradient centrifugation to isolate the bone marrow-derived mononuclear cells. The remaining 46 dogs (receiving surgical treatment only) were assigned as controls. Therapeutic efficacy was compared based on the rate of ambulatory recovery. Ambulatory recovery was observed in 88.9% and 56.5% of animals in the bone marrow-derived mononuclear cells and control groups, and a significant difference was found. No complications were found in bone marrow-derived mononuclear cells group. Bone marrow-derived mononuclear cell transplanting revealed a significant increase in the recovery rate and, as has been reported in rats and humans, bone marrow-derived mononuclear cell autotransplanting shows efficacy in canines as well.

Weight Bearing Through Lower Limbs in a Standing Frame with and Without Arm Support and Low-Magnitude Whole-Body Vibration in Men and Women with Complete Motor Paraplegia

The aim of the study was to determine the proportion of body weight borne through the lower limbs in persons with complete motor paraplegia using a standing frame, with and without the support of their arms. We also examined the effect of low-magnitude whole-body vibration on loads borne by the lower limbs. Vertical ground reaction forces (GRFs) were measured in 11 participants (six men and five women) with paraplegia of traumatic origin (injury level T3-T12) standing on a low-magnitude vibrating plate using a standing frame. GRFs were measured in four conditions: (1) no vibration with arms on standing frame tray, (2) no vibration with arms at side, (3) vibration with arms on tray, and (4) vibration with arms at side. GRF with arms on tray, without vibration, was 0.76 ± 0.07 body weight. With arms at the side, GRF increased to 0.85 ± 0.12 body weight. With vibration, mean GRF did not significantly differ from no-vibration conditions for either arm positions. Oscillation of GRF with vibration was significantly different from no-vibration conditions (P < 0.001) but similar in both arm positions. Men and women with paraplegia using a standing frame bear most of their weight through their lower limbs. Supporting their arms on the tray reduces the GRF by approximately 10% body weight. Low-magnitude vibration provided additional oscillation of the load-bearing forces and was proportionally similar regardless of arm position.

Acute Normovolemic Hemodilution Can Aggravate Neurological Injury After Spinal Cord Ischemia in Rats

Acute normovolemic hemodilution (ANH) is currently performed during thoracoabdominal aortic surgery. However, the effects of ANH on spinal cord ischemic injury are currently unknown. Because hemodilution below a certain level of hematocrit (Hct) aggravates the neurological damage after cerebral ischemia, we hypothesized that ANH may increase neurological damage after spinal cord ischemia. The aim of these experiments was to determine the effects of ANH on spinal cord ischemic injury. Thirty male Sprague-Dawley rats were randomly assigned to 1 of the following 3 groups: no hemodilution (group C), target Hct level of 30% (group HD30), and target Hct level of 25% (group HD25). ANH was performed upon withdrawal of blood and simultaneous replacement with the same volume with hydroxyethyl starch. Spinal cord ischemia and reperfusion were induced by using a balloon-tipped catheter placed in the descending thoracic aorta, and changes in mean arterial blood pressure were recorded. Neurological function of the hindlimbs was evaluated for 7 days and recorded using a motor deficit score (MDS) (0 = normal; 5 = complete paraplegia). The number of motor neurons within the spinal cord was counted after final MDS evaluation. Group HD25 developed hypotension during the latter part of the ANH procedure. Group C and group HD30 experienced 3 minutes of reperfusion hypotension, whereas 6 minutes of hypotension was observed in group HD25. Two rats in group HD25 died during the experimental period. Seven days after reperfusion, the MDS of group C, group HD30, and group HD25 was 1.0 (0.5-2.0), 1.0 (0.5-2.0), and 4.0 (2.8-4.2) (median [95% confidence interval]), respectively. Group HD25 showed significantly higher MDS compared with group C (corrected P = 0.0018; 95% CI for median difference = 1.0-3.5). Motor neuron numbers in the anterior horns of group C, group HD30, and group HD25 were 26.5 (25.0-27.5), 23.5 (22.0-26.5), and 12.5 (8.4-16.6) (median [95% CI]), respectively. Motor neuron numbers of group HD25 were significantly lower than those of group C (corrected P < 0.0001; 95% CI for median difference = 9.0-18.0). The results of the present study indicate that intraoperative ANH to an Hct of 25%, combined with coincident hypotension, caused a delayed recovery of baseline mean arterial blood pressure during the reperfusion period and aggravated neurological outcome after spinal cord ischemia.

Should post-traumatic thoracolumbar Frankel A paraplegia be operated as an emergency? Report of three cases and review of the literature

Spinal cord injury is an important contributing factor to morbidity. The thoracolumbar junction is a highly vulnerable axial region due to the biomechanical stresses and the risk of conus medullaris injuries in some cases. In the event of an incomplete neurological injury and if the patient's condition is stable, emergency surgical treatment should be considered. Yet, no clear consensus has emerged regarding the treatment modalities of complete injuries but surgical management is advocated to maximize neurological recovery and reduce the risk of decubitus ulcer formation. We report on the cases of three patients with L1 Frankel A paraplegia resulting from injury to the conus medullaris, treated within the first 6 hours from injury and demonstrating a very satisfactory neurological recovery since independent walking could be resumed at 2.5 years follow-up. Persistent urinary sphincter dysfunctions were observed in two of these patients. Early surgical management appears as an important predictive factor for neurological recovery in conus medullaris injuries. We believe that delayed surgical management in patients with complete paraplegia could be an inappropriate treatment option, which should be further studied.

Abstract P313: De-Conditioning Adversely Affects Subclinical Atherosclerosis in a Unique Cohort of Spinal Cord Injury

Introduction: Physical activity is presumed to improve cardiovascular disease (CVD), of which carotid artery intima-media thickness (CIMT) is a common indicator. Individuals with spinal cord injury (SCI) have limited mobility and therefore an expected increased risk for CVD. The purpose of this study was to determine which CVD risk factors predict CIMT among women with SCI, with the ultimate goal of targeting therapy to improve CVD in this population. Methods: One hundred twenty-two women with SCI who attended an outpatient SCI clinic and met inclusion and exclusion criteria participated in this study. SCI was categorized into 1 of 4 categories: complete tetraplegia, incomplete tetraplegia, complete paraplegia, and incomplete paraplegia. Maximum heart rate and VO2 max were obtained using bicycle ergometry with ventilatory gas exchange and continuous electrocardiogram. Hierarchical regression was used to predict CIMT, with the first block including demographic variables (age, race, smoking status) and the second block including physiologic variables (total cholesterol, heart rate, VO2 max, BMI, fasting serum glucose, hemoglobin A1c, and blood pressure). Results: Similar findings were observed for left and right CIMT, therefore only results from right CIMT are reported. The overall model was significant, F(16,46)=8.53, p=.000. Adjusted R square was .54 for the first block of variables and increased significantly (p=.006) to .66 when the second block of variables was added. Significant predictors at alpha=.05 included age (beta=.51, t=4.79, p=.000) and max/peak heart rate (beta=−.336, t=−2.39, p=.02). At alpha=.10, A1c was significant (beta=.187, t=1.99, p=.053). Conclusions: Although low aerobic conditioning is a purported CVD risk factor, quantitative measurements of such lack a demonstrable relationship with subclinical atherosclerosis (CIMT), perhaps because of its reduced importance relative to other CVD risk factors in a mobile population. We found expected relationships with CIMT in our SCI population (i.e., age), however we also found a quantitative measure of aerobic conditioning (max/peak heart rate) to be associated with CIMT. Our data indicate that SCI individuals may bear a greater CVD burden from cardiac de-conditioning than the general population and that investigation of a cohort with mobility limitation may provide a unique opportunity to study the impact of physical conditioning on CVD risk.

Measuring dynamic stability requirements during sitting pivot transfers using stabilizing and destabilizing forces in individuals with complete motor paraplegia

Dynamic stability requirements have never been quantified when long-term manual wheelchair users transfer themselves in a seated position from an initial surface to a target surface, a functional task commonly referred to as sitting pivot transfers (SPTs). Ten individuals with spinal cord injury (SCI), who rely on a manual wheelchair for mobility, underwent a comprehensive biomechanical SPT assessment. SPTs performed toward a target seat of same height (even) and a seat 10cm higher than the initial seat (uneven), repeated three times for each task, were assessed. A dynamic equilibrium model, continuously measuring the theoretical forces required to move the center of pressure to the limit of the base of support (destabilizing force) and to neutralize the kinetic energy and stop the displacement of the center of mass at the limit of the base of support (stabilizing force) at each instance during the performance of SPTs, was used to identify the phases of greatest instability during the SPT tasks. The greatest levels of instability were reached around the time the buttocks lost contact with the initial seat and around the time the buttocks landed on the target seat (pre- and post-lift transition phases). These transition periods, characterized by the lowest destabilizing force (424.7–487.1N) and the greatest stabilizing force (24.2–33.2N), confirmed the greatest level of instability. The height of the target seat had no significant effect (p=0.278–0.739) on dynamic postural stability requirements during the SPTs. During SPTs towards even and uneven target seats, the greatest postural instability occurs during the transition phases in individuals with complete motor thoracic SCI.