Incomplete Spinal Cord Lesions Research Articles

Pregnancy following Brown-Séquard syndrome: A rare case report

Brown-Séquard syndrome is an incomplete spinal cord lesion characterized by hemisection injury of the cord. We present a case of pregnancy, delivery and postpartum course following this rare neurological condition. A 42-year-old woman presented with past history of idiopathic hemicord myelitis leading to right sided hemiplegia with decreased contralateral sensation of pain and temperature, consistent with Brown-Séquard syndrome, which was treated with steroids and Therapeutic Plasma Exchange. Thereafter, she had near-complete motor recovery and complete sensory recovery over the next 3months. Three years later, she presented to us at 37+2 weeks of gestation with residual hemiparesis with motor power grade of 4/5 in right upper and lower limbs. She underwent Caesarean section for breech presentation, which was done under general anaesthesia in view of prior spinal cord lesion. She was discharged for follow-up in Neurology outpatient clinic and physical rehabilitation. At follow up after 12 months of delivery, she had complete motor and sensory recovery. Management of spinal cord lesions in pregnancy and delivery requires specialist multidisciplinary care due to risk of medical and obstetric complications. This case demonstrates a rare scenario of a primigravida at term gestation with residual deficits of a past spinal cord lesion.

Sensations Reported During Urodynamic Bladder Filling in Spinal Cord Injury Patients Give Additional Important Information.

PurposeThis study investigated the sensations reported during filling cystometry in patients with spinal cord lesions (SCLs) of different levels and completeness.MethodsIn this retrospective cohort study, information was gathered on patients’ age and sex, cause of SCL, American Spinal Injury Association Impairment Scale (AIS), and lower urinary tract-related sensations in daily life. Filling cystometry (videourodynamics) was performed following the International Continence Society Good Urodynamic Practice Guidelines. In addition to bladder filling sensations (first sensation of bladder filling, first desire to void, strong desire to void), other sensations, such as detrusor overactivity related sensation and pain, were noted.ResultsIn total, 170 patients were included (age, 45±17 years; 114 males and 56 females, 92 with complete and 78 with incomplete SCL). The test was done 6±4 years post-SCL. Sensation was reported by 57% of all patients. Half of the patients with complete SCL (46 of 92) had sensation, while 36% of those with incomplete SCL (28 of 78) reported no sensation. Bladder awareness was not predictable by the AIS. The filling sensations reported were equivalent to those given in the terminology of ICS. Pain was seldom present (6%, 10 of 170), and detrusor overactivity contraction was felt by 45 of 78 (58%). Very few patients used sensory information for bladder management at home.ConclusionsAfter SCL, most patients retained the ability to be aware of the lower urinary tract, and were assessable and gradable during urodynamic testing. The filling sensations were not different from those described in healthy individuals, but the number and sequence of the sensations were altered in a minority of patients. Pain and a sensation of unstable contractions gave additional important information. As different sensations relate to different spinal afferent pathways, the sensory evaluation during cystometry provided additional important information on the spinal cord’s condition.

Cervical Disc Herniation Producing Acute Brown-Sequard Syndrome: A Case Report

Background: Brown-Sequard Syndrome (BSS) is a kind of rare neurological condition characterized by incomplete spinal cord lesion which results in ipsilateral loss of motor function due to corticospinal tract compression on one side of the body, and contralateral loss of pain and temperature sensitivity as a result of spinothalamic tract dysfunction on the opposite side. The possible causes of Brown-Sequard Syndrome have been frequently observed in patients with spinal traumatic injuries and extramedullary spinal tumors. However, cervical disc herniation is an exceptional cause of this syndrome. Case presentation: A 42-year-old man presented with a one-day history of neck pain and activity limitation of right arm and leg after neck massage. The Computed Tomography (CT) scan of head indicated no abnormal sign. The cervical Magnetic Resonance imaging (MRI) showed a large right-side C4/5 disc herniation which caused rightside compression of spinal cord. The patient received subtotal vertebrectomy of C5 and reconstruction with titanium mesh cage through anterior approach. The muscle strength of patient was improved the contralateral sensory disorder of pain and temperature was alleviated after the surgery. Conclusion: The case demonstrated that a prompt diagnose followed by decompression of cervical spinal cord is essential for the prognosis of the patients who diagnosed as BSS.

Síndrome de lesão centro medular cervical traumática (schneider)

A lesão medular incompleta passou a ser o quadro clínico mais frequente nas unidades de tratamento e reabilitação nos últimos anos. Dentre elas o síndroma de lesão centro-medular ou Schneider é a mais comum. Revimos o atendimento realizado em 50 pacientes portadores desta síndrome na Unidade de Tratamento e Reabilitação de Traumatizados Raquimedulares do HAL-SARAH - Brasília DF, no período de 1986 a 1991. Observamos que estas lesões predominaram em 94% dos indivíduos do sexo masculino e em 68% dos pacientes acima de 40 anos de idade. A causa mais comum foi o trauma cansado por quedas. Todos foram transferidos para tratamento e reabilitação dentro das primeiras semanas, sendo que 36 estavam graduados em C na Escala de Frankel. A avaliação radiológica demonstrou que 26 (52%) apresentavam lesões osteoligamentares visíveis por mecanismo de flexão/rotação. Em 24 (48%) o mecanismo foi por extensão, sendo que em 16 havia sinais de osteoartrose e em 8 canal estreito congênito. Em 19 utilizamos mielografia para exploração do canal que, nos casos mais recentes da estatística, foi substituída por tomografia computadorizada e/ou ressonância magnética. Na fase aguda, o tratamento constou do uso de corticoesteróides e tração cervical para alinhamento e redução. 24 receberam apenas tratamento clínico. 15 foram operados por via anterior e 11 por via posterior e em 1 foi utilizada abordagem combinada. 38 foram internados por mais de 30 dias para reabilitação. A avaliação final demonstrou 28 pacientes totalmente independentes e 21 parcialmente independentes para as atividades de vida diária. Vinte e nove pacientes fizeram acompanhamento ambulatórial por um período médio de 2,6 anos. Trata-se de um grupo de pacientes com ótimo potencial de recuperação, em que o tratamento e a reabilitação podem resultar em substancial recuperação funcional. Por se caracterizar como a lesão parcial mais frequente e de melhora rápida e progressiva, o estudo deste grupo de pacientes permite avaliar e aperfeiçoar as condutas a serem utilizadas no tratamento e reabilitação dos pacientes com lesão medular mais grave

Incomplete spinal cord lesions: probably the commonest cause of radicular syndromes but difficult to diagnose (P4.044)

Incomplete spinal cord lesions: probably the commonest cause of radicular syndromes but difficult to diagnose (P4.044)

Traumatic Spinal Cord Injury: the Impact of Timing. A Prospective Cohort Study to Evaluate Outcomes after Early Surgery (and Reasons for Delays)

Introduction Traumatic spinal cord injury (tSCI) is a devastating condition affecting mostly young adults.1 Unfortunately, to date there are no standardized guidelines for treating these patients in the early phase and initial management can vary widely.2 Surgical decompression is considered to be a valid approach, however conclusive data regarding the best timing to perform it are still missing.3 The STASCIS trial evaluated the effect of surgical decompression pre- or 24 hours post-injury,4 however some aspects of its design have been criticized. The clinical study SCI-POEM aims to fill the gap of missing evidence by comparing the effect of early (<12 hour after injury) versus delayed (12 hour to 14 days after injury) surgical treatment.5 Material and Methods This is a prospective, multicenter, cohort study to test the superiority of early versus late surgery measured by the American Spinal Injury Association (ASIA) lower extremity motor score (ASIALEMS) pre-surgery and after 1 year. Inclusion criteria: Patients > 18 years old with tSCI, AIS grade A-D and indication of surgical management by the treating physician. To detect 6 points of difference in ASIALEMS with a power of 80%, a total of 300 patients are planned to be recruited in 17 clinics in 12 European countries within 3 years, assuming a 1:2 ratio of early vs delayed surgeries. Secondary outcome measures include different functional outcome scores and adverse events. Details about work, injury, main reason associated with a delayed surgery and steroid use are also collected. Results The study started recruitment in March 2013 and until August 2015, 137 eligible patients had been enrolled: 112 (81.8%) men and 25 (18.2%) woman with ages ranging from 18 to 89. Mechanism of injury was low energy trauma in 42 (30.7%) cases and high energy trauma in 95 (69.3%) cases. In 67 (48.9%) patients, traumatic lesion occurred at a single level. One third of cases suffered a complete spinal cord injury (ASIA A, postsurgery measurement). About 50% of decompression surgeries were performed within 12 hour after injury. Unwanted delays for tSCI treatment (as judged by the local investigator) occurred in 36 (26.3%) cases, of which 25 (69.5%) were caused by logistical issues (bed or imaging availability, transfer, etc) and 11 (30.5%) were due to medical reasons. Conclusion In our study, nearly two third of the cases had an incomplete spinal cord lesion (ASIA B-D), which highlights the relevance of appropriate and timely treatment to improve this situation. Strikingly, the actual rate of early vs delayed surgery is better than the anticipated 1:2 ratio. Even though 50% of the patients underwent early decompression, there was a considerable number of unwanted delays in the treatment of tSCI patients. The reasons for these delays are in most cases due to circumstances beyond the physician's control, such as time for transfer, availability of material resources or the medical condition of the patient. This information is important for future resource planning and suggests that improvements in material resources are needed across Europe. References Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global Burden of Disease and Risk Factors. New York: Oxford University Press; 2006 Fransen BL, Hosman AJ, van Middendorp JJ, Edwards M, van Grunsven PM, van de Meent H. Pre-hospital and acute management of traumatic spinal cord injury in the Netherlands: survey results urge the need for standardisation. Spinal Cord 2016;54(1):34–38 van Middendorp JJ, Hosman AJ, Doi SA. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013;30(21):1781–1794 Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS ONE 2012;7(2):e32037 van Middendorp JJ, Barbagallo G, Schuetz M, Hosman AJ. Design and rationale of a Prospective, Observational European Multicenter study on the efficacy of acute surgical decompression after traumatic Spinal Cord Injury: the SCI-POEM study. Spinal Cord 2012;50(9):686–694

Sacral neuromodulation for neurogenic non-obstructive urinary retention in incomplete spinal cord patients: a ten-year follow-up single-centre experience

To determine the success rate of percutaneous first stage of sacral neuromodulation (SNM) and the efficacy and safety of permanent SNM for incomplete spinal cord lesion (SCL) patients suffering from chronic neurogenic non-obstructive urinary retention (N-NOR). From January 2003 to December 2012, 85 individuals underwent the percutaneous first stage of SNM. Subsequently, only responders who reached a concomitant reduction by at least 50% of volume per catheterization and in the number of catheterizations per day comparing their 7-day voiding diaries at baseline underwent permanent SNM. Final follow-up was conducted by April 2013. Thirty-six individuals responded to percutaneous first stage of SNM. Post-surgery urodynamics documented all patients experiencing first sensation of bladder filling. A statistically significant increase in Qmax ml per sec and decrease in post-voiding residual urine per ml were documented. (P<0.01). First sensation of bladder filling at baseline represented a statistically significant parameter for the success of the first stage SNM (P<0.05). Eleven out of 34 patients at follow-ups were 'inconstant responders' because they returned to similar baseline voiding symptoms, but responded again with an implant on the controlateral S3 sacral root. Two failed twice and responded once again after an S4 sacral root implant. All but one failure occurred more than 3 years after the previous implant. Other drawbacks were resolved telemetrically. Research is needed to increase the success rate of the first stage SNM on incomplete SCL patients with N-NOR. Permanent SNM is highly efficacious in the medium follow-up.

Intravesical electrostimulation versus sacral neuromodulation for incomplete spinal cord patients suffering from neurogenic non-obstructive urinary retention

To compare the efficacy of intravesical electrostimulation (IVES) versus sacral neuromodulation (SNM) in patients with incomplete spinal cord lesions (SCL) and neurogenic non-obstructive urinary retention (N-NOR). In this retrospective study, 77 N-NOR patients underwent IVES (minimum 28 sessions), then after returning to voiding baseline symptoms, percutaneous first stage of SNM (lasting for minimum 4 weeks). After the two neuromodulation treatments, responders were categorized as patients experiencing both a 50% reduction of volume per catheterization per ml and a 50% reduction in number of catheterizations per day when comparing the 7-day voiding diaries at the end of both procedures to baselines. New urodynamics were performed subsequently. Responders to first stage of SNM underwent permanent SNM. Forty-eight patients responded to neither of the treatments, whereas 29 responded to both IVES and first-stage SNM. No significant statistical differences (P>0.05) were detected in the voiding diaries. Following the two procedures, the first sensation of bladder filling was either maintained or recovered by all responders, whereas the same 11 patients reached a bladder contractility index of >100. The 29 IVES responders lost their clinical benefits in a mean follow-up of 9.6 months. Only 10 out of the 29 patients became nonresponsive to permanent SNM, in a mean follow-up of 54 months. A strict correlation in terms of clinical and urodynamic patterns was demonstrated in patients with incomplete SCL and N-NOR, following IVES and first stage of SNM. However, voiding improvement through IVES was short-term when compared with the effects of permanent SNM.

The Validity of Administrative Data To Classify Patients with Spinal Column and Cord Injuries

International Classification of Diseases (ICD) codes are used to document patient morbidity in administrative databases. Although administrative data are used for research purposes, the validity of the data to accurately describe clinical diagnostic information is uncertain. We compared the clinical diagnoses for spinal cord and column injuries from a longitudinal patient registry, the Rick Hansen Spinal Cord Injury Registry (RHSCIR), to the ICD-10 spinal injury codes from the Discharge Abstract Database (DAD) at one institution. There were 603 RHSCIR participants with data describing the spinal cord injury, and 341 had data on the spinal column injury. The validity of DAD data to describe spinal injuries was evaluated using the sensitivity and positive predictive values of specific ICD-10 codes; 5.3% of the spinal column injuries and 10.9% of the spinal cord injuries documented in RHSCIR were missed in data from the DAD using ICD-10 codes. The most problematic spinal column ICD-10 code was the dislocation of the cervical vertebra (S13.1); only 14.0% of the dislocations of the cervical vertebrae in RHSCIR were correctly coded in the DAD. The most problematic spinal cord injury ICD-10 code was the incomplete lesion of the lumbar spinal cord (S34.1X); 66.7% of incomplete lesions of the lumbar spinal cord in RHSCIR were correctly coded in the DAD. The validity of DAD data to code spinal injuries is variable, and cannot be reliably used to classify all types of spinal injuries. Patient registries, such as RHSCIR, should be used if accurate detailed diagnostic data are required.

Recovery of assisted overground stepping in a patient with chronic motor complete spinal cord injury: A case report

Clinical studies have shown that after incomplete spinal cord lesions at the thoracic level, patients can develop functional gait patterns through gait training. To date, however, training has been ineffective in producing gait in patients with clinically motor complete spinal cord lesions. Here we report a patient with chronic motor complete spinal cord injury who regained locomotor function with assistance after intensive gait rehabilitation treatment. A fifteen year old female patient had sustained motor complete spinal cord injury (T6, AIS B) 2 years earlier, with severe bilateral extensor spasticity, and ineffective previous gait training with robotic systems. The therapy consisted of two months of gait training with a robotic system combined with bilateral functional electrical stimulation (FES) of the peroneal nerve, and one month of gait training with a special walker and FES of the left leg and occasionally on the right leg, due to flexor reflex could sometimes be initiated by the patient in the right leg without electrical stimulation. Neurophysiological studies and ten metres test were done. At the end of training, the patient was able to cover a distance of 200 metres without FES with a walker and assistance from a physiotherapist, who pulled the walker with each step to help her to accomplish effective overground stepping. Motor and somatosensory evoked potentials were absent in the lower limbs. Even after a motor complete lesion with some preservation of sensory pathways, the spinal cord may be able to retain some of its locomotor function through intensive gait rehabilitation.

Lokomat Robotic-Assisted Versus Overground Training Within 3 to 6 Months of Incomplete Spinal Cord Lesion

Background. About 75% of persons with ASIA (American Spinal Injury Association) Impairment Scale C and D incomplete spinal cord injury (SCI) achieve walking ability. Objective. To compare a walking reeducation program using Lokomat with conventional overground training among individuals with incomplete SCI of both traumatic and nontraumatic etiology. Methods. A total of 80 participants from 3 to 6 months after onset admitted to 1 site for rehabilitation were included in a single-blind randomized clinical trial of 2 parallel groups, with blind evaluation by independent observers. Patients received 40 walking reeducation sessions of equal time using a Lokomat program with overground practice or overground mobility therapy alone. Primary measurements of outcome were walking speed and the Walking Index for Spinal Cord Injury (WISCI II). Secondary outcomes were the 6-minute walk test, locomotor section of the Functional Independence Measure, Lower Extremity Motor Score (LEMS), Ashworth Scale, and Visual Analog Scale for pain. Results. No significant differences were found at entry between treatment groups. Walking speed for Lokomat (0.4m/s [0.6-0.2]) and overground therapy (0.3m/s [0.5-0.2]) groups did not differ. The WISCI II for the Lokomat group (16 [8.5-19]) was better than for overground therapy (9 [8-16]). The 6-minute walk test and LEMS displayed significant differences in favor of Lokomat therapy but were not corrected for multiple comparisons. Conclusions. Robotic-assisted training was equivalent to conventional walk training in patients with a variety of nonprogressive spinal cord pathologies for walking speed, but the need for orthotics and assistive devices was reduced, perhaps because of greater leg strength in the robotic group.

Kinematic Study of Locomotor Recovery after Spinal Cord Clip Compression Injury in Rats

After spinal cord injury (SCI), precise assessment of motor recovery is essential to evaluate the outcome of new therapeutic approaches. Very little is known on the recovery of kinematic parameters after clinically-relevant severe compressive/contusive incomplete spinal cord lesions in experimental animal models. In the present study we evaluated the time-course of kinematic parameters during a 6-week period in rats walking on a treadmill after a severe thoracic clip compression SCI. The effect of daily treadmill training was also assessed. During the recovery period, a significant amount of spontaneous locomotor recovery occurred in 80% of the rats with a return of well-defined locomotor hindlimb pattern, regular plantar stepping, toe clearance and homologous hindlimb coupling. However, substantial residual abnormalities persisted up to 6 weeks after SCI including postural deficits, a bias of the hindlimb locomotor cycle toward the back of the animals with overextension at the swing/stance transition, loss of lateral balance and impairment of weight bearing. Although rats never recovered the antero-posterior (i.e. homolateral) coupling, different levels of decoupling between the fore and hindlimbs were measured. We also showed that treadmill training increased the swing duration variability during locomotion suggesting an activity-dependent compensatory mechanism of the motor control system. However, no effect of training was observed on the main locomotor parameters probably due to a ceiling effect of self-training in the cage. These findings constitute a kinematic baseline of locomotor recovery after clinically relevant SCI in rats and should be taken into account when evaluating various therapeutic strategies aimed at improving locomotor function.

Cervical disc herniation producing acute Brown-Sequard syndrome: dynamic changes documented by intraoperative neuromonitoring

Brown-Sequard syndrome is an incomplete spinal cord lesion characterized by ipsilateral loss of motor function and contralateral loss of pain and temperature sensitivity, reflecting a hemi-compression or hemi-section of the spinal cord. Cervical disc herniation is an exceptional cause of this syndrome. We report a case of cervical disc herniation causing Brown-Sequard syndrome in a patient with an unusually rapid neurological deterioration associated to cervical extension, which was documented by neuromonitoring. A prompt diagnosis, followed by spinal cord decompression should be warranted. Intraoperative neuromonitoring is a useful tool in preservation of neurologic function in these cases.

Repetitive common peroneal nerve stimulation increases ankle dorsiflexor motor evoked potentials in incomplete spinal cord lesions

Plasticity of corticospinal tract (CST) activity likely plays a key role in motor function recovery after central nervous system (CNS) lesions. In non-injured adults, 30min of repetitive common peroneal nerve stimulation (rCPnS) increases CST excitability by 40-50% and the effect persists for at least 30min. The present study evaluated with transcranial magnetic stimulation (TMS) the changes in CST excitability after 30min of rCPnS in people with foot drop due to incomplete SCI. Suprathreshold rCPnS (25Hz, alternating 1s on 1s off stimulation cycle) was given for two 15-min periods, while the subject sat at rest with ankle and knee joints fixed. Before, between, and after the periods of stimulation, the tibialis anterior (TA) motor evoked potentials (MEPs) to TMS were measured at a TMS intensity that originally produced a half-maximum MEP (typically 10-20% above threshold) while the sitting subject provided 25-30% maximum voluntary TA contraction. In 10 subjects with SCI, the peak-to-peak TA MEP increased by 14±3% after rCPnS and the peak increase (+21±7%) occurred 15min after the cessation of rCPnS. The TA H-reflex, measured in separate experiments in 7 subjects, did not increase after rCPnS. The results indicate that rCPnS can increase CST excitability for the TA in people with incomplete SCI, although its effects appear smaller and shorter lasting than those found in non-injured control subjects. Such short-term plasticity in the CST excitability induced by rCPnS may contribute to long-term therapeutic effects of functional electrical stimulation previously reported in people with CNS lesions.

"No clinical puzzles more interesting": Harvey Cushing and spinal trauma, the Johns Hopkins Hospital 1896-1912.

Although Harvey Cushing played a central role in the establishment of neurosurgery in the United States, his work on the spine remains largely unknown. This article is not only the first time that Cushing's spinal cases while he was at Johns Hopkins have been reported, but also the first time his management of spinal trauma has been described. We report on 12 patients that Cushing treated from 1898 to 1911 who have never been reported before, including blunt and penetrating injuries, complete and incomplete spinal cord lesions, and both immediate and delayed presentations. Cushing performed laminectomies within 24 hours on patients with immediate presentations-both complete and incomplete spinal cord lesions. Among those with delayed presentations, Cushing did laminectomies on patients with incomplete spinal cord injuries. By the end of his tenure at Hopkins, Cushing advocated nonoperative treatment for all patients with complete spinal cord lesions. Four patients died while an inpatient, with meningitis and cystitis leading to the death of 1 and 3 patients, respectively. Cystitis was treated with intravesicular irrigation; an indwelling catheter was placed by a suprapubic cystostomy in four. Cushing was one of the first to report the use of x-ray in a spine patient, in a case that may have been one factor leading to his interest in the nervous system; Cushing also routinely obtained radiographs in those with spinal trauma. These cases illustrate Cushing's dedication to and rapport with his patients, even in the face of a dismal prognosis.

Cortical hyperexcitability in response to preserved spinothalamic inputs immediately after spinal cord hemisection

Chronic injury of the main somatosensory pathways ascending along the spinal cord - the dorsal columns and the spinothalamic tract - can produce both changes in the organization of cortical somatotopic maps and neuropathic pain. Little is known, however, about the early neurophysiological changes occurring immediately after injury. We bilaterally recorded the neural activity of the hindpaw representation of the primary somatosensory cortex evoked by stimuli delivered to the hindpaws before and immediately after a thoracic spinal cord hemisection in anesthetized rats. This unilateral spinal cord injury allowed us to separately investigate the cortical effects of deafferenting the dorsal column (stimuli ipsilateral to the hemisection) or the spinothalamic tract (stimuli contralateral to the hemisection). The hemisection produced immediate bilateral changes in the cortical responses evoked by stimuli delivered to the hindpaw ipsilateral to the hemisection (deafferented dorsal column): an expected loss of classical short-latency cortical responses, accompanied by an unexpected appearance of long-latency activations. At the population level, these activations reflected a progressive stimulus-induced transition of the hindpaw somatosensory cortex from up-and-down states to a sustained activated state. At the single-cell level, these cortical activations resembled the “wind-up” typically observed – with the same type of stimuli – in the dorsal horn cells originating the spinothalamic tract. Virtually no changes were observed in the responses evoked by stimuli delivered to the hindpaw contralateral to the hemisection (deafferented spinothalamic tract). These results suggest that spinal cord hemisection immediately produces an abnormal hyperexcitability of the primary somatosensory cortex in response to preserved spinothalamic inputs from the hindpaw. This immediate cortical hyperexcitability could be important to understand the long-term development of cortical reorganization and neuropathic pain after incomplete spinal cord lesions.

Impaired Transmission in the Corticospinal Tract and Gait Disability in Spinal Cord Injured Persons

Rehabilitation following spinal cord injury is likely to depend on recovery of corticospinal systems. Here we investigate whether transmission in the corticospinal tract may explain foot drop (inability to dorsiflex ankle) in persons with spinal cord lesion. The study was performed in 24 persons with incomplete spinal cord lesion (C1 to L1) and 15 healthy controls. Coherence in the 10- to 20-Hz frequency band between paired tibialis anterior muscle (TA) electromyographic recordings obtained in the swing phase of walking, which was taken as a measure of motor unit synchronization. It was significantly correlated with the degree of foot drop, as measured by toe elevation and ankle angle excursion in the first part of swing. Transcranial magnetic stimulation was used to elicit motor-evoked potentials (MEPs) in the TA. The amplitude of the MEPs at rest and their latency during contraction were correlated to the degree of foot drop. Spinal cord injured participants who exhibited a large foot drop had little or no MEP at rest in the TA muscle and had little or no coherence in the same muscle during walking. Gait speed was correlated to foot drop, and was the lowest in participants with no MEP at rest. The data confirm that transmission in the corticospinal tract is of importance for lifting the foot during the swing phase of human gait.

Recovery of overground locomotion following partial spinal lesions of different extent in the rat

In six rats with incomplete low thoracic spinal cord lesions of different extent, basic gait indices such as locomotor speed, step cycle duration, soleus (Sol) muscle activity duration, the interval between the onsets of Sol and tibialis anterior (TA) muscle activities and interlimb coordination were investigated by EMG analysis of the Sol and TA muscles recorded using chronic electrodes. The operated animals were divided into two subgroups: (1) those with a smaller lesion involving the dorsal quadrants of the spinal cord and, to a variable extent, the ventrolateral funiculi, and (2) those with an extensive lesion sparing only parts of the ventral funiculi. The locomotion of all rats was tested once a week for the first 5 weeks postsurgery and then once or twice a month, up to 3.5 months. The surgical lesions affected all analyzed gait indices: the locomotor speed decreased, while all other indices increased compared to recordings made preoperatively. In both subgroups the major improvement in locomotion occurred within the first 5 weeks following surgery and the rats reached a plateau in their recovery at around 2 months postoperatively. The late effects of injury depended on the severity of the spinal lesion: in the subgroup of rats with a smaller lesion, the postoperative changes in the different indices amounted to approximately 20%, while in the subgroup with extensive lesions this was increased by 20–50%, with changes in various indices being strongly correlated with the extent of the injury in individual animals. These postoperative changes were partly due to alterations in the relationships between the analyzed variables.

Proctectomy for rectal cancer in patients with prior spinal cord injury

Limited published information is available concerning the clinical course of spinal cord injured (SCI) patients who later develop rectal cancer and undergo proctectomy. We hypothesized that such patients would have poorer outcomes than comparable neurally-intact patients. We conducted a retrospective study of all SCI veterans receiving care at all Department of Veterans Affairs (DVA) Medical Centers who subsequently underwent proctectomy for rectal cancer during fiscal years 1993-2002. Only patients with SCI due to trauma who met American Spinal Injury Association type A criteria (complete cord injury) were analyzed. The search strategy utilized DVA datasets plus data extracted from medical records. There were 33,758 patients with ICD-9-CM diagnosis codes for SCI and 5246 patients with ICD-9-CM procedure codes for proctectomy due to rectal cancer; 72 patients were in both datasets. We received records for 72 patients and excluded 67 after chart review. Incorrect coding (44) and incomplete spinal cord lesions (9) were the most common exclusion criteria. Five patients were considered evaluable. The mean age at diagnosis was 65 (range 49-80). All five had symptomatic cancers and two (40%) had major comorbidities at admission. Postoperative complications occurred in four (80%). The winsorized mean length of stay was 28 days. The complication rate and length of stay for SCI patients undergoing proctectomy for rectal cancer were higher than those reported for otherwise comparable neurally-intact patients. SCI should be considered a risk factor for adverse outcomes in operations for rectal cancer as in other major surgery.

Neuropathic bladder dysfunction in patients with motor complete and sensory incomplete spinal cord lesion

A retrospective study of patients with motor complete spinal cord lesion and somatosensory preservation (American Spinal Injury Association (ASIA) impairment scale B). To determine whether neuropathic bladder dysfunction is more or less severe with more or fewer complications in patients with somatosensory preservation. 2nd Department of Physical and Rehabilitation Medicine, Neuropathic Bladder Unit, National Rehabilitation Center, EIAA, Athens, Greece. The classification of spinal cord injured patients was determined according to ASIA protocol. All patients underwent urodynamics and retrograde cystography, with a follow-up period of at least 18 months. The study sample consisted of 154 patients: 28 ASIA B patients compared with 126 ASIA A patients. We analyzed 140 traumatic and 14 nontraumatic lesions for (1) specific type of neuropathic bladder, (2) detrusor overactivity volume and pressure, (3) bladder compliance, (4) vesicoureteric reflux, (5) formation of bladder stones, (6) method of bladder emptying and (7) daily dose of anticholinergics needed to achieve safe bladder function. We also studied the presence of spasticity, autonomic dysreflexia and pain syndrome. Statistically significant differences were found between ASIA A and B patients in daily dose of anticholinergics needed to achieve safe bladder function, in the incidence of incontinence episodes and in formation of bladder stones. Patients with somatosensory incomplete lesion of spinal cord seem to have an advantage in the management of neuropathic bladder dysfunction (fewer anticholinergics needed, fewer incontinence episodes and fewer bladder stones).