Lower Extremity Loss Research Articles

The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1057 lumbar interbody fusions

BackgroundLumbar interbody spinal fusion (LIF) surgeries are performed to treat or prevent back pain in patients with degenerated intervertebral discs and a variety of spinal diseases. However, post-operative neurological complications may ensue. Intraoperative monitoring techniques have been used to predict and potentially reduce the risk of complications. MethodsThis study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict post-operative neurological deficits after LIF. All patients underwent LIF at UPMC from 2010 to 2012. One thousand fifty-seven patients had pre-operative baseline and continuous intraoperative SSEP monitoring. Statistical analysis was completed using SPSS version 22. No relevant disclosure. ResultsPatient outcomes were not significantly affected by age over 65, gender, obesity, and abnormal baselines. Lower extremity (LE) significant changes in SSEPs and LE loss of responses resulted in a sensitivity/specificity of 0.03/0.99 and 0.03/0.99; they had an AUC of 0.54/0.73 with a 95% confidence interval (CI) of [0.34, 0.74]/[0.29, 1.00]. ConclusionsSignificant SSEP changes during LIF are a very specific but poorly sensitive indicator of perioperative neurological deficits. The odds ratio for LE loss of responses was 29.14 with a 95% CI of 1.79-475.5, so LE SSEP loss of responses can serve as a biomarker of perioperative neurological deficits after LIF.

The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1036 posterior spinal fusions

Background: The goal of this study is to assess the sensitivity and specificity of somatosensory evoked potentials (SSEPs) in predicting perioperative neurological deficits during posterior spinal fusions (PSF).Methods: This study examined the diagnostic accuracy of significant changes of SSEPs and multimodal monitoring to evaluate and predict post-operative neurological deficits after PSF. All 1036 patients underwent PSF at the University of Pittsburgh Medical Center from 2010 to 2012. Statistical analysis was completed using SPSS version 22.Results: Of the 1036 patients included in the study, 35 (3.38%) patients had significant SSEP changes. Out of the 35 patients with significant SSEP changes, 22 (62.86%) patients had significant lower extremity (LE) SSEP changes. Ten (45.5%) of LE SSEP changes were loss of responses. Gender, obesity, and abnormal baselines did not significantly affect patient outcomes. Significant LE changes had an odds ratio of 13.18, 95% CI [3.44, 50.56], and LE loss of waveforms had an odds ratio of 19.48, 95% CI [3.76, 100.75].Conclusions: Patients with perioperative neurological deficits are 13 times more likely to have LE significant changes, and 19 times more likely to have a LE loss of SSEP responses. Our study results indicate that LE significant changes or LE loss of waveforms in SSEPs can serve as a marker of perioperative neurological deficits.

Bone microvascular flow differs from skin microvascular flow in response to head-down tilt.

Loss of hydrostatic pressures in microgravity may alter skin and bone microvascular flows in the lower extremities and potentially reduce wound healing and bone fracture repair. The purpose of this study was to determine the rate at which skin and bone microvascular flows respond to head-down tilt (HDT). We hypothesized that microvascular flows in tibial bone and overlying skin would increase at different rates during HDT. Tibial bone and skin microvascular flows were measured simultaneously using photoplethysmography (PPG) in a total of 17 subjects during sitting (control posture), supine, 6° HDT, 15° HDT, and 30° HDT postures in random order. With greater angles of HDT, bone microvascular flow increased significantly, but skin microvascular flow did not change. Tibial bone microvascular flow increased from the sitting control posture (0.77 ± 0.41 V) to supine (1.95 ± 1.01 V, P = 0.001) and from supine posture to 15° HDT (3.74 ± 2.43 V, P = 0.004) and 30° HDT (3.91 ± 2.68 V, P = 0.006). Skin microvascular flow increased from sitting (0.703 ± 0.75 V) to supine (2.19 ± 1.72 V, P = 0.02) but did not change from supine posture to HDT (P = 1.0). We show for the first time that microcirculatory flows in skin and bone of the leg respond to simulated microgravity at different rates. These altered levels of blood perfusion may affect rates of wound and bone fracture healing in spaceflight.NEW & NOTEWORTHY Our data show that bone microvascular flow increases more than cutaneous blood flow with greater degrees of head-down tilt. A higher level of perfusion in bone may give insight into the bone mineral density loss in lower extremities of astronauts and why similar tissue degradation is not observed in the skin of the same areas.

This is your new normal: A qualitative study of barriers and facilitators to physical activity in Veterans with lower extremity loss

BackgroundRegular physical activity (PA) is essential for aging well with a disability, preventing the onset or worsening of chronic conditions, functional loss, and maintaining or improving quality of life, yet PA levels are low in those with disabilities, including those with a lower extremity amputation (LEA). ObjectiveTo determine methods for promoting PA in this population, our objective was to better understand the barriers and facilitators to PA that persons with LEA face. MethodsSemi-structured interviews were conducted with male Veterans with a LEA. Two raters analyzed interview transcripts using a qualitative descriptive approach, involving both a priori and emergent themes. ResultsAmong the 27 male Veterans (mean age = 54 years) interviewed, facilitators to PA included acceptance of their limb loss, confidence (to try new activities or adapt activities), creating a daily routine involving PA, resources, supportive others, perceived benefit, and having a history of being physically active. Barriers to PA were illnesses/injuries, poorly-fitting prostheses, low self-efficacy, insufficient resources, unsupportive others, and hassle. ConclusionsOur study builds upon the literature indicating that individual, interpersonal, and environmental factors should be addressed to increase adoption and maintenance of PA, including making PA a regular, low-hassle activity, increasing access to resources that facilitate PA, and training health care providers, family and friends on how to best to support those with LEA to be more physically active. Addressing prosthetic socket issues that affect fit and stability and promoting acceptance and self-efficacy will also be instrumental.

The impact of physical activity and obedience of ergonomic rules on level of pain intensity reported by office staff

Abstract Introduction: This paper examines office staff’s knowledge and obedience of rules of computer workstation ergonomics and assesses how physical activity and obedience of ergonomic rules affect the level of pain intensity reported by office staff included in the study. Material and methods: The study group consisted of 136 persons (94 female and 42 male) aged between 20 and 46 (average 44,5±12,6 years) working on computer workstations. Results. Approximately 50% of the study group were spending their free time actively (72 persons, 52,9%). Preferred forms of activity were as follows: walking (72,1%), cycling (58,1%) and physical exercise (26,5%). Results: It was found that higher rates of physical activity significantly reduced the intensity of the pain resulting from computer work. On the contrary, a statistically significant number of people occasionally involved in physical activity more often suffered the following symptoms: pain in the shoulders (p=0,0224), hips (p=0,0036) and feet (p=0,0458), and tingling and sensory loss in lower extremities (p<0,0001). It was found that study group members regularly involved in physical activity less often suffered from the pain in the shoulders (22,9% vs 50,0%,), hips (14,3% vs 44,7%,) and feet (17,1% vs 31,6%), and tingling and sensory loss in lower extremities (2,9% vs 36,8%) when compared to the group with occasional physical activity. Statistically significant lower incidence of pain was observed in the study group members conforming to the rules of ergonomics at work as exemplified through the following symptoms: increased muscle tension in the shoulder areas (38,5% vs 61,8%, p=0,0303), pain in the upper parts of the spine (26,9% vs 50,9%, p=0,0274), eye pain, tearing and burning sensation (57,7% vs 80,0%, p=0,0170). Conclusions: 1. Only a small number of study group members complied with ergonomic rules at work. 2 It was observed that physical activity has a positive effect on pain reduction. 3. Adherence to ergonomic rules at work has a significant influence on reduction of pain intensity in examined groups.

P.17.13 Steroid-responsive polyneuropathy with MRI cauda equina root involvement in a girl with novel heterozygous POLG mutation

To describe a patient with genetically confirmed POLG mutation and partially treatment-responsive chronic immune demyelinating polyneuropathy. Patient and methods: A 16years old girl with predominantly sensory neuropathy, dysarthria and ataxia. Case description together with nerve conduction study, evoked potentials and MRI results are presented. She had history of 1.5years of slowly progressive walking difficulties. Developmental milestones were normal, but she was never good at sports. On admission she had ataxic gait, proprioceptive sensation disturbances, high arched feet, dysarthria, pansensory loss in lower extremities up to her knees, areflexia, positive Romberg sign. Nerve conduction studies demonstrated sensory-motor polyneuropathy of lower limbs. Evoked potentials studies confirmed disturbances of visual, brain stem and somatosensory pathways. Magnetic resonance imaging (MRI) of lumbar spine revealed gadolinium enhancement of spinal roots She had elevated CSF protein with normal leukocyte count. Preliminary diagnosis of chronic immune demyelinating neuropathy was made. Immunomodulatory treatment with methylprednisolone and IVIG led to marked improvement of gait, resolution of abnormalities of touch, temperature sensation, improved proprioception. Several weeks later she developed action-exacerbated myoclonus of her left lower extremity, partially responsive to treatment with clonazepam and levetiracetam. Myoclonus limited her ability to walk. MR Spectroscopy with voxel placed in lateral ventricle demonstrated increased lactate in CSF. DNA testing revealed heterozygous mutation of POLG, with paternally inherited W748S, and maternally inherited V1106A mutation of an evolutionary conserved POLG region. The case raises the question if mitochondrial disease triggered additional immune disease, or autoimmune polyneuropathy affected the clinical course of this rare hereditary disorder.

Comparison Of Blunt And Sharp Needles For Transforaminal Epidural Steroid Injections

The aim of this study was to compare the sharp and blunt needles in order to determine the incidence of complications during transforaminal anterior epidural steroid injections. In this retrospective study, 185 cases that undergo transforaminal epidural steroid injection with sharp or blunt needles were evaluated between June 2004 and December 2008. Patients age, sex, diagnosis, needle type (sharp or blunt), volume of local anesthetic and steroid injected, complications (paresthesia, dural puncture, bleeding, paralysis, intravascular penetration, headache, local back pain, temporary motor loss in lower extremities) was recorded. 3 cases in blunt needle group and 8 cases in sharp needle group showed paresthesia during the procedure. The difference was not found to be significant among the groups. Vascular penetration was observed in 2 cases in blunt and 13 cases in sharp needle group and the difference between groups was statistically significant (p<0.001). Dural puncture and headache incidence were not significant when the two groups are compared. The local back pain at the injection site had a higher incidence in the blunt needle group. When using the blunt needles, vascular penetration and paresthesia were less during transforaminal epidural steroid injections. Therefore blunt needles seem to be more advantageous.

Cauda equina syndrome in extruded lumbar disk herniation

Cauda equina syndrome (CES) is a rare consequence of lumbar disc prolapse. The reported incidence of CES due to an herniated lumbar disc varies from 1 to 6%. It is defined as a complex of symptoms that include lower back pain, unilateral or more typically bilateral sciatica, saddle sensory disturbances, and variable lower extremity motor and sensory loss, along with bladder, bowel, and erectile dysfunction. The motor loss varies from weakness to flaccid paralysis over time, with no upper motor neuron signs. Similarly, sensory symptoms include saddle anesthesia and a variable sensory loss in lower extremities. Low back pain can be divided into local and radicular pain: local pain is generally a deep aching pain resulting from soft-tissue and vertebral body irritation; radicular pain is generally a sharp, stabbing pain resulting from compression of the dorsal nerve roots and projects in dermatomal distributions. Urinary manifestations of cauda equina syndrome include retention, difficulty initiating micturition, decreased urethral sensation. Typically, urinary manifestations begin with urinary retention and are later followed by an overflow urinary incontinence. Bowel disturbances may include incontinence and/or constipation, and loss of anal tone and sensation.

Alemtuzumab in the reversal of encephalopathy associated with hypereosinophilic syndrome

A 63-year-old woman who had a 1-year history of FIP1L1PDGFRa-negative hypereosinophilic syndrome, presented with the sudden onset of ataxia and strength loss in lower extremities, spatial disorientation, and neglect of the left side of her body. She had an eosinophil count of 161AE8 · 10/l. Brain magnetic resonance imaging (MRI) with fluid-attenuated inversion recovery (FLAIR) sequence showed extensive bilateral and diffuse abnormalities situated in watershed regions (left panel). Therapy with corticosteroids, hydroxycarbamide, interferon-a (5 000 000 units/day), and low-dose subcutaneous cytarabine (20 mg/day) was effective in reducing her eosinophil count, which stabilized at 40 · 10/l. Neurological symptoms were also stable. Four months after this presentation, the patient was readmitted with significant worsening of her neurological symptoms, with cerebellar ataxia and urinary incontinence. The patient was treated with subcutaneous alemtuzumab at a dose of 30 mg/week. She had an excellent response, with the eosinophil count stabilizing at 5 · 10/l after three doses, achieving a partial haematological response. A 6-month MRI follow-up showed decrease in the size of the lesions (right panel).

Perspectivas diagnósticas e terapêuticas da osteoporose após lesão medular

A osteoporose é uma das reconhecidas complicações da lesão medular, mas restam dúvidas quanto à totalidade de mecanismos fisiopatológicos envolvidos e tratamento efetivo. Grande parte da perda óssea ocorre na fase aguda, com estabilização cerca de doze a dezesseis meses após. A perda óssea afeta todos os segmentos, mas é mais intensa naqueles paralisados e em áreas ricas em osso trabecular. Mecanismos envolvidos não são totalmente esclarecidos, mas englobam não só a perda da tensão mecânica, mas também fatores neurovasculares e alterações estruturais do colágeno. Tanto marcadores bioquímicos quanto estudos com o uso da histomorfometria óssea evidenciam aumento da reabsorção óssea em detrimento da formação óssea. Estudos com o uso da densitometria óssea evidenciam dissociação entre a perda a nível da coluna e quadril, com maior perda a nível do quadril e de membros inferiores, achado considerado típico e marcante deste grupo de pacientes. Como conseqüência, o aumento da incidência de fraturas que se situa entre 1 e 7%, sendo muitas vezes decorrentes de traumas mínimos. Trabalhos com ortostatismo e cinesioterapia não demonstraram benefício significativo no que diz respeito à redução da perda de massa óssea e trabalhos com estimulação elétrica funcional apresentam resultados divergentes, parecendo resultar em algum benefício local. O uso de medicação anti-reabsortiva parece constituir opção promissora, sobretudo na fase aguda, mas estudos são ainda necessários para avaliar a sua efetividade, ou seja, a redução da incidência de fraturas.