Prognosis For Neurological Recovery Research Articles

Outcome and complications of operatively treated subaxial cervical spine injuries: A population-based retrospective cohort study

ObjectiveThe aim was to study the outcome and complications of operative treatment for subaxial cervical spine injuries with respect to injury morphology and surgical strategy. MethodsA population-based cohort of 271 consecutive patients treated at Kuopio University Hospital from 2003 to 2018 was retrospectively reviewed. ResultsThe mean age was 52.4 (range 12–90) years and 78.6% were male. The AOSpine morphological classification was C in 56.5%, B in 24.7% and A in 17.0% of cases. The surgical approach was anterior in 70.8%, posterior in 20.3% and combined in 8.9% of patients. Fixation alignment was maintained in 96.9% of patients. Instrumentation failures were observed only in patients operated anteriorly but no statistical difference was found between the surgical approaches. The American Spinal Injury Association Impairment Scale (AIS) grade improved in 22.1% of patients. Patients with preoperative AIS grade C had significant potential for neurological improvement (OR 10.44; 95% CI 1.77–61.56; p = 0.010). Postoperative, mostly mild, complications manifested in 22.5% of patients. The posterior approach was associated with fewer postoperative complications (OR 0.18; 95% CI 0.06–0.51; p = 0.001). Preoperative AIS grade A was a significant predisposing factor for complications (OR = 4.90; 95% CI = 1.49–16.10; p = 0.009). The perioperative (90-day) mortality rate was 3.3%. The mean follow-up period was 64.7 ± 25.9 (radiological)/136.7 ± 174.8 (clinical) days. ConclusionsOperative treatment is safe and effective but the surgical approach should be patient- and injury-specific. The prognosis for neurological recovery from spinal cord injury is superior in patients with partially preserved motor function.

IJU this issue

In this issue of the journal, we have four Review Articles, six Original Articles, one Short Communication, one Case Report and two Letters to the Editor. I would like to pay close attention to the interesting papers that reported and discussed current topics of prostate cancer. Masuda et al. (Tokyo, Japan) explored the relationship between body mass index (BMI) and prostate cancer risk at biopsy in Japanese men, and compared the risk with that of Caucasian men. They retrospectively evaluated Japanese men with prostate-specific antigen (PSA) levels from 2.5 to 19.9 ng/mL undergoing an initial extended prostate biopsy. There was a significant positive relationship between BMI and prostate cancer risk at biopsy, with an increased risk observed in men whose BMI was ≥27.0, compared with the reference group. A significantly increased risk starting at BMI ≥25.0 was found in high-grade disease. In contrast to their results, there has been no reported increase in the risk of prostate cancer at biopsy in Caucasians within the overweight range (BMI of 25.0–29.9). The authors concluded that Japanese men within the overweight BMI range who have an elevated PSA also have a significant risk of harboring prostate cancer, especially high-grade disease, and that overweight Japanese might be at greater prostate cancer risk at biopsy than overweight Caucasians. The accuracy of the Japan Cancer of the Prostate Risk Assessment (J-CAPRA) score, which was developed as a risk stratification instrument for patients undergoing primary androgen deprivation therapy, was externally validated for predicting cause-specific survival (CSS) among patients in the USA community-based Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry; however, there have been no investigations to validate the accuracy of the J-CAPRA score in predicting progression-free survival (PFS) along with analysis of clinical situation. Kitagawa et al. (Kanazawa, Japan) examined whether the clinical outcomes of patients treated by combined androgen blockade (CAB) with bicalutamide could be stratified using the J-CAPRA score. The factors used in the J-CAPRA points were significant predictors of PFS, and clinical T stage and M stage were also significant predictors of PFS. The probabilities of PFS and CSS were significantly different among the groups categorized according to the J-CAPRA risk strata. The authors concluded that the J-CAPRA score is a useful tool for predicting the clinical outcomes of patients with prostate cancer treated by CAB including bicalutamide. Several papers of laparoendoscopic single-site surgery in urology have been published, but just a few cases of radical prostatectomy have been reported. Nakane et al. (Anjo, Japan) showed the early outcomes of an original two-port laparoendoscopic approach for radical prostatectomy. A multichannel port with three 5-mm trocars, providing easier instrument handling, was inserted extraperitoneally through a 2.5-cm lower umbilical “U” incision. An additional 12-mm port was inserted into the left fossa to allow an adequate working angle. The operation was successfully completed in all 22 patients with early-stage prostate cancer; only one patient required an additional 5-mm port to control bleeding. There were no intraoperative complications. The authors concluded that this new procedure can be safely carried out if the surgeon is familiar with conventional five-port laparoscopic radical prostatectomy. Paraneoplastic limbic encephalitis (PLE) is a rare tumor-related syndrome, and the prognosis for neurological recovery and survival is poor. The neoplasms most frequently associated with PLE are small cell lung cancer and testicular cancer. Jakobsen et al. (Viborg, Denmark) reported a rare case of prostate cancer-related PLE. The authors showed that high-risk prostate cancer can trigger PLE, a rapidly progressive neurological syndrome with a bad prognosis. None declared.

A Case of Inaccurate Prognostication After the ARCTIC Protocol

Therapeutic hypothermia (ARCTIC, or Advanced Resuscitation Cooling Therapeutics and Intensive Care protocol) is a widely recommended intervention to improve mortality and neurologic outcomes after cardiac arrest. However, neurologic outcomes are difficult to predict soon after cardiac arrest in the setting of hypothermia, as illustrated by this case report. A 60-year-old man had witnessed cardiac arrest at home. He was defibrillated twice, with return of spontaneous circulation, and cooled to 33°C for 24 hours. Neurologic exam on Day 6 revealed limited brainstem reflexes, and the intensive care unit team discussed with the patient’s family that his prognosis for neurologic recovery was poor. Palliative care was consulted to participate in a goals-of-care meeting. Just prior to the meeting on Day 7, the patient awoke. He fully recovered and walked out of the hospital on Day 18. Prior to induced hypothermia, indicators of poor outcome included lack of one or more brainstem reflexes (pupillary or corneal reflex), absence of motor response at 72 hours, myoclonus, status epilepticus, electroencephalogram with generalized suppression, and absent bilateral cortical N20 response to somatosensory-evoked potentials. However, several studies have found these indicators to be unreliable after hypothermia. This may be the result of sedatives, which can affect physical examination and electroencephalogram results, and delayed clearance. Because of the unreliability of prognostication tests within the first 72 hours of hypothermic protocols in the setting of sedation, it appears prudent in some cases to delay final prognosis discussions until at least six days postcardiac arrest and after neurologic evaluation is done with patients sedative-free.

Treatment of spinal fractures using Lubra plates

The purpose of this retrospective study was to review the clinical use along with the short- and long-term outcome in patients treated with Lubra plates to stabilize spinal fracture and dislocations that were considered unstable at time of surgery according to the 'three compartment theory'. The data that were collected included breed, age, gender, body weight of the patients, cause of injury, neurological grade (pre- and postoperative), radiographic findings, surgical treatment, and clinical and radiological outcome. Thirteen dogs and two cats were included with thoracic (1 case), thoracolumbar (3 cases), midlumbar (5 cases) and caudal lumbar (6 cases) vertebral fractures. For stabilization, the small-sized (3 cases), medium-sized (6 cases), and large-sized (6 cases) Lubra plates were used. The clinical outcome was excellent in 10/15 patients, functional in 2/15 and poor in 3/15 with a median follow-up period of nine years (range 2 months to 12 years). The fractures eventually stabilized by ventral spondylosis. No implant failure was seen, however demineralization of the spinous processes necessitated implant removal in one case. Our results suggest that Lubra plating is an appropriate technique for thoracolumbar and lumbar vertebral fractures as well as luxations in dogs and cats. The prognosis for neurological recovery was excellent when the animal had a neurological grade of 3 and was not paralyzed.

Spontaneous Spinal Epidural Haematomas and the Prognostic Implications of Interval to Surgical Decompression: A Report of Two Cases

Spontaneous spinal epidural haematomas (SSEHs) are rare causes of spinal cord compression. We present 2 cases of thoracic SSEHs with similar magnetic resonance imaging (MRI) features. Patient 1 was on long-term oral anticoagulants and patient 2 had uncontrolled hypertension. Patient 1 presented with a dense motor deficit, whereas patient 2 developed progressive lower limb weakness. Decompression laminectomy and haematoma evacuation was performed 51 hours later for patient 1 and 14 hours later for patient 2. Both had recovered their lower limb power, but neurological recovery was greater for patient 2. In patients with bleeding diatheses or uncontrolled hypertension, acute SSEHs must be suspected when they present with atraumatic back pain and signs of spinal cord compression. The interval to surgical decompression greatly influences the prognosis for neurological recovery.

Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases

The authors evaluated the mechanisms and patterns of thoracic, lumbar, and sacral spinal injuries in a pediatric population as well as factors affecting the management and outcome of these injuries. The records of 89 patients (46 boys and 43 girls; mean age 13.2 years, range 3-16 years) with thoracic, lumbar, or sacral injuries were reviewed. Motor vehicle accidents were the most common cause of injury. Eighty-two patients (92.1%) were between 10 and 16 years old, and seven (7.9%) were between 3 and 9 years old. Patient injuries included fracture (91%), fracture and dislocation (6.7%), dislocation (1.1%), and ligamentous injury (1.1%). The L2-5 region was the most common injury site (29.8%) and the sacrum the least common injury site (5%). At the time of presentation 85.4% of the patients were neurologically intact, 4.5% had incomplete injuries, and 10.1% had complete injuries. Twenty-six percent of patients underwent surgery for their injuries whereas 76% received nonsurgical treatment. In patients treated surgically, an anterior approach was used in six patients (6.7%), a posterior approach in 16 (18%), and a combined approach in one (1.1%). Postoperatively, six patients (26.1%) with neurological deficits improved, one of whom recovered fully from an initially complete injury. Thoracic and lumbar spine injuries were most common in children older than 9 years. Multilevel injuries were common and warranted imaging evaluation of the entire spinal column. Most patients were treated conservatively. The prognosis for neurological recovery is related to the initial severity of the neurological injuries. Some pediatric patients with devastating spinal cord injuries can recover substantial neurological function.

Recovery of neurologic function following nontraumatic spinal cord lesions in Israel.

Retrospective cohort study. To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs). NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce. The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patient's Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs). Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs. The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs.

The role of directly applied hypothermia in spinal cord injury.

The effect of intense local hypothermia was evaluated in a precision model of spinal canal narrowing and spinal cord injury in rats. The spinal cord injury was cooled with a custom cooling well used over the epidural surface. Basso, Beattie, and Bresnahan (BBB) motor scores and transcranial magnetic motor-evoked potential (tcMMEP) responses were used after injury to accurately evaluate neurologic recovery. This study was undertaken to determine whether the prognosis for neurologic recovery in a standardized rat spinal cord injury model is altered by the direct application of precisely controlled hypothermia to the area of injury. The role of hypothermia in the treatment of spinal cord injuries with neurologic deficits remains undefined. Hypothermia may decrease an area of spinal cord injury and limit secondary damage, therefore improving neurologic recovery. However, it has been difficult to consistently apply localized cooling to an area of spinal cord injury, and the use of systemic hypothermia is fraught with complications. This fact, along with the unavailability of a precise spinal cord injury model, has resulted in inconsistent results, both clinically and in the laboratory. In a rat model of spinal cord injury, 37 C and 19 C temperatures were used to study the role of hypothermia on neurologic recovery. Male Spraque-Dawley rats (n = 52; weight, 277.7 g) were anesthetized with pentobarbital and subjected to laminectomy at T10. The rats were divided into three groups: 1) placement of a 50% spacer in the epidural space (16 rats), 2) severe (25 g/cm) spinal cord injury (16 rats), 3) 50% spacer in combination with spinal cord injury (16 rats). Eight rats in each group were tested at two temperatures: normothermic (37 C) and hypothermic (19 C). With the use of a specially designed hypothermic pool placed directly over the spinal cord for 2 hours, epidural heating to 37 C, and epidural cooling to 19 C was accomplished. Simultaneous measurements of spinal cord and body temperatures were performed. The rats underwent behavior testing using the BBB motor scores and serial tcMMEPs for 5 weeks. Statistical methods consisted of Student's t tests, one-way analysis of variance, Tukey post hoc t tests and chi2 tests. There was a significant improvement in motor scores in rats subjected to hypothermia compared with those that were normothermic after insertion of a 50% spacer. This improvement was observed during the 5-week duration of follow-up. In the severe spinal cord injury group and the spinal cord injury-spacer groups, no significant improvement in motor scores were obtained when the spinal cord was exposed to hypothermia. The results demonstrate that there is a statistically significant (P < 0.05) improvement in neurologic function in rats subjected to hypothermia (19 C) after insertion of a spacer that induced an ischemic spinal cord injury. This indicates that directly applied hypothermia may be beneficial in preventing injury secondary to ischemic cellular damage. The data demonstrated minimal therapeutic benefit of hypothermia (19 C) after a severe spinal cord injury.

Hydatid Disease of the Spine

Vertebral hydatidosis is a relatively silent and slowly progressive disease with a latent period of many years. The prognosis for neurologic recovery in hydatid disease of the spine generally is regarded as poor and posterior surgical decompression is associated with a high recurrence rate. Reported here are the results after a long-term followup of four patients with hydatid disease of the spine with neurologic deficit which significantly improved after anterior surgical decompression and anthelmintic therapy. Adequate preoperative evaluation with magnetic resonance imaging and computed tomography scanning is essential in localizing the lesions and planning the surgical approach. The authors recommend radical excision of the involved vertebra and anthelmintic drugs to control the disease process.

Neurologic complications of surgery for anterior shoulder instability

Two-hundred eighty-two patients underwent anterior reconstruction for recurrent glenohumeral instability between 1981 and 1991. Twenty-three patients (8.2%) had a neurologic deficit after surgery. Seven had sensory disturbances only; 16 had sensorimotor neuropathies (8 having multiple deficits designated as a diffuse plexopathy and 8 having a more defined deficit in 1 or 2 cords or peripheral nerves). Complete resolution occurred in 18 of the 23 patients. Four patients had a residual deficit (1 patient was lost to followup). Three had persistent sensory disturbances; 1 had permanent biceps weakness. None of these patients underwent surgical exploration. Older age (P=.045) and a Bankart lesion (P=.029) were associated with a neurologic complication. At an average follow-up of 8.7 years, 252 patients responded to a questionnaire regarding shoulder outcome, including 20 of the 23 patients with nerve injuries. The difference in the median Rowe score of those with and without nerve injury was not significant (P=.072). Neurologic injuries after anterior shoulder surgery presumably arise as a result of traction. The prognosis for neurologic recovery is generally good. Neurologic injury did not interfere with the outcome of the stabilization procedure.

Update on Nerve Palsy Associated With Total Hip Replacement

Nerve palsy is an uncommon but acknowledged complication of total hip replacement. The overall prevalence is approximately 1%. The sciatic nerve, or the peroneal division of the sciatic nerve, is involved in nearly 80% of cases. The risk of nerve palsy in association with total hip replacement is increased for female compared with male patients, with a diagnosis of developmental dysplasia, and with patients undergoing revision surgery. In the majority of cases, the origin of the palsy is unknown. Because peripheral nerves are sensitive to compression, unrecognized compression may play a role in these cases. The prognosis for neurologic recovery is related to the degree of nerve damage. Complete, or essentially complete, recovery occurs in approximately 41% and another 44% have only a mild deficit. Approximately 15% have a poor outcome characterized by weakness that limits ambulation and/or persistent dysesthesia. Patients with some motor function immediately after the operation and those who recover some motor function within approximately 2 weeks of surgery have a good prognosis for recovery. In general, recovery of femoral nerve palsies is more predictable than that of sciatic palsies.

Neurologic injuries in pelvic ring fractures.

Unstable fractures of the pelvic ring are an increasingly frequent outcome of motor vehicle trauma. Neurologic injury after such injuries can be a cause of significant morbidity. The available literature on neurologic injuries was reviewed and compared with a clinical review of 90 unstable pelvic injuries treated during a 3-year period. Eighty-three patients were available for followup examination. Neurologic injuries were seen in 21 % of the patients. Thirty-seven percent of patients had sensory deficits alone whereas the remaining 63% had motor and sensory findings. All patients showed some evidence of neurologic recovery at an average or 24-months followup. At least 1 grade of muscle function improvement was consistently seen and 53% of patients had complete neurologic recovery. Improvement in function was seen as many as 24 months postinjury, but L5 function was least likely to progress to full recovery. The incidence of neurologic injuries and their distribution was similar to that reported in the literature, whereas the prognosis for neurologic recovery was significantly better. This may be related to techniques of early anatomic reduction and stabilization of unstable pelvic ring injuries.

Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery.

We analyzed the cases of seventy-three patients who were managed over a twenty-year period for rheumatoid involvement of the cervical spine and were followed for a minimum of two years, with an average follow-up of seven years. A neurological deficit did not develop in thirty-one patients (Ranawat et al. Class I) and paralysis developed in the remaining forty-two patients: Class II in eleven and Class III in thirty-one. Of the forty-two patients in whom paralysis developed, thirty-five had operative stabilization. Seven patients were managed with a soft cervical collar because they refused or were medically unable to have the operation; all of the had an increase in the severity of the paralysis. The posterior atlanto-odontoid interval and the diameter of the subaxial sagittal canal measured on the cervical radiographs demonstrated statistically significant correlations with the presence and severity of paralysis. All of the patients who had a Class-III neurological deficit had a posterior atlanto-odontoid interval or diameter of the subaxial canal that was less than fourteen millimeters. In contrast, the anterior atlanto-odontoid interval, which has traditionally been reported, did not correlate with paralysis. The prognosis for neurological recovery following the operation was not affected by the duration of the paralysis but was influenced by the severity of the paralysis at the time of the operation. The most important predictor of the potential for neurological recovery after the operation was the preoperative posterior atlanto-odontoid interval. In patients who had paralysis due to atlanto-axial subluxation, no recovery occurred if the posterior atlanto-odontoid interval was less than ten millimeters, whereas recovery of at least one neurological class always occurred when the posterior atlanto-odontoid interval was at least ten millimeters. If basilar invagination was superimposed, clinically important neurological recovery occurred only when the posterior atlanto-odontoid interval was at least thirteen millimeters. All patients who had paralysis and a posterior atlanto-odontoid interval or diameter of the subaxial canal of fourteen millimeters had complete motor recovery after the operation. In this series, although only patients who had a neurological deficit were operated on, we observed the range of the posterior atlanto-odontoid interval that was associated with poor or no recovery after the operation, and we identified the safe range on the basis of the patients in whom paralysis did not develop.(ABSTRACT TRUNCATED AT 400 WORDS)

Nerve palsy associated with total hip replacement. Risk factors and prognosis.

We reviewed the results of 3126 consecutive total hip replacements and identified postoperative neuropathy in the ipsilateral lower extremity after fifty-three (1.7 per cent) over-all and after 1.3 per cent of the primary arthroplasties. The prevalence was 5.2 per cent after the primary arthroplasties that had been done for congenital dislocation or dysplasia of the hip and 3.2 per cent after the revisions (all diagnoses). Thus, these two types of operations were risk factors (p less than 0.01). Limb-lengthening only partially accounted for the increased prevalence of neuropathy after these procedures. The sciatic nerve was involved in all but five extremities. The cause of the palsy was unclear or unknown in thirty (57 per cent) of the extremities. When the patients were last seen, at a minimum of one year and a maximum of sixteen and one-half years after the operation, seven extremities were normal neurologically, thirty-three had a mild neurological deficit, and thirteen had a major deficit. All patients who had complete recovery of neurological function had it by twenty-one months. Of thirty-six extremities that were evaluated at a minimum of twenty-four months after the operation, seven were neurologically normal, twenty-three had a mild persistent deficit, and six had a major persistent deficit. The ability to walk decreased for all patients who had a nerve palsy. The greatest disability was in the patients who had been forty-eight years old or less and had had a primary total hip replacement (p = 0.037). The prognosis for neurological recovery was related to the degree to which the nerve was damaged.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurologic Injury and Recovery Patterns in Burst Fractures at the T12 or L1 Motion Segment

Fourteen consecutive patients with burst fractures at T12 or L1, partial paralysis, and more than 30% canal compromise were prospectively evaluated pretreatment and posttreatment with roentgenograms to determine the initial fracture pattern, CT scans to determine the percent canal compromise and subsequent improvement, and a quantitative motor trauma index scale and bladder sphincter evaluation to determine neurologic recovery. The follow-up period averaged 32 months (range, 12-50 months). Treatment was as follows: nonoperative (three patients), Harrington rods and fusion (seven patients), and Harrington rods and fusion followed by anterior decompression and fusion (four patients). The initial severity of paralysis did not correlate with the initial fracture roentgenographic pattern or the amount of initial CT canal compromise. Neurologic recovery did not correlate with the treatment method or amount of canal decompression. Subsequent recovery did correlate with the initial fracture pattern. If the patient had a Type I or Type II fracture (both greater than 15 degrees kyphosis), greater than 90% neurologic recovery occurred, regardless of treatment. If the patient had a Type III fracture (less than 15 degrees kyphosis and the maximal canal compromise where bone encircles the canal) less than 50% neurologic recovery occurred. If the patient had a Type IV fracture (less than or equal to 15 degrees kyphosis and the maximal canal compromise at the level of the ligamentum flavum), the neurologic recovery was variable. Prognosis for neurologic recovery can be made based on initial roentgenograms. If greater than 15 degrees kyphosis is present, there is a good prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Ischaemic spinal cord injury after cardiac surgery.

The case records of eight children with an acute spinal cord lesion after cardiac surgery were reviewed. All had been operated on for congenital heart disease over the past 10 years. The prognosis for neurological recovery was poor and scoliosis and bladder dysfunction were common complications. Ischaemic cord injury is usually associated with coarctation of the aorta but may occur when surgery is performed for other cardiovascular defects.

Strangulation in Childhood

Feldman et al reviewed 233 cases of childhood strangulation to define causes, clinical course, prognosis for neurologic recovery, and methods of prevention from strangulation Cribs, ropes, and cords were leading causes of childhood strangulation in accidental or suicidal injury. All age groups were affected. Pacifier cords, low hanging cradle gyms, and toy cords caused strangulations during infancy. Toddlers to early school-aged children strangled on window cords, plant holders, electric car windows, high chairs, and looped rope swings. Jackets, ponchos, and scarves caused accidental mechanical suffocation by entanglement with unsafe playground equipment. Strangulations in older children resulted from rope loops, cords, belts, neckties, and rope or chain swings. Most accidents were the result of unsafe play, attention-seeking activities, suicidal attempts, or partial asphyxiation during autoerotic stimulation.

Strangulation in Childhood

Feldman et al reviewed 233 cases of childhood strangulation to define causes, clinical course, prognosis for neurologic recovery, and methods of prevention from strangulation Cribs, ropes, and cords were leading causes of childhood strangulation in accidental or suicidal injury. All age groups were affected. Pacifier cords, low hanging cradle gyms, and toy cords caused strangulations during infancy. Toddlers to early school-aged children strangled on window cords, plant holders, electric car windows, high chairs, and looped rope swings. Jackets, ponchos, and scarves caused accidental mechanical suffocation by entanglement with unsafe playground equipment. Strangulations in older children resulted from rope loops, cords, belts, neckties, and rope or chain swings. Most accidents were the result of unsafe play, attention-seeking activities, suicidal attempts, or partial asphyxiation during autoerotic stimulation.

Post-traumatic acute anterior spinal cord syndrome.

Thirteen patients with motor complete but sensory incomplete lesions following vertebral and spinal cord injuries are described. Sensory dissociation was present with more impairment of pain than touch or proprioception. The loss of pain sensation was complete in seven patients, but was incomplete in the other six subjects four of whom showed major motor recovery. The major point of interest of this study is to show that patients who retain not only touch but also pain sensation have a definitely better prognosis for neurological recovery.

Posterior fossa infarction: results of brain scanning.

The brain scans and clinical records of 25 patients with posterior fossa infarction were reviewed. In four patients with a clinical diagnosis of cerebellar hemisphere infarction, the brain scans showed focally increased uptake of 99mTc-pertechnetate in the affected hemisphere. In 21 patients with a clinical diagnosis of brainstem infarction, the brain scans were normal. In one patient who underwent serial scanning, the evolution of the scan abnormality was similar in time course to that described for cerebral hemisphere infarction. There was no apparent correlation between scan abnormality and prognosis for neurologic recovery.