Tetraplegia Research Articles

Função motora e qualidade de vida de indivíduos com paralisia cerebral

Objetivo: Avaliar e correlacionar a função motora grossa e a qualidade de vida de crianças com PC. Métodos: Foi verificado em 20 crianças o tipo clínico e anatômico, a função motora grossa pela GMFM (Gross Motor Function Measure) e a qualidade de vida pelo Questionário de Qualidade de Vida Pediátrico (PedsQL). Foi utilizado o teste de Shapiro-Wilk e o de Kruskal-Wallis. Para correlacionar utilizou-se da Análise de Correlação Canônica, o teste da Razão de Verossimilhança e a Estatística Multivariada de Wilks Lambda, com nível de significância de 5%. Resultados: Apresentaram idade média de 8,4±4,03 anos. Os indivíduos com hemiparesia espástica apresentaram função motora significativamente maior que os com tetraparesia atetóide e espástica. Verificou-se a existência de alta correlação canônica significativa entre as variáveis da GMFM e PedsQL. Conclusão: Os achados demonstram que quanto maior for o comprometimento da função motora grossa menor será a sua qualidade de vida.

Investigation of the causes of clinical symptom aggravation in process of intravenous thrombolysis with alteplase

Objective To explore the causes of aggravation of microcirculation disorders in the process of intravenous thrombolysis with alteplase and the clinical outcomes. Methods The clinical data of the aggravated signs and symptoms of 13 cases treated by alteplase were reported, and the onset characteristics and clinical outcomes were analysed to summarize emergency experiences. Results There were 13 patients with stenosis of intracranial large arteries occurred perforating branch infarctions caused by the blocking of carried arteries (8 cases in internal carotid system, 5 cases in vertebral-basilar system). In the process of thrombolytic therapy, main aggravated presentations including cortical ischemic symptom, quadriplegia, exacerbated disturbance of consciousness were seen. Imaging examinations showed multiple new petechial ischemic foci in cortex and watershed region or increasing of infarct foci in cerebellum and brain stem. The prognosis was favorable after expectant treatment. NIHSS score was 8.69 ± 3.42 at 24 h after treatment, and mRS score was 0.94 ± 0.37 at 3 month-follow-up. Neurologic deficit and quality of life were evidently improved. Conclusion In the course of intravenous thrombolytic therapy with alteplase. Aggravated clinical signs and symptoms may be related to various factors. Emboli disintegration inducing microcirculation disorder is inferred to be the main cause. For patients presenting aggravated signs and symptoms in thrombolysis process, favorable outcomes may occur as long as intensive care and timely treatment are performed.

Restoring Reach and Grasp in a Patient with Tetraplegia

Brain–machine interfaces (BMIs) may eventually allow patients with severe disabilities to exert direct neural control of assistive devices in a manner

Cancer as a Therapeutic Agent?

The author, concisely and generically, proposes experimental testing on suitable laboratory animals, in state-of-the-art international centers endowed with cancer reversal experimental techniques. Using mild carcinogens to induce more or less benign growths can be reversed back to a normal state by single or dual strategy: in spinal paralysis by medullar contusion in young rabbits; for blindness caused by the severing of the optic nerve in sheep; for neural deafness caused by severing the acoustic nerve in rabbits. If these techniques could be shown to be feasible and successful for higher order primates and if having then already cured for life a sufficient number of malignant cancers by cancer reversal by dual strategy in human beings, of course these methods could be then considered for patients.

SPINAL CORD INJURY: CURRENT MAMMALIAN MODELS

It is estimated that approximately 2.5 million people are affected by Spinal Cord Injury (SCI), with more than 130,000 new cases reported each year (International Campaign for Cures of Spinal Cord Injury Paralysis). Although there is currently no cure for SCI, various strategies including rehabilitative, cellular and molecular therapies have been tested in a variety of animal models. But questions remain as to the validity of animal models and whether they relate to the clinical conditions found in humans. This review aims to look at the different and most current models that are used to study SCI and their potential uses in mimicking the human condition. Several different animals models have been developed to study the problems of SCI, allowing exploration of mechanisms and properties of specific pathways such as; the MAPK pathway and spinal cord diseases such as; Syringomyelia and Central Cord Syndrome to name a few to be elucidated. SCI is complicated by cavitation and a glial scar that lines the cavity, reducing the possibility of axon regeneration. Mammalian models, particularly in mice and rats, have been used for many years to study the impact of SCI and potential therapies, however, questions remain as to the validity of these models and their potential usefulness.

The 6-min Push Test Is Reliable and Predicts Low Fitness in Spinal Cord Injury

The objective of this study is to assess 6-min push test (6MPT) reliability, determine whether the 6MPT is sensitive to fitness differences, and assess if 6MPT distance predicts fitness level in persons with spinal cord injury (SCI) or disease. Forty individuals with SCI who could self-propel a manual wheelchair completed an incremental arm crank peak oxygen consumption assessment and two 6MPTs across 3 d (37% tetraplegia (TP), 63% paraplegia (PP), 85% men, 70% white, 63% Hispanic, mean age = 34 ± 10 yr, mean duration of injury = 13 ± 10 yr, and mean body mass index = 24 ± 5 kg.m). Intraclass correlation and Bland-Altman plots assessed 6MPT distance (m) reliability. Mann-Whitney U test compared 6MPT distance (m) of high and low fitness groups for TP and PP. The fitness status prediction was developed using N = 30 and validated in N = 10 (validation group (VG)). A nonstatistical prediction approach, below or above a threshold distance (TP = 445 m and PP = 604 m), was validated statistically by binomial logistic regression. Accuracy, sensitivity, and specificity were computed to evaluate the threshold approach. Intraclass correlation coefficients exceeded 0.90 for the whole sample and the TP/PP subsets. High fitness persons propelled farther than low fitness persons for both TP/PP (both P < 0.05). Binomial logistic regression (P < 0.008) predicted the same fitness levels in the VG as the threshold approach. In the VG, overall accuracy was 70%. Eighty-six percent of low fitness persons were correctly identified (sensitivity), and 33% of high fitness persons were correctly identified (specificity). The 6MPT may be a useful tool for SCI clinicians and researchers. 6MPT distance demonstrates excellent reliability and is sensitive to differences in fitness level. 6MPT distances less than a threshold distance may be an effective approach to identify low fitness in person with SCI.

Atypical EMG activation patterns of the elbow extensors after complete C6 tetraplegia during isometric contractions: a case report

Atypical EMG activation patterns of the elbow extensors after complete C6 tetraplegia during isometric contractions: a case report S. Cremoux a , J. Tallet b , E. Berton a , F. Dal Maso b & D. Amarantini b c a ISM, Aix-Marseille Universite, Marseille, France b PRISSMH, Universite Paul Sabatier Toulouse 3, Toulouse, France c Departement de kinesiologie, Universite de Montreal, Montreal, Quebec, Canada

Respiratory Complications and Management of Mechanical Ventilation in Cervical Spine Injury

It is estimated that the annual incidence of spinal cord injury in the United States is 12 000 new cases per year. Victims of spinal cord injury are prone to developing respiratory complications such as atelectasis, pneumonia, and ventilatory failure secondary to physiologic derangements resulting from spinal shock and paralysis. Respiratory complications are the leading cause of death in those who survive the initial injury. The goal in ventilator management of spinal cord injury patients in the intensive care unit setting is to prevent these complications and optimize patients for early transfer to a spinal cord rehabilitation facility. To minimize atelectasis, current guidelines recommend the use of very high tidal volumes (15 mL/kg) or setting high tidal volumes (10 mL/kg) in addition to using positive end-expiratory pressure. In this article, the authors discuss the pulmonary complications that affect the mortality of these patients and review the evidence behind the current high tidal volume ventilation strategy.

Goel's technique for the treatment of atlantoaxial dislocation with basilar invagination

Objective To explore the surgical feasibility and clinical outcome of translateral mass and pars screws fixation (Goel's technique) in the treatment of atlantoaxial instability and dislocation. Methods Seventy ⁃ six patients were diagnosed as atlantoaxial dislocation, including 50 cases combined with occipitalization, and 26 patients with os odontoideum. Fifty ⁃ seven patients presented signs and symptoms of myelopathy or spinal cord injury. All of the patients underwent posterior operation of open reduction and arthrodesis with C1, 2 joint fixation with rods and screws in the lateral masses and pars articulars of the atlas and axis. Results Seventy⁃four cases obtained good outcome. The main Japanese Orthopaedic Association (JOA) scale increased from 9.43 ± 3.16 preoperation to 13.80 ± 2.07 postoperation (t = 4.063, P = 0.037). According to Odom's scoring system, 19 patients were assessed as excellent, 49 good, 7 fair and 1 poor. A complete reduction was achieved in 15 cases, 35 patients obtained partial reduction. Twenty ⁃ six patients underwent transoral anterior decompression. One patient occurred respiratory and cardiac arrest at 12 h after operation. One patient subjected disturbances of blood coagulation tetraplegia and recovered muscle power gradually recovered to grade 3. Fifty patients were followed up more than 3 months, all of them achieved articular fixation. JOA scale improved from 8.90 ± 1.22 before operation to 14.72 ± 1.57 (t = 4.914, P = 0.015) at the follow up period. In Odom's rank: assessment 18 patients were excellent, 30 good, 2 fair and 0 poor. Conclusion Posterior reduction and arthrodesis with rigid internal fixators by Goel's technique could achieve satisfactory outcomes in patients with atlantoaxial dislocation. DOI：10.3969/j.issn.1672⁃6731.2012.04.008

Inhibition of the motor command during motor imagery: a MEG study with a quadriplegic patient

Inhibition of the motor command during motor imagery: a MEG study with a quadriplegic patient

Mortality from Intrathecal Baclofen Withdrawal Following Posterior Spinal Fusion: A Case Report.

Baclofen, a centrally acting gamma-aminobutyric acid (GABA) receptor agonist, is a commonly used antispasmodic agent in children and young adults with cerebral palsy or other upper motor neuron disorders. Baclofen is frequently administered intrathecally via a pump and catheter system as this delivery method has the advantage of increased potency with fewer systemic side effects than oral baclofen1-5. Intrathecal baclofen (ITB) improves spasticity scores, decreases pain scores, and allows for increased ease of care in patients with substantial spasticity6,7. Patients with progressive neuromuscular scoliosis who receive ITB therapy pose a unique clinical dilemma. If a posterior spinal fusion is undertaken to treat the neuromuscular scoliosis, the surgical approach exposes the baclofen catheter that enters at the lumbar spine, and this exposure can potentially lead to mechanical complications that inhibit or alter the consistent delivery of ITB1,8-12. We present a case of baclofen withdrawal following posterior spinal fusion that resulted in the patient’s death. The parents of this patient were informed that data concerning the case would be submitted for publication, and they provided consent. A nineteen-year-old man of normal intelligence with C6 tetraplegia, caused by transverse myelitis in infancy, had a progressive neuromuscular scoliosis that prevented comfortable seating (Figs. 1-A and 1-B). He had received an ITB pump at age eleven years in order to control lower-extremity spasticity, with the intrathecal catheter entering at the L1-L2 level and ending proximally at the T3 level. He had undergone two pump and proximal catheter revisions at the ages of sixteen and eighteen years because of catheter malfunctions, but had maintained a good baseline function for at least eighteen months prior to the scoliosis surgery. Fig. 1-A Sitting posteroanterior radiograph of the spine demonstrates a collapsing apex right thoracolumbar neuromuscular scoliosis …

Evaluation of the influence of Active Rehabilitation camps on the functional abilities in persons with tetraplegia

Abstract Introduction: Every year, about 400 new patients with tetraplegia arise in Poland. The solution ensuring the continuation of the rehabilitation process of such patients is the activity of non-governmental organizations associating disabled people. Among them Foundation of Active Rehabilitation (FAR) has greatest experience in rehabilitation of people after SCI. Annually, about 70 persons with tetraplegia participate in Active Rehabilitation (AR) camps. Aim of this study was to estimate the influence of AR camps on the functional abilities in persons with tetraplegia. Material and methods: 40 men with tetraplegia were examined. Subjects were divided into two groups: participants of AR camps (group A, n=20) and control (group B, n=20). TheASIA motor score was used to estimate the degree of upper limb impairment. Functional Independence Measure (FIM)was used to assess functional abilities. All subjects were assessed in the beginning of the study and reassessed after 8 days. Results: Both groups during preliminary investigation were homogeneous under regard the ASIA motor score as well as the results of FIM. During final investigations significant improvement of FIM was noted only in group A. The mean value of FIM significantly increased about 10.8 points. In group A significant correlation between FIM scores and ASIA motor score were found (p&lt;0.001). Conclusion: Improvement of functional skills among patients with tetraplegia which participated in AR camps was observed. The highest improvement in FIM was observed among persons with a C6 tetraplegia. Obtained results (ceiling effect) through of examined persons from C7 tetraplegia were suggested the need of applying more sensitive tests.

Movement strategies during car transfers in individuals with tetraplegia: a preliminary study

Three-dimensional kinematic analysis of car transfer (CT) movement in four adult males with C6 tetraplegia. The aim of the present study was to assess the normal transfer technique movement from a wheelchair to a car (that is, CT) in subjects with tetraplegia. A better understanding of CT movement is invaluable knowledge for spinal cord injury rehabilitation. This type of knowledge will improve rehabilitation programs so that patients with tetraplegia will have greater societal participation. School of Comprehensive Rehabilitation, Osaka Prefecture University, Osaka, Japan. Four adult males with C6 tetraplegia, an impairment grade of A according to the American Spinal Injury Association guidelines, took part in the study. The subjects used their own wheelchair and car in our assessments of their CT movement technique. Movements were assessed using a three-dimensional video analysis system with six digital video cameras. CT data, which included lateral displacement of the head and buttocks, and angular displacement of neck flexion and trunk forward inclination, were collected and correlation coefficients were calculated. All four subjects demonstrated negative correlations in lateral displacements greater than 0.70. As for correlation coefficients of angular displacement, two subjects demonstrated negative correlations (r = -0.98 and r = -0.77) and one subject demonstrated a positive correlation (r = 0.75). The neck flexion and trunk forward inclination strategy was different among the four subjects. Each subject with C6 tetraplegia demonstrated different strategies during CT movement.

Isolated sulfite oxidase deficiency, a rare neurodegenerative disorder which mimics hypoxic-ischemic encephalopathy

Isolated sulfite oxidase deficiency is a rare but devastating autosomal recessive neurometabolic disorder character- ized by neonatal-onset encephalopathy mimicking hypoxic-ischemic insult with intractable seizures and profound neurological dysfunction. Infants who survive characteristically manifest severe psychomotor retardation, progressive microcephaly, spastic quadriparesis, opisthotonus, movement disorders and lens dislocation. Sulfite oxidase is a mitochondrial enzyme encoded by the SUOX gene and is essential for the detoxification of sulfite, the terminal reaction in the degradation of sulfur-containing amino acids. Laboratory evidence of the disease includes a positive urinary sulfite dipstick test, abnormal amino acid profile with elevated plasma or urinary S-sulfocysteine level, high taurine and reduced cysteine concentration in plasma whilst serum uric acid and urinary excretion of uric acid, xanthine and hypoxanthine are normal. Brain magnetic resonance imaging demonstrates a pattern reminiscent of that observed in hypoxic-ischemic encephalopathy characterized by temporal alterations of initial cerebral edema and later severe white matter cavitary changes representing cystic encephalomalacia. In the absence of perinatal asphyxia, isolated sulfite oxidase deficiency should prompt appropriate biochemical evaluation. This report describes a male infant who presented with neonatal seizures and neuroimaging findings suggestive of ischemic encephalopathy.

Motion Induced Artifact Mimicking Cervical Dens Fracture on the CT Scan: A Case Report

The diagnostic performance of helical computed tomography (CT) is excellent. However, some artifacts have been reported, such as motion, beam hardening and scatter artifacts. We herein report a case of motion-induced artifact mimicking cervical dens fracture. A 60-year-old man was involved in a motorcycle accident that resulted in cervical spinal cord injury and quadri plegia. Reconstructed CT images of the cervical spine showed a dens fracture. We assessed axial CT in detail, and motion artifact was detected.

Characteristics and clinical assessment of deglutition disorders and oral movement function in children with cerebral palsy

Objective To investigate the symptom characteristis as well as the clinical assessment methods of dysphagia and oral motor function in children with cerebral palsy(CP).Methods A total of 116 children with CP,aged 18 months to 96 months(66 boys and 50 girls),treated in Qingdao Rehabilitation Center for Disabled Children from June 2009 to September 2010,were included in the study.Diagnosis and subtype of CP were determined by neuropaediatrician,the dysphagia disorders survey(DDS)as well as oral motor assessment were conducted by the speech therapists.Results Of the 116 cases,22.4％ of the cases were with mild dysphagia and 34.5％ with moderate to severe dysphagia,resulting in a prevalence of dysphagia of 56.9％.The main problems of these cases occurred during oral phase and pharyngeal phase,including inadequate feeding skills(involving sucking,biting,chewing or/and swallowing),coughing,vomiting and choking during feeding,cry/overextension of neck and head during feeding,drooling,hypertonic tongue and inadequate tongue lateralization.The severe dysphagia was encountered frequently in children with spastic quadriplegic,dyskinetic or mixed type CP children.Of the 116 cases,90 cases(77.59％)were with oral motor dysfunction(including all spastic quadriplegic,dyskinetic or mixed type children).The oral motor scores of CP children were significantly lower than those of the controls(P ＜ 0.01).Conclusions Oral phase dysphagia and oral motor disorder might be considered as the common clinical problems among the patients with CP,and could be assessed by using DDS combined with oral motor assessment,but for dysphagia during pharyngeal or esophagus phase,the videofluoroscopic modified barium swallow should be used for further evaluation. Key words: Cerebral palsy; Deglutition disorder; Oral movement disorder; Clinical assessment

A Single-stage Operation for Reconstruction of Hand Flexion, Extension, and Intrinsic Function in Tetraplegia

Surgical reconstruction is an established method to restore grip and grasp function after traumatic cervical spinal cord injury and tetraplegia. It can offer the patient improved ability to perform activities of daily living. Traditionally, surgical reconstruction of hand function has required separate operations for flexors and extensors. Here, we present a combination of procedures that provides key pinch and finger flexion together with opening of hand as a 1-stage operation. This reconstruction includes 7 individual operations that are performed in the following order: (1) split flexor pollicis longus-extensor pollicis longus distal thumb tenodesis, (2) reconstruction of passive interossei, (3) thumb CMC arthrodesis (4) brachioradialis-flexor pollicis longus tendon transfer, (5) extensor carpi radialis longus-flexor digitorum profundus tendon transfer, (6) EPL tenodesis, and (7) extensor carpi ulnaris tenodesis. We have chosen to entitle this reconstruction the alphabet or ABCDEFG procedure, an abbreviation for Advanced Balanced Combined Digital Extensor Flexor Grip reconstruction. To reduce the risk of adhesions after this extensive surgery and to facilitate relearning the activation of transferred muscles with new functions, early active training is performed. It is concluded that this 1-stage combination of operations can reliably provide grip, grasp, and release function in persons with C6 tetraplegia, patient satisfaction is high, time and effort for patient and caregivers are less, and incidence of complications is comparable with other published treatment modalities.

Body composition modifications in people with chronic spinal cord injury after supervised physical activity

BackgroundQuantification of body composition variables is important for planning of better activities in relation to individuals with spinal cord injury (SCI).Objectives(1) To evaluate changes in body composition in patients with SCI after a supervised physical activity process; (2) To correlate total body fat with time since injury.DesignPre-post intervention.SettingSarah Rehabilitation Hospital Network, Brazil.ParticipantsFifty-three men with SCI aged 18–52 years with duration of injury >3 years.InterventionsThe subjects were divided into three groups: tetraplegia (TT) (C5–C8), high paraplegia (HP) (T1–T6), and low paraplegia (LP) (T7–L2). Body composition was estimated in the first and last weeks of hospitalization.Outcome measuresBody weight (kg), skinfolds sum (mm), absolute (kg), and relative (%) fat and lean body mass.ResultsBody weight increased in TT and decreased in HP (0.8 kg, 95%CI 0.1–1.5; and −1.0 kg, 95%CI −2.0 to 0.0, respectively; P < 0.05). Skinfolds sum decreased only in HP (−13.1 mm, 95%CI −20.7 to −5.5; P < 0.05). Absolute and relative body fat decreased significantly in the paraplegia groups. Lean body mass (LBM) percentage increased significantly in the paraplegia groups. Absolute LBM increased in TT and LP (0.8 kg, 95%CI 0.3–1.3; and 1.3 kg, 95%CI 0.8 to 1.8, respectively; P < 0.05). There was no correlation between time since injury and skinfolds sum for the three groups (P < 0.05).ConclusionTT, HP, and LP demonstrated favorable changes in body composition after 29 days of supervised physical activity. However, these changes were different in direction and magnitude.

Intraoperative Radiotherapy Combined with Posterior Surgery for Spinal Metastases

Patients with cancer often suffered from spinal metastasis, and spinal cord compression from spinal metastasis represents a substantial clinical problem. External beam radiotherapy (EBRT) or conventional surgical decompression of the spinal cord often results in unsatisfactory neurological recovery and local recurrence. To improve neurological recovery and local control in such cases, we introduced intraoperative radiotherapy (IORT) combined with posterior surgery in 1992. We report the results for neurological recovery and local control in patients who received IORT combined with posterior surgery. Between November 1992 and March 2009, 158 cases (133 patients) were treated using IORT combined with posterior surgery for spinal paresis due to spinal metastases of breast, renal, thyroid, colorectal, and lung cancer. 99 cases were nonambulatory and 59 cases ambulatory before surgery. After posterior decompression, a single large dose of electron beam irradiation was delivered to the exposed metastatic lesion. Percentage dose in the spinal cord was approximately 10 - 25% with a lead shield, however, scattering of electron beams spread from behind the shielded central spinal cord region to reach the posterior region of the vertebra body located directly anterior to the spinal cord. Median dose of IORT was 20 Gy (range, 10 - 35 Gy), and median energy was 16 MeV (range, 11 - 22 MeV). 61 cases were treated with EBRT before the surgery; the delivered median dose was 40 Gy (range, 7.5 - 60 Gy). 41 cases were treated with EBRT after the surgery; the delivered median dose was 35 Gy (range, 8 - 50.5 Gy). Neurologic improvement of at least one level according to Frankel's classification was attained in 106 cases (67%) with a median follow-up period of 12.8 months. Spinal paralysis completely disappeared after surgery in 34 cases (22%). Of all 158 cases, 136 cases (86%) were ambulatory after surgery. Of the 99 cases nonambulatory before surgery, 78 cases (80%) became ambulatory after surgery. Postoperatively, 14 cases (9%) experienced local recurrence and neurologic exacerbation of at least one level according to Frankel's classification. The median time to local recurrence was 10.6 months (range, 3.0 - 40.6 months) after the surgery. For all 158 cases, median survival time was 18.5 months (range, 0.5 - 111.8 months) after the surgery. One patient experienced radiation myelopathy, and another patient experienced radiation neuropathy of cauda equina during the follow-up period. IORT combined with posterior surgery is a useful technique for the treatment of spinal cord compression caused by spinal metastasis, offering significant neurologic recovery and a low rate of local recurrence.

Long-term follow-up study of outcomes of bladder management in spinal cord injury patients under the care of The Midlands Centre for Spinal Injuries in Oswestry

Retrospective longitudinal study of short- and long-term urinary complications in chronic spinal cord injury (SCI) patients managed at the Midlands Centre for Spinal Injuries (MCSI). MCSI, Oswestry, UK. A total of 185 SCI patients were admitted to the MCSI between 1984 and 1989. Only 119 patients who met the following criteria were included: traumatic SCI, Frankel grade A-D, admission within 6 weeks post injury, regular annual follow-up or alternate year at MCSI, follow-up longer than 8 years. Follow-up ranged between 8 and 21 years with a mean of 17.7 (s.d.=1.98). The method of bladder drainage varied from the time of injury. Drainage was by indwelling urethral catheterisation (IndUC) before admission to the MCSI. Within 24 h of admission, assisted clean intermittent catheterisation (ACIC) by the nursing staff was commenced. This was followed by clean intermittent self catheterisation (CISC) once the patient was mobilised in the wheel chair and trained in the procedure. When detrusor reflex activity develops, patients with good hand function were given a choice between CISC and reflex voiding (RV). Patients with poor hand function are given the choice between RV, suprapubic catheters or ACIC during hospitalisation and after discharge. Only a minority of these patients choose ACIC following discharge. RV was supplemented occasionally by sphincterotomy. There were 99 males and 20 females (5:1). The age at the time of injury was 16-63 years with a mean of 29 (s.d.=12). Instead of a single method, a pattern of bladder management was analysed in the context of three continuous phases: Phase1 preadmission to MCSI. Phase2 during first hospitalisation at MCSI. Phase3 post discharge. In each phase, the patients were divided into those with and without complications. The complications were analysed in relation to the management and other relevant factors. The total complication rate at all stages was 62%. Complications of the upper urinary tract accounted for 22.6%. These results compared favourably with published material. The sequential system of supervised bladder management commencing with brief IndUC followed by IntC and/or RV remains effective in keeping the complication rate relatively low in SCI patients, who undergo regular surveillance and timely intervention. The project was supported by SPIRIT, a charitable not for profit trust that supports teaching, training, clinical research and dissemination of knowledge about all aspects of spinal paralysis in the UK.