Quadriplegic Patients Research Articles

Sedation for the imminently dying: Survey results from the AAN Ethics Section

Objectives: Sedation for the imminently dying (SFTID) is a controversial practice that involves the provision of sedation to imminently dying patients with the intent of relieving their suffering when symptoms are refractory to other interventions. The goal of this research was to ascertain the opinions regarding SFTID that are held by neurologists who are interested in ethics and end-of-life care. Methods: Members of the American Academy of Neurology Ethics Section were surveyed regarding their familiarity and experience with SFTID and their opinions pertaining to it. To determine whether their opinions varied in relationship to clinical context, a single stem question for 5 different case scenarios was used. Results: A total of 96% of respondents agreed or strongly agreed that the primary purpose of SFTID was to relieve suffering, 83% disagreed or strongly disagreed that SFTID was morally equivalent to euthanasia, and 85% disagreed or strongly disagreed that SFTID was legally equivalent to euthanasia. For the case scenarios, 92% agreed or strongly agreed that SFTID was acceptable for imminently dying patients with metastatic cancer, while 50% agreed or strongly agreed that SFTID was acceptable for patients with end-stage amyotrophic lateral sclerosis, and only 7% agreed or strongly agreed that SFTID was acceptable for posttraumatic quadriplegic patients not at risk for imminent death. Conclusions: The overwhelming majority of neurologists surveyed endorse the concept that sedation for the imminently dying differs morally and legally from euthanasia and that it is an acceptable therapeutic option for some but not all patients who are imminently dying of a terminal illness.

Laparoscopic diaphragmatic pacer placement – a potential new treatment for ALS patients: a brief description of the device and anesthetic issues

The Diaphragm Pacing Stimulator (DPS) has been used to treat ventilatory insufficiency in quadriplegic patients. The FDA approved a trial using the DPS in patients with amyotrophic lateral sclerosis (ALS). Three patients with advanced ALS, who underwent laparoscopic diaphragmatic pacer placement, and their general anesthetic management, are presented.

UP-1.59: Urological features of quadriplegia: six years of experience

The quadriplegic patient, due to the complexity of his pathology, requires a particular approach by the physician. The aim of our study is to synthesize the urological features of quadriplegia based on our experience.

Impact of treadmill gait training with neuromuscular electrical stimulation on the urodynamic profile of patients with high cervical spinal cord injury.

To evaluate the impact of gait training with neuromuscular electrical stimulation on urodynamic parameters of patients with neurogenic bladder. Eight male quadriplegic patients with complete cervical injury level ranging from C4 to C7 comprised the study population. They underwent treadmill gait training with neuromuscular electrical stimulation for six months, only after having their quadriceps and tibialis anterior muscles stimulated for five months in order to support at least 50% of their body weight (pre-gait training). Urodynamic testing was performed before the treadmill gait training and six months after. The mean time after cervical lesion was 74.63 months. The urodynamic parameters before and after neuromuscular training by electrical stimulation did not show significant difference. This study demonstrated that neuromuscular training with electrical stimulation can benefit the urinary tract. This promising minimally invasive field requires further and more complete studies to confirm a possible benefit to the low urinary tract.

Use of Bioabsorbable Bone Graft in Osteomyelitis Associated with Ischial Pressure Sores

Sir: Traditional surgical principles in pressure sore management include soft-tissue débridement, removal of infected bone, and filling the dead space using local flaps. Antibiotic-impregnated methylmethacrylate beads have been used in chronic osteomyelitis to deliver antibiotics locally in high concentrations. However, once the antibiotics have leached out of the bead, the bead acts as a nidus for infection and requires removal.1 Bone graft substitutes impregnated with antibiotics have been used to replace bone defects in osteomyelitis of the long bones and spine with excellent results.2 However, their use has not been described in pressure sore–associated osteomyelitis. OsteoSet (Wright Medical Group, Inc., Arlington, Tenn.), a bioabsorbable calcium sulfate bone graft substitute, can be impregnated with antibiotics and used to fill the bony cavity.3 The concentration of antibiotics released from calcium sulfate preparations exceeds 100-fold the minimum inhibitory concentration in the first 24 hours and 10-fold the minimum inhibitory concentration for 3 to 4 days, with continued elution of the antibiotic beyond 10 days.4 New bone adheres to the reabsorbing OsteoSet and gradually fills in the defect. Obliteration of the bony dead space by bone graft substitutes reduces the need for extensive flap surgery. Our experience in three patients with ischial pressure sores and infected ischium was successful in curing osteomyelitis and closing wounds without extensive flap, and there was no occurrence of contralateral ischial pressure sores caused by traditional ischiectomy. After soft-tissue débridement, the outer cortex is opened with a dental burr to allow complete débridement of the infected cancellous bone. The remaining cortex is kept intact to provide housing for the bone graft substitute (Fig. 1). Multiple débridements may be required until the wound is clean. Then, OsteoSet antibiotic paste is molded into the bony cancellous defect within the cortical bone envelope, and layered closure of the wound is performed over a suction drain. Its placement should be deep; otherwise, subcutaneous bone formation will occur and can lead to ulceration. Culture-directed intravenous antibiotics are continued for 6 weeks.Fig. 1.: Ischial wound after soft-tissue and bony débridement shows preservation of ischial and pubic ramus bone cortex for placement of bone graft substitute antibiotic paste (above). Healed ischial area in a C7 quadriplegic patient after bone graft substitute and layered closure is seen at 42 months after surgery (below).Our first patient remained healed for 3 years after this procedure. A new area of osteomyelitis was then débrided and treated with OsteoSet. Healthy bone was noted in areas where OsteoSet had been placed initially. A second patient was recurrence free for over 3 years. Incidentally, he failed multiple conventional flap procedures for a contralateral ischial pressure sore that was treated at another institution. Our last patient underwent placement of OsteoSet with an inferior gluteal flap. Two recurrences at 3 and 5 years were managed with débridement, OsteoSet placement, and flap readvancement. The use of antibiotic-impregnated bone graft substitute is a simple and effective technique for pressure sore–associated osteomyelitis. Because recurrence rates can be as high as 69 percent after surgical management of pressure sores,5 it is common to exhaust most local flap options within a few years. Placement of a bone graft substitute obliterates the bony dead space and preserves local tissue to salvage future recurrences that are inevitable in this patient population. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Matthias Solomon, M.B.B.S. Division of Plastic Surgery Mayo Clinic Rochester, Minn. Peyton Davis, M.B.Ch.B. Department of Emergency Medicine Oxford University Oxford, United Kingdom Nho V. Tran, M.D. Division of Plastic Surgery Mayo Clinic Rochester, Minn. Michael Rock, M.D. Department of Orthopedic Surgery Mayo Clinic Rochester, Minn.

Hemorrhagic Shock and Encephalopathy Syndrome in a Quadriplegic Child

A case presentation of hemorrhagic shock and encephalopathy syndrome (HSES). To describe an unusual complication of uncontrolled fever in a tetraplegic child and to discuss possible pathophysiological mechanisms in these circumstances. HSES is a rare and dramatic disorder of unknown origin occurring mainly in infants and young children. Clinical features of HSES associate hyperpyrexia, acute diarrhea, circulatory collapse, coma, convulsions, and multiple organ failure (MOF). Altered physiologic thermoregulatory response in infants exposed to abruptly increased core temperature or altered thermal environment, and links with heat stroke, have been mentioned in previous publications. We report a case of HSES occurring in a 6-year-old girl with post-traumatic C4 quadriplegia. She eventually experienced hyperpyrexia, deep shock, watery diarrhea, and severe MOF developed rapidly. Despite rapidly resolving MOF, severe brain lesions consistent with HSES were observed and resulted in permanent neurologic impairment. Negative bacterial and viral screening eliminated a septic origin. In this child, impaired thermoregulatory response to acute hyperpyrexia resulting from complete quadriplegia could be the necessary condition for the development of HSES in the presence of acute hyperpyrexia of unknown origin. Quadriplegic patients, especially young children, could be considered at increased risk of developing severe MOF and acute central nervous system impairment consistent with HSES, when exposed to heat stress and should be treated promptly.

Treinamento de músculos inspiratórios em pacientes com quadriplegia

To determine whether inspiratory muscle training can increase strength and endurance of these muscles in quadriplegic patients. Eight quadriplegic patients (7 males and 1 female) with injury to the lower cervical spine (segments C4-C7) were submitted to inspiratory muscle training with a threshold inspiratory muscle trainer adjusted to 30% of MIP. The training sessions were carried out with the patients in a sitting position, 5 days a week for 8 weeks. Endurance time, MIP, MEP and FVC were determined at baseline, week 4 and week 8. In comparison with the mean baseline value, there was an increase in MIP, measured in the sitting position, at weeks 4 and 8 (-83.0 +/- 18.9 cmH2O vs. -104.0 +/- 19.4 cmH2O and -111.3 +/- 22.7 cmH2O). There was an increase in MEP, also in the sitting position, at week 4 (from 36.8 +/- 8.1 to 42.6 +/- 8.8 cmH2O). There was an improvement in FVC at week 4 (from 2.1 +/- 0.8 to 2.5 +/- 0.6 L, representing an increase of 24 +/- 22%). Although there was an increase in endurance (sitting) at week 8, the difference was not significant in comparison with the baseline value (29.8 +/- 21.0 vs. 35.9 +/- 15.5 min, an increase of 173 +/- 233%). Quadriplegic patients can benefit from training at low loads (30% of MIP), which can improve inspiratory muscle strength, FVC and expiratory muscle performance.

Sedation for the imminently dying

Sedation for the imminently dying (SFTID) is a controversial practice that involves the provision of sedation to imminently dying patients with the intent of relieving their suffering when symptoms are refractory to other interventions. The goal of this research was to ascertain the opinions regarding SFTID that are held by neurologists who are interested in ethics and end-of-life care. Members of the American Academy of Neurology Ethics Section were surveyed regarding their familiarity and experience with SFTID and their opinions pertaining to it. To determine whether their opinions varied in relationship to clinical context, a single stem question for 5 different case scenarios was used. A total of 96% of respondents agreed or strongly agreed that the primary purpose of SFTID was to relieve suffering, 83% disagreed or strongly disagreed that SFTID was morally equivalent to euthanasia, and 85% disagreed or strongly disagreed that SFTID was legally equivalent to euthanasia. For the case scenarios, 92% agreed or strongly agreed that SFTID was acceptable for imminently dying patients with metastatic cancer, while 50% agreed or strongly agreed that SFTID was acceptable for patients with end-stage amyotrophic lateral sclerosis, and only 7% agreed or strongly agreed that SFTID was acceptable for posttraumatic quadriplegic patients not at risk for imminent death. The overwhelming majority of neurologists surveyed endorse the concept that sedation for the imminently dying differs morally and legally from euthanasia and that it is an acceptable therapeutic option for some but not all patients who are imminently dying of a terminal illness.

Motor recovery mechanism in a quadriplegic patient with locked-in syndrome

Locked-in syndrome (LIS) is a rare neurologic condition caused by bilateral pontine lesions. Quadriplegia is one of the most serious clinical manifestations in patients with LIS. However, little is known about the motor recovery mechanism of quadriplegia in patients with LIS. In the current study, we present with a quadriplegic patient with bilateral pontine infarcts, whose motor function appeared to be reorganized into the peri-infarct areas of the infarcted pons, as demonstrated by diffusion tensor tractography (DTT). A 60-year-old was diagnosed as LIS due to bilateral pontine infarcts 6 years ago. The patient presented with complete paralysis of all four extremities at onset. After slow motor recovery, the patient was able to move all joint muscles against gravity and demonstrated some fine motor activity at the time of DTT scanning (6 years after onset). Results of DTTs for the corticospinal tract (CST) in both hemispheres showed that the CSTs originated from the primary motor cortex, descended along the known CST pathway, and passed through lateral areas of infarcts in the pons. Therefore, motor function of the four extremities of this patient appears to have been recovered by the CST, which passed through the lateral areas to the pontine infarcts.

TREATMENT OF PARALYTIC HIP DISLOCATION AMONG SPASTIC QUADRIPLEGIC CEREBRAL PALSY PATIENTS BY MEANS OF FEMORAL AND PELVIC OSTEOTOMY, WITHOUT OPENING THE JOINT CAPSULE (CAPSULOPLASTY)

Objectives: To show the preoperative planning and results from surgical treatment for paralytic hip dislocation among patients with cerebral palsy. The techniques used were proximal femoral varus derotation osteotomy in association with Dega iliac osteotomy, without opening the joint capsule. Methods: We performed a retrospective review of ten hips in eight patients with spastic quadriplegic cerebral palsy who underwent surgical treatment between 2003 and 2005, with the same surgical technique. The pre and postoperative clinical and radiological parameters, and the preoperative planning using an image intensifier, were assessed. The clinical parameters analyzed were: pain, hygiene-related difficulties and positioning difficulties. The radiological parameters were Reimer's index, the acetabular index and the neck-shaft angle. These results were subjected to statistical analysis. Results: We obtained good results with this technique. After a mean follow-up of three years, all the hips were observed to be stable at the last assessment, and there was a high degree of satisfaction among the families in relation to the treatment. We also showed that preoperative planning using an image intensifier allowed us to reduce and stabilize these hips without the need for capsuloplasty. Conclusion: The authors conclude that in treating hip dislocation among spastic quadriplegic cerebral palsy patients, capsuloplasty is unnecessary for stabilizing the coxofemoral joint.

Confirmation of epidural catheter placement in a quadriplegic patient using a nerve stimulator

To the Editor, Autonomic hyperreflexia (AH) may occur in up to 85% of patients with spinal lesions above the spinal level of T6 and manifests itself as marked hypertension, bradycardia, headache, and sweating. The triggers of AH include distention of the bladder, rectum, or cervix, and surgical stimulation below the level of lesion. The use of epidural to treat AH in patients with spinal cord injury has been described. 1 However, as assessment of motor and sensory loss is difficult to elicit in a patient with spinal cord injury, the correct placement of the epidural catheter can be challenging. In 1998, Tsui et al. described low current electrical stimulation (1–10 mA) to confirm epidural catheter placement. 2 This test has shown to have a sensitivity and specificity of 100% and 91.6%, respectively. We describe a case in which the placement of an epidural catheter in a patient with spinal cord injury was confirmed using a nerve stimulator. The authors received the patient’s written permission to report the case. Following a fall, a 30-yr-old female sustained a traumatic complete spinal injury at the level of C4. As a result of this injury, she was quadriplegic with sensory and motor levels of C4 and C6, respectively. Four years later, she presented to our hospital for ileal vesicostomy and creation of a pubovaginal sling. She had had a few episodes of AH triggered by bladder catheter blockage. Due to the intra and postoperative risks of AH, it was agreed that the patient would receive a combined thoracic epidural and general anesthesia. On the day of surgery, the patient’s skin was prepped while she was placed in the right lateral position, and the epidural space was identified in the midline at the T9-T10 level with a 17G Tuohy needle. An Arrow TM Flexi

A medico-legal review of cases involving quadriplegia following cervical spine surgery: Is there an argument for a no-fault compensation system?

Background:To determine whether patients who become quadriplegic following cervical spine surgery are adequately compensated by our present medico-legal system. The outcomes of malpractice suits obtained from Verdict Search (East Islip, NY, USA), a medico-legal journal, were evaluated over a 20-year period. Although the present malpractice system generously rewards many quadriplegic patients with substantial settlements/ Plaintiffs' verdicts, a subset receive lesser reimbursements (verdicts/settlements], while others with defense verdicts receive no compensatory damages.Methods:Utilizing Verdict Search, 54 cases involving quadriplegia following cervical spine surgery were reviewed for a 20-year interval (1988–2008). The reason(s) for the suit, the defendants, the legal outcome, and the time to outcome were identified. Operations included 25 anterior cervical procedures, 22 posterior cervical operations, 1 circumferential cervical procedure, and 6 cases in which the cervical operations were not defined.Results:The four most prominent legal allegations for suits included negligent surgery (47 cases), lack of informed consent (23 cases), failure to diagnose/treat (33 cases), and failure to brace (15 cases). Forty-four of the 54 suits included spine surgeons. There were 19 Plaintiffs' verdicts (average US $5.9 million, range US $540,000-US $18.4 million), and 20 settlements (average US $2.8 million, range US $66,500-US $12.0 million). Fifteen quadriplegic patients with defense verdicts received no compensatory damages. The average time to verdicts/settlements was 4.3 years.Conclusions:For 54 patients who were quadriplegic following cervical spine surgery, 15 (28%) with defense verdicts received no compensatory damages. Under a No-Fault system, quadriplegic patients would qualify for a “reasonable” level of compensation over a “shorter” time frame.

A Case of Atypical Distribution of Pulmonary Tuberculosis in Bedridden Patient with Quadriplegia

Pulmonary tuberculosis has intermediate prevalence in Korea. It is known that tuberculosis infection predominantly involves the upper lobes, based on the fact that multiplication of Mycobacterium tuberculosis is favored in areas with decreased pulmonary blood flow, impaired lymphatic drainage, and high oxygen tension. We report this case of a 40-year-old man who was brought to our hospital with hemoptysis and dyspnea. Prior to admission, the patient had been in a bedridden state for 15 years due to an injury of the cervical spine 4~5. A 3-Dimensional computed tomography showed predominantly longitudinal distribution of centrilobular nodules along the anterior chest wall, in the left lung. MTB-PCR and AFB culture of bronchial washing fluid revealed pulmonary tuberculosis. This case shows that long-standing supine posture and decreased motion of the anterior chest wall may change the distribution of preferential infection site of Mycobacterium tuberculosis in the lung, resulting in a ventral predominance of tuberculosis infection in the quadriplegic patient.

Eyegaze Detection from Monocular Camera Image for Eyegaze Communication System

An eyegaze interface is one of the key technologies as an input device in the ubiquitous-computing society. In particular, an eyegaze communication system is very important and useful for severely handicapped users such as quadriplegic patients. Most of the conventional eyegaze tracking algorithms require specific light sources, equipment and devices. In this study, a simple eyegaze detection algorithm is proposed using a single monocular video camera. The proposed algorithm works under the condition of fixed head pose, but slight movement of the face is accepted. In our system, we assume that all users have the same eyeball size based on physiological eyeball models. However, we succeed to calibrate the physiologic movement of the eyeball center depending on the gazing direction by approximating it as a change in the eyeball radius. In the gaze detection stage, the iris is extracted from a captured face frame by using the Hough transform. Then, the eyegaze angle is derived by calculating the Euclidean distance of the iris centers between the extracted frame and a reference frame captured in the calibration process. We apply our system to an eyegaze communication interface, and verified the performance through key typing experiments with a visual keyboard on display.

Small Bowel Volvulus in a Quadriplegic: A Rare Complication of the Simon Nitinol Inferior Vena Cava Filter.

The advent and use of inferior vena cava (IVC) filters have reduced the overall incidence of pulmonary embolism in hospitalized patients, but are not without potential complications. With the exponential increase in the utilization of IVC filters over the past two decades, it is important to consider the use of retrievable filters, where indicated, in order to potentially reduce long-term IVC filter-related complications. We report a rare case of small bowel volvulus due to IVC perforation by a Simon Nitinol filter strut in a quadriplegic patient 4 years after IVC filter insertion.

Long-term recovery of motor function in a quadriplegic patient with diffuse axonal injury and traumatic hemorrhage: A case report

There have been no studies on motor recovery in severe quadriplegic patients with traumatic brain injury (TBI) resulting from combined causes of weakness; this type of patient is often seen in rehabilitation clinics. We report on a quadriplegic patient who showed long-term motor recovery from severe weakness caused by a diffuse axonal injury (DAI) on the brainstem and a traumatic intracerebral hemorrhage (ICH) on left cerebral peduncle, as evaluated by diffuse tensor imaging (DTI) and functional MRI (fMRI). A 17-year-old male patient presented with quadriparesis at the onset of TBI. Over the 28-month period following the onset of the injury, the motor function of the four extremities slowly recovered to a range that was nearly normal. Two longitudinal DTIs (at 11 and 28 months from onset) and fMRI (at 28 months) were performed. Fractional anisotropy and an apparent diffusion coefficient were measured using the region of interest method, and diffusion tensor tractography was conducted using a DTI/fMRI combination. Fractional anisotrophy values in the brainstem, which were markedly decreased on the 11-month DTI, were increased on the 28-month DTI. On the fMRI performed at 28 months, the contralateral primary sensori-motor cortex was activated by the movement of either the right or left hand. Diffusion tensor tractography showed that fiber tracts originating from the motor-sensory cortex passed through the known corticospinal tract pathway to the pons. It seems that the weakness of this patient recovered due to the recovery of the damaged corticospinal tracts.

Train of Four Responses in Paretic Limbs

Quadriplegic patients pose difficulty for neuromuscular monitoring owing to nonavailability of accessible normal muscle. It is known that train of four responses (T4/T1 ratio) was exaggerated in paretic limbs. However, no studies have quantified the exaggeration at different degrees of block. This study was undertaken to quantify the exaggeration of train of four responses in paretic limbs with increasing levels of block after the administration of neuromuscular blocking drugs. Nine patients with normal motor power (group N) and 9 patients with paraplegia (group P) were studied. The mean difference in T4/T1 ratio (95% CI) between upper limb and lower limbs in normal group at T4/T1 81-90, T4/T1 71-80, T4/T1 51-70, T4/T1 31-50, and T4/T1 0-30 were 8.9 (0.8 to 16.9), 11.6 (3.8 to 19.5), 5.1 (-8.6 to 18.8), 7.6 (-6.8 to 21.9), and 3.8 (-0.9 to 8.5) and in paraplegic group, 14.5 (7.6 to 21.5), 25.1 (13.9 to 36.4), 35.6 (27.5 to 43.7), 29.1 (15.4 to 42.7), and 60 (39.4 to 80.7), respectively. There was a statistically significant difference in the train of four responses between normal and paretic limbs at all levels of block except at T4/T1 81-90. There was a significant positive correlation between difference in the T4/T1 ratio between the upper and lower limbs and intensity of block in the paraplegic group but no correlation in the normal group. The observation that T4/T1 ratio enhancement in denervated limbs is dependent on depth of neuromuscular block may have future implications for monitoring and reversal of neuromuscular block in this patient population.

Who Cares? We Do and We Always Will

Who Cares? We Do and We Always Will

Chemokines as possible targets in modulation of the secondary damage after acute spinal cord injury: a review.

In spite of many promising experimental studies, an effective treatment dramatically eliminating the secondary damage after spinal cord injury (SCI) is still missing. Since clinical data on the therapeutical effect after methylprednisolone treatment are not conclusive, new therapeutical modalities targeting specific components of secondary spinal cord damage needs to be developed. It is known that immune cells are recruited to injury sites by chemokines, which are small, structurally similar proteins released locally at the site of inflammation. Hence, this review was aimed to summarize possible roles of chemokines in the inflammation following SCI as well as to identify possible new therapeutical targets which can potentially be effective in ameliorating individual components of this inflammatory response. Data concerning inflammation reduction together with techniques improving axonal growth, cell replacement and remyelinization, may be crucial to move a small step forward in an attempt to make paraplegic and quadriplegic patients to walk.

The Outcome Of Neurogenic Bladder Dysfunction In Congenital And Acquired Spinal Cord Lesion: The Urotherapist Role In A Spina Bifida Unit

PURPOSE Congenital or acquired spinal cord lesions (SCL) result in a serious physical disability, reducing quality of life and restricting social activities. We conducted this prospective study to define the role of urotherapist in a multisciplinary approach to neurogenic bladder dysfunction (NBD) in a Spina Bifida Unit. MATERIAL AND METHODS 25 children, 16 males and 9 females, aged 0.1-16.3 years with acquired SCL and 29 children, 13 males and 16 females, aged 0.5-17,2 years, with spina bifida (SB) were evaluated. In all patients a complete neuro-urological evaluation was performed considering pad use, diaries, renal ultrasound, video-urodynamics. NBD were classified according to International Children Continence Society criteria. The neuro-urological therapeutich approach was evaluated in all patients considering: clean intermittent catheterization (CIC) or self administered CIC, pharmacotherapy, endoscopic and surgical treatment. Psychological and familiar dynamics was evaluated using CBCL as well as clinical neurological using ASIA and SCIM scale, and quality of life (QOL) was evaluated too. RESULTS Motor disability was related to lesion site and it was worse in acquired than congenital SCL. Quadriplegic patients and children CONCLUSIONS Loss of sphincters control influenced patients and relatives quality of life more than motor disability. A multidisciplinary approach facilitates the maximum recovery level. Urotherapists play a main role to understand and answer to families's and patients's requests.