Sixth Thoracic Vertebra Research Articles

Feasibility and accuracy of intraosseous endoscopy for inspection of thoracolumbar and lumbar pedicle drill tracts in a canine large-breed cadaveric model.

To evaluate the feasibility of endoscopic inspection of thoracolumbar and lumbar pedicle tracts in a canine large-breed model and its accuracy for the detection of breached versus nonbreached tracts. 2 greyhound cadavers. CT scans of 2 greyhound cadavers from the sixth thoracic vertebra to the sacrum were obtained. Fifty-six pedicles were randomized to have drill tracts with different modified Zdichavsky grades (nonbreached, partial/full medial breach, or partial/full lateral breach) using 3-D-printed guides. Endoscopy was performed on a single occasion from October 9 to 10, 2023, using a 1.9-mm 0-degree needle arthroscope in a randomized blinded fashion. The grading of drill tracts was performed on postoperative CT. Specificity, sensitivity, positive and negative predictive values, and time to assign endoscopic grade were investigated. Postoperative CT confirmed 43 nonbreached tracts, 7 medial breaches (partial/full), and 5 lateral breaches (partial/full). One tract was excluded because of guide misplacement. Intraosseous endoscopy was successfully performed in the remaining 55 drill tracts. Sensitivity to detect medial and lateral breaches was 71.4% and 60.0%. Negative predictive value was 93.1%. Specificity was 94.2%. Positive predictive value for detection of medial and lateral breaches was 83.3% and 54.5%. Median (range) time to assign an endoscopic grade was 118 (30 to 486) seconds. Intraosseous endoscopy of pedicle drill tracts may be a useful adjunct technique during pedicle screw/pin placement in dogs.

The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series.

This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.

Elongation of the proximal descending thoracic aorta and associated hemodynamics increase the risk of acute type B aortic dissection.

Acute type B aortic dissection (ATBAD) is a life-threatening aortic disease. However, little information is available on predicting and understanding of ATBAD. The study sought to explore the underlying mechanism of ATBAD by analyzing the morphological and hemodynamic characteristics related to aortic length. The length and tortuosity of the segment and the whole aorta in the ATBAD group (n= 163) and control group (n= 120) were measured. A fixed anatomic landmark from the distal of left subclavian artery (LSA) to the superior border of sixth thoracic vertebra was proposed as the proximal descending thoracic aorta (PDTA), and the dimensionless parameter, length ratio, was introduced to eliminate the individual differences. The significant morphological parameters were filtrated and the associations between parameters were investigated using statistical approaches. Furthermore, how aortic morphology influenced ATBAD was explored based on idealized aortic models and hemodynamic-related metrics. The PDTA length was significantly increased in the ATBAD group compared with the control group and had a strong positive correlation with the whole aortic length (r= 0.89). The length ratio (LR2) and tortuosity (T2) of PDTA in the ATBAD group were significantly increased (0.15 ± 0.02 vs 0.12 ± 0.02 and 1.73 ± 0.48 vs 1.50 ± 0.36; P< 0.001), and LR2 was positive correlation with T2 (r= 0.73). In receiver-operating curve analysis, the area under the curve was 0.835 for LR2 and 0.641 for T2. Low and oscillatory shear (LOS) was positive correlation with LR2, and the elevated LOS occurred in the distal of LSA. Elongation of PDTA is associated with ATBAD, and the length ratio is a novel predictor. Elongated PDTA induced more aggressive hemodynamic forces, and high LOS regions may correspond to the entry tear location. The synergy of the morphological variation and aggressive hemodynamics creates contributory conditions for ATBAD.

Unrecognised autonomic dysreflexia in neurogenic lower urinary tract dysfunction with spinal cord injury as a reason for admission to a cardiac surgical unit

BACKGROUND: In Russia, spinal cord injury occurs in 0.7–6.8% of total injuries. Due to emergence of new rehabilitation protocols, it is extremely important to know the time of occurrence of consequences of spinal cord injury and adequate diagnosis of complications, which allows timely identification of life-threatening conditions of one of the body systems.&#x0D; Clinical case description. We present a clinical case of autonomic dysreflexia in neurogenic lower urinary tract dysfunction after traumatic cervical spinal cord injury in a 17-year-old girl. In traumatic spinal cord injury above the level of the sixth thoracic vertebra, autonomic dysreflexia as a variant of autonomic dysfunction is a common complication. This clinical case will be of interest to clinicians of all specialties who encounter patients with spinal cord injury. It is shown that misinterpreted symptoms of increased blood pressure during bladder filling were the cause of observation and treatment by a cardiologist for arterial hypertension, as well as hospitalization in the cardiac surgery department for planned surgical treatment of renal artery stenosis, which was thought to be the cause of the episodic increases in blood pressure. Lack of knowledge about the presence of autonomic dysfunction in spinal cord injury patients may have led to unnecessary surgical treatment. During the joint management of the patient with a pediatric cardiac surgeon, signs of autonomic dysreflexia were detected against the background of traumatic spinal cord disease at the level of the cervical spine, hypotensive treatment and planned surgical intervention were canceled.&#x0D; Conclusion. Subsequently, an adequate regimen of periodic bladder catheterization and antimuscarinic drug therapy was prescribed, which successfully reduced the dysreflexia.

Unusual location of a central neurocytoma: Particularities of a rare brain tumor

Introduction: Central neurocytoma is a typically rare intraventricular glioneuronal tumor in young adults. Clinically, it is revealed by symptomatology of intracranial hypertension. Intra-parenchymal, extraventricular, and intramedullary localizations are exceptional. Central neurocytoma is considered a benign tumor that can recur locally, but craniospinal dissemination remains as an exception. Case Report: We report a case in a 35-year-old male subject who consulted for quadriparesis and genito-sphincter dysfunctions. The clinical examination noted a syndrome of intracranial hypertension, a kinetic and static cerebellar syndrome, spastic tetraplegia with crural predominance, and anesthesia going up to the sixth thoracic vertebra (T6). A magnetic resonance imaging (MRI) showed a heterogeneous left cerebellar lesion. This lesion was excised, and the sample was freshly sent to the pathological anatomy laboratory. Extemporaneous cytology using the Smear technique was performed and was consistent with a hemangioblastoma. The standard histological examination also revealed the diagnosis of hemangioblastoma, and an additional immunohistochemical (IHC) study was performed for better diagnostic accuracy. The study was conducted in a North African laboratory and was conclusive of a neurocytoma. The evolution was marked by cerebellar tumor regrowth at five months, then the death of the patient at eight (08) months after surgery. Conclusion: Central neurocytoma is a rare tumor that can be confused with several other tumors of the central nervous system. Immunohistochemistry is essential for diagnostic confirmation.

Retained Metallic Part of a Dislodged Knife in the Thoracic Spine with Paraparesis

The incidence of traumatic spinal cord injury is reported as 30-40 million per year. Among these, stab wounds to the spinal canal are usually rare. These injuries often lead to complete or incomplete neurological deficits. An appropriate management can ensure good functional recovery for approximately two-third of the patient. As these cases are uncommon, their treatment protocols are still controversial and under evaluation. Some literatures reveal various surgical approaches. Spinal canal injury with retained part of the causative agent (knife, bullet, glass etc.) or any other complication on the wound site demands immediate surgical exploration. Here we report on a patient with a retained metallic foreign body (tip of knife) in the thoracic region traversing the left pedicle of sixth thoracic vertebrae along with spinal canal with paraparesis and after neuro-surgical exploration and complete removal of the foreign body, patient shows gradual improvement of neuro-functional status. Proper wound care and long term close follow up was ensured during post operative period.

Surgical technique for preservation of extrathoracic collateral networks in thoracoabdominal aortic surgery.

Surgical technique for preservation of extrathoracic collateral networks in thoracoabdominal aortic surgery.

Pitfalls in Cancer Evaluation in Case of Chronic Superior Vena Cava Obstruction: Vertebral Enhancement and Hot Quadrate Sign in the Liver

A 42-year-old man suffering from superior vena cava (SVC) syndrome was diagnosed with having locally advanced lung adenocarcinoma (Fig. 1A). He was treated with radiochemotherapy followed by maintenance therapy with durvalumab leading to a partial response partial response on follow-up computed tomography (CT) (Fig. 1B). Although there were no secondary bone lesions on baseline CT (Fig. 1C), follow-up contrast-enhanced CT revealed the apparition of a densification affecting the left side of the fifth, sixth, and seventh thoracic vertebrae (Fig. 1D, arrow), raising suspicion of a metastatic evolution.

Functional anatomy and adaptation of the third to sixth thoracic vertebrae in primates using three-dimensional geometric morphometrics.

The morphology of the cranial thoracic vertebrae has long been neglected in the study of primate skeletal functional morphology. This study explored the characteristics of the third to sixth thoracic vertebrae among various positional behavioural primates. A total of 67 skeletal samples from four species of hominoids, four of cercopithecoids, and two of platyrrhines were used. Computed tomography images of the thoracic vertebrae were converted to a three-dimensional (3D) bone surface, and 104 landmarks were obtained on the 3D surface. For size-independent shape analysis, the vertebrae were scaled to the same centroid size, and the normalised landmarks were registered using the generalised Procrustes method. Principle components of shape variation among samples were clarified using the variance-covariance matrix of the Procrustes residuals. The present study revealed that the transverse processes were more dorsally positioned in hominoids compared to non-hominoids. The results showed that not only a dorsolaterally oriented but also a dorsally positioned transverse process in relation to the vertebral arch contribute to the greater dorsal depth in hominoids than in monkeys. The thoracic vertebrae of Ateles and Nasalis show relatively dorsoventrally low and craniocaudally long vertebrae with craniocaudally long zygapophyses and craniocaudally long base/short tip of the caudally oriented spinous process, accompanied by a laterally oriented and craniocaudally long base of the transverse process. Despite being phylogenetically separated, the vertebral features of Ateles (suspensory platyrrhine with its prehensile tail's aid) are similar to those of Nasalis (arboreal quadrupedal/jumping/arm-swing colobine). The morphology of the third to sixth thoracic vertebrae tends to reflect the functional adaptation in relation to positional behaviour rather than the phylogenetic characteristics of hominoids, cercopithecoids, and platyrrhines.

Autonomic dysreflexia associated with cervical spinal cord gliofibroma: case report

BackgroundAutonomic dysreflexia (AD) is an abnormal reflex of the autonomic nervous system normally observed in patients with spinal cord injury from the sixth thoracic vertebra and above. AD causes various symptoms including paroxysmal hypertension due to stimulus. Here, we report a case of recurrent AD associated with cervical spinal cord tumor.Case presentationThe patient was a 57-year-old man. Magnetic resonance imaging revealed an intramedullary lesion in the C2, C6, and high Th12 levels. During the course of treatment, sudden loss of consciousness occurred together with abnormal paroxysmal hypertension, marked facial sweating, left upward conjugate gaze deviation, ankylosis of both upper and lower extremities, and mydriasis. Seizures repeatedly occurred, with symptoms disappearing after approximately 30 min. AD associated with cervical spinal cord tumor was diagnosed. Histological examination by tumor biopsy confirmed the diagnosis of gliofibroma. Radiotherapy was performed targeting the entire brain and spinal cord. The patient died approximately 3 months after treatment was started.ConclusionsAD is rarely associated with spinal cord tumor, and this is the first case associated with cervical spinal cord gliofibroma. AD is important to recognize, since immediate and appropriate response is required.

Orthotics to Improve Pain in a Patient With Multiple Internal Fixations and Multilevel Thoracic Fusion.

The authors present the case of a 24-year-old man who sustained multiple injuries during a hard landing following a parachute jump. These injuries included a right sacral fracture, bilateral femoral fractures, a separated pubic symphysis, and compression fractures of the fifth and sixth thoracic vertebrae. He was treated with a right sacroiliac joint fixation, pubic symphysis fixation, open reduction internal fixation of his bilateral femurs, and fusion of the third through seventh thoracic vertebrae. The patient experienced back pain, bilateral hip pain, and bilateral knee pain resistant to chiropractic and medical treatments. The patient presented 2 years after his aforementioned surgical procedures for treatment of persistent postoperative pain at the Physical Medicine and Rehabilitation service at the Veterans Affairs Medical Center in Hampton, Virginia. His treatment involved gait correction achieved using a left-sided heel lift and a transition to custom molded orthotics that incorporated the lift. This treatment leveled his sacral base and resulted in a simultaneous decrease in his self-reported pain scores.

Mechanism of action of the erector spinae plane block: distribution of dye in a porcine model

This study aimed to describe the anatomical distribution of dye injected in the erector spinae plane (ESP) in a porcine living model, which could aid to reveal factors potentially relevant...

Unusual Foreign Bodies of Surgical Discovery on a Traumatic Spine

Introduction: Para-spinal non-metallic foreign bodies (fabrics or plastics) are rare and poorly documented. They are often unknown and discovered at the stage of infectious complications and present big therapeutic challenges. We report a rare case of three para-spinal foreign bodies (fabric, plastic and postoperative gauze) discovered during surgery of a traumatic thoracic spine. Case report: A 32-year-old man admitted for a polytrauma (collision motorcycle-cart). The admission examination noted closed trauma of the thoracic spine, an ASIA score of A, dyspnea, a penetrating wound of the left side of the chest. The CT scan showed a compressive left pleural effusion, multiple ribs fractures, pulmonary contusion, unstable fracture of fifth and sixth thoracic vertebrae associated with posterior epidural hematoma responsible for medullar compression. There was a rounded, para-spinal image, dotted with small areas of low density, air bubbles. We lifted the vital emergency by draining the left pleural effusion, debriding the penetrating chest wound, and administering broad-spectrum antibiotic therapy. Fourteen days later, we decided to stabilize the spine. After a posterior approach, we discovered free pus and para-vertebral three foreign bodies. Enterobacter spp.was isolated in pus susceptible to imipenem. The immediate operative follow-up was simple. Conclusion: The best treatment remains preventive by simple measures, exploration of penetrating wounds, repeated count and careful verification of gauze, because the infectious complications that they generate are source of mortality and serious medico-legal implications.

Primary extranodal natural killer/T-cell nasal-type lymphoma of spine

Rationale:Primary Extranodal Natural Killer/T-Cell Nasal-Type Lymphoma (ENKTCL) of spine is rarely reported. This case study presents a rare case of ENKTCL originating from the sixth thoracic vertebra.Patient concerns:Here, we present a case of 49-year-old Asian male with chest and back pain. Physical examination revealed the myodynamia of both lower limbs decreased from IV degree to 0 degree, reflexes of both lower limbs and a large area of cutaneous sensation below xiphoid process disappeared in 3 days.Diagnoses:In immunophenotype analysis, CD2, CD3, CD7, and CD68 were positive and CD56 was suspiciously positive. Granzyme B and T-cell intracellular antigen (TIA-1) were also positive and in situ hybridization was positive for Epstein–Barr virus–encoded mRNA (EBER). Ki-67 was 60%+. Nuclide bone scan showed that the nuclide was unusually concentrated in the sixth thoracic vertebra which considered extremely active and slightly concentrated in the right sacrolilac joint. Magnetic resonance imaging detected an abnormal signal in the sixth thoracic vertebra with corresponding paravertebral and intraspinal occupying lesion. Based on the above features, a diagnosis of ENKTCL was made.Interventions:This patient was treated with surgery and symptomatic supportive treatment.Outcomes:The myodynamia of patient's both lower limbs were elevated to I degree after the operation with chest and back pain partly relieved. However, the patient died about 3 months later.Lessons:ENKTCL could originate from spine. Clinicians should be alert for early stage diagnose and distinguish it from some common spinal tumor such as neurofibroma and hemangioma.

A rare variation of the hemiazygos vein draining into the persistent left superior vena cava

During an educational dissection of a 72-year-old Chinese male cadaver, the hemiazygos vein (HAV) coursing the left side that drains into the persistent left superior vena cava was observed. The HAV was formed at the junction of the 9th to 11th right posterior intercostal veins, right subcostal vein, 5th to 11th left posterior intercostal veins, and left subcostal vein; it then ascended posteriorly to the thoracic aorta. After collecting the accessory hemiazygos vein, it crossed over the aorta and the pedicle of the left lung via the hemiazygos arch, then converged with a communicative branch (vein of Marshall) that emerged from the left brachiocephalic vein to form the persistent left superior vena cava and entered the pericardium at the level of the sixth thoracic vertebra. Upon opening the pericardium of our cadaver, the persistent left superior vena cava was found to drain directly into the significantly dilated coronary sinus at the level of the eighth thoracic vertebra. The azygos vein was formed by the union of the first to eighth right posterior intercostal veins and appeared to be finer and shorter than the HAV. The persistent left superior vena cava might be the result of incomplete degeneration of the left posterior cardinal vein. Knowledge of such variations could be of great value to surgeons placing peripherally inserted central catheters because incorrect placement of the azygos venous system can be detrimental to the patient. In addition, during heart surgery, awareness of such variations may prevent major complications, such as hemorrhage or damage to vascular structures, and possibly also provide new insights and perspectives to cardiovascular surgeries.

Gross Morphological and Sex Wise Morphometrical Studies on the Fourth, Fifth and Sixth Thoracic Vertebrae of Blue Bull (Boselaphus tragocamelus)

The present study was carried out on the fourth, fifth and sixth thoracic vertebrae of six specimens of adult Blue bull (Boselaphus tragocamelus) of either sex. The first, second and third thoracic vertebrae were characterized by long supraspinous process, cylindrical, but shorter centrum. The length and breadth of supra spinous processes was observed to decrease from T4 to T6. The transverse process was thick, strong that presented a rounded non-articular mammillary process and a facet ventrally. The costal facets were placed on either side at the end of the articular extremities of the centrum. The cranial articular processes were represented by oval facets on the anterior part of the arch and faced upwards, whereas the caudal ones spring from the base of the dorsal supraspinous process. The Biometrical observations on different parameters of fourth, fifth and sixth thoracic vertebrae reflected significance (P

Biomechanical findings in horses showing asymmetrical vertical excursions of the withers at walk.

The walk and trot are inherently symmetrical gaits, making them potentially suitable for the detection of left-right asymmetries. The aims of this study were to describe asymmetrical vertical excursions of the withers at walk in non-lame high-level dressage horses and to seek associations between these asymmetric movements and other kinematic variables and vertical ground reaction forces (vGRFs). Seven dressage horses, judged clinically as being sound, walked unridden and unrestrained on a treadmill with an integrated force measuring system (480 Hz), from which spatiotemporal and vGRF variables were extracted. Markers were tracked by 12 infrared cameras (240 Hz). The vertical position of the sixth thoracic vertebra (T6), limb protraction and retraction distances throughout stance, and global limb lengths were determined. Contralateral trial-mean differences were calculated, including difference in T6 minimum vertical position between contralateral steps (T6minDiff). Mixed models were used to study associations between symmetry parameters. Trial-mean T6minDiff ranged between 0.3–23 mm. Of the seven horses, five consistently dropped the withers more in early left forelimb stance, one was fairly symmetrical, and one dropped the withers more in early right forelimb stance. Comparisons between contralateral limbs showed the following associations. The forelimb that was retracted when T6min was lowest showed greater retraction at toe-off (1 mm increase predicted 0.17 mm T6minDiff increase) and shorter stance duration (1 ms decrease predicted 0.3 mm T6minDiff increase). The hind limb that was in midstance when T6min was lowest showed a greater range of motion during the stance phase (1 mm increase in protraction or retraction predicted 0.2 mm T6minDiff increase). The haunches were displaced away from the side of the forelimb that was protracted when T6min was lowest (1 mm lateral shift predicted 0.07 mm T6minDiff increase). Forelimb and hind limb vGRF parameters were non-significant. Asymmetry of vertical withers movement in horses assessed as being sound at trot was related to a complex pattern of asymmetries in spatiotemporal variables throughout the stride cycle rather than to vertical load redistribution between the forelimbs. This suggests that the asymmetry may be due to inherent laterality rather than weight-bearing lameness.

The dose response of sufentanil as an adjuvant to ropivacaine in cesarean section for relief from somato-visceral pain under epidural anesthesia in parturients with scarred uterus.

Visceral pain is common during epidural anesthesia with mini dose local anesthetics in parturients during cesarean section. To reduce or avoid this complication caused by traction on the abdominal viscera, this study aimed to determine the 50% effective dose (ED50) and 95% effective dose (ED95) of epidural sufentanil as an adjuvant combination with local anesthetics for relief visceral pain in parturients with scarred uterus undergoing elective cesarean section.One hundred parturients with scarred uterus undergoing elective cesarean section under epidural anesthesia were enrolled in this randomized, double-blinded, dose-ranging study. Parturients received 5, 10, 15, 20, and 25 μg epidural sufentanil as an adjuvant with 10 mL of 0.65% ropivacaine. Successful epidural anesthesia was defined as a sixth thoracic vertebra (T6) sensory level achieved within 20 minutes after epidural drugs administration and/or no visceral pain by traction on the abdominal viscera during the cesarean section. The ED50 and ED95 were calculated with a logistic regression model.ED50 and ED95 of epidural sufentanil for successful of the pain-free from visceral pain were 10.7 μg [95% confidence interval (CI): 2.4–14.4 μg) and 28.1 μg (95% CI: 19.4–44.0 μg), respectively. The onset time to sensory block, maximum Bromage scale and duration of motor block were significant different with dose of sufentanil >20 μg (P < .05, compared with the other dose groups). With the dose of epidural sufentanil >20 μg could result in an increase of incidence of maternals’ adverse effects. Compared with a different dose of sufentanil, epidural administed sufentanil between 15 μg and 20 μg can maximize parturients’ satisfaction.Our study showed that sufentanil could be used in combination with ropivacaine for relief from somato-visceral pain in patients with scarred uterus during elective cesarean section during epidural anesthesia, and that maximized parturients’ satisfaction could be achieved when the use of sufentanil with the dose between 15 μg and 20 μg for epidural anesthesia.

Disreflexia Autonômica em Lesado Medular

A disreflexia autonômica é considerada uma emergência médica. É uma síndrome que ocorre em pacientes com traumatismo raquimedular (TRM) acima do nível da sexta vértebra torácica (T6). Ocorre entre 40% a 90% dos pacientes com TRM acimade T6. O diagnóstico é clínico e apresenta como principais sintomas cefaleia, sudorese e piloereção. Encontra-se associado a crise hipertensiva e bradicardia. Quando o diagnóstico ou tratamento é incorreto pode ocasionar consequências graves parao paciente. É importante reconhecer esta síndrome, principalmente nas emergências, onde seu diagnóstico tem sido pouco reconhecido, assim como, levar seu conhecimento aos familiares e cuidadores destes pacientes.

Arm Cycling Combined with Passive Leg Cycling Enhances VO2peak in Persons with Spinal Cord Injury Above the Sixth Thoracic Vertebra.

Objective: To test whether passive leg cycling (PLC) during arm cycling ergometry (ACE) affects peak oxygen uptake (VO2peak) differently in individuals with spinal cord injury (SCI) at/above the 6th thoracic vertebra (T6) and below T6. Methods: We conducted a cross-sectional study, analyzed by univariate and multivariate regression models. Between- and within-group differences were examined during (a) ACE only, (b) ACE combined with PLC (ACE-PLC), and (c) ACE combined with functional electrical stimulation cycling (FES hybrid). Fifteen SCI subjects were recruited and grouped according to injury level: at/above T6 (SCI-high, n = 8) or below T6 (SCI-low, n = 7). VO2peak tests during ACE only, ACE-PLC, and FES hybrid were performed in random order on separate days. Results: In the SCI-high group, mean (SD) VO2peak was 19% higher during ACE-PLC than during ACE only [21.0 (3.8) vs 17.7 (5.0) mL·kg-1·min-1; p = .002], while VO2peak during FES hybrid cycling was 16% higher than during ACE-PLC [24.4 (4.1) mL·kg-1·min-1; p = .001]. No significant differences among exercise modalities were found for the SCI-low group. Conclusion: Additional training modalities (eg, PLC) during ACE facilitate exercise in SCI-high individuals, but not to the level of the FES hybrid method. Conversely, additional training modalities may not increase training load in SCI-low individuals.