Diagnostic spinal anaesthesia in chronic spinal cord injury pain

In a double blind study, 21 patients with chronic spinal cord injury (SCI) pain underwent placement of a lumbar subarachnoid catheter and injection of placebo and lidocaine. The effects on pain intensity, distribution, altered sensations and sensory level of anaesthesia were monitored. Four patients responded briefly to placebo, while 13 demonstrated a mean reduction of pain intensity of 37.8 +/- 37% for a mean duration of 123.1 +/- 95.3 minutes in response to lidocaine. The pain response to subarachnoid lidocaine differed significantly (p less than 0.01) from placebo. Spinal anaesthesia was also associated with changes in pain distribution and altered sensation. A spinal anaesthetic-induced sensory level could not be achieved cephalad to the sensory level of neurological injury in 5 patients who presented with spinal canal obstruction. This study has demonstrated that response to diagnostic spinal anaesthesia in chronic SCI pain is complex, requiring individual interpretation in each patient and consideration of the following factors; symptomatology, etiology, pain perception, spinal canal anatomy, CSF chemistry and local anaesthetic pharmacology.

Continuous infusion of intrathecal baclofen: long-term effects on spasticity in spinal cord injury

The effects of intrathecal baclofen infusion were studied in 9 spinal cord injury patients whose spasticity had been refractory to oral medications. In a two stage, placebo controlled trial, baclofen was administered into the lumbar intrathecal space and subsequent clinical and neurophysiologic changes were assessed. In stage 1, 9 patients underwent a 5 day percutaneous infusion of baclofen and placebo via an external pump. Ashworth and reflex scores were assessed at time of enrollment, after infusion of that amount of baclofen which provided optimal spasticity control and after intrathecal infusion of placebo. The mean Ashworth grade decreased from 3.78 +/- 1.34 to 1.16 +/- 0.48 (p less than 0.001) while mean reflex score decreased from 3.57 +/- 1.05 to 0.64 +/- 0.87 (p less than 0.001). These values differed significantly from those associated with placebo therapy (Ashworth grade--2.54 +/- 1.04, p less than 0.001; reflex score--2.56 +/- 1.04, p less than 0.01). Objective improvements in functional abilities and independence were noted in 8 patients, while somatosensory and brainstem auditory evoked potentials were unchanged in all patients. Urodynamic evaluation revealed increased bladder capacity in 3 patients, while in 4 no change was observed. In Stage 2, permanent programmable infusion pumps were implanted in 7 patients who demonstrated a good response during Stage 1. In this group, mean Ashworth score decreased from 3.79 +/- 0.69 to 2 +/- 0.96 (p less than 0.001) and mean reflex score decreased from 3.85 +/- 0.62 to 2.18 +/- 0.43 (p less than 0.001). Baclofen dosage increased from 182 +/- 135 to 528 +/- 266 mcg/day over the 3-22 month follow-up period. Most of the dosage increase occurred within the initial 12 months following infusion pump implantation and tended to plateau thereafter. Minor complications such as catheter dislodgement/kinking and nausea occurred infrequently while no device related infections were observed. There was no clinical evidence of any significant baclofen neurotoxicity either in Stage 1 or 2. The only ambulatory patient developed marked lower extremity weakness during Stage 1 intrathecal baclofen infusion and was temporarily unable to walk. We conclude that continuous administration of intrathecal baclofen is an effective and safe modality for spasticity control in patients who are refractory to oral medications.

Use of plasmid analysis to determine the source of bacterial invasion of the urinary tract

Gram negative colonisation and infection of the urinary tract is a well recognised complication of the neuropathic bladder caused by spinal cord injury (SCI). K. pneumoniae accounts for one third of all urinary tract infections in hospitalised SCI patients. Plasmid analysis has been shown to reliably fingerprint bacterial strains, particularly K. pneumoniae, so that growth from two separate locations in or on the body can be accurately analysed as to migration from a reservoir to a target location. Eighty seven hospitalised SCI patients on intermittent catheterisation for a total of 586 patient-weeks were studied. Twice weekly catheterised urine specimens and once weekly rectal swab cultures were taken from each patient. Thirty seven patients experienced at least one clinically significant (colony count greater than 10,000/mL) urinary tract colonisation caused by K. pneumoniae, representing 66 total colonisations. Further analysis of 31 of these 37 patients revealed: K. pneumoniae in all of their stool cultures (p less than 0.05) and the identical strain of K. pneumoniae in the urine as well as the stool in 72% of the 66 colonisations (p less than 0.05). Analysis of 14 patients without K. pneumoniae urinary colonisations showed absence of faecal K. pneumoniae in 3, and predominant growth in only 4. In 22 of the 37 patients, multiple K. pneumoniae urinary colonisations were noted, representing 27 pairs of colonisation. Fifteen of the pairs were found to be relapsing (caused by two identical bacterial strains), and 12 were recurrent (caused by two different bacterial strains). Thirteen of the 15 relapsing pairs also had identical urine and stool K. pneumonia strains (p less than 0.05). All colonisations were treated with appropriate antibiotics based on culture and sensitivity reports. Fourteen of the 15 relapsing colonisation pairs have identical antibiograms (p less than 0.05), while all 12 of the recurrent colonisation pairs had different antibiograms (p less than 0.05). The differences noted on sensitivity patterns (antibiograms) correlated with differences among strains of K. pneumoniae based upon plasmid analysis. Treatment of bacteriuria did not affect the nature of repeated colonisations regardless of the antibiotic chosen, the route of administration or the duration of treatment.

Energy requirements of gamefield exercises designed for wheelchair-bound persons

This report presents energy requirements of three athletic exercises (power ramp, climber, and chin-ups) in a free-wheeling gamefield developed by the City of Houston for wheelchair-bound persons. Heart rate was monitored by telemetry. Expired gas samples were collected in Douglas bags. Oxygen and CO2 concentrations were determined by mass spectrometry and expired gas volumes by a wet gas meter. Pulmonary ventilation, O2 consumption, and CO2 production were calculated from expired gas samples. Laboratory studies were conducted on eight men with paraplegia and ten untrained, healthy, able-bodied men. The same persons were tested on the gamefield while propelling a wheelchair over the power ramp, the climber, and doing chin-ups. Age and weight were 32 +/- 4yrs vs 31 +/- 6yrs and 79.6kg vs 79.0kg, respectively, for paraplegic and healthy men. Paraplegic men had average heart rates of 133 +/- 11bpm, 133 +/- 19bpm, and 135 +/- 21bpm, respectively, for the power ramp, climber, and chin-ups. Heart rate values for able-bodied men were 136 +/- 26bpm, 139 +/- 24bpm, and 136 +/- 26bpm, respectively, for the same three exercises. The paraplegic men's VO2 measurements were 13.2 +/- 2.2, 11.5 +/- 2.8, and 6.4 +/- 2.9ml/min/kg, respectively, for the power ramp, climber, and chin-ups. The able-bodied men's VO2 measurements were 15.8 +/- 2.8, 15.4 +/- 3.6, and 9.2 +/- 2.8 ml/min/kg for the same exercises. Patients with paraplegia seemed to outperform able-bodied men in all events. Gamefield exercises appeared to tax the cardiorespiratory system at a level comparable to that usually prescribed for training purposes.

Increased current delivery and sperm collection using nifedipine during electroejaculation in men with high spinal cord injuries

Elevated blood pressure associated with autonomic hyperreflexia during electroejaculation in persons with high spinal cord injuries often prevents successful sperm retrieval. The ability of the calcium channel blocker nifedipine to reduce the effects of autonomic hyperreflexia, to facilitate greater current delivery, and to increase sperm collection was evaluated in six persons with spinal cord injuries. Ten milligrams of nifedipine given sublingually ten to 15 minutes before electroejaculation attempts helped to moderate autonomic hyperreflexia and the associated blood pressure elevations. These effects of nifedipine allowed greater current delivery and ultimately increased the chances of successful sperm retrieval in the six men. No adverse drug effects were observed.

Clonidine effect on spasticity: a clinical trial

Clonidine was used as an adjunct to baclofen in 55 patients with spasticity due to spinal cord injury. Dosage was held at the minimum effect amount for those who responded. No effect was seen in 24 patients (44%), although 31 (56%) benefitted from the drug. Patients were grouped as quadriplegics or paraplegics, having complete or incomplete lesions. Of all quadriplegics, seven of 11 complete (64%) and 17 of 25 incomplete patients (68%) responded; among the paraplegics, six of 15 complete (40%) and one of four incomplete patients (25%) improved. Side effects were limited to postural hypotension necessitating reduction in dosage in three patients that were successfully treated; in the unsuccessfully treated group, one patient had insomnia, one had dizziness, and one had drowsiness.

Profile of denials of durable medical equipment for SCI patients by third party payers

The difficulty in obtaining approval for payment of durable medical equipment by third party payers has impeded the rehabilitation program and discharge planning of many spinal cord patients throughout the country for many years. To gain some insight as to the number and level of patients affected, the kinds of equipment denied, the reasons given for the denial, which third party payers were mostly involved and how the patient and his/her family managed to cope or resolve this problem, a survey was undertaken. Letters were sent to 259 members of the American Spinal Injury Association (ASIA) asking them to list representative cases where requests for equipment deemed necessary were denied. Twenty-eight responses from different institutions were received from sixteen states describing 110 patients and 180 pieces of durable medical equipment denied in 1984 and 1985. Manual wheelchairs, motorized wheelchairs, shower/commode chairs, and environmental control units were the four most common equipment items denied by the third party payers. Government agencies ie., Medicaid, Medicare, Vocational Rehabilitation Departments and State Crippled Children's Services were the most frequent deniers, comprising 54% of the total sample. They were followed by private insurance (31%) and Workman's Compensation (3%). By far, the two most common reasons given for denials were: it was not covered by the insurance policy (38%) and it was not medically necessary (30%). Ninety (90) pieces of equipment (50%) were eventually obtained, most often by charity, or through the patient's family resources.

Postdischarge outcomes for ventilator-dependent quadriplegics

Based on data contributed to the National Spinal Cord Injury Data Base between the years 1975 and 1981, outcomes were assessed for 34 patients who had been injured approximately a year earlier and who were ventilator dependent when discharged from inpatient rehabilitation. Their outcomes were compared with those of 196 patients who required mechanical respiration some time during acute care or rehabilitation, but who were free of such assistance at discharge. Statistically significant differences were obtained between the groups in levels of spinal cord injury, duration of acute care hospitalization, duration of total hospitalization, extent of self-care capability, hours/week of hired attendant care, and hours of actual physical assistance/day. The groups did not differ significantly in terms of duration of inpatient rehabilitation, duration of rehospitalization, and vocational or prevocational status at follow-up.

The neurological and skeletal outcome in patients with closed cervical spinal cord injury

Sixty-one patients with closed cervical spinal cord injury were cared for within a defined protocol and followed for at least 1 year. Neurological recovery and healing of spinal structures were evaluated at intervals. Forty-three patients were managed without surgical intervention at the site of spine trauma, and the incidence of spontaneous fusion ("autofusion") was noted. Surgical fusion was performed on 17 patients, mainly to restore spinal stability and alignment. One patient underwent laminectomy without fusion. In both the surgical fusion and the autofusion groups, there were significant numbers of patients who improved neurologically, including some designated as having a complete spinal cord lesion at the initial neurological examination. As expected, better spinal alignment was achieved in the surgical group, although alignment in the nonsurgically treated group was generally acceptable. The majority of patients developed radiographically apparent callus formation anterior to the injured vertebral bodies, regardless of the mechanism of injury or the method of treatment. After 3 months all patients who underwent surgical fusion achieved spinal stability, as did the majority of patients in the autofusion group. Only individuals with flexion-distraction injuries who did not undergo surgical fusion appeared to be at risk for progressive spinal column deformity. Neither retropulsion of bone fragments nor angulation at the fracture site appeared to correlate with a poor neurological outcome, since improvement in neurological function occurred similarly in patients with and without these deformities.

Comparative study of electrophrenic nerve stimulation and mechanical ventilatory support in traumatic spinal cord injury

Over the past two decades, the number of surviving apneic spinal cord injured patients has been increasing. Mechanical ventilation for home maintenance has been supplemented by electrophrenic respiration (EPR) since 1970. Nineteen patients who were totally mechanical ventilator dependent at discharge from rehabilitation in a spinal cord centre are compared with 18 patients discharged on EPR. There were more young males in the EPR group while the overall average ages were approximately the same. The mortality rates were approximately equal although the mechanical ventilator dependent patients expired earlier than the EPR group. Survivors on mechanical ventilation lived longer on an average and the vast majority of both groups were discharged to their home. There needs to be the establishment of a ventilatory dependent registry for spinal cord injury.

An update on the early management of traumatic paraplegia (nonoperative and operative management)

Both the spinal cord physician and the spinal surgeon must be fully cognizant of the alterations of functions in multiple systems of the body caused by a spinal cord injury. Complications can easily arise, particularly within the respiratory, urinary, and integumentary systems. Most are preventable if the medical and nursing staff are sufficiently knowledgeable to anticipate them and if the necessary equipment and facilities are available. Regionalization of care with early referral to a spinal cord injury center has become a cost-effective way to manage these patients. Only if their medical needs are met and complications are prevented will surgery, performed to allow early mobilization, really accomplish the desired result. This update reviews the current medical and surgical points of view concerning diagnosis, fracture classification, spinal stability, reduction and stabilization of the fracture deformity, and spinal canal decompression.

Incidence of medical complications in spinal cord injury: patients in specialised, compared with non-specialised centres

Facilities providing a co-ordinated 'system' of care to the spinal cord injured are now more accepted as being preferable to fragmented 'non-system' facilities. Data reflecting the incidence of selected complications common to spinal cord injury were collected over a 2-year period from a system located outside the United States and from 'non-systems' within the United States. The latter was defined as care provided in community facilities prior to entry into one of 14 model United States spinal cord injury centres. All complications occurred more frequently in the American group, particularly decubitus ulcers and urinary tract infections. The data suggest that system care is preferable to non-system care in its capacity to prevent costly complications and the sooner the spinal cord injured patient is referred to a spinal cord centre capable of meeting all his needs, the less likely will he be exposed to complications that could slow the rehabilitation effort.

Neurophysiological approaches to chronic pain following spinal cord injury

Pain occurring in patients with spinal cord injury can be classified on clinical grounds into five types: peripheral, central, visceral, mechanical and psychic. An attempt has been made to correlate each type of pain with present neurophysiological knowledge. Mechanisms as to how unpleasant sensations reach the conscious level can be deduced when clinical and neurophysiological data are pooled. Eight case histories are presented which typify each class. The authors' evaluation and treatment offered is presented for each type.

Developing a system of comprehensive care for the spinal cord injured patient in Houston, Texas, U.S.A

The authors agree with the principle, widely accepted, that spinal cord injured (SCI) individuals should receive all their acute, rehabilitative and follow-up care in a spinal cord injury centre. The evolution of rehabilitation medicine and services in the United States, however, has favoured the separation of acute and rehabilitation care for spinal cord injured patients, as well as other disabilities. This has resulted partly from specialisation of medical and allied health personnel, physical separation of acute and rehabilitation facilities, and reluctance of some funders of health care to see rehabilitation as a natural extension of medical care in these patients. In Houston the proximity of a rehabilitation facility to three acute care university hospitals, representing three medical schools, provided an opportunity to improve communication among the medical personnel. These individuals have recognised the value of early rehabilitation even while the patient is acutely ill; they agreed to institute a system of care wherein the rehabilitation physician partakes in the early management in a designated area of the acute hospitals for spinal cord injured patients and works toward early transfer to the rehabilitation hospital in as ideal a condition as possible. Surgeons, who have initial primary responsibility, also visit the rehabilitation hospital, following their patient's progress at selected conferences and at the bedside. This paper describes how, a spinal cord injury service was established, how the major barriers to early transfer were confronted, and the results of the first 6 months of operation.

A multidisciplinary approach to chronic low-back pain in Western Australia

Fifty patients with chronic low-back pain were subjected to extensive medical, psychiatric, and psychosocial assessment by a comprehensive Low Back Pain Clinic. Most patients were found to have easily identifiable environment factors which influenced the persistence of the symptomatology. All patients were significantly functionally impaired, and whilst neurologic findings were uncovered in only 12 patients, most had restricted movement of the lumbar spine. The initiating cause of the low-back pain was usually from a minor injury or no injury at all. Thirty-two patients were given psychiatric diagnoses, but only one patient was thought to warrant psychiatric treatment. Whilst some were considered to be candidates for limited further conservative treatment, only two were subjected to further surgery (one fusion, one posterior facet rhizotomy). Only nine were admitted to an inpatient behavior modification program, and the results of this effort were modest. The major benefit was seen to be the definitive diagnosis, prognosis, and medical and social planning which was given to all 50 patients upon conclusion of the assessment. The assessment proved to be of benefit to the patient, the referring doctor, the team itself, as well as all other interested parties, such as his family, insurance company, and lawyer.

Electromyographic activity in paraspinal musculature in patients with idiopathic scoliosis before and after Harrington instrumentation

Ten patients with idiopathic scoliosis underwent electromyographic (emg) examination before and after Harrington instrumentation and fusion. Each patient had a normal emg preoperatively. At 3 weeks all 10 demonstrated spontaneous activity consistent with denervation, and voluntary activity was absent or markedly reduced. By 3 months and in some cases 6 months, denervation was significantly reduced or absent; voluntary activity had also reappeared and in most cases was equal to preoperative intensity. This rapid reversal of denervation after surgery within the paraspinal muscles in a young female population with no underlying disease suggests that interpretation of any postoperative emg should include considerations such as the time since surgery, the age of the patient, and the extent of preoperative pathology. No evidence was gained from this study that extensive posterior spinal surgery itself interfered significantly with paraspinal muscle function after 3 to 6 months.

Combined intravenous miconazole and intrathecal amphotericin B for treatment of disseminated coccidioidomycosis

A patient received a previously unreported combination of intravenous miconazole and intrathecal amphotericin B for the treatment of disseminated coccidioidomycosis with central nervous system involvement. After first having been treated with amphotericin B, followed by a course of miconazole therapy, the patient responded with remarkable clinical and serologic improvement to the combination of intrathecal amphotericin B and intravenous miconazole. The combination should be considered in the treatment of disseminated coccidioidomycosis with central nervous system involvement.

Intermittent bladder emptying via urethral catheterization or suprapubic cystocath: a comparison study

A prospective study was undertaken to compare patients with recent spinal cord injuries undergoing bladder training by conventional intermittent urethral catheterization with a similar group treated with the Cystocath. Our present information suggest there are no differences with respect to episodes of bacteriuria encountered or for time spent by the catheter team for each procedure. Paraplegics tended to reach balanced bladder status more easily without surgery while quadriplegics did not. The bladder training program was shorter on the average for the Cystocath group. Further investigation is necessary to determine whether this is significant. Problems encountered were minimal and fewer than reported in the literature. We find no reason not to employ the Cystocath in bladder training programs in spinal cord injured patients.

Anal sphincter stretch: a technique to overcome detrusor-sphincter dyssynergia

Intermittent catheterization has become a well-accepted method of management of the neurogenic bladder following spinal cord injury. Frequently, the presence of detrusor-sphincter dyssynergia interferes with the attainment of acceptable residual urine volumes in patients with upper-motor-neuron bladders. We have recently reported success in overcoming the problems of dyssynergia in some patients utilizing a technique called anal sphincter stretch in which relaxation of the external anal and urethral sphincters is produced by sustained distention of the anal sphincter. This has lessened the need for other measures that usually produce incontinence and has met with good patient acceptance. An update on the results of using this technique is presented. Although we have previously encountered quadriplegics who might have benefited from sphincter stretch, the lack of hand intrinsic muscle function required for the patient to perform it independently has precluded its use. We herein present a device that circumvents inadequate hand function, and which has enabled four C-7 quadriplegics to achieve satisfactory bladder emptying.