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.

Demographic study of a wild house sparrow population by DNA fingerprinting

Over the past twenty years, several techniques from biochemical and molecular genetics, such as enzyme electrophoresis and isoelectric focusing, have been widely and successfully applied to the study of population differentiation and evolution. However, they have been less applicable to demographic problems such as assigning parentage to individuals within a population. This stems from a general weakness of data derived from enzyme loci: allele frequencies at polymorphic loci are sufficiently skewed that the majority of individuals are of one or two genotypes. Many enzyme systems can only be examined post mortem, so that the loci are of little use if the animals are to be studied in the wild. The search for new and more sensitive techniques for detecting genetic variation has continued, and recently a major discovery has come from molecular biology. Jeffreys et al. have reported the detection of a type of hypervariable 'minisatellite' DNA that is extraordinarily polymorphic in human populations. We have applied their technique to several bird species and particularly to a population of house sparrows (Passer domesticus) near Nottingham. We report here that one of the human minisatellite clones is a suitable probe for sparrow DNA and that it reveals variation as extensive as that found in man. These results suggest that analysis of minisatellite DNA will be a powerful tool in the study of demographic population genetics.

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.

Evaluation of upper extremity vasculature with high-resolution ultrasound

Twenty-eight vascular and perivascular lesions of the upper extremity in 21 patients were studied from August 1982 to December 1982 by means of a 10 MHz real-time B-mode ultrasound unit. They included eight perivascular masses, 16 arterial repairs, and five thrombosed or occluded arteries. Imaging of arteries that ranged in size from a brachial to a digital artery was reliable. Vessels were tracked proximally and distally while changes in wall compliance, luminal diameter, wall diameter, intimal integrity, and luminal compression were observed dynamically. Size, location, acoustic characteristics, and extent of vascular involvement could be determined in cases of perivascular masses. Sonographic findings were confirmed by arteriography, dynamic radionuclide imaging, computerized tomography, or surgical exploration. Ultrasonography eliminated the need for preoperative arteriography in some cases. In no instances were our ultrasonographic impressions in error when correlated with results of more invasive techniques. No adverse effects were encountered. We concluded that real-time 10 MHz ultrasonography is a safe, noninvasive, reproducible, and accurate technique that can be used quantitatively and qualitatively on the upper extremity after surgery to assess patency, pulse dynamics, and anastomotic characteristics of arterial repairs and before surgery to evaluate perivascular masses for acoustic characteristics, location, and influence on adjacent vascular structures.

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.

Home positive-pressure ventilation. Twenty years' experience

We studied retrospectively 26 adults and 21 children with chronic respiratory failure whose condition was managed at home using positive-pressure ventilators in order to ascertain the outcome, benefits, and complications of this form of management. Twenty-six (55 percent) of the patients had injuries to the spinal cord. Among the 47 patients, nine were eventually weaned from the ventilator, and two died at home because of disconnection from their ventilators. Using life-table analysis, projected three-year survival was 74 percent for patients without spinal injury and 63 percent for patients with spinal injury. Mortality was greater for children than for adults. For a majority of patients, the cost of management at home was significantly less than management in the hospital, depending largely on the level of nursing care required. We suggest that mechanical ventilation at home may be a reasonable alternative to prolonged hospitalization for medically stable ventilator-dependent adults and children.

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.

Paralytic spinal deformity following traumatic spinal-cord injury in children and adolescents

We attempted to evaluate the effect on the spinal column of loss of muscular support following trauma to the spinal cord during childhood. The cases of fifty patients, newborn to seventeen years old at the time of injury, were analyzed. Thirty-one patients had scoliotic curves of more than 20 degrees; twenty-one of these were long paralytic curves of 40 degrees or more. Age at injury was the single most important risk factor in the development of scoliosis; spasticity was also a very significant factor. Patients with lesions at all neural levels were at risk, while laminectomy was not a significant cause of scoliosis. On lateral roentgenograms the predominant finding was a reversal of the lumbar lordosis into a kyphosis, with the resultant development of a long thoracolumbar kyphosis. In five patients the opposite deformity, thoracolumbar lordosis, developed.

Unilateral diaphragmatic paralysis in spinal cord injury patients

Since the inception of the Spinal Cord Injury Center of The Institute for Rehabilitation and Research in 1961, over 1600 spinal cord injury patients have been admitted. Of these patients, approximately 51 per cent or 821 are tetraplegics. A review of the medical records shows that 22 patients had unilateral diaphragmatic paralysis. All but one of these patients are male, and they range in age from 15 to 73 years of age at onset. All cases with unilateral diaphragmatic paralysis are reviewed as to side of paralysis, incidence of tracheotomy, initial vital capacity, final vital capacity, and estimation as to the duration of diaphragmatic paralysis.

Experiences with high tetraplegics

Of the 1468 patients with traumatic spinal cord injury who were admitted to the Texas Institute for Rehabilitation and Research (TIRR) between 1959 and 1977, 67 patients were complete tetraplegics with motor levels of C4 and above. The age, sex, motor level, aetiology of injury, and initial and final vital capacity of these patients are analysed. A substantial gain in vital capacity was attained in all C4 motor tetraplegics regardless of their initial vital capacity. Twenty patients with motor levels of C3 and above have been admitted to TIRR since 1963. Five of these 20 C3 and above tetraplegics have had bilateral phrenic stimulators implanted. The mortality rates and causes of death in these groups of patients are presented. Survival curves are presented on 615 traumatic spinal cord injuried patients as compared to a standard matched group. Survival curves are also presented for the two groups of high tetraplegics who were admitted to TIRR from 1963 through 1969 and from 1970 through 1977.

A system for clinically evaluating wheelchair pressure-relief cushions

Pressure-related decubitus ulcers are a frequent disability and life-threatening complication in the management and rehabilitation of patients with spinal cord injuries. This paper describes a system developed to quantitate and evaluate a patient's response to wheelchair pressure-relief cushions. Maximum pressure and the tissue pressure distribution on six varieties of wheelchair cushions were determined for a sample of 57 patients with a history of decubitus ulcers. Wide variations in (mean) maximum pressure were observed. However, even greater variations were found in the distribution (bony/soft tissue) of the pressure. These data demonstrate that no single cushion was clearly superior in relieving pressure for all patients. Therefore, individualization of wheelchair cushions for each patient may be essential in order to minimize the probability that the person will experience a tissue-pressure problem.

Immediate endocrine and metabolic consequences of traumatic quadriplegia in a young woman

Onset of paralysis by cervical spinal cord injury led immediately to temporary adrenocortical activation and, within 2 days, to sustained skin and bone breakdown. Urine cAMP was increased, blood parathyroid hormone, renin activity, and electrolytes were normal, and fluid and electrolytes balance became negative during the initial 6 days of paralysis.

Traumatic spinal cord injuries due to automobile accidents

Of the 1,164 patients with traumatic spinal cord injury admitted to the Texas Institute for Rehabilitation and Research from February 1959 through December 1975, 389 were injured in automobile accidents. The patients with spinal cord injury were predominantly male, and the average age was in the late 20s. Two thirds of the accidents involved a single automobile and occurred less than 50 miles from the residence. The driver's seat was the most common seating position. Seat belts were not worn in over 90% of the cases; many of the other victims wore their seat belts improperly. Some of the patients were probably injured because of structural defects of the automobile.

Steady state hormonal secretion in traumatic quadriplegia

Physiologically complete cervical spinal cord transection results in motor and sensory quadriplegia and interruption of the sympathetic neural pathways; this condition leads to metabolic deficiencies suggestive of abnormal endocrine function. An investigation of the non-stimulated secretion of some of the hormones influencing metabolism was undertaken by evaluating thyroxine, iodothyronine binding index, testosterone, growth hormone, calcitonin, and parathyroid hormone in venous blood of fasting healthy subjects and quadriplegic patients. The effect of the duration of the paralysis was examined by repeating the evaluations at different periods after onset. The results show that 1) thyroxine was low for 2 months after onset in 21 patients and normal thereafter in 53 patients, 2) testosterone was low throughout the study in 62 patients; the decrease is greatest during the first 2 months, 3) growth hormone was often increased in 46 patients for 8 months after onset, and nearly normal afterward in 25 patients, 4) calcitonin was normal in 22 patients throughout the study, and 5) parathyroid hormone was normal in relation to normal serum calcium as early as 6 days after onset in 79 out of 83 patients. These data do not preclude a parathyroid hormone increase at onset or alterations in the patterns of circadian secretion and in the responses to specific stimulation for the hormones evaluated. Therefore, it may be concluded only that the steady state secretion of these hormones is not altered by traumatic quadriplegia per se, but is temporarily modified by the original insult to the nervous system, and by changes in life pattern and the heavy sedation that follows. The results suggest that the minor endocrin changes occurring in quadriplegic patients during the early period of paralysis will be rapidly overcome by rehabilitation to an active life pattern.

Early neuromuscular development of the premature infant

A case study is presented which documents the neuromuscular development of a premature infant (34-35 weeks gestation) during the first eight weeks of postnatal life. The development of postural tone, spontaneous activity, and responsiveness to stimulation is described and compared with that of the full-term infant. This information is of value to physical therapists involved in evaluation and therapeutic intervention programs for high risk infants.

Bone metabolism in quadriplegia: dissociation between calciuria and hydroxyprolinuria

Relationships between duration of paralysis, recumbency, muscular activity, and urinary loss of calcium (Cau), phosphorus (Pu), and hydroxyproline (OHPu) were studied daily in 32 traumatic quadriplegic patients during comprehensive rehabilitation and randomly in those readmitted for treatment. Within days after onset, quadriplegic patients had increases in Pu, then OHPu, and finally, Cau. Patients actively engaged in rehabilitation exercises showed a steady fall in OHPu, whereas CAU remained high for up to 18 months. Patients paralyzed for over 18 months (late) had low Cau, Pu and OHPu; but if the patients were kept in bed, OHPu increased rapidly. Patients with early quadriplegia have an increased bone remodeling, suggesting that the excess OHPu and Cau are derived from resorbed bone. Patients with late quadriplegia have little bone remodeling, therefore the excess OHPu occurring during recumbency may be derived from the resorption of new collagen produced during the removal of weight bearing without further change in muscular activity. Resorbed new collagen is excreted in part as large, OHP-containing polypeptides; these were found in the urine of quadriplegic patients, and therefore were present in blood and may play a role in initiating ectopic bone and renal calculi. The presence of OHP in 11 bladder calculi from quadriplegic patients tends to support this hypothesis. These studies indicate that muscular activity and weight bearing influence the bone metabolism of quadriplegic patients and suggest that the presence in body fluids of increased catabolic products from bone may have a role in bone-related complications.