[Accident analytics for structural traumas of the cervical spine]

The differentiation between degenerative syndromes of the cervical spine and post-traumatic symptoms requires accident analysis. Experiments with human subjects yield data only in the low-energy range, and there are still no accident analyses of structural traumas of the cervical spine. From 1 January 2000 to 30 April 2002, 15 patients with structural injuries to the cervical spine due to car accidents were treated in the Department of Trauma Surgery of the University of Ulm. In 11 of these cases, the DEKRA Ulm completed an appraisal of the accident process.With lateral impacts, structural injuries to the cervical spine can occur even at speeds of only ca 10 km/h. Injuries to the alar ligaments are produced by frontal collisions with substantial differences in speed. Data from accident analysis of structural injuries to the cervical spine must be taken into consideration in causality examinations of distortions of the cervical spine.

Adductor tenotomy in spastic cerebral palsy. A long-term follow-up study of 78 patients

BACKGROUND

There is a risk of hip dislocation in children with spastic cerebral palsy. We evaluated the prophylactic effect of adductor tenotomy in patients with long-term follow-up.

PATIENTS AND METHODS

Our material comprised 78 patients (46 boys) with a mean age of 8 (2-17) years who underwent adductor tenotomy during the period 1986-1991. 40 patients had spastic diplegia and 38 had quadriplegia. For patients who had further hip surgery, follow-up was until the next hip operation. Those who had not undergone further surgery were invited to a follow-up examination. The migration percentage (MP) was measured on the preoperative and follow-up radiographs. The radiographic result was termed good if MP at follow-up was reduced or had increased less than 10%. The follow-up period was 10 (1.6-16) years, with a mean of 6 years for patients with later hip surgery and 13 years without such surgery.

RESULTS

The clinical outcome was good in 51 cases, poor in 12, and uncertain in 15. The radiographic result was good in 39 of the 53 patients with radiographs available both preoperatively and at follow-up. The patients with good radiographic results had lower preoperative MP than those with poor results (MP 34% versus 49%) and lower preoperative acetabular index. The mean increase in MP (worst hip in each patient) was 1.9% per year, which is considerably less than that in nonoperated patients. Further hip surgery was necessary in 27 patients, because of increasing MP in 14 cases and for clinical reasons in 13.

INTERPRETATION

Adductor tenotomy reduced the trend towards lateral displacement of the hip joints. The operation had a favorable outcome in approximately two-thirds of the patients. The operation should be performed before the MP reaches 50%.

Upper extremity reconstruction in the tetraplegic population, a national epidemiologic study

PURPOSE

More than 100,000 Americans live with the disability of tetraplegia. For these people their level of independence often is related to the function of the upper extremity. Reconstructive procedures can improve the use of the upper limb and multiple case series have shown benefit from these procedures for appropriate candidates. Discussions with patients and surgeons, however, suggest that these procedures rarely are performed. This study attempted to assess whether upper extremity reconstruction for the tetraplegic population is being used properly.

METHODS

Data from 2 inpatient national databases were used (the National Inpatient Sample and Veterans Affairs patient treatment files) for 1988, 1989, 1999, and 2000. Patients were selected by International Classification of Diseases (ICD-9) diagnosis codes for tetraplegia and procedure codes that could represent upper extremity reconstruction. The recommended rate of these surgeries was based on the annual incidence of tetraplegia (5,000) and expert opinion that suggests at least 50% of these people would benefit from upper extremity surgery.

RESULTS

Our health care data analysis showed that fewer than 355 of these surgeries were performed in the United States in any year queried. The calculated recommended rate was 2,500 procedures a year, meaning that only 14% of appropriate candidates were receiving upper extremity reconstruction. We also found changes in the expected primary payor, with Medicaid paying for far fewer procedures in 2000 compared with 1988 claims. Finally over the course of time it appears that far fewer of these procedures are being performed.

CONCLUSIONS

Functional upper extremity reconstruction for the tetraplegic population is profoundly underused in the United States. Various factors could be causing this disparity of care and we recommend further research into the potential barriers to health care for this vulnerable population.

Functional neurorehabilitation in locked-in syndrome following C0-C1 decompression

Today, thanks to intensive care treatment and modern diagnostic tools, increasingly more patients with severe brain and spinal cord lesions, mainly secondary to accidents, stroke, tumours, and congenital malformations survive the acute impact on the central nervous system (CNS). Complicated operative procedures and concomitant complication may also lead to severe impairment of the sensory motor and cognitive behavioural functioning as it can be described according to the WHO-ICF criteria. New developments of functional neurorehabilitation in neurosurgery can significantly improve patients' quality of life (QoL) in terms of both brain and body functioning and certain health-related components of well-being (such as social activities and leisure). Rehabilitation starts with assessment of the functional impairment and the underlying pathophysiology by using all modern diagnostic tools. Our concept of postoperative neurorehabilitation is exemplarily demonstrated in one patient who suffered from acute postoperative locked-in syndrome. Surgical decompression and fusion were required for post traumatic and recurrent congenital craniovertebral instability at C0-C1. Subsequent functional neurorehabilitation is based on careful planning in accordance with our concept of a holistic Spectrum of functional early Neurorehabilitation.

Physician perceptions of upper extremity reconstruction for the person with tetraplegia

PURPOSE

Upper extremity reconstruction for people with tetraplegia can improve upper-limb function substantially and enhance independence; however, these surgical procedures rarely are performed. This study attempted to identify barriers preventing appropriate candidates from receiving these procedures.

METHODS

A questionnaire was mailed to a national sample of 379 hand surgeons and 384 physiatrists with an interest in spinal cord medicine. The statistical model assessed 2 main outcomes of the physician survey: (1) whether the provider had been involved in at least one of these procedures in the past year and (2) whether the provider desired to be more involved. We hypothesized that these outcomes were associated with provider attitudes and beliefs and failures of the health care system referral networks.

RESULTS

Most hand surgeons and physiatrists believed that these procedures were beneficial; however, few had either performed or referred even one case over the past year. Multivariable models suggested that a predominant factor in whether these procedures were being performed was the presence of a relationship between the surgeon and physiatrist.

CONCLUSIONS

A lack of coordinated cross-specialty relationships appears to present the largest barrier to the appropriate use of upper extremity reconstruction for people with tetraplegia.

Tetraparesis due to exostotic osteochondroma at upper cervical cord in a patient with multiple exostoses–mental retardation syndrome (Langer–Giedion syndrome)

STUDY DESIGN

Case report of a severe upper cervical cord compression and tetraparesis by a massive cervical exostotic osteochondroma in a patient with multiple exostoses-mental retardation syndrome (Langer-Giedion syndrome; LGS).

OBJECTIVE

To describe this very rare pathological condition and the results of surgical intervention.

SETTING

Gifu, Japan.

METHODS

A 23-year-old man was referred to our clinic because of progressing tetraparesis. He had previously been diagnosed with hereditary multiple exostoses and mental retardation. As he had not complained of any symptoms, his family only noticed the tetraparesis after advanced deterioration. His face possessed the pathognomic features of LGS. A postmyelogram CT scan demonstrated an exostotic mass arising from the left-side C2 pedicle with associated severe spinal cord compression. He was diagnosed with LGS. Hemilaminectomy on the left side and resection of the osteochondroma were performed.

RESULTS

At 5 years postoperatively, a neurological examination showed the full return of all motor functions. The CT scan revealed no intracanalar recurrence of the tumor.

CONCLUSION

In this case of severe tetraparesis due to cervical osteochondroma, decompression by hemilaminectomy provided excellent results. In patients with LGS and intracanalar osteochondroma, the neurological deficit may be masked by mental retardation. Hence, awareness of this pathological condition will help clinicians diagnose it at an early stage.

New rehabilitation interventions in spinal cord injury

Progress in the care of people with spinal cord injury (SCI) spans every aspect, from research in neuroregeneration to pharmacologic interventions. This article focuses on advances in rehabilitation interventions, which have employed bioengineering, computerization, and advanced therapeutic techniques. These interventions are being applied to functional deficits of the bladder, bowel, upper extremities, and respiratory system, as well as to improvements in ambulation and mobility. Functional electrical stimulation (FES) is being used to augment the function of the lower extremities, the upper extremities (Freehand System), and the bowel and bladder (Vocare System). Tendon transfer is a reconstructive technique used to improve upper extremity function; it is sometimes combined with FES. Body weight-supported treadmill training is being used to improve ambulation in people with incomplete SCI, and advances in wheelchair technology are expanding options for mobility. Cushion design and pressure mapping are modalities being used to reduce the high risk for pressure ulcers in the SCI population. Research on shoulder stressors is being applied to transfer techniques, exercise regimens, adaptive equipment and wheelchair mechanics to minimize shoulder pain, another common complication. The effectiveness of rehabilitation interventions needs to be documented by evidence-based research. Researchers are focusing on the identification of outcomes measures that will form the basis for established standards of care for individuals with SCI. Perhaps the combination of conventional and newer therapies may enhance neurological recovery. Well-designed studies are needed before we can make this determination.

The role of clinical examination in excluding vascular injury in haemodynamically stable patients with gunshot wounds to the neck. A prospective study of 59 patients

OBJECTIVE

To prospectively evaluate the safety and accuracy of physical examination in determining the management of stable patients with gunshot wounds to the neck.

DESIGN

Prospective study of 59 patients with gunshot wounds to the neck.

PATIENTS AND METHODS

Fifty-nine stable patients with gunshot wounds to the neck managed between December 2001 and August 2003. All patients had a physical examination and routine angiography according to a written protocol approved by the research ethics committee. The sensitivity, specificity, and predictive values of physical examination were assessed and compared with the angiographic findings.

RESULTS

Thirteen patients with positive findings on physical examination (history of bleeding, haematoma, minimal bleeding, thrill, bruit and pulse deficit) and 10 patients without clinical signs of vascular injury had vascular injury. A sensitivity of 57%, specificity 53%, positive predictive value 43% and negative predictive value of 67% were calculated for physical examination alone in detecting vascular injury.

CONCLUSION

Findings on physical examination are not good predictors of vascular injury in stable patients with gunshot wounds to the neck. Our findings question the validity of physical examination alone, as a safe and accurate assessment of patients with gunshot wounds to the neck. Arteriography or ultrasonography is needed to identify vascular injuries.

The effect of selective tibial neurotomy and rehabilitation in a quadriplegic patient with ankle spasticity following traumatic brain injury

Ankle spasticity following brain injury leads to abnormal posture and joint contracture; making standing or walking impossible. This study investigates the efficacy of selective tibial neurotomy (STN) and intensive rehabilitation in a patient who suffered ankle spasticity after brain injury. This case describes a 37-year-old man whose traumatic brain injury (TBI) resulted in severe right ankle spasticity and contracture. He was unable to stand due to severe right ankle spasticity and contracture. Intensive rehabilitation and STN allowed him to walk without brace at 6 months and run at 12 months after STN. STN is an effective procedure to resolve localized spasticity of the ankle and it may be considered as a management strategy after local injection to alleviate ankle spasticity and/or contracture prior to orthopaedic surgery.

Heterotopic ossification after hip surgery in cerebral palsy

Heterotopic ossification is a post-surgery complication occasionally observed in patients with infantile cerebral palsy. In the majority of the cases such lesions are found at the hip after surgery on the skeleton and the soft tissues. At our Institute in the last five years, this complication has been observed four times, in 39 patients, who underwent mainly soft tissue releases because of flexion and adduction contracture of the hip. In these cases, as in a further patient with myelomeningocele, the periarticular heterotopic ossification appeared in the hip after tenotomy of the ilio-psoas at the lesser tronchater associated to other surgical procedures. Conversely, no cases of ossification have been found after tenotomy of the adductors or the gracilis or selective tenotomy of the psoas at the pelvic brim. The exact causes of this complication are still unclear, but after an analysis of the literature and patient history it can be hypothesised that it may be related to the surgical procedures carried out.

Psychometric rigor of the Grasp and Release Test for measuring functional limitation of persons with tetraplegia: a preliminary analysis

OBJECTIVE

The purpose of the study was to further develop the psychometric rigor of the Grasp and Release Test (GRT), a hand function assessment designed to measure tendon transfer and functional electrical stimulation (FES) outcomes on functional limitation of individuals with tetraplegia.

METHODS

Nineteen participants (21 hands) between 7 and 20 years of age with cervical-level spinal cord injuries (SCIs) participated in this study. Three participants (5 hands) had strong C6 or C7 function and underwent bilateral surgical tendon transfers to restore volitional thumb and finger flexion. The remaining 16 participants (16 hands) had C5- or weak C6-level SCI and underwent unilateral surgical implantation of the Freehand System for stimulated grasp and release. Preliminary evaluation of test-retest reliability, predictive validity, and sensitivity to change of the GRT was conducted. Reproducibility of test scores was evaluated by intraclass correlation coefficients (ICCs).

RESULTS

Three objects-which included a fork, paperweight, and videotape-had perfect correlation. For the 3 remaining GRT objects, ICC values were significant (block = 0.87, peg = 0.93, can = 0.99; P < 0.01). For predictive validity, the relationships between 12-month Functional Independence Measure (FIM) scores and the peg, block, paperweight, and total number of GRT objects were nonsignificant. Correlation was significant between 12-month FIM scores and the fork (rho = 0.624, P < 0.01), can (rho = 0.700, P < 0.01), and videotape (rho = 0.503, P < 0.05). Sensitivity to change was evident by a significant difference between baseline and postrehabilitation GRT scores for the fork (z = 3.05, P < 0.01), paperweight (z = 2.83, P < 0.01), and can (z = 2.66, P < 0.01), and between the total number of GRT objects that were manipulated following surgery as compared with the number prior to surgery (z = 3.40, P < 0.05).

CONCLUSION

Based on this study, the GRT has good test-retest reliability as evidenced by coefficients between 0.87 and 1.00, and is able to detect changes in hand function following tendon transfers and FES.

Primary amyloidoma of the axis and acute spinal cord compression: a case report

BACKGROUND

Localized primary amyloidosis is a disease characterized by a single tumor and localized amyloid deposit (amyloidoma) with no evidence of generalized amyloidosis. The occurrence of an amyloidoma in the spine is rare and only three cases affecting the axis have been previously reported. We describe the case of a 79-year-old woman presenting with a mass involving the odontoid process, responsible for an acute tetraparesia. Diagnosis of local primary amyloidosis was made after surgical excision.

RESULTS

Despite the critical presentation, outcome was excellent after total excision of the mass. This case can be classified as a primary localized amyloidoma. The patient did not exhibit any infection, tumor or inflammatory disease, and continued investigations failed to demonstrate other amyloid deposit after one-year follow-up.

CONCLUSIONS

Amyloidoma must be discussed in presence of a tumor-like mass of the odontoid process and may be responsible, as in our case, for spinal cord compression.

Motor capacities of upper limbs in tetraplegics: a new scale for the assessment of the results of functional surgery on upper limbs

STUDY DESIGN

Metrological investigation.

OBJECTIVES

To study the validity and the reliability of a Motor Capacities Scale (MCS) specifically designed for tetraplegics who undergo a functional surgery of upper limbs.

SETTING

Bouffard-Vercelli Centre, Cerbere, France.

METHODS

From diverse sources (observation of patients, review of literature, discussions with occupational therapists and physicians), we compiled a list of 300 activities relating to daily living tasks. From this list, 80 items of motor capacities were retained. They correspond to the abilities of a patient to perform basic and functional tasks regardless of contextual factors (environmental and personal factors). In a preliminary study, items were reviewed by occupational therapists and by 40 tetraplegics for criticism. An open study and an intermediate study were conducted to assess, respectively, the feasibility and the reliability of the MCS. A prefinal study was focused on construct validity. Convergent and divergent hypotheses were formulated and tested against other measures. Four criteria were identified for the elimination of some of the 36 remaining items: a variance of the item equal to 0, a low reproducibility, a high level of redundancy studied by item-to-item correlation and a low level of comprehension.

RESULTS

In all, 52 tetraplegics were included in the prefinal study. Global inter-rater reproducibility was excellent (intraclass correlation coefficient of 0.99). In accordance with the criteria of elimination, the number of items was reduced to 31. Correlations with the Sollerman test and the Asia Motor Score were, respectively, 0.959 and 0.7444 (P<0.0001). Correlation with the interval since the onset of the tetraplegia and the educational level were, respectively, 0.20 and 0.195 (P=0.163).

CONCLUSION

MCS displays a good apparent and content validity, and excellent reproducibility and construct validity. Metrological properties were good enough to allow the evaluation of sensitivity to change in the final study.

Use of the ICF conceptual framework to interpret hand function outcomes following tendon transfer surgery for tetraplegia

STUDY DESIGN

Clinical commentary

OBJECTIVE AND SETTING

This paper is a clinical commentary based on the Round Table discussion on Assessment and Outcomes at the 7th International Conference on Tetraplegia: Surgery and Rehabilitation, Bologna, Italy 6-8 June, 2001. It refers specifically to the 10-year re-review undertaken in 2001 at the Spinal Unit, Burwood Hospital, Christchurch, New Zealand.

SUBJECTS

In all, 24 tetraplegic persons at a minimum of 12 years and up to 18 years following bilateral forearm tendon transfer surgery.

METHOD

The data were interpreted using the International Classification of Functioning, Disability, and Health (ICF) conceptual framework as the basis of interdisciplinary understanding of the participation dimension.

RESULTS

The results of the study outlined confirm that outcome measurement at more than one level of functioning is desirable to determine the functional effects beyond grip strength levels and activities of daily living, to consider the dimension of participation.

CONCLUSIONS

Use of the ICF as a theoretical framework for interpretation of the results enhanced the clinical applicability of the outcome measures used in the 10-year re-review undertaken in New Zealand in 2001.

Perceived outcomes and utilization of upper extremity surgical reconstruction in individuals with tetraplegia at model spinal cord injury systems

STUDY DESIGN

Survey.

OBJECTIVE

To measure the utilization of upper extremity reconstructive surgery and the clinicians' perceptions of the outcomes provided for persons with tetraplegia across the Model Spinal Cord (SCI) Injury Systems.

SETTING

Model SCI Systems.

METHODS

PARTICIPANTS

A clinician from each of the Model Centers.

MAIN OUTCOME MEASURE

A mailed survey eliciting responses with respect to: (1) utilization of upper extremity reconstructive procedures and (2) the clinicians' perceived outcomes of these procedures.

RESULTS

In all, 76% responded positively about the availability and appropriateness of upper extremity surgical reconstruction at their center. Of the respondents, 75% felt that surgery recipients were generally satisfied with their surgeries, 80% felt that the surgery made a positive impact on recipients' lives, 81% felt that recipients showed increased independence, and 70% reported a positive impact on recipients' occupation. In all, 93% felt insurance companies should pay for the procedures. Compared to the satisfaction of surgery recipients using a similar instrument, clinicians anticipated slightly greater improvements in all areas except occupation.

CONCLUSIONS

There is a positive perception of the benefits of reconstructive surgery for tetraplegia; however, procedures are not routinely offered at all centers. The primary reasons reported for this include the misconception that insurance does not remit payment, that a surgeon is not available, and that surgical candidates are referred to another center.

Analyse critique des modalités d’évaluation des résultats de la chirurgie fonctionnelle du membre supérieur tétraplégique. Revue de la littérature sur les 50 dernières années

OBJECTIVE

To study the methods of assessment of upper limb functional surgery in the literature.

METHODS

The literature review relating to the years 1950-2002 was carried out with three data bases: Medline, Pascal, Embase. This review also involved a thorough study of non-indexed references.

RESULTS

Although many instruments or tests are used to assess outcome after surgery, their reliability, validity and responsiveness have not been adequately proven. Methodology appears to be the major failing of the various scales used to assess these patients. The conceptual models underlying the evaluation are all too often unspecified. There is a lack of pertinence of the selected tasks for tetraplegics. There is limited documentation of the guiding framework or conceptualisation. Furthermore, the process of item selection is often unknown. Scales or instruments are also deemed to be too insensitive to document the small but meaningful functional gains made by tetraplegics after functional surgery.

CONCLUSION

To answer the need for a specific assessment tool for tetraplegics who undergo functional surgery, we have developed a national, multicenter, prospective and longitudinal study based on two concepts: the first concept is related to Life Habits that are the activities of daily living and social roles recognised by the socio-cultural context of a person according to age, sex and social and personal identity. They include activities that should be accomplished on a daily basis (nutrition, fitness, personal care, communication, mobility, etc.). Life Habits presenting a significant level of disruption can create handicap situations. The second concept is in relation with Motor Capacities that correspond to the abilities of a patient to perform basic and functional tasks regardless of contextual factors (environmental and personal factors).

[Orthopaedic problems in adults with cerebral palsy]

BACKGROUND

There is little information about the need for orthopaedic surgery in adults with cerebral palsy; we wanted to assess this problem.

MATERIAL AND METHODS

The material included 37 adults with cerebral palsy (19 women and 18 men), mean age 39. The degree of physical disability was mild in 19 cases, moderate or severe in 18. The patients were assessed by clinical examination and radiographs of hips and spine.

RESULTS

15 patients had pain located to the spine or lower extremities but no-one had severe or invalidating pain. Subjects with moderate or severe disability had a markedly reduced range of motion in the hip and knee joints. Subluxation or dislocation of the hip joints was found in six patients but only one of them had hip pain. Orthopaedic surgery had been performed in 23 patients. In 8 patients we found indications for additional orthopaedic surgery aimed at relieving pain, reducing contractures or improving function. The most frequent procedures would be tenotomies in the hip and knee regions, heel cord lengthening, and triple arthrodesis of the foot.

INTERPRETATION

Regular follow-up of adults with cerebral palsy is recommended in order to reveal musculoskeletal problems that can be improved by orthopaedic surgery.

Functional reconstruction of the upper extremity in tetraplegia. Application of Möberg's and Allieu's procedures

The authors conducted a retrospective study to evaluate the benefit of 43 reconstructive procedures and tendon transfers, performed in 37 sessions to restore hand and arm function in 25 tetraplegic patients. These operative procedures were either single or multiple, depending on the patients' needs for restoration. The initial clinical situation was assessed based on a simplified version of the international classification of Giens, modified in Edinburgh. The results were evaluated through clinical assessment and simple functional testing. Gestural ability was improved in more than 80% of the patients and functional gain was important in more than half. The authors conclude that selected tetraplegic patients can benefit from these procedures. The diversity of clinical situations and the variety of surgical procedures result into small scattered series unfit for statistical analysis, and there is a need for unequivocal, internationally recognised assessment methods.

Progressive quadriparesis in adolescent with stenosis of the cervical spine

INTRODUCTION

Progressive quadriparesis in adolescents suffering from cervical stenosis is a very rare entity. Only three cases have been reported in the literature.

CASE REPORT

We report our own case of progressive quadriparesis in a young patient suffering from cervical stenosis, the first to be documented with pre- and postoperative magnetic resonance imaging.

Functional and cosmetic outcome of surgery for cerebral palsy in the upper limb

Function, cosmesis, hygiene, and ability to dress can be improved by appropriate surgery. This frequently involves multiple simultaneous procedures and addresses the muscles, their tendons, and the joints they pass over. The improvement in cosmesis is most profound in hemiplegic patients. Overall, patients are satisfied with the results of surgery.

The upper limb in cerebral palsy: surgical management of shoulder and elbow deformities

The authors report a simple chart that offers a comprehensive picture of spasticity of the upper limb and provides a more objective method of recording data. Distinction is made between fixed postures and the residual active range of motion at the shoulder and elbow. The presence and function of the muscles can be identified easily on dynamic EMG studies, which are essential for understanding the degree of spasticity and dyssynergy related to a single muscle. When spasticity of the upper arm is managed with a global approach and objectives are defined clearly in advance with the patient and caregivers, treatment of shoulder and elbow deformities can achieve important results for personal hygiene or functional targets.

Use of a free jejunal graft for oesophageal reconstruction following perforation after cervical spine surgery: case report and review of the literature

STUDY DESIGN

: Single-subject (male, 16 years of age) case.

OBJECTIVES

To demonstrate a suitable method for oesophageal repair after perforation as a complication of anterior spinal fusion in an individual with quadriplegia, and to review the literature on oesophageal perforation and repair.

SETTING

University hospital, large trauma centre with departments for spinal injuries and reconstructive surgery in Germany.

METHODS

A free jejunal graft used for oesophageal reconstruction in a post-traumatic situation after a complicated treatment course in a C6 quadriplegic patient.

RESULTS

A protuberant loose screw of the titanium plate after anterior spinal fusion perforated the oesophagus. Imbricating sutures and a fascia lata patch were insufficient to repair the oesophageal leakage. An 8 cm long segment of the cervical oesophagus including a fistula had to be excised, and a free microsurgical jejunal flap was used for restitution of continuity. The jejunal vessels were connected to the superior thyroid artery and external jugular vein. At 1 week after the oesophageal repair, an enteral contrast study showed a small amount of contrast medium leaking at the oesophago-pharyngeal anastomosis. A percutaneous gastric tube was inserted, and oral feeding was limited to tea and still water for 4 weeks. The further course was uneventful.

CONCLUSIONS

Oesophageal perforation is a rare but recognized complication after cervical spine surgery, which can mostly be managed using secondary suture techniques. The free jejunal flap is a reliable and innovative tool in the particularly complex situation of a segmental oesophageal loss. It should be considered in similar cases to reconstruct oesophageal continuity or to treat stricture and fistula formations.

Proximal femoral resection for subluxation or dislocation of the hip in spastic quadriplegia

Management of a painful or contracted hip dislocation in individuals with severe spastic quadriplegia is difficult. Clinical and radiographic results of 12 proximal femoral resection-interposition operations performed in seven non-ambulatory persons (five males, two females; mean age 14 years, 8 months; age range 6 years 11 months to 19 years 8 months) with severe spasticity were reviewed to determine if pain relief and restoration of motion were maintained. At a mean follow-up of 7 years 7 months (median 9 years 6 months) all participants maintained a good sitting position and a functional range of motion with improved hygiene. Hip pain was improved in all participants compared with their preoperative status. Proximal femur migration occurred causing slight pain in one person. Heterotopic ossification was observed but was not clinically significant. Complications included traction pin loosening and infection and a late supracondylar femur fracture 3 months after the operation. Proximal femoral resection effectively decreased pain and restored hip motion in those with severe spastic quadriplegia leading to improved sitting and perineal care.

[Reconstructive hand surgery improves hand function in tetraplegia. Basic research and clinical studies paved the way for this development]

Structural and mechanical changes in muscles and muscle cells were studied after spinal cord injury with tetraplegia as well as secondary to upper motor neural lesion with spasticity. A multi-level approach was applied. It included measuring human sarcomere length intraoperatively, designing and validating biomechanical models for muscle-tendon-joint systems, mechanically testing muscle and using molecular methods to identify muscle cytoskeletal fragments. Using this combination of muscle modeling and physiological testing, the actual effect of surgical intervention can be predicted. Our improved understanding of muscle mechanics has been critical for development of several therapeutic treatments including both muscle tendon transfer surgery and rehabilitation. Successful tendon transfer procedures improve patient function, which facilitates employability and allows patient to regain independence and reduce the need for a constant care.