Acute cervical epidural hematoma: case report

A 74 year-old patient with a nocturnal onset of neck and chest pain was brought to an emergency clinic. Physical examination and cardiac assessment were normal. Three hours after the addmittance, a flaccid paralysis of the four limbs supervened. Suspecting of an unusual onset of central nervous system infection, a lumbar puncture was performed, yielding 20 ml of normal cerebrospinal fluid. Thirty oinutes after the puncture, the patient completely regained neurological funcion. He was then referred to a General Hospital where a computed tomography (CT) scan was done showing a large cervical epidural bleeding in the posterolateral region of C4/C5 extending to C7/Th1, along with a C6 vertebral body hemangioma. A magnetic resonance imaging revealed the same CT findings. A normal selective angiography of vertebral arteries, carotid arteries and thyreocervical trunk was carried out. Spontaneous spinal epidural hematoma (ASSEH) is a rare but dramatic cause of neurological impairment. In this article we report a fortunate case of complete recovery after an unusual spine cord decompression. We also review the current literature concerning diagnosis and treatment of ASSEH.

Deltoid triceps transfer and functional independence of people with tetraplegia

STUDY DESIGN

Matched case control study.

SETTING

Two regional spinal units - Salisbury, UK (surgical centre) and London, UK (control centre).

OBJECTIVE

To compare the functional independence and wheelchair mobility of spinal cord injured subjects, post deltoid triceps transfer, with matched control subjects.

METHODS

Two matched groups of subjects, with tetraplegia resulting in triceps paralysis, were studied. The surgical group consisted of five of the six patients who had previously undergone deltoid triceps transfer at Salisbury. The control group (n=6) had not undergone surgical intervention but were comparable with respect to level of lesion, age, age at injury and duration of disability. All subjects completed standardised assessments of activities of daily living (Functional Independence Measure - FIM) and wheelchair mobility (10 m push and figure of 8 push). Surgical subjects completed additional questions, regarding the perceived effects of surgery on function.

RESULTS

It was not possible to demonstrate absolute functional differences with the chosen outcome measures in this small series of matched case controls. All surgical subjects cited specific functional improvements since surgery and recommended the procedure. However the FIM lacked sufficient sensitivity to detect these changes.

CONCLUSION

Further investigation of the functional outcome of deltoid triceps transfer in tetraplegia is warranted. Development of more sensitive outcome measures would be useful.

[Traumatic paraplegia: surgical measures]

Reduction and fixation of unstable spine injuries in patients with neurological deficit are the prerequisites for early rehabilitation. Diagnostic procedures and surgery in patients with para-/tetraplegia must be performed urgently to avoid further neurological damage and ensure recovery. In parallel administration, high-dose steroids are initiated immediately after admission. In general, unstable spine fractures are reduced in a closed or open manner and stabilised. Bony fragments occluding the spinal channel are removed and, if necessary, the anterior column is reconstructed. Unstable fractures of the cervical spine are operated on either from the back and/or anteriorly, although the techniques used in the upper cervical spine are quite different from those used in the lower cervical spine. Instabilities of the thoraco-lumbar junction are reduced and stabilised via a dorsal and/or anterior-lateral approach (transthoracic or retroperitoneal). Exact preoperative planning is necessary due to the proximity of large vessels and organs, as well as the narrow space for positioning of the implants. With early operative stabilisation of the spine paretic/paralysed patients can be mobilised immediately and personal care is facilitated. In this article the operative techniques are described on the basis of examples chosen from 606 patients treated at the Division of Trauma Surgery, University Hospital of Zurich from 1992 to 1997. 119 patients (19%) were diagnosed with incomplete/complete para-/tetraplegia and 51 with various degrees of neurological deficit.

Atlantal stenosis: a rare cause of quadriparesis in a child. Case report

The authors report the case of a 3-year-old boy who suffered from quadriparesis and respiratory distress after failing to execute a somersault properly. Neuroimaging revealed spinal cord contusion with marked spinal canal stenosis at the level of the atlas. No subtle instability, occult fracture, or other congenital abnormalities were confirmed. Spinal cord contusion with marked canal stenosis is rare, and only several adult cases have been reported. Severe stenosis at the level of the atlas may predispose individuals to severe spinal cord contusion, as occurred in our patient after sustaining trivial trauma.

Treatment of syringomyelia after posttraumatic paraparesis or tetraparesis

This retrospective study of 12 patients with syringomyelia related to spinal cord trauma with paraplegia or tetraplegia and secondary progressive neurologic deficits was conducted to evaluate various surgical treatments. Judging by the results of postoperative neuroradiologic examinations, 75% had incomplete reduction of the spinal fracture at the time of initial surgery. The secondary neurologic deterioration occurred within a delay of 146 +/- 16 months and included ascending sensory deficits in 92%, deafferentation pain in 83%, and increased motor weakness in 33%. There was a positive correlation between the severity of symptoms, incomplete reduction of spinal fracture, and the degree of arachnoid scarring in preoperative neuroradiologic examinations. Syringoperitoneal shunting was performed in 83% of patients, and laminectomy with arachnoid lysis and dural grafting were performed in 17%. Pain was improved in 75%, sensory deficits in 25%, and motor weakness in 8%. During the follow-up period of 44 +/- 25 months, 30% of patients with syringoperitoneal shunting required repeated operation for obstruction or infection, whereas the syringomyelia remained collapsed in the two patients with laminectomy with arachnoid lysis and dural grafting, but this did not require additional surgery. In conclusion, laminectomy with arachnoid lysis and dural grafting seems to be a promising alternative treatment for patients with secondary neurologic deterioration after traumatic paraplegia or tetraplegia. Syringoperitoneal shunting may be reserved for patients without severe arachnoid scarring.

Prosthetic interposition arthroplasty for the palliative treatment of end-stage spastic hip disease in nonambulatory patients with cerebral palsy

We reviewed our experience in using a prosthetic arthroplasty for the treatment of painful degenerative arthritis in 11 nonambulatory patients (14 hips) with cerebral palsy. Age of the patients ranged from 11 to 20 years. Three patients had previously undergone a salvage procedure. Radiographic follow-up averaged 16 months (range, 4 months to 5 years). Ten of the hips remained located on the latest radiographs, and four of the hips dislocated within 4 months of the procedure. No patient exhibited migration or failure of the implants, although one patient exhibited periprosthetic osteolysis, which remained unchanged over a 4-year period. Clinical follow-up averaged 5 years (range, 2-6 years). Ten patients (13 hips) had complete relief of hip pain. Caretaker satisfaction was high for these patients, with all 10 caretakers stating that they would recommend the procedure. One patient continued to have persistent pain in the hip, and the caretaker stated that she would not recommend the procedure.

[Anatomical study of the distal tendon of the brachial biceps muscle. Application to biceps-triceps transfer in tetraplegic patients]

In some cases of biceps-to-triceps transfer the muscle fibres of the biceps are inserted very distally, preventing correct setting of the transfer. A knowledge of the anatomy of the intramuscular part of the distal tendon of the biceps is useful to lengthen this tendon proximally. A study of 40 specimens showed that the intramuscular part of the distal tendon of the biceps is a large flattened lozenge-shaped aponeurosis located in a frontal plane. It receives muscle fibre insertions on both aspects. The length of the invisible part of the tendon can be estimated by a simple formula: 0.55 a + 4 cm, where "a" represents the length of the tendon between the most proximal tendinous point visible, and the most distal muscle point visible.

Cervical laminectomy without fusion in patients with rheumatoid arthritis

OBJECT

The authors performed a prospective study to determine whether cervical laminectomy without simultaneous fusion results in spinal instability.

METHODS

Because of clinical and radiographic signs of cord compression, 15 patients with rheumatoid arthritis (including one with Bechterew's disease) and severe involvement of the cervical spine underwent decompressive laminectomy without fusion performed on one or more levels. Preoperative flexion-extension radiographs demonstrated dislocation but no signs of instability at the level of cord compression. Clinical and radiological reexamination were performed twice at a median of 15 months (6-24 months) and 43 months (28-72 months) postoperatively. One patient developed severe vertical translocation 28 months after undergoing a C-1 laminectomy, which led to sudden tetraplegia. She required reoperation in which posterior fusion was performed. No signs of additional instability at the operated levels were found in the remaining 14 patients. In three patients increased but stable dislocation was demonstrated. The results of clinical examination were favorable in most patients, with improvement of neurological symptoms and less pain.

CONCLUSIONS

The authors conclude that decompressive laminectomy in which the facet joints are preserved can be performed in the rheumatoid arthritis-affected cervical spine in selected patients in whom signs of cord compression are demonstrated, but in whom radiographic and preoperative signs of instability are not. Performing a simultaneous fusion procedure does not always appear necessary. Vertical translocation must be detected early, and if present, a C-1 laminectomy should be followed by occipitocervical fusion.

Biceps-to-triceps transfer in tetraplegia. The medial route

Eight tetraplegic patients (13 elbows) were treated by biceps-to-triceps transfer. To avoid the risk of radial nerve injury, we chose a medial routing of the biceps. The mean follow-up after surgery was 17.8 months (range, 4-47 months). No complications were encountered. Active extension of the elbow was achieved in each case. The mean postoperative active range of motion of the elbow was 6 degrees extension and 137 degrees flexion. After the biceps-to-triceps transfer mean extension torque of the elbow was 3.7 Nm and mean flexion torque was 10 Nm. In eight elbows in which it was measured, there was a 47% reduction in elbow flexion power. Nevertheless no patient complained about that reduction, and all of them were satisfied.

A method of restoration of the abduction of the thumb in traumatic tetraplegic patients

A method of restoring extension and abduction of the thumb in traumatic tetraplegia is described. This method includes tenodesis of the abductor pollicis longus, transfer of the distal stump of the extensor pollicis brevis tendon to the flexor carpi radialis tendon, and transfer of the distal stump of the extensor pollicis longus tendon to the brachioradialis tendon. I performed this procedure on 6 hands in 5 patients and monitored each patient for 6 to 12 months. A significant increase in radial abduction of the thumb (0.5 +/- 0.2 cm to 2.8 +/- 0.2 cm) occurred in all hands.

Disabling injuries of the cervical spine in Argentine rugby over the last 20 years

OBJECTIVE

To investigate the incidence and risk factors of disabling injuries to the cervical spine in rugby in Argentina.

METHODS

A retrospective review of all cases reported to the Medical Committee of the Argentine Rugby Union (UAR) and Rugby Amistad Foundation was carried out including a follow up by phone. Cumulative binomial distribution, chi 2 test, Fisher test, and comparison of proportions were used to analyse relative incidence and risk of injury by position and by phase of play (Epi Info 6, Version 6.04a).

RESULTS

Eighteen cases of disabling injury to the cervical spine were recorded from 1977 to 1997 (0.9 cases per year). The forwards (14 cases) were more prone to disabling injury of the cervical spine than the backs (four cases) (p = 0.03). Hookers (9/18) were at highest risk of injury (p < 0.01). The most frequent cervical injuries occurred at the 4th, 5th, and 6th vertebrae. Seventeen of the injuries occurred during match play. Set scrums were responsible for most of the injuries (11/18) but this was not statistically significant (p = 0.44). The mean age of the injured players was 22. Tetraplegia was initially found in all cases. Physical rehabilitation has been limited to the proximal muscles of the upper limbs, except for two cases of complete recovery. One death, on the seventh day after injury, was reported.

CONCLUSIONS

The forwards suffered a higher number of injuries than the backs and this difference was statistically significant. The chance of injury for hookers was statistically higher than for the rest of the players and it was particularly linked to scrummaging. However, the number of injuries incurred in scrums was not statistically different from the number incurred in other phases of play.

Spontaneous ankylosis of the contralateral hip after unilateral adductor tenotomy in cerebral palsy

This is the case report of a 15-year-old black male with spastic quadriplegia cerebral palsy who developed heterotopic ossification and spontaneous ankylosis of his contralateral nonoperative hip after unilateral adductor tenotomy. To the authors' knowledge, this is the only reported case of such an occurrence. The mechanism and possible risk factors are discussed as well as management of this complication.

[Surgical management of tetraplegia]

The traumatic lesion of the cervical cord implies one of the most serious sequale after accident with severe consequences for lifetime. In patients with a relevant injury of the cervical spine in 28% neurological deficits are seen with an even higher incidence of 44% in the lower cervical spine. The risk of traumatic cervical cord injury further increases with progressing stenosis of the spinal canal and therefore a second peak of occurrence has to be observed in the elderly. In the preclinical phase even suspicion of a cervical cord lesion should lead to effective stabilization of the cervical spine and should be removed only after imaged proof of integrity. A high dosage therapy of methylprednisolon should be started as early as possible in every case of spinal cord injury. Diagnostic procedures are including x-rays of the whole spine, CT-scans for clearance of suspicious findings and pre-operative planning, image intensifiing under controlled stress for hidden instabilities and MRI for spinal cord injuries without abnormal radiological findings. Aims of operative treatment are consisting of decompression, reduction and stabilization with the aims of protection of the neurogenic structures and to secure intensive care treatment. These objectives can be met sufficiently by a single ventral approach in most instances. Dorsal approaches should be avoided whenever possible leaving the important innervation of the paracervical muscles intact. The postacute phase is marked by loss of systemic control mechanis as a consequence of the spinal shock. The consecutive deficits can be mastered only by treatment under intensive care standards. Respirator therapy is advisable especially for higher plegic lesions. Typical complications are frequent and should be watched for carefully because of the absence of pain sensation. Patients with cervical cord injuries should transferred to specialized paraplegic units for early rehabilitation as soon as possible since the rate of specific complications like decubital ulcera increases with the days of stay in non-specialized units.

Biceps-to-triceps transfer in tetraplegic patients: report of the medial routing technique and follow-up of three cases

We reviewed 4 biceps-to-triceps transfers for active elbow extension in 3 tetraplegic patients using a medial routing technique. The biceps-to-triceps transfer to regain active elbow extension in tetraplegic patients is an alternative to the more commonly described deltoid-to-triceps transfer. Before surgery, all 3 patients had absent triceps function and active biceps, brachialis, and supinator function. Postoperative results were assessed by a modified University of Minnesota Functional Improvement questionnaire and by follow-up evaluation of range of motion and muscle strength. All 3 patients had marked functional improvement in activities that involve active elbow extension, and no loss of function was noted in any activities. No patient achieved less than grade 4 extension strength; none had an extension lag greater than 8 degrees. Supination and flexion strength following transfer were rated as at least grade 4 in each limb. Based on the results of this study, we recommend the biceps-to-triceps transfer as an alternative to the deltoid-to-triceps transfer in spinal cord injury patients with active brachialis and supinator function. The medial routing technique has the advantage of avoiding the potentially devastating radial nerve injury that could occur with the previously described lateral routing.

Epidural analgesia in children with cerebral palsy

PURPOSE

Two modalities of epidural analgesia in children with two types of cerebral palsy (CP) were compared for differences in the incidence of common complications (inadequate analgesia, hypopnea, hypoxaemia, sedation, vomiting, pruritus, urinary retention, and seizures).

METHODS

Demographic, procedural and postoperative complication data were collected on children with CP receiving epidural analgesia. Information was recorded contemporaneously with the child's care by one of the authors on 92 consecutive children with CP (age, 107 +/- 50.1 mo; weight, 26 +/- 14.2 kg) who had undergone infra-umbilical orthopaedic or Nissen fundoplication procedures between December 1994 and December 1996. The first 44 patients received intermittent bolus (IB) epidural morphine and the next 48 received continuous infusion (CI) bupivacaine and fentanyl. Two forms of CP (spastic diplegia and quadriplegia) and the two modalities of analgesia were compared.

RESULTS

Excellent analgesia was obtained in 91/92 patients. Excessive sedation occurred in six patients (6.5%) but only in IB patients, (P < 0.02 vs CI). Emesis occurred in 52% of patients, and was more common in diplegic than in quadriplegic patients (68% vs 38%, P < 0.01). Pruritus was observed in 29% of patients and was more common in diplegia than quadriplegia (48% vs 12.5%, P < 0.001). The incidences of hypopnea, hypoxaemia, urinary retention and seizures were not affected by the types of CP or analgesia and no difference in sedation was observed between spastic diplegic and quadriplegic patients.

CONCLUSIONS

Continuous infusion of epidural bupivacaine and fentanyl provided excellent analgesia for children with CP without serious complications. Intermittent bolus epidural morphine was associated with a high incidence of excessive sedation and should be avoided in this population.

Gaining independence in tetraplegia. Cleveland technique

Considerable independence can be achieved by four simple operations that can be done for patients with tetraplegia. Transfers for wrist extension were done 17 times. Posterior deltoid transfers were done 59 times. Opponens transfers were done 112 times. Transfers for finger flexion were done 88 times. Opponens and finger flexion transfers should be done at the same time. There were 22 other operations done. The patients with C6, C7, and C8 complete neurologic motor levels were almost as independent after their tendon transfers as paraplegics. They could transfer from a chair, insert a catheter, write, type, hold a book, take care of their toilet needs, bathe themselves, eat food and drink, dress themselves, and perform other activities of daily living. The few patients with a C5 neurologic level that was surgically treated for wrist extension acquired automatic grasp or used a wrist driven splint. A posterior deltoid transfer was not done on any of the patients with a C5 neurologic level but it is recommended now.

Long-term cardiac ischemia leading to coronary artery bypass grafting in a tetraplegic patient

With increasing survival in the spinal cord injury (SCI) population, coronary heart disease (CHD) is becoming a leading source of morbidity and mortality. Known risk factors and characteristic signs and symptoms of CHD in the general population may be altered or absent in SCI. This report describes the long-term cardiovascular course and outcome of a man with C6 American Spinal Injury Association Impairment Scale A tetraplegia secondary to a motor vehicle crash. Cardiac risk factors included male gender, mild hypercholesterolemia, and sedentary lifestyle. In retrospect, intermittent tooth pain for 13 years was likely an atypical presentation of angina. Because of severe diffuse coronary and carotid atherosclerotic disease, he underwent simultaneous four-vessel coronary artery bypass graft and carotid endarterectomy. This case demonstrates the challenges to the physiatrist in the diagnosis and management of concurrent CHD and SCI, as well as the benefit of appropriate treatment in individuals with SCI.

Selective dorsal rhizotomy in children with cerebral palsy. Results in 18 cases at one year postoperatively

OBJECTIVE

Effects of selective dorsal rhizotomy (SDR) were studied in children with spastic cerebral palsy in orthopaedic and functional fields.

METHODS

In a prospective study, we compared the same population before SDR and 1 year after SDR. This population included children with spastic cerebral palsy, when spasticity was responsible for a halt in the motor skill acquisitions or for orthopaedic complications. All the children had intensive physiotherapy for 6 months postoperatively. We observed spasticity by a 4-point scale, isolation of movement by a 3-point scale, and orthopaedic status by the measure of range of motion, hip migration on the radiography, and function by Gross Motor Function Measure (GMFM) and Abbott scale. All the assessments were done by the same physiotherapist. We compared the results with a Wilcoxon statistic test.

RESULTS

18 quadriplegic children had spastic cerebral palsy; their mean age was 9 years (5.5-16.5 years). We observed a decrease in spasticity in all the muscular groups; increase in range of motion only on abduction and extension of the hips; no evolution of hip migration; an increase of 3.2% in the total GMFM score; 1 child was classified IV before SDR and V after SDR on the Abbott scale; 3 children had planned orthopaedic surgery in the year after SDR; 16 children and their families were highly satisfied with the result of the surgery.

CONCLUSIONS

The decrease in spasticity does not entail prevention of orthopaedic problems in children with quadriplegic spastic cerebral palsy. However, we observed an improvement in qualitative function that is outside the scope of current assessment scales.

[Femoral shortening osteotomy for chronic hip dislocation in patients with cerebral palsy]

Hip dislocation of several years duration in cerebral palsy needs treatment only if the patient has serious complaints. With the aim of reducing pain and problems with sitting function and perineal hygiene, we performed shortening osteotomy of the femur in 15 patients (12 girls and 3 boys) with spastic quadriplegia or diplegia at mean age of 14 (8-26) years. The patients were severely mentally and physically retarded, and only one patient had gait function, with support. A subtrochanteric shortening osteotomy of 3-5 cm was performed. The mean follow-up period was 5 (1-10) years. The symptomatic effect of the operation was good. The patients and parents were satisfied because the pain disappeared and the patients had less spasticity and stiffness. Complications were seen in two patients in the form of skin necrosis under both heels; this was caused by the plaster. Although reduction of the dislocation was not the aim of the surgery, radiographs at follow-up of 16 operated hips showed that five hips were reduced, whereas 11 hips remained subluxated or dislocated. We conclude that shortening osteotomy of the femur produces good symptomatic effects, probably due to reduction of the abnormally high muscle tension across the hip joint.

Intrathecal baclofen infusion and subsequent orthopedic surgery in patients with spastic cerebral palsy

Intrathecal baclofen infusion (IBI) is an effective treatment for spasticity secondary to cerebral palsy (CP).

OBJECT

To assess the need for orthopedic surgery of the lower extremities in such cases, the authors retrospectively reviewed the outcome in 48 patients with spastic CP who were treated with IBI.

METHODS

Pumps were placed in 40 patients (84%) suffering from spastic quadriplegia and eight patients (16%) with spastic diplegia. The patients' ages ranged from 5 to 43 years (mean 15 years). The mean follow-up period was 53 months (range 24-94 months). The mean baclofen dosage was 306 microg/day (range 25-1350 microg/day). At the time of pump placement, subsequent orthopedic surgery was planned in 28 patients (58%); however, only 10 (21%) underwent surgery after IBI therapy. In all 10 cases, the surgical procedure was planned at the time of initial evaluation for IBI therapy. In the remaining 18 patients, who did not subsequently undergo their planned orthopedic operation, it was believed that their lower-extremity spasticity had improved to the degree that intervention was no longer indicated. In addition, although six patients had undergone multiple orthopedic operations before their spasticity was treated, no patient required more than one operation after IBI treatment for spasticity.

CONCLUSIONS

The authors conclude that IBI for treatment of spastic CP reduces the need for subsequent orthopedic surgery for the effects of lower-extremity spasticity. In patients with spastic CP and lower-extremity contractures, spasticity should be treated before orthopedic procedures are performed.

Tendon transfers in tetraplegic patients: the Cleveland experience

The author has taken care of patients with spinal cord injury for over 30 years. A major part of these years was spent doing tendon transfers on the patients with tetraplegia. Thirteen were not better, but not worse out of the 285 patients who had an operation. All of the patients have had a period of rehabilitation, waited 1 year following spinal injury, and had a stable neurological examination. The goals of the surgery were wrist extension, elbow extension, thumb pinch, and finger grasp. This was based on the author's classification of the characteristic muscle strengths that are present in the completely paralysed tetraplegic patient. One group of patients had weak or no wrist extension. These patients needed a transfer of the brachioradialis to the extensor carpi radialis brevis. Some of these patients required a posterior deltoid transfer to act as an obstacle to the brachioradialis. The next group of patients had no elbow extension, but had brachioradialis and two radial wrist extensors. They required a posterior deltoid transfer, and an opponens transfer and a transfer to give finger flexion. The next group had elbow extension, brachioradialis, two radial wrist extensors and a pronator teres, and needed an opponens transfer, and a transfer to give finger flexion. The last group of patients had poor or no opposition, and required an opponens transfer.