The outcome of tendon transfers for C6-spared quadriplegics

The purpose of this study was to review retrospectively and evaluate a uniform group of C6-spared quadriplegics who had similar surgical procedures. Eight patients undergoing 12 procedures were reviewed at an average of 3.8 years follow-up. There were three bilateral procedures. All patients had extensor carpi radialis longus to flexor digitorum profundus and brachioradialis to flexor pollicis longus transfers to improve grip strength and key pinch. All patients reported subjective improvements in quality of life, activities of daily living and patient-centred goals. There were six excellent and two good results. Objective improvements included mild improvements in key pinch and grip strength.

Spinal extradural cysticercosis: a case report

An extremely rare case of extradural spinal cysticercosis in an adult male is presented. The patient had evidence of extradural granulation tissue with associated destruction of C4 and C5 pedicles and laminae, causing tetraparesis. Histopathological examination revealed evidence of a degenerated cysticercal cyst with host tissue reaction. The patient made a gradual and marked improvement after decompression. Though rare, cysticercosis as a possible etiology of extradural spinal compression may be considered in endemic area.

Sparing of sensation to pin prick predicts recovery of a motor segment after injury to the spinal cord

We have reviewed 59 patients with injury to the spinal cord to assess the predictive value of the sparing of sensation to pin prick in determining motor recovery in segments which initially had MRC grade-0 power. There were 35 tetraplegics (18 complete, 17 incomplete) and 24 paraplegics (19 complete, 5 incomplete), and the mean follow-up was 29.6 months. A total of 114 motor segments initially had grade-0 power but sparing of sensation to pin prick in the corresponding dermatome. Of these, 97 (85%) had return of functional power (> or = grade 3) at follow-up. There were 479 motor segments with grade-0 power but no sparing of sensation to pin prick and of these only six (1.3%) had return of functional power. Both of the above associations were statistically significant (chi-squared test, p < 0.0001). After injury to the spinal cord, the preservation of sensation to pin prick in a motor segment with grade-0 power indicated an 85% chance of motor recovery to at least grade 3.

Tetraparesis following dental extraction: case report and discussion of preventive measures for cervical spinal hyperextension injury

This concerns a patient with compression myelopathy following passive hyperextension of the cervical spine during a dental procedure. Although he had been asymptomatic prior to the procedure, subsequent cervical spinal imaging revealed advanced spondylosis and spinal stenosis. Spinal stenosis is often asymptomatic for a long time. However, when radiculomyelopathy occurs after minor trauma to the head or neck, the patient is often found to have spinal stenosis. Specifically, hyperextension of a cervical spine with spondylotic changes can lead to compression myelopathy. Acquired spinal stenosis correlates positively with aging. As the size of the elderly population continues to increase the prevalence of cervical spondylotic radiculo-myelopathy will likely increase as well. Since appropriate precautions against potential neurologic damage can be undertaken, we suggest radiographic screening for pre-existing spinal stenosis prior to a procedure requiring hyperextension of the neck. Preventive measures for individuals with asymptomatic spondylotic changes and education of all health-care professionals to avoid abrupt or prolonged hyperextension of the cervical spine is emphasized.

Cervical spine fusion: not protective of cervical spine injury and tetraplegia

The occurrence of tetraplegic spinal cord injuries in two patients who had preexisting cervical spine fusions highlights the vulnerable nature of such patients. One patient sustained a C5-6 fracture-dislocation after a motor vehicle accident, despite a spontaneously fused cervical spine as a consequence of his juvenile rheumatoid arthritis. A second patient sustained a C3-4 distraction injury in a sporting injury 2 years after he had undergone a posterior cervical spine fusion because of an aneurysmal bone cyst. Prior to their spinal cord injuries, both patients had no apparent neurologic deficits, were relatively active, and followed no specific precautions for their spines.

Soleus neurectomy for dynamic ankle equinus in children with cerebral palsy

Problems with the gastrocnemius-soleus muscle group can severely impair the gait of children with cerebral palsy. Treatments, including bracing, muscle lengthening, neurectomy, or a combination, have been used with mixed results. Soleus neurectomy was performed as the primary treatment for ankle clonus in 38 legs of 21 children with a variety of cerebral palsies. Concurrent heel cord or muscle lengthening was performed if needed. Patients were followed for an average of 9 years (range, 2 to 14 years). Clonus recurred in 4 treated ankles. In 2 cases, this was due to a nerve anomaly. Postneurectomy Achilles tendon lengthening was required in 8 of the treated ankles. Neurectomy was beneficial for 19 of 21 children. Functional improvements included better control of stopping, better balance, and less toe walking. The greatest improvement was seen in those patients who did not also have heel cord contractures.

Effect of timing of stabilization on length of stay and medical complications following spinal cord injury

This retrospective study examines length of acute hospital stay (LOS) and the development of medical complications in 64 patients with cervical, thoracolumbar or cauda equina injuries divided into two groups according to whether they underwent spinal stabilization < 24 hours after injury or > 24 hours after injury. The mean length of stay for the early stabilization group was 37.5 days (SD +/- 34.2) and for the late stabilization group 54.7 days (SD +/- 40.1). This difference was statistically significant by Mann Whitney U test (Z = 2.53, P = 0.01). There was no statistically significant difference between the early and the late groups with respect to the occurrence of common medical complications. There was a statistically significant difference in age in the early group (mean of 32.4 years) versus the late group (mean of 41.9 years) (t = 2.36, P = 0.02); however we do not feel that this age difference is clinically significant. There was not a statistically significant difference between the early group (17.9, SD = +/-7.2) and the late group (21.3, SD = +/- 8.3) (t = 1.71, p = 0.10) in mean injury Severity Scores (ISS). Also the correlation between length of stay and ISS scores was not significant (r = 0.18, P = 0.2). Timing of spinal stabilization appears to be an important factor in the management of spinal cord injury survivors. Our limited retrospective study suggests that when spinal stabilization is indicated, performance < 24 hours after injury is associated with a significantly shorter length of stay in the hospital. We suspect this is due to earlier mobilization of the patient. Medical complication rates were not significantly affected.

Intrinsic balancing in reconstruction of the tetraplegic hand

This article reviews 183 hand reconstructions in 135 consecutive tetraplegic patients. Comparisons were made between 103 extrinsic reconstructions with intrinsic balancing procedures and 80 extrinsic reconstructions without intrinsic balancing procedures. Extrinsic reconstructions (tendon transfers and tenodesis in the forearm muscles) were augmented by intrinsic reconstructive procedures (tendon transfers or tenodesis to improve the intrinsic balance of the fingers) in patients exhibiting digital imbalance. Intrinsic procedures included primarily the flexor digitorum superficialis (FDS) lasso procedure or the intrinsic tenodesis procedure. The patients were stratified by level of spinal cord injury and by type of extrinsic and intrinsic reconstruction. Hands reconstructed with intrinsic balancing versus without intrinsic balancing, as well as intrinsic balancing using a FDS lasso procedure versus an intrinsic tenodesis procedure, were compared with patients with the same level of spinal cord function. Patients who underwent reconstructions with intrinsic balancing had more grip strength, by an average of 13-26 N, than those who did not undergo intrinsic balancing. When different intrinsic procedures were compared, there was improvement in grip strength and function in activities of daily living for all hands, but there was no significant difference between FDS lasso or intrinsic tenodesis procedures. The indications for intrinsic balancing during extrinsic reconstruction are developed into treatment algorithms based on the senior author's surgical experience. The authors recommended that digital intrinsic procedures be included in hand reconstruction for tetraplegic patients exhibiting intrinsic imbalance to help improve digital function and provide increased grip strength.

Outcome of abdominal aortic aneurysm repair in patients with previous spinal cord injury in the Department of Veterans' Affairs hospitals

A retrospective review was carried out to determine the morbidity and mortality of abdominal aortic aneurysm repair in patients with previous spinal cord injury. A population-based study utilizing computer records on all patients in Department of Veterans' Affairs medical centers from 1987-1991 identified 31 patients with spinal cord injury who underwent subsequent infrarenal abdominal aortic aneurysm repair. Additional information was obtained from individual medical records. Some twenty patients (65%) were paraplegics and 11 (35%) were quadriplegics. Aneurysms were most commonly discovered incidentally during work-up of other conditions. All patients had no symptoms referable to their abdominal aortic aneurysm. In total, 29 patients (94%) underwent elective operations. The complication rate (57%) involved mostly pulmonary, cutaneous or urinary tract morbidity. The 30-day mortality rate was 3% for elective abdominal aortic aneurysm repair. Two patients were operated upon as emergencies for rupture, with one operative death. Long-term follow-up revealed a median survival duration of 5.4 years after aneurysm repair. In conclusion, abdominal aortic aneurysm repair in patients with previous spinal cord injury has a low mortality rate. Postoperative complications are often related to spinal cord injury and are potentially preventable; thus, such injury should not preclude surgical intervention for abdominal aortic aneurysm.

Unusual foreign body causing quadriparesis: case report

OBJECTIVE AND IMPORTANCE

An unusual foreign body traversing the spinal canal at the foramen magnum level is described. Interesting radiological findings and a review of nonmissile penetrating injuries are presented. This case demonstrates the importance of a thorough physical examination and the use of neurodiagnostic imaging in an inebriated, uncooperative patient with neurological dysfunction.

CLINICAL PRESENTATION

The patient presented with quadriparesis confounded by cocaine intoxication. A physical examination revealed only a small punctate lesion in the posterior occipital region.

INTERVENTION

After detection of the foreign body, the patient underwent immediate surgical exploration and removal of the object. The dura was repaired primarily, and the patient was maintained on intravenous antibiotics for 7 days.

CONCLUSION

With physical therapy, the patient was walking with assistance at 2 weeks postsurgery. Upper extremity strength, especially intrinsic hand movement, was most severely affected. At 10 months' follow-up, the patient's only deficits were mild intrinsic hand weakness and incoordination with fine finger movements. Immediate surgical exploration is indicated for patients with retained fragments and progressive neurological dysfunction.

Psoas and adductor release in children with cerebral palsy

In a retrospective study of 12 cerebral palsy patients with 17 hips treated for subluxation, clinical and radiographic results of psoas and adductor releases were reviewed. With an average follow-up of 4.05 years, the functional ability was improved in 3 spastic quadriplegics and 3 diplegics and maintained in 6 other patients. The CE-angle and femoral head coverage did not change significantly. The AC-index improved significantly (p = 0.01).

Pemberton pelvic osteotomy and varus rotational osteotomy in the treatment of acetabular dysplasia in patients who have static encephalopathy

Forty-four patients (fifty-two hips) who had static encephalopathy and acetabular dysplasia were managed with a Pemberton osteotomy as part of a comprehensive operative approach. Thirty-three patients had quadriplegia and were unable to walk; the remaining eleven patients had diplegia and could walk. The age at the time of the operation ranged from four years and five months to sixteen years and five months, as an open triradiate cartilage is a prerequisite for the Pemberton procedure. Concomitant operative procedures included a varus rotational osteotomy in fifty of the involved hips, a soft-tissue release in thirty-seven hips, and an open reduction in thirteen hips. The mean center-edge angle preoperatively was -11 degrees (range, -80 to 17 degrees), which improved to a mean of 27 degrees (range, 5 to 62 degrees) at the time of the latest follow-up. The mean duration of follow-up was four years (range, two years to eight years and eight months). At the time of writing, none of the hips had redislocated but one hip had subluxated. Eight of the hips had been painful preoperatively, but none of these was painful at the time of the most recent follow-up. One patient who had not had pain in the hip preoperatively had pain at the time of the follow-up evaluation. There were no complications attributable to posterior uncovering of the hip. The age of the patient at the time of the operation had no discernible effect on the result.

Variation between centers in electrophysiologic techniques used in lumbosacral selective dorsal rhizotomy for spastic cerebral palsy

The extent of variation between centers in the electrophysiologic techniques used in lumbosacral selective dorsal rhizotomy (SDR) for spastic cerebral palsy was studied using a questionnaire survey. Nineteen centers completed the questionnaire, and the responses were analyzed for those 16 centers in which the extent of dorsal root section was guided by intraoperative electrophysiologic responses. Consistent techniques included: use of unipolar stimulating electrodes (11 of 15 responses); stimulation < 4 cm from the root exit foramen (14 of 16); separation of dorsal roots into three to eight rootlets each (14 of 16); tetanic stimulation frequency of 50 Hz (11 of 16); tetanic stimulation at 100% of threshold (13 of 16); recording from multiple lower limb muscles simultaneously (16 of 16), and using contralateral spread of the response as a major criterion of electrophysiologic abnormality (13 of 16). There was more variation (< 11 of 16 concurrence) with respect to the use of a constant current versus constant voltage stimulator; the location of the cathode of the stimulating electrode relative to the anode; the definition of the threshold for a response; whether threshold was determined from stimulation of a dorsal root, or individual rootlets; the type of recording electrodes (needle versus surface), and the relative importance of electrophysiologic versus clinical findings in determining how much of each dorsal root to cut. In 10 centers, SDR would proceed without the benefit of electrophysiologic guidance if the equipment should fail intraoperatively (only if quadriplegic in 4), and this had happened in 6. The results indicate significant variation in many aspects of electrophysiologically guided SDR.

Percutaneous dilational tracheostomy after anterior cervical spine fixation

After spinal cord injury, quadriplegic patients generally require tracheostomy for ventilatory support and airway clearance. Early tracheostomy has several advantages over translaryngeal intubation, but in patients who undergo anterior surgical fixation of the spine, it is often delayed until after recovery of the surgical wound. We report the case of a quadriplegic patient who underwent a successful percutaneous dilational tracheostomy with the Ciaglia technique after surgical fixation of the spine. The percutaneous dilational technique minimizes the injury to the adjacent structures of the neck and the risk of stomal infection. Therefore, it should be considered the technique of choice when an early tracheostomy is indicated for quadriplegic patients who have undergone anterior surgical fixation of the cervical spine.

[Traumatic damage to the lower cervical spine--a diagnostic problem?]

Even today fractures and dislocations of the lower cervical spine are usually not recognized, or the interpretation of the results of the diagnostic procedures is not correct. These diagnostic failures are often caused by an incomplete representation of the cervical spine in the conventional radiograms, particularly in the lateral projection. Beyond that, the interpretation of the results of the neurological examination of patients with motoric or sensoric deficits after spine injury can be incorrect. Ignorance of the distribution of the segmental innervation of the upper extremities could lead to the wrong diagnosis of paraplegia in a tetraplegic patient. Two patients with injuries of the lower cervical spine are reported, in whom these problems led to an incorrect diagnosis. With regard to these cases we propose a standard diagnostic procedure for the clinical and radiological emergency examination of patients with neurological deficits after spine injury. The technical possibilities of obtaining correct radiographs of the lower cervical spine are described in detail.

Brachioradialis transfer for wrist extension in tetraplegic patients who have fifth-cervical-level neurological function

The brachioradialis tendon was transferred to the extensor carpi radialis longus and brevis tendons to restore active extension of the wrist in nine patients who had traumatic tetraplegia. The classification of neurological function was the fifth cervical level for all patients. The average time from the injury to the operation was six years (range, one to twenty years), and the average duration of follow-up was ten years (range, two to fifteen years). The evaluation of the patient included a determination of the preoperative and postoperative ranges of motion of the wrist, manual muscle-testing of the strength of the brachioradialis and the wrist extensors, a functional assessment of the ability to perform activities of daily living (eating, grooming, dressing, personal hygiene, and desktop activities [writing, typing, using a telephone, and so on]), and an assessment of functional independence. In addition, the result of the operation was evaluated subjectively by the patient. No patient had active extension of the wrist against gravity preoperatively. The strength of the wrist extensors improved postoperatively to a grade of good in six patients and to a grade of fair-plus in three. Function of the hand improved markedly in seven patients, and no patient had a loss of function. The patients had improvement in the ability to pick up objects, to feed and groom themselves, to tend to personal hygiene, to write and type, and to use a telephone.

Cervical kyphosis in patients who have Larsen syndrome

Four patients who had Larsen syndrome and cervical kyphosis were managed operatively and followed for an average of seventy months (range, forty to ninety-two months). The preoperative cervical kyphosis ranged from 35 to 65 degrees. The patients had had a posterior cervical arthrodesis alone when they were infants, at an average age fo fourteen months (range, ten to sixteen months). In three infants, the kyphosis either stabilized (one patient) or reversed into lordosis (two patients). Thus, the kyphosis corrected gradually by continued anterior growth in the presence of a solid posterior fusion. In the fourth infant, the kyphosis progressed to 110 degrees because of pseudarthrosis. This child had anterior decompression and arthrodesis for an acute neurological deficit. We believe that cervical kyphosis is sometimes present but not diagnosed in patients who have Larsen syndrome. Early diagnosis followed by operative stabilization should help such patients avoid neurological deficits. Posterior cervical arthrodesis alone, performed in infancy, provided stability and the opportunity for the gradual correction of the deformity by continued anterior growth in three of our four patients.

Effect of surgery on motor recovery following traumatic spinal cord injury

The influence of spine surgery on motor recovery between 1 month and 1 year was assessed prospectively in a group of 269 patients following traumatic spinal cord injury (SCI) using the classification system originally developed by the American Spinal Injury Association. The Allen classification was used to categorize cervical vertebral pathology and the Denis system was used for injuries to the thoracic and lumbar spine. Gunshot injuries were classified based upon the bullet trajectory and location relative to the spinal canal. Individuals undergoing surgery were divided into various subgroups depending on the type of surgery performed: anterior decompression with or without spine fusion and instrumentation, posterior decompression/laminectomy with or without spine fusion and instrumentation and spine fusion with instrumentation. Motor score recovery between 1 month and 1 year after injury was highly dependent (P < or = 0.001) on the level and completeness of injury averaging 0.7 +/- 2.7 for complete paraplegics, 7.8 +/- 4.8 for complete tetraplegics, 11.8 +/- 8.3, for incomplete paraplegics and 22.2 +/- 10.9 for incomplete tetraplegics. Motor recovery did not significantly differ between patients categorized in various surgical subgroups or between those having surgery and those treated non-operatively. Additionally, although the sample size was small, motor recovery among tetraplegic individuals did not depend on whether unilateral and bilateral facet dislocations were reduced and in patients with incomplete lesions, those with reductions actually had a poorer outcome than those who were left in a dislocated position.

Omental transposition in chronic spinal cord injury

The results of omental transposition in chronic spinal cord injury have been reported in 160 patients operated upon in the United States, Great Britain, China, Japan, India and Mexico, with detailed outcomes reported in few studies. Recovery of function to a greater degree than expected by natural history has been reported. In this series, 15 patients with chronic traumatic spinal cord injury (> 1.5 years from injury) underwent transposition of pedicled omentum to the area of the spinal cord injury. Of the first series of four patients who were operated upon in 1988, one died, one was lost to follow-up and two were followed with sequential neurological examinations and Magnetic Resonance Imaging (MRI) scans preoperatively, at 1 year post injury and 4 1/2 years post injury. Another 11 patients were operated in 1992 and underwent detailed neurological and neurophysiological examinations and had MRI scans preoperatively and every 4 months for at least 1 year after surgery. All patients completed a detailed self-report form. Of the total of 13 operated patients in both series followed for 1-4 1/2 years, six reported some enhanced function at 1 year and five of these felt the changes justified surgery primarily because of improved truncal control and decreased spasticity. MRI scans showed enlargement of the spinal cord as compared to preoperative scans in seven patients. Increased T2 signal intensity of the spinal cord was found by 1 year after surgery in eight of 13 operated patients. Neurophysiological examinations of 11 patients in the second series agreed with self-reports of increases or decreases in spasticity (r = 0.65, P < 0.03). Somatosensory evoked potentials and motor evoked potentials at 4 month intervals up to 1 year in these patients showed no change after surgery. Neurological testing, using the American Spinal Injury Association (ASIA) and International Medical Society of Paraplegia (IMSOP) international scoring standards, failed to show any significant changes when the 1-year post operative examination was compared to the first preoperative examination except for decreased sensory function after surgery which approached statistical significance. When the 11 patients in the second series were compared to eight non-operated matched patients, followed for a similar length of time, no significant differences were found. Complications encountered in the operated patients from both series included one postoperative death from a pulmonary embolus, one postoperative pneumonia, three chronic subcutaneous cerebrospinal fluid (CSF) fistulae requiring wound revision, and one patient who developed biceps and wrist extensor weakness bilaterally requiring graft removal. We conclude that the omental graft remains viable over time and this operation can induce anatomical changes in the spinal cord as judged by MRI. Some patients reported subjective improvement but this was not supported by objective testing. We, therefore, find no justification for further clinical trials of this procedure in patients who have complete or sensory incomplete lesions. Further testing in motor incomplete patients would seem appropriate only with compelling supportive data.

Split posterior tibial tendon transfer through the interosseus membrane in spastic equinovarus deformity

The split posterior tibial tendon transfer procedure was first reported by Green for correction of equinovarus hindfoot deformity in patients with cerebral palsy. A modification of the split posterior tibial tendon transfer combined with an Achilles tendon lengthening is described in 17 children (21 procedures) with a minimum follow-up of 3 years. This modified technique is indicated in young children with a continuously spastic posterior tibial tendon to correct a dynamic equinovarus. It restores active dorsiflexion when the anterior tibial and extensor muscles are weak. The anterior half of the split tibialis posterior is transferred through the interosseus membrane to the dorsum of the foot. Excellent or good results and two poor results were noted after a mean follow-up of 29 months. In the patients with an excellent or good result, marked improvement of their equinovarus foot deformity in stance and swing phase of gait was seen. In two patients, the procedure failed because of technical errors.

Candida mediastinitis and septic shock following occult esophageal perforation in a patient with posttraumatic quadriplegia

Unexplained septic shock was ultimately shown to be caused by Candida mediastinitis after perforation of the cervical esophagus by a dislodged cervical methylmethacrylate construct in a 25-year-old patient with traumatic quadriplegia. Communication between the prevertebral abscess and pleural space further led to the formation of a esophageal-pleural-cervical fistula. Despite antibiotics, surgical removal of the construct, and drainage of the esophagus and mediastinum, the patient died from refractory shock and respiratory failure.