Paraparesis or incomplete paraplegia? How should we call it?

INTRODUCTION

The neurological examination terminologies and definitions of the status of spinal cord injured (SCI) patients are of great importance to establish scales and provide standard nomenclatures. There is a disagreement between the classical neurological terminology and the definitions of complete and incomplete paraplegia that have been proposed in traumatic spinal cord injured patients.

OBJECTIVE

To discuss the adequacy and the impact of the terms incomplete paraplegia and paraparesis in current literature.

MATERIALS AND METHODS

A review of the origin of the terms, definitions and nomenclatures applied by the most widespread assessment scales in traumatic SCI published in peer review papers was performed, searching the scales cited on the references of the latest American Spinal Injury Association classification (2002; available in http://www.asia-spinalinjury.org/ ) up to the first classification, described by Frankel et al. [14].

RESULTS

The term "incomplete paraplegia" has been used to define clinical situations classically described as "paraparesis".

CONCLUSION

The terms "complete" and "incomplete" are adequately used to characterize the completeness of spinal cord lesion but inadequately used when associated to the term "plegia" as a qualifier. Therefore, patients with any preservation of motor strength below the injury level should be described as paraparetic and not as incomplete paraplegic.

Five additional mobility and locomotor items to improve responsiveness of the FIM in wheelchair-dependent individuals with spinal cord injury

STUDY DESIGN

Repeated-measures design.

OBJECTIVES

To assess the validity and responsiveness of five additional mobility and locomotor (5-AML) items when used in conjunction with the Functional Independence Measure (FIM) for assessing the mobility and locomotor function of individuals with spinal cord injury (SCI).

SETTING

Specialised acute spinal and rehabilitation units in Sydney, Australia.

METHODS

A previously published scale comprising five key mobility and locomotor skills was further refined. The five items included a bed mobility and vertical (floor-to-chair) transfer item and three wheelchair propulsion items (pushing 200 m over flat ground, pushing up a ramp and negotiating a kerb). A total of 43 eligible patients with SCI (ASIA A-C impairment) admitted consecutively to two acute SCI units in Sydney between 1999 and 2002 were recruited, with four being lost to follow-up. Locomotor and mobility outcomes were measured at regular intervals for up to 6 months with the FIM and the 5-AML. Construct validity of the 5-AML was assessed by testing ability of items to discriminate between different impairment groups (tetraplegia and paraplegia). Item responsiveness was assessed by analysing ability to detect changes in mobility and locomotor function over time. Factor analysis techniques were used to test the hypothesis that the 5-AML, when used in conjunction with the FIM, provides a more sensitive measure of mobility and locomotor function than the FIM alone.

RESULTS

The 5-AML items were shown to be valid and responsive, measuring aspects of 'real world' mobility and locomotor function not reflected by the FIM. The bed mobility item was highly responsive to change over time for the tetraplegic group, but quickly reached a ceiling in the paraplegic group. The vertical (floor-to-chair) transfer item showed greater responsiveness over time and less ceiling effect for the paraplegic group than any of the FIM locomotor or mobility items. The three wheelchair propulsion items better discriminated between people with tetraplegia and paraplegia, and were more sensitive to changes in locomotor ability over the 6-month period than FIM locomotor items. Results of a preliminary factor analysis indicated that the 5-AML items measure different aspects of mobility and locomotor function than the FIM.

CONCLUSION

The 5-AML items, when used in conjunction with the FIM, provides better delineation of function between people with tetraplegia and paraplegia and provides a more responsive measure of change in function over time than the FIM alone.

Semiquantitative assessment of hindlimb movement recovery without intervention in adult paraplegic mice

STUDY DESIGN

Experimental laboratory investigation of hindlimb movement recovery in chronic paraplegic mice.

OBJECTIVES

Development of an assessment method to discriminatively quantify motor and locomotor-like movements of paraplegic mice.

SETTING

Laval University Medical Center, Quebec, Canada.

METHODS

Signs of 'functional recovery' were examined in open-field condition during 1 month in adult mice with a complete spinal cord transection at the low-thoracic level.

RESULTS

None of the mice exhibited hindlimb movements after spinalization. At 7 days, 33% of them displayed weak nonbilaterally alternating movements (NBA). At 14 days, increased NBA were observed and the first bilaterally alternating movements (BA) in 10% of the mice. A progressive increase of movement frequency and amplitude was found after 2-3 weeks. By the end of the month, 86% displayed mixed NBA and BA. However, none of them recovered the ability to stand or bear their own weight with the hindlimbs.

CONCLUSION

This study reports signs of partial hindlimb movement recovery in chronic paraplegic mice and provides evidence of plasticity in sublesional circuits of neurons occurring in the absence of inputs from the brain, locomotor training or pharmacological treatment. This assessment method can be used to characterize hindlimb movements in complete spinal cord transected mice tested in open-field condition.

Survival and death-promoting events after transient spinal cord ischemia in rabbits: induction of Akt and caspase3 in motor neurons

OBJECTIVE

The mechanism of spinal cord injury has been thought to be related to the vulnerability of spinal motor neuron cells to ischemia. However, the mechanisms of such vulnerability are not fully understood. We previously reported that spinal motor neurons might be lost as a result of programmed cell death and investigated a possible mechanism of neuronal death by means of immunohistochemical analysis for CPP32 (caspase3) and serine-threonine kinase (Akt).

METHODS

We used a rabbit spinal cord ischemia model with use of a balloon catheter. The spinal cord was removed at 8 hours or 1, 2, or 7 days after 15 minutes of transient ischemia, and histologic changes were studied with hematoxylin and eosin staining. Western blot analysis for Akt and caspase3, temporal profiles of Akt and caspase3 immunoreactivity, and double-label fluorescence immunocytochemical studies were performed.

RESULTS

The majority of motor neurons were preserved until 2 days but were selectively lost at 7 days of reperfusion. Western blot analysis revealed no immunoreactivity for Akt and caspase3 in the sham-operated spinal cords. However, such immunoreactivity became apparent at 8 hours after transient ischemia, decreased at 1 day, and returned to the baseline level at 2 days. A double-label fluorescence immunocytochemical study revealed that both Akt and caspase3 were positive at 8 hours of reperfusion in the same motor neurons, which eventually die.

CONCLUSION

These results suggests that transient spinal cord ischemia activates both cell death and survival pathways after ischemia. The activation of Akt protein at the early stage of reperfusion might be one of the factors responsible for the delay in neuronal death after spinal cord ischemia.

Comparison of the revised 2000 American Spinal Injury Association classification standards with the 1996 guidelines

OBJECTIVE

This study was undertaken to determine the level of agreement between the most recent change in the American Spinal Injury Association International Standards (2000) and the previous (1996) classification.

DESIGN

In a spinal cord injury rehabilitation hospital, data were collected on 94 subjects who had an initial neurologic examination according to the International Standards within 1 wk of injury and again at 1 yr. Comparisons were examined of the level of agreement between the 1996 and 2000 revisions in classification of the motor incomplete levels and ability to prognosticate outcome at 1 yr on the basis of the initial examination.

RESULTS

Near perfect agreement between the 1996 and 2000 revised guidelines in the classification of motor incomplete injuries was found, with no statistically significant difference for prognosticating neurologic recovery at 1 yr on the basis of the initial examination.

CONCLUSION

The 2000 revisions do not offer a significant difference in American Spinal Injury Association impairment classification or in predicting neurologic recovery at 1 yr.

[Hereditary ataxias and paraplegias: a clinicogenetic review]

Hereditary ataxias encompass a series of syndromes basically characterised by progressive cerebellar ataxia of slow clinical course (occasionally, periodic ataxia or spastic paraparesis) and primary spinocerebellar degeneration. The prevalence ratio of these syndromes in Spain is 20 cases per 100,000 inhabitants. Initially the ataxias were classified on the basis of clinicopathological criteria. Starting from the seminal papers by Harding published 20 years ago, a clinicogenetic classification was introduced that has given way to the present molecular classification. There have been localised about forty loci. In dominant ataxias the most frequent molecular defect is a dynamic CAG expansion responsible for abnormal polyglutamine tract transcription. The identification of such molecular defect has made it possible detection of gene carriers in clinical practice, this involving both presymptomatic and prenatal diagnosis; moreover, such molecular discoveries have contributed to develop a new pathogenetic era. A homozygous and intronic GAA expansion is the molecular basis of Friedreich's ataxia. This finding has also made it possible a molecular diagnosis in clinical practice. Molecular studies have demonstrated that hereditary spastic paraplegia is another heterogeneous genetic disorder.

[Expert assessment within the scope of the severe disability regulation and social compensation law]

In the wake of the First and Second World Wars, an extensive system of social compensation and assistance for the war disabled evolved in Germany and later on also for civilians. Depending on the origin of the disability, the benefits are composed either of revenues and pensions and/or tax reductions and nonfinancial assistance. In any case, the extent of these benefits depends on the grade of disability (GdB/MdE) determined by medical examination and on expert opinions in accordance with detailed legal regulations.

Spinal cord compression injury in the mouse: presentation of a model including assessment of motor dysfunction

The purpose of this study was to develop a spinal cord injury model in the mouse. Various degrees of extradural compression were used to induce mild, moderate or severe compression injuries. Furthermore, a locomotor rating scale was developed by which the functional outcome of the spinal cord injury could be assessed. The introduction of such a model will be useful for further studies on the pathogenesis and treatment strategies of spinal cord injury. To assess hindlimb motor function, a 10-point scale was used. Initially, the animals were allowed to move freely in an open field and were rated 0-5, 0 being no movement and 5 being almost normal. Animals scoring a 5 were then assessed using steel bars with decreasing widths from 2 cm to 5 mm. For each bar successfully crossed over, they gained additional points. Before injury the hindlimb motor function score (MFS) in all the animals was 10. In mice with mild compression, MFS was decreased slightly on day 1 and recovered to 9 +/- 0.6 on day 14. For mice with moderate compression, the MFS decreased to 4.6 +/- 0.4 on day 1 after injury and gradually improved to 8.1 +/- 0.6 on day 14. Severe injury resulted in paraplegia of the hindlimbs day 1 after injury with a score of 0.6 +/- 0.2. By day 14 after injury, these animals gradually recovered to 3.9 +/- 0.1, could bear the weight on the hindlimbs and walk with a severe deficit. There was a 3%, 9% and 19% decrease in the total cross-sectional area of the spinal cord 14 days after mild, moderate and severe injury, respectively. Microtubule-associated protein immunostaining revealed that the gray matter decreased to 61 +/- 7% in moderately injured animals, while severe compression resulted in a complete loss of gray matter. White matter decreased to 86 +/- 6% in moderately injured animals and 29 +/- 11% in severely injured animals. This study shows that the mouse can be used to achieve reproducible spinal cord compression injuries of various degrees of severity. The force of the impact correlates well with the neurological and light microscopic outcome. The motor function test presented in this paper and the computerized quantification of tissue damage can be used to evaluate the efficacy of different treatment strategies.

Neurologic evaluation in thoracolumbar vertebral fractures

A standardized and universal neurologic evaluation is of essential importance in defining the prognosis, treatment, and long-term results in patients with spinal cord injury. The American Spinal Injury Association was the first to publish a neurologic classification in 1992. This classification, which was subsequently submitted to numerous revisions, was also adopted by the International Medical Society of Paraplegia and by the national scientific associations of many other countries. In Italy, too, the ASIA/IMSOP form has been accepted as a standard for neurologic evaluation, but with the exception of specialized centers, it is still not well-known. The authors critically analyze the international terminology and its translation, they define the technical aspects of the neurologic examination in relation to priorities, and to the specific goals. Finally, they report several thoughts deriving from clinical practice in the Spinal Unit of Florence.

Evaluating neurological group homogeneity in assessing the mortality risk for people with spinal cord injuries

A study of 3178 individuals injured in Britain between 1943 and 1990 and surviving the first year post-injury was conducted to evaluate the homogeneity of mortality risk ratios within groups based on varying degrees of neurological injury level and completeness of the injury. The study shows that it is less than optimal to combine individuals into neurological groupings of C1-C4 ABC, C5-C8 ABC and T1-S5 ABC since the risk ratios are not homogeneous within these groups. Similarly, combining individuals into neurological groupings of tetraplegia complete, tetraplegia incomplete, paraplegia complete and paraplegia incomplete may not be appropriate for the same reasons. The consequence of performing a survival analysis using either of the traditional sets of groups is to dilute the risk ratios for a subset of individuals within a particular group, thereby providing less discrimination between neurological groups. Cox proportional hazards regression was employed to determine a set of neurological groupings with homogeneous risk ratios within a group while providing better differentiation between groups.

Descriptive epidemiology of physical activity in university graduates with locomotor disabilities

The descriptive epidemiology of physical activity in a sample of 577 University of Illinois graduates (1952-1991) with locomotor disabilities was assessed by mail survey. The survey requested basic demographic information, age, gender, marital status, household income. Respondents were asked to rate their current activity levels and activity levels during their college years compared to others their age on a 5 point scale: (1) much less active to (5) much more active. Completed surveys were received from 229 alumni (40%); 59 semi-ambulatory, 115 paraplegic, 55 quadriplegic. Results indicated current physical activity was associated with mobility limitation. With more severe mobility limitations the percentage reporting being less/much less active increased (42.4% semi-ambulatory, 56.5% paraplegic, 66.7% quadriplegic, P < 0.001) and the percentage reporting being more active decreased (20.3% semi-ambulatory, 16.5% paraplegic, 13.0% quadriplegic, P < 0.001). Current physical activity was significantly lower (P < 0.05) with increasing age, lower self-rated health, higher disability severity and among those who were sedentary during college. Physical activity did not differ by gender, marital status or household income. Multiple regression analysis indicated that health status was a significant predictor of current physical activity in all mobility categories (P < 0.001) after controlling for age, gender, income, disability severity and college activity. Among both paraplegics and quadriplegics physical activity during college was significantly associated (P < 0.001 paraplegic; P < 0.01 quadriplegic) with current physical activity. These results document a low level of physical activity in a well-educated sample of individuals with locomotor disabilities and suggest that exposure to physical activity in an educational setting may be an effective technique for increasing physical activity in individuals with locomotor disabilities.

Locomotor activity in spinal man

We studied whether spinal locomotor centres of patients with paraplegia can be activated by external stimuli. In patients with complete paraplegia, coordinated stepping movements were induced by weight support and standing on a moving treadmill. The pattern of leg muscle electromyographic (EMG) activity was similar to that seen in healthy subjects although EMG amplitude was smaller. With daily training the amplitude of gastrocnemius EMG activity increased during weight-bearing phase of stepping and the degree of inappropriate tibialis anterior activity decreased. Patients with incomplete paraplegia profited from the training programme in that their walking on a stationary surface improved even when unsupported. Our results may suggest new ways to improve mobility of patients with paraplegia.

Prognostic value of cortical magnetic stimulation in spinal cord injury

Cortical magnetic stimulation was performed in a consecutive series of 10 patients presenting within 15 days of traumatic spinal cord injury. In those patients with complete paraplegia or quadriplegia, motor evoked potentials at presentation were absent below the level of the lesion. Six months after the injury, potentials had returned in the biceps brachii and abductor pollicis brevis muscles in some quadriplegic cases, but remained absent from the tibialis anterior in all of this group. None of those with a complete lesion made a significant functional recovery. Of the three patients with incomplete quadriplegia, two showed a significant recovery after 6 months. Motor evoked potentials were recordable below the level of the lesion at presentation in these cases, although the latencies were prolonged. In the remaining patient who failed to improve, potentials were unrecordable throughout the study. This small pilot study suggests that cortical magnetic stimulation may be useful in refining the prognosis in patients with an incomplete spinal cord injury.

The phenotype of "pure" autosomal dominant spastic paraplegia

We studied 23 families with "pure" autosomal dominant spastic paraplegia. Examination of 142 at-risk individuals allowed identification of 70 patients, including 12 who were clinically affected but unaware of symptoms. The frequency of lower limb muscle weakness, decreased vibration sense, hyperreflexia in the upper limbs, and sphincter disturbances increased with the disease duration. The distribution of age at onset was unimodal, with a mean onset of 29 years (range, 1 to 68). The clinical manifestations of "early-onset" (< 29 years) and "late-onset" (> 29 years) patients were not significantly different. Age at onset varied as much within families as among families; anticipation and imprinting did not occur. No clinical criteria allowed differentiation among the families studied. Only linkage studies can provide accurate classification of this disease.

Recovery following complete paraplegia

Motor and sensory recovery were quantified by serial examinations prospectively performed on 148 persons with paraplegia. Of the 142 patients who remained complete injuries at follow-up, none with an initial neurologic level of injury (NLI) above T9 regained any lower extremity motor function at follow-up. Thirty-eight percent of patients with an initial NLI at or below T9 had some return of lower extremity motor function, primarily in the hip flexors and knee initial NLI at or below T9 had some return of lower extremity motor function, primarily in the hip flexors and knee extensors. Twenty percent of the patients with an initial NLI at or below T12 regained sufficient hip flexor and knee extensor strength to reciprocally ambulate using conventional orthoses and crutches. Unlike motor function, recovery of light touch and sharp-dull discrimination was independent of the initial NLI. Six (4%) of the 148 patients demonstrated "late" conversion (more than 4 months after injury) from complete to incomplete spinal cord injury (SCI) status. Two of the 6 patients with an initial NLI at T12 and subsequent annual NLI at L1 and L2 reciprocally ambulated, and three of the 6 patients regained voluntary bladder/bowel control.

Prevalence of hereditary ataxias and spastic paraplegias in Molise, a region of Italy

An epidemiological survey of hereditary ataxias and paraplegias was conducted in Molise, a region of Italy (335, 211 inhabitants on 1 January 1989). Total prevalence was 7.5 x 10(-5) inhabitants (95% confidence limits 4.8-11.1). There were 7 patients with Friedreich's disease, 5 with early onset cerebellar ataxia with retained tendon reflexes, 4 with ataxia-telangiectasia, 9 with hereditary spastic paraplegias (2 autosomal dominant and 7 autosomal recessive cases). There was no patient with autosomal dominant cerebellar ataxia.

Rehabilitation in spinal cord injury

Caring for the new quadriplegic is an immense undertaking involving multiple health care professionals who must function as a team. The physician in charge must understand rehabilitation principles and be able to communicate with all members of the team caring for the patient. Rehabilitation principles, if considered early, can greatly decrease the length of stay of the patient and allow him to maximize his potential for recovery. A basic knowledge of physicial and occupational therapy in paraplegia and quadriplegia in the acute stage as well as functional expectations in the long term have been presented.

The Brown-Séquard syndrome. True or false?

In recent years the name of Brown-Séquard has been assigned to syndromes caused by spinal cord damage differing widely in extension. On the basis of a review of more than 600 published cases, we propose that Brown-Séquard-plus syndromes be distinguished from the pure Brown-Séquard syndrome. This distinction is shown to be justified on clinical, anatomic, and historical grounds. Two case histories are reported herein to illustrate the essential differences between these syndromes.

The (non)sense of the present-day classification system of sports for the disabled, regarding paralysed and amputee athletes

In order to guarantee fair competition amongst athletes, suffering from spinal paralysis with different neurological levels, a classification-system on a medical basis was introduced at the beginning of the annual Stoke Mandeville Paraplegic Games in the 1950s. The system was set up in such a way, that athletes with comparable degrees of disability were put together in the same class, in principle not depending on the actual sporting events. Subsequently a similar system was introduced for amputee athletes, and this system is still being used. In view of the large number of competitors, the Olympic Games for the Disabled in 1980 in the Netherlands were the basis for a statistical research analysis on the acquired data, studying the results of competition in connection with the medical classification data. The following types of sports were looked at: athletics, swimming, archery and weight-lifting. The objective was, to justify the (theoretical) medical classification-system by means of (practical) actual figures (results of competition). As a basic method the 'zero-hypothesis' has been used. Specifically the 'Student's t distribution' has been used in view of the small samples. The interim conclusion is, that the present-day classification-system is good with regards to those with poliomyelitis, and to tetraplegic and paraplegic sports people both with complete or incomplete lesions competing together, but the number of classes requires to be diminished in several sports events. The same research analysis of the results of the Olympic Games for the Disabled of 1984 will be made in order to compare the two studies and to make final conclusions.

Paraplegia due to intervertebral disc lesions: a review of 57 operated cases

In a review of 57 cases of paraplegia due to surgically confirmed disc protrusion (representing 0.9 per cent of all admissions to the National Spinal Injuries Centre), seven were in the cervical, 31 in the dorsal and 19 in the lumbar regions. Patients with dorsal disc protrusions treated by laminectomy had the worst neurological outcome. A recent decline in the incidence of neurological dysfunction following disc excision is noted and its probable causes discussed.