French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury

OBJECTIVES

To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury.

DESIGN

A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology.

RESULTS

The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

CONCLUSIONS

There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

Magnetoencephalography in stroke: a 1-year follow-up study

Recovery after stroke is closely linked to cerebral plasticity. Magnetoencephalography (MEG) is a non-invasive technique, which allows location of cerebral cells activities. In the present work, a cohort of patients has been studied with MEG. Twelve patients with a recent ischemic or hemorragic stroke were included as soon as possible after onset of stroke. Neurologic assessment, including standard neurologic examination, functional independence measure (FIM) and Orgogozo's scale was performed for 1 year in addition to a study of the somatosensory evoked field (SEF) using a 37-channel Biomagnetometer system. No response could be recorded in five patients at the first SEF exploration. In three cases, no response was ever recorded during the study. All these patients had a bad recovery. The location of the SEF sources was always in the normal non-infarcted cortex of the postcentral gyrus. Sensory recovery seemed to be linked to the reorganization of the persistent functional cortex, which was a limiting factor for recovery. These observations confirm the experimental results obtained in animal models. After stroke it can be assumed that in the case of incomplete lesion, an intensive sensory peripheral stimulation could maximize the use of residual sensory function and then contribute to improve the sensory deficit. In case of total sensory loss other techniques have to be used, such as visual monitoring of hand activity in order to improve hand function.

[Fractures of ossified Achilles tendon in cerebral palsy. Apropos of a case]

PURPOSE

To describe a case of ossification of the Achilles tendon fracture in cerebral palsy.

METHODS

From the detailed case report, review of the literature was performed.

RESULTS

A 49 years old patient who have presented a bilaterally pain syndrome of the ankles. Clinical investigations showed a bilaterally ossification of the Achilles tendon, with a fracture on the left side. The evolution was marked by the occurrence of an other fracture on the right side. Both needed surgery. Just a few cases of such ossification have been reported in literature. This ossification are more often asymptomatic. Complications such fracture are rare, no more than 20 cases have been reported, and only one case in cerebral palsy. The etiologic factors are multiple, including partial or complete rupture or surgery, with a probably great importance of tissular hypoxemia. Men older than 40 years old are more often concerned.

DISCUSSION

In the majority of case ossification of the Achilles tendon are painless, and fortuitously discovered. In case of ankle pain syndrome, a research of fracture must be done. Standard X-rays and RMI are the more instructive exams for diagnosis. The treatment of these fractures is more often the surgery. Orthopaedic treatments remain rarely used because of the duration of treatment and of a major risk of recurrence.

CONCLUSION

In adult cerebral palsy a standard X-rays of the two Achilles tendon must be realised in case of the occurrence of an ankle pain syndrome especially if an antecedent of Achilles tendon lengthening is known.