Ethics, health care and spinal cord injury: research, practice and finance

Dating back to ancient times, mankind has been absorbed with 'doing the right thing', that is, behaving in ways approved by the society and the culture during the era in which they lived. This has been and still is especially true for the medical and related health-care professions. Laws and professional codes have evolved over the years that provide guidelines as to how physicians should treat patients, beginning with the one authored by Hippocrates. Only more recently, however, have laws and codes been created to cover health-care research and the advances in health-care practice that have been brought to light by that research. Although these discoveries have clearly impacted the quality of life and duration of life for people with spinal cord injury and other maladies, they have also raised questions that go beyond the science. Questions such as when, why, how and for how long should such treatments be applied often relate more to what a society and its culture will condone and the answers can differ and have differed among societies depending on the prevailing ethics and morals. Modern codes and laws have been created so that the trust people have traditionally placed in their healers will not be violated or misused as happened during wars past, especially in Nazi Germany. This paper will trace the evolution of the rules that medical researchers, practitioners and payers for treatment must now follow and explain why guiding all their efforts that honesty must prevail.

Pilot trial of bacterial interference for preventing urinary tract infection

OBJECTIVES

To examine the safety and efficacy of bacterial interference in preventing symptomatic urinary tract infection (UTI).

METHODS

A prospective, nonrandomized, pilot clinical trial was conducted in patients with spinal cord injury who had neurogenic bladder and had frequent episodes of symptomatic UTI. The bladder of patients was inoculated with a nonpathogenic prototype of Escherichia coli 83972. The rate of symptomatic UTI in successfully colonized patients while colonized with E. coli 83972 was compared with (a) their own baseline prestudy rate and (b) the rate of symptomatic UTI in patients who were not successfully colonized.

RESULTS

Of 44 inoculated patients, 30 (68%) became colonized with E. coli 83972 for 1 month or longer. Only two episodes of symptomatic UTI occurred in the group of 30 patients while colonized with E. coli 83972 (a total of 34 patient-years), and none was attributed to E. coli 83972. The group of 30 patients experienced a 63-fold reduction in the rate of symptomatic UTI while colonized with E. coli 83972 versus their baseline prestudy period (mean 0.06 versus 3.77 episodes of symptomatic UTI/patient-year, P <0.001). The rate of symptomatic UTI was also 33-fold lower in this group of 30 patients while colonized with E. coli 83972 than in the well-matched group of 14 patients who were not successfully colonized (mean 0.06 versus 1.80 episodes of symptomatic UTI/patient-year, P <0.001).

CONCLUSIONS

The results of this pilot study indicate that bacterial interference using E. coli 83972 may be safe and effective in preventing UTI.

Intrathecal administration of 4-aminopyridine in chronic spinal injured patients

STUDY DESIGN

Intrathecal administration of 4-aminopyridine (4-AP) in chronic spinal cord injured (SCI) patients.

OBJECTIVE

To determine the safety and effects of intrathecal administration of 4-AP in a small population of chronic SCI patients.

SETTING

The post anesthesia care unit of a tertiary care hospital.

METHODS

Following animal mode studies to establish dosing safety, six subjects with chronic SCI were examined. In each subject, an intrathecal catheter was placed with the tip as close to the lesion level as possible. 4-AP was infused at 5 microg/h for a period of 4-5 h. Vital signs were recorded and sensory-motor physical examinations and pain questionnaires were administered for 24 h. In two patients, samples of cerebrospinal fluid for analysis were drawn from a second intrathecal catheter.

RESULTS

No adverse systemic side effects were noted. One patient showed transient improvement in sensory function; two showed transient increases in spasticity; three showed transient increases in cutaneomuscular reflexes and two showed an apparent small increase in volitional motor control. The concentration of 4-aminopyridine in the cerebrospinal fluid reached a peak of 163 ng/ml at 4 h in one subject and 122 ng/ml at 5 h in the other subject examined.

CONCLUSION

Intrathecal administration of 4-aminopyridine at a rate of 5 microg/h does not appear to cause adverse effects and may modify spinal cord function. This route of administration allows local cerebrospinal fluid concentrations equivalent to those produced by maximum tolerable systemic doses, which require 1000 times more drug substance to be delivered to the subject as a whole. Intrathecal administration offers the potential to focus therapeutic effects to the lesion site while minimizing systemic side effects.

Intravenous infusion of 4-AP in chronic spinal cord injured subjects

STUDY DESIGN

A prospective double blind cross over trial of intravenous 4-Aminopyridine (4-AP).

OBJECTIVE

To determine the efficacy of this drug in the treatment of spinal cord injured (SCI) patients for neurologic impairment, pain and spasticity.

SETTING

The post anesthesia care unit (PACU) of a tertiary care acute hospital.

METHODS

Twelve paraplegic patients were enrolled in a double blind cross over intravenous trial of 4-Aminopyridine (4-AP). Thirty milligrams of 4-AP or placebo were administered over a 2 h period. Patients were serially examined during and after the infusion clinically for pain, sensorimotor function, hypertonicity and motor control using electromyography (EMG). Samples of blood and cerebrospinal fluid (CSF) were also analyzed at similar intervals.

RESULTS

Despite penetration of 4-AP into the CSF, no significant differences were noted in the clinical and EMG parameters at the times measured. Individual changes in sensory function were reported by some patients in both the placebo and 4-AP trials, however mean values were not robust. Frequently, patients complained of unpleasant symptoms during the 4-AP infusion.

CONCLUSION

The intravenous route may not be the best way to administer this drug as no short term benefits were observed.

Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems

OBJECTIVE

To present data on neurologic recovery gathered by the Model Spinal Cord Injury (SCI) Systems over a 10-year period.

DESIGN

Case series.

SETTING

Twenty-one Model SCI Systems.

PATIENTS

A total of 3,585 individuals with traumatic SCI admitted between January 1, 1988 and December 31, 1997.

MAIN OUTCOME MEASURES

Neurologic impairment category; Frankel grade; American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade; motor score.

RESULTS

SCI caused by violence is more likely than SCI from nonviolent etiologies to result in a complete injury. Changes in severity of injury were similar using the older Frankel scale and the newer ASIA Impairment Scale. Individuals who were motor-complete with extended zones of sensory preservation but without sacral sparing were less likely to convert to motor-incomplete status than those with sacral sparing (13.3% vs 53.6%; p < .001). Motor score improvements at 1 year were related to severity of injury, with greater increases for better AIS grades except grade D, because of ceiling effects. Individuals with AIS grade B injuries have a mixed prognosis.

CONCLUSION

Neurologic recovery after SCI is influenced by etiology and severity of injury. Multicenter studies on prognostic features such as preserved pin sensation in grade B injuries may identify subgroups with similar recovery patterns. Identification of such groups would facilitate clinical trials for neurologic recovery in acute SCI.

Virulence properties of Escherichia coli 83972, a prototype strain associated with asymptomatic bacteriuria

Little is known about bacteria associated with asymptomatic bacteriuria (ABU) with regard to urinary tract colonization mechanisms. In this study, virulence properties of Escherichia coli 83972, a strain that was isolated from a clinical ABU episode, were examined. The genetic potential for expression of P and type 1 pili was demonstrated, and DNA sequences related to type 1C and G (UCA) pilus genes were also detected. However, E. coli 83972 did not express D-mannose-resistant or D-mannose-sensitive hemagglutination after growth under standard conditions in vitro or upon isolation from the urine of colonized test subjects. Limited uroepithelial cell adherence was observed in vivo, and weak D-mannose-sensitive hemagglutination was detected after extended growth in urine in vitro.

A test of the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury

This study was designed to test the 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury. One hundred and six professionals in the field of spinal cord injury attending an instructional course at the 1994 ASIA Meeting participated in the test. Participants completed a pretest and posttest in which they classified two patients who had a spinal cord injury (one with complete tetraplegia and one with incomplete paraplegia) by sensory and motor levels, zone of partial preservation (ZPP), ASIA Impairment Scale and completeness of injury. Between tests, three members of the ASIA Standards Executive Committee gave presentations on the neurological assessment, scoring, scaling and classification of spinal cord injury and a video of the actual examinations of the two cases was viewed. Percent 'correct' (as defined by the ASIA Standards Committee) was calculated for sensory and motor levels, ZPP, ASIA Impairment and completeness. Overall, the analyses showed that participants had very little difficulty in correctly classifying the patient with complete tetraplegia. Pretests scores ranged from 72% (left motor level) to 96% (complete injury), posttest scores from 73% (left motor level) to 100% correct (complete injury). For the patient with incomplete paraplegia (Case 2), scores were considerably lower. Pretest scores ranged from 16% (right motor level) to 95% correct (incomplete injury); posttest scores from 21% (right motor level) to 97% correct (incomplete injury). The results showed that further revisions of the 1992 Standards and more training is needed to ensure accurate classification of spinal cord injury.

Virulence factors of Escherichia coli isolates from patients with symptomatic and asymptomatic bacteriuria and neuropathic bladders due to spinal cord and brain injuries

Chronic bacteriuria is a common occurrence among spinal-cord injury patients and others with neuropathic bladders. If bacteria are present in the urinary tract, the patient may develop symptoms of infection or remain asymptomatic. We have compared virulence properties of 28 Escherichia coli isolates from patients with symptomatic urinary tract infections (UTI) and 29 E. coli isolates from patients with asymptomatic bacteriuria (ABU). Bacteria from patients with symptomatic UTI were more likely to be hemolytic than isolates from patients with ABU (P = 0.05) or fecal isolates obtained from healthy volunteers (P < 0.001). Bacteria from patients with symptomatic UTI were also more likely than strains isolated from patients with ABU (P = 0.08) or fecal strains (P < 0.001) to exhibit D-mannose-resistant hemagglutination of human erythrocytes. The results suggest that E. coli isolates from nonimmunocompromised patients who require intermittent catheterization and who develop symptomatic UTI may be distinguished from bacteria recovered from patients who remain asymptomatic and possibly from normal fecal E. coli.

Neurological issues

The case histories of two patients who had had a spinal cord injury (SCI) were selected by the senior author and sent to four experts in the field of SCI. Based on the 1992 American Spinal Injury Association (ASIA) and International Medical Society of Paraplegia (IMSOP) standards, the four participants plus the senior author recorded the motor and sensory scores, the ASIA impairment scale (AIS), the neurological level (NL) and the zone of partial preservation (ZPP). Several minor scoring errors occurred among the participants, especially with motor scores when key muscles could not be tested due to pain, or external immobilization devices. Difficulties with interpretation occurred with the motor levels and the ZPP for the patient with a complete injury. This exercise points to the need for all examiners of SCI patients to thoroughly familiarize themselves with the standards and to use the motor and sensory scores to arrive at a NL and ZPP. They also indicate a need to revise the standards to clarify the determination of sensory levels and how to score muscles whose strength is inhibited by pain.

Analysis of gram negative recolonization of the neuropathic bladder among patients with spinal cord injuries

Over a 4 year period, 119 acute spinal cord injury (SCI) patients were enrolled in this study. The 101 males and 18 females had a mean age of 35.9 years (range 16-87). Sixty-two patients were tetraplegic and 57 were paraplegic. All patients had a urine specimen taken for culture, colony count and sensitivity once weekly while they were receiving intermittent catheterization. Of these, 22 patients (18.5%), none of whom had underlying genito-urinary (GU) pathology, developed recolonization by an organism of the same species and genus previously cultured. All 22 reached sterile-urine between colonizations after being treated with antibiotics for at least 7 days. The 16 males and six females had a mean age of 35.1 years (range 17-79). Sixteen were tetraplegic and six were paraplegic. Plasmid analysis (PA) was used to determine whether these recolonizations were from the same or from a different strain. In those instances where the bacteria harbored no plasmids or where the results of plasmid analysis were otherwise inconclusive, bacteria were also compared using restriction fragment length polymorphism (RFLP) analysis. Recolonization was caused primarily by E. coli and K. pneumoniae. While there was no significant difference between the two organisms with respect to the number of days when sterile urine occurred to the time when recolonization was observed, there were significant differences seen in both organisms with regard to the time lapse from one colonization to the next: the average number of days to recolonization with an identical organism was 10.3 days, whereas with a different strain it was 15.9 days (P < 0.04). When a different organism was cultured between the recolonizations, the mean recolonization interval was 17.9 days. When no intervening organism occurred, the interval was 9.5 days (P < 0.005). Both intervals measured the days from the first sterile urine after the first colonization to the next colonization. These data indicate the proclivity for two common Gram negative normal bowel inhabitants to recolonize the neuropathic bladder of spinal cord injured patients even after adequate treatment. PA and RFLP provide a means of discriminating between relapses by the same organism versus recurrences by a different organism of the same species and genus. Those with the same identity tend to recur sooner than those of different identities and may be suspected when relapse occurs within two weeks of cessation of 7 day course of antibiotics. While an intervening organism may delay the relapse (or recurrence), it does not prevent it and identical organisms can reappear even after adequate therapeutic regimens. Since none of the patients in this study had GU pathology, recolonization by an identical strain (relapse) does not necessarily warrant an extensive investigation for disease within the GU tract.

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.

Operative and nonoperative management of spinal cord injury. A review

Technological developments over the last two centuries have advanced the spinal surgeon's capability to service the needs of the spinal cord injured person. While the role that surgery can play in shortening hospitalization for tetraplegics has yet to be proven, it does play a much needed role in the correction of instability and prevention of deformity when the possibility of these conditions exist. Surgical intervention for purposes of neural decompression has yet to be proven as justifiable in view of the risks involved. All surgical procedures must be undertaken only after due consideration of the patients' general medical condition, including coexisting trauma, the potential for and actual instability and deformity of the spine, and the neurological level and degree of incompleteness of the patient. In general, the greater the remaining neurological function, the more there is to be gained by early mobilization. Yet, in the face of progressive improvement in neurological function, caution is advised since there will be much to lose if anything goes wrong with the operation.

Hyperbaric oxygen therapy: implications for spinal cord injury patients with intrathecal baclofen infusion pumps. Case report

A patient with a cervical spinal cord injury receiving intrathecal baclofen for spasticity control underwent a 7 week course of hyperbaric oxygen therapy to induce healing of an ischial decubitus ulcer. After completion of this treatment and during a routine baclofen infusion pump refill, the actual pump reservoir volume exceeded computer measurements obtained with telemetry. Examination of the physiology of hyperbaric oxygen therapy in relation to infusion pump function revealed that the intraspinal pressures attained during hyperbaric oxygen therapy produced retrograde leakage of cerebrospinal fluid into the infusion pump reservoir.

Intrathecal baclofen: does tolerance occur?

Concern over the development of tolerance in patients on continuous intrathecal baclofen therapy has arisen as this new form of treatment for spasticity has gained wider use. We have studied time-dose relationships in 18 spinal cord injured patients who have undergone intrathecal baclofen infusion pump implantation since February 1988 in our facility. Our data show that there was a significant increase in baclofen dosage needed to control spasticity during the first 12 months post implantation. After 12 months, however, no significant changes in dosage requirement was detected. In addition, there was no significant difference between completely and incompletely spinal cord injured patients with regard to both the initial dose and the tolerance trend.

Neurological and skeletal outcomes in 113 patients with closed injuries to the cervical spinal cord

Neurological and skeletal outcomes were evaluated in 113 patients for one year following closed lower cervical spinal cord injuries. The extent of neurological recovery did not depend on surgical versus nonsurgical management, or the degree of spinal angulation, vertebral displacement, spinal stenosis, or inferred mechanism of injury based on the initial plain cervical x-rays. Assessment of skeletal outcomes demonstrated significantly less vertebral angulation, more rapid stabilization, and less anterior callus formation among the patients in the surgical group. In addition, the surgical patients had marginally shorter lengths of hospitalization.

Effects of intrathecal baclofen on lumbosacral and cortical somatosensory evoked potentials

We analyzed lumbosacral and cortical somatosensory evoked potentials in three spinal cord injury patients undergoing evaluation of intrathecal baclofen infusion for management of spasticity. The cauda equina propagating root wave (R wave) and conus medullaris postsynaptic responses (S and P waves) were analyzed before and during baclofen infusion. Baclofen abolished the concomitantly recorded H-reflex and markedly suppressed the P wave amplitude and area. The S wave amplitude and area were suppressed to a lesser degree. In contrast, there were no significant changes in cortical somatosensory evoked potentials.

Intrathecal baclofen for intractable axial dystonia

Following spinal instrumentation for scoliosis, a patient developed intractable axial dystonia refractory to conservative medical management. We describe the successful treatment of this dystonia with a continuous infusion of intrathecal baclofen and the subsequent long-term management.

Candida pyelonephritis complicating traumatic C5 quadriplegia: diagnosis and management

We present the first reported case of Candida pyelonephritis in a spinal cord injured patient. In addition to multiple courses of empiric antibiotics, the neurogenic bladder and alteration in cell-mediated immunity found in spinal cord injured patients may have increased this patient's susceptibility to fungal disease. A 50-year-old patient with C5 motor functional quadriplegia developed Candid albicans pyelonephritis while undergoing rehabilitation. The patient had several surgical procedures and multiple courses of antibiotic therapy during acute hospitalization. He continued to have a hectic fever curve, leukocytosis with increased band forms, lethargy, and progressive uremia during rehabilitation. Successful investigation of the patient's condition included assessment of serologic tests for Candida precipitin antigen; multiple blood and urine cultures; exclusion of other causes of hectic fever; abdominal computerized tomogram, which revealed a left kidney hypodensity with irregular margins; and a retrograde pyelogram, which demonstrated multiple renal pelvic-filling defects. Cystoscopically placed ureteral stents, which relieved the genitourinary obstruction, drained gross pus from which Candida albicans was cultured; the patient was treated with amphotericin B and showed clinical improvement. Pathogenesis, presentation, diagnosis, and treatment of Candida pyelonephritis are reviewed.

Diagnostic spinal anaesthesia in chronic spinal cord injury pain

In a double blind study, 21 patients with chronic spinal cord injury (SCI) pain underwent placement of a lumbar subarachnoid catheter and injection of placebo and lidocaine. The effects on pain intensity, distribution, altered sensations and sensory level of anaesthesia were monitored. Four patients responded briefly to placebo, while 13 demonstrated a mean reduction of pain intensity of 37.8 +/- 37% for a mean duration of 123.1 +/- 95.3 minutes in response to lidocaine. The pain response to subarachnoid lidocaine differed significantly (p less than 0.01) from placebo. Spinal anaesthesia was also associated with changes in pain distribution and altered sensation. A spinal anaesthetic-induced sensory level could not be achieved cephalad to the sensory level of neurological injury in 5 patients who presented with spinal canal obstruction. This study has demonstrated that response to diagnostic spinal anaesthesia in chronic SCI pain is complex, requiring individual interpretation in each patient and consideration of the following factors; symptomatology, etiology, pain perception, spinal canal anatomy, CSF chemistry and local anaesthetic pharmacology.

Continuous infusion of intrathecal baclofen: long-term effects on spasticity in spinal cord injury

The effects of intrathecal baclofen infusion were studied in 9 spinal cord injury patients whose spasticity had been refractory to oral medications. In a two stage, placebo controlled trial, baclofen was administered into the lumbar intrathecal space and subsequent clinical and neurophysiologic changes were assessed. In stage 1, 9 patients underwent a 5 day percutaneous infusion of baclofen and placebo via an external pump. Ashworth and reflex scores were assessed at time of enrollment, after infusion of that amount of baclofen which provided optimal spasticity control and after intrathecal infusion of placebo. The mean Ashworth grade decreased from 3.78 +/- 1.34 to 1.16 +/- 0.48 (p less than 0.001) while mean reflex score decreased from 3.57 +/- 1.05 to 0.64 +/- 0.87 (p less than 0.001). These values differed significantly from those associated with placebo therapy (Ashworth grade--2.54 +/- 1.04, p less than 0.001; reflex score--2.56 +/- 1.04, p less than 0.01). Objective improvements in functional abilities and independence were noted in 8 patients, while somatosensory and brainstem auditory evoked potentials were unchanged in all patients. Urodynamic evaluation revealed increased bladder capacity in 3 patients, while in 4 no change was observed. In Stage 2, permanent programmable infusion pumps were implanted in 7 patients who demonstrated a good response during Stage 1. In this group, mean Ashworth score decreased from 3.79 +/- 0.69 to 2 +/- 0.96 (p less than 0.001) and mean reflex score decreased from 3.85 +/- 0.62 to 2.18 +/- 0.43 (p less than 0.001). Baclofen dosage increased from 182 +/- 135 to 528 +/- 266 mcg/day over the 3-22 month follow-up period. Most of the dosage increase occurred within the initial 12 months following infusion pump implantation and tended to plateau thereafter. Minor complications such as catheter dislodgement/kinking and nausea occurred infrequently while no device related infections were observed. There was no clinical evidence of any significant baclofen neurotoxicity either in Stage 1 or 2. The only ambulatory patient developed marked lower extremity weakness during Stage 1 intrathecal baclofen infusion and was temporarily unable to walk. We conclude that continuous administration of intrathecal baclofen is an effective and safe modality for spasticity control in patients who are refractory to oral medications.

Use of plasmid analysis to determine the source of bacterial invasion of the urinary tract

Gram negative colonisation and infection of the urinary tract is a well recognised complication of the neuropathic bladder caused by spinal cord injury (SCI). K. pneumoniae accounts for one third of all urinary tract infections in hospitalised SCI patients. Plasmid analysis has been shown to reliably fingerprint bacterial strains, particularly K. pneumoniae, so that growth from two separate locations in or on the body can be accurately analysed as to migration from a reservoir to a target location. Eighty seven hospitalised SCI patients on intermittent catheterisation for a total of 586 patient-weeks were studied. Twice weekly catheterised urine specimens and once weekly rectal swab cultures were taken from each patient. Thirty seven patients experienced at least one clinically significant (colony count greater than 10,000/mL) urinary tract colonisation caused by K. pneumoniae, representing 66 total colonisations. Further analysis of 31 of these 37 patients revealed: K. pneumoniae in all of their stool cultures (p less than 0.05) and the identical strain of K. pneumoniae in the urine as well as the stool in 72% of the 66 colonisations (p less than 0.05). Analysis of 14 patients without K. pneumoniae urinary colonisations showed absence of faecal K. pneumoniae in 3, and predominant growth in only 4. In 22 of the 37 patients, multiple K. pneumoniae urinary colonisations were noted, representing 27 pairs of colonisation. Fifteen of the pairs were found to be relapsing (caused by two identical bacterial strains), and 12 were recurrent (caused by two different bacterial strains). Thirteen of the 15 relapsing pairs also had identical urine and stool K. pneumonia strains (p less than 0.05). All colonisations were treated with appropriate antibiotics based on culture and sensitivity reports. Fourteen of the 15 relapsing colonisation pairs have identical antibiograms (p less than 0.05), while all 12 of the recurrent colonisation pairs had different antibiograms (p less than 0.05). The differences noted on sensitivity patterns (antibiograms) correlated with differences among strains of K. pneumoniae based upon plasmid analysis. Treatment of bacteriuria did not affect the nature of repeated colonisations regardless of the antibiotic chosen, the route of administration or the duration of treatment.

Energy requirements of gamefield exercises designed for wheelchair-bound persons

This report presents energy requirements of three athletic exercises (power ramp, climber, and chin-ups) in a free-wheeling gamefield developed by the City of Houston for wheelchair-bound persons. Heart rate was monitored by telemetry. Expired gas samples were collected in Douglas bags. Oxygen and CO2 concentrations were determined by mass spectrometry and expired gas volumes by a wet gas meter. Pulmonary ventilation, O2 consumption, and CO2 production were calculated from expired gas samples. Laboratory studies were conducted on eight men with paraplegia and ten untrained, healthy, able-bodied men. The same persons were tested on the gamefield while propelling a wheelchair over the power ramp, the climber, and doing chin-ups. Age and weight were 32 +/- 4yrs vs 31 +/- 6yrs and 79.6kg vs 79.0kg, respectively, for paraplegic and healthy men. Paraplegic men had average heart rates of 133 +/- 11bpm, 133 +/- 19bpm, and 135 +/- 21bpm, respectively, for the power ramp, climber, and chin-ups. Heart rate values for able-bodied men were 136 +/- 26bpm, 139 +/- 24bpm, and 136 +/- 26bpm, respectively, for the same three exercises. The paraplegic men's VO2 measurements were 13.2 +/- 2.2, 11.5 +/- 2.8, and 6.4 +/- 2.9ml/min/kg, respectively, for the power ramp, climber, and chin-ups. The able-bodied men's VO2 measurements were 15.8 +/- 2.8, 15.4 +/- 3.6, and 9.2 +/- 2.8 ml/min/kg for the same exercises. Patients with paraplegia seemed to outperform able-bodied men in all events. Gamefield exercises appeared to tax the cardiorespiratory system at a level comparable to that usually prescribed for training purposes.

Increased current delivery and sperm collection using nifedipine during electroejaculation in men with high spinal cord injuries

Elevated blood pressure associated with autonomic hyperreflexia during electroejaculation in persons with high spinal cord injuries often prevents successful sperm retrieval. The ability of the calcium channel blocker nifedipine to reduce the effects of autonomic hyperreflexia, to facilitate greater current delivery, and to increase sperm collection was evaluated in six persons with spinal cord injuries. Ten milligrams of nifedipine given sublingually ten to 15 minutes before electroejaculation attempts helped to moderate autonomic hyperreflexia and the associated blood pressure elevations. These effects of nifedipine allowed greater current delivery and ultimately increased the chances of successful sperm retrieval in the six men. No adverse drug effects were observed.

Clonidine effect on spasticity: a clinical trial

Clonidine was used as an adjunct to baclofen in 55 patients with spasticity due to spinal cord injury. Dosage was held at the minimum effect amount for those who responded. No effect was seen in 24 patients (44%), although 31 (56%) benefitted from the drug. Patients were grouped as quadriplegics or paraplegics, having complete or incomplete lesions. Of all quadriplegics, seven of 11 complete (64%) and 17 of 25 incomplete patients (68%) responded; among the paraplegics, six of 15 complete (40%) and one of four incomplete patients (25%) improved. Side effects were limited to postural hypotension necessitating reduction in dosage in three patients that were successfully treated; in the unsuccessfully treated group, one patient had insomnia, one had dizziness, and one had drowsiness.

Profile of denials of durable medical equipment for SCI patients by third party payers

The difficulty in obtaining approval for payment of durable medical equipment by third party payers has impeded the rehabilitation program and discharge planning of many spinal cord patients throughout the country for many years. To gain some insight as to the number and level of patients affected, the kinds of equipment denied, the reasons given for the denial, which third party payers were mostly involved and how the patient and his/her family managed to cope or resolve this problem, a survey was undertaken. Letters were sent to 259 members of the American Spinal Injury Association (ASIA) asking them to list representative cases where requests for equipment deemed necessary were denied. Twenty-eight responses from different institutions were received from sixteen states describing 110 patients and 180 pieces of durable medical equipment denied in 1984 and 1985. Manual wheelchairs, motorized wheelchairs, shower/commode chairs, and environmental control units were the four most common equipment items denied by the third party payers. Government agencies ie., Medicaid, Medicare, Vocational Rehabilitation Departments and State Crippled Children's Services were the most frequent deniers, comprising 54% of the total sample. They were followed by private insurance (31%) and Workman's Compensation (3%). By far, the two most common reasons given for denials were: it was not covered by the insurance policy (38%) and it was not medically necessary (30%). Ninety (90) pieces of equipment (50%) were eventually obtained, most often by charity, or through the patient's family resources.

Postdischarge outcomes for ventilator-dependent quadriplegics

Based on data contributed to the National Spinal Cord Injury Data Base between the years 1975 and 1981, outcomes were assessed for 34 patients who had been injured approximately a year earlier and who were ventilator dependent when discharged from inpatient rehabilitation. Their outcomes were compared with those of 196 patients who required mechanical respiration some time during acute care or rehabilitation, but who were free of such assistance at discharge. Statistically significant differences were obtained between the groups in levels of spinal cord injury, duration of acute care hospitalization, duration of total hospitalization, extent of self-care capability, hours/week of hired attendant care, and hours of actual physical assistance/day. The groups did not differ significantly in terms of duration of inpatient rehabilitation, duration of rehospitalization, and vocational or prevocational status at follow-up.

The neurological and skeletal outcome in patients with closed cervical spinal cord injury

Sixty-one patients with closed cervical spinal cord injury were cared for within a defined protocol and followed for at least 1 year. Neurological recovery and healing of spinal structures were evaluated at intervals. Forty-three patients were managed without surgical intervention at the site of spine trauma, and the incidence of spontaneous fusion ("autofusion") was noted. Surgical fusion was performed on 17 patients, mainly to restore spinal stability and alignment. One patient underwent laminectomy without fusion. In both the surgical fusion and the autofusion groups, there were significant numbers of patients who improved neurologically, including some designated as having a complete spinal cord lesion at the initial neurological examination. As expected, better spinal alignment was achieved in the surgical group, although alignment in the nonsurgically treated group was generally acceptable. The majority of patients developed radiographically apparent callus formation anterior to the injured vertebral bodies, regardless of the mechanism of injury or the method of treatment. After 3 months all patients who underwent surgical fusion achieved spinal stability, as did the majority of patients in the autofusion group. Only individuals with flexion-distraction injuries who did not undergo surgical fusion appeared to be at risk for progressive spinal column deformity. Neither retropulsion of bone fragments nor angulation at the fracture site appeared to correlate with a poor neurological outcome, since improvement in neurological function occurred similarly in patients with and without these deformities.

Comparative study of electrophrenic nerve stimulation and mechanical ventilatory support in traumatic spinal cord injury

Over the past two decades, the number of surviving apneic spinal cord injured patients has been increasing. Mechanical ventilation for home maintenance has been supplemented by electrophrenic respiration (EPR) since 1970. Nineteen patients who were totally mechanical ventilator dependent at discharge from rehabilitation in a spinal cord centre are compared with 18 patients discharged on EPR. There were more young males in the EPR group while the overall average ages were approximately the same. The mortality rates were approximately equal although the mechanical ventilator dependent patients expired earlier than the EPR group. Survivors on mechanical ventilation lived longer on an average and the vast majority of both groups were discharged to their home. There needs to be the establishment of a ventilatory dependent registry for spinal cord injury.

An update on the early management of traumatic paraplegia (nonoperative and operative management)

Both the spinal cord physician and the spinal surgeon must be fully cognizant of the alterations of functions in multiple systems of the body caused by a spinal cord injury. Complications can easily arise, particularly within the respiratory, urinary, and integumentary systems. Most are preventable if the medical and nursing staff are sufficiently knowledgeable to anticipate them and if the necessary equipment and facilities are available. Regionalization of care with early referral to a spinal cord injury center has become a cost-effective way to manage these patients. Only if their medical needs are met and complications are prevented will surgery, performed to allow early mobilization, really accomplish the desired result. This update reviews the current medical and surgical points of view concerning diagnosis, fracture classification, spinal stability, reduction and stabilization of the fracture deformity, and spinal canal decompression.

Incidence of medical complications in spinal cord injury: patients in specialised, compared with non-specialised centres

Facilities providing a co-ordinated 'system' of care to the spinal cord injured are now more accepted as being preferable to fragmented 'non-system' facilities. Data reflecting the incidence of selected complications common to spinal cord injury were collected over a 2-year period from a system located outside the United States and from 'non-systems' within the United States. The latter was defined as care provided in community facilities prior to entry into one of 14 model United States spinal cord injury centres. All complications occurred more frequently in the American group, particularly decubitus ulcers and urinary tract infections. The data suggest that system care is preferable to non-system care in its capacity to prevent costly complications and the sooner the spinal cord injured patient is referred to a spinal cord centre capable of meeting all his needs, the less likely will he be exposed to complications that could slow the rehabilitation effort.

Neurophysiological approaches to chronic pain following spinal cord injury

Pain occurring in patients with spinal cord injury can be classified on clinical grounds into five types: peripheral, central, visceral, mechanical and psychic. An attempt has been made to correlate each type of pain with present neurophysiological knowledge. Mechanisms as to how unpleasant sensations reach the conscious level can be deduced when clinical and neurophysiological data are pooled. Eight case histories are presented which typify each class. The authors' evaluation and treatment offered is presented for each type.

Developing a system of comprehensive care for the spinal cord injured patient in Houston, Texas, U.S.A

The authors agree with the principle, widely accepted, that spinal cord injured (SCI) individuals should receive all their acute, rehabilitative and follow-up care in a spinal cord injury centre. The evolution of rehabilitation medicine and services in the United States, however, has favoured the separation of acute and rehabilitation care for spinal cord injured patients, as well as other disabilities. This has resulted partly from specialisation of medical and allied health personnel, physical separation of acute and rehabilitation facilities, and reluctance of some funders of health care to see rehabilitation as a natural extension of medical care in these patients. In Houston the proximity of a rehabilitation facility to three acute care university hospitals, representing three medical schools, provided an opportunity to improve communication among the medical personnel. These individuals have recognised the value of early rehabilitation even while the patient is acutely ill; they agreed to institute a system of care wherein the rehabilitation physician partakes in the early management in a designated area of the acute hospitals for spinal cord injured patients and works toward early transfer to the rehabilitation hospital in as ideal a condition as possible. Surgeons, who have initial primary responsibility, also visit the rehabilitation hospital, following their patient's progress at selected conferences and at the bedside. This paper describes how, a spinal cord injury service was established, how the major barriers to early transfer were confronted, and the results of the first 6 months of operation.

A multidisciplinary approach to chronic low-back pain in Western Australia

Fifty patients with chronic low-back pain were subjected to extensive medical, psychiatric, and psychosocial assessment by a comprehensive Low Back Pain Clinic. Most patients were found to have easily identifiable environment factors which influenced the persistence of the symptomatology. All patients were significantly functionally impaired, and whilst neurologic findings were uncovered in only 12 patients, most had restricted movement of the lumbar spine. The initiating cause of the low-back pain was usually from a minor injury or no injury at all. Thirty-two patients were given psychiatric diagnoses, but only one patient was thought to warrant psychiatric treatment. Whilst some were considered to be candidates for limited further conservative treatment, only two were subjected to further surgery (one fusion, one posterior facet rhizotomy). Only nine were admitted to an inpatient behavior modification program, and the results of this effort were modest. The major benefit was seen to be the definitive diagnosis, prognosis, and medical and social planning which was given to all 50 patients upon conclusion of the assessment. The assessment proved to be of benefit to the patient, the referring doctor, the team itself, as well as all other interested parties, such as his family, insurance company, and lawyer.

Electromyographic activity in paraspinal musculature in patients with idiopathic scoliosis before and after Harrington instrumentation

Ten patients with idiopathic scoliosis underwent electromyographic (emg) examination before and after Harrington instrumentation and fusion. Each patient had a normal emg preoperatively. At 3 weeks all 10 demonstrated spontaneous activity consistent with denervation, and voluntary activity was absent or markedly reduced. By 3 months and in some cases 6 months, denervation was significantly reduced or absent; voluntary activity had also reappeared and in most cases was equal to preoperative intensity. This rapid reversal of denervation after surgery within the paraspinal muscles in a young female population with no underlying disease suggests that interpretation of any postoperative emg should include considerations such as the time since surgery, the age of the patient, and the extent of preoperative pathology. No evidence was gained from this study that extensive posterior spinal surgery itself interfered significantly with paraspinal muscle function after 3 to 6 months.

Combined intravenous miconazole and intrathecal amphotericin B for treatment of disseminated coccidioidomycosis

A patient received a previously unreported combination of intravenous miconazole and intrathecal amphotericin B for the treatment of disseminated coccidioidomycosis with central nervous system involvement. After first having been treated with amphotericin B, followed by a course of miconazole therapy, the patient responded with remarkable clinical and serologic improvement to the combination of intrathecal amphotericin B and intravenous miconazole. The combination should be considered in the treatment of disseminated coccidioidomycosis with central nervous system involvement.

Intermittent bladder emptying via urethral catheterization or suprapubic cystocath: a comparison study

A prospective study was undertaken to compare patients with recent spinal cord injuries undergoing bladder training by conventional intermittent urethral catheterization with a similar group treated with the Cystocath. Our present information suggest there are no differences with respect to episodes of bacteriuria encountered or for time spent by the catheter team for each procedure. Paraplegics tended to reach balanced bladder status more easily without surgery while quadriplegics did not. The bladder training program was shorter on the average for the Cystocath group. Further investigation is necessary to determine whether this is significant. Problems encountered were minimal and fewer than reported in the literature. We find no reason not to employ the Cystocath in bladder training programs in spinal cord injured patients.

Anal sphincter stretch: a technique to overcome detrusor-sphincter dyssynergia

Intermittent catheterization has become a well-accepted method of management of the neurogenic bladder following spinal cord injury. Frequently, the presence of detrusor-sphincter dyssynergia interferes with the attainment of acceptable residual urine volumes in patients with upper-motor-neuron bladders. We have recently reported success in overcoming the problems of dyssynergia in some patients utilizing a technique called anal sphincter stretch in which relaxation of the external anal and urethral sphincters is produced by sustained distention of the anal sphincter. This has lessened the need for other measures that usually produce incontinence and has met with good patient acceptance. An update on the results of using this technique is presented. Although we have previously encountered quadriplegics who might have benefited from sphincter stretch, the lack of hand intrinsic muscle function required for the patient to perform it independently has precluded its use. We herein present a device that circumvents inadequate hand function, and which has enabled four C-7 quadriplegics to achieve satisfactory bladder emptying.