Experimental spinal cord trauma, II: Blood flow, tissue oxygen, evoked potentials in both paretic and plegic monkeys.

Graded clinical motor deficits were produced in a series of Rhesus monkeys subjected to experimental spinal cord trauma from a variety of impact loads. An argon washout technique was used to measure spinal cord blood flow; tissue oxygen carbon dioxide, and somatosensory evoked potentials (SEPs) were also monitored. Each animal received a clinical grade and, after a week of study, the spinal cords were removed for histopathological grading. Blood flow in paraplegic animals was significantly decreased at two hours and seven days following injury (5 ml/min/100 gms tissue); paraparetic animals showed no significant difference from preinjury levels (14 ml/min/100 gms tissue). Animals which completely recovered demonstrated increased flow (27 ml/min/100 gms tissue). Composite tissue oxygen was generally depressed in paraplegic animals (28 mm Hg/kg) but showed no clear pattern in other groups. Only 8% of monkeys rendered paraplegic preserved a somatosensory evoked potential (SEP) at five minutes after injury. Paraparetic animals were more likely (40%) to show initial preservation of the SEP and in normal animals, the SEP always returned by three hours. Histopathological grading tended to parallel clinical grading in 92% of the cases. Although the extremes of possible postinjury deficits (complete paraplegia or recovery) can be predicted from a combination of these measurements, incomplete lesions (whether judged clinically or pathologically) present a more variable picture.     

Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?

Introduction: Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland.

Design: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG).

Methods: Study patients were identified from the period 1992–1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined.

Results: 34,903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation.

Conclusion: Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.     

Recurrent spinal cord injury without radiographic abnormalities in children

Spinal cord injury without radiographic abnormality is a well-known entity in the pediatric age group. Age-related elasticity of the vertebral ligaments as well as immaturity of the osseous structures in the pediatric spine allow momentary subluxation in response to deforming forces. The resultant neurological injuries range from transient dorsal column dysfunction to complete cord transection. Between 1960 and 1985, 42 such injuries were treated at the Children's Hospital of Pittsburgh. Management of these radiographically occult spinal cord injuries consisted of cervical immobilization for 2 months in a hard collar and restriction of contact sports. Recurrent cord injury occurred in eight cases during the 2-month immobilization period. A clearly defined traumatic episode was identified in seven of the eight patients, although in four children the recurrent trauma to the spine was trivial. Five of the children removed their collars briefly before the second injury, and two children incurred reinjury with the hard collar in place. The remaining child was too young for hard-collar immobilization, and recurrent neurological deterioration occurred during sleep. Serial flexion-extension films failed to detect frank instability in any of the eight cases. The children most susceptible to reinjury were those who sustained mild or transient neurological deficits from an initial cord injury and who rapidly resumed normal activities. Radiographically occult spinal instability resulting from the initial injury to the vertebral and paravertebral soft tissues presumably made these children vulnerable to recurrent spinal cord injury, often from otherwise insignificant trauma. During the last 21 months, 12 additional children have been managed with a more stringent protocol combining neck immobilization in a rigid cervical brace for 3 months and restriction of both contact and noncontact sports, together with a major emphasis on patient compliance. With this new protocol, no recurrent cord injuries have been documented.     

Cervical myelopathy in patients with congenital cervical block vertebrae

Summary Thirty-two patients with congenital cervical block vertebrae are reviewed. Twenty-nine patients had single level fusion, one had two-level fusion, and the remaining two had multilevel fusion. Eighteen patients had cervical myelopathy; five of these had related trauma and 13 had no history of trauma. The five patients who had cervical myelopathy following trauma underwent magnetic resonance imaging (MRI); three of them had abnormalities in the spinal cord at the segment adjacent to fusion. In all five patients the symptoms and signs were attributed to the segment adjacent to fusion. Myelography, computed tomographic myelography and MRI were performed in 11 of the 13 patients with cervical myelopathy without trauma. In 9 of them maximum compression of the spinal cord was not seen at the segment adjacent to fusion. The major factor contributing to cervical myelopathy was associated spinal canal stenosis. Seven patients with cervical myelopathy without history of trauma were treated surgically, six of whom had spinal canal stenosis treated by enlargement of the spinal canal: subtotal corpectomy and arthrodesis was performed in three, and open-door expansive laminoplasty in three. Anterior interbody arthrodesis was performed in one patient without spinal canal stenosis. All recovered from the myelopathy postoperatively. When a trauma occurs, it concentrates stress at the segment adjacent to fusion, resulting in possible spinal cord injury. On the other hand, when there is no trauma, spinal canal stenosis is the principal factor contributing to cervical myelopathy.     

Intradural spinal arachnoid cysts in adults

BACKGROUND: Idiopathic arachnoid cysts are rare lesions not associated with trauma or other inflammatory insults. To date, there have been few large series describing the presentation and management of these lesions. METHODS: Twenty-one cases of intradural spinal arachnoid cysts were identified (1994-2001). Pediatric patients and cases with antecedent trauma were excluded. There were eight women and 13 men with an average age of 52 years. Follow-up averaged 17 months. RESULTS: Cysts were most commonly found in the thoracic spine (81%). Fifteen cysts were dorsal to the spinal cord and six were ventral to the spinal cord. All patients underwent laminectomy with cyst fenestration and radical cyst wall resection. Based upon intraoperative ultrasonography, four cysts were also shunted to the subarachnoid space, and seven patients had an expansile duraplasty with freeze-dried dural allograft. Of the seven patients with syringomyelia, three resolved with extramedullary cyst resection alone. Four required syrinx to subarachnoid shunting. Follow-up MRI demonstrated cyst resolution in all cases. All seven intramedullary syrinxes were decreased in size and four resolved completely. Weakness (100%), hyperreflexia (91%), and incontinence (80%) were more likely to improve than neuropathic pain (44%) and numbness (33%). One patient had increased numbness postoperatively. CONCLUSIONS: Ventral cysts are more likely to cause weakness and myelopathic signs. Preoperative symptoms of neuropathic pain and numbness are less likely to improve than weakness and myelopathy. Utilizing intraoperative ultrasound to guide aggressive surgical treatment with the adjuncts of shunting and duraplasty results in a high rate of cyst and syrinx obliteration.     

The results of treatment of acute injuries of the upper thoracic spine with paralysis

We studied the cases of 218 patients who had had trauma to the upper region of the thoracic spine (first to tenth thoracic vertebra) that resulted in paralysis. Of these, 184 patients had a complete and thirty-four had an incomplete lesion of the spinal cord. Of the 184 patients who had a complete lesion of the spinal cord, none of the 149 patients who were followed for two to fifteen years recovered any significant neurological function, regardless of the type of operative or non-operative treatment. Thirty of the patients with an incomplete lesion of the spinal cord were followed for two to twenty years. Three others were lost to follow-up, and one died with ascending necrosis of the spinal cord and pulmonary failure three months after the laminectomy. Of the remaining thirty patients, twenty-three had an anterior cord syndrome, four had a central cord syndrome, and three had a Brown-Séquard syndrome. Five patients with an incomplete lesion were treated without surgery. Three of these patients recovered the ability to walk while two recovered some function but were still not able to walk. Seventeen patients with an incomplete lesion of the spinal cord were treated by laminectomy. Of these patients, two also had cord-cooling, two had a posterior fusion, and one had cord-cooling, spine fusion, and posterior instrumentation with Harrington rods. Five patients recovered partial ability to walk with braces, four did not, and eight lost neurological function or became completely paraplegic after surgery and did not recover. Eight patients with an incomplete lesion of the spinal cord were treated with anterior transthoracic decompression and fusion, three of whom had had a previous laminectomy that had not improved their status. Five patients recovered the ability to walk without aids, two walked with braces, and one recovered some motor function but was not able to walk. From this study, we concluded that laminectomy is contraindicated for incomplete lesions of the upper region of the thoracic spinal cord and that anterior transthoracic decompression and fusion offers the best chance of recovery of neurological function.     

Childhood scoliosis revealing spinal cord tumors

Spinal cord tumors typically show slow and insidious growth and scoliosis may be the only presenting feature of these lesions. The aim of this study is to determine the clinical and/or imaging signs that can contribute in uncovering the underlying etiology of a presumed “idiopathic” scoliosis. We retrospectively reviewed seven cases of histologically confirmed spinal cord tumors presenting as scoliosis and diagnosed with MRI in our institution between 1996 and 2003. The children (six males and one female) were aged from 3 to 10 years. The scoliosis was associated with spinal pain and/or stiffness in all cases. Accurate neurological evaluation showed a motor deficit and/or mild neurological signs in all cases. Plain radiographs showed widening of the spinal canal in three patients. MRI allowed the diagnosis of spinal cord tumor in all patients. Associated syrinx was noted in five cases. Of which one child was presented with a “torticolis”, one with a localized thoraco–lumbar hyperkyphosis, three with left-sided thoracic curve and two with right-sided thoracic curve. All patients underwent surgical resection. Histological study concluded to astrocytomas (n=4), ependymoma (n=2) and epidermoïd cyst (n=1). Scoliosis should be considered as idiopathic only occult causes have been excluded. Neurological evaluation of these patients must be accurate. Early age of onset, male gender spinal pain and/or stiffness, left-sided curve, neurological signs, radiographic widening of the spinal canal are considered as atypical features and must lead to further investigation by MRI.     

Increased Osteoclast-Like Cells Formation in Long-Term Bone Marrow Cultures from Patients with a Spinal Cord Injury

Patients with a spinal cord section loose a significant amount of bone. After paraplegia, bone loss occurs below the lesional level and is the more dramatic in iliac bones and in the metaphyseal area of long bones. A peak of urinary calcium and hydroxyprolinuria is observed approximately 6 weeks after their lesion. To further understand the mechanisms underlying the bone damage, we used long-term bone marrow cultures to compare osteoclast-like (OCL-like) cell formation above and below the lesional level. Seven paraplegic, one quadriparetic, one quadriplegic patients and five normal subjects were investigated. Six weeks after their spinal cord section, the number of OCL-like cells formed in iliac bone marrow cultures was significantly greater than those formed in sternal bone marrow cultures for all paraplegic patients tested. No significant differences were seen between iliac and sternal bone marrow cultures for the quadriparetic, the quadriplegic patient, or for the five normal subjects. Conditioned media (CM) from iliac marrow of paraplegic patients increased OCL-like cell formation in normal bone marrow cultures. IL-1, TNF-alpha, IL-6, and PGE₂ were measured in the CM after 3 weeks of culture. IL-6 was found to be significantly higher in iliac CM compared with sternal CM in six out of seven paraplegic patients. In two patients, addition of an anti-IL-6 monoclonal antibody to the marrow cultures significantly decreased the number of OCL-like cells formed at 3 weeks. We conclude that paraplegia caused by a cord section locally induces an increase in the capacity of progenitors to form OCL-like cells in long-term bone marrow cultures. A locally increased IL-6 production in the marrow below the lesional level could be partly responsible for this observation. Received: 25 July 1997 / Accepted: 5 March 1998     

Traumatic spinal cord infarction in a child: case report and review of literature

BACKGROUND: Traumatic spinal cord infarction was initially described in the era previous to the availability of MRI. This entity occurs in children and affects the thoracic spinal cord, usually presenting as a delayed cord injury. Patients have a high incidence of associated blunt thoracic or retroperitoneal trauma and arterial hypotension at admission. The described mechanism of injury is a traumatic occlusion of the aortic branches nourishing the spinal cord. It shares several characteristics with SCIWORA. In past years, the presence of this injury has received little importance. CASE DESCRIPTION: A 5-year-old boy suffered from high-energy blunt trauma over the thoracoabdominal area, presenting hypotension, retroperitoneal injury, and delayed complete thoracic SCI. An MRI showed spinal cord infarction located in the territory of AKA. During subsequent examinations, the boy did not show signs of neurological improvement. CONCLUSION: It is important to include TSCIf in the diagnosis of children who present delayed SCI (hours to 4-5 days), especially if the injury is located in the thoracic cord and is accompanied by blunt thoracic or abdominal trauma. Because the conventional radiographic tests are normal, TSCIf can be considered as a special type of SCIWORA.     

Neurophysiologic diagnosis in uncooperative trauma patients: confounding factors.

Median, ulnar, and posterior tibial nerve somatosensory evoked potential (SSEP) studies were performed on a total of 239 comatose or uncooperative trauma patients with head injuries. Twenty-six of those patients were suspected of having an additional spinal cord injury. One patient had more than one suspected spinal cord injury and two patients had a suspected spinal cord injury and a suspected peripheral nerve injury. Eleven of the suspected spinal cord injuries were confirmed and 13 were not confirmed by the SSEP studies. In three patients the SSEP study proved inadequate to add further information on the suspected spinal cord injury. Sixteen patients with suspected spinal cord injuries were able to cooperate with a neurologic examination approximately 6 months after injury and the SSEP findings were clinically verified in all 16 patients. Eleven patients were suspected of having an additional peripheral nerve injury. Four injuries were confirmed and seven not confirmed by the SSEP studies. Eight of those patients were able to cooperate with the follow-up neurologic examination, and the SSEP findings were clinically verified in all eight. Two patients suspected of having an additional spinal cord injury had unsuspected peripheral nerve injuries discovered by the SSEP studies. One patient was cooperative at follow-up and the SSEP findings were clinically verified. In our experience, SSEP studies have been an important diagnostic tool in the study of uncooperative trauma patients.     

Die retrograde Marknagelung kniegelenknaher Frakturen bei Querschnittgelähmten

INTRODUCTION: Patients with spinal cord lesions suffer injury even by marginal trauma, especially in the area of the knee joint. Because of lost sensitivity and proprioception, the treatment of the fracture has to be minimally invasive but stable enough for physiotherapy. METHODS: There were 18 patients with 20 fractures near the knee: 15 fractures of the supracondylar femur were treated with a retrograde intramedullary GSH nail and 5 fractures of the proximal tibia with a new retrograde nailing technique. RESULTS: At review all patients had a good motion range of the knee joint (> 100 degrees), and ankle joint motion was free. CONCLUSION: We saw in this study that the GSH nail is an excellent method for stabilizing supracondylar fractures of the femur in paraplegic patients because the treatment is minimally invasive and the fracture is stable enough for physiotherapy. The retrograde nailing of proximal fractures of the tibia is a good alternative method for treatment of patients with spinal cord lesions.     

Sensitivity of the short-range spinal interneurons of the cat to experimental spinal cord trauma.

The technique of retrograde axoplasmic transport was used to demonstrate the effect of experimental spinal cord injury on the spinal interneurons in the upper lumbar and lower thoracic segments of cats. Force of varied intensity was applied to the dorsal surface of the spinal cord and horseradish peroxidase (HRP) was injected into the next caudal segment. A large impact (250 to 350 gm-cm) inducing permanent paraplegia of the hind legs blocked the axoplasmic transport instantaneously in both cranial and caudal directions. If 1 week elapsed between the trauma and injection, neurons cranial to the trauma did not show any evidence for retrograde axoplasmic transport, while few neurons in the caudal direction were labeled with HRP. A moderate impact (150 gm-cm) which rendered the animals only transiently paraplegic spared the axoplasmic transport in some neurons both cranially and caudally to the injection. No obvious recovery or additional loss in the number of HRP-labeled neurons could be found in the cats if the injections followed the trauma by 1 week. The loss of spinal cord neurons following the injury seems to be the immediate mechanical consequence of the trauma.     

Imaging diagnosis of cervical spine and spinal cord injuries in children

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Spontaneous spinal subdural haematoma during general anaesthesia.

Spontaneous spinal subdural haematoma causing acute spinal cord compression is a well recognized condition and often responds well to early surgical intervention. In the elderly, the haematoma usually occurs as a result of minor trauma or atherosclerosis with hypertension. We present in this report the history of a patient who became paraplegic during a general anaesthetic for an operation for removal of a ureteral calculus. Rupture of a spinal vascular malformation was found to be responsible for the subdural haematoma, which remained undiagnosed until surgical exploration.     

创伤性上升性脊髓缺血损伤

脊椎损伤后,脊髓损伤平面上升较为少见。作者报告了５例,其中Ｔ１０－１１骨折脱位２例：１例于伤后２周内,截竣平面上升至Ｃ２,呼吸麻痹死亡,１例上升至颈部脊髓,双上肢无力;另３例为Ｔ１２骨折２例,Ｌ３骨折１例：其中截竣平面上升至Ｔ９至１例,Ｔ８者２例。５例患者双下肢皆呈软竣,１例死亡患者尸检见脊髓完整,Ｔ９－１０段脊髓前后动静脉血栓,其向上至Ｃ３,向下至Ｓ１,脊髓前血管、中央血管、髓内小血管多处 栓,     

Functional recovery in chronic paraplegic rats after co-grafts of fetal brain and adult peripheral nerve tissue

BACKGROUND: In recent years, experimental studies have sought some type of functional improvement in traumatic paraplegia by transplanting neural tissue into the injured spinal cord. The aim of this work is to study the possibility of functional recovery in chronic paraplegic rats after co-transplantation of fetal cerebral tissue and adult peripheral nerve tissue. METHODS: Seventy adult female Wistar rats were subjected to spinal cord injury at the T6-T8 level, causing complete paraplegia. Three months later, in 50 rats (grafted group) the injured spinal cord tissue received a graft of fetal brain cortex associated with crushed adult peripheral nerve. All the animals (grafted and control groups) were subjected to daily rehabilitation procedures from the first week after the injury, and evaluated weekly for motor and sensory recovery. Statistical analysis of different behavioral data between control and grafted animals was performed using the Kruskal-Wallis ANOVA and the nonparametric Wilcoxon test. RESULTS: Between 8 and 12 months after transplantation, progressive signs of functional recovery were observed in the grafted animals, associated with an increase in muscle mass in the lower extremities, findings that were significantly different from those in nongrafted animals (p < 0.05). At this time, donor cerebral tissue is integrated into previously injured spinal cord and results in formation of bundles of nerve fibers that emerge from the area of the transplant and surround the spinal cord beneath the lesion. CONCLUSIONS: Delayed co-transplantation of fetal cerebral tissue and peripheral nerve tissue can be used to achieve anatomical remodeling and long-term functional recovery in rats rendered paraplegic as result of severe spinal cord injury. These findings support the possibility of functional recovery after chronic traumatic paraplegia.     

Paraplegia and pregnancy: anaesthesic management

Pregnancy is a rare occurrence in patient suffering from spinal cord lesion. The authors report the case of labour and delivery in a paraplegic patient who was suffering from lesion located T6 level. In early labour epidural analgesia was maintained and the vaginal delivery was successful without associated fluctuation of blood pressure or other signs of autonomic hyperreflexia. The epidural catheter was maintained for 48 h post-partum. The main risks and anaesthesic management of pregnancy in paraplegic patients are discussed.     

Long bone fracture in a spinal-cord-injured patient: complication of treatment--a case report and review of the literature

Long bone fractures in patients with spinal cord injuries are difficult to manage. A case is presented in which complications arose after a femur fracture in a paraplegic patient was treated by closed fixation in a long leg circular plaster cast and the literature on management of long bone fractures in patients with spinal cord injuries is reviewed.     

Neurogenic gastroduodenal ulceration and bleeding associated with spinal cord injuries.

Twenty-four of 576 consecutive patients with spinal cord injuries developed acute gastroduodenal ulceration and hemorrhage. Twenty-two were males and two were females: 88% were 12 to 25 years old. Seventeen patients sustained injuries to the spinal cord in sports and recreation related activities. Twenty-three patients had lesions of the spinal cord above the sympathetic outflow. Twenty patients developed gastroduodenal perforation or bleeding within 4 weeks following the injury. Ten patients developed perforation of gastric or duodenal ulcer and "shoulder tip" pain was a symptom of perforation in six patients. Six patients of seven who had gastroscopy and upper GI series were found at laparotomy to have ulcers. Gastric (nine) and duodenal (seven) ulcers were evenly distributed. There were no deaths due to gastroduodenal hemorrhage in the present series. A single cause for the pathogenesis of gastroduodenal ulceration and hemorrhage cannot be pinpointed. However, ischemia of gastric mucosa produced in various ways and altered equilibrium between the parasympathetic and sympathetic neural pathways following trauma to the spinal cord seem to be important in initiating the process.     

Cervical spinal cord injury in children.

We examined 19 children under 10 years of age with cervical spinal cord injury using clinical records and radiographs. The children were divided into two groups: Eight had immediate and complete spinal cord injury, and 11 had incomplete or partial spinal cord injury. Those with complete spinal cord injury were injured in motor vehicle accidents with a proximal spinal cord injury. Eighty-eight percent had cervical spine fractures/instability with a distraction pattern of injury. Half had associated trauma. The mortality rate was 25%, and those who survived showed no neurologic improvement. Most of the children with partial spinal cord injury were injured at birth. Many had no radiographic evidence of cervical fracture. One-quarter had associated trauma. The neurologic improvement averaged 1.9 Frankel grades. Half of both groups required posterior cervical fusion, and there was a significant complication rate. Eight-eight percent developed scoliosis, and 71% developed hip subluxation.