[Thoracic injuries associated with acute traumatic paraplegia of the upper and middle thoracic spine]. / Die Akutbehandlung der traumatischen Brustmarklähmung Wird das Thoraxtrauma übersehen oder unterschätzt?

AIM: The aim of this study was to analyse the number of thoracic injuries associated with acute traumatic paraplegia of the upper and middle thoracic spine and review the early management in respect to treatment standards. METHODS: Using a prospective study protocol, data were sampled and analyzed from 12 December 2000 to 31 March 2002 at a level 1 trauma center. RESULTS: Twenty-two consecutive patients were included in the study. Sixteen suffered severe chest traumata. Lung contusion was diagnosed in 81%, followed by haemopneumothorax (75%) and fracture of the bony chest (75%). Intubation was performed 12 times in all. Chest drainage was performed in 14 patients. The mean duration of artificial ventilation was 20 days (range 2-93) and of intensive care treatment 25 days (range 2-93). Five patients died. CONCLUSIONS: Acute traumatic paraplegia of the upper and middle thoracic spine caused by high energy trauma is highly associated with severe chest trauma. Therefore, respiratory impairment must be kept in mind during the early treatment. If respiratory failure becomes more evident, emergency procedures such as intubation and chest drainage have to be performed. Secondary transfer should be avoided.

Increasing resistance against antibiotics in bacteria isolated from the lower urinary tract of an outpatient population of spinal cord injury patients.

OBJECTIVE: To investigate changes of the bacterial spectrum and susceptibility in bacteria isolated from urine samples of spinal cord injury patients followed in a strict outpatient setting. SUBJECTS AND METHODS: Due to neurogenic dysfunction, urinary tract infections are common in spinal cord injury patients. Nosocomial urinary tract infections and resistance against antibiotics are increasing problems in hospitalized spinal cord injury patients. Urine samples were obtained by aseptic catheterization during 1,293 outpatient appointments at our institution over a period of 6 years. The urine samples were analyzed for bacterial colonization and microbiologically evaluated. RESULTS: We demonstrate significant changes in both bacterial spectrum and bacterial resistance in an outpatient population as well. Even multiresistant staphylococcus species were detected, in spite of excluding nosocomial infections. CONCLUSIONS: Antibiotic treatment should be limited to symptomatic urinary tract infections and be initiated after sensitivity testing only. Empiric use of antibiotics must be limited to highly symptomatic infections until the results of sensitivity testing are available.

Noncontiguous unstable spine fractures.

STUDY DESIGN: Evaluation of 1054 patient charts and 100 random roentgenogram charts as well as clinical investigation of 39 patients. OBJECTIVES: Noncontiguous unstable spine fractures are rare, easy overlooked, and difficult to treat. The purpose of the study was to evaluate the delay in diagnosis and clinical and radiologic outcome of these fractures. SUMMARY OF BACKGROUND DATA: Noncontiguous spine fractures are reported in about 1.6-16.7% in the literature. In most of the studies stable fractures, which did not need any special treatment, were also included. Therefore, in this study only unstable fractures requiring treatment were reinvestigated. METHODS: A total of 1054 patients with fractures of the spine were treated over a period of 14 years in the spinal cord injury unit and retrospectively reviewed; 141 (13.4%) of the patients had multiple fractures, but only 39 (3.7%) had a noncontiguous spine fracture, most frequently from a fall or jump from a greater height, or traffic accidents. RESULTS: Thirty patients (76.9%) had all fractures diagnosed at the first examination. Nine patients (23.1%) had a delayed diagnosis of the secondary lesion, but this delay resulted in no neurologic deterioration. A total of 32 extraspinal injuries were diagnosed and treated 14 times surgically. Loss of correction was seen after surgical treatment (n = 21), and increasing deformity occurred after conservative treatment (n = 18). The neurologic deficit improved in 10 conservatively (4) and operatively (6) treated patients and deteriorated in one patient after surgery. CONCLUSION: A delayed diagnosis of the second fracture was frequently seen without clinical consequences, and neurologic improvement occurred after conservative and operative treatment. Surgical treatment resulted in significantly earlier mobilization and less kyphotic deformity.

Sacral bladder denervation for treatment of detrusor hyperreflexia and autonomic dysreflexia.

OBJECTIVES: Detrusor hyperreflexia after spinal cord injury may cause urinary incontinence and chronic renal failure. In patients refractory to conservative treatment and not eligible for ventral sacral root stimulation for electrically induced micturition, we investigated the therapeutic value of sacral bladder denervation as a stand-alone procedure. METHODS: Nine patients (8 men and 1 woman) between 21 and 58 years old (mean 30.2) with traumatic suprasacral spinal cord lesions underwent sacral bladder denervation for treatment of detrusor hyperreflexia and/or autonomic dysreflexia. RESULTS: Detrusor hyperreflexia and autonomic dysreflexia were eliminated in all cases. Bladder capacity increased from 177.8 +/- 39.6 to 668.9 +/- 64.3 mL; intravesical pressure decreased from 89.3 +/- 19.1 to 20.2 +/- 2.7 cm H(2)O. For facilitating clean intermittent catheterization (CIC), 4 patients received a continent vesicostomy in a second-stage procedure; one of them in combination with bladder augmentation. Four patients empty their bladder by way of urethral CIC. One completely tetraplegic patient has an indwelling urethral catheter. In the 5 patients with autonomic dysreflexia, the systolic blood pressure was lowered from 196 +/- 16.9 to 124 +/- 9.3 mm Hg and the diastolic blood pressure from 114 +/- 5.1 to 76 +/- 5.1. The annual frequency of urinary tract infections decreased from 9 +/- 1.2 to 1.8 +/- 0.7. In all patients, renal function remained stable. CONCLUSIONS: In selected patients with detrusor hyperreflexia and/or autonomic dysreflexia, sacral bladder denervation is a valuable treatment option. It is only moderately invasive in nature, requires neither sophisticated nor expensive medical equipment, and is an attractive alternative to urinary diversion using intestinal segments.

[Prevention of thromboembolism in spinal fractures with spinal cord injuries. Standard heparin versus low-molecular-weight heparin in acute paraplegia]. / Thromboembolieprophylaxe bei Wirbelsäulenfrakturen mit Rückenmarkverletzungen. Standard-Heparin versus niedermolekulares Heparin bei frischen Querschnittsyndromen.

In a prospective, randomized, open study, the therapeutic efficacy of a long-term prophylaxis with standard heparin (SH) was compared with that of low-molecular-weight heparin (LMWH) Dalteparin in 166 patients who had spinal fractures with spinal cord injury. 86 patients were treated with SH 2 x 7500 U s.c. and 80 patients were treated with LMWH 1 x 5000 anti-Xa U s.c. once daily. The screening was implemented by daily bedside-examination. In case of clinical thromboembolism-symptoms patients had confirmatory venography or lung scans. In the SH-group 12 (14.0%) patients had deep vein thrombosis and in the LMWH-group 6 (7.5%). Pulmonary embolism was detected two times in the SH-group (2.33%) and only one time in the LMWH-group (1.25%). A significant difference could not be shown, but is descriptive evident.

Urodynamic and rectomanometric findings in patients with spinal cord injury.

Patients with spinal cord lesion suffer from complex disorders of bladder and anorectal function. We assessed the value of urodynamics and anorectal manometry as prognostic and diagnostic tools in these patients and evaluated the usefulness of these techniques for the differentiation between complete and incomplete spinal cord lesions. Thirty patients with suprasacral spinal cord injury (six women, 24 men; mean age, 31 years) underwent anorectal manometry and urodynamics within the first 40 days after injury. The findings were compared to the results of a clinical neurologic evaluation. Fifteen patients were classified as complete lesions on their clinical signs, three of these lesions were incomplete according to urodynamic testing and five were incomplete according to visceral sensory testing by anorectal manometry. Despite significant differences in maximum bladder capacity (589 versus 465 mL), maximum detrusor pressure (18 versus 31 cm H2O) was not significantly different between patients with complete and patients with incomplete spinal cord injury. Anorectal manometry did not reveal any significant differences in resting pressure, abdominal pressure, and maximal rectum volume between these groups. Urodynamics and anorectal manometry may be superior to neurologic assessment of completeness of spinal cord lesions. Urodynamics and anorectal manometry were not helpful in the prediction of onset or severity of detrusor hyperreflexia. Thus, we do not regard anorectal manometry as a standard diagnostic tool in spinal cord injury patients.

Combined intravesical and oral oxybutynin chloride in adult patients with spinal cord injury.

OBJECTIVES: Detrusor hyperreflexia with elevated storage pressures presents a major risk factor for renal damage in patients with neurogenic lower urinary tract dysfunction. If standard anticholinergic treatment is unsuccessful, surgical treatment must be considered. We evaluated the effects of intravesical oxybutynin treatment on detrusor hyperreflexia in patients in whom standard oral treatment had failed. METHODS: Twenty-five patients (mean age 36. 7 years) with storage pressures greater than 40 cm H(2)O despite standard anticholinergic treatment received intravesical (15 mg three times daily) and oral oxybutynin chloride treatment. The follow-up evaluations included urodynamic testing, renal ultrasound, urine examination (urinalysis and urine culture), and evaluation of side effects. RESULTS: The mean follow-up was 6 months. Intravesical treatment led to an increase in bladder storage volume from 349 to 420 mL. The mean maximum storage pressure was significantly reduced from 54 to 26.5 cm H(2)O. Detrusor storage pressures returned to values less than 40 cm H(2)O in 21 of 25 patients. Dysreflexia was treated successfully in 3 of 5 patients. No patient developed renal damage. No severe side effects or drug-related discontinuation of treatment were observed. CONCLUSIONS: Intravesical oxybutynin therapy seems to be a safe and effective treatment option for detrusor hyperreflexia in adults and avoids surgical treatment in most patients. Long-term observations concerning side effects, acceptance, and efficacy are needed.

Post-traumatic syringomyelia.

Post-traumatic syringomyelia is estimated to develop in more than 20% of individuals with traumatic spinal cord injury (SCI). The development can give rise to clinical symptoms 6 months to 26 years after the injury, and presentation 40 years post-injury has been seen by one of the authors.1234 We present an unusual case for comments and discussion.

[Reconstruction of an extensive anterior tracheal defect in a tetraplegic patient during long-term ventilation by autologous cartilage clasps within a pectoralis major flap]. / Rekonstruktion eines ausgedehnten Trachealvorderwanddefekts bei beatmungspflichtiger Tetraplegie durch Pectoralis-major-Lappen und autologe Knorpelspäne.

Tetraplegic patients on permanent respirator therapy are likely to develop cuff related pressure ulceration of the trachea with subsequent tracheomalacia in the cuff level. Regional flaps for the reconstruction of anterior defects are insufficient due to the lack of rigidity and resulting intolerance of the cuff-pressure. Tracheal prostheses are not suitable in the inflammatory tissue in patients requiring continuous respirator therapy. A case report on a permanent reconstruction of an extensive anterior defect of the trachea employing a pedicled pectoralis--major flap incorporating autologous cartilage is presented. Due to "upside-down" rotation of the flap with the cartilage clasps implanted subcutaneously, an epithelialized reconstruction of the anterior tracheal wall was achieved in a length of 10 cm. Sufficient stability of this reconstruction is now given for 42 months.

Carotid and vertebral artery injury following severe head or cervical spine trauma.

In order to determine the frequency of neck vessel injuries, Doppler investigations were performed in 60 patients following either severe head injury (n = 29), cervical spine injury (n = 26), or combined head and cervical spine injury (n = 5). The majority of patients were referred to our hospital for early rehabilitation; before admission Doppler investigations had been performed in only 2 patients. Clinically, 3 patients sustained severe cerebral ischemia due to neck vessel trauma: 1 patient with left-sided ICA dissection after head trauma revealed Doppler abnormalities only in the early phase of the disease; the second patient demonstrated persistent Doppler abnormalities due to traumatic right-sided ICA and VA occlusion. The third patient sustained a fatal vertebral and basilar artery thrombosis following cervical spine injury. In 57 patients without clinical signs suspicious of neck vessel trauma, sonography revealed abnormalities in 3 patients (11%) with severe head injury and in 6 patients (20%) with cervical spine or combined head and spine injury, in both groups mainly related to the vertebrobasilar system. Neck vessel injury is probably an underdiagnosed complication of severe head or cervical spine trauma. Although interpretation of Doppler findings may be difficult, particularly in the vertebrobasilar system, Doppler investigations can be recommended as a screening method to exclude neck vessel injuries.

[Cerebral and basilar artery thrombosis following cervical spinal injury]. / Thrombose der Vertebral- und Basilararterie nach Verletzung der Halswirbelsäule.

Vertebral artery injury may complicate cervical spine injury and may result in severe neurological impairment. We present a case of a 54 year-old male who sustained a hyperextension injury of the neck during horse-back riding with cervical spine dislocation of C3/4. As a consequence of right-sided traumatic vertebral artery thrombosis and extension of the thrombus into the basilar artery the patient developed a brainstem and bilateral cerebellar infarction with fatal outcome. In a review of the literature the characteristics of 33 cases with vertebral artery injuries following cervical spine trauma and with associated neurological complications are described. The problems of vertebral artery injury are discussed concerning diagnosis and therapy.

Anorectal functions in patients with spinal cord injury.

We wished to establish anorectal functions in patients with spinal cord lesions, related to the level of lesion and its completeness. We also wished to determine the value of neurophysiological tests for completeness of transsections in comparison with manometry and visceral sensory testing. In 32 patients (31.5 +/- 14.1 years, 25 males) with spinal trauma, completeness of transsection was assessed clinically. In 16 of these patients (30 +/- 15.6 years, nine males), a neurological work-up included recording of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) from the pudendal nerve within the first week after trauma. Also, anal sphincter EMG and pudendal nerve terminal motor latency (PNTML) were assessed. All patients also underwent conventional anorectal manometry and visceral sensory testing. Of all 32 patients, 15 were judged as 'complete' based on their clinical signs. Of those 16 tested neurologically, seven were labelled 'complete' since no MEP or SEP were detectable; one had pudendal SEP and MEP present, while SEP were present but delayed (47.0 +/- 8.8 msec) in the remaining patients. In four of these patients, also MEP were recorded (27.9 +/- 5.2 msec) and normal. PNTML was present in 12/16 patients independent of the completeness of lesion, and was rated normal in nine and delayed in three patients. EMG was normal in five, and pathological in 11 cases. In 5/15 cases of those judged as 'complete' (in 3/7 evaluated neurologically), visceral sensory testing revealed a minimal threshold for rectal perception of distension of 44 mL (range: 10-130), which sometimes was also perceived as urge to defecate. In a further case, manometry showed major voluntary action of the anal sphincter. These patients had lesions at all levels of the spinal column, ranging from cervical (C4,C6,C7) via thoratical (2 x T7,T8,T12) to lumbar segments. Anorectal function testing, and specifically visceral sensory testing may be superior to neurological assessment of 'completeness' of spinal cord lesions. It may be that visceral afferent pathways others than spinothalamic tract are involved in rectal perception that are less accessible to conventional neurophysiological diagnostic work-up.

[Traumatic paraplegia. Possibilities of therapy and rehabilitation in a modern treatment center]. / Die traumatische Querschnittlähmung. Möglichkeiten von Therapie und Rehabilitation an einem modernen Behandlungszentrum.

After foundation of treatment centres for paraplegics using the concept of comprehensive care by Sir Ludwig Guttmann in 1943, the treatment goal includes the activation of the patient and the integration into society. This is achieved by the immediate admission for surgical treatment of the injured person into a specialized treatment centre which can guarantee all procedures of re-integration. This has to contain a comprehensive medical care including neurourological and physical therapy by using equipment and staff comparable to a hospital of maximum care. Simultaneously, all social and job related steps for integration have to be initiated. The concentration of all therapeutic options in one treatment centre moves the patient into the focus of interest and facilitates a cost-effective and quality oriented work for individual therapy concepts.

The surgical treatment of acute spinal paralysed patients.

Following the basic principles of Sir Ludwig Guttmann in respect of the comprehensive care and management of spinal cord injured patients, the German SCI centers try to admit those freshly injured preferably on the first day of onset, providing spinal surgery and intensive care. In our series of recent comprehensive spinal paralysed patients admitted from Jan 1st 1993 to Dec 31st 1995 178 patients requested operative decompression and stabilization out of a total of 255 patients. 51.4% of the patients had been operated within the first 24 h, but 10.5% later than 2 weeks. A high incidence of reoperations (45.2%) must be noted in cases operated prior to the admittance to the SCI center due to failures of instrumentation or lack of anterior reconstruction. Nineteen patients with various spinal tumors underwent surgical treatment, and seven patients with spondylitis and severe neurological deficit. Only 64.4% of the 1st day admissions came in time for administration of high dose methylprednisolone according to the NASCIS II study. The additional pelvic and long bone fractures were operated on following the principles of the Swiss AO, thus achieving immediate mobilization as was also possible after surgical spine stabilization. Neurological recovery could only be found in those with incomplete lesions in more than 50% but also two with neurological deterioration had to be accepted in the paraplegic cohort. Eight who were tetraplegic and 14 with paraplegia died within the first 3 months, but nine with paraplegia had a tumor or spondylitis.

Urodynamically controlled management of spinal cord injury in children.

Spinal cord injuries in children are relatively uncommon. However, infants with cervical spine injury have an especially high risk of renal damage. Six patients, 4 of them tetraplegic, aged 15 months to 8 years, were primarily treated by oral anticholinergic medication and intermittent catheterization. With this concept, satisfactory results were achieved in 4 of 6 children for a mean follow-up of 17.7 months. Mean bladder capacity increased by 128% and intravesical pressure was reduced by 35%. While all patients initially presented with a detrusor leak point pressure above 40 cm H2O, in 4 patients detrusor leak point pressure could be sufficiently reduced by initial treatment. One patient required intravesical instillation of oxybutynin; in another patient sphincterotomy was performed. No patient had signs of renal damage. In summary, even in tetraplegic infants, oral anticholinergic medication and intermittent catheterization is a safe and well-tolerated treatment.

The cost of ventilator-dependent spinal cord injuries-patients in the hospital and at home.

The number of ventilator-dependent SCI-patients is increasing steadily but also are the costs of adequate treatment in and outside hospital. Various technical aids for ventilation, mobility, nursing, and individual needs are available for a qualified life in the family, but the costs of these add up to $116.450. As phrenic nerve stimulators are very expensive, the cost for permanent ventilation cannot be reduced although diaphragmatic pacemakers have a real significant benefit for the patient's independence and quality of life. As the hospital charge is equal for all paraplegic, tetraplegic and ventilator-dependent patients including all medical and rehabilitative treatments, drugs and disposable materials, SCI-departments have a marked financial reduction of $481 daily compared with the amount of $1027 which has to be raised daily for the qualified care at home. This challenge can only be met by help from the community and from insurance companies and it is only then possible to provide these severely disabled patients with a good quality of life.

[Hyperbaric oxygen therapy--an adjuvant therapeutic procedure with problem cases in reconstructive bone surgery]. / Die hyperbare Sauerstofftherapie--Ein adjuvantes Therapieverfahren bei Problemfällen in der knöchernen Wiederherstellungschirurgie.

Prolonged and compromised wound-healing, i.e. in scar tissue or after irradiation, often causes problems, especially when free transplants, for example for bony reconstruction of the mandible after resection of tumor, are used. Hyperbaric Oxygen Therapy (HBO) means breathing of pure (100%) oxygen under increased athmospherical pressure. HBO induces high oxygen partial pressure in all tissues and also has an antioedematous effect, causes activation of fibroblasts and macrophages, stimulates angioneogenesis and has a bacteriostatic and bacteriocidic effect. We used HBO since 1991 in 27 patients, nine of them underwent bony reconstruction of the mandible. In our opinion HBO is a very helpful tool in the management of problem-wound-healing, assisting the classical surgical principles.

[Spondylodiscitis with spinal and radicular involvement. Limits of conservative treatment]. / Spondylodiszitis mit spinaler und radikulärer Beteiligung. Grenzen der konservativen Behandlung.

During 1988 to 1992 18 patients with spondylodiscitis and neurological deficits were treated in our clinic. Tuberculous spondylodiscitis was diagnosed in 4 patients and 14 suffered from non specific spondylodiscitis. The mean age was 59 years (range 25-77). 16 (89%) of the patients had risk factors like diabetes mellitus, genitourinary tract infection, respiratory tract infection, rheumatism, intervertebral disc operation and old spine fracture. MR-tomography revealed the most valuable diagnostic method. 14 patients with progressive spinal cord compression, and root lesions because of gross vertebral damage and epidural abscess underwent operative removal of the focus with intercorporal spondylodesis. Postoperative neurological examination revealed improvement in 7 and no changes in the other 7 patients. In 4 patients with non specific spondylodicitis and radicular deficits conservative treatment was performed and spontaneous interbody fusion without persisting neurological complaints occurred.