An unusual presentation of gluteal hematoma during anticoagulation therapy for deep venous thrombosis in spinal cord injury.

Soft tissue bleeding can be manifested clinically by swelling, skin discoloration, pain and tenderness. Early recognition can be difficult in the spinal cord-injured population in whom sensation is impaired. We are presenting a case of occult bleeding into the gluteal region during anticoagulation therapy in a paraplegic patient that presented as migrating pain and tenderness in the hip and pelvic area.

Ground reaction forces, center of pressure, and duration of stance with and without an ankle-foot orthosis.

We analyzed the effects of an ankle-foot orthosis (AFO) on the ground reaction forces, the position of the center of pressure, and the timing of stance phase events during walking in 18 healthy volunteers between the ages of 19 and 38 years. The magnitude and direction of the ground reaction forces and the locus of the center of pressure were recorded every one-sixtieth of a second during free-speed ambulation. The horizontal force components of the ground reaction force were plotted vectorially, and the vertical force component was displayed by its magnitude expressed in percentage body weight. All this information was superimposed on the subject's footprint and statistically analyzed, comparing right to left, narrow to wide, and ipsilateral to contralateral use of an AFO. The results showed a significant reduction in the mean duration of the stance phase of 4.83% (p less than 0.05) with the AFO. This reduction was due primarily to the significant reduction during midstance of 7% (p less than 0.025), which was more pronounced with the use of the wide AFO. Using an AFO also resulted in a mean increase of 20% (p less than 0.05) in the vertical force magnitude at the end of push-off. With the use of an AFO, there was a shift of the point of impact at heel strike to a more posterior location and a shift of the trajectory of the center of pressure to a more lateral position throughout the stance phase. These changes should be kept in mind when prescribing an ankle-foot orthosis.

Posttraumatic syringomyelia associated with heavy weightlifting exercises: case report.

Posttraumatic syringomyelia is a well-recognized late sequel to spinal trauma occurring in 1% to 3.2% of spinal cord injured patients. Its clinical presentation is usually marked by pain, ascending sensory loss, increased muscle weakness, and depressed deep tendon reflexes. The case of a 25-year-old man with C8 complete quadriplegia, who developed a syrinx five years after his initial injury, is presented. This patient kept a log of his daily physical workout which consisted of lifting weights of 50 to 60 pounds with his neck extensors and biceps. The diagnosis was made clinically and confirmed by magnetic resonance imaging. Repeated valsalva maneuvers from daily heavy weightlifting exercises most likely predisposed this patient to the development and extension of his syringomyelia. Dramatic improvement followed surgical placement of a subarachnoid shunt.

The value of the ice water test in the management of the neurogenic bladder.

Ice water tests (IWT) and gas cystometrograms were performed on 30 consecutive spinal cord injury in-patients on an intermittent catheterization program over a 6-month period. The tests were used to determine the presence of bladder reflex activity. A three-step grading system was formulated to clinically determine the degree of detrusor reflex activity on IWT. A 3+ IWT was used to indicate the expulsion of the catheter from the bladder and urethra following instillation of recently thawed ice; a 2+ IWT meant voiding around the catheter after instillation of 90 ml of ice water; and a 1+ IWT indicated voiding around the catheter after instilling a total of 300 ml of ice water into the bladder. The study shows that the ice water test was more sensitive test than CO2 cystometrogram in detecting the presence of detrusor reflex activity.

Superior mesenteric artery syndrome after resection of an arteriovenous malformation in the cervical cord.

Any disease process decreasing the angle between the superior mesenteric artery and the abdominal aorta can result in the external compression of the duodenum and subsequent intestinal obstruction. This unusual type of intestinal obstruction known as superior mesenteric artery syndrome is a well-recognized clinical entity. It is diagnosed radiologically by an abrupt, vertical cutoff of barium flow in the third portion of the duodenum. The management is primarily medical but occasionally surgical correction is required. Herein, the diagnosis of superior mesenteric artery syndrome was made in an incomplete quadriplegic woman who had recently undergone surgical resection of an arteriovenous malformation in the cervical cord. This case was managed successfully with gastrointestinal decompression, proper positioning in the side-lying position, and adequate nutrition.

Pneumatosis cystoides intestinalis in quadriplegia: a case report.

Pneumatosis cystoides intestinalis is an uncommon clinical entity with nonspecific symptomatology of the gastrointestinal system. Its diagnosis is made by radiologic demonstration of multiple gas-filled cysts in the submucosa or subserosa of the intestinal tract. There are two major clinical types--idiopathic and secondary. A case report of a spinal cord injured patient with this condition is presented. Since gastrointestinal disturbances are common in spinal cord injured patients, health care professionals should be aware of this condition. Identification of pneumatosis cystoides intestinalis is important since it represents a benign condition and usually requires no treatment.

Burns in functional electric stimulation: two case reports.

Electric stimulation of nerve and muscle is a widely used procedure for diagnosis and therapy in spinal cord injured patients. Damage from such stimulation can occur in the form of tissue burns. Two cases of burns in spinal cord patients receiving functional electric stimulation are presented. It is concluded that to avoid burning of tissue: a stimulating electrode with a large surface should be used; uniform contact between the electrode and the skin should be insured; a good conducting-material interface between the electrode and skin is required; adequate ventilation for heat dissipation should be provided; sharply cut electrode corners, wire insulation damage, and cuts in lead wires must be avoided.

Integrated communication/environmental controller system for the physically disabled.

A wireless integrated communication/environmental controller system (ICECS) is described, which offers total communication as well as environmental control for the disabled person. The system is flexible and simple enough to be used from the wheelchair by patients with spinal cord injuries. The system has three parts: the mobile unit, the base unit, and a set of remote-control receiver modules. The mobile unit and the base unit are linked together by radio, while the base unit and the remote receiver modules communicate over a power line carrier. The telephone mode allows telephone calls to be placed and received. Different electrical devices are controlled by the environmental control mode. The intercom mode permits two-way communication with an attendant or the nursing station. The modes can be switched simply by pressing a button on the mobile unit. Sixteen soft-touch switches arranged in a 4 X 4 matrix allow operation by hand or mouthstick.

Ground reaction forces during ambulation in parkinsonism: pilot study.

Gait abnormality in parkinsonism is unique and easily recognizable. A pilot study was designed at our Human Gait Laboratory to learn how this gait abnormality is reflected in ground reaction forces of patients with parkinsonism. The system permitted the collection of kinematic and force data from a subject in real time. Analysis showed an abnormality in the vertical force (Fz) component, the second peak being significantly reduced in size, with asymmetry in the duration of the stance phase. These abnormalities were also reflected in the stance phase and in the angular changes in the knee. Similar analyses should be helpful in following the progress of the disease.

Ultrasound therapy: a comparative study of different coupling media.

Four different materials, water, oil, gel, and silicon, were considered for their relative efficiency as coupling media for ultrasonic therapy. The power loss (attenuation) as a function of distance in each medium was experimentally studied. The degree of impedance match (power reflection into the transmitter) between the medium and transducer head was also determined by measuring the standing wave ratio. The results of the study indicated that oil and water have a large degree of attenuation as well as poor impedance match with the sound head. Gel offered a smaller degree of attenuation and better impedance match. Silicon appeared to offer little attenuation but the encasing material has so much impedance mismatch with the sound head that very little power is transmitted into the silicon medium. For future automated clinical applications, the use of encased silicon such as is used for breast implant is proposed, if mismatch is reduced.

Esophagocutaneous fistula in spinal cord injury: a complication of anterior cervical fusion.

Esophageal perforation can be a difficult management problem in a patient with spinal cord injury. Meticulous history taking and physical examination are essential for diagnosis. A quadriplegic patient with the unusual complication of esophagocutaneous fistula following anterior cervical fusion was admitted to our spinal cord injury service for intensive rehabilitation. Although early surgery is the usual treatment, conservative management with emphasis on local wound care can lead to satisfactory healing of the fistula. Because of the halo vest traction device used to maintain the surgical reduction of the cervical fracture, it was decided to treat the patient's fistula conservatively. Difficulties with feeding, diarrhea, and recurrent drainage that complicated the nonoperative treatment were successfully managed while the patient underwent intensive and comprehensive rehabilitation. The patient was discharged ambulating independently without any orthotic device a day after complete closure of the esophagocutaneous fistula.

Pseudomembranous colitis in spinal cord injury.

Pseudomembranous colitis is a well-known disease associated with antibiotic administration and caused by the Clostridium difficile toxin. Clinical presentation is usually marked by watery diarrhea, crampy abdominal pain, and fever. Since early appropriate therapy can reduce morbidity and mortality, it is important for health care professionals to be aware of this disease. Patients with spinal cord injury have a relatively high incidence of respiratory and urinary tract infections that are treated with antibiotics. Therefore, these patients theoretically have a higher risk of contracting pseudomembranous colitis. This article presents a case report of a spinal cord injured patient with this disease who has several of the common difficulties encountered in the diagnosis and treatment, such as indeterminate assays and relapses. The clinical presentation, diagnosis, and treatment of pseudomembranous colitis are described.

Micturition alert device.

The determination of an accurate postvoid residual (PVR) is essential to a successful intermittent catheterization program. A light (40g), simple electronic device that alerts the hospital staff by means of a buzzer or an LED, when a patient is voiding, is described.