Peripheral nervous system involvement in chronic spinal cord injury.

INTRODUCTION: Upper motor neuron disorders are believed to leave the peripheral nervous system (PNS) intact. In this study we examined whether there is evidence of PNS involvement in spinal cord injury (SCI). METHODS: Twelve subjects with chronic low cervical or thoracic SCI were included prospectively. Needle electromyography was done in 10 different muscles in each subject bilaterally. Nerve conduction studies (NCS) were conducted in the fibular, tibial, and femoral motor and fibular and sural sensory nerves. RESULTS: Half the subjects had widespread abnormal spontaneous activity (SA), and the amount of SA correlated inversely with reflex activity and nerve length. Fibular nerve entrapment across the knee was seen in 6 subjects, and sciatic nerve entrapment was seen in 1. Apart from entrapment neuropathies, NCS changes were found predominantly in motor nerves. CONCLUSION: The presence of widespread electrophysiologic changes outside entrapment sites indicates that SCI has a significant impact on the entire PNS, affecting the motor part predominantly.

The artificial somato-autonomic reflex arch does not improve lower urinary tract function in patients with spinal cord lesions.

PURPOSE: The artificial somato-autonomic reflex arch (Xiao procedure) was proposed as treatment for neurogenic bladder dysfunction. We investigated the effects of the procedure on lower urinary tract function. MATERIALS AND METHODS: Seven and 3 patients with a median age of 46 years (range 19 to 64) had AIS A and B spinal cord injury, respectively. In these patients an anastomosis was created between the ventral (motor) part of L5 and the ventral part of the S2 root. Urodynamics were performed and a standard questionnaire was completed at baseline and 18 months postoperatively. RESULTS: Artificial reflex arch stimulation did not initiate voiding or increase bladder pressure. Maximum bladder capacity did not change significantly from baseline to followup (median 427.5 ml, range 168 to 581 vs 498.5, range 271 to 580, p = 0.09). Likewise, bladder compliance did not significantly differ at baseline and followup (median 16.9 ml/cm H2O, range 15.0 to 65.0 vs 25.1, range 17.5 to 50.0, p = 0.95). No difference was found in awareness of bladder emptying, incontinence episodes, bladder emptying method or medication use for neurogenic bladder dysfunction. The only statistically significant change was a decreased incidence of leakage at followup on urodynamics (p = 0.03). Postoperatively decreased genital sensation and erectile dysfunction developed in 1 patient and another experienced a minor cerebrovascular accident with no long-term complications. CONCLUSIONS: In contrast to earlier findings, creation of an artificial somato-autonomic reflex arch in patients with spinal cord injury had no clinically relevant effect on lower urinary tract function.

A novel microsurgical method for the treatment of spinal nerve root cysts.

INTRODUCTION: The treatment of spinal nerve root cysts is not uniform. In the past decades, microsurgical resection to preserve nervous tissue has been reported. We report on our microsurgical method and present the clinical results in relation to surgical outcome. MATERIAL AND METHODS: Retrospective review of a consecutive series of patients who underwent surgical cyst closure from 2006 to 2010. RESULTS: Twelve patients, all female, with a total of 23 cysts underwent surgery for 20 symptomatic cysts. The mean age was 45 (range 13-75) years. Following treatment with this procedure, 95% of the cysts were closed and 5% had notably diminished at post-operative magnetic resonance imaging. Clinical improvement was seen in 67% of the patients; one improved temporarily, two remained unchanged and one had worsened at the last follow-up. The mean post-operative follow-up period was 11 (range 3-19) months. Clinical outcome was associated with none of the pre-operative parameters, i.e. pain-provoking postural position, cyst size, number of treated cysts, educational level or pre-operative sick leave. CONCLUSION: We find that our surgical technique is suit-able for closure of spinal nerve root cysts; however, the clinical outcome after surgery was sub-optimal according to preoperative clinical judgement. Consequently, we have established a dedicated outpatient clinic that performs extensive pre-operative assessment and investigation of patients with symptomatic spinal nerve root cysts. We hereby hope to improve surgical outcome in the future.

[Surgical reinnervation with nerve anastomosis technique for neurogenic bladder and bowel dysfunction]. / Kirurgisk reinnervation med nerveanastomoseteknik har potentiale til behandling af neurogen blære- og tarmdysfunktion.

Neurogenic bladder and bowel dysfunction are among the major problems faced by patients with spinal cord injury and myelomeningocele. New treatment modalities enforcing more natural patient control of voiding and defecation are therefore appealing. We present a historical review of crossover surgery as treatment for such deficiencies and, further, describe the principles as well as the documentation for modern surgical intervention in the form of a somato-autonomic reflex arch.

Decreased incidence of myelomeningocele at birth: effect of folic acid recommendations or prenatal diagnostics?

PURPOSE: In Denmark, prevention to reduce the spina bifida birth rate has focused on two areas: folic acid supplementation (1997) and changes in the national ultrasonography screening programme (2004). Myelomeningocele (MMC) is the most severe malformation among the spina bifidas. Taking into consideration the potential negative effect of high-dose folic acid consumption, we found a need to look into the effectiveness of these two strategies in our complete MMC population. METHODS: All spina bifida patients born in the western part of Denmark are differentiated into proper subgroups based on MR imaging, giving us a unique chance to study a true MMC population. The total number of the group of MMC children since 1983 is 121. One hundred and eight (89%) parents answered a questionnaire. RESULTS: Following the changes in the prenatal ultrasonography screening programme in 2004, a significant decline of 60% live birth MMC per year was noted, incidence rate ratio (IRR) = 40% (22-73%), p = 0.3%. We found no change in MMC birth rate after introduction of folic acid supplementation, IRR = 121% (81-181%), p = 36%. CONCLUSION: Our findings demonstrate no effect of folic acid recommendation due to lack of compliance among women of reproductive age in Denmark. However, we found an improved early detection rate of prenatal MMC by high-quality ultrasonography. Subsequent early termination of pregnancy has led to a significant reduction of birth rate of babies with MMC.

Polymicrobial subdural empyema: involvement of Streptococcus pneumoniae revealed by lytA PCR and antigen detection.

The authors report a case of a subdural empyema (SDE) caused by a coinfection with Streptococcus intermedius and Streptococcus pneumoniae, initially considered a S. intermedius infection only. An otherwise healthy 11-year-old female was admitted to the hospital after 5 days of illness. Symptoms were consistent with classical SDE symptoms and progressed rapidly with finally somnolence before the first neurosurgical procedure despite relevant antibiotic treatment. Primary MRI showed an interhemispheric SDE and a postoperative control CT scan showed progression of the empyema infratentorially. The empyema was evacuated twice, day 8 and 18, with good results. Primary samples showed growth of S. intermedius only. The severity of the clinical picture elicited supplementary samples, which were additionally positive for S. pneumoniae by an in-house specific lytA PCR and/or a commercial antigen test.

[Prolonged symptoms following mild traumatic brain injury]. / Langvarige symptomer efter commotio cerebri.

INTRODUCTION: Patients with mild traumatic brain injury (MTBI) do not undergo consistent follow-up in Denmark and the risk factors for long-term symptoms are not fully known. The purpose of this study was to look into symptom frequency, sick-leave frequency and to try to identify risk factors for long-term symptoms following MTBI. MATERIAL AND METHODS: Patients were recruited from the emergency room at Viborg Hospital. Initial data were registered and telephone interviews were conducted one month and one year after trauma. RESULTS: 60% were asymptomatic within the first month; an additional 11% became asymptomatic within the next year, leaving 29% with residual symptoms one year after trauma. 70% reported a sick leave period < 2 days, 19% > one month and 2% > one year. The average trauma-to-emergency room contact reached 158 min (median 65 min). Gender, age, blood pressure (BP), pulse, Glasgow coma score (GCS), admission to hospital, unconsciousness, amnesia, alcohol intake, time or type of trauma were not associated with long term symptoms. CONCLUSION: Even patients with minor head trauma have a relatively high risk of long-term symptoms regardless of gender, age, BP, pulse, GCS, admission to hospital, unconsciousness, amnesia, alcohol intake, time or type of trauma. Nevertheless, the risk of long-term sick leave is relatively small.

A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics.

PURPOSE: We aim to correlate the frequency of infections after ventriculoperitoneal (VP) shunt placement in neonates with myelomeningocele (MMC) who did not receive prophylactic antibiotics to the timing of VP shunt placement and the frequency of cerebrospinal fluid (CSF) leakage at the MMC wound. METHODS: Fifty-nine newborns with MMC underwent VP shunt insertion in the period 1983-2007. We reviewed retrospectively all records. RESULTS: After MMC closure, 24 out of 59 newborns had an infection. The relative risk (RR; 95%) of having an infection is significantly higher [RR = 4,69 (1.145397-19.23568; P = .03761817)], and neuroinfection showed a tendency towards RR = 3.5 (.7067445-17.03112; P = .15414095) in newborns without symptomatic hydrocephalus at birth when we had a wait-and-watch policy (late shunt placement) compared with newborns with prompt shunt placement. The RR (95%) of having an infection [RR = 6,8 (3.314154-13.95228; P = 1.235e-07)] and also neuroinfections [RR = 4,76 (2.043019-11.09025; P = .00044478)] was highly significant if the child presented with MMC wound with CSF leakage before VP shunt insertion (Table 3). CONCLUSIONS: Centers with a conservative antibiotic policy should be even more careful to avoid CSF leakage before shunt placement as this gives a highly significant increased risk of both infections in total and neuroinfections, and they should reconsider this conservative policy in newborns with MMC due to the significantly high infection rate.

Folic acid supplementation in pregnant women.

INTRODUCTION: Folic acid (FA) deficiency is associated with neural tube defects (NTD). In a non-risk pregnancy, The Danish National Board of Health recommends FA supplementation from planned pregnancy until three months after conception. We explored pregnant women's knowledge about and actual supplementation with FA and related this to education, number of pregnancies and age. MATERIAL AND METHODS: Eighty-four consecutive pregnant women with a midwife consultation were included in the period 25-28 August 2008. All filled in a unified questionnaire. RESULTS: 82% had knowledge of FA supplementation and 89% received FA supplementation. 51% followed national recommendations. We found a statistically significant correlation between higher educational level and knowledge about FA supplementation, actual supplementation of FA and FA supplementation in accordance with national recommendations. No statistical associations were found between number of pregnancies or age and any FA-related parameters. Family, friends, general practitioner (GP) and the internet were the main information sources. CONCLUSION: Correct FA supplementation is quite low; conversely, knowledge about and actual FA supplementation are fairly high. Further intervention is necessary to increase the level of correct FA supplementation. Women with a low educational level--which may herald low socio-economic status--seem to form a suitable target group for information campaigns. Multiple pregnancies or higher age should not be perceived as indicators of a higher information level. Dissemination of information to the pregnant women including family, friends, GPs or the internet is recommended.