Long-term follow-up study of outcomes of bladder management in spinal cord injury patients under the care of the Midlands Centre for Spinal Injuries in Oswestry.

STUDY DESIGN: Retrospective longitudinal study of short- and long-term urinary complications in chronic spinal cord injury (SCI) patients managed at the Midlands Centre for Spinal Injuries (MCSI). SETTING: MCSI, Oswestry, UK. METHOD: A total of 185 SCI patients were admitted to the MCSI between 1984 and 1989. Only 119 patients who met the following criteria were included: traumatic SCI, Frankel grade A-D, admission within 6 weeks post injury, regular annual follow-up or alternate year at MCSI, follow-up longer than 8 years. Follow-up ranged between 8 and 21 years with a mean of 17.7 (s.d.=1.98). The method of bladder drainage varied from the time of injury. Drainage was by indwelling urethral catheterisation (IndUC) before admission to the MCSI. Within 24 h of admission, assisted clean intermittent catheterisation (ACIC) by the nursing staff was commenced. This was followed by clean intermittent self catheterisation (CISC) once the patient was mobilised in the wheel chair and trained in the procedure. When detrusor reflex activity develops, patients with good hand function were given a choice between CISC and reflex voiding (RV). Patients with poor hand function are given the choice between RV, suprapubic catheters or ACIC during hospitalisation and after discharge. Only a minority of these patients choose ACIC following discharge. RV was supplemented occasionally by sphincterotomy. There were 99 males and 20 females (5:1). The age at the time of injury was 16-63 years with a mean of 29 (s.d.=12). Instead of a single method, a pattern of bladder management was analysed in the context of three continuous phases: Phase1 preadmission to MCSI. Phase2 during first hospitalisation at MCSI. Phase3 post discharge. In each phase, the patients were divided into those with and without complications. The complications were analysed in relation to the management and other relevant factors. RESULTS: The total complication rate at all stages was 62%. Complications of the upper urinary tract accounted for 22.6%. These results compared favourably with published material. CONCLUSION: The sequential system of supervised bladder management commencing with brief IndUC followed by IntC and/or RV remains effective in keeping the complication rate relatively low in SCI patients, who undergo regular surveillance and timely intervention. SPONSORSHIP: The project was supported by SPIRIT, a charitable not for profit trust that supports teaching, training, clinical research and dissemination of knowledge about all aspects of spinal paralysis in the UK.

A review of published reports on neuroprotection in spinal cord injury.

STUDY DESIGN: Literature review. OBJECTIVES: To review the main published current neuroprotection research trends and results in spinal cord injury (SCI). SETTING: This paper is the result of a collaboration between a group of European scientists. METHODS: Recent studies, especially in genetic, immune, histochemical and bio (nano)-technological fields, have provided new insight into the cellular and molecular mechanisms occurring within the central nervous system (NS), including SCIs. As a consequence, a new spectrum of therapies aiming to antagonize the 'secondary injury' pathways (that is, to provide neuroprotection) and also to repair such classically irreparable structures is emerging. We reviewed the most significant published works related to such novel, but not yet entirely validated, clinical practice therapies. RESULTS: There have been identified many molecules, primarily expressed by heterogenous glial and neural subpopulations of cells, which are directly or indirectly critical for tissue damaging/sparing/re-growth inhibiting, angiogenesis and neural plasticity, and also various substances/energy vectors with regenerative properties, such as MAG (myelin-associated glycoprotein), Omgp (oligodendrocyte myelin glycoprotein), KDI (synthetic: Lysine-Asparagine-Isoleucine 'gamma-1 of Laminin Kainat Domain'), Nogo (Neurite outgrowth inhibitor), NgR (Nogo protein Receptor), the Rho signaling pathway (superfamily of 'Rho-dopsin gene-including neurotransmitter-receptors'), EphA4 (Ephrine), GFAP (Glial Fibrillary Acidic Protein), different subtypes of serotonergic and glutamatergic receptors, antigens, antibodies, immune modulators, adhesion molecules, scavengers, neurotrophic factors, enzymes, hormones, collagen scar inhibitors, remyelinating agents and neurogenetic/plasticity inducers, all aiming to preserve/re-establish the morphology and functional connections across the lesion site. Accordingly, modern research and experimental SCI therapies focus on several intricate, rather overlapping, therapeutic objectives and means, such as neuroprotective, neurotrophic, neurorestorative, neuroreparative, neuroregenerative, neuro(re)constructive and neurogenetic interventions. CONCLUSION: The first three of these therapeutical directions are generically assimilated as neuroprotective, and are synthetically presented and commented in this paper in an attempt to conceptually systematize them; thus, the aim of this article is, by emphasizing the state-of-the art in the domain, to optimize theoretical support in selecting the most effective pharmacological and physical interventions for preventing, as much as possible, paralysis, and for maximizing recovery chances after SCI.

Multilevel spinal injuries. Incidence, distribution and neurological patterns.

Spinal injury at more than one level is not uncommon. Awareness of multilevel injury of the spine and associated neurological patterns is important for the proper initial management of the patient. This study presents the incidence, pattern of signs and the neurological consequences of multilevel spinal injury. A review of 935 patients with spinal injuries revealed that lesions occurred in multiple levels in 9.7%; in over half of the cases, neurological lesions were incomplete. Multiple level non-contiguous lesions at more than two levels had the worst prognosis with 70% of patients suffering complete paraplegia.

Minitracheotomy in the early respiratory management of patients with spinal injuries.

Minitracheotomy is a new technique of tracheal suction by the introduction under local anaesthetic of a small bore tube into the trachea through the cricothyroid membrane. The use of minitracheotomy in the early management of respiratory problems in patients with spinal injuries is described with a few illustrative cases. This technique is an adjunct to good physiotherapy in clearing secretions from the trachea. Its advantages and disadvantages are discussed.

A clinical review of the adult hip guidance orthosis (Para Walker) in traumatic paraplegics.

Twenty Adult traumatic paraplegics with neurologically complete lesions between C8 and T12 have ambulated using a ParaWalker (adult hip guidance orthosis), for a minimum of 6 months at home. At follow up, on average 20 months from the date of issue of the orthosis, 17 patients (85%) were still regularly using their ParaWalker. Patients achieved independent use of the orthosis and low energy ambulation both indoors and outdoors on a variety of surfaces. A new classification of adult paraplegic ambulation using an orthosis is described.

Augmentation of the Oswestry Parawalker orthosis by means of surface electrical stimulation: gait analysis of three patients.

The Oswestry 'Parawalker' orthosis has been supplied to 15 adult thoracic level complete paraplegic patients enabling them to achieve a reciprocal gait with an inherent low energy demand. In order to further off-load the work demands on the upper limb girdle musculature during ambulation, three of these patients have undergone electrical stimulation of the gluteal muscles in stance phase. This was shown to increase the stability of the adduction and also provided forward propulsion by driving the stance-leg into extension. Bilateral stimulation of the quadriceps muscles has been shown to facilitate standing and sitting in the orthosis. Using a Kistler force platform, the crutch impulse can be seen to be reduced by as much as 36%. We speculate that this leads to a similar order of reduction in the work done by the upper limbs in these patients.

Fractures of the sternum associated with spinal injury.

Twelve cases of sternal injury associated with spinal fractures have been reviewed. The sternum is regularly buckled or fractured in patients with high thoracic spinal fractures. Our review suggests that sternal injuries may also be associated with spinal fractures outside this region, and with types of fracture other than crushing of vertebral bodies. Injury to the sternum, when due to indirect violence, is almost always associated with a severe spinal column injury. A displaced fracture of the thoracic spine, with or without an associated sternal fracture, can produce significant widening of the mediastinal shadow on a chest radiograph. This is caused by a paravertebral haematoma, and can be difficult to differentiate from widening due to an aortic rupture.

Prophylactic anticoagulant therapy in patients with spinal cord injury.

One hundred and two consecutive acute traumatic spinal injury patients admitted between 1976 and 1979 to a male ward at Stoke Mandeville Hospital were considered for prophylactic anticoagulant therapy. Sixty-six were anticoagulated. Thirty-six were not due to various contra-indications. Nineteen patients had pulmonary emboli. None of these were effectively anticoagulated. These results are compared with a similar previous series where there was a smaller incidence of emboli. The main reason for this was due to the delay in admitting patients to the Centre so that they could not be anticoagulated early enough to prevent pulmonary embolus occurring. In these patients who had a pulmonary embolus or were considered to be a high risk, anticoagulant therapy was continued for 6 months.

Bladder cancer after spinal cord injury.

We reviewed 25 patients who developed carcinoma of the bladder following spinal cord injury among a series of 6744 paraplegic and tetraplegic patients. An analysis of the incidence, presentation, possible predisposing factors and prognosis was carried out. The majority presented at a younger age and there was a significantly higher incidence of squamous carcinoma than in the non-paraplegic population. The anterior bladder wall was involved in about 25 per cent of the cases. The prognosis is poor.