Elbow extension and flexion-supination deformities in tetraplegia.

This paper demonstrates the flexion-supination and extension deformities of the elbows in complete tetraplegics and describes the outcome of simple treatments. The principal conclusion is that these two deformities are easily corrected by very simple methods. After treatment the patients could fully extend and flex their elbows and fully supinate and pronate their forearms. One of 11 patients, whose bilateral deformities kept recurring, was a failure.

Tendon transfers in tetraplegic patients: the Cleveland experience.

The author has taken care of patients with spinal cord injury for over 30 years. A major part of these years was spent doing tendon transfers on the patients with tetraplegia. Thirteen were not better, but not worse out of the 285 patients who had an operation. All of the patients have had a period of rehabilitation, waited 1 year following spinal injury, and had a stable neurological examination. The goals of the surgery were wrist extension, elbow extension, thumb pinch, and finger grasp. This was based on the author's classification of the characteristic muscle strengths that are present in the completely paralysed tetraplegic patient. One group of patients had weak or no wrist extension. These patients needed a transfer of the brachioradialis to the extensor carpi radialis brevis. Some of these patients required a posterior deltoid transfer to act as an obstacle to the brachioradialis. The next group of patients had no elbow extension, but had brachioradialis and two radial wrist extensors. They required a posterior deltoid transfer, and an opponens transfer and a transfer to give finger flexion. The next group had elbow extension, brachioradialis, two radial wrist extensors and a pronator teres, and needed an opponens transfer, and a transfer to give finger flexion. The last group of patients had poor or no opposition, and required an opponens transfer.

Gaining independence in tetraplegia. Cleveland technique.

Considerable independence can be achieved by four simple operations that can be done for patients with tetraplegia. Transfers for wrist extension were done 17 times. Posterior deltoid transfers were done 59 times. Opponens transfers were done 112 times. Transfers for finger flexion were done 88 times. Opponens and finger flexion transfers should be done at the same time. There were 22 other operations done. The patients with C6, C7, and C8 complete neurologic motor levels were almost as independent after their tendon transfers as paraplegics. They could transfer from a chair, insert a catheter, write, type, hold a book, take care of their toilet needs, bathe themselves, eat food and drink, dress themselves, and perform other activities of daily living. The few patients with a C5 neurologic level that was surgically treated for wrist extension acquired automatic grasp or used a wrist driven splint. A posterior deltoid transfer was not done on any of the patients with a C5 neurologic level but it is recommended now.

Limb fractures in patients with spinal cord injury.

Limb fractures that occur late in patients with spinal paralysis are considered to be different enough to warrant variations in treatment. In the author's experience, treatment ensures that the functional level is unchanged when healing occurs. Treatment includes use of splints, made of soft materials, that are effective, inexpensive, safe, and allow for good healing. There is motion at the fracture site but, in the author's experience, healing occurs in all fractures except those at the femoral neck. Treatment with soft materials is the least expensive treatment method because it does not require hospitalization, surgery is not recommended, the bone is so soft and pathological that it does not hold firmly with internal fixation, rehabilitation is simplified.

Tendon transfers in patients with cervical spinal cord injury.

Between 1983 and 1988, 32 patients with cervical spinal cord injuries underwent 124 upper limb tendon transfers during 85 procedures. Of the numerous surgical procedures that have been recommended for treatment of this condition, my experience indicates that the most successful are posterior deltoid-to-triceps transfer, restoration of finger flexion, and restoration of thumb opposition. Longitudinal incisions prove to be quite cosmetic.

The team approach to urinary bladder management in spinal cord injury patients: a 26-year retrospective look at the Highland View Hospital Urinary Catheter Care Team.

The Highland View Hospital Urinary Catheter Care Team was organised in 1962, primarily in response to the problems of increasingly drug resistant urinary infections and their complications in a chronic disease population which included patients with strokes, renal and liver failure and heart disease as well as those with spinal cord injury (SCI). When the spinal cord injury centre was formed in 1970 the team became an integral part of the service. The early problems in organising the team, its evolution into a valuable, economically viable, patient care service and its role in urological clinical research, are discussed.

Intraoperative assessment of wrist extensor muscle force.

Surgical restoration of hand grasp in the patient with spinal cord injury at the sixth cervical level often involves use of one of the two radial wrist extensors. Because the loss of the remaining wrist function would be devastating, it is important to establish techniques for quantitatively predicting postoperative function before tendon transection. An in situ method has been developed for determining muscle strength during tendon transfer surgery. Buckle transducers are placed on the tendons of the extensor carpi radialis brevis and longus for simultaneous measurement of strength of each individual muscle during voluntary and/or electrically stimulated extension of the wrist. The measured strength of the extensor carpi radialis brevis is examined to determine whether sufficient wrist extension torque would remain if the long wrist extensor is transferred. This technique allows accurate measurement of the force developed in any voluntarily activated muscle that has a long tendon of insertion.

New concepts on treatment of the upper limb in the tetraplegic. Surgical restoration and functional neuromuscular stimulation.

Today, many tetraplegics benefit from surgical restoration of hand function. New concepts of functional neuromuscular stimulation are impacting the care of those patients who are more severely paralyzed and are unable to benefit from surgery alone. Grasp, pinch, wrist extension, and elbow extension restoration are now possible.

The brachioradialis: anatomy, properties, and value for tendon transfer in the tetraplegic.

We have studied the brachioradialis muscle both physiologically and clinically for its suitability for tendon transfer in the tetraplegic. Intraoperative measurements have shown that the muscle is strong, provides excellent excursion, and is commonly available for transfer in the absence of other candidate muscles. The anatomic features that limit its use can be overcome during the operation. Postsurgical assessment of the muscle using electromyography and muscle-force measurement have shown that the muscle is voluntarily activated and provides strength for the intended function. Our experience with transfer of the brachioradialis to the hand of a tetraplegic patient has been highly positive.

The posterior deltoid to triceps transfer: a clinical and biomechanical assessment.

Transfer of the posterior deltoid muscle to the triceps insertion for elbow extension provides improved function in patients with C5 and C6 level tetraplegia. We have modified the surgical technique using the tibialis anterior tendon as a graft. The length-tension characteristics and available amplitude of the posterior deltoid muscle were determined with intraoperative electrical stimulation. The excursion of the posterior deltoid muscle was 7.31 cm with a standard deviation of 1.23 cm. Postoperative mean torque measurements of elbow extension power were 36.4 kg cm with a standard deviation of 15 kg cm. All patients had maximal strength between 90 degrees and 120 degrees of elbow flexion. Length-tension curves for the posterior deltoid muscle showed a large range of effective strength and helped confirm optimum tension of the posterior deltoid muscle and proper shoulder and elbow positions at surgery. Clinical results in 10 patients were excellent.

Postoperative results of opponensplasty and flexor tendon transfer in patients with spinal cord injuries.

Key pinch, palmar pinch, and grasp strength were evaluated after opponensplasty and flexor tendon transfer in 24 patients who had suffered cervical spinal cord injuries during a 17-year period. The patients had 57 tendon transfers: 35 opponensplasties and 22 flexor tendon transfers. The average follow-up was 4.2 years. The brachioradialis and pronator teres were the most frequently used motors for the opponensplasty and flexor tendon transfer. Key pinch strength averaged 1.47 kg (range of 0.13 to 4.70 kg). Grasp strength averaged 2.81 kg (range of trace to 10.0 kg). Palmar pinch was obtained in 45% of the extremities; the overall result was 1.04 kg (range of 0.20 to 3.00 kg). In general, patients with higher functional classifications achieved better results. We believe that intraoperative length-tension studies were an important factor in improving the results. The choice of muscle for opponensplasty or flexor transfer when two different adequate motors were available did not seem to affect the outcome of key pinch or grasp. We believe that tendon transfers are beneficial and should be considered in all patients with spinal cord injuries regardless of age at injury if at least 1 year has elapsed since injury and the patients are neurologically stable and have participated in a rehabilitation program.

Charcot's arthropathy of the spine following spinal cord injury. A report of five cases.

Between 1955 and 1968, we treated five patients who had post-traumatic Charcot's arthropathy of the spine. All of the patients had a neurologically complete spinal-cord lesion. A laminectomy was implicated as the cause in four of the five patients. Spinal arthrodesis was used successfully to correct the deformity, stabilize the spine, restore sitting balance, and prevent complications resulting from neuropathic arthropathy of the vertebrae following complete spinal-cord injury.

Tendon transfer for the restoration of upper limb function after a cervical spinal cord injury.

During the past 22 years, 68 patients with cervical spinal cord injuries had 142 tendon transfers and tenodeses. The procedures were performed to provide improved upper limb control, including elbow extension, finger grasp, and thumb pinch for better prehension. The operations were effective in increasing function in all but four patients, who did not improve because of insufficient muscle strength. The educational, vocational, recreational, and social aspects of life improved for many patients. Tendon surgery should be considered for all tetraplegics 1 year after injury, provided that they have undergone an effective rehabilitation program and that their neurologic examination is stable.

Severe fracture complications in myelodysplasia.

Prevention of fractures in the patient with myelodysplasia is aided by minimizing disuse osteoporosis by continuing weight-bearing whenever possible. The presentation and treatment of lower extremity fractures in the postoperative myelodysplasic patient have been reviewed. After these fractures severe systemic dysfunction can occur. A clinical situation involving hypovolemia and suggestive of fat embolism has responded well to immobilization in the posterior half of the spica cast and to fluid replacement.

Pyogenic and fungal vertebral osteomyelitis with paralysis.

A retrospective review of the cases of sixty-one patients with vertebral osteomyelitis revealed that the associated diseases of diabetes mellitus and rheumatoid arthritis as well as increased age and a more cephalad level of infection predisposed to paralysis. For patients with paralysis and a long-term follow-up, the prognosis for isolated nerve-root deficits is good with or without surgery. For patients with spinal cord compression, the results generally are better with anterior decompression and stabilization than with laminectomy. Early treatment should be directed at prevention of intrinsic spinal-cord damage, which is irreversible.

Vertebral osteomyelitis in infants.

Four infants between 2 and 13 weeks of age developed vertebral osteomyelitis. Their symptoms were different from those of children with discitis in that our patients were systemically ill, there was almost complete dissolution of involved vertebral bodies with either normal or nearly normal adjacent vertebral endplates, and three of the four children had recurrence of infection. The importance of long-term antibiotic treatment is emphasised. Years later the radiographic appearance of these children can be identical to congenital kyphosis with either anterior failure of segmentation or posterior hemivertebrae. The treatment should be the same as for congenital kyphosis with early bracing in extension and early fusion for progressive kyphosis.