Superimposed myasthenia gravis in chronic spinal cord injury: a case report.

STUDY DESIGN: Case report. BACKGROUND/OBJECTIVE: Myasthenia gravis (MG) complicating spinal cord injury (SCI) is extremely rare. We report a patient with SCI developing MG leading to death. There are no similar articles at present on literature search. CASE REPORT: A 54-year-old man, paralysed at the T12 level (ASIA A) for 40 years, was admitted for surgical repair of his grade IV sacral pressure sore. During the admission he developed diplopia, fluctuating dysphagia and slurred speech. Elevated anti-acetylcholine receptor antibodies and single fibre electromyography confirmed the diagnosis of MG and pyridostigmine was commenced. His admission was complicated by intermittent episodes of unexplained tachycardia and tachypnoea. He succumbed following cardio respiratory within 6 weeks of admission. Post mortem examination was inconclusive of a definite cause of death. In the presence of SCI, it can be challenging to diagnose MG or its complications like myasthenic and cholinergic crisis. CONCLUSION: The case highlights the difficulty in diagnosis and management of MG in persons with SCI.

A comparison of heparin/warfarin and enoxaparin thromboprophylaxis in spinal cord injury: the Sheffield experience.

OBJECTIVES: To compare the safety and effectiveness of two different thromboprophylactic protocols in the management of patients with spinal cord injury - one using heparin/warfarin and the other using enoxaparin. STUDY DESIGN: Retrospective. SETTING: Princess Royal Spinal Injuries Unit, Sheffield, UK. METHODS: Retrospective review of two cohorts of patients with acute spinal injury admitted to a supra-regional spinal injuries centre and treated with different pharmacological agents. One group received heparin/warfarin in combination with antiembolism stockings and mechanical measures for thromboprophylaxis whereas the second group received enoxaparin in combination with the other measures. Patients who developed clinical symptoms suggestive of deep vein thrombosis or pulmonary embolism were investigated as appropriate. RESULTS: Four of the 101 patients on heparin/warfarin developed symptoms of venous thromboembolism compared to 13 of the 72 who were on enoxaparin. Of the 13, three had been on 40 mg of enoxaparin daily and 10 on 20 mg enoxaparin daily. Six patients on enoxaparin and one patient on warfarin developed thromboembolic complications after they had been mobilised and the anticoagulant discontinued. Eight patients on warfarin prophylaxis and three patients on enoxaparin developed haemorrhagic complications necessitating cessation of therapy. CONCLUSION: This study suggests that the traditional protocol of warfarin/heparin for thromboprophylaxis in spinal cord injury patients remains a safer option than enoxaparin.

Neuropathic lumbar spondylolisthesis--a rare trigger for posture induced autonomic dysreflexia.

STUDY DESIGN: Case report. OBJECTIVES: Description of a rare trigger for autonomic dysreflexia. SETTING: Princess Royal Spinal Injuries Unit, Sheffield. METHODS AND RESULTS: A case of Charcot's spine (neuropathic spinal arthropathy) in a woman with a traumatic T5 paraplegia is described. She developed symptoms of autonomic dysreflexia, brought on by changes in posture. The postural variation was attributable to a freely mobile neuropathic spondylolisthesis at the L4/5 level. A laminectomy performed for the implantation of a sacral anterior root stimulator was identified as a causative factor in the development of the neuropathic joint. Surgical stabilisation and fusion resulted in amelioration of her symptoms. CONCLUSION: Neuropathic spine is a rare cause of autonomic dysreflexia that should be considered when other more common factors have been excluded. The development of Charcot's spine in the spinal cord injured population is facilitated by surgical procedures involving the vertebrae.

New-wave nursing: back to the basics?

The experience of nurse leaders in a multi-institutional system from the initial stages of deliberation to the concluding consensus to commit to an extensive restructuring project is described in this article. Significant factors in evaluating the potential for success or failure of such a project are described, and the impact of restructuring on nursing practice is considered. Change is inevitable; restructuring is an appropriate way to accomplish change, and leadership may direct the change to create something new while also preserving nursing's strengths.

Variations of gait parameters in Duchenne muscular dystrophy.

The gait parameters (speed, stride length and cadence) of nine boys with Duchenne muscular dystrophy were compared with those of 21 normal boys in the same age range. Differences found were due to the altered ability to control their dynamic state and, to a lesser extent, physical limitations of joint range. This simple method of quantifying gait is proposed as a way in which progression or response to treatment in muscular dystrophy might be monitored. The information obtained may alert the clinician to the fact that the progressive muscle weakness and joint contractures have begun to cause compensatory mechanisms during walking to fail. It is also useful to obtain information on gait in clinical treatment trials as there are very few reliable methods for testing function in muscular dystrophy.

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.

The use of double support time for monitoring the gait of muscular dystrophy patients.

Children with muscular dystrophy eventually lose the ability to walk and with it, their independence. Timely operative or orthotic intervention may delay this critical point. Quantifiable parameters, which aid in making this prediction should, therefore, be actively sought. In this study, using a simple gait analysis system, the gait. parameters of 10 boys with muscular dystrophy (MD) were compared with those of 22 normal boys in the same age range, and with their own parameters at subsequent follow-up. The results suggest that observation of the gait of MD boys and measurement of their double support time may be useful in monitoring the progress of their disease.

Knee moments in Duchenne muscular dystrophy.

The gait of 7 boys with Duchenne muscular dystrophy (DMD) who could walk unaided and 21 normal boys was analysed by means of a video recording technique linked to a Kistler force plate. An electronic device was used to superimpose the patient's ground reaction vector on the video recording of their walking. This recording was analysed to obtain sequential values for the moments developed around the knee during the walking cycle. The equinus gait of boys with DMD is shown to be a necessary adaptation to keep the forces about proximal joints, particularly the knee, within limits controllable by weakened muscles. These findings explain the observation that elongation of the Achilles tendon to correct contracture at the ankle can have irrevocably damaging effects on gait.

Low energy cost reciprocal walking for the adult paraplegic.

The hip guidance orthosis which allows paraplegic children to walk reciprocally has been further developed for adult traumatic paraplegics. Since December 1981, 11 adult complete paraplegics have walked using this device, designated a 'Parawalker'. Our understanding of the mechanics of this form of ambulation and our early work with functional electrical stimulation leave us hopeful of achieving a realistic goal for these patients.