Survival, neurological recovery and morbidity after spinal cord injuries following road accidents in Israel.

DESIGN: A retrospective cohort study. OBJECTIVE: Assess outcomes in patients with spinal cord injuries (SCI) following road accidents, and factors that affect them. SETTING: Loewenstein Rehabilitation Hospital, Raanana, Israel. SUBJECTS: A total of 143 patients admitted for rehabilitation between 1962 and 2004. METHODS: Survival rates were estimated using the product limit (Kaplan-Meyer) method and their association with risk factors was analyzed with the Cox model. Neurological recovery was determined by comparing the Frankel grade at admission to rehabilitation and at discharge. The relation between recovery and various factors was tested with logistic regression. RESULTS: The risk of SCI in road accidents is higher among car drivers and motorcycle or bicycle riders. Median survival was 43 years. Survival was negatively associated with age at injury (P<0.0002) and with diagnosis of pressure sores (P=0.0065). Recovery of at least one Frankel grade occurred in 29.1% of patients. Useful recovery (upgrade to Frankel grade D or E) occurred in 23.1% of all patients. Neurological recovery was negatively associated with the severity of neurological deficit (P<0.001) and with thoracic injuries (P=0.046). The most common complications were pressure sores and those of the urinary and respiratory systems. CONCLUSIONS: In SCI following road accidents, survival rates were higher and recovery rates lower than in mixed types of trauma. This may be related to better compensation followed by better nursing for road accident victims in Israel, which may prevent life-shortening complications, and to more severe injuries caused by road accidents.

The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.

PURPOSE: To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. METHOD: Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. RESULTS: Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbach's alpha was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P<0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. CONCLUSIONS: The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

Repeated botulinum toxin injections can improve mobility in patients with spinal cord lesions.

AIM: The aim of this study was to increase the knowledge about the response to botulinum toxin (BTX) injections to spastic leg muscle motor points (MP) in spinal cord lesion (SCL) patients, and describe improvement of mobility with repeated BTX injections. METHODS: Six patients with ASIA grade C or D SCL were studied at the Loewenstein Rehabilitation Center, Israel. The main outcome measures were: modified Ashworth scale scores, range of motion (ROM), and mobility spinal cord independence measure (SCIM) scores. BTX was injected twice within a few weeks' interval to the MP of spastic leg muscles. The outcome measures were monitored before each injection and 2 weeks or more after the second injection. RESULTS: Following the first BTX injection the tonus decreased, ROM increased in all 6 patients, and mo- bility functioning improved in 4 of them. Following the repeated injection the tonus further decrea- sed, ROM further improved in 5 of 6 patients, and mobility functions further improved in 4 of 6 patients. CONCLUSION: BTX can improve mobility in patients with SCL. Repeated injections may enhance the effect despite the concern for resistance formation. Further research is needed to support the findings and determine the optimal BTX doses and intervals between injections.

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation.

BACKGROUND: A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version. OBJECTIVE: To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis. DESIGN: Multicenter cohort study. SETTING: Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East. SUBJECTS: 425 patients with spinal cord lesions (SCL). INTERVENTIONS: SCIM III assessments by professional staff members. Rasch analysis of admission scores. MAIN OUTCOME MEASURES: SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries. RESULTS: Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found. CONCLUSIONS: The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Clinical and economic consequences of volume- or time-dependent intermittent catheterization in patients with spinal cord lesions and neuropathic bladder.

STUDY DESIGN: Open comparative study. OBJECTIVE: To compare the impact of volume-dependent intermittent catheterization (VDIC) and time-dependent intermittent catheterization (TDIC) on financial burden and clinical outcomes in patients with spinal cord lesions (SCL). SETTING: Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Israel. METHOD: Economic and clinical outcomes were examined in 13 SCL patients treated with VDIC following bladder volume measurement by a portable ultrasound device (the study group), and in 11 patients treated with TDIC (the control group). Patients were followed for 12-30 days. Costs were calculated according to December 2003 prices at Loewenstein Hospital. The t-test and the Fisher's Exact Test were employed for comparisons between the groups. RESULTS: The number of catheterizations per patient per day, the time required to perform volume measurements and catheterizations, and their total cost, were approximately 44, 49, and 46% lower in the study group than in the control group. SCIMU (representing bladder management functioning) increased during the study in both groups, and the increase was 31% higher in the study group than in the control group. Urinary infection was found in three patients in the control group and in none in the study group. CONCLUSION: VDIC has economic and probably also clinical advantages over TDIC.

Carbamazepine toxicity following Oxybutynin and Dantrolene administration: a case report.

OBJECTIVE: To report a case of Carbamazepine toxicity following the administration of Oxybutynin and Dantrolene. STUDY DESIGN: A case report. SETTING: The Spinal Rehabilitation Department, Loewenstein Hospital, Raanana, Israel. METHODS: A patient with C6D tetraplegia who sustained intoxication because of drug interaction is presented. She had been treated by Carbamazepine 1000 mg/day for neuropathic pain for 2 years without clinical or laboratory signs of toxicity. After administration of Oxybutynin concomitantly with an increase in the dose of Dantrolene, she presented the clinical symptoms and laboratory finding of Carbamazepine intoxication. Trying to adjust the treatment to the patient's requirements, Carbamazepine together with Oxybutynin and Dantrolene was readministrated in lower doses. RESULTS: The combination of these drugs, even small doses, caused toxicity. Adding Dantrolene and Oxybutynin elevated the blood level of Carbamazepine, possibly by inhibition of cytochrome P450. CONCLUSION: A possible pharmacokinetic interaction between Dantrolene and Oxybutynin should be borne in mind when considering Carbamazepine medication for a patient with a spinal cord lesion.

Outcomes in patients admitted for rehabilitation with spinal neurological lesions following intervertebral disc herniation.

BACKGROUND: Little information is available about the survival, neurological recovery, and length of stay in hospital for rehabilitation (LOS) of patients with spinal neurological deficit following disc herniation (DH). STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To report on outcomes and factors affecting these. SETTING: The Spinal Research Laboratory, Loewenstein Rehabilitation Hospital, Israel. SUBJECTS: A total of 158 patients with DH spinal neurological lesions (DHSNL). METHOD: Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method; relative mortality risk by the Cox proportional hazard model. Neurological recovery was evaluated by calculating the change in Frankel grades, and factors that affect it were assessed by logistic regression. LOS associations were analyzed with ANOVA. RESULTS: The median age at lesion onset was 48 years, and the median survival 29 years. Age and gender had a significant effect on survival, but not so lesion severity, level, or decade of onset. Of the 69 patients who had Frankel grades A, B, or C on admission, 72% achieved useful recovery to grades D or E. The severity and level of the spinal neurological lesion (SNL) had a significant effect on recovery. The mean LOS was 87 days; it was significantly affected by lesion severity and level and by the decade of admission to rehabilitation, and decreased with time. CONCLUSIONS: Patients with DHSNL who were admitted for rehabilitation have favorable survival and recovery rates compared with previously studied patients with other types of SNL. Their LOS is probably a function of medical requirements, but is decreasing with time.

Length of stay in hospital following spinal cord lesions in Israel.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To monitor length of stay (LOS) in a specialist spinal cord lesion (SCL) department in Israel, evaluate factors that affect it, and assess its association with other outcome measures. SETTING: Loewenstein Rehabilitation Hospital, Raanana, Israel. METHODS: In all, 1367 SCL patients treated between 1962 and 2000, and a group of 44 patients admitted between 1996 and 2002 were recruited. LOS, factors that affect it, and Spinal Cord Independence Measure second version (SCIM-II) gain and efficiency were measured. Data were collected from hospital charts and from the Population Registry of the Israel Ministry of Internal Affairs. LOS associations were analyzed with ANOVA, ANCOVA, Pearson's chi(2) test, Pearson's correlation, and Cox proportional hazard model. RESULTS: The mean LOS was 239 days for traumatic SCL (SD=168) and 106 days for non-traumatic SCL (SD=137). SCL etiology, SCL severity, and decade of admission to rehabilitation, were associated with the LOS (P<0.001). SCIM II gain correlated with LOS in the first 70 days after admission (r=0.81-0.82; P<0.001). In some patients, longer LOS was associated with a considerable increase in ability, through 5-8 months from admission. CONCLUSIONS: LOS of patients with SCL in Israel is within the customary LOS range in Europe. Longer LOS in a specialist SCL department may be positively associated with improved rehabilitation outcome. Further study is required to determine the LOS that allows optimal achievements.

Survival following spinal cord injury in Israel.

BACKGROUND: Survival following spinal cord injury (SCI) has greatly improved since the unsuccessful attempts to repair the damaged spinal cord were replaced by systematic prevention and treatment of complications caused by the neural damage. OBJECTIVE: To evaluate the main outcome measures in patients with spinal cord injury. DESIGN: Retrospective cohort study. SETTING: Loewenstein Rehabilitation Hospital, the major referral center for rehabilitation medicine for hospitals throughout Israel. SUBJECTS: 250 consecutive patients, injured between 1959 and 1992. MAIN OUTCOME MEASURES: Survival rates and mortality risk factors. METHOD: Demographic, clinical, and mortality data were collected from the hospital charts and from the Population Registry of the Israel Ministry of Internal Affairs. Survival rates were estimated using the product limit (Kaplan-Meyer) method, and their association with known risk factors was analyzed with the Cox proportional hazard model. RESULTS: The survival rate after injury was 81% after 10 years, 75% after 20 years, and 62% after 30 years, and 50% after about 36.5 years. Survival was found to be negatively associated with age (P=0.01) and with high spinal level of injury (P=0.003). CONCLUSIONS: Survival rates in the studied population are similar to those reported in other countries, and are close to those of the general population living in Israel in the same time period. The study demonstrates that developing countries can reach survival rates comparable to those of developed countries, and may contribute to better survival predictions of patients with SCI.

Rasch analysis of the Catz-Itzkovich spinal cord independence measure.

BACKGROUND: The Spinal Cord Independence Measure (SCIM) is a new disability scale developed specifically for patients with spinal cord lesions (SCL). Its original and second versions (SCIM and SCIM II) were found to be reliable and more sensitive than the Functional Independence Measure (FIM) to functional changes in SCL patients. OBJECTIVE: To further validate the SCIM II, examining its components on a larger population. DESIGN: Retrospective cohort study. SETTING: Two rehabilitation centers in Israel. SUBJECTS: Two hundred and two inpatients with SCL. INTERVENTIONS: Routine SCIM assessments by staff nurses. Rasch and accompanying analyses. MAIN OUTCOME MEASURES: Unidimensionality of subscales (areas of function); goodness of fit of the tasks to the Rasch model; relationship of total-patient and single-task performance-ability; usability of task categories and the order of threshold locations between them; subscale discrimination of ability and difficulty and hierarchical nature; discrimination of task-categories ability, ie, distribution of thresholds along ability levels; and differential task behavior by age, gender and examination subgroups. RESULTS: Four unidimensional subscales were identified, and an acceptable goodness of fit to the Rasch model was demonstrated in most of their tasks (infit mean square=0.8-1.2, outfit mean square=0.6-1.4). However, some tasks showed overfit (bathing lower body) and some showed misfit (wheelchair-car transfer). Additional analyses performed to check for reasons for less than acceptable fit revealed flaws in a minority of the outcome measures. CONCLUSIONS: The findings of this analysis confirm the validity and reliability of the SCIM II. To a large extent we can infer that the SCIM II construct allows for the detection of any level of disability in any patient with SCL. A few item categories, however, should be rephrased or removed.

The Catz-Itzkovich SCIM: a revised version of the Spinal Cord Independence Measure.

PURPOSE: To examine the suitability of the revised Spinal Cord Independence Measure, the Catz-ltzkovich SCIM, for evaluation of patients with spinal cord lesions, as compared to the original SCIM and to the Functional Independence Measure (FIM). METHOD: The revised SCIM was applied by paired independent teams of occupational therapists, physiotherapists and nurses and the FIM by a single nurse. The examiners assigned scores to the functional capabilities of 28 patients with spinal cord lesions. The scores by the revised SCIM were analysed for reproducibility as between the two teams of examiners (interrater reliability) and for their correlation with the FIM scores. RESULTS: The frequency of identical scoring by two independent examiners (total agreement) was 80% or higher for 13/18 individual functions listed in the revised SCIM. In the self-care category it was 80-99%, as compared to 75-87% before revision. In neither bowel management nor bed mobility was there an increase over the original SCIM in the frequency of identical scores, despite rephrasing and restructuring of the scoring criteria. A high correlation was noted between the paired scores for all functions listed as well as for those comprising each of the four functional categories (r = 0.90-0.96, p <0.001). The total revised-SCIM scores were significantly correlated with those derived by the FIM (r = 0.835, p < 0.001). CONCLUSIONS: The findings indicate that the newly revised SCIM (Catz-Itzkovich) is a valid and highly reproducible measure of daily function in patients with spinal cord lesions, and is superior to the original SCIM. We recommend that it supersede the original SCIM.

Spinal pain independence measure--a new scale for assessment of primary ADL dysfunction related to LBP.

PURPOSE/METHOD: SPIM Spinal Pain Independence Measure. a new disability scale designed for patients with chronic low back pain disability, has been developed and studied at the Spinal Department of Loewenstein Rehabilitation Hospital. The SPIM differs from other existing scales for evaluation of chronic back disability, in that it is designated particularly for patients with deficits in primary ADL and evaluates function by observation. RESULTS/CONCLUSIONS: This study shows the SPIM to be reliable: it supports the validity of the scale and points out a possible advantage of the SPIM over existing scales in sensitivity to functional change of patients with prominent disability. Further elaboration and examination of the SPIM is still needed.

The treatment dilemma in post-traumatic syringomyelia.

PURPOSE: The aim of the present study was to compare the functional effect of conservative and surgical treatment in post-traumatic syringomyelia. METHOD: The files of 10 male patients treated for posttraumatic syringomyelia were retrospectively reviewed from 1986 to 1996. RESULTS: The spinal lesion was complete in five patients and incomplete in five. All patients underwent rehabilitation, five of them following surgery. The operative procedures included drainage by syringosubarachnoid shunting (four patients) and decompressive laminectomy (one patient). Rehabilitation alone improved the functional status in all five patients so treated. After surgery, function deteriorated in four of the five operated patients, and rehabilitation failed to restore the preoperative functional status in any of them. CONCLUSION: In view of the results it is suggested that patients with post-traumatic syringomyelia undergo rehabilitation with very close clinical and magnetic resonance imaging follow-up.

The role of external sphincterotomy for patients with a spinal cord lesion.

For the last three decades external sphincterotomy has been well accepted as a treatment for bladder outlet obstruction in patients with a spinal cord lesions. Recently, however, its value has been brought into question. To assess the current place of this procedure in the treatment of the neuropathic bladder of spinal origin, we studied the outcomes of sphincterotomy in 32 patients. Post-voiding residual urine volume decreased after surgery in 27 patients (84%), considerably in 22 (69%) of them. Clinical infection resolved in 14 out of 19 patients (74%), hydronephrosis disappeared in two out of three (66%), and vesicourethral reflux improved in three out of five (60%) and was cured in two (40%). Six of the patients (19%) were freed from catheterization, but two patients (6%) lost partial continence. Sphincterotomy is an important tool in the treatment of spinal patients with bladder outlet obstruction and should be considered when the proper indications exist.

Course and outcome of patients in vegetative state of nontraumatic aetiology.

A follow up study is reported of 100 consecutive unconscious patients admitted to an intensive care coma facility with a history of 30 days or more of unconsciousness of nontraumatic cause. Twenty recovered consciousness, all within 5 months of injury. 31 of the remaining patients died within 6 months following injury, while 49 continued unconscious until death. The mean life expectancy of these 49 was 26-34 months from that time. All 20 patients who recovered awareness continued to suffer from major disability. The prognosis for life or death and for recovery or not of consciousness was not significantly correlated with age or aetiology of the vegetative state. Among those who recovered consciousness, the younger patients showed somewhat better results in three parameters of function: locomotion, ADL and day-placement, but not in cognition, behaviour or speech accuracy and fluency. The overall results for these nontraumatic patients with postcomatose unawareness are clearly worse than those for patients with a similar period of unconsciousness following craniocerebral trauma.

Ovulation induction for in vitro fertilisation using clomiphene citrate and low-dose human menopausal gonadotrophin.

Ovulation induction using a low dose of human menopausal gonadotrophins and clomiphene citrate for in vitro fertilisation and embryo transfer is described. Sixty-two cycles of ovulation induction were initiated in 37 patients. Forty-six laparoscopies were performed, yielding 116 oocytes. Of these, 90 (77.6%) cleaving embryos developed, and in 36 transfers 10 pregnancies (27.8%) were established. The use of low-dose hMG in conjunction with a programme on an outpatient basis may prove to be optimal for the purpose of in vitro fertilisation and embryo transfer.

Spectral analysis of the EEG in craniocerebral trauma.

The objectives of the present study were to evaluate the relationship between the fractional amplitudes of the EEG derived from power spectral analysis (PSA) of the electroencephalogram (EEG) and depth of coma measured clinically with the Glasgow Coma Score, and to assess the accuracy of PSA in predicting long-term outcome. Thirty-two patients rendered unconscious by blunt head injury (mean (GCS = 7) had intermittent EEG recordings daily from 1-10 days post injury. There was a significant correlation between fractional amplitude of the EEG and the GCS. The rate and magnitude of change in the EEG and GCS were also correlated. There were significant differences in PSA parameters between improved and deteriorated patient groups at the termination of monitoring (p = .02) and in the change of PSA parameters over time (p = .02). Using linear discriminant analysis of PSA parameters, the accuracy of outcome prognostication based on the six month outcome was approximately 75%. Accurate classification of outcome was possible in a number of patients in whom there was little or no change in the GCS during the period of monitoring.

A simple method for cryopreservation of human sperm.

A simple method of cryopreservation of human sperm is discussed. Fifteen randomly collected samples were frozen and assessed after storage in liquid nitrogen. The mean recovery rate was 77% (range 62-91%) with no significant deterioration after 4 weeks' storage. The cryopreserved sperm is used in an artificial insemination by donor clinic and also sent to distant centres in the RSA and neighbouring countries. The method is also used for the cryopreservation of specimens of the sperm of patients undergoing vasectomy or radiotherapy, and in the Groote Schuur Hospital in vitro fertilization programme. Modification of the method will also allow human embryos to be frozen.

Effect of neonatal pinealectomy on circadian periodicity of adrenocortical activity.

Newborn male and female rats aged between 24 and 48 hours were pinealectomized (Px) or sham-operated (Sh). Animals were sacrificed at 45 and 60 days of age, at the trough and peak of the adrenocortical diurnal cycle. Blood was collected for corticosterone determinations and the adrenal glands weighed. Adrenal gland weight was greater at 45 days (p less than 0.01) in Px rats than in Sh rats. This difference in adrenal gland weight disappeared in the group sacrificed 60 days post-operatively. On the other hand, the diurnal plasma rhythm of corticosterone remained intact in male and female rats with or without pineal at 45 and 60 days. Furthermore, the trough and peak plasma corticosterone levels were not different in Px 45 and 60 days post-operatively. These data do not support the assumption of the important role of the pineal in the newborn rat for the maintenance of a normal circadian rhythm of the pituitary-adrenal system.

Brain sarcoma of meningeal origin after cranial irradiation in childhood acute lymphocytic leukemia. Case report.

The authors report their experience with an unusual case of intracerebral sarcoma of meningeal cell origin in an 8 1/2-year-old girl. This tumor occurred 6 1/2 years after cranial irradiation at relatively low dosage (2200 rads) had been delivered to the head in the course of a multimodality treatment for acute lymphocytic leukemia. The tumor recurred approximately 10 months after the first surgical intervention. Macroscopic total excision of the recurrent growth followed by whole-brain irradiation (4500 rads) failed to eradicate it completely and local recurrence prompted reoperation 18 months later. This complication of treatment in long-term childhood leukemia survivors is briefly discussed, as well as the pathology of meningeal sarcomas.