Rectal wall properties in patients with acute and chronic spinal cord lesions.

PURPOSE: Most patients with spinal cord injuries suffer from constipation or fecal incontinence. This study was designed to observe rectal wall properties and the rectoanal inhibitory reflex in patients with acute and chronic spinal cord injury. METHODS: Rectal wall properties were studied by rectal impedance planimetry, a method for simultaneous registration of pressure and rectal cross-sectional area during distention. Twenty-five patients with spinal cord injury (14 with supraconal lesions and 11 with conal/cauda equina lesions) were studied one to four weeks after injury, and 17 were available for follow-up after 6 to 14 months. Results were compared with 15 healthy volunteers. RESULTS: Rectal tone was significantly higher (P < 0.05) than normal in patients with acute and chronic supraconal lesions but significantly lower (P < 0.05) in patients with acute and chronic conal/cauda equina lesions. The proportion of subjects with single giant rectal contractions was significantly higher than normal (33 percent) after acute supraconal spinal cord injury (77 percent; P = 0.02) but not after acute conal/cauda equina lesions (45 percent; P = 0.69). Phasic giant contractions only occurred in patients with spinal cord injury (once or more in 8 of 25 patients), but they were not correlated with the level of the lesion. Rectal tone and the number of giant rectal contractions did not change significantly from the acute to the chronic phase of spinal cord injury. The amplitude of the rectoanal inhibitory reflex at distention pressures of 5 and 10 cm H2O was significantly lower than normal in patients with acute and chronic conal/cauda equina lesions (acute, -5 and 44 percent vs. 37 and 82 percent (P < 0.05); chronic, 6 percent (P < 0.05) and 66 percent (P = NS)) but not in patients with supraconal spinal cord injury (acute, 32 and 83 percent; chronic, 61 and 85 percent (all P = NS)). CONCLUSION: Rectal tone is stimulated by the sacral spinal cord but inhibited by supraspinal centers within the central nervous system. Likewise, rectal contractility is inhibited by supraspinal centers, and the rectoanal inhibitory reflex is stimulated by the sacral spinal cord. Alterations caused by either type of spinal cord lesion are present after one to four weeks and do not change significantly within the first year.

Gastrointestinal and segmental colonic transit times in patients with acute and chronic spinal cord lesions.

STUDY DESIGN: Longitudinal study among patients with acute and chronic spinal cord injuries (SCI). OBJECTIVES: To compare total gastrointestinal transit times (GITT) and segmental colorectal transit times (CTT) in SCI patients with acute and chronic lesions to those of healthy volunteers. Furthermore, to examine the impact of time elapsed since injury on GITT and CTT, and finally to compare the pattern of colorectal dysfunction in patients with supraconal versus conal/cauda equina lesions. SETTING: Surgical Research Unit and Department of Neurosurgery, University Hospital of Aarhus, Denmark. METHODS: Patients took 10 radioopaque markers on six consecutive days and an abdominal X-ray was taken on day 7. GITT and CTTs were computed from the number of markers in the entire colorectum and in each colorectal segment respectively. We studied 26 patients with acute spinal cord lesions (15 supraconal and 11 conal/cauda equina lesions; time since injury=11 - 24 days) and 18 patients were available for follow-up 6 - 14 months later. Results were compared to 24 healthy volunteers. RESULTS: In patients with acute supraconal or conal/cauda equina lesions GITT and CTTs of the ascending, transverse, and descending colon were significantly prolonged, but rectosigmoid transit time was only significantly prolonged in patients with conal/cauda equina lesions. In patients with chronic supraconal lesions GITT and CTTs of the transverse colon and the descending colon were significantly prolonged. In patients with chronic conal/cauda equina lesions GITT and CTT of the transverse, the descending colon and the rectosigmoid were significantly prolonged. Thus, supraconal SCI resulted in generalized colonic dysfunction whereas chronic conal/cauda equina lesions resulted in severe rectosigmoid dysfunction. CONCLUSION: SCI results in severely prolonged colonic transit times both in the acute and chronic phase. However, the type of colorectal dysfunction depends on the level of SCI.

The Copenhagen Neck Functional Disability Scale: a study of reliability and validity.

OBJECTIVE: To determine whether a newly developed disability scale for patients with neck pain demonstrated acceptable reliability and validity. METHODS: Testing was conducted using three different samples of patients with neck pain (n = 162). Test-retest reliability of the scale was carried out on the same day with one sample (n = 39), and between-day reliability was carried out with another (n = 21). Differential item functioning with regard to the influence of gender and age was carried out with these two patient groups, as was construct validity. Responsiveness was measured using patients participating in a clinical trial involving patients with chronic neck pain (n = 102). Additionally, scale scores were compared with a wide range of physical measurements using the patients in the clinical trial. RESULTS: Short-term, between-day and postal questionnaire reliability coefficients were all extremely high. The Cronbach's alpha coefficient for internal consistency was 0.9 for the entire scale, and the coefficients for individual items were all greater than 0.88. Disability scale scores correlated strongly to pain scores as well as to doctor and patient global assessments, indicating good construct validity. Relative changes in disability scores demonstrated a moderately strong correlation to changes in pain scores after treatment. Scale scores correlated weakly to all physical measurements. CONCLUSIONS: The disability scale demonstrated excellent practicality and reliability. The scale accurately reflects patient perceptions regarding functional status and pain as well as doctor's global assessment and is responsive to change over long periods of time. We feel that this scale can be a valuable tool for the assessment of patients in future clinical trials and quality of care studies.

Colorectal function in patients with spinal cord lesions.

PURPOSE: This study was designed to describe the frequency and severity of colorectal problems among patients with spinal cord lesions and to determine whether these problems are associated with age, gender, time since the lesion, and level and severity of the lesion. PATIENTS AND METHODS: A detailed questionnaire describing colorectal and bladder function was sent to all 589 members of The Danish Paraplegic Association; 424 responded (72 percent). RESULTS: Only 19 percent felt a normal desire to defecate, whereas the remaining patients felt no desire to defecate (38 percent) or a combination of abdominal discomfort (37 percent) and headache, physical uneasiness, and perspiration (25 percent). Digital stimulation of the anal canal before defecation or digital evacuation of the rectum was used regularly by 65 percent of patients. Fecal incontinence was experienced by 75 percent of patients; however, most patients only had a few episodes of fecal incontinence each month (15 percent) or each year (56 percent). Overall, 39 percent of patients reported that colorectal dysfunction caused some or major restrictions on social activities or on their quality of life, and 30 percent regarded colorectal complaints to be worse than both bladder and sexual dysfunction. The severity of most symptoms was significantly correlated with the severity of the lesion, and the self-reported impact on social activities or quality of life was significantly more severe among women than men. CONCLUSION: Colorectal dysfunction is very common among spinal cord-injured patients, often causing restriction on social activities and quality of life. Therefore, these problems deserve more attention in the treatment of spinal cord-injured patients.

Localized cranial hyperostosis of meningiomas: a result of neoplastic enzymatic activity?

Cranial hyperostosis is a common secondary manifestation of intracranial meningiomas. This may occur with or without neoplastic invasion, apart or even remote from the growth. Alkaline phosphatase (AP) is one of many enzymes produced by meningiomas and is known to possess indirect ossifying properties. Meningiomatous cranial hyperostosis could possibly be mediated by a humoral mechanism. This hypothesis was tested using chemical and histochemical determination of the occurrence of the enzyme in a series of hyperostosing and non-hyperostosing meningiomas. In the hyperostosing type the content of AP was in average more than three times as high as in the non-hyperostosing type. The results thus are in favour of the induction hypothesis.

[Rotatory atlanto-axial luxation in children]. / Rotatorisk atlanto-aksial luksation hos børn.

Two cases of atlanto-axial rotatory dislocation following ear and head surgery are presented. Reduction was followed by Halo bandage in one, and by wedge C1-2 arthrodesis and Halo bandage in the other. The importance of early recognition by diagnostic CT-scan is emphasized.

[Fractures of the thoracolumbar spine. Surgical treatment using the Harrington-Luque method]. / Fractura columnae thoracalis et lumbalis. Operative behandling a.m. Harrington-Luque.

In the period of 1984-87 five women and 20 men aged 15 to 67, underwent open reduction and stabilization of thoraco-lumbar spine fractures with Harrington or Luque rods, segmental wires and interlaminar bone-chips. Half the patients had complete spinal cord lesions and these remained so. Criteria for instability were based on the three-column concept, the demand for early mobilization (10 days), or progression in neurological deficits. No operative complications nor deterioration in neurological findings occurred. Fusion and stability was obtained in all cases. Incomplete cord lesions and, particularly, cauda equina lesions improved substantially. Open reduction and stabilization in the early postinjury period performed by cooperation between a neurosurgeon and an orthopedic surgeon in centres experienced in the treatment of paraplegia is recommended.

[Organization and management of a department for patients with paraplegia. Patient clientele during the first 2 years]. / Organisation og funktion af et paraplegiafsnit. De to første års patienter.

Since January 1st 1985 seven, later only four, beds in the neurosurgical department, Rigshospitalet, were used to care for the problems associated with spinal cord or cauda equina damage. In the first two years, 21 women and 95 men aged 15 to 75 were treated in collaboration with an out-patient clinic and a rehabilitation hospital for patients with spinal cord injuries. Forty-five were admitted in the acute phase. Unstable fractures/dislocations were treated with spondylodesis in 22. General principles of management included intermittent catheterization, turning every 2-3 hours and anticoagulation therapy. Spinal stability was obtained in all cases submitted to operation. Incomplete lesions from medullary cone or cauda equina improved substantially, while complete spinal cord lesions remained so (in 27 patients). Next to urinary infection and concretions decubitus was the most frequent reason for admission in later phases in the remaining 71 patients 6 months to 40 years after the injury. Comprehensive, specialized care for patients with para- or tetraplegia in the acute phase and also in later phases can reduce the number of complications and the economic costs, encourage research work and reduce insecurity for the patients.

Percutaneous radiofrequency facet denervation in low-back and extremity pain.

The present series includes 47 patients (35 females 12 males) with an average observation time of 8 months after percutaneous lumbar facet denervation by radiofrequency electrocoagulation. All patients had static and kinetic lumbar pain; 90% of them had pain radiating into the legs. None had clinical or radiologic (radiculography and/or CT scan) evidence of a lumbar disc herniation, and all had exhausted conservative therapy. All but one had provocation of their habitual pain on arthrography of the relevant intervertebral lumbar joints and/or on intraoperative stimulation prior to electrocoagulation. 22/47 of the patients had no immediate or late beneficial effect of the electrocoagulation. Eight of the remaining 25 patients had satisfactory relief of pain at follow-up. The failures included all patients with previous multiple lumbar operations except for three.

Epidural application of cortico-steroids in low-back pain and sciatica.

Seven women and nine men, aged 27-59 years (mean 45), with lumbar pain and sciatica had epidural blocks once with 80 mg of depo-medrol and lidocaine in individual doses. All had static and kinetic lumbar pain up to 16 years and all but four also pain radiating to the lower limbs. Radiculography was "negative" in all patients, but three exhibited minor neurological abnormalities. Five patients had had a lumbar hemilaminectomy previously. In case of segmental pain in the lower limbs the appropriate level was used, in all other patients injection was done in L3-4 interspace. By means of a visual analogous scale 10 patients (62%) stated relief of half the pain the following day. One month later only 7 patients (43%) stated relief of one third of the pain. Only one patient benefited ultimately (after 6 months). In the remainder complaints were unaffected by the epidural injection. These discouraging results are not compatible with other reports, and a planned double-blind randomized investigation was abandoned. For the present category of patients (long-lasting complaints, previous "disc" operations) we found the epidural steroid injection useless.

Spontaneous intracerebral haematomas. Clinical and computertomographic findings and long-term outcome after surgical treatment.

Fifty-four patients, aged 15 to 81 years had a spontaneous intracerebral haematoma surgically removed (51 patients) or had ventricular drainage. One-third had arterial hypertension. Two thirds were alert or drowsy preoperatively and two thirds presented with hemiparesis or decerebrate rigidity. Lobar haematomas constituted 72%, deep supratentorial constituted 21% and cerebellar haematomas 7%. Volume of the haematomas ranged from 10 to 205 ml. 10 patients died in the early postoperative phase and 8 patients died later. Among 36 survivors, 35 were evaluated 15-115 months postoperatively. 10 had resumed part of their earlier occupation. Another 12 were incapacitated and the remaining 13 patients needed nursing care. No patient was neurologically or neuropsychologically intact, but 19 had only slight disabilities. CT-changes at follow-up ranged from no abnormalities at all to low-density lesions, possibly associated with dilatation of a lateral ventricle or porencephaly depending on the size of the haematoma and possible ventricular penetration. Surgical evacuation of ICH is recommended in lobar or deep supratentorial haematomas exceeding 20 ml except in patients older than 60 already unconscious. Smaller haematomas with intraventricular extension may benefit from ventricular drainage or, in the fossa posterior, even from evacuation in case of increasing brain stem compression.

Cranio-cerebral injuries from Slaughterer's gun.

3 patients attempted suicide by a powder-activated cattle skull impacting tool (Slauthterer's gun). While captive bolt pre-slaughter stunning in pigs and ruminants is safe, two of the patients remainded conscious after the shot and survived. Despite much lower impact velocity (less than 50 m/sec) these self-inflicted brain lesions are as serious as "low velocity" (less than 300 m/sec) penetrating gunshot wounds, mainly because of impaction of bone fragments and the dynamic energy possessed by the bolt.

Lateral cervical facetectomy. The surgical pathology of radicular brachialgia.

In 113 patients with radicular brachialgia and neuropathy without spinal cord affection surgical treatment consisted in facetectomy and exposure of the extrathecal part of the cervical root from the axilla to the lateral border of the root canal. In 27 patients disc herniation, and in 43 uncovertebral exostosis, was detected. In 59 patients a thick, fibrous periradicular cuff tightened the exposed root. The surgical pathology of radicular brachialgia is discussed. A total of 70 patients recovered.

Cervical osteochondrosis and disc herniation. Eighteen years' use of interbody fusion by Cloward's technique in 755 cases.

Seven hundred and forty patients (mean age 51 years) underwent anterior cervical interbody fusion by the method of Cloward in an 18-year period because of cervical osteochondrosis/disc herniation. Fifty-nine needed re-spondylodesis (same or different level or levels in the period. Ninety-six percent presented with radicular symptoms or signs, or both, while seven percent presented with "long tract" symptoms and signs. Myelography was done in all cases except three. Kiel-surgibone was used in 83% of 560 one-level, 177 two-level, and 3 three-level fusions. Eighty-one percent reported total or partial relief of preoperative (predominantly redicular) symptoms and signs postoperatively, but ultimately (observation time 1-13 years) only 71% benefited with regard to neck pain, radicular brachialgia, and neuropathy, and only 42% of those with symptoms and signs of spinal cord compression benefited. Operative complication rate was 4%, and Kiel-surgibone graft problems occurred in 2% of 958 interbody fusions. Beneficial results could be related to short period of symptoms, free intraspinal disc fragments, and a cautious attitude to multi-level fusions. Cloward's interbody fusion is found to be reliable, but delineated attitude to the different types of alternative operations (disc resection, facetectomy or laminectomy) is emphasized.