[Giant recurrent trochanteric pressure sore: A complex medico-surgical care]. / Escarre trochantérienne géante récidivante : une prise en charge médico-chirurgicale complexe.

BACKGROUND: Pressure sores are a frequent complication in spinal injured people. Their treatment is often long and complex. OBSERVATION: We report the case of a 60-year-old man affected with complete paraplegia who developed a right trochanteric pressure ulcer complicated with osteoarthritis of the coxofemoral joint. The treatment was done in three steps. First, a large excision of necrotic tissues and a femoral head-neck resection is performed. Then, the defect is partly covered with a Gluteus Maximus and a Biceps Femoris myocutaneous flaps. Finally, the residual defect is covered with a cutaneous pedicled groin flap called McGregor's flap. Later, the patient showed a right para-scrotal pressure sore on a heterotopic ossification of the ischial tuberosity. DISCUSSION: McGregor's flap is rarely employed for treating trochanteric pressure sores. It was here the only pedicled flap available. It was necessary to autonomize it in order to get enough length and to place a hip external fixation. The para-scrotal pressure sore illustrates the fact that bone resection surgery lifts the weight-bearing zones and can lead to pressure sores in unusual locations. CONCLUSION: The surgical treatment of these "giant" pressure sores requires a perfect collaboration between teams of rehabilitation and several surgical areas. Without a good adherence of the patient, the treatment is doomed to fail.

Five years follow-up study and failures analysis of Botulinum toxin repeated injections to treat neurogenic detrusor overactivity.

INTRODUCTION: The aim of this work was to follow prospectively a cohort of patients suffering from neurogenic overactive bladder, treated by botulinum toxin A, study the efficiency of this treatment, analyse the primary failures, secondary and surrender. PATIENTS AND METHODS: Thirty-one patients suffering from neurogenic OAB received a detrusor injection of 300 units of Botox™ (ALLERGAN, Irvine, CA) and were followed prospectively (median 5 years). They were evaluated by voiding diary, Qualiveen™ questionnary and urodynamics before treatment, 2 months after the first injection and the last re-injection. RESULTS: Five years after the beginning of the treatment, 17 patients of 31 (54.8%) were still injected, it means 60.7% of the primary responders. Eleven patients had left up the treatment, after at least one effective injection. We identified three reasons of surrender: echapment of treatment for two patients of 11 (7.1%); cessation of self catheterize for six patients of 11 (54.6%) and the surrender of the treatment without clinical or urodynamical failure, for three patients of 11 (27.3%). Although the cessation of self catheterize was more frequent for patients suffering from multiple sclerosis, no predictive factor of surrender was statically significant. CONCLUSION: In this series, bladder BTA injections was efficient at middle term to treat neurogenic OAB. The echapment was a rare event (7%). The major cause of surrender was the increase difficulty to self catheterize, due to progression of disability, more frequent for patients suffering of multiple sclerosis.

Reach to grasp kinematics and EMG analysis of C6 quadriplegic subjects.

The aim of the present study was to assess the kinematics and the muscular activity of the upper limb of subjects suffering from a spinal cord injury (SCI) at the C6 level during a grasping task. Data were compared to a control group composed of able-bodied subjects. The electrical activity of six major upper limb muscles and 3D motion of the arm were recorded. Results showed higher relative muscular solicitation for C6 patients especially for deltoïdus posterior and the pectoralis major and modifications of the range of motion of the corresponding joint angles. It appeared that, for C6 SCI subjects, the role of shoulder complex is highly relevant to initiate and control upper extremity movement, and so is important for their autonomy. Such data may be used to help clinician in decision making, e.g. for reconstructive surgery by musculotendinous transfer.

What are the risk factors of occurence and chronicity of neuropathic pain in spinal cord injury patients?

OBJECTIVE: Analyze the epidemiological data on neuropathic pain in spinal cord injury patients and determine the risk factors for its occurrence and chronicity. METHOD: Review and analysis of the literature. RESULTS: Epidemiological data report that 40% of spinal cord injury (SCI) patients suffer from neuropathic pain and 40% of these patients report an intense neuropathic pain. Some factors do not seem to be predictive for the onset of neuropathic pain: the level of injury, complete or incomplete injury, the existence of an initial surgery, sex. However, old age at the time of injury, bullet injury as the cause of trauma, early onset of pain in the weeks following the injury, their initial nature, intensity and continuous pain, as well as associated symptoms all appear to be negative prognostic factors. CONCLUSION: Neuropathic pain in SCI patients is a major issue, its determining factors still need to be evaluated properly by refining the epidemiological data.

[Neuroradiological investigations in mild brain injuries: state of the art and practical recommendations]. / La neuro-imagerie après traumatisme crânien léger: mise au point et recommandations pratiques.

OBJECTIVES: To clarify the contribution of each technique of neuroradiological and nuclear medicine investigations after mild brain injuries. To analyze the pathophysiological mechanisms of the lesions. To update indications for imaging techniques in the short or long term management. To define the practical recommendations. METHOD: The international databases were consulted for each neuroradiological technique; the most valuable articles were retained for study (PubMed, ). RESULTS AND DISCUSSION: Standard skull X-rays are obsolete. Craniofacial (bony windows) and brain CT-scan (parenchymal windows) is the most efficient diagnosis tool in the acute phase because of its accessibility. Brain MRI is less accessible in the emergency setting but is feasible in some centers. It is the best choice in the first weeks following mild brain injury but may be normal. Taking into account the limitations of morphological imaging, functional imaging techniques (SPECT, fMRI, PET-scan) are necessary as they may show axonal damage or brain atrophy. There is however the problem of availability. SPECT is the most accessible. Spectro-MRI is promising. In spite of progress in neuroradiological investigation methods, the neuropsychological evaluation and multi-disciplinary treatment of these patients by a skilled team remains of utmost importance.

[Hyperparathyroidism induced by lithium. A new case]. / Hyperparathyroïdie induite par le lithium. Un nouveau cas.

INTRODUCTION: Lithium salts, used for the first time in 1949, had proved to be a highly effective preventive measure in bipolar illness. The first report of lithium-induced hyperparathyroidism was suggested by Garfinkel et al. in 1973. About 40 cases have been reported since, suggesting an enhancement of occurrence of hyperparathyroidism in patients cured by lithium carbonate. We report here a new case discovered by a systematic measurement of calcemia after a surgical intervention for a hip joint prosthesis. EXEGESIS: Unusual metabolic features associated with this case of hyperparathyroidism include low urinary calcium excretion, normal cyclic AMP excretion and lack of calcic nephrolithiasis. The mechanism probably results from lithium linking with the calcium receptor on the parathyroid and then stimulating PTH secretion. In the same way it could enhance the tubular reabsorption of urinary calcium. Lithium withdrawal is often inefficient in clinical and laboratory test abnormalities and surgery is usually required. CONCLUSION: It is very important to recognise this particular secondary effect of lithium therapy because clinical symptoms of hypercalcemia can simulate a worsening of the bipolar illness.

Paraplegia and decompression sickness.

Decompression sickness may include spinal cord damage, which sometimes persists. Casual divers are exposed, as well as professionals. In this study we have reviewed the clinical records of divers admitted with symptoms of spinal cord injuries in our area in the last 6 years. This study is divided into two groups: those who fully recovered (19 divers) and those with neurological sequelae (12 divers).

Effects of tiludronate on bone loss in paraplegic patients.

Immobilization secondary to spinal cord injury is associated with a marked and rapid atrophy of trabecular bone (disuse osteoporosis). This is due to an early increase of osteoclastic bone resorption associated with a pronounced decreased osteoblastic bone formation. Bisphosphonates are antiosteoclastic compounds and they have been effective in preventing disuse osteoporosis. However, some of them also depress osteoblastic activity and may impair the mineralization process. Tiludronate was shown effective in reducing bone resorption in several metabolic bone diseases without inducing mineralization defects. Twenty paraplegic patients (6 females and 14 males) were randomly assigned to three groups: 6 patients entered the placebo group; 7 patients received tiludronate 200 mg/day; and 7 received 400 mg/day. Histomorphometric analysis was performed on transiliac bone biopsies before and after 3 months treatment. An insignificant decrease of bone volume was observed in the placebo group and the 200 mg group. In patients receiving 400 mg/day, a slight increase was noted. Osteoid parameters changed nonsignificantly in three groups although the 400 mg group exhibited a slight tendency to decrease osteoid volume and thickness. Eroded surfaces increased in all groups. The number of osteoclasts (identified histochemically by TRAP staining) increased in the placebo group but decreased in groups receiving tiludronate. Tiludronate appears effective in reducing bone resorption without impairing bone formation in a manner that preserved bone mass and bone cell coupling.

[Intensive care ... and after?]. / La réanimation ... et après?

The relations between reanimation's and reeducation's sets are very important. Reanimation's set prepare brain or spinal injured patients to go to the reeducation unit. Aims of reeducation open on quality of life and rehabilitation.