Operative treatment of progressive deformity in spinal tuberculosis.

We report on 14 patients with tuberculosis of the spine treated by operation. All had disease of three or more vertebrae with involvement of both the anterior and posterior columns and a progressive kyphotic deformity in spite of conservative treatment. We consider such spines to be 'unstable' and have found that anterior as well as posterior fusion with instrumentation is necessary.

Electronic design of a multichannel programmable implant for neuromuscular electrical stimulation.

An advanced stimulator for neuromuscular stimulation of spinal cord injured patients has been developed. The stimulator is externally controlled and powered by a single encoded radio frequency carrier and has four independently controlled bipolar stimulation channels. It offers a wide range of reprogrammability and flexibility, and can be used in many neuromuscular electrical stimulation applications. The implant system is adaptable to patient's needs and to future developments in stimulation algorithms by reprogramming the stimulator. The stimulator is capable of generating a wide range of stimulation waveforms and stimulation patterns and therefore is very suitable for selective nerve stimulation techniques. The reliability of the implant has been increased by using a forward error detection and correction communication protocol and by designing the chip for structural testability based on scan test approach. Implemented testability scheme makes it possible to verify the complete functionality of the implant before and after implantation. The stimulators architecture is designed to be modular and therefore its different blocks can be reused as standard building blocks in the design and implementation of other neuromuscular prostheses. Design for low-power techniques have also been employed to reduce power consumption of the electronic circuitry.

Reduction of bladder outlet resistance by selective sacral root stimulation using high-frequency blockade in dogs: an acute study.

Detrusor-sphincter dyssynergia is a main problem in supra-sacral spinal cord injured patients. The problem of high pressure voiding is also encountered in most electrically induced micturition because of the mixed somatic and autonomic fiber components of the ventral sacral root. We studied the effect of selective high-frequency blockade at the sacral nerve root in an acute spinalized canine model to prevent the deleterious consequences associated with the elevated bladder outlet resistance. A new functional electrical stimulation system which can generate one signal composed of two independent adjustable current waveforms delivered via a single bipolar electrode was used in 11 dogs. The selectivity resulted from the inhibition of the sphincteric somatic innervation by a high frequency pulse while the low frequency stimuli activated the bladder autonomic fibers. Bladder and urethral pressure as well as electromyograms of external urethral sphincter were recorded to determine whether selective high-frequency blockade occurred. Our experiments showed that we were able to achieve selective blockade of the external urethral sphincter during the simultaneous detrusor stimulation, thus obtaining a more physiologic voiding.

Implantable volume monitor and miniaturized stimulator dedicated to bladder control.

This paper describes a new miniaturized implantable bladder controller that is composed of 4 main parts: a volume monitoring device based on the tomography approach, a fully programmable miniaturized central processor and stimulator, a bidirectional data and power link, and an external controller. The proposed system is intended to restore both normal bladder functions (retention and voiding) to spinal cord injured patients. The system contains a mixed-signal (analog/digital) feedback loop to command the bladder functions through neuromuscular stimulation techniques. The implantable circuitry is powered by a single encoded radiofrequency carried and may have up to 8 independently controlled monopolar (4 bipolar) channels. The microstimulator is able to generate a wide range of stimulation patterns, including selective stimulation waveforms. In addition, an optical link transmits the state of the implant and volume monitoring results to the external controller.

Implantable multiprogrammable microstimulator dedicated to bladder control.

An implantable multiprogrammable microstimulator that is intended to restore normal bladder functions (retention and incontinence) to spinal cord injured patients is presented. The implantable microstimulator circuitry is externally controlled and is powered by a single encoded radio frequency carrier and has four bipolar (eight monopolar) independently controlled channels. It offers a higher degree of reprogrammability and flexibility and can be used in any neuromuscular applications. The implant system is adaptable to the patient's needs and to future developments in stimulation algorithms, without changing the implant. Features of the microstimulator include its capabilities to generate a wide range of waveforms and to combine up to four different programmable frequencies in each wave train. By using a forward error detection and correction communication protocol, the reliability of the implant is increased. The chip has been designed for structural testability by means of a scan-based test approach and uses circuit techniques to reduce power consumption and ensure long-term stability.

Epidemiological survey of spinal cord injury: A study of 377 patients.

The total number of patients admitted to the Spinal Cord Injury Unit, Riyadh Central Hospital, Riyadh, Saudi Arabia from June 1979 to March 1984 approached 450 patients. Of those, 377 (369 males and 8 females) patients with complete records and sustaining traumatic injury were studied. The patients were divided into four groups: cervical, dorsal, dorsolumbar and lumbar. In each group, the following parameters were studied: age, sex, nationality, length of period prior to admission, and source of admission. The cause of injury was divided into four groups, including road traffic accident, industrial injuries, domiciliary injuries and gunshot wounds. The study included the type of bony injury and associated injuries, complications both on admission and during hospital course and neurological deficit and progress. The results of treatment are displayed in a variety of tables with explanations in the text. It is hoped that this work would be a pointer to the size of the problem in Saudi Arabia, and would highlight the difficulties encountered and tentatively put forth suggestions for correction.

Evaluation of radiological investigations in spinal tuberculosis.

Thirty-four cases of spinal tuberculosis were investigated by plain radiography, computerised tomography and myelography followed by computerised tomography. All the patients were operated on and the findings compared with the results of the investigations.

Bifacetal dislocation following tuberculosis of the cervical spine.

We present a case of bifacetal dislocation following tuberculosis of the cervical spine with a minimal neurological deficit and a huge retropharyngeal abscess in a 14-year-old Saudi child. Treatment was by anterior debridement, decompression and bone grafting followed 2 weeks later by posterior wiring and fusion from C2 to C5. We also review the literature relating to this subject.

Spinal brucellosis.

The findings in 44 patients with back pain and brucellosis are described. Radiological changes tended to occur in older patients with a longer duration of disease. The younger patients more often experienced an acute arthritis with sacroiliitis resembling a reactive disease. Bone scanning was more sensitive than radiographs, particularly in detecting acute sacroiliitis and hip involvement. The lumbar spine was the most frequently involved site although no part of the spine was spared. Extensive destruction of a vertebral body with little involvement of the adjacent vertebrae, lower lumbar spondylolysis and spondylolisthesis, and discitis with calcification were striking radiological findings hitherto undescribed in brucellosis. Computerized axial tomography (CAT) scanning revealed vertebral-arch destruction in three cases of spondylolisthesis. Circumferential sclerosis of the vertebral bodies was another CAT-scan finding.

Atypical forms of spinal tuberculosis.

Twenty-three patients with atypical forms of spinal tuberculosis treated between 1975 and 1985, are described. All presented with signs and symptoms of compression of the spinal cord or cauda equina, ranging from paraesthesiae and increasing weakness of extremities to paraplegia and loss of sphincter control. None of them showed visible or palpable spinal deformity nor the typical radiographic appearance of destruction of the intervertebral disc and the two adjoining vertebral bodies. These atypical forms constituted about 12 percent of all the cases of spinal tuberculosis seen (a total of 190 cases); and fell into three well-defined groups: those with the involvement of neural arch only; those with the involvement of a single vertebral body; and, those without bony involvement. The correct surgical approach in these groups was found to be different: spinal cord compression caused by the tuberculous disease of the neural arch was best treated by laminectomy; whereas single vertebral body disease required an anterior or anterolateral approach. Spinal computerized tomography was helpful in defining the extent of disease and planning the surgical approach. Histological confirmation of tuberculosis was obtained in all the cases and acid fast bacilli (A.F.B.) were found in, and cultured from, the biopsy specimens of 18 cases.

Desmoplastic fibroma--a rare tumour in a rare site.

We report the occurence of a desmoplastic fibroma in the terminal phalanx of the big toe in a 42-year-old male. The tumour is rare, only 66 cases have been reported in the English language journals. The case history together with review of the literature is presented.

Osteitis of the humerus following BCG vaccination.

A 22-month-old Saudi child developed a granulomatous lesion of the left humerus following BCG vaccination in the overlying deltoid area 15 days after birth. The clinical picture, investigations and the histopathology reports are presented. The literature regarding BCG vaccine complications and their frequency is reviewed.

Severe mincer injuries of the hand in children in Saudi Arabia.

A review of twenty-two children with a mean age of 1.9 +/- 0.3 years who sustained injuries to the fingers and hand by domestic mincer machine. In each case the child inserted his hand in the machine while in motion. The pattern of injury is discussed and recommendations to avoid these mutilating injuries are made.

Is avoidance of sunlight a cause of fractures of the femoral neck in elderly Saudis?

A study of the frequency of admitted cases of femoral neck fractures to Riyadh Central Hospital, Riyadh, Saudi Arabia, showed admission of 95 patients over 40 years of age in a period of one year. The male to female ratio was 64% males to 36% females. Vitamin D nutritional status of patients with fractures of the neck of the femur expressed as 25-(OH)D3 was significantly lower (5.9 +/- 2.9 ng/ml) than of controls (9.7 +/- 4.7 ng/ml). Comparison of the housing types of both patients and controls showed that those living in traditional mud houses have significantly lower levels of 25-(OH)D3 than those occupying villas or flats. A third group of patients with low stores of vitamin D were exposed to natural ultraviolet light for a short period. This resulted in a significant increase in the levels of serum 25-(OH)D3 and a decrease in alkaline phosphatase activity. It is concluded that low levels of serum 25-(OH)D3 may play a role in the pathogenesis of femoral neck fractures in elderly Saudis and this may be due to minimal exposure to natural ultraviolet irradiation.

Sunlight and vitamin D status in normal Saudi subjects.

Serum levels of the circulating form of vitamin D3, 25-hydroxycholecalciferol [25-(OH)D3], were determined in 59 university students, 26 males and 33 females, aged 18 to 26 yr and in 24 elderly subjects, 13 males and 11 females, with a mean age of 62 +/- 13 yr. The level of 25-(OH)D3 was significantly lower in the elderly persons (p less than 0.001) than in young students of both sexes, and was significantly higher in females than in males. Serum levels of 1, 25- and 24, 25-dihydroxycholecalciferol were measured in adult males and found to be within the normal range. A group of elderly patients were exposed to natural uv light, and the circulating levels of 25-(OH)D3, serum phosphorus, and alkaline phosphatase were determined both before and 1 day after the last exposure. The exposure to natural uv light resulted in a 2 1/2-fold increase in the level of 25-(OH)D3 and a significant decrease in the activity of alkaline phosphatase, but no significant change in serum phosphorus concentrations was observed. It is concluded that the low vitamin D3 status in Saudis is mainly due to avoidance of sunlight exposure and other factors discussed below.

The wrinkly skin syndrome: a report of two siblings from Saudi Arabia.

A brother and sister born to a Saudi couple showed aging appearance, wrinkled skin over the hands and feet, inelastic skin, prominent veins over the hands, and other musculoskeletal and connective tissue manifestations. Both children were small for their age and had congenital dislocation of the hips. The paper describes the main manifestations and compares them with the previously described two families.

Congenital spinal extradural cyst (lateral meningocele) simulating acute transverse myelitis. Report of a case.

Congenital spinal extradural cysts are rare and may be the cause of acute paraplegia. In their clinical features they closely resemble acute transverse myelitis. Immediate decompression of the spinal cord and removal of the cyst may lead to restoration of normal function. Myelography differentiates these two conditions by showing a cyst in communication with the spinal canal. This investigation must be mandatory.