The risk of paraplegia through medical treatment.

In the Orthopedic University Hospital of Heidelberg (section Orthopedics II, treatment and rehabilitation of paraplegics), 21 patients with iatrogenic paraplegia were treated between 1968 and 1991. Paraplegia occurred in nine cases after procedures close to the spinal cord. In 12 cases paraplegia complicated medical treatment. Procedures close to the spinal cord, such as laminectomy, vertebrotomy, spondylodesis, and peridural anaesthesia, involve the risk of mechanical damage to the spinal cord, the level of paraplegia depends on the area of treatment. Any previous damage to the spinal cord increases the risk of paraplegic complications. The main risks in procedures distant from the spinal cord, such as vascular surgery, angiography, radiotherapy, bronchial artery embolisation, and umbilical artery injection, are disturbances of the blood supply or toxic mechanisms. The ischaemic genesis of spinal cord damage is obvious in the case of vessel ligatures or cross-clamping of the aorta with resulting hypotonic discirculation. In radiomyelopathy as well, the damage to the spinal vessels outweighs the direct neuronal damage. Corresponding to the vascular cause, lesions are more likely to occur at the level of borderlines of blood supply in the middle thoracic cord or in the area of a non-anastomosed great radicular artery in the lumbar spinal cord. Knowledge of the consequences and side effects of medical treatment is imperative. Knowing about the risk of a paraplegic lesion, we need a strict indication for diagnostic and therapeutic interventions. Due to progress in science some of the reasons of iatrogenic paraplegia have become manageable. Especially in radiotherapy, vascular surgery and angiography the risk of neurological complications has been lowered.

Chronic pain/dysaesthesiae in spinal cord injury patients: results of a multicentre study.

The aim of the multicentre study entitled 'Description and Documentation of Painful States in Spinal Cord Injury Patients', in addition to the description and documentation of chronic pain and stressful dysaesthesiae in SCI patients, was the search for correlations between these symptoms and medical and psychosocial variables. To this end, the sample was selected to be as representative as possible. All patients referred for in-patient or out-patient treatment at the centres taking part were enrolled in the study in order of presentation, providing they gave consent and met the inclusion criteria. Psychosocial, medical and demographic data were elicited by a standardized battery of questions and a standardized physical examination, as were any chronic pain/dysaesthesiae (P/D) present in any localization. Among 901 patients, 34% had no chronic pain or dysaesthesiae, 50% had pain only, 11% had painful dysaesthesiae and 5%, non-painful but chronic and distressing dysaesthesiae. The intensity of P/D was noted as seven or more on a 10 cm visual analogue scale by 61% of the patients affected and was experienced as rather or very distressing in 75% of cases. Most (86%) P/D were located below the spinal lesion or in the transition zone. There were significant correlations between the presence of P/D and age on questioning and at onset of the paraplegia/tetraplegia, problems with rectal paralysis, expectations of life as a paraplegic/tetraplegic, and subjective assessment of changes in working life. Highly significant correlations were found with subjective distress resulting of paraplegia/tetraplegia as such, depressed mood and psychosomatic disturbances of wellbeing. Overall, among the selected variables of our study, we found that correlations between P/D and psychosocial variables were more frequent and closer than those between P/D and medical variables.

[Meaning, dimension and problems in home care of spinal cord injured persons]. / Inhalt, Ausmass und Problematik der häuslichen Pflege von Querschnittgelähmten.

Today, patients with paraplegia who have successfully passed a course of clinical treatment and rehabilitation in a specialized hospital, are no longer considered as 'sick' or as 'chronically sick'. Rather, they are considered as 'healthy', however, under conditions of being continuously, often severely, handicapped. Nevertheless, the lasting impairment determined the need for the patient to subject herself/himself for a lifetime to well-defined measures of regular checking of body functions, e.g. a monitoring of respiration, circulation, excretion and motor functions. This includes in particular the adherence to basic hygienic requirements. Depending on the degree of existing paralysis, i.e. complete or incomplete paraplegia or tetraplegia, but also on the age of the patient or the presence or absence of severe complications, spinal cord injury patients will remain dependent on care administered by other persons rendering such services or become largely or completely independent in that respect. Special attention has to be given to measures such as regular emptying of the paralysed bladder and the paralysed bowels, prevention of bed sores, skin conditions and of contractures. Depending on the patient's personality structure and the extent to which the handicap and the body functions including the severe disturbance of the body scheme are mastered psychosocially, deviant behaviour ranging from exaggerated and biased body care to almost suicidal negligence of this aspect can be observed. The necessity of education towards a behaviour that is in conformity with the requirements of hygiene during the stay at the special hospital and of checking of the resulting necessities by the attending practitioner is pointed out.

[25 years Heidelberg Rehabilitation Center for Spinal Cord Injuries--retrospect and prospects]. / 25 Jahre Rehabilitationszentrum für Querschnittgelähmte Heidelberg--Rückblick und Ausblick.

In the framework of a commemorative gathering and scientific symposium in November 1991, an account was given of the 25 years of service of the Rehabilitation Centre for Spinal Cord Injured Persons of the Heidelberg Orthopaedic University Hospital Foundation. Tribute was at the same time paid to the lifework of Kurt Lindemann, former director of the Orthopaedical University Hospital and rector magnificus of the Heidelberg Ruperto Carola University, in memory of the 25th anniversary of his death in 1966. Encouraged by the father of SCI rehabilitation Sir Ludwig Guttmann, of Stoke Mandevillehospital, England, Kurt Lindemann had taken the initiative for establishing this centre and prepared its opening in 1966. Comprising a clinical department, the Ludwig Guttmann House, and a department for vocational-social rehabilitation, the Kurt Lindemann House, the centre has since enabled provision of all measures required for comprehensive rehabilitation of spinal cord injured women, men and children--starting at the day of injury till full resettlement of this population in family, occupation, and society. Erected a quarter century ago, the centre has in the last two years been brought up to date architecturally and structurally; further measures for implementing the most recent state of the art in rehabilitating spinal cord injured patients lie ahead.

[Pain symptoms in paraplegic patients]. / Schmerzsymptomatik bei Querschnittlhmungen.

The number of paraplegics who survive their initial trauma by decades is on the increase. A considerable percentage of these patients will, sooner or later, temporarily or permanently, manifest a pain syndrome and/or phantom pain. Accurate differentiation of the disagreeable sensations, which are often difficult to describe (dysesthesia, paresthesia), is frequently a big problem. The pathogenesis still remains unclear, and therapy often proves unsatisfactory.

Cystic degeneration following severe spinal trauma. Clinical observations in 30 patients.

Secondary, in most cases ascending neurological deterioration following severe spinal trauma has been known since the beginning of this century. The alterations are caused by cystic cord degeneration and probably are due to venous circulatory disturbances. In a review of the literature 680 cases were found. The present paper describes findings in our 30 patients. Modern diagnostic methods provide exact localization and evaluation of the cysts. These can then be drained microsurgically. Short-term success is good in many cases, long-term developments will be observed carefully. The functional loss of only one segment can, depending on the level of the original lesion, result in dramatic consequences for the patient.

[A medical view of the rank of technical aids in rehabilitation (author's transl)]. / Der Stellenwert der technischen Hilfe in der Rehabilitation aus ärztlicher Sicht.

Severe congenital or acquired physical impairments result in disabilities that, in the first instance, entail various disorders of functions the "normal" person has at his or her disposal. These, on the other hand, engender grave disturbances of the interpersonal and social reference systems every human being is fitted into, and which are a premise of existence as a "person". Rehabilitation conceived as an effort towards overcoming such disorders and disturbances must make use of any means and possibilities at its disposal in order to compensate for, or alleviate, these repercussions at all levels of the reference system. Within the entirety of these efforts and increasingly important part falls to the development and utilisation of modern technology. The person's relationship with the environment, and his or her ties with it, are in many respects brought about by the technico-instrumental aids;--communication, handling, locomotion, eating and drinking, food processing, production and reproduction, and many more. The kaleidoscope of technical aids available today is outlined, as is the need for a correct, and above all individualised, approach in the process of procurement and training in their use. The physician as well as the para-medical staff involved require comprehensive factual knowledge but at the same time far-reaching commitment to these tasks to enable them to make optimal use of existing possibilities, and to cope with the difficulties that arise. Special mention must be made in this context of administrative impediments and economic constraints.

Analysis of 139 spinal cord injuries due to accidents in water sports.

Between 1967 and 1978, a total of 2587 patients received primary treatment in the Spinal Cord Injury Centre at the University of Heidelberg. In 212 cases the paralysis was caused by sports or diving accidents. Injuries resulting from accidents in water sports totalled 139, 131(61.7 per cent) of which could be classified as actual diving accidents. These 131 cases consisted of 129 tetraplegias and only 2 paraplegias. In 5 cases, the tetraplegia resulted from high diving and in 3 cases from scuba-diving. The subjects of the analysis are causes of accidents, segmental diagnosis of neurological deficiency symptoms and prognosis.

[Trampoline jumping--a dangerous sport? Analyses of injuries and preventive measures]. / Trampolinspringen--ein gefährlicher Sport? Verletzungsanalysen und prophylaktische Massnahmen.

Trampoline Jumping--A Dangerous Sport? Injury Analyses and Prophylactic Measure: Trampoline jumping enjoys an increasing popularity yet it is not without its dangers. More than 7000 schoolchildren are reputedly injured at this sport annually. The numerous distortions, fractures and luxations of the extremities are relatively harmless injuries. However, severe traumata with tetraplegia appear with increasing frequency. We have seen 25 cases in 10 years. The causes and exact mechanism of injury became apparent from thorough analysis of the accidents. Improvement of the safety measures is urgently necessary. The mini-trampoline should be abolished from school lessons.

The significance of bladder capacity under aspect of continence and micturition in neurogenic bladder dysfunction.

The bladder capacity of patients with a neurogenic bladder disorder was determined. Since the bladder capacity varies according to the type of neurogenic lesion (supranuclear, infranuclear), it was to be determined, whether reflex detrusor activity and duration of the lesion would influence bladder capacity. It was found that in supranuclear lesions s sufficient bladder capacity can be maintained with a balanced micturition, and that spincterotomy does not result in reduced bladder capacity. In infranuclear lesions intermittent catheterization is a good therapeutic method to preserve continence and an intact renal function as well.

[Paraplegia due to sports and bathing accidents (author's transl)]. / Paraplegie durch Sport- und Badeunfälle.

An analysis of 2346 paraplegics treated in the Heidelberg University orthopaedic hospital showed that 194 of the lesions (= 8,3%) were caused by accidents during sports and bathing. Of 123 bathing accidents, 98.4% produced a lesion of the cevical part of the medulla, the site of paresis being mostly below C 5 or C 6. The predominant accident mechanism of the most frequently occurring luxation fractures was hyperextension and hyperflexion. 71 of the 194 cases (= 36,6%) were genuine sports accidents. 35 cases of tetraplegia occured preferably during gymnastics, jumping on the trampoline, and high-tower diving, whereas 36 paraplegias were due to accidents during riding, skiing and mountaineering. Flexion and compression fractures mainly concern the pelvic region of the vertebral column. Only 4 of the 194 injured patients (= 2.1%) died as a result of their accident.

Scoliotic growth in children with acquired paraplegia [proceedings].

1. 166 children with paraplegia occurring before the age of 15 are presented, of whom 116 are available for the study. 2. Scoliosis of more than 15 degrees developed in approximately one-half of the children. 3. Children with thoracic paralysis appear to be particularly endangered. 4. The primary spinal column injury as a result of an accident plays only a minor role in the development of scoliosis. 5. The asymmetric neurological level of paralysis is seen as a significant cause of scoliosis. 6. As prophylaxis, a spinal support as well as standing and walking exercises, including balance exercises, are recommended. 7. As possible therapy in cases with proven asymmetric neurological paralysis, rhizotomy of several thoracic spinal nerves may be discussed in order to achieve a balanced paralysis.