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Study Design: Cross-sectional OBJECTIVE: To investigate the association between skeletal muscle mass and spasticity in people with spinal cord injury (SCI)., Setting: Tertiary level hospital in Seoul, Korea METHODS: Spasticity was evaluated in 69 participants with SCI using the spasticity sum score (SSS), Penn Spasm Frequency Scale (PSFS), and Spinal Cord Assessment Tool for Spastic Reflexes (SCATS). Skeletal muscle mass was measured using a dual-energy X-ray absorptiometry scanner, and skeletal muscle index was calculated by dividing skeletal muscle mass by height squared. Laboratory parameters including hemoglobin, albumin, creatinine, fasting glucose, and cholesterol were measured. Spearman's correlation analysis was performed to assess the association between the skeletal muscle mass and spasticity scales. Multiple linear regression analysis was used to present the independent association between them., Results: The participants' mean age was 41.8 years; 54 (78.3%) were male, and 46 (66.7%) were tetraplegic. Skeletal muscle index of lower extremities was significantly correlated with all spasticity scales. Spearman's correlation coefficients were 0.468, 0.467, 0.555, 0.506, and 0.474 for SSS, PSFS, SCATS clonus, SCATS flexor, and SCATS extensor with p-values < 0.001, respectively. After adjustment for age, sex, level of injury, body mass index, and serum creatinine, all spasticity scales were significantly associated with skeletal muscle index of lower extremities in multiple regression analysis. Standardized coefficients were 0.228, 0.274, 0.294, 0.210, and 0.227 for SSS, PSFS, SCATS clonus, SCATS flexor, and SCATS extensor., Conclusions: Spasticity was significantly correlated with the skeletal muscle mass even after adjusting for possible confounders. Spasticity may need to be considered as an influencing factor in interventions such as electrical stimulation to preserve skeletal muscle mass.

Study Design: Single case report., Objective: We present a case of paraplegia due to neuromyelitis optica (NMO) with poor rehabilitation outcome., Setting: University hospital, Japan., Case Report: A 27-year-old woman with NMO presented with T5 paraplegia of ASIA impairment scale grade A. Spinal cord magnetic resonance imaging revealed a lesion spanning C3 to L1 level. After acute phase treatment, flaccid paraplegia below T5 and a T2-weighted hyperintense lesion from T6 to T10 level remained. Rehabilitation aimed at independence of activities of daily living with wheelchair assistance, including transfer activity, was provided for 19 months. However, flaccid paralysis of the trunk and limbs persisted, and safe independent transfer was not achieved., Conclusion: Spinal lesions spanning many vertebral segments, a characteristic of NMO, can cause extensive flaccid paralysis of the trunk and limbs. Rehabilitation may achieve poorer functional recovery than that for spinal cord injury.

Study Design: Cross-sectional controlled study., Objectives: To evaluate the elbow joint with ultrasound in paraplegic patients, determine the related factors and compare it with healthy controls., Setting: A training and research rehabilitation hospital in Istanbul., Methods: A total of 30 paraplegic patients and 20 healthy controls were included in the study. Patients demographic data, pain in the elbow joint, level and duration of injury, ambulation status, type of wheelchair used, daily duration of wheelchair and other ambulation equipment usage, transfers being dependent or independent, daily number of push-ups were recorded. Elbow joints were evaluated with ultrasound for presence of fluid and thickness of the triceps tendon., Results: Mean triceps tendon thickness values of the right side were larger in spinal cord injury (SCI) patients when compared with those of healthy controls'. Joint effusion on the right elbow joint was also found to be more common in SCI patients than in normal subjects. Triceps tendon thickness measurements were not found to be correlated with demographic and clinical factors. Seven paraplegic patients (23%) reported that they have pain in the elbow., Conclusion: In this preliminary study, our results showed that right elbow effusion was more frequent and right triceps tendon was thicker in SCI patients when compared with healthy subjects.

Study Design: Descriptive case series., Objectives: Describe the unusual etiology and pattern of spinal cord injury due to terrorist suicide bombings in Pakistan., Settings: Spinal Rehabilitation Unit, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan., Methods: Hundreds of suicide attacks on civil and military forces have occurred over the last 6 years in Pakistan. These have resulted in thousands of death and many more injured. Six victims of terrorist suicide bombings were admitted over the years 2006 to 2009, who had a spinal cord injury (SCI). This is the first case series of SCI, secondary to terrorist suicide blast., Results: All patients were males. The mean age was 30±11 years. Most (five) were injured directly due to splinters from the blast. On admission to rehabilitation, all patients had thoracic complete paraplegia and their SCI was managed conservatively for their spinal injuries. Associated injuries included intestinal perforations, fracture metatarsals, humerus and brachial plexus injury. Pressure ulcer was the commonest complication (3 patients). Two patients had neurological improvement at 1-year follow-up., Conclusion: Suicide bombing is an effective weapon of terrorists in the modern world of today. The resulting injuries can be diverse and devastating. Spinal cord injury is an uncommon sequel of suicide bombing, which should be kept in mind while dealing with victims of suicide bombing.

Study Design: Case report., Objectives: The aim of this report was to describe an example of pulmonary embolism (PE), recently suggested to be highly prevalent in persons with chronic spinal cord lesions., Setting: Veterans Affairs Hospital, Boston, MA, USA., Methods: Chart review., Results: A 60-year-old man with paraplegia, T10 motor complete, underwent laminectomy for correction of an arteriovenous malformation. After 41 days, he sustained a massive PE-suggested by right bundle branch block (RBBB) on an electrocardiogram (ECG) and diagnosed by perfusion lung scanning. He was treated with anticoagulants, the lung scan and RBBB resolving within 1 month of initiating treatment. After 5 years, he developed vertebral osteomyelitis at L5-S1 and was treated with antibiotics and bed rest. After 7 days, he was mobilized to a wheelchair, and during a transfer back to bed, he developed anxiety, dyspnea, fluctuating consciousness, low blood pressure and RBBB, absent by ECG 4 days earlier. He expired 20 min after onset of symptoms. The autopsy revealed a fresh thromboembolus occluding both main stem branches of the pulmonary artery., Conclusion: Massive PE after surgery in a patient with chronic paraplegia recurred 5 years later in association with severe infection and mobilization after bed rest, which resulted in death.

Study Design: Cross-sectional study., Objective: To evaluate isokinetic shoulder flexor-extensor (F/E) and abductor-adductor (Ab/Ad) torque ratios in individuals with paraplegia using a new interpretative approach. We proposed to study torque ratios according to joint angle sections (15 degrees angle subgroups) over a selected range of motion., Setting: Pathokinesiology Laboratory, Montreal, Canada., Method: Sixteen individuals with complete motor paraplegia, without shoulder pain or impairment, were included in this study. After a preloading period of 1 s, maximum isokinetic concentric contractions of all muscle groups were completed at 30, 60 and 120 degrees s(-1) over the entire tested ranges of motion (70 to -35 degrees for the flexion-extension and 15 to 60 degrees for the abduction-adduction). After the continuous torque curves were rebuilt, the mean F/E and Ab/Ad torque ratios were calculated and analyzed every 15 degrees., Results: A significant modification of the F/E (F=66.3; P<0.001) and Ab/Ad (F=100.6; P<0.001) torque ratios was observed according to the 15 degrees angle subgroup evaluated. More precisely, a progressive decline of both the F/E and Ab/Ad ratios was noted as the shoulder flexion or abduction progressed. Angular velocity did not have any influence on torque ratio values., Conclusion: Angle subgroup torque ratio analysis leads to a better estimation of the balance between the agonist and antagonist muscle groups than does traditional peak torque ratio analysis. In individuals with paraplegia, this precise estimation of torque ratios may lead to the development of specific shoulder strengthening programs to prevent muscle imbalance and its consequences.

Study Design: Unrandomized trial., Objectives: To investigate the structural and functional relationships and the progression of muscle atrophy up to 20 years of spastic paraplegia., Setting: Clinical follow-up in Vienna, Austria; muscle biopsies analyzed by light microscopy in Padova and by electron microscopy (EM) in Chieti, Italy., Methods: Force was measured as knee extension torque; trophism by computer tomography scan; tissue composition and fiber morphology by histopathology and EM., Results: In the long-term group of patients (17.0+/-2.6 years), force and size of thigh muscles were only slightly different from those of mid-term subjects (2.2+/-0.5 years). Histology and ultrastructure confirm that the difference in average size of muscle fibers between long-term and mid-term paralyzed leg muscles is actually very small. In addition, muscle fibers maintain the striated appearance characteristic of normal skeletal fibers even after 14-20 years of paralysis. Ultrastructural alterations of the activating and metabolic machineries, and the presence of fibers with lower motor neuron denervation features, may explain the low-force output and the reduced endurance of paretic muscles., Conclusion: The stable muscle atrophy that characterizes long-lasting spastic paraplegia suggests that there are no upper-time limits to begin a training program based on functional electrical stimulation.

Study Design: A case report of spinal cord dysfunction following meningococcal meningitis., Objectives: To describe a rare complication of meningococcal meningitis., Setting: Spinal Unit, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan., Methods: A young healthy male developed meningococcal meningitis followed by acute onset low thoracic flaccid paraplegia with complete motor and sensory loss and sphincter disturbance. He responded well to antibiotics but was not investigated for causes of paraplegia. While at home in a rural area, he developed pressure ulcers, anemia and depression. Magnetic resonance imaging of the whole spine and computed tomography scan of the brain performed after 4 and 10 weeks were normal., Results: The patient had a comprehensive rehabilitation at our institute. Recovery was complicated by ossification in the right thigh, which responded well to radiotherapy. At 1-year follow-up, the motor deficit and neurogenic bladder and bowel persisted and the patient remained wheelchair dependent for mobility., Conclusion: Several mechanisms have been proposed to explain spinal cord damage after meningitis. These include spinal cord infarction; autoimmune-mediated inflammatory myelopathy and direct infection of the cord. Most probable cause of spinal cord dysfunction in this case was thoracic myelopathy.

Study Design: Experimental., Objective: To determine the effects of a porous tube transplant in spinal cord transected rats., Setting: Acadia University, Wolfville, Nova Scotia, Canada., Methods: Female rats were randomly assigned to three experimental groups: control (Con, n=8), spinal cord transected (Tx, n=5) and spinal cord transected with transplant (TxTp, n=7). The rats in the TxTp and Tx groups received a complete spinal cord transection at the T10 level and the TxTp group immediately received a porous tube transplant., Results: Locomotor activity rated on the Basso, Beattie, Bresnahan scale improved significantly in the TxTp animals over the 4 weeks such that final scores were 21, 1.4 and 7.1 for the Con, Tx and TxTp groups, respectively. As expected, the muscle to body mass ratios of the hindlimb skeletal muscles of the Tx group were decreased (soleus 35%, plantaris 29% and gastrocnemius 29%) and this was also observed in the TxTp group (soleus 33%, plantaris 23% and gastrocnemius 30%). Cytochrome c oxidase (CYTOX) activity in the plantaris was decreased by Tx but maintained in the TxTp group (Con=82.2, Tx=44.8 and TxTp=72.8 U/min/g)., Conclusion: Four weeks after the spinal cord transection, plantaris CYTOX activity and locomotor function improved with porous tube implantation., Sponsorship: Natural Sciences and Engineering Research Council.

Study Design: Case report., Objective: To describe the difficulty in diagnosing spinal pseudomeningocoele., Setting: Department of Rehabilitation Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia., Case Report: A case of progressive sacral swelling in a paraplegic man who sustained spinal cord injury 14 years ago is presented. Although his clinical features were suggestive of pseudomeningocoele, we were unable to confirm the diagnosis preoperatively., Conclusion: Traumatic spinal pseudomeningocoele is very rare. Even with the available modern diagnostic imaging techniques, it is still difficult to diagnose a spinal pseudomeningocoele.

Study Design: Case report., Objectives: To report a rare cause of spinal subdural hematoma., Setting: A tertiary care university hospital in Andhra Pradesh, India., Methods: Detailed evaluation and reporting of a case admitted in the hospital., Results: A case of antiphospholipid antibody syndrome (APS) was found to present with spontaneous spinal subdural hematoma and paraplegia. This is a very rare presentation of APS., Conclusion: This article describes a rare case of APS presenting with disseminated bleeding and spontaneous spinal subdural hematoma, resulting in paraplegia.

Study Design: Case report., Objectives: To describe a rare case of oncocytoma arising from the spinal cord in a 40-year old woman., Setting: Republic of Korea., Methods: The patient's history, physical examination, radiological and pathological findings were reviewed., Results: A 40-year-old woman presented with 3-month history of low back pain. Magnetic resonance imaging revealed an intradural extramedullary mass located between L1 and L4. She refused any surgical treatment and so was discharged. At 10 days after discharge, an emergency operation was performed because of sudden paralysis in both lower extremities. The confirmed diagnosis is oncocytoma. At 4 months after surgery, the patient failed to obtain neurological recovery from complete paraplegia., Conclusions: Since the progression of an intradural extramedullary mass that shows minor neurological symptoms can lead to complete paraplegia in a short time, close observation and early surgical decompression are necessary.

Background: Postprandial hypotension (PPH) appears in various conditions with autonomic failure and was symptomatic in a patient with thoracic paraplegia, but was not remarkable in patients with tetraplegia., Objective: To determine whether the pathology causing PPH may include a thoracic but not a cervical spinal cord lesion (SCL)., Design: An experimental controlled study., Setting: The spinal research laboratory, Loewenstein Hospital, Raanana, Israel., Subjects: Thirteen healthy subjects, 10 patients with traumatic T(4)-T(6) paraplegia, and 11 patients with traumatic C(4)-C(7) tetraplegia., Main Outcome Measures: Heart rate (HR), blood pressure (BP), HR and BP spectral components (LF, HF, LF/HF), cerebral blood flow velocity (CBFV), and cerebrovascular resistance index (CVRi)., Methods: The effects of a standard liquid meal on the outcome measures were compared between the three subject groups monitored for HR, BP, and CBFV, from 55 min before to 45 min after the start of the meal. The recorded signals were digitized online and analyzed off-line in the time and frequency domains., Results: After meal, BP decreased only in the paraplegia group (P<0.01), HR increased more prominently in this group (P<0.01), CVRi tended to decrease only in the paraplegia group, CBFV did not change significantly in any group, and HR LF/HF increased (P<0.001) in all groups but tended to increase more in paraplegia., Conclusions: Patients with mid-thoracic SCL may develop PPH. The pathology causing PPH can include a thoracic but not a cervical SCL. The normal hemodynamic reaction to liquid meal ingestion is mediated through the mid-thoracic spinal cord. The sympathovagal balance increases after food ingestion, more prominently in patients with PPH, and cerebrovascular resistance changes during PPH may help maintain the cerebral circulation.

Study Design: Clinical case report with comments by colleagues from Sweden, Poland, Spain, Brazil, Japan, Belgium and Switzerland., Objectives: To discuss the role of disodium etidronate therapy for prevention of calcium phosphate vesical calculi in persons with spinal cord injury, who have hypercalciuria and biochemical evidence of increased bone resorption., Setting: Regional Spinal Injuries Centre, Southport, UK., Methods: A 21-year-old male sustained paraplegia (T-10; ASIA scale: A) in a road traffic accident in June 2001. He had an indwelling urethral catheter until the end of August 2001, when he started self-catheterisation. He developed bladder stones and electrohydraulic lithotripsy (EHL) was performed in May 2002. All stone fragments were removed. Recurrence of vesical calculi was noted in October 2002. These stones were fragmented by lithoclast lithotripsy in two sessions, in December 2002 and February 2003; all stone fragments were removed at the end of the second session. This patient reverted to indwelling catheter drainage when vesical calculi recurred. In September 2003, X-ray of the abdomen showed recurrence of vesical calculi. By February 2004, the stones had increased in size and number. EHL of vesical calculi was again performed in April 2004. Complete clearance was achieved., Results: A 24-h urinalysis detected hypercalciuria--18.7 mmol/day (reference range: 2.5-7.5). Biochemical analysis of vesical calculus revealed calcium phosphate (85%) and magnesium ammonium phosphate (15%). Plasma C-terminal telopeptide (CTX) was increased - 1.06 ng/ml (reference range: 0.1-0.5 ng/ml). Free deoxypyridinoline/creatinine ratio (fDPD/Cr) in urine was also increased - 20.2 (reference range: 2.3-5.4). In April 2004, this patient was prescribed disodium etidronate 400 mg day. Nearly 3 months after commencing therapy with etidronate, plasma CTX decreased to 0.87 ng/ml. fDPD/Cr in urine also decreased to 12.4. After 4 months of etidronate therapy, 24-h urinary calcium excretion had decreased to 6.1 mmol/day., Conclusion: Etidronate (400 mg daily) is a very effective inhibitor of calcium phosphate crystallisation. Etidronate decreased urinary excretion of calcium, an important factor in prevention of calcium phosphate bladder stones. Etidronate therapy is not a substitute for other well-established methods for prevention of vesical calculi in spinal cord injury patients, for example, large fluid intake, avoiding long-term catheter drainage. Intermittent therapy with etidronate may be considered in selected patients, in whom hypercalciuria persists after instituting nonpharmacological therapy for an adequate period, for example, early mobilisation, weight-bearing exercises, and functional electrical stimulation. However, possible side effects of etidronate, and the fact that etidronate is not licensed in United Kingdom for prevention of urolithiasis, should be borne in mind.

Study Design: A case report., Setting: Regional Spinal Injuries Centre, Southport, UK., Case Report: A 56-year-old male with complete paraplegia at T-4 underwent visual internal urethrotomy of bulbous urethral stricture with a cold knife at 12 o'clock position. There was brisk arterial bleeding. Despite receiving antibiotics, this patient developed hypotension, tachycardia and tachypnoea. He was resuscitated and mechanical ventilation was instituted. After he recovered from this life-threatening episode of urinary tract-related sepsis, colour Doppler ultrasound imaging of bulbous urethra was performed to locate urethral arteries. In the bulbous urethra, single urethral artery was seen at 12 o'clock position., Conclusion: Since the sites of urethral arteries vary among patients, it is advisable to assess individually the location of urethral arteries preoperatively and plan the site of incision accordingly. Persons with injury to cervical or upper dorsal spinal cord have decreased cardiac and respiratory reserve as well as alteration in immune function. Therefore, all possible measures should be taken to prevent acute blood loss and bacteraemia in this group of patients.

Study Design: Case report., Objectives: To report a case of a thoracic intramedullary spinal cord metastasis of ovarian tumor in a 59-year-old woman., Setting: Shiga, Japan., Case Report: A case of a thoracic intramedullary spinal cord metastasis of ovarian tumor in a 59-year-old woman is reported. She received abdominal ovariectomy for the ovarian adenocarcinoma 4 years before she suffered from back pain and showed neurological symptoms. The thoracic intramedullary lesion was confirmed by preoperative magnetic resonance imaging. She showed complete paralysis before operation. The excision of the tumor was achieved through the posterior approach. Histologically, the diagnosis of metastasis of adenocarcinoma was made., Conclusion: Although she did not show any postoperative neurologic recovery, her general condition was good and there was no evidence of recurrence 24 months after surgery.

Study Design: Case report., Objective: To report a rare cause of spinal cord compression., Setting: University Hospital, Wales, UK., Case Report: A 67-year-old gentleman on oral anticoagulation for atrial fibrillation presented with a 4-h history of progressive loss of sensation and weakness in both legs; there was no history of trauma. On examination, he had a flaccid paraplegia with altered sensation in the L1,2,3 dermatomes and complete anaesthesia in the L4,5 distribution. Knee and ankle jerk reflexes were absent, plantars were equivocal and anal sphincter tone was reduced. The patient's international normalized ratio (INR) was 4.1. An MR scan showed an extensive intradural haematoma compressing the cauda equina. The anticoagulation was reversed and an urgent T12-L2 laminectomy was performed; findings were a circumferential haematoma at L1 extending in the anterior canal between T10 and L3. The patient had an uneventful postoperative course generally, but at 1 week there was no neurological recovery., Conclusion: This case highlights that anticoagulation even when well controlled is not without risk. This is particularly of concern as the number of patients receiving long-term anticoagulation therapy has doubled between 1993 and 1998.

Study Design: The 5 year review of patients referred to one center., Objective: To report spinal cord infarction secondary to vascular occlusion from disease in a lower thoracic intervertebral foramen., Method: The clinical and imaging findings of two cases with acute spinal cord dysfunction are presented., Setting: Midlands Centre for Spinal Injuries, England., Results: The CT and MR imaging features revealed lower thoracic unilateral foraminal occlusion due to acute facet joint septic arthritis in a diabetic patient, and secondary to chronic hypertrophic osteophytes in a second hypertensive individual. The presumed mechanism of infarction was occlusion of the artery of Adamkiewicz., Conclusion: Foraminal disease in the lower thoracic levels needs to be entertained in cases of unexplained nontraumatic acute spinal cord dysfunction.

Study Design: A case report., Objectives: To present and discuss some of the difficulties in the diagnosis of brucellar spondylitis., Setting: Ankara University, Ibni Sina Hospital, Turkey., Methods: We report a patient with paraplegia, misdiagnosed as having a malignancy or tuberculosis who actually suffered from brucellar spondylitis. Diagnosis was established by her history and a compatible clinical picture together with a standard tube agglutination (Wright test) titer of > or =1/160 of antibodies for brucellosis. The patient was treated with oral doxycycline, rifampicin, and ciprofloxacin combination., Results: At the end of the treatment, the blood Brucella Wright and anti-human globulin T titer levels decreased. Her lower limb weakness improved. She could walk, and climb stairs with the help of a cane. Urinary retention and fecal incontinence also resolved., Conclusion: Brucellosis is a systemic infection involving the musculoskeletal and nervous systems. Spondylitis frequently occurs in elderly patients. An early diagnosis of brucellar spondylitis can often be difficult. In endemic regions, as in the case of our country, brucellar spondylitis should always be considered in the differential diagnosis of older patients with back pain and constitutional symptoms. An early diagnosis will help to prevent the development of more severe complications such as spinal cord compression.

Study Design: Case report., Objective: To report complete recovery after paraplegia in an elderly patient after removal of meningioma at C7-T1 level., Setting: Department of Neurosurgery, Reggio Calabria, Italy., Methods: An 82-year-old lady with 48 months of progressive weakness and numbness was admitted with complete paraplegia lasting 15 days. Investigations (magnetic resonance imaging (MRI)) demonstrated a meningioma at C7-T1. The tumour compressed the extremely thinned spinal cord. MRI after surgery showed no evidence of residual tumour and the spinal cord was of normal dimensions. The patient recovered fully and locomotion was restored., Conclusion: Surgical decompression gave an excellent result. The result raises the possibility of neuronal plasticity.

Objectives: To investigate the morphological aspects of blood microvasculature of the skin and subcutaneous tissues in subjects with paraplegia with heterotopic ossification (HO)., Methods: In two patients with traumatic spinal cord injury and HO, punch biopsies of skin and hypodermic soft tissue in the region of HO near the hip were studied with histological and ultrastructural methods., Results: Alterations of endothelial cell and basement membrane of capillaries and small vessels were observed. Hyperactive endothelium, thickening and reduplication of the basement membrane, changes of the perivascular connective tissues and microcalcifications in the subcutaneous fat tissue were also seen., Conclusions: This present study indicates microvascular changes in the skin and subcutaneous tissue in the region of HO near the hip of two subjects with paraplegia. In our opinion the described vascular changes may induce hypoxiemic alterations of the soft para-articular tissues leading metabolic changes which may contribute to the development of HO. Therefore, it cannot be concluded whether these changes are directly responsible for HO induction.

Study Design: The bone mineral density (BMD) in 22 male subjects with complete lesion paraplegia sustained 1.8 to 27 years previously was measured. The measurements were used in screening each subject for a research programme investigating the restoration of standing using functional electrical stimulation (FES)., Objectives: To assess the extent of bone loss in this group of subjects and correlation to age, time post-injury and level of lesion., Setting: District General Hospital in the UK., Methods: BMD was measured by dual energy X-ray absorptiometry (DEXA) in the lumbar spine and femoral neck and expressed as an indirect index to an age matched 'normal' population. Fracture risk was described from this score using published data indicating that the risk increased with each standard deviation difference from the 'normal' mean., Results: The bone density in the lumbar spine was better preserved than in the femoral neck. BMD in the lumbar spine was found to be greater than the mean from the age matched population in 57.1% of subjects. Bone loss at the femoral neck suggested that 81.8% of the subjects were at increased risk of fracture, but only 22.7% were at a high risk. No correlation was found between BMD at the lumbar spine or the femoral neck and age, lesion level or time post-injury., Conclusion: The study indicates that further investigation into baseline BMD values for the SCI population is required to improve information provided to patients and assessment of fracture risk on an individual basis.

Background: The study was concerned with the secondary functional compromise persons with long-term paraplegia contend with, that has been shown to be associated with wheelchair use. Of particular interest was the relationship between the level of thoracic spinal cord injury (SCI) and factors predisposing to rotator cuff disorders (RCD), one of the most common upper extremity musculoskeletal complications linked with long-term SCI. Disorders of these peri-articular structures have previously been associated with impaired trunk postural control and abnormal muscle strength ratios in both able-bodied groups and in paraplegic athletes. Despite their neurologically intact shoulder joint musculature, high-level and low-level paraplegics have different degrees of trunk and pelvic stability available to them during activities of daily living (ADL). This fundamental functional anatomical difference between high-level and low-level paraplegics had not previously been related to the diagnosis of RCD in a non-athletic long-term paraplegic population., Methods: A descriptive cross sectional study was undertaken to demonstrate the differences in the prevalence of clinically diagnosed RCD in a high-level (n=22) and a low-level (n=20) group of persons with long-term paraplegia. Any perceived differences were then related to the functional anatomical variations between the two groups. Inferences were made based on factors predisposing to RCD known to exist among both able-bodied and paraplegic athletes. The 42 subjects completed the Wheelchair User's Shoulder Pain Index (WUSPI) to establish the presence or absence of shoulder pain and the Musculoskeletal Function Assessment (MFA) instrument to determine differences in functional ability and perceived degree of difficulty within five categories of ADL. Each participant underwent a clinical examination using validated provocative clinical tests and isometric muscle strength ratio testing., Results: There was a higher prevalence of RCD in the high-level group (P=0.009) which correlated with decreased trunk control (P=0.009). Differences in ability to perform functional tasks were not shown to be greater in the high-level group, although there was a higher degree of perceived difficulty in ADL. Muscle strength imbalances between the shoulder adductors and abductors were shown to be greater in the high-level group., Conclusions: The results of this study suggest that the functional anatomical differences that exist within paraplegia contribute to the propensity of high-level paraplegic persons to suffer from RCD. These findings send a clear message to service-providers that greater acknowledgement of the differences in trunk postural control specific to the level of thoracic SCI is required. This may have implications for the prescription of wheelchairs, assistive devices and instruction for alternative ADL techniques to this specific population.

We report on a 29-year-old male patient with multiple intracerebral and spinal cavernomas. Bleeding in the thoracic cord at admission and additional bleeding which occurred 12 days later in the cervical cord resulted in complete paraplegia below thoracic level 4 (Th4). Four years earlier multiple cerebral cavernomas had been diagnosed by magnetic resonance imaging (MRI). Based upon reported cases in the literature multiple intracerebral and spinal cavernomas are exceptional. Additionally, the clinical presentation in our case is uncommon.

Introduction: The effect of spinal deformity with posttraumatic kyphosis and stenosis of the spinal canal in producing secondary changes of the spinal cord has been discussed for quite some time. Since the advent of magnetic resonance imaging (MRI), 20-40% of patients with posttraumatic paraplegia are found to develop hydromyelia. PURPOSE OF OUR STUDY: To evaluate the influence of residual spinal deformity, defined by the extent of the posttraumatic kyphosis and stenosis, in the development of posttraumatic hydromyelia., Material and Methods: Two hundred and seven cases of traumatic paraplegia with MRI follow-up were reviewed retrospectively. A minimum of 3 years duration between trauma and MRI study was required (mean 10.6 years [3.2-38.3]). For statistical analysis two groups of patients were formed: with hydromyelia and without hydromyelia. After healing of the fracture, the extent of the kyphosis and stenosis, as well as the characteristics of the paraplegia were noted., Results: We found that 53 patients had hydromyelia. A highly significant correlation was found for the extent of spinal stenosis and the amount of kyphosis. Cluster analysis indicated that patients with more than 15 degrees of posttraumatic kyphosis and more than 25% of stenosis were twice as likely to develop hydromyelia. The level of the lesion and the remaining neurological function was not proven to have any influence towards the development of hydromyelia., Conclusions: These results support the idea that chronic mechanical stress to the spinal cord increases the risk for the development of hydromyelia. Surgical reconstruction should be considered for all patients to prevent secondary changes of the spinal cord.

A case of an immunocompetent 60 year old patient is reported, who suffered extensive thoracic spinal injury and paraplegia after polytrauma. In the course of rehabilitation he developed aspergillus spondylodiscitis in a part of the thoraco-lumbar spine which was primarily uninjured. The diagnostic assessment and therapeutic approach of this rare disorder is elucidated and discussed in the context of paraplegia and polytrauma. Possible mechanisms of inoculation and spreading of the moulds as well as predisposing factors of the disease are discussed in this paper and a review of the recent literature is provided.

Persons with spinal cord injury lose lean tissue mass and bone but gain body fat. There is a need to quantify the magnitude of these changes in body composition because there are associated skeletal and cardiovascular health risks. We have compared total body and regional (lower limb) differences in body composition in a group of males with paraplegia and in healthy able-bodied males matched for age, and height using dual energy X-ray absorptiometry. Although patients and controls had similar body mass indices, significant reductions in lean tissue mass (16% less) and bone (12% less) were observed in those with spinal cord injury. Group differences were even more pronounced in the lower limb. DEXA also revealed large increases in fat mass in subjects who did not look obese, total fat mass being 47% higher in the paraplegic group. We suggest that DEXA provides a simple and practical means to quantify both whole body and regional changes in body composition associated with spinal cord injury.

Spinal cord injury (SCI) patients are at high risk of developing cystitis, and vesical neoplasia. As abnormal growth regulation of urothelium may be a predisposing factor for cystitis and vesical neoplasia, we studied alterations if any, in the expression and localization of epidermal growth factor receptor (EGRF) in the vesical urothelium by an immuno-histochemical technique, using monoclonal mouse anti-human epidermal growth factor receptor antibody (DAKO-EGFRI) in cold-cup biopsies taken from the trigone of the urinary bladder in 18 adult SCI patients who had a neuropathic bladder. Abnormal localisation of EGFR-p, i.e. cytoplasmic, was noted in 13 patients. A linear localization of EGFR-p along the cell membrane of the urothelium, considered as an essential requirement for effective function, was observed in only three cases. Combined cytoplasmic and cell membrane location of EGFR-p was seen in two patients. The three patients with cell membrane location of EGFR-p showed a strong expression of EGFR-p (2+, 2-3+, and 4+, respectively); the intensity of EGFR-p expression in cases of cytoplasmic immunostaining varied considerably. Histopathology revealed denuding cystitis in one; follicular cystitis in four; active inflammatory infiltrate in three; lymphocytic infiltrate in three; squamous metaplasia in six; and intestinal metaplasia in three biopsy specimens. The three specimens showing cell membrane location of EGFR-p were from patients who did not have an indwelling urethral catheter (a paraplegic man practising intermittent self-catheterisation, a tetraplegic patient on penile condom drainage, and a tetraplegic woman with reflex voiding), and histopathology revealed very little inflammatory infiltrate. In contrast, the biopsies from all the nine patients, who were on indwelling urethral catheter drainage and in whom the bladder biopsy revealed varying degree of cystitis, showed only cytoplasmic location of EGFR-p. Similarly, the biopsies from patients with bladder stone (n = 6) showed only cytoplasmic localisation of EGFR-p. In conclusion, abnormalities in vesical urothelial expression in EGFR in SCI patients may play a role in the pathogenesis of cystitis, vesical urothelial metaplasia, dysplasia and neoplasia.

Many models have been developed to study spinal cord injury (SCI), such as cryogenic lesioning, hot water injury, scalpel lesioning, compressive trauma using clips, electromechanical devices, extradural cuffs, and weight-drop techniques. In this study, the radiofrequency (RF) lesion was used for inducing an experimental SCI in cats. The neuropathology was correlated with the MRI. In this model, 4 cats were injured at the thoracic spinal cord (T11-T12) with a lesion of 65 degrees C for 1 min using a micromanipulated penetrating RF electrode. The MRI of the lesions after 2, 3, 5, and 6 weeks post-injury as well as the correlative histological changes were obtained. The RF-induced lesion was discrete with little spreading across the spinal cord. There was a good correlation between the histopathology findings and the MRI. We conclude that experimental RF lesioning of the spinal cord can produce a consistent lesion with predictable histopathological changes in experimental animals. A 65 degree C injury for 1 min induced a clinical picture of an incomplete SCI. The RF lesioning should be considered as a new model to study SCI, particularly those with a penetrating component.