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Objective/background: To assess frequency domain heart rate variability (HRV) parameters at rest and in response to postural autonomic provocations in individuals with spinal cord injury (SCI) and investigate the autonomic influences on the heart of different physical activities., Design: Cross-sectional study., Methods: Ten subjects with complete cervical SCI and fourteen subjects with complete low thoracic SCI were prospectively recruited from the community and further divided in sedentary and physically active groups, the latter defined as regular weekly 4 hour physical activity for the preceding 3 months. Sixteen healthy individuals matched for sex and age were recruited to participate in the control group. The Low Frequency (LF), High Frequency (HF) powers and the LF/HF ratio of HRV were measured from continuous electrocardiogram (ECG) recordings at rest and after sitting using a fast Fourier transformation., Outcome Measures: The LF,HF, and the LF/HF ratio at rest and after sitting., Results: A significant decrease in all HRV parameters in patients with SCI was found compared to controls. The change in HF, LF and LF/HF following sitting maneuver was significantly greater in controls as compared with the SCI group and greater in subjects with paraplegia as compared to subjects with tetraplegia. Better HRV values and enhanced vagal activity appears to be related to the type of physical activity in active subjects with paraplegia., Conclusion: In this cohort of subjects spectral parameters of HRV were associated with the level of the injury. Passive standing was associated with higher HRV values in subjects with paraplegia.

Objectives: To examine body composition, including the relationship between body mass index (BMI) and total body fat, in women and men with complete motor paraplegia and to make comparisons with able-bodied controls., Methods: In 13 subjects with traumatic, complete motor paraplegia (six women, seven men) and 39 sex-, age-, and BMI-matched controls from the community (18 women, 21 men), we measured total and regional (upper extremities, trunk, and lower extremities) lean and fat mass using total body dual-energy X-ray absorptiometry., Results: Both women and men with paraplegia had significantly lower lean mass in their lower extremities, as would be expected, and in their total body when compared with controls. However, they had significantly greater lean mass in their upper extremities than controls (4.4 kg vs. 3.6 kg, P = 0.004 and 8.6 kg vs. 6.7 kg, P < 0.001 in women and men, respectively); all subjects with paraplegia studied used manual wheelchairs. Although total body fat mass was significantly greater in women (P = 0.010) and men (P = <0.001) with paraplegia compared with controls, for the equivalent total body fat mass, BMI was actually lower in women and men with paraplegia than controls (e.g. 20.2 kg/m² vs. 25.0 kg/m², respectively)., Conclusion: We report on body composition in persons with complete motor paraplegia, including women on whom limited information is currently available. Our results support the need to define better assessments of obesity in both women and men following spinal cord injury, particularly of central body fat distribution, as BMI underestimates adiposity in this population.

Objective: Spinal cord injury (SCI) causes muscle atrophy, which is particularly severe, due to inability to perform tetanic contractions, when lower motor neurons (LMN) are involved. We performed a longitudinal study in 25 Europeans suffering from complete conus cauda syndrome from 0.7 to 8.7 years comparing functional and structural thigh muscle properties before and after 2 years of home-based daily training by functional electrical stimulation (FES). The mid-term results after 1 year and preliminary muscle biopsy observations at project end-point from a subset of subjects are here reported., Methods: Muscles were electrically stimulated at home by means of large surface electrodes and a custom-designed stimulator. The poor excitability of the LMN denervated muscles was first improved by twitch-contraction training. Then, tetanic contractions against progressively increased loading were elicited. Finally, standing-up exercises were daily performed. The bulk of thigh muscle was estimated by transverse computer tomography (CT) scan and force measurements. Needle biopsies of vastus lateralis were harvested before and after 2 years of FES., Results: The 1 year home-based daily FES training induced: (1) very similar increases in muscle excitability and contractility in right and left legs; (2) feasibility to elicit tetanic contractions by means of train-stimulation with about ten times improvement of muscle force; (3) increase in the 26% of muscle bulk, as shown by CT scan analyses, improving appearance of limbs and muscle cushioning; (4) myofiber size increase (+94%) in a small series of muscle biopsies obtained after 2 years of FES. None of the subjects that performed 1 year home-based daily FES training (20 persons) had worsened their functional class, while 20% (4/20) improved to functional class 4, that is, the ability to stand., Discussion: The European Union (EU) Project Rise shows that 'home-based daily FES training' is a safe and effective therapy that may maintain life-long physical exercise by active muscle contraction (FES is the only option for denervated muscle) as a procedure to recover the early-lost tetanic contractility of denervated muscle, and to counteract muscle atrophy in order to prevent clinical complications.

Objectives: A new non-invasive method was developed to analyse macroscopic and microscopic structural changes of human skeletal muscle based on processing techniques of medical images, here exemplified by monitoring progression and recovery of long-term denervation by home based functional electrical stimulation., Methods: Spiral computer tomography images and special computational tools were used to isolate the quadriceps muscles and to make three-dimensional reconstructions of denervated muscles. Shape, volume and density changes were quantitatively measured on each part of the quadriceps muscle. Changes in tissue composition within the muscle were visualized associating Hounsfield unit values of normal or atrophic muscle, fat and connective tissue to different colors. The minimal volumetric element (voxel) is approximately ten times smaller than the volume analysed by needle muscle biopsy. The results of this microstructural analysis are presented as the percentage of different tissues (muscle, loose and fibrous connective tissue, and fat) in the total volume of the rectus muscle and displaying the first cortical layer of voxels that describe the muscle epimysium directly on the muscle three-dimensional reconstruction., Results: In normal and paraplegic patients, this new monitoring approach provides information on macroscopic shape, volume, and the increased adipose and fibrous tissue content within the denervated muscle. In particular, the change displayed at epimysium level is structurally important and possibly functionally relevant. Here we show that muscle restoration induced by homebased functional electrical stimulation is documented by the increase in normal muscle tissue from 45 to 60% of the whole volume, while connective tissue and fat are reduced of 30 and 50% with respect to the pre-treatment values. These changes are in agreement with the muscle biopsy findings, and self-evident when epimysium thickness is depicted., Conclusion: Color three-dimensional imaging of human skeletal muscle is an improved computational approach of non-invasive medical imaging able to detect not only macroscopic changes of human muscle volume and shape, but also their tissue composition at microscopic level.

Objective: To discuss functional electric stimulation (FES) gait training of upper motoneuron spinal cord injured complete paraplegics considering ambulation performance, physiologic and metabolic responses as well as psychologic outcome, while providing myologic insight into ambulation via FES when training starts many years post-injury., Methods: Transcutaneous FES using the Parastep stimulation system, gait training methods with and without major emphasis on muscle reinforcement, cardiovascular and respiratory conditioning. Examination of myofiber tissues and correlation of normal muscles histology versus innervated muscles of upper motor neuron and of denervated muscles of lower motor neuron paraplegics., Results: Published works in literature reviewed in this paper report average walking distance of 440 m/walk when major muscle reinforcement and preconditioning cardiovascular and respiratory systems precedes gait training, versus average 115 m/walk when undergoing direct gait training. Medical, metabolic and psychologic outcomes, as reported in several works, point to benefits of FES walking, including 60% increase in blood flow to lower extremities. Myofiber tissues of patients with upper motor neuron paralysis compare well with those of normal tissue even many years post-injury, while adipose tissue substitute muscle fibers in patients with lower motor neuron lesions., Discussion: Transcutaneous FES allows considerably longer walking distances and speed at the end of training when training involves an extensive pre-conditioning program than with direct gait training. Medical and psychologic benefits are observed, especially concerning blood flow to the lower extremities. Myofiber examinations provide myologic understanding of effectiveness of FES many years post-injury.

Background/objective: Salmonella spondylodiskitis is an uncommon type of vertebral infection. The aim of this study was to present a case of progressive paraplegia caused by Salmonella spondylodiskitis and epidural abscess after endoscopic cholecystectomy., Methods: The patient underwent posterior instrumentation and posterior fusion between T6 and T12, hemilaminotomies at levels T8-T9-T10, and drainage of the abscess. Through a left thoracotomy, anterior T8-T10 corpectomy, debridement, anterior stabilization, and fusion were conducted., Results: Fifteen months later, final follow-up showed no complications secondary to the vertebral and hip surgeries, and neurological status improved to Frankel grade E. Laboratory investigations showed no evidence of Salmonella infection., Conclusion: Immunocompromised patients who undergo endoscopic intervention are vulnerable to Salmonella infections. One must consider Salmonella infection in those who develop acute progressive spondylodiskitis.

We report two cases of spinal cord compression by AL amyloid deposits in the setting of multiple myeloma. The first patient, a 57 year old man, had a surgical procedure late in his course, when his neurological status worsened despite medical treatment. The second patient, a 61 year old man, had surgical treatment as soon as vertebral body collapse and epiduritis were diagnosed and spinal amyloidosis revealed a non secretory myeloma. Neurological recovery was significant in both cases and neither developed manifestations of systemic amyloidosis 4 years later.

This pilot study examined the effects of composite implants of cultured embryonal nerve cells and laser irradiation on the regeneration and repair of the completely transected spinal cord. Embryonal spinal cord nerve cells dissociated from rat fetuses and cultured on biodegradable microcarriers and embedded in hyaluronic acid were implanted in the completely transected spinal cords of 24 adult rats. For 14 consecutive post-operative days, 15 rats underwent low power laser irradiation (780 nm, 250 mW), 30 min daily. Eleven of the 15 (73%) showed different degrees of active leg movements and gait performance, compared to 4 (44%) of the 9 rats with implantation alone. In a controlgroup of seven rats with spinal cord transection and no transplantation or laser, six (86%) remained completely paralyzed. Three months after transection, implantation and laser irradiation, SSEPs were elicited in 69% of rats (p = 0.0237) compared to 37.5% in the nonirradiated group. The control group had no SSEPs response. Intensive axonal sprouting occurred in the group with implantation and laser. In the control group, the transected area contained proliferating fibroblasts and blood capillaries only. This suggests: 1. These in vitro composite implants are a regenerative and reparative source for reconstructing the transected spinal cord. 2. Post-operative low power laser irradiation enhances axonal sprouting and spinal cord repair.

Sarcoidosis is a chronic, multisystem noncaseating granulomatous disease of unknown etiology. Sarcoidosis typically presents clinically in individuals between the ages of 20 and 40 years. Although sarcoidosis most commonly affects the respiratory system, nearly any organ system can be involved. Spinal cord involvement by sarcoidosis is a rare event, occurring in less than 1% of patients with systemic disease. The case presented is that of a 29-year-old black male with benign past medical history who presented with a 6-week history of progressive incomplete paraplegia and bowel dysfunction. Magnetic resonance imaging revealed an intramedullary mass at the T-4-T-5 levels. The patient underwent thoracic laminectomy and debulking of the mass. The pathology was consistent with granulomatous disease. Postoperatively, the patient was placed on prednisone. He subsequently received comprehensive inpatient and outpatient rehabilitation and at present is bowel and bladder continent and ambulating at community levels with a rolling walker. The diagnosis of sarcoidosis; potential treatment options, including debulking and long-term steroid use; and prognosis will be discussed.

Carcinoma arising from a suprapubic cystostomy site in patients with spinal cord injury has been infrequently described. In all previously reported cases, they have been squamous cell carcinomas. Our patient is a 68 year old male with T10 complete thoracic paraplegia who presented with an exophytic mass extending from his suprapubic cystostomy tract. Biopsy revealed mucinous adenocarcinoma. Carcinoma of the suprapubic cystostomy tract should be considered in those patients who present with bloody drainage and/or masses arising from the suprapubic cystostomy site.

A 19-year-old man presented with delayed paraplegia on the second day after a stab injury of the spine. Magnetic resonance imaging showed herniation of the spinal cord through the dural defect. After emergency surgery, his paraplegia recovered leaving a Brown-Sequard syndrome immediate after injury. Spinal cord herniation should be considered as one of the possible factors in patients developing neurological deterioration after a stab injury of the spine. The possible pathogenesis of symptomatic non-spontaneous spinal cord herniation is discussed.