Search

Prospective longitudinal experimental study.The aim of this study was to assess the sensitivity to change of the electrical perceptual threshold (EPT) test during the longitudinal monitoring of neurological changes in patients with incomplete spinal cord injury (SCI).National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, Buckinghamshire, UK.Perceptual threshold to 3 Hz cutaneous electrical stimulation was measured in 11 patients with incomplete SCI at selected American Spinal Injuries Association (ASIA) sensory key points on four occasions. The first three measurements were performed within a 5-day period (baseline) and the fourth measurement (follow-up) at least 9 months later. The results were tested for statistical significance and the effect sizes were calculated.There were no significant differences between the EPT results of the three baseline assessments. When the mean baseline and follow-up EPT results were compared, there were no significant differences in EPT values above the sensory level of lesion, but a significant difference (reduction in threshold values) was found at and below the level of SCI, with medium and large effect sizes, respectively.The EPT test showed good sensitivity to change in dermatomes at and directly below the sensory level of the SCI. This makes it a potentially useful quantitative sensory instrument for detecting changes in sensory function during longitudinal monitoring of patients with SCI.

Prospective experimental.The aim of this study was to develop a quantitative sensory test (QST) that could be used for assessing the level and the density (degree of impairment) of spinal cord injury (SCI) and for monitoring neurological changes in patients with SCI.National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, UK.Perceptual threshold to 3 Hz cutaneous electrical stimulation was measured in 30 control subjects and in 45 patients with SCI at American Spinal Injuries Association (ASIA) sensory key points for selected dermatomes between C3 and S2 bilaterally. Electrical perceptual threshold (EPT) was recorded as the lowest ascending stimulus intensity out of three tests at which the subject reported sensation. The level of SCI according to EPT results was established for right and left sides as the most caudal spinal segment at which patient's EPT was within the control range (mean +/- 2 standard deviation (SD)). The level of SCI, according to EPT, was then compared with clinical sensory level derived according to ASIA classification.In the control group, EPT depended on the dermatome tested and was lowest for T1 (1.01 +/- 0.23 mA, mean +/- SD) and highest for L5 (3.32 +/- 1.14 mA). There was strong correlation between corresponding right and left dermatomes and between repeated assessments. In the SCI group, the level of lesion according to EPT and clinical testing was the same in 43 of the 90 tests (48%). In 37 cases (41%), the EPT level was higher than the clinical level, and in 10 cases (11%), it was lower. Below the level of lesion in incomplete SCI and in the zone of partial preservation in complete SCI, the EPT values in most dermatomes were raised compared with the control group.EPT is a simple, reproducible QST that can assess both the level and the density of SCI. It seems to add sensitivity and resolution to the standard clinical testing and could be a useful adjunct in longitudinal monitoring of patients with SCI for research purposes during natural recovery and therapeutic interventions.International Spinal Research Trust (ISRT), UK, Grant CLI001.

Study design: Longitudinal. Objectives: (1) To perform standard clinical neurological examinations and establish the pattern of clinical change with time following incomplete spinal cord injury (iSCI). (2) To establish the pattern of change in corticospinal electrophysiological function with time after iSCI. (3) To correlate clinical with electrophysiological findings. Setting: The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK and Imperial College School of Medicine, Charing Cross Hospital, London, UK. Methods: Neurological assessments and classification were performed according to American Spinal Injuries Association and International Medical Society of Paraplegia (ASIA/IMSOP) standards. Twenty-one patients (ages 18–72 years) with iSCI (level C2–C7, ASIA impairment grades C–D) and 10 healthy control subjects (ages 27–57 years) were studied. Electrophysiological tests of corticospinal function were carried out using transcranial magnetic stimulation (TMS) of the motor cortex and electromyographic (EMG) recordings from thenar muscles. Both tests were performed on a number of occasions, beginning 19–384 days and ending 124–1109 days post-injury, and the group data were pooled into time epochs of 50 or 100 days post-injury for analysis. Seven of the patients were studied on seven or more occasions and were also assessed individually. Results: Individual and pooled data indicated that neurological scores improved progressively and tended to stabilise by around 300 days post-injury. When the patients were first assessed, the mean latency for motor evoked potentials (MEPs) and inhibition of voluntary EMG were significantly different from control values. There was no significant change in latency on subsequent sessions for either the grouped or individual patient data. There was no correlation between clinical assessment and electrophysiological data. Conclusion: We conclude that the weakened inhibition seen following iSCI is established within a few days of the time of spinal cord trauma. We argue that reduced corticospinal inhibition may be a prerequisite for the recovery of useful motor function. Sponsorship: The work was supported by a project grant from The Wellcome Trust. Spinal Cord (2000) 38, 292–300.

STUDY DESIGN Cross-sectional clinical review. OBJECTIVES To assess the relationship between late spinal deformity in childhood onset spinal cord injury (SCI) and level of spinal cord lesion, severity of lesion, age at onset, duration of paralysis and pelvic deformities. SETTING People with spinal cord injury (onset in childhood) treated and followed up at the National Spinal Injuries Center (identified from case notes review, contacted and agreed to participate). METHOD One hundred and eighty-nine subjects satisfying study inclusion criteria (acute onset SCI before the 16th birthday) were identified by case note review of 8200 records. Eighty formed the group attending for clinical review including whole spine radiographs (AP and lateral). Clinical examination included neurological status and joint range of movements. Demographic data was recorded. RESULTS Scoliosis occurred more frequently and was more severe in those injured at a younger age, 38 degrees, compared with 24 degrees in those injured later (P

Synchronisation of motor unit discharges is commonly seen in hand muscles of normal man but is absent following neurologically complete spinal cord injury and reduced after stroke. These findings support the notion that some corticospinal inputs to motoneurones are shared and contribute to the observed synchrony of discharge. In this study we have examined motor unit discharge in hand muscles below the level of an incomplete spinal cord injury in an attempt to relate strength of synchrony to the integrity of the corticospinal tract. Eight patients with incomplete spinal cord injury (neurological level C3-C7) and eight control subjects took part in the study. The patients had sustained injury 14-191 weeks prior to the recordings and had since regained good motor function in their hands. Two concentric needle electrodes were inserted into the first dorsal interosseus muscle which subjects were instructed to contract weakly so that potentials from individual motor units could be reliably identified on both recordings. Synchrony was detected by constructing cross-correlograms between the discharges of pairs of individual motor units. The amount of synchronous firing was determined from the magnitude of any peak in the cross-correlogram, as the probability above chance (XP) of one motor unit firing with respect to the other and vice versa. The degree of synchrony was lower (P < 0.05) in the patient group (mean XP 0.06) than in the control group (mean XP 0.09). The incidence of significant synchrony was lower in the patient group (41.8 %) than in the control group (92.9 %). The mean (+/- S.E.M.) frequency of motor unit discharge was slightly lower (P < 0.05) in patients (9.7 +/- 0.4 impulses s-1) than controls (10.8 +/- 0.5 impulses s-1). The mean width of synchrony peaks was narrower (P < 0.05) in patients (11.4 +/- 1.1 ms) than controls (13.2 +/- 0.6 ms). We conclude that the weaker synchrony of motor unit discharge in incomplete spinal cord injury may reflect permanent damage to some corticospinal axons.

A study of 3178 individuals injured in Britain between 1943 and 1990 and surviving the first year post-injury was conducted to evaluate the homogeneity of mortality risk ratios within groups based on varying degrees of neurological injury level and completeness of the injury. The study shows that it is less than optimal to combine individuals into neurological groupings of C1-C4 ABC, C5-C8 ABC and T1-S5 ABC since the risk ratios are not homogeneous within these groups. Similarly, combining individuals into neurological groupings of tetraplegia complete, tetraplegia incomplete, paraplegia complete and paraplegia incomplete may not be appropriate for the same reasons. The consequence of performing a survival analysis using either of the traditional sets of groups is to dilute the risk ratios for a subset of individuals within a particular group, thereby providing less discrimination between neurological groups. Cox proportional hazards regression was employed to determine a set of neurological groupings with homogeneous risk ratios within a group while providing better differentiation between groups.

The aims of this study were to examine long-term survival in a population-based sample of spinal cord injury (SCI) survivors in Great Britain, identify risk factors contributing to deaths and explore trends in cause of death over the decades following SCI. Current survival status was successfully identified in 92.3% of the study sample. Standardised mortality ratios (SMRs) were calculated and compared with a similar USA study. Relative risk ratio analysis showed that higher mortality risk was associated with higher neurologic level and completeness of spinal cord injury, older age at injury and earlier year of injury. For the entire fifty year time period, the leading cause of death was related to the respiratory system; urinary deaths ranked second followed by heart disease related deaths, but patterns in causes of death changed over time. In the early decades of injury, urinary deaths ranked first, heart disease deaths second and respiratory deaths third. In the last two decades of injury, respiratory deaths ranked first, heart related deaths were second, injury related deaths ranked third and urinary deaths fourth. This study also raises the question of examining alternative neurological groupings for future mortality risk analysis.

One hundred and fifty three patients who had sustained a spinal cord injury more than 20 years previously were assessed neurologically and by MRI scanning of their spinal cords. The spinal cord pathologies shown were, in order of prevalence, extended atrophy, malacia, syrinx, cyst, disruption and tethering. There was no relationship between the prevalence of any type of pathology and the degree of spinal canal compromise or angulation of the spine adjacent to the level of injury. Neurological changes after initial neurological stabilisation were seen only in patients with extended atrophy, malacia or a syrinx, not in those with only a cyst or cord disruption. Tethering is always associated with other lesion(s). Longer syrinxes were more likely to have associated neurological changes than shorter ones. The most common neurological change was pain.

Study design: Preliminary longitudinal clinical trial. Objectives: To test the efficacy of repetitive transcranial magnetic stimulation (rTMS) in modulating corticospinal inhibition and improving recovery in stable incomplete spinal cord injury (iSCI). Setting: National Spinal Injuries Centre, Stoke Mandeville Hospital, Bucks, UK and Division of Neuroscience, Imperial College Faculty of Medicine, Charing Cross Hospital, London, UK. Methods: Four stable iSCI patients were treated with rTMS over the occipital cortex (sham treatment) and then over the motor cortex (real treatment). Patients were assessed using electrophysiological, clinical and functional measures before treatment, during sham treatment, during the therapeutic treatment and during a 3-week follow-up period. Results: Cortical inhibition was reduced during the treatment week. Perceptual threshold to electrical stimulation of the skin, ASIA clinical measures of motor and sensory function and time to complete a peg-board improved and remained improved into the follow-up period. Conclusion: In this preliminary trial, rTMS has been shown to alter cortical inhibition in iSCI and improve the clinical and functional outcome. Sponsorship: This work was supported by the International Spinal Research Trust.

Study design: Case report of two subjects. Objective: Charcot joints of the spine as a cause of Autonomic Dysreflexia in spinal cord lesions. Setting: Stoke Mandeville Hospital, UK. Method: Two patients with long standing spinal cord lesions developed symptoms of headaches and sweating associated with sitting up and transfers. In both cases no other cause was found to account for Autonomic Dysreflexia. Result: Charcot Joints of the spine below the level of injury were demonstrated in both cases and symptoms resolved with prolonged bed rest. Conclusion: As care of spinally injured patients continues to improve, they live longer and lead a more active lifestyle, it is expected that the incidence and prevalence of Charcot's joints will increase. Therefore the knowledge and heightened awareness of this entity, early diagnosis and detection with plain X-rays for urinary surveillance, may reduce the morbidity in spinal cord injured patients.

Prospective observational.To examine inter-rater reliability of motor and sensory examinations performed according to American Spinal Injury Association (ASIA) standards.National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, UK.Results of ASIA motor and sensory examinations performed by two experienced examiners on 45 patients with spinal cord injury (SCI) were compared.Total ASIA scores showed very strong correlation between the two examiners, with Pearson correlation coefficients and intraclass correlation coefficients exceeding 0.96, P0.01 for total motor, light touch and pin prick scores. The agreement for individual muscle testing of the 10 ASIA key muscles showed substantial agreement for majority of muscles, with the weighted Kappa coefficient range 0.649-0.993, P0.05. The overall agreement in assignment of manual muscle testing grades (0-5) was 82% on the right and 84% on the left, with the strongest agreement for grade '0' and the weakest for grade '3'. The unweighted Kappa coefficient for agreement in motor and sensory levels ranged from 0.68 to 0.78 (P0.01). There was no difference in ASIA impairment grades derived from the two examiners' results.Our study results showed very good levels of agreement in ASIA clinical examinations between two experienced examiners. The established degree of variability due to inter-rater differences should be taken into account in study design of clinical trials with more than one assessor..

Clinical practice and scientific research may soon lead to treatments designed to repair spinal cord injury. Repair is likely to be partial in the first trials, extending only one or two segments below the original injury. Furthermore, treatments that are becoming available are likely to be applied to the thoracic spinal cord to minimise loss of function resulting from damage to surviving connections. These provisos have prompted research into the improvement of clinical and physiological tests designed (1) to determine the level and density of a spinal cord injury, (2) to provide reliable monitoring of recovery over one or two spinal cord segments, and (3) to provide indices of function provided by thoracic spinal root innervation, presently largely ignored in assessment of spinal cord injury. This article reviews progress of the Clinical Initiative, sponsored by the International Spinal Research Trust, to advance the clinical and physiological tests of sensory, motor and autonomic function needed to achieve these aims.

Previous studies have estimated that between 25% and 45% of people with spinal cord injury report severe levels of chronic pain. Few studies have examined this longitudinally. This study examines the primary pain sites, intensity and variability of perceived pain in 76 patients, 6 weeks post injury and 45 patients from the same cohort, 8 year post discharge. Demographic information reveals a close similarity with the database (40 000) from Stover and Fine's cohort (1986). Data was assessed using visual analogue scales, measures were also taken of functional independence (FIM), emotional status and coping. At 6 weeks post injury, most pain is sited in the thoracic spine area, and in the upper and lower limbs. At 1 year post discharge, most pain is reported to be in the thoracic spine area, the lumbar region and the chest. Twenty-three per cent of the 6 week group reported that the intensity of their pain was severe, whilst at 1 year, 41% of the sample complained of severe pain. Factors associated with the pain at both time points were explored using correlational analyses. The emotional, functional and psychological factors that predict pain severity were explored using multiple regression analysis. Twenty-four per cent of those reporting moderate to severe pain at 6 weeks post injury were still reporting pain at 1 year post discharge. This study examines the relative contribution of psychological factors in reported pain.

The case histories of two patients who had had a spinal cord injury (SCI) were selected by the senior author and sent to four experts in the field of SCI. Based on the 1992 American Spinal Injury Association (ASIA) and International Medical Society of Paraplegia (IMSOP) standards, the four participants plus the senior author recorded the motor and sensory scores, the ASIA impairment scale (AIS), the neurological level (NL) and the zone of partial preservation (ZPP). Several minor scoring errors occurred among the participants, especially with motor scores when key muscles could not be tested due to pain, or external immobilization devices. Difficulties with interpretation occurred with the motor levels and the ZPP for the patient with a complete injury. This exercise points to the need for all examiners of SCI patients to thoroughly familiarize themselves with the standards and to use the motor and sensory scores to arrive at a NL and ZPP. They also indicate a need to revise the standards to clarify the determination of sensory levels and how to score muscles whose strength is inhibited by pain.

Mortality, morbidity, health, functional, and psychosocial outcomes were examined in 834 individuals with long term spinal cord injuries. All were treated at one of two British spinal injury centres: the National Spinal Injuries Centre at Stoke Mandeville Hospital or the Regional Spinal Injuries Centre in Southport; all were 20 or more years post injury. Using life table techniques, median survival time was determined for the overall sample (32 years), and for various subgroups based on level and completeness of injury and age at injury. With the number of renal deaths decreasing over time, the cause of death patterns in the study group as it aged began to approximate those of the general population. Morbidity patterns were found to be associated with age, years post injury, or a combination of these factors, depending upon the particular medical complication examined. A current medical examination of 282 of the survivors revealed significant declines in functional abilities associated with the aging process. Declines with age also were found in measures of handicap and life satisfaction, but three quarters of those interviewed reported generally good health and rated their current quality of life as either good or excellent.

A postlaminectomy pseudomeningocele is a spherical, fluid-filled space with fibrous capsule lying dorsal to the thecal canal in the laminectomy opening that occasionally develops after surgery. Eight cases were found in 400 symptomatic postlaminectomy patients undergoing computed tomographic examination. The contents are of cerebrospinal fluid density and mayor may not have demonstrable communication with the subarachnoid space. Whether they are the cause of symptoms is conjectural; none of these eight patients had surgical removal.

The physiologically responses to hypoglycaemia induced by fish insulin were studied in nine tetraplegic subjects with physiological complete cervical spinal cord transection between C4 and C8. During hypoglycaemia there was a reduction in both systolic and diastolic blood pressure unlike in normal subjects. This was accompanied by a rise in heart rate. The normal rise in plasma adrenaline levels did not occur. Plasma human insulin levels were suppressed. The usual neuroglycopenic symptoms accompanying hypoglycaemia did not occur in the tetraplegics.

1. The cardiovascular and hormonal effects of intravenous saralasin (0.5, 1 and 5 μg min−1 kg−1) were assessed in nine tetraplegic patients (with complete cervical spinal cord transaction above the sympathetic outflow) and in six normal subjects. 2. In the tetraplegic patients, saralasin caused an immediate transient pressor response which was not dose-dependent and substantially greater than the pressor response in normal subjects. The pressor response in the tetraplegic patients was not accompanied by a rise in levels of plasma noradrenaline. 3. In the tetraplegic patients, after α-adrenoceptor blockade with thymoxamine (1 mg kg−1 h−1), twice the dose of intravenous noradrenaline was needed to induce the same pressor response. The pressor response to saralasin (5 μg kg−1 min−1), however, was unaffected by thymoxamine. 4. Saralasin caused minimal changes in levels of plasma renin activity and plasma aldosterone in both groups. There was no relationship between basal plasma renin activity and the pressor response in either group. 5. We therefore conclude that the immediate transient pressor response to saralasin in man is not due to central sympathetic stimulation, is unlikely to be due to peripheral sympathetic activation and is probably the result of intrinsic angiotensin II-like myotropism.

1. The effect of endogenous sympathetic stimulation (induced by urinary bladder stimulation) and intravenous infusion of noradrenaline and isoprenaline on blood pressure, heart rate and levels of plasma renin activity and plasma aldosterone were studied in six tetraplegic patients. Data from infusion studies were compared with data from six normal subjects studied in an identical manner. 2. Bladder stimulation in the tetraplegic patients caused a marked rise in blood pressure and fall in heart rate, but no change in plasma renin activity or plasma aldosterone. 3. Noradrenaline infusion resulted in an enhanced pressor response in the tetraplegic patients when compared with the normal subjects. Heart rate fell in both groups. Plasma renin activity and plasma aldosterone did not change in either group. 4. Isoprenaline infusion caused a fall in both systolic and diastolic blood pressure in the tetraplegic patients, unlike the normal subjects in whom there was a rise in systolic and a fall in diastolic blood pressure. Heart rate and plasma renin activity rose in both groups. Plasma aldosterone did not change in either group. 5. We conclude that in tetraplegic patients neither endogenous sympathetic stimulation by bladder stimulation nor infusion of noradrenaline raises plasma renin activity. Isoprenaline increases plasma renin activity to the same extent as in normal subjects. Renin release mechanisms in tetraplegic patients therefore do not appear to be hypersensitive to catecholamines. Plasma aldosterone is not influenced by any of the stimuli.

1. Plasma catecholamines, plasma renin activity, plasma aldosterone and haematocrit were measured in four subjects with physiologically complete cervical spinal cord transections, before, during and after head-up tilt to 45° for 30 min. Plasma catecholamines were measured in five normal male volunteers in the supine position and after head-up tilt to 45° for 10 min. 2. After 10 min of head-up tilt, the plasma noradrenaline rose 14% in the tetraplegic patients and 115% in the control subjects. These findings indicate a failure of sympathetic activity in response to head-up tilt in the tetraplegic patients, probably caused by interruption of pathways by which the brain normally controls sympathetic outflow. 3. In the tetraplegic patients the resting plasma renin activities were above normal, and rose more quickly and greater on head-up tilt than in published studies of normal subjects. It is likely that the renal baroreceptors are important in the control of renin release. 4. In the tetraplegic patients, there was a late rise in plasma aldosterone which was probably due to the elevation in plasma renin activity.

Eight patients with spinal cord lesions due to decompression sickness are described. The cord lesions were in the cervical cord in four cases and in the upper dorsal cord in the other four, seven patients had incomplete lesions, one had a complete lesion, all patients were spastic. The diving details and description of the onset of paralysis are given and possible pathological processes are discussed. Prophylaxis is by adequate use of decompression stops. The most satisfactory treatment is immediate recompression.

Since Sir Ludwig Guttmann introduced the comprehensive modern clinical approach to the rehabilitation of spinal cord injured patients much experience has been accumulated. Modern spinal cord injuries centres have opened throughout the world, treating mainly acute spinal cord injuries in young patients. At Stoke Mandeville Hospital we have had the opportunity to treat several spinal patients who had suffered previous neurological or orthopaedic disorders. These complicated combinations affected the rehabilitation process and the presentations show clearly different aspects of the problem.

One hundred and fifty patients with spinal cord lesions due to diving accidents were admitted to Stoke Mandeville Hospital between 1944--77. Most of the patients were young men, 65 had dived into the sea, 48 into swimming pools, 21 into rivers and 3 into lakes. Injuries due to diving into the deep end of swimming pools appear to have been eliminated in Great Britain but injuries due to diving into the shallow end of swimming pools and into the sea continue to occur. The public need further education about the dangers of diving.

We studied the haemodynamic effects of clonidine (2 micrograms/kg/iv) in 7 tetraplegics and 7 normal subjects. Measurements of blood pressure, stroke volume, cardiac output and digital (finger) skin blood flow were made before and after clonidine for 60 minutes. Blood pressure, stroke volume and cardiac output did not fall in tetraplegics, unlike normals. Resting digital skin blood flow was higher in tetraplegics and fell after clonidine. In normal subjects however, an increase in digital skin blood flow occurred after clonidine. The pressor and digital vasoconstrictor responses to bladder stimulation were attenuated after clonidine. The inability of clonidine to induce a fall in blood pressure, stroke volume, cardiac output and cause peripheral vasodilation in tetraplegics is consistent with its central sympatholytic effects. Attenuation of the responses to bladder stimulation suggest an effect on spinal sympathetic neurones.

Blood pressure, plasma catecholamines and prostaglandins during artificial erection in a male tetraplegic

Aqualung diving is practised by some paralysed sportsmen. Close cooperation between suitable disabled persons and their medical advisers is emphasised.

1. Six patients with long-standing physiologically complete cervical spinal cord lesions and two normal subjects were examined. 2. In the tetraplegic subjects, arterial blood pressure, heart rate, plasma noradrenaline and adrenaline were measured at rest and during bladder percussion, during electrical stimulation of muscles and during infusion of noradrenaline. 3. In the normal subjects arterial blood pressure and heart rate were recorded before and during noradrenaline infusion. 4. Bladder percussion and muscle stimulation caused a rise in plasma noradrenaline from a subnormal level, together with a rise in blood pressure. 5. A similar rise in blood pressure due to noradrenaline infusion occurred at a very much greater level of plasma noradrenaline. 6. It is concluded that hypertension in tetraplegic subjects who have bladder percussion or muscle stimulation, is due to sympathetic overactivity rather than adrenal medullary secretion. Findings are consistent with, but not conclusive of, supersensitivity of the blood vessels of tetraplegic subjects to noradrenaline.

The arterial blood pressure, heart rate and electrocardiograph were recorded, and plasma electrolytes, arterial blood gases and pH, and plasma catecholamines were estimated in seven patients with physiologically complete cervical spinal cord transections who needed intermittent possitive pressure ventilation (I.P.P.V.) or were undergoing urological surgery under general anaesthesia. In the tetraplegics on I.P.P.V., bradycardia, and in two patients even cardiac arrest, occurred during tracheal suction, especially in the presence of hypoxia. In one tetraplegic being anaesthetised, cardiac arrest occurred during endotracheal intubation. This reflex bradycardia and cardiac arrest appeared to be due to a vago-vagal reflex, unopposed by sympathetic activity or by the pulmonary (inflation) vagal reflex. Atropine was effective in preventing this reflex. In the tetraplegics undergoing urological surgery, severe hypertension resulting from visceral stimulation was effectively reduced by halothane. In these patients, control of arterial blood pressure with lower concentrations of halothane may also be achieved with I.P.P.V.

Cortical perfusion-rates were measured with a xenon-133 inhalation technique in seventeen patients with physiologically complete spinal-cord transections. Twelve patients were tetraplegic, with lesions in the cervical spinal cord above the sympathetic nervous outflow, and five were controls, with lesions complete below T3-4. When the patients developed hypocapnœa by voluntary overbreathing, the cortical perfusion-rate of the controls fell normally but that of the patients with cervical-cord lesions remained unchanged. In these subjects arterial hypertension induced by reflex activity in the isolated spinal cord was accompanied by a slight fall in cortical perfusion-rate, and hypercapnœa produced a substantial rise, indicating that the cerebral blood-vessels were capable of constriction and dilatation. These observations are compatible with the view that the cerebral vasoconstriction which normally accompanies hyperventilation is dependent on supraspinal control through a pathway in the cervical spinal cord and the sympathetic outflow above T2.

The effects of bladder stimulation, skeletal muscle spasms and head-up tilting were observed in seven patients with complete cervical cord lesions. Measurements were made on intra-arterial blood pressure, heart rate, hand, forearm and calf blood flow and peripheral venous activity. On bladder stimulation there was an increase in blood pressure and a decrease in heart rate, calf blood flow and hand blood flow; there was venoconstriction. Skeletal muscle spasms caused similar changes. Head-up tilting caused a fall in blood pressure with a rise in heart rate. There was a decrease in forearm blood flow and there was some venoconstriction.

The sensation of breath holding and the ability to detect added external respiratory resistance was investigated in nine patients with complete cervical cord lesions. (Eight patients with lesions between C5 and C7 and one patient with a complete lesion below C3.) All the patients could detect added resistive loads normally. All the patients except the one with the C3 lesion had normal sensations of breath holding. It is concluded that the information about pressure changes reached consciousness via the vagi and that the sensation of breath holding is dependent on contractions of the diaphragm.

Six hundred and twelve patients with closed spinal injuries are described. The incidence of various types of fracture and fracture-dislocation and the degree of reduction achieved by postural reduction is analysed in relation to the initial and late neurological lesions. The average time that the patients were kept in bed is given for the various types of skeletal injury. Only 4 patients developed late instability of the spine.

The sensitivity to penicillin of 255 Gram-negative urinary pathogens was determined to a maximum concentration of 200 units /ml. All strains of E. coli, nearly all strains of Providence and more than half the strains of Proteus mirabilis were inhibited by concentrations easily attainable in urine. All the other Gramnegative pathogens were resistant to 200 units ml.

Five paraplegic patients with traumatic perforations of the rectum are described. One was caused by sigmoidoscopy, one by digital evacuation and three by enemas. Two patients died. The causes and treatment are described and discussed.

Four patients with physiologically complete high cervical spinal-cord lesions, sustained within the previous 6 weeks, were observed. All needed intermittent positive-pressure ventilation. In the stage of spinal shock, stimuli to the trachea induced bradycardia, and in two patients cardiac arrest resulted. The bradycardia occurred when the patients were hypoxic, and seemed to be due to a vaso-vagal reflex. Normally this reflex is opposed by sympathetic activity, and during hypoxia by increased pulmonary (inflation) vagal reflex activity due to increased breathing. In these patients, however, compensatory sympathetic activity was prevented by the cervical cord lesion, and increased pulmonary vagal reflex activity by the fact that the breathing was artificial and therefore did not increase with hypoxia. Treatment in emergency includes the administration of atropine. Adequate oxygenation and, if this cannot be achieved, maintenance atropin should prevent the bradycardia and cardiac arrest associated with stimulation of the trachea in artificially ventilated tetraplegic patients.

1. The role of the sympathetic nervous system in the release of renin during head-up tilt has been studied in five normal subjects and in four tetraplegic patients with cervical spinal-cord transection above the sympathetic outflow. Blood pressure, heart rate and concentrations of plasma noradrenaline, plasma adrenaline and plasma renin activity were measured during head-up tilt to 45° before and after acute β-adrenoreceptor blockade with intravenous propranolol. 2. In the normal subjects there were minimal changes in blood pressure during head-up tilt and there was a rise in both plasma noradrenaline concentration and plasma renin activity. After propranolol values of plasma renin activity at rest fell with little change occurring during head-up tilt. 3. In the tetraplegic patients there was a substantial fall in blood pressure during head-up tilt. Concentrations of plasma noradrenaline and adrenaline did not change but there was a marked increase in plasma renin activity. Values of plasma renin activity both at rest and during head-up tilt were unaffected by propranolol. 4. We conclude that in tetraplegic patients renin release during head-up tilt may occur independently of sympathetic nervous activity and is probably largely dependent on activation of renal vascular receptors.

We have studied the haemodynamic, hormonal and urinary effects of postural change in 6 tetraplegic patients, 6 paraplegic patients and 6 normal subjects. Measurements of blood pressure and heart rate, plasma renin activity, plasma aldosterone, urine volume and electrolyte excretion were made for 60 minutes while sitting and 60 minutes while recumbent. In tetraplegics the blood pressure was lower when sitting and rose during recumbency, unlike paraplegics and normal subjects. Plasma renin activity and aldosterone were higher in tetraplegics when sitting compared to normal subjects and did not fall during recumbency. Urine output increased significantly after recumbency in tetraplegics, but not in paraplegics or normal subjects. Both urinary sodium and potassium excretion were lower in tetraplegics and higher in paraplegics compared to normal subjects when sitting. In paraplegics the fall in both sodium and potassium excretion did not appear to be related to change in posture. Our observations indicate that recumbency induces a diuresis in tetraplegics but not in paraplegics or in normal subjects. The diuresis in tetraplegics may be related to the accompanying haemodynamic and hormonal changes induced by recumbency.

1. Arterial blood pressure and heart rate were measured before, during and after cutaneous and visceral stimulation in subjects tetraplegic due to severe cervical spinal cord damage. Stimulation resulted in marked hypertension as a result of reflex sympathetic overactivity. 2. Mixed venous blood from a catheter situated in the right atrium was obtained before and after stimulation and plasma prostaglandin E and prostaglandin F were measured. A consistent and significant rise in plasma prostaglandin E, but not plasma prostaglandin F, accompanied the hypertension. 3. It is suggested that prostaglandin E is released during this sympathetic nervous activity and may be related to neurogenic hypertension.

In a review of 57 cases of paraplegia due to surgically confirmed disc protrusion (representing 0.9 per cent of all admissions to the National Spinal Injuries Centre), seven were in the cervical, 31 in the dorsal and 19 in the lumbar regions. Patients with dorsal disc protrusions treated by laminectomy had the worst neurological outcome. A recent decline in the incidence of neurological dysfunction following disc excision is noted and its probable causes discussed.

Sixty-six patients with cervical, called ‘high’ lesions, were compared with 23 low thoracic, lumbar or sacral cord lesions (due in all cases to accidental spinal trauma) as to their awareness of abdominal hunger, abdominal dread and abdominal nausea before and since their injury. The changes reported suggest that such visceral sensations from the abdomen proper are mediated by the vagus and not the sympathetic supply.

This paper deals with the management of the paralysed bladder during an 11-year period in 476 traumatic paraplegics and tetraplegics—409 male and 67 female—who were admitted to Stoke Mandeville within the first 14 days, most of them within the first 48 hours, after injury. The patients were followed up after discharge from the Centre at least yearly but often more frequently. In 370 patients, the urine was sterile on admission; of these 278 had either intermittent catheterisation (174) or no catheterisation (104) before admission. One hundred and six patients were infected on admission, the majority of them following previous indwelling catheter drainage by Foley catheters (81). The method of choice employed at Stoke Mandeville in the management of the paralysed bladder was the non-touch technique of intermittent catheterisation (Guttmann, 1949, 1953). This method has proved highly effective in preventing infection of the paralysed bladder, especially in male patients where the catheterisation was carried out exclusively by the medical officer in charge of the case. 64.8 per cent. male and 49.3 per cent. female patients (62.2 per cent. of the total of the 476 patients) had sterile urine on discharge from hospital. 70.4 per cent. of the 186 incomplete lesions and 56.9 per cent. of the 290 complete lesions were sterile on discharge. Details of late complications are given and attention is drawn to the low incidence of hydronephrosis, vesico-ureteric reflux and calculosis, and in particular to the complete absence of urethral fistulae in patients with sterile or infected urine. The non-touch technique of intermittent catheterisation has proved superior to any other form of early management of the paralysed bladder hitherto described and has disproved the prejudice held against intermittent catheterisation for so many years by urologists and other workers in the field of spinal paraplegia.