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Patients with central apnoea may use electro ventilation, provided their phrenic nerves and diaphragm muscles are normal. A tendency towards better survival has been found, and both an improved quality of life and facilitated nursing have been claimed with electro ventilation compared to mechanical ventilation. The high investment for the device may form a hurdle for fund providers like our hospital administration board. We, therefore, from our first patient onwards, collected clinically meaningful data in a special register of all patients using electro ventilation and their controls on mechanical ventilation. Since 1988 172 patients left our institution dependent on a respiratory device. Of these, all 48 patients with preserved phrenic nerves chose phrenic nerve stimulation. A patient on mechanical ventilation who agreed to participate was chosen as a control (n = 44). All patients were seen at least once a year. 90 patients suffered high tetraplegia, and 2 suffered central apnoea for other reasons. There is a tendency towards better survival, and there is a lower frequency of decubital ulcers (0.02) and respiratory tract infections (p0.000) with electro than with mechanical ventilation. The frequency of respiratory infections turned out to be a better measure of the quality of respiratory care than survival. The resulting decrease in the need for airway nursing, and the reduced incidence of respiratory infections repaid the high investment in electro ventilation within one year in our setting. Informed patients prefer electro to mechanical ventilation; fund providers might also agree with this preference. publishedVersion

To study the mortality, cause and risk indicators of death in German patients with traumatic spinal cord injury, patients with traumatic spinal cord injury admitted to Berufsgenossenschaftliches Trauma Hospital Hamburg between 1 January 1997 and 31 December 2018, aged between 16 and 60 with a minimal survival of one year after injury, were included. Further criteria were the absence of life-limiting comorbidities at the time of injury. 223 deceased patients with traumatic spinal cord injury were identified, investigated on and partly compared to the surviving subjects. We aimed to discover specific complications that were related to Spinal Cord Injury and responsible for a possibly limited life expectancy. Data collection was performed during in- and outpatient treatment. A statistical analysis was performed to compare groups. The post-injury life expectancy was 25.0 years with a significant correlation regarding the level of lesion and severity of injury. The leading causes of death were cardiovascular diseases and pneumonia. Bladder cancer was the most common fatal malignant tumor. The life expectancy of patients suffering from traumatic spinal cord injury is limited. The longer a patient survives after injury and the lower the level of lesion, the more likely an age-related cause of death becomes. Bladder cancer is significantly more frequent when compared to the overall distribution of tumor diseases in Germany.

This study aims to assess if there is an evident correlation between fusion length and rehabilitation success after trauma to the cervical spine that could potentially be used to predict functional outcomes. This monocentric study was conducted in the Spinal-Cord-Injury center of the Berufsgenossenschaftliches Klinikum Hamburg. Data sets of 199 patients from the Spinal-Cord-Injury center admitted between the beginning of 2003 and the end of 2018 were subjected to statistical analyses. The Spinal Cord Independence Measure II (SCIM II) difference between admission and discharge was chosen as the primary outcome variable of a multiple linear regression analysis, including several other variables. The length of fusion, SCIM at admission and the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) values at admission could be identified as significant predictors. The cervical fusion length could be identified as an independent predictor of the functional outcome within our model. This correlation most likely mediates for the range of motion as well as partly for injury severity. This is much harder to evaluate in a newly admitted rehabilitation patient than a single numerical value that represents its rehabilitative implications, such as fusion length. Together with an initial assessment of the SCIM and ISNCSCI, it provides a solid basis for outcome prediction.

Study design Cross-sectional explorative observational study. Objectives To identify factors which have an association to the self-perceived Quality of Life (QoL) for persons with acquired spinal cord injury (SCI). Setting Eight specialized SCI-centers in Germany. The GerSCI survey is the German part of the International Spinal Cord Injury Survey (InSCI). Methods Self-disclosure questionnaire, created from the InSCI group, translated and adapted for Germany. The questionnaire collects a very broad range of data and, and due to its design as a self-report, is particularly suitable for the analysis on QoL. Because of the content, which is binding for all participating states, it allows a direct comparability of the results. Included in Germany were 1479 persons with acquired SCI aged 18 years and older. Results Various factors were identified with high associations to QoL, including changeable and unchangeable ones, such as those of particular importance: pain, sleep problems, sexual dysfunction, age, and time since onset of SCI. Some results confirmed reports of previous studies, others were surprising. Conclusion this study provides an important basis for the planned analysis of the InSCI participating countries in the 6 WHO regions. Germany was able to contribute the largest study population. The concrete study design of InSCI allows us to directly compare data and helps us to improve ourselves within the framework of a “learning health system”. Medical measures can be orientated towards the found results, in order to ensure the best possible care and support by the therapeutic team, individually adapted to the person, place of residence and impairment.

Study design Longitudinal study. Objectives To describe the severity of spinal cord injury/disease (SCI/D), type and management of neurogenic lower urinary tract dysfunction, tumor characteristics, and bladder cancer latency period in SCI/D patients. Setting Spinal cord injury centers in Germany, Austria, and Switzerland. Methods Data of SCI/D patients diagnosed with bladder cancer were collected between Jan 2012-Dec 2019 in the course of annual surveys in the neuro-urological departments of all 28 centers. Demographic and paralysis-specific data, data on the type and management of neurogenic lower urinary tract dysfunction, and histopathological tumor characteristics were collected. Results Regarding histopathological tumor characteristics, no significant differences were found in 135 individuals with SCI/D when stratified for bladder management without chronic catheterization, SCI/D severity, and ASIA classification. The mean latency period between the onset of SCI/D and the diagnosis of bladder cancer was significantly longer in patients with catheter-free emptying methods compared to patients with intermittent catheterization, and in patients with LMNL (Lower Motor Neuron Lesion) compared to patients with UMNL (Upper Motor Neuron Lesion). Conclusions Urinary bladder carcinomas are late events in the long-term course of SCI/D. Follow-up and approaches to screening must therefore be intensified with increasing duration of long-term SCI.

Background The aim of the study was to clarify whether clinical and/or urodynamic parameters could be used to infer the probability of neutralizing antibody (NAb) formation as a possible cause of therapy failure (non-response, NR) in patients with neurogenic detrusor overactivity (NDO) due to acquired spinal cord injury/disease (SCI/D) treated with intradetrusor botulinum neurotoxin A (BoNT-A) injections. Methods A retrospective chart review was performed of all patients with SCI/D who underwent both intradetrusor onabotulinumtoxin A injections and the determination of neutralizing antibodies against BoNT-A between January 1, 2002, and December 31, 2018. NR was defined as urodynamically confirmed persistent or reappearing NDO. Results A total of 2700 BoNT-A injections in 414 patients were ascertained. In 69 patients with primary NR after the first BoNT-A injection (n = 6) or with secondary NR after more than one BoNT-A injection (n = 63), an antibody analysis was performed. Antibody examination showed 36 (52.2%) negative, 5 (7.2%) borderline and 14 (each 20.3%) each of positive and highly positive values. Subgroup analysis indicated a correlation between NAb formation and the duration of BoNT-A therapy (p = 0.015), the mean number of BoNT-A injections (p = 0.011) and the time interval between BoNT-A applications (p = 0.022). Urodynamic data analysis indicate significant differences with cut-off values of MCC (p = 0.038) and MDP (> 45 cmH2O, p = 0.040). However, in the regression analysis models, the predictive value for the occurrence of NAb was too low (MCC: ROC AUC 0.62, MDP: ROC AUC 0.52) to distinguish with sufficient certainty between NAb-positive and NAb-negative NR patients. Conclusions Despite significant correlations, clinical and urodynamic parameters are only partially suitable for predicting antibody formation against BoNT-A.

Purpose For successful long-term rehabilitation of patients with neurogenic lower urinary tract dysfunction (NLUTD), it is necessary to define the objective requirement for urological aids based on a scientifically validated basis. Methods This was a cross-sectional multicenter study, based on a questionnaire. Data concerning bladder management and daily consumption of urological appliances for patients with NLUTD in a community setting were collected through a standardized survey. Results Seven hundred and sixty-seven records were analyzed: 543 males, 221 females (N/A = 3). Patients using intermittent catheterization (n= 608) required 5.06 (mean) single-use catheters per day. Out of them, 94 (15.5%) required additional pads (mean: 2.29 per day), 34 patients (5.6%) additionally used pants (mean: 2.55 per day) and 46 patients (7.6%) utilized condom catheters (mean: 3.81 per day) between catheterizations. Among all, 126 patients (16.4%) used pads (mean: 5.03 per day), and 51 patients (6.6%) used pants (mean: 3.03 per day). Women needed both pads (p

Background Traumatic spinal cord injury (SCI) is also a combat-related injury that is increasing in modern warfare. The aim of this work is to inform medical experts regarding the different course of bladder cancer in able-bodied patients compared with SCI patients based on the latest medical scientific knowledge, and to present decision-making aids for the assessment of bladder cancer as a late sequela of traumatic SCI. Methods A study conducted between January 1998 and December 2019 in the BG Trauma Hospital Hamburg formed the basis for the decision-making aids. Urinary bladder cancer was diagnosed in 40 out of 7396 treated outpatient and inpatient SCI patients. General patient information, latency period, age at initial diagnosis, type of bladder management and survival of SCI patients with bladder cancer were collected and analysed. T category, grading and tumour entity in these patients were compared with those in the general population. Relevant bladder cancer risk factors in SCI patients were analysed. Furthermore, relevant published literature was taken into consideration. Results Initial diagnosis of urinary bladder cancer in SCI patients occurs at a mean age of 56.4 years (SD ± 10.7 years), i.e., approximately 20 years earlier as compared with the general population. These bladder cancers are significantly more frequently muscle invasive (i.e., T category ≥ T2) and present a higher grade at initial diagnosis. Furthermore, SCI patients show a significantly higher proportion of the more aggressive squamous cell carcinoma than that of the general population in areas not endemic for the tropical disease schistosomiasis. Consequently, the survival time is extremely unfavourable. A very important finding, for practical reasons is that, in the Hamburg study as well as in the literature, urinary bladder cancer is more frequently observed after 10 years or more of SCI. Based on these findings, a matrix was compiled where the various influencing factors, either for or against the recognition of an association between SCI and urinary bladder cancer, were weighted according to their relevance. Conclusions The results showed that urinary bladder cancer in SCI patients differs considerably from that in able-bodied patients. The presented algorithm is an important aid in everyday clinical practice for assessing the correlation between SCI and bladder cancer.

Background. Neutralization of central nervous system neurite growth inhibitory factors, for example, Nogo-A, is a promising approach to improving recovery following spinal cord injury (SCI). In animal SCI models, intrathecal delivery of anti-Nogo-A antibodies promoted regenerative neurite growth and functional recovery. Objective. This first-in-man study assessed the feasibility, safety, tolerability, pharmacokinetics, and preliminary efficacy of the human anti-Nogo-A antibody ATI355 following intrathecal administration in patients with acute, complete traumatic paraplegia and tetraplegia. Methods. Patients (N = 52) started treatment 4 to 60 days postinjury. Four consecutive dose-escalation cohorts received 5 to 30 mg/2.5 mL/day continuous intrathecal ATI355 infusion over 24 hours to 28 days. Following pharmacokinetic evaluation, 2 further cohorts received a bolus regimen (6 intrathecal injections of 22.5 and 45 mg/3 mL, respectively, over 4 weeks). Results. ATI355 was well tolerated up to 1-year follow-up. All patients experienced ≥1 adverse events (AEs). The 581 reported AEs were mostly mild and to be expected following acute SCI. Fifteen patients reported 16 serious AEs, none related to ATI355; one bacterial meningitis case was considered related to intrathecal administration. ATI355 serum levels showed dose-dependency, and intersubject cerebrospinal fluid levels were highly variable after infusion and bolus injection. In 1 paraplegic patient, motor scores improved by 8 points. In tetraplegic patients, mean total motor scores increased, with 3/19 gaining >10 points, and 1/19 27 points at Week 48. Conversion from complete to incomplete SCI occurred in 7/19 patients with tetraplegia. Conclusions. ATI335 was well tolerated in humans; efficacy trials using intrathecal antibody administration may be considered in acute SCI.

Die akute Verletzung von Wirbelsaule und Ruckenmark kann sowohl isoliert als auch im Rahmen von Mehrfachverletzungen auftreten. Wahrend die Ursache einer Querschnittslahmung vor wenigen Jahrzehnten noch fast ausschlieslich traumatisch war, ist das Verhaltnis von traumatischen zu nicht traumatischen Ursachen in Deutschland derzeit nahezu gleich. Bei der Akutbehandlung der Querschnittslahmung stehen die Wiederherstellung und der Erhalt der Vitalfunktionen, eine gezielte Steuerung der Kreislaufparameter sowie eine Vermeidung eines lagerungs- oder transportbedingten Zusatzschadens im Vordergrund. Dieser Artikel informiert uber die leitliniengerechte Notfallbehandlung von Patienten mit akuter Verletzung von Wirbelsaule und Ruckenmark in der praklinischen Phase.

Retrospective, single centre cohort study. To determine factors associated with ventilator weaning success and failure in patients with acute spinal cord injury (SCI); determine length of time and attempts required to wean from the ventilator successfully and determine the incidence of pneumonia. BG Klinikum Hamburg, Level 1 trauma centre, SCI Department, Germany. From 2010 until 2017, 165 consecutive patients with cervical SCI, initially dependent on a ventilator, were included and weaned discontinuously via tracheal cannula. Data related to anthropometric details, neurological injury, respiratory outcomes, and weaning parameters were prospectively recorded in a database and retrospectively analysed. Seventy-nine percent of all patients were successfully weaned from ventilation. Average duration of the complete weaning process was 37 days. Ninety-one percent of the successfully weaned patients completed this on first attempt. Age (>56 years), level of injury (C4 and/or above), vital capacity ( 25 kg/m2), and chronic obstructive pulmonary disease (COPD) significantly decreased the chance of successful weaning. These factors also correlated with a higher number of weaning attempts. High level of injury, older age, and reduced vital capacity also increased the duration of the weaning process. Patients with low vital capacity and concurrent therapy with Baclofen and Dantrolene showed higher rates of pneumonia. We conclude that mentioned factors are associated with weaning outcome and useful for clinical recommendations and patient counselling. These data further support the complexity of ventilator weaning in the SCI population due to associated complications, therefore we recommend conducting weaning of patients with SCI on intensive or intermediate care units (ICU/IMCU) in specialised centres.

Mit ca. 2000 neuen Fallen/Jahr in Deutschland ist die akute Querschnittlahmung (QSL) aus traumatischer oder nicht traumatischer Ursache quantitativ zwar ein weniger bedeutsames intensivmedizinisches Krankheitsbild als z.B. die Sepsis, gilt aber aufgrund der Auswirkungen auf den Patienten, der Komplexitat der Behandlung und auch der enormen Folgekosten als bedeutsames Krankheitsbild. Auserhalb spezialisierter Zentren besteht oft wenig Routine im Umgang mit Querschnittgelahmten, insbesondere bei hoher Halsmarklahmung. In Abhangigkeit von Lahmungshohe und -ausmas kann es sowohl in der Akutphase als auch in der weiteren stationaren Rehabilitation sowie der hauslichen Umgebung zu Komplikationen kommen, die eine intensivmedizinische Behandlung erfordern. Bei hoher oder ultrahoher QSL stellt die Dauerbeatmungspflicht zudem eine eigenstandige intensivmedizinische Behandlungsform dar, zu der inzwischen mehr Erfahrungen vorliegen. Neuere Therapieoptionen, wie z.B. die Implantation eines Zwerchfellnervenschrittmachers, erfordern die Auseinandersetzung mit dem Thema, da heute deutlich mehr Patienten mit (hoher) Querschnittlahmung rehabilitiert werden konnen und deren Lebenserwartung standig steigt.

Replacement of the cervical intervertebral disc by artificial implants, known as cervical total disc replacement (CTDR), is becoming a generally applied method instead of using the gold standard of the anterior cervical discectomy and fusion. Hypothetically, the preserved mobility results in the protection of the neighboring segments. There is growing evidence that results in patients who underwent CTDR were not inferior when compared to results in patients who underwent anterior cervical discectomy and fusion. The authors report a case of a healthy 53-year-old man who suffered an incomplete paraplegia below C-6 following the dislocation of an artificial CTDR device into the spinal canal with consequent compression of the spinal cord.

Background Stability of threshold currents during long-term use of phrenic nerve stimulation has been questioned. Methods and Results Between January 5, 1988, and March 5, 2008, 49 patients with functional C2-tetraplegia received an Atrostim PNS (Atrotech Ltd., Tampere, Finland) as treatment of their respiratory insufficiency; a follow-up of 35 of such patients was carried out exclusively in our institution for 6.3 (4.44) 0.04–15.75 years (mean [standard deviation (SD)] range). The device employed four-pole sequential nerve stimulation, which provided four threshold currents subsequently evaluated for each phrenic nerve. Stimulation data were prospectively recorded. The differences between threshold currents recorded 1 year after implantation and the last recorded values were 0.33–0.43 (0.44–0.63) 0–2.9 mA. After having excluded the data of eight patients with values >1 mA (= mean + SD), we registered the differences for the remaining patients of 0.15–0.24 (0.14–0.24) 0–0.95 mA, which is just twice the adjustment accuracy of the device. Out of the eight problem cases one had, and two were suspected to have, surgical trauma; all three nerves recovered. In two cases the values steadily increasing over years might have been caused by unspecific foreign body reaction. Two cases with values >1mA for different durations at different electrodes might be caused by biofilm, and one patient displaying steadily increasing values lived, unwilling to live, only 2 years after the implantation. Conclusion Thus, there was no permanent nerve injury and in 77% of the presented cases threshold currents remained stable.

Mono-centric, retrospective study.Analysis of correlation between bladder management and age in respirator-dependant high-tetraplegic patients. Additionally suprapubic catheter (SPC) and intermittent catheterisation (IC) were reviewed concerning urological complications and quality of life (QoL).Level 1 trauma centre.A QoL questionnaire 'International Consultation on Incontinence' (ICIQ-SF) was sent to 56 tetraplegic respirator device-dependant (RDD)-spinal cord injury (SCI) patients. Their scores concerning urological morbidity were reviewed. For analysis reasons they were divided in three groups: SPC, IC and others.SPC 38, IC 12 and others 6 patients. Significant difference in age (SPC vs IC=49.9 vs 31.8 years) was observed but no disparity in gender. Within a follow-up period 2-26 years (median 8 years) significant urological complications in patients with IC (P0.05) were ascertained. These were in general minor complications. Especially renal deterioration or bladder cancer was not diagnosed in any of the group. The questionnaire return rate was high (83.9%) with complete answers (SPC=32, IC=11). Self assessment of QoL with ICIQ-SF revealed no significant difference for both groups on low level, but SPC patients tend to score better.In our study, tetraplegic RDD-SCI patients with SPC suffered less urological complications and tend to score a better QoL. Therefore we recommend SPC as a serious alternative for these selected patients and concurrently underline the necessity of close urological surveillance at least annually.

Monocentric cohort study.To investigate the acquisition of knowledge about spinal cord injury (SCI)-related complications in SCI patients.Level 1 trauma center.All patients with a traumatic or non-traumatic SCI were included in the study. Data were collected at admission, post-admission at 1 and 3 months and post-discharge at 6, 18 and 30 months. The discharge of all patients was between 3 and 6 months post-admission. Knowledge about pressure ulcers and bladder management was tested using the 'Knowledge' score. This score has a minimum and maximum of 0 and 20 points. To detect differences across the multiple time intervals, the Friedman test was used. Differences in the number of patients with poor (0-8), average (9-12) and good knowledge (13-20) between the different age classifications (age at injury) were calculated using a χ (2)-test.A total of 214 patients were included. At discharge subjects had increased their knowledge score to 11.2 compared with 5.4 on admission (P0.001). After 30 months, however, the mean score decreased to 10.8 points. At the time of discharge, the number of patients who achieved poor, average or good knowledge were 48 (22.4%), 65 (30.4%) and 101 (47.2%), respectively. Subjects of ∼50 years old and tetraplegics had better (P0.001) knowledge compared with subjects of ∼50 years old and paraplegics, respectively.In this study, less than 50% of SCI patients had good knowledge about bladder management and pressure ulcers after being discharged.

Item does not contain fulltext STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To compare the neurological outcome between paraplegic patients with acute spinal cord ischaemia syndrome (ASCIS) or traumatic spinal cord injury (tSCI) and to investigate the influence of SCI aetiology on the total Spinal Cord Independence Measure (SCIM)-II score. SETTING: Level 1 trauma centre. METHODS: Initial (0-40 days) and chronic-phase (6-12 months) American Spinal Injury Association (ASIA) sensory scores, lower extremity motor score (LEMS) and chronic-phase total SCIM-II scores were analysed. Differences between ASCIS and tSCI patients were calculated using Student's t-tests and Wilcoxon signed-rank tests. To assess which variables give rise to the prediction of total SCIM-II score, a multiple linear regression analysis was used. These predictor variables included complete (ASIA impairment scale A) or incomplete SCI (AIS B, C, and D), aetiology, age and gender. RESULTS: Out of 93 included patients, 20 ASCIS and 73 tSCI patients were identified. In the complete SCI group, the initial pinprick scores were higher (P

Monocentric Cohort Study. Development of a multi-dimensional outcome score of the rehabilitation of spinal cord injury (SCI) patients. Level 1 Trauma centre with large spinal unit. During the rehabilitation of 161 patients with SCI between 2005 and 2007 following outcome parameters were assessed at different time points: functional status, pain, emotion, energy, sleep, social isolation, knowledge and self-management attitude. The results for these parameters were statistically evaluated with regard to different grades of paralysis and analyzed for socio-demographic influence factors. Correlation and factor analysis were then applied to evaluate the dependencies of the parameters and the dimensional structure of the applied score. For all factors a positive trend was found during the course of rehabilitation. Only the functional status is caused by spinal cord lesion. Age, sex and social isolation have no direct influence on the result with regard to functional status. For interactive dependencies of the parameters a three-dimensional structure was found: Success in the parameters, emotion, energy or social status, is independent of success in the parameter functional status. The result of the functional status is, next to the type of spinal injury, mainly influenced by the self-management attitude. The level of knowledge gained during rehabilitation is independent of the success in the other parameters. By the combination of functional, psychological and cognitive parameters into a result score it is possible to determine the quality of a rehabilitation process in its multiple dimensions and for different levels and grades of palsy. By this it is possible to analyze and compare the effectiveness and efficiency of rehabilitation on a national and international level. Longitudinal comparison of the long-term effects of rehabilitation after SCI is also possible, for example, in the course of follow-up examinations. Deutsche Gesetzliche Unfallversicherung (German Statutory Occupational Accident Insurance).

Introduction. Cervical spinal cord injuries due to traumatic fractures are associated with persistent neurological deficits. Although clinical evidence is weak, early decompression, defined as Case Presentation. A 37-year-old patient was hospitalized after being hit by a shying horse. After diagnosis of C4/5 fracture dislocation and complete paraplegia, she was intubated and sedated with deep relaxation. Emergency reduction was performed at approximately 120 minutes after trauma. Subsequently, a standard anterior decompression, discectomy, and fusion were carried out. She was then transferred to a specialized rehabilitation hospital. Her neurologic function improved from AIS grade A on admission to grade B postoperatively and grade D after four months of rehabilitation. One year after the accident, she was ambulatory without walking aids and restarted horse riding.Discussion and Conclusion. Rarely in clinical practice, decompression of the spine canal can be performed as early as in this case. This case highlights the potential benefit of utmost early reduction in cervical fracture dislocations with compression of the spinal cord.

Non-interventional, descriptive-observational cohorts study.To assess the incidence of urinary tract infection (UTI) after urodynamic examination in patients with spinal cord injury (SCI) according to bladder management.Level 1 trauma center.Between January and December 2010 a total of 133 consecutive, hospitalized SCI patients were included and classified according to their bladder management. Urine specimen was obtained at the beginning of the urodynamic studies (UDS) and 3-5 days thereafter. 'Significant bacteriuria' (SBU) is defined by a CBU per ml level ≥10(5) in a urine culture. UTI thus is defined as a combination of a SBU and ≥100 leukocytes per μl in urine analysis.The overall incidence of UTI post UDS was 15.79%. In patients with sterile urine prior to urodynamics UTI was ascertained in 8.6% (de-novo-UTI). In contrast, 32.5% of the patients with SBU prior to UDS showed UTI 3 days later. There were only minor differences in the incidence of de-novo-UTIs in SCI patients who emptied their bladder by intermittent self catheterization or intermittent catheterization by attendant (8.82% and 6.67%, respectively). In SCI patients with reflex voiding however, the frequency of de-novo-UTIs was twice as high (14.28%).The recommendation of antibiotic prophylaxis for all SCI patients undergoing urodynamic examination is not commonly accepted and according to our data not justified. However, the analysis of subgroups revealed that SCI patients with unsuspected SBU prior to UDS and patients with reflex voiding are possibly at higher risk to acquire post-UDS infection.

Although there is a clear trend toward internal fixation for ankle arthrodesis, there is general consensus that external fixation is required for cases of posttraumatic infection. We retrospectively evaluated the technique and clinical long term results of external fixation in a triangular frame for cases of posttraumatic infection of the ankle. From 1993 to 2006 a consecutive series of 155 patients with an infection of the ankle was included in our study. 133 cases of the advanced "Gächter" stage III and IV were treated with arthrodesis. We treated the patients with a two step treatment plan. After radical debridement and sequestrectomy the malleoli and the joint surfaces were resected. An AO fixator was applied with two Steinmann-nails inserted in the tibia and in the calcaneus and the gap was temporary filled with gentamicin beads as the first step. In the second step we performed an autologous bone graft after a period of four weeks. The case notes were evaluated regarding trauma history, medical complaints, further injuries and illnesses, walking and pain status and occupational issues. Mean age at the index procedure was 49.7 years (18-82), 104 patients were male (67,1%). Follow up examination after mean 4.5 years included a standardised questionnaire and a clinical examination including the criteria of the AO-FAS-Score and radiographs. 92,7% of the cases lead to a stable arthrodesis. In 5 patients the arthrodesis was found partly-stable. In six patients (4,5%) the infection was not controllable during the treatment process. These patients had to be treated with a below knee amputation. The mean AOFAS score at follow up was 63,7 (53-92). Overall there is a high degree of remaining disability. The complication rate and the reduced patient comfort reserve this method mainly for infection. Joint salvage is possible in the majority of cases with an earlier stage I and II infection.

Item does not contain fulltext STUDY DESIGN: Prospective multi-center cohort study. OBJECTIVES: To compare the neurological and functional recovery between tetraplegic Brown-Sequard-plus syndrome (BSPS) and incomplete tetraplegia (non-BSPS). SETTING: European Multicenter Study of Human Spinal Cord Injury (EM-SCI). METHODS: BSPS was defined as a traumatic incomplete spinal cord injury (SCI) with ipsilateral weakness and contralateral loss of pinprick sensation at neurologic levels C2-T1. Acute (0-15 days) and chronic phase (6 or 12 months) were assessed for the American Spinal Injury Association (ASIA) sensory scores, upper extremity motor scores and lower extremity motor scores. Furthermore, chronic phase scores of all Spinal Cord Independence Measure (SCIM) II items were analyzed. Differences in neurological and functional outcome between BSPS patients and non-BSPS patients were calculated using Student's t-tests and Wilcoxon signed rank tests. RESULTS: Out of 148 tetraplegic patients, 30 were diagnosed with BSPS. Patients with an ASIA impairment scale (AIS) B were significantly (P

Dr Silver addresses the importance of applying strict inclusion criteria to investigate a homogeneous group of patients.