Alvin A. Freehafer

Incidence and clinical features of autonomic dysreflexia in patients with spinal cord injury

The histories of 444 patients admitted to this spinal cord injury service were reviewed for the incidence of autonomic dysreflexia (A.D.). Forty-eight per cent of 213 patients with complete cord lesions at T6 or above exhibited A.D. The time of onset post-injury, exciting causes, unusual manifestations of attacks, and the persistence of the condition were studied. These findings and the experience with attempts at prevention by education and by the use of an alpha-adrenergic blocker and a non-adrenergic vasodilating agent are reported.

Determination of muscle-tendon unit properties during tendon transfer

Data on passive lengthening and active shortening from electrical stimulation to give a total functional excursion are presented. Length-tension characteristics of certain muscles used for transfer are given. Electrical stimulation of the newly transferred tendon gives useful information that is reproducible. This new knowledge obtained at operation is an important adjunct to the traditional techniques and provides helpful information in performing better procedures.

Lower Extremity Fractures in Patients with Spinal-Cord Injury

From experience gained from the treatment of forty-six fractures occurring in patients with spinal-cord injury, it is obvious that conventional methods of fracture care are not always applicable to fractures occurring in paraplegic patients. Pillow splints and well padded plaster casts are very useful methods of treating fractures below the mid-femoral shaft in paraplegic patients. Fractures of the hip region usually received no treatment other than positioning of the involved extremity. Treatment should strive to achieve fracture healing with minimum danger to the patient, should cause little or no interference with the patients daily routine, and should ensure that functional capacity will be unchanged after healing occurs.

Limb fractures in patients with spinal cord injury

Limb fractures that occur late in patients with spinal paralysis are considered to be different enough to warrant variations in treatment. In the authors experience, treatment ensures that the functional level is unchanged when healing occurs. Treatment includes use of splints, made of soft materials, that are effective, inexpensive, safe, and allow for good healing. There is motion at the fracture site but, in the authors experience, healing occurs in all fractures except those at the femoral neck. Treatment with soft materials is the least expensive treatment method because it does not require hospitalization, surgery is not recommended, the bone is so soft and pathological that it does not hold firmly with internal fixation, rehabilitation is simplified.

Transfer of the Brachioradialis to Improve Wrist Extension in High Spinal-cord Injury

A method to improve wrist extension in the severely paralyzed hand has been described. The ability to dorsiflex the wrist and to perform automatic grasp is one of the quadriplegics most important functions. Four of six hands with transfer of a good or normal brachioradialis to weak or absent radial wrist extensors gained this most important function with effective grasp. The other two had improved posture of their hands and were pleased with their results.

Lower extremity fractures in patients with spinal cord injury

Lower limb fractures occurring in patients with established spinal paralysis were considered different enough to warrant variations in treatment usually provided to patients without paralysis. Treatment should ensure that the functional level will be unchanged after healing occurs. Splints made of soft materials were effective, inexpensive, safe, and allowed for good healing with early rehabilitation.

Tendon Transfers to Improve Grasp after Injuries of the Cervical Spinal Cord

Twenty-four hands of twenty carefully selected patients with injury to the cervical spinal cord and paralysis of the upper extremities had better grasp after tendon transfers. Grouping the patients with these injuries according to the presence of certain voluntarily functioning muscles was helpful in planning treatment. When a proper program of positioning, exercises, and splinting was carried out, most quadriplegic patients achieved useful grasp by means of the tenodesis effect of the automatic hand. Voluntary wrist extension was the key to good grasp with or without surgery. If effective prehension was not acquired after a rehabilitation program had been completed, and improvement in neural function had ceased, transferring suitable motors improved grasp by providing finger flexion and thumb opposition.

The posterior deltoid to triceps transfer: A clinical and biomechanical assessment

Transfer of the posterior deltoid muscle to the triceps insertion for elbow extension provides improved function in patients with C5 and C6 level tetraplegia. We have modified the surgical technique using the tibialis anterior tendon as a graft. The length-tension characteristics and available amplitude of the posterior deltoid muscle were determined with intraoperative electrical stimulation. The excursion of the posterior deltoid muscle was 7.31 cm with a standard deviation of 1.23 cm. Postoperative mean torque measurements of elbow extension power were 36.4 kg cm with a standard deviation of 15 kg cm. All patients had maximal strength between 90 degrees and 120 degrees of elbow flexion. Length-tension curves for the posterior deltoid muscle showed a large range of effective strength and helped confirm optimum tension of the posterior deltoid muscle and proper shoulder and elbow positions at surgery. Clinical results in 10 patients were excellent.

Tendon transfers in patients with cervical spinal cord injury

Between 1983 and 1988, 32 patients with cervical spinal cord injuries underwent 124 upper limb tendon transfers during 85 procedures. Of the numerous surgical procedures that have been recommended for treatment of this condition, my experience indicates that the most successful are posterior deltoid-to-triceps transfer, restoration of finger flexion, and restoration of thumb opposition. Longitudinal incisions prove to be quite cosmetic.

Destructive Lesions of the Spine in Rheumatoid Ankylosing Spondylitis

Three patients with ankylosing spondylitis complicated by destructive vertebral lesions have been reported. One patient had three separate lesions over a ten-year period. Another patient sustained a fracture through the posterior elements prior to the occurrence of granuloma formation of the intervertebral space. The third patient had spinal-cord compression with complete paralysis from which he had a partial recovery following recumbency, lateral rachitomy, and fusion. The etiology of these lesions is unknown, but it is suggested that they represent response to delayed union or non-union of fractures occurring in rheumatoid spondylitis.