Franklin C. Wagner

Classification of the severity of acute spinal cord injury: implications for management

Sensory and motor function scales using a comprehensive neurological examination in emergency departments were developed during a 5-year prospective study of the epidemiology of acute spinal cord injury. Cross-classification of the scales on 133 patients identified 18.8 per cent who had severe motor impairment but minimal or no sensory loss. This discrepancy was not associated with older age or comorbidity but these patients tended to have a higher prevalence of fracture dislocations, hyperesthesia and Brown-Sequard Syndrome. The discrepancy between sensory and motor function was almost certainly due to the pathology of the cord lesion. Overall, motor function was more likely than sensory function to show improvement during the acute hospitalisation. This was especially true for patients admitted with good sensory but poor motor function. These patients need to be delineated soon after injury if we are to fully understand the aetiology of spinal cord injury and appropriately manage and evaluate different therapeutic modalities.

Glioblastoma multiforme: Treatment by large dose fraction irradiation and metronidazole☆

In an attempt to overcome the possible radioresistance of glioblastoma multiforme related to the large shoulder on the in vitro survival curves and to sensitize hypoxic tumor cells, a treatment protocol was instituted at Yale University Medical Center and affiliated hospitals, using large dose fraction irradiation therapy in conjunction with the hypoxic cell sensitizer metronidazole. Nineteen patients with biopsy-confirmed, previously untreated, cerebral grade IV glioblastoma multiforme were, following surgery, irradiated once a week at 600 rad per fraction, 3.5 to 4 hours after ingestion of metronidazole, 6 gm/m2. A total of 7 treatments were employed, with all patients maintained on antiseizure medications and corticosteroids. Metronidazole levels were determined prior to each treatment and patients were followed closely clinically and with serial computerized tomography (CT) scans. The treatment was well tolerated, in general, with no untoward side effects related to the high dose fraction irradiation. The majority of the patients experienced varying degrees of gastrointestinal upset lasting up to several hours following metronidazole administration. Three patients died of pulmonary emboli. One patient experienced moderately severe ototoxicity. A median survival of 9.4 months was obtained for all 19 patients, suggestive of a prolongation of survival compared to historical controls treated with conventionally fractionated radiation or with unconventional radiation fractionation schemes and metronidazole or misonidazole.