H L Frankel

The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia

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.

Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago

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.

The value of intermittent catheterisation in the early management of traumatic paraplegia and tetraplegia

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.

Long-term survival in spinal cord injury : a fifty year investigation

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.

Factors associated with acute and chronic pain following traumatic spinal cord injuries

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 Fines 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.

Ascending cord lesion in the early stages following spinal injury

Sir LUDWIG GUTTMANN (Great Britain). The chairman of the afternoon session will be Dr. George Bedbrook from Perth, Western Australia. Most of you know of the great work he is doing for spinal cord sufferers in Australia. But for some years he was also engaged to spread the gospel of modern treatment of paraplegics and tetraplegics to various countries in the Far East. I visited him first in 1957 when his unit was small and only two years old. It was just the time when he became disillusioned with the result of surgery in fractures of the spine, especially open reduction and metal plate fixation. When I visited him again in 1962 on the occasion of the first British Commonwealth Paraplegic Games held in Perth, his unit had expanded to a first class Spinal Centre. Dr. Bedbrook was one of the first in Australia to realise the need of hostels for those paraplegics and, in particular, tetraplegics who for one reason or another are unable to return home. This is now a very important problem which concerns all of us who are engaged in work with these severely disabled people in view of the ever increasing number of these patients and their prolonged life expectancy. These patients just cannot be managed in geriatric units or similar institutions. They develop bedsores and other complications very soon and have to be readmitted to hospitals or spinal units for usually very long lasting inpatient treatment. To obviate this sorry state of affairs it is essential to erect hostels with sheltered workshop facilities for these patients in the neighbourhood of spinal units, with a skeleton staff to look after them and supervised by the staff of the spinal unit. In Great Britain the first of such a hostel of 30 beds has been introduced by me at Stoke Mandeville Hospital a few years ago and has proved highly successful. It is to be hoped that more hostels of this kind will be set up in the country. In Perth Dr. Bedbrook has taken the initiative in this respect and I am sure he will succeed. Now it is a great pleasure to ask Dr. Bedbrook to take the chair.

THE MOTILITY OF THE PELVIC COLON FOLLOWING COMPLETE LESIONS OF THE SPINAL CORD.

Sigmoid activity was studied in 26 patients with complete lesions at various levels of the spinal cord.The resting unstimulated motility of the pelvic colon was found to differ in patients with high cord lesions both from that of normal subjects and patients with low thoraco-lumbar lesions. In high cord transection with intact isolated cord below the lesion, resting colonic activity was reduced compared with normal subjects, while patients with low cord lesions showed a significantly increased colonic motility.The mechanism underlying the changes of resting colonic motility is discussed.Factors influencing colonic motility were also studied and the effects of intake of food, the psycho-visceral reflex, rectal distension, sigmoidoscopy, and intrathecal alcohol injection are described.

Organisation of the sympathetic skin response in spinal cord injury

Objectives: The sympathetic skin response (SSR) is a technique to assess the sympathetic cholinergic pathways, and it can be used to study the central sympathetic pathways in spinal cord injury (SCI). This study investigated the capacity of the isolated spinal cord to generate an SSR, and determined the relation between SSR, levels of spinal cord lesion, and supraspinal connections. Methods: Palmar and plantar SSR to peripheral nerve electrical stimulation (median or supraorbital nerve above the lesion, and peroneal nerve below the lesion) were recorded in 29 patients with SCI at various neurological levels and in 10 healthy control subjects. Results: In complete SCI at any neurological level, SSR was absent below the lesion. Palmar SSR to median nerve stimuli was absent in complete SCI with level of lesion above T6. Plantar SSR was absent in all patients with complete SCI at the cervical and thoracic level. In incomplete SCI, the occurrence of SSR was dependent on the preservation of supraspinal connections. For all stimulated nerves, there was no difference between recording from ipsilateral and contralateral limbs. Conclusions: No evidence was found to support the hypothesis that the spinal cord isolated from the brain stem could generate an SSR. The results indicate that supraspinal connections are necessary for the SSR, together with integrity of central sympathetic pathways of the upper thoracic segments for palmar SSR, and possibly all thoracic segments for plantar SSR.

Magnetic brain stimulation can improve clinical outcome in incomplete spinal cord injured patients.

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.

Towards improved clinical and physiological assessments of recovery in spinal cord injury: a clinical initiative

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.