James H. Frisbie

Fractures After Myelopathy: The Risk Quantified

Fractures of the lower extremities have been recognized as a complication of paralysis with myelopathy due to spinal cord injury and impairment (SCI), but the risk has not been quantified and the effect of age, a correlate of predisposing osteoporosis, has not been documented. A long term follow-up review of patients with SCI was conducted to answer these questions. One hundred twenty male SCI patients (91 percent traumatic) were reviewed; the duration of paralysis at follow-up was 21.1 +/- 12.1 years. Forty patients (33 percent) had sustained 76 fracture events resulting in 103 fractures (82 percent in the long bones of the lower extremities). The incidence of fracture events was directly related to age (14.5, 31.1 and 45.7 events per 1000 patient years for age intervals of 20 to 39, 40 to 59 and 60 to 79 years, respectively). Incidence rates for femoral (including hip) fracture in SCI patients were greater than those for the general population of men by factors of 104 and 24 at ages 50 and 70, respectively. In conclusion, the risk of fracture of lower extremity long bones in men is markedly increased by myelopathy and is raised further with aging.

Low dose heparin prophylaxis for deep venous thrombosis in acute spinal cord injury patients: a controlled study

Acute spinal cord injury patients were assigned alternately to a control and a heparin prophylaxis group to determine the effect of 5,000 μ sodium heparin subcutane-ously every 12 hours on the incidence of venous thrombosis as detected by impedance plethysmography of the lower extremities. Venous thrombosis was unexpectedly uncommon in both the control (1 of 17) and the heparinised (1 of 15) group, suggesting an unidentified, overriding prophylactic factor.

Increasing survival and changing causes of death in myelopathy patients.

Survival, mortality rates, and causes of death were determined for 132 myelopathy patients during the 9-year period between April 1973 and March 1982. The average age was 54; 81% were paralyzed by trauma. Average survival was 15 years. Myelopathy mortality was eight times that of the general population for the third decade of life but comparable by the seventh decade. The major causes of death were pulmonary (41 patients- 71% with pneumonia or bronchitis), vascular (37 patients - 54% with ischemic heart disease), gastrointestinal (19 patients - 42% with carcinoma, 32% with peritonitis), and urinary (16 patients - 50% with renal failure and 44% with carcinoma). As survival of myelopathy patients has improved, deaths due to pneumonia, ischemic heart disease, carcinoma, and renal failure have become the major causes of death.

Prostate atrophy and spinal cord lesions

Study design:A single blinded, quantifiable survey of prostate size in spinal cord injury (SCI) patients.Objective:A small prostate gland is sometimes found on routine digital rectal examination (DRE) in SCI patients. Interruption of neurohormonal supply to the prostate gland might lead to atrophy. To test this interpretation, transrectal ultrasonic (TRUS) examinations have been carried out in SCI patients stratified by severity of paralysis.Subjects:Nine severely paralyzed spinal cord-injured men (levels at T10 or above and ASIA A, B, or C) were compared with 12 less severely paralyzed men (levels lower than T10 at any grade or ASIA D at any level). The groups were age matched.Methods:All patients were examined with a 90° sector TRUS probe that measured the prostate gland in three dimensions and calculated the prostate volume and weight. Prostate-specific antigen (PSA) levels were also measured.Results:By TRUS the prostate size was smaller in the severely paralyzed (range 8–16 g, mean 13 g) than in the less severely paralyzed (range 10–70 g, mean 28 g), P=0.02. The PSA level of the severely paralyzed group tended to be lower (0.5–2.1, mean 0.7 ng/ml versus 0.5–10.4, mean 2.2 ng/ml), P=0.08.Conclusion:The prostate gland of severely paralyzed SCI patients is small. Interruption of neurohormonal pathways due to extensive cord damage may be a factor.

Low Prevalence of Prostatic Cancer among Myelopathy Patients

To test the hypothesis that carcinoma of the prostate (CAPR) is uncommon among patients previously paralyzed due to myelopathy, the prevalence of CAPR in patients with high grade (severe) paralysis was compared to that in patients with low grade paralysis. Sixty-six records of patients with CAPR following myelopathy were recalled from the Department of Veterans Affairs medical database for a seven-year period, 1986-1992. Thirty-four patients were unable to stand (high grade paralysis) and 32 patients could stand (low grade paralysis). The minimal, expected ratio of high to low grade paralysis is 2.3, based on general myelopathy populations, but the observed ratio was 1.1, p < 0.01. Patient age and racial distribution, duration and level of paralysis, stage and fraction of CAPR diagnosed incidentally were similar in the high and low paralysis groups. We conclude that severe paralysis due to myelopathy is underrepresented among myelopathy patients with CAPR and is therefore a relatively low risk factor for carcinoma of the prostate gland.

Circadian and circannual rhythm of nonfatal pulmonary embolism.

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Effect of Enterostomy on Quality of Life in Spinal Cord Injury Patients

To determine the difference in the bowel care of spinal cord injury patients before and after enterostomy, we interviewed 20 patients--19 men and one woman. Their ages were 27-75, median 55 years. The paralytic lesions were spastic in ten and flaccid in ten. A total of 24 enterostomies were done for the following reasons: fecal contamination of decubitus ulcer in seven, colonic tumor in six, perforation of the colon in four, prolapse of the large intestine in four, inconvenience of bowel care in two, and perirectal abscess in one. There were 17 sigmoid and five transverse colostomies, and two ileostomies. (Two patients accounted for six procedures.) Follow-up time ranged from three months to six years, median nine months. Bowel care time was reduced from 0.7-14 hours, median 6.0 hours per week preoperatively, to 0.3-7 hours, median 1.0 hours per week postoperatively. Reversal of fecal leakage, abdominal pain, gas and anorexia were also reported. All patients were happier with their bowel care after surgery. We conclude that enterostomy in the spinal cord injury patient makes bowel care considerably more convenient, and improves the quality of life as well.

Waist and neck enlargement after quadriplegia.

Changes in waist and neck size in quadriplegic patients after paralysis, noted clinically, were assessed systematically. Twenty quadriplegic men, aged 60 +/- 13 years (mean +/- 1 SD) and 20 neurologically intact men, aged 63 +/- 17 years, selected by absence of weight gain, were questioned about changes in their waist and shirt collar sizes since the onset of paralysis (20 +/- 13 years) or during the previous 20 years for control subjects. Waist size expanded 7.0 +/- 0.3 inches for quadriplegic and 1.7 +/- 1.7 inches for control subjects (p < 0.001). Changes in neck size of 0.7 +/- 1.1 inches for quadriplegic and 0 +/- 0.7 inches for control subjects were found (p < 0.02). We conclude that quadriplegia is often followed by increased waist and neck size. These changes may relate to the impaired breathing mechanisms in quadriplegia.

Circadian rhythm of pulmonary embolism in patients with acute spinal cord injury

Thrombotic events with a circadian rhythm have been described during the past several years, with onset of myocardial infarction and stroke predominating in the morning hours.1,2 Recently, a circadian rhythm for pulmonary thromboembolism has been reported; the onset of these events also prevailed in the morning hours.3 Patients with spinal cord injury are known to be at risk for pulmonary embolism during the early course of their paralysis.4 Because all of the patients with acute spinal cord injury are a hospitalized population in whom the onset of pulmonary embolic events can be observed and documented, we examined the issue of a circadian rhythm for pulmonary embolism.

Cancer of the prostate in myelopathy patients: lower risk with higher levels of paralysis.

Abstract Purpose: The prevalence of cancer of the prostate (CAP) among patients with myelopathy is lower among the more severely paralyzed. The objective of this study was to determine whether this phenomenon could be more precisely defined. Methods: Men 50 years of age or older who were registered with the spinal cord injury (SCI) service of the Department of Veterans Affairs Medical Center (West Roxbury, Massachusetts) in 1989 were classified by level and grade of paralysis. Cases of CAP were identified by review of the hospital tumor registry and autopsies over the ensuing 11 years. The difference in the incidence of CAP between patients with high and low levels of paralysis was tested by comparison of proportions. Results: Eight cases of CAP were found in 2594 patient-years of follow-up. CAP developed in 3 of 218 patients paralyzed at C2 to T10 and in 5 of 60 patients paralyzed at Tll to 52. Incidence rates were 0.15 versus 0.91 per 100 patient-years, respectively (P = .015) . When patients with incomplete paralysis were excluded, the incidence rates were 0 and 2 .1 per 100 patient-years for the higher and lower lesions, respectively (P <.001). Conclusion: The incidence of CAP is lower in myelopathy patients with higher levels of paralysis (T10 or above) than in those with lesions at T11 or below.