Robert L. Waters

International standards for neurological and functional classification of spinal cord injury

International Standards for Neurological and Functional Classification of Spinal Cord Injury

Motor and Sensory Recovery Following Incomplete Paraplegia

Fifty-four individuals admitted for rehabilitation with a diagnosis of incomplete paraplegia due to trauma underwent serial prospective examinations to quantify motor and sensory recovery. Motor and sensory scoring guidelines recommended by the American Spinal Injury Association were used to assess changes. Lower extremity motor scores (LEMS) differed significantly (p < .03) between groups of patients partitioned by category of initial neurologic level of injury (NLI) with the following averages at 1 month after injury: 6.8 +/- 11.3 above T12, 15.0 +/- 8.2 at T12 and 18.3 +/- 11.4 below T12. However, the amount of motor recovery was independent of the NLI with the differences between the NLI groups remaining essentially constant from 1 month to 2 years. While the LEMS increased significantly (p < .001) an average of 11.9 +/- 8.7 points between 1 month and 1 year, the annualized rate of motor recovery rapidly declined in the first 6 months and then subsequently plateaued. All patients having a 1-month LEMS greater than 10 points (28 cases) with hip flexion or knee extension strength > or = 2/5 were able to ambulate in the community with a reciprocal gait pattern using crutches and orthoses at 1-year follow-up.

Pulmonary function in chronic spinal cord injury: A cross-sectional survey of 222 Southern California adult outpatients☆☆☆★★★♢♢♢

OBJECTIVESnTo evaluate risk factors for respiratory morbidity in chronic spinal cord injury (SCI).nnnSETTINGnModel SCI care system based at an urban public rehabilitation medical center.nnnDESIGNnCase series with evaluation of pulmonary function by conventional spirometric testing.nnnPARTICIPANTSnTwo hundred twenty-two adults with SCI of more than 1-year duration who were not chronically dependent on mechanical ventilation, including 98 with tetraplegia (62 with complete and 26 with incomplete motor lesions) and 124 with paraplegia (87 with complete and 37 with incomplete motor lesions).nnnMAIN OUTCOME MEASURESnForced vital capacity (FVC), forced expired volume in 1 second (FEV1), and peak expiratory flow rate (PEFR), all measured in the supine and erect seated positions and compared with predicted normal values for industrial workers.nnnRESULTSnFVC and FEV1 were normal in persons with low-level paraplegia who had never smoked, but both decreased similarly with rising SCI level, more markedly in those with tetraplegia. PEFR decreased with rising SCI level. Incomplete lesions mitigated function loss in those with tetraplegia. In middle-aged individuals with tetraplegia, longer duration of injury was associated with greater function loss, independent of age. Current smokers showed excess function loss, except for those with high tetraplegia. Most people with complete tetraplegia showed FVC and FEV1 increases in the supine position relative to the erect position.nnnCONCLUSIONSnPulmonary function is compromised by most lesions of the spinal cord, even in those with paraplegia, and is affected relative to the level of lesion. Efforts to help SCI patients minimize respiratory complications-in particular, assistance in smoking cessation-should be given high priority.

Shoulder Pain and Functional Disability in Spinal Cord Injury Patients

Sixty spinal cord injured patients were examined to determine the incidence of nontraumatic shoulder pain and associated functional disability during the first 18 months after spinal cord injury (SCI). Seventy-eight percent of quadriplegics and 35% of paraplegics had pain in the first six months. When reexamined six to 18 months after SCI, 33% of the quadriplegics and 35% of the paraplegics continued to have pain. The functional disability resulting from shoulder pain was not a significant problem for the paraplegics; however, 84% of the quadriplegics having pain had either moderate or severe functional disability during the first six months after SCI, and this impairment persisted in patients with shoulder spasticity at follow-up evaluation between six and 18 months postinjury.

The effects of removal of bullet fragments retained in the spinal canal : a collaborative study by the national spinal cord injury model systems

Serial motor and sensory examinations were conducted on 90 patients with bullet fragments lodged in the spinal canal. Annual follow-up examinations were completed on 66 patients. Despite the fact that approximately 20% of the bullets had perforated the alimentary canal, no cases of infection were noted. Statistical analyses indicated that removal of the bullet fragments made no significant difference with regard to reducing pain or improving the recovery of sensation. However, bullet removal did have an effect on motor recovery, depending on the level at which the lesion occurred. Among those patients with lesions between vertebral levels T12 and L4, there was significantly greater (P < 0.001) motor recovery in those patients from whom the bullet was removed from than in patients not having bullet removal. Bullet removal from the canal between T1 and T11 had no significant effect on motor recovery.

The effect of residual neurological deficit on serum lipoproteins in individuals with chronic spinal cord injury

Subjects with spinal cord injury (SCI) have been shown to have an adverse lipid profile. Prior studies performed with smaller numbers of subjects have not been able to demonstrate any relationship between the level and degree of the neurological deficit and plasma lipid levels. Over a 2 year period we investigated the lipid profiles in 541 subjects from Rancho Los Amigos Medical Center, Downey, California. Subjects were grouped by tetraplegia (Tetra; n=247) or paraplegia (Para; n=294) and by subgroup for degree of neurological deficit: complete Tetra (n=156), incomplete Tetra (n=91), complete Para (n=206) and incomplete Para (n=88). The serum high-density lipoprotein (HDL) cholesterol level was lower in the Tetra than in the Para group (38±0.7 vs 45±0.8, P<0.01). The group with Tetra had a higher percentage of subjects with serum HDL cholesterol values <35u2002mg/dL [an independent risk factor for coronary heart disase (CHD)] than those with Para (38% vs 21%, P<0.0001). A significant inverse relationship was found for degree of neurological deficit and mean serum HDL cholesterol level (r=0.19, P<0.001), with the greater the deficit, the lower the serum HDL cholesterol level. Serum total cholesterol levels were higher in the Para group than in the Tetra group (198±2.6 vs 184±2.6, P<0.01). However, the ratio of total cholesterol to HDL cholesterol (a discriminator of risk for CHD) was significantly lower in the Para group than the Tetra group (4.8 vs 5.2%, P<0.01). Thus, in persons with SCI a spectrum of depressed serum HDL cholesterol levels and increased cardiovascular risk occur, with the most adverse lipid changes correlating with the severity of neurological deficit.

Spinal cord injuries from gunshot wounds to the spine.

Although vehicular trauma traditionally has accounted for the majority of spinal cord injuries, gunshot wounds are the second most common cause. Furthermore, the proportion of spinal cord injuries caused by gunshot wounds are increasing although the proportion of injuries caused by high-speed vehicular trauma is decreasing. Gunshot wounds to the spine commonly are thought to be stable injuries. There is, however, a potential for instability if the bullet passes transversely through the spinal canal and fractures pedicles and facets. Injuries to the thoracic region of the spine are the most common, followed by the thoracolumbar area and the cervical spine. Completeness of injury is related to the anatomic region. Patients with incomplete injuries and patients with injuries in the thoracolumbar region have the greatest improvement in motor function. Approximately (1/4) of individuals are able to ambulate 1 year after injury. Surgical decompression of bullets from the spinal canal has been shown to improve neurologic recovery below the T12 level. Improvement of neurologic recovery after bullet removal has not been shown in other regions of the spine. Rare instances of late neurologic decline because of retained bullet fragments have been documented.

Emergency, acute, and surgical management of spine trauma

OBJECTIVESnTo assess trends in emergency, acute, and surgical management of spinal cord injury (SCI), and evaluate the relations between surgery and the occurrence of specific complications.nnnSETTINGnModel SCI Care Systems.nnnDESIGNnCase series.nnnPARTICIPANTSnConsecutive samples of 3,756 acute spinal injuries admitted to the Midwest Regional Spinal Cord Injury Care System between 1990 and 1999, 2,204 individuals admitted to a Model SCI System within 24 hours of injury before 1995, and 941 individuals who were injured between December 1995 and August 1998 and were admitted to a Model System within 24 hours of injury.nnnMAIN OUTCOME MEASURESnFrequencies of injury types, nonoperative treatment and types of spine surgeries, and time sequence associated complications including postoperative wound infections, pressure ulcers, deep vein thrombophlebitis, pulmonary embolism, and pneumonia or atelectasis.nnnRESULTSnEighty-eight percent of cases entering a Model System through acute care were admitted within 72 hours of injury, 85% were admitted within 24 hours. Comparing 1990 with 1998, the number of persons admitted to Model Systems within 72 hours of injury declined 11%. Operative treatment within the Model Systems increased 5% (p < .01), with increases due to decompression surgeries. Complication rates of nonoperative and surgical cases were not different.nnnCONCLUSIONSnThe reduction in 72-hour admissions suggests an increasing percentage of admissions are directly to rehabilitation at a Model System after receiving acute care elsewhere. The increase in the use of surgical procedures involving surgical decompression of the spine is probably due to advances in surgical technology and increased experience and confidence in spine surgery. Surgery does not influence complication development beyond the usual expectations for those who sustain SCI.

The Relationship of the Interosseous Membrane to the Axis of Rotation of the Forearm

Fresh anatomic specimen forearms were studied using a mechanical device, the axis finder, to locate the axis of rotation. The relationship of the axis to the membrane was demonstrated directly using a small jig. The axis of rotation of the forearm is constant and independent of elbow flexion or extension. It runs from the center of the radial head to the center of the distal ulna. All fibers of the interosseous membrane cross the axis of rotation near their distal insertion into bone. This relationship of the ligaments to the axis of rotation is similar to those of the ankle, knee, and thumb joints. The membrane does not limit forearm rotation and can provide little stability if the bony ring is disrupted.

Gunshot wounds to the spine associated with a perforated viscus

The cases of 42 patients with low-velocity gunshot wounds to the spine with an associated perforated viscus were reviewed. All viscus perforations occurred prior to the spinal injury. There were a total of 51 perforations, including 14 of the colon, 15 of the small bowel, 15 of the stomach, five of the esophagus, and two of the pharynx. All patients had significant neurologic deficits, with 23 patients suffering a complete neurologic injury. Average clinical follow-up was 18 months (range: 4-64 months). Only three patients developed documented spinal or paraspinal infections. One case of acute meningitis occurred after an isolated stomach perforation, while two other patients developed psoas abscesses after colon injuries. The roles of initial antibiotic therapy and of early bullet removal were evaluated in regard to infection. An extended course of broad spectrum antibiotics combined with bedrest appeared to significantly reduce the risk of spinal or paraspinal infection as compared with a previous study. Early bullet removal did not appear to be a significant factor in the prevention of infection. Prospective studies are needed to accurately delineate the role of initial antibiotic therapy for the prevention of spinal infection in these injuries.