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Sensorimotor function of patients with spinal cord injury (SCI) is commonly assessed according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). From the ISNCSCI segmental motor and sensory assessments, upper and lower extremity motor scores (UEMS and LEMS), sum scores of pinprick (PP) and light touch (LT) sensation, the neurological level of injury (NLI) and the classification of lesion severity according to the American Spinal Injury Association Impairment Scale (AIS) grade are derived. Changes of these parameters over time are used widely to evaluate neurological recovery. Evaluating recovery based on a single ISNCSCI scoring or classification variable, however, may misestimate overall recovery. Here, we propose an Integrated Neurological Change Score (INCS) based on the combination of normalized changes between two time points of UEMS, LEMS, and total PP and LT scores. To assess the agreement of INCS with clinical judgment of meaningfulness of neurological changes, changes of ISNCSCI variables between two time points of 88 patients from an independent cohort were rated by 20 clinical experts according to a five-categories Likert Scale. As for individual ISNCSCI variables, neurological change measured by INCS is associated with severity (AIS grade), age, and time since injury, but INCS better reflects clinical judgment about meaningfulness of neurological changes than individual ISNCSCI variables. In addition, INCS is related to changes in functional independence measured by the Spinal Cord Independence Measure (SCIM) in patients with tetraplegia. The INCS may be a useful measure of overall neurological change in clinical studies.

Extraforaminal lumbar disk herniations are characterized by distinct clinical features in comparison to paramedian lumbar disk herniations.We applied the quantitative sensory testing (QST) protocol of the German Research Network on Neuropathic Pain in 63 patients with a single lumbar disk herniation. They were categorized in 2 groups: (I) an intraspinal (group I; n = 47, 75%) and an extraforaminal (group E; n = 16, 25%).The wind-up ratio for assessing endogenous pain-modulating pathways was higher in group E (2.9 ± 2) than in group I (1.4 ± 1; P = 0.021). After a subsequent series of pinprick stimuli, an increase in pain assessed by the numeric rating scale could be shown in group E (2.1 ± 2 vs 1.1 ± 1; P = 0.032).Extraforaminal compression is associated with chronic as well as neuropathic pain, presumably caused by direct compression of the dorsal root ganglion, which may preferentially promote specific chronic pain mechanisms. Muscle Nerve 58: 676-680, 2018.

Traumatic brain injury (TBI) is an important cause of death and disability. Safety and pharmacodynamics of 4-amino-tetrahydrobiopterin (VAS203), a nitric oxide (NO)-synthase inhibitor, were assessed in TBI in an exploratory Phase IIa study (NOSynthase Inhibition in TRAumatic brain injury=NOSTRA). The study included 32 patients with TBI in six European centers. In a first open Cohort, eight patients received three 12-h intravenous infusions of VAS203 followed by a 12-h infusion-free interval over 3 days (total dose 15 mg/kg). Patients in Cohorts 2 and 3 (24) were randomized 2:1 to receive either VAS203 or placebo as an infusion for 48 or 72 h, respectively (total dose 20 and 30 mg/kg). Effects of VAS203 on intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain metabolism using microdialysis, and the therapy intensity level (TIL) were end points. In addition, exploratory analysis of the extended Glasgow Outcome Score (eGOS) after 6 months was performed. Metabolites of VAS203 were detected in cerebral microdialysates. No significant differences between treatment and placebo groups were observed for ICP, CPP, and brain metabolism. TIL on day 6 was significantly decreased (p0.04) in the VAS203 treated patients. The eGOS after 6 months was significantly higher in treated patients compared with placebo (p0.01). VAS203 was not associated with hepatic, hematologic, or cardiac toxic effects. At the highest dose administered, four of eight patients receiving VAS203 showed transitory acute kidney injury (stage 2-3). In conclusion, the significant improvement in clinical outcome indicates VAS203-mediated neuroprotection after TBI. At the highest dose, VAS203 is associated with a risk of acute kidney injury.

The rupture of a catheter near the spine is rare. There are no evidence-based guidelines for diagnosis and therapy. Opinions derived from German anesthesiologists, neurosurgeons, orthopaedics and trauma surgeons are: Infants should have immediate surgery. In an asymptomatic adult, the catheter fragment does not require removal surgery. Antibiotic prophylaxis is not necessary. If symptomatic, the catheter fragment should be localized by a thin slice computed tomography or fluoroscopy. Otherwise surgical exploration is indicated. Direct surgery is recommended for cases with neurological symptoms, infections, loss of spinal fluid, pain and local discomfort. Relative indications for surgery are severe pain, tissue infection and intrathecal localization of the fragment. Surgery should be performed in prone position and under general anesthesia. Starting at the entry wound, the surgical access should be microsurgical and preferably by a neurosurgeon. If the entry is not detectable, a midline incision is suggested.

The main challenge in the surgical treatment of chronic low back pain lies in the poor knowledge of its etiology. Surgery, however, requires the identification of a surgically curable lesion. In cases of radiologically obvious structural spinal disease like stenosis, instability or deformity, surgery is indicated after failure of conservative measures and achieves acceptable success rates. The vast majority of patients, however, demonstrates only unspecific segmental degeneration. Fusion is only somewhat effective and there is no evidence-based data for the abundant modern and less invasive techniques.

The rupture of a catheter near the spine is rare. There are no evidence-based guidelines for diagnosis and therapy. Opinions derived from German anesthesiologists, neurosurgeons, orthopaedics and trauma surgeons are: Infants should have immediate surgery. In an asymptomatic adult, the catheter fragment does not require removal surgery. Antibiotic prophylaxis is not necessary. If symptomatic, the catheter fragment should be localized by a thin slice computed tomography or fluoroscopy. Otherwise surgical exploration is indicated. Direct surgery is recommended for cases with neurological symptoms, infections, loss of spinal fluid, pain and local discomfort. Relative indications for surgery are severe pain, tissue infection and intrathecal localization of the fragment. Surgery should be performed in prone position and under general anesthesia. Starting at the entry wound, the surgical access should be microsurgical and preferably by a neurosurgeon. If the entry is not detectable, a midline incision is suggested.