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Acute spinal cord trauma is a devastating injury which often leads to severe disability. The tissue response following the initial insult extends the cord damage, while there is limited repair potential with regards to axon regeneration resulting in permanent neurological deficits. Management of acute cord injury is an area of active research in order to stabilize the spine in a timely manner, minimize the secondary insult and promote regeneration. Methyl-prednisolone administration for limitation of the secondary injury phase and acute versus late operative treatment are areas of current debate among several authors. This article is an overview of all aspects of early and long term spinal cord injury management. It focuses on the patho-physiological mechanisms of the acute injury phase and the different clinical types of cord injury syndromes. The treatment principles are described along with an updated view on the controversial issues.

Background context Spinal cord trauma is a major cause of mortality and morbidity. Although no known treatment for spinal cord injury exists, a limited number of effective treatment modalities and procedures are available that improve secondary injury. Hyperbaric oxygen (HBO) treatment has been used to assist in neurologic recovery after cranial injury or ischemic stroke. Purpose To report the findings on the effectiveness of HBO treatment on rats with experimental traumatic spinal cord injury. Improvement was evaluated through motor strength assessment and nitrite level assay testing. Study design We randomly distributed 40 rats among 5 groups of 8 rats each: sham incurable trauma, induced trauma, HBO treatment begun at the 1st hour, HBO treatment begun at the 6th hour, and HBO treatment begun at the 24th hour. Method The HBO treatment was administered to rats in three of the groups and conducted in two 90-minute sessions, under an absolute atmospheric pressure of 2.4 at 100% oxygen for 5 days. In the motor strength evaluations, all the rats were observed during the inclined plane test and clinical motor examination on the first, third, and fifth days. In addition, the nitrite levels of spinal cord tissues on the sixth day were also studied. Results Results from the inclined plane levels and motor strength test from all the three groups undergoing HBO treatment were higher than those from Group 2. It was also determined that early HBO treatment resulted in higher recovery rates (groups 3 and 4). The highest levels were seen in the group in which the HBO treatments were started in the first hour (Group 3). It was noted that nitrite levels of rats in the group exposed to trauma increased, compared with the sham group, but increased levels also diminished after HBO treatments. Again, the greatest decrease in nitrite levels was evident in the group where the HBO treatment was started the earliest (Group 3). Conclusions Prompt HBO treatment after trauma significantly contributed to the clinical, histopathologic, and biochemical recovery of the rats.

Spine trauma is a devastating clinical condition that affects many people annually on a worldwide basis. Management of spinal trauma has become much more surgically oriented with advances in stabilization techniques over the past two decades. The degree of injury to the spinal cord dictates the prognosis of the patient in cervical and thoracolumbar trauma. Traumatic spinal cord injury is a major area of socioeconomic burden and, as such, is a burgeoning area of ongoing research interest.

A 2-year-old castrated male Holland lop rabbit ( Oryctolagus cuniculus ) was presented for loss of hind limb motor function after leaping from the owner's arms. Results of a neurologic examination revealed appropriate mentation, normal thoracic limb posture and gait, paralysis in the right pelvic limb, and voluntary movement of the left pelvic limb. Superficial pain perception and withdrawal reflexes were present bilaterally in the hind limbs. Bilateral proprioception was evident in the forelimbs but absent in the hind limbs. Standard radiographs and a myelogram were performed, revealing subluxations at T5-T6, L1-L2, and L3-L4, a comminuted fracture of the T9 vertebral body, fractures of the right articular facets of L3-L4, and spinal cord swelling at T9. The clinical signs continued to decline, resulting in paraplegia with loss of deep pain perception in the left hind limb after the myelogram procedure. The owners of the rabbit were given a guarded-to-poor prognosis for the animal to regain mobility in the hind limbs. The rabbit was hospitalized and medical treatment including pain management, intravenous fluid therapy, nutritional support, and cage rest was initiated. After the initial decline of the clinical signs, the neurologic deficits stabilized during hospitalization. At the time of discharge, partial voluntary movement had been regained in the right hind limb, but there was no movement or pain perception in the left hind limb. This gradually resolved over 3 months of conservative therapy, at which point the rabbit had recovered the voluntary movement in both hind limbs and was able to ambulate by walking and hopping. This case report documents acute spinal cord trauma in a rabbit, as well as recovery of the neurologic deficits after prolonged medical management.

Background The ability to objectively analyze gait in a clinical environment is challenging due to time, space and cost constraints. This study investigated the validity of a portable gait assessment tool in objectively assessing the temporal gait parameters in subjects with spinal cord injury. The portable gait assessment tool consisted of a pair of insoles instrumented with force sensing resistors that were strategically positioned over the sole of each foot. Aim To demonstrate the validity of the gait assessment tool by assessing the change in walking ability in incomplete spinal cord injured (ISCI) subjects, who participated in a robot-assisted gait training program. Methods Eighteen subjects with either an acute or chronic ISCI participated in this study (age range 26–63 years). Each subject participated in a robot assisted gait training programme for 6 weeks. Assessments were performed using the gait assessment tool before during and after the intervention. Results The gait assessment tool showed greater sensitivity to the change in the subject's gait, when compared to clinical assessments such as the walking index in spinal cord injury (WISCI II). Subjects with an acute ISCI showed a statistically significant ( p Discussion and conclusion This study for the first time has used the gait assessment tool in an ISCI population and has demonstrated that gait parameters can be measured and changes can be quantified within a clinical environment. The statistically significant changes during the first 3 weeks of training may indicate that an effective dose of robotic training can be administered within a relatively short period in ISCI subjects during the acute phase.

Spinal cord injury (SCI) is the sudden onset of a traumatic disabling condition. It impacts on people with SCI physiologically, psychologically and socially. People face major life changes and the lifelong challenges of disabilities that affect every aspect of their lives. This paper is a reflection on the impact of individual music therapy sessions and combined social work and music therapy group sessions, the music therapy program (MTP), on adjustment to SCI. Reflections focused on data drawn from group discussions, semi-structured satisfaction interviews of 13 men with SCI, who had undergone primary rehabilitation in the Royal Talbot Rehabilitation Centre, Melbourne, Australia; findings from an independent evaluation of MTP; and practitioner perceptions. Three themes were identified during this reflection. These were: Music as a conduit; Music and the body; and Music as a connector. Reflections identify a number of benefits of incorporating the MTP in rehabilitation programs for men with SCI.

Aim To document the detection of underlying low-attenuation spinal cord or brain stem injuries in the presence of the “pseudo-CT myelogram sign” (PCMS) on post-mortem computed tomography (PMCT). Materials and methods The PCMS was identified on PMCT in 20 decedents (11 male, nine female; age 3–83 years, mean age 35.3 years) following fatal blunt trauma at a single forensic centre. Osseous and ligamentous craniocervical region injuries and brain stem or spinal cord trauma detectable on PMCT were recorded. PMCT findings were compared to conventional autopsy in all cases. Results PMCT-detected transection of the brain stem or high cervical cord in nine of 10 cases compared to autopsy (90% sensitivity). PMCT was 92.86% sensitive in detection of atlanto-occipital joint injuries ( n= 14), and 100% sensitive for atlanto-axial joint ( n= 8) injuries. PMCT detected more cervical spine and skull base fractures ( n= 22, and n= 10, respectively) compared to autopsy ( n= 13, and n= 5, respectively). Conclusion The PCMS is a novel description of a diagnostic finding, which if present in fatal craniocervical region trauma, is very sensitive for underlying spinal cord and brain stem injuries not ordinarily visible on PMCT. Its presence may also predict major osseous and/or ligamentous injuries in this region when anatomical displacement is not evident on PMCT.

Resume Objectif Evoquer l’atteinte rachidienne des arthropathies neurogenes. Observation Nous rapportons l’observation d’un blesse medullaire, paraplegique T9, qui developpe une arthropathie destructrice de la charniere lombosacree. Discussion Les osteoarthropathies neurogenes peuvent emailler l’evolution de certaines maladies neurologiques chroniques. Elles affectent autant les membres que le rachis ou elles sont responsables d’une destruction discovertebrale majeure. Chez le blesse medullaire, il faut les evoquer devant l’apparition de troubles statiques du rachis ou une modification de l’examen neurologique. Leur traitement necessite une osteosynthese rachidienne pour lever les compressions neurologiques et retablir la stabilite rachidienne.

Resume Objectif Rappeler la physiopathologie et les consequences d’un traumatisme vertebromedullaire en particulier a distance de la phase aigue. Detailler la prise en charge perioperatoire de ces patients ainsi que les differentes techniques anesthesiques realisables. Source de donnees Articles references dans la base de donnees Medline, texte des conferences des principaux congres d’anesthesie et de reanimation francais, articles de l’encyclopedie medicochirurgicale, analyse des bibliographies. Synthese des donnees Au total, 40 000 personnes en France ont ete victimes d’un traumatisme vertebromedullaire responsable d’un handicap important, ainsi que de complications frequentes surtout urologiques et orthopediques. Ces patients necessitent des recours frequents a la chirurgie pour corriger ces lesions, mais aussi pour des pathologies intercurrentes. L’anesthesiste y sera donc regulierement confronte. En dehors du deficit sensitivomoteur auquel elle conduit, l’interruption de la conduction medullaire debouche sur un desequilibre entre le systeme sympathique et le systeme parasympathique responsable de phenomenes dysautonomiques parfois severes. La realisation d’une anesthesie pour tout geste invasif, meme sur un territoire repute « insensible », est donc une necessite afin de prevenir ces accidents pouvant mettre en jeu le pronostic vital. Toutes les techniques anesthesiques sont efficaces et utilisables, sous reserve d’une mise œuvre progressive et prudente chez ces patients aux capacites d’adaptation cardiovasculaires et respiratoires limitees. L’utilisation de succinylcholine peut entrainer une hyperkaliemie de denervation jusqu’a dix ans apres la lesion initiale avec un pic de frequence a six mois. Conclusion Malgre le trouble sensitif resultant d’une lesion medullaire, la realisation de tout geste invasif en particulier chirurgical implique une anesthesie.

Resume Objectif Etudier le retentissement d’une pratique physique et sportive reguliere sur l’autonomie et la qualite de vie du paraplegique tunisien. Materiels et methodes L’etude porte sur 25 paraplegiques divises en deux groupes : dix paraplegiques sportifs et 15 paraplegiques sedentaires chez lesquels on a procede a une evaluation du degre d’autonomie par l’echelle de mesure de l’independance fonctionnelle et la qualite de vie par le questionnaire de qualite de vie SF36 dans sa version traduite en arabe. Resultats L’analyse des resultats montre une difference significative du score global de la mesure de l’independance fonctionnelle entre les deux groupes, les paraplegiques sportifs ayant developpe une meilleure autonomie aux activites de la vie quotidienne affichant un score total moyen de 115,10 contre 93,87 ( p p p p Conclusion Cette etude nous a permis de montrer que l’activite physique et sportive reguliere avait un effet positif aussi bien sur l’optimisation des capacites fonctionnelles du paraplegique que sur l’amelioration de sa qualite de vie, favorisant ainsi une meilleure reinsertion socioprofessionnelle.

Resume Objectif Rapporter la prevalence, les etiologies et l’evolution des cancers de la vessie dans notre population de patients neurologiques. Materiels et methodes Les dossiers des 1825 patients neurologiques suivis dans notre service entre 2000 et 2006 ont ete revus retrospectivement. En cas de tumeur vesicale, les donnees suivantes ont ete relevees : âge, sexe, tabagisme, etiologie de la maladie neurologique, mode de vidange vesical, duree d’evolution de la vessie neurologique, mode de decouverte, type histologique, grade, stade TNM, traitement entrepris et evolution. Resultats Huit patients (0,44%) neurologiques ont eu un cancer de la vessie. L’âge moyen a ete de 58,8 ± 13,7 ans (36-72). Le rapport homme/femme a ete de 3. Les vessies neurologiques concernaient : des blessures medullaires (n=4), une sclerose en plaque (n=l), un spina bifida (n=l), une paraplegie spastique familiale (n=l) et un syndrome peripherique idiopathique (n=l). Trois cas de cancers epidermoides (37,5%) ont ete diagnostiques. Sept tumeurs etaient de haut grade et 7 etaient invasives ( pT2). Le recul moyen a ete de 27,8 ± 23,5 mois (14-71). Trois patients etaient decedes. Conclusion Les cancers de la vessie chez les patients neurologiques avaient une incidence proche de celle de la population generale. En revanche, il y avait davantage de carcinomes epidermoides invasifs d’emblee, necessitant des traitements agressifs. Pour autant, seul le GENULF a publie a ce jour un protocole de surveillance adapte a cette population base sur une cystoscopie/cytologie annuelle au-dela de 15 ans d’evolution.

Resume L’incontinence anale et les troubles digestifs representent une des causes majeures d’alteration de la qualite de vie des patients ayant une pathologie neurologique. De plus, les patients ont tres souvent honte d’en parler et evoquent rarement spontanement leur probleme. Enfin, les problemes de constipation chronique amenent a une maceration microbienne qui est un facteur de risque reconnu d’infection de l’arbre urinaire. Dans cet article, nous reprenons les elements principaux de la physiologie permettant une exoneration normale, puis nous en decrivons les principales atteintes dans les differentes pathologies neurologiques. Enfin, nous decrivons leur prise en charge.

Scelza WM, Kirshblum SC, Wuermser LA, Ho CH, Priebe MM, Chiodo AE. Spinal cord injury medicine. 4. Community reintegration after spinal cord injury. This self-directed learning module highlights community reintegration after spinal cord injury (SCI). It is part of the study guide on spinal cord injury medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on physical, social, psychologic, and environmental barriers that affect people with SCI and on how these issues affect relations with others. Recreational and exercise options are also discussed. Overall Article Objective To summarize the barriers and opportunities of community reintegration for people with spinal cord injury.

Resume Objectif Dans le but d’une prise en charge optimale des patients victimes d’un traumatisme medullaire sans lesions osseuses compressives ou de dislocation du rachis cervical, les auteurs decrivent leur experience de l’IRM cervicale dynamique pour rechercher une instabilite rachidienne. Materiel et methode Depuis janvier 2000, 95 patients victimes de traumatismes medullaires cervicaux ont ete suivis dans le service. Ils ont tous beneficie d’une IRM dans leur bilan lesionnel. L’IRM dynamique etait realisee quand un doute d’instabilite rachidienne existait et que la realisation de cliches dynamiques standard de bonne qualite etait impossible (coma, deficit severe, etude la charniere cervico-thoracique). Resultats L’IRM dynamique a permis de diagnostiquer une lesion instable du rachis cervical chez 6 patients dont la moyenne d’âge etait de 65 ans (extremes : 45-75 ans) ; le mecanisme de l’instabilite etait une extension chez 4 patients, une entorse grave entrainant une hernie discale cervicale chez 1 patient, et une instabilite aussi bien en flexion qu’en extension dans un cas. Le diagnostic etabli des le debut de la prise en charge permettait une stabilisation chirurgicale precoce, facilitant le nursing et la reeducation des patients, puis le transfert en centre. Conclusion La pratique d’une IRM dynamique chez certains patients victimes de traumatisme medullaire cervical, sans elements compressifs apparents sur le bilan fait en position neutre (IRM, TDM), nous parait etre un examen pertinent pour la recherche d’instabilite rachidienne responsable de la blessure medullaire.

Resume Objectifs Identifier les facteurs qui concourent au developpement de la fatigue apres lesion de la moelle epiniere et a ses consequences fonctionnelles. Methodes Une revue systematique de la litterature a ete effectuee sur Medline et Reedoc selon les mots cles suivants : spinal cord injury , fatigue , intrinsic muscular fatigue , chronic fatigue , ageing, training , electrostimulation , quality of life et leurs equivalents francais. Resultats Apres blessure de la moelle epiniere, il existe deux types de fatigue : une fatigue intrinseque des muscles paralyses au niveau et au-dessous de la lesion ; cette fatigue peripherique est la consequence de la denervation totale ou partielle; elle s'accompagne de modifications histologiques et biochimiques du muscle ; elle est bien evaluee par les techniques d'electrophysiologie neuromusculaire ; son evolution semble peu influencee par la spasticite et les automatismes moteurs ; elle est partiellement reversible par l'application d'une electrostimulation au long cours. Les neuroprotheses, en l'etat actuel, ne permettent pas de compenser les consequences de cette fatigue intrinseque et limiter le cout energetique excessif pour faciliter la station debout ou la locomotion ; une fatigue chronique s'inscrit dans l'evolution a long terme du blesse medullaire ; elle est liee au deconditionnement physique et aux perturbations physiologiques, psychologiques et sociales observees au cours du vieillissement ; un certain nombre d'arguments permet de rapprocher cette fatigue chronique du syndrome postpoliomyelitique et du syndrome de fatigue chronique, evoquant sa nature centrale ; les programmes de reconditionnement physique peuvent en retarder l'apparition et en limiter les consequences. Conclusion La fatigue apres blessure de la moelle epiniere a une expression a la fois peripherique (muscles partiellement ou totalement paralyses) et centrale en lien avec le vieillissement. Cette double expression necessite une anticipation par application de programmes d'electrostimulation des muscles atteints et les programmes visant a lutter contre le deconditionnement physique et psychosocial.

Resume Objectifs. – Evaluer la douleur et son retentissement fonctionnel chez les blesses medullaires. Methodes. – Les patients blesses medullaires, souffrant de douleurs chroniques, ont ete interroges, par voie postale, au moyen de deux types de questionnaires : le « Multidimensional Pain Inventory » dans sa version du blesse medullaire, qui inclut une echelle visuelle numerique et le questionnaire de qualite de vie SF-36. Resultats. – Sur 28 patients inclus dans cette etude (neuf femmes, 19 hommes), 22 reponses ont ete obtenues. La localisation de la douleur, par frequence decroissante, est : membres inferieurs, membres superieurs et tronc. Au plan semiologique, la douleur est le plus souvent de type neuropathique. L'intensite de la douleur est estimee en moyenne a 7,2 ± 2,16. Elle altere notablement le sommeil chez 11 patients. Chez 17 patients, la douleur est cause de limitation des activites de la vie quotidienne (deux patients, alors hospitalises, n'ont pas repondu). Parmi les patients qui ont une activite professionnelle (6/22), cinq sont genes par leur douleur. Les scores globaux du SF-36, qui refletent l'etat de la sante physique et mentale, sont nettement inferieurs aux moyennes de la population generale. Discussion–conclusion. – Bien que cette etude n'ait porte que sur un petit echantillon et que la version francaise du « Multidimensional Pain Inventory » ne soit pas validee, ces resultats preliminaires montrent que la douleur altere de facon importante l'autonomie et la qualite de vie des patients blesses medullaires.

Although intramedullary spinal cord cavernous malformations are now well described, there have been, to our knowledge, no prior reports focusing on presentation after trauma. We report a patient with a thoracic intramedullary cavernous malformation presenting with hematomyelia and acute neurologic deterioration after spinal chiropractic manipulation. A review of previously published case reports then identifies additional cases of deterioration after spinal cord trauma or exertion. Traumatic injury and exertion may be uncommon but real causes of hematomyelia in intramedullary cavernous malformations of the spinal cord. The frequency of such presentations is estimated to be 1.37% to 4.79%.

Objectifs Decrire les aspects en IRM des lesions medullaires post traumatiques initiales et les correler a l’evolution clinique et en imagerie. Materiels et methodes Etude retrospective de 5 cas de traumatismes medullaires survenant chez des sujets jeunes (7 a 30 ans) colliges de 2001 a 2003 et explores par imagerie par resonance magnetique (IRM) au stade precoce avec un controle IRM a distance. Resultats Dans 4 cas, il s’agissait d’accident de la voie publique et dans 1 cas d’une chute. Le deficit moteur est constant avec 3 cas de paraplegie, un cas de monoplegie et un cas de tetraparesie. L’atteinte etait cervicale dans 1 cas, dorsale haute dans 2 cas et dorsale basses dans les autres cas. L’IRM initiale montrait 3 contusions hemorragiques et 2 contusions œdemateuses. L’evolution clinique etait marquee par l’absence de recuperation motrice avec des complications dues a l’alitement dans 1 cas, la persistance de sequelles neurologiques dans 2 cas avec recuperation totale dans deux cas. L’IRM de controle montrait l’apparition d’une zone de cavitation kystique (1 cas), restitution « ad integrum » (2 cas), atrophie segmentaire avec gliose sequellaire (2 cas). Conclusion Dix a 15 % des traumatismes du rachis s’accompagnent de lesions medullaires. Les traumatismes de la moelle touchent essentiellement les adultes jeunes. Les accidents de la voie publique sont a l’origine de la majorite de ces traumatismes. L’imagerie joue un role incontournable dans leur prise en charge (PEC). L’avenement de l’IRM a bouleverse la PEC des lesions traumatiques de la moelle, puisqu’elle constitue le seul examen qui permet une visualisation directe des lesions medullaires.

Resume Deux cas de syndrome de Brown-Sequard consecutifs a une plaie medullaire cervicale par arme blanche sont rapportes. La section medullaire etait a chaque fois confirmee par une imagerie par resonance magnetique (IRM) et par l’exploration chirurgicale. Dans le premier cas, une suture de pie-mere a ete realisee dans le but de rapprocher les berges de la plaie, esperant par ce geste diminuer les risques de syringomyelie post-traumatique. La recuperation neurologique etait satisfaisante dans les deux cas, avec un suivi respectif de 10 et 2 ans, puisque les patients etaient capables de marcher et qu’un des deux avait repris son travail. L’interet de l’exploration chirurgicale, d’une suture de pie-mere ainsi que les mecanismes de la recuperation neurologique sont discutes.

Resume L'adolescence est une periode de recherche d'identite sexuee. Comment se construire sur ce plan lorsqu'on est un jeune para ou tetraplegique ? Comment les soignants peuvent-ils l'aider a resoudre ce questionnement et a quel stade de l'evolution de son handicap ? Nous abordons dans un premier temps la question de l'erection et de la qualite des rapports et dans un deuxieme temps celle de l'autoconservation spermatique. Il s'agit principalement d'une information concrete, donnee suffisamment tot, adaptee a la definition neurologique de la para- ou tetraplegie, et surtout d'une action de conservation preventive de sperme avant que ne surviennent les complications infectieuses et urologiques. Nous faisons part de notre experience aupres de 24 adolescents blesses medullaires lors de nos consultations specialisees au CMPA de Neufmoutiers et au CECOS de l'hopital Cochin de Paris.

The life expectancy of patients with spinal cord injury has increased linearly in the past five decades, but continues to be below that of their non disabled peers. This improvement was achieved through better knowledge of the pathophysiology of the multisystem impairments caused by spinal cord injury. The main treatment goals in spinal cord injury are to prevent complications, to obtain optimal function (depending on the affected neurological level), to facilitate social re-integration, and to provide specialized follow-up throughout life. This comprehensive management must be provided in spinal units, using a multidisciplinary approach.

RESUME La section de la moelle epiniere est une lesion irreversible. Les axones provenant des cellules meres du cerveau, lors de la repousse apres leur section, n’avancent pas vers les motoneurones peripheriques. La raison de cette « non-permissivite » au passage de la cicatrice medullaire n’est pas encore claire. Ce travail decrit les tentatives de l’auteur de franchir cet obstacle cicatriciel medullaire grâce a une recherche sur les rats et sur les singes menee par differents protocoles chirurgicaux. Le dernier en date utilise une greffe de nerf sciatique autologue permettant de connecter la substance blanche laterale de la moelle en amont de la lesion directement aux nerfs peripheriques propres des muscles paralyses. L’operation a aussi ete executee sur des etres humains : volontaires, pleinement informes, atteints d’une section totale de la moelle entre T8 et Tll. Le premier cas clinique, opere par connexion du moignon proximal de la moelle avec les nerfs peripheriques, a obtenu une deambulation rudimentaire, fatiguante, mais efficace. La premiere patiente operee peut marcher avec des cannes tripodes. La connexion fonctionne, bien que les neurones d’origine des fibres motrices proviennent des regions cerebrales differentes. Ces cellules s’activent simultanement et donnent la contraction selective des differents muscles. Les muscles repondent meme si le motoneurone central utilise comme neuro-transmetteur le glutamate (tandis que la plaque motrice normale utilise des recepteurs pour racetyleholine). L’analyse par immunoblot de l’ChAT, VAChT, Vglut-1, GluRl et GluR2 des muscles a montre l’evidence que les recepteurs des plaques motrices passent des Acetilcholinergiques aux Glutamatergiques.

This study aims to evaluate the effects of gamma-hydroxybutyrate (GHB) after spinal cord trauma (SCT). Twenty rabbits were divided equally into four groups: group I was the sham-operated group, group II suffered from SCT but received no treatment, group III was given a dose of 400 mg/kg of GHB intravenously before SCT and group IV received the same dose after SCT. Cerebrospinal fluid (CSF) samples were obtained 30 min before SCT (T(0)), at 60 (T(1)) and 120 min (T(2)) after SCT. There was a threefold increase in lactate levels from baseline value at T(2) in group II, while statistically significant elevation of the lactate levels were not observed in groups III and IV. Glucose levels at T(1) and T(2) were significantly lower in groups III and IV compared with the control group. The findings of this study demonstrate that GHB can control the increase of CSF lactate and glucose levels following SCT and that this metabolic effect may be associated with neuroprotective physiological changes.

Central nervous system (CNS) trauma is a significant cause of morbidity and mortality in the United States. Each year, 500,000 patients with head injuries are seen in emergency departments (EDs), and, of these, more than 50,000 die from their injuries. There are 12,000 cases of severe spinal cord injury each year, with a mortality rate approaching 50%. Many patients who survive suffer permanent disability. Clearly, prevention of CNS injuries is the ideal solution. Anesthesiologists are often involved in the care of patients who present to hospitals, whether it be resuscitation in the ED or management of anesthesia in the operating room. Head-injured patients commonly require surgery for acute decompression of subdural hematomas, epidural hematomas, or intracerebral hemorrhages. Trauma patients with spinal cord injuries present acutely for decompression in the setting of neurologic deterioration, or for reduction and stabilization procedures when conservative measures do not achieve these objectives. In addition, patients with CNS trauma often undergo surgery unrelated to their neurologic injuries. This article provides an overview of the perioperative management of patients with CNS trauma.

We describe a 81-year-old man who after falling face forward and hyperextending his neck suffer an acute cervical spinal cord injury consistent with acute traumatic central cord syndrome (ATCCS) who developed a peculiar posture with arm abduction at the shoulders and flexion at the elbows and wrists resembling the pose of a bodybuilder.

Resume La prise en charge des patients blesses medullaires suppose la connaissance de quelques specificites non urologiques qui exposent ces patients a des complications particulieres : les escarres, le developpement d’une spasticite ou la survenue d’une hyperreflexie autonome. Le risque d’escarre est eleve chez les patients blesses medullaires puisqu’on estime que la presque totalite des patients en developpera au moins une dans sa vie. Lors d’un sejour a l’hopital, l’equipe soignante dans son ensemble doit etre particulierement attentive a prevenir ces problemes qui, une fois installes, peuvent evoluer sur plusieurs mois voire annees avant de cicatriser. L’hyperreflexie viscerale et la spasticite peuvent avoir comme origine une cause urologique. Ces deux pathologies peuvent entrainer un inconfort important pour les patients, et doivent etre consideres chez eux comme des equivalents a la douleur qu’ils ne peuvent parfois plus ressentir du fait de troubles de la sensibilite. Sans rentrer dans le detail de chacune des trois pathologies qui vont etre decrites dans la suite de cet article, il est capital, si l’on veut prendre en charge des patients blesses medullaires, de connaitre ces trois risques particuliers que sont les escarres, la spasticite et l’hypereflexie autonome (HRA).

Fifteen patients who sustained spinal cord trauma were evaluated by MR within 72 hours of injury. Nine patients had hemorrhagic and six had nonhemorrhagic traumatic spinal cord lesions. Three patients with hemorrhagic and all six patients with nonhemorrhagic lesions showed some degree of neurological improvement on follow-up examinations. In two of the three patients with hemorrhagic lesions who improved, the hemorrhage was extensive. This supports the observation that hemorrhagic lesions are not always associated with a poor clinical outcome.

Although there have been important advances in our understanding of the underlying pathogenesis of many brain and spinal cord disorders over the last few decades, most remain largely incurable, and thus the ambition to attempt neuronal rescue and brain repair is a pertinent one and remains a major aim of modern neuroscience. Indeed, the development of reparative strategies is a focus for many research groups internationally, some of which interact as part of the “European Network for CNS Transplantation and Repair (NECTAR)”. NECTAR was founded in 1990 with the aim of developing reliable, safe, and ethically acceptable transplantation therapies for neurodegenerative diseases. At this time, the major diseases of interest were Parkinson's disease (PD) and Huntington's disease (HD), although the organisation is not intended to be disease-specific and there are member groups with interests in other conditions such as spinal cord trauma and multiple sclerosis. NECTAR has fostered interaction between scientists and clinicians in the field of neuronal repair and restoration and has been the background for numerous initiatives to facilitate and guide such research, including the generation of tools for the clinical assessment of surgical interventions in PD and HD [10] and [16], and the generation of ethical guidelines [1]. One forum that NECTAR uses for discussion and exchange of ideas is its annual scientific meeting, which has been, in recent years, held in early December. In this current issue of BRB, papers are presented from the 14th and 15th scientific meetings held in Amsterdam and Brussels, respectively.

Research findings and clinical experience obtained over the past 20 years have clearly established the principles of brain resuscitation in the management of closed head injuries. It is proposed that with regard to resulting morbidity, the same pathophysiological and mechanistic phenomena occur in acute spinal cord trauma. Specifically, it is secondary cord injury caused by hypoxia, edema, and aberrations in cell membrane potential that are largely responsible for resulting neurological deficits. The concept of spinal cord resuscitation is proposed as an attempt to reverse secondary changes that occur to obtain maximal neurological recovery. Such measures would include (1) prompt relief of cord deformation, (2) administration of intravenous corticosteroids, and (3) initiation of measures to facilitate spinal cord perfusion.

This article reviews the pathophysiology of spinal cord injury. The focus is on the role of post-traumatic membrane lipid changes, including lipid hydrolysis with enzymatic lipid peroxidation (ie, eicosanoid production) and nonenzymatic, free radical-induced lipid peroxidation in the secondary autodestruction of injured spinal cord tissue. A speculative etiopathogenesis of secondary injury is presented in an attempt to explain the importance and order of the pathophysiologic events that result in tissue death and the apparent effectiveness of diverse pharmacologic agents in the treatment of experimental spinal cord injury.

The neuropathology of the spinal cord is described and illustrated from the viewpoint of a neuropathologist observing at necropsy the many traumas and pathologic diseases affecting the spinal cord. The article provides the clinician with an insight into the disease processes and anatomic derangements underlying the neurologic deficits in paraplegia and quadriplegia. Today, the clinical examination of patients with spinal cord trauma or spinal cord disease is greatly assisted by many anciliary investigations, notably, radiology and the newer imaging techniques now applied to successfully to the spinal cord. Comparison of the patient's neuropathology with the classical neurophathology of the spinal cord, provided in this article, remains important for the clinician.

Spinal cord injuries disproportionately affect young males in their peak wage-earning years, with catastrophic personal and economic consequences. New pharmacological and surgical interventions have evolved from extensive research on the pathophysiology and biomechanics of SCI. Management of SCI must be individualized and will depend on the level and severity of the injury and the patient's medical condition. Rehabilitation is integral to the treatment of SCI to help patients achieve their highest possible level of function. Prevention of spinal cord injuries, however, is the optimal strategy, and neurosurgeons should actively participate in prevention programs.

RESUME La revue tres systematisee de 417 observations en provenance de trente huit centres differents et concernant 317 hommes et 100 femmes a ete realisee selon un protocole d’etude precis en vingt et un points, concernant non seulement les niveaux lesionnels et en particulier le score ASIA initial et au recul, mais aussi les divers elements de la phase pre hospitaliere (circonstances de l’accident, transports, duree) et de la phase hospitaliere avec les divers examens complementaires, les diverses donnees de l’acte chirurgical et son resultat un an apres le traumatisme (juge trop precoce par l’auteur).Pour les deux annees d’inclusion dans ce protocole precis, 1738 dossiers ont ete consultes, mais seulement 417 dossiers ont ete retenus, ce qui represente 25 % du nombre de cas estime sur les deux annees en France. Les resultats demontrent clairement, mises a part les donnees epidemiologiques connues, que des gestes simples tels que l’immobilisation immediate du blesse et le recours aux amines pressives pour le maintien d’une pression arterielle moyenne (PAM)suffisante en limitant le remplissage vasculaire deviennent la regle appliquee par tous. Elle souligne le fait que les hospitalisations intermediaires retardent la prise en charge chirurgicale. Elle montre enfin que toutes les lesions sont susceptibles d’amelioration. La decompression chirurgicale precoce est un facteur favorisant cette recuperation : seuls les patients porteurs de lesions cervicales incompletes qui n’ont pas ete operes n’ont presente aucune amelioration du score ASIA moteur.

On 13 August 1989 a fully laden commercially operated balloon carrying 12 passengers and a pilot was involved in a midair collision with another balloon, just north of Alice Springs. The collision resulted in the balloon sustaining a major tear of the envelope. Rapid deflation of the envelope led to an approximately 600 metre fall to the desert floor, with the basket partially disintegrating on impact. With one exception, the occupants were found still within the basket at the accident site. Full autopsies were performed on all occupants. The autopsies revealed a marked similarity in the injury patterns. Facial soft tissue and skeletal trauma was severe, associated with anterior third skull base fracture. A high incidence of perineal lacerations and pelvic burst fractures were present with relatively few spinal fractures. An unusual form of brain stem and spinal cord trauma was identified. The injuries sustained to feet, ankles, and legs were of the pattern associated with vertical decelerative force. The injury pattern is described and interpreted with reference to the basket of the balloon and the form of impact.

Previous studies by others indicated that PGs were present in brain, spinal cord, and c.s.f. of several mammalian species. In the present study we compared levels of PGE and PGF by R.I.A. in spinal cord tissue from traumatized cats and cats pretreated with indomethacin prior to trauma to those of baseline and sham operated controls in order to assess for the first time, to our knowledge, whether meaningful changes in levels of PGE and PGF could be detected which might shed new light on the etiology of spinal cord trauma. Levels of PGF (nanograms/gram wet wt) in the cord segment immediately adjacent to the point of trauma were 8.05 ± 1.50, and 13.13 ± 1.38 for baseline and sham operated cats respectively. Spinal trauma led to more than a 100% increase in PGF levels to 29.26 ± 3.58. Although pretreatment with indomethacin 30 min prior to trauma gave the expected blockade of the PGF response to trauma, a measurable level of PGF (2.55 ± 0.17) was found in the cord after indomethacin. Cord levels of PGF declined after 3 hr in both sham operated and traumatized animals. PGF was maximally stimulated by trauma during the first 3 hr with little effect at 72 hr. Although carefully examined, PGE levels in cat spinal cord appeared to be virtually unaffected by trauma. These findings clearly demonstrate for the first time that traumatic injury to the spinal cord is accompanied by marked increases in PG levels at the site of trauma, and that the observed elevation in PGF in response to trauma can be blocked by indomethacin in vivo . Whether PGF changes are causally related to the etiology of spinal cord trauma, or merely represent a manifestation of PG release as a result of non-specific tissue injury, remains to be seen.

Three hundred twenty-one patients with traumatic head and spinal cord injuries were studied. Forty-two of these patients (13.1%) received psychiatric consultation services. Two types of consultation patients were identified—one receiving psychiatric consultation services in the acute-care hospital and one receiving psychiatric services in the post-acute care, long-term rehabilitation center. In order to assess the impact of psychiatric co-morbidities on hospital length of stay and changes, 40 consultation patients (23 acute and 17 rehabilitation) were matched to 87 control patients who received no psychiatric services. Matching was done on severity of injury, age, and sex. Psychiatric consultation cases had significantly longer stays than did matched controls. There were no differences on total charges.

The clinical features of combined injuries of the brachial plexus and spinal cord in 31 patients are described. Diagnosis of the brachial plexus lesion was delayed in 17 instances, and the reasons for this are discussed. Early diagnosis is important so that definitive treatment and long-term plans can be instituted without delay. This dual lesion constitutes a very severe disability; as a direct result of their brachial plexus paralysis, 9 paraplegics did not achieve their predicted level of independence. Possible mechanisms of injury are suggested. Motorcycle accidents are particularly likely to cause these injuries, and a plea is made for further legislation to reduce the risks of injuries to young motorcyclists.

Summary The results of this study indicate that naloxone diminishes ironinitiated and catalyzed peroxidation in liposomes in a concentration-dependent manner. This supports the hypothesis that the action of naloxone in vivo during amelioration of spinal cord trauma and hemorrhagic shock may substantially involve its lipid antioxidant properties.

The spinal cords of 16 normal dogs were exposed via dorsal laminectomies and damaged with a known impact force. In eight dogs the injured portions of the spinal cords were irrigated, without durotomy, for 2 h with normothermic saline. The remaining eight dogs were used as controls and were not irrigated. The results showed that normothermic irrigation of damaged spinal cords, immediately after impact trauma, had a significant beneficial effect on the functional recovery of the spinal cords.

Short-latency somatosensory-evoked potentials after peroneal nerve stimulation were recorded in 25 patients with long-standing incomplete spinal cord injuries. The results were correlated with the patient's ability to walk. Nine patients had normal latencies, and four of these patients had no useful function in their lower limbs. Sixteen patients had prolonged latencies, and eight of these had useful ambulation. It is concluded that the scalp-recorded somatosensory-evoked potentials from peroneal nerve stimulation does not reliably predict function after spinal cord trauma.

The successful use of external transthoracic pacing is described in a case of spinal cord trauma with profound bradycardia. This modality achieved blood pressures equal to transvenous pacing. In patients in whom venous access is difficult or represents a risk of infection, transthoracic pacing may offer a worthwhile alternative.