Post operative epidural haematomas following spinal surgery : P58

Introduction: Compressive epidural haematomas occurring following spine surgery are very rare but can potentially lead to irreversible damage. The evacuation of the haematoma as an emergency procedure remains the only effective treatment providing though alerting signs are detected on time. Few studies exist on this subject probably due to its rarity. The etiological factors as well as the place of imaging studies prior to urgent haematoma evacuation remain controversial. Two cases of delayed post-operative compressive epidural haematomas following lumbar-spine surgery were detected in our unit between April 2003 and January 2009. In both cases new onset of pain, aggravation of existing neurological deficit or development of new deficit along with worsening of pre-existing walking difficulties were noted. Emergency computer tomography (CT) could not exclude compression in both cases due to important artefacts. Emergency surgery was performed confirming the presence of haematoma in both cases and leading to a complete neurological recovery following its evacuation. As only risk factors common to both cases we identified drain removal and resuming of thromboprophylaxis. Conclusion: Obstacles in early detection of post-operative compressive epidural haematomas occurring following spine surgery are patients presenting with multiple complaints as well as shift work pattern of staff who might not always be trained in detecting early changes in neurological status. We therefore established a checklist for post-operative neurological observations to be carried out on spine surgery patients during the postoperative period. We describe our adopted attitude considering the etiological factors observed in our unit. Further studies including in a multi centre setting would be necessary in order to ascertain our observations.

Le soignant face au patient lombalgique chronique: l'expérience clinique de l'Unité Rachis à l'Hôpital orthopédique [The health professional's approach to chronic lumbago: clinical experience at the Spinal Cord Unit at the orthopedic hospital]

The treatment of back pain patients refers to the biopsychosocial model of care. This model includes illness in patient's personal and relational life. In this context, it is not only the physical symptom of the patient which is focused but also his psychological distress often hidden by algic complain. Clinical interviews conducted with back pain patients have highlighted psychosocial aspects able to influence the relationship between health care user and provider. Taking account of psychosocial aspects implies an interdisciplinary approach that identify and assesses patients' needs through adequate tools. As a result, the different health care providers implied with back pain patients have to collaborate in a structured network.

Indigenous people's mobilization and their struggle for rights in Colombia

This text aims at showing the history of indigenous peoples’ mobilization in Colombia, the effects that it has brought about on Colombian democracy and political system, and the state’s reactions to their claims and actions. It will show how they have moved from class-based claims to a politics where identity claims have been central in their agenda and part of their strategies to negotiate with the state. It will also show the existing constitutional and legal framework that recognizes the rights of indigenous peoples, despite the context of persecution, murder, and forced displacement.

Rehabilitation needs assessment in persons with spinal cord injury following the 2010 earthquake in Haiti: a pilot study using an ICF-based tool.

OBJECTIVE: The aim of this pilot study was to describe problems in functioning and associated rehabilitation needs in persons with spinal cord injury after the 2010 earthquake in Haiti by applying a newly developed tool based on the International Classification of Functioning, Disability and Health (ICF). DESIGN: Pilot study. SUBJECTS: Eighteen persons with spinal cord injury (11 women, 7 men) participated in the needs assessment. Eleven patients had complete lesions (American Spinal Injury Association Impairment Scale; AIS A), one patient had tetraplegia. METHODS: Data collection included information from the International Spinal Cord Injury Core Data Set and a newly developed needs assessment tool based on ICF Core Sets. This tool assesses the level of functioning, the corresponding rehabilitation need, and required health professional. Data were summarized using descriptive statistics. RESULTS: In body functions and body structures, patients showed typical problems following spinal cord injury. Nearly all patients showed limitations and restrictions in their activities and participation related to mobility, self-care and aspects of social integration. Several environmental factors presented barriers to these limitations and restrictions. However, the availability of products and social support were identified as facilitators. Rehabilitation needs were identified in nearly all aspects of functioning. To address these needs, a multidisciplinary approach would be needed. CONCLUSION: This ICF-based needs assessment provided useful information for rehabilitation planning in the context of natural disaster. Future studies are required to test and, if necessary, adapt the assessment.

Neues aus Diagnostik und Therapie der spinalen Erkrankungen [Novel aspects of diagnostics and therapy of spinal cord diseases].

BACKGROUND: Both non-traumatic and traumatic spinal cord injuries have in common that a relatively minor structural lesion can cause profound sensorimotor and autonomous dysfunction. Besides treating the cause of the spinal cord injury the main goal is to restore lost function as far as possible. AIM: This article provides an overview of current innovative diagnostic (imaging) and therapeutic approaches (neurorehabilitation and neuroregeneration) aiming for recovery of function after non-traumatic and traumatic spinal cord injuries. MATERIAL AND METHODS: An analysis of the current scientific literature regarding imaging, rehabilitation and rehabilitation strategies in spinal cord disease was carried out. RESULTS: Novel magnetic resonance imaging (MRI) based techniques (e.g. diffusion-weighted MRI and functional MRI) allow visualization of structural reorganization and specific neural activity in the spinal cord. Robotics-driven rehabilitative measures provide training of sensorimotor function in a targeted fashion, which can even be continued in the homecare setting. From a preclinical point of view, defined stem cell transplantation approaches allow for the first time robust structural repair of the injured spinal cord. CONCLUSION: Besides well-established neurological and functional scores, MRI techniques offer the unique opportunity to provide robust and reliable "biomarkers" for restorative therapeutic interventions. Function-oriented robotics-based rehabilitative interventions alone or in combination with stem cell based therapies represent promising approaches to achieve substantial functional recovery, which go beyond current rehabilitative treatment efforts.

Notch1 control of oligodendrocyte differentiation in the spinal cord.

We have selectively inhibited Notch1 signaling in oligodendrocyte precursors (OPCs) using the Cre/loxP system in transgenic mice to investigate the role of Notch1 in oligodendrocyte (OL) development and differentiation. Early development of OPCs appeared normal in the spinal cord. However, at embryonic day 17.5, premature OL differentiation was observed and ectopic immature OLs were present in the gray matter. At birth, OL apoptosis was strongly increased in Notch1 mutant animals. Premature OL differentiation was also observed in the cerebrum, indicating that Notch1 is required for the correct spatial and temporal regulation of OL differentiation in various regions of the central nervous system. These findings establish a widespread function of Notch1 in the late steps of mammalian OPC development in vivo.

Late outcome of spinal cord stimulation for unreconstructable and limb-threatening lower limb ischemia.

OBJECTIVES: To determine whether the initial benefits of spinal cord stimulation (SCS) treatment for critical limb ischemia (CLI) persist over years. DESIGN: Analysis of data prospectively collected for every CLI patient receiving permanent SCS. Follow-up range 12 to 98 months (mean 46+/-23, median 50 months). POPULATION: 87 patients (28% stage III, 72%stage IV) with unreconstructable CLI due (83%) or not (17%) to atherosclerosis and with an initial sitting/supine transcutaneous pO2 gradient >15 mmHg. METHODS: Assessment of actuarial patient survival (PS), limb salvage (LS) and amputation-free patient survival (AFPS). Analysis of the impact of 15 risk factors on long-term outcomes using the Fischer's exact test for categorical variables and the t test for continuous variables. RESULTS: Follow-up was complete for patient and limb survival. A single non-atherosclerotic patient died during follow-up. Among atherosclerotic patients PS decreased from 88% at 1y, to 76% at 3y, 64% at 5y and 57% at 7y. LS reached 84% at 1y, 78% at 2y, 75% at 3y and remained stable thereafter. Diabetes was found to affect LS (p<0.05) and heart disease to reduce PS (p<0.01). AFPS was reduced in heart patients (p<0.01), diabetics (p<0.05) and in patients with previous stroke (p<0.05). CONCLUSIONS: In CLI patients the beneficial effects of SCS persist far beyond the first year of treatment and major amputation becomes infrequent after the second year.

Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial.

BACKGROUND: Recent clinical recommendations still propose active exercises (AE) for CNSLBP. However, acceptance of exercises by patients may be limited by pain-related manifestations. Current evidences suggest that manual therapy (MT) induces an immediate analgesic effect through neurophysiologic mechanisms at peripheral, spinal and cortical levels. The aim of this pilot study was first, to assess whether MT has an immediate analgesic effect, and second, to compare the lasting effect on functional disability of MT plus AE to sham therapy (ST) plus AE. METHODS: Forty-two CNSLBP patients without co-morbidities, randomly distributed into 2 treatment groups, received either spinal manipulation/mobilization (first intervention) plus AE (MT group; n = 22), or detuned ultrasound (first intervention) plus AE (ST group; n = 20). Eight therapeutic sessions were delivered over 4 to 8 weeks. Immediate analgesic effect was obtained by measuring pain intensity (Visual Analogue Scale) before and immediately after the first intervention of each therapeutic session. Pain intensity, disability (Oswestry Disability Index), fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire), erector spinae and abdominal muscles endurance (Sorensen and Shirado tests) were assessed before treatment, after the 8th therapeutic session, and at 3- and 6-month follow-ups. RESULTS: Thirty-seven subjects completed the study. MT intervention induced a better immediate analgesic effect that was independent from the therapeutic session (VAS mean difference between interventions: -0.8; 95% CI: -1.2 to -0.3). Independently from time after treatment, MT + AE induced lower disability (ODI mean group difference: -7.1; 95% CI: -12.8 to -1.5) and a trend to lower pain (VAS mean group difference: -1.2; 95% CI: -2.4 to -0.30). Six months after treatment, Shirado test was better for the ST group (Shirado mean group difference: -61.6; 95% CI: -117.5 to -5.7). Insufficient evidence for group differences was found in remaining outcomes. CONCLUSIONS: This study confirmed the immediate analgesic effect of MT over ST. Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic mechanisms at cortical level should be investigated more thoroughly. TRIAL REGISTRATION: Trial registration number: NCT01496144.

Metastatic spinal cord compression: Full Guideline

Metastatic spinal cord compression: Diagnosis and management of patients at risk of or with metastatic spinal cord compressionThis Guideline is published in recognition that patients with metastatic spinal cord compression (MSCC) sometimes suffer delays and avoidable disability. It considers the available evidence and makes recommendations (to ensure that facilities are available and treatment is co-ordinated) to promote best practice and whenever possible to prevent paralysis from adversely affecting the quality of life for people with metastatic cancer.

Metastatic spinal cord compression: Implementing NICE guidance

Metastatic spinal cord compression: Implementing NICE guidanceThis presentation has been written to help you raise awareness of the NICE clinical guideline on Metastatic spinal cord compression: Diagnosis & management of adults at risk of and with MSCC. This guideline has been written for healthcare professionals and other staff who care for people with metastatic spinal cord compression..

Primary spinal epidural lymphoma: patients' profile, outcome, and prognostic factors: a multicenter Rare Cancer Network study

RESUME Objectif : Les lymphomes épiduraux primaires représentent moins de 10% des tumeurs épidurales et de 0,1 à 3,3% de tous les lymphomes. Le but de cette étude a été d'évaluer le profil clinique de cette maladie rare, son traitement, ses résultats ainsi que ses facteurs de pronostic. Matériel et méthode : Entre 1982 et 2002, 52 patients présentant un lymphome épidural primaire ont été traités dans neuf institutions membres du Rare Cancer Network. Les critères d'inclusion comprenaient : une biopsie confirmant le lymphome non-hodgkinien, un stade IE et IIE selon la classification de Ann Arbor, un traitement à visée curative de radiothérapie combinée ou non à une chimiothérapie et un suivi d'au moins six mois. Selon la Working Formulation, 12 patients (23%) présentaient un lymphome de bas grade, 28 (54%) un grade intermédiaire et 12 (23%) un haut grade. Les hommes étaient atteints 1.9 fois plus fréquemment que les femmes. L'âge moyen était de 61 ans (intervalle : 21 à 96). Le bilan incluait un Ct-scan spinal (98%), une IRM (52%), un CT-scan thoraco-abdominal (77%) et une aspiration ou biopsie de moelle osseuse (96%). Les symptômes les plus fréquents comprenaient des douleurs dorsales (79% des patients), une faiblesse musculaire (92%) et des déficits sensoriels (71 %). Quarante-huit patients ont subi une laminectomie de décompression avec résection partielle ou complète (42% et 13% des cas respectivement), tous ont reçu une radiothérapie seule (20 patients) ou en combinaison avec une chimiothérapie (32 patients). La dose médiane totale était de 36 Gy (intervalle 6-50 Gy) avec une moyenne de 20 Gy par fraction (intervalle : 1-25). Le suivi moyen était de 71 mois (intervalle : 22-165 mois). Résultats : Suite au traitement, une progression locale a été observée chez 6 patients après un temps de latence moyen de 6 mois. Le taux de rechute systémique a été de 42% (22 patients) le plus souvent dans les ganglions lymphatiques (n=9) après un intervalle de temps moyen de 20 mois. Lors du dernier contrôle, 28 patients étaient vivants et 24 patients étaient décédés. Le taux de survie à 5 ans, le taux de survie sans maladie et le contrôle local étaient de 69%, 57% et 88% respectivement. En analyse univariée, les facteurs pronostics favorables statistiquement significatifs concernant la survie sans maladie étaient un âge inférieur à 63 ans, ainsi qu'une réponse neurologique complète. Pour la survie à 5 ans, les facteurs favorables étaient un âge inférieur à 63 ans. En analyse multivariée, les facteurs pronostics favorables pour la survie globale à 5 ans étaient une réponse neurologique complète, un traitement combiné, un volume de radiothérapie plus que focal, une dose totale de radiothérapie supérieure à 36 Gy et une résection partielle ou complète de la tumeur. En ce qui concerne la survie sans maladie, les facteurs pronostics favorables étáient un âge inférieur à 63 ans et un traitement combiné. Conclusion : Ce qui ressort de cette analyse est que le bilan diagnostic devrait inclure une IRM ou un CT-scan, un échantillon de tissu pour poser le diagnostic pathologique définitif de la lésion, une histoire médicale et un examen physique complet, une chimie sanguine, un CTscan thoraco-abdominal et une biopsie de la moelle osseuse, un PET-scan devrait également faire partie du bilan. Le traitement devrait consister, dans la phase aiguë, en une chirurgie de décompression avec ou sans résection, suivie d'une radiothérapie d'au moins 36Gy en 2 Gy par fraction et d'une chimiothérapie. Tous les patients présentant un lymphome de haut grade ou de grade intermédiaire devraient pouvoir bénéficier d'un traitement combiné.

A morphological grading of spinal stenosis: a radiological study on LSS and LBP patients : P173

Introduction: Clinical symptoms and degree of spinal stenosis based on cross sectional dural sac area correlate only weakly in lumbar spinal stenosis (LSS) patients. We conceived a four grade classification system (A, B, C & D) based on the morphology of the dural sac and its contents as seen on T2 axial MRI images. The categories take into account the rootlet/CSF ratio. We applied this grading to three patient groups: LSS scheduled for surgery; LSS following conservative treatment and patients with low back pain (LBP) without leg pain. Materials/Methods: A total of 346 T2 axial MRI images taken from LSS and LBP patients were included in this retroperspective study. 37 patients had decompressive surgery (132 MRI images), 31 conservative treatment (116 MRI images) and 27 patients had unspecific LBP (98 MRI images). Dural sac cross-sectional surface area and morphological grading of the canal were measured digitally both at disc and pedicle level. Intra- and inter-observer reliability were assessed (weighted Cohen's kappa statistics) from 50 MRI images taken from the surgery group. Results: At the most severe disc level, grade A (mild stenosis) was found in 3% of MRI images of the surgical group as opposed to 51% in the conservatively treated group and 85% in the LBP group. Grade B occurred in 8% of the surgical, 20% of the conservative and was negligible in LBP group (below 1%). Grade C and D (severe stenosis) was found in 89% of the surgical group, as opposed to 30% in conservative group and 11% in LBP group. The grades of all groups were comparable at the pedicle levels, exhibiting in 94% a grade A with a maximum at the A1 grade. Pedicle and disc level cross-sectional area were smallest in the surgery group and smaller in the conservative group as compared to the LBP group at the levels L2, L3 and L4. According to cross-sectional area measurements patients from the surgery group seems to have smaller vertebral canal although this was not related to smaller stature. Validation of grading: Average intra-and inter observer kappas were 0.76 and 0.69 respectively, for physicians working in the study originating institution. Combining all observers the kappa values were 0.57 +/- 0.19. and 0.44 +/- 0.19 respectively. Dural sac cross-sectional area measurements showed no statistically significant differences between observers. Conclusion: Since no specific measurement tools are needed the grading suits everyday clinical practice and favours communication of degree of stenosis between practising physicians. In our institution Grade A stenosis was less likely to require surgical treatment. This grading can therefore be an aid in surgical patient selection in teaching units.

Spinal modulations accompany peripheral fatigue during prolonged tennis playing.

To examine the time course of alteration in neural process (spinal loop properties) during prolonged tennis playing, 12 competitive players performed a series of neuromuscular tests every 30 min during a 3-h match protocol. Muscle activation (twitch interpolation) and normalized EMG activity were assessed during maximal voluntary contraction (MVC) of plantar flexors. Spinal reflexes and M-waves were evoked at rest (i.e., H(max) and M(max) , respectively) and during MVC (i.e., H(sup) , V-wave, M(sup) , respectively). MVC torque declined significantly (P<0.001) across the match protocol, due to decrease (P<0.001) in muscle activation and in normalized EMG activity. The impairment in MVC was significantly correlated (r=0.77; P<0.05) with the decline in muscle activation. H(max) /M(max) (P<0.001), H(sup) /M(sup) (P<0.01) and V/M(sup) (P<0.05) ratios were depressed with fatigue and decreased by ∼80%, 46% and 61% at the end of exercise, respectively. Simultaneously, peak twitch torque and M-wave amplitude were significantly (P<0.01) altered with exercise, suggesting peripheral alterations. During prolonged tennis playing, the compromised voluntary strength capacity is linked to a reduced neural input to the working muscles. This central activation deficit partly results from a modulation in spinal loop properties.