II POSTER PRESENTATIONS

Topic 1: Infection and Isolation in SCI

1 Delayed presentation of hydrocephalus as an unusual complication
of cervical spine injury – Report of two cases

G Joseph, MH Fraser, D Philip, MV Jigajini, AN McLean
Queen Elizabeth national spinal injuries unit, Glasgow, United Kingdom

Aim: To report two cases of hydrocephalus presenting as a delayed complication after
a cervical spine injury.

Case report:
Case 1: Sixty year man with ankylosing spondylitis had fracture of C5/C6 with
tetraplegia. After a few weeks on ventilatory support he became drowsy and developed
nystagmus and seizure like activity at the angle of the mouth. CT showed
hydrocephalus, which was treated with an omaya drain. One year down, he is still
tetraplegic and still dependent on ventilatory support.

Case 2: 19 year male had a stab injury to the upper cervical spine at the C1 level with
MRI showing a partial cord injury. After five months on a ventilator, his condition
deteriorated and he developed twitching of eyes. CT showed hydrocephalus treated
with a V-P shunt. 4 years down he is ventilator dependent at night and wheel chair
bound.

Hypothesis: Hydrocephalus may be caused by blood from cervical injury entering the
CSF and leading to a communicating type of hydrocephalus.
Conclusion: Hydrocephalus as a result of cervical spine injury is rare but should be
considered if the condition of the patient with an upper cervical spine injury deteriorates
or if the patient develops seizures without any evidence of head injury.

2 Charcot Spine with Infection signs: a diagnosis challenge

S Salvador, A Montoto, M Piñeiro, I Garcia, ME Ferreiro, A Rodriguez
Spinal Cord Injuries Unit. Hospital Juan Canalejo. A Coruña. Spain

Neuropathic arthropathy was described by Charcot in 1868, in patients with tabes
dorsalis, and afterward in other diseases of nervous system. In 1970’ decade, Charcot
spine was recognized in patients with long lasting spinal cord injuries, and nowadays it
is well known as a spinal cord injury sequelae. Anyway, diagnosis and treatment are
still under controversy, as it is debated in several communications, specially in
reference with septic spondylitis (Pritchard 1993; Mikawa 1989; Knight 1988; Kalen
1987; Goodman 1985).

We expose two cases of patients with long lasting spinal cord injuries, that presented
signs of Charcot spine but a diagnosis problem with infection was established. The first
case was a 32 year-old man, with paraplegia T5 that during the postoperative care of a
ischiatic scar suffered sepsis by Staphylococcus aureus and subsequently a cutaneous
fistula at the inferior thoracic region, with radiological signs of neuropathic spine.

Surgical approach permitted pathological study. The second one was a 57 year-old
man, C6 tetraplegic, with fever and a mass at the posterior thoracic region, which was
demonstrated to be of liquid nature. Imaging studies led to a differential diagnosis with
infectious spondylitis. Surgical approach was carried out, with pathological result
compatible with neuropathic spine, being all microbiological studies negative.
Diagnosis of neuropathic spine in spinal cord injured patients may be difficult, specially
in association with infectious signs, being treatment and outcome insidious.

References: Pritchard JC & Coscia MF. Spine 1993; 18: 764-767. Mikawa Y et al.
Spine 1989; 14: 892-5. Knight D et al. Eur J Nucl Med 1988 ; 13 : 523-6. Kalen V et al.
Spine 1987 ; 12 : 42-7. Goodman MA & Swartz W. J Bone Joint Surg (Am) ; 1985 ; 67 :
642-3.

3 Staphyloccocical bacteraemia and source of infection in spinal
cord injuried patients

S Salvador, M Piñeiro, ME Ferreiro, I García, A Montoto, A Rodríguez.
Spinal Cord Injuries Unit. Hospital Juan Canalejo. A Coruña. SPAIN

Staphyloccocical infections in spinal cord injured patients have become an important
risk of morbility and mortality in hospital units. The objective of this review is to identify
original sites of infection in cases of bacteriemia and its interference on the in-patient
stay.

Material: Retrospective review of the patients that presented Staphyloccocical
bacteriemia (STB) during a period of five years.

Results: 26 patients were identified, that suffered 32 episodes of STB. They were
96.2% men and their spinal cord injury was at thoracolumbar level in 65.4%. The
patients had complete injuries in 50% and 33% had spinal surgical procedure.
Staphyloccoci were oxacillin-resistant (SAMR) in 37.5%, Staphyloccocus aureus
oxacillin-sensible 34.4%, St. epidermidis 18.8% and other Staphyloccocus 9%. The
original site of bacteriemia was not determined in 34.4% of episodes, the rest being
identified as phlebitis 21.9%, spinal surgery wound 18.8% and pressure sores 9.4% as
noticeable. In 7 patients the source of infection was the spinal surgery, and in four of
them extraction of the material of spinal fixation was indicated. Antibiotic treatment was
administered during a mean of 31.1 days. Eight patients (30.7%) were under isolation
measures throughout 87 days on average.

Discussion: In our experience, infection of spinal arthrodesis and colonization on
pressure sores are factors of STB in spinal cord injuries that lead to long-time antibiotic
therapy and isolation measures that increase the length-of-stay, cost of hospitalization
and interfere with the rehabilitation process.

4 A paraparesis due to tuberculosis n a 14 year old boy, a case report
of Pott disaese.

IE Eriks, AM van Furth, PIJM Wuisman, JIML Verbeke, GThJ van Well, E Blankman
Rehabilitation Center Amsterdam

A 14 year old boy was admitted to the Rehabilitation Center Amsterdam (RCA) after
surgery of the lumbar spine.

He presented himself 1 month earlier with low back pain, weight loss and progressive
loss of muscle strength and loss of sensibility. He was no longer able to walk There
were no changes in defecation pattern or bladder function.

Physical examination showed atrophic muscles, weakness of the quadriceps, loss of
sensibility and absent reflexes. MRI showed a tumor at the level L2 with compression
of the dural sac (figure).

Laminectomy L2 and medial facetomie L2-L3 was performed immediately. The tissue
removed showed a positive PCR for Mycobacterium tuberculosis. Patient was treated
with tuberculostatics. Re-operation after 1 month was performed due to neurological
decline.

Patient was admitted to the RCA. During admittance there was no significant change in
neurological picture. MRI showed no decline of the tumor.

After 6 months a second operation was performed. A ventral spondylodesis L1-L4 was
performed with XIA anterior fixation and tumor cage L2-L3.

Post-operative muscle strength improved (MRC 4-5) and sensibility returned to normal.
2 months after discharges he was able to walk 30 minutes with crutches. He still
receives physical therapy and is soon starting school.

5 Trends of Bacteriuria in Spinal Cord-Injured Patients

JH Kim, SY Lee, IS Choi, SG Lee
Department of Physical Medicine and Rehabilitation, Research Institute of
Medical Sciences, Chonnam National University Hwasun Hospital, Gwangju City, Korea

Introduction : Loss of normal bladder function results in increased risk of developing
urinary tract infection (UTI). Recurrent bacteriuria contribute to be a inevitable problem
in most spinal cord-injured patients. The purpose of this study was to know the trends
of bacteriuria in the patients with acute spinal cord injury (SCI) on the tertiary hospital
setting.

Method : We studied 241 records at our hospital retrospectively for 12 years and
reviewed the data, including demographic characteristics, associated factors, methods
of urinary drainage, bladder type, urological complications, causative organism and the
incidence of resistant antibiotics in UTI.

Results : 1) The level of spinal cord injury were cervical, 99 cases (41.1%); upper
thoracic, 29 cases (12.0%); lower thoracic, 79 cases (32.8%); lumbosacral, 34 cases
(14.1%) and the classification according to the AISA were A, 32.7%; B, 9.9%; C,
12.9%; D, 43.2%; E, 1.7%. 2) The incidence of the symptomatic bacteriuria was 22.4%
and it was greater in the complete lesion and the tetraplegics than that of the
incomplete lesion and the paraplegics. 3) The methods of urinary drainage in patients
with symptomatic bacteriuria were as follows; catheterization, 43.8%; clean intermittent
catheterization, 24.6; Valsalva and Crede method, 21.1%; suprapubic cystostomy,
7.0%; other reflex voiding, 1.7%. 4) The most common organism was E. coli (32.3%)
and the incidence of it’s infection showed increasing tendency. On the other hand,
Enterococcus (22.6%) and Enterobacter (5.5%) showed decreasing tendency. 5) The
incidence of resistant antibiotics tends to be increasing except tetracyclin and
gentamycin. 6) The urological complications of UTI were as follows; vesicoureteral
reflux, 37.0%, renal stone, 22.2%, hydronephrosis, 14.8, sepsis, 14.8%, pyelonephritis,
11.1%.

Conclusion : This study may provide the clinical information regarding the trends of
bacteriuria in the patients with acute SCI and would be helpful for the understanding of
the management for the bacteriuria.

6 Successful Revision of Intrathecal Baclofen Pump In a Young
Tetraparetic Man – Infection of The Pump Tube

A. Salaha, E. Anastasiu, H. Kumbulis, A. Bader.
General Hospital of Elefsis “Thriasio”, Athens, Greece.

A 23 years old young man with severe spastic tetraplegia after a road accident at 01-
01-2004 (traumatic brain injury, fracture of A5, fracture of left brachial and femur bone).
He underwent an emergency trachiostomy which remains, surgical fixation of the
fractures, and conservatine treatment of the A5 fracture. The patient stayed at the
intensive care unit for 45 days. There are no information about the ASIA Scale at that
phase. Hypertony has been reported since the first month after the accident, gradually
increasing with no correspondence to the p.os baclofen. So, an intrathecal baclofen
pump had to be used (01-07-2004), with no limitation of the spasticity even under a
dosis of 500 mcg/day. Two months later a revision of the intrathecal tube was made,
but with no results.

The patient referred to our rehabilitation depertment at 23-11-2004 for revision of
the intrathecal tube. The patient had an A6 complete spastic tetraplegia (Asworth grade
4-5, elbows in flexion knees in extension). Spasticity has been reduced with a dosis of
250 mcg baclofen intrathecal per day after the revision of the intrathecal tube at 23-11-
2004 (Asworth grade 1 for the lower extremities, hands flexion 4 –topic intramuscular
injection with botulinum toxin at a second time). The patient during his stay in our
hospital had a low fever of unknown origin, and two positive cultures of CNF fluid taken
from the tube of the baclofen pump for Gram + Staph. MRSA, with no signs of
meningitis. He underwent i.v. antibiotic therapy (vancomycin, teicoplanin) for 4 weeks
with simoultaneous injection of vancomycin into the intrathecal tube (20mg/2nd day, 4
injections). New CNF cultures were negative.

7 Frequency and type of urological complications, analysis of epidemiological
and antibacterial therapy of urinary tract infections at SCI Department of NRC “Vaivari, in 2004

D.Namniece, Z.Kalnberza, A.Nulle
SCI Department of National Rehabilitation Centre “Vaivari”, Latvia

Aims:
Analyse urological complications of SCI patients, including, the frequency of urinary
tract infections, the spectrum of micro organisms and antibacterial sensitivity.
Analyse criteria for selection of the type and medications of antibacterial therapy,
determining the most efficient therapy approach.

Material and methods:
Medical records of 108 patients, who in 2004 received rehabilitation at the SCI
Department of NRC “Vaivari”, were analysed. The study is going on in 2005. In cases
of recurring and problematic urinary tract infections, microbiological analysis of urine
along with determination of antibacterial sensitivity has been performed.

Results:
The method for selection of urination disturbance solution is intermittent
catheterizations, upon renewal of spontaneous mixture – spontaneous mixture and
intermittent catheterizations for excretion of urine remains.

Complications of urological nature are found to most of patients. Complications of most
frequent occurrence are the following: infection of lower urinary tract, generalized
infection of urinary tract, urolithiasis.

Agents of recurring urinary tract infections are the following: Pseudomonas
aeruginosae, Escerihia coli, Proteus mirabilis, etc., which in several cases were multiresistant
to widely used antibiotics. Treatment of light lower urinary tract infections was
performed empirically, by using uro-antiseptics (trimetroprime/sulpfhamethoxazolum,
acidum pipimimidinicum, nitroholinum and nitrofurane class medications), local
instillations of antiseptics, more seldom, antibacterial therapy with fluorchinolons
(ciprofloxacinum) and cephalosporines antibacterial medications.
Phythotherapy and local instillations with nitrofurane liquid once-twice a day also
maintain their place.

Conclusions:
1. In case of urological complications SCI patients with spinal cord
impairment need a differential approach, depending on the treatment
approach.
2. For commencement of treatment it is advisable to use antibiotics with large
antibacterial spectrum of action, towards which no micro organism
resistance has been observed in respect of the contingent treated in this
medical institution.
3. When selecting antibiotics in cases of recurring urinal tract infections, it is
necessary to follow the results of micro organism sensitivity analysis.
4. It is necessary to perform control of nosocomial infection.

8 The management of paralysed patients with multiresistant
pseudomonas aeruginosa

YB Kalke, J Baeuerle, K. Huch
Orthopaedic Department and SCI Centre of the University of Ulm

In a SCI- /SCD- centre paralysed patients with multiresistant pseudomonas aeruginosa
should be treated under the same hygienic conditions as patients with multiresistant
staphyloccoccus aureus (MRSA) -, vancomycin-resistant enterococcus (VREC) - or
extended spectrum ß-lactamase (ESBL) E. coli- or ESBL klebsiella.

According to expert opinions we established a special management in our centre for
patients with pseudomonas only in the bladder and for more problematic patients with
pseudomonas in different skin areas.

Due to the infectious risk individual training conditions have to be developed for the
affected patients. A paraplegic patient from Bulgaria suffered from therapy-resistant
pseudomonas in the groin and had to be isolated. He received ventral fusion of the
spine and developed a Frankel D status. Under quarantine we could offer parallel bars,
walker and crutches training, whereas step climbing was realised on the fire-escape.
The execution of urodynamics appears very problematical in all patients with therapyresistant
pseudomonas.

9 Lower Lumbar Arthropathy – A Cause of Spasticity

A. Anthony
Burwood Hospital, Christchurch, New Zealand

Introduction
Four tetraplegic patients (>20 years post injury), presented with marked spasticity
triggered by postural changes causing loss of sleep and discomfort experienced by
both patients and partners

Material & Method
All four tetraplegic patients were investigated extensively including CT, MRI scan and
bone scan. All four had advanced lower lumbar arthropathy.
All had joint injection with steroid and local anaesthetic under CT guidance.

Results
All four patients had relief of their spasticity for periods varying from three to six months.

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