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PubMed1997

A study of desmopressin and blood loss during spinal fusion for neuromuscular scoliosis: a randomized, controlled, double-blinded study.

BACKGROUND: Studies examining the use of desmopressin acetate (DDAVP) have shown variable results in DDAVP's efficacy for reducing blood loss. Studies of adults having cardiac surgery and of children having spinal fusion have suggested that patients with complicated medical histories and complex surgical procedures may benefit from use of DDAVP. Therefore, this study was designed to examine the homeostatic effects of DDAVP in children with severe cerebral palsy undergoing spinal fusion. METHODS: A randomized, double-blinded, and placebo-controlled trial of DDAVP was designed to enroll 40 patients. However, termination of the study was advised by the Institutional Review Board after 21 patients were enrolled. All patients had spastic quadriplegic-type cerebral palsy and were randomly assigned to one of two groups. The DDAVP group received 0.3 microg/kg DDAVP in 100 ml normal saline, and the placebo group received normal saline alone. All patients were anesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl. Factor VIIIC and von Willebrand's factor (vWF) concentrations were measured in blood drawn before DDAVP infusion and 1 h after infusion. Blood pressure was maintained at a systolic pressure of less than 100 mmHg. Use of crystalloids, packed erythrocytes, platelets, and fresh frozen plasma were based on criteria established by protocol. Estimated blood loss was assessed by weighing sponges and measuring suctioned blood from canisters. RESULTS: Estimated blood loss (intraoperative and postoperative) and amount of packed erythrocytes transfused were similar for the DDAVP and placebo groups. Concentrations of both factor VIIIC and vWF were significantly greater after DDAVP infusion when compared with concentrations after placebo infusion. CONCLUSIONS: In the children who had complex spinal fusion, there was no difference in estimated blood loss between those who received DDAVP and those who received a placebo. Administration of DDAVP significantly increased factor VIIIC and vWF levels.

Adolescent↗
PubMed1985

Ammonia intoxication: effects on cerebral cortex and spinal cord.

The effect of an acute systemic ammonia intoxication on the metabolic states of the cerebral cortex and the spinal cord of the same animal was studied in the cat. The intravenous infusion of ammonium acetate (2 and 4 mmol/kg body weight/30 min) increased the gross levels of tissue NH4+, glutamine, glutamine/glutamate ratio, lactate, and the lactate/pyruvate ratio in the cerebral cortex and the spinal cord. Pyruvate increased, but significantly only in the spinal cord; aspartate decreased, but significantly only in the cerebral cortex. The infusion of ammonium acetate did not significantly change the levels of phosphocreatine, ATP, ADP, AMP, total adenine nucleotides, adenylate energy charge, glucose, glutamate, alpha-ketoglutarate, and malate in either tissue. The changes of NH4+, glutamine, and lactate levels as well as glutamine/glutamate and lactate/pyruvate ratios in the spinal cord correlated significantly with the corresponding changes of these metabolites in the cerebral cortex. Thus, cerebral cortex and spinal cord show certain specific and comparable metabolic changes in response to a systemic ammonia intoxication. The effect of ammonia intoxication on the increases of glutamine and lactate levels is discussed.

Acetates↗
PubMed1999

Continuous intrathecal baclofen infusions. An introduction and overview.

Continuous intrathecal baclofen infusion (CIBI) is a relatively new treatment modality for severe spasticity of spinal cord origin. Literature review suggests relief of severe spasms and rigidity is proven with CIBI, in patients with spinal cord injury and multiple sclerosis, while ongoing research exists for patients with acquired brain injury and cerebral palsy. Criteria for patient selection, the screening trial process, an outline of the surgical procedure, and generalities of maintenance therapies, will be reviewed broadly as per literature, as well as specifically to the Vancouver experience with adults. Additionally, reported patient outcomes and implications for nursing will be shared.

Adult↗
PubMed1989

[Experimental model of ischemic injury of the spinal cord after temporary occlusion of the thoracic artery in the dog].

An experimental model for the ischemic damage of the spinal marrow is described by occlusion of the descending thoracic aorta at a level with the 5th or 6th thoracic vertebrae during 30 min. 17 dogs were operated in general anesthesia. The thoracic aorta was clamped by a Pean's clamp in the 1st group (11 animals). One dog was not paralysed, another dog died after thrombosis of the aorta in the locality of clamping. The occlusion was carried out by means of a tourniquet in a 2nd group (6 animals) and pH, blood gas values, and blood pressure in the axillary artery or the common carotid artery were measured. An increase of the blood pressure above the initial value was prevented by slow infusion of nitroprusside. The oxygen pressure in the spinal marrow tissue was measured continuously simultaneously. All these animals survived the operation and a complete damage of the spinal marrow occurred.

Animals↗
PubMed2001

Cervical lymph cannulation to investigate the efflux and effects of intracerebroventricular cytokine infusions.

It is well documented that there is communication between the cerebral spinal fluid (CSF) and cervical lymphatics. Recently, it has been demonstrated that tumor necrosis factor alpha (TNF-alpha) introduced into the CSF appears in the cervical lymph. However, the functional significance of this is less clear. Here we describe a protocol to quantitate the efflux of TNF-alpha from the CSF into cervical lymph. In addition, we describe a methodology to examine the effects of an intracerebroventricular (i.c.v.) infusion of TNF-alpha on lymph volume, cellularity and cell phenotype. While TNF-alpha was recovered in the cervical lymph following infusion of 125-I labeled TNF-alpha, the dosage of TNF-alpha used in this study had no effect on cervical lymph flow, cellularity or cell subsets. This protocol can be used to study the efflux of i.c.v. injected macromolecules and their effects on lymphocytes in cervical lymph and the regional lymph nodes.

Animals↗
PubMedDate not supplied

Surgical management of spasticity and spasms in spinal cord injury: an overview.

Spasms and spasticity constitute a significant problem in spinal cord injured individuals. Surgical intervention may be indicated when spasms and spasticity cannot be satisfactorily controlled by medications and physical therapy. Surgical procedures carried out on the nervous system include neurotomy, rhizotomy, myelotomy, cordectomy and spinal cord stimulation. The various procedures and their indications will be discussed.

Baclofen↗
PubMed1995

Intrathecal administration of endothelin-1 in the rat: impact on spinal cord blood flow and the blood-spinal cord barrier.

The purpose of this study was to examine the integrity of the blood-spinal cord barrier after intrathecal administration of endothelin-1 (ET-1) in the rat spinal cord. A laser Doppler probe was positioned in the exposed subarachnoid space at the T8 vertebral level. In the first experiment, horseradish peroxidase (HRP), a marker of barrier integrity, was given intravenously prior to the intrathecal application of ET-1. Blood flow was then recorded for 3 h, after which the anesthetized animals were euthanized. In the second experiment, animals exposed to endothelin were recovered after confirming a 50% reduction in blood flow. HRP was given 10 min prior to euthanasia at 24 h post infusion. The intensity of staining for HRP was quantified by optical density in fixed sections of spinal cord. There was a significant sustained reduction in spinal cord blood flow and significant barrier breakdown to HRP at both 3 and 24 h after administration of the peptide. Based upon these results we conclude that intrathecal infusion of ET-1 reduces spinal cord blood flow and results in prolonged breakdown of the blood-spinal cord barrier.

Animals↗
PubMed1998

Epidural fentanyl produces labor analgesia by a spinal mechanism.

BACKGROUND: The purpose of this study was to determine if epidural fentanyl produces analgesia in laboring patients by a primary spinal or supraspinal action. METHODS: Fifty-four parturients were randomized to receive epidural 0.125% bupivacaine plus one of three treatments: epidural saline-intravenous saline, epidural fentanyl (20 microg/h)-intravenous saline, or epidural saline-intravenous fentanyl (20 microg/h). The study treatments were administered by continuous infusion, whereas epidural bupivacaine use was patient controlled. RESULTS: Epidural bupivacaine use was significantly reduced by epidural (11.5+/-4.6 ml/h) but not by intravenous fentanyl (15.9+/-4.5 ml/h) compared with saline control (16+/-5.9 ml/ h). Analgesia characteristics and side effects were similar among groups. CONCLUSIONS: Low-dose epidural infusions of fentanyl produce labor analgesia by a primary spinal action.

Adult↗
PubMed2005

An unusual cause of overdose after baclofen pump implantation: case report.

OBJECTIVE AND IMPORTANCE: Intrathecal baclofen delivery for the treatment of spasticity has been used for almost 20 years with a great deal of success. A wide variety of complications and pitfalls have been described. This report details a novel complication involving inadvertent and initially unrecognized canalization of the subdural space with the spinal catheter, which ultimately resulted in an overdose. CLINICAL PRESENTATION: An intrathecal pump system was implanted in a 15-year-old girl with spasticity. This initially resulted in a lack of therapeutic effect. The diagnostic workup ultimately led to contrast administration through the pump system, which precipitated a baclofen overdose when sequestered medication in the subdural compartment was released into the intrathecal space. INTERVENTION: The spinal catheter was subsequently revised, and the patient made a full recovery. CONCLUSION: The possibility of a subdural catheter should be included in the differential diagnosis in patients who experience a lack of drug effect after pump implantation, despite increases in dosage. Close monitoring is required because of the risk of spontaneous or induced overdose, which may occur when a communication develops between the subdural and intrathecal compartments.

Adolescent↗
PubMed2002

Proteinases and proteinase-activated receptor 2: a possible role to promote visceral hyperalgesia in rats.

BACKGROUND & AIMS: PAR-2s are highly expressed throughout the gastrointestinal tract. These receptors are cleaved by trypsin and mast cell tryptase and can be activated by peptides corresponding to the tethered ligand of the receptor (SLIGRL-NH2 for rat). The aim of this study was to determine whether colonic administration of PAR-2 agonists affects visceral sensitivity to rectal distention in conscious rats. METHODS: Abdominal contractions (a criteria of visceral pain) were recorded in rats equipped with intramuscular electrodes. Rectal distention was performed at various times after intracolonic infusion of SLIGRL-NH2 and trypsin. Inflammation parameters and permeability were followed in the colon after the intracolonic injections. Fos expression at a spinal level (L4-L6) was also studied 2 hours after intracolonic injection of SLIGRL-NH2. RESULTS: Rectal distention significantly increased abdominal contractions starting at the RD volume of 0.8 mL. Intracolonic injection of SLIGRL-NH2 (200 microg/rat) and trypsin (200 U/rat), but not vehicle, LRGILS-NH2 (control peptide), boiled trypsin, or SLIGRL-NH2 injected IP, significantly increased (P < 0.05) abdominal contractions for high volumes of distention, 10- and 24-hour postinfusion. SLIGRL-NH2-induced hyperalgesia was inhibited by a NK1 receptor antagonist (SR 140333) but not by indomethacin. Intracolonic injection of SLIGRL-NH2 elevated spinal Fos expression and caused increased intestinal permeability but did not cause detectable inflammation. CONCLUSIONS: Intracolonic infusion of subinflammatory doses of PAR-2 agonists activated spinal afferent neurons and produced a delayed rectal hyperalgesia that involves changes in intestinal permeability and the activation of NK1 receptors. These results identify a possible role for proteinases and PAR-2 in the genesis of visceral hyperalgesia.

Animals↗
PubMed1992

Continuous intrathecal baclofen treatment of severe spasms in two children with spinal-cord injury.

This study reports the use of intrathecal baclofen in two ventilator-dependent children with severe spasms secondary to spinal-cord injury. Baclofen was delivered via a subcutaneously implanted, programmable pump. The children were followed for 12 and 24 months. Baclofen dramatically reduced spasms, resulting in more stable ventilation, improved ease of care, reduced distress and better integration into the community. Although effective, intrathecal baclofen represents a significant intervention; careful consideration must be given to potential complications and the need for long-term management. Full effectiveness was dependent on free CSF flow.

Adolescent↗
PubMed1999

Effect of amiloride analogs on DOCA-salt-induced hypertension in rats.

Intracerebroventricular infusions of an amiloride analog, benzamil, reduce blood pressure in several rat models of hypertension. This effect has been attributed to an inhibition of amiloride-sensitive Na+ channels in the brain. This study examines whether intracerebroventricular benzamil would prevent the onset of deoxycorticosterone acetate (DOCA)-salt-induced hypertension in rats and whether this effect correlates with an inhibition of ion transport through the known amiloride-sensitive cation channels at the blood-brain barrier. We also examine whether the effects of benzamil on blood pressure are mediated by a Na+ channel by comparing the effects of different amiloride analogs. Benzamil (0.15 and 0.5 microgram/h icv) did significantly attenuate the increase in blood pressure induced by DOCA treatment. This antihypertensive effect, however, was not associated with an alteration in a blood-brain barrier ion transport as assessed by measurements of blood-to-brain 22Na transport and cerebral spinal fluid Na+ and K+ concentrations. Indeed, intracerebroventricular infusion of dimethyl amiloride, an amiloride analog with low affinity for Na+ channels, also attenuated the increase in blood pressure induced by DOCA-salt treatment. Comparisons of the effects of benzamil, dimethyl amiloride, and 3,4-dichlorobenzamil, another amiloride analog, suggest that these antihypertensive effects are mediated by an inhibition of Na+/Ca2+ exchange in the brain.

Amiloride↗
PubMed2003

The very-high-efficacy 5-HT1A receptor agonist, F 13640, preempts the development of allodynia-like behaviors in rats with spinal cord injury.

Central neuropathic pain after spinal cord injury (SCI) presents a challenging clinical problem with limited treatment options. [(3-chloro-4-fluoro-phenyl)-[4-fluoro-4-([(5-methyl-pyridin-2-ylmethyl)-amino]-methyl)piperidin-1-yl]]-methadone (F 13640) is a recently discovered very-high-efficacy, selective 5-HT1A receptor agonist that produces a remarkably powerful, central analgesia through unprecedented neuroadaptive mechanisms. In a rat model of spinal cord injury pain, we previously found that chronic infusion of F 13640 alleviated pain-like behaviors. Here, we report that infusion of 0.63 mg/day of F 13640 for 8 weeks starting 24 h before the induction of injury significantly attenuates the development of chronic allodynia-like behavior in rats sustaining a photochemically-induced, ischaemic injury of the dorsal laminae of the L3-L5 segments of the spinal cord. Importantly, the preemptive effect of F 13640 persisted for 2 months after treatment was discontinued. The data warrant the study of the possible effects of the early administration of F 13640 in patients sustaining spinal cord injury.

Animals↗
PubMed1999

Epidural blood patch under fluoroscopic control: non-surgical treatment of lumbar cerebrospinal fluid fistula following implantation of an intrathecal pump system.

The treatment of lumbar cerebrospinal fluid fistula in the presence of an intrathecal catheter is known to be difficult. Open revision surgery is recommended in the literature, although the rate of recurrence is high. The epidural blood patch technique is well established as a successful treatment for post-dural-puncture headaches. Recent work about the distribution of the injected blood and theoretical considerations about the mechanism of action make this method suitable for the occlusion of spinal leakage even in the presence of an intrathecal catheter. In this note technical details are given for a successful therapy of lumbar cerebrospinal fluid fistula including the right positioning of the opening of the needle (cerebrospinal fluid can be expected intrathecally and epidurally) by injection of contrast medium first for myelography then for epidurography. In this procedure the (epidural) distribution of autologous blood can be indirectly controlled by compression of the dural sac. The method is easy to perform, and the possible risks are small.

Adult↗
PubMed2005

Baclofen pump intervention for spasticity affecting pulmonary function.

INTRODUCTION: Muscle spasticity may adversely affect pulmonary function after spinal cord injury (SCI). However, there is limited information regarding the treatment of spasticity as a determinant of pulmonary function. This study presents the case of a man with C4 tetraplegia who had severe spasticity and difficulty weaning from ventilatory support. METHODS: Case presentation. RESULTS: Severe spasticity likely contributed to respiratory compromise in this patient. Successful and rapid weaning from the ventilator occurred within 3 weeks of baclofen pump placement. CONCLUSIONS: Randomized clinical trials among SCI patients with significant spasticity are needed to determine whether intervention with a baclofen pump facilitates earlier ventilatory weaning.

Baclofen↗
PubMed1999

Midthoracic catheter tip placement for intrathecal baclofen administration in children with quadriparetic spasticity.

OBJECTIVE: In an effort to increase the effect of intrathecal baclofen on upper-extremity spasticity, the tip of the intrathecal catheter was placed at the T6-T7 level rather than at the traditional T11-T12 level in children with spastic quadriparesis. METHODS: Twelve children with spastic quadriparesis from varying causes had significant reductions in spasticity after a test dose of intrathecal baclofen and subsequently underwent placement of a programmable pump and intrathecal catheter tip placed at the T6-T7 level with fluoroscopic guidance. With the use of Ashworth scores for four muscle groups in both the upper and lower extremities, degrees of spasticity were determined by a physiatrist preoperatively and at 1, 3, 6, and 12 months postoperatively. Mean changes in upper- and lower-extremity Ashworth scores and baclofen dosages for the entire cohort were compared with published results in which the catheter tip had been placed at the T11-T12 level. RESULTS: Spasticity was significantly reduced in all muscle groups (P < 0.001). The lower-extremity reduction in spasticity of 1.6 points at 3 and 12 months was greater than published reductions of 1.1 points at 3 and 12 months. The upper-extremity reduction in spasticity was noticeably greater at 3 and 12 months (1.7 and 2.0 points, respectively) than published results at 3 and 12 months (0.4 and 0.6 points, respectively). At 3, 6, and 12 months, our mean baclofen dosage remained below the dosages administered at the T11-T12 level. There were no complications related either to the positioning of the catheter higher in the spinal canal or to the administration of baclofen at the T6-T7 level. CONCLUSION: Compared with published results, placement of the tip of the intrathecal catheter at the T6-T7 level was associated with greater relief of upper-extremity spasticity without loss of effect on the lower extremities. The mean dosages of baclofen in our study group were lower compared with mean dosages administered at the T11-T12 level. There was no morbidity related to the more rostral location of the catheter.

Baclofen↗
PubMed2000

Basic fibroblast growth factor (bFGF) enhances functional recovery following severe spinal cord injury to the rat.

We have recently demonstrated that following a moderate contusion spinal cord injury (SCI) to rats, subsequent administration of basic fibroblast growth factor (bFGF) significantly enhances functional recovery and tissue sparing. To further characterize the effects of bFGF, we evaluated its efficacy after a more severe contusion injury at T(10) using the NYU impactor. Immediately after SCI, osmotic minipumps were implanted into the lateral ventricle and lumbar thecal sac to deliver bFGF at 3 or 6 microg per day versus control vehicle for 1 week. Animals were behaviorally tested for 6 weeks before histological assessment of tissue sparing through the injured segment and glial reactivity distal to the lesion. Compared to moderate SCI, all rats had more prolonged and sustained functional deficits 6 weeks after severe contusion. Subjects treated with bFGF had pronounced recovery of hindlimb movements from 2 to 6 weeks compared to controls, manifested in significantly higher behavioral scores. Only marginal tissue sparing was seen rostral to the injury in bFGF-treated spinal cords versus controls. Optical density measurements of astrocyte and microglial cell immunoreactivity in bFGF-treated spinal cords showed that after 6 weeks they approximated controls, although astrocyte immunoreactivity remained higher in controls rostrally. In summary, intrathecal infusion of bFGF following severe SCI significantly restores gross hindlimb motor function that is not correlated with significant tissue sparing. In light of previous evidence that pharmacological intervention with bFGF after moderate SCI enhances tissue preservation, the current findings indicate that yet undefined mechanisms contribute to the enhanced functional recovery following bFGF treatment.

Analysis of Variance↗