The potassium channel blocking drug 4-aminopyridine (4-AP) was administered to eight patients with chronic spinal cord injury, in a therapeutic trial based on the ability of the drug to restore conduction of impulses in demyelinated nerve fibers. The study was performed using a randomized, double-blind, crossover design, so that each patient received the drug and a vehicle placebo on different occasions, separated by 2 weeks. Drug and placebo were delivered by infusion over 2 h. An escalating total dose from 18.0 to 33.5 mg was used over the course of the study. Subjects were evaluated neurologically before and after the infusion. Two subjects returned for a second trial after 4 months and were examined daily for 3 to 4 days following drug infusion. Side effects were consistent with previous reports. Administration of the drug was associated with significant temporary neurologic improvement in five of six patients with incomplete spinal cord injury. No effect was detected in two cases of complete paraplegia and one of two severe incomplete cases (Frankel class B). Improvements in neurologic status following drug administration included increased motor control and sensory ability below the injury, and reduction in chronic pain and spasticity. The effects persisted up to 48 h after infusion of the drug, and patients largely returned to preinfusion status by 3 days. Compared with the more rapid elimination of the drug, these prolonged neurologic effects appear to involve a secondary response and are probably not a direct expression of potassium channel blockade.
A retrospective review of 20 patients with common peroneal nerve palsy treated with decompression between 1986 and 1997 was undertaken. Subjects were evaluated preoperatively and postoperatively by electromyography, nerve conduction, and clinical measures. The mean interval between the onset of symptoms to surgery (operative delay) was 15.9 months. The mean postoperative follow-up was 32.2 months with a minimum follow-up of 1 year. Decompression was performed at the level of the fibular neck and slightly distally at the tendinous origin of the peroneus longus using a standard approach to release tight fascial structures or scar tissue. External neurolysis was performed using the operating microscope in two cases for which scarring of the nerve was identified intraoperatively. Postoperatively, 19 of 20 patients showed improvement in ankle dorsiflexion as assessed by the Medical Research Council scale. Electromyographic examination was useful in the preoperative evaluation and selection of patients for decompression surgery. In conclusion, decompression even after a 1-year delay may offer benefit and suggest early intervention in patients with a severe lesion.
The problem of inaccurate placement of gonad shields in children has been highlighted by several publications nationally and internationally over the past decade and more. Here, we review the literature and present the results of a regional audit designed to assess the use and accuracy of placement of gonad shields for hip and pelvis radiographs in children. 100 consecutive anteroposterior hip or pelvis radiographs in patients under the age of 16 years were reviewed in each of 9 centres. We also included the most recent and all previously available relevant radiographs. A total of 2405 radiographs were reviewed with regard to the presence of a shield and to the accuracy of any shield placement with respect to gonad protection and visualization of orthopaedic landmarks. It is recommended that gonad shields are used in all follow-up paediatric pelvis radiographs. Our results show they were only used in 70% of such cases. When placed, only 38% of all shields were considered to be positioned accurately. For cases where shielding was indicated, an accurately placed shield was present in just 26% of radiographs. Formal written departmental guidelines for shield use were only available in two centres. We conclude that clear guidelines need to be formulated which, together with shield redesign, improved training and audit, should increase effective gonad protection for children.
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