Gastrointestinal complications of spinal cord injury.

The incidence, nature, and radiographic features of gastrointestinal complications encountered in a group of 567 consecutive spinal-cord-injury patients are reported. Eighty-seven episodes of gastrointestinal complications developed in 63 (11%) patients. During the first month postinjury, these complications consisted of ileus, gastric dilatation, the body cast syndrome, peptic ulcer disease, and pancreatitis. More chronically these patients presented with fecal impactions, peptic ulcer disease, the superior mesenteric artery syndrome, hepatitis, amyloidosis, and the precocious appearance of diverticulosis, hiatus hernia, and gastroesophageal reflux. Radiographic findings were diagnostic in the majority of cases and aided in the early diagnosis of these potentially life-threatening complications.

Complications of sublaminar wiring.

Complications of sublaminar wiring are reported, including four cases that involved the cervical spine and one case that included the thoracolumbar spine. The complication rate at our institution involving the cervical spine was about 7% and less than 1% for the thoracic spine. A direct correlation exists between the degree of anterior bowing, number of consecutive laminae the wire passes beneath, and the complication rate. The clinical presentations, radiologic findings, and indications for surgical removal of the wires are discussed. To our knowledge, nothing has been reported in the literature regarding the complications caused by sublaminar wiring of consecutive vertebrae.

The reconstructed esophagus.

Reconstruction of the esophagus has been used for more than half a century. Benign as well as malignant diseases are treated in this manner. Viscera used for reconstruction are: colon, jejunum, and stomach. The different modalities of surgical intervention have been briefly summarized. Complications have been enumerated with the major ones stressed in more detail. The exact nature of surgical procedure should be known before attempting to evaluate roentgenologically a reconstructed esophagus. Preoperative roentgen evaluations, including barium study and angiography, are indicated for better postoperative results. Postoperative roentgen studies are needed to detect most of the postoperative complications.

Radiologic manifestations of iatrogenic changes of the esophagus.

The review of the roentgen manifestations of iatrogenic changes in the esophagus permits their grouping into two major categories of intentional and nonintentional alterations. In the first group, iatrogenic changes are encountered following reconstructive or other types of surgery, radiotherapy, and their respective complications. Nonintentional changes of the esophagus include injuries induced during diagnostic procedures, life-saving measures, and drug therapy. The knowledge of the spectra of possible iatrogenic alterations is important for accurate radiologic evaluation of the patients and the recognition of complications.

Adenocarcinoma in tubular duplication of the sigmoid colon.

A rare case of mucus-secreting adenocarcinoma in a tubular duplication of the sigmoid colon is presented. The pertinent radiographic manifestations were: a calcium containing soft tissue mass located at the blind end of a 20 cm barium filled tubular duplication originating at the sigmoid colon.

Lumbar fracture-dislocation related to range-of-motion exercises.

Range-of-motion exercises are an established and widely accepted therapeutic modality in the treatment of the person with spinal cord injury and are usually uneventful. Occasionally, however, accidents do occur; among them are fractures and dislocations of limbs. An unusual "slice" fracture of L4, related to range of motion exercises, occurred in a young man who was a quadriplegic and converted him from upper to lower motor neuron bowel, bladder and sexual function. This iatrogenic fracture, although extremely rare, can be prevented if symptoms are properly interpreted.

Unilateral pulmonary edema.

Unilateral pulmonary edema was found to occur following or in conjunction with 18 different clinical situations. In half of them the edema developed on the same side as the causative factor and was related to conditions altering the delicate balance at the alveolar-capillary interface. In the other situations, pulmonary capillary perfusion was deficient on the opposite side prior to the onset of edema.

Secondary spinal lesions in spinal cord injury patients.

On hospital admission, 6 spinal cord injured patients were noted to have second noncontiguous levels of spinal injury that were previously unrecognized. These secondary levels of spinal injury were diagnosed as a result of routine admission total spine radiographic examinations. Two cases are described in detail, one with the secondary spinal lesion above and the other below the primary spinal cord injury. Careful total spine radiographic studies are recommended to prevent complications, in the event that such lesions are initially unrecognized.

Bacterial or nonbacterial pneumonia: accuracy of radiographic diagnosis.

The initial chest radiographs of 31 patients with laboratory-proved pneumonia were evaluated by a panel of 6 radiologists who had no prior knowledge of the clinical data. No statistical reliability was found for distinguishing bacterial from nonbacterial pneumonia. Radiographic diagnoses were 67% accurate for the 16 cases of bacterial pneumonia, and 65% accurate for the 9 viral cases. Six cases of Mycoplasma pneumonia were diagnosed as nonbacterial 19% of the time, and as "bacterial pneumonia" 81% of the time.

Surgical fusion of the posttraumatic spine: a radiologic assessment.

Radiological assessment of surgical fusion of fractures and dislocations of the cervical, thoracic, and lumbar spine are an integral part of management of spinal cord injury patients. A meaningful assessment of such fusions can be done properly only when there is adequate knowledge of the types of surgical fusions, the biological material used, and metallic devices applied. Early surgical reduction and internal fixation of the traumatized spine facilitate rapid restoration of spinal alignment, make nursing care less difficult, and sometimes lead toward improvement of neurological function. Complications can occur in all types of surgical fusions. They can affect the fusion material, the metallic device, or the alignment of the spine. Most of those complications are radiologically detected.

Evaluation of the urethra in males with spinal cord injury.

Of 358 antegrade voiding urethrograms obtained in 200 males with spinal cord injury, the urethra was satisfactorily shown by 154 (77%), permitting evaluation of alterations related to cord damage, surgery, or iatrogenic trauma. In 105 cases the neurogenic urethra was normal, demonstrated only minor distension, or had a patulous appearance, in contrast to urinary tract changes such as a markedly neurogenic bladder, vesicoureteral reflux, and bladder calculi. In 49 patients, abnormalities included (a) changes related to surgical alleviation of sphincter dyssynergia; (b) iatrogenic changes such as diverticula strictures, undermining of the external sphincter ("spiral sign"), and intravasation of contrast material; and (c) pressure necrosis of the urethra. Some changes need no special treatment; others, such as pressure necrosis, require early recognition and prompt therapy.

Multiple level spinal injuries: importance of early recognition.

Patients with severe trauma may simultaneously sustain more than one level of spinal injury. Often, the second or third levels of injury are not recognized early enough to prevent clinically significant extension of the neurologic deficit, pain pattern, spinal instability, and/or deformity. A review of 710 spinal injury patients admitted to the Midwest Regional Spinal Cord Injury Care System yielded 4.5% multiple noncontiguous vertebral injuries. Thirty cases were studied in respect to location and type of primary and secondary injury. Of the secondary lesions, 40% occurred above and 60% below the primary lesion. In half of the patients, there was a mean of 52.6 days delay in diagnosis of the secondary lesion. Three major patterns of injury emerged from this analysis. Knowledge of these patterns and careful total spine radiography in patients with severe trauma may be a significant aid in early recognition of multiple level injuries and possible prevention of their complication.

Sinography in management of decubitus ulcers.

Draining sinuses are considered a major complication of decubitus ulcers in spinal cord injury patients. Of 144 such patients with decubitus ulcers admitted in 1975 and 1976, 15 had draining sinuses. Twenty-one sinograms were obtained in the process of their evaluation prior to treatment. In 6 patients, sinography resulted in unexpected findings such as excessive depth of the sinus tract, abscess formation, undermining of previous graft, and extension into neighboring joints, affecting both the management of the decubitus ulcers and the surgical approach. It is concluded that sinography should become an integral part of management of decubitus ulcers with draining sinuses.

Radiology of pressure sores.

Pressure sores occur frequently in patients with spinal cord injuries and require radiographic evaluation for adequate management. Plain radiography, computed tomography, direct magnification radiography, sinography, and ultrasonography were used to evaluate 218 pressures sores. The role of each of these modalities in the management of patients with pressure sores is defined, and recommendations for their use are made.

Radiologic evaluation of surgical cervical spine fusion.

Preoperative, intraoperative, and postoperative radiologic evaluation of surgical cervical spine fusion plays an integral part in the management of cervical spine injuries. The radiographic anatomy of the basic types of anterior, posterior, and combined fusions and the indications for their performance are discussed. A retrospective review of 210 consecutive cervical spine fusions showed a 21.1% radiographic complication rate for anterior fusions and only 3.9% for posterior fusions. The high complication rate of anterior fusions is related to the performance of anterior fusion in the presence of unrecognized posterior instability. Radiographically identified complications must be correlated with the clinical neurologic examination in each case since the spectrum of radiographic complications may be compatible with a clinically satisfactory result.

Thoracic and lumbar spine fusion: postoperative radiologic evaluation.

A retrospective review of 206 consecutive thoracic and lumbar fusions revealed a variety of surgical procedures performed for instability and malalignment after severe trauma. Stabilization procedures included insertion of 103 Harrington distraction and 15 Harrington compression rods, 84 Weiss spings, six Luque rods, and 10 miscellaneous plates and wires as single or multiple devices in combination with anterior and/or posterior fusions. Complications of surgical fusion included nine unhooked rods, six fatigue fractures of rods and springs, five overdistractions of vertebrae, four cases of severe kyphosis, and two failures of reduction. A meaningful postoperative radiologic evaluation can be accomplished only when indications for surgical techniques, their radiologic appearance, and possible complications are known.

Renal osteodystrophy in patients on hemodialysis as reflected in the bony pelvis.

Roentgen studies in a group of 131 patients on maintenance hemodialysis reveal renal osteodystrophy in 25 patients (19 per cent). In 24 patients of the latter group (98 per cent), the various manifestations of renal osteodystrophy appear in the bony pelvis. These include: osteomalacia; osteitis fibrosa; osteosclerosis; dialysis osteopenia; and extraosseous calcifications. Some of the changes, i.e., bending of bone, Looser's lines, metaphyseal fractures and dialysis osteopenia, are due, at least in part, to the weight bearing nature of the bony pelvis. These findings are ararely, if ever, seen in the digits or in other non-weight bearing bones. It is therefore proposed to evaluate the bony pelvis, together with the magnification digital roentgenogram, when a less costly and less time consuming skeletal survey is needed in hemodialized patients.

Urosonography in spinal cord injury patients.

Urosonography, ultrasound of the urinary tract, is a noninvasive imaging method used to evaluate renal masses, renal parenchymal disease, hydronephrosis, bladder volume and calculi. The applicability of ultrasound was studied in 54 spinal cord injury patients by correlating uroradiological examinations with ultrasound. Emphasis was placed on ultrasonic imaging of ureterectasis and vesicoureteral reflux. Ultrasound confirmed all positive radiographic findings of renal and bladder abnormalities (renal calculi, chronic pyelonephritis, trabeculated bladder and bladder calculi), and yielded additional information in 27 per cent of the kidney and 13 per cent of the bladder studies. Ultrasound was used to confirm vesicoureteral reflux in 56 per cent of the patients and ureterectasis in 33 per cent. It is recommended that spinal cord injury patients undergo a baseline excretory urogram followed by periodical ultrasound examinations to detect hydronephrosis, renal parenchymal disease, and renal and bladder calculi, and to measure bladder volume and residual urine. Whenever real-time equipment and experienced ultrasonologists are available ultrasound can be used as an alternate to voiding cystourethrography to detect vesicoureteral reflux.

The role of imaging in infertility management.

In a retrospective review of 211 female infertility patients receiving ovulation induction agents, the role of sonography in infertility management is defined. Sonography is used to determine imminence of ovulation for timing of insemination and in vitro fertilization. It is also used to diagnose ovarian hyperstimulation syndrome. To identify characteristics of the ovarian follicles of women able to conceive that might differentiate them from those unable to become pregnant, patients were assigned to "pregnant" (30.8%) or "nonpregnant" subgroups. In 259 sonographically monitored cycles reviewed, follicular size and configuration were not different for the two groups. The cumulus oophorus was seen in 28% of pregnant patients (8/28) and in only two nonpregnant patients. Low-level echoes were seen in the mature follicles of 11 patients but not in the large follicles of nonpregnant patients. Low-level intrafollicular echogenicity may be a prognostic indicator of fertility and may represent a periovulatory state, optimal, in the appropriate clinical setting, for artificial insemination or in vitro fertilization.