Switching from onabotulinum toxin A to abobotulinum toxin A for treating detrusor overactivity in spinal cord injured patient, does it really work?

AIM: To assess the efficacy of switching to Abobotulinumtoxin A (ATA) intradetrusor injections (IDI) after failure of Onabotulinumtoxin A (OTA) IDI for the treatment of neurogenic detrusor overactivity in patients with spinal cord injury (SCI). MATERIALS AND METHODS: A single-centre retrospective chart review study. All SCI patients who started OTA IDI after 2011 and had an ATA IDI switch were included. The primary outcome was the clinical and urodynamic efficacy of the switch to ATA IIDs at the last follow-up. Secondary outcomes were initial efficacy, duration of ATA treatment, and patient outcome including the occurrence of augmentation enterocystoplasty at last follow-up. RESULTS: Sixty-two patients were included. Eighteen patients (28.9%) were initially responders to ATA IDI. Nine patients (14.5%) remained responders at last follow-up after a median of 17 months (AE 8.8-29). Thirty-two patients (51.6%) had had or were awaiting augmentation enterocystoplasty with a follow-up time of 18.5 months (IQR 8-27). Eleven patients (17.7%) were on ATA IDI with low efficacy. Seven patients (11.3%) were switched back to OTA and 3 patients (4.8%) changed their voiding pattern. CONCLUSION: Switching from OTA to ATA toxin for IDI in the treatment of detrusor overactivity after spinal cord injury have long-term efficacy for a limited number of patients but may delay the need for surgery.

[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]. / Recommandations sur la gestion du risque et la prise en charge urologique du patient adulte atteint de dysraphisme spinal (spina bifida).

INTRODUCTION: Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population. MATERIALS AND METHODS: National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached. RESULTS: Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible). CONCLUSION: Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

Pregnancy and Delivery in Women with Lower Urinary Tract Reconstruction: A National Multicenter Retrospective Study from the French-Speaking Neuro-Urology Study Group (GENULF) and the Neuro-Urology Committee of the French Association of Urology.

PURPOSE: Management of pregnancy and delivery in women with lower urinary tract reconstruction is challenging and the currently available literature is insufficient to guide clinical practice. We report pregnancy and delivery outcomes in this specific population. MATERIALS AND METHODS: We conducted a national multicenter retrospective study (16 centers) including 68 women with 96 deliveries between 1998 and 2019. These women had at least 1 successful pregnancy and delivery after augmentation enterocystoplasty, catheterizable channel creation and/or artificial urinary sphincter implantation. Maternal and fetal complications during pregnancy and delivery were reported, as well as postpartum functional outcomes, according to the delivery mode. The chi-square test and Student's t-test were used to compare categorical and continuous variables, respectively. RESULTS: Overall 32% of reported pregnancies were complicated by febrile urinary tract infections, 13.5% by renal colic and 14.6% required upper urinary tract diversion. In addition, 10% of patients reported transient self-catheterization difficulties and 13.5% reported de novo or increased urinary incontinence. The preterm delivery rate was 35.3%. Elective C-section was performed in 61% of pregnancies. Twenty complications occurred during delivery (20%), including 19 during elective C-section. Urinary continence at 1 year was unchanged for 93.5% of deliveries. Delivery mode (p=0.293) and multiparity (p=0.572) had no impact on urinary continence. CONCLUSIONS: In this population C-section appeared to be associated with a high risk of complications. In the absence of any obstetric or neurological contraindications, vaginal delivery should be proposed as the first line option to the majority of these women.

[Bladder cancer in neurogenic patients: A retrospective study of management and follow-up]. / Cancers de vessie chez les patients neurologiques : étude rétrospective de prise en charge et de suivi.

INTRODUCTION: The prevalence of bladder cancer (BC) in neurological patients seems to be similar to that of the general population. However, they are more aggressive with a higher rate of muscle-invasive forms and squamous cells carcinomas. The aim of the current study was to report etiologies, management and outcomes of BC in neurological population. MATERIAL AND METHOD: Were enrolled all neurological patients with a BC diagnosed between 2004 and 2017. The following data were retrospectively reported: age, gender, duration of the disease, mode of discovery, histological type, treatment and outcomes. RESULTS: In total, 27 patients were included: 11 spinal cord injuries, 7 Parkinson's disease, 5 multiple sclerosis, 3 head trauma, 3 brain strokes, 2 cerebral palsies and 1 spina bifida. The histological subtypes were as follows: 22 transitional cells carcinomas, 4 squamous cell carcinomas (SCC), one mucinous adenocarcinoma, one sarcomatoid and one neuroendocrine with 19 high-grade tumors and 15 muscle-invasive bladder cancer. Seven patients (26%) were diagnosed before 15 years history of neurogenic bladder. The mean follow-up was 14 months (1-210 months). Eight deaths were observed, with 5 related to bladder cancer. In our study, smoking habits, voiding mode, lithiasis or infection histories were not related with a more aggressive pattern, such as SCC. CONCLUSION: The high rate of muscle-invasive bladder cancer and aggressive patterns justify neuro-urological follow-up, even before 15 years of neurogenic bladder. LEVEL OF EVIDENCE: 4.

Global audit on bowel perforations related to transanal irrigation.

PURPOSE: Transanal irrigation is increasingly used against chronic constipation and fecal incontinence in selected patients. The aims were to estimate the incidence of irrigation-related bowel perforation in patients using the Peristeen Anal Irrigation(®) system, and to explore patient- and procedure-related factors associated with perforation. METHODS: External independent expert audit on the complete set of global vigilance data related to Peristeen Anal Irrigation from 2005 to 2013. RESULTS: In total, 49 reports of bowel perforation had been recorded. Based on sales figures, this corresponds to an average risk of bowel perforation of 6 per million procedures. The latest two-year data indicate a risk of 2 per million procedures. In 29 out of 43 evaluable cases (67 %), perforation happened within the first 8 weeks since start of treatment. After 8 weeks, long-term use has an estimated risk of less than 2 per million procedures. Among patients with non-neurogenic bowel dysfunction, 11 out of 15 (73 %) had a history of pelvic organ surgery compared to 5 out of 26 (19 %) in neurogenic bowel dysfunction. In 11 of 46 (24 %) evaluable cases, burst of the rectal balloon was reported. CONCLUSION: Enema-induced perforation is a rare complication to transanal irrigation with Peristeen Anal Irrigation, which increases the benefit risk ratio in support of the further use of transanal irrigation. Increased risk is present during treatment initiation and in patients with prior pelvic organ surgery. Careful patient selection, patient evaluation and proper training of patients are critical to safe practice of this technique.

Sepsis of the hip due to pressure sore in spinal cord injured patients: advocacy for a one-stage surgical procedure.

STUDY DESIGN: Retrospective study reporting characteristics and management of septic arthritis of the hip due to pressure sores in spinal cord-injured patients. OBJECTIVES: To describe clinical and biological data of septic arthritis of the hip and its treating management. SETTING: The database of the regional SCI referral center, Nantes, France. METHODS: We retrospectively collected data from 33 cases of septic arthritis of the hip in the medical files of 26 patients. RESULTS: We analyzed 33 cases of septic arthritis of the hip treated in one French referent center for spinal cord-injured patients from January 1988 to December 2009. Most patients had a thoracic complete paraplegia and nearly two-third (17 out of 26) had no systematic follow-up. In 25 out of 33 cases, the septic arthritis of the hip was due to a trochanteric pressure sore. The causal pressure sore was most frequently associated with a persistent drainage. The standard radiological examination led to the diagnosis in 30 cases and, in 7 questionable cases, magnetic resonance imaging was more contributory. Surgery always consisted of a wide carcinological-like excision and of a subtrochanteric proximal femoral resection including both greater and lesser trochanters. A musculocutaneous flap was realized for all cases and the choice of the muscle depended on the localization of the causal pressure sore but also of the remaining choices, as most of the patients had already undergone a prior surgery. An antibiotic treatment was adapted to multiple samples during surgery. CONCLUSION: We do advocate for a one-stage procedure including a subtrochanteric proximal femoral resection and a musculocutaneous flap.

[Post-traumatic syringomyelia: What should know the urologist?]. / Syringomyélie post-traumatique : ce que doit savoir l'urologue ?

The incidence of post-traumatic syringomyelia (PTS) is estimated according to recent studies at 25 to 30% of patients with traumatic spinal cord injuries in magnetic resonance imaging (MRI), which remains the gold standard exam for syringomyelia diagnosis and monitoring. Syringomyelia is translated by an increased cord signal (similar to CSF) with low-density T1-weighted image and high-density T2-weighted image, which extends beyond site of initial lesion at least to two vertebral segments. Two conditions are required for development of PTS: traumatic spinal cord injury and blocked the flow of CSF epidural. The mean interval from spinal cord injury to diagnosis SPT was 2.8years (range, 3months to 34years). The commonest symptoms are pain and sensory loss. PTS should be suspected if the patient has new neurological symptoms above level of injury, such as dissociated sensory injuries, reflexes abolition, and motor deficit, after the neural function becomes stable for certain time. In urologic practice, new neurological symptoms could be bladder and/or erectile dysfunction. The medical management based on prevention efforts with closed-glottis pushing, which could aggravate the syrinx cavity. In urology, extracorporeal shockwave lithotripsy, and laparoscopic or robotic surgery could extend the syrinx cavity for the same reason (increase abdominal pressure). The indications for surgical intervention and optimal surgical treatment technique for patients with PTS are not consensual. The literature demonstrated that surgery PTS is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes.

Perilesional myeloradiculopathy with tethered cord in post-traumatic spinal cord injury.

STUDY DESIGN: A retrospective series of cases. OBJECTIVE: To identify, among post-traumatic myelopathies, a specific entity in which clinical and radiological features are not extensive but are strictly limited to the perilesional zone. SETTING: The data set of the Regional Spinal Cord Injury Department of Nantes, France. METHODS: A systematic analysis of all traumatic spinal cord injury (SCI) patients who presented with a neurological aggravation delayed from initial injury, without syringomyelia or extensive myelomalacia. RESULTS: Twelve patients presenting with this type of complication were identified (that is, four tetraplegics and eight paraplegics). The neurological worsening consisted in weakness of the muscles close to the motor level in five patients, and in isolated at-level neuropathic pain in seven patients. A tethered cord was evidenced by the magnetic resonance imaging (MRI) results in all of the patients. Roots were involved by the tethering on the MRI results in eight cases. Surgery, with untethering and expansile duraplasty, was performed in all cases. Surgery allowed motor recovery in patients who presented with a motor loss (motor score gain range=1-7 points; median=3) and decreased pain in all pain patients (decrease on the 10-point numerical rating scale: range=1-6 points; median=4). CONCLUSIONS: In traumatic SCI patients, a tethered cord could be responsible for clinical and radiological changes, which are strictly localised to the perilesional area. The term perilesional myeloradiculopathy is proposed for this complication, which requires cord release surgery.

Chronic neuropathic pain in spinal cord injury patients: what relevant additional clinical exams should be performed?

OBJECTIVE: Study the indications and level of evidence of clinical exams that might be relevant in exploring the causes of neuropathic pain in spinal cord injury patients. METHOD: Literature review from three databases: PubMed, Embase, Pascal. RESULTS: Disparity and heterogeneity of the answers given by the attendees to the experts conference of the French Society of Physical Medicine and Rehabilitation (SOFMER) and the physicians surveyed via the SOFMER website. These results corroborate the shortage of available data on this topic in the literature. From this analysis, we can however validate spinal MRI imaging as a mandatory exam for the diagnosis of post-traumatic syringomyelia (cystic myelopathy) - this exam can even be considered a Gold Standard. Furthermore, we can also recommend using electrodiagnostic studies for compressive neuropathies. However, it is not possible to validate the relevance of additional clinical exams for radicular pain, segmental deafferentation pain, central deafferentation pain as well as Complex Regional Pain Syndrome (CRPS) type 1; for these types of pain we can only formulate experts recommendations in light of the dearth of available data on the subject. CONCLUSION: For the neuropathic pain of spinal cord injury patients' additional clinical exams should be used in the framework of an etiological diagnosis.

Chronic neuropathic pain in spinal cord injured patients: what is the effectiveness of surgical treatments excluding central neurostimulations?

OBJECTIVES: Analyzing the literature and elaborating recommendations on the following topics: relevance of dorsal root entry zone (DREZ) lesions, surgical treatment for posttraumatic syringomyelia, other therapeutic approaches (peripheral nerve root pain, nerve trunk pain and Sign Posterior Cord [SCI] pain). MATERIAL AND METHODS: The methodology used, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic review of the literature, the gathering of information regarding current clinical practices and a validation by a multidisciplinary panel of experts. RESULTS: Ninety-two articles were selected, 10 with a level of evidence at 2, 82 with a level of evidence at 4. Some articles lacked information on the type of injury, the pain characteristics and the symptoms' evolution over time. DREZ: This type of procedure has been validated for its effectiveness on pain at the level of injury (transitional zone pain), but is inefficient for pain located below the level of injury. Posttraumatic syringomyelia (PTS): suspected when there is an increased neurological impairment, changes below the level of injury (mainly bladder dysfunctions) or a sudden onset of pain. The surgery associates arachnoid grafting, cyst drainage, expansile dural plasty (same treatment for posttraumatic tethered spinal cord and posttraumatic myelomalacia). PERIPHERAL NERVE ROOT, NERVE TRUNK OR TRANSITIONAL ZONE PAIN: Surgical implants (screws or clips) can generate radicular pain caused by inflammation and they can even move around with time. The material-induced constraints can also trigger pain. Surgical removal of osteosynthesis material (with an eventual saddle block) remains a simple procedure yielding good results. Correcting surgeries can also be performed (malunion and nonunion). Finally, compressive neuropathies (carpal tunnel syndrome, ulnar nerve entrapment) already have a well-defined treatment. CONCLUSION: The literature review can define the relevance of surgical treatments on some types of SCI pain. However, the results of many articles are difficult to analyze, as they do not report clinical or follow-up data.

Pain management: what's the more efficient model?

OBJECTIVES: Conduct a literature review on the organization models for the chronic neuropathic pain management of spinal cord injury (SCI) patients. METHODS: Bibliographical research on Medline based on the following keywords: chronic neuropathic pain in spinal cord injury-comprehensive management-multidisciplinary approaches. RESULTS AND DISCUSSION: No data was found in the literature on this specific topic. We took the option to report the data from the French laws regarding chronic non-cancer pain management. Chronic pain in SCI patients needs a specific and rigorous approach, justifying the role of the physical medicine and rehabilitation (PM&R) physician within specialized pain management centers as a key referent physician and coordinator for this type of patient. Furthermore, SCI pain is a chronic pain and as such requires a global care management; engulfing its emotional, affective, cognitive and behavioral aspects. These particular aspects need to be evaluated within specialized centers dedicated to chronic pain that provide specific therapies such as behavioral and cognitive therapies. CONCLUSION: Specific pain management centers or hospital units remain the benchmark place for chronic pain in SCI patients. PM&R physicians play a key role in the care management of chronic SCI pain. The partnership PM&R-Pain management center aims to provide the most efficient and coordinated care for SCI patient.

[Efficacy of repeat injections of botulinum A toxin to the detrusor in neurogenic bladder overactivity]. / Efficacité des injections intradétrusoriennes répétées de toxine A dans l'hyperactivité vésicale d'origine neurologique.

PURPOSE: Toxin injections are an effective treatment for neurogenic detrusor overactivity. The efficacy of repeat injections is not well documented. The objective of this study was to evaluate the efficacy of repeat injections of toxin A to the detrusor in patients with neurogenic overactive bladders. MATERIALS AND METHODS: Patients who had received 300-UI injections of Botox(R) were retrospectively studied. The clinical data included continence, duration of the absence of incontinence, changes in anticholinergic dosage or pad use and patient satisfaction. Urodynamic data analyzed were maximal cystometric capacity, bladder contraction and detrusor pressure during contraction. Data were analyzed by Wilcoxon and Kruskal-Wallis tests. RESULTS-DISCUSSION: Data for 42 patients (30 men, 12 women) were analysed. Pathologic features were trauma to the spinal cord, multiple sclerosis or varied causes of myelopathy. Patients received 1 to 6 injections of Botox(R). The mean duration of efficacy was 6 months. Efficacy did not differ among successive injections. Anticholinergic drugs were discontinued in 43% of patients and pad use in 48%. A total of 80% of the patients were satisfied with the treatment. Bladder contraction disappeared in 70% of patients. The mean maximal cystometric capacity increase was 144 ml. CONCLUSION: Clinical and urodynamic data show that repeat injection of toxins to the detrusor remains an effective therapy for neurogenic bladder overactivity. Efficacy for continence is maintained during successive injections.

[Brindley technique with intradural deafferentation and extradural implantation by a single sacral laminectomy]. / Technique de Brindley par deafferentation intra-durale et electrodes de stimulation extra-durales en "tout sacre".

AIM: We propose an improved technique for implanting a sacral root stimulator associated with dorsal sacral rhizotomy ("Brindley's technique") in a single intra-sacral approach. METHOD: This novel technique only requires a single sacral laminectomy, consisting in a sacral deafferentation at the level of the dural cul-de-sac, facilitated by the anatomical identification of the sacral roots at this level. RESULTS: Four patients underwent surgery using this technique since October 2002, resulting in a very satisfactory micturition status. DISCUSSION: The aim of this technique, which is as rapid as the conventional intra-dural technique, is to obtain complete deafferentation and to induce non traumatic transdural motor stimulation at the same level. In this way, surgical goals can be reached more readily with greater safety than with other techniques.

Partial return of motor function in paralyzed legs after surgical bypass of the lesion site by nerve autografts three years after spinal cord injury.

Spinal cord injuries often result in irreversible loss of motor and somatosensory functions below the lesion level. Treatment is limited to physiotherapy aimed at compensating disability. We previously showed that re-establishment of tissue continuity can be achieved in animal models through nerve autografts implanted between the rostral spinal ventral horn and the caudal ventral roots. Rostral motor neuron axons could thus reach peripheral targets, leading to some return of motor function. We used a similar approach in a paraplegic patient with stabilized clinical states three years after spinal cord traumatic damage at the T9 level. Three segments from autologous sural nerves were implanted into the right and left antero-lateral quadrant of the cord at T7-8 levels, then connected to homolateral L2-4 lumbar ventral roots, respectively. Eight months after surgery, voluntary contractions of bilateral adductors and of the left quadriceps were observed. Muscular activity was confirmed by motor unit potentials in response to attempted muscle contraction. Motor-evoked potentials from these muscles were recorded by transcranial magnetic stimulation. These data support the hypothesis that muscles have been re-connected to supra-spinal centers through motor neurons located in the rostral stump of the damaged cord. They suggest that delayed surgical reconstruction of motor pathways may contribute to partial functional recovery.

Supralesional and sublesional bone mineral density in spinal cord-injured patients.

This study was performed to evaluate supra- and sublesional bone mineral density (BMD) in spinal cord-injured (SCI) patients after 1 year postinjury, and to correlate the BMD to the neurological level; to correlate the sublesional demineralization to functional parameters (duration postinjury, duration of the initial bedrest); and to assess the role of classic methods of prevention such as walking or standing. Thirty-one SCI patients, all male, were studied vs. 31 controls (age matched). The mean age of the population was 36 years (range 18-60 years). Eleven were tetraplegic and 20 were paraplegic. Twenty-six patients dysplayed a complete motor lesion. The BMD was measured by dual-photon absorptiometry on the lumbar spine and on the femoral neck, and the bone mineral content (BMC) on whole-body scans. Particular attention was paid to the distal femur and proximal tibia upper third. Blood samples and urine samples included phosphocalcic parameters, with determination of urinary hydroxyproline and deoxypyridinoline. SCI patients showed a decrease of sublesional BMD of 41% in comparison with controls. This loss of bone mass is higher at the distal femur (-52%) and proximal tibia (-70%), which are the most common sites of fracture. The degree of demineralization for the lumbar spine, the pelvis, and the lower limbs is independent of the neurological level. The duration of acute posttraumatic immobilization (mean 43.3 days) and the time postinjury increase the loss of bone mass for lower limbs (p = 0.04) and particularly for the proximal tibia (p = 0.02). The study of biomechanical stress (i.e., standing, walking, sitting) does not influence the sublesional BMC. This study underlines the major role of the neurological lesion on the decrease of sublesional BMC in SCI patients and the absence of influence of biomechanical stress.

Ischaemic myelopathy following aortic surgery or traumatic laceration of the aorta.

Paraplegia is one of the major complications following repair of aortic aneurysms or congenital malformations and from trauma of the aorta. In a series of 12 surviving patients we describe the clinical features as well as the evolution and pathophysiology of ischaemic lesions of the spinal cord. The clinical characteristics: loss of tendon reflexes, preservation of light touch sensation and bladder function, and the special topography of pin prick impairment, suggest involvement of the central grey matter. This lesion of the grey matter is incomplete in most of the patients and tends to extend for 2-10 segments. In some cases it can extend downward to the conus resulting in complete flaccid paraplegia. On follow-up we have observed limited improvement in most cases. No patient has recovered fully. Except in cases of traumatic laceration, where symptoms existed before surgery, paraplegia followed surgical repair in all other cases. Ischaemia can be related to the duration and the site of crossclamping of the aorta. Clamping above the left subclavian artery and/or a ligation of the intercostal arteries without previous visualisation of the spinal cord arteries can be dangerous. Other factors such as the phenomena of revascularisation and the presence of free radicals are discussed. These could explain delayed postischaemic spinal cord hypoperfusion.

Post-traumatic syringomyelia and post-traumatic spinal canal stenosis: a direct relationship: review of 75 patients with a spinal cord injury.

This study aims to demonstrate predictive factors for post traumatic syringomyelia (PTS), and in particular to correlate the role of insufficiency of reduction of a spinal fracture with the occurrence of syringomyelia. One hundred and twenty-eight spinal cord injured patients (SCI) were studied during the years 1992 and 1993. Among them, 75 underwent a complete and reliable evaluation including: review of the initial vertebral lesion, and of the surgery report, and a radiological study of the lesion site with standard X-rays, a CT scan, and an MRI. The CT Scan included slices in sagittal reconstructions and in the axial plane at the site of injury with the calculation of a percentage of canal stenosis in the two planes of the space. An MRI was carried out with T1 and T2 weighted images, including sagittal entire cord images in addition to sagittal and axial slices centred on the site of injury. A syrinx was diagnosed in 28% of the patients. The occurrence of a syrinx is significantly correlated with spinal canal stenosis in the sagittal plane (delta D) with a P < 0.001 and in the axial plane (delta S) (P < 0.05). This present study demonstrates the major role of the insufficiency of reduction of the vertebral lesion in the genesis of a syrinx. The quality of the initial treatment of the vertebral injury is the first step in the prevention of a syrinx. The treatment of a syrinx, besides techniques of drainage, must also take into account the spinal realignment.

Laryngotracheal stenosis after intubation or tracheostomy in patients with neurological disease.

OBJECTIVE: This retrospective study evaluated the incidence of airway complications in neurological patients following translaryngeal intubation, tracheostomy, or both. DESIGN: The medical records of 315 consecutive patients (200 with traumatic brain injuries, 31 traumatic tetraplegics, and 84 with other neurological disorders) were reviewed. The type of artificial airway, duration of intubation, and use of nocturnal ventilation were recorded. Eighty-six percent of the patients underwent some combination of tracheal tomograms, flow-volume loop analysis, and fiberoptic tracheolaryngoscopy. Stenosis was classified as severe if it required surgery, if it required maintaining the tracheostomy, or was lethal. It was classified as benign if it was successfully treated by medical or local means. RESULTS: Fifty-five percent of the patients were intubated translaryngeally only (mean = 17 days). Three percent underwent tracheostomy only, and 42% underwent tracheostomy after intubation for a mean of 13 days. The overall incidence of airway stenosis was 20%, 1/4 of which was severe. Fifteen percent of these patients died as a result of tracheal complications. The incidence of stenosis was higher following tracheostomy than following intubation only (29% vs 13%, p < .01). The incidence of severe stenosis in intubated-only patients was low (1%) compared with that following tracheostomy (10%, p < .01). No significant relationship was found between the length of intubation or the timing of tracheostomy. CONCLUSION: Fewer complications are associated with transtracheal intubation than with tracheostomy. The data suggest that longer periods of intubation be used when attempting ventilator weaning before restoring to tracheostomy if weaning fails.