Neurogenic bladder in patients with traumatic spinal cord injury: treatment and follow-up.

STUDY DESIGN: Multi-center, cross-sectional study. OBJECTIVES: Our aim was to evaluate the treatment methods and follow-up of neurogenic bladder in patients with traumatic spinal cord injury retrospectively using a questionnaire. SETTING: Turkey. METHODS: Three hundred and thirty-seven patients who had spinal cord injury for at least 2 years were enrolled from six centers in the neurogenic bladder study group. They were asked to fill-out a questionnaire about treatments they received and techniques they used for bladder management. RESULTS: The study included 246 male and 91 female patients with a mean age of 42±14 years. Intermittent catheterization (IC) was performed in 77.9% of the patients, 3.8% had indwelling catheters, 13.8% had normal spontaneous micturition, 2.6% performed voiding maneuvers, 1.3% used diapers and 0.6% used condom catheters. No gender difference was found regarding the techniques used in bladder rehabilitation (P>0.05). Overall, 63.2% of patients used anticholinergic drugs; anticholinergic drug use was similar between genders (P>0.05). The most common anticholinergic drug used was oxybutynin (40.3%), followed by trospium (32.6%), tolterodine (19.3%) darifenacin (3.3%), propiverine (3.3%) and solifenacin (1.1%). The specialties of the physicians who first prescribed the anticholinergic drug were physiatrists (76.2%), urologists (22.1%) and neurologists (1.7%). Only four patients had previously received injections of botulinum-toxin-A into the detrusor muscle and three of them stated that their symptoms showed improvement. Most of the patients (77%) had regular follow-up examinations, including urine cultures, urinary system ultrasound and urodynamic tests, when necessary; the reasons for not having regular control visits were living distant from hospital (15.3%) and monetary problems (7.7%). Of the patients, 42.7% did not experience urinary tract infections (UTI), 36.4% had bacteriuria but no UTI episodes with fever, 15.9% had 1-2 clinical UTI episodes per year and 5% had ⩾3 clinical UTIs. The clinical characteristics of patients with and without UTI (at least one symptomatic UTI during 1 year) were similar (P>0.05). The frequency of symptomatic UTI was similar in patients using different bladder management techniques (P>0.05). CONCLUSION: The most frequently used technique for bladder rehabilitation in patients with SCI was IC (77.9%). In all, 63.2% of patients used anticholinergic drugs, oxybutynin being the most commonly used drug. Also, 77% of patients had regular control visits for neurogenic bladder; 42.7% did not experience any UTIs.

Intermittent catheterization in patients with traumatic spinal cord injury: obstacles, worries, level of satisfaction.

OBJECTIVES: The aim of this study is to examine the obstacles in people with traumatic spinal cord injury (SCI) face performing intermittent catheterization (IC), also their worries and level of satisfaction. METHODS: Two hundred sixty-nine patients performing IC for at least 3 months were asked to fill-out a questionnaire about their opinions on IC. RESULTS: In total, 69.5% of patients performed IC themselves, 10.4% had performed by their mothers, 7.8% by another caregiver and 7.4% by their spouse. For the 72 (26%) patients unable to apply IC, reasons were insufficient hand function (56.1%), being unable to sit appropriately (35.4%) and spasticity (8.5%). In all, 70% of male patients had insufficient hand function, 20% could not sit and 10% had spasticity while 56.3% of female patients could not sit, 37.5% had insufficient hand function and 63% had spasticity. Difference between sexes was found to be statistically significant (P<0.05). Worries patients had when starting IC were fear of being dependent on IC (50.2%), accidentally injuring self (43.8%), embarrassment (43.2%), causing an infection (40.2%), bleeding (32.7%), fear of feeling pain (30.2%) and hygiene (24.7%). More women felt embarrassment; other items were similar in both sexes. In all, 46.9% of patients had urinary incontinence in intervals. CONCLUSION: In total, 69.5% of patients performed IC themselves. Men's most common obstacle was insufficient hand function while women's was being unable to sit appropriately. Patients' most common worries were being dependent on IC for life. In all, 46.9% had incontinence in intervals; 47.9% said IC improved their life quality; and 97.4% preferred IC over continuous catheterization.

Effects of different bladder management methods on the quality of life in patients with traumatic spinal cord injury.

STUDY DESIGN: Multi-center, cross-sectional study. OBJECTIVES: To investigate the effects of different bladder management methods on the quality of life (QoL) in patients with spinal cord injury (SCI). SETTING: Turkey. METHODS: Consecutive SCI patients (n=195, 74.4% males), for whom at least 6 months had elapsed since the injury, were included and evaluated in five groups: normal spontaneous micturition (NSM), micturition with assisted maneuvers (MAM), aseptic intermittent catheterization by patient (IC-P), aseptic IC by an attendant/caregiver (IC-A) and indwelling catheterization. The King's Health Questionnaire was used to evaluate the patients' QoL. RESULTS: The bladder management groups were similar regarding age, time elapsed since injury, education level, marital and occupational status. There was no difference among the groups in general health perception, personal relationships and sleep/energy domain scores. While the NSM group had generally the lowest scores, that is, better QoL, the IC-A group had the highest scores, that is, poorer QoL, in most of the domains. When the patients were grouped according to the frequency of urinary incontinence or American Spinal Injury Association Impairment Scale grades, no difference was found in the domain scores of the groups except the symptom severity domain scores. No significant difference was found between paraplegic and tetraplegic patients in the King's Health Questionnaire domains. CONCLUSION: The QoL was notably affected in SCI patients in IC-A group and negative effects on emotional status, physical and social activity limitations were observed, as well.

The effects of phenol neurolysis of the obturator nerve on the distribution of buttock-seat interface pressure in spinal cord injury patients with hip adductor spasticity.

OBJECTIVES: Hip adductor spasticity may adversely effect shear-force and pressure distribution on the buttocks, where ulcerations most frequently appear in patients with spinal cord injury (SCI). Phenol neurolysis of the obturator nerve (ON) is commonly used to manage hip adductor spasticity. This study aimed to determine the effects on the distribution of buttock-seat interface pressure (BSIP) in a group of SCI patients with adductor spasticity that underwent ON blockade with phenol. METHODS: We reviewed the records of SCI patients that were admitted to our clinic between January 2009 and December 2009. BSIP values (obtained with an X-sensor 48) and hip adductor spasticity levels of SCI patients with hip adductor spasticity that underwent ON blockade with phenol were collected. BSIP distributions of the patients were divided into two portions: first one is the BSIP distribution at the pressure ≤37 mm Hg, and the second one is at the pressure >37 mm Hg. RESULTS: The study included 20 SCI patients (19 males and 1 female), with a mean age of 42.85±13.24 years. Although the percentage of BSIP distribution at ≤37 mm Hg range increased significantly (P<0.001), after ON neurolysis, BSIP distribution at >37 mm Hg range decreased significantly (P<0.001). In addition, mean hip adductor spasticity decreased significantly after ON neurolysis (P<0.001). CONCLUSION: Phenol neurolysis of the ON is a promising treatment for the management of hip adductor spasticity in SCI patients and also has positive effects on BSIP, which has a crucial function in the development of pressure ulcers.

Coccyx fractures in patients with spinal cord injury.

AIM: The aim of this study was to report whether coccyx fractures are present in spinal cord injury (SCI) patients, who suffered from painful symptoms in the low back, gluteal, hip and thigh regions; and to determine the pain characteristics of coccydynia in these patients. METHODS: Twenty males and six females with traumatic SCI (mean age: 31.57+/-12.23 years) who described painful symptoms in the low back, hip, gluteal or thigh regions were included in the study. Pain assessment was done by using visual analogue scale (VAS) and the short form of McGill pain questionnaire. Radiological assessment comprised two-sided lumbar vertebrae, hip and coccyx X-ray graphics. RESULTS: Mean duration of SCI was 19.54+/-30.08 months. Nine patients (34.62%) had coccyx fractures. Sensory Pain Index and total McGill scores were found to be significantly higher in patients with coccyx fractures. Correlation analyses revealed significant correlations between VAS, SPI, affective pain index, present pain intensity and McGill total scores (all P<0.05). Duration of SCI was correlated with SPI (P=0.03) and total McGill scores (P=0.05). CONCLUSION: Coccyx fractures have been detected in patients with SCI and the presence of such fractures seems to affect the pain scenario unfavorably. Involved patients will be treated promptly and their rehabilitation process will be enhanced when these fractures are recognized early.

Evaluation of the Amor and ESSG classification criteria for spondylarthropathies in a Turkish population.

This study evaluated the Amor and European Spondylarthropathy Study Group (ESSG) classification criteria for spondyloarthropathies in Turkish patients seen from October 1990 to August 1993 at the Physical Medicine and Rehabilitation Department of the GATA Haydarpasa Training Hospital. The Amor and ESSG criteria were evaluated in 157 patients with spondylarthropathies and in 124 controls with a variety of other rheumatic diseases. The sensitivity, specificity, positive predictive value, and negative predictive value of each criteria set were calculated, as well as the sensitivity and specificity of each of the 24 criteria used in these sets. For Amor's criteria, sensitivity was 88.5%, specificity was 91.9%, positive predictive value was 93.3% and negative predictive value was 86.4%. For the ESSG criteria, sensitivity was 86.6%, specificity was 91.1%, positive predictive value was 92.5% and negative predictive value was 84.3%. No significant differences were found between the two criteria sets. Our data show that the Amor and ESSG criteria are of similar value for the classification of spondylarthropathies and are comparable in terms of sensitivity and specificity. They also demonstrate the need for monitoring patients with equivocal clinical patterns using both sets of criteria as tools that complement each other.

Paraplegia: an unusual presentation of Ewing's sarcoma.

STUDY DESIGN: Single-subject case. OBJECTIVES: To describe the atypical presentation of a rare tumor and difficulties in diagnosis. SETTING: Spinal cord unit of a rehabilitation and care center in Ankara, Turkey. METHODS: A 22-year-old male patient with paraplegia was admitted to our center for rehabilitation. He underwent various diagnostic procedures to explain his clinical situation. RESULTS: Abdominal ultrasound and computed tomography revealed a mass and vertebral destruction. The pathology report confirmed the diagnosis of Ewing's sarcoma. CONCLUSION: Spinal cord compression is an important complication of primary or metastatic malignant tumors. Although it is a late complication in most cases, some tumors including Ewing's sarcoma may present with paraplegia. Trauma may be found in the patient's history. An atypical clinical course in a musculoskeletal or neurological condition should alert us to a possible underlying malignant disease.

Neurobrucellosis and a demonstration of its involvement in spinal roots via magnetic resonance imaging.

OBJECTIVE: To present a neurobrucellosis case with spinal root involvement by means of magnetic resonance imaging (MRI). METHODS: A case of neurobrucellosis resembling Guillain-Barré syndrome is being reported. This case is unique in a way that spinal root involvement because of brucellosis was for the first time confirmed by MRI. SETTING: Spinal cord unit of a rehabilitation and care center in Ankara, Turkey. RESULTS: The correct diagnosis was made with cerebrospinal fluid culture. The patient showed a significant improvement with antimicrobial therapy and rehabilitation. CONCLUSION: Polyradiculopathy because of neurobrucellosis may mimic neurological syndromes. Rehabilitation should also be a part of its treatment.

Nursing care in spinal cord injuries in Turkey.

The organized management of spinal cord injury is a team activity and the nurse is at the central position of that team. Nursing activities and caring should be superior in a spinal cord injury rehabilitation department. Nevertheless, nurses seldom undertake caring activities and usually perform therapeutic activities in developing countries. We recorded the care of 15 spinal cord injured patients around the clock for 10 working days. We asked the nurses, patients and their family carers to record every activity they performed on the forms. The activities were as follows: Oral care, face care, hand care, foot care, nail care, genitalia care, perineal care, catheterization, head bath, bed bath, bath, positioning, mobilization, exercising, wound dressing, room activities and the other nursing activities. The total number of nursing activities, performed was 3573. Subtotals were as follows: 2545 caring activities, 364 room activities, and 664 other nursing activities. While nurses performed 550 of the caring activities, patients and their family carers performed 988 and 1007 patient care activities. The distribution of the nurses' activities was as follows: 40% for caring, 11% for room activities, 48% for others. We discuss the importance of caring activities and the role of nurses in the rehabilitation team.