Transurethral sphincterotomy provides significant relief in autonomic dysreflexia in spinal cord injured male patients: long-term followup results.

PURPOSE: An evaluation of the results of transurethral sphincterotomy in spinal cord injured patients for the relief of autonomic dysreflexia is presented. MATERIALS AND METHODS: The study describes experience with the treatment of 46 consecutive spinal cord injured males presenting with frequent symptoms of autonomic dysreflexia and inadequate voiding. The selection criteria include patients injured above the thoracic 6 level with subjective symptoms of autonomic dysreflexia who did not want to be catheterized or were unable to perform intermittent catheterization. Patients were studied with complex urodynamics before and at least 3 months after undergoing transurethral sphincterotomy. During cystometrogram the maximum increase in systolic and diastolic blood pressure was recorded. After transurethral sphincterotomy patients were followed for a mean of 5.4+/-3.1 years (range 1 to 12). RESULTS: There was subjective relief in autonomic dysreflexia following transurethral sphincterotomy in all patients, which correlated well with a significant decrease in systolic and diastolic blood pressure (p<0.0001). Mean decrease in maximal systolic and diastolic blood pressure after transurethral sphincterotomy was 55+/-25 and 29+/-17 mm Hg, respectively. Mean post-void residual urine decreased significantly from 233+/-151 to 136+/-0.34 ml after transurethral sphincterotomy. However, there was no significant change in mean maximum voiding pressures. CONCLUSIONS: Blood pressure monitoring during cystometrogram provides an objective assessment of the presence of autonomic dysreflexia due to neurogenic bladder dysfunction, enabling better therapeutic management to control autonomic dysreflexia. Persistence of significant autonomic dysreflexia needs urodynamic evaluation if other factors for autonomic dysreflexia have been excluded.

Reproducibility of noninvasive cardiac output during arm exercise in spinal cord injury.

The carbon dioxide (CO(2)) rebreathing method is a noninvasive technique to estimate cardiac output during exercise, but few data are available on the validity and reliability of this measure in individuals with spinal cord injury (SCI). Sixteen male subjects with SCI (mean age 45 +/- 9, seven paraplegic and nine tetraplegic) underwent three submaximal steady state arm ergometer exercise tests. We estimated cardiac output using the exponential CO(2) rebreathing technique at an individualized exercise intensity approximating 50% of peak oxygen uptake. Mean values for the cardiac output measurements were 13.0 +/- 2.4, 13.3 +/- 2.0, and 13.4 +/- 1.7 L/min; the difference among the trials was not significant (p = 0.54). The typical error was 1.80 +/- 0.85 L/min, the limits of agreement were 11.3 to 15.3 L/min, the coefficient of variation was 5.4% +/- 3.4%, and the intraclass correlation coefficient was 0.85 (95% confidence interval = 0.70-0.94). The test-to-test variation in estimated cardiac output during arm ergometry in individuals with SCI is similar to that observed in studies that used this technique in ambulatory persons. The 5% relative variation between tests suggests that the CO(2) rebreathing technique for estimating cardiac output can be performed in SCI individuals with acceptable reproducibility.

Aortoiliac hemodynamic and morphologic adaptation to chronic spinal cord injury.

BACKGROUND: Reduced lower limb blood flow and resistive hemodynamic conditions potentially promote aortic inflammation and aneurysmal degeneration. We used abdominal ultrasonography, magnetic resonance imaging, and computational flow modeling to determine the relationship between reduced infrarenal aortic blood flow in chronic spinal cord injury (SCI) subjects and risk for abdominal aortic aneurysm (AAA) disease. METHODS: Aortic diameter in consecutive SCI subjects (n = 123) was determined via transabdominal ultrasonography. Aortic anatomic and physiologic data were acquired via magnetic resonance angiography (MRA; n = 5) and cine phase-contrast magnetic resonance flow imaging (n = 4) from SCI subjects whose aortic diameter was less than 3.0 cm by ultrasonography. Computational flow models were constructed from magnetic resonance data sets. Results were compared with those obtained from ambulatory control subjects (ultrasonography, n = 129; MRA/phase-contrast magnetic resonance flow imaging, n = 6) who were recruited at random from a larger pool of risk factor-matched individuals without known AAA disease. RESULTS: Age, sex distribution, and smoking histories were comparable between the SCI and control groups. In the SCI group, time since injury averaged 26 +/- 13 years (mean +/- SD). Aortic diameter was larger (P < .01), and the prevalence of large (> or = 2.5 cm; P < .01) or aneurysmal (> or = 3.0 cm; P < .05) aortas was greater in SCI subjects. Paradoxically, common iliac artery diameters were reduced in SCI subjects (< 1.0 cm; 48% SCI vs 26% control; P < .0001). Focal preaneurysmal enlargement was noted in four of five SCI subjects by MRA. Flow modeling revealed normal flow volume, biphasic and reduced oscillatory flow, slower pressure decay, and reduced wall shear stress in the SCI infrarenal aorta. CONCLUSIONS: Characteristic aortoiliac hemodynamic and morphologic adaptations occur in response to chronic SCI. Slower aortic pressure decay and reduced wall shear stress after SCI may contribute to mural degeneration, enlargement, and an increased prevalence of AAA disease.

C-reactive protein, metabolic syndrome, and insulin resistance in individuals with spinal cord injury.

BACKGROUND/OBJECTIVE: High-sensitivity C-reactive protein (hsCRP) has been shown to be indicative of elevated risk of cardiovascular disease (CVD). We examined this blood marker in persons with spinal cord injury (SCI) in order to determine its potential for predicting elevated cardiac risk. METHODS: In a cross-sectional analysis, we examined the relationship between hsCRP and insulin resistance and metabolic syndrome among 93 individuals with SCI (50.2 +/- 13 years). Fasting lipids, insulin, glucose, plasma hsCRP, and anthropometric data were gathered from each subject. Comparisons were made with population reference values. RESULTS: Metabolic syndrome and insulin resistance were present in nearly one quarter of the SCI population (22.6%). Subjects with fasting insulin resistance had significantly higher mean hsCRP (4.29 +/- 3.25 mg/L) than those who were not insulin resistant (2.24 +/- 2.02) (P < 0.05). Moreover, hsCRP was significantly elevated in individuals who presented with high cardiovascular risk including severe dyslipidemia (> or = 4 abnormal lipid values) and Framingham Risk scores < or = 6 (P < 0.05 for both values). In addition, the homeostasis model assessment of insulin resistance was mildly correlated with hsCRP (r = 0.33). CONCLUSIONS: In individuals with SCI who are insulin resistant and/or display components of the metabolic syndrome, hsCRP is elevated suggesting a clinically important association with cardiovascular risk in this population.

Heart rate as a predictor of energy expenditure in people with spinal cord injury.

This study evaluated the accuracy of heart rate calibrated from a maximum exercise test for predicting energy expenditure during five activities of daily living (ADL) in participants with spinal cord injury (SCI). Thirteen individuals with SCI underwent maximum exercise testing, followed by portable heart rate and metabolic testing during five ADL. A regression equation was developed from heart rate and oxygen uptake responses during the maximum exercise test for each subject. Based on this individualized equation, heart rate measured during the ADL was used to estimate energy expenditure for each participant. Predicted energy expenditure from heart rate was compared with that measured by indirect calorimetry with the use of oxygen uptake. Heart rate derived from the individualized regression equations explained 55% of the variance in measured energy expenditure, compared with only 8.3% from heart rate alone. However, calibrated heart rate consistently overestimated the actual kilocalories used; on average, the estimated energy expenditure was roughly 25% higher than that measured by oxygen uptake. Heart rate can be used as a gross estimate of energy expenditure during higher-intensity ADL in people with SCI when individual calibration of heart rate from maximum exercise testing is used.

Donald Munro Lecture 2003. Neurogenic bladder: past, present, and future.

The foundation of the management of neurogenic bladder can be attributed to a pioneer in spinal cord injury medicine. Dr. Donald Munro, a neurosurgeon, who also had experience in urologic surgery, established the first Spinal Cord Injury Service of 10 beds in the Boston City hospital in the 1930s. He later became adviser to the US Army and the Veterans Administration (VA). On his recommendation, paraplegic centers were created in US army hospitals and later in the VA hospitals from 1943 to 1945. This article reviews the evolution of the management of neurogenic bladder in patients with spinal cord injuries from the past century to the present. The role of urodynamics in defining neurologic lesions is critical to the appropriate management of the voiding dysfunction. Key advances, such as the diagnosis of detrusor sphincter dyssynergia (DSD), recognition of its association with autonomic dysreflexia, and its definitive management, have been emphasized. The role of transrectal linear array sonography using a rectal probe was found useful for defining bladder outlet dysfunction during urodynamics. It also helped to recognize secondary bladder neck obstruction and diagnose false passages in the urethra. Clean technique intermittent catheterization (IC) was evaluated and recommended. In about 28% patients with DSD that led to secondary bladder neck obstruction, a consequence of IC was reported. Transurethral laser sphincterotomy (TURS) was first reported by me in 1991, and later, durable 7-year follow-up results were reported in 78% of the first 99 patients. We reported a surgical technique to lengthen the penis. We also reported the long-term success with semirigid implants in 92% of patients with SCI. This technique helped maintain external condom drainage on a small phallus and improved the sex life of patients, as well as their quality of life. The author's pertinent areas of interest in the past one-half century were aimed at recognizing specific urologic problems associated with neurologic impairment. Management was aimed at preventive care, early recognition, and timely management to reduce secondary complications and enhance quality of life.

Prostate cancer diagnosed in spinal cord-injured patients is more commonly advanced stage than in able-bodied patients.

OBJECTIVES: To determine the incidence and characteristics of prostate cancer in men with spinal cord injury (SCI). Little is known about the characteristics of prostate cancer in men with SCI, because prostate cancer screening is not aggressively performed in this population. METHODS: In one fiscal year, 648 men with SCI older than age 50 years were actively enrolled with the SCI service, 20,949 able-bodied men older than age 50 years were actively enrolled in the outpatient clinic database, and 945 patients with prostate cancer were in the cancer registry at our facility. These three databases were cross-referenced for prostate cancer diagnosis and stage and compared with the presence of SCI. RESULTS: Of the 648 patients with SCI, 12 patients with a prostate cancer diagnosis that preceded their injury were excluded. Of the remaining 636 patients, 11 (1.7%) had been diagnosed with prostate cancer since their injury. In contrast, of the 20,949 able-bodied men older than age 50 years seen at our facility in fiscal year 1999, 919 (4.4%) had prostate cancer. Of the patients with SCI and prostate cancer, 7 (63.6%) had locally advanced (Stage T3) or metastatic prostate cancer compared with 267 (29.1%) in the able-bodied population (P = 0.012). CONCLUSIONS: Although the proportion of patients with a prostate cancer diagnosis was greater in the able-bodied patients, the prostate cancer detected in the patients with SCI tended to be of a more advanced stage and grade. The difference was likely a result of the decreased use of prostate cancer screening in this population.

Which stoma works better for colonic dysmotility in the spinal cord injured patient?

BACKGROUND: The formation of an intestinal stoma is very effective in the treatment of colonic dysmotility associated with spinal cord injury (SCI). Little is known about the difference in the long-term outcome among left-sided colostomies, right-sided colostomies, and ileostomies in this patient population. METHODS: The records of 45 SCI patients with intestinal stomas at our institution were reviewed retrospectively. Operative details and preoperative colonic transit times (CTT) were recorded. Patients who were alive and available were interviewed using a questionnaire designed to assess the quality of life (QOL), health status, and time to bowel care before and after stoma formation. RESULTS: Between 1976 and 2002, 45 patients underwent a total of 48 intestinal stomas. A left-sided colostomy (LC) was formed in 21 patients, right-sided colostomy (RC) in 20, and ileostomy (IL) in 7. Three of the patients in the RC group ultimately underwent total abdominal colectomy and ileostomy. The indications for stoma formation and CTT were different in the three groups. Bloating, constipation, chronic abdominal pain, difficulty evacuation with prolonged CTT was the main indication in 95% of patients in the RC group, 43% of patients in the LC group, and 29% in the IL group. Management of complicated decubitus ulcers, perineal and pelvic wounds was the primary indication in 43% of patients in the LC group, 5% in the RC group, and none in the IL group. Preoperative total and right CTTs were longer in the RC group compared with the LC group: 127.5 versus 83.1 hours (P <0.05) and 53.7 versus 28.5 hours (P <0.05), respectively. Eighty-two percent of patients (37 of 45) were interviewed at a mean follow-up of 5.5 years after stoma formation. Most patients who were interviewed were satisfied with their stoma (RC, 88%; LC, 100%; IL, 83%) and the majority would have preferred to have the stoma earlier (RC, 63%; LC, 77%; and IL, 63%). The QOL index significantly improved in all groups (RC, 49 to 79, P <0.05; LC, 50 to 86, P <0.05; and IL, 60 to 82, P <0.05), as well as the health status index (RC, 58 to 83, P <0.05; LC, 63 to 92, P <0.05; IL, 61 to 88, P <0.05). The average daily time to bowel care was significantly shortened in all groups (RC, 102 to 11 minutes, P <0.05; LC, 123 to 18 minutes, P <0.05; and IL, 73 to 13 minutes, P <0.05.). CONCLUSIONS: Regardless of the type of stoma, most patients had functional improvement postoperatively. Patients who underwent RC had longer CTT and more chronic symptoms related to colonic dysmotility, reflecting the preoperative selection bias. The successful outcome noted in all groups suggests that preoperative symptoms and CTT studies may have been helpful in optimal choice of stoma site selection.

Displacement sequence and elastic properties of anterior prostate/urethral interface during micturition of spinal cord injured men.

The management of complex micturition problems frequently encountered in patients with spinal cord injury (SCI) may be facilitated by characterization of the elastic properties of the prostate. To this end, we have developed a method of evaluating changes in prostate biomechanics using ultrasound (US) images obtained during routine diagnostic urodynamic evaluations. Ultrasound video sequences of the prostate and urethra during voiding were digitized simultaneously with bladder pressure measurement on 76 patients with spinal cord injury, having a mean age of 47 +/- 16 years. Computer enhancement of the bladder/prostate/urethral interface from sequences of 2-D US images facilitated measurement of midprostatic urethral displacement during micturition. Of 76 patients, 21 were able to initiate voiding. Maximum urethral diameter was 12.0 +/- 1.3 mm, with corresponding maximum voiding pressure of 61.6 +/- 1.9 cmH(2)O. Urethral/prostatic pressure strain elastic modulus (Ep) was 960 +/- 624 N/m(2) and stiffness (beta) calculated as the inverse of compliance was 2.8 +/- 0.1. The diameter of the urethra at P(det50+), during the opening phase, was 0.4 +/- 0.1 mm and, during the closing phase, was 0.7 +/- 0.1 mm. During voiding, the anterior prostate was displaced to a greater extent than the posterior prostate. These observations suggest that distension of the prostate/urethra during micturition is hysteretic and nonuniform and indicates regional differences in compliance within the prostate/urethra interface. These regional differences lend support to the concept that the posterior prostate is implicated in the active process of micturition involving the fibromuscular stroma. Clinical application of this method could include quantification of the biomechanics of micturition consequent to spinal injury, prostatic enlargement, and the impact of targeted evaluation of pharmacological interventions.

The effects of colostomy on the quality of life in patients with spinal cord injury: a retrospective analysis.

PURPOSE: The purpose of this study was to evaluate the effects of colostomy on the quality of life (QOL) in patients with spinal cord injury (SCI) by designing a questionnaire that used self-reported data and correlating these data with the clinical information obtained from patients' medical records. MATERIALS AND METHODS: A comprehensive QOL questionnaire was designed to specifically address the following 5 domains: physical health, psychosocial adjustment, body image, self-efficacy, and recreation/leisure. This questionnaire was completed during a telephone or an in-person interview. The subjective data derived from the questionnaire were correlated with objective medical information obtained from a review of medical records. RESULTS: The QOL improved significantly (t = 9.1 28, P < .0001) after colostomy. All 27 (100%) patients were "satisfied," and 16 (59%) of them were "very satisfied" with colostomy. Nineteen (70%) patients would have preferred to have the colostomy done earlier, and only 3 (11%) patients wished it reversed. Colostomy reduced the number of hospitalizations caused by chronic bowel dysfunction by 70.4%. After colostomy, the average amount of time spent on bowel care was reduced from 117.0 min/day to 12.8 min/day (t = 7.964, P < .0001). All patients stated that colostomy simplified bowel care routine and increased independence. Significant improvements were recorded in the areas of physical health, psychosocial adjustment, and self-efficacy. Stoma prolapse and wound dehiscence were the most common complications of stomal surgery. When compared with medical data, patients were able to reliably recall average time with bowel problems (r = .881, P < .0001) and stomal surgery complications (r = .810, P < .0001). CONCLUSION: Colostomy is a safe and effective treatment for chronic bowel dysfunction in patients with spinal cord injury. It is well accepted by the patients and significantly improves QOL and bowel management procedures. Correlation analysis indicates that subjective patient-reported data are consistent with objective data obtained from the medical records.

Electrocardiographic findings in patients with chronic spinal cord injury.

OBJECTIVE: To demonstrate the prevalence and prognostic value of electrocardiographic abnormalities in patients with chronic spinal cord injury. METHODS: All electrocardiographs obtained in the Palo Alto Veterans Affairs Medical Center since 1987 have been digitally recorded and stored in a computerized database. For this study, only the first electrocardiograph was considered for analysis. The subjects were divided according to age and level of spinal cord injury. The Social Security Death Index was used to ascertain vital status as of December 1999. RESULTS: Annual mortality was similar in those with chronic spinal cord injury and the able-bodied. However, individuals with a higher level of injury had a significantly higher death rate than those with a lower level of injury. The prognostic characteristics of electrocardiographic abnormalities were similar in both the able-bodied and those with spinal cord injury. CONCLUSION: In general, electrocardiographic abnormalities had the same prevalence in the spinal cord injury subjects as in the able-bodied ones. The prognostic value of electrocardiographic abnormalities in subjects with spinal cord injury is similar to that observed in able-bodied subjects.

Early repolarization in patients with spinal cord injury: prevalence and clinical significance.

OBJECTIVES: The objective was to examine the prevalence of early repolarization in a spinal cord injury (SCI) clinic and the relationship of level of injury to this electrocardiogram (ECG) finding. BACKGROUND: ST elevation on the resting ECG can be either a normal variant or a sign of acute ischemia, evolving myocardial infarction, or pericarditis. It is frequently seen as a normal variant (early repolarization) in healthy individuals, but has also been reported in individuals with SCI. While the etiology of benign ST elevation (early repolarization) has not been clearly defined, current opinion is that this finding is seen in individuals with high vagal tone. METHODS: Retrospective analysis was made of 31 5 individuals with SCI at T5 or above (140 with complete injuries), and 1 98 with SCI at T6 or below, and who had ECGs in the computerized database at the Palo Alto VA Medical Center. A comparison cohort of 32,841 able-bodied male controls also was identified in the same ECG database. Patient demographics and computerized ST measurements were analyzed. RESULTS: The prevalence of ST elevation was significantly higher in both the total high-level injury group (19%) and the complete high-injury group (24.5%) than in either the low-injury (6.5%) or control groups (13%), with P < 0.001 for comparisons between both high- and low-injury groups and high injury vs control. The magnitude of ST elevation was also higher in the high-injury groups vs the low-injury and control groups. CONCLUSION: There is a higher prevalence of early repolarization in individuals with SCI at levels of injury that can disrupt central sympathetic command of the heart. It appears that either enhanced vagal tone or loss of sympathetic tone is responsible for ST elevation.

Occult maxillary sinusitis as a cause of fever in tetraplegia: 2 case reports.

Common causes of fever in tetraplegia include urinary tract infection, respiratory complications, bacteremia, impaired autoregulation, deep vein thrombosis, osteomyelitis, drug fever, and intra-abdominal abscess. We report 2 acute tetraplegic patients who presented with fever of unknown origin. After extensive work-up, they were diagnosed with occult maxillary sinusitis. A search of current literature revealed no reports of sinusitis as a potential source of fever in recently spinal cord--injured patients. Patients with tetraplegia, especially in the acute phase of spinal cord injury, often undergo nasotracheal intubation or nasogastric tube placement, which may result in mucosal irritation and nasal congestion. All of the previously mentioned factors, in combination with poor sinus drainage related to supine position, predispose them to developing maxillary sinusitis. The 2 consecutive cases show the importance of occult sinusitis in the differential diagnosis of fever in patients with tetraplegia.