Sigmoid colon rupture secondary to Credé's method in a patient with spinal cord injury.

Credé's method is a manual suprapubic pressure exerted with a clenched fist or fingers, used to initiate micturition, in patients with spinal cord injury (SCI) who have neurovesical dysfunction. It is usually a benign maneuver unassociated with any major complications. This paper will illustrate a case report involving a sigmoid colon rupture secondary to Credé's method in a patient with SCI. Various techniques of Credé's method are briefly described. It is recommended that patients with quadriplegia avoid forceful use of Credé's method, as it may cause contusion of the abdominal wall and injuries to internal viscera, possibly leading to colonic rupture. It is believed that this is the first reported case of such an unusual complication of Credé's method in patients with SCI.

Autonomic dysreflexia/hyperreflexia.

As alluded to at the onset, our purpose is to provide a periodic reminder about autonomic dysreflexia/hyperreflexia (AD). Some historical background was offered since so much of the recent literature has been obtained from Medline which started in 1966. There were a number of early pioneers who first labored with AD. Kewalramani, in his fine paper, found various names for AD in the literature: sympathetic hyperreflexia, paroxysmal hypertension, spinal poikilopiesis, autonomic spasticity, paroxysmal hyperactive autonomic reflexes and paroxysmal neurogenic hypertension. Why not use only one term for this life threatening syndrome: autonomic dysreflexia/hyperreflexia.

Surgical aspects of autonomic dysreflexia.

Autonomic dysreflexia (AD) is a characteristic syndrome that occurs in spinal cord injury (SCI) patients with lesions above the sympathetic outflow at T6 and rarely in those with lesions below T10. Symptoms are initiated by noxious stimuli below the level of injury which result in massive sympathetic discharges from the isolated cord. These produce what may be called a sympathetic storm manifest by severe life threatening hypertension. Anesthesiologists and surgeons dealing with SCI patients must know how to recognize this syndrome, how to prevent its occurrence and how to manage it aggressively. Choice of anesthesia is frequently difficult and, in particular, it may be difficult to decide which type of anesthesia is best for patients susceptible to the syndrome. Therefore, we have conducted a retrospective study of SCI patients in the Department of Veterans Affairs Medical Center, Long Beach, California, where the Spinal Cord Injury Service is one of the largest in the country.

Vitamin D, parathormone, and calcitonin profiles in persons with long-standing spinal cord injury.

Rapid immobilization after acute spinal cord injury (SCI) leads to increased bone resorption, net calcium efflux from the bone, hypercalciuria, depressed parathormone (PTH) and increased calcitonin release. However, the effects, if any, of long-standing SCI on calcium regulatory system is not well understood. We measured plasma concentrations of 25 hydroxy (OH) vitamin D, 1,25(OH)2 vitamin D (calcitriol), intact PTH molecule, calcitonin, ionized calcium [Ca++] and phosphorus in 40 clinically stable men with long-standing SCI of 3-year to 50-year duration (22 persons with paraplegia and 18 persons with quadriplegia). The results were compared with those obtained in 14 able-bodied control men. Plasma PTH concentration in the SCI group was significantly lower than that found in the able-bodied controls despite virtually identical concentrations of ionized calcium. Likewise, plasma calcitriol concentration in the SCI group was significantly lower than the value found in the able-bodied control group and lower in persons with quadriplegia than in those with paraplegia. In contrast, plasma calcitonin concentration in the quadriplegic group was significantly higher than that in persons with paraplegia and insignificantly higher than that in the control group. No significant difference was noted in serum ionized calcium between the study groups. PTH and calcitriol levels were positively related to one another (r = 0.35, p < .01) and negatively related to the level of injury (r = -0.43, p < .002 and r = -0.54, p < .001, respectively). In conclusion, long-standing SCI is associated with significant depression of calcitriol and PTH concentrations despite normal ionized calcium concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrinolytic and protease inhibitory systems in spinal cord injured patients with end-stage renal disease.

Earlier studies have revealed a variety of coagulation abnormalities in patients with long-standing spinal cord injury (SCI) and end-stage renal disease (ESRD). The present study was undertaken to examine the fibrinolytic and protease inhibitory systems in this population. Twelve spinal cord injured men with ESRD were studied. All patients had chronic active urinary tract infections, pressure ulcers and were practically bed-bound. The results were compared with those obtained in a group of 32 normal volunteers. Plasma plasminogen and unstimulated tissue-type plasminogen activator (t-PA) concentrations in the SCI-ESRD group were comparable with those found in the control group. No significant difference was found in plasma plasminogen activator inhibitor (PAI) activity in the two groups. In contrast, plasma alpha 2-antiplasmin antigen concentration and antiplasmin activity were significantly reduced in the study population. In addition, plasma alpha 1-antitrypsin activity and antigen concentration were significantly increased while the alpha 2-macroglobulin activity-to-antigen concentration ratio was significantly reduced in the SCI-ESRD group. Although the mechanism of the observed reduction in alpha 2-antiplasmin and total antiplasmin activity is uncertain, its presence could enhance fibrinolysis in this otherwise thrombosis-prone population. Likewise, elevated alpha 1-antitrypsin could attenuate tissue damage by leukocyte-derived proteases in the face of persistent suppurative infections. The reduced alpha 2-macroglobulin activity-to-antigen concentration ratio was thought to reflect the presence of alpha 2-macroglobulin complexes with various proteases generated by the activation of leukocytes, coagulation, fibrinolytic and other proteolytic systems.

Erythropoietin profile in spinal cord injured patients.

Patients with spinal cord injury (SCI) have a high incidence of anemia. Intact erythropoietin (EPO) production is essential to the maintenance of erythrocyte mass and prevention and correction of anemia. However, the effect of chronic SCI on EPO production remains unclear. We measured plasma EPO concentration in 83 men with longstanding SCI and a group of normal able-bodied individuals. The SCI patients showed a significant reduction in hematocrit, a high prevalence of anemia, and an increased plasma EPO concentration. Active smokers showed a significantly higher hematocrit and lower EPO concentration than nonsmokers. No significant difference was found in hematocrit or EPO between individuals with paraplegia and those with quadriplegia. A negative correlation was found between EPO and hematocrit in SCI patients lacking significant lung disease. Thus, in the absence of renal insufficiency, EPO response to anemia is qualitatively preserved in SCI patients and is largely independent of the level of injury.

Effects of chronic spinal cord injury and pressure ulcer on 25(OH)-vitamin D levels.

We studied 92 spinal cord injured (SCI) men (50 paraplegics and 42 quadriplegics) with normal renal function, 38 of whom had single or multiple pressure ulcers. The results were compared with those of 28 able-bodied normal controls. Serum concentrations of calcium and magnesium were measured by atomic absorption spectrometry, and 25(OH)-vitamin D was quantitated by a specific competitive binding assay using a sensitive vitamin D binding protein and tritiated 25(OH)-vitamin D. The SCI group exhibited significant reductions in serum 25(OH)-vitamin D and total calcium concentrations as compared to the normal control group. Although the mean serum concentration of 25(OH)-vitamin D in the quadriplegic patients as a whole was lower than that found in the entire paraplegic group, the difference did not attain statistical significance. Similar observations were made when the ulcer-free subgroups of paraplegics and quadriplegics were compared. The SCI subgroup which was least physically active, i.e., those with pressure ulcers, showed the greatest depression of serum 25(OH)-vitamin D, calcium, and magnesium concentrations. The observed reduction in serum 25(OH)-vitamin D in SCI patients appears to be partly related to reduced cutaneous vitamin D biosynthesis from sunlight deprivation occasioned by physical disability and hospitalization. In addition, nutritional deficiency and altered intestinal transport may be involved. The reduction in serum calcium concentration may be related to abnormal vitamin D metabolism and hypoalbuminemia (reduced protein-bound calcium).

Pressure ulcer, fibronectin, and related proteins in spinal cord injured patients.

Pressure ulcer is a common occurrence in spinal cord injured (SCI) patients and can lead to serious complications. With proper management, some patients exhibit satisfactory healing whereas others show slow or nonhealing ulcers. Fibronectin has been shown to accumulate in wound, opsonize macroaggregate debris for phagocytosis, promote revascularization, and facilitate fibroblast migration and proliferation. We explored the relationship of plasma fibronectin with healing potential in 21 SCI men with pressure ulcer. They received standard wound care and were observed for eight weeks. Ten otherwise healthy SCI men without pressure ulcer (SCI-controls) and 32 able-bodied normal individuals (normal controls) were also studied. Plasma fibronectin and related proteins, ie, fibrinogen, plasminogen, alpha 2-antiplasmin and Factor XIII, were measured. Ten of 21 SCI patients with pressure ulcer showed rapid healing within four weeks and had significantly higher fibronectin levels as compared with the 11 patients with poor healing ulcers, SCI controls, and normal controls. Factor XIII and alpha 2-antiplasmin were mildly reduced and fibrinogen values were significantly increased in all SCI groups. Plasminogen concentrations were comparable in all groups studied. It thus appears that plasma fibronectin rises in patients with fast healing ulcers but fails to do so in those with poor healing ulcers and as such may be predictive of the course of pressure ulcers.

Fatal cerebral hemorrhage due to autonomic dysreflexia in a tetraplegic patient: case report and review.

Autonomic dysreflexia is the most important specific complication of high level spinal cord injury both in tetraplegic and in paraplegic patients above the midthoracic neural segment. It is a life threatening emergency that may lead to apoplexy. We present a case of fatal cerebral hemorrhage due to autonomic dysreflexia in order to demonstrate the gravity of this particular syndrome.

Decreased systemic clearance of lorazepam in humans with spinal cord injury.

Serum concentration-time course profiles, serum protein binding, and disposition parameters of lorazepam (LRZ), a benzodiazepine with sedative-hypnotic, anxiolytic, and anti-seizure properties, were studied as part of a systematic effort to define population-specific pharmacokinetic behavior in humans with chronic spinal cord injury (SCI). Twenty-four healthy subjects (nine tetraplegic, six paraplegic, nine able-bodied) were given an IV bolus of 2.0 mg of LRZ. Noncompartmental estimation of pharmacokinetic parameters disclosed a 37% decrease in the total systemic clearance (CL) of LRZ in tetraplegic patients. Altered LRZ clearance was observed independently of significant changes in volume of distribution or serum protein binding. The early elimination of LRZ (0-10 hr) was characterized by wide fluctuations in serum concentration suggestive of impaired enterohepatic circulation and could be distinguished from LRZ elimination observed in able-bodied subjects. We conclude that decreased systemic CL and the altered terminal elimination profile of LRZ are attributable to the pathophysiology of SCI.

Muscle release in the management of spasticity in spinal cord injury.

Muscle spasticity and contractures in the spinal cord injured are a big problem interfering with rehabilitation, leading to inconveniences and complications in these patients. Management is based on pharmacotherapy, physiotherapy and surgeries. The authors are against central neurosurgery except on rare occasions. They have been practicing peripheral surgeries chiefly on muscles and tendons with satisfactory results in selected cases. The guidelines and procedures are presented.

Pharmacokinetics of amikacin in serum and in tissue contiguous with pressure sores in humans with spinal cord injury.

Pressure sores are a common occurrence in immobilized patients. They increase morbidity and mortality and impede rehabilitation. Antibiotics are routinely used to assist in effecting a cure when infection is present. Nevertheless, for patients with spinal cord injuries (SCI), strategies for effective therapy with antibiotics based on measurement of concentrations in tissue and pharmacokinetic behavior in extravascular spaces do not exist. By analyzing the concentration-time profile and protein binding of amikacin in the interstitial fluid (IF) in contact with pressure sores, we found that the disposition of amikacin in the tissue contiguous with pressure sores appears to be governed by simultaneous first-order and capacity-limited pharmacokinetic behavior. Amikacin disposition in IF proceeded without a simple relationship to amikacin concentrations in serum, and the time course in IF was not accurately simulated by linear models of amikacin pharmacokinetic behavior. Total amikacin clearance estimated from a pharmacokinetic model using simultaneous first-order and nonlinear intercompartmental transfer of amikacin was not significantly different from clearance calculated by us in a prior study of amikacin pharmacokinetic behavior in patients with SCI. In patients with SCI, optimal use of amikacin in the treatment of infected pressure sores is contingent upon accurate characterization of the pharmacokinetic behavior of this aminoglycoside in serum and in the IF in contact with these lesions. Only methods which quantitate amikacin concentration and protein binding in IF and incorporate a model that can simultaneously simulate nonlinear and linear disposition processes should be relied upon to influence therapeutic decision making.

Amikacin pharmacokinetics in patients with spinal cord injury.

The influence of chronic (greater than 1 yr duration) spinal cord injury (SCI) on the disposition of amikacin was studied in seven healthy subjects with SCI (five paraplegic, two tetraplegic) and seven able-bodied controls (intact neuraxes). The time course of amikacin serum concentration after a 30-minute infusion (7.5 mg/kg) was followed for up to 8.5 hours using fluorescence polarization immunoassay. Pharmacokinetic values were estimated by a noncompartmental analysis (NC). Amikacin steady-state volume of distribution (Vss) was increased to 0.20 +/- 0.04 l/kg (mean +/- SD) as compared to 0.17 +/- 0.02 l/kg in able-bodied controls (p 0.03), and its mean terminal elimination half-life in patients with SCI was prolonged by 0.64 hours over the control value of 2.11 +/- 0.27 hours (p 0.01). The NC estimated mean residence time (MRT) in patients with SCI (3.65 +/- 0.75 hrs) was 0.89 hours longer than that observed in controls (p 0.03). Our data suggest that the Vss, half-life, and MRT of amikacin are increased in persons with chronic SCI. As a result, amikacin dosing regimens developed in able-bodied humans may demonstrate diminished efficacy when extrapolated uncritically to these patients.

The use of the carbon dioxide laser beam in the surgery of pressure sores.

The use of CO2 Laser in surgery for decubitus ulcers was assessed in 139 spinal cord injury patients. This technique is valuable for debridement and or excision of the ulcers as well as repair. It accomplishes hemostasis and wound sterility. It was found very helpful in patients with ill health, bleeding tendencies and active infections. It helped avoid amputation in a few paraplegics whose joints were involved or peripheral vessels compromised. Although the apparatus is expensive, its use on a large scale in specialized centers can be a good investment since it saves blood loss, transfusions, antibiotics, and hospital stay, the later so important with the current health care system in the USA known as DRG. However, operators should be very knowledgeable in the basic science of laser, the mechanics of the apparatus and its control for the most efficient, effective and safe utilization.

Protein C abnormalities in spinal cord injured patients with end-stage renal disease.

Patients with chronic spinal cord injury (SCI) and end-stage renal disease (ESRD) exhibit antithrombin III deficiency and several other coagulation abnormalities. In view of increasing recognition of protein C (PC) as an important, naturally occurring anticoagulant and fibrinolytic factor, we studied plasma PC in this population. PC antigen concentration and its anticoagulant activity were measured in nine SCI men with ESRD maintained on hemodialysis and in a control group of ten normal able-bodied men. The results showed a significant increase in PC anticoagulant activity in the SCI group. Consequently, the ratio of the PC activity to its concentration, which is a measure of the functional integrity of PC molecule, was markedly depressed. These findings are indicative of the presence of inactive or abnormal PC in SCI-ESRD patients and may suggest its in vivo activation. The combination of impaired PC activity shown in this study, with previously demonstrated antithrombin III deficiency and other coagulation abnormalities, is suggestive of a hypercoagulable state.

Theophylline disposition in tetraplegic man.

We studied the time-course of serum theophylline concentration after a 30-minute intravenous infusion of aminophylline (6 mg/kg) in 18 traumatic tetraplegic (nine smoking, nine nonsmoking) and in six control (nonsmoking) subjects. All study subjects were healthy men with normal renal function. Pharmacokinetic parameters were calculated from a linear regression analysis of the terminal log-linear portion of the log serum theophylline concentration-time curves. The terminal elimination kinetics of theophylline in this study were best characterized by first order elimination from a one compartment-open model. A statistically significant difference (P less than .05) was demonstrated between the means and variances of theophylline clearance (Cl ml/kg/min) and hours of half-life (t1/2) for control subjects and smoking tetraplegics. Total body clearance of theophylline was greater in all tetraplegic subjects, the greatest difference in total clearance of theophylline adjusted to body weight being observed between tetraplegic smokers and nonsmoking controls with an intact central nervous system (P less than .05). Theophylline volume of distribution (Vdarea) did not differ significantly from Vdarea in able-bodied subjects. Tetraplegic individuals have multiple disorders and marked pharmacokinetic variation, which might be expected to make serum concentration and toxicity of theophylline unpredictable using population averages.

Extrinsic and common coagulation pathways in end-stage renal disease associated with spinal cord injury.

Data on the effects of combined long-standing spinal cord injury (SCI) and end-stage renal disease (ESRD) on blood coagulation system are limited. We studied the extrinsic and common pathways of blood coagulation system in 9 men with SCI-ESRD treated with maintenance hemodialysis. Plasma procoagulant activities of factors (F)VII, X and II were measured in a clotting assay using appropriate deficient plasmas as substrate. In addition, the antigen concentration of FII was measured using monospecific antibodies against human FII raised in goat in a gradient plate immunodiffusion system. Also measured were plasma fibrinogen concentration and platelet count. The results were compared with those obtained in a group of 10 ambulatory ESRD patients and 8 normal control volunteers. Plasma coagulant activity of FVII was markedly elevated and plasma fibrinogen concentration was moderately increased in SCI-ESRD patients. In contrast, plasma FII was mildly depressed while platelet count was within normal limits in SCI-ESRD patients. The data indicate that the combination of SCI and ESRD can lead to the alteration of the extrinsic and common coagulation pathways. Further studies are needed to elucidate the precise mechanism and the clinical significance of the observed abnormalities.