Does sacral posterior rhizotomy suppress autonomic hyper-reflexia in patients with spinal cord injury?

OBJECTIVE: To study the occurrence of autonomic hyper-reflexia (AHR) after intradural sacral posterior rhizotomy combined with intradural sacral anterior root stimulation, performed to manage the neurogenic hyper-reflexic bladder and to determine the pathophysiological basis of the uncontrolled hypertensive crisis after sacral de-afferentation. PATIENTS AND METHODS: Ten patients with spinal cord injury operated using Brindley's method between September 1990 and February 1994 were reviewed. Systematic continuous non-invasive recordings of cardiovascular variables (using a photoplethysmograph) were made during urodynamic recordings and the pre- and post-operative vesico-urethral and cardiovascular data compared. RESULTS: Nine of the 10 patients were examined using a new prototype measurement system; one woman refused the last urodynamic assessment. Eight of the nine patients who presented with AHR before operation still had the condition afterward. There was a marked elevation in systolic and diastolic blood pressure during the urodynamic examination in all eight patients, despite complete intra-operative de-afferentation of the bladder in five. The elevation of blood pressure started during the stimulation-induced bladder contractions and increased during voiding in all cases. Five patients showed a decrease in heart rate during the increase in blood pressure. However, in three patients the heart rate did not change or even sometimes slightly increased as the arterial blood pressure exceeded 160 mmHg, when the blood pressure and heart rate then increased together. CONCLUSIONS: These results confirm that even after complete sacral de-afferentation. AHR persisted in patients with spinal cord injury and always occurred during the stimulation-induced voiding phase. In cases of incomplete de-afferentation, small uninhibited bladder contractions without voiding occurred during the filling phase. The blood pressure then increased but never reached the value recorded during stimulation-induced micturition. Stimulation of afferents that enter the spinal cord by the thoracic and lumbar roots and that are not influenced by sacral rhizotomy could explain why AHR increases during urine flow. The distinct threshold of decreased heart rate by increasing blood pressure to > 160 mmHg focuses attention on the chronotropic influences of the sympathetic nerves in the heart by an exhausted baroreceptor reflex.

Has botulinum toxin type A a place in the treatment of spasticity in spinal cord injury patients?

OBJECTIVE: To present and discuss treatment of severe spasms related to spinal cord injury with botulinum toxin type A. DESIGN: A 2-year follow-up study of an incomplete T12 paraplegic patient, who was reluctant to undergo intrathecal baclofen therapy, presenting severe painful spasms in his lower limbs treated with intramuscular injections of botulinum toxin type A. SETTING: Department of Physical Medicine and Rehabilitation, Hôpital de Gravelone, Sion, Switzerland. SUBJECT: Single patient case report. MAIN OUTCOME MEASURE: Spasticity, spasms and pain measured with the modified Ashworth scale, spasm frequency score and visual analogue scale. RESULTS: Treatment of spasticity with selective intramuscular injections of botulinum toxin type A resulted in subjective and objective improvement. CONCLUSION: Botulinum toxin type A has its place in the treatment of spasticity in spinal cord injury patients. This treatment is expensive and its effect is reversible. It can complement intrathecal baclofen in treating upper limb spasticity in tetraplegic patients. Tolerance does occur to the toxin. Although high doses of the product are well tolerated, the quantity should be tailored to the patient's need. The minimal amount necessary to reach clinical effects should be adhered to and booster doses at short period intervals should be avoided.

Prostaglandin E2 measurements: their value in the early diagnosis of heterotopic ossification in spinal cord injury patients.

OBJECTIVE: To look for a possible relation between the occurrence of heterotopic ossification (HO) and the modifications of the 24-hour prostaglandin E2 (PGE2) urinary excretion. DESIGN: A 5-year prospective study to determine the 24-hour urinary excretion of PGE2 by radioimmunoassay with specific antisera not cross-reacting with TXA2, TXB2, 15-keto-PGE2 alpha, PGI2, 6-keto-PGF1 alpha. SETTING: The laboratory of a division of endocrinology and diabetology of a university hospital. PATIENTS: Of 262 acute spinal cord injury patients screened, 44 were eligible for the study. INTERVENTIONS: Serial diagnostic quantitative bone scannings with technetium 99m Tc methylene diphosphate (99mTc-MDP) and therapeutic assessment of radiotherapy and indomethacin. MEAN OUTCOME MEASURE: Hypothetical increase of PGE2 before and during HO formation. RESULTS: Of 44 patients, 8 developed an HO (18.8%) with concomitant marked increase of the PGE2 excretion for as long as the HO had not reached maturity. The results of the radiotherapy were inconclusive. Indomethacin was shown to be efficacious in holding back or slowing down the HO evolution. CONCLUSIONS: Measurement of the 24-hour PGE2 urinary excretion appears to be a valuable indicator in the early diagnosis of HO. Indomethacin should be considered as an alternative to other existing therapies.

The value of sympathetic skin response recordings in the assessment of the vesicourethral autonomic nervous dysfunction in spinal cord injured patients.

PURPOSE: We assessed the degree of sparing of the descending sympathetic spinal tract and correlated these findings with bladder neck function in spinal cord injured patients. MATERIALS AND METHODS: Sympathetic skin responses of the right hand and foot were recorded and compared to the urodynamic findings in 27 spinal cord injured patients. RESULTS: All tetraplegic and paraplegic patients with a lesion above the T6 level who presented with bladder neck dyssynergia associated with autonomic hyperreflexia had abnormal sympathetic skin responses in the right hand and foot. All patients with a lesion below the T6 and above the T12 levels with an abnormal sympathetic skin response in the right foot also had bladder neck dyssynergia. CONCLUSIONS: Evidence is presented that the integrity of the descending sympathetic spinal tract is necessary for a synergic function of the vesicourethral complex and that sympathetic skin responses are of value in the diagnosis of bladder neck dyssynergia. For lesions below the T12 level other investigative methods to exclude bladder neck dyssynergia are necessary.

Autonomic hyperreflexia revisited.

PURPOSE: To analyze autonomic hyperreflexia (AHR) associated with neurogenic bladder dysfunction in high spinal cord-injured patients. MATERIAL AND METHODS: Sixty-five patients were examined using a new recording system. Seventeen suffered from a spinal cord lesion above the T5-T6 level and presented with neurogenic voiding disorders and AHR. Mean arterial pressure (MAP) changes were analyzed during 3 different urodynamic phases: bladder filling; isometric bladder contraction, and voiding. RESULTS: Of the 17 tetraplegic and high paraplegic patients, 6 dropped out and 11 entered the study. Nine of these eleven patients displayed uninhibited bladder contractions and voiding. In these 9 cases MAP increased progressively during bladder contraction until a maximal bladder pressure was reached. An ongoing elevation of MAP was observed during voiding which returned to normal values within 5 min after micturition. In 2 patients detrusor-sphincter dyssynergia prevented voiding. As opposed to the 9 previously mentioned patients, maximal MAP occurred at or before the maximal bladder pressure in these 2 cases and decreased thereafter. CONCLUSIONS: Evidence is presented that the posterior urethral receptors and their ascending pathway played a major role in the maintenance of AHR during micturition.

Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients.

PURPOSE: The paralytic effect of botulinum-A toxin injections on the external urethral sphincter was investigated prospectively in patients with neurogenic voiding disorders. MATERIALS AND METHODS: Transurethral versus transperineal botulinum-A toxin injections were performed in 24 spinal cord injury male patients with detrusor-sphincter dyssynergia and the respective efficacy was compared. RESULTS: In 21 of 24 patients detrusor-sphincter dyssynergia was significantly improved with a concomitant decrease in post-void residual volumes in most cases. Botulinum-A toxin effects lasted 3 to 9 months, making reinjections necessary. CONCLUSIONS: Although costly, botulinum-A toxin injections, which aim at suppressing detrusor-sphincter dyssynergia but not bladder neck dyssynergia, appear to be a valid alternative for patients who do not desire surgery or are unable to perform self-catheterization.

Post-traumatic syringomyelia (cystic myelopathy): a prospective study of 449 patients with spinal cord injury.

OBJECTIVES: To assess the incidence of post-traumatic syringomyelia (PTS), to correlate the presence of PTS with its most common signs and symptoms, and to compare results from the Swiss Paraplegic Centre with those reported in the medical literature. METHODS: A total of 449 recent traumatic paraplegic and tetraplegic patients admitted to the Swiss Paraplegic Centre in Zurich between 1 January 1987 and 31 December 1993 were prospectively analysed. Yearly clinical tests with conventional radiographs and additional T1 and T2 weighted images were performed as soon as PTS was diagnosed. RESULTS: Of these 449 patients 20 patients displayed symptoms of PTS (4.45%). Ten non-operated patients remained clinically stable (average time: 37 months). Ten worsened--three refused operation, seven were operated on. Mean worsening time was 97 months. Deterioration was closely related to the enlargement of the cyst whereas in operated patients neurological improvement or stabilisation correlated with collapse of the cyst. CONCLUSIONS: Delay between appearance of the first symptoms of PTS and deterioration making surgery necessary may be long (mean five years in the seven operated patients) underlining the need for regular tests. "Slosh" and "suck" mechanisms could explain cyst enlargement as surgical realignment of the spine resulted in a complete cyst collapse in two of the operated patients (normalisation of CSF flow? ). Cord compression, tense syrinx at the fracture site, and kyphosis seemed to be closely linked to the enlargement of the cyst with subsequent further neurological deterioration.

Detrusor bladder neck dyssynergia revisited.

To our knowledge, direct measurement of active closure of the bladder neck during bladder contraction resulting in bladder neck dyssynergia and outflow obstruction has not yet been demonstrated. A total of 34 spinal cord injury patients underwent urodynamic investigation with 2 micro-transducer catheters in the urethrovesical and anorectal regions, respectively. Proper localization of the transducers was done with an image intensifier. The respective role of the striated and smooth muscles on bladder neck activity was evaluated after pudendal nerve blocks and phentolamine injections. Of the patients 25 had active bladder neck dyssynergia with concomitant detrusor-sphincter dyssynergia. Pressures were higher in the bladder neck than in the bladder. Pudendal blocks abolished detrusor-sphincter but not bladder neck dyssynergia, which was decreased by additional phentolamine but only in patients in whom bladder neck dyssynergia was associated with autonomic hyperreflexia. Evidence is presented that active bladder neck dyssynergia may exist in patients with a neurogenic bladder and that it is seemingly dependent on alpha 1-postsynaptic and alpha 2-presynaptic adrenoreceptors.

[Effects of Botulinum A Toxin on the periurethral striated sphincter of the neurogenic bladder. Preliminary study]. / Effets de la Toxine Botulinique A sur le sphincter strié périurétral des vessies neurogènes. Etude préliminaire.

The goal of this study was to try to determine the effects of the Botulinum A Toxin on the spasticity of the rhabdosphincter in 9 men with spinal cord injury and detrusor-sphincter dyssynergia. The cystometrography, before and after the endoscopic injection of 100 units of Botulinum A Toxin, consisted of recording the bladder, urethral and rectal pressures with microtip transducers the anatomical position of which was radiographically controlled. The subjective and objective results of that study allow us to conclude that the Botulinum A Toxin has a place in the treatment of spinal injuries with detrusor-sphincter dyssynergia. Due to his blocking effect on the release of acetylcholine in the motor nerve endings, the Botulinum A Toxin suppresses or decreases the spasticity of the rhabdosphincter and improves voiding. Although its relatively short living action (2-3 months) may require renewed injections, it has the advantage to hold off a surgical treatment such as a sphincterotomy and to give the patient another chance to reach a balanced bladder function secondary to the postinjection changes of reflexes which may have taken place between the bladder and the rhabdosphincter and vice versa.

A case of post-traumatic syringomyelia. Neuropathological findings after 1 year of cystic drainage.

A 58-year-old man sustained C4-C5 post-traumatic myelopathy with C3-C4 subluxation, slight compression of C3 vertebral body, C4 spinous process fracture and C6 compression fracture. He subsequently developed syringomyelia from C4 to C6, which was shunted into the subarachnoid space. Postoperatively, there was some but insignificant improvement of his symptoms although a postoperative metrizamide spinal computerised tomography showed complete drainage of the cyst. This patient died 1 year later. Autopsy examination of the spinal cord showed extensive damage of the posterior half of the cord at C3-C4 but the damage was much less extensive from C4 to C6 (where the syrinx was located), affecting mainly the right dorsal column at C4 and the right dorsal column and right anterior horn at C5-C6. In this patient, the syrinx developed in the partially damaged segments of the cord at the level of the spinal fractures and complete drainage of the cyst was not followed by satisfactory relief of his symptoms.

Experience in vibratory and electro-ejaculation techniques in spinal cord injury patients: a preliminary report.

More than 90 per cent of complete spinal cord injury patients have major fertility problems, depending upon the site and type of injury. During the last 5 years 34 patients were treated by vibratory and/or electrostimulation at our center, and semen was produced in all but 5. In 8 patients ejaculation was attempted by vibratory stimulation alone and in 22 electrostimulation also was used. Vibratory stimulation is the easier and less cumbersome of the 2 methods. No major side effects were noted with either technique. Stimulation was performed by a rectal electrode incorporated in a silicone finger glove with a current of 0.1 msec. in duration, a frequency of 30 Hz. and an average of 60 volts. Vibratory stimulation was applied to the frenulum and/or glans penis with a specially constructed vibrator at a frequency of 80 Hz. and a peak-to-peak oscillation of 1.6 to 2.4 mm. Semen obtained during the first 6 months after injury was not of a quality consistent with successful fertilization owing to poor motility. However, semen quality and motility were better in patients who had been injured for more than 6 months. Repeated electro-ejaculation did not improve the quality of semen. The effects of bladder outlet surgery and autonomic blockers were noted in 5 patients.

5-microtransducer catheter in evaluation of neurogenic bladder function.

Recent use of the multiple microtransducer catheter in the evaluation of neurogenic bladder due to spinal-cord injuries leads us to believe that the use of the inferior edge of the symphysis pubis as the zero point for resting bladder pressure is more accurate than its superior edge, changes in resting bladder pressure at various volumes are influenced more by body position than by intravesical position of the sensor, back-to-back microtransducers indicate significant pressure difference at the external sphincter zone, and detrusor bladder neck dyssynergia during autonomic dysreflexia in patients with spinal cord injury is more likely of skeletal than of smooth muscle origin.

Carcinoma in chronic pressure sores: a fulminant disease process.

Four cases of squamous cell carcinoma arising from chronic pressure sores in paraplegic and tetraplegic patients are presented and the literature reviewed. These pressure-sore carcinomas are characterized by a shorter latency period and a fulminant clinical course with a very high metastatic rate. Very aggressive treatment including even hemicorporectomy must be considered if a cure is to be achieved.

Electrodiagnostic abnormalities in 15 patients with posttraumatic syringomyelia: pre- and postoperative studies.

A review of 15 patients with posttraumatic syringomyelia indicates that the most reliable electrodiagnostic criteria for the diagnosis of syrinx are the loss of motor unit numbers with increase in motor unit amplitude and duration nd synchronous firing. Prolongation of F wave latency in a previously stable patient is a useful observation. Return of function and improvement of F wave latencies can occur rapidly following decompression of the syrinx. Forty per cent of the patients studied had concomitant involvement of at least one peripheral nerve as one would expect invoking the double crush hypothesis.

Posttraumatic cervical syringomyelia. Incidence, clinical presentation, electrophysiological studies, syrinx protein and results of conservative and operative treatment.

In eleven years, 30 (3.2%) of 951 patients with spinal cord injury developed cervical syringomyelia. This condition was found in 22 (4.5%) of 488 posttraumatic tetraplegic and 8 (1.7%) of 463 posttraumatic paraplegic patients; the incidence was about 8 per cent in patients with complete tetraplegia. This study demonstrated the rarer clinical manifestations of syringomyelia, namely autonomic dysfunction, alterations in the sensory level with postural changes, the early occurrence of tendon areflexia and painless motor deterioration. Prolonged F wave latencies were present in all patients with a demonstrable syrinx and a higher protein content was found in the syrinx than in the cisternal fluid. Some of the symptoms and signs in a proportion of the patients treated conservatively remained stable without operative treatment over a number of years. Most of the patients in whom operation was performed for progressive motor weakness or severe pain had good postoperative results although a few developed late sensory or motor changes. There was no benefit in operating on a patient with a small syrinx.

The treatment of spinal fractures with Harrington compression rods and segmental sublaminar wiring. A dangerous combination.

The increasing use of more rigid internal fixation constructs for spinal fractures, especially in association with spinal cord injury, has led surgeons to combine sublaminar segmental wiring with Harrington instrumentation systems. Two clinical cases whose neurologic condition deteriorated postoperatively were shown to have sustained direct cord injury by the combination of Harrington compression rods with segmental sublaminar wiring. Myelographic and surgical evidence of hook protrusion into the spinal canal with direct cord injury is presented. Laboratory spine simulations duplicating the clinical situation did demonstrate that sublaminar wiring of the Harrington compression rod system caused the standard hooks to protrude dangerously into the spinal canal. Caution should be exercised not to combine Harrington compression rods with segmental sublaminar wiring.

Forces in the halo-vest apparatus.

A previous study by Koch and Nickel (1978) determined the changes in the distraction forces in the halo-vest during different activities. The present study determined the variations of forces in different directions between the halo and the vest also during different activities. Clip-on strain gauges were used to measure the strains in the bars, while an on-line computer system was used to compute the forces. Anterior-posterior forces were found to be comparable with vertical ones. These forces and the changes during a particular activity were caused by gravity forces of the head in activities involving a change in attitude; and vest distortion from changes in body shape, direct pushing from the lower abdomen, the arms and shoulders, or from supporting surfaces. Activities producing the highest force changes included bending forwards from a seated position and reaching over sideways while lying. Medial-lateral forces were small in comparison with vertical and anterior-posterior forces. Implications of the study were that pin-skull forces were multidirectional, and that certain improvements in design could be effected by accounting for the factors causing high forces and consequently cervical motion.

Complete sensory and motor recovery from anterior spinal artery syndrome after sprain of the cervical spine. A case report.

A patient sustained C7-C8 incomplete myelopathy with dissociated sensory loss after a whiplash injury. Cervical radiograms showed no fracture or dislocation but separation of the C4-C5 and C5-C6 spinous processes and anterior tilting on C5 on C6 vertebral body only in the head-neck flexed position. Complete sensory and motor recovery occurred after neck immobilization. The patient's transient neurologic deficits were probably caused by vascular insufficiency of an anterior radicular artery at the C5-C6 intervertebral foramen.

Management of neurogenic bladder in female spinal cord injury patients.

Twenty-two female spinal cord injury patients were admitted to the Spinal Cord Injury Service at the West Roxbury VAMC during a period of 17 years (1965-1982). Bladder status and means of drainage were evaluated. Twelve patients (55%) required no means of drainage, nine of them were dry all the time, while the other three needed pamper support to counteract occasional wetness. Seven were on constant indwelling catheters, two were on self-catheterization, while one had an intestinal loop diversion. It appears that female spinal cord injury patients depend more on constant indwelling catheters than their male counterparts. In some instances, female paraplegics do well on self-catheterization. Catheter complications in female spinal cord injury patients appear to be less than in males.