Survival after short- or long-term ventilation after acute spinal cord injury: a single-centre 25-year retrospective study.

STUDY DESIGN: A retrospective review of acute spinal cord injury patients having assisted ventilation on or after admission between 1981 and 2005. OBJECTIVE: To assess survival after acute ventilatory support. SETTING: Northwest Regional Spinal Injuries Centre, Southport, England. METHODS: Causes of death were ascertained from the Office of National Statistics. Kaplan-Meier analysis of survival was calculated according to ventilator-wean status at discharge. Risk factors were obtained by Cox regression analysis. RESULTS: Over 50% of deaths in weaned and ventilated patients were respiratory in origin. The mean survival of weaned patients in the age group 31-45 was 19.3 compared with 10.5 years for ventilated patients (P=0.047). Those under 30 survived a further 22.1 and 18.4 years (P=0.31), while those over 45 lived for 11.0 and 8.3 years (P=0.50), values for weaned and ventilated patients, respectively. The survival advantage for weaned patients in the middle age group was less evident when the 1-year survivors were compared. The mean survival time of younger patients with diaphragm pacing was 1.8 years longer than those on mechanical ventilation (P=0.142). The variables with significant hazard ratios were any comorbidity (3.07); mechanical ventilation on discharge (2.26); and older age at injury, (3.1). CONCLUSIONS: The survival time for patients with high tetraplegia on long-term ventilation compares with other datasets and older patients have a proportionately greater loss in life expectancy. Self-ventilating patients with tetraplegia remain at considerable risk from respiratory death and consideration needs to be given to more effective preventative measures.

The use of tracheal stoma stents in high spinal cord injury: a patient-friendly alternative to long-term tracheostomy tubes.

STUDY DESIGN: Case series. SETTING: North West Regional Spinal Injuries Unit, Southport and Formby District General Hospital, UK. OBJECTIVES: To identify a novel type of tracheal stents for use in patients with high spinal cord injury. Patients with high spinal cord injury (above C4) frequently have significant respiratory impairment and may require long-term access to the trachea for respiratory support. For the most part, tracheostomy tubes are used for this purpose but a tracheal stoma stent can offer a suitable alternative in selected cases and deserves wider recognition. METHODS: Following completion of a patient questionnaire survey, the authors describe the use of stoma stents in nine patients, five of whom had full-time diaphragm pacing. The stent in these cases is for retention of access for positive pressure ventilation, and for the prevention of obstructive sleep apnoea. This was also the indication in one self-ventilating patient with tetraplegia and sleep apnoea. Two patients with recurrent chest infections, in whom chest physiotherapy was difficult, benefited from the stoma stents. One patient, after ventilator weaning, required a further 4 months of tracheal access on account of episodic hypoventilation and temporarily had a tracheal stent as an inpatient. CONCLUSION: Patients who have had the benefit of tracheal stents report significant improvement in relation to local discomfort, tracheobronchial secretions and vocalization. With suitable training, the stents can be changed and cleaned easily in the home setting.

Bedside assessment of sympathetic skin response after spinal cord injury: a brief report comparing inspiratory gasp and visual stimulus.

STUDY DESIGN: A case control study in five controls, and 20 tetraplegic and paraplegic patients, complete and incomplete. OBJECTIVE: The aim was to assess the feasibility of a simple test for sympathetic system preservation after spinal cord damage in a pain-free manner and which could be undertaken worldwide without specialist equipment or manpower. SETTINGS: Patients were attending the Southport Regional Spinal Injuries Centre, England, either as outpatients or as in-patients during rehabilitation. METHODS: The sympathetic skin response (SSR) was recorded on a single-channel ECG recorder from the right hand and right foot in turn after inspiratory gasp (IG) or visual stimulation. RESULTS: Unlike the visually evoked SSR, the gasp-evoked SSR was reliable, albeit of variable amplitude, and there was little difference between the hand and foot. Paraplegics had similar SSRs in the hands as the controls. There was minor insignificant habituation of response for the gasp reflex. There was occasional unexpected SSR distally in patients with complete lesions, and in patients with incomplete lesions the responses could not have been predicted from the sensory motor pattern. CONCLUSIONS: Trained IG induces an SSR which is sufficient to elucidate sympathetic loss following spinal cord injury. It is superior to visual stimulation in this respect. Habituation is not a problem with at least 1 min between tests, and high doses of anticholinergics agents may impair the response.

Prediction of tracheostomy tube size for paediatric long-term ventilation: an audit of children with spinal cord injury.

BACKGROUND: There are no published data to predict tracheostomy tube size as growth proceeds in children requiring long-term ventilation. METHODS: A retrospective audit was undertaken of children having long-term ventilation, managed from the Southport spinal injuries unit. The dates of step-up in size of tracheostomy tube were noted together with the tube inside and outside diameters (ID and OD) and the lateral tracheal diameter. The data were aggregated for each increment in tube size to calculate the Pearson correlation coefficients for age and weight of the children. Linear regression was then used to generate predictive equations based on age and weight. RESULTS: Out of 12 children, data from seven boys and two girls, with a mean age of 5.9 (range 1.5-13.75) yr, were obtained. Average length of follow-up was 7 yr, with an average of 3.5 tube changes per patient equating to a larger tube every 2 yr. The inside and outside tracheal tube diameters, as well as the lateral tracheal diameter, correlated significantly with age and weight (P<0.01). The appropriate tracheostomy tube internal diameter is conveniently expressed by the formula: ID mm=age yr/3 + 3.5 CONCLUSIONS: The step-up in size of the tracheostomy tube as growth proceeds should be undertaken as a planned procedure at least every 2 yr to avoid nocturnal desaturation. Age appears to be a convenient and reliable predictor.

Intravenous anaesthesia and repetitive transcranial magnetic stimulation monitoring in spinal column surgery.

BACKGROUND: Transcranial magnetic stimulation with motor evoked potential monitoring is a non-invasive method for monitoring motor tracts during surgery. However, anaesthetic agents such as propofol and volatile agents reduce responses to single transcranial magnetic stimulation. We assessed an intravenous technique for anaesthesia to allow motor evoked potentials (MEPs) to be monitored using repetitive transcranial magnetic stimulation (rTMS). METHODS: We applied three-pulse rTMS (TriStim) in 11 patients undergoing spinal column surgery after spinal column injury and recorded the latency and peak-to-peak amplitude of MEPs. Anaesthesia was maintained with propofol and remifentanil. RESULTS: MEPs were monitored successfully intraoperatively in all patients. CONCLUSIONS: It is possible to monitor intraoperative MEP using rTMS during anaesthesia with propofol and remifentanil.

Location of urethral arteries by colour Doppler ultrasound.

STUDY DESIGN: A case report. SETTING: Regional Spinal Injuries Centre, Southport, UK. CASE REPORT: A 56-year-old male with complete paraplegia at T-4 underwent visual internal urethrotomy of bulbous urethral stricture with a cold knife at 12 o'clock position. There was brisk arterial bleeding. Despite receiving antibiotics, this patient developed hypotension, tachycardia and tachypnoea. He was resuscitated and mechanical ventilation was instituted. After he recovered from this life-threatening episode of urinary tract-related sepsis, colour Doppler ultrasound imaging of bulbous urethra was performed to locate urethral arteries. In the bulbous urethra, single urethral artery was seen at 12 o'clock position. CONCLUSION: Since the sites of urethral arteries vary among patients, it is advisable to assess individually the location of urethral arteries preoperatively and plan the site of incision accordingly. Persons with injury to cervical or upper dorsal spinal cord have decreased cardiac and respiratory reserve as well as alteration in immune function. Therefore, all possible measures should be taken to prevent acute blood loss and bacteraemia in this group of patients.

Pseudo-tumours of the urinary tract in patients with spinal cord injury/spina bifida.

OBJECTIVE: To raise awareness of pseudo-tumours of urinary tract, as pseudo-tumours represent benign mass lesions simulating malignant neoplasms. Accurate diagnosis helps to avoid unnecessary surgery in spinal cord injury patients. SETTING: Regional Spinal Injuries Centre, Southport, UK CASE REPORTS: Pseudo-tumour of kidney: A 58-year-old man with tetraplegia developed a right perirenal haematoma while taking warfarin; ultrasound and CT scanning showed no evidence of tumour in the right kidney. The haematoma was drained percutaneously. After 8 months, during investigation of a urine infection, ultrasound and CT scan revealed a space-occupying lesion in the mid-pole of the right kidney. CT-guided biopsy showed features suggestive of an organising haematoma; the lesion decreased in size over the next 13 months, thus supporting the diagnosis. Pseudo-tumour of urinary bladder: A frail, 34-year-old woman, who had spina bifida, marked spinal curvature and pelvic tilt, had been managing her neuropathic bladder with pads. She had recurrent vesical calculi and renal calculi. CT scan was performed, as CT would be the better means of evaluating the urinary tract in this patient with severe spinal deformity. CT scan showed a filling defect in the base of the bladder, and ultrasound revealed a sessile space-occupying lesion arising from the left bladder wall posteriorly. Flexible and, later, rigid cystoscopy and biopsy demonstrated necrotic slough and debris but no tumour. Ultrasound scan after 2 weeks showed a similar lesion, but ultrasound-guided biopsy was normal with nothing to explain the ultrasound appearances. A follow-up ultrasound scan about 7 weeks later again showed an echogenic mass, but the echogenic mass was seen to move from the left to the right side of the bladder on turning the patient, always maintaining a dependent position. The echogenic bladder mass thus represented a collection of debris, which had accumulated as a result of chronic retention of urine and physical immobility. CONCLUSION: Recognising the true, non-neoplastic nature of these lesions enabled us to avoid unnecessary surgical procedures in these patients, who were at high risk of surgical complications because of severely compromised cardiac and respiratory function.

Calculus anuria in a spina bifida patient, who had solitary functioning kidney and recurrent renal calculi.

STUDY DESIGN: Clinical case report with comments by colleagues from Austria, Belgium, Germany, Japan, and Poland. OBJECTIVES: To discuss challenges in the management of spinal bifida patients, who have marked kyphoscoliosis and no vascular access. SETTING: Regional Spinal Injuries Centre, Southport, UK. METHODS: A female patient, who was born with spina bifida, paraplegia and solitary right kidney, had undergone ileal loop urinary diversion. Renal calculi were noted in 1986. Percutaneous nephrostolithotomy was performed in 1989 and there was no residual stone fragment. However, she developed recurrence of calculi in the lower pole of the right kidney in 1991. Intravenous urography, performed in 1995, revealed right staghorn calculus and hydronephrosis. Chest X-ray showed markedly restricted lung volume due to severe kyphoscoliosis. In 2000, she was declared unsuitable for anaesthesia due to a lack of venous access and a high likelihood of difficulty in weaning off the ventilator in the postoperative period. In June 2002, she developed anuria (urine output=18 ml/24 h) due to ball-valve-type obstruction by a renal stone at the ureteropelvic junction. Urea: 14.4 mmol/l; creatinine: 236 microl/l. Ultrasound showed right hydronephrosis. Percutaneous nephrostomy was performed. RESULTS: Following relief of urinary tract obstruction, there was postobstructive diuresis (3765 ml/24 h). However, the patient expired 19 days later due to progressive respiratory failure. CONCLUSION: In this spina bifida patient, who had reached the age of 35 years, severe kyphoscoliosis and lack of vascular access presented insurmountable challenges to implement the desired surgical procedure for removal of stones from a solitary kidney.

A comparison of the efficacy of alfentanil and remifentanil analgesic infusions for spinal surgery.

The use of alfentanil infusion was compared with that of remifentanil infusion for spinal cord surgery in a retrospective review. The aim was to compare the outcome when methohexitone was used as the only hypnotic agent in the two groups. Over a 3-year period, 5 patients (group 1) had Alfentanil infusion and 11 patients (group 2) had remifentanil infusion for analgesia during spinal cord surgery. Results showed that remifentanil lead to a faster onset of recorvery than alfentanil. It also provided better haemodynamic stability than alfentanil without excesive hypotension (p > 0.05). Our experience here indicated that remifentanil provided better flexibility of use with less tachycardia and respiratory depression than alfentanil for spinal surgery.

Respiratory alkalosis and associated electrolytes in long-term ventilator dependent persons with tetraplegia.

STUDY DESIGN: A pilot case control study of the acid-base and electrolyte status in 30 long-term ventilator-dependent (LTVD) and 30 self ventilating persons with tetraplegia. OBJECTIVES: To assess the extent of respiratory alkalosis and screen for associated hypokalaemia, hypomagnesaemia and/or hypophosphataemia. SETTING: Medically stable persons with tetraplegia under the long-term care of the Southport Spinal Injuries Centre, England. METHODS: Blood gases and electrolytes were sampled from 30 control patients with tetraplegia and from 30 patients having been LTVD for more than 12 months. RESULTS: All the blood gas measurements in the LTVD group lay outside both the reference range and the 95% confidence intervals (CI) of the control group: pH 7.46 (0.06); PCO(2) 3.46 (1.1) kPa; bicarbonate 18.3 (3.8) and base excess -3.2 (2.8) mmol/l; PO(2) 13.8 (2.8) kPa (means and standard deviations). The serum potassium, magnesium, phosphate, and sodium means lay within the reference ranges but the potassium, phosphate and calcium were at or below the 95% CI of the control values. One patient on part-time ventilatory support having less bicarbonate compensation had low serum electrolytes during ventilation. CONCLUSION: There was no evidence of biochemical jeopardy from long-term mechanical hyperventilation although acutely administered hyperventilation has the potential to cause falls in serum potassium, magnesium and phosphate and so caution should be exercised in part-time ventilated persons. The full range of electrolytes should be assayed during stabilisation in LTVD and periodically thereafter. Hyperventilation helps to maintain good oxygenation in LTVD persons with paralysis and normal lungs. SPONSORSHIP: None.

Community-care waiting list for persons with spinal cord injury.

OBJECTIVES: To disseminate the concept of community care waiting lists for spinal cord injury (SCI) patients with particular reference to carer support for management of neuropathic bladder by a regime of intermittent catheterisation. METHODOLOGY: The surgical waiting list focuses only on operative procedures, and ignores the wider requirements for ensuring satisfactory rehabilitation of people with spinal cord injury in the community. A community-care waiting list for individuals with spinal cord injury should include the following aspects of community care: (1) Home adaptation; (2) Provision of appropriate mobility needs (including wheelchair and cushion); (3) Equipment for comfortable living (including provision of hoist, pressure relieving mattress); (4) Psychological support for spinal cord injury patients and their partners; (5) Nursing home or residential care placement where appropriate; (6) Carer support for global management of complex needs associated with spinal cord injury (eg neuropathic bladder and bowel). RESULTS: Whereas full physical adaptation of the home can wait for some time after discharge, carer support for intermittent catheterisation is required from the first day after discharge from a spinal unit. Lack of such support means that some SCI patients are discharged with long-term indwelling urinary catheters, even though clean intermittent catheterisation is known to be the safest regime for managing the neuropathic bladder. Therefore, the absence of a community care waiting list means that best practice cannot be achieved for some tetraplegic subjects. CONCLUSION: We believe that a community care waiting list for bladder management will help to provide optimum care for neuropathic bladder and, hopefully, reduce the complications related to long-term indwelling catheters in spinal cord injury patients.

Bilateral extracorporeal shock wave lithotripsy in a spinal cord injury patient with a cardiac pacemaker.

OBJECTIVES: To review the precautions to be observed before and during extracorporeal shock wave lithotripsy (ESWL) in spinal cord injury (SCI) patients with a cardiac pacemaker and the safety of bilateral ESWL performed on the same day. DESIGN: A case report of bilateral ESWL in a SCI patient with a permanent cardiac pacemaker. SETTING: The Regional Spinal Injuries Centre, Southport, the Lithotripsy Unit, the Royal Liverpool University Hospitals NHS Trust, Liverpool, and the Department of Cardiology, Manchester Royal Infirmary, Manchester, UK. SUBJECT: A 43-year-old male sustained a T-4 fracture and developed paraplegia with a sensory level at T-2. During the post-injury period, he developed episodes of asystole requiring implantation of a dual chamber (DDD) permanent pacemaker. Twenty-one months later, he developed a right ureteric calculus with hydronephrosis. A radio-opaque shadow was seen in the left kidney with no hydronephrosis. During right ureteric stenting, the ureteric stone was pushed into the renal pelvis. 1,500 shock waves were delivered to this stone on the right side, followed by ESWL to the left intra-renal stone with 1250 shock waves. RESULTS: The patient tolerated ESWL to both kidneys. The pacemaker was reprogrammed to a single chamber ventricular pacing mode at 30 beats per minute with a reduced sensitivity during lithotripsy. There were no untoward cardiac events during or after lithotripsy. The serum creatinine was 45 micromol/l before lithotripsy and 44 micromol/l two weeks after ESWL. CONCLUSION: SCI patients with a cardiac pacemaker may be able to undergo extracorporeal shock wave lithotripsy following temporary reprogramming of the pacemaker. Bilateral, simultaneous ESWL is safe in the vast majority of patients provided that there is no risk of simultaneous ureteric obstruction by stone fragments. However, it should be remembered that a decrease in renal function could occur following bilateral ESWL of renal calculi.

Doctor-patient communication: do people with spinal cord injury wish to receive written information about their medical condition from the physicians after an outpatient visit or after a readmission in the spinal unit?

STUDY DESIGN: A survey of spinal cord injury patients attending a follow-up clinic in a Regional Spinal Injuries Centre. OBJECTIVES: To investigate whether spinal cord injury patients wish to receive written information about any changes in their medical condition after an outpatient visit or, following readmission in a spinal unit. SETTING: Regional Spinal Injuries Centre, Southport, United Kingdom. METHODS: A questionnaire was developed to assess the following: (1) Whether spinal cord injury patients wished to receive written information about changes in their medical condition after an outpatient visit or following readmission in a spinal unit; and (2) Whether provision of such written information would cause needless anxiety to patients and/or their relatives/carers. RESULTS: A total of 128 adults with spinal cord injury filled in this questionnaire. One hundred and six persons (83%) wished to receive written information about any changes in their medical condition after an outpatient visit, whereas eight (6%) felt that provision of such written information was not required. 115 individuals with spinal cord injury (90%) preferred to receive a copy of the MRI scan report, with interpretation of the findings, while 11 (9%) would be happy not to receive such information. 115 persons with spinal cord injury (90%) felt that written information about their medical condition would be valuable for showing to a locum General Practitioner (GP), if necessary, who may not be acquainted with their medical status. Only eight (6%) did not perceive a need for written information to appraise a locum GP. One hundred and twenty-two persons with spinal cord injury (95%) did not feel that provision of written information would cause needless anxiety to them; only four (3%) felt the other way. One hundred and nineteen (93%) individuals with spinal cord injury wished to receive written information about changes in their medical condition after a readmission to the spinal unit, while six (5%) did not wish to receive such information. CONCLUSION: Although the vast majority of people with spinal cord injury reported they wished to receive written information, a small proportion of patients did not wish to receive such information. Acceptance of written information is not universal and clinicians must ensure that provision of written information to people with spinal cord injury should be tailored to the needs of individual patients.