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.

Neurourology of spinal cord-injured patients.

To simply perform a rectal examination is not adequate. The interpretation is of paramount importance. Often in cauda equina lesions, tone found in the sphincteric site will be misinterpreted to mean somatic reflex tone. The tone found in these low lesions with areflexic bladders is caused by the fact that the internal anal sphincters are innervated by the sympathetic fibers, which are still intact in these patients. One may often have to rule out physical tone--an intrinsic property of tissue. When performing the dermatome examination for sensation, it is important that the examiner orders the patient to close his eyes. Then the examiner hits the air only while asking the patient. "Do you feel anything now?" It is surprising how many patients will respond by saying, "I feel it!" These patients do a great deal of wishful thinking or have paresthesias or dysesthesias. If these two factors are not ruled out, the examiner can be misled. The examiner should not stimulate two sites simultaneously (eg, leaning with the elbow on the thigh of the patient while testing the anogenital dermatomes, particularly if sensation is present in the thigh). This error in technique can produce a false-positive response while pinning the anogenital sites, which may be anesthetic. It is unsatisfactory for the examiner to state that the patient has sensation without specifically stating whether it is pinprick, light touch, or even hypalgesic, especially when referring to the sacral segments. Additionally, the examiner must state whether the sensation is unilateral or bilateral. To examine only the perianal dermatomes is insufficient; the penile and scrotal dermatomes must also be examined.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary fistulae after radical ischiectomies in surgery of ischial pressure sores.

In the early fifties, total ischiectomy was in vogue as a procedure in the surgical treatment of ischial pressure sores. The immediate results by various authors were impressive. One of us, however (A.E.C.), reported the later development of urethral fistulae and the high incidence of perineal urethral diverticulae. The procedure has been abandoned and few surgeons recommend less radical ischiectomy supplemented by muscle transplantation.

Autonomic dysreflexia (hyperreflexia).

This author has presented his personal experience and observations concerning acute and chronic dysreflexia. The various causes of dysreflexia are discussed. The importance of bladder balance is stressed as the number one cause with the anorectal site being second. The methods of treatment that the author uses for both acute and chronic dysreflexia are described.

Urological management of the traumatic cord bladder.

Time and patience are the two prerequisites for treatment of the traumatic cord bladder. The experienced physician knows when early intervention is necessary. Intermittent catheterization from onset of injury is as of today the accepted method of treatment in most large centers over the world. "Lack of personnel" is the usual answer where this procedure is not being carried out. Administrative people do not realize that with this method the patients can be discharged more quickly and have less complications; complications lead to a great variety of surgery, which is costly to any institution. And above all, what is best for the patient should always be our goal. Medicine travels fast these days; therefore, physicians must keep an "open mind" for the newer developments. The ileal conduit and the cutaneous vesicostomy have their place in the armamentarium of the treatment of the traumatic cord bladder: the proponents should make a greater effort to create more spedific indications. It will be interesting to see what the results of suprapubic needling will produce. Electrical stimulation is still in a research stage. The latter two methods have a noble goal, i.e., prevention of infection. Experience with chronic bladder infection over the past 28 years suggests that the majority of our patients possibly may survive because of "local tissue immunity." The ultimate solution is a presently unknown preventative method of treatment of chronic urinary tract infection.

General surgery problems in patients with spinal cord injuries.

Twenty-four patients with spinal cord injuries were studied to correlate their responses to intra-abdominal disease with the level and completeness of the cord lesion. Patients with complete cervical lesions and lesions of the upper part of the thoracic region (C-4 to T-6) usually responded by early noniocalized abdominal pain associated with signs of autonomic dysreflexia. As the disease progressed to involve the parietal peritoneum, these patients were more capable of localizing pain to the corresponding dermatome, whereas patients with incomplete lesions were able to localize their pain earlier. Patients with lumbar lesions and lesions of the lower part of the thoracic region (T-7 to L-3) were able to localize their pain earlier than those with lesions located higher in the thoracic region. All patients had delayed diagnoses except those with hemorrhage of the upper part of the gastrointestinal tract. Irrespective of level of cord lesion, increased pulse rate was themost prominent objective acute intra-abdominal pathologic finding. Shoulder pain in the quadriplegic is a most helpful sign.