Douglas B. Barber

Long-term results for malone antegrade continence enema for adults with neurogenic bowel disease

OBJECTIVES To determine the long-term outcomes from the Malone antegrade continence enema (ACE) procedure in adult neurogenic patients. METHODS A retrospective review of adult patients who underwent the ACE procedure for neurogenic bowel was done. Patients were studied if they had follow-up of greater than 4 years. We compared pre-ACE and post-ACE toileting times, bowel continence status, and complications, and elicited patient subjective satisfaction with their quality of life. RESULTS Six patients were available for study. Mean age was 35 years with a mean follow-up of 4.5 years. Urinary diversion was done in 5 patients. Pre-ACE toileting time was 190 +/- 45 minutes versus post-ACE toileting time of 28 +/- 20 minutes (P <0.001). Four of six patients pre-ACE were incontinent of stool per rectum compared with 1 of these 4 patients post-ACE (P = 0.03). Five patients were continent of stool per ACE stoma. Four patients (67%) had complications. Three of five patients (60%) who underwent synchronous urinary diversion required postoperative re-exploration. Five patients (83%) were satisfied with their outcome and rated their quality of life higher after the ACE procedure compared with pre-ACE. CONCLUSIONS The ACE procedure is effective in the long-term management of adult neurogenic bowel. The complication and re-exploration rates are high. Patients must be properly selected to determine appropriate motivation.

The treatment of immature heterotopic ossification in spinal cord injury with combination surgery, radiation therapy and NSAID.

Heterotopic ossification (HO) is a frequent complication associated with spinal cord injury. Management of HO consists of a combination of range-of-motion, diphosphonates, nonsteroidal antiinflammatory agents, radiation therapy, and in some cases, surgical resection. The appropriate timing of surgical resection has traditionally been based on maturity of the HO. The case presented is that of a 33-year-old male with T8 complete paraplegia who developed HO about the left hip resulting in impaired sitting. The patient underwent successful surgical wedge resection of the HO despite apparent immaturity of the HO. A comprehensive review of the literature is presented which suggests that early resection of immature HO may not be predictive of a higher recurrence rate.

Midodrine hydrochloride and the treatment of orthostatic hypotension in tetraplegia : two cases and a review of the literature

Study Design: A report of two cases of orthostatic hypotension in acute tetraplegia that were resistant to classic treatment interventions.Objective: To discuss the use of midodrine hydrochloride for the treatment of orthostatic hypotension in early tetraplegia.Setting: Department of Rehabilitation Medicine, The University of Texas Health Science Center at San Antonio, Texas, USA.Methods: Presentation of two cases.Results: Midodrine hydrochloride successfully treated two cases of orthostatic hypotension that had been refractory to classic treatment interventions.Conclusion: Midodrine hydrochloride should be included in the armamentarium of the physician treating orthostatic hypotension in spinal cord injury.Spinal Cord (2000) 38, 109–111.

MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE

PURPOSE We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion. MATERIALS AND METHODS Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed. RESULTS Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion). CONCLUSIONS Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.

Osteonecrosis: an overuse injury of the shoulder in paraplegia: case report

The shoulder of the wheelchair dependent paraplegic is subject to overuse injury with subsequent pain. The major overuse syndromes observed include soft tissue injuries and secondary degenerative arthritis. This report presents a case in which bilateral osteonecrosis of the humeral heads was found to be the source of pain in the shoulders of an active paraplegic without any evidence of disease or medical treatment associated with the development of osteonecrosis. Osteonecrosis should be entertained in the differential diagnosis of overuse injuries of the shoulder in paraplegia.

Malone Antegrade Continence Enemas for Autonomic Dysreflexia Secondary to Neurogenic Bowel

A 42-year-old man with T-4 ASIA B thoracic paraplegia presented with chronic constipation, fecal incontinence, and bowel-related autonomic dysreflexia (AD) refractory to conservative bowel program. His usual toileting time lasted one to five hours. Antegrade continence enemas (ACE) were performed. The ACE technique, which requires creating a continent catheterizable appendicocecostomy, is described. Postoperatively, a daily enema was given through the stoma. The patients toileting time was reduced to 20 minutes and his AD resolved. The role of the ACE is discussed in adult spinal cord injury (SCI).

Sacral insufficiency stress fracture as etiology of positional autonomic dysreflexia: Case report

The medical literature is replete with case reports of the syndrome known as autonomic dysreflexia. Although the majority of cases are known to be induced by either bladder or bowel distention, there does exist a small number of cases in which the inciting stimulus is more obscure. In such cases, a comprehensive medical evaluation is necessary to ensure proper identification of the source of irritation and the appropriate medical management of the patient. We present a patient with a heretofore unreported suspected etiology of autonomic dysreflexia, axial loading of a sacral stress fracture.

Intramedullary sarcoidosis presenting as incomplete paraplegia: case report and literature review.

Abstract Sarcoidosis is a chronic, multisystem noncaseating granulomatous disease of unknown etiology. Sarcoidosis typically presents clinically in individuals between the ages of 20 and 40 years. Although sarcoidosis most commonly affects the respiratory system, nearly any organ system can be involved. Spinal cord involvement by sarcoidosis is a rare event, occurring in less than 1% of patients with systemic disease. The case presented is that of a 29-year-old black male with benign past medical history who presented with a 6-week history of progressive incomplete paraplegia arid bowel dysfunction. Magnetic resonance imaging revealed an intramedullary mass at the T-4-T-5 levels. The patient underwent thoracic laminectomy and debulking of the mass. The pathology was consistent with granulomatous disease. Postoperatively, the patient was placed on prednisone. He subsequently received comprehensive inpatient and outpatient rehabilitation and at present is bowel and bladder continent and ambulating at community levels with a rolling walker. The diagnosis of sarcoidosis; potential treatment options, including debulking and long-term steroid use; and prognosis will be discussed.

Latex allergy in adults with spinal cord injury: a pilot investigation

Abstract Latex allergy is a well-known complication of repeated exposure to natural rubber latex (NRL) products. The medical literature is replete with studies investigating the prevalence of NRL allergy in myelodysplastic children. However, the prevalence of NRL allergy in adults with spinal cord injury (SCI) has received little attention. Patients with a history of NRL exposure secondary to long-term indwelling urinary catheter usage were recruited as subjects. The presence of NRL allergy was established using the radioallergosorbent assay technique (RAST). Serum from 15 subjects who had been injured an average of 23.8 ± 11.9 years and who had used an indwelling urinary catheter an average of 17.1 ± 11 .5 years was obtained. RAST for NRL was positive in 7 of the 15 (47%). Of note, serum obtained in a control group of 4 subjects who had been injured an average of 54.4 ± 3.1 years and had no significant history of long-term indwelling urinary catheter usage were all RAST negative. This study suggests that adults with SCI and significant NRL exposure via long-term indwelling urinary catheter usage may be at risk for the development of NRL allergy.

Neuroarthropathy: An Overuse Injury of the Shoulder in Quadriplegia

The shoulder joint of the spinal cord injured patient is the primary joint used for transfer and wheelchair propulsion. In addition to ordinary use, the shoulder is subject to overuse injury with resultant functional impairment. Frequent overuse injuries of the shoulder include subdeltoid bursitis, bicipital tendonitis, rotator cuff tear and secondary degenerative arthritis. Neuroarthropathy of the shoulder, an overuse injury of an insensate shoulder girdle, has been rarely described in the literature. The case presented is that of an active 47 year old, right hand dominant, C7 complete quadriplegic male with a one week history of painless right shoulder girdle swelling. Radiologic evaluation documented right proximal humerus destruction. Magnetic Resonance Imaging (MRI) confirmed syringomyelia. The pathophysiology of neuroarthropathy is presented here and limited treatment options are discussed.