Mehdi Sarkarati

Cervical spinal cord injury complicating ankylosing spondylitis.

Within a period of 12 years 466 patients with acute spinal cord injury were admitted to our Centre, seven of these having ankylosing spondylitis (AS). A history of alcohol consumption preceding the accident was present in five patients, and in four there was a history of neurological deterioration before their admission. An epidural hematoma was found in one patient and four expired within 3 months of their injury.The incidence of ankylosing spondylitis in cervical cord injury was 1.5%, and an associated epidural hematoma was present in some 14% of the patients. The mortality rate was 57%. There was a high incidence of alcoholic use before the accident. Neurological deterioration commonly occurred before admission.

Role of Striated and Smooth Muscle Components in the Urethral Pressure Profile in Traumatic Neurogenic Bladders: A Neuropharmacological and Urodynamic Study. Preliminary Report

Urodynamic investigations with urethral pressure profile, and vesical, intrarectal and anal pressure recordings were performed in 37 patients with spinal cord lesions. The recordings were done before and after phentolamine injections and/or pudendal nerve blocks to evaluate the respective contribution of sympathetic and somatic innervation to the maximum urethral closure pressure in the mid and distal portions of the membranous urethra. A pressure gradient was demonstrated in the membranous urethra with higher values in the distal than in the mid portion. These results emphasize that the interrupted withdrawal technique is superior to the continuous technique in patients with upper motor neuron bladders. Mid urethral striated and smooth muscle components were shown to represent approximately 60 and 30 per cent of the maximum urethral closure pressure, respectively. In the distal urethra striated and smooth components are more abundant than in the mid portion and contribute in equal proportion to the maximum urethral closure pressure. No substantial role was found for the vascular bed in the maximum urethral closure pressure. The greatest pressure decrease in the mid and distal urethra of patients with lower motor neuron bladders was believed to be an effect of denervation supersensitivity. The results of pudendal blocks showed sphincter dyssynergia to be mediated through pudendal nerves via spinal reflex arcs. Phentolamine effects on bladder activity suggest that blockade of alpha-adrenergic receptors inhibits primarily the transmission in vesical and/or pelvic parasympathetic ganglia and acts secondarily through direct depression of the vesical smooth muscle. Our neuropharmacological results raise strong doubts as to the existence of a sympathetic innervation of the striated urethral muscle in humans.

Urodynamics in spinal shock patients.

We investigated 17 spinal shock patients with traumatic complete cord lesions with cystometry, urethral pressure profile, anal and rectal pressure recordings, and electromyography of the pelvic floor sphincters. Bladder filling was accompanied by an elevation of resistance in the bladder neck area, with a concomitant increase of pressure in the external sphincter zone but without a simultaneous increase of the electromyographic activity. These results indicate an increased sympathetic activity in the smooth muscle component of the entire urethra. In the majority of patients the continuous withdrawal pressure profile had higher values in the membranous urethra than the interrupted withdrawal pressure profile had higher values in the membranous urethra than the interrupted withdrawal pressure profile, revealing the importance of sensory afferents from the urethral mucosal receptors in producing artifactual reflex activity in the pelvic floor muscles. In the majority of interrupted withdrawal urethral pressure profiles higher pressures were recorded in the juxtabulbous region than in the mid part of the membranous urethra. A somewhat decreased electromyographic activity was found in the anal and urethral sphincters at rest. It did not often relate to the amount of resistance recorded in either sphincter. High urethral sphincter pressures and somatic activity of the conus medullaris reflexes show that external urethral and anal sphincters escape spinal shock, the primary characteristic of which is areflexia.

Experience in the Urologic Management of 120 Early Spinal Cord Injury Patients

More than 120 patients with recent spinal cord injuries have been admitted to our hospital during the last 3 years. Intermittent catheterization has been the preliminary step in the urologic management of these patients. The transcutaneous suprapubic cystocath with intermittent aspiration of urine also has been used in 7 cases. A bladder outlet operation after 3 months was indicated 3 times more often in patients with complete than in those with incomplete neurologic lesions. Results and indications are discussed.

Colorectal Carcinoma and Myelopathy

The incidence and pathological features of colorectal carcinoma in a population of veterans disabled by myelopathy were examined by record review. Thirteen cases of colorectal carcinoma were found among the 1023 such individuals (99 percent male) who were hospitalized and subsequently followed between April 1, 1973 and September 22, 1983. The age adjusted incidence rates ranged from 316 per 100,000 person years in the sixth decade to 1886 per 100,000 person years in the ninth decade of age. These rates were two to six times the highest reported rates for general male populations (P less than 0.05). The location of carcinoma was proximal to the rectosigmoid colon in 62 percent of the 13 paralyzed patients, but in only 12 percent of 31 nonparalyzed male patients with colorectal carcinoma diagnosed at the same hospital in 1977-1979 (P less than 0.001). The stage of the tumor at diagnosis was Dukes Kirklin C in 83 percent of paralyzed patients and 48 percent of the nonparalyzed patients (P less than 0.001). We conclude that colorectal carcinoma is more common, more proximal in location, and more advanced at diagnosis in male subjects with myelopathy than in nonparalyzed male subjects.

The respective contribution of smooth and striated components in the urethral pressure profile of the spinal cord injured. a neuropharmacological and urodynamic study

The respective contribution of smooth and striated components in the urethral pressure profile of the spinal cord injured. a neuropharmacological and urodynamic study

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.

The value of fibular intersomatic fusion in the treatment of recent cervical spinal cord injuries.

A Series of six patients with recent cervical spine fracture and spinal cord injury treated by corpectomy and fibular strut graft is presented. Three patients had a complete sensorimotor tetraplegia and the other three had an incomplete sensory but complete motor lesion. All patients had fractures of one or two adjacent vertebrae with concomitant displacement which was corrected by skull traction prior to surgery. Gas myelography in three patients revealed herniated disc material in two instances. Corpectomy and fusion were carried out on the 12th, 13th, 29th, 32nd, 33rd, and the 58th post-traumatic day. There was no immediate mortality or major complication associated with the procedure. One late death in an elderly patient 6 months post-operatively is felt to be unrelated to the procedure. In this series gas myelography was carried out at a later date following the injury. The goal of the operation was therefore not primarily to decompress the cord but to stabilise the fractured spine in order to allow earlier mobilisation than traditional treatment in traction. Average time out of bed was 9 days post-operatively and 36 days post-injury. Solid fusion sufficient to allow discontinuation of all neck support was achieved in 3 months in all patients. There were no episodes of graft displacement or dislocation and in only one patient was there a moderate increase in angulation at the fracture site. In the patient who died 6 months postoperatively gross and histologic examinations showed incorporation and union at the ends of the graft and bridging of the injured area by new bone. The authors feel the above procedure in selected patients—six out of 62 patients admitted with cervical spine and spinal cord injury within 4 weeks of trauma during the past 39 months—is an important adjunct to the treatment and rehabilitation at their spine fracture and spinal cord injury.