Yesim Akkoc

Spinal epidural hematoma associated with oral anticoagulation therapy.

Spontaneous spinal epidural hematoma is an uncommon cause of spinal cord compression. It may be associated with various causative factors, but in many patients, anticoagulation can be implicated. It is noteworthy that many of the reported cases were anticoagulated in the therapeutic range. Spontaneous spinal epidural hematoma should be suspected in any patient receiving anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. Early diagnosis and treatment are very important for the functional recovery of the patient. Spinal magnetic resonance imaging is the most suitable neuroradiological method for early diagnosis. Although primary management is the surgical evacuation of the spinal epidural hematoma via laminectomy, rare cases in which the patient is improving rapidly and progressively could be treated conservatively. A 22-yr-old man with a spontaneous spinal epidural hematoma who was receiving warfarin treatment for a mechanical aortic valve is presented in this article.

Comparison of intravaginal electrical stimulation and trospium hydrochloride in women with overactive bladder syndrome: a randomized controlled study

Objective: To compare the effects of trospium hydrochloride and electrical stimulation on urodynamic parameters, bladder diary, quality of life and psychological symptoms in female patients with overactive bladder syndrome. Design: Prospective, randomized controlled trial. Setting: Department of Physical Medicine and Rehabilitation, University Hospital. Subjects: Thirty-five patients were divided into either trospium chloride (Group 1) or intravaginal electrical stimulation therapy (Group 2). Main outcome measures: All patients were assessed at the beginning of the treatment, at weeks 6 (end of treatment), 10 and 18 according to urodynamic parameters, voiding diary parameters, severity of urgency (visual analogue scale, VAS), the Incontinence Impact Questionnaire Short Form (IIQ-7), and the Beck Depression Inventory. Results: Statistically significant improvements were observed in both groups according to some urodynamic parameters, voiding diary parameters, VAS urgency severity, Incontinence Impact Questionnaire Short Form and Beck Depression Inventory scores at the end of the treatment (P<0.05). During the 18-week follow-up period, deteriorations were observed in many parameters in both groups although improvements in the frequency of urgency, the frequency of incontinence episodes, VAS urgency severity, and Beck Depression Inventory score in Group 2 persisted (P<0.05). Significant differences were not detected between groups at the end of the treatment or during the posttreatment follow-up controls (P>0.05). Conclusion: No difference was detected between trospium hydrochloride and intravaginal electrical stimulation in the treatment of female overactive bladder syndrome. Discontinuation of both treatments caused deterioration in most of the objective and subjective symptoms of overactive bladder syndrome.

Effects of different bladder management methods on the quality of life in patients with traumatic spinal cord injury.

Study design:Multi-center, cross-sectional study.Objectives:To investigate the effects of different bladder management methods on the quality of life (QoL) in patients with spinal cord injury (SCI).Setting:Turkey.Methods:Consecutive SCI patients (n=195, 74.4% males), for whom at least 6 months had elapsed since the injury, were included and evaluated in five groups: normal spontaneous micturition (NSM), micturition with assisted maneuvers (MAM), aseptic intermittent catheterization by patient (IC-P), aseptic IC by an attendant/caregiver (IC-A) and indwelling catheterization. The King’s Health Questionnaire was used to evaluate the patients’ QoL.Results:The bladder management groups were similar regarding age, time elapsed since injury, education level, marital and occupational status. There was no difference among the groups in general health perception, personal relationships and sleep/energy domain scores. While the NSM group had generally the lowest scores, that is, better QoL, the IC-A group had the highest scores, that is, poorer QoL, in most of the domains. When the patients were grouped according to the frequency of urinary incontinence or American Spinal Injury Association Impairment Scale grades, no difference was found in the domain scores of the groups except the symptom severity domain scores. No significant difference was found between paraplegic and tetraplegic patients in the King’s Health Questionnaire domains.Conclusion:The QoL was notably affected in SCI patients in IC-A group and negative effects on emotional status, physical and social activity limitations were observed, as well.

Complex regional pain syndrome in a patient with spinal cord injury: management with pulsed radiofrequency lumbar sympatholysis

Study design:Short communication.Objectives:To report a case with bilateral lower extremity complex regional pain syndrome (CRPS) in a patient with paraplegia occurring following spinal disc herniation surgery, who was treated successfully with pulse radiofrequency (PRF) lumbar sympatholysis.Setting:Departments of Physical Medicine and Rehabilitation, Algology Department of Anaesthesiology and Nuclear Medicine, Medical Faculty of Ege University, Izmir, Turkey.Methods:A 55-year-old woman had neuropathic pain in her lower extremities after T12–L1 disc herniation surgery. The pain decreased to a tolerable level with conservative treatment and her condition remained stable for the following 6 months; then she developed swelling, redness and severe burning pain in both feet. Physical examination showed edema and redness in the feet. On the basis of clinical findings and Tc-99m methylene diphosphonate (MDP) three-phase bone scintigraphy, she was diagnosed to have CRPS.Results:The patient underwent a diagnostic sympathetic ganglion blockade with bupivacaine, which resulted in a marked decrease in the pain and edema of the feet. Consequently, PRF lumbar sympatholysis was performed with a successful outcome in pain, edema and color changes in the feet.Conclusion:When treatment of CRPS fails with conventional modalities, PRF sympatholysis may be used for control of pain and other symptoms in such patients.

Neurogenic bladder in patients with traumatic spinal cord injury: treatment and follow-up

Study design:Multi-center, cross-sectional study.Objectives:Our aim was to evaluate the treatment methods and follow-up of neurogenic bladder in patients with traumatic spinal cord injury retrospectively using a questionnaire.Setting:Turkey.Methods:Three hundred and thirty-seven patients who had spinal cord injury for at least 2 years were enrolled from six centers in the neurogenic bladder study group. They were asked to fill-out a questionnaire about treatments they received and techniques they used for bladder management.Results:The study included 246 male and 91 female patients with a mean age of 42±14 years. Intermittent catheterization (IC) was performed in 77.9% of the patients, 3.8% had indwelling catheters, 13.8% had normal spontaneous micturition, 2.6% performed voiding maneuvers, 1.3% used diapers and 0.6% used condom catheters. No gender difference was found regarding the techniques used in bladder rehabilitation (P>0.05). Overall, 63.2% of patients used anticholinergic drugs; anticholinergic drug use was similar between genders (P>0.05). The most common anticholinergic drug used was oxybutynin (40.3%), followed by trospium (32.6%), tolterodine (19.3%) darifenacin (3.3%), propiverine (3.3%) and solifenacin (1.1%). The specialties of the physicians who first prescribed the anticholinergic drug were physiatrists (76.2%), urologists (22.1%) and neurologists (1.7%). Only four patients had previously received injections of botulinum-toxin-A into the detrusor muscle and three of them stated that their symptoms showed improvement. Most of the patients (77%) had regular follow-up examinations, including urine cultures, urinary system ultrasound and urodynamic tests, when necessary; the reasons for not having regular control visits were living distant from hospital (15.3%) and monetary problems (7.7%). Of the patients, 42.7% did not experience urinary tract infections (UTI), 36.4% had bacteriuria but no UTI episodes with fever, 15.9% had 1-2 clinical UTI episodes per year and 5% had ⩾3 clinical UTIs. The clinical characteristics of patients with and without UTI (at least one symptomatic UTI during 1 year) were similar (P>0.05). The frequency of symptomatic UTI was similar in patients using different bladder management techniques (P>0.05).Conclusion:The most frequently used technique for bladder rehabilitation in patients with SCI was IC (77.9%). In all, 63.2% of patients used anticholinergic drugs, oxybutynin being the most commonly used drug. Also, 77% of patients had regular control visits for neurogenic bladder; 42.7% did not experience any UTIs.

Intracranial dural arteriovenous fistula draining into spinal perimedullary veins: a rare cause of myelopathy.

We report a rare case of progressive myelopathy caused by intracranial dural arteriovenous fistula with venous drainage into the spinal perimedullary veins. A 45-yr-old man developed urinary and fecal incontinence and muscle weakness in the lower limbs. Magnetic resonance imaging revealed brainstem edema and dilated veins of the brainstem and spinal cord. Cerebral angiography showed a dural arteriovenous fistula fed by the neuromeningeal branch of the left ascending pharyngeal artery. Occlusion of the fistula could be achieved by embolization after a diagnostic and subsequent therapeutic delay. There was no improvement in clinical condition. For the neurologic outcome of these patients it is important that fistula must be treated before ischemic and gliotic changes become irreversible.

Longitudinal study of bone loss in chronic spinal cord injury patients.

[Purpose] This prospective longitudinal study evaluated the changes in bone metabolism markers and bone mineral density of spinal cord injury patients over 3 years. We also assessed the relationships among the bone mineral density, bone metabolism, and clinical data of spinal cord injury patients. [Subjects and Methods] We assessed the clinical data (i.e., immobilization due to surgery, neurological status, neurological level, and extent of lesion) in 20 spinal cord injury patients. Bone mineral density, and hormonal and biochemical markers of the patients were measured at 0, 6, 12, and 36 months. [Results] Femoral neck T score decreased significantly at 36 months (p < 0.05). Among the hormonal markers, parathyroid hormone and vitamin D were significantly elevated, while bone turnover markers (i.e., deoxypyridinoline and osteocalcin) were significantly decreased at 12 and 36 months (p < 0.05). [Conclusion] Bone mineral density of the femoral neck decreases significantly during the long-term follow-up of patients with spinal cord injury due to osteoporosis. This could be due to changes in hormonal and bone turnover markers.

Intermittent catheterization in patients with traumatic spinal cord injury: obstacles, worries, level of satisfaction

Objectives:The aim of this study is to examine the obstacles in people with traumatic spinal cord injury (SCI) face performing intermittent catheterization (IC), also their worries and level of satisfaction.Methods:Two hundred sixty-nine patients performing IC for at least 3 months were asked to fill-out a questionnaire about their opinions on IC.Results:In total, 69.5% of patients performed IC themselves, 10.4% had performed by their mothers, 7.8% by another caregiver and 7.4% by their spouse. For the 72 (26%) patients unable to apply IC, reasons were insufficient hand function (56.1%), being unable to sit appropriately (35.4%) and spasticity (8.5%). In all, 70% of male patients had insufficient hand function, 20% could not sit and 10% had spasticity while 56.3% of female patients could not sit, 37.5% had insufficient hand function and 63% had spasticity. Difference between sexes was found to be statistically significant (P<0.05). Worries patients had when starting IC were fear of being dependent on IC (50.2%), accidentally injuring self (43.8%), embarrassment (43.2%), causing an infection (40.2%), bleeding (32.7%), fear of feeling pain (30.2%) and hygiene (24.7%). More women felt embarrassment; other items were similar in both sexes. In all, 46.9% of patients had urinary incontinence in intervals.Conclusion:In total, 69.5% of patients performed IC themselves. Men’s most common obstacle was insufficient hand function while women’s was being unable to sit appropriately. Patients’ most common worries were being dependent on IC for life. In all, 46.9% had incontinence in intervals; 47.9% said IC improved their life quality; and 97.4% preferred IC over continuous catheterization.

Efficacy and safety of urinary catheters with silver alloy coating in patients with spinal cord injury: a multicentric pragmatic randomized controlled trial. The ESCALE trial

BACKGROUND Patients with spinal cord injury (SCI) who carry indwelling urinary catheters have an increased risk of urinary tract infection (UTI). Antiseptic silver alloy-coated (SAC) silicone urinary catheters prove to be a promising intervention to reduce UTIs; however, current evidence cannot be extrapolated to patients with SCI. PURPOSE This study aimed to assess the efficacy of SAC urinary catheters for preventing catheter-associated urinary tract infections. DESIGN/SETTING This is an open-label, multicenter (developed in Spain, Portugal, Chile, Turkey, and Italy), randomized clinical trial conducted in 14 hospitals from November 2012 to December 2015. PATIENT SAMPLE Eligible patients were men or women with traumatic or medical SCI, aged ≥18 years, requiring an indwelling urinary catheter for at least 7 days. OUTCOME MEASURES The primary outcome was the incidence of symptomatic UTIs. The secondary outcome included bacteremia in the urinary tract and adverse events. MATERIALS AND METHODS Patients were randomized to receive a SAC urinary catheter (experimental group) or a standard catheter (control group) for at least 7 days. Data were compared using chi-squared test and also calculating the absolute risk difference with a 95% confidence interval. An adjusted analysis including different risk factors of UTI was performed. This study was mainly funded by La Marató de TV3 Foundation (grant number # 112210) and the European Clinical Research Infrastructures Network organization. The funders had no role in the interpretation or reporting of results. RESULTS A total of 489 patients were included in the study, aged 55 years in the experimental group and aged 57 in the control group (p=.870); 72% were men; 43% were hospitalized patients, and 57% were outpatients (p=1.0). The most frequent cause of SCI was traumatic (73.75%), and the localization was mainly the cervical spine (42.74%). Most of the patients had an A score (complete spinal injury and no motor and sensory is preserved) on the ASIA scale (62.37%). The median time of urethral catheterization was 27 days in the experimental group and 28 days in the control group (p=.202). Eighteen patients (7.41%) in the experimental group and 19 in the control (7.72%) group had a symptomatic UTI (odds ratio [OR] 0.96 [0.49-1.87]). The adjusted analysis revealed no change in the results. Only three patients in the experimental group had bacteremia within the urinary tract. The experimental group presented more adverse events related to the use of a catheter than the control group (OR 0.03 [0.00-0.06]). CONCLUSIONS The results of this study do not support the routine use of indwelling antiseptic SAC silicone urinary catheters in patients with SCI. However, UTIs associated to long-term urinary catheter use remain a challenge and further investigations are still needed.

Overactive bladder symptoms in patients with multiple sclerosis: Frequency, severity, diagnosis and treatment

Objective: To determine the frequency and severity as well as the diagnosis and treatment of overactive bladder problems in patients with multiple sclerosis (MS) followed up at five centers in Turkey. Design: Survey study. Setting: Outpatient tertiary clinics of physical medicine and rehabilitation and neurology. Participants: Consecutive MS patients scheduled for outpatient follow-up (n = 309). Intervention: MS patients were asked to complete a questionnaire regarding the frequency and severity, as well as the diagnosis and treatment of their overactive bladder problems. Results: The mean age ± SD was 39.3 ± 10.6 years. Urinary urgency was the most common urinary symptom (62%), followed by frequency (50.4%), urge incontinence (44.7%) and nocturia (33%). Residual urine volume was measured using a portable ultrasound instrument in 13.3% of the patients and by catheterization in 16.2% of them. Urodynamic investigations and urinary tract ultrasound were performed on 26.5% and 35.3% of the patients, respectively. Anticholinergic medications were prescribed for 27.5% of the patients. Intermittent catheterization and indwelling catheterization were used on 8.1% and 1.9% of the patients, respectively. The overactive bladder symptom score (OABSS) was significantly higher in patients who had had residual urine measurement (P < 0.001), upper urinary tract assessment by ultrasound (P < 0.001), urodynamic assessment (P < 0.001), admitted to a doctor for urinary symptoms (P < 0.001), and current or past catheter use (P = 0.002). Conclusion: Urgency was the most common urinary symptom followed by frequency, urge incontinence and nocturia in MS patients. The patients with lower OABSS had detailed urological assessments less frequently than the patients with higher OABSS.