Biomedical subjects
Publications and source records attributed to I Perkash.
We report an unusual case of a sarcoma at the patch site of an ileocystoplasty. The tumor proved to be an aggressive neoplasm that metastasized widely. The literature is reviewed concerning neoplasms occurring in urinary diversion procedures.
Fifty consecutive spinal injury patients who underwent simultaneous EMG of the peri-urethral and perianal striated muscles along with cystometrogram on a multiple channel recorder are analysed. Bladder filling, voiding and also influence of spasticity on the EMG activity of both perianal and periurethral striated muscles were compared. Periurethral striated EMG along with CMG has a better diagnostic value (95 per cent) as compared to perianal EMG-CMG which was diagnostic in 72 per cent patients.
Our experience in the screening and detection of hypothyroidism in 225 spinal injury patients is described. Clinical features compatible with hypothyroidism are frequently encountered in these patients and require thyroid function testing to exclude or confirm thyroid hypofunction. Two cases of hypothyroidism, equivocal on clinical grounds alone, were first detected by a low value in screening tests for serum thyroxine levels and subsequently confirmed by a high serum TSH level. Low serum triiodiothyronine level is frequently found in apparently euthyroid patients with tetraplegia and is necessarily not an indicator of clinical hypothyroidism in these patients.
Cerebral somatosensory evoked potentials (SEP's) were elicited by electrical stimulation of the median nerve in the arm (SEPA) and of the posterior tibial nerve in the leg (SEPL) in 23 patients with incomplete localized lesions (including traumatic injuries, neoplasms, vascular malformations and infarcts) of the low cervical, thoracic, or lumbar spinal cord. In eight of 46 attempts (left and right sides), SEPL could not be recorded. Of the remaining 38 sides, spinal somatosensory conduction velocity (SSCV, indirectly estimated) was abnormally slow (less than 35 m/sec) in 20, and the amplitude of SEPL relative to SEPA (L:A ratio) was abnormally low (less than 0.5) in 20 (p less than 0.001 in each case, compared to normal controls). All three criteria yielded a combined 72% incidence of abnormality, correlating best with impairment of joint position sense. Serial postoperative studies in four cases documented an increase in the SSCV and L:A ratio following spinal decompression. These results demonstrate that the latency and amplitude characteristics of the cerebral SEP's from arm and leg permit quantitative evaluation of the functional status of the spinal somatosensory system.
During a 28-month interval 70 spinal cord injury patients in the initial rehabilitation hospitalization underwent 5,052 days of intermittent catheterization. Intermittent catheterization was done with a sterile technique and a neomycin-polymyxin irrigant. At the time of transfer to our facility 39 patients were using Foley catheter drainage but no difficulty was encountered when these patients were changed to intermittent cateterization. While on intermittent catheterization 52 urinary tract infections occurred, half caused by gram-positive cocci, 24 by gram-negative bacilli and 2 by Candida albicans. These infections occurred in 38 patients (54 per cent) at an over-all rate of 10.3 infections per 1,000 patient-days of intermittent catheterization. Only 2 infections were symptomatic and these occurred in patients on pass who unilaterally discontinued intermittent catheterization. Only 6 infections were not cured by antimicrobial therapy. Urinary tract infection was less common in patients who had incomplete spinal cord injuries. Infections caused by organisms susceptible to the irrigant containing neomycin-polymyxin occurred almost exclusively in patients catheterized 3 or fewer times daily. Infection was rare after 3 months on intermittent catheterization. Intermittent catheterization with our technique poses little infection hazard and can be introduced readily in acute spinal cord injury patients before transfer to specialized facilities.
Herein attention is focused on the documentation of high blood pressure response with detrusor-sphincter dyssynergia in spinal cord injury patients and with its amelioration after extended sphincterotomy. During cystomanometric evaluation of the bladder the monitored blood pressure response in 53 spinal injury patients, 27 non-dyssynergic spinal injury patients and 18 non-spinal injury patients was compared. A high correlation was observed among the magnitudes of blood pressure increase, level of injury and the severity of detrusor-sphincter dyssynergia in spinal injury patients. During cystomanometry blood pressure increases of greater than 20 mm. Hg systolic and 10 mm. Hg diastolic in normotensive paraplegics (below T5) and also in non-spinal injury patients were significant to suspect detrusor-sphincter dyssynergia. In normotensive tetraplegic patients blood pressure increases of greater than 40 mm. Hg systolic and 20 mm. Hg diastolic were significant to suspect detrusor-sphincter dyssynergia. The mechanism of blood pressure increase is elucidated. The management of this high blood pressure response in patients with detrusor-sphincter dyssynergia by drug therapy and extended sphincterotomy is discussed. Based on our experience the use of carbon dioxide for cystomanometry seems preferable in patients with spinal lesions above T5 since expedient deflation of the bladder can prevent an inordinate blood pressure increase.
Some characteristics are described for detrusor-sphincter dyssynergia and the dyssynergic response in spinal injury patients with complete lesions. The urodynamic evaluation and clinical problems are analyzed in 53 patients to identify the importance of early recognition of sphincter dyssynergia. Cystomanometric and urethral profile pressures vary from 30 to 150 cm. water. Although high voiding pressure, particularly associated with autonomic dysreflexia, may be indicative of sphincter dyssynergia it is not diagnostic. Relevant characteristics of patients with detrusor-sphincter dyssynergia are 1) rhythmic detrusor contractions on cystomanometry with associated marked increase in electromyographic activity on attempted voiding. These characteristics enable early recognition of dyssynergia and afford expediency in its management. The modified approach to external sphincterotomy as practiced by the author provides optimal surgical approach for urological rehabilitation of dyssynergic patients. Thus, the rationale for characterization of dyssynergia and its management by modified sphincterotomy can help to terminate long-term intermittent catheterization, remove indwelling catheter, prevent renal damage and ameliorate autonomic dysreflexia.
Two cases of spinal cord injury with detrusor-sphincter dyssynergia and detrusor hyperreflexia are presented. In 1 patient bilateral hydronephrosis developed between 3 and 7 months after injury while he was on intermittent catheterization. In the other patient early sphincterotomy (3 1/2 months post-injury) was not followed by upper tract changes. Urodynamic evaluation should be done before intermittent catheterization is continued for more than 3 months after spinal cord injury. The importance of early diagnosis and appropriate management of detrusor-sphincter dyssynergia associated with detrusor hyperreflexia is discussed.
Fifty acute SCI patients are reviewed retrospectively for incidence of deep vein thrombosis and pulmonary embolism and the problems encountered in the diagnosis. The possible role of some risk factors in triggering thromboembolism and the consequent implications in anticoagulant therapy are discussed.
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Whole body 99mTc-pyrophosphate scans were obtained and correlated with skeletal radiographs for detection of heterotopic calcification in 122 spinal injury patients. There were 27 patients with recent injury (less than 6 months) and 95 with injury of 6 months to 25 years duration. Ectopic calcification was detected in 8 of the 27 patients (30%) with recent injury and in 32 of the 95 (34%) with injury of over 6 months duration. Ectopic calcification seen on radiographs were also seen on scans in all instances. The scan was a sensitive indicator of the ectopic calcification particularly at its early stage, and detected its presence before observable radiographic changes in 5 patients with injury of 1-3 months duration. In 3 of the 5 patients, the ectopic calcification mimicked deep vein thrombosis in presentation, and the scan was valuable in identifying the nature of the complication.
Forty-six patients with spinal injury with dysfunctional neurogenic bladder were analyzed. Fourteen patients on prolonged intermittent catheterization from 12 weeks to more than 1 year did not develop a balanced bladder, 14 patients had indwelling catheters after intermittent catheterization failed elsewhere and 18 patients on external condom drainage presented with difficult voiding and repeated infections. There were 16 quadriplegics (1 incomplete), 21 paraplegics, and 9 incomplete cauda equina lesions. Urologic and urodynamic evaluation revealed detrusor-sphincter dyssynergia in 15 patients, vesicoureteral reflux in 10, and areflexic bladders in 11. Five patients over the age of 55 years showed slight enlargement of the prostrate. Some degree of bladder neck fibrosis was suspected in 26. More than one urologic pathology was encountered in the same patient. Transurethral sphincterotomy was carried out in 38 patients and only one transurethral resection of the prostrate (TURP) in an incomplete quadriplegic patient. In seven patients with no obvious urodynamic abnormality, a balanced bladder was achieved with intermittent catheterization; however, one of these patients needed a transurethral sphincterotomy on subsequent admission. A balanced bladder was achieved in all patients except the one with incomplete quadriplegia. Significant improvement in vesicoureteral reflux and relief from autonomic dysreflexic symptoms were recorded in all patients.
Based on the experience to date with central cord syndrome, most or all of the following conditions should be present before considering transurethral sphincterotomy: (1) minimal neurological recovery within 6 months of injury; (2) four plus spasticity in patients over the age of 50 years; (3) prolonged intermittent catheterisation over 6 months, with persistent residual urine over 300 ml; (4) persistent and repeated use of diazepam, dantrolene sodium to control pelvic floor spasticity; (5) demonstrable detrusor-sphincter dyssynergia.
An attempt to understand and treat dysfunctions during bladder rehabilitation in 150 spinal cord injury patients is presented. The 25 problem patients were further analyzed to identify and manage the dysfunctional bladder and bladder neck, dyssenergic pelvic floor, vesicoureteral reflux, areflexic detrusor muscle and also to discontinue prolonged intermittent catheterization. The initial excellent results with a modified approach to sphincterotomy and the bladder neck operation in 15 patients are presented. Early recognition of patients in whom intermittent catheterization may not be successful will allow one to intervene and establish an early catheter-free status. A new concept of the existence of receptors in the posterior urethra has been postulated.
Indications, technique and results of a modified approach to an extended sphincterotomy in spinal cord injury patients with voiding dysfunctions is presented. There were 32 patients who underwent surgery and were subjected to analysis for their dysfunctional bladder and bladder-neck problems. Overall satisfactory results were obtained in about 90 per cent patients following sphincterotomy. Early recognition of patients where intermittent catheterisation may not succeed is presented to intervene and establish an early catheter-free status in such patients. Foley indwelling catheter in ten patients, being worn from seven months to four years, where intermittent catheterisation had not succeeded elsewhere, were decatheterised following surgery. Excellent results were obtained in ten patients with vesico-urethral reflux; external sphincterotomy, therefore, seems to be the treatment of choice for complete spinal cord transection with vesico-ureteral reflux. An attempt has also been made to present physiology of micturition reflex in spinal cord injury patients.
A review was made of 111 spinal cord injury patients who underwent bladder rehabilitation. The essential mode of treatment was intermittent catheterization. About 91 per cent of the patients were free of the catheter after 3 to 168 days of intermittent catheterization. Acute patients given an initial dosage of 30 to 40 mg. bethanechol chloride 3 times daily for 2 to 3 weeks recovered reflex activity in almost half the period (average of 32 days compared to 79 days). Modified sphincterotomy at the bladder neck was performed in 10 patients. This procedure improved the results to 98 per cent catheter-free reflex bladder status in the group of patients.
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