Autonomic hyperreflexia in spinal cord injury patient during percutaneous nephrolithotomy for renal stone: a case report

Autonomic hyperreflexia or autonomic dysreflexia is a syndrome seen in approximately 85% of all quadriplegic patients and constitutes the only medical emergency related to spinal cord injury. We report on a paraplegic patient with a C5 to C7 spinal cord injury who suffered autonomic hyperreflexia during percutaneous nephrolithotomy for a right renal stone. The reflex-induced hypertension subsided with termination of the operation, and administration of an alpha and beta-adrenergic blocking agent (labelatol hydrochloride). The stone was removed successfully by pyelolithotomy with the patient under general anesthesia 4 days later.     

Perioperative autonomic hyperreflexia in high spinal cord lesions: a case report

We report the case of a 20-year-old man with serious perioperative attacks of autonomic hyperreflexia starting during urological surgery 14 months after a complete C6-C7 spinal cord injury. The intraoperative attacks were controlled by deepening the level of anaesthesia, while the postoperative attacks were treated with emepronium bromide. A brief discussion of the pathophysiology and treatment is given.     

The analgesic effect of intravenous ketamine and lidocaine on pain after spinal cord injury

BACKGROUND: Pain following spinal cord injury (SCI) is a therapeutic challenge. Only a few treatments have been assessed in randomized, controlled trials. The primary objective of the present study was to examine the analgesic effect of ketamine and lidocaine in a group of patients with neuropathic pain below the level of spinal cord injury. We also wanted to assess sensory abnormalities to see if this could help us to identify responders and if treatments resulted in changes of sensibility. METHODS: Ten patients with spinal cord injury and neuropathic pain below the level of injury were included. The analgesic effect of ketamine 0.4 mg kg(-1) and lidocaine 2.5 mg kg(-1) was investigated. Saline was used as placebo. The drugs were infused over 40 min. A randomized, double-blind, three-period, three-treatment, cross-over design was used. Systemic plasma concentrations of ketamine and lidocaine were assessed. Pain rating was performed using a visual analogue scale (VAS). Sensory function was assessed with a combination of traditional sensory tests and quantitative measurement of temperature thresholds. RESULTS: Response to treatment, defined as 50% reduction in VAS-score during infusion, was recorded in 5/10 in the ketamine, 1/10 in the lidocaine and 0/10 in the placebo groups. Neither ketamine nor lidocaine changed temperature thresholds or assessments of mechanical; dynamic and static sensibility. Nor could these sensory assessments predict response to treatment in this setting. Lidocaine and particularly ketamine were associated with frequent side-effects. CONCLUSION: Ketamine but not lidocaine showed a significant analgesic effect in patients with neuropathic pain after spinal cord injury. The pain relief was not associated with altered temperature thresholds or other changes of sensory function.     

Transient anisocoria after a traumatic cervical spinal cord injury: A case report

Context: Autonomic dysreflexia and dysautonomia can be a common complication following spinal cord injury, especially at levels of T6 and above and can lead to complications associated with the pupil. In this case report, we review autonomic dysreflexia, the anatomy and physiology of the sympathetic nervous system of the eye, as well as review the clinical relevance in understanding autonomic and pupillary changes in response to autonomic dysfunction.

Findings: We present a patient with an incomplete C4 level injury who was found to have isolated anisocoria on two separate occasions during his acute inpatient rehabilitation stay.

Conclusion/Clinical Relevance: Anisocoria associated with abnormal sympathetic activation may be a clinical sign of dysautonomia.     

Autonomic dysreflexia in a parturient with spinal cord injury

Autonomic dysreflexia (ADR) is a syndrome of imbalanced reflex sympathetic discharge occurring in patients with spinal cord injury (SCI) at or above the level of splanchnic sympathetic outflow (T6). We present the case of a 29 year-old, gravida 3, para 1 Caucasian female at 28 weeks gestation, with a history of T3 SCI secondary to a gunshot wound 9 years prior, who developed ADR during preterm labor and received epidural anesthesia during 6 days of labor followed by spinal anesthesia for cesarean section. Spinal anesthesia may be superior to epidural anesthesia for providing hemodynamic protection against ADR during cesarean section.     

Fournier gangrene in spinal cord injury: a case report

BACKGROUND: Fournier gangrene is a necrotizing fasciitis of the perineal and genital region resulting from polymicrobial infection in which infection spreads along fascial planes, causing soft-tissue necrosis. If surgical debridement and control of infection are delayed, the disease can progress and result in septic shock, multiorgan failure, and death. Initial symptoms are severe pain in the genital region followed by swelling and erythema. In patients with spinal cord injury (SCI), lack of pain sensation could cause delay in seeking medical attention. SCI patients are at higher risk for Fournier gangrene secondary to neurogenic bladder, neurogenic bowel, and impaired sensation. A literature search resulted in only 1 report of Fournier gangrene with localized necrosis of the scrotum in a patient with SCI. METHODS: Case report of a 47-year-old man with C4 tetraplegia. RESULTS: Patient presented with a necrotic ulceration on the ventral aspect of the penis and scrotum of 2 days duration and was diagnosed with fulminant Fournier gangrene. CONCLUSIONS: Patients with SCI are at higher risk for Fournier gangrene secondary to neurogenic bladder, neurogenic bowel, and impaired sensation. Mortality is high. Prevention and early diagnosis are essential. Prompt aggressive intervention is warranted to maximize outcomes.     

Pilomyxoid astrocytoma of the cervical spinal cord successfully treated with chemotherapy: case report

A 15-month-old girl presented with a spinal pilomyxoid astrocytoma manifesting as a 3-month history of dysphagia. Magnetic resonance imaging showed an intramedullary mass of the cervical spinal cord at C1-C6 with syringobulbia. She underwent partial removal of the tumor and received postoperative chemotherapy with cisplatin and etoposide. The tumor completely responded to the treatment and has not relapsed for 64 months. Pilomyxoid astrocytoma frequently occurs in the opticohypothalamic regions but is rare in the spine. The present case suggests that surgery followed by chemotherapy with cisplatin and etoposide may be an effective therapeutic option for pilomyxoid astrocytoma of the cervical spinal cord.     

Diagnostic pitfalls: case report of scurvy in a man with spinal cord injury

BACKGROUND: A 49-year-old man with spinal cord injury (SCI) developed a progressive purpuric rash and painful swelling of the lower extremities, in addition to chronic purpura over the ischial tuberosities. DESIGN: Case report. FINDINGS: Following an extensive workup for presumed vasculitis, a skin biopsy showed evidence of scurvy. Risk factors for scurvy included limited means of transportation, living alone, and alcohol abuse. CONCLUSIONS: Scurvy can be confused with disorders common among SCI patients, such as vasculitis, venous thrombosis, occult trauma, and pressure injury. Scurvy should be considered in the differential diagnosis of skin lesions, especially in individuals who abuse alcohol and live alone.     

Fulminant Clostridium difficile colitis in a patient with spinal cord injury: case report

BACKGROUND: In certain patients with Clostridium difficile colitis (CDC), a life-threatening systemic toxicity may develop despite appropriate and timely medical therapy. DESIGN: Literature search and case report. FINDINGS: A 39-year-old man with T10 paraplegia presented with a distended, quiet abdomen following recent treatment with antibiotics for pneumonia. Diarrhea was not present. Complete blood counts demonstrated a marked leukocytosis. A CT scan of the abdomen demonstrated a state of diffuse pancolonic inflammation with peritoneal fluid. The patient was taken to the operating room and underwent total abdominal colectomy with oversewing of the rectal stump and end ileostomy for treatment of the fulminant CDC. CONCLUSION: Patients with spinal cord injury (SCI) often receive antibiotics for infections of the aerodigestive tree and urinary tract and for problems with skin integrity. A heightened awareness of the development of fulminant CDC remains essential in the care of patients with SCI. Any unexplained abdominal illness after recent antibiotic administration should alert the physician to CDC and its potential as a fulminant, potentially fatal illness.     

Posttraumatic syringomyelia developing soon after spinal cord injury. A case report

We report a case of posttraumatic syringomyelia (PTS) that developed 10 months after spinal cord injury (SCI), A 46-year-old man was involved in a motorcycle accident, in which he received a severe spinal cord injury due to a burst fracture at the T6 level. The patient underwent posterior fixation without decompression at another hospital, and was transferred to our hospital for rehabilitation. Ten months after the SCI, he complained of back and neck pain caused by bending his head backward. MRI showed syringomyelia shaped like a cone extending from the T6 to the C6 level, enlarged by cerebrospinal fluid (CSF) flow toward the syringomyelia at the T6 level. Pain was relieved by syringosubarachnoid shunt implantation and the syrinx disappeared after the operation. PTS emerging 10 months after spinal cord injury is relatively rare. From the radiological and operative findings, PTS was enlarged by the CSF flow, which was hindered at the T6 level by compression of the vertebral body to the spinal cord. In cases of SCI in patients who undergo posterior fixation with insufficient decompression, close attention to PTS is required in the postoperative follow-up.     

Ischemic spinal cord injury after aortocoronary bypass operation. A case report

Although spinal ischemia is a very well recognized complication after operation on the thoraco-abdominal and abdominal aorta, it is very rare following coronary artery bypass surgery. A case of a 56-year-old man, who had juxtarenal aortic occlusion and became paraplegic after internal mammary artery grafting for ischemic heart disease is reported. The complete paraplegia was thought to be due to interruption of critical collateral blood supply to the spinal cord.