Bowel management in children and adolescents with spinal cord injury

There is little in the literature regarding bowel management in children and adolescents with spinal cord injuries (SCI). This study was undertaken to examine specific patterns of bowel care, individual levels of satisfaction with bowel management, the incidence of incontinence in this population, and effects on lifestyle because of time commitment and dependence in bowel management. Surveys were sent to all persons (n = 45) under age 19 with a diagnosis of SCI who had received care at our medical center since 1985. Thirty-one subjects (69 percent) returned the surveys. The average age at injury was 8.1 years, with an average follow-up period of 3.9 years. Fifty-five percent were individuals with tetraplegia and 77 percent had a complete injury (ASIA Class A). A bowel management program, including medications or manual manipulation, was required for 81 percent of the subjects; only two were independent in their bowel management. Over half of the subjects performed evening bowel care and over half performed their care daily. Digital stimulation tended to be used more commonly by younger children. Medications, either oral, rectal, or both, were used by 88 percent. Sixty percent of the subjects reported they were completely or very satisfied with their bowel management. About half the subjects had limited freedom because of their bowel programs, which caused some dissatisfaction. Sixty-eight percent reported occasional or frequent interference with school activities because of their bowel programs. No correlation was found between bowel accidents and satisfaction with bowel management, despite the fact that almost 84 percent of the children reported at least rare accidents. Lifestyle limitations, bowel accidents, dependence in bowel management, and subject and family dissatisfaction continue to be significant problems for children and adolescents with SCI.     

Surgical management of post-SCIWORA spinal deformities in children

Background  

Patients with spinal cord injury without radiographic abnormality (SCIWORA) are prone to develop spinal deformities. The purpose of this study is to report on the clinical and radiological features of post-SCIWORA spinal deformities.     

Surgical management of spinal disease in renal recipients

Abstract: Object and background: The survival of renal recipients improved dramatically and long-term survival of renal graft patients is common, which in turn increases the chance of these patients requiring spinal surgery. However, there are few appropriate reports about the results of spine surgery on renal recipients. This study was undertaken to analyze the authors’ experience of spine surgery after renal transplantation. Methods: Thirty-two renal recipients who underwent spine surgery with regular follow-up of more than 24 months were included in this study. The patients’ medical records and the radiological reports were reviewed retrospectively and their postoperative conditions were evaluated during their regular visits or by telephone. Results: The mean duration from the renal transplantation to spinal surgery was 6 ± 1.2 yr. Among spinal diseases of renal recipients, there were 23 cases of degenerative spinal diseases, seven cases of vertebral compression fracture, and two spinal cord tumors. The operation methods were conventional spine surgery with or without bone fusion (27 cases), percutaneous vertebroplasty (three cases) and tumor resection (two cases). The mean values of the Prolo scale in the preoperative (4.5 ± 0.3) and postoperative (7.4 ± 0.4) period showed significant clinical improvement after the operation. Postoperative renal function was not deteriorated in any patients and there were no major complications. Conclusion: Spine surgery can be performed with acceptable clinical results and without major complications in renal recipients. Spine surgery has no aggravating effect on the patients’ renal function. Surgery is a valuable, safe option for the treatment of spinal disease in this rare distinct group of patients.     

Surgical management of spinal cord hemangioblastomas in patients with von Hippel-Lindau disease

OBJECT: Von Hippel-Lindau (VHL) disease is an autosomal-dominant disorder frequently associated with hemangioblastomas of the spinal cord. Because of the slow progression, protean nature, and high frequency of multiple spinal hemangioblastomas associated with VHL disease, the surgical management of these lesions is complex. Because prior reports have not identified the factors that predict which patients with spinal cord hemangioblastomas need surgery or what outcomes of this procedure should be expected, the authors have reviewed a series of patients with VHL disease who underwent resection of spinal hemangioblastomas at a single institution to identify features that might guide surgical management of these patients. METHODS: Forty-four consecutive patients with VHL disease (26 men and 18 women) who underwent 55 operations with resection of 86 spinal cord hemangioblastomas (mean age at surgery 34 years; range 20-58 years) at the National Institutes of Health were included in this study (mean clinical follow up 44 months). Patient examination, review of hospital charts, operative findings, and magnetic resonance imaging studies were used to analyze surgical management and its outcome. To evaluate the clinical course, clinical grades were assigned to patients before and after surgery. Preoperative neurological status, tumor size, and tumor location were predictive of postoperative outcome. Patients with no or minimal preoperative neurological dysfunction, with lesions smaller than 500 mm3, and with dorsal lesions were more likely to have no or minimal neurological impairment. Syrinx resolution was the result of tumor removal and was not influenced by whether the syrinx cavity was entered. CONCLUSIONS: Spinal cord hemangioblastomas can be safely removed in the majority of patients with VHL disease. Generally in these patients, hemangioblastomas of the spinal cord should be removed when they produce symptoms or signs.     

Surgical management of Crohn's disease in children.

Crohn's disease is more common in children than has generally been appreciated. Based on a 12 year review of cases from the UCLA Hospital, approximately 57 per cent of children with this disease require operation for the management of its complications.In 28 of 50 children undergoing operation, the disease was confined to the terminal ileum and ascending colon. Each of these patients underwent localized resection with ileocolostomy, although two children had preliminary cutaneous ileostomy; 25 per cent had mild recurrence within 5 years but only two required reoperation. Obstruction is the major symptom in this group, whereas perianal fistulas and abscesses are uncommon.Approximately one third of the patients (17 of 50) had primary Crohn's disease of the colon and rectum. Diarrhea and growth failure are common with this form of the disease. Eighty-two per cent had anal fistulas and abscesses requiring surgical treatment. Although intestinal diversion or intestinal resection, or both, with reanastomosis were tried in the majority of these patients, 14 of the 17 eventually required proctocolectomy for relief of severe symptoms. Recurrent disease in the terminal ileum occurred in 64 per cent of these patients.Only a rare patient with granulomatous disease of the small intestine alone will benefit from surgical resection.Bowel rest and total parenteral nutrition before and after resectional surgery appear to minimize the likelihood of postoperative obstruction or anastomotic leak and also to reduce the length of intestine required for resection.     

Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management

Surgical management is indicated for children and adolescents with spondylolysis and low-grade spondylolisthesis (< or =50% slip) who fail to respond to nonsurgical measures. In situ posterolateral L5 to S1 fusion is the best option for those with a low-grade slip secondary to L5 pars defects or dysplastic spondylolisthesis at the lumbosacral junction. Pars repair is reserved for patients with symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects. Screw repair of the pars defect, wiring transverse process to spinous process, and pedicle screw-laminar hook fixation are surgical options. The ideal surgical management of high-grade spondylolisthesis (>50% slip) is controversial. Spinal fusion has been indicated for children and adolescents with high-grade spondylolisthesis regardless of symptoms. In situ L4 to S1 fusion with cast immobilization is safe and effective for alleviating back pain and neurologic symptoms. Instrumented reduction and fusion techniques permit improved correction of sagittal spinal imbalance and more rapid rehabilitation but are associated with a higher risk of iatrogenic nerve root injuries than in situ techniques. Wide decompression of nerve roots combined with instrumented partial reduction may diminish the risk of neurologic complications. Pseudarthrosis and neurologic injury presenting as L5 radiculopathy and sacral root dysfunction are the most common complications associated with surgical management of high-grade spondylolisthesis.     

Surgical management of neuromuscular deformities of the foot and ankle in children and adolescents

Foot and ankle deformity in the face of neuromuscular involvement will challenge the podiatric surgeon's ingenuity. The basic principles of management of the various major conditions encountered in spastic and flaccid muscle paralysis-paresis has been discussed. The use of a combined approach of hard and soft tissue surgery is emphasized as well as an intimate understanding of the specific neuromuscular process itself.     

Self-injurious behavior in children and adolescents with spinal cord injuries

STUDY DESIGN: A case report of self-injurious behavior in four children and adolescents with spinal cord injuries (SCI). OBJECTIVES: To report a relatively unusual complication of pediatric-onset SCI, focusing on the potential role that dysesthesia may play in self-injurious behavior. SETTING: A Spinal Cord Injury Program in a Children's Hospital in Chicago that serves children from midwestern and south-central United States of America. METHOD: Case reports and literature review. RESULTS: Case reports are presented of four children or adolescents with SCI who exhibited self-injurious behavior. Two of the subjects had symptoms consistent with dysesthesia. The self-injurious behavior in these two subjects and a very young child responded to treatment with anticonvulsants. The self-injurious behavior in the fourth patient was probably the result of poor technique of using his mouth to move his hands, which responded to conservative management including education, occupational therapy and gloves. CONCLUSION: Self-injurious behavior is a relatively unusual complication of pediatric onset SCI, and may be a manifestation of dysesthesia and be responsive to treatment with anticonvulsants.     

Surgical management of children with urolithiasis

The management of urolithiasis in children poses specific technical challenges that require planning before endoscopy and that affect the risks and outcomes of these procedures. The indications for operative intervention in children and adults are similar:infection, persistent symptoms of flank pain, nausea, and vomiting, as well as the failure to pass a ureteral stone after an appropriate trial of observation (3-6 weeks). Specific adjustments for performing extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and cystolithotomy in children are discussed.     

脊柱转移瘤的外科治疗

目的：脊柱转移瘤可引起顽固性疼痛及脊髓压迫，其外科治疗仍存在许多争议，探讨脊柱转移瘤外科治疗的临床效果。方法：自1998年7月－2001年7月，北京大学人民医院骨肿瘤科手术治疗脊柱转移瘤患者62例，包括颈椎转移6例，胸椎转移37例，腰椎转移19例。无明显神经系统受累者19例；出现神经系统受损者43例，其中完全瘫痪者19例，不完全瘫痪者24例。病变累及一个脊柱节段者43例，二个脊柱节段者14例，三具脊柱节段者5例。结果：62例患者中，58例（94％）术后疼痛得到缓解。43例有神经功能损害的患者中，33例术后麻痹症状改善。25例术前膀胱及直肠功能受损的患者中，术后12例膀胱及直肠功能明显改善。术前Frankel A、B级的患者，5例术后恢复到E级或D级，9例改善为C或D级。结论：从肢体功能减退到完全瘫痪所经历的时间是最重要的预后因素，在48h内完全瘫痪为预后不良的重要因素；膀胱和直肠功能的完全丧失也提示预后不良。甲状腺癌和乳腺癌的脊柱转移一般预后较好，肺癌和肝癌的脊柱转移通常存活期较短。     

Boeck's disease with spinal involvement and retroperitoneal fibrosis]

Sarcoidosis (Morbus Boeck) is a frequently found disease of the reticulohistiocytic system. Etiology and pathogenesis were mostly unknown until today. Histologic study of sarcoidosis shown granuloma with epitheloid cells similar to tuberculosis, often with hyalinization but without cheesy necrosis. The disease mostly starts with a mediastinal and cervical lymphadenopathy. Radiographically, the disease shows three typical stages when spreading to the lungs. Bone involvement in lymphomas, especially vertebral involvement, is found to be rare. A case with an additional retroperitoneal fibrosis is reported from our own hospital.     

Late spinal deformity in quadriplegic children and adolescents

Sixty-four quadriplegic children and adolescents were evaluated to determine the benefits of bracing and spinal fusion on the progression and extent of their spinal curves. All those injured before 14 years of age developed a spinal deformity. Bracing in a body jacket assists in maintaining sitting balance and posture and also helps to minimize complications of quadriplegia such as pressure sores. Bracing within 6 months of injury, when the spine is still straight, lessens the incidence, extent, and progression of deformity. Spinal fusion and instrumentation are often necessary for progressive curves to maintain sitting balance and preserve existing function.