High bone density masks architectural deficiencies in an individual with spinal cord injury

Context

Spinal cord injury (SCI) causes a decline of bone mineral density (BMD) in the paralyzed extremities via the gradual degradation and resorption of trabecular elements. Clinical tools that report BMD may not offer insight into trabecular architecture flaws that could affect bone''s ability to withstand loading. We present a case of a woman with a 30-year history of SCI and abnormally high distal femur BMD.

Findings

Peripheral quantitative-computed tomography-based BMD for this subject was ∼20% higher than previously published non-SCI values. Computed tomography (CT) revealed evidence of sclerotic bone deposition in the trabecular envelope, most likely due to glucocorticoid-induced osteonecrosis. Volumetric topologic analysis of trabecular architecture indicated that the majority of the bone mineral was organized into thick, plate-like structures rather than a multi-branched trabecular network. Visual analysis of the CT stack confirmed that the sclerotic bone regions were continuous with the cortex at only a handful of points.

Conclusions

Conventional clinical BMD analysis could have led to erroneous assumptions about this subject''s bone quality. CT-based analysis revealed that this subject''s high BMD masked underlying architectural flaws. For patients who received prolonged glucocorticoid therapy, excessively high BMD should be viewed with caution. The ability of this subject''s bone to resist fracture is, in our view, extremely suspect. A better understanding of the mechanical competency of this very dense, but architecturally flawed bone would be desirable before this subject engaged in activities that load the limbs.     

Laser therapy and photosensitive medication: a review of the evidence

In the 2009 guidelines from the BMLA, the use of non-essential aesthetic lasers was contraindicated in patients receiving medication that causes whole-body photosensitisation as well as those causing local light sensitisation. Following this and anecdotal advice, many laser centres refuse to treat patients who are on known photosensitive medication. Therefore, specific patient cohorts that would benefit from laser therapy are being denied because of medications, such as long-term antibiotics for chronic facial acne. This article reviews the published literature on lasers and photosensitive medications, the mechanisms of photosensitivity and the role of laser in its production. The aim is to analyse the available evidence regarding adverse reactions to laser treatment related to photosensitive medication. A PubMed review of published article titles and abstracts was performed using the search term Laser with each of the following terms individually: photosensitive, photosensitiser, photosensitizer, phototoxicity, photoallergy, complications, case-report, tetracycline, minocycline, amiodarone, nitrofurantoin and medication. Four publications were identified, none of which reported any complication in the use of laser in patients taking photosensitising medication. As there are no published accounts of adverse effects of laser in patients with photosensitive medication, we performed a review of the mechanism of photosensitivity by compiling a list of photosensitive medication and the peak wavelength of radiation required to activate the drug. We recommend a national database of drugs and the wavelengths causing photosensitive reactions of each which a laser department can access prior to treatment.     

Open reconstruction of recurrent vesicourethral anastomotic stricture after radical prostatectomy

Objectives

To determine the outcomes of open vesicourethral anastomotic reconstruction (VUAR) for outlet stenosis following radical prostatectomy (RP).

Methods

Review of all cases of VUAR within an IRB-approved database was performed. Preoperative factors assessed included cancer treatment modality, duration of symptoms, prior treatments, and length of defect. Outcomes reviewed included length-of-stay (LOS), complications, maintenance of patency, continence, and need for additional procedures.

Results

Twelve cases of VUAR performed by a single surgeon (BJF) from 2004 to 2012 were identified. Surgical approaches were either abdominal (7), perineal (3), or abdominoperineal (2). All patients underwent prior RP, with 25 % having subsequent radiotherapy. Among patients with stenosis, 43 % were completely obliterated. Two cases had prior anastomotic disruption in the early postoperative period after RP. The median length of stenosis was 2.5 cm (range 1–5 cm) and median LOS was 3.0 days (range 1–7 days). At a median follow-up of 75.5 months (range 14–120 months), 92 % of men retained patency; only 25 % were continent.

Conclusion

In experienced hands, VUAR can restore durable patency for men afflicted with outlet stenosis after RP. Despite anatomic restoration, incontinence is likely.