Intracerebral hemorrhage secondary to autonomic dysreflexia in a young person with incomplete C8 tetraplegia: A case report

Intracerebral hemorrhage is an unusual complication of autonomic dysreflexia and can be fatal if massive bleeding occurs with brain herniation. We report the case of a man in his midthirties with incomplete tetraplegia who suffered right putaminal hemorrhage during an episode of autonomic dysreflexia. Prompt recognition and removal of the triggering factors of autonomic dysreflexia quickly brought his blood pressure under control and the patient had a favorable functional outcome after rehabilitation. A review of the literature suggests that the location of hemorrhage in autonomic dysreflexia-induced cases is similar to that in the general population. The most common triggering factors are bladder distension in men and labor induction in women. Hemorrhagic stroke can also occur in patients with incomplete spinal cord injury (SCI) who develop autonomic dysreflexia. The role of sympathetic skin response examination is also discussed. This life-threatening complication should be kept in mind in the case of people with SCI.     

Lidocaine Anal Block Limits Autonomic Dysreflexia During Anorectal Procedures in Spinal Cord Injury: A Randomized, Double-Blind, Placebo-Controlled Trial

PURPOSE Autonomic dysreflexia is a common and potentially dangerous hypertensive response to stimulation below the level of injury that occurs in patients with spinal cord injury at T6 or above. Rectosigmoid distention and anal manipulation are among the stimuli that may precipitate autonomic dysreflexia. Instillation of topical local anesthetic into the rectum is the recommended prophylaxis against autonomic dysreflexia of anorectal origin. However, a previous randomized, double-blind, placebo-controlled trial showed that topical lidocaine in the rectum does not blunt the autonomic dysreflexia response to anorectal procedures. The purpose of this study was to determine whether lidocaine anal sphincter block would be effective in limiting anorectal procedure-associated autonomic dysreflexia.METHODS We enrolled patients with chronic, complete spinal cord injury above T6, who were having anorectal procedures (flexible sigmoidoscopy and/or anoscopic hemorrhoid ligation). In a double-blind fashion, patients were randomized for intersphincteric anal block with 1 percent lidocaine or normal saline (placebo) before the procedure. Blood pressure was measured before, during, and after the block and procedure.RESULTS Thirteen patients received lidocaine, and 13 received placebo. The groups were similar in age, level of injury, duration of spinal cord injury, type of procedure, and procedure duration. The mean maximal systolic blood pressure increase for the lidocaine group was 22 ± 14 mmHg, significantly lower than the placebo group’s 47 ± 31 mmHg (P = 0.01).CONCLUSIONS Lidocaine anal block significantly limits the autonomic dysreflexia response in susceptible patients undergoing anorectal procedures.     

CSF withdrawal for the treatment of intracranial hypertension in acute head injuries

Summary Long-term ICP recording was carried out in 151 acute head injury patients—131 comatose patients admitted to ICU, and 20 non-comatose patients harbouring intracerebral mass lesions (lacerations or haematomas) in whom a decision to operate was doubtful. CSF withdrawal was used in 39 cases: by intermittent subtraction in 23 patients, and by continuous ventricular drainage (VD) in the remainder. In the acute stage, within 72 hours of injury, CSF subtraction proved of little use in influencing ICP or clinical time course. Conversely, at a latter stage, CSF withdrawal either by repeated intermittent subtraction or by continuous VD could very often control raised ICP. However, some patients had to undergo permanent shunting eventually. Elevated ICP was also safely controlled in four out of eight patients with intracerebral mass lesions and stationary symptoms. Such patients recovered quickly, and operation was avoided.     

Optimal exposure parameters for digital radiography of the infant skull: a pilot study

AIM: To determine optimal exposure parameters when performing digital skull radiographs in infants with suspected non-accidental injury (NAI). METHOD: Anteroposterior and lateral post-mortem skull radiographs of six consecutive infants with suspected NAI were made at six exposure levels for each projection. Entrance surface doses ranged from 75-351 microGy. Exposures were made with a Fuji 5000R computed radiography system onto a standard resolution imaging plate. In three patients exposures were repeated using a high-resolution imaging plate. Hard copy images with an edge-enhancement factor of 0.5 were produced. Six observers assessed and scored the radiographs from 1=poor to 5=excellent for visualization of five criteria. The criteria scored included outer table of skull vault, inner table of skull vault, suture margins, vascular markings and soft tissues of the scalp. Radiographs were then ranked in order of overall image quality. Film density and sensitivity values were recorded. Local research committee approval was obtained. RESULTS: Current parameters give an average entrance surface dose of 253 microGy and 246 microGy for anteroposterior and lateral radiographs, respectively. The study demonstrated no perceived improvement in image quality above an entrance surface dose of 200 microGy (80% of current dose) or by the use of a high-resolution imaging plate. CONCLUSION: The potential exists to reduce radiation exposure in infants. A study has commenced to determine the effects of dose reduction on diagnostic accuracy in suspected NAI.     

Clearing the cervical spine after polytrauma: implementing unified management for unconscious victims in the intensive care unit

Determining the best method for excluding cervical spine injury while a polytrauma victim is unconscious remains a controversial topic despite a number of published guidelines. A structured questionnaire demonstrated major differences between intensivists, neurosurgeons, orthopaedic surgeons and spinal surgeons with regard to the imaging modalities requested, the perception of their performance, the relative risks of missed injuries and the complications of immobilisation. Unconscious victims of polytrauma often come under the care of several subspecialties, with the direct consequence that management can be contradictory and lack standardisation. Advanced Trauma Life Support and Eastern Association for the Surgery of Trauma guidelines can reinforce and even contribute to non-standardised care. Having performed this clinician survey, we have now developed a multidisciplinary management protocol appropriate for Northern Ireland.     

Traumatic bowing of the forearm bones in roller machine injuries

Slow bending forces created by rollers of rotating machines and acting on forearm bones can result in traumatic bowing even in adults. Four patients having this peculiar injury pattern in industrial accidents have been reported in this paper. Three of these had concomitant fractures of ipsilateral humerus. There were problems in appropriate reduction of the deformity due to the presence of associated overlying soft tissue injury. The literature has also been reviewed for this injury and 13 reports defining the injury profile, problems in realigning forearm bones and their subsequent maintenance have been described. The eventual outcome of such machine injuries has not been good due to persistence of some degrees of bowing and associated restriction of forearm rotation.     

Bridging plate osteosynthesis of humeral shaft fractures

This study was approved by the Ethics Committee of the Faculty of Medical Sciences and developed during November 2000 and July 2001 in the Orthopedic and Traumatology Department of UNICAMP. There were 15 patients, 11 males, age between 14 and 66 years. All fractures were unilateral. Of the 15 patients eight were polytraumatised, two of them had open fractures. The others had an isolated fracture of the humerus, of which one was open. None of the patients had previous lesions of the radial nerve, but in two patients there was a lesion of the brachial plexus. All of the patients underwent a bridging plate osteosynthesis of the humeral shaft fractures using only two small incisions proximal and distal to the fracture site. We used broad or narrow D.C.P.^® plates for large fragments mostly with 12 holes, fixed with two or three screws at each end. All cases united with an average time of 8-12 weeks, with the exception of one case with a grade III open fracture and a brachial plexus lesion on the same side. We had no major complications. All patients recovered good function of the limb without significant residual deformity.     

Full-thickness skin necrosis after arginine extravasation--a case report and review of literature

The arginine test is highly useful in the evaluation of short-stature children and adolescents. Extravasation of arginine can cause full-thickness skin necrosis that requires serious surgical intervention with aesthetic and functional sequellea. The authors describe a case of distal forearm skin necrosis caused by arginine extravasation that was treated by wide debridement and a combination of groin flap and later with split-thickness skin graft. The authors emphasize the need for early and active management of arginine extravasation injuries.