Challenges in Diagnosis and Treatment of a Cervical Spinal Cord Injury Patient with Melanoma, Adenocarcinoma, and Hepatic and Osteolytic Metastases: Need to Implement Strategies for Prevention and Early Detection of Cancer in Spinal Cord Injury Patients

A male tetraplegic patient with, who had been taking warfarin, developed haematuria. Ultrasound scan revealed no masses, stones, or hydronephrosis. Urinary bladder had normal configuration with no evidence of masses or organised haematoma. Urine cytology revealed no malignant cells. Four months later, CT urography revealed an irregular mass at the base of urinary bladder. Cystoscopic biopsy revealed moderately differentiated adenocarcinoma, which contained goblet cells and pools of mucin showing strongly positive immunostaining for prostatic acid hosphatase and patchy staining for prostate specific antigen. Computed Tomography revealed multiple hypodense hepatic lesions and several osteolytic areas in femoral heads and iliac bone. With a presumptive diagnosis of prostatic carcinoma, leuprorelin acetate 3.75 mg was prescribed. This patient expired a month later. Conclusion. (i) Spinal cord injury patient, who passed blood in urine while taking warfarin, requires repeated investigations to look for urinary tract neoplasm. (ii) Anti-androgen therapy should be prescribed for 2 weeks prior to administration of gonadorelin analogue to prevent tumour flare causing bone pain, bladder outlet obstruction, uraemia, and cardiovascular risk due to hypercoagulability associated with a rapid increase in tumour burden. (iii) Spinal cord physicians should adopt a caring and compassionate approach while managing tetraplegic patients with several co-morbidities, as aggressive diagnostic tests and therapeutic procedures may lead to deterioration in the quality of life

Infarct of the Right Basal Ganglia in a Male Spinal Cord Injury Patient: Adverse Effect of Autonomic Dysreflexia

Autonomic dysreflexia is a clinical emergency that occurs in individuals with spinal cord injury at level T-6 and above. We present a 58-year-old male patient with paraplegia who developed a severe, recurrent, throbbing headache during the night, which was relieved by emptying the urinary bladder by intermittent catheterisation. As this person continued to get episodes of severe headache for more than 6 months, computed tomography (CT) of the brain was performed. CT revealed an infarct measuring 1.2 cm in the right basal ganglia. In order to control involuntary detrusor contractions, the patient was prescribed propiverine hydrochloride 15 mg four times a day. The alpha-adrenoceptor blocking drug doxazosin was used to reduce the severity of autonomic dysreflexia. Following 4 weeks of treatment with propiverine and doxazosin, the headache subsided completely. We learned from this case that bladder spasms in individuals with spinal cord injury can lead to severe, recurrent episodes of autonomic dysreflexia that, in turn, can predispose to vascular complications in the brain. Therefore, it is important to take appropriate steps to control bladder spasms and thereby prevent recurrent episodes of autonomic dysreflexia. Intermittent catheterisations along with an alpha-adrenoceptor blocking drug (doxazosin) and an antimuscarinic drug (propiverine hydrochloride) helped this individual to control autonomic dysreflexia, triggered by bladder spasms during the night

Are urological procedures in tetraplegic patients safely performed without anesthesia? a report of three cases

<p>Abstract</p> <p>Background</p> <p>Some tetraplegic patients may wish to undergo urological procedures without anaesthesia, but these patients can develop autonomic dysreflexia if cystoscopy and vesical lithotripsy are performed without anaesthesia.</p> <p>Case presentation</p> <p>We describe three tetraplegic patients, who developed autonomic dysreflexia when cystoscopy and laser lithotripsy were carried out without anesthesia.</p> <p>In two patients, who declined anaesthesia, blood pressure increased to more than 200/110 mmHg during cystoscopy. One of these patients developed severe bleeding from bladder mucosa and lithotripsy was abandoned. Laser lithotripsy was carried out under subarachnoid block a week later in this patient, and this patient did not develop autonomic dysreflexia.</p> <p>The third patient with C-3 tetraplegia had undergone correction of kyphoscoliotic deformity of spine with spinal rods and pedicular screws from the level of T-2 to S-2. Pulmonary function test revealed moderate to severe restricted curve. This patient developed vesical calculus and did not wish to have general anaesthesia because of possible need for respiratory support post-operatively. Subarachnoid block was not considered in view of previous spinal fixation. When cystoscopy and laser lithotripsy were carried out under sedation, blood pressure increased from 110/50 mmHg to 160/80 mmHg.</p> <p>Conclusion</p> <p>These cases show that tetraplegic patients are likely to develop autonomic dysreflexia during cystoscopy and vesical lithotripsy, performed without anaesthesia. Health professionals should educate spinal cord injury patients regarding risks of autonomic dysreflexia, when urological procedures are carried out without anaesthesia. If spinal cord injury patients are made aware of potentially life-threatening complications of autonomic dysreflexia, they are less likely to decline anaesthesia for urological procedures. Subrachnoid block or epidural meperidine blocks nociceptive impulses from urinary bladder and prevents occurrence of autonomic dysreflexia. If spinal cord injury patients with lesions above T-6 decline anaesthesia, nifedipine 10 mg should be given sublingually prior to cystoscopy to prevent increase in blood pressure due to autonomic dysreflexia.</p