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PubMed1993

Defects of pars interarticularis in athletes: a protocol for nonoperative treatment.

The purpose of this study was to report the results of a specific treatment protocol for athletes with spondylolysis or spondylolisthesis of the lumbar spine. A retrospective study with recent follow-up was performed on 82 patients treated with restriction of activity, bracing, and physical therapy. All of the patients were involved in sports at first onset of symptoms. Sixty-six patients were boys and 16 were girls. Activities involving repetitive hyperextension and/or extension rotation of the lumbar spine were described as painful in 98% of the patients. Of the 62 patients with spondylolysis, 53 (85%) had an L5 defect and nine (15%) an L4 defect (90% of these 62 patients' defects were located in the most caudad mobile vertebra). Thirty-seven patients had bilateral pars defects, and 25 had unilateral defects. Eight patients had normal roentgenograms, but these eight had abnormal bone scans. Nine patients with spondylolysis underwent posterolateral fusion. Average follow-up was 4.2 years. Fifty-two (84%) had excellent results, eight had good results, and two had fair results. Twenty patients had a spondylolisthesis: 12 were grade I, six were grade II, and two were grade III. Twelve patients (60%) required surgery; 9 had excellent results, one had good results, one had a fair result, and one had a poor result. Pars defects must be suspected in the differential of low back pain in young athletes. Oblique radiographs are frequently diagnostic; however, if the history and examination are suggestive despite normal plain films, a bone scan should be obtained. Nonoperative management of pars defects is frequently successful.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

Selective sacral rhizotomy for the management of neurogenic bladders in spina bifida patients: long-term followup.

Selective sacral rhizotomy was introduced for the management of high pressure neurogenic bladders commonly encountered in myelodysplastic patients. In 1992, 2 of us (I.F. and W.K.) first reported results with selective sacral rhizotomy and cord untethering in 8 spina bifida patients. We report long-term followup of our original 8 patients and 3 additional patients. This followup demonstrates remarkable success in maintaining bladder volume and low pressures after rhizotomy and cord untethering. Uninhibited contractions resolved in all patients postoperatively. A more favorable response occurred in the patients younger than 9 years, supporting early intervention with selective sacral rhizotomy.

Adolescent↗
PubMed1996

Submucosal bladder neck injection of bovine dermal collagen for stress urinary incontinence in the pediatric population.

PURPOSE: The surgical management of stress urinary incontinence in the pediatric population includes various surgical techniques of which the simplest is outpatient transurethral or periurethral injection of a bulking agent. Currently purified bovine dermal collagen cross-linked with glutaraldehyde (Contigen) is the only Food and Drug Administration approved bulking agent available. Patients with stable detrusor function are ideal candidates. We review our initial experience with children. MATERIALS AND METHODS: Between January 1994 and June 1995, 23 boys and 9 girls 4 to 17 years old (mean age 9) consecutively underwent submucosal bladder neck injection with cross-linked bovine dermal collagen. Incontinence was secondary to spinal dysraphism in 24 patients, complete epispadias in 4, classic bladder exstrophy in 3 and neurogenic bladder secondary to a sacral teratoma in 1. Preoperative video urodynamics documented intrinsic sphincteric deficiency in all patients with leak point pressure of 15 to 60 cm. water (mean 37). Injection volumes ranged from 2.5 to 17 cc (mean 10). Continence results were defined as dry-requiring no protection while on a 4-hour clean intermittent catheterization program, good-improved but requiring 1 to 5 pads daily and failure-no postoperative improvement or still requiring diapers. RESULTS: Of the children with neurogenic bladder 20% became dry following the first injection and an additional 28% had a good result. Furthermore, of the 6 children with exstrophy or epispadias who underwent a Young-Dees-Leadbetter procedure 50% were dry and 17% had a good result after the first injection. Complications were limited to a febrile urinary tract infection associated with urinary retention in 1 patient and transiently worse continence in 2. CONCLUSIONS: Despite the limited success rate, we believe that transurethral collagen injection therapy has a viable role in the treatment of intrinsic sphincteric deficiency in select pediatric patients, particularly since the procedure has low morbidity and can be performed on an outpatient basis. Preoperative counseling should be given with realistic expectations.

Administration, Intravesical↗
PubMed1998

Renal deterioration in myelodysplastic children: urodynamic evaluation and clinical correlates.

PURPOSE: We determined which factors portend a higher risk of renal deterioration in the myelodysplastic child, and evaluated the sensitivity and predictive value. MATERIALS AND METHODS: We retrospectively reviewed the medical history, imaging studies and urodynamics of 90 children with spinal dysraphism. Median patient age at initial evaluation was 3 months and average followup ranged between 2 and 25 years (average 11). We evaluated the relation of urodynamic parameters and sex to upper tract changes and the resolution of these changes. RESULTS: Statistically significant relationships were identified between the urodynamic parameters of leak point pressure, compliance and detrusor-sphincter dyssynergia, and renal deterioration but not with resolution of deterioration. Boys and girls did not demonstrate a significant difference among urodynamic parameters. Female patients had a higher incidence of reflux and parenchymal loss. CONCLUSIONS: With knowledge of the inherent sensitivity, specificity and predictive value of urodynamic parameters, selective use of urodynamics will assist in identifying patients at risk of renal deterioration. Female patients with reflux are at greatest risk of parenchymal loss. We advocate early institution of intermittent catheterization in patients identified as high risk for deterioration by urodynamics.

Adolescent↗
PubMed2000

Outcome of gastrocystoplasty in tertiary pediatric urology practice.

PURPOSE: Although the use of stomach for bladder reconstruction has become popular during the last decade, it is not a panacea. We review our experience with gastrocystoplasty. MATERIALS AND METHODS: We completed a retrospective chart review of 11 females and 12 males, 1.5 to 22.5 years old (mean age 10) who underwent gastrocystoplasty at Hôpital Sainte-Justine, Montreal, Quebec and Children's Hospital, Winnipeg, Manitoba, Canada between December 1990 and 1998. Primary diagnoses included spinal dysraphism in 14 patients, posterior urethral valves in 3, cloacal exstrophy in 2, cloacal outlet anomaly in 2, multiple failed ureteral reimplantations with bladder dysfunction in 1 and neurogenic bladder of uncertain etiology in 1. Three patients presented with chronic renal failure. Concurrent reconstructive surgery included ureteral reimplantation in 10 patients, bladder neck plasty in 4 or closure in 4, and continent urinary diversion in 5. RESULTS: Acute postoperative complications included urosepsis in 2 cases, bowel obstruction in 2 and ureteral obstruction in 1. Followup ranged from 4 to 86 months (mean 45). Long-term complications consisted of intractable hematuria-dysuria syndrome in 5 cases, inability to catheterize in 3, perineal urinary fistula in 2, new onset hydronephrosis in 2, continent stomal stenosis in 1 and bladder calculus in 1. Proton pump inhibitors and/or histamine 2 antagonists were used in 16 of the 23 patients to prevent the hematuria-dysuria syndrome. In 5 cases the hematuria-dysuria syndrome was poorly controlled medically and 3 were converted to another form of urinary reconstruction. In 18 of 20 cases voiding cystourethrography revealed no vesicoureteral reflux, and in 18 of 21 ultrasound documented stable or improved upper tracts. Socially acceptable urinary continence was attained in 19 of the 21 patients. CONCLUSIONS: The use of stomach for bladder augmentation may be considered in patients with cloacal exstrophy and/or metabolic acidosis. Histamine blockers and/or proton pump inhibitors may be required to prevent the hematuria-dysuria syndrome. Symptoms of the hematuria-dysuria syndrome may be disabling and may mandate alternative forms of urinary tract reconstruction.

Acidosis↗
PubMed2001

Diseases of the spine in South American mummies.

OBJECTIVE: The skulls and spinal columns of people from ancient civilizations, which frequently are found in a preserved state at archeological sites, can provide a large amount of information about these individuals' physical condition through paleopathological investigation. METHODS: This study represents the examination of more than 700 human remains dating back more than 8000 years that were recovered from archaeological excavations in the Andean region of southern Peru and northern Chile. RESULTS: Examples of congenital malformations, degenerative processes, infectious diseases, neoplasias, and traumatic diseases were discovered. Congenital anomalies such as spina bifida occulta were relatively common in these populations. No cases of meningomyelocele were discovered. The most common pathological findings were degenerative changes of the vertebral bodies. Large cervical and lumbar osteophytes were identified in some remains. Several cases of cervical spondylosis were determined to be the result of an occupational disease resulting from carrying heavy loads on the back. These heavy loads were supported by wearing around the forehead a tumpline, known as a capacho. The most common infectious disease process in the spine was due to tuberculosis. The diagnosis was made by radiological and histopathological studies, and in several cases the organism Mycobacterium tuberculosis was identified in the soft tissues. Metastatic lesions on the vertebral bodies were identified in a single case. Examples of traumatic spinal injury were rare. Compression fractures were noted infrequently. CONCLUSION: Diseases of the spinal column in the ancient inhabitants of the Andean region of South America were similar to those that affect the present-day population of that area.

Adult↗
PubMed1997

Spondylolysis associated with Arnold-Chiari malformation and syringomyelia. A report of two cases.

STUDY DESIGN: This is a report of two cases. OBJECTIVE: To document the occurrence and association of spondylolysis and Arnold-Chiari malformation Type I. SUMMARY OF BACKGROUND DATA: The association of spinal dysraphism has been reported with Arnold-Chiari Type II, but not with Arnold-Chiari Type I. METHODS: The senior author was involved in the care of these patients. All medical records, laboratory and radiologic investigations, and related literature were reviewed. RESULTS: The presence of cephalic and caudal neuropore maldevelopment may be present in various combinations. The presence of spondylolysis, with or without spina bifida occulta, associated with Arnold-Chiari malformation type I and syringohydromyelia, is demonstrated. CONCLUSIONS: In some patients, the presence of spondylolysis may represent a congenital anomaly and may be associated with cephalic neuropore maldevelopment, such as cerebromedullary malformation syndrome (i.e., Arnold-Chiari malformation Type I).

Adolescent↗
PubMed2001

Gastrointestinal problems in the handicapped child.

Gastrointestinal issues are a major chronic problem in 80 to 90% of children with cerebral palsy and in children with neurodevelopmental disabilities who are at special risk of developing malnutrition because of uncoordinated swallowing, gastroesophageal reflux, and constipation. In addition to poor linear growth, there is a decrease in muscle strength and coordination, impaired cerebral function leading to decreased motivation and energy. Significant neurodevelopmental progress can be achieved with improved nutritional status. A multidisciplinary approach, with input from neurologists, gastroenterologists, nurses, occupational therapists, and dieticians, can make a major contribution to the medical wellbeing and quality of life of these children. Different neurological diseases ( eg, spinal dysraphism, syringomyelia, tethered cord syndromes) can give rise to gastrointestinal dysfunction and symptoms that may need different gastrointestinal or surgical management. The introduction of new drugs, including proton pump inhibitors and innovative endoscopic and surgical techniques in the management of gastroesophageal reflux disease and constipation also may have an impact on the treatment of neurologically handicapped children in the future.

Child↗
PubMed2004

A case with cauda equina syndrome due to bacterial meningitis of anterior sacral meningocele.

STUDY DESIGN: A case of a patient with anterior sacral meningocele that was misdiagnosed as perianal abscess is presented. After the transrectal aspiration, the patient developed meningitis and cauda equina syndrome. OBJECTIVE: To report a rare case of anterior sacral meningocele in which primary presentation was mimicking perianal abscess. SUMMARY AND BACKGROUND DATA: Anterior sacral meningocele is a rare example of spinal dysraphism. It is created by a herniation of a dural sac through a defect in the sacral wall. It is usually asymptomatic until later decades. Most of the presenting symptoms are related to the pelvic organs. In the management of anterior sacral meningocele, surgical treatment is necessary. METHODS: The reported case is that of a 35-year-old female with cauda equina syndrome due to bacterial meningitis of the anterior sacral meningocele. At the beginning, she presented signs and symptoms resembling perianal abscess. She was misdiagnosed as anorectal abscess according to the computed tomography findings. The patient then underwent transrectal aspiration. Following the aspiration, meningitis and cauda equina syndrome were developed. Meningitis was treated with the appropriate antibiotics, and the patient underwent rehabilitation for paraplegia and bladder and bowel incontinence. RESULTS: Following the rehabilitation program, the patient has recovered completely within 8 months. CONCLUSION: This case represents a rare example of anterior sacral meningocele in which the patient was misdiagnosed as perianal abscess. Meningitis either iatrogenic or spontaneous may occur during the course of anterior sacral meningocele. Once it has occurred, it may result in severe morbidity and mortality. However, our case had been treated effectively, and she had regained her health with rehabilitation program.

Abscess↗
PubMed2004

Recovery of neurologic function following nontraumatic spinal cord lesions in Israel.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs). SUMMARY OF BACKGROUND DATA: NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce. METHOD: The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patient's Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs). RESULTS: Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs. CONCLUSIONS: The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs.

Adolescent↗
PubMed2003

Computerized tomography guided access for percutaneous nephrostolithotomy.

PURPOSE: Access for percutaneous nephrostolithotomy (PNL) using conventional fluoroscopic guidance may carry an increased risk of damage to surrounding organs in patients with renal calculi and aberrant anatomy. In these situations cross-sectional anatomical imaging may facilitate safe percutaneous access. We describe our experience with computerized tomography (CT) guided percutaneous access for such patients undergoing PNL. MATERIALS AND METHODS: Between June 2000 and December 2001, 154 patients underwent PNL at our institution. Five of these patients (3%) required a total of 6 percutaneous access tracks under CT guidance. All patients in this group had anatomical abnormalities precluding standard access to the collecting system without risk to adjacent organs. These abnormalities included a retrorenal colon in 2 and a severely distorted body habitus due to spinal dysraphism in 3. RESULTS: Percutaneous access was achieved without complication in all cases. At subsequent PNL 5 of the 6 renal units (83%) were rendered completely stone-free. CONCLUSION: CT guided percutaneous access is infrequently required for PNL. However, there is a select group of patients with anatomical anomalies that may predictably require this procedure to facilitate safe and efficacious PNL.

Adult↗
PubMed2003

Autoaugmentation by detrusor myotomy: its lack of effectiveness in the management of congenital neuropathic bladder.

PURPOSE: We present our long-term results in 17 patients with myelomeningocele undergoing autoaugmentation by vesicomyotomy. MATERIALS AND METHODS: Surgery was performed from 1990 to 1994 on 17 patients with neurogenic bladder due to spinal dysraphism. Indications for autoaugmentation included upper tract deterioration and/or incontinence secondary to hypperreflexia, hypocompliance or low bladder volume. All patients had failed to respond to conservative medical and pharmacological treatments. Median patient age at surgery was 10.2 years (range 2.2 to 13.2). Outcomes were evaluated retrospectively according to changes in upper tract status, continence and urodynamic parameters. Median clinical and urodynamic followup is 75 months (range 4 to 126). RESULTS: Progressive hydronephrosis developed in 5 patients, which required subsequent enterocystoplasty in 4. Of 13 patients 8 (62%) remain incontinent. Of the 17 cases 12 (71%) were considered clinical failures on the basis of upper tract deterioration and/or ongoing incontinence. There were few clinically significant improvements in urodynamic parameters, as 14 of 15 cases (93%) were considered urodynamic failures on the basis of persistent hypocompliance and/or less than expected gains in safe bladder capacity with somatic growth. CONCLUSIONS: Although short-term reports of autoaugmentation have been promising, they do not appear durable. This procedure cannot be endorsed for the management of congenital neuropathic bladder.

Adolescent↗
PubMed2003

What is the variability between 2 consecutive cystometries in the same child?

PURPOSE: We compared the results of 2 cystometrograms (CMGs) performed during a single session in the same child to determine the variability between consecutive cystometries. MATERIALS AND METHODS: Subjects underwent 2 consecutive bladder fillings performed at the same rate and position. Maximum cystometric bladder capacity (CBC), pressure at CBC, leak point pressure, maximum flow rate, pressure at maximum flow, maximum voiding pressure, residual urine and pressure specific volumes (PSV) less than 20, 30 and 40 cm water were compared between studies. Uninhibited detrusor contractions (UICs), defined by the previous and new International Children's Continence Society definitions of UIC, were also compared. Data were analyzed using paired t test, chi-square and interclass correlation. RESULTS: CMGs in 32 male and 34 female children were available for analysis. Mean subject age was 7.4 years (range 1 month to 18 years). Of the children 43 (65%) had spinal dysraphism, 4 (6%) had cerebral palsy, 5 (8%) had posterior urethral valves, and 14 (21%) had recurrent urinary tract infection, daytime incontinence and frequency/urgency symptoms. Maximum CBC, pressure at CBC, leak point pressure, maximum flow rate, pressure at maximum flow, maximum voiding pressure and residual urine did not differ between the 2 studies. PSVs less than 20, 30 and 40 cm water were highly correlated between the 2 CMGs (interclass correlation coefficients 0.795, 0.683 and 0.850, respectively). There were more UICs on the first than the second study (p = 0.02 and 0.03) as defined by the previous and new definitions of UIC. UIC threshold volume was less on the first CMG (p = 0.00 and 0.03). UICs were either present or absent on both studies in 56 of the 66 (85%) children by the previous UIC definition and in 51 (77%) by the new UIC definition. CONCLUSIONS: There is no difference in CBC, PSV and pressure flow parameters when performing consecutive urodynamic studies in the same child. However, UICs are more frequent on the first study. We conclude that repeat cystometry is not indicated in the absence of UICs on the first study and suggest that the second consecutive CMG be used for clinical interpretation when repeat studies are performed in the same session.

Adolescent↗
PubMed2004

Efficacy of polydimethylsiloxane injection to the bladder neck and leaking diverting stoma for urinary continence.

PURPOSE: Achieving urinary continence is a major goal in the treatment of patients with bladder exstrophy/epispadias, spinal dysraphism and other urological disorders. Endoscopic injection of bulking materials is an evolving, minimally invasive procedure that provides an attractive alternative to open bladder surgery to increase outlet resistance. We evaluated the efficacy of bladder outlet (bladder neck and diverting stoma) polydimethylsiloxane injection (BOMI) to achieve continence in children. MATERIALS AND METHODS: We retrospectively reviewed the continence status of 33 patients prior to and following BOMI for urinary incontinence. The variables evaluated as predictors of success were underlying disease, ambulatory status, voiding status, bladder capacity, type and time from previous bladder neck reconstruction, anticholinergic treatment, injection site, amount of polydimethylsiloxane used, detrusor leak point pressure and immediate or delayed clean intermittent catheterization. Improvement was considered a 2-fold increase in the dry interval or 4 hours between bladder emptying in patients on clean intermittent catheterization and a 2-fold decrease in the number of absorbent pads needed. RESULTS: Between 1998 and 2002, 25 male and 8 female patients 4 to 19 years old (mean age 12.4 +/- 3.9) underwent 42 BOMIs for incontinence. Mean followup was 13 +/- 9 months (range 3 to 42). Incontinence was via the urethra in 28 cases and via a diverting stoma in the remaining 5. Of the 28 patients with leakage via the urethra none were cured, 12 (42%) were improved and 16 (58%) had no change in continence status. However, 3 of the 5 inpatients (60%) with leakage via a diverting stoma were cured. No perioperative complications were recorded. Injecting to a diverting stoma was the only factor found to be predictive of success. Extrusion of polydimethylsiloxane during the procedure was the only factor predictive of failure (3 of 3 cases or 100%). New onset dilatation of the collecting system was noted in 2 patients and all had improved continence following injection. CONCLUSIONS: Injection to the bladder neck did not result in any cure and had a low improvement rate of 42%. BOMI is a good therapeutic option for patients with leakage from a diverting stoma. Although no perioperative complications were recorded, 2 patients had new dilatation of the upper tract on ultrasound. Hence, long-term followup is warranted.

Administration, Intravesical↗
PubMed2005

An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida.

PURPOSE: Neurogenic bladder is a major problem for children with spina bifida. Despite rigorous pharmacological and surgical treatment, incontinence, urinary tract infections and upper tract deterioration remain problematic. We have previously demonstrated the ability to establish surgically a skin-central nervous system-bladder reflex pathway in patients with spinal cord injury with restoration of bladder storage and emptying. We report our experience with this procedure in 20 children with spina bifida. MATERIALS AND METHODS: All children with spina bifida and neurogenic bladder underwent limited laminectomy and a lumbar ventral root (VR) to S3 VR microanastomosis. The L5 dorsal root was left intact as the afferent branch of the somatic-autonomic reflex pathway after axonal regeneration. All patients underwent urodynamic evaluation before and after surgery. RESULTS: Preoperative urodynamic studies revealed 2 types of bladder dysfunction- areflexic bladder (14 patients) and hyperreflexic bladder with detrusor external sphincter dyssynergia (6). All children were incontinent. Of the 20 patients 17 gained satisfactory bladder control and continence within 8 to 12 months after VR microanastomosis. Of the 14 patients with areflexic bladder 12 (86%) showed improvement. In these cases bladder capacity increased from 117.28 to 208.71 ml, and mean maximum detrusor pressure increased from 18.35 to 32.57 cm H2O. Five of the 6 patients with hyperreflexic bladder demonstrated improvement, with resolution of incontinence. Urodynamic studies in these cases revealed a change from detrusor hyperreflexia with detrusor external sphincter dyssynergia and high detrusor pressure to nearly normal storage and synergic voiding. In these cases mean bladder capacity increased from 94.33 to 177.83 ml, and post-void residual urine decreased from 70.17 to 23.67 ml. Overall, 3 patients failed to exhibit any improvement. CONCLUSIONS: The artificial somatic-autonomic reflex arc procedure is an effective and safe treatment to restore bladder continence and reverse bladder dysfunction for patients with spina bifida.

Adolescent↗