Traumatic spinal cord injury (SCI) has devastating consequences for the physical, social and vocational well-being of patients. The demographic of SCIs is shifting such that an increasing proportion of older individuals are being affected. Pathophysiologically, the initial mechanical trauma (the primary injury) permeabilizes neurons and glia and initiates a secondary injury cascade that leads to progressive cell death and spinal cord damage over the subsequent weeks. Over time, the lesion remodels and is composed of cystic cavitations and a glial scar, both of which potently inhibit regeneration. Several animal models and complementary behavioural tests of SCI have been developed to mimic this pathological process and form the basis for the development of preclinical and translational neuroprotective and neuroregenerative strategies. Diagnosis requires a thorough patient history, standardized neurological physical examination and radiographic imaging of the spinal cord. Following diagnosis, several interventions need to be rapidly applied, including haemodynamic monitoring in the intensive care unit, early surgical decompression, blood pressure augmentation and, potentially, the administration of methylprednisolone. Managing the complications of SCI, such as bowel and bladder dysfunction, the formation of pressure sores and infections, is key to address all facets of the patient's injury experience.

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Traumatic spinal cord injury

Context: Spinal cord injury (SCI) is a devastating condition that can lead to significant neurological impairment and reduced quality of life Despite advancements in our understanding of the pathophysiology and secondary injury mechanisms involved in SCI, there are currently very few effective treatments for this condition The field, however, is rapidly changing as new treatments are developed and key discoveries are madeMethods: In this review, we outline the pathophysiology, management, and long-term rehabilitation of individuals with traumatic SCI We also provide an in-depth overview of emerging therapies along the spectrum of the translational pipelineEvidence synthesis: The concept of “time is spine” refers to the concept which emphasizes the importance of early transfer to specialized centers, early decompressive surgery, and early delivery of other treatments (eg blood pressure augmentation, methylprednisolone) to affect long-term outcomes Another important evolution in management has been 

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Assessment and management of acute spinal cord injury: From point of injury to rehabilitation.

Urinary tract infections (UTI) are one of the most common and serious bacterial infections encountered by paediatricians and primary care physicians. Although the diagnosis and management of UTI appear simplistic, they remain among the most contentious issues in paediatrics. In part, UTI controversies stem from the absence of classic clinical symptoms, inappropriate urine specimen collection, modified urinary tract imaging recommendations, and diverse treatment and prevention strategies. Recently published guidelines and large clinical trials have attempted to clarify UTI diagnostic and management strategies. In this manuscript, we review the diagnosis and management of acute and recurrent UTI in the paediatric and adolescent populations.

The clinical diagnosis and management of urinary tract infections in children and adolescents

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

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Update on critical care for acute spinal cord injury in the setting of polytrauma.

Background Females with congenital adrenal hyperplasia (CAH) and atypical genitalia often undergo complex surgeries; however, their outcomes remain largely uncertain. Methods We searched several databases through 8 March 2016 for studies evaluating genital reconstructive surgery in females with CAH. Reviewers working independently and in duplicate selected and appraised the studies. Results We included 29 observational studies (1178 patients, mean age at surgery, 2.7 ± 4.7 years; mostly classic CAH). After an average follow-up of 10.3 years, most patients who had undergone surgery had a female gender identity (88.7%) and were heterosexual (76.2%). Females who underwent surgery reported a sexual function score of 25.13 using the Female Sexual Function Index (maximum score, 36). Many patients continued to complain of substantial impairment of sensitivity in the clitoris, vaginal penetration difficulties, and low intercourse frequency. Most patients were sexually active, although only 48% reported comfortable intercourse. Most patients (79.4%) and treating health care professionals (71.8%) were satisfied with the surgical outcomes. Vaginal stenosis was common (27%), and other surgical complications, such as fistulas, urinary incontinence, and urinary tract infections, were less common. Data on quality of life were sparse and inconclusive. Conclusion The long-term follow-up of females with CAH who had undergone urogenital reconstructive surgery shows variable sexual function. Most patients were sexually active and satisfied with the surgical outcomes; however, some patients still complained of impairment in sexual experience and satisfaction. The certainty in the available evidence is very low.

Genital Reconstructive Surgery in Females With Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis.

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury.

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Neurogenic bladder in spinal cord injury patients.

Objective. To determine the long-term stricture-free rate after visual internal urethrotomy following initial and follow-up urethrotomies. Methods. The records of all male patients who underwent direct visual internal urethrotomy for urethral stricture disease in our hospital between July 2004 and May 2012 were reviewed. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, third, fourth, and fifth urethrotomies. Results. A total of 301 patients were included. The overall stricture-free rate at the 36-month follow-up was 8.3% with a median time to recurrence of 10 months (95% CI of 9.5 to 10.5, range: 2–36). The stricture-free rate after one urethrotomy was 12.1% with a median time to recurrence of eight months (95% CI of 7.1–8.9). After the second urethrotomy, the stricture-free rate was 7.9% with a median time to recurrence of 10 months (95% CI of 9.3 to 10.6). After the third to fifth procedures, the stricture-free rate was 0%. There was no significant difference in the stricture-free rate between single and multiple procedures. Conclusion. The long-term stricture-free rate of visual internal urethrotomy is modest even after a single procedure.

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Visual Internal Urethrotomy for Adult Male Urethral Stricture Has Poor Long-Term Results.

Objective: The objective of this paper is to evaluate the effectiveness of transobturator vaginal tape (TOT) in the treatment of female stress urinary incontinence (SUI) and to analyze functional results and quality of life after 24 months follow-up. Methods: The study included all women with SUI who underwent a TOT procedure in which the sling passes from the obturator foramen from the outside to the inside, under general or regional anesthesia from December 2004 to January 2006. All study patients must have had a minimal follow-up of 24 months. The patients were prospectively evaluated, and the following factors were assessed: number of pads used per day, physical examination including pelvic examination, urinalysis, urogenital distress inventory (UDI-6), analog global satisfaction scale (GSS), pad weight test, and urodynamic studies including filling cystometry and Valsalva leak point pressure (VLPP) test. Results: Fifty-two consecutive patients who fulfilled the inclusion criteria underwent TOT procedure by 1 surgeon. The mean age was 50 ±9 (range 37-72) and minimal follow-up was 24 months (range 24-30 months). Two patients were lost to follow-up after 12 months and 3 patients did not come for the 24-month evaluation. The mean operative time was 18 minutes ±4 (range 15-31), with an average amount of bleeding 57 cc ±22cc. Our results demonstrate a 92% cure or improvement rate after 12 months, and an 85% after 24 months. Conclusion: The transobturator approach from outside to inside is a very effective treatment of SUI with low morbidity. However, longer follow-up in larger populations should assess the longterm reliability of this procedure. Objectif : L’objectif de notre etude est d’evaluer l’efficacite de la bandelette transobturatrice mise en place par voie vaginale dans le traitement de l’incontinence urinaire d’effort (IUE) et d’analyser les resultats fonctionnels et la qualite de vie apres un suivi de 24 mois. Methodologie : Notre etude a inclus toutes les femmes atteintes d’IUE chez qui on avait pose une bandelette transobturatrice passant par le trou obturateur de l’exterieur vers l’interieur, sous anesthesie generale ou regionale entre decembre 2004 et janvier 2006. Toutes les patientes devaient avoir ete suivies pendant un minimum de 24 mois apres l’intervention. Les patientes etaient evaluees de facon prospective, et les facteurs suivants ont ete evalues : nombre de culottes de protection contre les fuites urinaires utilisees chaque jour, examen physique comprenant un examen pelvien, analyse d’urines, questionnaire UDI-6 (urogenital distress inventory), echelle analogique de satisfaction globale, test du poids de la culotte de protection, et etudes urodynamiques comprenant une cystometrie de remplissage et une evaluation du seuil de pression de fuite de Valsalva (methode VLPP). Resultats : Cinquante-deux patientes consecutives repondant aux criteres d’inclusion se sont vu poser une bandelette transobturatrice par le meme chirurgien. L’âge moyen etait de 50 ans ± 9 (de 37 a 72 ans) et le suivi minimal etait de 24 mois (de 24 a 30 mois). Deux patientes avaient ete perdues de vue lors du suivi apres 12 mois et 3 patientes ne se sont pas presentees a l’evaluation au 24e mois. La duree moyenne de l’intervention etait de 18 minutes ± 4 (de 15 a 31 minutes), et la quantite moyenne de sang perdu de 57 mL ± 22. Nos resultats montrent un taux de guerison ou d’amelioration de 92 % apres 12 mois, et de 85 % apres 24 mois. Conclusion : La technique de la bandelette transobturatrice posee de l’exterieur vers l’interieur est un traitement tres efficace de l’IUE accompagnee d’un faible taux de morbidite. Cependant, un suivi plus long avec des cohortes plus importantes est requis pour evaluer la fiabilite a long terme de cette intervention.

Transobturator tape for female stress incontinence: follow-up after 24 months.

Objectives: There is a paucity of data on the long-term outcome of genital reconstruction of female children with congenital adrenal hyperplasia (CAH) as they become adult women. We report on the surgical outcome general condition and marriage status. Materials and Methods: We reviewed the medical records of women 20 years or older with CAH who had genital reconstruction. We interviewed married patients utilizing the female sexual function index (FSFI-6) questionnaire and compared them to age-matched controls. Results : We identified 43 women with CAH with a median age of 24.2 ± 3.9 years and a median follow-up of 23.4 ± 4.6 years. Salt wasting and the severity of virilization affected most patients, parents were commonly cousins, children were reared as boys for a protracted period and surgical reconstruction was usually complex. Only five women had married. Compared with single women, married women had significantly more frequent normal menses, emergency hospital admissions and number of repeated reconstructive surgery. There was no significant difference in FSFI score between patients and controls. Four women conceived and three gave birth to one healthy child. There was no significant difference in the number of children between patients and controls. Conclusions: CAH has a significant impact on adult women in our region. Most of the patients remain single. Few women get married and these are able to lead a nearly normal sexual life and give birth to healthy children.

Long-term outcome of genital reconstruction of Middle Eastern women with congenital adrenal hyperplasia.

Robotic reconstruction of the retrocaval ureter is gaining momentum as the method of choice for surgically treating this rare condition. Maintaining the retrocaval ureteric segment further facilitates the procedure. We report a case of a 23-year-old man who underwent intraperitoneal robotic resection anastomosis and repositioning of the retrocaval ureter. We also discuss the advantages of this technique.

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Waleed Al Taweel

Papers

Neurogenic bladder in spinal cord injury patients.

Visual Internal Urethrotomy for Adult Male Urethral Stricture Has Poor Long-Term Results.

Transobturator tape for female stress incontinence: follow-up after 24 months.

Long-term outcome of genital reconstruction of Middle Eastern women with congenital adrenal hyperplasia.

Robotic uretero-ureterostomy of the retrocaval ureter without excision of the retrocaval segment