Vaidyanathan S, Soni B M, Oo T, Hughes P L, Singh G, Mansour P
Regional Spinal Injuries Centre, District General Hospital, Southport, UK.
Spinal Cord. 2004 Oct;42(10):598-602. doi: 10.1038/sj.sc.3101631.
Case report.
To report insidious development of autonomic dysreflexia and hydronephrosis due to dyssynergic voiding following discontinuation of intrathecal baclofen therapy.
Regional Spinal Injuries Centre, Southport, UK.
A male patient with paraplegia at T-5 (ASIA-A) had implantation of Medtronic Synchromed 8615 s programmable pump to control intractable spasms. After 4 years, the baclofen pump needed replacement because of battery exhaustion. At this time, he was taking oxybutynin 2.5 mg twice a day. He wore a penile sheath and performed intermittent catheterisation three times a day. Intravenous urography showed no dilatation of pelvicalyceal systems or ureters. During the course of the next 4 months, the dose of baclofen had to be increased gradually to 820 microg/day in order to control the spasms. Investigations revealed disconnection of the tube from the pump. The patient decided to undergo explantation of the pump and discontinue intrathecal baclofen therapy altogether. Following removal of the pump, he was prescribed baclofen 20 mg four times a day and diazepam 5 mg twice a day. He continued penile sheath drainage with oxybutynin 2.5 mg twice a day. Although spasms were controlled with oral baclofen and diazepam, he started getting transient, mild headache during reflex voiding. After nearly 2 years, he developed unbearable and pounding headache while passing urine.
The dose of oxybutynin was increased to modified release formulation, 20 mg, once daily. He was prescribed modified release alfuzosin 10 mg once a day. Indwelling urethral catheter drainage was instituted. Intravenous urography showed dilation of left renal pelvis and calyces, and left ureter. After a fortnight, the dose of modified release oxybutynin was increased further to 25 mg once a day. After a month, he started performing self-catheterisation every 3 h and symptoms of autonomic dysreflexia subsided completely. A follow-up intravenous urography performed 6 months later, showed normal appearances of the left kidney.
Spinal cord injury patients, in whom intrathecal baclofen therapy is terminated, need close monitoring of their urological status. Medications, which are prescribed for neuropathic bladder, and the method of bladder drainage, may need suitable changes, as discontinuation of intrathecal baclofen therapy can result in reappearance of detrusor-sphincter dyssynergia in previously susceptible patients.
病例报告。
报告鞘内注射巴氯芬治疗中断后，因排尿协同失调导致自主神经反射异常和肾积水的隐匿性发展情况。
英国南港地区脊髓损伤中心。
一名T-5节段截瘫（美国脊髓损伤协会分级A）的男性患者植入了美敦力Synchromed 8615 s可编程泵以控制顽固性痉挛。4年后，由于电池耗尽，巴氯芬泵需要更换。此时，他每天服用两次2.5毫克的奥昔布宁。他佩戴阴茎套，每天进行三次间歇性导尿。静脉肾盂造影显示肾盂肾盏系统和输尿管无扩张。在接下来的4个月中，为了控制痉挛，巴氯芬的剂量不得不逐渐增加至每天820微克。检查发现导管与泵断开连接。患者决定取出泵并完全停止鞘内注射巴氯芬治疗。取出泵后，给他开了每天四次20毫克的巴氯芬和每天两次5毫克的地西泮。他继续佩戴阴茎套引流，每天服用两次2.5毫克的奥昔布宁。尽管口服巴氯芬和地西泮可以控制痉挛，但他在反射性排尿时开始出现短暂的轻度头痛。将近2年后，他在排尿时出现了难以忍受的搏动性头痛。
奥昔布宁的剂量增加至控释制剂，每天一次，每次20毫克。给他开了每天一次10毫克的控释阿夫唑嗪。开始留置尿道导管引流。静脉肾盂造影显示左肾盂、肾盏和左输尿管扩张。两周后，控释奥昔布宁的剂量进一步增加至每天一次25毫克。一个月后，他开始每3小时进行一次自我导尿，自主神经反射异常的症状完全消退。6个月后进行的随访静脉肾盂造影显示左肾外观正常。
终止鞘内注射巴氯芬治疗的脊髓损伤患者，需要密切监测其泌尿系统状况。由于鞘内注射巴氯芬治疗的中断可能导致先前易患患者的逼尿肌-括约肌协同失调再次出现，因此可能需要适当改变用于神经源性膀胱的药物和膀胱引流方法。
