Spinal Shock

Case: A 26-year-old male with spinal shock and recovery

2 MONTHS AFTER INJURY: A 26-year-old male suffered a C5 spinal cord injury 2 months ago, while sledding.  He is currently on the Physical Medicine and Rehabilitation service after receiving his trauma care.  His bladder is currently being managed with CIC using either a 14-French catheter or a red rubber catheter.  He is being catheterized every 3 hours, sometimes by himself or other times by Nursing.  His volumes widely vary anywhere between 150 cc to 1100 cc.  He denies incontinence in between catheterizations.  On physical examination, his level of sensation is from the nipples and above.  His bladder is not palpable.  GU exam is unremarkable.  Abdominal ultrasound shows no hydronephrosis. 

Ultimately, he may be converting out of his spinal shock phase and may have changes in his neurogenic bladder which could contribute to frequent urinary tract infections.  In order to determine this, we will plan on performing a fluorourodynamics test to evaluate the state of his detrusor. Obviously, should he have poor compliance and a high pressure bladder with high detrusor leak point pressure, it may be necessary to begin him on anticholinergic therapy.  In addition, we would recommend renal and bladder ultrasound to evaluate for presence of hydronephrosis and stones within the bladder.  He should continue on CIC every 3-4 hours ideally to keep volumes less than 400 cc per catheterization at this time.  We will have more specific recommendations following his fluorourodynamics.  [VIDEO]

8 MONTHS AFTER INJURY: The patient has been catheterized every 3 to 4 hours during the day and at night.  His estimated volumes are under 300 mL. Now he reports having urinary incontinence 3 to 4 times each week.  The incontinence occurs at night necessitating that he wear a pad and diaper.  He reports having autonomic dysreflexia approximately 1 time each month.  This occurs when he waits too long an interval between catheterizations. 
Urodynamic study was performed under fluoroscopy. This revealed his bladder neck to be closed at rest.  The contour of his bladder was trabeculated.  His compliance was abnormal with a pressure rise of 12 cm of water.  He had a reflex contraction.  He had DSD. [VIDEO]

The patient was prescribed to start medication: oxybutynin 15 mg daily, Begin terazosin 1 mg at bedtime, imipramine 10 mg b.i.d. and advised to visit the clinic in 4 to 6 weeks for reassessment. 

Comments and Lessons: Patient is unstable for the first 3 years after injury and lower urinary tract function will continue to evolve. In this case we would have started the anticholinergic agents and the other agents very early even before recovery of reflex bladder contractility if possible. Patient treated early on are easier to manage over the first three years while waiting for high pressure DSD to develop may mitigate against successful resolution of the high bladder pressures with drugs alone.
For more detailed information, please also refer to the spinal shock and the management.

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