A 22-year-old man has a motorcycle crash and obtains a T4 injury to his spinal cord. He is wheelchair bound and has to strain to pass urine.
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1 What is the classification of his injury?
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Correct answer:
Supra-sacral. Supra-sacral injuries occur between the pons of the brainstem and L5 spinal segment.
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2 Name three possible findings in those with suprasacral injuries?
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Correct answer:
- Neurogenic detrusor overactivity is often found in those with suprasacral type injuries.
- Detrusor–sphincter dysynergia can also be a finding as the patient can experience detrusor overactivity with sphincter spasticity leading to abnormally high bladder pressures.
- Autonomic dysreflexia can also occur in suprasacral lesions above the level of T6. If present this is a medical emergency.
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3 What is the single most important investigation required to assist with this patient’s management?
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Correct answer:
Video-urodynamics. This is the best investigation as it permits assessment of both anatomy and function of the lower urinary tract.
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4 If the video-urodynamic test confirmed neurogenic detrusor overactivity with detrusor–sphincter dysynergia, how would you treat this patient?
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Correct answer:
The main aim of treatment is keeping the bladder pressures low. In the first instance this could be done by teaching him intermittent self-catheterisation, as this normalises bladder pressures and avoids the complications of long-term catheterisation.
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5 How do you treat autonomic dysreflexia?
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Correct answer:
Autonomic dysreflexia is a medical emergency and should be identified without delay. Remove the offending stimulus, sit the patient up and administer nifedipine.
