Determine the infection risk of nonoperative versus operative repair of extraperitoneal bladder ruptures in patients with pelvic ring injuries. Pelvic ring injuries with extraperitoneal bladder ruptures were identified from a prospective trauma registry at two level 1 trauma centers from 2014 to 2020. Patients, injuries, treatments, and complications were reviewed. Using Fisher's exact test with significance at P value < 0.05, associations between injury treatment and outcomes were determined. Of the 1127 patients with pelvic ring injuries, 68 (6%) had a concomitant extraperitoneal bladder rupture. All patients received IV antibiotics for an average of 2.5 days. A suprapubic catheter was placed in 4 patients. Bladder repairs were performed in 55 (81%) patients, 28 of those simultaneous with ORIF anterior pelvic ring. The other 27 bladder repair patients underwent initial ex-lap with bladder repair and on average had pelvic fixation 2.2 days later. Nonoperative management of bladder rupture with prolonged Foley catheterization was used in 13 patients. Improved fracture reduction was noted in the ORIF cohort compared to the closed reduction external fixation cohort (P = 0.04). There were 5 (7%) deep infections. Deep infection was associated with nonoperative management of bladder rupture (P = 0.003) and use of a suprapubic catheter (P = 0.02). Not repairing the bladder increased odds of infection 17-fold compared to repair (OR 16.9, 95% CI 1.75 – 164, P = 0.01). Operative repair of extraperitoneal bladder ruptures substantially decreases risk of infection in patients with pelvic ring injuries. ORIF of anterior pelvic ring does not increase risk of infection and results in better reductions compared to closed reduction. Suprapubic catheters should be avoided if possible due to increased infection risk later. Treatment algorithms for pelvic ring injuries with extraperitoneal bladder ruptures should recommend early bladder repair and emphasize anterior pelvic ORIF

Aims. Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES. Methods. A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI. Results. The study confirms the low predictive value of ‘red flag’ symptoms and signs. Of note ‘bilateral sciatica’ had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed ‘low-risk’ of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy. Conclusion. This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677–682

Bladder catheterisation following joint arthroplasty is not uncommon but delaying catheterisation in the postoperative period until the patient is symptomatic can produce an atonic bladder due to the distension. This can prolong catheterisation and increase the risk of urinary tract infection. We prospectively determined if we could identify patients needing pre-operative catheterisation. Method: 150 consecutive patients undergoing knee and hip arthroplasty were recruited. Pre-operative symptoms of frequency, nocturia, retention, incontinence and previous bladder or prostate surgery along with prior history of catheterisation were recorded. The type of anaesthesia and post-operative analgesia was noted. Details of catheterisation included duration, antibiotic administration, and reason for catheterisation and incidence of urinary tract infection. Results: Patients mean age was 67.7 years. 47 patients required catheterisation of which 56.6% were female. The mean age of patients catheterised was 70.6 years in comparison to 66.3 years (Mann-Whitney P< 0.01). The frequency of catheterisation was unrelated to the surgical procedure. Nocturia was significantly more common in-patients requiring catheterisation (Kruskal Wallis P=0.04) and its combination with pre-operative symptoms of frequency, retention or incontinence increased the significance further to P=0.001. Patient age of greater then 66 years had a 76.6% predictive value for the subsequent need of catheterisation. This further increased to 91.5% when combined with a previous history of either catheterisation or nocturia. The type of anaesthesia or the post-operative analgesia did not significantly influence catheterisation frequency. Conclusion: Patients aged greater then 66 years undergoing joint arthroplasty with previous history of catheterisation or nocturia may benefit from pre-operative bladder catheterisation. Peri-operative catheterisation of high-risk patients in theatre reduces patient discomfort caused by the observation period and avoids bladder atonia consequent of the distention, which may subsequently prolong catheterisation

1. Ten patients with neurological evidence of damage to the intrathecal sacral nerve roots of the cauda equina by verified lumbar disc prolapse are described. 2. The nature of the bladder paralysis has been investigated by cystometry and the findings contrasted with published opinions. 3. The prognosis of the bladder paralysis has been established by review up to six years after removal of the disc prolapse. No evidence of recovery of complete bladder paralysis has been found, but the consequences of persistent bladder paralysis have been much less severe than previous reports have stated. Reasons have been suggested for this. 4. Principles of recognition and management of bladder paralysis due to cauda equina lesions have been stated and methods suggested

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. Cite this article: Bone Joint J 2024;106-B(3):227–231

Introduction: Postoperative overdistention of the bladder produces chronic, irreversible changes in the detrusor muscle. This study investigated whether an effective epidural, may cause postoperative overdistention of the bladder. Methods: A retrospective single surgeon/unit study of 144 male patients who had undergone spinal surgery over a two year period was undertaken. Data was collected into two groups: Patients requiring catheterisation and those that did not. All patients received a 16G epidural catheter inserted at the end of the procedure. Demographics, operation type and epidural rate were all correlated with the need for catheterization. In all cases the residual volumes were recorded. Results: Patients remained on postoperative epidural analgesia for an average of 50hours. 54 patients required urinary catheterisation. The average postoperative duration until catheterisation was 18hours, with a maximum of 33hours. The average residual volume at catheterization was 936mls, with a maximum of 2200mls. All patients were managed with intermittent catheterisation, most, (63%) requiring only a single episode before spontaneously voiding. Discussion: Although patients in the catheterised group were older, (p< 0.05), we found no other significant differences in patients that subsequently required catheterisation, when compared for operation type, or epidural infusion rates. We were therefore unable to predict which patients would require catheterisation. Questioning and bladder palpation was found to be unreliable when assessing overdistention. Our study demonstrated that patients undergoing spinal surgery using epidural analgesia should be closely monitored in order to prevent overdistention of the bladder and has led to a proactive regimen for spinal patients with epidural analgesia in our unit

Purpose and background:. Cauda Equina Syndrome (CES) is a rare condition which, even in the presence of prompt surgical decompression, can have devastating consequences for patients in terms of bladder and bowel dysfunction. The aim of this project was to develop a post-operative pathway for the assessment and management of bladder and bowel dysfunction in patients with CES. Method:. Beaumont Hospital performs a high volume of spinal surgeries. A small number are lumbar decompression surgeries due to CES. While sphincter function is routinely screened by a physiotherapist post-operatively, to date there has been no protocol in place for assessment and management of bladder and bowel dysfunction in this population. This project was carried out in collaboration with consultants in urology and colorectal surgery, as well as clinical nurse specialists in both areas. Results:. All patients undergoing lumbar decompression due to CES will be referred to a colorectal surgeon for post-operatively review and out-patient monitoring. A routine bladder ultrasound will be completed post-operatively to assess for urinary retention with a post void residual > 150 mls of urine indicating the need for referral to a urologist for in-patient review and out-patient follow-up. A patient education leaflet has also been developed. Conclusions:. A pathway has been implemented at Beaumont Hospital to ensure timely referral to specialised teams for both assessment and management of bladder and bowel dysfunction in CES. This pathway will ensure prompt access to specialised and supportive multi-disciplinary teams in the days/weeks/months/years post-operatively thereby minimising the emotional distress and health risks associated with secondary complications of CES

INTRODUCTION. There is historical evidence of increased incidence of transitional cell tumours of the renal tract in workers exposed to high levels of metal ions. This study was designed to establish any correlation between Metal on metal bearing hip arthroplasty and TCC. METHODS. A prospective North-East database of 2900 Urology/Oncology cases was compared with the Freeman Joint Registry, which is a prospective database of all Arthroplasty performed since 2001 to establish any correlation with TCC. After comparing the Urology database with the Freeman Joint Registry from 2001 to 2011, a group of patients was identified who underwent hip replacement and had TCC of bladder. The incidence of TCC was calculated in patients who had metal on metal hip replacement and those who had metal on poly hip replacement. On comparing both the groups no significant difference in incidence of TCC of bladder was recorded. RESULTS. No increase in the incidence of transitional cell carcinoma was observed in patients who had metal on metal hip replacements compared to the one who had metal on polyethylene hips

An 86-year-old male presented with a loose total hip replacement (THR) ten years after implantation. At revision for anticipated aseptic loosening, watery pus was found in the joint and Bacille-Calmette-Guérin (BCG) was seen on culture. The bacterial strain was identified and was identical to the BCG used in the intravesicular treatment of superficial bladder carcinoma in this patient ten months earlier. After revision he received a full course of antituberculous treatment. The clinical and radiological results were excellent after follow-up for 30 months with his uncemented THR showing satisfactory incorporation. His inflammatory markers were normal and his Harris hip score was 95 points. The diagnosis of a tuberculous infection can be easily missed, but must be considered, especially if sterile pus is encountered

Introduction purpose and background. Implicit in the diagnosis of CES is the presence of leg pain with a spectrum of bladder and/or bowel disturbance and/or peri-anal sensory loss. Current research describes the clinical features of patients with radiologically confirmed CES, but the specificity of these features is not known. This study explores the accuracy of patient self reported bladder or bowel dysfunction and numbness of the bottom in individuals presenting with lumbar nerve root pain. Methods and Results. A retrospective review of patient completed questionnaires, of 281 consecutive patients with leg dominant back pain, presenting to an interface service. 26% of patients reported bottom numbness. 25% reported recent bladder or bowel (B/B) changes. Following a comprehensive assessment including anal tone testing 10 patients were referred to the spinal on-call service. Of these 1 had surgical decompression for radiologically confirmed CES. A review of the hospital records suggests that none of the remaining sample were subsequently admitted for CES within 2 months of the assessment. Individually bottom numbness and recent changes to the B/B had a sensitivity of 1 and a specificity of 0.73. When both numbness of the bottom and changes to B/B are reported the sensitivity was 1 and the specificity was 0.9. Conclusion. Self reported clinical features suggestive of CES are not uncommon in this highly selective population. Individually numbness of the bottom and changes to B/B were highly sensitive and had moderate specificity. However, when both bottom numbness and changes to B/B are reported, the specificity is also high. The potential for improved clinical outcomes for the individual identified with confirmed CES is emphasised. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

This is a prospective study to determine if we could identify patients who may benefit from preoperative catheterisation in lower limb arthroplasty.

211 consecutive patients undergoing total hip and knee arthroplasty were recruited. There were 131 female (62%) and 80 male (32%), the mean age (+−1 S.D.) was 68+−12 years old. Patients’ demographic details and pre-operative urinary symptoms were recorded. Previous urological surgery and past history of urinary catherisation were also documented. The anaesthetist who was blinded from the study selected the type of anaesthesia and the post-operative analgesia regime. All patients were required to produce mid-stream urine sample before surgery and at post-operation. Urine tract infection was confirmed on a positive microbiological culture. Regression analysis was used to assess various co-variables to identify the high-risk groups.

35 female (56%) and 27 male (44%) were catheterised, the mean age (+−1 S.D.) was 72+/−14 years old. The frequency of catheterisation was unrelated to the surgical procedure, the type of anaesthesia or the postoperative pain control regime. Age over 65 years old and nocturia were significant indicators for urinary catheterisation (p< 0.05). Patients with urinary incontinence and nocturia were strong determinant for urinary catheterisation (p< 0.03). Males over the age 65 years with a past history of urinary catheterisation (p=0.037) were more likely to be catheterised than females of the same group (p=0.947). This has become more evidential if patients have coexisting urinary incontinence and nocturia (p=0.005). Females over the age of 65 years with urinary incontinence were also significant (p=0.013).

The sensitivity for urinary catheterisation in patients over the age of 65 years with previous history of catheterisation, urinary incontinence or nocturia was 89.7%. This group of patients would benefit from pre-operative urinary catheterisation.

Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours. Cite this article: Bone Joint J 2022;104-B(12):1284–1291

Aims. The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected. Methods. The search strategy used electronic databases (PubMed, Medline, EMBASE, and AMED) for publications between January 1996 and November 2021. All studies that reported mPVR in patients in whom the diagnosis of CES was suspected, followed by MRI, were included. Results. A total of 2,115 studies were retrieved from the search. Seven fulfilled the inclusion criteria. These included 1,083 patients, with data available from 734 being available for meta-analysis. In 125 patients, CES was confirmed by MRI. The threshold value of mPVR reported in each study varied and could be categorized into 100 ml, 200 ml, 300 ml, and 500 ml. From the meta-analysis, 200 ml had the highest diagnostic accuracy, with 82% sensitivity (95% confidence interval (CI) 0.72 to 0.90) and 65% specificity (95% CI 0.70 to 0.90). When compared using summative receiver operating characteristic curves, mPVR of 200 ml was superior to other values in predicting the radiological confirmation of CES. Conclusion. mPVR is a useful tool when assessing patients in whom the diagnosis of CES is suspected. Compared with other values a mPVR of 200 ml had superior sensitivity, specificity, and positive and negative predictive values. In a patient with a suggestive history and clinical findings, a mPVR of > 200 ml should further raise the suspicion of CES. Caution is recommended when considering the mPVR in isolation and using it as an ‘exclusion tool’, and it should only be used as an adjunct to a full clinical assessment. Cite this article: Bone Joint J 2023;105-B(5):487–495

Aims. Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471

Aim. There is insufficient evidence to support bony reconstruction of the pubis after a type III internal hemipelvectomy (resection of all or part of the pubis). In this study, we compared surgical complications, postoperative pain, and functional outcome in a series of patients who had undergone a type III internal hemipelvectomy with or without bony reconstruction. Methods. In a retrospective cohort study, 32 patients who had undergone a type III hemipelvectomy with or without allograft reconstruction (n = 15 and n = 17, respectively) were reviewed. The mean follow-up was 6.7 years (SD 3.8) for patients in the reconstruction group and 6.1 years (SD 4.0) for patients in the non-reconstruction group. Functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system and the level of postoperative pain with a visual analogue scale (VAS). Results. The mean MSTS score of the patients was significantly better in patients after reconstruction (26 (SD 1.7) vs 22.7 (SD 2.0); p < 0.001). The mean visual analogue scale score for pain was significantly less in the reconstruction group (2.1 (SD 2) vs 4.2 (SD 2.2); p = 0.016). One infection occurred in each group. Bladder herniation occurred in three patients (17.6%) in the non-reconstruction group but none in the reconstruction group. Five patients (29.4%) in the non-reconstruction group and one (7%) in the reconstruction group had a limp. Graft displacement occurred in two patients in the reconstruction group. Conclusion. We recommend reconstruction of the bony defect after a type III hemipelvectomy: it gives a better functional result, less postoperative pain, and fewer late surgical complications. Cite this article: Bone Joint J 2021;103-B(6):1155–1159

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study. Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation. Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed. The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

Objective. To investigate the relationship between the pattern of pelvic or acetabular fracture, and bladder injuries. Methods. A total of 173 patients admitted at our Academic Hospital from January 2006 to March 2012 with cystograms done for pelvic or acetabular fractures were studied retrospectively. Records of pelvic X-Rays, CT scans and cystograms were reviewed. Tile's classification and Young & Burgess classification were used for pelvic fractures and Judet & Letournel classification system for acetabular fractures. Results. Out of 173 patients 16% had bladder injuries of which 22% were intra-peritoneal and 70% were extra-peritoneal. The bladder injuries mostly occurred among male patients; 16 males compared to 9 female patients. Out of the 21 fractures of the acetabulum only 2 sustained bladder injury and they were secondary to gunshot wounds. Lateral compression fractures accounted for 67% of bladder injuries. Motor vehicle accidents were the leading mechanism of injury accounting for 117 patients in total and 81% of those with bladder injuries. Among the patients with bladder rupture 55% had at least 3 rami involved and only one patient (4%) with 1 ramus involved had a bladder injury. Overall 44 (34%) of patients with 3 or more rami fractured had bladder injury. Conclusion. Bladder injury appears to be related to the mechanism of injury. We recommend that a cystogram be done routinely when a patient presents with a type III lateral compression fracture. In isolated acetabulum fractures, single ramus fractures and lateral compression type I fractures, request for cystogram should be correlated with clinical signs and symptoms, and not done routinely. NO DISCLOSURES