Neuropathic bladder in ankylosing spondylitiswith spinal diverticula

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JASWANT S . SACHDEV, M .P . MEENA BELLAPRAVALI7 . M .D . From the Services of Surgery, :Neurology, and Radiology, Veterans Administration Medical Center, Phoenix, Arizona

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re of syndrome with neuropathic bladder is a rare but known cornoj long-standing ankylosing spondylitis . From, 1968 until now, diverticula from the sr rce eroding into the bodies of the l-urnbosacrai vertebrae have been reported in 46 cases losing spondylitis with cauda equina syndrome and netrapathic bladder. We report 3 cases ) atitic bladder and ankylosing spondylitis with cauda equine symptoms, In 1 of the 3 base rarely encountered spinal dioerticula were demonstrated by computerized tornograscan . The etiology of these dicerticula and their treatment are rev iowed,

description of the spell ankyS), several reports on the published .'-° It was, howintil 1968 that Mathews, 1 ° for the first orted the finding of posterior diverticlumbar spine in a case of ankylosing 'th cauda equina syndrome (CES), than 46 cases have been reed.-'r' CES appears several years after the -)toms have abated and after has become apparently inactive, sensory disturbances such as lanin the legs, numbness or loss of cedar wasting, diminished or ab-, progressive sphincter disturbv incontinence, constipau fecal incontinence, arid 's nnpotenee,e .11 .11 The symptoms are et and are often masked by the radii aalns f h these patients habitually e sphincteric symptoms are usually attract attention of the patier :t, rv ones, The slowness with toms evolve explains the im1i occur in the urinary tract

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VOLUME XXXV, NUMBER 4

G~ had the opportun 3 such patients who suffered fr 'ng AS along with CES . The CT roves the presence of multiple asynunet erosions of the posterior elements of the huebar spine which correlated with thecal diverticula in 1 patient, ther patients (one HLB-2i' positive) did ibit p' al diverticula. Case Reports Casc

A sixty-1 -year-old white man stz have symptoms of AS since the age of twen His general health had been poor for sometime . He had chronic obstructive pulmonary disease, and arteriosclerotic and peptic ulcer disease, HIe wN as admitted in August 1985 for recurrent gross hematuria . He had been complaining for the last two years of the following : (1) numbness in both legs up to the knee l more pronounced an the right side ; (2) lancinatin„ pain from the perineum down to the toes, more pronounced on the right side : (3 progressive weakness of the legs, much worse on the right side, and (4) conHion and fecal incontinence when the stools

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Case I . Bladder trann

cell car-

de .3, with muscle Inc

Bienai scan ryas normal . Cystosccp} e a neuropathic bladder and a bladder t near the left ureteral orifice . The tunxir wa sected endoscopically on August 12 and to be a transitional cell carcinoma, wading muscle (Fig . 1), Bone scan an tomograrns were negative . His bladder was treated by radiotheraliy. The CT se vealed multiple asymmetric eposterior elements of the lumbar spine . The cystometrograrn revealed a flat cur 3) . The volume of the voided urine w mL ; the volume of the residual urine w mL ; the bladder efficiency was calculate 580/730 (79%) . The patient died on Mafel 1986 . Case 2 A white male ti n Jan ry .23, 1`151 went back so es (at ages 2' and 31 years) . , including pa . left leg and neuropathic bladder but no tenet . A S was diagnosed when he was tP eight years old :: he is HLB-27 positive . given ureeholine and later on intermitten catheterization . The spine roentgeno show minimal AS changes, After voidi intravenous pyelogram shows a large b measuring 1.2 x 10 cm . The eystorneiir curve is flat, Findings on evstoseop within normal limits, and the CT scan show any spinal erosions . Case 3

P'1c ur s, z . ("asp 1 . CT scan si Qir1141 a . erosions of laminae and spinout processes e?f brat, (black and white arrows) at multiple lere's by eraehnoid divertic ala .

ceased s rations in both cgs, more so on the right, absence of position sense and of ankle jerks in the lower eXtremrtiees, muscular atrophy of the muscles of the legs (worse on the right side), and a decreased anal tone .

A forty-five-year-old white man who', much older had AS for over twenty years . months ago he had a colostomy for reds verticulitis . He also suffers from hvner He had Bell's palsy as well as peronea (left foot drop) from which he is recover presented himself for impotence . ills C did not show spinal erosions .

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Case 1, flat Curve o;

UROLOGY

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Case 4 . CT scan rove rra (black arrow-

sually they could be xmly when done pine osition. . e myelogram is 'nit to perform and does not seer ssarv for the diagnosis .' sosi Supin a )a ded if non-oil-base con( erode deep into the , and into the spinal canal .' This marked certainly facilitated by the softosteoporosis of the bones that inalways accompanied by spinal these patients . Two of our 3 padiverticula . When the CT the myelogram may reveal ith arachnoiditis.'s Both ould be late sequelae s existing at an earlier stage of e . In-ts This early arachnoiditis can laadhesions with the formation of vhich could then expand with a of bone ." This etiologic r supported by the raised cereprotein seen in sonic of these pathis is not the only possible rokeci to explain the ctiopa,ondition,, two other possible exbeen advanced .S 4 le 11 )retical explanation is a pi ; •tz=e withi n tyre spinal canal as action of arterial expansion 7r even from gravit 'ebral foramina by

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extensive posteric r soft tissue ossif explain . in some cases at least, the p C ES .ro . i s Since these spinal diverticula are posteik. position and will not encroach on the intervertebral foramina, it has been very difficult to explain the mechanism by which these diverticula could cause CES . We raise the question of whether or not these diverticula as well as the neurologic symptoms could both be the result of the same etiologic factors . The other controversial area is whether or not these patients should be operated on . Several patients who were subjected to surgical. operations did not show an improvement,' However, it has been speculated that early decompressive operation could give better suits ." When spinal stenosis is noted, surgical es arv.'°

Since submissio opportunity of ev ti (age 67) with AS and ncuropathie lumbar CT scan revealed, at the level oo al diverticulum in the earliest stage of -or nation yet seen or described (Fig . 4) . The AS was presently quiescent . The patient was taking ranitidine for esophageal reflux and had an adenoearcinoma of the prostate ('Gleason pattern 4332 E' ficcadilty Road Arizona 85018 fIADD AD) AC;LNOWLHZ7C,32}]I'..1 . To jean ( - rosier for her con inuous and timely efforts in providing as with copies of the refer, epees .

References on Bekhtcrew W ; Steificheit der Wirbelsauh. id is be.sonder Erkrankensforas, Neaiol 261 12 : 429

o o isc,hanator he IInterstr_c _ caber .1 1)IISeh Z ;enhviik 15 : fl. (1 4 . Babiaski J : Pseu ;do-tabesspool (1903) . 5 . Garc n h anti Fr t c rn .Fl L'-n cas de pseindo-tubas spoor lcrique do Babinski, Rev Rhewtt 15 : 133 (194S) . t3 . Bowie F.A, and Glasgow GL : Caucia equine lesions associated with arikyksing spcmdvtai_s, report of 3 casts . Br Mod 12: 24 (1961) . 7, Flange T : Chronic rheumatoid polyarth sts and spondvlarthrita associated with neurological syn .ptnms and signs and ocaaonali, simulating an intraspinal e a sive _rrrctiss_ Acta Chir

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Seand 120 195 (190 6 Leo NUM .. and eo u vieations of a a:yiosina a r7„d •° truth j ( 9S ILO&21 . g.cal svndror assrndated 9 Mr(All 1;(; : An :. ` ankvlesr¢,u, 0aondyl . a Rep 1Iat 33 )19116) . :0 Mathews WIt : The no r r 1logica fompIicoinons (il' an kylo, 3ndvlrlis. Jtb`auro! Sri 6: .M 1 :s, I, MI ., Cordon DA . Ogryado MA .. and Me .Phedr n d eye in a syndremc- or a hlo .ii gsaondelits, Ann 3 51 x,1973)_ Xendat \4J, and %hitfield AG',V Nervous s}st('an in a ihuhisinp ape ndyitis, Br bled 1 1 : 145 (1974), 13 . Ma_fhees TV Cauda ecniina rsndrone ,n ankylosing pondyli'as, Br Mod j L 5 7 (197€) . I1. Hassan 1 : Cauda egniriaasyndrome in amkylo irg sgondy I to : a report f i casm, j Nerd Noaromug Psychol 39 : (1976} . 15 . Cumu ing WJK . and Saunters M : Badioulopat~hv as a conpiicallon of anky!asia spond lsts I Nmnnl'heurosurg PsyAcl 41 : 569 (1975) .

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15 . Luken MG III, AS DV, and Liitnan 5411 : S spinal sto nasi associated with ask ' s ud soar dydtia I1 : 710 (982) . 7 .7 . Aarfies~,n Ji3 et ak Canda equiaaa sy nan rao nor, nii7ig ankyl n-g spondybtis, Ann Neoro1 12 : 6C' ( osman H, Crazy B, and St -cues EL : c'f of lu ing ankto_sing spands tits with eauda egnina ayndrorne 1(77 (1953) . 1 .9 . Gt i .e Pi . P:3c:A flt B Ciiford E, and Weight C11 : In cyst with compression of the eauda egoiina in ankylosing a [is, Sur Noosel. 23 :: 162 (1955) . 20, Tiigner 61, and Portin D >3 k)'iriatng sxondyj eauda equina syndrome, case report, MNO Mewl S2 : 70g,(, 2.1 . Byri e j k' : Case of the seaon,Semis h :cntgort=al(1346) . 22, Baudennarcg1etai :Erosi nsla :aadrnr, aspect(( Con ;Ctrignl dons ke }nlrurne sic Ta acne do oheval au spondyl rtl rite anksh s i .lie, Ann Radical (Paris) 29 : 48 23 . I ahrousse C, as ci : Les s aJromss de la grece de la sTomidyla rttritc r kdcsante a i ve':alier ur lop( Rheuus 54 : 289 (19,37)

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