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The Repercussions of Spinal Cord Injury on the Action of the Diaphragmatic Crura for Gastroesophageal Reflux Containment

Silva, Cleuza B. MS*; Martinez, Júlio C. MD, PhD†; Yanagita, Edison T. MD†; Morais, José F. MS*; Carvalho, Luciane B. PhD‡; Herani-Filho, Benedito MD, PhD§; Moraes, Daniel G. MD¶; Vianna, Patrícia C. MD‖; Prado, Gilmar F. MD, PhD**

doi: 10.1097/BRS.0b013e31818a2c59
Cervical Spine

Study Design. Cross-sectional and nonexperimental.

Objective. To detect and compare functional abnormalities in the esophagus and esophagogastric junction in 2 groups with chronic spinal injuries, 1 with injuries at the phrenic innervation level and the other at upper thoracic levels, and to relate these to gastroesophageal reflux containment.

Summary of Background Data. There are no studies on esophageal manometry with pH metering among spinal cord injury patients. Worldwide statistics reveal that the prevalence of gastroesophageal reflux disease among spinal cord injury patients is greater than among the general population, at around 22% to 27%. The “diaphragmatic crura” has been recognized as an important antireflux barrier and should functionally be considered to be a muscle separated from the costal diaphragm. However, doubts remain regarding whether this difference relates to its innervation.

Methods. This was a cross-sectional study on 29 patients with complete spinal cord injuries: 14 quadriplegics (level C4) and 15 paraplegics (levels T1-T7). Functional abnormalities of the esophagogastric junction, esophagus, and diaphragm were investigated using esophageal manometry and diaphragmatic video fluoroscopy. Presence of gastroesophageal reflux was investigated subjectively (pyrosis and regurgitation) and objectively (pH metering and endoscopy).

Results. The incidence of gastroesophageal reflux disease was 27.6%, without difference between the groups. This became statistically significant when the mean diaphragmatic crural pressures were compared (quadriplegics: 37.5 ± 17.8; paraplegics: 26.6 ± 7.2; P = 0.048). It was also significant in relation to the prevalence of at least one of the objective and/or subjective reflux findings and/or esophageal peristaltism (quadriplegics: 85.7%; paraplegics: 40.0%; P = 0.011).

Conclusion. Spinal injury at the level of the phrenic innervation did not predispose the quadriplegics toward greater risk of developing gastroesophageal reflux disease. Paradoxically, manometry showed significantly greater crural contractility among the quadriplegics.

The study evaluated the functional modifications of the esophagogastric junction comparing tetraplegic and paraplegic subjects, using endoscopy, manometry, and pH metering. There was a high prevalence of gastroesophageal reflux disease and greater pressure of the diaphragmatic crura in tetraplegic subjects, even with spinal injury at the level of the phrenic roots.

From the *Discipline of Emergency Medicine and Evidence-Based Medicine; †Digestive Physiology Sector (SEFIDI), Discipline of Surgical Gastroenterology; ‡Discipline of Emergency Medicine and Evidence-Based Medicine; §Digestive Endoscopy Sector; ¶Radiology and Ultrasonography Sector, Hospital Sao Paulo; ‖Rehabilitation Center Lar Escola Sao Francisco; and **Department of Medicine and Department of Neurology, Universidade Federal de Sao Paulo, Brazil.

Acknowledgment date: June 22, 2008. First revision date: July 30, 2008. Acceptance date: July 30, 2008.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Patient Consent Form and Research Ethics Committee: The participants signed a consent form that had been approved by the Research Ethics Committee of the Universidade Federal de Sao Paulo (# 0741/03).

Address correspondence and reprint requests to Dr. Cleuza Braga Silva, MS or Gilmar Fernandes Prado, MD, PhD, Alameda dos Arapanés, 419-Apt 175, Sao Paulo-SP, Brazil, CEP 04524-000; E-mail: or

© 2008 Lippincott Williams & Wilkins, Inc.