Bilateral extracorporeal shock wave lithotripsy in a spinal cord injury patient with a cardiac pacemaker

Objectives: To review the precautions to be observed before and during extr acorporeal shock wave lithotripsy (ESWL) in spinal cord injury (SCI) patien ts with a cardiac pacemaker and the safety of bilateral ESWL performed on t he same day. Design: A case report of bilateral ESWL in a SCI patient with a permanent c ardiac pacemaker. Setting: The Regional Spinal Injuries Centre, Southport, the Lithotripsy Un it. the Royal Liverpool University Hospitals NHS Trust, Liverpool, and the Department of Cardiology, Manchester Royal Infirmary, Manchester, UK. Subject: A 43-year-old male sustained a T-4 fracture and developed parapleg ia with a sensory level at T-2. During the post-injury period, he developed episodes of asystole requiring implantation of a dual chamber (DDD) perman ent pacemaker. Twenty-one months later, he developed a right ureteric calcu lus with hydronephrosis. A radio-opaque shadow was seen in the left kidney with no hydronephrosis. During right ureteric stenting, the ureteric stone was pushed into the renal pelvis. 1,500 shock waves were delivered to this stone on the right side, followed by ESWL to the left intra-renal stone wit h 1250 shock waves. Results: The patient tolerated ESWL to both kidneys. The pacemaker was repr ogrammed to a single chamber ventricular pacing mode at 30 beats per minute with a reduced sensitivity during lithotripsy. There were no untoward card iac events during or after lithotripsy. The serum creatinine was 45 mu mol/ l before lithotripsy and 44 mu mol/l two weeks after ESWL. Conclusion: SCI patients with a cardiac pacemaker may be able to undergo ex tracorporeal shock wave lithotripsy following temporary reprogramming of th e pacemaker. Bilateral, simultaneous ESWL is safe in the vast majority of p atients provided that there is no risk of simultaneous ureteric obstruction by stone fragments. However, it should be remembered that a decrease in re nal function could occur following bilateral ESWL of renal calculi.