Relation Between Right-to-Left Shunts and Spinal Cord Decompression Sickness in Divers

Abstract

The role of right-to-left shunting (RLS) in spinal cord decompression sickness (DCS) remains uncertain and could differ according to the distribution of lesion in spinal cord with a higher risk of upper spinal cord involvement in divers presenting a large patent foramen ovale. The aims of this study were to assess the prevalence of RLS with transcranial doppler ultrasonography in 49 divers referred for spinal cord DCS and compare it with the prevalence of RLS in 49 diving controls, and to determine a potential relation between RLS and lesion site of spinal cord. The proportion of large RLS was greater in DCS divers than in healthy control divers (odds ratio, 3.6 [95 % CI, 1.3 to 9.5]; p = 0.017). Shunting was not associated with the increased incidence of cervical spinal cord DCS (OR, 1.1 [95 % CI, 0.3 to 3.9]; p = 0.9) while a significant relationship between large RLS and spinal cord DCS with thoracolumbar involvement was demonstrated (OR, 6.9 [95 % CI, 2.3 to 20.4]; p < 0.001). From the above results, we conclude that the risk of spinal cord DCS in divers with hemodynamically relevant RLS is higher than in divers without RLS, particularly in their lower localization.

diving - decompression sickness - spinal cord - transcranial doppler ultrasonography - right‐to‐left shunting

References

• 1 Balestra C, Germonpre P, Marroni A. Intrathoracic pressure changes after Valsalva strain and other maneuvers: implications for divers with patent foramen ovale.  Undersea Hyperb Med. 1998;  25 171-174
• 2 Blatteau J E, Peny C, Pontier J M, Gempp E, Louge P. Influence of repetitive open sea dives and physical exercises on right-to-left shunting in healthy divers.  Br J Sports Med. 2007;  DOI: 10.1136/bjsm.2007.042226
• 3 Bove A. Risk of decompression sickness with patent foramen ovale.  Undersea Hyperb Med. 1998;  25 175-178
• 4 Boycott A E, Damant C, Haldane J S. The prevention of compressed air illness.  J Hyg Cambridge. 1908;  8 342-344
• 5 Cantais E, Louge P, Suppini A, Palmier B. Right-to-left shunt and risk of decompression illness with cochleo-vestibular and cerebral symptoms in divers: case control study in 101 consecutive dive accidents.  Crit Care Med. 2003;  31 84-88
• 6 Cartoni D, De Castro S, Valente G, Costanzo C, Pellicia A, Beni S. Identification of professional scuba divers with patent foramen ovale at risk for decompression sickness.  Am J Cardiol. 2004;  94 270-273
• 7 Francis T JR, Mitchell S J. Pathophysiology of decompression sickness. Brubbak AO, Neuman TS, eds. The Bennett and Elliot's physiology and medicine of diving. 5th ed. London; WB Saunders 2003: 530-556
• 8 Germonpré P, Dendale P, Unger P, Balestra C. Patent foramen ovale and decompression sickness in sports divers.  J Appl Physiol. 1998;  84 1622-1626
• 9 Hennessy T R. On the site of origin, evolution and effects of decompression microbubbles. Brubakk AO, Hemmingsen BB, Sundnes G, eds. Supersaturation and bubble formation in fluids and organisms. Trondheim, Norway; Tapir 1989
• 10 Kerut E D, Truax W D, Borreson T E, Van Meter K W, Given M B, Giles T D. Detection of right to left shunts in decompression sickness in divers.  Am J Cardiol. 1997;  79 377-378
• 11 Klotzsch C, Janssen G, Berlit P. Transesophageal echocardiography and contrast-TCD in the detection of a patent foramen ovale: experiences with 111 patients.  Neurology. 1994;  44 1603-1606
• 12 Moon R E, Camporesi E M, Kisslo J A. Patent foramen ovale and decompression sickness in divers.  Lancet. 1989;  1 513-514
• 13 Schwarze J, Sander D, Kukla C, Wittich I, Babikian V L, Klingelhöfer J. Methodological parameters influence the detection of right-to-left shunts by contrast transcranial Doppler ultrasonography.  Stroke. 1999;  30 1234-1239
• 14 Schwerzmann M, Seiler C, Lipp E, Guzman R, Lovblad K O, Kraus M, Kucher N. Relation between directly detected patent foramen ovale and ischemic brain lesions in sport divers.  Ann Intern Med. 2001;  134 21-24
• 15 Spencer M. Detection of cerebral arterial emboli. Newell DW, Aaslid R, eds. Transcranial Doppler. New York; Raven Press Ltd. 1992: 216-230
• 16 Torti S, Billinger M, Schwerzmann M, Vogel R, Zbinden R, Windecker S, Seiler C. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale.  Eur Heart J. 2004;  25 1014-1020
• 17 Vik A, Jenssen B M, Brubbak A O. Arterial gas bubbles after decompression in pigs with patent foramen ovale.  Undersea Biomed Res. 1993;  20 121-131
• 18 Wilmshurst P, Bryson P. Relationship between the clinical features of neurological decompression illness and its causes.  Clin Sci. 2000;  99 65-75
• 19 Wilmshurst P, Byrne J, Webb-Peploe M. Relation between interatrial shunts and decompression sickness in divers.  Lancet. 1989;  2 1302-1306
• 20 Wilmshurst P, Davidson C, O'Connell G, Byrne C. Role of cardiorespiratory abnormalities, smoking and dive characteristics in the manifestations of neurological decompression illness.  Clin Sci. 1994;  84 297-303