# Clearance of Lower Renal Calyceal Residual Fragments Following Lithotripsy in a Patient With Spinal Cord Injury: A Case Report

## TL;DR

A patient with a spinal cord injury developed a method to clear kidney stone fragments by using a specific body position and bladder maneuver.

## Contribution

A novel empirical protocol for clearing residual kidney stones in spinal cord injury patients through positional therapy and the Credé maneuver.

## Key findings

- The right lateral decubitus position combined with the Credé maneuver led to the spontaneous passage of residual kidney stone fragments.
- Follow-up imaging confirmed complete clearance of residual fragments after three days of the protocol.
- The posture may create a more direct pathway for fragment expulsion in the left calyceal region.

## Abstract

The clearance of residual fragments after lithotripsy is a problem of clinical relevance. Residual stone fragments can serve as nucleation centers for the deposition of calcified material, leading to recurrent formation of calculi. This case report presents a 63-year-old male with paraplegia of lower limbs who, through an empirical observation, managed to develop a protocol that resulted in clearance of residual calcified fragments of a lithotripsy performed 267 days ago. Preoperative imaging revealed the presence of kidney stones localized in the lower left renal calyces. The patient underwent laser ureterorenolithotripsy using a flexible device, followed by extracorporeal shock wave lithotripsy (ESWL) approximately six months later. These interventions were not entirely successful, as significant amounts of calcified debris persisted. Approximately four months after the ESWL, after attending a physiotherapy session for osteopathic treatment, the patient reported the spontaneous passage of multiple residual stones during urination. The patient noted a correlation between the right lateral decubitus position and expulsion of stone fragments. To test his hypothesis, he adopted this position once a day for 40 minutes, immediately followed by the Credé maneuver to void the bladder. After each session, multiple residual stones were expelled. By the third day, no further stones were eliminated, and follow-up X-rays showed no remaining fragments. The findings of this case report may contribute to improving kidney stone elimination in patients with spinal cord injuries. A possible mechanism for the clearance of residual stones in the left calyceal region while in the right lateral decubitus position is that this posture creates a more direct pathway for fragment expulsion, optimizing the effects of gravity and urinary flow.