Complete Spinal Cord Lesion Research Articles

Titration of serum anti-ganglioside antibodies in patients with chronic medular injury previous to treatment with GM1 ganglioside

Anti-ganglioside serum titers were evaluated by ELISA in 150 patients with complete spinal cord lesion for 6 to 12 months (IgG monosialo GM1, IgM monosialo GM1, IgG asialo GM1, IgM asialo GM1, IgG disialo GD1b e IgM disialo GD1b) prior to treatment with GM1 100 mg/day i.m. Only 4 patients showed positive titers for anti-asialo-GM1 (IgM) antibodies . All patients were clinically examined during and after treatment. No important side effects were observed with GM1 therapy. These results suggest that GM1-ganglioside administration in patients with chronic spinal cord injury is safe.

Olfactory ensheathing glia transplantation: a therapy to promote repair in the mammalian central nervous system.

A therapy to treat injuries to the central nervous system (CNS) is, to date, a major clinical challenge. The devastating functional consequences they cause in human patients have encouraged many scientists to search, in animal models, for a repair strategy that could, in the future, be applied to humans. However, although several experimental approaches have obtained some degree of success, very few have been translated into clinical trials. Traumatic and demyelinating lesions of the spinal cord have attracted several groups with the same aim: to find a way to promote axonal regeneration, remyelination, and functional recovery, by using a simple, safe, effective, and viable procedure. During the past decade, olfactory ensheathing glia (OEG) transplantation has emerged as a very promising experimental therapy to promote repair of spinal cords, after different types of injuries. Transplants of these cells promoted axonal regeneration and functional recovery after partial and complete spinal cord lesions. Moreover, olfactory ensheathing glia were able to form myelin sheaths around demyelinated axons. In this article, we review these recent advances and discuss to what extent olfactory ensheathing glia transplantation might have a future as a therapy for different spinal cord affections in humans.

Nocturnal penile tumescence and effects of complete spinal cord injury: possible physiologic mechanisms

Objectives To determine the role of the spinal cord in the initiation and/or modulation of nocturnal erectile activity, we measured nocturnal penile tumescence (NPT) in men with complete spinal cord injuries at known locations. Methods Eighteen men between the ages of 27 and 57 years (mean 45) with known complete spinal cord lesions and no history of other medical problems adversely affecting erectile function completed International Index of Erectile Function questionnaires and underwent RigiScan testing for two consecutive nights. RigiScan tracings were evaluated for the presence and quality of NPT activity. Erectile episodes lasting longer than 10 minutes with base and tip rigidity greater than 70% were designated “good”; the remainder were designated “borderline,” “poor,” or “absent.” Results Of 9 men with cervical injuries and 9 with thoracic injuries, 8 and 3, respectively, had evidence of NPT. Of the 9 men with cervical injuries, 3 had one or more “good” nocturnal erections, and 1 of 9 men with thoracic injuries had one or more “good” nocturnal erections. The mean duration of the single longest erectile event was 26 minutes in men with cervical spinal injuries and 12 minutes in men with thoracic spinal injuries. Men with cervical and thoracic injuries had a mean overall International Index of Erectile Function score of 10 and 16 and a mean erectile domain score of 2 and 3, respectively. Conclusions Spinal regulation is critical for nocturnal erectile activity, and the isolated thoracic cord is less effective than the isolated cervical cord in maintaining NPT. Despite the presence of nocturnal erectile activity, volitional erectile function in spinal cord-injured men is significantly impaired.

Spinal hydatid disease and its neurological complications.

Bone infection is estimated to represent 0.5-2.5% of cases of hydatid disease. Of these cases, the spine is affected in about 50%. 11 cases of histologically confirmed spinal hydatid disease treated surgically in 2 institutions in Spain and Lebanon were followed up clinically and radiologically for an average of 20 y (1-34 y). On presentation, all patients had severe neurological deficits. All patients underwent posterior spinal decompression, curettage, drainage and washout of paravertebral cyst cavities. Over the period of follow-up, patients underwent an average 4.8 spinal surgical procedures. Neurologically, all patients had partial or complete spinal cord lesions. All patients had recurrences and 18% died as a consequence of the disease. Extravertebral dissemination occurred in 82% of the cases, most commonly to the liver.

Automatic vs hand-controlled walking of paraplegics

A rule-based control and its application in functional electrical stimulation (FES) assisted walking of subjects with paraplegia are described in this paper. The design of rules for control comprises the following two steps: (1) determination of muscle activation patterns by using a fully customized spatial (3D) model of paraplegic walking, and (2) learning of rules, that is, correlation between the muscle activation patterns and kinematics of walking by means of an artificial neural network. The adopted FES system activated eight muscle groups with surface electrodes. The only joints allowing movement in the coronal plane were the hips, and externally controlled joints in sagittal plane were ankles, knees and hips. The simulation minimized the tracking error of the joint angles and the total activation of all eight muscles being stimulated. A radial-basis function artificial neural network was applied for learning of rules. Three automatically controlled modes (slow, near-normal, and near-ballistic) and hand-controlled walking were evaluated in six subjects with a complete spinal cord lesion (T8-T10). The performance of walking was assessed by the following: (1) energy consumption based on oxygen uptake, (2) physiological cost index, (3) maximum speed of walking, and (4) a questionnaire. The results showed that all modes of walking are achievable and that automatic control leads to more efficient and faster walking. The speed of walking achieved by automatic control was almost three times bigger compared with the speed of hand-controlled walking. The energy cost and rate decreased significantly when automatic control was applied; yet, they were still much bigger than the values measured in able-bodied subjects. The objective outcome measures suggest that the near-ballistic walking was the most effective, yet a questionnaire shows that most subjects preferred slow walking. The most likely reason for the preference of lower efficiency walking over the faster end energy efficient near-ballistic walking was that paraplegic patients had difficulties in synchronizing the voluntary movement of the trunk and arms to the artificially controlled movements of legs.

An overview of the state of the art of noninvasive FES for independent ambulation by thoracic level paraplegics

This paper is an overview of the status of transcutaneous noninvasive (unbraced) functional electrical stimulation (FES) for independent standing and for independent ambulation by traumatic spinal-cord injured (SCI) paraplegics with complete spinal cord lesions at the thoracic level. The paper discusses aspects of patient selection, patient training, system performance, ambulation range, medical benefits and psychological benefits. It also considers problems relating to system adoption and long term system use. Furthermore, the paper discusses the various aspects of transcutaneous noninvasive FES as compared with implanted FES systems for ambulation by thoracic level SCI patients. [Neurol Res 2002; 24: 431-442]

Cardiovascular responses during submaximal electrical stimulation-induced leg cycling in individuals with paraplegia.

This study investigated the cardiovascular responses during electrical stimulation-induced leg cycling (ES-LCE) in people with paraplegia (PARA) compared with voluntary leg cycling (VOL) at similar levels of oxygen uptake in able-bodied (AB) individuals. Six PARA with sensory and motor complete spinal cord lesions (TS-T9) and six AB participated in this study. Oxygen uptake (VO2), stroke volume (SV), heart rate (HR) and cardiac output (Q) were measured at rest and during submaximal, steady-state leg cycling. At the highest power output achieved (9.2 +/- 2.4 W for PARA versus 42.8 +/- 1.0 W for AB), VO2 was augmented above resting levels to 0.75 +/- 0.11 min(-1) in PARA and to 0.74 +/- 0.071 min(-1) in AB. HR and SV were also increased during ES-LCE in PARA (92.1 +/- 8-6 beats min(-1) and 93.9 +/- 11.3 ml bea(-1), respectively) and during VOL in AB (83.9 +/- 9.2 beats min(-1) and 89.7 +/- 9.0 ml beat(-1), respectively). At an equivalent submaximal VO2, HR and SV were not different between the two groups, however, Q was higher in PARA (6.6 +/- 0.7 versus 4.1 +/- 0.9 1 min l(-1) deltaVO2). These data suggest that ES-LCE at relatively low power outputs elicits increases in several cardiovascular variables in PARA. Furthermore, it is possible that ES-LCE leads to a 'hyperkinetic circulation' (a greater Q for a given VO2).

Sympathetic skin response in human below a complete spinal cord lesion elicited by pudendal nerve stimulation

Sympathetic skin response in human below a complete spinal cord lesion elicited by pudendal nerve stimulation

Control of paraplegic ankle joint stiffness using FES while standing

The goal of this work was to investigate the feasibility of ankle stiffness control using functional electrical stimulation (FES) while standing, as relevant to the development of feedback systems for balance control in paraplegia. The work was carried out using apparatus in which the subject stands with all joints above the ankles braced, and where ankle moment is provided via FES of the ankle flexor and extensor muscles. A feedback control strategy for ankle stiffness control is proposed in which the ankle moment is controlled to a reference value equal to the product of the desired stiffness and the measured ankle angle. Two subjects participated in the study: one neurologically-intact person, and one paraplegic person with a complete thoracic spinal cord lesion. The results show that during forward-leaning postures, when the plantarflexor muscles are stimulated, relatively high ankle moments of up to 60 Nm can be generated and accurate moment tracking is achieved. As a consequence, ankle stiffness is close to the desired value. During backward lean, on the other hand, the dorsiflexor muscles are stimulated. These muscles are relatively weak and only modest ankle moments of up to around 15 Nm can be produced. As a result, dorsiflexor stimulation readily saturates giving poor stiffness control. It was further observed that when the desired stiffness is higher more external force has to be applied to perturb the body away from the neutral (upright) position. We conclude that: (i) accurate ankle stiffness control, up to the fundamental strength limits of the muscles, can be achieved with controlled FES; (ii) ankle stiffness control using FES in paraplegia has the potential to ease the task of stabilising upright posture by application of additional upper-body forces.

Development of functional electrical stimulators utilizing cochlear implant technology

In 1983, R. Davis proposed the development of a functional electrical stimulator, based on multi-channel cochlear implant technology, for the restoration of function in spinal cord injured paraplegic subjects. In 1984, the US Veteran Administration funded the initial investigations including animal experiments and purchase of a FES stimulator based on the Nucleus 22 cochlear implant. In 1987, the US Food and Drug Administration approved an Investigational Device Exemption (IDE# G870142) for this FES project. In 1991, the first stimulator was implanted in a 21-year old male paraplegic subject (complete thoracic spinal cord lesion at level #10), who was subsequently able to stand and to perform one-handed tasks for up to 1 h. In 1996–1997 development started on a new multi-function FES system. In 1998, a stimulator was implanted in a 35-year-old male paraplegic subject (complete thoracic spinal cord lesion at level #10). After 8 months of use providing multiple functions including bladder voiding, the implant's internal antenna wire broke. A modified implant (FES 24-B) is due to be implanted in July 2001.

Denervation techniques

The bladder can be denervated at several levels: centrally, at the level of the sacral nerves; peripherally, on the pelvic nerves; or in the bladder, by cutting the relevant structures, by injecting substances toxic to nerves, or by hyperbaric bladder distension. These procedures target the sensory or motor nerves to weaken or to interrupt the detrusor reflex arc. Most of the procedures introduced previously, e.g. bladder trans-section by open operation, endoscopic or transvesical phenolization, hyperbaric bladder distension, and peripheral denervation of the bladder, have now been abandoned. Although some of these techniques had a high initial success rate in abolishing detrusor overactivity and in controlling incontinence, the relapse rate within 18 months approached 100%. In the early 1950s, much of the denervation surgery was performed on sacral roots and nerves. Nowadays, sacral de-afferentiation of the bladder by dorsal sacral root rhizotomy of S2-S5, using specialized techniques, either intradurally or at the conal level, has proved to be a very effective procedure for patients with spinal cord injuries and detrusor hyper-reflexia, functional low compliance and reflex incontinence, which cannot be managed by any other means. In conclusion, although in approximately 90% of patients the symptoms of an overactive bladder will be eliminated or improved by conservative methods of treatment, bladder denervation procedures still have a place in the management of these patients. In particular, with these procedures a low-pressure bladder system can be obtained and urinary continence restored in patients with complete suprasacral spinal cord lesions.

Prediction of functional outcome after spinal cord injury: a task for the rehabilitation team and the patient.

Descriptive analysis of data gathered in an information system. To explore the predictions of professionals and patients regarding functional outcome after spinal cord injury related to the final results after inpatient rehabilitation, in order to make prognostics of rehabilitation outcome more successful and enlarge the role of the patient in selecting realistic rehabilitation goals. Data from 55 patients with spinal cord injury admitted to the rehabilitation centre. Expectations of the rehabilitation team and the patients regarding future independence in performing six daily activities were compared to the functional results at discharge. The results of patients with different level and extent of lesion were analyzed. In 52% of all performed skills, independence was achieved at discharge. Professionals and patients made similar predictions. If they both expected independence after rehabilitation. 90% of the skills were performed independently at discharge. If they both did not expect independence only 3% of the functional results were positive. Of all combined predictions 64% was correct. Correct predictions were most often found regarding self-care skills of patients with paraplegia and regarding mobility of patients with complete lesions. Prediction of self-care outcome of patients with tetraplegia is far more complicated. There was a considerable variation in predictions of mobility potential, especially regarding patients with incomplete lesions. If the team and patients agreed upon expected independence in mobility skills of these patients, the final results were mostly positive. Prediction of functional outcome after spinal cord injury was most successful if the expectations of the team and patients were combined. Prognosis of self-care outcome of patients with paraplegia and mobility potential of patients with complete spinal cord lesions was usually clear at admission. However, selection of realistic goals concerning self-care skills of patients with tetraplegia and mobility skills of patients with incomplete lesions is far more complicated. Gradual adjustment of objectives is needed during the rehabilitation process in close collaboration between the professionals and the patients.

Urodynamic and rectomanometric findings in patients with spinal cord injury.

Patients with spinal cord lesion suffer from complex disorders of bladder and anorectal function. We assessed the value of urodynamics and anorectal manometry as prognostic and diagnostic tools in these patients and evaluated the usefulness of these techniques for the differentiation between complete and incomplete spinal cord lesions. Thirty patients with suprasacral spinal cord injury (six women, 24 men; mean age, 31 years) underwent anorectal manometry and urodynamics within the first 40 days after injury. The findings were compared to the results of a clinical neurologic evaluation. Fifteen patients were classified as complete lesions on their clinical signs, three of these lesions were incomplete according to urodynamic testing and five were incomplete according to visceral sensory testing by anorectal manometry. Despite significant differences in maximum bladder capacity (589 versus 465 mL), maximum detrusor pressure (18 versus 31 cm H2O) was not significantly different between patients with complete and patients with incomplete spinal cord injury. Anorectal manometry did not reveal any significant differences in resting pressure, abdominal pressure, and maximal rectum volume between these groups. Urodynamics and anorectal manometry may be superior to neurologic assessment of completeness of spinal cord lesions. Urodynamics and anorectal manometry were not helpful in the prediction of onset or severity of detrusor hyperreflexia. Thus, we do not regard anorectal manometry as a standard diagnostic tool in spinal cord injury patients.

Spinal and Supraspinal Mechanisms of Neuropathic Pain

Neuropathic pain is associated with abnormal tactile and thermal responses that may be extraterritorial to the injured nerve. Importantly, tactile allodynia and thermal hyperalgesia may involve separate pathways, since complete and partial spinal cord lesions have blocked allodynia, but not hyperalgesia, after spinal nerve ligation (SNL). Furthermore, lesions of the dorsal column, and lidocaine microinjected into dorsal column nuclei block only tactile allodynia. Conversely, thermal hyperalgesia, but not tactile allodynia was blocked by desensitization of C-fibers with resiniferotoxin. Therefore, it seems that tactile allodynia is likely to be mediated by large diameter A beta fibers, and not susceptible to modulation by spinal opioids, whereas hyperalgesia is mediated by unmyelinated C-fibers, and is sensitive to blockade by spinal opioids. Additionally, abnormal, spontaneous afferent drive in neuropathic pain may contribute to NMDA-mediated central sensitization by glutamate and by non-opioid actions of spinal dynorphin. Correspondingly, SNL elicited elevation in spinal dynorphin content in spinal segments at and adjacent to the zone of entry of the injured nerve along with signs of neuropathic pain. Antiserum to dynorphin A(1-17) or MK-801 given spinally blocked thermal hyperalgesia, but not tactile allodynia, after SNL, and also restored diminished morphine antinociception. Finally, afferent drive may induce descending facilitation from the rostroventromedial medulla (RVM). Blocking afferent drive with bupivicaine also restored lost potency of PAG morphine, as did CCK antagonists in the RVM. This observation is consistent with afferent drive activating descending facilitation from the RVM, and thus diminishing opioid activity, and may underlie the clinical observation of limited responsiveness of neuropathic pain to opioids.

The impact of contemporary bladder management techniques on struvite calculi associated with spinal cord injury

To evaluate the incidence, risk factors and complications of upper tract struvite calculi, often associated with spinal cord injury (SCI), as such patients have a high incidence of urinary infection complicating their neurogenic voiding dysfunction, by reviewing a large population of patients with SCI in whom modern techniques of bladder management were used. Between 1982 and 1996, 1669 patients with SCI were admitted to our institution; 1359 of these patients sustained their injuries during the study period. During this time, their bladder management was based on urodynamic and imaging criteria, using techniques such as early intermittent catheterization, sphincterotomy and bladder augmentation where possible to create a catheter-free, low-pressure reservoir. All instances of upper tract struvite calculi in this population were documented. Risk factors for stone development, presentation and complications, management and recurrence rates were assessed. Over the 15 years, 58 patients (3.5% of the SCI population) were treated for a total of 144 episodes of struvite calculi. The incidence of stones in those injured since 1982 was 1. 5%; 67% of these patients had complete spinal cord lesions, 54% had lesions of the cervical cord and 53% developed their first stone >10 years after injury. Only 22% presented within 2 years of injury. The group of patients developing stones had a significantly higher incidence of indwelling catheters (49%), bladder stones (52%) and vesico-ureteric reflux (28%) than those who were stone-free. The development of recurrent urinary tract infections was the most common mode of presentation. The stone-free rate after treatment was 87%. Normal renal function was preserved in 72% of patients. In a large population of patients with SCI managed using contemporary bladder techniques the incidence of upper tract calculi was 3.5%; 30% of these stones were complete or partial staghorns. Those patients with complete cord lesions, permanent indwelling catheters and vesico-ureteric reflux were at the highest risk. Stone clearance was 87% and recurrent stones occurred in 69% of patients. Struvite renal calculi continue to be a significant problem in the spinal cord injury population.

Differential response of fast hindlimb extensor and flexor muscles to exercise in adult spinalized cats.

Adult cats were spinal transected (T12-13) and maintained for approximately 6 months. Spinal cats were either not trained (N-T) or trained for 30 min/day to either step on a treadmill (Stp-T) or stand (Std-T). Spinalization resulted in a decrease in the mass and maximum tension potential of the medial gastrocnemius (MG), a fast ankle extensor. These adaptations were ameliorated in Std-T but not Stp-T cats. The maximum rate of shortening was elevated by 18 (ns), 34, and 19 (ns)% in the N-T, Std-T, and Stp-T cats, respectively, a finding consistent with a shift in the percentage of fast fibers, a decrease in the percentage of fibers expressing only type I myosin heavy chain, and an increase in myofibrillar adenosine triphosphatase activity. The shift toward a faster fiber type profile in the tibialis anterior (TA), a fast ankle flexor, was of a lesser magnitude than in the MG. There were no significant effects on the contractile properties of the TA in any group of spinal cats. The greater preservation of muscle mass, shift toward faster physiological and biochemical properties, and fatigability in the MG of Std-T than Stp-T cats suggest that factors other than the level of activation and force generation must play a role in muscle homeostasis. From a clinical perspective, the results indicate that muscles innervated by motor neurons below the level of a complete spinal cord lesion are affected differentially by specific neuromuscular activity patterns.

Chapter 31 Locomotor Performance and Adaptation after Partial or Complete Spinal Cord Lesions in the Cat

Publisher Summary Much of the information on the role of various structures of the central nervous system (CNS) in the regulation of different aspects of locomotion in the cat comes from the studies based on microstimulation, unit recordings, or acute ablations. Less attention has been paid to the performance and functional reorganization of locomotor control after chronic lesions of these central structures. In part, this may be because interpretation of the results of such studies is problematic in that it has to take into consideration the fact that the consequences of the lesion on the expression of the remaining functions are a mixture of deficits due to the removed structures and due to compensation by other structures. Nevertheless, some indication of the degree of compensation can be obtained by comparing the short- and long-term locomotor performance. In the short term, the deficits represent the uncompensated state and give some indication of the normal role of a given structure in the control of locomotion. Later, after the maximal compensation has taken place, the remaining permanent behavioral deficits give a fair indication of the essential contributions of the ablated structures and the limits of other structures to replace, totally or in part, the function of the missing structures. This chapter summarizes the results of the different studies in which the locomotor performance of chronically instrumented cats was documented before and after either partial or complete spinal lesions. It discusses some of the kinematic and electromyographic (EMG) changes that occur during ordinary treadmill locomotion and briefly describes how these lesioned cats adapt their locomotion to more demanding situations (slopes, tilts, and obstacles). Finally, it correlates these changes with the current knowledge on the function of different supra-spinal structures in the control of locomotion obtained from unit recording and microstimulation studies.

Sacral Anterior Root Stimulation for Bladder Control: Clinical Results

The Brindley bladder stimulator delivers intermittent stimulation to the anterior sacral roots. The stimulus parameters can be adjusted and set specifically for individuals. Its primary purpose is to improve bladder emptying, thereby to eliminate urinary infection and to preserve kidney function. It also assists in defecation and enables male patients to have a sustained full erection. In our unit so far 38 patients with a complete spinal cord lesion have received a Brindley bladder stimulator implant. One patient died 2 weeks after the surgery due to pulmonary embolism. Two other patients died due to unrelated causes during the follow up period. They used their implants for less than 1 year. Results relating to these 2 patients and the remaining 35 patients who regularly use their implant are presented. The follow-up period ranged from 3 months to 12 years. Residual urine volumes are substantially reduced in all patients; in 24 patients the residual urine volume is less than 30 ml. All patients have increased bladder capacity. Thirty-one patients are continent. Out of 33 males 29 can achieve a sustained full erection using the stimulator. Twenty-seven patients use the implant for bowel function. The following complications were encountered: (1.) Cerebro-spinal fluid collection occurred around the implant in 3 patients during the post-operative period; (2.) Receiver failure occurred in 3 patients. A successful replacement with a new receiver block was carried out in these cases. It is concluded that the use of a bladder stimulator in selected patients gives long term favourable results.

Exercise-induced overexpression of key regulatory proteins involved in glucose uptake and metabolism in tetraplegic persons: molecular mechanism for improved glucose homeostasis.

Complete spinal cord lesion leads to profound metabolic abnormalities and striking changes in muscle morphology. Here we assess the effects of electrically stimulated leg cycling (ESLC) on whole body insulin sensitivity, skeletal muscle glucose metabolism, and muscle fiber morphology in five tetraplegic subjects with complete C5-C7 lesions. Physical training (seven ESLC sessions/wk for 8 wk) increased whole body insulin-stimulated glucose uptake by 33+/-13%, concomitant with a 2.1-fold increase in insulin-stimulated (100 microU/ml) 3-O-methylglucose transport in isolated vastus lateralis muscle. Physical training led to a marked increase in protein expression of GLUT4 (378+/-85%), glycogen synthase (526+/-146%), and hexokinase II (204+/-47%) in vastus lateralis muscle, whereas phosphofructokinase expression (282+/-97%) was not significantly changed. Hexokinase II activity was significantly increased, whereas activity of phosphofructokinase, glycogen synthase, and citrate synthase was not changed after training. Muscle fiber type distribution and fiber area were markedly altered compared to able-bodied subjects before ESLC training, with no change noted in either parameter after ECSL training. In conclusion, muscle contraction improves insulin action on whole body and cellular glucose uptake in cervical cord-injured persons through a major increase in protein expression of key genes involved in the regulation of glucose metabolism. Furthermore, improvements in insulin action on glucose metabolism are independent of changes in muscle fiber type distribution.

Sacral Rhizotomies and Electrical Bladder Stimulation in Spinal Cord Injury. 2. Cost-Effectiveness and Quality of Life Analysis

Objectives: To present a cost-effectiveness analysis of sacral rhizotomies and electrical bladder stimulation compared with conventional care of neurogenic bladder dysfunction in patients with spinal cord injury. Methods: During a 3-year inclusion period, data on costs and quality of life before the intervention were collected to describe conventional care. Data on the pre-implantation period, the implantation and a follow-up period of 2 years were collected following a strict protocol simultaneous with medical and urodynamic data and were used to calculate the costs and effects on quality of life of the implantation of the stimulator. Results: Between June 1991 and June 1994, 52 patients with complete cervical or thoracic spinal cord lesions underwent sacral posterior rhizotomies and implantation of a Finetech-Brindley sacral anterior root stimulator. Although the initial costs of sacral anterior root stimulation are high, they are earned back in this series in about 8 years after the implantation. General indicators of the quality of life show no significant changes after the implantation. Factors related to psychological well-being and the patients' satisfaction with the emptying of the bladder increased significantly whereas the experienced problems of micturition and incontinence all decreased significantly. Conclusion: Sacral rhizotomies and electrical bladder stimulation make a cost-effective method of treatment of lower urinary tract dysfunction in patients with spinal cord injury. Considerable savings on health care costs are possible in the long run with simultaneous positive effects on aspects of health status.