Spinal Shock Phase Research Articles

Urodynamic assessment of detrusor function in the very acute phase of traumatic spinal cord injury: A prospective cohort study.

The bladder is believed to be acontractile due to the phase of spinal shock and there is a lack of data on the detrusor function within the first few days after spinal cord injury (SCI). This study intended to assess the detrusor function with invasive urodynamics (UDS) during the first 15 days of SCI. This prospective observational study was carried out from January 2020 to June 2021 and consecutive stable patients older than 18 years of age who had a history of traumatic SCI within the past 15 days were screened for inclusion. For each patient, the International Standards for Neurological Classification of SCI Worksheet was filled. All patients underwent bedside invasive UDS within 15 days of injury. There were a total of 41 patients with a mean age of 35 years. The thoracic cord was most commonly involved (46.3%) with Type A AISA grade being the most common (68.2%). The mean duration of injury at the time of UDS was 6 days. Abnormality in the filling phase could be identified in six patients. Three patients had neurogenic detrusor overactivity (NDO), with one having a high-pressure phasic NDO and one having a sustained NDO. Two patients had poor compliance and one had borderline poor compliance. None of the patients generated any detrusor pressure during voiding cystometry. In patients with SCI, 14.5% of the patients had abnormal findings during the filling phase on the UDS performed within 15 days of the injury. These findings are in stark contrast to the traditional understanding that the detrusor is acontractile during the early phase of the SCI and merit further evaluation.

Postinjury Bladder Overdistension Deteriorates the Lower Urinary Tract’s Storage Function in Patients with Spinal Cord Injury

Introduction: A recent article has reported that postinjury bladder overdistension (OD) deteriorates lower urinary tract function in the mouse spinal cord injury (SCI) model. However, there have been no reports examining the effect of postinjury bladder OD on lower urinary tract function in human SCI patients. Objective: The aim of the study was to investigate the effect of postinjury bladder OD during the acute bladder-areflexia phase on the subsequent lower urinary tract storage function in patients with SCI. Methods: Thirty-one patients with OD (OD group) and 19 patients without OD (non-OD group) during the acute bladder-areflexia phase were included in the study. All patients were confirmed to be completely paralyzed. Their lower urinary tract function was retrospectively evaluated through urodynamic studies 1, 3, and 5 years after injury. Qualiveen-30 questionnaire was used for the evaluation of quality of life. Results: No significant difference was observed in the maximum cystometric capacity between the OD and non-OD groups in their urodynamic evaluation; however, the maximum bladder pressure was significantly higher, and the bladder compliance was significantly lower in the OD group. The incidence of detrusor overactivity tended to be higher in the OD group, but no significant difference was observed. The use of anti-muscarinics was significantly higher in the OD group. No significant differences were observed in Quali­veen-30 scores between both groups. Conclusions: These results suggest that postinjury bladder OD during the acute phase deteriorates lower urinary tract storage function in patients with SCI during the later phase. Thus, it is assumed that a well-planned regular intermittent catheterization in the early spinal shock phase would be important for control of patients’ subsequent storage function.

Early Sacral Neuromodulation in Spinal Cord Injury—Can It Regenerate Nerves?

The extent of neurologic deficit in spinal cord injury (SCI) is dependent on the primary injury, biologic responses to injury, including inflammation, edema, and scar formation, and neural restructuring. During the recovery phase of SCI, which follows a period of spinal shock lasting weeks to up to 2 years, uninhibited spinal reflexes result in detrusor overactivity with dyssynergia of the urethral sphincter, associated with progressive lower urinary tract dysfunction and potentially upper tract deterioration. Minimization of secondary injury following acute SCI and optimization of nerve regeneration may maximize functional recovery and limit end organ dysfunction, including of the lower urinary tract. Early administration of neuromodulation via electrical or electromagnetic stimulation has been shown to limit secondary injury and potentially restore function. Low-frequency electrical stimulation accelerates axonal growth in the peripheral nervous system and may have a similar benefit in the central nervous system. Limited evidence suggests that sacral neuromodulation has the potential to limit or even prevent maladaptive neural restructuring of the lower urinary tract when administered during the spinal shock phase, when the bladder is areflexic. Herein, we review the pathophysiology of voiding dysfunction following acute injury, existing evidence for the benefit of early SNM in SCI, and possible mechanisms of action, including neural regeneration.

Should sperm be cryopreserved after spinal cord injury?

AbstractIn spinal cord injured (SCI) patients, three main factors may cause infertility: erectile dysfunction, ejaculatory dysfunction and impaired semen quality. This letter aims to discuss how we can manage SCI patients’ fertility in accordance with patient-centred care. For such SCI patients aged 20 to 40, having children represents hope for the future. Furthermore, it is a way to rebuild a life after the spinal injury and must be seen as an important part of the rehabilitation program. We suggest that sperm cryopreservation may contribute to patient-centred care management of SCI patients’ fertility, although there is no scientific evidence that cryopreservation will improve fertility outcome after SCI. Indeed, sperm cryopreservation is an affordable and simple technique in specialised centres with trained staff. Here, a protocol to manage SCI patients’ fertility is discussed: we propose PVS for sperm banking to all SCI patients after the phase of spinal shock during the rehabilitation program. If live sperm are retrieved, they are frozen and stored; however, if no live sperm are retrieved, electroejaculation and/or surgical sperm extraction are proposed only for patients who desire biological fatherhood. Prospective studies on the evolution of semen parameters, ejaculatory dysfunction, post-infectious obstructions and spermatogenesis impairment in chronic SCI patients are urgently needed to provide robust data for the evidence-based management of SCI patients’ fertility. Even if use rates are expected to be low, sperm banking may be a simple and affordable preventative measure for selected male SCI patients.

The treatment of neurogenic bladder dysfunction in patients with spinal cord injury

Neurogenic bladder dysfunction, resulted from demage to the neural structures in spinal lesion present a major problem for the patient, his environment and health care workers. Proper diagnosis of neurogenic bladder dysfunction allows you to implement appropriate treatment plan that will allow adequate emptying and prevention of complications that may endanger the patient's life. The evolution of spinal cord injuries can distinguish three phases: 1) spinal shock phase, 2) the recovery phase, 3) final phase. After spinal trauma bladder is affected mostly in two ways: 1) Spastic (reflex) bladder caused in lesion above voiding center (S2-S4 segments), 2) Flaccid (atonic) neuropathic bladder emerges in lesion at the voiding center (S2-S4) or below it, as well as lesions of the peripheral innervation of bladder, 3) Autonomic disreflection syndrome develops in patient with cervical or high thoracic spinal cord lesions, above the Th 1 segment, 4) Uninhibited neurogenic bladder develops in incomplete nerve pathway lesions in cerebral cortex, pyramidal pathway or in spinal cord-cerebral voiding control debilitate. The diagnosis of neurogenic bladder dysfunction is established by urodynamic examination, laboratory blood and urine findings as well as radiographic, computed tomography and nuclear magnetic resonance imaging of the spinal column. Bladder emptyng can be made by intermitetnt catheterization, Crede's procedure, suprapubic stimulation, smooth bladder muscle electrostimulation and by medications. The necessity of an Interdisciplinary approach to the treatment of these patients indicates all hardness in spinal cord injury patientes and consequent bladder dysfuncion.

Behandlungsverfahren der Blase bei Querschnittlähmung und Myelomeningozele

The established treatment of neurogenic lower urinary tract dysfunction (NLUTD) in patients with spinal cord injury (SCI) or meningomyelocele (MMC) is mainly conservative and is aimed at the lower urinary tract. For example, oral antimuscarinic medication is the standard treatment of neurogenic detrusor overactivity. Recently, however, treatment aiming directly or indirectly at the innervation of the urinary tract has gained increasing attention. Current evidence does not justify the use of nerve rerouting but the existing preliminary data are more promising for MMC patients than for those with SCI. Sacral neuromodulation is already a therapeutic option for incomplete SCI patients. Initial data from a pilot study indicate that in patients with complete SCI implementation in the spinal shock phase may prevent the development of NLUTD. Licensing of onabotulinum toxin A (Botox®) facilitated its clinical use for treating NLUTD but it is limited to the indication of neurogenic detrusor overactivity incontinence with a dosage of 200 IU. The mentioned unconventional treatments, although discussed controversially, are promising future treatment options for NLUTD.

Atuação Fisioterapêutica na Lesão Medular em Unidade de Terapia Intensiva: Atualização de Literatura

Objective. Collate and update knowledge in relation to physical therapy in spinal cord injury (SCI) in the intensive care unit (ICU). Method. We performed a literature update in the databases Lilacs, PubMed and Scielo, crossing the descriptors spinal cord injury, cinesiotherapy, physiotherapy, mobilization, rehabilitation, intensive care unit, respiratory therapy and electrotherapy in the period of 2005 to 2010. Results. We found 21 studies, however, only five articles met the inclusion criteria. Kinesiotherapy is essential since the phase of spinal shock, since it favors the maintenance of joint range of motion and flexibility, and to prevent circulatory complications caused/ resulted from prolonged immobilization in bed. Respiratory therapy promotes bronchial hygiene, correction of abnormal respiratory patterns and respiratory diseases. The electrotherapy is a feature still little used by physiotherapists in the intensive care units. Conclusions. The physical therapy in SCI in ICU is focused on motor rehabilitation through kinesiotherapy and intervention through the respiratory bronchial hygiene and training of respiratory muscles. New treatment modalities such as electrotherapy, there have been in intensive environment, there is a need for more studies to confirm benefits and risks of this feature in the spinal cord.

Adaptation of motor function after spinal cord injury: novel insights into spinal shock

The mechanisms underlying spinal shock have not been clearly defined. At present, clinical assessment remains the mainstay to describe progression through spinal shock following traumatic spinal cord injury. However, nerve excitability studies in combination with conventional nerve conduction and clinical assessments have the potential to investigate spinal shock at the level of the peripheral axon. Therefore, peripheral motor axon excitability was prospectively and systematically evaluated in more than 400 studies of 11 patients admitted to hospital after traumatic spinal cord injury, with cord lesions above T9 (nine cervical, two thoracic). Recordings commenced within 15 days of admission from the median nerve to abductor pollicis brevis in the upper limb and the common peroneal nerve to tibialis anterior in both lower limbs, and were continued until patient discharge from hospital. Excitability was assessed using threshold tracking techniques and recordings were compared with data from healthy controls. In addition, concurrent clinical measures of strength, serum electrolytes and nerve conduction were collected. High threshold stimulus-response relationships were apparent from the early phase of spinal shock that coincided with depolarization-like features that reached a peak on Day 16.9 (± 2.7 standard error) for the common peroneal nerve and Day 11.8 (± 2.0 standard error) for the median nerve. Overall, changes in the common peroneal nerve were of greater magnitude than for the median nerve. For both nerves, the most significant changes were in threshold electrotonus, which was 'fanned in', and during the recovery cycle superexcitability was reduced (P < 0.001). However, refractoriness was increased only for the common peroneal nerve (P < 0.05). Changes in the spinal injured cohort could not be explained on the basis of an isolated common peroneal nerve palsy. By the time patients with spinal injury were discharged from hospital between Days 68 and 215, excitability for upper and lower limbs had returned towards normative values, but not for all parameters. Electrolyte levels and results for nerve conduction studies remained within normal limits throughout the period of admission. Contrary to prevailing opinion, these data demonstrate that significant changes in peripheral motor axonal excitability occur early during spinal shock, with subsequent further deterioration in axonal function, before recovery ensues.

Management of the spinal cord injured using a 12-week programme in which patients' relations are involved: a report of 10-year experience

Background: There is dearth of designated spinal centers in Nigeria and in Enugu state, there is none. Therefore, spinal injured patients go to teaching and government-owned orthopaedic hospitals to be treated and these are not able to absorb all. Hence, private orthopaedic hospitals are flooded by the spinal injured. Due to this, a 12-week programme of management of the spinal cord injured in which patients' relations were actively involved was initially studied at privately-run Hilltop Orthopaedic Hospital, Enugu for 5years and later expanded to a consultant orthopaedic unit in the University of Nigeria Teaching Hospital, Enugu and extended to10years. The aim is to get such patients quickly back into the society as useful and independent as possible and to see if the outcome achieved in the preliminary study could be reproduced in this extended study. Methods: Staged weekly programmes of assessment and treatment were mapped out to end at the 12th week. Spinal cord injured patients were entered onto the programme as they come. The study was from January 1996 to December 2005. Outcome for each patient was assessed at the end of the 12th week. Results: 256 patients were admitted into the study. 98 patients had incomplete cord injury of Frankel B and C grades while 158 had clinically complete cord injury of Frankel A on admission. 58 patients died on the whole, of which only 2 were from incomplete cord injury. 90 of the incomplete cord injured improved from Frankel B and C to D during the 12-week programme and walked home. From the clinically complete cord injured, 62 were found to still be in spinal shock phase. 16 of these recovered from Frankel A to D and walked by the 12th week. The remaining surviving 86 ended up as permanent cord injured. 82 of these were conversant with wheelchair use at the 12th week. Conclusion: The outcome of this programme is similar to that of the preliminary study. Keywords: spinal cord injured; management; relation involvement

Lesões vértebro-medulares – A perspectiva da reabilitação

The present study provides an overview of the spinal cord injury focusing mainly on aspects related to rehabilitation.Spinal cord injury affects young people in an active phase of life, determining severe handicaps. Most of the lesions are traumatic, caused by car accidents.Until fifty years ago, the survival of individuals with spinal cord injury was very reduced and the leading cause of death was renal failure. Due to developments in medical knowledge and technical advances, the survival rates have significantly improved. The causes of death have also changed being respiratory complications, particularly pneumonia, the leading causes.Immediately after a spinal cord lesion there is a phase of spinal shock which is characterized by flaccid paralysis and bladder and bowel retention. Progressively there is a return of the spinal cord automatism with the beginning of some reflex activities. Based on neurological evaluation it is pos-sible to predict motor and functional recovery and establish the rehabilitation program.We can consider three phases on the rehabilitation program: the first while the patient is still in bed, directed to prevent or treat complications due to immobility and begin sphincters reeducation; the second phase is intended to achieve wheelchair autonomy; the last phase is training in ortostatism. The rehabilitation program also comprises sports and recreational activities, psychological and social support in order to achieve an integral of the individual with a spinal cord injury.

Urinary bladder hyperreflexia: a rat animal model.

In this work, we are presenting a rat animal model for bladder hyperreflexia after suprasacral spinal cord transection. Our aim was to standardize an animal model that can be useful in studying this condition. After standardizing the animal model in a pilot study, 26 female Sprague-Dawley rats were subjected to spinal cord transection at the level of T10 vertebra. Four animals were subjected to cystometrogram (CMG) 24 hr after spinalization and six rats 3 weeks post-spinalization. These CMGs were compared to that of six normal controls. The detailed description of the model presented in this manuscript, is the final result after several modifications. All the animals consistently developed hyperreflexia after an initial period of spinal shock phase. Expressed volume of urine continued to decrease until it reached a plateau after peaking at 1-week post-spinalization. The attrition rate reached 27.3% after several improvements in the animal model and was mostly from self-inflicted injuries. Post-operative complications included hypothermia, decubitus ulcers, hematuria, urinary tract infection in addition to the unexplained death of two animals. In conclusion, we believe that this animal model closely resembles the clinical condition of hyperreflexia and follows similar course. The relative low cost of this animal model and the easy maintenance makes it a valuable tool to study such a condition.

ULTRASTRUCTURAL CHANGES OF THE NEURONAL COMPONENT IN THE DETRUSOR MUSCLE FOLLOWING SACRAL ROOT STIMULATION OF DECENTRALIZED DOGS

Objectives To study ultrastructural changes in the neuronal component of the detrusor muscle during the spinal shock phase and following early electric neurostimulation in an animal model. Material and Methods 12 dogs were decentralized at the levels from S1 to S3, while three animals were provided as normal controls. The decentralized animals were divided into four groups according to the method of bladder voiding: Group 1A: intermittent catheterization without neurostimulation, Group 1B: intermittent catheterization followed by neurostimulation, Group 2A: early prolonged neurostimulation and Group 2B: early neurostimulation followed by intermittent catheterization. From the different groups, bladder tissue blocks were dissected, fixed in glutaraldehyde and processed for electron microscopic study. Results Early prolonged sacral root neurostimulation demonstrated a significant reduction of degenerated axons (mean = 28.9% ± 1.7), an increased frequency of cholinergic axons (mean = 16% ± 0.75) and an exhibited significant narrowing of the neuroeffector gap junctions (mean = 117.25 ± 22.6 nm) in comparison to non-stimulated animals (mean values were 80.5% ± 0.75, 5.4% ± 1.7, and 281 ± 62.6 nm, respectively) which were voided with intermittent catheterization. However, early sacral root stimulation followed by intermittent catheterization displayed a significant reduction of axonal degeneration (mean = 48.3% ± 1.8) in comparison to late stimulation following the intermittent catheterization (mean = 83.3% ± 2.8). Conclusion Early sacral root electric stimulation decreased the incidence of neuronal degeneration in decentralized detrusor muscle, together with improving the regenerative potential of cholinergic axons. African Journal of Urology Vol. 7 No. 1 (Jan 2001): pp1-12 Key Words

URODYNAMICS OF SPINAL CORD INJURY

Historically, urologic complications have been the major source of morbidity and mortality among spinal cord injured (SCI) patients. All SCI patients should undergo urodynamic evaluation, with the initial urodynamics study done after the patient is beyond the spinal-shock phase. Management of the urinary tract in SCI individuals should be based on urodynamic principles and findings rather than on the neurologic history.

The effects of 4 weeks treatment with cisapride on cystometric parameters in spinal cord injury patients. A double-blind, placebo controlled study

A group of 21 complete spinal cord injury patients, beyond the phase of spinal shock, were given a treatment of cisapride at random, 10 mg four times a day for 4 weeks. Cystometry was performed first before the start and during the following 4 weeks. No statistically significant difference could be found in the urodynamic parameters between the two groups at the first cystometry. No statistically significant change of the urodynamic parameters could be demonstrated with the treatment, although a non-statistically significant bladder stimulating effect was present in a majority of the patients in the cisapride group.

Acute hypotension associated with terbutaline nebuliser therapy in a traumatic tetraplegic patient during the spinal shock phase. Case report

Acute hypotension was observed during the spinal shock stage of a 35-year-old C3 complete tetraplegic patient after receiving nebulised terbutaline for respiratory therapy. Nine weeks later, when he had recovered from spinal shock, he again received nebulised terbutaline but there was no significant fall in arterial blood pressure. This case illustrates the possibility of a serious degree of hypotension occurring in such patients with this drug.

Use of Sacral Reflex Latency Measurements in the Evaluation of Neural Function of Spinal Cord Injury Patients: A Comparison of Neuro-Urophysiological Testing and Urodynamic Investigations

Complete suprasacral spinal cord injury is followed by great changes in the neural control and function of the lower urinary tract. In the literature there is some controversy about the relationship between detrusor function and results of neurophysiological tests of sacral root conduction after the spinal shock phase. Therefore, we studied this relationship in a group of 73 patients with clinical as well as neurophysiological documented complete suprasacral spinal cord injury, and compared sacral reflex latency measurements (bulbocavernosus and urethro-anal reflexes) with detrusor function, documented by urodynamic investigation.A high incidence of sacral reflex latency abnormalities was found. Comparison of sacral reflex latencies with detrusor reflex activity showed a statistical significant correlation. No such relationship could be found between urodynamic characteristics of the detrusor in patients with detrusor hyperreflexia and sacral reflex latency measurements. We conclude that sacral reflex latency measurements can give an indication about the existence of reflex detrusor activity. On the other hand, these neurophysiological measurements do not provide a reliable indication of the detrusor function after complete spinal cord injury.

A transcutaneous implantable bladder controller.

We describe a computerized experimental system to investigate the effect of early electrical stimulation of the bladder during the spinal shock phase in paraplegic dogs. This system is composed of two main devices; an external part (or controller) based on a portable microcomputer, and a versatile implant (internal) based on a multichannel CMOS microstimulator. Using a new operative technique, this system enabled us to obtain many favorable results.

Effect of early bladder stimulation on spinal shock: Experimental approach

The period of spinal shock which frequently follows spinal cord injury is associated with bladder areflexia and urinary retention. We studied the effect of early bladder electric stimulation on detrusor activity during the spinal shock phase in the dog. The animals had a spinal cord section at T10 vertebra, and their bladder management was assigned to one of the three following groups: intermittent catheterization, indwelling catheterization, and electric bladder stimulation. The parameters for evaluating each treatment included: blood chemistry, and radiographic and urodynamic tests. The most important finding was the early return of detrusor activity in the group of animals treated by early electric stimulation of the bladder.

Computerized transcutaneous control of a multichannel implantable urinary prosthesis.

In the present paper we describe a personal computer interface of a multichannel implantable urinary prosthesis. This system is composed of two main parts: the first one is internal and consists of an implant using a 4-microns CMOS gate array chip controlling a wide variety of waveforms via eight monopolar channels. The second, an external controller featuring a versatile software, a PCB card plugged in a portable microcomputer, and a radiofrequency-coupled technique. This device is used to transmit the power, the data and the synchronization clock to the implant by a simple binary signal modulating a 20 MHz carrier. We also report the features of implant encapsulation and electrode design and fabrication. In the experimental phase, we studied the effect of early electric stimulation of the bladder during the spinal shock phase in the dog. We present the operative techniques that enabled us to perform chronic electrostimulation of the sacral roots and discuss the results.

Role of Electric Stimulation in Bladder Evacuation Following Spinal Cord Transection

Neural stimulation is potentially a valuable therapeutic tool in the treatment of neurogenic bladder with detrusor areflexia. We studied 20 dogs in different groups, up to eight months, and compared the effect of electric stimulation with intermittent catheterization, specially during spinal shock phase. We found that early stimulation hastened the return of detrusor activity. When stimulation was delayed, the bladder could still regain its activity, and when the pace-maker was turned off, the detrusor activity was gradually decreased. Neurostimulation can completely empty bladder up to eight months. The lowest A.Ch. content in detrusor muscle was found in intermittent catheterization group and in this group the detrusor strips showed marked supersensitivity to urecholine stimulation than the bladders managed by electric stimulation. Also, we found that electric stimulation reduced the complications caused by intermittent catheterization and protected kidney function.