Suprasacral Spinal Cord Injuries Research Articles

A Urodynamic Comparison of Neural Targets for Transcutaneous Electrical Stimulation to Acutely Suppress Detrusor Contractions Following Spinal Cord Injury.

ObjectivesTo assess and compare the effect of transcutaneous Dorsal Genital Nerve Stimulation (DGNS), Tibial Nerve Stimulation (TNS), Sacral Nerve Stimulation (SNS), and Spinal Stimulation (SS) on Neurogenic Detrusor Overactivity (NDO) and bladder capacity in people with Spinal Cord Injuries (SCI).Materials and MethodsSeven male participants with supra-sacral SCI were tested. Standard cystometry (CMG) was performed to assess bladder activity at baseline and with stimulation applied at each site. This was conducted over four separate sessions. All stimulation was monophasic, 15 Hz, 200 μS pulses and applied at maximum tolerable amplitude. Results were analysed against individual control results from within the same session.ResultsDorsal Genital Nerve Stimulation increased bladder capacity by 153 ± 146 ml (p = 0.016) or 117 ± 201%. DGNS, TNS and SNS all increased the volume held following the first reflex contraction, by 161 ± 175, 46 ± 62, and 34 ± 33 ml (p = 0.016, p = 0.031, p = 0.016), respectively. SS results showed small reduction of 33 ± 26 ml (p = 0.063) from baseline bladder capacity in five participants. Maximum Detrusor Pressure before leakage was increased during TNS, by 10 ± 13 cmH2O (p = 0.031) but was unchanged during stimulation of other sites. DGNS only was able to suppress at least one detrusor contraction in five participants and reduced first peak detrusor pressure below 40 cmH2O in these 5. Continuous TNS, SNS, and SS produced non-significant changes in bladder capacity from baseline, comparable to conditional stimulation. Increase in bladder capacity correlated with stimulation amplitude for DGNS but not TNS, SNS or SS.ConclusionIn this pilot study DGNS acutely suppressed detrusor contractions and increased bladder capacity whereas TNS, SNS, and SS did not. This is the first within individual comparison of surface stimulation sites for management of NDO in SCI individuals.

Efficacy of transcutaneous electrical nerve stimulation versus biofeedback training on bladder and erectile dysfunction in patients with spinal cord injury

Background Spinal cord injury is associated with urinary and erectile dysfunction. Objective This study compared the efficacy of transcutaneous electrical nerve stimulation (TENS) with pelvic floor biofeedback (PFBFB) training in the treatment of bladder and erectile dysfunction for male patients with traumatic partial spinal cord injury. Methods The study included 30 male patients with bladder and erectile dysfunction (precipitancy overactive bladder) after traumatic partial spinal cord injury above the level of T12 within 6-18 months after injury. Patients were randomly divided into two equal groups: the study group was subjected to TENS and pelvic floor exercises and the control group was subjected to PFBFB training in addition the exercises. Patients were assessed before and after treatment by means of cystometric measurements, electromyography activity of pelvic-floor muscles, and International Index of Erectile Function (IIEF-5) Questionnaire. Results Before treatment, there was no significant difference in cystometric measurements, pelvic-floor muscle strength, and IIEF-5 score. In the TENS group, the treatment produced significant improvement in bladder volume at first desire to void (P = 0.001), maximum bladder capacity (P = 0.001) and maximum flow rate (P = 0.001), detrusor pressure at maximum flow (P = 0.002), strength of pelvic floor muscles (P = 0.001), and IIEF-5 score (P = 0.001). PFBFB training resulted in significant improvement only in the maximum flow rate (P = 0.042). Conclusion TENS of pelvic floor muscles is a promising, safe, effective, and inexpensive physical therapy technique to improve urinary and erectile dysfunction in patients with partial suprasacral spinal cord injuries.

Pressure Changes Under the Ischial Tuberosities During Gluteal Neuromuscular Stimulation in Spinal Cord Injury: A Comparison of Sacral Nerve Root Stimulation With Surface Functional Electrical Stimulation

ObjectiveTo compare the magnitude of interface pressure changes during gluteal maximus contraction by stimulating sacral nerve roots with surface electrical stimulations in patients with spinal cord injuries (SCIs). DesignPilot interventional study. SettingSpinal injury research laboratory. ParticipantsAdults (N=18) with suprasacral complete SCI. InterventionsSacral nerve root stimulation (SNRS) via a functional magnetic stimulator (FMS) or a sacral anterior root stimulator (SARS) implant; and surface functional electrical stimulation (FES). Main Outcome MeasuresInterface pressure under the ischial tuberosity (IT) defined as peak pressure, gradient at peak pressure, and average pressure. ResultsWith optimal FMS, a 29% average reduction of IT peak pressure was achieved during FMS (mean ± SD: 160.1±24.3mmHg at rest vs 114.7±18.0mmHg during FMS, t5=6.3, P=.002). A 30% average reduction of peak pressure during stimulation via an SARS implant (143.2±31.7mmHg at rest vs 98.5±21.5mmHg during SARS, t5=4.4, P=.007) and a 22% average decrease of IT peak pressure during FES stimulation (153.7±34.8mmHg at rest vs 120.5±26.1mmHg during FES, t5=5.3, P=.003) were obtained. In 4 participants who completed both the FMS and FES studies, the percentage of peak pressure reduction with FMS was slightly greater than with FES (mean difference, 7.8%; 95% confidence interval, 1.6%–14.0; P=.04). ConclusionsSNRS or surface FES can induce sufficient gluteus maximus contraction and significantly reduce ischial pressure. SNRS via an SARS implant may be more convenient and efficient for frequently activating the gluteus maximus.

Neuroanatomy, Neurophysiology, and Dysfunction of the Female Lower Urinary Tract

The 2 major functions of the lower urinary tract are the storage and emptying of urine. These processes are controlled by complex neurophysiologic mechanisms and are subject to injury and disease. When there is disruption of the neurologic control centers, dysfunction of the lower urinary tract may occur. This is sometimes referred to as the "neurogenic bladder." The manifestation of dysfunction depends on the level of injury and severity of disruption. Patients with lesions above the spinal cord often have detrusor overactivity with no disruption in detrusor-sphincter coordination. Patients with well-defined suprasacral spinal cord injuries usually present with intact reflex detrusor activity but have detrusor sphincter dyssynergia, whereas injuries to or below the sacral spinal cord usually lead to persistent detrusor areflexia. A complete gynecologic, urologic, and neurologic examination should be performed when evaluating patients with neurologic lower urinary tract dysfunction. In addition, urodynamic studies and neurophysiologic testing can be used in certain circumstances to help establish diagnosis or to achieve better understanding of a patient's vesicourethral functioning. In the management of neurogenic lower urinary tract dysfunction, the primary goal is improvement of a patient's quality of life. Second to this is the prevention of chronic damage to the bladder and kidneys, which can lead to worsening impairment and symptoms. Treatment is often multifactorial, including behavioral modifications, bladder training programs, and pharmacotherapy. Surgical procedures are often a last resort option for management. An understanding of the basic neurophysiologic mechanisms of the lower urinary tract can guide providers in their evaluation and treatment of patients who present with lower urinary tract disorders. As neurologic diseases progress, voiding function often changes or worsens, necessitating a good understanding of the underlying physiology in question.

The interaction of cortico-spinal pathways and sacral sphincter reflexes in subjects with incomplete spinal cord injury: a pilot study.

To reveal the effectiveness of corticospinal drive in facilitating the pudendal reflex in the anal sphincter muscle, as a surrogate marker for the urethral sphincter, in incomplete spinal cord injury (iSCI). Three neurologically normal subjects and twenty-six subjects with incomplete, supra-sacral spinal cord injuries and symptoms of a neuropathic bladder were recruited. Incontinence was assessed using the International Consultation on Incontinence Modular Questionnaire (ICIQ). Electromyographic activity of the external anal sphincter was recorded. The pudendo-anal reflex (PAR) was elicited by electrical stimulation of the dorsal penile nerve (DPN). Motor cortical excitation was achieved using transcranial magnetic stimulation (TMS). Preliminary findings in normal and iSCI subjects showed facilitation of the PAR by prior TMS with an optimal interval of 20-40 msec. Of 23 iSCI subjects, 12 showed facilitation to TMS applied 30 msec before DPN stimulation. Eight of the 12, and a further five iSCI subjects, had an anal sphincter MEP in response to TMS alone. There was a weak tendency (r(2) = 0.22, P = 0.03) for those with higher ICIQ values to have larger PAR responses but no significant difference in ICIQ scores between those with (ICIQ = 4.9 ± 4.0 mean ± SD) and those without (ICIQ = 7.2 ± 4.7) cortical facilitation of the PAR. Cortical TMS was effective in facilitating the PAR in some iSCI subjects. The presence of cortical facilitation of the PAR was not related to the degree of urinary continence.

Effect of repeated detrusor onabotulinumtoxina injections on bladder and renal function in patients with chronic spinal cord injuries

To investigate the therapeutic effects of repeated detrusor onabotulinumtoxinA injections on urinary incontinence and renal function in patients with chronic spinal cord injuries (SCI). Patients with suprasacral SCI were enrolled. OnabotulinumtoxinA 200 U detrusor injections were repeated every 6 months for four times. Patients were instructed to perform clean intermittent catheterization during the treatment and follow-up periods. Videourodynamic study and 99mTc-DTPA renal scanning for glomerular filtration rate (GFR) were performed at screening and every 3 months to assess the therapeutic effects on bladder and renal function. Quality of life was measured by the UDI-6, IIQ-7, and self-assessed QoL indices. Adverse events were also recorded. A total of 33 patients completed the study, 30 had improvement in incontinence grade (n = 18) or became completely dry (n = 12) after initial and subsequent onabotulinumtoxinA injections. Mean bladder capacity increased from 207 ± 111 to 412 ± 33 ml and mean detrusor pressure decreased from 39.8 ± 21.7 to 20.6 ± 19.1 cmH(2) O (all P < 0.05). However, the mean GFR decreased from 93.4 ± 20.4 to 83.5 ± 24 ml/min (P = 0.028). A significant reduction in GFR was noted in patients with bladder compliance that increased by <10 cmH(2) O (P = 0.002) and in patients with Pdet decreased by <10 cmH(2) O after treatment (P = 0.036). All 30 patients with improvement in incontinence grade satisfied with treatment result. This pilot study revealed that repeated detrusor injections of 200 U onabotulinumtoxinA could reduce incontinence grade, increase bladder capacity, and decrease intravesical pressure but this study did not demonstrate an improvement in GFR over a 24-month period in patients with chronic SCI.

Economic consequences of an implanted neuroprosthesis for bladder and bowel management

Creasey GH, Dahlberg JE. Economic consequences of an implanted neuroprosthesis for bladder and bowel management. Arch Phys Med Rehabil 2001;82:1520-5. Objective: To determine whether an implanted neuroprosthesis for bladder and bowel management is less costly than conventional techniques. Design: Retrospective cost-identification analysis with comparison before and after implantation of the neuroprosthesis. Setting: Life-care planning interviews in patients' homes. Patients: Twelve patients with complete suprasacral spinal cord injuries and neurogenic bladder and bowel. Intervention: Implantation of a neuroprosthesis for electric stimulation of the sacral nerves and posterior sacral rhizotomy. Main Outcome Measures: Annual costs of bladder and bowel care with and without the neuroprosthesis, projected over 10 years. Results: Bladder and bowel care costs were reduced by over 80%, from a median of $8152 a year for conventional care to a median of $948 a year. With the neuroprosthesis, median annual costs for bladder supplies were reduced from $3368 to $58; for medications, from $1866 to $108; for medical care, from $656 to $96; and for bowel care supplies, from $205 to $87. After 5 years, the cumulative costs of treatment with the neuroprosthesis, including the cost of the device and its implantation and maintenance, equaled those of conventional care. Thereafter, savings from the implanted neuroprosthesis are projected to increase progressively throughout the patient's life. Conclusion: A neuroprosthesis implant with posterior rhizotomy greatly reduces the cost of managing the neurogenic bladder and bowel. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Clinical significance of detrusor sphincter dyssynergia type in patients with post-traumatic spinal cord injury

Objectives. To investigate the significance of categorizing detrusor sphincter dyssynergia (DSD) by type in patients with chronic spinal cord injury. Methods. A retrospective review of the charts, video-urodynamic studies, and upper tract radiographic studies of 269 patients with post-traumatic, suprasacral spinal cord injuries was performed. The patients were categorized according to the DSD type (intermittent or continuous), level and completeness of injury, intravesical pressure at leak, upper tract complications, and interval since injury. Results. Of the 269 patients, 20 (7.4%), 216 (80.3%), and 33 (12.3%) had no DSD, intermittent DSD, and continuous DSD, respectively. No significant association between the specific level of injury and the DSD type was found ( P = 0.71). The presence of DSD was associated with complete injuries, elevated intravesical pressures, and upper tract complications ( P <0.01); these associations were more prominent with continuous DSD than with intermittent DSD. The proportion of patients with no DSD, intermittent DSD, and continuous DSD was unchanged during the chronic follow-up period. Conclusions. The clinical significance of DSD type is not crucial, since patients with both intermittent and continuous DSD require urodynamic surveillance and expedient treatment to minimize urologic complications. However, the presence of continuous DSD is one of several factors that may require earlier urodynamic follow-up.

Detrusor Function In Suprasacral Spinal Cord Injuries

A total of 21 patients with chronic, stable suprasacral spinal cord injuries underwent a comprehensive neurological evaluation. A second lumbosacral lesion was excluded. The urodynamic findings were relatively constant as 95% of the patients showed detrusor hyperreflexia with elevated pressures, sphincteric dyssynergia and a competent bladder neck during the filling phase. The urodynamic findings of unexpected detrusor function in high spinal cord injury, for example areflexia and hypocontractility, should raise the clinician’s suspicion that there is a lesion or dysfunction involving the sacral cord. Accepted for publication January 24, 1992. Supported by the Vivian L. Smith Foundation for Restorative Neurology.

Detrusor inhibition in suprasacral spinal cord injuries: is it due to sympathetic overactivity?

The authors report five patients with detrusor inactivity in suprasacral spinal cord lesions with perineal spasticity. In all of these cases with cervical or high thoracic lesions treatment with an alpha-blocking drug (Phenoxybenzamine) allowed bladder activity to return. These results suggest that the sacral parasympathetic centre is under the inhibitory influence of the sympathetic nervous system.

Urethral Hypotonicity After Suprasacral Spinal Cord Injury

Established suprasacral spinal cord injuries usually are associated with detrusor hyperreflexia and varying degrees of detrusor-sphincter dyssynergia. Occasionally, such injuries result in detrusor areflexia or urethral hypotonicity or both. The results of the urodynamic evaluation of 4 patients with suprasacral spinal cord injuries are described. Detrusor areflexia and urethral hypotonicity were demonstrated in 3 cases and urethral smooth muscular hypotonia but preserved reflex detrusor function in 1. It is shown that destruction of the thoracolumbar sympathetic outflow can cause the complete loss of urethral smooth muscular closing function and that resting urethral closure is totally independent of preganglionic cholinergic influences.

Detrusor-Sphincter Dyssynergia

We followed 62 patients with complete suprasacral spinal cord injuries and detrusor-sphincter dyssynergia for at least 2 years. The patients were evaluated urodynamically at regular intervals and 50 per cent were subjected to external sphincterotomy, after which they were compared for the presence of bacteriuria and upper urinary tract changes. Patients on prolonged intermittent catheterization did as well as those who achieved balanced bladder function as a result of sphincterotomy.