Nerve cuff electrode with shape memory alloy armature: design and fabrication

In this paper, a new nerve cuff electrode with shape memory alloy armature is presented. The proposed electrode is dedicated either to peripheral nerve stimulation or recording and its manufacturing does not require any expensive or complex technique. Shape Memory Alloy (SMA) armature ensures the complete and firm closing of the electrode, so that the complexity of the installation procedure is considerably reduced. A preliminary analysis of the electrode mechanical behavior prior, during and after installation has been done through numerical simulations and in vitro testing. It was proved theoretically and experimentally that the SMA electrode closes completely with an appropriate few second delay after its installation. No external fixation such as sutures is needed to secure permanent electrode-nerve contact. Furthermore, theoretical analysis has shown that the design of SMA electrode can be adapted for safe close-fitting installation, thanks to the device partial opening in case of nerve swelling.

Reduction of bladder outlet resistance by selective stimulation of the ventral sacral root using high frequency blockade: a chronic study in spinal cord transected dogs

PURPOSE

The use of electrical neural stimulation as treatment for neurogenic bladder is complicated by simultaneous contraction of the striated sphincter. This result is due to the composition of the ventral sacral roots, which contain somatic fibers innervating the external urethral sphincter and preganglionic parasympathetic fibers innervating the detrusor, among others. The somatic fibers have a larger caliber than the parasympathetic fibers and, as large diameter fibers, need a lower stimulus amplitude for activation than smaller fibers. Activation of the smaller fibers is always accompanied by activation of the larger fibers. We studied the effect of chronic application of selective combined low and high frequency current stimulation of the ventral sacral root on bladder evacuation and urethral resistance in chronically spinalized (spinal cord transected above the spinal micturition center) male dogs for daily bladder evacuation.

MATERIALS AND METHODS

A total of 14 male mongrel dogs weighing 20 to 25 kg. underwent transection of the spinal cord at the T10 vertebra. The S2 ventral sacral root was wrapped with a bipolar electrode connected to a subcutaneous microstimulator. Daily bladder evacuation by neural stimulation with determination of the voided and residual urine volumes was done for 8 months. The animals were stimulated only with low frequency current during the 1-month spinal shock phase. Selective parameters of combined low frequency stimulation and high frequency blockade currents were subsequently applied for 6 months. For the last study month the animals were again stimulated by low frequency current alone. Bladder and urethral pressure as well as electromyography of the external urethral sphincter and pelvic floor muscles were evaluated monthly. Histopathological testing of the chronically stimulated nerve and external sphincter was performed.

RESULTS

Of the 14 dogs 12 completed the followup study. During the shock phase with the application of low frequency only stimulation the animals voided 26% of mean functional bladder capacity with the early return of detrusor activity. Mean detrusor pressure plus or minus standard error of mean was 76.4 +/- 21.6 cm. water, while mean urethral pressure was 83.6 +/- 16.8 cm. water. During the application of selective combined low and high frequency stimulation 7 animals (58%) evacuated the bladder completely with post-void residual urine less than 10% of mean individual functional bladder capacity and 5 (42%) had mean post-void residual urine less than 20% of mean individual bladder capacity. Mean detrusor pressure was 73.5 +/- 20 cm. water and mean urethral pressure was 44 +/- 7.3 cm. water. There was a 45.19% reduction in the mean electromyography activity of the external sphincter. Stimulation of the dogs for the last month by low frequency current resulted in the voiding of 33% of mean bladder capacity with an increase in mean urethral pressure and electromyography activity.

CONCLUSIONS

These results of reducing external sphincter activity by the simultaneous application of high frequency current blockade of the somatic fibers and activation of the autonomic fibers of the bladder by low frequency stimulation are promising.

Implantable selective stimulator to improve bladder voiding: design and chronic experiments in dogs

Among the treatments to enhance the bladder voiding, the sacral roots neurostimulation is one of the most promising techniques. The electrostimulation of sacral nerves provokes a simultaneous contraction of the detrusor muscle as well as the external urethral sphincter (EUS). A new simplified-architecture implantable stimulator with its wireless controller have been designed to investigate high-frequency inhibition stimulation strategies. This innovative technique based on high-frequency inhibition reduces sphincter activity during stimulation. Low-frequency current pulses also applied to the sacral roots induces contraction of the detrusor muscle resulting in low pressure voiding. Chronic experiments were carried out on ten male mongrel paraplegic dogs. One cuff electrode was implanted along with each stimulator for eight months. The animals were stimulated twice a day using the prototypes of our implantable selective stimulator while voided and residual urine volume were measured during the procedure. These experiments revealed that the proposed stimulation strategy enhances bladder voiding by more than 50% in comparison with low-frequency only stimulation. The residual urine volume was reduced to an average of 9% and low pressure micturition was achieved as shown by weekly cystourethrogram.

Implantable measurement technique dedicated to the monitoring of electrode-nerve contact in bladder stimulators

A fully integrated electrode-nerve contact monitoring circuit intended to increase safety and reliability in implantable bladder stimulators is described. The proposed integrated circuit converts a measurement of the impedance of two electrode-nerve contacts into frequency. The measurement is derived from a test current generated by the stimulation current source. The obtained results is the frequency of a square wave signal. This frequency is then converted into 8-bit data, which are serially transmitted to an external controller through an inductive link. The whole circuit can be set in idle model during stimulation, ensuring low energy consumption. It is fully testable, and an internal calibration technique makes it possible to reduce errors due to temperature and process variations. The total area of the proposed monitoring circuit is 0.1 mm2 when fabricated with a 0.35 micron technology, including a digitally controlled, current source. The design has been fabricated and successfully tested.

New easy to install nerve cuff electrode using shape memory alloy armature

This paper presents an easy to install nerve cuff electrode dedicated to functional electrical stimulation (FES). In this new device, a shape memory alloy (SMA) armature is used to perform the closing of the electrode. This technique makes the electrode installation around the nerve much easier, quicker, and safer. Both remarkable mechanical properties of SMA materials, namely, shape memory effect and superelasticity, can be used to obtain the desired mode of electrode closing. The fabrication procedure of the new electrode is described. It does not require any expensive or complex techniques. Bipolar and tripolar electrodes have been manufactured with an inner diameter of 1.6 mm and a cuff wall thickness of 0.8 mm. These electrodes are to be used for FES of the bladder in spinal cord injured patients. Acute studies in dogs are being carried out to validate the device and the implantation procedure.

Reduction of bladder outlet resistance by selective sacral root stimulation using high-frequency blockade in dogs: an acute study

Detrusor-sphincter dyssynergia is a main problem in supra-sacral spinal cord injured patients. The problem of high pressure voiding is also encountered in most electrically induced micturition because of the mixed somatic and autonomic fiber components of the ventral sacral root. We studied the effect of selective high-frequency blockade at the sacral nerve root in an acute spinalized canine model to prevent the deleterious consequences associated with the elevated bladder outlet resistance. A new functional electrical stimulation system which can generate one signal composed of two independent adjustable current waveforms delivered via a single bipolar electrode was used in 11 dogs. The selectivity resulted from the inhibition of the sphincteric somatic innervation by a high frequency pulse while the low frequency stimuli activated the bladder autonomic fibers. Bladder and urethral pressure as well as electromyograms of external urethral sphincter were recorded to determine whether selective high-frequency blockade occurred. Our experiments showed that we were able to achieve selective blockade of the external urethral sphincter during the simultaneous detrusor stimulation, thus obtaining a more physiologic voiding.

Reduction of bladder outlet resistance by selective sacral root stimulation using high-frequency blockade in dogs: an acute study

Detrusor-sphincter dyssynergia is a main problem in supra-sacral spinal cord injured patients. The problem of high pressure voiding is also encountered in most electrically induced micturition because of the mixed somatic and autonomic fiber components of the ventral sacral root. We studied the effect of selective high-frequency blockade at the sacral nerve root in an acute spinalized canine model to prevent the deleterious consequences associated with the elevated bladder outlet resistance. A new functional electrical stimulation system which can generate one signal composed of two independent adjustable current waveforms delivered via a single bipolar electrode was used in 11 dogs. The selectivity resulted from the inhibition of the sphincteric somatic innervation by a high frequency pulse while the low frequency stimuli activated the bladder autonomic fibers. Bladder and urethral pressure as well as electromyograms of external urethral sphincter were recorded to determine whether selective high-frequency blockade occurred. Our experiments showed that we were able to achieve selective blockade of the external urethral sphincter during the simultaneous detrusor stimulation, thus obtaining a more physiologic voiding.

Implantable stimulation system dedicated for neural selective stimulation

A functional electrical stimulation system is presented, which is dedicated for the selective neural stimulation of the bladder. The proposed system is composed of an internal stimulator (implant) and an external controller. The system is used to produce low-pressure voiding of the bladder in spinal cord injured patients. The implant is powered and operated by the external controller via radio-frequency electromagnetic coupling. All stimulation parameters are chosen externally using the controller and are sent to the implant, which produces the desired stimuli. These stimuli are applied directly to the S2 nerve which is linked to the sphincter and bladder muscles. A high-frequency signal is used to inhibit the contraction of the sphincter muscle, and low-frequency pulses stimulate the bladder muscle (the detrusor). Dedicated computer software is used by the physician to select the optimal parameters for each patient and to activate the implant through a parallel port interface with built-in transmitter. The parameters are then transferred to a hand-held controller which is used by the technical staff and by the patients themselves. Acute studies have been performed to validate the selective stimulation strategy, and chronic experimentation is currently underway in dogs.

Proposed new bladder volume monitoring device based on impedance measurement

A new implantable bladder volume-monitoring device based on the impedance measurement of the detrusor muscle is described. The system is completely autonomous and forms a mixed-signal (analogue/digital) feedback loop with a neuro-stimulator to rectify bladder dysfunctions (incontinence and retention) through neuromuscular stimulation techniques. A programmable instrumentation amplifier and a signal processing block, to eliminate the artefacts caused by the patient's movements, have been designed and tested. The layout for the signal processing block has been realised in 0.8 micron BiCMOS technology.

Implantable volume monitor and miniaturized stimulator dedicated to bladder control

This paper describes a new miniaturized implantable bladder controller that is composed of 4 main parts: a volume monitoring device based on the tomography approach, a fully programmable miniaturized central processor and stimulator, a bidirectional data and power link, and an external controller. The proposed system is intended to restore both normal bladder functions (retention and voiding) to spinal cord injured patients. The system contains a mixed-signal (analog/digital) feedback loop to command the bladder functions through neuromuscular stimulation techniques. The implantable circuitry is powered by a single encoded radiofrequency carried and may have up to 8 independently controlled monopolar (4 bipolar) channels. The microstimulator is able to generate a wide range of stimulation patterns, including selective stimulation waveforms. In addition, an optical link transmits the state of the implant and volume monitoring results to the external controller.

Stimulator design and subsequent stimulation parameter optimization for controlling micturition and reducing urethral resistance

An implantable computerized electrical stimulation system designed to induce bladder evacuation in animal models (dogs) after spinal cord transection has been realized and evaluated. This fully programmable system is based on a handheld device and generates a wide range of stimuli through multichannel implantable miniaturized stimulator. Using the new bladder stimulator and inducing reversible fatigue to the external sphincter via the pudendal nerve enables us to reduce the bladder outlet resistance, resulting in the proper emptying of the bladder during stimulation without the need for sacral nerve rhizotomies and the pudendal nerve neurectomies. Four chronically affected dogs were studied to determine the optimal stimulation parameters for inducing a sphincter fatigue that would reliably empty the bladder for the duration of the experiment. These parameters were: maximum amplitude of 1.5 mA +/- 0.5 SD, stimuli composed of a high frequency signal of 200 Hz +/- 50 SD modulated by a low frequency signal of 10 Hz +/- 5 SD, pulse width controlled by a duty-cycle of 20% +/- 10 SD, sacral nerve stimulation of 50 s +/- 25 SD and fatiguing duration of 20 s +/- 5 SD.

Implantable multiprogrammable microstimulator dedicated to bladder control

An implantable multiprogrammable microstimulator that is intended to restore normal bladder functions (retention and incontinence) to spinal cord injured patients is presented. The implantable microstimulator circuitry is externally controlled and is powered by a single encoded radio frequency carrier and has four bipolar (eight monopolar) independently controlled channels. It offers a higher degree of reprogrammability and flexibility and can be used in any neuromuscular applications. The implant system is adaptable to the patient's needs and to future developments in stimulation algorithms, without changing the implant. Features of the microstimulator include its capabilities to generate a wide range of waveforms and to combine up to four different programmable frequencies in each wave train. By using a forward error detection and correction communication protocol, the reliability of the implant is increased. The chip has been designed for structural testability by means of a scan-based test approach and uses circuit techniques to reduce power consumption and ensure long-term stability.

Long-term effect of sphincteric fatigue during bladder neurostimulation

Commercially available stimulators lack several features, including multiple channel capability and flexible stimulation parameters. These factors limit clinical application. A new computerized electrical stimulator system was developed by our team and evaluated for its efficacy in bladder evacuation in an animal model after spinal cord transection. The system can generate a wide range of stimulation characteristics and has the feature of being a programmable multichannel pacemaker. It has enabled us to induce a reversible fatigue to the external sphincter that results in proper bladder emptying on stimulation. Using this new bladder pacemaker, 8 dogs were studied. We applied the concept of fatiguing of the external sphincter via the pudendal nerve to avoid rhizotomy. We determined the optimal stimulation parameters that can reliably empty the dog's bladder for the duration of the experiment, which lasted for 8 months. The new computerized electrical stimulation system achieved the objective of reducing bladder outlet resistance without the need for sacral rhizotomy.

A new bladder stimulator--hand-held controller and miniaturized implant: preliminary results in dogs

A new urinary-tract stimulator that is intended to restore normal bladder function to patients who have spinal-cord injuries is described. The system is composed of two principal parts. The first, which is external, consists of a hand-held device based on an inductive-coupling technique. This controller incorporates all the circuitry necessary to transmit data transdermally. The second, a fully programmable implantable device, includes a complementary metal oxide semiconductor gate-array integrated circuit controlling eight monopolar (or four bipolar) stimulation channels. To protect the tissues and the device, three different biocompatible polymers encapsulate the implant. In the experimental phase, the authors investigated the effect of early electrical stimulation of the bladder during the spinal-shock phase in paraplegic dogs. In addition, using the stimulator, they localized the parameters of stimulation that give the best results in terms of effective bladder pressure and voiding a high volume of urine.

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.

Electrical stimulation induced sphincter fatigue during voiding

The stimulation of the sacral nerves to induce voiding is often associated with simultaneous contraction of the striated sphincter rendering micturition difficult or impossible. Rhizotomy of some sacral nerves was found to be necessary to facilitate voiding with stimulation. An main objective in the present experiment was to evaluate the feasibility of achieving the same result using electrical stimulation to fatigue the sphincter. In order to compare the effect of rhizotomy and fatiguing striated sphincter, the bladder outlet resistance was measured. S2 nerves were stimulated with 3 V, 35 Hz and 100 microseconds duration for 5 to 10 sec. Following S2 nerves stimulation the pudendal nerve was stimulated till we obtained sphincteric fatigue. The optimal parameter to induce sphincter fatigue were 3 V, 100-500 Hz and 100 microseconds. for 15-20 sec. The combined pressure-flow studies showed that fatiguing the sphincter via the pudendal nerve using these parameters was as good as cutting it in achieving bladder emptying with stimulation.

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.

The effect of early bladder stimulation on spinal shock: a preliminary report

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, radiographic and urodynamic tests. The salient feature was the early return of detrusor activity in the group of animals treated by early electric stimulation of the bladder.