The role of nerve blocks in management of traumatic cord bladders: spinal anesthesia, subarachnoid alcohol injections, pudendal nerve anesthesia and vesical neck anesthesia

The Current Practice of Spinal Anesthesia in Anesthetists at a Comprehensive Specialized Hospital: A Single Center Observational Study

Background

Spinal anesthesia block is the most widely practiced anesthesia technique due to its safety margin. It is an invasive procedure that could be associated with a variety of complications like total spinal, cardiovascular collapse, meningitis, paralysis, and even death. The aim of this study to assess the current practice of spinal anesthesia.

Methods

A Cross-sectional study design was conducted in Debre Tabor Comprehensive Specialized Hospital from November 01 to December 15, 2020. All anesthesia professionals who are working in the study Hospital were surveyed by the Purposive sampling technique. A standardized structured checklist prepared from recommendations of New York school of regional anesthesia guideline regarding the current Practice of spinal anesthesia was used to collect the data after taking written informed consent. Descriptive statistics were employed to summarize the results.

Results

A total of 24 anesthetists were observed of their practice before, during, and after administer of spinal anesthesia. All of the anesthetists were practicing the preparation and assembling of all necessary anesthesia equipments, resuscitation drugs, and basic monitors while all of the anesthetists did not wash their hands, wore a sterile gown, and draped the back of the patient with fenestrated drapes in a sterile fashion.

Conclusion

Most of the anesthesiology professionals in our setting have a good preparation of all necessary anesthesia equipments, and resuscitation drugs, while the assessment of patient’s emotional reaction and pain during injection, the skin preparation allowed to being dry and assessment of the degree of sensory and motor block of the patient were insufficient.

Chapitre C-2 A - Traitement de l’hyperactivité détrusorienne neurologique : méthodes chirurgicales de dénervation vésicale

Various treatment options are available in the case of failure of standard medical treatments, including the little known neurosurgical options which, in some cases when the bladder retains satisfactory compliance, can be a solution to create neurogenic bladder augmentation. However, some of these treatments can lead to complications without providing any long-term stable benefit for patients. In this article, the authors review these various treatment modalities in order to determine which treatments can still be considered to be valid in 2007.

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.

Technique of pudendal nerve localization for block or stimulation

A diagnostic technique is described for study of the pudendal nerve via a dorsal rather than perineal approach. The method offers unique advantages for the urodynamic study of sphincteric function. The patient is placed in the prone position with slight flexion of the hips. The position of the ischial spine is identified topographically using the ischial tuberosities, greater trochanter and lower edge of the ischial-tuberous ligament. Local anesthesia and electrical stimulation then are used to position a needle tip adjacent to the pudendal nerve. This approach allows for specific localization of the nerve for accurate temporary or permanent nerve block. It also permits continuous urodynamic monitoring of pelvic floor behavior with stimulation of the pudendal nerve to assess functional integrity of the nerve and the pelvic floor striated muscles.

Role of the pudendal nerves on the dynamics of micturition in the dog evaluated by pressure flow EMG and pressure flow plot studies

The role of the pudendal nerves on the dynamics of micturition was studied using 16 decerebrated dogs. The voiding cycles were analyzed by pressure flow EMG and pressure flow plot studies under 3 conditions: control, after unilateral, and after bilateral pudendal nerve transection. In the control condition, highly reproducible reflex micturition with bladder contraction and spasmodic rhythmic sphincter contractions was demonstrated. Two patterns were noted following pudendal nerve transection: reflex micturition and overflow incontinence. Even though reflex micturition could be achieved in 9 out of 16 dogs after bilateral transection, there was decreased bladder emptying as well as absence of spasmodic rhythmic sphincter contractions. Overflow incontinence developed in the remaining 7 dogs (5 dogs after bilateral transection and 2 dogs after unilateral transection). It appears that the pudendal nerves play an important role in emptying the bladder of the dog.

Vesicourethral motility following acute spinal cord transection in the cat

The cause of urinary retention during the phase of spinal shock is still uncertain. In the cat with intact spinal cord, reflex voiding shows a coordination between the longitudinal and circular urethral muscles, the detrusor and the periurethral striated muscles. After transection of the spinal cord in cervical and/or thoracic segments, 26 of 28 cats failed to void. An incoordination between longitudinal, circular, detrusor and periurethral striated muscles was noticed simulating a urethro-urethral and urethrovesical dyssynergia. The 2 cats that voided 6 hours after the cord section showed a return of synergism between longitudinal, circular, detrusor and periurethral striated muscles. The conventional pharmacologic manipulation used during the early period following spinal cord transection, bethanechol chloride and phentolamine, failed to achieve proper bladder emptying because it did not correct the dyssynergic pattern.

Regulation of bladder and colon--rectum in patients with spinal lesions

Parasympathetic cholinergic stimulation is excitatory for bladder and colon--rectum, normal as well as uninhibited. This is documented by pharmacological and neuroanatomical studies in man. The bladder and the left half of colon and rectum have motor supply in common as demonstrated by surgical intervention on sacral nerves. More detailed studies can be performed by electrical stimulation of sacral roots or rootlets. Sympathectomy may cause alteration of voiding pattern, but often only temporarily, and generally with no alteration of defecation habits. The sympathetic innervation is sparse in the human bladder, but alpha- and beta-adrenergic receptors have been demonstrated. The alpha-adrenergic blocking agent thymoxamine is able to cause a shift in the cystometrogram to the right, and to relax the spastic pelvic sphincters by i.v. administration. Like other alpha-adrenergic blocking agents, it can relax the proximal part of the urethra. The effect of other stimulating and blocking adrenergic compounds are reported, but further studies are needed. No simultaneous reactions are generally recorded in the uninhibited bladder and rectum, and no correlation was found between the hyperactivity of the uninhibited neurogenic bladder and colon.

Role of striated and smooth muscle components in the urethral pressure profile in traumatic neurogenic bladders: a neuropharmacological and urodynamic study. Preliminary report

Urodynamic investigations with urethral pressure profile, and vesical, intrarectal and anal pressure recordings were performed in 37 patients with spinal cord lesions. The recordings were done before and after phentolamine injections and/or pudendal nerve blocks to evaluate the respective contribution of sympathetic and somatic innervation to the maximum urethral closure pressure in the mid and distal portions of the membranous urethra. A pressure gradient was demonstrated in the membranous urethra with higher values in the distal than in the mid portion. These results emphasize that the interrupted withdrawal technique is superior to the continuous technique in patients with upper motor neuron bladders. Mid urethral striated and smooth muscle components were shown to represent approximately 60 and 30 per cent of the maximum urethral closure pressure, respectively. In the distal urethra striated and smooth components are more abundant than in the mid portion and contribute in equal proportion to the maximum urethral closure pressure. No substantial role was found for the vascular bed in the maximum urethral closure pressure. The greatest pressure decrease in the mid and distal urethra of patients with lower motor neuron bladders was believed to be an effect of denervation supersensitivity. The results of pudendal blocks showed sphincter dyssynergia to be mediated through pudendal nerves via spinal reflex arcs. Phentolamine effects on bladder activity suggest that blockade of alpha-adrenergic receptors inhibits primarily the transmission in vesical and/or pelvic parasympathetic ganglia and acts secondarily through direct depression of the vesical smooth muscle. Our neuropharmacological results raise strong doubts as to the existence of a sympathetic innervation of the striated urethral muscle in humans.

Experience with electromyography of the external urethral sphincter in spinal cord injury patients

Simultaneous recordings of electromyography of the external urethral sphincter and bladder pressure during voiding were done for 71 male patients with spinal cord injury. Discordant activities between the anal and the external urethral sphincters were noted in 39 per cent of the patients. The degree of bladder dysfunction was related more to the degree of dyssynergia of the urethral than the anal sphincter. This detrusor-sphincter dyssynergia was found in 67 per cent of our patients regardless of the differences in cystometric patterns and the level of spinal injury. The importance of electromyography of the external urethral sphincter in the diagnosis of neurogenic bladder dysfunction was stressed. The management of detrusor-sphincter dyssynergia is discussed briefly.

[About the relief of severe spasticity in paraplegics (author's transl)]

The treatment of spasticity following spinal cord injuries demands a well coordinated team of neurologists, neuro-surgeons, surgeons and orthopedic surgeons. The causes of the beginnings of spasms, circumstances, by which the intensity of existing spasticity is supplementary advanced, will be described. The intensity of spasms in joints of the paralysed limbs can be improved by controlled "Passive Body Exercises" for a short time. But we have never seen relievings of spasticity by drugs. In certain cases a systematic rehabilitation takes only effect, if intractable spasticity--especially concerning the knee and hip joints--is either completely removed or at least recovered. By means of a posterior rhizotomy by Förster (posterior nerve rotts section) spasms following traumatic spinal cord lesions can be eliminated completely or at least changed for the better just depending largely upon the level of the injury to the cord.

Dyssynergic vesicourethral responses during bladder rehabilitation in spinal cord injury patients: effects of suprapubic percussion, credé method and bethanechol chloride

Five normal men and 70 spinal cord injury male patients underwent 100 studies with the multiple pressure recording technique, incorporating the continuous infusion principle for sphincter pressure monitoring. Gross cystosphincteric dyssynergia was noted in the majority of patients with complete upper motor neuron bladders less than 2 years in duration. Some form of synergic voiding patterns was noted, mostly in patients with incomplete upper motor neuron bladders. The external sphincter tends to be synergic in late cases of upper moto neuron bladders. Internal sphincter dyssynergia is uncommon in cases of injuries less than 2 years in duration, with the exception of patients who have autonomic dysreflexia. Bladder neck obstruction seems to be more common in late lesions secondary to global hypertrophy of the bladder. Rehabilitation maneuvers and bethanechol chloride administration may exaggerate detrusor sphincter dyssynergia and injudicious use of such procedures could be detrimental to the urinary tract.

Anterior bladder tube for continence in neurogenic bladder. Experimental study

Experimental studies designed to evaluate the anterior bladder tube as a method of maintaining continence in the neurologically deprived bladded achieved a 50 to 60 per cent success rate. This success rate is not sufficient to warrant its clinical use.