New trends in urologic management of spinal cord injured patients

Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions

OBJECTIVE

To investigate the relationship between lesion severity and other clinical factors and bladder function recovery.

PATIENTS AND METHODS

The charts of 269 patients with traumatic and non traumatic spinal cord lesion (SCL) were reviewed and the following information was recorded: lesion to admission time, injury variables, length of stay and neurological status. At five months, urological outcome was assessed by voiding modalities, and urodynamics according to International Continence Society. Logistic approach with univariate and multivariate analysis.

RESULTS

Both ASIA impairment at admission and age were significantly correlated with bladder function outcome. None of the patients with ASIA A impairment at admission reached volitional voiding at five months. ASIA B patients had a 90% lower probability of achieving good bladder control and ASIA C ones a 65% lower than ASIA D patients (p < 0.05). Older patients had a significant lower probability (60%) of achieving volitional voiding than younger ones (p < 0.05). Of the 121 patients with ASIA D impairment at discharge only 78 voided spontaneously and showed a higher frequency of cervical lesions and a lower frequency of detrusor-external sphincter dyssynergia.

DISCUSSION AND CONCLUSION

Bladder recovery in patients with complete SCL is limited. ASIA B patients showed a better neurological recovery and, concurrently, better bladder function recovery than ASIA A patients, thus demonstrating the importance of sensation preservation for recovery. Younger patients show better bladder recovery than older ones, probably because of different efficiency of spinal cord plasticity. Finally, patients with good neurological recovery may not achieve volitional voiding. Patients with bladder function recovery show a higher frequency of central cord and Brown-Sequard syndromes (with better prognosis) and a lower frequency of detrusor-sphincter dyssynergia.

Imaging in chronic spinal cord injury--indications and benefits

As most patients who have suffered spinal cord injury can now expect a normal life span, the late complications of these injuries are seen increasingly frequently. Regular surveillance of both the renal tract and the central nervous system (CNS) is important as the treatment of impending, potentially fatal complications can be implemented before damage has progressed too far. Renal tract complications are particularly dangerous as they are often clinically silent but regular surveillance to detect early deterioration in renal function, particularly from reversible causes such as reflux or obstruction can pre-empt problems. Follow-up protocols depend on the bladder management regime but most centres advocate regular ultrasound with less frequent isotope function studies. With the increasing ability to diagnose and treat the neurological complications, surveillance of the state of the spinal cord with MRI is also important and many centres now advocate checks every few years with sagittal midline T2W sections are sufficient unless changes are noted, when axial T1W sections can be added without significant examination time penalty. Imaging is critical in acute problems. In addition to suffering from the usual normal conditions, patients with spinal cord injury suffer others peculiar to, or particularly related to, the injury, which may be missed as their symptomatology is greatly altered by their paraplegic or quadriplegic status and they may often present as generally unwell but with no obvious cause. This review discusses the role of radiology in routine surveillance of the CNS and the renal tract as well as in assessing specific conditions such as deteriorating neurology or renal function, pain, spinal instability, pressure sores, ectopic ossification, muscular spasm, spinal instability, airway problems and elective operations on the renal tract.

Early predictors of bladder recovery and urodynamics after spinal cord injury

Our purpose was to determine if intact perianal (S4-5) pin sensation (PPS) and bulbocavernosus (S2-4) reflex (BCR) shortly after spinal cord injury (SCI) are predictive of bladder function recovery. Twenty-eight SCI patients (aged 18-68 years, Frankel Classification A-D, spinal injury level C4-T12), admitted within 72 hours of injury, underwent evaluation of initial PPS and BCR. The presence of intact PPS and BCR were correlated with the patient's voiding function and urodynamic evaluation results 1 year postinjury. Of the 28 patients within 72 hours of SCI, PPS was intact in 17 (60%) and absent in 11(40%), while 15 patients (54%) demonstrated a positive BCR and 13 (46%) did not. One year after SCI, no patient with absent PPS voided unassisted, while of the 17 patients with preserved PPS, 11 (65%) were voiding spontaneously. Of these 11 patients, urodynamic evaluation revealed detrusor areflexia in 1 (9%), normal detrusor function in 2 (18%), and detrusor hyperreflexia in 8 (73%), with 3 of these 8 patients (38%) also demonstrating detrusor-sphincter dyssynergia. At 1 year postinjury, only 2 of 13 patients (15%) with an absent BCR voided spontaneously, while 9 of 15 patients (60%) with an intact BCR were able to void. Although PPS and BCR are moderately sensitive in predicting the return of spontaneous voiding, they cannot predict detrusor hyperreflexia and sphincter dyssynergia. Therefore, urodynamic study remains an essential component of initial urologic evaluation after SCI.

Comparison of long-term renal function after spinal cord injury using different urinary management methods

OBJECTIVE

To determine the effect of different bladder management methods on long-term renal function in persons with spinal cord injury (SCI).

DESIGN

Cohort study.

SETTING

Model SCI care system within a large teaching hospital.

PATIENTS

Consecutive sample of 1,114 persons with SCI who were injured between 1969 and 1994.

MAIN OUTCOME MEASURE

Total and individual kidney effective renal plasma flow (ERPF).

RESULTS

ERPF was generally lower in persons with cervical injuries or kidneys that had a renal stone, older persons, and women. Overall, there was very little change in renal function as time postinjury increased, and there were no clinically meaningful differences in the change in renal function over time among persons using different bladder management methods.

CONCLUSION

Renal function was adequately preserved in the great majority of persons and did not appear to be influenced to any great extent by method of bladder management.

Spinal cord injury and bladder recovery

OBJECTIVE

To investigate whether spinothalamic tract preservation and posterior column sparing are predictors of neurogenic recovery of bladder function after spinal cord injury (SCI). DESIGNS AND PARTICIPANTS: In a retrospective review, the initial perianal pinprick sensation (S4.5 dermatomes) and position sense of the great toes were examined and correlated with bladder function at 1 year after SCI in 19 consecutive spinal cord injured patients (age 18 to 68 years), Frankel A-D, with spinal injury (level C-4-T-12). All patients were admitted to the Regional Spinal Cord Injury Center of Delaware Valley (RSCIDDV) within 72 hours of injury between July 1990 and June 1991 and were available for a 1-year follow-up evaluation.

MAIN OUTCOME MEASURES

The correlation of initial perianal pinprick and great toe position sensation with bladder management approximately 1 year after SCI.

RESULTS

During the initial 72 hours, 10 of the 19 patients had positive perianal pinprick sensation and 9 did not feel the pin. Eight patients had positive great toe position sense, and 11 had no proprioception. At the 1-year follow-up visit, 7 of the 10 patients with initial preserved perianal pinprick were voiding volitionally, whereas none of the 9 patients who did not have pinprick voided volitionally at 1-year after SCI. Six of the 8 with initial preserved great toe position sense were voiding volitionally at 1 year, but only 1 of the original 11 without initial toe position sense was voiding volitionally.

CONCLUSIONS

Both perianal pinprick sensation and toe position sense are sensitive in predicting return of bladder function. Although both tests have positive predictive value, their negative predictive values are much more noteworthy. A patient without initial position sense of the great toes will likely not regain volitional voiding, whereas a patient without initial perianal pinprick sensation will definitely not regain volitional voiding.

Prospective comparison of external sphincter balloon dilatation and prosthesis placement with external sphincterotomy in spinal cord injured men

The purpose of our investigation was to compare external sphincterotomy, the traditional method of treatment of detrusor-external sphincter dyssynergia (DESD), with two newer methods, balloon dilatation or internal stenting of the external sphincter. Sixty-one spinal cord injured (SCI) men were prospectively evaluated. The indications for treatment were DESD and voiding pressure greater than 60 cmH2O demonstrated during video-urodynamic study. Twenty patients were treated with balloon dilatation of the external sphincter, 26 with an internal stent prosthesis, and 15 with traditional external sphincterotomy. Age and duration of SCI were similar among the three treatment groups. A significant decrease in both voiding pressure and residual urine from presurgery levels persisted during the follow-up period of 3 to 26 months (mean, 15 months) in all three groups. Bladder capacity remained constant, renal function improved or stabilized, and autonomic dysreflexia (AD) improved in all three groups. Balloon dilatation and prosthesis placement are associated with a significantly shorter length of surgery (p = 0.045), length of hospitalization (p = 0.005), decrease in hospitalization cost (p = 0.01), and decrease in hemoglobin postoperatively (p = 0.046) when compared to external sphincterotomy. Complications of stent insertion included device migration (three patients) and secondary bladder neck obstruction (two patients). In the balloon dilatation group, three recurrent sphincter obstructions, one case of bleeding requiring transfusion, and one case of bulbous urethral stricture occurred. After external sphincterotomy, two patients developed recurrent obstruction, two required blood transfusion, and 1 patient noted erectile dysfunction. Balloon dilatation and prosthesis placement both proved to be as effective as external sphincterotomy in the treatment of DESD.(ABSTRACT TRUNCATED AT 250 WORDS)

Micturition patterns after spinal trauma as a measure of autonomic functional recovery

The purpose of these experiments was to determine whether experimental spinal trauma would result in urological dysfunction similar to that seen clinically and whether recovery of normal micturition can be correlated with motor functional recovery. A standard rat model of spinal impact trauma was employed. Neurologic evaluation included a modified 7 point hindlimb Tarlov scale applied weekly for 4 weeks after injury. Micturition measurement was accomplished by placing the animal in a metabolic cage for 24-hour periods and collecting urine on an electronic scale connected to Lotus Measure data acquisition software. All assessments were performed in a blinded fashion. Animals were categorized as normal control (N = 10), sham injured (N = 11), spinal cord injury (SCI) without (N = 11) and with locomotor recovery (N = 11). There were no differences in total micturition volume among the 4 groups, while the number of micturitions per 24 hours was significantly less for SCI without locomotor recovery (10.4 +/- 5.9) than for control (21.3 +/- 4.5). The volume per micturition was significantly greater for SCI (2.0 +/- 0.7 ml.) than for control (0.8 +/- 0.2 ml.). There were no differences among groups in the ratio of number of micturitions night/day. The SCI group had significantly greater largest and smallest micturitional volumes. Results clearly show alterations in micturition patterns induced by SCI. These were proportional to, but did not correlate fully with, the severity of injury and degree of motor recovery. Thus, recovery of a normal micturition pattern did not occur to the same extent as did motor functional recovery. This difference underscores the potential value of autonomic measures of SCI for distinguishing outcome categories after experimental SCI.

Relation of changes in radionuclide measures of effective renal plasma flow and glomerular filtration rate in spinal cord injury patients

The association of changes in radionuclide measures of effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) in relation to the time since spinal cord injury (SCI) was investigated in 30 male SCI patients ages 28-72 (mean 49), with intervals from injury ranging from two to 48 years. ERPF and GFR were determined from plasma clearance curves following bolus injections of I-131 orthoiodohippurate (OIH) and Tc-99m diethylenetriaminepentaacetic acid (DTPA) respectively, and were compared with published age-adjusted normal values. Fifteen patients had decreased ERPF and 13 had decreased GFR, with decline in ERPF tending to precede a similar change in GFR. Among 18 patients < or = 20 years post-SCI, GFR was abnormal in six (33 percent), while ERPF was decreased in 10 (56 percent). In twenty-four patients (80 percent), GFR and ERPF were either both normal (n = 13) or both abnormal (n = 11), but filtration fraction (FF = GFR/ERPF) was increased to > 0.23 in 18 patients, including nine with normal GFR. Only 2 patients had normal ERPF/abnormal GFR, both of whom were > 35 years post-SCI and had FF < 0.20. In the SCI population, decreases in ERPF tend to precede similar changes in GFR, with resultant increase in FF in the majority of patients.

The value of urodynamics and bladder management in predicting upper urinary tract complications in male spinal cord injury patients

A review of 160 male patients admitted to the Shepherd Spinal Center was completed to determine the influence of urodynamic findings and choice of bladder management program on the risk of developing upper urinary tract distress following acute spinal injury. Within the context of this investigation, upper urinary tract distress was defined as presence of hydronephrosis, febrile urinary tract infection, urolithasis or vesicoureteral reflux. Three groups were identified according to the urodynamic findings and the bladder management program. Thirty-four subjects with preservation of detrusor function managed their bladders by spontaneous voiding. Seventy patients with detrusor areflexia managed their bladders via intermittent catheterization; and 56 males who had detrusor hyperreflexia on urodynamics were managed by a reflex voiding program with condom drainage. None of the subjects with preservation of spontaneous voiding function experienced upper tract distress. Seven percent of those on intermittent catheterization and 32% of those managed by a reflex voiding program experienced upper tract distress. The presence of detrusor hyperreflexia with or without vesicosphincter dyssynergia influenced the likelihood that subjects would experience upper urinary tract distress following spinal injury. While traditional urodynamics failed to distinguish patients managed by a reflex voiding program who experienced upper tract distress from those who did not, calculation of a new urodynamic variable, the urethral pressure gradient, was found to assist in this prediction.