Bladder function following spinal cord injury: a urodynamic analysis of the outcome

Acute, severe traumatic spinal cord injury: improving urinary bladder function by optimizing spinal cord perfusion

OBJECTIVE

The authors sought to investigate the effect of acute, severe traumatic spinal cord injury on the urinary bladder and the hypothesis that increasing the spinal cord perfusion pressure improves bladder function.

METHODS

In 13 adults with traumatic spinal cord injury (American Spinal Injury Association Impairment Scale grades A-C), a pressure probe and a microdialysis catheter were placed intradurally at the injury site. We varied the spinal cord perfusion pressure and performed filling cystometry. Patients were followed up for 12 months on average.

RESULTS

The 13 patients had 63 fill cycles; 38 cycles had unfavorable urodynamics, i.e., dangerously low compliance (< 20 mL/cmH2O), detrusor overactivity, or dangerously high end-fill pressure (> 40 cmH2O). Unfavorable urodynamics correlated with periods of injury site hypoperfusion (spinal cord perfusion pressure < 60 mm Hg), hyperperfusion (spinal cord perfusion pressure > 100 mm Hg), tissue glucose < 3 mM, and tissue lactate to pyruvate ratio > 30. Increasing spinal cord perfusion pressure from 67.0 ± 2.3 mm Hg (average ± SE) to 92.1 ± 3.0 mm Hg significantly reduced, from 534 to 365 mL, the median bladder volume at which the desire to void was first experienced. All patients with dangerously low average initial bladder compliance (< 20 mL/cmH2O) maintained low compliance at follow-up, whereas all patients with high average initial bladder compliance (> 100 mL/cmH2O) maintained high compliance at follow-up.

CONCLUSIONS

We conclude that unfavorable urodynamics develop within days of traumatic spinal cord injury, thus challenging the prevailing notion that the detrusor is initially acontractile. Urodynamic studies performed acutely identify patients with dangerously low bladder compliance likely to benefit from early intervention. At this early stage, bladder function is dynamic and is influenced by fluctuations in the physiology and metabolism at the injury site; therefore, optimizing spinal cord perfusion is likely to improve urological outcome in patients with acute severe traumatic spinal cord injury.

The Video-Urodynamic and Electrophysiological Characteristics in Patients With Traumatic Spinal Cord Injury

Purpose

To investigate the video-urodynamic and pelvic floor electrophysiological characteristics in patients with traumatic spinal cord injury.

Methods

This retrospective reviewed the clinical records, urodynamic and pelvic floor electrophysiological data of 647 patients with traumatic spinal cord injury (SCI) and out of spinal shock. Patients were classified based on American Spinal Injury Association (ASIA) Impairment Scale and urodynamic findings.

Results

Of the 647 patients, detrusor overactivity (DO) with or without detrusor sphincter dyssynergia (DSD) was found in 79.5%, 61%, 35.2%, 35%, and 19.2% of patients with cervical, thoracic (T1-9), thoracic (T10-12), lumbar, and conical cauda injury, respectively. Other patients manifested detrusor areflexia (DA). Patients with DO and/or DSD had a longer duration of SCI at each injury level than patients with DA. In suprasacral injury patients with DA, 63.0% (58/92) had a normal bulbocavernosus reflex (BCR) response. Compared with patients without bladder sensation, bladder capacity during urine leakage was far higher in those with bladder sensation. The manifestation of BCR and somatosensory-evoked potential (SEP) was associated with the level of injury.

Conclusions

This study showed a significant correlation between the level of SCI and video-urodynamic findings, but clinical examination cannot by predict bladder function; urodynamic testing is also necessary. In addition, the role of BCR and SEP for guiding bladder management is limited. Moreover, bladder sensation is important for urinary control in patients with traumatic SCI.

Association between detrusor muscle function and level of the spinal cord injury

Introduction

Traumatic spinal cord injury (TSCI) is among the most severe disabilities with an estimation of 2.5 million people affected worldwide. The purpose of this study was to investigate the association between detrusor muscle function and the level of the spinal cord injury.

Material and methods

All patients with TSCI who underwent urodynamic evaluation at the Brain and Spinal Injury Research Center (BASIR) of Imam Khomeini hospital complex from March 2014 to March 2016 were retrospectively entered in this cross-sectional study. The patients were divided into three groups of suprasacral (C1-T12), sacral (L1-S5) and combined (both suprasacral and sacral) lesions.

Results

Medical records of 117 patients with spinal cord injury were reviewed. The mean age of the patients was 35.64 (±12.01) years. 86 patients (73.5%) were male and 31 female (26.5%). While 66 (56.4%), 28 (23.9%) and 19 (16.2%) patients had suprasacral, sacral, and combined suprasacral and sacral lesions, respectively. The relationship between the level of injury and emptying disorder (P = 0.50), storage disease (P = 0.20), first desire to void (P = 0.82), hypocompliance (P = 0.95), voided urine volume (P = 0.38) and residual urine volume (P = 0.76) were not significant. We found a significant association between the level of injury and the type of detrusor function (P = 0.019).

Conclusions

Our study showed an association between detrusor muscle function and level of the spinal cord injury. However, there was no exact relationship between the level and the completeness of the spinal cord injury with the urodynamic characteristics.

Urodynamic patterns after traumatic spinal cord injury

OBJECTIVES

To study the correlation between neurological level of spinal injury and bladder functions as detected by urodynamic study.

STUDY DESIGN

Analytical study.

SETTING AND PARTICIPANTS

Seventy individuals with traumatic spinal cord injury (SCI) admitted to the Department of Physical Medicine and Rehabilitation, S.M.S. Medical College and Hospital, Jaipur. Detailed clinical, neurological evaluation as per American Spinal Injury Association Classification and radiological assessment were done along with clinical examination of bladder and urodynamic study.

RESULTS

Out of 65 patients with suprasacral injuries, 53 (81.5%) demonstrated hyperreflexia with or without detrusor sphincter dyssynergia, 6 (9.2%) detrusor areflexia, and 6 (9.2%) had normal bladders, 41 (59.4%) low compliance (<20 ml/cmH2O), and 47 (72.30%) had high detrusor leak pint pressures (>40 cmH2O). Of the five patients with sacral injuries, one (20%) showed detrusor hyperreflexia, four (80%) detrusor areflexia, and one (20%) had low bladder compliance; all five (100%) had high detrusor leak point pressures.

CONCLUSIONS

The correlation between somatic neurologic findings, spinal imaging studies, and urodynamic findings in patients with SCI is not exact. Therefore, bladder management should not completely rely only on clinical bladder evaluation or neurological examination alone, but should always include urodynamic studies.

Radiofrequency sacral rhizotomy for the management of intolerable neurogenic bladder in spinal cord injured patients

Objective

To investigate the effect of radiofrequency (RF) sacral rhizotomy of the intolerable neurogenic bladder in spinal cord injured patients.

Method

Percutaneous RF sacral rhizotomy was performed on 12 spinal cord injured patients who had neurogenic bladder manifested with urinary incontinence resisted to an oral and intravesical anticholinergic instillation treatment. Various combinations of S2, S3, and S4 RF rhizotomies were performed. The urodynamic study (UDS) was performed 1 week before RF rhizotomy. The voiding cystourethrogram (VCUG) and voiding diaries were compared 1 week before and 4 weeks after therapy. Total volume of daily urinary incontinence (ml/day) and clean intermittent catheterization (ml/time) volume of each time were also monitored.

Results

After RF sacral rhizotomy, bladder capacity increased in 9 patients and the amount of daily urinary incontinence decreased in 11 patients. The mean maximal bladder capacity increased from 292.5 to 383.3 ml (p<0.05) and mean daily incontinent volume decreased from 255 to 65 ml (p<0.05). Bladder trabeculation and vesicoureteral reflux findings did not change 4 weeks after therapy.

Conclusion

This study revealed that RF sacral rhizotomy was an effective method for neurogenic bladder with uncontrolled incontinence using conventional therapy among spinal cord injured patients.

Management and rehabilitation of neuropathic bladder in patients with spinal cord lesion

The patients with spinal cord lesion (SCL) develop problems of urination due to impaired neural control of the lower urinary tract, such as incontinence or retention; these conditions constitute risks for the upper urinary tract and should be treated appropriately over the various phases of the disease. The therapeutic approach in the acute and subacute post-traumatic phase is of particular importance for the early and late management of the subsequent urinary disturbances. When the rehabilitation program is completed, it is estimated that deficiencies in sphincter control have greater impact on personal and social life of individuals than the movement disability. Currently, as the number of sufferers from SCLs is constantly increasing, medical science faces two great challenges: (i) to develop and apply modern treatment modalities in the framework of advanced neurorehabilitation programs, and (ii) to provide well-organized follow-up management. All efforts should be directed towards the functional integrity of the upper urinary tract and the acquirement of the greatest possible independence for the patient.

Cauda equina syndrome

Single or double-level compression of the lumbosacral nerve roots located in the dural sac results in a polyradicular symptomatology clinically diagnosed as cauda equina syndrome. The cauda equina nerve roots provide the sensory and motor innervation of most of the lower extremities, the pelvic floor and the sphincters. Therefore, in a fully developed cauda equina syndrome, multiple signs of sensory disorders may appear. These disorders include low-back pain, saddle anesthesia, bilateral sciatica, then motor weakness of the lower extremities or chronic paraplegia and, bladder dysfunction. Multiple etiologies can cause the cauda equina syndrome. Among them, non-neoplastic compressive etiologies such as herniated lumbosacral discs and spinal stenosis and spinal neoplasms play a significant role in the development of the cauda equina syndrome. Non-compressive etiologies of the cauda equina syndrome include ischemic insults, inflammatory conditions, spinal arachnoiditis and other infectious etiologies. The use of canine, porcine and rat models mimicking the cauda equina syndrome enabled discovery of the effects of the compression on nerve root neural and vascular anatomy, the impairment of impulse propagation and the changes of the neurotransmitters in the spinal cord after compression of cauda equina. The involvement of intrinsic spinal cord neurons in the compression-induced cauda equina syndrome includes anterograde, retrograde and transneuronal degeneration in the lumbosacral segments. Prominent changes of NADPH diaphorase exhibiting, Fos-like immunoreactive and heat shock protein HSP72 were detected in the lumbosacral segments in a short-and long-lasting compression of the cauda equina in the dog. Developments in the diagnosis and treatment of patients with back pain, sciatica and with a herniated lumbar disc are mentioned, including many treatment options available.

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.

Urodynamic evaluation in spinal cord injuries

Spinal cord injury, regardless of its level, causes flaccid paralysis during the shock phase affecting the detrusor and rectal musculature. Then, depending on the level and severity of the lesion, the bladder gains spasticity or remains flaccid. Monitoring the reflex behaviour of detrusor and sphincter activities helps to select the treatment modalities. Thirty patients with cord injuries of various levels have been urodynamically tested at 3-month intervals. The shock phase of the acutely tested patients lasted about 8-9 weeks. Eventually, 23 of the cases were hyperreflexic, while 7 cases remained areflexic: 2 had detrusor-sphincter dyssynergia. The response to treatment has been investigated by cystometrographical and electromyographical methods.

Sphincterotomy: long-term complications and warning signs

Transurethral sphincterotomy is a commonly performed operation in spinal cord injury patients. Sixty-three patients who have had transurethral sphincterotomy were evaluated at our spinal cord injury unit for the risk and possible predictors of long-term outcome associated with this procedure. In addition to history and physical examination, all patients had urine culture, blood urea and creatinine, intravenous pyelogram and/or KUB with renal ultrasound, 4 channel videourodynamics, voiding cystourethrogram, and cystocopy when indicated. Their mean age was 53 years, and their level of injury was cervical 32, thoracic 25, and lumbar 6. The mean time since injury was 27 years (3-50), and the mean follow-up since their last sphincterotomy was 11 years (2-30). The mean number of sphincterotomies was 1.74 (1-4). Urine culture revealed bacteruria (asymptomatic) in 48 and sterile urine in 15 patients. Renal function was normal in 61 patients and abnormal in 2 patients. Videourodynamics revealed detrusor hyperreflexia in 60, detrusor areflexia in 3, abnormal detrusor compliance in 9, and detrusor sphincter dyssynergia in 34 patients. The mean Leak point pressure was 36.4 cm H2O (5-100), and the mean maximum detrusor pressure was 54.7 cm H2O (12-100). Nineteen (30%) patients had significant upper tract complications including; renal calculi, atrophic kidney, vesicoureteral reflux, and renal scarring with impaired renal function. Fifty percent of upper tract complications developed more than 2 years after sphincterotomy. Thirty patients had lower tract complications including; recurrent symptomatic urinary tract infection, bladder stones, urethral diverticulum, urethral stricture, bladder neck stenosis, and recurrent epididymitis.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Renal and bladder functions in patients after spinal cord injuries

Thirty-eight patients with spinal cord lesions, 22 recent and 16 sustained more than three years previously, were investigated with intravenous pyelography, chrome EDTA clearance, cystoscopy and urodynamic studies. Analyses of bladder biopsies for tissue concentrations of nor-adrenaline and occurrence of acetylcholinesterase staining of nerves were also performed. Despite high incidence of fairly mild infections and trabeculation of the bladder, renal function was normal in most patients. Apart from incontinence, stone formation and recurrent urinary tract infections were the most common complications. The concentrations of noradrenaline and the numbers of acetylcholinesterase-stained nerves in bladder tissue specimens did not differ from control findings. The organization of the nerve structures did not vary with time after the injury, suggesting unchanged adrenergic and cholinergic innervation.

Sacral root stimulation for controlled micturition: prevention of detrusor-external sphincter dyssynergia by intraoperative identification and selective section of sacral nerve branches

Electrical stimulation of the S2 nerve root can be used to produce detrusor contraction and voiding in patients with spinal cord injury, but concurrent stimulation of the external urethral sphincter causes detrusor-sphincter dyssynergia. This has been managed with a second surgical procedure, peripheral transection of the pudendal nerve. In this study, performed in dogs after spinal cord transection, laminectomy and ventral foraminotomy permitted tracing of the S2 root into the pelvis, where its branches were identified by electrical stimulation and urodynamic recording. The pudendal (somatic) branch was sectioned; the autonomic branch innervating the detrusor was preserved. Electrical stimulation of the proximal S2 root then produced detrusor contraction without contraction of the external urethral sphincter. This approach, which requires a single operation and spares pudendal nerve functions mediated by nerve roots other than S2, may enable a neurostimulator to provide effective voiding, without detrusor-external sphincter dyssynergia, in man.

Function of the conus medullaris and cauda equina in the early period following spinal cord injury and the relationship to recovery of detrusor function

A total of 26 patients with an early suprasacral spinal cord injury underwent comprehensive neurourological evaluation to determine if there was any correlation between the return of detrusor function and neural function of the sacral cord. In addition, the incidence of a subclinical sacral neural dysfunction early after spinal cord injury was assessed. Lumbosacral evoked potentials to tibial nerve stimulation were used to assess the sensory root and cord gray matter of the L5 to S2 segments, while urodynamic evaluation was performed to assess detrusor function. Of those patients with normal lumbosacral evoked potentials 82% recovered detrusor contractility as opposed to 66% with abnormal evoked potentials. Four patients (23.5%) had persistent detrusor areflexia when studied 9 to 20 months following the acute injury. The potential problems attempting to correlate the neurophysiological and urodynamic studies are multiple and are extensively discussed. Despite these potential problems the return of detrusor function correlated well with associated normal lumbosacral evoked potentials suggesting that this test can be used in the early phase following spinal cord injury to predict return of bladder function, since it is independent of the level of spinal cord excitability. Of the patients studied 38% had coexistence of an occult lumbosacral dysfunction. This rate is higher than that found in the chronic stabilized spinal cord injury population (20.5%), since the cases in our study may represent a more severe lesion.

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.

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.

Bladder and sphincter behavior in patients with spinal cord lesions

To ascertain the relationship between the clinical neurological level, and bladder and sphincter behavior, the video-urodynamic studies of 489 patients with spinal cord lesions due to a variety of causes were retrospectively analyzed. Patients were classified based on the clinical neurological level, etiology of the lesion and presence or absence of signs of sacral cord involvement. Urodynamic findings were classified as either detrusor hyperreflexia, detrusor-external sphincter dyssynergia, detrusor areflexia or normal. The results indicate that although there was a general correlation between the neurological level of injury and the expected vesicourethral function, it was neither absolute nor specific. For example, 20 of 117 cervical cord lesions had detrusor areflexia, 42 of 156 lumbar cord lesions had detrusor-external sphincter dyssynergia and 26 of 84 sacral cord had either detrusor hyperreflexia or detrusor-external sphincter dyssynergia. However, if one considers the presence of neurological abnormalities, 84% of the suprasacral cord lesions with detrusor areflexia have sacral cord signs. In contrast, all suprasacral cord lesions with no evidence of sacral cord involvement have either detrusor hyperreflexia or detrusor-external sphincter dyssynergia. The positive predictive value for positive sacral cord signs and detrusor areflexia was 87%. The positive predictive value for negative sacral cord signs and detrusor hyperreflexia/detrusor-external sphincter dyssynergia was 81%. These data suggest that the clinical neurological examination alone is not an adequate barometer to predict neurourological dysfunction and that video-urodynamic evaluation provides a more precise diagnosis for each patient.

Lack of relationship of conus reflexes to bladder function after spinal cord injury

A series of 20 patients with acute complete suprasacral cord lesions underwent serial urodynamic assessment of vesicourethral function and serial measurement of sacral reflex latency times (SRL) and reflex threshold throughout a follow-up period of 42 to 83 weeks (mean 50). No correlation was found between any pattern of SRL latencies or reflex thresholds and subsequent bladder behaviour. The reproducibility of sacral reflex latencies was found to be poor (mean variation of serial measurements from initial reading 21%) and could not be explained on the basis of "dynamic" neurological recovery. Studies using the bladder as a stimulus site were unreliable. The value of SRL studies in detecting subtle neurophysiological changes is discussed.

Clinical significance of ureteric diameter on intravenous urography after spinal cord injury

The ureteric diameter on IVU was compared with the MCU findings of reflux or lower urinary tract dysfunction in a group of patients followed up after spinal cord injury. A wide ureter was associated with reflux in 20%, but 8 normal sized ureters on IVU also refluxed--5 of them to a significant degree. In the non-refluxing group, wide ureters were noted more often in patients whose bladder pressures were high and wildly fluctuating than in those with normal bladder pressures. Similarly, the incidence of reflux was higher in patients with high bladder pressures and wild fluctuations of bladder pressure than in those with normal pressures. While a wide ureter on IVU should arouse suspicion that reflux or lower urinary tract dysfunction might be present, these conditions are not necessarily excluded by the finding of a ureter of normal size.

Cystometrographic patterns in predicting bladder function after spinal cord injury

The cystometrographic patterns together with and sphincter electromyograms of 62 patients with recent spinal cord injury wer analysed. Four main patterns could be distinguished. The patients with well-developed detrusor reflex gained easy emptying of the bladder significantly more often than those with supranuclear injury but weak or unsustained detrusor contractions, or those with mixed spinal lesions. The patients with mixed lesions and low compliance bladders had the most severe incontinence problems. One fourth of the total series had various degrees of upper tract dilatation in their first urogram, and these changes occurred more often in patients with high detrusor activity. Urinary tract infections occurred in all patients but less often in those with areflexic bladders. This group of patients was also most suitable for intermittent self-catheterisation.

Bladder outlet surgery in men with spinal cord injury

The effect of bladder outlet surgery on voiding ability, changes in the upper urinary tract and urinary infections was studied in 51 men with spinal cord injury. In 24 patients reoperation was required after varying periods of time to achieve satisfactory bladder voiding. Eight of the 22 men who had undergone external sphincterotomy had constant dribbling of urine postoperatively. Dilation of the upper urinary tract was completely reversed or reduced in 13 of 18 patients following the primary operation on the bladder outlet. Vesico-ureteric reflux was found in 6 of the 8 men in whom deterioration of the upper urinary tract persisted after the initial operation or appeared during the follow-up years. Bacteriuria usually persisted, despite bladder outlet surgery, but febrile attacks of urinary tract infection ceased or became less frequent in 15 of the 22 patients who had experienced such episodes preoperatively.