Deafferentation of the urinary bladder and implantation of a sacral anterior root stimulator (SARS) for treatment of the neurogenic bladder in paraplegic patients.

Since 25 years electrical stimulation has become an established and widely acknowledged therapy option. Today, FES is widely employed, e.g. for cardiostimulation, diaphragm stimulation, kinetotherapy, for treatment of tremor in Parkinson patients, and finally for bladder stimulation in patients with bladder voiding dysfunctions. Brindley was the first researcher who succeeded in stimulating the spinal nerves via implanted electrodes in an animal model. In the years 1978/79 Brindley implanted five paraplegic patients with so-called sacral anterior root stimulators; all of them were able to void under stimulation. This method of sacral anterior root stimulation (SARS) proved an alternative to frequent one-way catheterisation for patients with severe voiding dysfunctions, without achieving complete continence, however. The following study is to provide an overview over the latest insights in the context of implanting sacral anterior root stimulators; it discusses the preconditions required for such interventions and presents criteria to decide in which cases there is a contraindication for sacral deafferentation of the posterior roots. Moreover, it contrasts advantages and disadvantages of the intradural and extradural implantation methods and presents the currently available long-term follow-up results with SDAF and SARS for treatment of bladder voiding dysfunctions.     

Sacral anterior root stimulation for bladder control: clinical results

The Brindley bladder stimulator delivers intermittent stimulation to the anterior sacral roots. The stimulus parameters can be adjusted and set specifically for individuals. Its primary purpose is to improve bladder emptying, thereby to eliminate urinary infection and to preserve kidney function. It also assists in defecation and enables male patients to have a sustained full erection. In our unit so far 38 patients with a complete spinal cord lesion have received a Brindley bladder stimulator implant. One patient died 2 weeks after the surgery due to pulmonary embolism. Two other patients died due to unrelated causes during the follow up period. They used their implants for less than 1 year. Results relating to these 2 patients and the remaining 35 patients who regularly use their implant are presented. The follow-up period ranged from 3 months to 12 years. Residual urine volumes are substantially reduced in all patients; in 24 patients the residual urine volume is less than 30 ml. All patients have increased bladder capacity. Thirty-one patients are continent. Out of 33 males 29 can achieve a sustained full erection using the stimulator. Twenty-seven patients use the implant for bowel function. The following complications were encountered: (1.) Cerebro-spinal fluid collection occurred around the implant in 3 patients during the post-operative period; (2.) Receiver failure occurred in 3 patients. A successful replacement with a new receiver block was carried out in these cases. It is concluded that the use of a bladder stimulator in selected patients gives long term favourable results.     

Stimulation of the spinal cord in the treatment of traumatic injuries of cervical spine

Since 1974, clinical experiments have been conducted at the Rehabilitation Clinic in Konstancin (Poland) on the effects of electrostimulation on the damaged spinal cord. 30 patients with stimulation after injury to the cervical spinal cord are reported. Patients with complete and incomplete cervical cord injury were compared. The patients were treated by surgical decompression with simultaneous implantation of stimulating electrodes in contact with the spinal cord. The control group of patients were operated upon in the same period for similar injuries, but had no stimulators implanted. Neurological improvement was better in the stimulated compared to the nonstimulated patients, both as regards number of neurological improvements as well as quality of neurological function. The comparison also confirmed a favorable effect of spinal cord stimulation on the development of bladder automatism.     

发射式植入刺激器的研制及其在截瘫狗排尿功能障碍时的应用

介绍一种体外发射式植入刺激器的结构和电路原理。该机不但体积较小,耗电少,且可选择较强刺激电压,其植入部分的生物相容性较好,并初步观察了用此刺激器刺激骶神经以恢复截瘫狗排尿功能的情况。     

Sacral anterior root stimulation and cryotechnique: A new option for selective urethral sphincter block and reversible deafferentation in the future?

A possible application of cryotechnique might be a selective block of nerve fiber activity during sacral anterior root stimulation to achieve selective block of urethral sphincter and reversible deafferentation. In 13 foxhounds, electrical stimulation of sacral anterior roots S2 was performed while the accompanying spinal nerves were simultaneously cooled down from +25 degrees C in a stepwise fashion until a block of urethral sphincter activity was observed. The effects of cold block on the urethral sphincter and bladder were monitored by urodynamic investigation. In 2 additional dogs sacral posterior roots S2 were cooled down to +3 degrees C while accompanying anterior and posterior roots were stimulated distal to the cryothermode. Compound action potentials (APs) were registered proximal to the cryothermode before, during and after cooling and recovery time of cold blocked nerves was evaluated. Complete cold block of the urethral sphincter during spinal nerve cooling was achieved in all cases. Block temperature averaged +12 degrees C. Detrusor pressure was a mean 5,2 cm water. Recovery time was on average 5 min. The cold block was always reversible. In both dogs of the second series the compound action potentials disappeared nearly completely at +3 degrees C. Three min after the end of the cooling period the appearance of the compound action potentials was back to normal. In this study, cryotechnique proved to be effective for selective and reversible block of nerve fibers during sacral anterior root stimulation. In functional electrical stimulation this technique may lead to an improvement of quality of life in para- or tetraplegic patients resulting in optimization of voiding, standing, walking and grasping and does so without the necessity of surgical dorsal root rhizotomy.     

Outcome following implantation of a peripheral nerve stimulator in patients with chronic nerve pain

This study evaluated the usefulness of the implanted peripheral nerve stimulator in patients with pain following injury to a peripheral nerve. The patient sample (n = 17) consisted of 7 men and 10 women with a mean age of 48 years (SD = 18 years). The mean follow-up time since implantation of the stimulator was 21 months (SD = 15 months). Workers' compensation and/or litigation were involved in 11 cases. Peripheral nerve stimulators were placed in the upper extremity in 12 patients and in the lower extremity in 5 patients. Pain relief following implantation was rated as excellent by five patients, good by six patients, fair by four patients, and poor by two patients. A statistically significant decrease in reported pain level was found postoperatively (p < 0.0003). There was no statistically significant difference in postoperative pain level between men and women (p = 0.30), between cases involving workers' compensation or litigation and those not involving these issues (p = 1.0), or between patients who received an upper-extremity implant and those who received a lower-extremity implant (p = 0.56). Of the 12 patients who were unable to work before the operation, 6 returned to work after the operation. In conclusion, peripheral nerve stimulators can be useful in decreasing pain in carefully selected patients with severe neurogenic pain.     

Dorsal root entry zone lesions in the treatment of pain following brachial plexus avulsion, spinal cord injury and herpes zoster

This paper details the long-term results in patients treated with dorsal root entry zone (DREZ) lesions for the treatment of pain following brachial plexus avulsion, spinal cord injury, and herpes zoster. With our current operative technique, 82% of patients with brachial plexus avulsion injuries were afforded long-term pain relief. Patients with pain confined to dermatomes just below the level of spinal injury also did well with DREZ lesions, although the results were less good in patients with diffuse pain or with sacral pain. The postoperative results in patients with postherpetic pain were disappointing.     

前后联合入路微创治疗合并神经损伤的不稳定骶骨骨折

目的:探讨前后联合入路锁定加压钢板(LCP)微创治疗合并神经损伤的骶骨不稳定骨折的效果。方法:前后联合入路按照杜明奎等方法[1]采用LCP固定治疗合并神经损伤的不稳定骶骨骨折患者5例:L5神经根损伤2例,骶丛神经损伤3例。前方入路暴露骨盆前环重建钢板固定,后方入路经皮下锁定加压钢板骨折复位固定术,椎管探查减压以MRI显示有无神经压迫为据。结果:5例均获随访,时间3～20(14.8±7.2)个月。2例L5神经根损伤和3例骶丛神经损伤者Frankel分级由C级恢复至E级,术后功能根据Matta评分标准评定:优3例,良2例。结论:前后联合入路LCP微创治疗合并神经损伤的骶骨不稳定骨折是一种简单微创有效的方法,值得临床推广。     

个体化生物反馈训练联合早期排便功能训练对低位直肠癌保肛术后患者肠道功能、肛肠动力学和生活质量的影响

摘要 目的：探讨个体化生物反馈训练联合早期排便功能训练对低位直肠癌保肛术后患者肠道功能、肛肠动力学和生活质量的影响。方法：纳入我院2018年4月~2021年9月期间收治的90例行低位直肠癌保肛术患者。按照住院号奇偶数将患者分为对照组（早期排便功能训练,45例）和研究组（对照组基础上结合个体化生物反馈训练,45例）。对比两组肠道功能、肛肠动力学和生活质量、肛门失禁情况及控便满意度。结果：两组干预后排便受饮食影响、便频便急、排便感觉异常评分均下降,但研究组高于对照组（P<0.05）。两组干预后健康调查量表简表（SF-36）各维度评分均升高,且研究组高于对照组（P<0.05）。研究组的肛门失禁例数少于对照组,控便满意度则高于对照组（P<0.05）。两组干预后肛管静息压、肛管最大收缩压、直肠最大耐受容量均下降,但研究组高于对照组（P<0.05）。结论：个体化生物反馈训练联合早期排便功能训练可促进低位直肠癌保肛术后患者肠道功能恢复,改善肛肠动力学和生活质量,减少肛门失禁情况发生,控便满意度较好。     

生物反馈训练辅助治疗梗阻性便秘对粪便性状、排便时间及排便频度的影响

目的:探讨生物反馈训练辅助治疗梗阻性便秘患者对粪便性状、排便时间与排便频度的影响。方法:选取我院收治的90例梗阻性便秘患者,根据随机数字表法分为3组,A组接受常规治疗,B组于常规治疗基础上进行固定式生物反馈训练(FBF),C组于常规治疗基础上进行自适应式生物反馈训练(ABF),比较3组治疗前后肛直肠功能、粪便性状、排便时间、排便频度和临床疗效。结果:治疗后,直肠肛门压力梯度:A组B组C组(P0.05),矛盾性收缩率:A组B组C组(P0.05),B组与C组肛管静息压、直肠肛门抑制反射阈值显著小于A组(P0.05),且肛管松弛率显著大于A组(P0.05);C组粪便性状4～7型占比明显高于其余两组(P0.05),且B组4～7型占比明显高于A组(P0.05);排便时间:A组B组C组(P0.05),排便频度:A组B组C组(P0.05);C组总有效率显著高于A组与B组(P0.05)。结论:生物反馈训练尤其是ABF可有效改善梗阻性便秘患者肛直肠功能,在改善粪便性状、缩短排便时间、增加排便频度上具有明显优势,可获得更好的临床疗效。     

Nerve growth factor-induced stimulation of dorsal root ganglion/spinal cord co-grafts in oculo: enhanced survival and growth of CGRP-immunoreactive sensory neurons

Intraocular co-grafts of rat fetal spinal cord and dorsal root ganglia were used to examine the enhanced survival, growth, and differentiation of sensory neurons by nerve growth factor. E14 lumbar spinal segments were implanted into the anterior eye chamber of capsaicin-pretreated rats. Two weeks later, an E14 dorsal root ganglion was implanted beside the spinal cord graft. Nerve growth factor or vehicle was injected weekly for 4 weeks into the anterior eye chamber. Co-grafts were examined weekly and, at 6 weeks, processed for calcitonin gene-related peptide (CGRP) immunofluorescence. No differences in overall size were determined for the grafts. Co-grafts treated with nerve growth factor contained many more CGRP neurons (19.4 cells/20 microm) that were significantly larger (mean 764 microm2) than neurons from control co-grafts (8.6 cells/20 microm; mean 373 microm2). In co-grafts treated with nerve growth factor, CGRP-immunoreactive fibers were extensive in the dorsal root ganglion, adjacent iris, and spinal cord compared to control co-grafts. A few CGRP-positive motoneurons were observed in the spinal cord, but no differences in number or size of motoneurons were found. The current report demonstrates that spinal cord and dorsal root ganglia can be co-grafted in oculo for long periods of time. Many dorsal root ganglion neurons survive and send peripheral processes into the iris and central processes into the spinal cord under the influence of exogenous nerve growth factor. The intraocular graft paradigm can be of use to further examine the role of neurotrophic factors in regulating or modulating dorsal root ganglion and spinal cord neurons.     

Lower gastrointestinal disorders in patients with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal system characterized by abdominal pain related to bowel emptying, defecation impairment and abdominal distention. The aim of the study was to objectify lower gastrointestinal system disturbances in IBS patients. Thirty IBS patients and 30 healthy subjects were included in the study. IBS patients were divided into two subgroups: IBS with predominant diarrhea (IBSd) and IBS with predominant constipation (IBSc). All study subjects underwent physical examination (including digitorectal examination), standard laboratory testing and anorectal manometry. Endoscopy was performed only in group of IBS patients. A statistically significant difference was recorded in most manometric parameters between healthy subjects and IBS patients, which was even more pronounced in IBSd patients. Study results showed that the intestinal motility disorder underlying IBS could be objectified by use of anorectal manometry.     

In lumbosacral plexus injuries can we identify indicators that predict spontaneous recovery or the need for surgical treatment? Results from a clinical study on 72 patients

Background

Post-traumatic lumbosacral plexus injuries seem to be rare events, spontaneously recovering in high percentage: as surgery is often challenging and results in poor outcome, many Authors have advocated conservative treatment only. Nevertheless surgery should not be ruled out: in invalidating injuries, it can restore basic function in the lower extremities. Therefore, it might be necessary to establish guidelines for the management and the indication to surgery in such cases. This study aims to identify indicators predicting spontaneous recovery or the need for surgery.

Method

The clinical and radiological data of 72 patients with a post-traumatic lumbosacral plexus injury were reviewed. A follow up equal or superior to 3 years is available in 42 cases.

Results

Lumbosacral plexus injuries mostly occurred during road accidents. The incidence of associated lesions was relevant: bone injuries were found in 85% of patients, internal lesions in 30% and vascular injuries in 8%. Lumbosacral trunk and sacral plexus palsies were the most frequent injury patterns. Root avulsions were revealed in 23% of cases and only in sacral plexus and complete lumbosacral plexus injuries: L5 and S1 were the roots more prone to avulsions. About 70% of cases recovered spontaneously, mostly in 18 months. Spontaneous recovery was the rule in lumbar plexus and lumbosacral trunk injuries (where root avulsions never occurred) or in sacral and complete lumbosacral plexus palsies due to compression injuries. The causative mechanism correlated with the injury pattern, the associated bone injury being often predictive of the severity of the nerve injury. Lumbosacral plexus injuries occurred in car crashes were generally associated with fractures causing compression on the nerves, thus resulting in injuries often amenable of spontaneous recovery. Motorcycle accidents implied high kinetic energy traumas where traction played an important role, as the high percentage of sacroiliac joint separations demonstrated (found in more than 50% of cases and always associated to root avulsions). Loss of sphincteral control and excruciating leg pain were also invariably associated with avulsions.

Conclusions

Clinical and radiological data can help to predict the occurrence of spontaneous recovery or the need for surgery in post-traumatic lumbosacral plexus injuries.     

Implantable Electrical Vesical Stimulator: Review of the Literature and Report of a Successful Case

Considerable interest has been shown recently in electrical stimulation of the incompetent urinary bladder. Two types of bladder stimulation have been attempted in dogs and in humans: (a) stimulation of nervi erigentes and (b) direct stimulation of the detrusor urinae muscle.After several years of animal experimentation, a vesical stimulator, built on a new electronic principle, was implanted successfully in a paraplegic patient who has a complete post-traumatic lower motor neuron lesion. The stimulator has been working satisfactorily since November 1965.This stimulator could eventually also be used in purely sensory sacral lesions, in well-selected incomplete lower motor neuron lesions, and in flaccid detrusors of the myogenic type.A review of the literature up to the time of this report shows only a few encouraging but incomplete results in humans. The techniques and the complexities involved in this problem are discussed.     

Carotid sinus nerve stimulation in the management of intractable angina pectoris: four-year follow-up

Since February 1969 carotid sinus nerve stimulators have been implanted in 13 patients with intractable, incapacitating angina pectoris, unrelieved by medical management and, in some cases, revascularization procedures. Four patients died, one on the third postoperative day, the others at 15, 31 and 49 months postoperatively. Two other patients sustained myocardial infarcts, at two weeks and two months postoperatively. Complications were few and transient. The condition of two patients is now deteriorating.In all cases there was relief of pain and a decrease in blood pressure and heart rate. Exercise could be performed at a heavier load or for a longer time. Use of the stimulator was both intermittent and continuous, proving especially valuable in the relief of nocturnal angina. All patients were markedly improved and able to leave hospital.Four patients underwent aortocoronary bypass 14, 15, 22 and 28 months after implantation of the device; three obtained good results and no longer require the CSNS although it remains in place. The fourth obtained little improvement and continues to use the stimulator.     

Neurophysiological evaluation of central-peripheral sensory and motor pudendal fibres

Extensive neurophysiological investigations were carried out in 18 healthy volunteer subjects, and 6 patients with neurological disease. The tests consisted of spinal and scalp somatosensory evoked potentials (SEPs) to stimulation of the dorsal nerve of penis/clitoris, motor evoked potentials (MEPs) from the bulbocavernosus muscle (BC) and anal sphincter (AS) in response to scalp and sacral root stimulation, and measurement of sacral reflex latency (SRL) from BC and AS.In the control subjects, the mean sensory total conduction time (sensory TCT), as measured at the peak of the scalp P40 wave was 40.9 msec (range: 37.8–44.2). The mean sensory central conduction time (sensory CCT = spine-to-scalp conduction time) was 27.0 msec (range: 23.5–30.4).Transcranial brain stimulation was performed by using a magnetic stimulator both at rest and during voluntary contraction of the examined muscle. Sacral root stimulation was performed at rest. Motor total conduction times (motor TCT) to BC and AS muscles were respectively 28.8 and 30.0 msec at rest, and 22.5 and 22.8 msec during contraction. Motor central conduction times (motor CCT) to sacral cord segments controlling BC and AS muscles were respectively 22.4 and 21.2 msec at rest, and 15.1 and 12.4 msec during contraction.The mean latencies of SRL were respectively 31.4 msec in the bulbocavernosus muscle and 35.9 msec in the anal sphincter. Combined or isolated abnormalities of SEPs, MEPs and SRL were found in a small group of patients with neurological disorders primarily or secondarily affecting the genito-urinary tract.     

Treatment of spasmodic torticollis by dorsal column stimulation.

A new method is described to treat spasmodic torticollis with the implantation of a dorsal column stimulator at the C1--2 level or with transcutaneous stimulation. 22 patients were evaluated. 3 had sufficient relief to be treated with transcutaneous stimulation only. An additional 6 patients had surgically implanted dorsal column stimulators. It was empirically determined that a frequency of 800--1,100 Hz gave the best relief from torticollis. 1 patient had an excellent result; 3 have had good results; 1 had a fair result, and 1 had a poor result. An additional patient with dystonia musculorum deformans was considerably improved by the use of dorsal column stimulation.     

Fos Protein Expression in Sacral Spinal Cord in Relation to Early Phase of Cauda Equina Syndrome in Dogs

1. The aim of the present study is to map the incipient phase of Fos expression in the sacral spinal cord neuronal pools of multiple cauda equina constrictions canine model.2. Fos-positive neurons were found bilaterally in the lateral portion of superficial dorsal horn layers (Laminae I–III) and along the lateral edge of the dorsal horn accompanied by the lateral collateral pathway, fibers of Lissauer's tract, terminating at the sacral parasympathetic nucleus. Similarly, high Fos expression was detected in the ventral portion of the dorsal sacral commissure and in the dorsomedial portion of the anterior horns at S₁–S₃ segment level. Finally, a clearly expressed Fos-positivity was disclosed bilaterally in the neuropil of the nucleus Y in the anterior horn.3. Data from the present study show that continuous stimulation of the central fibers of sacral dorsal root ganglia neurons, i.e., fibers of sacral primary afferents, unlike those using various stimulations of the peripheral fibres offers an unusual pattern of Fos-like immunoreactivity.     

Advances in nonimplantable electrical stimualtors for correction of urinary incontinence.

The nonimplantable electrical stimulators are widely used as rehabilitation aids for correction of urinary incontinence. The advances in the field of the design of nonimplantable electrical stimulators such as automatic vaginal electrical stimulator VAGICON-X and anal pressure controlled electrical stimulator are described. The evaluation of VAGICON-X in patients suffering from stress and urge incontinence as well as preliminary results of acute application of anal pressure electrical stimulation in patients with stress incontinence as presented.     

自适应式与固定式生物反馈训练对出口梗阻型便秘患者肛直肠功能和心理状态的影响

目的:探讨自适应式与固定式生物反馈训练对出口梗阻型便秘(OOC)患者肛直肠功能和心理状态的影响。方法:选取2017年4月～2019年12月期间晋城大医院收治的OOC患者98例,根据随机数字表法将患者分为对照组(n=49,固定式生物反馈训练)和研究组(n=49,自适应式生物反馈训练),比较两组患者疗效、肛直肠功能、排便次数、排便困难评分和心理状态。结果:研究组治疗8周后的临床总有效率93.88%(46/49),高于对照组的77.55%(38/49)(P0.05)。两组治疗8周后排便次数增加,排便困难评分降低(P0.05),研究组治疗8周后排便次数多于对照组,排便困难评分低于对照组(P0.05)。两组治疗8周后直肠肛门抑制反射阈、肛管静息压均较治疗前下降,模拟排便时直肠肛管压力梯度较治疗前升高(P0.05)。两组治疗8周后焦虑自评量表(SAS)、抑郁自评量表(SDS)评分均较治疗前下降,且研究组低于对照组(P0.05)。结论:与固定式生物反馈训练相比,自适应式生物反馈训练可获得与之效果相当的肛直肠功能改善程度,并可进一步减轻患者症状及改善心理状态,疗效显著。