Outcomes of lumbar to sacral nerve rerouting for spina bifida.

PURPOSE: Restoring bladder and bowel function in spina bifida by creation of a skin-central nervous system-bladder reflex arc via lumbar to sacral nerve rerouting has a reported success rate of 87% in China. We report 1-year results of the first North American trial on nerve rerouting. MATERIALS AND METHODS: Nine subjects were enrolled in the study. Intradural lumbar to sacral nerve rerouting was performed. Subjects underwent urodynamic testing with stimulation of the cutaneous dermatome and careful neurological followup. Adverse events were closely monitored along with changes in bowel and bladder function. RESULTS: At 1 year 7 patients (78%) had a reproducible increase in bladder pressure with stimulation of the dermatome. Two patients were able to stop catheterization and all safely stopped antimuscarinics. No patient achieved complete urinary continence. The majority of subjects reported improved bowel function. One patient was continent of stool at baseline and 4 were continent at 1 year. Of the patients 89% had variable weakness of lower extremity muscle groups at 1 month. One child had persistent foot drop and the remainder returned to baseline by 12 months. CONCLUSIONS: At 1 year a novel reflex arc with stimulation of the appropriate dermatome was seen in the majority of subjects. Improvements in voiding and bowel function were noted. Lower extremity weakness was mostly self-limited, except in 1 subject with a persistent foot drop. More patients and longer followup are needed to assess the risk/benefit ratio of this novel procedure.

US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience.

Objective. To report our experience with creating a skin-central nervous system-bladder reflex arc with intradural lumbar to sacral motor root microanastomosis to restore bladder/bowel function in spina bifida patients. Methods. Urinary/bowel changes from baseline to three years were evaluated with questionnaires, voiding diaries, urodynamics (UDS), and renal function studies. Treatment response was defined as CIC ≤ once/day with stable renal function, voiding efficiency > 50%, and no worsening of motor function. Results. Of 13 subjects (9 female, median age 8 years), 3 voided small amounts at baseline, one voided 200 cc (voiding efficiency 32%), 4/13 reported normal bowels, and 2/13 were continent of stool. Postoperatively, all had transient lower extremity weakness; one developed permanent foot drop. Over three years, renal function remained stable and mean maximum cystometric capacity (MCC) increased (P = 0.0135). In the 10 that returned at 3 years, 7 were treatment responders and 9 had discontinued antimuscarinics, but most still leaked urine. Only 2/8 with baseline neurogenic detrusor overactivity (NDO) still had NDO, all 3 with compliance <10 mL/cm H2O had normalized, 7/10 considered their bowels normal, 5/10 were continent of stool, and 8/10 would undergo the procedure again. Conclusion. Lumbar to sacral nerve rerouting can improve elimination in spina bifida patients. This trial is registered with ClinicalTrials.gov NCT00378664.

Successful monitoring of transcranial electrical motor evoked potentials with isoflurane and nitrous oxide in scoliosis surgeries.

STUDY DESIGN: This is a case series studying the efficacy of concomitant inhalational anesthesia and transcranial electrical motor-evoked potential (tceMEP) monitoring in spinal deformity surgery. OBJECTIVE: To determine the affects of inhalational anesthesia on the efficacy of tceMEP monitoring. SUMMARY OF BACKGROUND DATA: Inhalational agents inhibit transmission of evoked potentials from the motor cortex. Consequently, many authors have recommended using total intravenous anesthesia during motor-evoked potential monitoring. METHODS: A total of 247 consecutive patients, aged 1 to 83 years (156 patients <22 years), undergoing spinal fusion for scoliosis, excluding those with history of seizure or myelopathy, were monitored with tceMEP intraoperatively. Isoflurane with or without nitrous oxide (per anesthesiologist preference) was administered with vecuronium and i.v. agents including propofol and/or narcotic. Vecuronium was titrated for a goal of 2/4 twitches, and isoflurane was decreased (if necessary) to a maximum level at which tceMEP responses were monitorable (patient specific). Patients were grouped according to whether they received nitrous oxide and the anesthetic depth at which responses were monitored (<0.5, 0.5-0.9, 1-1.4, and >1.5 MAC). RESULTS: A total of 232 (94%) patients received nitrous oxide. Of these patients, responses were obtained throughout the case in 20 (8.6%) at <0.5 MAC, 118 (50.9%) at 0.5 to 0.9 MAC, 85 (36.6%) at 1 to 1.4 MAC, and 9 (3.9%) at >1.5 MAC. Of the remaining 15 (6%) who received no nitrous oxide, responses were monitored in 3 (20%) at <0.5 MAC, 10 (66.7%) at 0.5 to 0.9 MAC, 2 (13.3%) at 1 to 1.5 MAC, and 0 at >1.5 MAC. No false-positive and 1 true-positive (transient) loss of responses occurred. No operations resulted in postoperative motor deficit. CONCLUSION: Although isoflurane and nitrous oxide diminish tceMEP responses, reliable monitoring can still be accomplished while using significant levels of inhalational anesthetic agents.