[Voluntary micturition after intradural nerve anastomosis]. / Willentlich steuerbare Miktion durch intradurale Nervenanastomose.

INTRODUCTION: One of the major challenges in neuro-urology is the restoration of voluntary voiding in a patient after spinal cord injury (SCI). ANIMAL EXPERIMENTS: The earliest reports on reconstruction of urinary bladder function by bridging nerve roots from above the SCI to the below this level were published by Carlsson and Sundin 1968. In another approach, a possible reflex pathway below the SCI to reinitiate voluntary voiding was investigated. The result was a modified somatic reflex arc rostral to the sacral spinal micturition center. FUTURE RESEARCH: Medical reports in numerous publications are still very enthusiastic about the possibility of cell or gene therapy. Such results report the successful bridging of small nerve gaps. The latest approach is the intravenous application of stem cells to aid the recovery of the SCI. CLINICAL APPROACH: The first reports on attempts to reconstruct the nervous pathways to the bladder in patients were published 1967. In two cases, a nerve anastomosis from Th(12) (the lowest intact segment) to S(2+3), bilaterally to the SCI, allowed spontaneous micturition after 8-12 months with reported sensitivity at the base of the penis. With a modification in surgical technique, another group reported a success rate of 100% using the anastomosis of intercostal nerves Th(11+12) to sacral roots S(2+3) to establish a reflex voiding and, in 72% of patients, reappearance of the bulbocavernous and cremaster reflexes. Xiao et al. published, with a 3 year follow-up, the creation of a micturition reflex through anastomosing the ventral roots of L(5) to S(2/3) in complete SCI patients with a 67% success rate a year after surgery. CONCLUSION: There is still a great deal of work required before cell therapy becomes a therapeutic option. Today, the published data strongly suggest that it is possible to treat first line urinary bladder dysfunctions in SCI or spina bifida patients. Before one of these techniques becomes widely used, it should be proven effective in specialized institutions, such as the Department of Urology in collaboration with the Department of Neurosurgery at the University of Tuebingen, Germany.

Rehmanniae Radix provides most of the free fructose and glucose in Si-Wu-Tang decoction.

Our previous study showed that free fructose is an important active constituent responsible for Si-Wu-Tang's (SWT) effect promoting hematopoiesis and immunity. However, the contribution from SWT's four ingredient drugs to the free fructose content in the SWT decoction was not clear. To answer this question, in this study, the fructose, glucose and sucrose content in the SWT decoction, in the decoctions of each single ingredient drug, and in the decoctions of the four formulae lacking each single ingredient drug were determined by HPLC-ELSD. The results showed that the fructose and glucose content in the decoction of single Rehmanniae Radix were almost the same as those in the SWT decoction. In the single Rehmanniae Radix decoction concentrations were: 4.25 ± 0.53 mg/mL for fructose, and 3.43 ± 0.60 mg/mL for glucose; in the SWT decoction concentrations were: 4.10 ± 0.43 mg/mL for fructose, and 3.42 ± 0.32 mg/mL for glucose, while the content of fructose and glucose in the decoctions of single Angelica Radix, single Paeoniae Radix, single Chuanxiong Rhizoma and the formula lacking Rehmanniae Radix were either very small or undetectable. On the other hand, the fructose and glucose content in the decoctions of the formulae lacking Angelica Radix, lacking Paeoniae Radix and lacking Chuanxiong Rhizoma also were approximately the same as those in the SWT decoction. This indicated that Rehmanniae Radix provides most of the free fructose and glucose in the SWT decoction, and therefore plays an important role in SWT's effect promoting hematopoiesis and immunity. As for sucrose in the SWT decoction, Angelica Radix was shown to be a major donor.

A possible new reflex pathway for micturition after spinal cord injury.

In order to restore bladder function after spinal cord injury, a controllable new reflex pathway has been established in rats. It involves a somatic reflex arc with an artificially modified efferent branch which passes the somatic motor impulses to the bladder. This is achieved by intradural microanastomosis of the left L4 ventral root to L6 ventral root, while leaving the L4 dorsal root intact as a starter of micturition. The 'skin-CNS-bladder' reflex pathway is designed to initiate voiding by scratching the skin. After axonal regeneration, 15 of the 24 rats with the new pathway underwent electrophysiological study. Single stimuli (0.3-3 mA, 0.02-0.2 ms duration) to the left L4 nerve resulted in evoked potentials (0.5-1 mV) recorded from the left L6 nerve distal to the anastomosis. The bladder detrusor contraction was very quickly initiated by trains of the stimuli and bladder pressures increased rapidly to levels similar to controls. Neural tracing study with horseradish peroxidase (HRP) on six rats with the pathway demonstrated that the somatic motor axons regenerated successfully into the pelvic nerve, and the bladder was reinnervated by the L4 somatic motor neurons. The bladder contraction can also be initiated by electrostimulation of left sciatic nerve as well as scratching the L4 related skin. A new concept may be derived from the skin-CNS-bladder reflex pathway: the impulses delivered from the efferent neurons of a somatic reflex arc can be transferred to initiate responses of an autonomic effector.

"Skin-CNS-bladder" reflex pathway for micturition after spinal cord injury and its underlying mechanisms.

PURPOSE: A "skin-CNS-bladder" reflex pathway for inducing micturition after spinal cord injury has been established in cat. This reflex pathway which is basically a somatic reflex arc with a modified efferent limb that passes somatic motor impulses to the bladder, has been designed to allow spinal cord injured patients to initiate voiding by scratching the skin. MATERIALS AND METHODS: The skin-CNS-bladder reflex was established in the cat by intradural microanastomosis of the left L7 ventral root (VR) to the S1 VR while leaving the L7 dorsal root (DR) intact to conduct cutaneous afferent signals that can trigger the new micturition reflex arc. After allowing 11 weeks for axonal regeneration, urodynamic, pharmacological and electrophysiological studies were conducted in pentobarbital or chloralose anesthetized animals. RESULTS: A detrusor contraction was initiated at short latency by scratching the skin or by percutaneous electrical stimulation in the L7 dermatome. Maximal bladder pressures during this stimulation were similar to those activated by bladder distension in control animals. Electrophysiological recording revealed that single stimuli (0.3 to 3 mA, 0.02 to 0.2 msec duration) to the left L7 spinal nerve in which the efferent axons had degenerated evoked action potentials (0.5 to 1 mV) in the left S1 spinal nerve distal to the anastomosis. In addition, increases in bladder pressure were elicited by trains of the stimuli (5 to 20 Hz, 5 seconds) applied to the L7 spinal nerve. Urodynamic studies including external sphincter EMG recording demonstrated that the new reflex pathway could initiate voiding without detrusor-external urethral sphincter dyssynergia. Atropine (0.05 mg./kg., i.v.) or trimethaphan (5 mg./kg., i.v.), a ganglionic blocking agent, depressed the bladder contractions elicited by skin stimulation. The skin-CNS-bladder reflex could also be elicited after transecting the spinal cord at the L2-L3 or L7-S1 levels. CONCLUSION: The cross-wired somato-autonomic bladder reflex is effective in initiating bladder contractions and coordinated voiding in cats with an intact neuraxis and can also induce bladder contractions after acute transection of the lumbar spinal cord. The new pathway is mediated by cholinergic transmission involving both nicotinic and muscarinic receptors. It is concluded that somatic motor axons can innervate bladder parasympathetic ganglion cells and thereby transfer somatic reflex activity to the bladder smooth muscle.