Successful sacral neuromodulation treatment of refractory faecal incontinence in a patient with spina bifida and partial sacral agenesis.

A woman in her early 20s with a history of lumbosacral lipomyelomeningocele with associated partial sacral agenesis and tethered cord was referred for possible sacral neuromodulation treatment of her refractory faecal incontinence. Anorectal testing revealed a thinned and weakened anal sphincter complex with absent left-sided bulbocavernosus and anal wink reflexes.Through a two-stage approach, she underwent successful placement of a chronic tined quadripolar sacral nerve lead and implanted pulse generator. Despite significant distortion of normal bony anatomic landmarks, bilateral S3 and S4 foraminal entry was possible, with intraoperative motor and sensory testing providing key confirmation of appropriate lead placement. The patient had a substantial improvement in her baseline frequency and urgency with a near-complete resolution of faecal incontinence episodes during her test phase.

Strategies for Difficult Fluoroscopic Landmarking During Sacral Neuromodulation Lead Placement.

OBJECTIVES: Fluoroscopic guidance is a key tool used in combination with sensory and motor testing to ensure optimal sacral neuromodulation lead placement. The objectives of this video are to briefly review bony landmarks for fluoroscopic imaging and provide strategies to overcome common obstacles during fluoroscopic mapping for sacral neuromodulation lead placement. METHODS: Our video is divided into 2 parts. First, we review anatomic landmarks in anterior-posterior (AP) fluoroscopic imaging for identification of the sacrum and the medial edge of the bilateral sacral foramina. We then provide a series of nonideal fluoroscopic images, explaining the cause of the difficult interpretation and strategies to overcome these obstacles. In the second half, we similarly review the identification of S3 and optimal needle angle trajectory during lateral fluoroscopic imaging. We again provide a series of nonideal imaging examples to highlight strategies for needle placement in difficult cases. RESULTS: We provide an overview of normal fluoroscopic landmarks for both AP and lateral fluoroscopic imaging during sacral neuromodulation lead placement, along with a series of 6 nonideal examples. Strategies for overcoming barriers to identification of bony anatomy on fluoroscopy are provided in the context of these examples. CONCLUSION: While appropriate patient preparation and positioning are important to optimize fluoroscopic guidance during sacral neuromodulation lead placement, patient anatomy and other factors often obscure or distort expected anatomic landmarks. We demonstrate our approach to overcoming common fluoroscopic obstacles and provide strategies for improvement of operative efficiency. These strategies can be combined with other intraoperative information such as tactile feedback, additional fluoroscopic views, and intraoperative complex nerve mapping to help optimize sacral neuromodulation lead placement and improve operative efficiency.

Characteristics associated with subjective and objective measures of treatment success in women undergoing percutaneous tibial nerve stimulation vs sham for accidental bowel leakage.

INTRODUCTION AND HYPOTHESIS: In randomized trials both percutaneous tibial nerve stimulation (PTNS) and sham result in clinically significant improvements in accidental bowel leakage (ABL). We aimed to identify subgroups who may preferentially benefit from PTNS in women enrolled in a multicenter randomized trial. METHODS: This planned secondary analysis explored factors associated with success for PTNS vs sham using various definitions: treatment responder using three cutoff points for St. Mark's score (≥3-, ≥4-, and ≥5-point reduction); Patient Global Impression of Improvement (PGI-I) of ≥ much better; and ≥50% reduction in fecal incontinence episodes (FIEs). Backward logistic regression models were generated using elements with significance of p<0.2 for each definition and interaction terms assessed differential effects of PTNS vs sham. RESULTS: Of 166 women randomized, 160 provided data for at least one success definition. Overall, success rates were 65% (102 out of 158), 57% (90 out of 158), and 46% (73 out of 158) for ≥3-, ≥4-, and ≥5-point St Mark's reduction respectively; 43% (68 out of 157) for PGI-I; and 48% (70 out of 145) for ≥50% FIEs. Of those providing data for all definitions of success, 77% (109 out of 142) met one success criterion, 43% (61 out of 142) two, and 29% (41 out of 142) all three success criteria. No reliable or consistent factors were associated with improved outcomes with PTNS over sham regardless of definition. CONCLUSIONS: Despite exploring diverse success outcomes, no subgroups of women with ABL differentially responded to PTNS over sham. Success results varied widely across subjective and objective definitions. Further investigation of ABL treatment success definitions that consistently and accurately capture patient symptom burden and improvement are needed.