Long-term course of sacral anterior root stimulation in spinal cord injured individuals: The fate of the detrusor.

AIMS: To investigate the long-term course of the detrusor pressure during sacral anterior root stimulation in spinal cord injury (SCI) patients. METHODS: Retrospective evaluation of 111 patients who had undergone sacral deafferentation and implantation of an anterior root stimulator at a single SCI rehabilitation center with a minimum follow-up time of 5 years. RESULTS: The median follow-up time was 11.7 years (range 5.0-24.9 years). The maximum detrusor pressure (Pdet_max) during stimulation was higher in men compared to women (P = 0.0004) and decreased over time (P = 0.0006). However, there were no significant (P ≥ 0.06) differences in the median Pdet_max during stimulation between the first measurement time point and any follow-up time point. The Pdet_max during stimulation decreased from 62 cmH2 O (95%CI 57-73 cmH2 O) to 53 cmH2 O (95%CI 47-69 cmH2 O) (P = 0.9). The time had also a significant effect on Pdet_max during the storage phase (P < 0.0001) and bladder compliance (P = 0.0007). The Pdet_max during the storage phase decreased, whereas bladder compliance increased during the follow-up period. There were no significant (P ≥ 0.1) changes over time in bladder capacity, the number of daily stimulations and the residual urine volume after voiding. CONCLUSIONS: The detrusor pressure during sacral anterior root stimulation decreases over time in SCI individuals. However, the changes do not seem to be clinically relevant during the first decade after surgery.

Predictive factors of stress incontinence after posterior sacral rhizotomy.

AIMS: The Brindley procedure, used since the 1980s, consists of implantation of a stimulator for sacral anterior root stimulation combined with a posterior sacral rhizotomy to enable micturition. Patients suitable for the procedure are patients with detrusor overactivity and a complete spinal cord lesion with intact sacral reflexes. S2 to S4 posterior sacral rhizotomy abolishes sacral hyperreflexia and may lead to decreased urethral closure pressure and loss of reflex adaptation of continence, leading to stress incontinence. METHODS: In this retrospective study of 96 patients from Nantes or Le Mans, implanted with a Finetech-Brindley stimulator, we analyzed the incidence of stress incontinence one year after surgery and looked for predictive factors of stress incontinence one year after posterior sacral rhizotomy: age, gender, level of injury between T10 and L2 , previous urethral surgery, incompetent bladder neck, Maximum Urethral Closure Pressure before surgery less than 30 cmH2 O, compliance before surgery less than 30 ml/cmH2 0. Patients with persistent involuntary detrusor contractions with or without incontinence after surgery were excluded. RESULTS: One year after surgery, 10.4% of the patients experienced stress incontinence. Urethral closure pressure was significantly decreased by 18% after posterior sacral rhizotomy (P = 0.002). This study highlights the only significant predictive factor of stress incontinence after rhizotomy: incompetent bladder neck (P = 0.002). CONCLUSIONS: As screening of patients undergoing the Brindley procedure is essential to achieve optimal postoperative results, on the basis of this study, we propose preoperative assessment to select the population of patients most likely to benefit from the Brindley procedure.

Electrical nerve stimulation to promote micturition in spinal cord injury patients: A review of current attempts.

AIMS: In this review, we focus on the current attempts of electrical nerve stimulation for micturition in spinal cord injury (SCI) patients. METHODS: A literature search was performed through PubMed using "spinal cord injury," "electrical nerve stimulation AND bladder," "sacral anterior root stimulation/stimulator" and "Brindley stimulator" from January 1975 to January 2014. RESULTS: Twenty studies were selected for this review. CONCLUSION: Electrical nerve stimulation is a clinical option for promoting micturition in SCI patients. Well-designed, randomized and controlled studies are essential for further investigation.

Charcot arthropathy of the spine in spinal cord injured individuals with sacral deafferentation and anterior root stimulator implantation.

AIMS: To investigate the occurrence of Charcot spinal arthropathy (CSA) after sacral deafferentation (SDAF) and sacral anterior root stimulation (SARS) of the bladder in patients suffering from neurogenic lower urinary tract dysfunction (NLUTD) as a result of spinal cord injury (SCI). METHODS: Retrospective evaluation of patients who had undergone SDAF/SARS at a single SCI rehabilitation centre. The occurrence rate of stimulation dysfunction was determined, and the medical records and radiological images of the included patients were examined for CSA. The diagnosis of CSA was based on radiological criteria. The occurrence rate of CSA was estimated for all SARS patients and for those with SARS dysfunction, and the odds ratios (OR) for the occurrence of CSA were calculated. RESULTS: In 11/130 SARS patients (8%), CSA was observed a median 8 years (95% CI 5-16 years) after SDAF/SARS or a median 21 years (95% CI 9-41 years) after SCI had occurred. The median follow-up time was 14 years (range 6-25 years). The proportion of patients with CSA was significantly (P = 0.036) greater in patients with SARS dysfunction (7/41) than in patients without SARS dysfunction (4/89). The odds of CSA were four times greater (OR 4.3, 95% CI 1.0-21.5) in patients with SARS dysfunction compared to those without. Furthermore, the odds of CSA were 20 times greater (OR 20.2, 95% CI 8.4-47.0) in patients with SARS compared to those without. CONCLUSIONS: Charcot spinal arthropathy should be considered a potential long-term complication of SDAF/SARS, and spinal instability is a possible reason for SARS dysfunction.

Sacral Anterior Root Stimulation and Visceral Function Outcomes in Spinal Cord Injury-A Systematic Review of the Literature Over Four Decades.

OBJECTIVE: Sacral anterior root stimulation (SARS) was developed 40 years ago to restore urinary and bowel functions to individuals with spinal cord injury. Mostly used to restore lower urinary tract function, SARS implantation is coupled with sacral deafferentation to counteract the problems of chronic detrusor sphincter dyssynergia and detrusor overactivity. In this article, we systematically review 40 years of SARS implantation and assess the medical added value of this approach in accordance with the PRISMA guidelines. We identified 4 axes of investigation: 1) impact on visceral functions, 2) implantation safety and device reliability, 3) individuals' quality of life, and 4) additional information about the procedure. METHODS: A systematic review was performed. Three databases were consulted: PubMed, EBSCOhost, and Pascal. A total of 219 abstracts were screened and 38 articles were retained for analysis (1147 implantations). RESULTS: The SARS technique showed good clinical results (85.9% of individuals used their implant for micturition and 67.9% to ease bowel movements) and improved individual quality of life. Conversely, several sources of complications were reported after implantation (e.g., surgical complications and failure). CONCLUSIONS: Despite promising results, a decline in implantations was observed. This decline can be linked to the complication rate, as well as to the development of new therapeutics (e.g., botulinum toxin) and directions for research (spinal cord stimulation) that may have an impact on people. Nevertheless, the lack of alternatives in the short-term suggests that the SARS implant is still relevant for the restoration of visceral functions after spinal cord injury.

Clinical utility of neurostimulation devices in the treatment of overactive bladder: current perspectives.

OBJECTIVES: This review describes the evidence from established and experimental therapies that use electrical nerve stimulation to treat lower urinary tract dysfunction. METHODS: Clinical studies on established treatments such as percutaneous posterior tibial nerve stimulation (P-PTNS), transcutaneous electrical nerve stimulation (TENS), sacral nerve stimulation (SNS) and sacral anterior root stimulation (SARS) are evaluated. In addition, clinical evidence from experimental therapies such as dorsal genital nerve (DGN) stimulation, pudendal nerve stimulation, magnetic nerve stimulation and ankle implants for tibial nerve stimulation are evaluated. RESULTS: SNS and P-PTNS have been investigated with high-quality studies that have shown proven efficacy for the treatment for overactive bladder (OAB). SARS has proven evidence-based efficacy in spinal cord patients and increases the quality of life. TENS seems inferior to other OAB treatments such as SNS and P-PTNS but is noninvasive and applicable for ambulant therapy. Results from studies on experimental therapies such as pudendal nerve stimulation seem promising but need larger study cohorts to prove efficacy. CONCLUSION: Neurostimulation therapies have proven efficacy for bladder dysfunction in patients who are refractory to other therapies. SIGNIFICANCE: Refinement of neurostimulation therapies is possible. The aim should be to make the treatments less invasive, more durable and more effective for the treatment of lower urinary tract dysfunction.

Electrical management of neurogenic lower urinary tract disorders.

Management of lower urinary tract dysfunction (LUTD) in neurological diseases remains a priority because it leads to many complications such as incontinence, renal failure and decreased quality of life. A pharmacological approach remains the first-line treatment for patients with neurogenic LUTD, but electrical stimulation is a well-validated and recommended second-line treatment. However, clinicians must be aware of the indications, advantages and side effects of the therapy. This report provides an update on the 2 main electrical stimulation therapies for neurogenic LUTD - inducing direct bladder contraction with the Brindley procedure and modulating LUT physiology (sacral neuromodulation, tibial posterior nerve stimulation or pudendal nerve stimulation). We also describe the indications of these therapies for neurogenic LUTD, following international guidelines, as illustrated by their efficacy in patients with neurologic disorders. Electrical stimulation could be proposed for neurogenic LUTD as second-line treatment after failure of oral pharmacologic approaches. Nevertheless, further investigations are needed for a better understanding of the mechanisms of action of these techniques and to confirm their efficacy. Other electrical investigations, such as deep-brain stimulation and repetitive transcranial magnetic stimulation, or improved sacral anterior root stimulation, which could be associated with non-invasive and highly specific deafferentation of posterior roots, may open new fields in the management of neurogenic LUTD.