Translumbosacral Anorectal Magnetic Stimulation Test for Fecal Incontinence.

BACKGROUND: Neuropathy may cause fecal incontinence and mixed fecal incontinence/constipation, but its prevalence is unclear, partly due to the lack of comprehensive testing of spino-anorectal innervation. OBJECTIVE: This study aimed to develop and determine the clinical usefulness of a novel test, translumbosacral anorectal magnetic stimulation for fecal incontinence. DESIGN: This observational cohort study was conducted from 2012 to 2018. SETTINGS: This study was performed at a tertiary referral center. PATIENTS: Patients with fecal incontinence, patients with mixed fecal incontinence/constipation, and healthy controls were included. INTERVENTIONS: A translumbosacral anorectal magnetic stimulation test was performed by using an anorectal probe with 4 ring electrodes and magnetic coil, and by stimulating bilateral lumbar and sacral plexuses, uses and recording 8 motor-evoked potentials at anal and rectal sites. MAIN OUTCOME MEASURES: The prevalence of lumbar and/or sacral neuropathy was examined. Secondary outcomes were correlation of neuropathy with anorectal sensorimotor function(s) and morphological changes. RESULTS: We evaluated 220 patients: 144 with fecal incontinence, 76 with mixed fecal incontinence/constipation, and 31 healthy controls. All 8 lumbar and sacral motor-evoked potential latencies were significantly prolonged (p < 0.01) in fecal incontinence and mixed fecal incontinence/constipation groups compared with controls. Neuropathy was patchy and involved 4.0 (3.0) (median (interquartile range)) sites. Lumbar neuropathy was seen in 29% to 65% of the patients in the fecal incontinence group and 22% to 61% of the patients in the mixed fecal incontinence/constipation group, and sacral neuropathy was seen in 24% to 64% and 29% to 61% of these patients. Anal neuropathy was significantly more (p < 0.001) prevalent than rectal neuropathy in both groups. There was no correlation between motor-evoked potential latencies and anal sphincter pressures, rectal sensation, or anal sphincter defects. LIMITATIONS: No comparative analysis with electromyography was performed. CONCLUSION: Lumbar or sacral plexus neuropathy was detected in 40% to 75% of patients with fecal incontinence with a 2-fold greater prevalence at the anal region than the rectum. Lumbosacral neuropathy appears to be an independent mechanism in the pathogenesis of fecal incontinence, unassociated with other sensorimotor dysfunctions. Translumbosacral anorectal magnetic stimulation has a high yield and is a safe and clinically useful neurophysiological test. See Video Abstract at http://links.lww.com/DCR/B728. PRUEBA DE ESTIMULACIN MAGNTICA TRANSLUMBOSACRAL ANORECTAL PARA LA INCONTINENCIA FECAL: ANTECEDENTES:La neuropatía puede causar incontinencia fecal y una combinación de incontinencia fe-cal/estreñimiento, pero su prevalencia no está clara, en parte debido a la falta de pruebas comple-tas de inervación espino-anorrectal.OBJETIVO:Desarrollar y determinar la utilidad clínica de una nueva prueba, estimulación magnética trans-lumbosacral anorrectal para la incontinencia fecal.DISEÑO:Estudio de cohorte observacional del 2012 al 2018.ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes con incontinencia fecal, combinación de incontinencia fecal/estreñimiento y controles sanos.INTERVENCIONES:Se realizó una prueba de estimulación magnética translumbosacral anorrectal utilizando una sonda anorrectal con 4 electrodos anulares y bobina magnética, y estimulando los plexos lumbares y sacros bilaterales y registrando ocho potenciales evocados motores las regiones anal y rectal.PRINCIPALES MEDIDAS DE RESULTADO:Se examinó la prevalencia de neuropatía lumbar y/o sacra. Los resultados secundarios fueron la correlación de la neuropatía con las funciones sensitivomotoras anorrectales y cambios morfológi-cos.RESULTADOS:Evaluamos 220 pacientes, 144 con incontinencia fecal, 76 con combinación de incontinencia fe-cal/estreñimiento y 31 sujetos sanos. Las ocho latencias de los potenciales evocadas motoras lum-bares y sacras se prolongaron significativamente (p <0,01) en la incontinencia fecal y el grupo mixto en comparación con los controles. La neuropatía fue irregular y afectaba 4,0 (3,0) (mediana (rango intercuartílico) sitios. Se observó neuropatía lumbar en 29-65% en la incontinencia fecal y 22-61% en el grupo mixto, y neuropatía sacra en 24-64% y 29-61 % de pacientes respectivamen-te. La neuropatía anal fue significativamente más prevalente (p <0,001) que la rectal en ambos grupos. No hubo correlación entre las latencias de los potenciales evocadas motoras y las presio-nes del esfínter anal, la sensación rectal o los defectos del esfínter anal.LIMITACIONES:Sin análisis comparativo con electromiografía.CONCLUSIÓNES:Se detectó neuropatía del plexo lumbar o sacro en el 40-75% de los pacientes con incontinencia fecal con una prevalencia dos veces mayor en la región anal que en el recto. La neuropatía lumbo-sacra parece ser un mecanismo independiente en la patogenia de la incontinencia fecal, no asocia-do con otras disfunciones sensitivomotoras. La estimulación magnética translumbosacral anorrec-tal tiene un alto rendimiento, es una prueba neurofisiológica segura y clínicamente útil. Consulte Video Resumen en http://links.lww.com/DCR/B728.

Nerve conduction assessment and magnetic resonance imaging for the diagnosis of localized hypertrophic neuropathy of the sciatic nerve and the lumbo-sacral plexus.

Localized hypertrophic neuropathy (LHN) are slowly growing nerve lesions causing progressive nerve deficit and weakness. We present the case of a 32-year old woman with long history of motor and sensory deficit complains along the sciatic nerve territory. The muscles involved were featured by delay in F waves at nerve conduction assessment. Magnetic resonance imaging (MRI) showed specific patterns, low intense on T1 and abnormally hyper intense on short tau inversion recovery (STIR) and T2, with no obvious enhancement, features compatible with either LHN or intraneural perineurioma (IP) of the sciatic nerve and/or the lumbosacral plexus. Focal thickening and hypertrophy of the sciatic nerve with preserved fascicular configuration and progressive enlargement of the right lumbosacral plexus could be noted. A nerve conduction assessment followed by an MRI eventually allowed to diagnose LHN, without performing a nerve biopsy. Although similar, LHN and IP are two distinct lesions which should be diagnosed and differentiated as soon as possible, to avoid potential complications due to delayed diagnosis and/or misdiagnosis.

A Supervised 3 Weeks Test Phase in Sacral Neuromodulation with a 1-Year Followup.

PURPOSE: We sought to determine whether prolonged interventional test phase increases cumulative success rate and compared success rates between early responders (ie within 1 week) and those in need for reprogramming (due to lack of efficacy) of sacral neuromodulation after 1-year followup. MATERIALS AND METHODS: In a single tertiary center prospective study (August 2015 to November 2018) 90 patients refractory to first line treatment were eligible for sacral neuromodulation, including 48 overactive bladder wet (53%), 8 overactive bladder dry (9%) and 34 nonobstructive urinary retention (38%). Patients were evaluated at weekly intervals during test phase and those not successful were reprogrammed. This could be repeated after the second week. Primary outcome was success rate after 3-week test phase and after 1-year followup. Statistical analysis was done by nonparametric tests for numeric (Mann-Whitney U) and categorical (chi2) data. RESULTS: After 3 weeks of test period 56 patients (62%) were considered successful. Prolonged interventional testing increased cumulative success. A 1-year followup showed no significant difference in success rate between early responders and those in need for reprogramming (chi2, p=0.562). There was no difference in age (Mann-Whitney U, p=0.222), sex (chi2, p=0.952) or indication (chi2, p= 0.975). CONCLUSIONS: A 3-week test phase with close followup increases cumulative success rate. During this supervised 3-week test phase 42% of the initial nonresponders after the first week became successful candidates after reprogramming. Patients who required this additional programming did equally as well as those without need for reprogramming. A supervised 3-week test phase is therefore strongly recommended.

Long-term outcomes of sacral neuromodulation for lower urinary tract dysfunction: A 23-year experience.

AIMS: To evaluate the long-term outcomes of sacral neuromodulation (SNM), and patient characteristics that may predict long-term success or complications. METHODS: A single-center retrospective cohort study was performed of all patients who underwent SNM testing and implantation. Outcome results, resolution of symptoms, and device removal were reported. Multivariable logistic regression was used to identify predictors of success. Cox proportional hazards model was used to identify predictors for device removal. RESULTS: Four hundred and thrity four patients underwent SNM test phase of which 241 (median age 48.0 years, 91.7% [221/241] female) had device implantation and were followed up for median [range] time of 4.0 (3 months-20.5 years) years. Multivariable logistic regression showed that male gender (odds ratio: 0.314; 95% confidence interval: 0.164-0.601, p = .0005) was independently associated with decreased peripheral nerve evaluation success. At final follow-up for patients who originally had device implantation, median (interquartile range) percent of symptoms resolution of all patients was 60.0% (0%-90%) and 69.3% (167/241) had SNM successful outcomes. Cox proportional hazards model showed no difference for time to SNM device removal with respect to patient age, gender, or diagnosis. 69.3% (167/241) patients had at least 1 surgical re-intervention. The most common reason at first surgical re-intervention was lead change only (26.3%, 44/167). CONCLUSION: SNM is a minimally invasive procedure with good long-term success rates. There is a high revision rate but overall, SNM has a good safety profile and excellent long-term outcomes.

Diabetic Lumbosacral Radiculoplexus Neuropathy (Diabetic Amyotrophy).

Diabetic lumbosacral radiculoplexus neuropathy, also known as diabetic amyotrophy, has a characteristic course of sudden onset of unilateral pain in the thigh and hip, which may spread to the other side in weeks to months and proceeds with progressive lower extremity weakness, often resulting in the inability to walk unassisted. The syndrome is typically monophasic, and most patients will recover at least to some degree. Less typical features include lack of pain, distal predominant weakness, absence of diabetes, and upper extremity involvement. This article provides a series of interesting cases to highlight the diagnostic challenges and discusses management decision making.

Magnetic resonance neurography of the lumbosacral plexus at 3 Tesla - CSF-suppressed imaging with submillimeter resolution by a three-dimensional turbo spin echo sequence.

PURPOSE: To investigate magnetic resonance neurography (MRN) of the lumbosacral plexus (LSP) with cerebrospinal fluid (CSF) suppression by using submillimeter resolution for three-dimensional (3D) turbo spin echo (TSE) imaging. MATERIALS AND METHODS: Using extended phase graph (EPG) analysis, the signal response of CSF was simulated considering dephasing from coherent motion for frequency-encoding voxel sizes ranging from 0.3 to 1.3 mm and for CSF velocities ranging from 0 to 4 cm/s. In-vivo MRN included 3D TSE data with frequency encoding parallel to the feet/head axis from 15 healthy adults (mean age: 28.5 ± 3.8 years, 5 females; acquisition voxel size: 2 × 2 × 2 mm3) and 16 pediatric patients (mean age: 6.7 ± 4.1 years, 7 females; acquisition voxel size: 0.7 × 0.7 × 1.4 mm3) acquired at 3 Tesla. Five of the adults were scanned repetitively with changing acquisition voxel sizes (1 × 2 × 2 mm3, 0.7 × 2× 2 mm3, and 0.5 × 2 × 2 mm3). Measurements of the bilateral ganglion of the L5 nerve root, averaged between sides, as well as the CSF in the thecal sac were obtained for all included subjects and compared between adults and pediatric patients and between voxel sizes, using a CSF-to-nerve signal ratio (CSFNR). RESULTS: According to simulations, the CSF signal is reduced along the echo train for moving spins. Specifically, it can be reduced by over 90% compared to the maximum simulated signal for flow velocities above 2 cm/s, and could be most effectively suppressed by considering a frequency-encoding voxel size of 0.8 mm or less. For in-vivo measurements, mean CSFNR was 1.52 ± 0.22 for adults and 0.10 ± 0.03 for pediatric patients (p < .0001). Differences in CSFNR were significant between measurements using a voxel size of 2 × 2 × 2 mm3 and measurements in data with reduced voxel sizes (p ≤ .0012), with submillimeter resolution (particularly 0.5 × 2 × 2 mm3) providing highest CSF suppression. CONCLUSIONS: Applying frequency-encoding voxel sizes in submillimeter range for 3D TSE imaging with frequency encoding parallel to the feet/head axis may considerably improve MRN of LSP pathology in adults in the future because of favorable CSF suppression.

Neural pathway of bellows response during SNM treatment revisited: Conclusive evidence for direct efferent motor response.

BACKGROUND: In sacral neuromodulation (SNM) patients, it is thought the bellows response elicited upon sacral spinal nerve stimulation is reflex-mediated. Therefore the mechanism of action of SNM is considered to be at the spinal or supraspinal level. These ideas need to be challenged. OBJECTIVE: To identify the neural pathway of the bellows response upon sacral spinal nerve stimulation. DESIGN, SETTING, AND PARTICIPANTS: Single tertiary center, prospective study (December 2017-June 2019) including 29 patients with overactive bladder refractory to first-line treatment. INTERVENTION: Recording of the pelvic floor muscle response (PFMR) using a camcorder and electromyography (EMG) (intravaginal probe and concentric needles) upon increasing stimulation during lead or implantable pulse generator placement. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The lowest stimulation intensity needed to elicit a visual PFMR and electrical PFMR was determined. Electrical PFMRs were subdivided according to their latency. OUTCOME: the association between visual and electrical PFMRs. Statistical analyses were performed using the weighted kappa coefficient. RESULTS: Three different electrical PFMRs could be identified by surface and needle EMG, corresponding with a direct efferent motor response (R1), oligosynaptic (R2), and polysynaptic (R3) afferent reflex response. Only the R1 electrical PFMR was perfectly associated with the visual PFMR (κ = 0.900). CONCLUSIONS: The visual PFMRs upon sacral spinal nerve stimulation are direct efferent motor responses. A reopening of the discussion on the mechanism of action of SNM is possibly justified.

Refractory overactive bladder patients who chose sacral neuromodulation therapy after failed OnabotulinumtoxinA treatment: A systematic review and meta-analysis.

OBJECTIVE: To systematically review outcomes in patients with refractory overactive bladder (OAB) patients who underwent sacral neuromodulation therapy (SNM) therapy after unsuccessful onabotulinumtoxinA (BTX) therapy, and to compare outcomes with those who SNM as initial therapy. METHODS: A systematic search of Cochrane Library, Pubmed and Embase databases from July 2002 to November 2019, to analyze randomized controlled trials and retrospective studies of SNM therapy after failed initial BTX therapy. Two reviewers independently screened the studies and extracted data. A quality assessment of the included literature was conducted using Newcastle-Ottawa Scale (NOS), and Stata 12.0 software was used to conduct a meta-analysis of the collected data. RESULTS: A total of seven studies involving 319 patients were finally included. The success rate in refractory OAB patients who used SNM therapy after failed BTX therapy was 58.5%, 95% CI (0.47-0.70). There was no significant difference between refractory OAB patients who chose SNM as replacement therapy after failed BTX therapy and those who used SNM therapy as first choice [RR = 0.96, 95%CI (0.72-1.26), P = 0.735]. CONCLUSION: OAB patients for whom an initial choice of BTX therapy ends in failure or dissatisfaction may consider switching to SNM therapy. There is no difference in outcomes between these patients and those whose first choice was SNM therapy.

Rehabilitation strategies for low anterior resection syndrome. A systematic review.

OBJECTIVE: To summarize the evidence in the literature about rehabilitative treatments that reduce low anterior resection syndrome (LARS) symptoms in patients who underwent surgery for colorectal cancer. METHODS: We have search in PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health and Scopus databases. Studies selected were limited to those including only patient undergone low rectal resection with sphincter preservation and with pre-post assessment with a LARS score. Five articles fit the criteria. RESULTS: The percutaneous tibial nerve stimulation demonstrated moderate results and sacral nerve stimulation was found to be the best treatment with greater symptom improvement. Only one study considered sexual and urinary problems in the outcomes assessment. CONCLUSIONS: In clinical practice patients should evaluate with the LARS and other score for evaluation of urinary and sexual problems. Future research must be implemented with higher quality studies to identify the least invasive and most effective treatment/s.

Comparing the Efficacy of OnabotulinumtoxinA, Sacral Neuromodulation, and Peripheral Tibial Nerve Stimulation as Third Line Treatment for the Management of Overactive Bladder Symptoms in Adults: Systematic Review and Network Meta-Analysis.

The American Urological Association guidelines for the management of non-neurogenic overactive bladder (OAB) recommend the use of OnabotulinumtoxinA, sacral neuromodulation (SNM), and peripheral tibial nerve stimulation (PTNS) as third line treatment options with no treatment hierarchy. The current study used network meta-analysis to compare the efficacy of these three modalities for managing adult OAB syndrome. We performed systematic literature searches of several databases from January 1995 to September 2019 with language restricted to English. All randomized control trials that compared any dose of OnabotulinumtoxinA, SNM, and PTNS with each other or a placebo for the management of adult OAB were included in the study. Overall, 17 randomized control trials, with a follow up of 3-6 months in the predominance of trials (range 1.5-24 months), were included for analysis. For each trial outcome, the results were reported as an average number of episodes of the outcome at baseline. Compared with the placebo, all three treatments were more efficacious for the selected outcome parameters. OnabotulinumtoxinA resulted in a higher number of complications, including urinary tract infection and urine retention. Compared with OnabotulinumtoxinA and PTNS, SNM resulted in the greatest reduction in urinary incontinence episodes and voiding frequency. However, comparison of their long-term efficacy was lacking. Further studies on the long-term effectiveness of the three treatment options, with standardized questionnaires and parameters are warranted.

MR neurography of lumbosacral nerve roots: Diagnostic value in chronic inflammatory demyelinating polyradiculoneuropathy and correlation with electrophysiological parameters.

PURPOSE: MR neurography(MRN) is an advanced imaging technique to visualize peripheral nerves. Our aim was to determine the value of morphological features of lumbosacral nerve roots on MRN in diagnosing chronic inflammatory demyelinating polyradiculoneuropathy(CIDP) and analyze their correlations with electrophysiological parameters. METHODS: MRN of lumbosacral plexus was performed in 21 CIDP patients and 21 healthy volunteers. The cross-sectional areas(CSAs) and signal intensities(SI) of L3 to S1 nerve roots were measured and compared between two groups. Receiver operating characteristic(ROC) curves were plotted to assess the diagnostic accuracy. All patients also underwent nerve conduction studies. Correlations between CSAs and SI of lumbosacral nerve roots and electrophysiological parameters were analyzed. RESULTS: Compared with control group, CIDP patients showed significantly increased CSAs and SI from L3 to S1 nerve root (P < 0.001 and P < 0.05 respectively for all nerve roots). The CSAmean and SImean were 28.04 ± 8.55mm2, 1.314 ± 0.199 for patient group and 14.91 ± 2.36mm2,1.155 ± 0.094 for control group. ROC analysis revealed the best diagnostic accuracy for the CSAmean with an area under the curve of 0.968 and optimal cut-off value of 19.20 mm2. CSAs of L5 or S1 nerve root correlated positively with central latency and negatively with conduction velocity of tibial nerve. SI of L5 also had a positive correlation with latency of sural nerve. CONCLUSIONS: Evaluation of lumbosacral nerve roots on MRN in a quantitative manner may serve as an important tool to support the diagnosis of CIDP.

Early sacral neuromodulation ameliorates urinary bladder function and structure in complete spinal cord injury minipigs.

AIMS: To determine the effects of early sacral neuromodulation (SNM) and pudendal neuromodulation (PNM) on lower urinary tract (LUT) function, minipigs with complete spinal cord injury (cSCI) were analyzed. SNM and PNM have been proposed as therapeutic approaches to improve bladder function, for example after cSCI. However, further evidence on efficacy is required before these methods can become clinical practice. METHODS: Eleven adults, female Göttingen minipigs with cSCI at vertebral level T11-T12 were included: SNM (n = 4), PNM (n = 4), and SCI control (SCIC: n = 3). Tissue from six healthy minipigs was used for structural comparisons. Stimulation was started 1 week after cSCI. Awake urodynamics was performed on a weekly basis. After 16 weeks follow-up, samples from the urinary bladder were taken for analyses. RESULTS: SNM improved bladder function with better capacities and lower detrusor pressures at voiding and avoided the emergence of detrusor sphincter dyssynergia (DSD). PNM and untreated SCI minipigs had less favorable outcomes with either DSD or constant urinary retention. Structural results revealed SCI-typical fibrotic alterations in all cSCI minipigs. However, SNM showed a better-balanced distribution of smooth muscle to connective tissue with a trend towards the reduced progression of bladder wall scarring. CONCLUSION: Early SNM led to an avoidance of the emergence of DSD showing a more physiological bladder function during a 4 month follow-up period after cSCI. This study might pave the way for the clinical continuation of early SNM for the treatment of neurogenic LUT dysfunction after SCI.

Radiofrecuencia pulsada del ganglio de la raíz dorsal en el síndrome radicular lumbosacro crónico refractario a los esteroides epidurales / Pulsed radiofrequency of the dorsal root ganglion for chronic lumbosacral radicular syndrome refractory to epidural steroid injections

Introducción: Aproximadamente, el 20 % de los pacientes con síndrome radicular lumbosacro crónico no responden a las inyecciones epidurales de esteroides. La radiofrecuencia pulsada del ganglio de la raíz dorsal (GRD) es una alternativa terapéutica en ellos. Objetivos: Evaluar el efecto analgésico de la radiofrecuencia pulsada del GRD en pacientes con síndrome radicular lumbosacro crónico, refractario a los esteroides epidurales. Material y método: 31 pacientes con síndrome radicular lumbosacro crónico que no respondieron a dos inyecciones epidurales de esteroides fueron tratados con radiofrecuencia pulsada del GRD a 45 V y 42 °C, en 2 ciclos de 120 segundos. Se utilizó el Inventario Abreviado de Dolor para evaluar los resultados. Se consideró una respuesta satisfactoria al procedimiento una disminución de dos puntos en la escala verbal numérica (EVN) evaluada en la pregunta 6 del inventario abreviado de dolor. Los índices de intensidad y de interferencia fueron calculados antes y después del tratamiento. Resultados: La EVN se redujo de 7,7 +/- 2,2 a 5,9 +/- 3 (p < 0,01). Los índices de intensidad e interferencia disminuyeron de 7,1 +/- 1,5 a 5,9 +/- 2,1 (p < 0,01) y 7,1 +/- 1,9 a 6,0 +/- 2,3 (p < 0,02) respectivamente. 12 de los 30 pacientes (40 %) presentaron una respuesta analgésica satisfactoria. En estos, la EVN disminuyó de 8,0 +/- 1,5 a 3,8 +/- 2,6 y los índices de intensidad e interferencia de 7,4 +/- 1,3 a 3,9 +/- 1,5 (p < 0,0001) y 7,7 +/- 1,9 a 4,9 +/- 2,7 (p = 0,002), respectivamente. Conclusiones: La aplicación de radiofrecuencia pulsada en el GRD reduce en forma discreta pero estadísticamente signifi cativa la intensidad del dolor y su interferencia funcional en pacientes con síndrome radicular lumbosacro refractario a las inyecciones epidurales de esteroides, al mes de realizada. En aproximadamente el 40 % se obtuvieron respuestas analgésicas satisfactorias que, en algunos casos, se extendió a tres meses tras realizar el procedimiento

Introduction: Approximately 20 % of patients with chronic lumbosacral radicular syndrome do not respond to epidural steroid injections. Pulsed radiofrequency of the dorsal root ganglion (DRG) is proposed as an alternative treatment. Objetive: To evaluate the analgesic effect of pulsed radiofrequency of the DRG in patients with chronic lumbosacral radicular syndrome, refractory to epidural steroid injections. Patients and method: 31 patients with chronic lumbosacral radicular syndrome that failed to at least two epidural steroid injections, received pulsed radiofrequency of the DRG, utilizing two cycles of 120 seconds, 45 V and 42 °C. Evaluation was carried out a month later. Brief Pain Inventory was applied before procedure and one month later. A reduction of 2 points in the verbal numerical scale (VNS) assessed with the question 6 of the Brief Pain Inventory, was considered a satisfactory analgesic response. Intensity and Interference Scores were calculated. Results: The VNS score decreased from 7.7 +/- 2,2 to 5.9 +/- 3 (p < 0.01). Intensity and Interference Scores were reduced from 7.1 +/- 1.5 to 5.9 +/- 2.1 (p < 0.01) and 7.1 +/- 1.9 to 6.0 +/- 2.3 (p < 0.02) respectively. In 12 patients (40 %) a satisfactory analgesic response was observed. In these patients the VNS decreased from 8.0 +/- 1.5 to 3.8 +/- 2.6. Intensity and Interference Scores were reduced from 7.4 +/- 1.3 to 3.9 +/- 1.5 (p < 0.0001) y 7.7 +/- 1.9 to 4.9 +/- 2,7 (p = 0.002) respectively. Conclusions: DRG pulsed radiofrequency produce a mild but statistically signifi cant reduction in VNS and pain interference, in patients with chronic lumbosacral radicular syndrome. However, in 40 % of the patients a satisfactory analgesic effect was observed. In some of them this changes persist after 3 months of the procedures

[Sacral neuromodulation in under- and overactive detrusor-quo vadis? : Principles and developments]. / Sakrale Neuromodulation bei unter- und überaktivem Detrusor ­ quo vadis? : Prinzipien und Entwicklungen.

BACKGROUND: Sacral neuromodulation (SNM) has been used in the treatment of refractory overactive bladder syndrome, nonobstructive urinary retention and faecal incontinence for almost 40 years now. It is not to be confused with the sacral anterior root stimulation which is exclusively used for bladder dysfunction due to spinal paraplegia. MECHANISM OF ACTION: The principles of SNM are yet to be fully understood. Nevertheless, there is proof of modulating the activity of several micturition-associated, afferent neurons in the spine, brainstem and cerebrum. Thus, premature detrusor contractions are suppressed, the desire to void is delayed and detrusor-sphincter coordination improves. TECHNIQUES OF IMPLANTATION AND STIMULATION: Motor reactions are an important indicator of correct electrode placement. The implantation procedure consists of two stages with an initial trial phase to determine the best possible treatment response through an external generator before implanting the whole stimulating device. Yearly check-up examinations are recommended; wireless adjustments allow for long-lasting symptom reduction. INDICATION AND OUTCOME: Success rates in the treatment of the refractory overactive bladder syndrome and the non-obstructive urinary retention lie above 70% and can still be perceived as sufficient after 5 years of ongoing SNM therapy. There is also profound evidence of SNM being an effective option for patients with faecal incontinence or chronic obstipation. CONTRAINDICATIONS AND RISKS: Children, pregnant women and patients in need of frequent MRI examinations are usually not eligible for SNM therapy. Infection of the implant, technical failure (including lead displacement and battery depletion) and pain in the implantation site are important adverse effects which might require surgical revision. CONCLUSIONS: The indications for SNM in the German health care system can be expected to be expanded upon the chronic pelvic pain syndrome, erectile dysfunction and additional gastrointestinal conditions. Technical progress will continue to improve the risk-benefit ratio of SNM.

First-in-human implantation of a mid-field powered neurostimulator at the sacral nerve: Results from an acute study.

INTRODUCTION: Commercially approved implantable systems for sacral neuromodulation require the implantation of a multipolar lead subcutaneously connected to an implantable pulse generator (IPG). Eliminating the need for an IPG would eliminate the need for tunneling of the lead, reduce procedure time, infection risk, and the need for IPG replacement. The objective was to demonstrate the feasibility of implanting the AHLeveeS System in the S3 Foramen to stimulate the S3 sacral nerve. MATERIALS AND METHODS: A first-in-human, prospective, single center, nonrandomized, acute feasibility clinical investigation at the Maastricht University Medical Center+. Patients with refractory overactive bladder underwent acute implantation of the AHLeveeS neurostimulator before the InterStim procedure. Outcome measurements included motor responses, procedural time and a scoring of the difficulty of the implant and explant procedure. Retrospectively, qualitative responses to the stimulation protocol were assessed by video motion analyses. Only descriptive statistics were used. RESULTS: During the stimulation a motor response to stimulation was seen in four of the five subjects. In all implantations the AHLeveeS was correctly placed. The median time for complete procedure was 24 minutes. The implant and explant procedures were successfully performed and no device or procedure related adverse events occurred. CONCLUSIONS: The results from this acute first-in-human study demonstrate the feasibility of implantation and acute stimulation of the sacral nerve with this mid-field powered system. Future clinical studies will focus on safety and efficacy of a chronically implanted device.

A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature.

BACKGROUND: Giant Tarlov cysts are always symptomatic and mimic many serious pathologic entities. We present the largest, to our knowledge, reported Tarlov cyst. CASE DESCRIPTION: A 33-year-old woman with Marfan syndrome suffered from right kidney hydronephrosis because of ureter obstruction, for which she was treated with nephrostomy. Her neurologic examination was unremarkable. The role of magnetic resonance imaging in the management of this case is described. Absence of intractranial hypotension symptoms after cerebrospinal fluid (CSF) overdrainage suggested the presence of a valve-like mechanism. The patient was planned for surgical cyst remodeling by the application of titanium clips. The cyst's neck was exposed through an L5-S2 laminectomy. L5 and S1 laminae were severely eroded. CSF leaked out of the underlying, bulging, and thinned dura at each attempt for clip application. Intraoperatively, multiple responses from the S1, S2, and S3 roots were simultaneously recorded at each stimulation. Therefore, we decided to abandon this technique and performed a nonwatertight duroplasty followed by a layered wound closure instead. A week later, the patient received a lumbar-peritoneal shunt. The patient remained neurologically intact, the cyst shrunk, and the nephrostomy was removed. CONCLUSIONS: Indirect evidence was helpful to assess for the presence of a valve-like mechanism. Intraoperatively, the surgeon must keep on high alert for sacral erosion to avoid inadvertent dural tear and rootlet injury. Finally, lumboperitoneal diversion remains a valid alternative in the management of our giant Tarlov cyst because it reduced the intracystic pressure that resulted in cyst regression.

Repeatability of tools to assist in the follow up and troubleshooting of sacral neuromodulation patients using the sensory response.

PURPOSE: Sacral neuromodulation (SNM) is an established minimally invasive therapy for functional disorders of the pelvic organs in which electrodes are stimulated in proximity of the sacral spinal nerves. Reprogramming of the electrodes is regularly required and is based on the sensory response. This study assesses the repeatability of a pelvic chart and grading system to enable a more objective assessment of the sensory response upon electrode stimulation. MATERIAL AND METHODS: In 26 SNM patients, with OAB or NOUR, assessment of the sensory response was done using the sensory threshold (ST) and a pelvic chart with 1 cm2 coordinates, each coordinate corresponding with a dermatome and location of sensation (LoS). A grading system was developed based upon the ST and LoS. Repeatability of ST was assessed using a two-way mixed effects, absolute agreement, single rater/measurement intraclass correlation coefficient (ICC), and displayed using a correlation and Bland Altman plot. Repeatability of dermatomes, LoS, and grading system was assessed using kappa correlation coefficient. RESULTS: On average, 1.55 ± 0.85 coordinates were used to point out the area where the stimulation was perceived. The mean amount of coordinates between the area pointed at during the first and second measurement was 0.47 ± 0.74. ST showed excellent repeatability (ICC 0.93, 95%CI 0.90-0.94, P < 0.001). Dermatomes, LoS and grading system showed a substantial to almost perfect agreement (κ = 0.740-0.833, P < 0.001). CONCLUSIONS: The pelvic chart and grading system, using the sensory response upon electrode stimulation, are repeatable tools and can be used to assist in follow up and troubleshooting of SNM patients.

A prospective, multicenter study of a novel, miniaturized rechargeable sacral neuromodulation system: 12-month results from the RELAX-OAB study.

AIMS: Historically, providing SNM therapy required use of a non-rechargeable implantable pulse generator (IPG) with an average device lifespan of 4.4 years. Multiple device replacement surgeries are necessary with this device for long-term overactive bladder (OAB) management. A longer-lived device can reduce and potentially eliminate the need for replacement surgeries, thereby improving the long-term safety and cost-effectiveness of SNM therapy. The objective of this study was to evaluate the safety and efficacy of a miniaturized, rechargeable SNM system. METHODS: This prospective, multi-center study implanted 51 subjects with the SNM system in a single stage procedure without an external trial period. Subjects had overactive bladder as demonstrated on a 3-day voiding diary (≥8 voids/day and/or ≥2 incontinence episodes over 72-h). Outcome measures at 1-year follow-up included quality of life (evaluated by ICIQ-OABqol questionnaire), therapy responder rates (≥50% reduction in voids and/or leaks or <8 voids per day), subject satisfaction questionnaire, and adverse events (AEs). RESULTS: At 1-year, 94% of Test Responders continued to respond to r-SNM therapy based on bladder diary criteria. Subjects experienced significant improvement of 21.1 points on the ICIQ-OABqol. 84% of subjects were satisfied with r-SNM therapy and 98% found their charging experience acceptable. Device-related AEs occurred in 21% of subjects, with discomfort due to stimulation occurring in 20% of subjects. This AE was resolved with reprogramming in all instances. CONCLUSIONS: The Axonics r-SNM System provides sustained clinically significant improvements in OAB subjects after 1-year. Subjects were satisfied with r-SNM therapy and reported an easy and acceptable recharging experience.