Subarachnoid space of the optic nerve sheath and intracranial hypertension: a macroscopic, light and electron microscopic study.

PURPOSE: The optic nerve (ON) is an extension of the central nervous system via the optic canal to the orbital cavity. It is accompanied by meninges whose arachnoid layer is in continuity with that of the chiasmatic cistern. This arachnoid layer is extended along the ON, delimiting a subarachnoid space (SAS) around the ON. Not all forms of chronic intracranial hypertension (ICH) present papilledema. The latter is sometimes asymmetric, unilateral, or absent. The radiological signs of optic nerve sheath (ONS) dilation, in magnetic resonance imaging, are inconsistent or difficult to interpret. The objective of this study was to analyze the anatomy, the constitution, and the variability of the SAS around the ON in its intraorbital segment to improve the understanding of the pathophysiologic mechanism of asymmetric or unilateral or absent papilledema in certain ICH. METHODS: The study was carried out on nine cadaveric specimens. In four embalmed specimens, macroscopic analysis of the SAS of the ONS were performed, with description about density of the arachnoid trabecular meshwork in three distinct areas (bulbar segment, mid-orbital segment and the precanal segment). In three other embalmed specimens, after staining of SAS by methylene blue (MB), we performed macroscopic analysis of MB progression in the SAS of the ONS. Then, in two non-embalmed specimens, light and electron microscopy (EM) analysis were also done. RESULTS: On the macroscopic level, after staining of SAS, we found in all cases that MB progressed on 16 mm average throughout the SAS of the ONS without reaching the papilla. In four embalmed specimens, in the SAS of the ONS, the density of the arachnoid trabecular meshwork showed inter-individual variability (100%) and intra-individual variability with bilateral variability (50%) and/or variability within the same ONS (88%). On the microscopic level, the arachnoid trabeculae of the ONS are composed of dense connective tissue. The EM perfectly depicted its composition which is mainly of collagen fibers of parallel orientation. CONCLUSION: The variability of the SAS around the ONS probably impacts the symmetrical or asymmetrical nature of papilledema in ICH.

Anatomy of the greater occipital nerve: implications in posterior fossa approaches.

PURPOSE: Because of its superficial location in the dorsal regions of the scalp, the greater occipital nerve (GON) can be injured during neurosurgical procedures, resulting in post-operative pain and postural disturbances. The aim of this work is to specify the course of the GON and how its injuries can be avoided while performing posterior fossa approaches. METHODS: This study was carried out at the department of anatomy at Bordeaux University. 4 specimens were dissected to study the GON course. Posterior fossa approaches (midline suboccipital, paramedian suboccipital, retrosigmoid and petrosal) were performed on 4 other specimens to assess potential risks of GON injuries. RESULTS: The GON runs around the obliquus capitis inferior (100%), crosses the semispinalis capitis (100%) and the trapezius (75%) or its aponeurosis (25%). Direct GON injuries can be seen in paramedian suboccipital approaches. Stretching of the GON can occur in midline suboccipital and paramedian suboccipital approaches. We found no evidence of direct or indirect GON injury in retrosigmoid or petrosal approaches. CONCLUSION: Our study provides interesting data regarding the risk GON injury in posterior fossa approaches. Direct GON injuries in paramedian suboccipital approaches can be avoided with careful dissection. Placing retractors in contact with the periosteum and performing a minimal retraction may help to avoid excessive GON stretching in midline suboccipital and paramedian suboccipital approaches. Furthermore, the incision for retrosigmoid approaches should be as lateral as possible and not too caudal. Finally, avoiding extreme patient positioning reduces the risk of GON stretching in all approaches.

Growth-promoting action and growth factor release by different platelet derivatives.

Abstract Platelet derivatives are commonly used in wound healing and tissue regeneration. Different procedures of platelet preparation may differentially affect growth factor release and cell growth. Preparation of platelet-rich fibrin (PRF) is accompanied by release of growth factors, including platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF) and transforming growth factor ß1 (TGFß1), and several cytokines. When compared with the standard procedure for platelet-rich plasma (PRP), PRF released 2-fold less PDGF, but >15-fold and >2-fold VEGF and TGFß1, respectively. Also, the release of several cytokines (IL-4, IL-6, IL-8, IL-10, IFNγ, MIP-1α, MIP-1ß and TNFα) was significantly increased in PRF-conditioned medium (CM), compared to PRP-CM. Incubation of both human skin fibroblasts and human umbilical vein endothelial cells (HUVECs) with PRF-derived membrane (mPRF) or with PRF-CM enhanced cell proliferation by >2-fold (p<0.05). Interestingly, PRP elicited fibroblast growth at a higher extent compared to PRF. At variance, PRF effect on HUVEC growth was significantly greater than that of PRP, consistent with a higher concentration of VEGF in the PRF-CM. Thus, the procedure of PRP preparation leads to a larger release of PDGF, as a possible result of platelet degranulation, while PRF enhances the release of proangiogenic factors.

[Intracranial hemorrhage in adults: place of antithrombotic treatment]. / Hémorragies intracrâniennes de l'adulte : implication de plus en plus importante des traitements antithrombotiques ?

BACKGROUND AND PURPOSE: Antithrombotic (anticoagulants and antiplatelets) are responsible for iatrogenic accidents, with a specific impact in neurosurgery. Bleeding complications are the most common and best-known. But the link to antiplatelet or to dual association of antithrombotic treatment with intracranial haemorrhage is not complete yet. We studied the proportion of patients under antithrombotic treatment, when an intracranial hemorrhage occurred, as well as the morbi-mortality of each group of patients (with or without antithrombotic treatment). Finally, we studied the proportion of off-label prescriptions. METHODS: We conducted a monocentric and comprehensive prospective study on a group of patients. All patients that had been admitted for intracranial hemorrhage to our hospital, in a 5-month period were included in the study. RESULTS: One hundred and sixty patients admitted for an intracranial hemorrhage were included during 70days of call. Seventy-four of these patients (46.25%) were under antithrombotic treatment: 40 under antiplatelet treatment (54%), 29 under anticoagulant treatment (39.2%), four under dual antithrombotic treatment (5.4%), and one under Arixtra(®). Half of the patients under antithrombotic treatment had poor prognosis as compared to 40% of patients without antithrombotic treatment. Off-label antithrombotic therapy was estimated at 27.3% of all prescriptions. CONCLUSIONS: The prevalence of antithrombotic therapy in patients is high when intracranial hemorrhage occurs. Some complications could be avoided by decreasing the number of off-label prescriptions and by better controlling their use (using standardized INR). Antiplatelet treatments and new antithrombotic therapies require better drug monitoring which could be part of the establishment of a specific register.

An unusual case of attempted suicide by a depressive woman: self-inflicted intracranial stabbing.

Self-inflicted stab injury to the skull, particularly in the neurocranium, is a rare method used to commit suicide. Herein is presented a case of a 26-year old woman with a temporal wound found by her partner in their home. No weapon was found in the approximate environment and the victim said that she fell. A CT scan performed at admission to the emergency room was interpreted as being compatible with injury from falls. A second CT scan in a neurosurgical unit suggested a cranio-cerebral injury from a sharp object; aggression was suspected. The discording elements led to an interview with a psychiatrist and diagnosis of attempted suicide through the action of a knife in the context of severe depression. This is a rare case that implicates a depressive woman and stabbing directly to the neurocranium.

Adipocyte-released insulin-like growth factor-1 is regulated by glucose and fatty acids and controls breast cancer cell growth in vitro.

AIMS/HYPOTHESIS: Type 2 diabetes and obesity are associated with increased risk of site-specific cancers. We have investigated whether metabolic alterations at the level of adipose-derived differentiating cells may affect specific phenotypes of breast cancer cells. METHODS: Growth profiles of breast cancer cell lines were evaluated in co-cultures with differentiated adipocytes or their precursor cells and upon treatment with adipocyte conditioned media. Production and release of cytokines and growth factors were assessed by real-time RT-PCR and multiplex-based ELISA assays. RESULTS: Co-cultures with either differentiated mouse 3T3-L1 or human mammary adipocytes increased viability of MCF-7 cells to a greater extent, when compared with their undifferentiated precursors. Adipocytes cultured in 25 mmol/l glucose were twofold more effective in promoting cell growth, compared with those grown in 5.5 mmol/l glucose, and activated mitogenic pathways in MCF-7 cells. Growth-promoting action was also enhanced when adipocytes were incubated in the presence of palmitate or oleate. Interestingly, 3T3-L1 and human adipocytes released higher amounts of keratinocyte-derived chemokine/IL-8, the protein 'regulated upon activation, normally T expressed, and secreted' (RANTES), and IGF-1, compared with their precursor cells. Their levels were reduced upon incubation with low glucose and enhanced by fatty acids. Moreover, both undifferentiated cells and differentiated adipocytes from obese individuals displayed about twofold higher IGF-1 release and MCF-7 cell growth induction than lean individuals. Finally, inhibition of the IGF-1 pathway almost completely prevented the growth-promoting effect of adipocytes on breast cancer cells. CONCLUSIONS/INTERPRETATION: IGF-1 release by adipocytes is regulated by glucose and fatty acids and may contribute to the control of cancer cell growth in obese individuals.

[Orbital tumors. Neurosurgical activity]. / Tumeurs orbitaires. Activité neurochirurgicale.

In this chapter, we report the results of orbital tumor management in a few neurosurgical departments and compare it to a Paris neurosurgical department that has developed a close relation with an ophthalmological department. These departments' activity is quite low, treating mainly sphenoorbital meningiomas. Other tumor groups are unequally and sporadically managed.

[Study of the junction between the cortical bridging veins and basal cranial venous sinus]. / Etude anatomique du drainage des veines corticales inférieures dans le sinus transverse.

INTRODUCTION: The cerebral venous system is poorly known and is best appreciated based on macroscopic anatomical considerations. We present an anatomical and immunohistochemical study to better define the morphological characteristics of the junction between the inferior cortical veins and the transversal sinuses. MATERIAL AND METHODS: Sixteen cadaveric specimens from the anatomy laboratory of the University Victor-Segalen of Bordeaux were studied. The venous junctions with the transversal sinuses were observed under the operating microscope. Thirty vein-sinus junctions were immunohistochemically stained with smooth muscle actin. Ten venous junctions were observed under the electronic microscope. RESULTS: The inferior cortical veins drain into the transverse sinus either directly or through a tentorial sinus. The venous orifices in the transverse sinuses share the same characteristics. They are oval with semicircular superior dural reinforcement and follow an orientation opposite venous flow in the transversal sinus. The histologic study showed that the walls of the cortical veins contained smooth muscle cells as well as the dural reinforcement of the transversal sinuses. CONCLUSION: The venous orifices of the inferior cortical veins have the anatomical features of true sphincters. Their function in the regulation of the cerebral blood flow needs further exploration.

Junction between the great cerebral vein and the straight sinus: an anatomical, immunohistochemical, and ultrastructural study on 25 human brain cadaveric dissections.

The cerebral venous system is poorly understood, and best appreciated under macroscopic anatomical considerations. We present an anatomical and immunohistochemical studies to better define the morphological characteristics of the junction between the great cerebral vein and the straight sinus. Twenty-five cadaveric specimens from the anatomy laboratory of the University Victor Segalen of Bordeaux were studied. The observation of the venous junctions with the straight sinus was performed under an operating microscope. The smooth muscular actin immunohistochemical staining was performed for 18 veno-sinosal junctions. Five venous junctions were observed using an electron microscope. We observed 3 different anatomic aspects: type 1 was a junction with a small elevation in its floor and a posterior thickening (14 cases); type 2 was a junction with an outgrowth on the floor like a cornice (7 cases); and type 3 was a junction presenting a nodule. Microscopic study of type 1 and 2 junctions showed a positive coloration to orceine attesting the presence of elastic fibers. Immunohistochemistry revealed the presence of smooth muscular actin and S 100 protein attesting the presence of smooth muscular fibers and nervous fibers. We observed in the ultrastructural study, a morphological progression of the endothelium. The venous orifice of the great cerebral vein into the straight sinus could be anatomically assimilated as a true "sphincter." Its function in the regulation of the cerebral blood flow needs further exploration.

Peritumoral edema and prognosis in intracranial meningioma surgery.

Peritumoral brain edema (PTBE) is often associated with meningiomas. PTBE is probably implicated in the complications occurring in intracranial meningiomas. The goal of this study was to determine the exact implication of PTBE in prognosis. Thirty consecutive patients who underwent surgery for intracranial meningiomas were investigated over a 1-year period. We focused on the clinical and radiological status before and after surgery, and postoperative complications. Multiple regression analysis revealed a close correlation (p<0.05) between PTBE and symptoms, type of arterial supply, difficulty of surgical removal, and postoperative complications. PTBE is likely implicated in the morbidity of intracranial meningiomas. We suggest predictive factors for difficult surgical resection, and emphasise the importance of medical preoperative management and post-operative follow-up.

[Chordoma radicular metastasis following cerebrospinal fluid dissemination]. / Métastase radiculaire d'un chordome secondaire à une dissémination dans le liquide cérébrospinal.

INTRODUCTION: Chordoma metastases are usually found at advanced stages of the disease. The metastases occur generally in lung, bones, liver and lymph nodes. We report a rare case of radicular chordoma metastasis. CLINICAL CASE: A 59-year-old man, operated for a clival chordoma six years ago, was admitted for atypical S1 radiculopathy. The MRI showed lumbar intradural tumor compressing the cauda equina. Surgery was performed. RESULTS: After opening of the dura mater, the tumor was seen tightly attached to the nerve roots and was totally removed. The histological examination confirmed a metastasis of the known chordoma without local recurrence. CONCLUSION: Chordomas are slowly growing, aggressive malignancies. Mostly complete microsurgical resection reduces local and distant recurrences. Intradural metastases are rare and follow cerebrospinal fluid dissemination from tumor cells. These metastases must be actively cured to achieve longer survival and better quality of life.

beta(2)-Microglobulin amyloidosis caused spinal cord compression in a long-term haemodialysis patient.

STUDY DESIGN: A case report of cervical myelopathy caused by epidural beta (2)-microglobulin (beta2m) amyloid deposits in a 50-year-old woman with haemodialysis treatment. OBJECTIVE: Long-term haemodialysis in patients with end-stage renal disease leads to several complications based on beta2m deposits, which can affect, in the cervical spine, the intervertebral disk, and in rare cases, they may compress the spinal cord and nerves. The objective of this report is to describe the clinical and radiological follow-up preceding the indispensable surgical excision of an amyloid mass in a 50-year-old woman with haemodialysis treatment. Long-term postoperative cervicalgia owing to subcondylian bone cyst-associated atlanto-occipital instability is also described and discussed. SETTING: Department of Neurosurgery A, Hop Pellegrin, Bordeaux, France. CASE REPORT: We present a clinical case of a patient with spinal cord compression. The patient was treated by surgical excision of an amyloid mass subsequent to a C2-C3 laminectomy. The patient experienced clinical improvement with a regression of all of her neurological symptoms. Histological findings confirm the diagnosis of beta2m amyloid deposition. However, 5 years after surgery the subcondylian bone cysts were still observed and atlanto-occipital instability required her to wear a minerva. CONCLUSION: Our case report confirms that surgical excision of beta2m epidural deposits is necessary and relevant when neurological prognosis is discussed, and that pain is still the major symptom of disease evolution. The use of high-flux synthetic membranes could decrease the beta2m blood level and early renal graft is the only method to prevent such complications.

Results in the Operative Treatment of Elderly Patients with Spinal Meningiomas

Objective : With the life expectancy in the industrial nations increasing over the last two decades; the number of patients older than 70 years with spinal tumors and; especially; meningiomas is rising. Our objective is to assess the outcome of surgically treated spinal meningiomas in patients in their eighth or ninth decade of life and to analyze the possible role of some prognostic factors. Patients and methods : Twenty seven consecutive patients over 70 years of age (mean age; 78.3 years) were operated on for spinal meningiomas between 1995 and 2005 in Bordeaux's Neurosurgery Departement. The preoperative neurologic status of the patients was graded with the Solero score; and the general health conditions were staged according to the American Society of Anesthesiology classification. Tumor were removed totally in 26 cases and subtotally removed in one. The follow-up period ranged from 12 to 81 months (mean; 27.1 months). Results: There was no operative mortality; and morbidity was not significant. Although not significant; neurologic outcome was better in patients with a low preoperative Solero score than those with a high one (P 0.01). Clinical outcome was not influenced by the preoperative general health conditions according to American Society of Anesthesiology classification (p0.07). Clinical outcome was influenced by the duration of symptoms before surgery (p0.05). No recurrence was observed during the follow-up period. Conclusion: Neurologic outcome following surgery was favorable in the vast majority of patients; with no mortality or significant morbidity. Surgery is the only treatment in elderly patients with symptomatic spinal meningiomas; even for those with a poor preoperative neurologic condition. Whenever there is an acceptable risk from an anesthesiological point of view

[Side-to-end hypoglossal-facial nerve anastomosis with intratemporal facial nerve translocation. Long-term results and indications in 15 cases over 10 years]. / L'anastomose hypoglosso-faciale latéro-terminale avec déroutement du nerf facial intrapétreux. Résultats à long terme et indications. Une expérience de 10 ans sur 15 cas.

OBJECTIVES: To describe functional results concerning facial and lingual mobility after side-to end hypoglossal facial nerve anastomosis. MATERIAL AND METHODS: 15 patients were operated on between 1993 and 2002 (11 cases of facial nerve injury during vestibular schwannoma surgery, and 4 cases of brainstem stroke). Were assessed at a minimum of 18 months postop tonus and facial voluntary movements recovery (modified House Brackmann (HB) grading), lingual mobility (amyotrophy and self-evaluation questionnaire), and patients' overall satisfaction (questionnaire). RESULTS: The mean delay to evaluation was 57.5 months. The tonus recovery appeared within 6 to 8 months (mean 28.5 weeks, SD 4.6 weeks). All patients recovered a normal tonus. The facial function was evaluated HB grade III in II cases (73.3%), grade IV in 3 cases (20%) and grade V in one (6.6%). Eye occlusion was obtained within 13.6 months on average (SD 2.6 months) in all cases except one. The blepharorraphy was maintained in 2 patients. No facial spasm was noted. The lingual motricity troubles were absent in 93.3% of cases. Patients were satisfied in 93.3% of cases. The less satisfactory results were observed when patients were managed late (>2 years after nerve section) and in case of brainstem stroke. CONCLUSION: This technique seems to be very efficient. It presents the advantage to preserve lingual motricity and to decrease postoperative problems of midface spasticity.

[Facial paralysis after temporal bone trauma]. / Paralysies faciales après fracture de l'os temporal.

OBJECTIVES: To evaluate functional outcome in 64 cases of facial paralysis following temporal bone fracture and discuss decisive arguments leading either to medical treatment or surgical management. METHODS: Sixty-four patients suffering from post-traumatic facial paralysis were managed between 1995 and 2003: 38 (59%) were given medical treatment and 26 (41%) underwent surgery. A combined middle fossa and transmastoid approach was mostly used (58%). Electrophysiological testing and CT scan results were the main points of the decision algorithm. RESULTS: Electroneuromyography seems to be the most accurate exploration for guiding treatment. Good results (grades I to II on the House and Brackmann scale) were obtained in 63% of cases after medical management and in 39% of cases after surgical treatment. Grades III or IV were obtained in 13% of medically-treated patients and 42% of surgically-treated patients. CONCLUSION: Management of facial paralysis following temporal bone fracture in accordance with electrophysiological testing (evoked EMG) together with CT scan findings enabled accurate indications for surgical treatment. A good grade I or II result can be expected after medical management. A grade III is at best reached after nerve anastomosis.

[Management of cerebellopontine angle meningiomas and the posterior part of the temporal bone. Report on 44 cases]. / Approches thérapeutiques des méningiomes de l'angle ponto-cérébelleux et de la face postérieure du rocher. A propos de 44 cas.

OBJECTIVES: To review and study the management of CPA meningiomas through the experience of an otoneurosurgical team. MATERIAL AND METHODS: Fourty-two patients (44 meningiomas) were considered. Seventy-seven per cent of tumors (34 cases) were operated on; 6 tumors (14.6%) were exclusively irradiated using fractionated radiation therapy (FRT) and four only surveyed (9,8%). RESULTS: transpetrosal approaches were exclusively used. These were translabyrinthine (TLA) in 47%, widened retrolabyrinthine (WRLA) in 41% of cases, transcochlear approach (TCA) in three cases and a middle fossa in one. A transtentorial approach was combined in 35% of cases (8 TLA, 4 WRLA). Surgical removal was incomplete in 11,8% of cases; in 3 cases growing tumor was treated by FRT included one case of anaplasic tumor Postoperative complications were: 1 meningitis, 1 wound abscess, 2 hydrocephalus (6%) and 4 CSF fistulas (12%). No complications have been observed during the last 7 years (21 cases). House and Brackmann Grade 1 or 2 facial function was obtained in 59% of cases (but 10 patients had a preoperative facial nerve paresis). A normal or subnormal AAO-HNS Class A-B Hearing could be preserved in 57% of WRLA. Radiation therapy allowed tumor shrinkage in all cases. In 3 cases this regression was of more than 50%. CONCLUSION: Surgery is the gold standard in treating CPA meningiomas. Transpetrosal approaches and particularly WRLA pure or combined to a transtentorial approach are for us the best way to remove these tumors in preserving hearing and facial nerve function. When hearing is poor or when tumor extension to the clivus or the premeatal area is consistent a TLA is either planned preoperatively or obtained from a WRLA.

[Gross tumor volume (GTV) and clinical target volume (CTV) in radiotherapy of benign skull base tumors]. / Volume tumoral macroscopique (GTV) et volume-cible anatomoclinique (CTV) dans la radiothérapie des tumeurs bénignes de la base du crâne.

Skull base tumours represent about 35 to 40% of all intracranial tumours. There are now many reports in the literature confirming the fact that about 80 to 90% of such tumours are controlled with fractionated radiotherapy. Stereotactic and 3-dimensional treatment planning techniques increase local control and central nervous system tolerance. Definition of the gross tumor volume (GTV) is generally easy with currently available medical imaging systems and computers for 3-dimensional dosimetry. The definition of the clinical target volume (CTV) is more difficult to appreciate; it is defined from the CTV plus a margin, which depends on the histology and anterior therapeutic history of the tumour. It is important to take into account the visible tumour and its possible extension pathways (adjacent bone, holes at the base of skull) and/or an anatomic region (sella turcica + adjacent cavernous sinus). It is necessary to evaluate these volumes with CT Scan and MRI to appreciate tumor extension in a 3-dimentional approach, in order to reduce the risk of marginal recurrences. The aim of this paper is to discuss volume definition as a function of tumour site and tumour type to be irradiated.

Management of facial paralysis resulting from temporal bone fractures: Our experience in 115 cases.

OBJECTIVE: The goal of this study was to review decision factors and overall results regarding surgical and nonsurgical management of post-traumatic facial nerve paralysis (FP). STUDY DESIGN: A retrospective study and literature review were performed. METHODS: Between 1984 and 1990, 115 cases of post-traumatic FP were handled. Patients were evaluated through clinical, audiologic, radiologic, and electromyogram assessment. Depending on examination results, patients were treated either medically or surgically through total facial nerve decompression. RESULTS: Forty-nine of the 50 medically treated patients experienced a normal or subnormal facial function recovery (grade I-II). Of the 65 (56.5%) surgically treated patients, 52 (80%) had immediate, 2 had delayed, and 11 (17%) had unknown delay-associated FP. The approaches chosen were middle fossa and transmastoid (75.3%), translabyrinthine (10.7%), or pure transmastoid according to facial nerve nonmotor branch evaluation, hearing, location of the fracture line, and the patient's general condition. Lesions were predominantly found in the geniculate ganglion area (66.2%). A nerve gap was found in only 13.8% of the cases. At 2 years after surgery, 93.8% had a grade I to III recovery. None had grade V or VI. CONCLUSION: The rarity of severe nerve lesions encountered in surgically treated patients raises the question of better selection of candidates for surgery. Surgery is clearly indicated when FP is total, is of immediate onset, and is associated with a bad prognosis electromyogram pattern. In other settings, decisions are to be made based on high-resolution CT data and electromyogram results, thanks to a clinical survey and second electromyogram evaluation.

Dorsal rhizotomy with anterior sacral root stimulation for neurogenic bladder.

A spinal cord lesion above the sacral micturition center results in a loss of voluntary control and development of bladder sphincter dysynergia with hyperreflexia of the detrusor and spasticity of the sphincter. Sacral rhizotomy and implantation of an anterior sacral root stimulator appears as an effective method for the treatment not only of voiding dysfunction but also of defecation and sexual disturbance. The surgical technique is described as are the clinical and electrophysiological controls. The results of our series of operated patients with intradural implantation and sacral deaffentation show a constant improvement. 90% have satisfactory continence and no longer require an incontinence appliance. Bladder capacity and compliance have increased to 120% and urethral closure pressure has decreased. 80% have complete voiding or a post-void residue of not more than 50 ml. So, urinary infection rate is dramatically decreased.