Sacral neuromodulation for neurogenic bladder dysfunction in children.

PURPOSE: We report a prospective randomized controlled study to evaluate the possible benefits of sacral neuromodulation (SNM) for the management of neurogenic bladder dysfunction in children. MATERIALS AND METHODS: We included in the study subjects between the ages of 5 and 21 years presenting with urinary incontinence due to neurogenic bladder. Before study inclusion all previous treatment was discontinued. Patients were randomly divided into the control group treated conventionally and the implant group treated with SNM. Treatment outcome was compared every 3 months for a minimum of 12 months based on clinical examination, voiding diary and urodynamic evaluation. RESULTS: A total of 26 boys and 16 girls with a mean age of 11.9 years were enrolled in this study. There were 21 patients in each group. The main underlying etiology was spina bifida. The 2 groups were comparable with regard to sex, age and urodynamic variables. Total disappearance of urinary leakage was observed in 1 patient who underwent implantation but he still required intermittent catheterization. Comparison of urodynamic variables disclosed no significant statistical difference except with regard to functional bladder capacity which was better in the control group and the leak point pressure which was better in the implant group (p <0.05). Evaluation of interindividual variations in the implant group revealed significant improvement in compliance and functional bladder capacity at 6 and 9 months but not at 12 months. Nine patients in the implant group reported improvement in intestinal transit, 5 total disappearance of urinary infection and 6 persistent sensation of a full bladder. No patient in the control group reported any improvement. Revision surgery was required in 3 cases due to lead migration, faulty connection and wound infection. CONCLUSIONS: SNM is a promising new therapeutic modality. Implant placement is minimally invasive, nondestructive and reversible. Use in children with neurogenic bladder has not been previously reported. Although some improvement was noted in patients treated with SNM, the difference with the control group was not significant. A larger multicenter study is warranted to evaluate SNM.

Proton magnetic resonance neurospectroscopy and EEG cartography in corticobasal degeneration: correlations with neuropsychological signs.

OBJECTIVE: To document the asymmetrical functional brain lesions in corticobasal degeneration (CBD) using proton magnetic resonance neurospectroscopy (MRS) and EEG cartography (EEGq). METHODS: Eight patients with probable CBD were included in the study after full neurological examination and extensive neuropsychological testing, single photon emission computed tomography, anatomical x ray tomodensitometry (TDM), magnetic resonance imaging, and MRS examination. RESULTS: MR spectra were abnormal in all seven patients in whom the examination could be completed. The EEG was also always modified in the CBD patients, and the abnormalities were enhanced by activation procedures. There was a good correlation between MRS anomalies and clinical presentation, between EEG modifications and neuropsychological patterns, and between metabolic (MRS) impairment and electrophysiological (EEG) slowing. CONCLUSIONS: These results confirm the asymmetrical features of CBD. Combined EEGq/MRS examinations at disease onset and during its subsequent course could provide strong diagnostic evidence of CBD.

Value of electrophysiological assessment after surgical treatment of spinal dysraphism.

PURPOSE: This study was conducted in children treated surgically for spinal dysraphism between 1994 and 2000 to determine the value of electrophysiological parameters for followup in comparison with clinical, radiological and urodynamic findings. MATERIALS AND METHODS: Electrophysiological examination was performed based on electromyographic detection of perineal muscle activity with evaluation of the sacral reflexes and measurement of lower limb and perineal evoked potentials. Clinical and radiological assessment consisted of physical examination, kidney ultrasonography and retrograde cystouretrography. Urodynamic assessment included determination of urethral pressure profile, bladder activity, compliance, voiding pressure and sphincter synergy. A total of 45 children were included in the study. In 28 cases electrophysiological assessment was performed routinely in 20 children (group 1) before and after (6 months and annually thereafter) surgical treatment (mean followup 30 months) and in 8 children (group 2) only after surgical treatment (mean followup 65 months). Electrophysiological findings were correlated with the urodynamic and clinical findings. Sensitivity, specificity and positive and negative predictive values were calculated. In 17 children (group 3) electrophysiological assessment was performed only once either before or after surgery. RESULTS: Electrophysiological assessment with combined electromyographic detection and perineal evoked potentials was highly sensitive in predicting urodynamic impairment, particularly vesico-sphincter dyssynergia (sensitivity 100%) or bladder dysmotility (sensitivity 86%). Specificity of perineal evoked potentials for detecting urodynamic dysfunction was 90%. Electromyographic detection and perineal evoked potentials also demonstrated satisfactory sensitivity in confirming urological impairment (sensitivity 79%, negative predictive value 90%). CONCLUSIONS: Electromyographic detection and perineal evoked potentials are valuable for assessment of patients after surgical treatment of spinal dysraphism. Because these techniques are minimally invasive and highly reproducible, they are suitable for baseline assessment in most cases (tethered cord, lipoma, syringomyelic cavities). Urodynamic assessment should be reserved for patients at high risk for secondary neurogenic bladder dysfunction such as myelomeningocele or sacral agenesis.

Lyme disease presenting as isolated acute urinary retention caused by transverse myelitis: an electrophysiological and urodynamical study.

Several neurological manifestations of Lyme disease, both central and peripheral, have been described. Reported here is a case of acute transverse myelitis related to a Lyme neuroborreliosis that presented with isolated acute urinary retention and no lower-extremity impairment. This case, documented by urodynamic and electrophysiological investigations, partially resolved after 6 weeks of intravenous ceftriaxone, affording the removal of the indwelling catheter. Alpha blocker therapy was needed for 3 months, until the complete normalisation of urodynamic and electrophysiological records. This case study indicates that whenever urinary retention is encountered associated with acute transverse myelitis or alone, the patient should be investigated for Lyme disease.

[Abdominal neuropathy of motor expression of diabetic origin. Apropos of a case]. / Neuropathie abdominale à expression motrice d'origine diabétique. A propos d'un cas.

Authors report a case of diabetic truncal neuropathy presenting as a painful abdominal swelling. This entity, which frequently is probably under estimated, may mimic abdominal visceral pathology and patients may be subjected unnecessary to extensive diagnosis procedures.

[Neurophysiological study of propofol (2-6 diisopropylphenol): experimental data]. / Etude neurophysiologique du propofol (2-6 diisopropylphenol): données expérimentales.

Propofol was assessed in laboratory animals using an experimental technique which leads to an over all appreciation of central nervous system function. After Bimar and Naquet, (1966) a battery of neurophysiological tests in the cat investigate specific primary pathways (visual evoked potentials), non specific pathways (arousal reaction) and hemodynamic response to painful aggression (stimulation of dentine). Propofol appears to be a powerful narco-hypnotic drug. More, it have an original property which is quite rapidly effective and unconnected with narcosis: a protective hemodynamic ("sympathoplegic or neuroleptic") effect. So, propofol, a new anesthetic agent, seems to be a progress with regard to other drugs used previously.

[Functional and urodynamic study of cecocystoplasties with or without detubation]. / Etude fonctionnelle et urodynamique des caecocystoplasties avec ou sans détubulisation.

The authors analyse and compare the clinical and urodynamic results of 16 tubed caecocystoplasties and 5 detubed ileocaecocystoplasties. The urodynamic assessments were performed between 2 months and up to 4 years after the operation. After a period of about 6 months, there was a functional difference between these two types of reservoir. The loss of pressure peaks in detubed reservoirs is not sufficient to ensure complete nocturnal continence. Neovesico-sphincteric synergy is responsible for real sphincteric self-re-education. Rationally, a detubing procedure in bladder replacement is only desirable in the case of a "deficient" sphincter.

[A therapeutic trial in patients with spasmophilia]. / Essai thérapeutique chez les spasmophiles.

As the clinical manifestations of spasmophilia are characterized by their striking polymorphism, quantitative assessment, which is requisite in order to evaluate therapeutic effectiveness, is a difficult task. The authors have attempted to analyze clinical, electrical and biological data from 30 patients. Each of these patients, given only manganese-cobalt oligosol and magnesium oligosol for two months, in two daily doses, had at least two groups of symptoms. Analysis of results shows that the most significant improvement was clinical: improvement was satisfactory or very satisfactory in 83% of patients tested, with muscular relaxation being recorded first, In relation with these clinical results, is the 59% improvement rate in EMG controls. Improvement in overall laboratory data was conclusive in only 24% of patients; however, if only the changes in intraerythrocytic magnesium, which is the only parameter with real clinical value (60% of abnormal results before treatment) are considered, improvement or return to normal values was recorded in 83% of cases.

[Vesico-anal correlations during miction in human beings]. / Corrélations vésico-anales durant la miction chez l'homme.

1. The electrical activity of external anal sphincter (EAS) and internal anal sphincter (IAS), and the endo-anal pressure were recorded during the miction on 10 male adults with no signs of anorectal nor urologic affection. 2. During the premictionary period, the sympathetic hypertonicity was due to a large vesical proprioceptive activity; that initiated a higher frequency and amplitude of the IAS slow potential oscillations, and masked the inhibitory parasympathetic effect usually triggered by rectal distension. 3. During the vesical systolic phase the vesico-anal reflex induced by a parasympathetic activation and by: (a) a total absence of the EAS electrical activity during the duration of the miction period; (b) a two stage development of the IAS electrical activity: a tonic first stage of short duration and constant activity, followed by a second larger stage of variable form in accordance with the type of pattern (tonic, intermediary of which followed a similar developmental stage to that of the IAS. 4. This vesico-anal reflex makes it possible to assume that IAS activity plays a specific and important functional role in the maintenance of anal continence.

[Comparison of the effects of analgesia-producing peripheral and central stimulations in cats. Effect of nalorphine (author's transl)]. / Comparaison des effets de stimulations analgésiantes périphériques et centrales, chez le chat. Effet de la nalorphine.

The effects of weak intensity percutaneous peripheral stimulations (SPPc) on the transmission of nociceptive messages induced by stimulation of the dental pulp have been studied on anaesthetized cats. 1. The jaw opening reflex (ROG) and the evoked potentials in the thalamic center median (CM), by stimulation of the dental pulp, disappear after a mean of 30 min after the start of SPPc. 2. These effects are analogous to those obtained by stimulation of the periaqueductal gray matter (St.GC) or by I.V. morphine injection. 3. The I.V. injection of the morphine antagonist (Nalorphine) blocks both the effects of the SPPc and those of the St.GC. 4. The authors put forth the hypothesis of a common mechanism of action of the SPPc and the St.GC which, through the liberation of endogenous morphinomimetic substances, would activate descending inhibitor impulses.

[Nociceptive afferent blockade by percutaneous peripheral stimulation in the cat]. / Blocage des afférences nociceptives par stimulation pérphérique percutanée chez le chat.

Experiments have been performed in order to study the effects of percutaneous peripheral stimulation (PCPS) both on the transmission of messages elicited by recruiting sensory units of the tooth pulp at the thalamic Centrum Medianum Level and on the jaw opening reflex (JOR). Both evoked potentials and JOR were inhibited by stimuli applied to the limbs by means of percutaneous (needle) electrodes. Observed inhibitory effects were not immediate: there was a latency period and progressive induction of these phenomena. The site of the inhibition is still unknown, nevertheless, the demonstration that PCPS was able to inhibit both evoked potentials in Centrum Medianum and JOR support the hypothesis that the analgesic effects may be due to descending inhibition blocking transmission of nociceptive information through the spinal cord.

[The effect of nalorphine on analgesia induced by peripheral stimulation]. / Effets de la nalorphine sur les analgésies induites par stimulations périphériques.

The blockade of effects induced by percutaneous peripheral stimulation were abolished by injection of an opiate antagonist as nalorphine. Our results lead to the hypothesis that central and peripheral stimulations act by the same mechanism in producing blockade of noxious impulses. One may suggest that peripheral stimulations induce release of endogenous morphine-like substances which in turn give descending inhibition.

[Role of transcutaneous electric stimulation in indication for implantation of an analgesic stimulator]. / Place de la stimulation electrique cutanée dans l'indication d'implantation d'un stimulateur analgésique

UNLABELLED: The author's describe: I. METHODS OF ANALGESIC CUTANEOUS STIMULATION: I) Transcutaneous analgesic stimulation: Stimulations realized by biphasic asymetrical "waves" of 0 to 80 milliamps intensity for a frequency of 10 to 100 cycles/S. -Place of the stimulation: a painful area. -Stimulation length: 15 to 20 minutes, repeated during several days. RESULTS: appreciate patients tolerance to the tingling sensation. Test the analgesic effect, sometimes sufficient to treat the patient. 2) Analgesic percutaneous stimulation: The percutaneous electrode is applicated to the dura, without penetrating it. Same types of results as for transcuteneous stimulation but more precise. II. DEFINITION of the indication of chronic implantation of an analgesic stimulator. Studying results of repeated analgesic transcutaneous stimulations allows to distinguish between several possibilities. I) Intolerance of the sensation of stimulation: Contra-Indication or increasing of the pain. 2) Complete and lasting amelioration leads to: Chronic transcutaneous neurostimulation. 3) Partial amelioration, No amelioration leads to: Acute percutaneous stimulation either successful results after stimulation, : Chronic implantation: -of peripheral nerve -on a peripheric nerve -of dorsal column -on dorsal column, either paraesthesis without Analgesia:? III - EXPERIMENTAL APPROACH TO THE MECHANISM OF ACTION OF THE "ANALGESIANT" ELECTRIC STIMULATION. A cutaneous "analgesiant" stimulation produces, in the cat, the inhibition of evocated potential in C.M. by "nociceptive" stimulation of the sciatic nerve. The inhibition only appears after a 30 minutes latence. This let suppose different mechanisms from the "Gate Control" theory. The authors specify their personal results (Tab. 2.)

Anatomical and functional heterogeneity of the medullary respiratory neurons.

In a systematic study we attempted to activate the respiratory neurons antidromically by stimulating the spinal cord and the vagus. This has led to an anatomical and functional classification of the neurons: bulb-spinal neurons whose axons enter the spinal cord, vagal motoneurons, propriobulbar neurons which cannot be activated antidromically. We used simultaneously other tests (localization, response to Hering-Breuer reflexes or to cortical stimulation) which gave positive results. Two groups of respiratory neurons were apparent: a dorsal respiratory nucleus with only inspiratory bulbo-spinal neurons and a ventral respiratory nucleus with inspiratory and expiratory bulbo-spinal neurons, vagal motoneurons and propriobulbar neurons. The bulbo-spinal neurons and some propriobulbar neurons are normally related to Hering-Breuer reflexes evoked by lung inflation or deflation, but the recurrent laryngeal motoneurons or fibres and some propriobulbar neurons can give a paradoxical response to lung inflation. By cortical stimulation the propriobulbar neurons show only an arrest of their discharge, whereas the bulbo-spinal neurons give a burst of spikes followed by an inhibition. These results led to the following conclusions: (i) the propriobulbar neurons do exist; (ii) some neurons classified as medullary respiratory neurons have not really a ventilatory function: they belong to the laryngeal system; (iii) it is fundamental to use systematically the antidromic test and some other ones to know exactly the hodological situation of the neurons in the respiratory complex.