Treatment of neurogenic incontinence with botulinum toxin A.
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Botulinum Toxins, Type A↗
Biomedical subjects
B Schurch
Publications and source records attributed to B Schurch.
Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results.
PURPOSE: We evaluated the efficacy of botulinum-A toxin injections into the detrusor muscle in patients with spinal cord injury, detrusor hyperreflexia and urge incontinence resistant to anticholinergic drugs. The purpose of treatment was to suppress incontinence episodes and increase functional bladder capacity. MATERIALS AND METHODS: Included in our prospective nonrandomized study done at 2 clinics were 31 patients with traumatic spinal cord injury who emptied the bladder by intermittent self-catheterization. These patients had severe detrusor hyperreflexia and incontinence despite a high dose of anticholinergic medication. Pretreatment evaluation included a clinical examination and complete urodynamic investigation. Under cystoscopic control a total of 200 to 300 units of botulinum-A toxin were injected into the detrusor muscle at 20 to 30 sites (10 units per ml. per site), sparing the trigone. Clinical and urodynamic followup was planned for 6, 16 and 36 weeks after treatment. Patients were asked to decrease their intake of anticholinergic drugs during week 1 after treatment. RESULTS: Of the 21 patients 19 underwent a complete examination 6 weeks after the botulinum-A toxin injections, and 11 at 16 and 36 weeks. At the 6-week followup complete continence was restored in 17 of 19 cases in which anticholinergic medication was markedly decreased or withdrawn. Less satisfactory results in 2 cases were associated with an insufficient dose of 200 units botulinum-A toxin. After the injections overall mean reflex volume and mean maximum cystometric bladder capacity plus or minus standard deviation significantly increased from 215.8 +/- 90.4 ml. to 415.7 +/- 211.1 (p <0.016) and 296.3 +/- 145.2 to 480.5 +/- 134.1 (p <0.016), respectively. There was also a significant decrease after treatment in mean maximum detrusor voiding pressure from 65.6 +/- 29.2 cm. water to 35 +/- 32. 1 (p <0.016). Mean post-void residual urine volume catheterized at the end of the urodynamic examination increased significantly from a mean of 261.8 +/- 241.3 ml. to 490.5 +/- 204.8 (p <0.016). Moreover, autonomic dysreflexia associated with bladder emptying that manifested as a hypertensive crisis during voiding disappeared after treatment in the 3 patients with tetraplegia. Satisfaction was high in all successfully treated patients and no side effects were observed. Ongoing improvement in urodynamic parameters and incontinence was already present in all patients reevaluated at 16 and 36 weeks. CONCLUSIONS: Botulinum-A toxin injections into the detrusor seem to be a safe and valuable therapeutic option in spinal cord injured patients with incontinence resistant to anticholinergic medication who perform clean intermittent self-catheterization. Successfully treated patients become continent again and may withdraw from or markedly decrease anticholinergic drug intake. A dose of 300 units botulinum-A toxin seems to be needed to counteract an overactive detrusor. The duration of bladder paresis induced by the toxin is at least 9 months, when repeat injections are required.
Adolescent↗
Sildenafil in the treatment of sexual dysfunction in spinal cord-injured male patients.
OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of sildenafil in the treatment of erectile dysfunction (ED) in spinal cord-injury (SCI) patients. Moreover, we looked for neurological conditions permitting therapeutic success and for the ideal dose needed to achieve sufficient erections. METHODS: 41 SCI patients were prospectively examined. Sexual dysfunction was assessed by means of anamnesis, the International Index of Erectile Function (IIEF) questionnaire, and neurological examination. Psychogenic erection capacity was tested by audiovisual stimulation and reflexive erection using a vibrator device. Neurophysiological recordings and cystomanometry were performed in parallel to clinical examinations. Neurophysiological recordings included sympathetic skin responses (SSR), pudendus somatosensory evoked potentials (pSSEP), and bulbocavernous reflex (BCR). Urodynamics aimed at classifying the neurogenic bladder dysfunction (upper motoneuron lesion versus lower motoneuron lesion). Intracavernous injection tests with PGE1 were performed in all patients to exclude major organic disease. 50 mg sildenafil was first given 3 times. Thereafter, the doses were adapted according to patients' reports. RESULTS: Clinically, 28 subjects preserved either reflexive erections (24) or psychogenic erections (4), 11 had both types and only 2 presented with a complete loss of erection. 38 patients (93%) had a positive response to sildenafil and reached a penile rigidity sufficient to permit sexual intercourse. 3 patients dropped out because of non-response despite having increased the dosis up to 100 mg. 22 patients (58%) showed functional erections 1 h after 50 mg sildenafil, whereas 14 (37%) required higher doses of 75-100 mg. By comparing the IIEF questionnaire scores before and after therapy, there was a significant improvement in erectile function and intercourse satisfaction from 9.2+/-4.4 SD) and 4.5 (+/-2.5 SD) to 25.5 (+/-4.2 SD) and 10.5 (+/-2.1 SD) points, respectively (p<0.05). Nearly 10% (4/41) suffered from side effects such as headache or dizziness. Two of them stopped therapy because of the side effects. At least 36 patients (88%) continue treatment with sildenafil. Absence of both psychogenic (nonsomesthetic supraspinally elicited) and reflexive (somesthetic spinally elicited) erections, confirmed by urodynamical and electrophysiological findings (SSR perineum, BCR and pSSEP), seems to exclude a successful treatment. In contrast, SCI male patients with preserved function of at least one component of the erection phenomenon (psychogenic/reflexive) responded well to sildenafil and the dose required to achieve erections sufficient for sexual intercourse did not differ between the two groups. CONCLUSIONS: Sildenafil proves to be a valuable and safe therapeutic management in ED of SCI patients. Therefore, patient acceptance and satisfaction are high. The most common dose required to achieve a satisfying erection is 50 mg. The efficacy of sildenafil depends on sparing of either sacral (S2-S4) or thoracolumbar (T10-L2) spinal segments which, in this study, have been shown to be of relevance in mediating psychogenic erections in male SCI patients. Complete disturbance of any neurogenic impulses excludes successful treatment.
Adult↗
Bladder neck incompetence in patients with spinal cord injury: significance of sympathetic skin response.
PURPOSE: We investigated whether recording the perineal sympathetic skin response, which reflects the sympathetic function of the thoracolumbar spinal cord, represents a reliable and accurate diagnostic tool for assessing bladder neck competence and incompetence. MATERIALS AND METHODS: We compared the sympathetic skin response recorded from the hand, foot and perineal skin with urodynamic findings in 90 patients with neurogenic bladder dysfunction, including 66 with spinal cord injury and 24 with cauda equina lesions. RESULTS: Video urodynamics revealed an incompetent bladder neck in 11 of 32 patients (34%) with complete and 7 of 34 (21%) with incomplete spinal cord injury but in only 1 of 24 (4%) with the conus-cauda equina syndrome. This association significantly correlated with the lesion level at T10 to L2 in 12 of 26 cases (46%) as well as with the loss of perineal but preserved hand and foot sympathetic skin response in 13 of 18 (72%). CONCLUSIONS: Recording the perineal sympathetic skin response in addition to that of the hand and foot represents a sensitive diagnostic tool for assessing sympathetic nerve function within the thoracolumbar spinal cord. It is of diagnostic value for evaluating neurogenic bladder neck incompetence in spinal cord injured patients.
Adult↗
The predictive value of plantar flexion of the toes in the assessment of neuropathic voiding disorders in patients with spine lesions at the thoracolumbar level.
OBJECTIVE: To correlate the presence of voluntary contraction of the plantar flexors of the toes with neuropathic voiding disorders in patients with spinal cord injury (SCI) after thoracolumbar fracture. SUBJECTS AND METHODS: Sixty-three SCI patients with thoracolumbar fractures were prospectively examined neurologically (American Spinal Cord Injury Association protocol) and urodynamically during their first hospitalization. To assess neurologic recovery, patients were reassessed after at least 1 year. Bladder function was also reevaluated and correlated to neurologic evaluation performed on the same day. SETTINGS: Primary care center, university facility. RESULTS: There was a significant correlation between score of the plantar flexors of the toes and the presence or absence of voluntary contraction of the external anal/urethral sphincter (p < .001). However, this was of no predictive value concerning neuropathic bladder type (p > .05). Seven patients recovered from their neuropathic voiding disorders. There was a significant correlation between the reappearance of a voluntary external anal/urethral sphincter contraction and bladder recovery (p < .01), but there was no significant correlation between the score obtained for the plantar flexors of the toes and the presence or absence of the bulbocavenosus reflex (p > .05). CONCLUSIONS: It appears that in SCI patients with thoracolumbar fractures, the presence of a voluntary contraction of the plantar flexors of the toes correlates with active contraction of the external anal/urethral sphincter but does not enable differentiation of the types of neuropathic voiding disorders. Urodynamic examination remains mandatory for assessment of the functional aspect of the neuropathic voiding disorders.
Adolescent↗
Intraurethral sphincter prosthesis to treat hyporeflexic bladders in women: does it work?
OBJECTIVE: To assess the efficacy and safety of a new intraurethral sphincter prosthesis to treat hyporeflexic bladders in women. PATIENTS AND METHODS: Between July 1997 and December 1998, 18 women (mean age 45.8 years, range 26-84) with neurogenic voiding disorders and a hyporeflexic bladder were examined prospectively. All but one patient (who used the Crédé manoeuvre) emptied their bladder using clean intermittent catheterization. The women were fitted with a prosthesis consisting of a valve and a pump inside a short self-retaining silicone device, which was activated by a magnetic remote control unit. The evaluation before implantation comprised a medical history, a neurological evaluation, urodynamic recordings and urine cultures. The follow-up after implantation included a monthly clinical assessment, a symptom questionnaire, urine culture, ultrasonographic examinations and replacement of the device if necessary. Urine samples were also cultured if there was any discomfort or fever. RESULTS: At 16 months of follow-up, only six of 18 patients continued to use the implant (mean follow-up 9.6 months) and were satisfied. In 10 patients major incontinence around the catheter, or irritation, led to removal of the device. Two patients were unable to learn how to transfer to the toilet to empty their bladder; therefore, their implant was removed and they were treated with a suprapubic catheter. Two patients died from unrelated causes. Twelve patients had positive bacteriuria while fitted with the device; six of them became symptomatic. Usually, only symptomatic lower urinary tract infections were treated. Technical problems occurred often; 14 catheters showed technical dysfunction and had to be replaced early and three external remote control units broke for no reason. Despite normal short-term cystoscopic findings (three patients), long-term urethral damage cannot be excluded. Indeed, the six patients who remain fitted with the device already show some widening of their urethra. CONCLUSION: This experience with the new device was disappointing; in eight of the 18 patients incontinence appeared or worsened and led to removal of the device. Technical problems were common. The other concern is that significant long-term urethral damage could be expected, as observed with indwelling catheters over time. Thus, although this device may function for a short period, it is unsuitable for long-term use.
Adult↗
Botulinum A toxin in spinal cord injury.
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Botulinum Toxins, Type A↗
The 'Dejerines': an historical review and homage to two pioneers in the field of neurology and their contribution to the understanding of spinal cord pathology.
Our purpose, in this number of Spinal Cord devoted to the French speaking Society of Paraplegia (AFIGAP), is to render homage to two very distinguished doctors, who by their work at the end of the XIXth and the beginning of our century contributed greatly to our knowledge of the nervous system and in particular the spinal cord (SC). This was at the time a field of considerable interest in France and abroad. Professor Jules Dejerine was from 1911-1917 the holder of the Chair for Nervous System Diseases created for Charcot. Dejerine and his American born wife, Augusta Klumpke, and had very limited means for investigation compared to actual technological advances. They relied mainly on their superb clinical observations and neuropathological examinations. Dejerine was also a pioneer in the growing field of neuroanatomy. In 1895 he published a treatise on the anatomy of the nervous system, which is still considered worldwide to be a masterpiece. Augusta Dejerine-Klumpke, the first woman Intern in Paris Hospitals, was not only a fine clinician, neuroanatomist and pathologist, but also contributed greatly to her husband's work. Amongst other things she is known for the 'Klumpke palsy'. She was also a pioneer in France, during the First World War and subsequent following years, in the treatment and rehabilitation (medical and vocational) of the large number of soldiers afflicted by wounds of the nervous system and especially of the SC. During the same period, many authors contributed to SC pathology, but only a few to the treatment and rehabilitation of these patients. This was brought to our attention, in the sixties, by Professor Pierre Houssa, pioneer in Belgium in the field of comprehensive care of those who have SC lesions. Augusta Dejerine-Klumpke also contributed to our present knowledge of heterotopic ossification following a SC injury, including its pathogenesis. Most of their clinical and pathological findings and discussions are recorded in Dejerine's famous monograph which was published in 1914: La séméiologie des Affections du Système Nerveux (The Semiology of the Diseases of the Nervous System).
History, 20th Century↗
Does sacral posterior rhizotomy suppress autonomic hyper-reflexia in patients with spinal cord injury?
OBJECTIVE: To study the occurrence of autonomic hyper-reflexia (AHR) after intradural sacral posterior rhizotomy combined with intradural sacral anterior root stimulation, performed to manage the neurogenic hyper-reflexic bladder and to determine the pathophysiological basis of the uncontrolled hypertensive crisis after sacral de-afferentation. PATIENTS AND METHODS: Ten patients with spinal cord injury operated using Brindley's method between September 1990 and February 1994 were reviewed. Systematic continuous non-invasive recordings of cardiovascular variables (using a photoplethysmograph) were made during urodynamic recordings and the pre- and post-operative vesico-urethral and cardiovascular data compared. RESULTS: Nine of the 10 patients were examined using a new prototype measurement system; one woman refused the last urodynamic assessment. Eight of the nine patients who presented with AHR before operation still had the condition afterward. There was a marked elevation in systolic and diastolic blood pressure during the urodynamic examination in all eight patients, despite complete intra-operative de-afferentation of the bladder in five. The elevation of blood pressure started during the stimulation-induced bladder contractions and increased during voiding in all cases. Five patients showed a decrease in heart rate during the increase in blood pressure. However, in three patients the heart rate did not change or even sometimes slightly increased as the arterial blood pressure exceeded 160 mmHg, when the blood pressure and heart rate then increased together. CONCLUSIONS: These results confirm that even after complete sacral de-afferentation. AHR persisted in patients with spinal cord injury and always occurred during the stimulation-induced voiding phase. In cases of incomplete de-afferentation, small uninhibited bladder contractions without voiding occurred during the filling phase. The blood pressure then increased but never reached the value recorded during stimulation-induced micturition. Stimulation of afferents that enter the spinal cord by the thoracic and lumbar roots and that are not influenced by sacral rhizotomy could explain why AHR increases during urine flow. The distinct threshold of decreased heart rate by increasing blood pressure to > 160 mmHg focuses attention on the chronotropic influences of the sympathetic nerves in the heart by an exhausted baroreceptor reflex.
Adolescent↗
Prostaglandin E2 measurements: their value in the early diagnosis of heterotopic ossification in spinal cord injury patients.
OBJECTIVE: To look for a possible relation between the occurrence of heterotopic ossification (HO) and the modifications of the 24-hour prostaglandin E2 (PGE2) urinary excretion. DESIGN: A 5-year prospective study to determine the 24-hour urinary excretion of PGE2 by radioimmunoassay with specific antisera not cross-reacting with TXA2, TXB2, 15-keto-PGE2 alpha, PGI2, 6-keto-PGF1 alpha. SETTING: The laboratory of a division of endocrinology and diabetology of a university hospital. PATIENTS: Of 262 acute spinal cord injury patients screened, 44 were eligible for the study. INTERVENTIONS: Serial diagnostic quantitative bone scannings with technetium 99m Tc methylene diphosphate (99mTc-MDP) and therapeutic assessment of radiotherapy and indomethacin. MEAN OUTCOME MEASURE: Hypothetical increase of PGE2 before and during HO formation. RESULTS: Of 44 patients, 8 developed an HO (18.8%) with concomitant marked increase of the PGE2 excretion for as long as the HO had not reached maturity. The results of the radiotherapy were inconclusive. Indomethacin was shown to be efficacious in holding back or slowing down the HO evolution. CONCLUSIONS: Measurement of the 24-hour PGE2 urinary excretion appears to be a valuable indicator in the early diagnosis of HO. Indomethacin should be considered as an alternative to other existing therapies.
Acute Disease↗
Recovery of bladder function in patients with acute spinal cord injury: significance of ASIA scores and somatosensory evoked potentials.
The significance of the ASIA (American Spinal Injury Association) scores and SSEP (somatosensory evoked potentials) recordings in predicting the recovery of bladder function was evaluated in 70 patients with acute, traumatic spinal cord injury (SCI). The patients were examined following admission to the rehabilitation centre (mean 10 days post-trauma) both clinically by the ASIA scores and electrophysiologically by tibial and pudendal SSEP recordings. The results of the initial examinations were related to the degree of recovery of bladder function of the patients assessed by urodynamic examination at the end of the rehabilitation programme (at least 6 months post-trauma). The recovery of somatic nerve function (external urethral sphincter function) involved in bladder function was correlated to both the initial ASIA scores and SSEP recordings (Spearman correlation, P < 0.001). The latter parameters, however, were not related to the outcome of autonomic nerve function (eg detrusor vesicae function) (Spearman correlation, P = 0.1). Therefore, the initial clinical and electrophysiological examinations are of value in assessment of the degree to which the patient will recover somatic nervous control of bladder function. However, these examinations are not indicative of urodynamic impairment. Therefore, urodynamic examination should be mandatory for the diagnostic assessment and therapeutical approach of bladder dysfunction in patients with acute SCI.
Adult↗
Assessment of autonomic dysreflexia in patients with spinal cord injury.
OBJECTIVES AND METHODS: To assess the impairment of supraspinal control over spinal sympathetic centres and the occurrence of autonomic dysreflexia in patients with spinal cord injury. Autonomic dysreflexia is caused by the disconnection of spinal sympathetic centres from supraspinal control and is characterised by paroxysmal hypertensive episodes caused by non-specific stimuli below the level of the lesion. Therefore, patients with spinal cord injury were examined clinically and by different techniques to assess the occurrence of autonomic dysreflexia and to relate disturbances of the sympathetic nervous system to episodes of autonomic dysreflexia. RESULTS: None of the paraplegic patients, but 59% (13/22) of tetraplegic patients (91% of the complete, 27% of the incomplete patients) presented signs of autonomic dysreflexia during urodynamic examination. Only 62% of the tetraplegic patients complained about symptoms of autonomic dysreflexia. Pathological sympathetic skin responses (SSRs) of the hands were related to signs of autonomic dysreflexia in 93% of cases. No patient with preserved SSR potentials of the hands and feet showed signs of autonomic dysreflexia, either clinically or during urodynamic examination. Ambulatory blood pressure measurements (ABPMs) indicated a loss of circadian blood pressure rhythm (sympathetic control) but preserved heart rate rhythm (parasympathetic regulation) only in patients with complete tetraplegia. Pathological ABPM recordings were seen in 70% of patients with symptoms of autonomic dysreflexia. CONCLUSIONS: The urodynamic examination was more sensitive in indicating signs of autonomic dysreflexia in patients with spinal cord injury, whereas SSR allowed the assessment of the degree of disconnection of the sympathetic spinal centres from supraspinal control. Using ABPM recordings the occurrence of episodes of autonomic dysreflexia over 24 hours and the effectiveness of therapeutical treatment can be assessed.
Adolescent↗
Botulinum A toxin as a treatment of detrusor-sphincter dyssynergia in patients with spinal cord injury: MRI controlled transperineal injections.
OBJECTIVES: To correlate clinical and urodynamic findings with MRI in patients with spinal cord injury and detrusor-sphincter dyssynergia who were consecutively treated with transperineal injections of botulinum-A toxin (BTX-A) under EMG control. METHODS: Six patients with spinal cord injury and upper motor neuron bladder dysfunction associated with detrusor-sphincter dyssynergia were prospectively analysed. One hundred international units (IU) BTX-A (Botox in 1 ml normal saline without preservative) diluted 1 to 1 with 1 ml gadopentetate were injected transperineally under EMG control. MRI was started immediately after needle withdrawal. RESULTS: In all six patients gadopentetate was located in the external urethral sphincter on MRI. In no patient did traces of gadopentetate appear in the perineal musculature located in the vicinity of the external urethral sphincter. No patient developed resistance to BTX-A. All patients showed an (ongoing) improvement of their voiding function after BTX-A injections. CONCLUSIONS: Transperineal injections of BTX-A under EMG control are efficient in the release or amelioration of lower urinary tract obstruction due to detrusor sphincter dyssynergia in patients with spinal cord injury. Despite well described methods, EMG of the external urethral sphincter is difficult and it is not possible to definitively exclude false recordings of the surrounding perineal musculature. By the use of MRI it was shown that both the EMG recordings and transperineal injection method are precise.
Botulinum Toxins, Type A↗
Autonomic hyperreflexia revisited.
PURPOSE: To analyze autonomic hyperreflexia (AHR) associated with neurogenic bladder dysfunction in high spinal cord-injured patients. MATERIAL AND METHODS: Sixty-five patients were examined using a new recording system. Seventeen suffered from a spinal cord lesion above the T5-T6 level and presented with neurogenic voiding disorders and AHR. Mean arterial pressure (MAP) changes were analyzed during 3 different urodynamic phases: bladder filling; isometric bladder contraction, and voiding. RESULTS: Of the 17 tetraplegic and high paraplegic patients, 6 dropped out and 11 entered the study. Nine of these eleven patients displayed uninhibited bladder contractions and voiding. In these 9 cases MAP increased progressively during bladder contraction until a maximal bladder pressure was reached. An ongoing elevation of MAP was observed during voiding which returned to normal values within 5 min after micturition. In 2 patients detrusor-sphincter dyssynergia prevented voiding. As opposed to the 9 previously mentioned patients, maximal MAP occurred at or before the maximal bladder pressure in these 2 cases and decreased thereafter. CONCLUSIONS: Evidence is presented that the posterior urethral receptors and their ascending pathway played a major role in the maintenance of AHR during micturition.
Autonomic Nervous System Diseases↗
Posterior sacral rhizotomy and intradural anterior sacral root stimulation for treatment of the spastic bladder in spinal cord injured patients.
PURPOSE: The efficacy of intradural sacral posterior rhizotomy combined with intradural sacral anterior root stimulation in the treatment of the neurogenic hyperreflexic bladder was evaluated. MATERIALS AND METHODS: We reviewed 10 spinal cord injured patients who underwent surgery between September 1990 and February 1994. Bladder function was compared preoperatively and postoperatively. Intraoperative data on electrostimulation of the detrusor and striated muscles were analyzed. RESULTS: Stimulation of the anterior S3 and S4 roots was mostly used to empty the bladder (7 of 10 cases). Preoperative reflex incontinence disappeared in all patients postoperatively. Mean postoperative bladder capacity increases and mean postoperative post-void residual decreases were at least 340 ml. (p < 0.01) and 140 ml. (p < 0.01), respectively. Preoperative vesicorenal reflux disappeared in 2 and improved in 3 cases after sacral deafferentation. Autonomic hyperreflexia, which was present preoperatively in 6 patients, never disappeared but significantly improved after deafferentation. No major complications were noted postoperatively. CONCLUSIONS: Intradural sacral posterior rhizotomy combined with intradural sacral anterior root stimulation is a valuable method to treat the hyperreflexic bladder with incontinence resistant to conservative therapy in spinal cord injured patients. Autonomic hyperreflexia was decreased but not suppressed by posterior sacral rhizotomy.
Adolescent↗
The value of sympathetic skin response recordings in the assessment of the vesicourethral autonomic nervous dysfunction in spinal cord injured patients.
PURPOSE: We assessed the degree of sparing of the descending sympathetic spinal tract and correlated these findings with bladder neck function in spinal cord injured patients. MATERIALS AND METHODS: Sympathetic skin responses of the right hand and foot were recorded and compared to the urodynamic findings in 27 spinal cord injured patients. RESULTS: All tetraplegic and paraplegic patients with a lesion above the T6 level who presented with bladder neck dyssynergia associated with autonomic hyperreflexia had abnormal sympathetic skin responses in the right hand and foot. All patients with a lesion below the T6 and above the T12 levels with an abnormal sympathetic skin response in the right foot also had bladder neck dyssynergia. CONCLUSIONS: Evidence is presented that the integrity of the descending sympathetic spinal tract is necessary for a synergic function of the vesicourethral complex and that sympathetic skin responses are of value in the diagnosis of bladder neck dyssynergia. For lesions below the T12 level other investigative methods to exclude bladder neck dyssynergia are necessary.
Autonomic Nervous System↗
Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients.
PURPOSE: The paralytic effect of botulinum-A toxin injections on the external urethral sphincter was investigated prospectively in patients with neurogenic voiding disorders. MATERIALS AND METHODS: Transurethral versus transperineal botulinum-A toxin injections were performed in 24 spinal cord injury male patients with detrusor-sphincter dyssynergia and the respective efficacy was compared. RESULTS: In 21 of 24 patients detrusor-sphincter dyssynergia was significantly improved with a concomitant decrease in post-void residual volumes in most cases. Botulinum-A toxin effects lasted 3 to 9 months, making reinjections necessary. CONCLUSIONS: Although costly, botulinum-A toxin injections, which aim at suppressing detrusor-sphincter dyssynergia but not bladder neck dyssynergia, appear to be a valid alternative for patients who do not desire surgery or are unable to perform self-catheterization.
Adolescent↗
Post-traumatic syringomyelia (cystic myelopathy): a prospective study of 449 patients with spinal cord injury.
OBJECTIVES: To assess the incidence of post-traumatic syringomyelia (PTS), to correlate the presence of PTS with its most common signs and symptoms, and to compare results from the Swiss Paraplegic Centre with those reported in the medical literature. METHODS: A total of 449 recent traumatic paraplegic and tetraplegic patients admitted to the Swiss Paraplegic Centre in Zurich between 1 January 1987 and 31 December 1993 were prospectively analysed. Yearly clinical tests with conventional radiographs and additional T1 and T2 weighted images were performed as soon as PTS was diagnosed. RESULTS: Of these 449 patients 20 patients displayed symptoms of PTS (4.45%). Ten non-operated patients remained clinically stable (average time: 37 months). Ten worsened--three refused operation, seven were operated on. Mean worsening time was 97 months. Deterioration was closely related to the enlargement of the cyst whereas in operated patients neurological improvement or stabilisation correlated with collapse of the cyst. CONCLUSIONS: Delay between appearance of the first symptoms of PTS and deterioration making surgery necessary may be long (mean five years in the seven operated patients) underlining the need for regular tests. "Slosh" and "suck" mechanisms could explain cyst enlargement as surgical realignment of the spine resulted in a complete cyst collapse in two of the operated patients (normalisation of CSF flow? ). Cord compression, tense syrinx at the fracture site, and kyphosis seemed to be closely linked to the enlargement of the cyst with subsequent further neurological deterioration.
Adolescent↗