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PubMed2003

Neurophysiological evidence may predict the outcome of sacral neuromodulation.

PURPOSE: Chronic stimulation of the sacral nerves has now become one of the most accepted stimulation therapies for functional lower urinary tract symptoms refractory to conservative treatment. Despite the existence of a large amount of literature on sacral neuromodulation (SNM) showing a fairly high percent of significant improvement in clinical outcome there are few experimental studies of SNM stimulus parameters and/or neurophysiological monitoring. We evaluated the specific action of SNM on the primary sensory cortical area. Somatosensory evoked potentials (SEPs) of the pudendal and posterior tibial nerves were evaluated in patients implanted with a monolateral permanent quadripolar electrode. MATERIALS AND METHODS: A total of 24 patients underwent stage 1 monolateral sacral nerve implantation. Three SEP patterns were evaluated; namely before implantation, 1 month after stage 1 with stimulation set at 21 Hz and again with a pulse rate of 40 Hz. RESULTS: In all patients SNM produced a significant decrease in pudendal SEP latency of the first positive deflection between baseline SNM stimulation at different pulse rates at the ipsilateral and contralateral implant sites. This finding was evidence of the effect of S3 SNM on the cortical sensory area and the specificity of pudendal SEPs in measuring how SNM modulates the afferent pathway from the spinal nerve to the cortical sensory area. CONCLUSIONS: Our study confirms previous observations that SNM acts by the afferent pathway at the cortical site level and it sheds light on so-called idiopathic lower urinary tract symptoms. A modification of SEPs induced by SNM seems to be a prognostic factor of clinical outcomes. The action of SNM on the afferent pathway from the sacral area to the somatosensory cortex is specific and neurophysiological evaluation via pudendal SEPs provides evidence to this effect.

Adolescent↗
PubMed2005

Interaction between neurotransmitter antagonists and effects of sacral neuromodulation in rats with chronically hyperactive bladder.

OBJECTIVE: To investigate to what extent antagonists of spinal neurotransmitters interact with the effects of sacral neuromodulation in a rat model of a chronically hyperactive urinary bladder. MATERIALS AND METHODS: In female rats the urinary bladder was instilled with turpentine oil 2.5% to induce cystitis. After surviving for 10 days the rats were anaesthetized with urethane, the bladder catheterized and connected to a pressure transducer. Stimulating electrodes were placed in the sacral foramina bilaterally. The spinal cord was exposed by a laminectomy, and a small pool was placed on the cord for intrathecal administration of neurotransmitter antagonists. Sacral neuromodulation was applied before and after administering the antagonists. The antagonists used were: memantine, an antagonist for N-methyl-D-aspartate (NMDA) receptors; CNQX, an antagonist for non-NMDA receptors, and L-NAPNA, a blocker of nitric oxide synthase. RESULTS: With no electrical neuromodulation, memantine and L-NAPNA abolished the cystitis-induced bladder contractions for approximately 4 and approximately 37 min, respectively. The effect of CNQX was similar to that of artificial cerebrospinal fluid. Electrical sacral modulation with no antagonists also transiently abolished the bladder contractions; at the highest intensity used, the pause was 2-3 min. Superfusion of the spinal cord with CNQX reduced this effect of neuromodulation significantly, whereas memantine had no influence, and L-NAPNA increased the neuromodulation-induced pause. CONCLUSIONS: The results suggest that non-NMDA receptors are involved in the effects of sacral neuromodulation, whereas NMDA receptors appear to have no role. Nitric oxide is essential for maintaining the chronic hyperactive state of the urinary bladder.

6-Cyano-7-nitroquinoxaline-2,3-dione↗
PubMed2002

Electrical stimulation for the treatment of bladder dysfunction: current status and future possibilities.

Electrical stimulation of peripheral nerves can be used to cause muscle contraction, to activate reflexes, and to modulate some functions of the central nervous system (neuromodulation). If applied to the spinal cord or nerves controlling the lower urinary tract, electrical stimulation can produce bladder or sphincter contraction, produce micturition, and can be applied as a medical treatment in cases of incontinence and urinary retention. This article first reviews the history of electrical stimulation applied for treatment of bladder dysfunction and then focuses on the implantable Finetech-Brindley stimulator to produce bladder emptying, and on external and implantable neuromodulation systems for treatment of incontinence. We conclude by summarizing some recent research efforts including: (a) combined sacral posterior and anterior sacral root stimulator implant (SPARSI), (b) selective stimulation of nerve fibers for selective detrusor activation by sacral ventral root stimulation, (c) microstimulation of the spinal cord, and (d) a newly proposed closed-loop bladder neuroprosthesis to treat incontinence caused by bladder overactivity.

Animals↗
PubMed1998

Cholinergic neurons and terminal fields revealed by immunohistochemistry for the vesicular acetylcholine transporter. II. The peripheral nervous system.

The peripheral sympathetic and parasympathetic cholinergic innervation was investigated with antibodies directed against the C-terminus of the rat vesicular acetylcholine transporter. Immunohistochemistry for the vesicular acetylcholine transporter resulted in considerably more detailed visualization of cholinergic terminal fields in the peripheral nervous system than reported previously and was well suited to also identify cholinergic perikarya. Vesicular acetylcholine transporter immunoreactivity completely delineated the preganglionic sympathetic terminals in pre- and paravertebral sympathetic ganglia, and in the adrenal medulla as well as postganglionic cholinergic neurons in the paravertebral chain. Cholinergic terminals of sudomotor and vasomotor nerves of skeletal muscle were optimally visualized. Mixed peripheral ganglia, including periprostatic and uterovaginal ganglia, exhibited extensive preganglionic cholinergic innervation of both noradrenergic and cholinergic postganglionic principal neurons which were intermingled in these ganglia. Varicose vesicular acetylcholine transporter-positive fibres and terminals, representing the cranial parasympathetic innervation of the cerebral vasculature, of salivary and lacrimal glands, of the eye, of the respiratory tract and of the upper digestive tract innervated various target structures including seromucous gland epithelium and myoepithelium, respiratory epithelium, and smooth muscle of the tracheobronchial tree. The only macrovascular elements receiving vesicular acetylcholine transporter-positive innervation were the cerebral arteries. The microvasculature throughout the viscera, with the exception of lymphoid tissues, the liver and kidney, received vesicular acetylcholine transporter-positive innervation while the microvasculature of limb and trunk skeletal muscle appeared to be the only relevant somatic target of vesicular acetylcholine transporter innervation. Vesicular acetylcholine transporter immunoreactivity was particularly useful for identification of parasympathetic intrinsic ganglia, and their terminal fields, in heart, uterus, and other peripheral organs receiving parasympathetic innervation. Extensive vesicular acetylcholine transporter-positive terminal fields were apparent in both atrial and ventricular tissues of the heart targeting cardiomyocytes as well as cardiac microvessels. Pericardiac brown adipose tissue was also supplied by vesicular acetylcholine transporter-positive varicose fibres. The enteric ganglia of the myenteric and submucous plexus, their synaptic junctions with circular and longitudinal smooth muscle, and terminal fields of the lamina propria of the stomach and intestine and of the local microvasculature were intensely vesicular acetylcholine transporter positive. Vesicular acetylcholine transporter-positive innervation was delivered to the exocrine and endocrine pancreas originating from vesicular acetylcholine transporter-positive intrapancreatic ganglia. Vesicular acetylcholine transporter immunoreactivity in urogenital organs revealed the patterns of terminal cholinergic fields arising from the sacral parasympathetic innervation of these structures. Components of the cholinergic nervous system in the periphery whose existence has been controversial have been confirmed, and the existence of new components of the cholinergic nervous system has been documented, with vesicular acetylcholine transporter immunohistochemistry. Visualization of vesicular acetylcholine transporter will allow documentation of changes in synaptic patency during development, in disease, and during changes in neurotransmission accompanying injury and dystrophy, in the peripheral nervous system.

Acetylcholine↗
PubMed2003

Sacral neuromodulation for the treatment of refractory interstitial cystitis: outcomes based on technique.

Patients with refractory interstitial cystitis (IC) underwent testing with sacral nerve modulation via either a traditional percutaneous approach or a staged procedure. Implanted patients were followed with scaled questionnaires and voiding diaries. Twenty-six patients who had a permanent InterStim placed had a reduction in 24-h voids of 51%. More than two-thirds of patients reported a moderate or marked improvement in urinary frequency, urgency, pelvic pain, pelvic pressure, incontinence and overall quality of life. The test to implant rate of a traditional percutaneous procedure was 52%, compared to a staged procedure of 94%. Assessing sensory response at the time of implant reduced the reoperation rate from 43% to 0%. Ninety-six per cent stated they would undergo an implant again and recommend the therapy to a friend. We concluded that sacral nerve modulation can treat refractory IC symptoms. The response to therapy and the reoperation rate are dependent on the technique used to test and implant the device.

Adolescent↗
PubMed2006

Preliminary results of sacral neuromodulation in 23 children.

PURPOSE: Sacral nerve stimulation with InterStim is approved in the United States for use in adults. Limited data on the effectiveness of sacral nerve stimulation in children are available. We report our experience with patients who underwent InterStim placement for the treatment of severe dysfunctional elimination syndrome, which is defined as a constellation of functional urinary and gastrointestinal symptoms in patients without anatomical anomalies or obvious neurological disease, in whom intensive medical and behavioral therapies have failed to improve symptoms. MATERIALS AND METHODS: A total of 23 patients 6 to 15 years old with presenting symptoms of dysfunctional voiding, enuresis, incontinence, urinary tract infections, bladder pain, urinary retention, urgency, frequency, constipation and/or fecal soiling were followed for a mean of 13.3 months after InterStim placement. RESULTS: Of the 19 patients with urinary incontinence 3 (16%) had complete resolution, 13 (68%) had improvement, 2 (11%) were unchanged and 1 (5%) was worse (sign test, p = 0.002). Among the 16 patients with nocturnal enuresis 2 (13%) had resolution, 9 (56%) improved, 4 (25%) were unchanged and 1 (6%) was worse (sign test, p = 0.0063). Of the 15 patients with urinary retention requiring intervention 9 (60%) had improvement and 1 had worsening symptoms (sign test, p = 0.022), while 2 of 6 patients (33%) on intermittent catheterization were able to stop. One patient had development of new incontinence and enuresis. Bladder pain, urgency, frequency and constipation improved in 67% (8 of 12), 75% (12 of 16), 73% (11 of 15) and 80% (12 of 15) of the patients, respectively. Medications required postoperatively decreased by an average of 3 per patient (p < 0.001). The overall patient satisfaction rate was 64%, while that of the caregiver was 67%. Two leads were explanted from the 23 patients. Complications encountered included 1 seroma, 1 episode of skin sensitivity, 2 device failures and 1 lead revision. CONCLUSIONS: Sacral nerve stimulation in children is an option for carefully selected patients who have failed other therapies. Our results show that sacral nerve stimulation was effective in the majority of patients with the dysfunctional elimination syndrome. However, longer followup is needed.

Child↗
PubMed1997

Sacral rhizotomies and electrical bladder stimulation in spinal cord injury. Part I: Clinical and urodynamic analysis. Dutch Study Group on Sacral Anterior Root Stimulation.

OBJECTIVES: To present the clinical and urodynamic results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral rhizotomies and electrical bladder stimulation with the Finetech-Brindley stimulator during a 3-year inclusion and study period. METHODS: 226 patients with spinal cord lesion and urological problems due to hyperreflexia of the bladder were screened for sacral rhizotomies and electrical bladder stimulation. In 52 patients complete posterior sacral root rhizotomies were performed and a Finetech-Brindley sacral anterior root stimulator implanted. All patients were screened and followed with a standard protocol. RESULTS: Complete continence during daytime was achieved in 73% of patients with 6-month follow-up and in 86% at night. Significant increase in bladder capacity and bladder compliance was achieved in all patients. Residual urine was reduced significantly, resulting in a decrease of the incidence of urinary tract infections. CONCLUSIONS: The treatment of neurogenic bladder dysfunction in spinal cord injury by anterior sacral root stimulation with the Finetech-Brindley stimulator in combination with sacral posterior root rhizotomy produces excellent results with limited morbidity.

Adolescent↗
PubMed2005

Sacral nerve stimulation can be successful in patients with ultrasound evidence of external anal sphincter disruption.

PURPOSE: This study was designed to determine whether patients with fecal incontinence and endoanal ultrasound evidence of anal sphincter disruption may be successfully treated by sacral nerve stimulation. METHODS: Five consecutive females with incontinence to solids and endoanal ultrasound evidence of anal sphincter disruption were treated by a two-week trial of sacral nerve stimulation. If successful, patients then proceeded to permanent sacral nerve stimulation implantation. RESULTS: Five patients, aged 34 to 56 years, were treated by temporary sacral nerve stimulation. Four had symptoms starting after childbirth. Two had previously had an anterior sphincter repair. After a two-week trial, three females reported full continence and an improvement in all aspects of their Rockwood fecal incontinence quality of life scores. These three females underwent permanent sacral nerve stimulation implantation. The remaining two patients reported no improvement and underwent dynamic graciloplasty or end colostomy respectively. CONCLUSIONS: Sacral nerve stimulation may successfully restore bowel continence in some patients with endoanal ultrasound evidence of a defect in their external anal sphincter.

Adult↗
PubMed2003

Update on sacral neuromodulation: indications and outcomes.

Tanagho and Schmidt first introduced sacral nerve neuromodulation in 1981. Since then, it has become increasingly popular and the indications for this procedure are growing. The purpose of this article is to discuss the established indications for sacral nerve stimulation (SNS). The outcomes of the most recent studies and trials dealing with SNS are presented. An overview of the most recent techniques used for neuromodulation is detailed.

Adult↗
PubMed2002

[Chronic sacral bilateral neuromodulation. Using a minimal invasive implantation technique in patients with disorders of bladder function].

The implantable neuromodulation system described by Tanagho and Schmidt enables unilateral sacral nerve stimulation. Reports have been made on sacral neuromodulation failures of up to 50% in patients undergoing this procedure. We chose the bilateral electrode implantation and a minimal invasive laminectomy to ensure a more effective modulation and better placement and fixation of the electrodes. After successful assessment using a peripheral nerve evaluation test, 20 patients (14 with detrusor instability, 6 with hypocontractile detrusor) underwent minimally invasive laminectomy and bilateral electrode placement. In the patients with detrusor instability, the incontinence episodes were reduced from 7.2 to 1 per day and the bladder capacity improved from 198 to 352 ml. In patients with hypocontractile detrusor, the initial residual urine level of 450 ml dropped to 108 ml. Maximum detrusor pressure during micturition rose from 12 cmH2O initially to 34 cmH2O. The average follow up period was 17.5 months. There was no sign of deterioration in the modulation effect in any of the patients. Bilateral electrode implantation and the new sacral approach allow optimal neuromodulation in patients with bladder dysfunction. Laminectomy enables optimum electrode placement and fixation with minimal trauma.

Electric Stimulation Therapy↗
PubMed2004

A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation.

OBJECTIVE: The aim of this study was to evaluate in a prospective, randomized setting if the 2-stage implant, compared to a 1-stage implant, leads to a superior subjective or objective outcome of sacral nerve stimulation after implantation of the pulse generator in patients with lower urinary tract symptoms. PATIENTS AND METHODS: We implanted a sacral (S3) foramen lead and a pulse generator (model 3023, Medtronic Inc, Minneapolis, MN, USA) in 42 patients. They were randomized in a 1-stage or a 2-stage implant if a more than 50% improvement in voided volume or reduction of residual urine was seen during the test stimulation phase as compared to baseline. RESULTS: At 24 months follow-up, subjective (visual analogue scale) and objective (voided volume or residual urine) assessment were significantly better in the 2-stage group. Ten patients (24%) failed therapy, 7 in the 1-stage implant and 3 in the 2-stage group. Two patients were lost to follow-up. Logistic regression analysis revealed that failure was positively related to the 1-stage implant and negatively to the age of the patients. 76% of the treated patients had sustained clinical benefit with 23 revisions performed. The mean cost is respectively for the PNE (2006 Euro), for the 2-stage implant (10826 Euro) and for the 1 stage implant (8505 Euro). CONCLUSION: With this study, we demonstrated that the 2-stage implantation technique of the sacral neuromodulation therapy performed as a longer test stimulation phase has a higher success rate.

Algorithms↗
PubMed1999

Hyperbaric oxygen corrects sacral plexopathy due to osteoradionecrosis appearing 15 years after pelvic irradiation.

In 1982, a 55-year-old woman was treated by total cystectomy and adjuvant radiotherapy/chemotherapy for a leiomyosarcoma of the bladder. Fifteen years later she presented with symptoms and signs of sacral plexopathy. Investigations revealed osteoradionecrosis of the sacrum. Hyperbaric oxygen therapy (HBO2) was instituted and progressive resolution of the neurological complaints followed. HBO2 should be considered when managing late-onset sequelae in previously irradiated patients.

Bone Diseases↗
PubMed1982

Involvement of the Onuf nucleus in Werdnig-Hoffmann disease.

Contrary to contention that Onuf nucleus is spared in Werdnig-Hoffmann disease (WHD) as it is in ALS, we found central chromatolysis in the Onuf neurons of the sacral cord from all five WHD patients. They were less depopulated but the central chromatolysis appeared more frequently than in anterior motor neurons. In contrast, the sacral autonomic neurons were not affected in any of the five cases. This argues against the view that the Onuf nucleus is autonomic and is spared with other autonomic neurons.

Anterior Horn Cells↗
PubMed2000

Long-term results of sacral nerve stimulation (S3) for the treatment of neurogenic refractory urge incontinence related to detrusor hyperreflexia.

PURPOSE: We assess clinical and urodynamic results of sacral nerve stimulation for patients with neurogenic (spinal cord diseases) urge incontinence and detrusor hyperreflexia resistant to parasympatholytic drugs. MATERIALS AND METHODS: Since 1992, 9 women with a mean age of 42.6 years (range 26 to 53) were treated for refractory neurogenic urge incontinence with sacral nerve stimulation. Neurological spinal diseases included viral and vascular myelitis in 1 patient each, multiple sclerosis in 5 and traumatic spinal cord injury in 2. Mean time since neurological diagnosis was 12 years. All patients had incontinence with chronic pad use related to detrusor hyperreflexia. Intermittent self-catheterization for external detrusor-sphincter dyssynergia was used by 5 patients. Social life was impaired and these patients were candidates for bladder augmentation. A sacral (S3) lead was surgically implanted and connected to a subcutaneous neurostimulator after a positive test stimulation trial. RESULTS: Mean followup was 43.6 months (range 7 to 72). All patients had clinically significant improvement of incontinence, and 5 were completely dry. Average number of voids per day decreased from 16.1 to 8.2. Urodynamic parameters at 6 months after implant improved significantly from baseline, including maximum bladder capacity from 244 to 377 ml. and volume at first uninhibited contraction from 214 to 340 ml. Maximum detrusor pressure at first uninhibited contraction increased in 3, stabilized in 2 and decreased in 4 patients. Urodynamic results returned to baseline when stimulation was inactivated. All patients subjectively reported improved visual analog scale results by at least 75% at last followup. CONCLUSIONS: Sacral nerve stimulation can be used as a reversible treatment option for refractory urge incontinence related to detrusor hyperreflexia in select patients with spinal lesions.

Adult↗
PubMed2002

[Footdrop during pregnancy or labor due to obstetric lumbosacral plexopathy].

Two women, aged 27 and 28 years, presented with an isolated dropping foot developed during labour and the third trimester of pregnancy, respectively. Lumbosacral plexopathy was diagnosed in both cases. Of the relatively rare maternal obstetric complications, lumbosacral plexopathy is the most common. It is caused by compression of the truncus lumbosacralis against the sacral ala by the foetal head. Symptoms are often misdiagnosed as peroneal or ischiadic neuropathy or lumbosacral radiculoopathy. Therefore for a correct diagnosis, a consultation with a neurologist is indicated. The prognosis for lumbosacral plexopathy is excellent.

Adult↗
PubMed2004

[Value of magnesium sulfate and/or valium in preventing local anesthetic toxicity of sacral block].

OBJECTIVE: To study the effects of magnesium sulfate and/or valium in preventing local anesthetic toxicity induced by sacral block. METHODS: A total of 240 adult patients scheduled for sacral block were randomized equally into four groups matched for sex, age and body weight. Ten minutes before sacral block, the patients in group B received valium (0.1 mg/kg), group C received magnesium sulfate (50 mg/kg), group D received both valium (0.1 mg/kg) and magnesium sulfate (50 mg/kg). The control (group A) received neither valium nor magnesium sulfate. Local anesthetic toxicity was observed and recorded in all the groups. RESULTS: Local anesthetic toxicity was significantly decreased in group B and group C compared with group A (P<0.05), and the toxicity was even more significantly decreased in group D(P<0.01 vs group A). CONCLUSION: Local anesthetic toxicity of sacral block can be significantly decreased by intravenous injection of valium or magnesium sulfate, and their combination produces stronger effects.

Adolescent↗
PubMed2001

Evaluation of the sacroanal motor pathway by magnetic and electric stimulation in patients with fecal incontinence.

PURPOSE: The aim of this controlled study was to examine whether it was feasible to use magnetic stimulation as a new diagnostic tool to evaluate the motor function of the sacral roots and the pudendal nerves in patients with fecal incontinence. PATIENTS AND METHODS: Nineteen consecutive patients (17 females) with a median age of 67 (range, 36-78) years referred for fecal incontinence and 14 healthy volunteers (six females) with a median age of 42 (range, 23-69) years were examined. Latency times of the motor response of the external anal sphincter were measured after electric transrectal stimulation of the pudendal nerve and magnetic stimulation of the sacral roots. RESULTS: The success rates of pudendal nerve terminal motor latency and sacral root terminal motor latency measurements were 100 and 85 percent, respectively, in the control group and 94 and 81 percent, respectively, in the fecal incontinence group. Median left pudendal nerve terminal motor latency was 1.88 (range, 1.4-2.9) milliseconds in the control group and 2.3 (range, 1.8-4) milliseconds in the fecal incontinence group (P < 0.006). Median right pudendal nerve terminal motor latency was 1.7 (range, 1.3-3.4) milliseconds in the control group and 2.5 (range, 1.7-6) milliseconds in the fecal incontinence group (P < 0.003). Median left sacral root terminal motor latency was 3.3 (range, 2.1-6) milliseconds in the control group and 3.7 (range, 2.8-4.8) milliseconds in the fecal incontinence group (P < 0.03). Median right sacral root terminal motor latency was 3 (range, 2.6-5.8) milliseconds in the control group and 3.9 (range, 2.5-7.2) milliseconds in the fecal incontinence group (P = 0.15). CONCLUSIONS: Combined pudendal nerve terminal motor latency and sacral root terminal motor latency measurements may allow us to study both proximal and distal pudendal nerve motor function in patients with fecal incontinence. Values of sacral root terminal motor latency have to be interpreted cautiously because of the uncertainty about the exact site of magnetic stimulation and the limited magnetic field strength.

Adult↗
PubMed2002

Sacral nerve neuromodulation improves physical, psychological and social quality of life in patients with fecal incontinence.

There are several therapeutic options for fecal incontinence but often they do not achieve good results in the long run. This study dealt with sacral nerve modulation, a new therapeutic option. Twenty-one patients underwent pudendal nerve evaluation (PNE) at our institution. Nine patients were affected by both fecal and urinary incontinence, 3 had fecal incontinence and anal pain, 5 had fecal incontinence and pelvic floor dyssynergia, and 4 had isolated fecal incontinence. They underwent morphological, functional and psychological tests prior to PNE, showing no sphincter rupture, almost normal anal pressures, impaired rectal sensation and deficient psychological pattern. All patients underwent at least two nerve evaluations. Four of 21 patients (19%) were selected to receive a permanent sacral electrode, as PNE seemed to have improved their symptoms by >75%. A median follow-up of 15 months (range, 6-24 months) showed that this method decreases weekly episodes of incontinence and increases maximal squeeze pressure. We demonstrated an increase in basal pressure in 3 of 4 patients (all with isolated fecal incontinence). Rectal sensation threshold decreased in three patients; urge threshold decreased in two patients and increased in two patients, but in each patient we got a stabilization. We evaluated the quality of life by applying the Short Form Health Survey test (SF-36). All 4 patients showed a significant increase in the scores of physical, emotional and social role functioning after the permanent implant. In conclusion, sacral nerve modulation may improve physical, physiological and social quality of life in selected groups of incontinent patients without gross sphincter lesions and with impaired rectal sensation.

Adult↗