Protective effect of preserved bladder-filling sensation on upper urinary tract in patients with spinal cord injury

Acute Implantation of a Bioresorbable Polymer Scaffold in Patients With Complete Thoracic Spinal Cord Injury: 24-Month Follow-up From the INSPIRE Study

BACKGROUND

Based on 6-month data from the InVivo Study of Probable Benefit of the Neuro-Spinal Scaffold for Safety and Neurological Recovery in Patients with Complete Thoracic Spinal Cord Injury (INSPIRE) study (NCT02138110), acute implantation of an investigational bioresorbable polymer device (Neuro-Spinal Scaffold [NSS]) appeared to be safe in patients with complete thoracic spinal cord injury (SCI) and was associated with an ASIA Impairment Scale (AIS) conversion rate that exceeded historical controls.

OBJECTIVE

To evaluate outcomes through 24 months postimplantation.

METHODS

INSPIRE was a prospective, open-label, multicenter, single-arm study. Eligible patients had traumatic nonpenetrating SCI with a visible contusion on MRI, AIS A classification, neurological level of injury at T2-T12, and requirement for open spine surgery ≤96 hours postinjury.

RESULTS

Nineteen patients underwent NSS implantation. Three patients had early death determined by investigators to be unrelated to the NSS or its implantation procedure. Seven of 16 evaluable patients (44%) had improvement of ≥1 AIS grade at 6 months (primary end point) to AIS B (n = 5) or AIS C (n = 2). Three patients with AIS B at 6 months had further neurological improvement to AIS C by 12 (n = 2) and 24 (n = 1) months, respectively; none have deteriorated per latest available follow-up. No unanticipated or serious adverse device effects were reported.

CONCLUSION

In this small group of patients with complete thoracic SCI, acute NSS implantation within the spinal cord appeared to be safe with no long-term neurological issues identified during the 24-month follow-up. Patients remain stable, with additional AIS conversions observed in some patients at 12 months and beyond. These data further support the safety and probable benefit of NSS implantation in this patient population.

Disruption of sensation-dependent bladder emptying due to bladder overdistension in a complete spinal cord injury: A case report

BACKGROUND

Autonomic dysreflexia (AD) can be a life-threatening condition in patients with spinal cord injury. It is important to prevent bladder overdistension in these patients as it may trigger AD. Sensation-dependent bladder emptying (SDBE), as a method of bladder management, improves the quality of life and allows physiologic voiding. In this study, we report disruption of the SDBE habit after bladder overdistension leading to AD with chest pain.

CASE SUMMARY

A 47-year-old male with a diagnosis of C4 American Spinal Cord Injury Association impairment scale A had been emptying his bladder using the clean intermittent catheterization method with an itchy sensation in the nose as a sensory indication for a full bladder for 23 years, and the usual urine volume was about 300-400 mL. At the time of this study, the patient had delayed catheterization for approximately five hours. He developed severe abdominal pain and headache and had to visit the emergency room for bladder overdistension (800 mL) and a high systolic blood pressure (205 mmHg). After control of AD, a hypersensitive bladder was observed despite using anticholinergic agents. The sensation indicating bladder fullness changed from nose itching to pain in the abdomen and precordial area. Moreover, the volume of the painful bladder filling sensation became highly variable and was noted when the bladder urine volume exceeded only 100 mL. The patient refused intermittent clean catheterization. Finally, a cystostomy was performed, which relieved the symptoms.

CONCLUSION

Patients using physiologic feedback, such as SDBE, for bladder management are recommended to avoid bladder overdistension.

Sensations Reported During Urodynamic Bladder Filling in Spinal Cord Injury Patients Give Additional Important Information

Purpose

To study sensations reported during filling cystometry in patients with different levels and completeness of spinal cord lesion (SCL).

Methods

A retrospective cohort study. Patient age and sex, cause of SCL, American Spinal Injury Association Impairment Scale (AIS), and lower urinary tract -related sensations in daily life were gathered. Filling cystometry (video-urodynamics) was performed following ICS good urodynamic practice guidelines. Beside bladder filling sensations (first sensation of bladder filling, first desire to void, strong desire to void), other sensations as detrusor overactivity related sensation and pain were noted.

Results

170 patients were included, age 45 ± 17 years, 114 male and 56 female, 92 complete and 78 incomplete SCL. The test was done 6 ± 4 years post SCL. Sensation was reported by 57% of all patients. In complete SCL half (46/92) had sensation, while 36% with incomplete SCL (28/78) reported no sensation. Bladder awareness was not predictable by the AIS. The filling sensations reported were equal to those given in the terminology of ICS. Pain was seldom present 10/170 (6%), Detrusor overactivity contraction was felt by 45/78 ( 58%). Very few patients used sensory information for bladder management at home.

Conclusion

After SCL, most patients retain the ability to be aware of the LUT, assessable and gradable, during urodynamic testing. Filling sensations were not different from those described in healthy, but the number and sequence of the sensations were altered in the minority. Pain and sensation of unstable contractions gave additional important information. As different sensations relate to different spinal afferent pathways, the sensory evaluation during cystometry provided additional important information on the spinal cord's condition.

Combining different evaluations of sensation to assess the afferent innervation of the lower urinary tract after SCI

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To study a combination of three evaluations of sensation in the lower urinary tract (LUT) in patients with spinal cord injury (SCI).

SETTING

University Antwerp Belgium, Unicenter study.

METHODS

Evaluation of perineal sensation with light digital touch, reporting of filling sensation during a standardised urodynamic investigation and determination of the electrical perception threshold (EPT) were evaluated in patients with SCI.

RESULTS

150 individuals were included: 97 men and 53 women, mean age 46 ± 17 years. Patients had different levels and completeness of SCI, and different techniques for bladder emptying. Seventy-four patients (49%) reported sensation to touch in the perineal area. Sensation of bladder filling was reported in different patterns by 81 patients (54%). EPT was determined in 69 patients of which 50 (72%) reported sensation in different patterns. The outcome of absence/presence of sensation between the three tests differed greatly: with perineal sensation absent 53% had filling sensation (p = 0.040) and 58% positive EPT (p = 0.009). With filling sensation absent 59% had EPT sensation (not significant). Perineal sensation was strongly associated with level and completeness of SCI, while a significant association existed for filling sensations FSF, FDV, SDV and EPT in the distal urethra.

CONCLUSIONS

Our study shows that different evaluations of sensation in the LUT of individuals with SCI complement each other. and we therefore propose combined use in the urological evaluation of patients with SCI to allow a more complete picture of the LUT sensations.

An unresolved relationship: the relationship between lesion severity and neurogenic bladder in patients with spinal cord injury

OBJECTIVES

We aimed to investigate the relationship between the severity of the spinal lesion and urodynamic findings, bladder drainage method at discharge, and incidence of renal calculi in patients with spinal cord injury (SCI). STUDYDESIGN: Retrospective.

SETTING

In-patient rehabilitation unit of a tertiary research hospital.

METHODS

A total of 131 patients who were admitted to our clinic with a diagnosis of SCI and placed into a rehabilitation program were included in the study. The severity of the lesion was determined according to the American Spinal Injury Association Impairment Scale (AIS). We evaluated the relationship between the severity of the lesion and the detrusor hyperactivity and compliance as determined by urodynamic investigation, the bladder drainage method used at discharge, and the renal calculi rate as determined by ultrasonography.

RESULTS

While no difference was found between the patients with complete and incomplete injuries in terms of age, sex, disease duration, detrusor hyperactivity and compliance, the bladder drainage method was found to show a significant change according to the severity of the lesion. None of the patients were found to have hydronephrosis and the rate of renal calculi showed no statistically significant difference according to the severity of the lesion.

CONCLUSIONS

We concluded that urodynamic examination is required in each patient with SCI as the severity of the lesion is not sufficient to determine the bladder type, and patients with complete and incomplete injuries should be monitored with the same sensitivity in terms of complications.