The determination of sensation-dependent bladder emptying time in patients with complete spinal cord injury above T11

Integration of brain-computer interfaces with sacral nerve stimulation: a vision for closed-loop, volitional control of bladder function in neurogenic patients through real-time cortical signal modulation and peripheral neuro-stimulation

Sacral nerve stimulation (SNS) and brain-computer interfaces (BCI) are emerging neuromodulation therapies that offer innovative solutions for chronic neurological disorders. SNS, primarily used in the management of conditions such as urinary incontinence and chronic pelvic pain, demonstrates significant therapeutic potential. In contrast, BCIs are rapidly advancing in their ability to restore lost motor functions and improve the quality of life of patients with severe neurological impairments, such as spinal cord injury and stroke. The integration of SNS and BCI technologies presents a promising avenue for enhancing neuromodulation outcomes by leveraging the potential of both systems. This article explores the combined operation of SNS and BCI, addressing current challenges, future directions, and the potential for these combined therapies to revolutionise the field of functional neuromodulation.

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.

Urodynamic findings, bladder emptying methods and therapeutic approaches in patients with upper lumbar and lower lumbar-sacral spinal cord injury

There have been previous reports of both demographic and clinical features with urodynamic evaluation results of patients with traumatic spinal cord injury (SCI). These studies were conducted on patients with cervical and thoracal SCI, but there has been no comparative study evaluating the urodynamic outcomes of patients with lumbosacral SCI. Therefore, it was aimed to investigate the bladder features and treatment options in patients with lumbosacral SCI to be able to take appropriate therapeutic decisions. The urodynamic data of 121 patients with lumbar and sacral SCI were obtained retrospectively using the urodynamics unit records. The patients were grouped as upper lumbar (L1 and L2) SCI (ULSCI) and lower lumbar-sacral (L3 to S5) SCI (LLSSCI). The patients were 92 males (76 %) and 29 (24 %) females, comprising 74 (61.2 %) ULSCI patients and 47 (38.8 %) LLSSCI patients. Detrusor hypocompliancy and anticholinergic prescription were more frequent in the ULSCI group than in the LLSSCI group, while alpha-blocker prescription was more frequent in the LLSSCI group than in the ULSCI group. There was a statistically significant difference between the groups in respect of the rates of bladder-emptying method on admission. A higher mean micturated urine volume was observed in the LLSSCI group than in the ULSCI group. The rates of bladder-filling sensation, detrusor overactivity, bladder-storage and emptying disorders, prescribed emptying method, and residual urine volume were similar in both groups. These results showed that there are differences in neurogenic bladder features and treatment options for patients with upper lumbar and lower lumbar-sacral SCI.

The assessment of bladder and urethral function in spinal cord injury patients

The correlation between the anatomic site of spinal cord injury and real-time conditions of bladder and urethral function was assessed in order to provide a reasonable basis for the clinical treatment of neurogenic bladder. A total of 134 patients with spinal cord injuries (105 males, 29 females; averaged 34.1 years old) were involved in this retrospective analysis, including urodynamic evaluation, clinical examination and imaging for anatomical position, and Bors-Comarr classification. The associations between the levels of injury and urodynamic findings were analyzed. The results showed that mean follow-up duration was 16.7 months (range 8-27 months). Complete spinal cord injuries occurred in 21 cases, and incomplete spinal cord injuries in 113 cases. Of the 43 patients with upper motor neuron (UMN) injuries, hyperreflexia and (or) detrusor sphincter dyssynergia were demonstrated in 30 (69.8%), 31 (72.1%) suffered low bladder compliance (less than 12.5 mL/cmH(2)O), 28 (65.1%) had high detrusor leak point pressures (greater than 40 cmH(2)O), and 34 (79.1%) had residual urine. Of the 91 patients with lower motor neuron (LMN) injuries, areflexia occurred in 78 (85.7%), high compliance in 75 (82.4%), low leak point pressures in 80 (87.9%), and residual urine in 87 (95.6%), respectively. The associations between the anatomical site of spinal cord injury and urodynamic findings were ill defined. In patients with spinal cord injury, this study revealed a significant association between the level of injury and the type of voiding dysfunction. The anatomical site of spinal cord injury can not be predicted in real-time condition of bladder and urethral function. Management of neurogenic bladder in patients with spinal cord injury must be based on urodynamic findings rather than inferences from the neurologic evaluation.