Neurogenic bladder in spinal cord injury patients

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.

External Pelvic Floor Biofeedback for Children With Spinal Cord Injury: A Case Series

IMPORTANCE

Neurogenic bladder can negatively affect quality of life for children with incomplete spinal cord injury. Occupational therapy practitioners are uniquely able to provide individualized care to address this, which may include external pelvic floor biofeedback.

OBJECTIVE

To describe the implementation of external pelvic floor biofeedback for bladder management within the context of toileting for children with neurogenic bladder dysfunction following incomplete spinal cord injury.

DESIGN

Retrospective case series.

SETTING

Inpatient rehabilitation unit within a pediatric hospital.

PARTICIPANTS

Three children with incomplete spinal cord injury were enrolled.

INTERVENTION

External pelvic floor biofeedback.

OUTCOMES AND MEASURES

The study used the Functional Independence Measure for Children (WeeFIM®), Activity Measure for Post-Acute Care (AM-PAC) Daily Activities Short Form, Pediatric Spinal Cord Injury Activity Measures (PEDI-SCI AM) Short Forms, and voiding characteristics.

RESULTS

No adverse events occurred. Following biofeedback, all children improved their AM-PAC toileting scores, and PEDI-SCI AM scores improved for 2 of 3 children, whereas daily catheterization requirements decreased for all children. The WeeFIM did not detect changes in bladder management for 2 of 3 children.

CONCLUSIONS AND RELEVANCE

This case report described how occupational therapy practitioners used external pelvic floor biofeedback as an adjunct conservative treatment strategy when providing care for pediatric children with recent incomplete spinal cord injury. Plain-Language Summary: Neurogenic bladder dysfunction following incomplete spinal cord injury can negatively affect a child's quality of life and social participation. Occupational therapy practitioners are uniquely able to address bladder management within the context of toileting for children with acquired incomplete spinal cord injury. A multimodal approach, which includes biofeedback, may improve the child's level of independence with toileting.

John J, Haag-Molkenteller C, Freund P, Guest J, Mikol DD, Harkema S, Trumbower RD, Fehlings MG, Weidner N, Hogge GS, Field-Fote EC, Baptista MA, Curt A, Hsieh J, Jones L. Lessons Learned and Recommendations from a SCOPE Spinal Cord Injury Neurorestorative Clinical Trials Update

The Spinal Cord Outcomes Partnership Endeavors presented a clinical trials update (CTU) in collaboration with the International Spinal Research Trust as a precourse to their annual meeting. Selected trials adhered to a priori considerations, prioritizing novelty and a focus on neurorestorative approaches. The sessions featured 13 speakers, covering 4 in-preparation, 4 in-progress, and 4 recently completed trials. In addition to in-person attendance, individuals worldwide viewed a live stream of the presentations. Approximately 1600 participants, comprising clinicians, researchers, industry stakeholders, foundations, and individuals with lived experiences, engaged in the CTU through both in-person and virtual channels. Presentations represented a variety of approaches, including drug, biological, and device-based therapeutics. This summary provides high-level summaries of the trials presented and the resulting discussions including lessons learned. Rather than recapitulating published data, the presentations and discussions emphasized the novelty and strengths of each trial, practical aspects of translation, and lessons learned. Throughout the day, several discussion themes surfaced. These included reflections on the suitability of outcome measures and the distinction between statistically or clinically meaningful effects and meaningful changes in quality of life. Additional topics included novel trial designs, selection of inclusion criteria, recognizing the indispensable role of rehabilitation, tailoring approaches to individual needs, the importance of integrating lived experience, and emphasizing the importance of establishing robust pre-clinical data packages before venturing into clinical translation. Importantly, strategic directives are summarized to address these challenges, focusing resources and efforts to steer forthcoming trials effectively.

Effects of a self-efficacy-centered self-management program on neurogenic bladder after spinal cord injury: A randomized controlled trial

PURPOSE

The present research aimed to investigate the effects of a self-efficacy-centered self-management program on persons with neurogenic bladder (NGB) after spinal cord injury (SCI).

DESIGN

A randomized controlled trial.

MATERIALS AND METHODS

Eighty-two individuals with NGB after spinal cord injury (SCI) were randomized into either the control or intervention group. The control group received standard admission and discharge education and follow-up. The intervention group received the self-efficacy-centered self-management program. Self-efficacy was assessed at preintervention, 4, 8, and 12 weeks post-intervention. Self-management ability, the incidence of urinary tract infection (UTI), residual urine volume, bladder safety capacity, and quality of life were assessed at 12 weeks post-intervention.

RESULTS

Of the 82 recruited participants, only 79 participants (control group: n = 39, 67% males, intervention group: n = 40, 58% males) received the full intervention. A significant difference was observed in self-efficacy score between the control and intervention groups (2.54 ± .247 versus 2.71 ± .218, mean difference = .174, 95% confidential interval: .070-.278, p = .001) at 12 weeks post-intervention. The intervention group demonstrated significantly better outcomes than the control group at 12 weeks post-intervention in self-management ability, urinary tract infection (UTI) incidence, residual urine volume and bladder safety capacity. There were significant differences in quality of life (vitality [VT] and mental health [MH] subscales) between the two groups.

CONCLUSIONS

The self-efficacy-centered self-management program developed in this study can significantly increase participants' self-efficacy and bladder self-management ability, thereby improving their bladder functional status and quality of life.

Induction of Neural Differentiation and Protection by a Novel Slow-Release Nanoparticle Estrogen Construct in a Rat Model of Spinal Cord Injury

Spinal cord injury (SCI) is a complex debilitating condition leading to permanent life-long neurological deficits. Estrogen (E2) treatment is known to be neuroprotectant in SCI. This hormone is highly pleiotropic and has been shown to decrease apoptosis, modulate calcium signaling, regulate growth factor expression, act as an anti-inflammatory, and drive angiogenesis. These beneficial effects were found in our earlier study at the low dose of 10 µg/kg E2 in rats. However, the dose remains non-physiologic, which poses a safety hurdle for clinical use. Thus, we recently devised/constructed a fast release nanoparticle (NP) estrogen embedded (FNP-E2) construct and tested a focal delivery system in a contused SCI rat model which showed protection in the short run. In the current study, we have developed a novel slow-release NP estrogen (SNP-E2) delivery system that shows sustained release of E2 in the injured spinal cord and no systemic exposure in the host. The study of E2 release and kinetics of this SNP-E2 construct in vitro and in vivo supported this claim. Delivery of E2 to the injured spinal cord via this approach reduced inflammation and gliosis, and induced microglial differentiation of M1 to M2 in rats after SCI. Analysis of spinal cord samples showed improved myelination and survival signals (AKT) as demonstrated by western blot analysis. SNP-E2 treatment also induced astrocytic differentiation into neuron-like (MAP2/NeuN) cells, supported the survival of oligodendrocyte precursor cells (OPC), and improved bladder and locomotor function in rats following SCI. These data suggest that this novel delivery strategy of SNP-E2 to the injured spinal cord may provide a safe and effective therapeutic approach to treat individuals suffering from SCI.

Decisional regret and impacts on quality of life following genitourinary reconstruction for neurogenic bladder: A comparison between acquired and congenital spinal cord injury

INTRODUCTION

Patient expectations and baseline health are important drivers of outcomes following major genitourinary reconstructive surgery for neurogenic bladder (NGB). Differences in expectations and quality of life (QoL) improvements among different populations with NGB remain insufficiently explored in the literature.

OBJECTIVE

To compare decisional regret (DR) and urinary-related QoL (UrQoL) in patients undergoing urinary diversion for NGB arising from spinal cord injury of acquired (A-SCI) and congenital (C-SCI) etiologies. We hypothesize that patients with A-SCI have higher expectations of improvement in QoL following surgery when compared with C-SCI, which may lead to higher DR and decreased UrQoL, postoperatively.

DESIGN

In this cross-sectional survey study, we compared A-SCI to C-SCI in terms of DR, UrQoL, and postoperative changes in self-reported physical health, mental health, and pain using validated patient-reported outcome measures.

SETTING

Participants were enrolled from a quaternary care institution via mail and MyChart.

PARTICIPANTS

The A-SCI group consisted of 17 patients with traumatic spinal cord injury; the C-SCI group was composed of 20 patients with spina bifida.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Decisional Regret Scale, Short form- Qualiveen (SF-Qualiveen), and Patient-reported outcomes measurement Information system-10 (PROMIS-10) Global Health surveys.

RESULTS

The A-SCI group displayed poorer preoperative physical health than the C-SCI cohort, but absolute postoperative changes in this score, along with mental health score and pain level, were not significant after adjusting for baseline scores and follow-up time. SF-Qualiveen scores revealed significantly worse impact of NGB in UrQoL for A-SCI than for C-SCI when adjusted for other factors. No differences in DR were seen between the groups.

CONCLUSIONS

Patients with A-SCI demonstrate lower self-reported baseline physical health compared with patients with C-SCI, which may have implications in setting patient expectations when undergoing urinary diversion. In this small cohort, we found a milder self-reported postoperative impact of NGB in UrQoL in patients with C-SCI.

["Pressure kills kidneys": protection of the upper urinary tract through neuro-urological management]

Low compliance is not an independent disease but a severe manifestation resulting from various disorders of the storage and excretory function of the bladder. Reduced distensibility of the detrusor muscle can lead to a pressure load on the upper urinary tract but also to urge-dominant LUTS and urinary tract infections. Neurogenic causes, especially spinal cord injury/spina bifida but also iatrogenic damage or subvesical obstruction, can contribute to the development. This article is intended to provide information about the epidemiology and complex pathogenetic mechanisms as well as the necessary diagnostic steps. Various medical, interventional and surgical treatment strategies are evaluated on the basis of current scientific findings, thus supporting the reader in the care of this complex patient group.

Autonomic impairment is not explained by neurological level of injury or motor-sensory completeness

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Determine how well common clinical assessments of level and completeness of injury are correlated with symptoms of autonomic blood pressure instability and secondary medical complications after spinal cord injury (SCI).

SETTING

Academic medical center, United States.

METHODS

Eighty-two individuals with (n = 48) and without (n = 34) SCI had symptoms of autonomic blood pressure instability quantified with the Autonomic Dysfunction Following SCI (ADFSCI) survey. Health histories quantified the secondary medical complications through number of urinary tract infections and hospitalizations in the past year, time to complete bowel program, and lifetime pressure injuries. Regression models were completed to identify strengths of associated correlations.

RESULTS

ADFSCI scores were significantly higher in individuals with SCI than controls. Neurological level of injury and ASIA impairment scale were both minimally correlated to symptoms of autonomic blood pressure instability, accounting for only 11.5% of variability in regression models. Secondary medical complications had similar, minimal correlations to level and motor/sensory completeness of SCI (R2 = 0.07 and R2 = 0.03 respectively). Contrasting this, symptoms of blood pressure instability on ADFSCI far outperformed the common clinical motor/sensory bedside exam, with moderately strong correlations to the ranked number of secondary medical complications after SCI (R2 = 0.31).

CONCLUSION

Neurological level of injury and motor/sensory completeness provided limited insights into which individuals with SCI would have blood pressure instability or secondary medical complications. Interestingly, symptoms of blood pressure instability outperform the clinical motor/sensory bedside exam, with higher correlations to secondary medical complications after SCI.

A retrospective study of uropathogen and its antibiotic resistance among children with urinary tract infection from a single center in China

Urinary tract infection (UTI) is a well-known bacterial infection posing serious health problem in children. A retrospective study was conducted to explore the uropathogen and its antibiotic resistance in children with UTI. Data of urine culture and antimicrobial susceptibility test was collected. Consequently, 840 children were included. The overall culture-positive UTI was 458 (54.52 %) with Escherichia coli 166 (36.24 %), followed by Enterococcus faecalis 59 (12.88 %), Enterococcus faecium 70 (15.28 %) and others. They were highly resistant to the most commonly used antibiotics. In 694 children with complicated UTI, there were 8 children with fungal infection. Multiple drug resistance (MDR) was recorded in 315 (80.98 %). The overall proportion of Extended Spectrum β-Lactamase (ESβL) production was 25 (6.43 %). In 146 children with simple UTI, MDR were also detected in 47 (77.05 %). There were 6 (9.84 %) positive for ESβL production. Our study found that complicated UTI was relatively common. Escherichia coli was the most prevalent isolate, followed by Enterococcus faecium and Enterococcus faecalis. These organisms were highly resistant to the most commonly used antibiotics. Relatively high prevalence of MDR and low ESβL-producing organisms were observed.

Vesicocutaneous fistula at site of closed suprapubic tube tract as the first presenting sign of giant bladder stone

Bladder stones represent approximately 5% of all cases of urolithiasis and are typically identified and managed long before causing irreversible renal injury. We present a case of a man in his 40s with a prior history of a gunshot wound to the abdomen who presented with leakage from a previously healed suprapubic tube tract and was found to have a giant bladder stone with a resulting renal injury. He subsequently underwent a combined open cystolithotomy and vesicocutaneous fistulotomy during his hospitalisation, which helped to improve his renal function. In addition to there being few reported cases of bladder stones >10 cm, this represents the first report in the literature of an associated decompressive 'pop-off' mechanism through a fistulised tract.

Anatomical Location of the Vesical Branches of the Inferior Hypogastric Plexus in Human Cadavers

We have demonstrated in canines that somatic nerve transfer to vesical branches of the inferior hypogastric plexus (IHP) can be used for bladder reinnervation after spinal root injury. Yet, the complex anatomy of the IHP hinders the clinical application of this repair strategy. Here, using human cadavers, we clarify the spatial relationships of the vesical branches of the IHP and nearby pelvic ganglia, with the ureteral orifice of the bladder. Forty-four pelvic regions were examined in 30 human cadavers. Gross post-mortem and intra-operative approaches (open anterior abdominal, manual laparoscopic, and robot-assisted) were used. Nerve branch distances and diameters were measured after thorough visual inspection and gentle dissection, so as to not distort tissue. The IHP had between 1 to 4 vesical branches (2.33 ± 0.72, mean ± SD) with average diameters of 0.51 ± 0.06 mm. Vesical branches from the IHP arose from a grossly visible pelvic ganglion in 93% of cases (confirmed histologically). The pelvic ganglion was typically located 7.11 ± 6.11 mm posterolateral to the ureteral orifice in 69% of specimens. With this in-depth characterization, vesical branches from the IHP can be safely located both posterolateral to the ureteral orifice and emanating from a more proximal ganglionic enlargement during surgical procedures.

Efficacy in Using Urodynamic Parameters of Intravesical Electrical Stimulation for Detrusor Underactivity

OBJECTIVE

Intravesical electrical stimulation (IVES) remains a controversial therapy for detrusor underactivity (DUA). The purpose of this study is to determine the efficacy of IVES in patients with DUA using pre- and post-IVES urodynamic parameters.

METHODS

Intravesical electrical stimulation procedure is performed using a specific catheter equipped with an internal electrical electrode (cathode). The anode is subsequently affixed to the lower abdomen (suprapubic). Afterward, this specialized catheter is connected to a stimulator. Patients undergo a series of 12 IVES procedures in 1 month with the following predetermined parameters: 20 mA amplitude, 20 Hz frequency, 200 µs pulse width, and 60 minutes stimulation time. Patients underwent a follow-up urodynamic examination 1 month after the IVES series is completed.

RESULTS

After IVES, several notable changes were observed, including an increase in Qmax from 7.28 ± 5.24 to 7.29 ± 4.09 (P=.030), a decrease in post-void residual (PVR) from 73.03 ± 43.91 to 62.07 ± 39.10 (P=.005), and an increase in PDet@tQmax from 17.10 ± 12.35 to 18.87 ± 12.47 (P=.009). The aetiologies of DUA were categorized into 3 groups: chronic obstruction (CO), idiopathic (Idio), and neurological disorder (ND). The CO group exhibited significant changes in urodynamic parameters, specifically Qmax (P=.001), PVR (P=.001), and PDet@Qmax (P=.035). Similarly, the idiopathic group also demonstrated improvements in Qmax (P=.008), PVR (P=.037), and PDet@ Qmax (P=.033).

CONCLUSION

Intravesical electrical stimulation has been shown to have a positive effect on patients diagnosed with DUA, particularly those whose DUA is idiopathic or due to chronic obstruction.

Priorities, needs and willingness of use of nerve stimulation devices for bladder and bowel function in people with spinal cord injury (SCI): an Australian survey

STUDY DESIGN

Anonymous online survey OBJECTIVES: To investigate the priorities, needs and willingness to adopt nerve stimulation devices for managing neurogenic bladder and bowel function in people with spinal cord injury (SCI) living in Australia.

SETTING

Online survey of people living with SCI in Australia.

METHODS

This anonymous online survey used Qualtrics and was advertised via standard communication channels, such as advocacy groups representing the SCI community in Australia, social media, attending SCI sporting events and by word-of-mouth.

RESULTS

Responses from 62 individuals (32% female, 68% male) were included. Bladder emptying through urethra without catheter was the highest priority for bladder function. Reducing time required for bowel routines and constipation were the top priorities regarding bowel function. The highest concern for internal/implanted devices was the 4% chance of device surgical removal, while wearing wires under the clothes was the main concern for external devices. 53% of respondents were willing to trial an implanted nerve stimulation device, while 70% would trial an external device to improve and gain independence in bladder and bowel function.

CONCLUSION

The findings of this study highlighted the potential role in which nerve stimulation can have in addressing bladder and bowel dysfunction in people with SCI, and have also identified that there was a need for Australian physiotherapists to evaluate their role in bladder and bowel dysfunction. Results from this study can help guide further research in nerve stimulation devices for bladder and bowel dysfunction in people with SCI.

SPONSORSHIP

n/a.

Acute ampakines increase voiding function and coordination in a rat model of SCI

Neurogenic bladder dysfunction causes urological complications and reduces the quality of life in persons with spinal cord injury (SCI). Glutamatergic signaling via AMPA receptors is fundamentally important to the neural circuits controlling bladder voiding. Ampakines are positive allosteric modulators of AMPA receptors that can enhance the function of glutamatergic neural circuits after SCI. We hypothesized that ampakines can acutely stimulate bladder voiding that has been impaired due to thoracic contusion SCI. Adult female Sprague-Dawley rats received a unilateral contusion of the T9 spinal cord (n = 10). Bladder function (cystometry) and coordination with the external urethral sphincter (EUS) were assessed 5 d post-SCI under urethane anesthesia. Data were compared to responses in spinal-intact rats (n = 8). The 'low-impact' ampakine CX1739 (5, 10, or 15 mg/kg) or vehicle (2-hydroxypropyl-beta-cyclodextrin [HPCD]) was administered intravenously. The HPCD vehicle had no discernible impact on voiding. In contrast, following CX1739, the pressure threshold for inducing bladder contraction, voided volume, and the interval between bladder contractions were significantly reduced. These responses occurred in a dose-dependent manner. We conclude that modulating AMPA receptor function using ampakines can rapidly improve bladder-voiding capability at subacute time points following contusion SCI. These results may provide a new and translatable method for therapeutic targeting of bladder dysfunction acutely after SCI.

Complications of different methods of urological management in people with neurogenic bladder secondary to spinal cord injury

OBJECTIVE

To investigate the association between multiple types of urological management and urological complications in patients with spinal cord injury (SCI).

DESIGN

A retrospective cohort study.

SETTING

Single medical center.

METHODS

Medical records of SCI patients with regular follow-up of more than two years were reviewed. Urological management was classified into five groups: indwelling urethral catheter (IUC), clean intermittent catheterization (CIC), reflex voiding, suprapubic catheter (SPC), and self-voiding. We analyzed the incidence of urinary tract infection (UTI), epididymitis, hydronephrosis, and renal stone across the different urological-management groups.

RESULTS

Of 207 individuals with SCI, the most common management type was self-voiding (n = 65, 31%) followed by CIC (n = 47, 23%). The IUC and SPC groups included more people with complete SCI than the other management groups. Compared with the IUC group, the SPC and self-voiding groups had lower risks of developing UTI (relative risk [RR] = 0.76, 95% CI, 0.59-0.97 and RR = 0.39, 95% CI, 0.28-0.55, respectively). The SPC group tended to have a lower risk of epididymitis than the IUC group (RR = 0.55, 95% CI, 0.18-1.63).

CONCLUSION

Long-term IUC use was associated with a higher incidence of UTI in people with SCI. As compared to those with IUC, a lower risk of UTI was found in persons with SPC. These findings may have implications for shared clinical decision-making.

Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations

PURPOSE

Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD.

METHODS

After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.

Symptomatic Treatment of Myelopathy

OBJECTIVE

This article discusses the effects of myelopathy on multiple organ systems and reviews the treatment and management of some of these effects.

LATEST DEVELOPMENTS

Recent advances in functional electrical stimulation, epidural spinal cord stimulation, robotics, and surgical techniques such as nerve transfer show promise in improving function in patients with myelopathy. Ongoing research in stem cell therapy and neurotherapeutic drugs may provide further therapeutic avenues in the future.

ESSENTIAL POINTS

Treatment for symptoms of spinal cord injury should be targeted toward patient goals. If nerve transfer for upper extremity function is considered, the patient should be evaluated at around 6 months from injury to assess for lower motor neuron involvement and possible time limitations of surgery. A patient with injury at or above the T6 level is at risk for autonomic dysreflexia, a life-threatening condition that presents with elevated blood pressure and can lead to emergent hypertensive crisis. Baclofen withdrawal due to baclofen pump failure or programming errors may also be life-threatening. Proper management of symptoms may help avoid complications such as autonomic dysreflexia, renal failure, heterotopic ossification, and fractures.

Prediction of early bladder outcomes after spinal cord injury: The HALT score

AIMS

Neurogenic bladder (NB) is a prevalent and debilitating consequence of spinal cord injury (SCI). Indeed, the accurate prognostication of early bladder outcomes is crucial for patient counseling, rehabilitation goal setting, and personalized intervention planning.

METHODS

A retrospective exploratory analysis was conducted on a cohort of consecutive SCI patients admitted to a rehabilitation facility in China from May 2016 to December 2022. Demographic, clinical, and electrophysiological data were collected within 40 days post-SCI, with bladder outcomes assessed at 3 months following SCI onset.

RESULTS

The present study enrolled 202 SCI patients with a mean age of 40.3 ± 12.3 years. At 3 months post-SCI, 79 participants exhibited complete bladder emptying. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analyses identified the H-reflex of the soleus muscle, the American Spinal Injury Association Lower Extremity Motor Score (ASIA-LEMS), and the time from lesion to rehabilitation facility (TLRF) as significant independent predictors for bladder emptying. A scoring system named HALT was developed, yielding a strong discriminatory performance with an area under the receiver operating characteristics curve (aROC) of 0.878 (95% CI: 0.823-0.933). A simplified model utilizing only the H-reflex exhibited excellent discriminatory ability with an aROC of 0.824 (95% CI: 0.766-0.881). Both models demonstrated good calibration via the Hosmer-Lemeshow test and favorable clinical net benefits through decision curve analysis (DCA). In comparison to ASIA-LEMS, both the HALT score and H-reflex showed superior predictive accuracy for bladder outcome. Notably, in individuals with incomplete injuries, the HALT score (aROC = 0.973, 95% CI: 0.940-1.000) and the H-reflex (aROC = 0.888, 95% CI: 0.807-0.970) displayed enhanced performance.

CONCLUSION

Two reliable models, the HALT score and the H-reflex, were developed to predict bladder outcomes as early as 3 months after SCI onset. Importantly, this study provides hitherto undocumented evidence regarding the predictive significance of the soleus H-reflex in relation to bladder outcomes in SCI patients.

Experiences of people with spinal cord injuries readmitted for continence-related complications: a qualitative descriptive study

STUDY DESIGN

Qualitative descriptive.

OBJECTIVES

To describe the experiences of people with Spinal Cord Injury (SCI) re-admitted to the hospital due to continence-related complications.

SETTING

Inpatient service of a large spinal unit in North-West of Italy.

METHODS

Semi-structured interviews were conducted on a purposive sample of people with SCI (n = 11; age range 22-66 years, n = 5 females, n = 6 with cervical injuries), audio-recorded, and transcribed verbatim (duration range 38-52 min). Data were analysed inductively using the thematic analysis approach as described by Braun and Clarke.

RESULTS

Three main themes were identified: (i) managing the frustration of continence-related complications; (ii) finding your way to deal with continence-related complications; (iii) identifying precise needs to deal with continence-related complications. Obtained findings highlighted the perceived emotional and physical burden suffered by people with SCI and their caregivers regarding the constant look for solutions and renounces to social participation, the different strategies implemented to address continence-related complications, and the unmet or partially met needs of people with SCI regarding support in transition to the community, infrastructure, and reliable information or education.

CONCLUSIONS

Continence-related complications have a significant impact on the lives of people with SCI and their families. Interventions using technological tools and peer participation could reduce the burden associated with continence-related complications. Specific instruments are needed to facilitate evaluation, goal setting, and promote discussion of continence to allow HCPs to support people with SCI. Structured follow-up for SCI survivors should also focus on their needs to improve knowledge, facilitate decision making, and promote preventive behaviours.

Acute ampakines increase voiding function and coordination in a rat model of SCI

Neurogenic bladder dysfunction causes urological complications and reduces the quality of life in persons with spinal cord injury (SCI). Glutamatergic signaling via AMPA receptors is fundamentally important to the neural circuits controlling bladder voiding. Ampakines are positive allosteric modulators of AMPA receptors that can enhance the function of glutamatergic neural circuits after SCI. We hypothesized that ampakines can acutely stimulate bladder voiding that has been impaired due to thoracic contusion SCI. Adult female Sprague Dawley rats received a unilateral contusion of the T9 spinal cord (n=10). Bladder function (cystometry) and coordination with the external urethral sphincter (EUS) were assessed five days post-SCI under urethane anesthesia. Data were compared to responses in spinal intact rats (n=8). The "low impact" ampakine CX1739 (5, 10, or 15 mg/kg) or vehicle (HPCD) was administered intravenously. The HPCD vehicle had no discernable impact on voiding. In contrast, following CX1739, the pressure threshold for inducing bladder contraction, voided volume, and the interval between bladder contractions were significantly reduced. These responses occurred in a dose-dependent manner. We conclude that modulating AMPA receptor function using ampakines can rapidly improve bladder voiding capability at sub-acute time points following contusion SCI. These results may provide a new and translatable method for therapeutic targeting of bladder dysfunction acutely after SCI.

Changes in bladder emptying during inpatient rehabilitation after spinal cord injury and predicting factors: data from the Dutch Spinal Cord Injury Database

STUDY DESIGN

Secondary analysis of multicentre prospective observational data.

OBJECTIVES

To describe methods of bladder emptying at admission and discharge in patients with recently acquired spinal cord injury (SCI) and to describe predictors of bladder emptying methods at discharge.

SETTING

First inpatient rehabilitation in specialised rehabilitation centres in the Netherlands.

METHODS

Data from the Dutch Spinal Cord Injury Database collected between 2015 and 2019 were used. McNemar-Bowker test was used to evaluate if bladder emptying methods differed over time; One-Way ANOVA and Chi-Square tests to see if bladder emptying methods differed by demographic and injury-related characteristics. Binary logistic regression was used to predict the type of bladder emptying at discharge with demographic and injury-related characteristics measured at admission.

RESULTS

Of 1403 patients, 44.1% had cervical, 38.4% thoracic and 17.5% lumbosacral lesions at admission. AIS classification was mostly D (63.8%). The method of bladder emptying changed significantly (p < 0.001) from admission to discharge: decrease of clean intermittent assisted catheterisation (17.1% to 4.1%) and indwelling catheter (33.4% to 16.3%) and increase in clean intermittent self-catheterisation (CISC, 7.8% to 22.2%) and normal voiding (40.2% to 56.1%). Age, sex, SCI level, AIS classification and level of independence predicted the method of bladder emptying at discharge (all p < 0.001).

CONCLUSIONS

During first inpatient rehabilitation, the method of bladder emptying changed resulting in more patients discharged with normal voiding and CISC. Age, sex, SCI level, AIS classification and level of independence in self-care were all confirmed as factors playing a role in this change.

Stem Cell Therapy in Spinal Cord Injury-Induced Neurogenic Lower Urinary Tract Dysfunction

Spinal cord injury (SCI) is a devastating condition that enormously affects an individual's health and quality of life. Neurogenic lower urinary tract dysfunction (NLUTD) is one of the most important sequelae induced by SCI, causing complications including urinary tract infection, renal function deterioration, urinary incontinence, and voiding dysfunction. Current therapeutic methods for SCI-induced NLUTD mainly target on the urinary bladder, but the outcomes are still far from satisfactory. Stem cell therapy has gained increasing attention for years for its ability to rescue the injured spinal cord directly. Stem cell differentiation and their paracrine effects, including exosomes, are the proposed mechanisms to enhance the recovery from SCI. Several animal studies have demonstrated improvement in bladder function using mesenchymal stem cells (MSCs) and neural stem cells (NSCs). Human clinical trials also provide promising results in urodynamic parameters after MSC therapy. However, there is still uncertainty about the ideal treatment window and application protocol for stem cell therapy. Besides, data on the therapeutic effects regarding NSCs and stem cell-derived exosomes in SCI-related NLUTD are scarce. Therefore, there is a pressing need for further well-designed human clinical trials to translate the stem cell therapy into a formal therapeutic option for SCI-induced NLUTD.

The temporal burden of preparing catheters for re-use in adults with spinal cord injury: a cross-sectional study

STUDY DESIGN

Cross-sectional OBJECTIVES: Neurogenic lower urinary tract dysfunction is common among people with spinal cord injury (SCI). Although single-use clean intermittent catheterization is recommended to facilitate routine bladder emptying, catheter re-use is common. Barriers associated with the preparation (i.e., cleaning) of catheters for re-use are unknown. This study examined barriers to catheter re-use in adult individuals with SCI by assessing (1) the time needed to clean a catheter, and (2) the perceived difficulty of the catheter cleaning routine.

SETTING

Laboratory METHODS: Twenty individuals with chronic SCI ( ≥ 1 year since injury; Group 1 = 10 with tetraplegia; Group 2 = 10 with paraplegia) completed the study. Using a standardized cleaning procedure (i.e., Milton method), catheter cleaning was timed for each participant. Perceived difficulty was assessed using a 5-point Likert scale. Functional impairment was assessed with the Upper Extremity Motor Score (UEMS).

RESULTS

Significant between-group differences were observed for total cleaning time (Group 1 = 1584.1 ± 179.8 s; Group 2 = 1321.0 ± 93.8 s, p = 0.004) and perceived difficulty [Group 1 = 2.6 (2, 3); Group 2 = 2 (1.7, 2.3), p = 0.028]. Total cleaning time was significantly correlated with UEMS (ρ = -0.709, p ≤ 0.001) and perceived difficulty (ρ = 0.468, p = 0.037). UEMS emerged as an independent predictor of total cleaning time (R2 = 0.745, β = -0.833, p ≤ 0.001).

CONCLUSIONS

Preparing catheters for re-use is time-intensive and difficult for people with higher SCI level, severity and more pronounced upper limb motor impairment, which was independently associated with total cleaning time. Performing this routine on a consistent basis would require a substantial time commitment and would have a profoundly negative impact on overall quality of life.

Central nervous system sulfatide deficiency as a causal factor for bladder disorder in Alzheimer's disease

BACKGROUND

Despite being a brain disorder, Alzheimer's disease (AD) is often accompanied by peripheral organ dysregulations (e.g., loss of bladder control in late-stage AD), which highly rely on spinal cord coordination. However, the causal factor(s) for peripheral organ dysregulation in AD remain elusive.

METHODS

The central nervous system (CNS) is enriched in lipids. We applied quantitative shotgun lipidomics to determine lipid profiles of human AD spinal cord tissues. Additionally, a CNS sulfatide (ST)-deficient mouse model was used to study the lipidome, transcriptome and peripheral organ phenotypes of ST loss.

RESULTS

We observed marked myelin lipid reduction in the spinal cord of AD subjects versus cognitively normal individuals. Among which, levels of ST, a myelin-enriched lipid class, were strongly and negatively associated with the severity of AD. A CNS myelin-specific ST-deficient mouse model was used to further identify the causes and consequences of spinal cord lipidome changes. Interestingly, ST deficiency led to spinal cord lipidome and transcriptome profiles highly resembling those observed in AD, characterized by decline of multiple myelin-enriched lipid classes and enhanced inflammatory responses, respectively. These changes significantly disrupted spinal cord function and led to substantial enlargement of urinary bladder in ST-deficient mice.

CONCLUSIONS

Our study identified CNS ST deficiency as a causal factor for AD-like lipid dysregulation, inflammation response and ultimately the development of bladder disorders. Targeting to maintain ST levels may serve as a promising strategy for the prevention and treatment of AD-related peripheral disorders.

Efficacy of the magnetic stimulation of sacral nerve roots combined with Tui-na on neurogenic bladder after spinal cord injury: preliminary short-term results

OBJECTIVE

Neurogenic bladder (NGB) is a serious complication after spinal cord injury (SCI), a destructive neurological disease. This study focused on exploring the efficacy of the magnetic stimulation of sacral nerve roots combined with Tui-na in treating NGB after SCI.

METHODS

One hundred patients with NGB after SCI were studied, and intermittent clean catheterization was performed with a water intake program, and patients were grouped into four groups by the random number table method: general treatment group, Tui-na group, magnetic stimulation group, and combined treatment group. A series of relevant factors (voiding diary, urodynamics, and quality of life scores) and clinical efficacy of patients in the four groups before and after treatment were observed.

RESULTS

The magnetic stimulation of sacral nerve roots alone, Tui-na alone, and the combination of both were all effective in improving bladder function and quality of life in patients with NGB after SCI, including improvements in voiding frequency, single urine output, maximum urine output, residual urine output, bladder volume and quality of life scores in patients with NGB after SCI. The efficacy of the magnetic stimulation of sacral nerve roots combined with Tui-na was better than that of the magnetic stimulation of sacral nerve roots alone and the Tui-na alone.

CONCLUSION

This research demonstrates that the magnetic stimulation of sacral nerve roots combined with Tui-na treatment could effectively improve the urinary system and the quality of life of patients with NGB after SCI, which is worthy of clinical promotion and application.

Spinal muscular atrophy-like phenotype in a mouse model of acid ceramidase deficiency

Mutations in ASAH1 have been linked to two allegedly distinct disorders: Farber disease (FD) and spinal muscular atrophy with progressive myoclonic epilepsy (SMA-PME). We have previously reported FD-like phenotypes in mice harboring a single amino acid substitution in acid ceramidase (ACDase), P361R, known to be pathogenic in humans (P361R-Farber). Here we describe a mouse model with an SMA-PME-like phenotype (P361R-SMA). P361R-SMA mice live 2-3-times longer than P361R-Farber mice and have different phenotypes including progressive ataxia and bladder dysfunction, which suggests neurological dysfunction. We found profound demyelination, loss of axons, and altered sphingolipid levels in P361R-SMA spinal cords; severe pathology was restricted to the white matter. Our model can serve as a tool to study the pathological effects of ACDase deficiency on the central nervous system and to evaluate potential therapies for SMA-PME.

Magnetically controlled artificial urinary sphincter: An overview from existing devices to future developments

BACKGROUND

Urinary incontinence is a common clinical problem in the world today. Artificial urinary sphincter is a good treatment approach for severe urinary incontinence, which is designed to mimic the action of the human urinary sphincter and assist patients to regain urinary function.

METHODS

There are many control methods based on artificial urinary sphincter, such as hydraulic control, electromechanical control, magnetic control, and shape memory alloy control. In this paper, the literature was first searched and documented based on PRISMA search strategy for selected specific subject terms. Then, a comparison of artificial urethral sphincters based on different control methods was conducted, and the research progress of magnetically controlled artificial urethral sphincters was reviewed, and their advantages and disadvantages were summarized. Finally, the design factors for the clinical application of magnetically controlled artificial urinary sphincter are discussed.

RESULTS

As magnetic control allows for non-contact force transfer and does not generate heat, it is proposed that magnetic control may be one of the more promising control methods. The design of future magnetically controlled artificial urinary sphincters will need a variety of considerations, including the structural design of the device, manufacturing materials, manufacturing costs, and convenience. In addition, validation of the safety and effectiveness of the device and device management are equally important.

CONCLUSIONS

The design of an ideal magnetically controlled artificial urinary sphincter is of great importance to enhance patient treatment outcomes. However, there are still great challenges to be faced for the clinical application of such devices.

Effects of repetitive functional magnetic stimulation in the sacral nerve in patients with neurogenic detrusor overactivity after suprasacral spinal cord injury: a study protocol for a randomized controlled trial

BACKGROUND

Neurogenic detrusor overactivity (NDO) is a serious and common complication after spinal cord injury, affecting patients' quality of life seriously. Therefore, we developed this research protocol to evaluate the efficacy of repetitive functional magnetic stimulation (rFMS) in the sacral nerve in patients with neurogenic detrusor overactivity (NDO) after suprasacral spinal cord injury (SCI) and provide more options for rFMS in treating NDO after suprasacral SCI.

METHODS

This study is a single-center, randomized, parallel-group clinical trial. We will recruit the patients with NDO after suprasacral SCI in the Rehabilitation Department of the Affiliated Hospital of Southwest Medical University from September 2022 to August 2023. They will be assigned to the rFMS group and the sham stimulation group randomly. The sample size is 66, with 33 patients in each group. The rFMS group will receive real rFMS treatment of the sacral nerve (100% stimulation intensity, 5 Hz, 20 min each time, five times a week), and the sham group will receive sham stimulation. Both groups will receive similar treatment strategies, including medication, standard urine management, acupuncture treatment, and health education. The bladder compliance (bladder capacity/detrusor pressure) and pudendal nerve electromyography will be evaluated at baseline, 8th week of treatment. The residual volume of the bladder and bladder diary will be recorded once a week during 8 weeks of treatments. SCI-QOL and NBSS will be evaluated at baseline, the 4th and 8th week of treatment. In addition, the above assessments will be followed up at 8 weeks after the end of treatment.

DISCUSSION

It is expected that the bladder function, symptoms, and quality of life might be significantly improved after rFMS of the sacral nerve.

TRIAL REGISTRATION

The China Clinical Trials Registry has approved this study, registration number: ChiCTR2100045148. Registered on April 7, 2021.

Urinary Dysfunction: Frequency, Risk factors, and Interventions in patients with Cancer during Acute Inpatient Rehabilitation

Introduction: Urinary dysfunction has a strong impact clinically, socially, and economically. Although the development of acute urinary dysfunction in hospitalized patients with cancer is common in clinical practice, its occurrence and management strategies are scant in the literature. It has been reported as one of the more common medical complications in patients with cancer undergoing acute inpatient rehabilitation. This study assessed the frequency of and risk factors for acute urinary dysfunction among these patients and identified the interventions used for management. Methods: This is a retrospective study of consecutive patients admitted to a National Cancer Institute Comprehensive Cancer Center's acute inpatient rehabilitation service from 9/1/2020 through 3/15/2021. We excluded patients that were readmissions during the study time frame. We collected patients' demographic, clinical, and functional data. We defined acute urinary dysfunction as the development of any new urinary symptom(s) or diagnosis, which involved additional work-up and/or management after admission to the acute inpatient rehabilitation service. Results: Of the 176 total patients included in this study, 47 (27%; 95% confidence interval [CI], 20-34) patients had acute urinary dysfunction. The most frequent diagnoses were urinary tract infection (32%) and neurogenic bladder (26%). The most common tests were urine cultures (32%) and urinalyses (30%). The most commonly prescribed medications were antibiotics (32%) and alpha-1 blockers (15%). Other most frequent interventions included timed voiding (34%) and intermittent catheterization with bladder scans (28%). Acute urinary dysfunction was associated with an increased length of stay on the inpatient rehabilitation service (odds ratio [OR], 1.13; 95% CI, 1.06-1.20; P<.001), surgery during the index admission (OR, 2.50; 95% CI, 1.21-5.16; P=.014), and fecal incontinence (OR, 6.41; 95% CI, 1.83-22.44; P=.004). Conclusion: Acute urinary dysfunction was noted to be a substantial problem in this cohort. This is an overlooked dimension of inpatient cancer rehabilitation that deserves more attention. Patients at risk for acute urinary dysfunction may benefit from close monitoring for medical management and rehabilitation interventions to maximize functional independence with bladder care. More research regarding acute urinary dysfunction types and management approaches in post-acute care settings for patients with cancer is justified.

Analysis of factors affecting permanent clean intermittent catheterization and bladder function after primary neurosurgical repair of lipomyelomeningocele

AIMS

This study was conducted to identify potential risk factors for permanent clean intermittent catheterization (CIC) and incontinence in patients with lipomyelomeningocele (LMMC) and evaluate how LMMC affects bladder function prognosis, measured by urodynamic (UD) score.

METHODS

This retrospective study analyzed the electronic health records of patients who underwent primary neurosurgical repair for LMMC at a single tertiary referral center between January 2012 and December 2016 and were followed at least 3 years after surgery. Data regarding bladder function were obtained from medical records for multiple time points, including before surgery, after surgery but before hospital discharge, 3 months after surgery, and at outpatient visits during follow-up.

RESULTS

This study enrolled 120 patients. At a mean follow-up of 62.6 ± 13.9 months after primary neurosurgical LMMC repair, 22 (18.3%) patients continued to require CIC for bladder emptying, only 7 (31.8%) of whom maintained bladder continence. A multivariate logistic regression model identified age at the time of surgery and the type of LMMC as significant presurgical prognostic risk factors for permanent CIC. In addition, postoperative urinary retention and a UD score greater than or equal to 5 measured 3 months after surgery were identified as significant postsurgical risk factors for permanent CIC and urinary incontinence. A linear mixed model adjusted for age at the time of surgery showed that patients with a transitional or chaotic LMMC type were more likely to experience gradual bladder function decline than patients with other LMMC types.

CONCLUSIONS

This study identified both presurgical (age at the time of surgery, LMMC type) and postsurgical (postoperative urinary retention, UD score greater than or equal to 5 at 3 months postsurgery) risk factors for permanent CIC and urinary incontinence. In addition, LMMC type was identified as a prognostic risk factor for bladder function decline. These results will enhance the current understanding of bladder function outcomes in patients who undergo surgical treatment for LMMC.

Efficacy of abobotulinumtoxinA versus onabotulinumtoxinA for the treatment of refractory neurogenic detrusor overactivity: a systematic review and indirect treatment comparison

AIMS

To compare the efficacy and safety of abobotulinumtoxinA (aboBoNT-A) and onabotulinumtoxinA (onaBoNT-A) for the treatment of refractory neurogenic detrusor overactivity (NDO), using an indirect treatment comparison (ITC).

MATERIALS AND METHODS

A systematic literature review was used to identify randomized controlled trials (RCTs) that evaluated botulinum toxin type A for the treatment of refractory NDO. Treatments were compared using a Bucher ITC approach. Efficacy outcomes were reduction in number of weekly urinary incontinence (UI) episodes at 6, 12, and 24 weeks of follow-up. The safety outcome was the proportion of patients with treatment-emergent urinary tract infections (TE-UTIs) during follow-up. Subgroup/sensitivity analyses were performed to investigate the impact of heterogeneity.

RESULTS

Fifteen studies of botulinum toxin type A were identified. Among these, onaBoNT-A 200 U was the only botulinum toxin type A considered an appropriate comparator for aboBoNT-A 600 U and 800 U. As such, six RCTs that evaluated onaBoNT-A or aboBoNT-A were included in the ITC. In base-case analyses, there were no statistically significant differences between aboBoNT-A and onaBoNT-A in terms of UI episodes or TE-UTIs. Numerically, the trend favored aboBoNT-A (either dose) for all endpoints and time points. At 12 and 24 weeks, the difference in reduction of UI episodes per week was considered clinically relevant when comparing aboBoNT-A 800 U with onaBoNT-A 200 U, but not when comparing the lower dose of aboBoNT-A (600 U) with onaBoNT-A 200 U. Results from subgroup/sensitivity analyses were consistent with the base case.

LIMITATIONS

Heterogeneity across studies was observed; however, strong consistency of trends across analyses suggests the impact of heterogeneity is low.

CONCLUSIONS

There may be potential advantages of aboBoNT-A over onaBoNT-A, in terms of UI reduction, in patients with refractory NDO. More confirmatory studies are needed owing to the sparsity of current evidence.

Outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction

OBJECTIVE

To evaluate the early and late outcomes of continent and incontinent external urinary diversion in management of patients with refractory non-malignant lower urinary tract dysfunction (LUTD).

MATERIALS AND METHODS

The charts of patients with refractory non-malignant LUTD who underwent continent or incontinent external urinary diversion at University of Cincinnati hospitals in the period between March 2012 and December 2019 were retrospectively reviewed. The demographic and baseline characteristics, surgery indications, operative data, early and late outcomes were collected, analyzed, and compared.

RESULTS

A total of 78 patients including 55 patients with neurogenic bladder (NGB) and 23 patients with non-neurogenic bladder (non-NGB) refractory non-malignant LUTD were included. Fifty-three patients underwent incontinent urinary diversions (IUD), while 25 patients underwent continent urinary diversions (CUD). During the first 4 postoperative weeks, 53.85% (n=42) of patients developed complications, and the incidence was nonsignificantly higher in patients with NGB than those with non- NGB (56.36% vs 47.83%, p-value=0.490). Fever was exclusively encountered in patients with NGB earlier, while stomal retraction occurred only in patients with non-NGB later. More non- NGB patients had early wound infection. There was an overall improvement of urological symptoms in 52 patients (66.67%), and the rate was non-significantly higher in non-NGB patients than NGB patients (78.26% vs 61.82%, p-value=0.160). Late complications were reported in 47 patients and were more encountered in those with non-NGB than those with NGB (65.22% vs 58.18%). Stomal leakage and stenosis occurred more with CUD than with IUD (52% vs 0% and 28% vs 3.77%, respectively).

CONCLUSIONS

External urinary diversion can achieve a reasonable level of urological symptoms control in patients with refractory non-malignant LUTD, but with associated adverse outcomes. Although non-significantly, these complications tend to be higher in patients with IUD and/or NGB during the early postoperative period and higher with CUD and/or non-NGB on the long-term.

Thermo-sensitive hydrogel combined with SHH expressed RMSCs for rat spinal cord regeneration

Purpose: Spinal cord injury (SCI) has a damaging impact on patients, amid being a worldwide problem with no effective treatment. Herein, we reported a method for functional therapy of SCI in rats, wherein we combined thermo-sensitive hydrogel with Sonic Hedgehog (SHH) expressed in rat bone-marrow derived mesenchymal stem cells (RMSCs).

Methods: Bone marrow-derived mesenchymal stem cells (BMSCs) were isolated from Sprague-Dawley (SD) female rats. The SHH was optimized and transferred into RMSCs via cationic liposomes, while thermo-sensitive hydrogel was reformed with hyaluronate (HA) and Pluronic F127. Then, a rat model with SCI was established accordingly by male SD rats and randomized into sham, model, RMSCs with hydrogel and SHH-RMSCs with hydrogel. The evaluation of SCI repair based on Basso, Beattie Bresnahanlocomotor rating scale (BBB scale) and inclined plate score. Immunofluorescence, immunohistochemistry and hematoxylin-eosin were utilized to explore the expression of protein (GFAP, GAP43, NF200 and MBP) and histopathology.

Results: It was demonstrated that transfection of SHH with cationic liposomes exhibited more effect in RMSCs than lipofectamine 2000. As shown in SEM, 3.5% HA-F127 demonstrated porous structure. In the MTT and dead/live assay, 3.5% HA-F127 showed good biocompatibility for RMSCs. Both RMSCs and SHH-RMSCs groups could significantly promote BBB and inclined plate scores (p < 0.01) compared with the model. Furthermore, the SHH-RMSC group was significantly improved than RMSC with the expression of related proteins, where NF200, MBP, and GAP43 were principally enhanced with the GFAP expression being virtually down-regulated.

Conclusion: All in all, the results suggested that transplantation of RMSCs with SHH could improve the function of SCI and promote nerve regeneration.

The Outcomes of Robotic Rehabilitation Assisted Devices Following Spinal Cord Injury and the Prevention of Secondary Associated Complications

Spinal cord injuries (SCIs) have major consequences on the patient’s health and life. Voluntary muscle paralysis caused by spinal cord damage affects the patient’s independence. Following SCI, an irreversible motor and sensory deficit occurs (spasticity, muscle paralysis, atrophy, pain, gait disorders, pain). This pathology has implications on the whole organism: on the osteoarticular, muscular, cardiovascular, respiratory, gastrointestinal, genito-urinary, skin, metabolic disorders, and neuro-psychic systems. The rehabilitation process for a subject having SCIs can be considered complex, since the pathophysiological mechanism and biochemical modifications occurring at the level of spinal cord are not yet fully elucidated. This review aims at evaluating the impact of robotic-assisted rehabilitation in subjects who have suffered SCI, both in terms of regaining mobility as a major dysfunction in patients with SCI, but also in terms of improving overall fitness and cardiovascular function, respiratory function, as well as the gastrointestinal system, bone density and finally the psychosocial issues, based on multiple clinical trials, and pilot studies. The researched literature in the topic revealed that in order to increase the chances of neuro-motor recovery and to obtain satisfactory results, the combination of robotic therapy, a complex recovery treatment and specific medication is one of the best decisions. Furthermore, the use of these exoskeletons facilitates better/greater autonomy for patients, as well as optimal social integration.

Spinal Cord Injury and Autonomic Dysreflexia: A Case Report on an Overlooked Complication of Spinal Cord Injury

Autonomic dysreflexia (AD) is a life-threatening condition that affects patients with spinal cord injuries (SCI) at the sixth thoracic vertebrae (T6) and above due to a noxious stimulus below the level of spinal cord injury. This is a case report of a 48-year-old man with a history of paraplegia T1 (American Spinal Injury Association Impairment Scale - ASIA A) spinal cord injury due to a road traffic accident 16 years ago who presented with recurrent episodes of hypertension, sweating, bradycardia, and hypothermia. Previous hospitalizations suggested that his symptoms were caused by sepsis from a urinary tract infection; however, further assessment revealed that his symptoms were consistent with untreated and undiagnosed autonomic dysreflexia. This case report provides an overview of AD, including its distinctive presentation, etiology, pathophysiology, and management. Autonomic dysreflexia can be a life-threatening condition associated with spinal cord injury patients at the T6 level and above due to various noxious stimuli below the neurological level of injury. Bladder distension appears to be the trigger in most of the cases reported. AD can be easily missed by medical staff unfamiliar with this condition. Patient and healthcare provider education and a thorough evaluation are essential for diagnosis and management.

Psychometric properties of the Persian version of neurogenic bladder symptom score questionnaire: A methodological study on patients with multiple sclerosis and stroke

OBJECTIVES

Concerning the impact of neurogenic lower urinary tract dysfunction (NLUTD) on quality of life, besides the lack of standard psychometrically-analyzed Persian tools, the present study investigated the validity and reliability of the Persian version of the neurogenic bladder symptom score (NBSS) questionnaire.

METHODS

A total of 279 multiple sclerosis (MS) or stroke/cerebrovascular accident (CVA) patients over 18 years of age with NLUTD referred to the neurology clinics entered the study in 2021-2022. After translation, back-translation, and developing a Persian version, its validity and reliability were determined. The content validity index (CVI) and content validity ratio (CVR) were calculated quantitatively. To determine the internal consistency and scale reliability, a test-retest was used.

RESULTS

The Cronbach's α coefficient was 0.83 and the intraclass correlation coefficient (95% confidence interval) was 0.85 (0.82, 0.88). Cronbach's α in all domains (incontinence, storage and voiding, and consequence) was greater than 0.70. The criterion validity also showed a positive correlation of NBSS with the International Consultation on Incontinence Questionnaire-overactive bladder (p < 0.001 and r = 0.55). The face validity was acceptable according to the opinion of 10 participants. To determine the CVI and the CVR, 10 experts' panels reviewed all items related to the questionnaire in terms of necessity, clarity, transparency, and relevancy. Based on the expert panel all NBSS criteria got a high score, and all criteria were essential to assess NLUTD (CVI: 0.78-1).

CONCLUSIONS

Regarding validity and reliability, the Persian version NBSS questionnaire can properly evaluate NLUTD in MS or stroke/CVA patients.

Pharmacological and non-pharmacological therapeutic interventions for the treatment of spinal cord injury-induced pain

Spinal cord injury (SCI) is a complex neurophysiological disorder, which can result in many long-term complications including changes in mobility, bowel and bladder function, cardiovascular function, and metabolism. In addition, most individuals with SCI experience some form of chronic pain, with one-third of these individuals rating their pain as severe and unrelenting. SCI-induced chronic pain is considered to be "high impact" and broadly affects a number of outcome measures, including daily activity, physical and cognitive function, mood, sleep, and overall quality of life. The majority of SCI pain patients suffer from pain that emanates from regions located below the level of injury. This pain is often rated as the most severe and the underlying mechanisms involve injury-induced plasticity along the entire neuraxis and within the peripheral nervous system. Unfortunately, current therapies for SCI-induced chronic pain lack universal efficacy. Pharmacological treatments, such as opioids, anticonvulsants, and antidepressants, have been shown to have limited success in promoting pain relief. In addition, these treatments are accompanied by many adverse events and safety issues that compound existing functional deficits in the spinally injured, such as gastrointestinal motility and respiration. Non-pharmacological treatments are safer alternatives that can be specifically tailored to the individual and used in tandem with pharmacological therapies if needed. This review describes existing non-pharmacological therapies that have been used to treat SCI-induced pain in both preclinical models and clinical populations. These include physical (i.e., exercise, acupuncture, and hyper- or hypothermia treatments), psychological (i.e., meditation and cognitive behavioral therapy), and dietary interventions (i.e., ketogenic and anti-inflammatory diet). Findings on the effectiveness of these interventions in reducing SCI-induced pain and improving quality of life are discussed. Overall, although studies suggest non-pharmacological treatments could be beneficial in reducing SCI-induced chronic pain, further research is needed. Additionally, because chronic pain, including SCI pain, is complex and has both emotional and physiological components, treatment should be multidisciplinary in nature and ideally tailored specifically to the patient.

Varied presentations of cervical spondylotic myelopathy presenting to a chiropractic clinic: a report of 3 cases

Cervical spondylotic myelopathy (CSM) is the leading cause of acquired spinal cord dysfunction worldwide and may be expected to increase in prevalence due to an aging global population. Clinical features of CSM are highly variable, and chiropractors frequently manage patients with common signs and symptoms of CSM such as neck pain, extremity weakness, and gait imbalances. Early recognition of signs consistent with myelopathy may mitigate future disability and improve quality of life. Key predictors of patient outcome are the age of initial presentation, baseline CSM severity (as measured by mJOA score), and the presence of gait disturbances. This report describes three cases of CSM presenting to a chiropractic clinic. Each case illustrates a unique manifestation of CSM, including myelopathy, myeloradiculopathy, and distal neuropathic pain (funicular referral). In addition, a review of CSM terminology, epidemiology, pathobiology, clinical features, imaging, and management is provided.

Knowledge, Attitudes, and Practice of Pelvic Floor Muscle Training in People With Spinal Cord Injury: A Cross-Sectional Survey

BACKGROUND

There is emerging evidence that pelvic floor muscle training (PFMT) may be useful for treating some urogenital conditions in people with spinal cord injury (SCI). Future clinical investigations would benefit from understanding the extent to which people with SCI are aware of and practicing PFMT, and their attitude toward this therapy.

OBJECTIVE

The goal of this study was to assess the knowledge, attitudes, and practices related to PFMT among people with SCI.

METHODS

We distributed an internet survey internationally via SCI related organizations for 2 months. We used descriptive statistics to summarize each survey item, and Chi-square and Mann-Whitney U tests to explore the differences in results between sexes and level of motor-function.

RESULTS

Complete data from 153 respondents were analyzed. Sixty-two percent of respondents were female and 71% reported having complete paralysis. More than half of respondents reported being aware of PFMT (63%); more females than males reported knowledge of PFMT (p = 0.010). Females (p = 0.052) and people with partial paralysis (p = 0.008) reported a stronger belief that they would benefit from PFMT. Few people with SCI had practiced PFMT (20%), and of those who practiced, most of them had SCI resulting in partial paralysis (p = 0.023).

CONCLUSIONS

While people with SCI may be aware of and have favorable attitudes toward PFMT, few had practiced PFMT and there were notable differences in attitudes toward PFMT depending on the sex and level of motor function of the respondents.

Advances in Assistive Electronic Device Solutions for Urology

Recent technology advances have led urology to become one of the leading specialities to utilise novel electronic systems to manage urological ailments. Contemporary bladder management strategies such as urinary catheters can provide a solution but leave the user mentally and physically debilitated. The unique properties of modern electronic devices, i.e., flexibility, stretchability, and biocompatibility, have allowed a plethora of new technologies to emerge. Many novel electronic device solutions in urology have been developed for treating impaired bladder disorders. These disorders include overactive bladder (OAB), underactive bladder (UAB) and other-urinary-affecting disorders (OUAD). This paper reviews common causes and conservative treatment strategies for OAB, UAB and OUAD, discussing the challenges and drawbacks of such treatments. Subsequently, this paper gives insight into clinically approved and research-based electronic advances in urology. Advances in this area cover bladder-stimulation and -monitoring devices, robot-assistive surgery, and bladder and sphincter prosthesis. This study aims to introduce the latest advances in electronic solutions for urology, comparing their advantages and disadvantages, and concluding with open problems for future urological device solutions.

Association between Spinal Cord Injury and Alcohol Dependence: A Population-Based Retrospective Cohort Study

Spinal cord injury (SCI) is a devastating disorder. Alcohol abuse has been recognized as hindering SCI patients from rehabilitation, thus leading to longer length of days and poorer prognosis. This article aimed to investigate the association between spinal cord injury (SCI) and alcohol dependence. Data were derived from the National Health Insurance Research Database (NHIRD). The incidence of alcohol dependence between SCI and non-SCI groups was compared. Other possible risk factors were also analyzed. Patients (N = 5670) with SCI from 2000 to 2009 were initially assessed for eligibility. After propensity score matching, 5639 first-time SCI survivors were included. The Cox proportional hazard regression model was used to assess differences in the incidence of alcohol dependence syndrome. Based on the adjusted hazard ratios (HR), the SCI group had a higher hazard for alcohol dependence syndrome compared to the non-SCI group (adjusted HR: 1.39, 95% CI: 1.03~1.86, p = 0.0305). The injury level did not have an impact on the incidence of alcohol dependence syndrome. A higher incidence of alcohol dependence syndrome was related to male patients, lower insurance levels, higher Deyo’s CCI, and psychiatric OPD times. A lower incidence of alcohol dependence syndrome was related to elder age. The incidence of alcohol dependence increased after the occurrence of SCI and was also related to age, sex, monthly income, comorbidities, and psychiatric problems. The injury level did not affect the incidence of alcohol dependence after SCI.

Autologous fascial slings for stress urinary incontinence in patients with neuropathic bladder

STUDY DESIGN

Retrospective review.

OBJECTIVES

Stress urinary incontinence in the neurogenic population can have a profound effect on quality of life. It can lead to significant skin breakdown and non-healing pressure sores. Surgical management options for stress incontinence include an autologous pubovaginal sling (PVS). We performed a retrospective review of female patients undergoing PVS insertion in a specialised unit to assess short-term efficacy and safety in this complex neurogenic population.

SETTING

Princess Royal Spinal Injuries Unit, Sheffield, UK.

METHODS

A retrospective review of all patients (n = 22) who had undergone insertion of a PVS was carried out in a single specialised spinal injury unit between 2015 to 2019. Patients were identified from a prospectively maintained database and from the electronic theatre records. Data was collected from the database, electronic patient records and radiological systems. All procedures were carried out by two experienced neurourology consultants.

RESULTS

The majority of patients were continent (n = 19, 86.4%) and 2 (13.5%) patients had an improvement in SUI following PVS insertion at a mean follow-up of 20 months. Pad use decreased from 5 to <1 and mean ICIQ-UI score improved from 17 to 1. One patient had a recurrence of stress urinary incontinence at 28 months. The median length of stay was three days. Three patients (13.6%) had a Clavien-Dindo Grade III-IV complication. One patient developed de-novo neurogenic detrusor overactivity.

CONCLUSION

The autologous PVS is a safe and efficacious procedure for the management of stress urinary incontinence in the neurogenic population with an acceptable morbidity and excellent short-term outcomes.

Multisite Transcutaneous Spinal Stimulation for Walking and Autonomic Recovery in Motor-Incomplete Tetraplegia: A Single-Subject Design

OBJECTIVE

This study investigated the effect of cervical and lumbar transcutaneous spinal cord stimulation (tSCS) combined with intensive training to improve walking and autonomic function after chronic spinal cord injury (SCI).

METHODS

Two 64-year-old men with chronic motor incomplete cervical SCI participated in this single-subject design study. They each underwent 2 months of intensive locomotor training and 2 months of multisite cervical and lumbosacral tSCS paired with intensive locomotor training.

RESULTS

The improvement in 6-Minute Walk Test distance after 2 months of tSCS with intensive training was threefold greater than after locomotor training alone. Both participants improved balance ability measured by the Berg Balance Scale and increased their ability to engage in daily home exercises. Gait analysis demonstrated increased step length for each individual. Both participants experienced improved sensation and bowel function, and 1 participant eliminated the need for intermittent catheterization after the stimulation phase of the study.

CONCLUSION

These results suggest that noninvasive spinal cord stimulation might promote recovery of locomotor and autonomic functions beyond traditional gait training in people with chronic incomplete cervical SCI.

IMPACT

Multisite transcutaneous spinal stimulation may induce neuroplasticity of the spinal networks and confer functional benefits following chronic cervical SCI.

Iatrogenic spinal cord ischemia: A patient level meta-analysis of 74 case reports and series

Background

Methods

Results

Conclusions

Urinary catheter management: what neurologists need to know

Patients with neurological disorders often have lower urinary tract dysfunction, manifesting as urinary retention or urinary incontinence, and so commonly use catheters. Neurologists should therefore be aware of the different types of catheters and appliances and their risks, benefits and complications. Clean intermittent self-catheterisation is preferable to an indwelling catheter; however, if this is not possible, then a suprapubic indwelling catheter is preferable to a urethral catheter for long-term management. We review the decision-making process when selecting catheters for neurological patients, the evidence base regarding the different options and how neurologists can recognise and address complications. We also discuss alternatives to catheterisation, such as non-invasive containment products and surgical treatments, and the indications for urological referral.

Effectiveness of Acupuncture on Urinary Retention: A Meta-Analysis

Objectives

This study aimed to evaluate the safety and efficacy of acupuncture in the treatment of urinary retention (UR).

Methods

Randomized controlled trials investigating the effectiveness of acupuncture in the treatment of UR were identified by searching seven comprehensive databases (Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database, and Chinese Biomedical Literature Database) prior to September 2020. Data analysis was performed using RevMan, version 5.3, and Stata software, version 14.0.

Results

A total of 12 studies with 979 participants were included. A random-effects model was used to conduct a meta-analysis on the acupuncture group and the control group. The results show that acupuncture can effectively promote spontaneous urination and reduce anxiety in patients with poor urination (relative risk: 1.35; 95% confidence interval (CI): 1.19–1.53; P < 0.00001). The random-effects model showed significant differences in residual urine volume between the acupuncture group and the control group (MD: −84.79, 95% CI: −135.62 to −33.94; P=0.001).

Conclusion

Acupuncture is safe and effective in the treatment of UR. However, since the current level of evidence is limited, high-quality, large-sample, multi-center, clinical randomized controlled trials are needed to further confirm our conclusions in the future.

Chinese medicine therapies for neurogenic bladder after spinal cord injury: A protocol for systematic review and network meta-analysis

BACKGROUND

Neurogenic bladder (NB), a refractory disease, is characterized by voiding dysfunction of bladder and/or urethra, and spinal cord injury (SCI) is a common cause. Chinese medicine therapies have been applied extensively in the treatment of NB, especially in China, and the results are promising but varying. Thus, the aim of this work is to assess the efficacy and safety of various Chinese medicine therapies for NB after SCI.

METHODS

A retrieval will be performed in 8 online databases (the Cochrane Library, Web of Science, PubMed, EMBASE Database, China Biological Medicine Database, Chinese Scientific Journals Database, Wan Fang databases, and China National Knowledge Infrastructure) from their inception throughout June 2021. Only randomized controlled trials of testing Chinese medicine therapies for NB after SCI will be enrolled. The outcome indicators measured will be overall response rate, urodynamic tests, clinical assessment, and safety assessments. The methodological quality of this Bayesian-based network meta-analysis will be conducted with the "Risk of Bias" tool. Stata14.0 and WinBUGS 1.4.3 will be used to analyze the data. Furthermore, the assessment of heterogeneity, inconsistency, subgroup, sensitivity, and publication bias will also be taken into consideration with the help of Cochrane Collaboration's tool.

RESULTS

The findings of this study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This work will furnish evidence-based recommendations to figure out the optimal Chinese medicine therapy or their combinations for NB induced by SCI, and in turn contribute to further research and public health.