Sacral rhizotomy: a salvage procedure in a patient with autonomic dysreflexia.

STUDY DESIGN: Case report. OBJECTIVES: To show the feasibility of sacral deafferentation as a salvage procedure to resolve life-threatening autonomic dysreflexia. SETTING: Paraplegic center in Switzerland. METHOD AND RESULTS: In a patient presenting with acute autonomic dysreflexia leading to cardiac arrest, sacral deafferentation could prevent further episodes of autonomic dysreflexia. CONCLUSION: In patients with spinal cord injury, autonomic dysreflexia can be triggered by the bladder even without detrusor overactivity. In these cases, sacral deafferentation may be the only salvage procedure to prevent further serious health problems. Thus, this procedure augments the armamentarium of urologists dealing with patients suffering from spinal cord lesions.

'Neurogenic' urinary tract dysfunction: don't overlook the bowel!

STUDY DESIGN: Case report. OBJECTIVES: To demonstrate that massive constipation is a rare cause for bladder dysfunction. SETTING: Paraplegic centre in Switzerland. METHOD AND RESULTS: In two patients presenting with acute deterioration of bladder dysfunction, evaluation demonstrated compression of the urinary tract by massively distended colon due to excessive constipation. CONCLUSION: Colorectal dysfunction may intensify neurogenic urinary tract dysfunction simply by mechanical compression. Treatment of constipation can improve bladder function in these patients. With increasing time since spinal cord injury, the possibility of this finding should be taken into account in patients with newly diagnosed upper or lower urinary tract obstruction.

Perineal abscess formation as a complication of intermittent self-catheterization.

STUDY DESIGN: Case report. OBJECTIVES: To present a rare but severe complication of intermittent catheterization. SETTING: Paraplegic centre in Switzerland. METHOD AND RESULTS: A 52-year-old man presenting with fever and septicaemia was diagnosed with a perineal abscess due to a bulbar urethral lesion caused by acute false passage during intermittent catheterization. CONCLUSION: Especially in patients with a history of urethral strictures performing intermittent catheterization, the possibility of perineal abscess formation should be taken into account when treating such a patient with fever of unknown origin.

Urinary bladder biopsies in spinal cord injured patients.

STUDY DESIGN: A series of 94 urinary bladder biopsies in spinal cord injured (SCI) patients were histopathologically and statistically analysed. OBJECTIVES: The following hypotheses were examined: (1) The number of clinical bladder infections per year in each patient does not influence the histopathological type of inflammation of the urinary bladder; (2) The duration of the spinal cord lesion does not have a strong effect on the type of inflammation; (3) The different neurological levels (upper and lower motor neuron lesions) do not relate to a specific histopathology. SETTINGS: All patients received their treatment at the Swiss Paraplegic Centre in Nottwil, near Lucerne (Switzerland). METHODS: The samples were taken from the bladder fundus during endoscopic urologic operations. Histopathological standard procedures were carried out. Statistical analysis including Kruskal-Wallis and Chi-square tests were performed. RESULTS: Histopathological analysis showed abnormal alterations of the urinary bladder mucosa in 86 SCI-patients: (91.5%). 63 cases (67.0%) showed a chronic type and 23 cases (24.5%) showed a subacute type of inflammation. A normal urinary bladder was found in eight cases (8.5%). The three hypotheses were statistically not rejected. CONCLUSION: Results demonstrated no correlation between the number of bladder infections per year, the period since injury, the neurologic level of the spinal cord lesion and the histopathology of the urinary bladder mucosa.

Bladder tissue biopsies in spinal cord injured patients: histopathologic aspects of 61 cases.

It was the aim of this histopathologic study to examine and compare results of bladder tissue biopsies in spinal cord injured (SCI) patients. The study group consisted of 61 SCI patients who received treatment at the Swiss Paraplegic Centre in Nottwil, near Lucerne, Switzerland. The mean age of the study group was 41 years (range, 17-73) and the mean duration of spinal cord lesion was 10 years and 4 months (range, 5 months to 44 years). The male:female ratio was 57:4. Bladder infections had occurred in each patient one to six times per year (median, 3.2). All samples were taken from the trigone of the bladder during endoscopic urologic procedures with a flexible cystoscope. Histopathologic analysis showed abnormal alterations of bladder tissue in 56 SCI patients (91.8%). Forty-six SCI patients (75.4%) had a chronic type and 10 SCI patients (16.4%) a subacute type of inflammation. Normal bladder tissue was found in five cases (8.2%). Further observation revealed the presence of fibrosis (34.4%), edema (9.8%), and lymphoid hyperplasia (6.6%). A t-test for independent samples showed a lack of significant correlation between the number of clinical bladder infections per year, the duration of injury, the neurologic level of the spinal cord lesion, and histopathologic types of infections.

Classification, oscillatory and alternating oscillatory firing of alpha 1 (FF) and alpha 2-motoneurons (FR) in patients with spinal cord lesion.

Single-nerve fibre action potentials (APs) were recorded extracellularly from sacral nerve roots of people with spinal cord lesion (patients with paraplegia). Single-fibre APs of certain fibres were identified by the conduction velocity and the AP waveform, and simultaneous impulse patterns were extracted from the summed impulse traffic and analysed with respect to spacio-temporal relationships. The velocity values of components of compound APs, induced by electrical nerve root stimulation or electrical intravesical stimulation, were similar to the group conduction velocity values obtained from single-nerve fibre APs of natural impulse traffic. When changing the root temperature in one case from 32 degrees C to 35.5 degrees C, the group conduction velocities changed in the following way: secondary muscle spindle afferents (SP2): 40 m/s (32 degrees C) to 50 m/s (35.5 degrees C); bladder stretch afferents (S1): 31.3 to 40 m/s; bladder tension afferents (ST): 25 to 33.8 m/s; mucosal afferents (M): 12.5 to 13.8 m/s; alpha 1:-; alpha 2-motoneurons: 40 to 50 m/s; alpha 3: 33 to 40 m/s. The group conduction velocities showed different temperature dependence apart from SP2 fibres and alpha 2-motoneurons, which were therefore used for calibration. The distance between two Pacinian corpuscle (PC) receptors in a sacral dermatome of one paraplegic patient was calculated to be approximately 20 mm. A similar distance between PC receptors was found in a brain-dead individual. Receptor densities seem therefore to remain unchanged following spinal cord lesion. Motoneurons fired irregularly repeatedly with impulse trains. In paraplegics the oscillation periods and the interspike intervals of the impulse trains varied much more than observed for brain-dead and normal individuals. Motoneurons could therefore not always be identified by their pattern of oscillatory firing. Alternating long and short oscillation periods (T) could be measured in an oscillatory firing alpha 1 (T = 125 ms) and alpha 2-motoneuron (T = 150 ms). In both cases the average difference between the alternating oscillation periods was 5 ms. Tremor, alternating long and short oscillation periods, cellular oscillator properties, and recurrent excitation and inhibition are discussed with respect to the oscillator theory of the functioning of the human central nervous system. Mathematical predictions from populations of interacting biological oscillators are compared to measurements on neuronal network data.

Detrusor-sphincteric dyssynergia in paraplegics compared with the synergia in a brain-dead human by using the single-fibre action potential recording method.

(1) Humans with spinal cord lesions often show detrusor-sphincteric dyssynergia of the urinary bladder which is reflected urodynamically in the detrusor pressure and a simultaneous increase in electromyographic pelvic floor activity. (2) The time-course of the increase in the secondary muscle spindle afferent activity, induced by the parasympathetic nervous system in muscle spindles contributing to continence, is very similar to that of detrusor pressure. The detrusor-sphincteric dyssynergia is therefore analysed by comparing the natural impulse patterns of secondary muscle spindle afferents (SP2) and sphincteric motoneurons in a brain-dead human with those in patients with spinal cord lesion. The parasympathetic nervous system was activated by painful bladder catheter pulling. (3) In a brain-dead human the sphincteric motoneurons subserving continence were inhibited at a time, when preganglionic parasympathetic efferents increased their activity for 10 s and an SP2 fibre increased its activity for several minutes. In a paraplegic with a strong bladder dysfunction, the SP2 fibre activity increased, due to parasympathetic activation, lasted for approx. 1 min, showed undulations and its amplitude was smaller than that measured in a brain-dead human. The sphincteric motoneurons were not inhibited. (4) In the brain-dead human, an SP2 fibre showed doublet firing with interspike intervals (IIs) of a duration between 10 and 14 ms for low level parasympathetic activation. For high level parasympathetic activation this single parent spindle afferent fibre showed multi-ending regular firing of up to 6 endings with IIs of a duration of predominantly 15 to 25 ms. In one paraplegic with a strong bladder dysfunction the doublet firing was less regular, even though two II peaks at 10.2 and 11.2 ms occurred in a II distribution similar to the brain-dead human. The multi-ending regular firing was replaced by a repeated burst firing. In a second paraplegic with strong detrusor-sphincteric dyssynergia the burst firing consisted of up to 6 impulses with increasing IIs and a first II of approx. 0.2 ms (transmission frequency 5000 Hz). In a third paraplegic with a lesser dysfunction of the bladder a highly activated SP2 fibre showed an activity pattern intermediate to those of multi-ending regular firing and burst firing. (5) The time constant for the activity decrease of a spindle afferent fibre following parasympathetic activation was to 31 s in a paraplegic and approx. 40 s in a brain-dead human. It is concluded that the muscle spindles are unchanged following spinal cord lesion.(ABSTRACT TRUNCATED AT 400 WORDS)

Detrusor-sphincteric dyssynergia in humans with spinal cord lesions may be caused by a loss of stable phase relations between and within oscillatory firing neuronal networks of the sacral micturition center.

(1) Single-fibre action potentials (APs) were recorded with 2 pairs of wire electrodes from lower sacral nerve roots during surgery in patients with spinal cord lesions and in a brain-dead human. Conduction velocity distribution histograms were constructed for afferent and efferent fibres, nerve fibre groups were identified and simultaneous impulse patterns of alpha and gamma-motoneurons and secondary muscle spindle afferents (SP2) were constructed. Temporal relations between afferent and efferent APs were analysed by interspike interval (II) and phase relation changes. (2) In a paraplegic with hyperreflexia of the bladder, urinary bladder stretch (S1) and tension receptor afferents (ST) fired already when the bladder was empty, and showed a several times higher bladder afferent activity increase upon retrograde bladder filling than observed in the brain-dead individual. Two alpha 2-motoneurons (FR) innervating the external bladder sphincter were already oscillatory firing to generate high activity levels when the bladder was empty. They showed activity levels with no bladder filling, comparable to those measured at a bladder filling of 600 ml in the brain-dead individual. A bladder storage volume of 600 ml was thus lost in the paraplegic, due to a too high bladder afferent input to the sacral micturition center, secondary to inflammation and hypertrophy of the detrusor. (3) In a brain-dead human, 2 phase relations existed per oscillation period of 160 ms between the APs of a sphincteric oscillatory firing alpha 2-motoneuron, a dynamic fusimotor and a secondary muscle spindle afferent fibre. Following stimulation of mainly somatic afferent fibres, the phase relations changed only little. (4) In a paraplegic with dyssynergia of the urinary bladder also 2 phase relations existed per oscillation period of 110 ms in a functional unit between the APs of a sphincteric alpha-motoneuron, a fusimotor and a secondary spindle afferent fibre. The phase relations changed with time following stimulation of mainly somatic afferents. A second functional unit organized by phase-related interactions was phase related to the first functional unit. (5) Following painful bladder catheter pulling, the parasympathetic division was transiently activated several times in the paraplegic. At times of activation of the parasympathetic division, 3 broad phase relations occurred within and between the two functional units, indicating that the parasympathetic division in the sacral micturition and defecation center channeled an additional input to the somatic oscillatory firing neuronal networks driving motoneurons which innervate the external bladder and/or anal sphincters.

Interspike intervals of secondary muscle spindle and urinary bladder afferents in relation to the oscillation periods of sacral spinal oscillators for continence in man.

Two pairs of wire electrodes were used to record afferent and efferent single fibre extracellular action potentials (APs) from human nerve root filaments. The nerve fibres were identified according to the group to which they belong by comparing the afferent and efferent conduction velocity distribution histograms and identifying peaks and ranges of nerve fibre groups. Secondary muscle spindle afferents and alpha 2-motoneurones (FR) were identified by having the same peak group conduction velocity (calibration relation), which is 50 m/s at 36 degrees C. On the basis of AP wave form comparisons, the natural impulse patterns of five secondary muscle spindle afferents, two fusimotor motoneurones and two oscillatory firing alpha 2-motoneurones could be identified in the dorsal S4 root. The patterns of single endings of secondary spindle afferent fibres could be identified. The shortest interspike intervals of single endings of all secondary muscle spindle afferents had the same duration as the shortest interspike intervals of the two fusimotor fibres (80 ms) and equalled a half of the oscillation period of one repetitively firing alpha 2-motoneurone (6 Hz) probably innervating the external anal sphincter (three AP impulse train firing). In another more rostral dorsal root filament (probably S3 or S2) of the same human, the interspike intervals of six secondary spindle afferents were more variable. The values of peaks in the interspike interval distributions ranged from 60 to 102 ms. In the coccygeal root, the interspike interval duration ranged from 160 to 185 ms, directly contributing to the drive of the oscillatory firing alpha 2-motoneurone. The different agreement between the oscillation period and the interspike intervals of the spindle afferents in different segments indicate that the oscillatory firing CNS circuitry was localized within S3 to S5 segments of the conus medullaris for the drive of the anal sphincter. An alpha 2-motoneurone firing repeatedly with 1 to 2 AP impulse trains, innervating most likely the external urethral sphincter, fired at a frequency of 9.1 to 6.7 Hz, a similar frequency of the oscillation as the interspike intervals from two activated stretch receptors of the urinary bladder wall. The measurements of this brain-dead human indicates that in this case the neuronal circuitry driving the external anal sphincter was mainly confined to the sacral micturition and defecation centre, mainly located in the S3 to S5 segments.