Effects of Lower Thoracic Spinal Cord Stimulation on Bowel Management in Individuals With Spinal Cord Injury.

OBJECTIVE: To systematically determine whether use of the spinal cord stimulation (SCS) system to restore cough may improve bowel management (BM) in individuals with spinal cord injury (SCI). DESIGN: Experimental studies (clinical trial). SETTING: Inpatient hospital setting for electrode insertion; outpatient setting for measurement of respiratory pressures; home setting for application of SCS. PARTICIPANTS: Participants (N=5) with cervical SCI. INTERVENTION: A fully implantable SCS cough system was surgically placed in each subject. SCS was applied at home, 2-3 times/d, on a chronic basis, every time bowel regimen was performed and as needed for secretion management. Stimulus parameters were set at values resulting in near maximum airway pressure generation, which was used as an index of expiratory muscle strength. Participants also used SCS during their bowel routine. MAIN OUTCOME MEASURES: Airway pressure generation achieved with SCS. Weekly completion of Bowel Routine Log including BM time, mechanical measures, and medications used. RESULTS: Mean pressure during spontaneous efforts was 30±8 cmH2O. After a period of reconditioning, SCS resulted in pressure of 146±21 cmH2O. The time required for BM routines was reduced from 118±34 minutes to 18±2 minutes (P<.05) and was directly related to the magnitude of pressure development during SCS. Mechanical methods for BM were completely eliminated in 4 patients. No patients experienced fecal incontinence as result of SCS. Each participant also reported marked overall improvement associated with BM. CONCLUSIONS: Our results of this pilot study suggest that SCS to restore cough may be a useful method to improve BM and life quality for both patients with SCI and their caregivers. Our results indicate that the improvement in BM is secondary to restoration of intra-abdominal pressure development.

Fluoroscopy-Guided Transfacet Lumbar Epidural Steroid Injection for Symptomatic Synovial Cyst Treatment: A Case Report.

We report the case of a patient with a right-sided L4 synovial cyst, which had been causing significant pain, who had a successful transfacet epidural steroid injection to rupture the cyst. Using fluoroscopy, the needle was advanced through the right L4 facet joint and the cyst was ruptured using saline. The needle was then advanced into the epidural space and a transfacet epidural steroid injection was done. The patient's symptoms resolved. Repeat magnetic resonance imaging (MRI) done 2 years later showed no recurrence of the cyst. We discuss the role of transfacet epidural steroid injection in synovial cysts treatment.

Restoration of cough via spinal cord stimulation improves pulmonary function in tetraplegics.

Background: Spinal cord injury (SCI) results in significant loss in pulmonary function secondary to respiratory muscle paralysis. Retention of secretions and atelectasis and, recurrent respiratory tract infections may also impact pulmonary function. Objective: To determine whether usage of lower thoracic spinal cord stimulation (SCS) to restore cough may improve spontaneous pulmonary function in individuals with chronic SCI. Design/Methods: 10 tetraplegics utilized SCS system on a regular daily basis. Spontaneous inspiratory capacity (IC), maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) were measured at baseline prior to usage of the device and repeated every 4-5 weeks over a 20-week period. Maximum airway pressure generation (P) during SCS (40 V, 50 Hz, 0.2 ms) at total lung capacity (TLC) with subject maximal expiratory effort, at the same timepoints were determined, as well. Results: Following daily use of SCS, mean IC improved from 1636 ± 229 to 1932 ± 239 ml (127 ± 8% of baseline values) after 20 weeks (P < 0.05). Mean MIP increased from 40 ± 7, to 50 ± 8 cmH2O (127 ± 6% of baseline values) after 20 weeks, respectively (P < 0.05). MEP also improved from 27 ± 3.7 to 33 ± 5 (127 ± 14% of baseline values) (NS). During SCS, P increased from baseline in all participants from mean 87 ± 8 cmH2O to 117 ± 14 cmH2O at weeks 20, during TLC with subject maximal expiratory effort, respectively (P < 0.05). Each subject stated that they experienced much greater ease in raising secretions with use of SCS. Conclusion: Our findings indicate that use of SCS not only improves expiratory muscle function to restore cough but also results in improvement inspiratory function, as well.

Complete Restoration of Respiratory Muscle Function in Three Subjects With Spinal Cord Injury: Pilot Interventional Clinical Trial.

OBJECTIVES: The aim of this study was to assess the safety and efficacy of complete restoration of respiratory muscle function in subjects with spinal cord injury. METHODS: This was an interventional study investigating three subjects maintained on a diaphragm pacing system who were implanted with the spinal cord stimulation system to restore cough. Peak expiratory airflow and airway pressure generation were the primary physiologic outcome measures; an assessment of the degree of difficulty in raising secretions was the primary clinical outcome measure. RESULTS: Mean peak expiratory airflow and airway pressure generation during spontaneous efforts were 1.7 ± 0.2 L/s and 31 ± 7 cmH2O, respectively. When spinal cord stimulation was applied after pacing volume associated with the subject's maximum inspiratory effort and synchronized with the subject's maximum expiratory effort, peak expiratory airflow and airway pressure generation were 9.0 ± 1.9 L/s and 90 ± 6 cmH2O, respectively (P < 0.05). Moreover, each subject experienced much greater ease in raising secretions and marked improvement in the ease in raising secretions compared with other methods. CONCLUSIONS: Complete restoration of respiratory muscle function can be safely and effectively achieved in the same individuals with spinal cord injury. Spinal cord stimulation results in peak expiratory airflow and airway pressure generation characteristic of a normal cough, whereas diaphragm pacing was successful in maintaining patients off mechanical ventilation.

Case report: Minimally invasive method to activate the expiratory muscles to restore cough.

CONTEXT: Spinal cord stimulation (SCS) via disc electrodes surgically placed via laminotomy incisions has been shown to restore an effective cough in subjects with spinal cord injury (SCI). The purpose of this study was to evaluate a new method of expiratory muscle activation utilizing spinal cord wire leads, which can be implanted with minimally invasive techniques. METHODS: In a subject with SCI, parallel wire leads with two electrode contacts were inserted percutaneously through a needle, advanced to the T9, T11 spinal levels and connected to an implanted radiofrequency receiver. Stimulus parameters were set at values resulting in near maximum airway pressure generation (Paw) (40V, 50Hz, 0.2ms). Paw was measured at functional residual capacity (FRC) and total lung capacity (TLC) as an index of expiratory muscle strength. RESULTS: Paw during spontaneous efforts was 20 cmH2O (8.6% predicted). Bipolar (T9-T11) SCS resulted in Paw of 84 and 103 cmH2O, at FRC and TLC respectively. Monopolar (T9 only) SCS resulted in Paw of 61 and 86 cmH2O, at FRC and TLC respectively. This subject experienced much greater ease in raising secretions with use of SCS and no longer required other methods of secretion management. CONCLUSION: SCS via wire leads, which can be implanted using minimally invasive techniques, may provide a new useful method to restore an effective cough and possibly reduce the morbidity and mortality associated with respiratory tract infections in patients with SCI.

Economic Consequences of an Implanted Neuroprosthesis in Subjects with Spinal Cord Injury for Restoration of an Effective Cough.

Objective: To determine if an implanted neuroprosthesis for restoration of an effective cough is less costly than conventional methods of respiratory management. Methods: Nonrandomized clinical trial of participants (N = 14) with spinal cord injury (SCI) using the Cough Stimulator device in the inpatient hospital setting for Cough Stimulator implantation and outpatient hospital or residence for follow-up. A neuroprosthesis was implanted for restoration of an effective cough. The annual costs associated with respiratory management, without (pre implantation) and with (post implantation) the neuroprosthesis, were examined over a 4-year period. Results: The total cost related to implantation of the Cough Stimulator was $59,891, with no maintenance costs over subsequent years. The incidence of respiratory tract infections and the need for caregiver support fell significantly following implantation. The costs associated with respiratory tract infections fell significantly from a mean of $36,406 ± 11,855/year to $13,284 ± 7,035/year (p < .05) pre and post implantation, respectively. Costs fell further to $8,817 ± 5,990 and $4,467 ± 4,404 following the 2nd and 3rd years post implantation (p < .05), respectively. The costs associated with caregiver support fell significantly from $25,312 ± 8,019/year to $2,630 ± 2,233/year (p < .05) pre and post implantation, respectively, and remained low in subsequent years (p < .05). Other costs related to secretion management fell significantly and remained low in subsequent years (p < .05). Break-even analysis demonstrated that this point was reached in the first year. Conclusion: The results of this investigation demonstrate that implantation and use of the Cough Stimulator resulted in significant reductions in the overall costs of respiratory management in this patient population.

Outcome of Percutaneous Lumbar Synovial Cyst Rupture in Patients with Lumbar Radiculopathy.

BACKGROUND: Lumbar synovial cysts can result from spondylosis of facet joints. These cysts can encroach on adjacent nerve roots, causing symptoms of radiculopathy. Currently the only definitive treatment for these symptoms is surgery, which may involve laminectomy or laminotomy, with or without spinal fusion. Surgery has been reported to successfully relieve radicular pain in 83.5% of patients by Zhenbo et al. Little information is available concerning the efficacy and outcome of percutaneous fluoroscopic synovial cyst rupture for treatment of facet joint synovial cysts. OBJECTIVE: The goal of this investigation was to assess the efficacy of fluoroscopically guided lumbar synovial cyst rupture, in particular for its relief of radicular symptoms and its potential to reduce the need for surgical intervention. STUDY DESIGN: Retrospective evaluation of a case series. SETTING: University hospital and urban public health care system. METHODS: With approval from the Institutional Review Board of Case Western Reserve University/ MetroHealth Medical Center, we reviewed the medical charts of patients with lumbar radiculopathy who underwent percutaneous lumbar synovial cyst rupture. The 30 patients in the cohort were treated by one pain specialist between 2006 and 2013. These patients were diagnosed with moderate to severe lower back pain, radiculopathy, and ranged in age from 42 to 80 years. Patients were followed up for a minimum of 6 months and up to 24 months. Pre- and post-procedure pain assessments were reviewed by clinical chart review. In addition post-procedure pain assessments and duration of pain relief were obtained with telephone interviews. Pain had been reported by the patients using a numeric rating scale of 0 - 10 (0 = no pain; 10 = worst possible pain). Charts were reviewed to determine if surgery was eventually performed to correct radicular symptoms. RESULTS: More than 6 months of pain relief was achieved in 14/30 patients (46%) and between one and 6 months of pain relief was achieved in 7/30 patients (23.3%). Nine patients (30.0%) had recurrence of the synovial cyst requiring repeat rupture and 6 patients (20.0%) required surgical intervention for cyst removal. A Wilcoxon signed-rank test demonstrated that the difference in numeric pain rating scale scores before and after the procedure was statistically significant (P < 0.0001). The average pain reduction was 71.2%. No complications were reported. LIMITATIONS: The results are limited by the retrospective nature of the data collection and the lack of detailed information regarding patients' functional improvement. CONCLUSIONS: Rupture of percutaneous lumbar synovial cysts in patients with lumbar radiculopathy was associated with immediate relief of radicular symptoms. In 80% of the patients, synovial cyst rupture eliminated the need for surgical interventions over the measured term. This minimally invasive procedure helps relieve pain in a subset of a patient population associated with these characteristics and is useful for management of this condition. Cyst expansion and failure to rupture with possible neuronal compression are the potential complications of this procedure. This complication did not occur in the study population. KEY WORDS: Fluoroscopically guided lumbar synovial cyst rupture, lumbar synovial cyst, lumbar zygapophyseal joint cyst, nonsurgical intervention, radiculopathy, spondylosis.