MR defecography detects pelvic floor dysfunction in participants with chronic complete spinal cord injury.

STUDY DESIGN: A prospective single arm study. OBJECTIVES: Previously we have demonstrated that magnetic resonance (MR) defecography is feasible in participants with complete spinal cord injury (SCI). The main aim of this study is to evaluate whether MR defecography can provide objective parameters correlating with the clinical manifestations of neurogenic bowel dysfunction (NBD) in participants with SCI. SETTING: A monocentric study in a comprehensive care university hospital Spinal Cord Injury Center. METHODS: Previously published MR defecography parameters (anorectal angle (ARA), hiatal descent (M-line) and hiatal width (H-line)) of twenty participants with SCI were now compared to a standardized clinical assessment of NBD. Descriptive statistics, correlations and t-tests for independent samples were calculated. RESULTS: The significantly higher values for the ARA at rest and M-line at rest in participants with SCI correlated with the clinical assessment of bowel incontinence. Furthermore, in nearly half of the investigated SCI cohort the normally positive difference between ARA, M-line and H-line at rest and during defecation became negative suggesting pelvic floor dyssynergia as a potential mechanism underlying constipation in people with complete SCI. In fact, these participants showed a more severe clinical presentation of NBD according to the total NBD score. CONCLUSIONS: MR defecography provides objective parameters correlating with clinical signs of NBD, such as constipation and bowel incontinence. Therefore, MR defecography can support pathophysiology-based decision-making with respect to specific therapeutic interventions, which should help to improve the management of NBD.

3T MR-defecography-A feasibility study in sensorimotor complete spinal cord injured patients with neurogenic bowel dysfunction.

INTRODUCTION: To investigate whether MR-defecography can be employed in sensorimotor complete spinal cord injury (SCI) subjects as a potential diagnostic tool to detect defecational disorders associated with neurogenic bowel dysfunction (NBD) using standard parameters for obstructed defecation. MATERIAL AND METHODS: In a prospective single centre clinical trial, we developed MR-defecography in traumatic sensorimotor complete paraplegic SCI patients with upper motoneuron type injury (neurological level of injury T1 to T10) using a conventional 3T scanner. Defecation was successfully induced by eliciting the defecational reflex after rectal filling with ultrasonic gel, application of two lecicarbon suppositories and digital rectal stimulation. Examination was performed with patients in left lateral decubitus position using T2-weighted turbo spin echo sequence in the sagittal plane at rest (TE 89ms, TR 3220ms, FOV 300mm, matrix 512×512, ST 4mm) and ultrafast-T2-weighted-sequence in the sagittal plane with repeating measurements (TE 1.54ms, TR 3.51ms, FOV 400mm, matrix 256×256, ST 6mm). Changes of anorectal angle (ARA), anorectal descent (ARJ) and pelvic floor weakness were documented and measured data was compared to reference values of asymptomatic non-SCI subjects in the literature to assess feasibility. RESULTS: MR-defecography provides evaluable imaging sequences of the induced evacuation phase in SCI patients. Measurement results for ARA, ARJ, hiatal width (H-line) and hiatal descent (M-line) deviate significantly from reference values in the literature in asymptomatic subjects without SCI. The overall mean values in our study for SCI patients were: ARA (rest) 127.3°, ARA (evacuation) 137.6°, ARJ (rest) 2.4cm, ARJ (evacuation) 4.0cm, H-line (rest) 7.6cm, H-line (evacuation) 8.1cm, M-line (rest) 2.6cm, M-line (evacuation) 4.2cm. CONCLUSIONS: MR-defecography is feasible in sensorimotor complete SCI patients. Individual MR-defecography findings may help to determine specific therapeutical options for respective patients suffering from severe NBD.

Ultrasonic measurement of rectal diameter and area in neurogenic bowel with spinal cord injury.

OBJECTIVE: The aim of this study was to determine the efficacy of measuring the diameter and area of the rectum using ultrasonography as an additional parameter for the evaluation of neurogenic bowel in patients with spinal cord injury (SCI). PARTICIPANTS: In total, 32 patients with SCI (16 patients with upper motor neuron neurogenic bowel (UMNB) and 16 patients with lower motor neuron neurogenic bowel (LMNB)) participated in this study. We divided the patients by the type of neurogenic bowel: UMNB, patients with supraconal lesions and recovery state of spinal shock or LMNB, patients with infraconal/caudal lesions or spinal shock state). INTERVENTION: Ultrasound was applied on the abdomen and measured the diameter and area of the rectum were measured twice each before and after defecation, respectively. OUTCOME MEASURE: We compared rectal diameter and area before/after defecation between the two groups, and significant differences were found in both rectal diameter and area before/after defecation in each group. RESULTS: After defecation, those in the UMNB group had smaller rectal diameters and areas than those in the LMNB group. Significant reduction of rectal diameter and area was observed after defecation as well. The LMNB group showed slightly increased rectal area after defecation, but the increase was not statistically significant. CONCLUSION: Using ultrasound to measure rectal diameter and area seems helpful for classifying neurogenic bowel types and for understanding the neurogenic bowel among SCI patients with symptoms of neurogenic bowel.

The artificial somato-autonomic reflex arch does not improve bowel function in subjects with spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Although introduced for neurogenic bladder dysfunction, it has been suggested that the artificial somato-autonomic reflex arch alleviates neurogenic bowel dysfunction (NBD). We aimed at evaluating the effects of the reflex arch on NBD. SETTING: Denmark. METHODS: Ten subjects with supraconal spinal cord injury (SCI) (nine males, median age 46 years) had an anastomosis created between the ventral part of the fifth lumbar or first sacral nerve root and the ventral part of the second sacral nerve root. Standardized assessment of segmental colorectal transit times with radiopaque markers, evaluation of scintigraphic assessed colorectal emptying upon defecation, scintigraphic assessment of colorectal transport during stimulation of the reflex arch, standard anorectal physiology tests and colorectal symptoms were performed at baseline and 18 months after surgery. RESULTS: No significant change was observed in colorectal emptying upon defecation (median 31% of the rectosigmoid at baseline vs 75% at follow-up, P=0.50), no movement of colorectal contents was observed during stimulation of the reflex arch. Segmental colorectal transit times, anal sphincter pressures and rectal capacity did not change, and no change was seen in NBD score (median 13.5 (baseline) vs 12.5 (follow-up), P=0.51), St Marks fecal incontinence score (4.5 vs 5.0, P=0.36) and Cleveland constipation score (6.0 vs 8.0, P=0.75). CONCLUSIONS: The artificial somato-autonomic reflex arch has no effect on bowel function in subjects with supraconal SCI.