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Thread: prognosis advice help

  1. #1

    prognosis advice help

    My sister is post op day #2 for evacuation of an epidural hematoma T12-L2 after an elective epidural for pregnancy. She had symptoms for 20 hours or so before they intervened. she also has a conus contusion. This is post op AM #2. On the left she has 2/5 voluntary at great toe and slight 2/5 and ankle on. 1/5 hip extensors. R is much better- 4/5. To my knowledge she has no perineal sensation or voluntary rectal tone. She has pin vs blunt sensation that diminishes towards the foot. I think the perineal information make her a "complete" or ASIA A. I'm reaching out for realistic information and, like most people here, a miracle. Are there any chances she'l regain continence and ability to walk given this info? thanks for resource info etc. Best

  2. #2
    Quote Originally Posted by s dawson View Post
    My sister is post op day #2 for evacuation of an epidural hematoma T12-L2 after an elective epidural for pregnancy. She had symptoms for 20 hours or so before they intervened. she also has a conus contusion. This is post op AM #2. On the left she has 2/5 voluntary at great toe and slight 2/5 and ankle on. 1/5 hip extensors. R is much better- 4/5. To my knowledge she has no perineal sensation or voluntary rectal tone. She has pin vs blunt sensation that diminishes towards the foot. I think the perineal information make her a "complete" or ASIA A. I'm reaching out for realistic information and, like most people here, a miracle. Are there any chances she'l regain continence and ability to walk given this info? thanks for resource info etc. Best

    You must be referring to conus compression from the hematoma. Usually, the word contusion refers to a sudden impact trauma.

    Based on your description, it sounds as if your sister will recover walking. Loss of perineal sensation and sphincter contraction is due to the conus injury. Many people with conus injuries recover walking.

    The conus injury, however, is disabling because it results in loss of pelvic sensation and sphincter function, with corresponding disruption of bladder, anal, and sexual function. However, it is still very early after the injury and she may still recover some conus function.

    I assume that she has had MRI images of her conus. There should be increased MRI signal in the conus. This may give some idea of the severity of the conus injury.

    In males, the preservation of the bulbocavernosus reflex (BCR) suggests preservation of the lower (sacral) segments and predicts less disruption of sphinter and sexual function [1]. In females, the BCR is more difficult to test but sphincter electromyography [2], electrospinogram [3], and cystography [4] may provide additional prognostic information. Somatosensory evoked potentials activated from the posterior tibialis may have shorter latencies but this is not necessarily prognostic of perineal function [5].

    If the conus injury is severe, i.e. damaged much of the gray matter in the conus, spontaneous recovery is limited. However, unlike spinal cord injury where the prognosis can be predicted from the initial completeness of neurological loss in segments below the injury, I don't think that there is an equivalent "complete" versus "incomplete" prognosis for conus injury.

    A conus injury is associated with a "saddle" distribution of sensory loss, i.e. the area of skin that would be in contact with a saddle. There is loss of rectal, anal, and vaginal sensation. In addition, bladder sphincter may be affected as well with associated incontinence and bladder flaccidity. Urological investigation is important [6].

    Although some investigators believe that the state of bladder reflexes is not predictive of bladder function after spinal cord injury [7], loss of bladder reflexes predicts the development of a flaccid bladder. An occult conus injury may occur in as many as a third of people with spinal cord injury [8]. The presence of bladder reflexes is a good prognostic sign [9].

    Damage to the conus medullaris during spinal anesthesia is not uncommon. Reynolds [10] described seven cases in 2001. The symptoms include pain during insertion of the needle and free flow of cerebrospinal fluid before spinal injection, often associated with insertion of the needle above L3.

    There will be novel therapies (involving stem cells and progentior cells) to replace autonomic and motor neurons in the sacral cord [11-12]. In addition, reinnervation of the pudendal nerve may help, a procedure called the Xiao procedure where the L2 ventral root is bridged to the S2 root and pudendal nerve [13-19]


    1. Ertekin C, Reel F, Mutlu R and Kerkuklu I (1979). Bulbocavernosus reflex in patients with conus medullaris and cauda equina lesions. J Neurol Sci 41: 175-81. The clinical value and practical application of the electrically induced BC reflex was investigated in 40 patients with traumatic or compressive lesions of the conus medullaris or cauda equina. It was shown that the BC reflex was either absent or delayed depending upon the invovlement of the sacral 2--4 spinal and radicular segments. The latency of the BC reflex was normal in patients with mainly epiconus and lumbar cord involvement. The loss of the BC reflex in the acute period of traumatic lesions was an adverse prognostic sign while the presence of the reflex whether or not delayed, indicated a more benign final outcome of sphincter and sexual reflex disturbances. In chronic progressive compression, the latency of BC reflex was often delayed.
    2. James HE, Mulcahy JJ, Walsh JW and Kaplan GW (1979). Use of anal sphincter electromyography during operations on the conus medullaris and sacral nerve roots. Neurosurgery 4: 521-3. The mechanical activity of the anal sphincter can be translated into electrical activity and recorded on graph paper or an oscilloscope. The activity of the anal sphincter may be extrapolated to activity of the external urethral sphincter because both are striated muscles innervated by the pudendal nerve that arises from S-2, S-3, and S-4. Stimulation of these nerves causes contraction of the sphincter muscles, and a deflection of the recording device occurs. This technique was employed intraoperatively in monitoring operations on the conus medullaris and sacral nerve roots in 10 patients with spinal dysraphism (age range, 3 weeks to 15 years). Their diagnoses were tethered conus, 4; lipomeningocele, 3; spinal hamartoma, 1; syringocele, 1; and sacral arachnoiditis, 1. With general anesthesia, and the patient in the prone position, an electrode-containing anal plug was inserted or two needle electrodes were inserted into the anal sphincter muscle. The electrodes were connected to the electromyography recording stylus of the urodynamic bladder diagnostic unit. During the spinal operation, whenever a structure could not be identified clearly, it was stimulated with the disposable electrical stimulator and, if oscillations of the stylus occurred (indicating contraction of the anal sphincter), the structure was preserved. This technique permitted spinal operations in these 10 patients without changes in neurological or urological function.
    3. Ertekin C, Mutlu R, Sarica Y and Uckardesler L (1980). Electrophysiological evaluation of the afferent spinal roots and nerves in patients with conus medullaris and cauda equina lesions. J Neurol Sci 48: 419-33. The clinical value and practical application of the lumbosacral evoked electrospinogram (Espg) and somatosensory cerebral evoked potentials (SEP) were investigated in 52 patients with conus medullaris or cauda equina lesions. It was shown that the destruction or compression of the conus/cauda equina region by traumatic fracture and dislocation of upper lumbar vertebrae, by midline herniation of the nucleus pulposus and by tumoral mass, produced significant reduction in amplitude and delay in latency of Espg recorded just above the lesion site, and the SEP behaved in a similar way. The degree of abnormality was found to be in accord with the severity of clinical sensorimotor deficits in the legs. Tumoural compression caused more significant delay in evoked responses than traumatic injury. From the diagnostic point of view, Espg and SEP were useful in showing latent and manifest involvement of the lumbosacral sensory roots and these are discussed in relation to other electrodiagnostic tests.
    4. Pavlakis AJ, Siroky MB, Goldstein I and Krane RJ (1983). Neurourologic findings in conus medullaris and cauda equina injury. Arch Neurol 40: 570-3. Fifty-seven patients with documented conus medullaris and cauda equina injury underwent neurourologic evaluation consisting of cystometrography (CMG), perineal floor electromyography (EMG), and bethanechol chloride supersensitivity testing (BST). The bulbocavernosus reflex was normal in only 16% of the patients, and perineal sensation and muscle stretch reflexes were absent or significantly diminished in 77%. The predominant CMG finding was detrusor areflexia (93%). Neuropathic EMG changes were noted in 67% and a positive BST response in 95% of the cases. Statistical analysis showed significant correlations between (1) a compromised bulbocavernosus reflex and perineal floor neuropathy (.01 less than P less than .05) and (2) sex of the patient and incidence of urinary incontinence among subjects with perineal floor neuropathy (P less than .01). The major neurourologic features in these patients (1) An absent or substantially diminished bulbocavernosus reflex, (2) detrusor areflexia on CMG, (3) neuropathic perineal EMG changes, and (4) a positive BST response.
    5. Ertekin C, Sarica Y and Uckardesler L (1984). Somatosensory cerebral potentials evoked by stimulation of the lumbo-sacral spinal cord in normal subjects and in patients with conus medullaris and cauda equina lesions. Electroencephalogr Clin Neurophysiol 59: 57-66. Somatosensory cerebral evoked potentials were recorded by intrathecal stimulation of the lumbo-sacral cord and roots in 16 normal subjects and patients having cauda/conus injury (group A, 15 cases), compressive lesions of cauda equina (group B, 13 cases) and lesions of both types covering the lumbar cord (group C, 24 cases). The shape of the intrathecally evoked cerebral potential (IECP) was basically the same as that obtained by posterior tibial nerve stimulation from 12 normal subjects except that the early components were 10-15 msec shorter in latency in the former potential, with an average of 12 msec. IECPs were easily recorded in groups A and B, but a significant delay was found in both groups, especially group A. It was difficult to obtain the IECP in group C, When it could be recorded the latency increase was apparent. These findings were explained on the basis of degeneration of the ascending spinal nerve fibers proximal to the lesion site.
    6. Dudognon P, Labrousse C, Lubeau M, Carne P, Rabiller M and Boulesteix JM (1986). Early vesico-ureteral reflux following conus medullaris injury: case report. Paraplegia 24: 194-200. The authors describe severe vesico-ureteral reflux and simultaneous renal insufficiency which occurred after a spinal cord injury to the conus medullaris. They point out the misleading character of these injuries when there are only minimal neurological signs in the trunk and limbs. The main clinical consequence may be an isolated neuropathic bladder which, if not detected, delays treatment. Additionally, they underline the role of mixed bladder and sphincter lesions in the development of renal insufficiency; also the role of increased intravesical pressure during filling and emptying with bilateral vesico-ureteral reflux.
    7. Lucas MG and Thomas DG (1989). Lack of relationship of conus reflexes to bladder function after spinal cord injury. Br J Urol 63: 24-7. Department of Urology, Lodge Moor Hospital, Sheffield. A series of 20 patients with acute complete suprasacral cord lesions underwent serial urodynamic assessment of vesicourethral function and serial measurement of sacral reflex latency times (SRL) and reflex threshold throughout a follow-up period of 42 to 83 weeks (mean 50). No correlation was found between any pattern of SRL latencies or reflex thresholds and subsequent bladder behaviour. The reproducibility of sacral reflex latencies was found to be poor (mean variation of serial measurements from initial reading 21%) and could not be explained on the basis of "dynamic" neurological recovery. Studies using the bladder as a stimulus site were unreliable. The value of SRL studies in detecting subtle neurophysiological changes is discussed.
    8. Beric A and Light JK (1992). Function of the conus medullaris and cauda equina in the early period following spinal cord injury and the relationship to recovery of detrusor function. J Urol 148: 1845-8. Department of Neurology, Hospital for Joint Diseases, New York University, New York. A total of 26 patients with an early suprasacral spinal cord injury underwent comprehensive neurourological evaluation to determine if there was any correlation between the return of detrusor function and neural function of the sacral cord. In addition, the incidence of a subclinical sacral neural dysfunction early after spinal cord injury was assessed. Lumbosacral evoked potentials to tibial nerve stimulation were used to assess the sensory root and cord gray matter of the L5 to S2 segments, while urodynamic evaluation was performed to assess detrusor function. Of those patients with normal lumbosacral evoked potentials 82% recovered detrusor contractility as opposed to 66% with abnormal evoked potentials. Four patients (23.5%) had persistent detrusor areflexia when studied 9 to 20 months following the acute injury. The potential problems attempting to correlate the neurophysiological and urodynamic studies are multiple and are extensively discussed. Despite these potential problems the return of detrusor function correlated well with associated normal lumbosacral evoked potentials suggesting that this test can be used in the early phase following spinal cord injury to predict return of bladder function, since it is independent of the level of spinal cord excitability. Of the patients studied 38% had coexistence of an occult lumbosacral dysfunction. This rate is higher than that found in the chronic stabilized spinal cord injury population (20.5%), since the cases in our study may represent a more severe lesion.
    9. Beric A and Light JK (1992). Detrusor function with lesions of the conus medullaris. J Urol 148: 104-6. Division of Restorative Neurology, Baylor College of Medicine, Houston, Texas. Conventional urodynamic evaluation is unable to distinguish between a pure conus lesion and one with concomitant cauda equina involvement. Lumbosacral evoked potentials to tibial nerve stimulation assesses the sensory root and dorsal horn interneurons of the L5 to S2 spinal cord segments. This allows for the diagnosis of a pure lesion of the conus medullaris with preservation of the sensory root response (R wave) with absence of the dorsal horn gray matter response (S wave). Urodynamic evaluation in 5 patients with a conus lesion showed a variety of detrusor responses ranging from hyperreflexia through areflexia with decreased compliance to areflexia with normal compliance. The ability to diagnose a pure conus lesion may have prognostic significance as newer modalities of treatment emerge, all of which require intact gray matter of the spinal cord.
    10. Reynolds F (2001). Damage to the conus medullaris following spinal anaesthesia. Anaesthesia 56: 238-47. Department of Anaesthetics, St Thomas' Hospital, London SE1 7EH, UK. Seven cases are described in which neurological damage followed spinal or combined spinal-epidural anaesthesia using an atraumatic spinal needle. All patients were women, six obstetric and one surgical. All experienced pain during insertion of the needle, which was usually believed to be introduced at the L2-3 interspace. In all cases, there was free flow of cerebrospinal fluid before spinal injection. There was one patchy block but, in the rest, anaesthesia was successful. Unilateral sensory loss at the levels of L4-S1 (and sometimes pain) persisted in all patients; there was foot drop in six and urinary symptoms in three. Magnetic resonance imaging showed a spinal cord of normal length with a syrinx in the conus (n = 6) on the same side as both the persisting clinical deficit and the symptoms that had occurred at insertion of the needle. The tip of the conus usually lies at L1-2, although it may extend further. Tuffier's line is an unreliable method of identifying the lumbar interspaces, and anaesthetists commonly select a space that is one or more segments higher than they assume. Because of these sources of error, anaesthetists need to relearn the rule that a spinal needle should not be inserted above L3.
    11. Hoang TX and Havton LA (2006). Novel repair strategies to restore bladder function following cauda equina/conus medullaris injuries. Prog Brain Res 152: 195-204. Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, 710 Westwood Plaza, Los Angeles, CA 90095-1769, USA. Trauma to the thoracolumbar junction or lumbosacral spine may result in a conus medullaris or cauda equina syndrome. In both conditions, symptoms typically include paraparesis or paraplegia, sensory impairment, pain, as well as bladder, bowel, and sexual dysfunctions. We present in this review a series of neural repair strategies that have been developed to address the unique features and challenges of subjects with a conus medullaris or cauda equina syndrome. We address, in particular, neural repair strategies that may have a translational research potential to restore bladder function. Recent animal injury models have suggested that a progressive retrograde death of both autonomic and motor neurons may contribute to the neurological deficits in subjects with conus medullaris and cauda equina injuries. For subjects with acute injuries, we present novel strategies to promote neuroprotection, axonal regeneration, and functional reinnervation of the lower urinary tract. For subjects with chronic injuries, we discuss new approaches to replace lost autonomic and motor neurons. A brief discussion on a variety of outcome measures that may be suitable to evaluate the function of the lower urinary tract in rodent neural repair models is also provided.
    12. Hoang TX, Nieto JH, Dobkin BH, Tillakaratne NJ and Havton LA (2006). Acute implantation of an avulsed lumbosacral ventral root into the rat conus medullaris promotes neuroprotection and graft reinnervation by autonomic and motor neurons. Neuroscience 138: 1149-60. Department of Neurology and Brain Research Institute, David Geffen School of Medicine at UCLA, 710 Westwood Plaza, Los Angeles, CA 90095-1769, USA. Trauma to the conus medullaris and cauda equina may result in autonomic, sensory, and motor dysfunctions. We have previously developed a rat model of cauda equina injury, where a lumbosacral ventral root avulsion resulted in a progressive and parallel death of motoneurons and preganglionic parasympathetic neurons, which are important for i.e. bladder control. Here, we report that an acute implantation of an avulsed ventral root into the rat conus medullaris protects preganglionic parasympathetic neurons and motoneurons from cell death as well as promotes axonal regeneration into the implanted root at 6 weeks post-implantation. Implantation resulted in survival of 44+/-4% of preganglionic parasympathetic neurons and 44+/-4% of motoneurons compared with 22% of preganglionic parasympathetic neurons and 16% of motoneurons after avulsion alone. Retrograde labeling from the implanted root at 6 weeks showed that 53+/-13% of surviving preganglionic parasympathetic neurons and 64+/-14% of surviving motoneurons reinnervated the graft. Implantation prevented injury-induced atrophy of preganglionic parasympathetic neurons and reduced atrophy of motoneurons. Light and electron microscopic studies of the implanted ventral roots demonstrated a large number of both myelinated axons (79+/-13% of the number of myelinated axons in corresponding control ventral roots) and unmyelinated axons. Although the diameter of myelinated axons in the implanted roots was significantly smaller than that of control roots, the degree of myelination was appropriate for the axonal size, suggesting normal conduction properties. Our results show that preganglionic parasympathetic neurons have the same ability as motoneurons to survive and reinnervate implanted roots, a prerequisite for successful therapeutic strategies for autonomic control in selected patients with acute conus medullaris and cauda equina injuries.
    13. Lin H, Hou C and Zhen X (2008). Bypassing spinal cord injury: surgical reconstruction of afferent and efferent pathways to the urinary bladder after conus medullaris injury in a rat model. J Reconstr Microsurg 24: 575-81. Department of Orthopedic Surgery, Changzheng Hospital, The Second Military Medical University, Shanghai, P. R. China. Afferent and efferent nerve function in the atonic bladder caused by conus medullaris injury in a rat model was established by intradural microanastomosis of the left L5 ventral root (VR) to right S2 VR to restore pure motor-to-motor reinnervation coupled with extradural postganglionic spinal nerve transfer of L5 dorsal root (DR) to S2 DR for pure sensory-to-sensory reinnervation. Early function of the reflex arc was evaluated by electrophysiological study, as well as by intravesicular pressure measurement and histological examination. The results demonstrated that single focal stimulation of the left S2 DR elicited evoked potentials at the left vesicular plexus before and after horizontal spinal cord damage between the L6 and S4 level. Bladder contraction was successfully initiated by trains of stimuli targeting the left L5-S2 DR anastomosis. Achievable bladder pressures and amplitude of bladder smooth muscle complex action potentials were unchanged before and after induced paraplegia and comparable to those of the control. Prominent axonal sprouting was seen in the distal part of nerve graft. Both afferent and efferent nerve pathways in the atonic bladder can be reconstructed by suprasacral motor-to-motor and sensory-to-sensory nerve transfer after spinal cord injury in rats. This reconstructive strategy has significant potential in clinical application.
    14. Lin H, Hou CL, Zhong G, Xie Q and Wang S (2008). Reconstruction of reflex pathways to the atonic bladder after conus medullaris injury: preliminary clinical results. Microsurgery 28: 429-35. Department of Orthopedic Surgery, Changzheng Hospital, The Second Military Medical University, Shanghai, People's Republic of China. Neurogenic bladder dysfunction following spinal cord injury is a major medical and social problem for which there is no ideal treatment strategy. In this study, spinal root anastomoses were performed in 10 paraplegic patients with traumatic lesions of the conus medullaris, in an attempt to reinnervate the paralyzed bladder. For the operation, the functional T11 ventral root (VR) above the lesion was transected and anastomosed to the S2 ventral roots unilaterally through a nerve graft. The T11 dorsal root was left intact as the trigger for micturition after axonal regeneration. All patients underwent urodynamic evaluation before surgery and at follow-up. The mean follow-up duration was 2 years. Of the 10 patients, 7 (70%) regained satisfactory bladder control within 18-24 months after VR microanastomosis. In these seven patients, the average bladder capacity decreased from 508 +/- 83 (mean +/- SD) to 370 +/- 59 ml, residual urine decreased from 477 +/- 98 to 35 +/- 11 ml, and urinary infections were not observed. Patients with impaired renal function experienced a full recovery. Three patients failed to show any improvement after the operation. These results suggest that a restitutive process occurs in the bladder following reinnervation from new T11 VR connections to the bladder nerves. Spinal cord lesions that may benefit from such a nerve crossover surgery are those located at the conus, whereby a functional suprasacral nerve can be connected to the sacral roots to bypass the injury in an attempt to restore central connections to the bladder.
    15. Xiao CG, de Groat WC, Godec CJ, Dai C and Xiao Q (1999). "Skin-CNS-bladder" reflex pathway for micturition after spinal cord injury and its underlying mechanisms. J Urol 162: 936-42. Department of Urology, the Long Island College Hospital, SUNY Health Science Center at Brooklyn, New York 11203, USA. PURPOSE: A "skin-CNS-bladder" reflex pathway for inducing micturition after spinal cord injury has been established in cat. This reflex pathway which is basically a somatic reflex arc with a modified efferent limb that passes somatic motor impulses to the bladder, has been designed to allow spinal cord injured patients to initiate voiding by scratching the skin. MATERIALS AND METHODS: The skin-CNS-bladder reflex was established in the cat by intradural microanastomosis of the left L7 ventral root (VR) to the S1 VR while leaving the L7 dorsal root (DR) intact to conduct cutaneous afferent signals that can trigger the new micturition reflex arc. After allowing 11 weeks for axonal regeneration, urodynamic, pharmacological and electrophysiological studies were conducted in pentobarbital or chloralose anesthetized animals. RESULTS: A detrusor contraction was initiated at short latency by scratching the skin or by percutaneous electrical stimulation in the L7 dermatome. Maximal bladder pressures during this stimulation were similar to those activated by bladder distension in control animals. Electrophysiological recording revealed that single stimuli (0.3 to 3 mA, 0.02 to 0.2 msec duration) to the left L7 spinal nerve in which the efferent axons had degenerated evoked action potentials (0.5 to 1 mV) in the left S1 spinal nerve distal to the anastomosis. In addition, increases in bladder pressure were elicited by trains of the stimuli (5 to 20 Hz, 5 seconds) applied to the L7 spinal nerve. Urodynamic studies including external sphincter EMG recording demonstrated that the new reflex pathway could initiate voiding without detrusor-external urethral sphincter dyssynergia. Atropine (0.05 mg./kg., i.v.) or trimethaphan (5 mg./kg., i.v.), a ganglionic blocking agent, depressed the bladder contractions elicited by skin stimulation. The skin-CNS-bladder reflex could also be elicited after transecting the spinal cord at the L2-L3 or L7-S1 levels. CONCLUSION: The cross-wired somato-autonomic bladder reflex is effective in initiating bladder contractions and coordinated voiding in cats with an intact neuraxis and can also induce bladder contractions after acute transection of the lumbar spinal cord. The new pathway is mediated by cholinergic transmission involving both nicotinic and muscarinic receptors. It is concluded that somatic motor axons can innervate bladder parasympathetic ganglion cells and thereby transfer somatic reflex activity to the bladder smooth muscle.
    16. Dai CF and Xiao CG (2005). Electrophysiological monitoring and identification of neural roots during somatic-autonomic reflex pathway procedure for neurogenic bladder. Chin J Traumatol 8: 74-6. Department of Orthopedic Surgery, Shenzhen People's Hospital, Jinan University School of Medicine, Guangdong 518020, China. OBJECTIVE: To identify and separate the ventral root from dorsal root, which is the key for success of the artificial somatic-autonomic reflex pathway procedure for neurogenic bladder after spinal cord injury (SCI). Here we report the results of intra-operating room monitoring with 10 paralyzed patients. METHODS: Ten male volunteers with complete suprasacral SCI underwent the artificial somatic-autonomic procedure under general anesthesia. Vastus medialis, tibialis anticus and gastrocnemius medialis of the left lower limb were monitored for electromyogram (EMG) activities resulted from L4, L5, and S1 stimulation respectively to differentiate the ventral root from dorsal root. A Laborie Urodynamics system was connected with a three channel urodynamic catheter inserted into the bladder. The L2 and L3 roots were stimulated separately while the intravesical pressure was monitored to evaluate the function of each root. RESULTS: The thresholds of stimulation on ventral root were 0.02 ms duration, 0.2-0.4 mA, (mean 0.3 mA+/-0.07 mA), compared with 0.2-0.4 ms duration, 1.5-3 mA (mean 2.3 mA+/-0.5 mA) for dorsal root (P<0.01) to cause revoked potentials and EMG. Electrical stimulation on L4 roots resulted in the EMG being recorded mainly on vastus medialis, while stimulation on L5 or S1 roots caused electrical activities of tibialis anticus or gastrocnemius medialis respectively. The continuous stimulation for about 3-5 seconds on S2 or S3 ventral root (0.02 ms, 20 Hz, and 0.4 mA) could resulted in bladder detrusor contraction, but the strongest bladder contraction over 50 cm H2O was usually caused by stimulation on S3 ventral root in 7 of the 10 patients. CONCLUSIONS: Intra-operating room electrophysiological monitoring is of great help to identify and separate ventral root from dorsal root, and to select the appropriate sacral ventral root for best bladder reinnervation. Different parameters and thresholds on different roots are the most important factors to keep in mind to avoid damaging the roots and to assure the best results.
    17. Xiao CG, Du MX, Li B, Liu Z, Chen M, Chen ZH, Cheng P, Xue XN, Shapiro E and Lepor H (2005). An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida. J Urol 173: 2112-6. Departments of Urology, Tongji Medical College, Xiehe Hospital, Huazhong University of Science and Technology, Wuhan, China. PURPOSE: Neurogenic bladder is a major problem for children with spina bifida. Despite rigorous pharmacological and surgical treatment, incontinence, urinary tract infections and upper tract deterioration remain problematic. We have previously demonstrated the ability to establish surgically a skin-central nervous system-bladder reflex pathway in patients with spinal cord injury with restoration of bladder storage and emptying. We report our experience with this procedure in 20 children with spina bifida. MATERIALS AND METHODS: All children with spina bifida and neurogenic bladder underwent limited laminectomy and a lumbar ventral root (VR) to S3 VR microanastomosis. The L5 dorsal root was left intact as the afferent branch of the somatic-autonomic reflex pathway after axonal regeneration. All patients underwent urodynamic evaluation before and after surgery. RESULTS: Preoperative urodynamic studies revealed 2 types of bladder dysfunction- areflexic bladder (14 patients) and hyperreflexic bladder with detrusor external sphincter dyssynergia (6). All children were incontinent. Of the 20 patients 17 gained satisfactory bladder control and continence within 8 to 12 months after VR microanastomosis. Of the 14 patients with areflexic bladder 12 (86%) showed improvement. In these cases bladder capacity increased from 117.28 to 208.71 ml, and mean maximum detrusor pressure increased from 18.35 to 32.57 cm H2O. Five of the 6 patients with hyperreflexic bladder demonstrated improvement, with resolution of incontinence. Urodynamic studies in these cases revealed a change from detrusor hyperreflexia with detrusor external sphincter dyssynergia and high detrusor pressure to nearly normal storage and synergic voiding. In these cases mean bladder capacity increased from 94.33 to 177.83 ml, and post-void residual urine decreased from 70.17 to 23.67 ml. Overall, 3 patients failed to exhibit any improvement. CONCLUSIONS: The artificial somatic-autonomic reflex arc procedure is an effective and safe treatment to restore bladder continence and reverse bladder dysfunction for patients with spina bifida.
    18. Xiao CG (2006). Reinnervation for neurogenic bladder: historic review and introduction of a somatic-autonomic reflex pathway procedure for patients with spinal cord injury or spina bifida. Eur Urol 49: 22-8; discussion 28-9. Department of Urology, Xiehe Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. Neurogenic bladder caused by SCI or spina bifida is a major problem. Research in restoring functional micturition has mainly focused on electrical stimulation for many decades with good progress, but it is still not the definitive solution for majority of the SCI patients. An alternative approach has been to investigate restoring innervation to the lower urinary tract after spinal SCI. Different animal and clinical studies were reviewed historically in this article, focused on mainly cross over nerve surgery for reinnervation of the bladder. An artificial somatic-autonomic reflex pathway procedure and its mechanisms were introduced. Clinical application and the satisfactory results of the new procedure were reviewed in details in restoring voluntary bladder control in patients with SCI or spina bifida.
    19. Wang HZ, Li SR, Wen C, Xiao CG and Su BY (2007). Morphological changes of cholinergic nerve fibers in the urinary bladder after establishment of artificial somatic-autonomic reflex arc in rats. Neurosci Bull 23: 277-81. Department of Neurobiology, Third Military Medical University, Chongqing 400038, China. OBJECTIVE: To establish an artificial somatic-autonomic reflex arc in rats and observe the following distributive changes of neural fibers in the bladder. METHODS: Adult Sprague-Dawley rats were randomly divided into three groups: control group, spinal cord injury (SCI) group, and reinnervation group. DiI retrograde tracing was used to verify establishment of the model and to investigate the transport function of the regenerated efferent axons in the new reflex arc. Choline acetyltransferase (ChAT) in the DiI-labeled neurons was detected by immunohistochemistry. Distribution of neural fibers in the bladder was observed by acetylcholine esterase staining. RESULTS: DiI-labeled neurons distributed mainly in the left ventral horn from L3 to L5, and some of them were also ChAT-positive. The neural fibers in the bladder detrusor reduced remarkably in the SCI group compared with the control (P < 0.05). After establishment of the somatic-autonomic reflex arc in the reinnervation group, the number of ipsilateral fibers in the bladder increased markedly compared with the SCI group (P < 0.05), though still much less than that in the control (P < 0.05). CONCLUSION: The efferent branches of the somatic nerves may grow and replace the parasympathetic preganglionic axons through axonal regeneration. Acetylcholine is still the major neurotransmitter of the new reflex arc. The controllability of detrusor may be promoted when it is reinnervated by the pelvic ganglia efferent somatic motor fibers from the postganglionic axons.

    Last edited by Wise Young; 06-07-2011 at 05:32 AM.

  3. #3

    Thank you!!...

    For the very complete, insightful and inspiring message. We are about 4weeks out. Her left is her week side, where the neurosurgeon descirbes the "contusion" of the conus..or bruising. She feels a sensation of fullness in bowel and bladder and has been told with regarfs to bowel this could be a reflex. Trileptal has been started to help reduce the constant sensation she needs to have a bm. She still cannot release urine. She reports she can feel the cath enter and stool exit albeit mildly. Left hip flexors give 5-10degree arc amd still has foot drop. Cannot raise knee from lying down, right is better. I susect there may be more recovery with time and rehab. Is there any benefit to long term inpatient rehab vs outpatient? At some point too i suspect recovery typically slows yet may still trickle. 3m? 6m..12m? Her attitude has been life changing for me. Once again i want to let you know how much I appreciate the time and effort you made to help us with our questions and concerns... Please take care Wise Young!

  4. #4
    She should do an intensive inpatient acute rehab program at a SCI specialty center (not just any rehab center). The typical stay for this with an injury like hers would be 3-4 weeks, not "long term". This will provide the intensity of therapy, education/training, counseling and other services she needs at this time. She can then transition into an outpatient program at discharge.

    Ideally the center should be either a Model SCI System Center or at least CARF accredited as a Spinal Cord System of Care (SCSC). It is worth going out of town for such a program vs. a general rehab center where they mostly treat stroke victims and rarely see a SCI patient.


  5. #5
    Consider this in the differential diagnosis...

    The main symptom of pudendal neuropathy is pain in the areas innervated by the pudendal nerve or one of its branches. Possible symptoms include burning, loss of sensation or numbness, increased sensitivity, electric shock or stabbing pain, knife-like or aching pain, feeling of a lump or foreign body, twisting or pinching, abnormal temperature sensations, constipation, pain and straining with bowel movements, straining or burning when urinating, painful intercourse, and sexual dysfunction – including hyperarousal or decreased sensitivity. The pain can be on one or both sides and in any of the areas innervated by the pudendal nerve, depending on which nerve fibers and which nerve branches are affected. The symptoms can start suddenly or develop slowly over time. Often the pain gets worse as the day progresses and is worse with sitting. Causes There are numerous possible causes for pudendal neuropathy. Some of the possible causes are an inflammatory or autoimmune illness, frequent infections, tension on the nerve, a nerve entrapment similar to carpel tunnel syndrome, or trauma to the nerve from an accident/fall, exercise, childbirth, prolonged sitting, or surgery. Sometimes there is no apparent explanation and some doctors have theorized that the problem can be hereditary due to a musculoskeletal predisposition. Occasionally the problem originates in the spine or sacral area rather then the peripheral pudendal nerve.

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