Spinal cord injury

1
Spinal cord injury

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital Hualien

2
Leading causes Location of Spinal cord injury

• Motor vehicle accidents (47)
• Falls (21)
• Sports (14)
• Act of violence (14)
• Location of SCI cervical (53), thoracic (35),
  lumbar and sacral (10)

3
Urinary tract symptoms in Acute spinal cord
injury

• Spinal shock stage detrusor areflexia, complete
  anesthesia of fullness or voiding
• Recovery of micturition reflex gradually about
  1-3 months after recovery of somatic reflexes
• Prolonged recovery of voiding reflex may be due
  to overdistension of the bladder after injury or
  complication

4
Micturition Control

• Micturition reflex center sacral cords S 2-4
• Sympathetic nucleus T10-L1
• Micturition control center pons
• Sensory motor center frontal lobe
• Limbic system
• Cerebellum, Basal ganglia

5
Pathophysiology of lower urinary tract
dysfunction after SCI

• Suprasacral cord lesion interruption of
  coordination of detrusor contraction and
  sphincter relaxation
• Lesion above T6 SCI sympathetic hyperactivity
  during activation of visceral input, bladder
  distension, rectal distention, cold and noxious
  stimulation, surgery and infection

6
Chronic spinal cord injury and urinary tract
dysfunction

• Autonomic dysreflexia SCI above T5,6
  (sympathetic nucleus)
• Detrusor external sphincter dyssynergia (DESD)
  lesion above S2-4
• Detrusor hyperreflexia complete or incomplete
  SCI above sacral cords
• Detrosor areflexia sacral cord SCI or cauda
  equina lesions

7
Urodynamic findings in SCI
Cervical (n68) Thoracic (n53) Sacral or infrasacral (n40)
Detrusor hyperreflexia 47(69) 29 (55) 2 (5)
Detrusor areflexia 21(31) 24 (45) 38 (95)
DESD
Presence 41(60) 20 (38) -
Absence 27(40) 33 (62) 40 (100)
AD
Presence 22(32) 1 (2) -
Absence 46(68) 52 (98) 40 (100)
DESSDetrusor external sphincteric dyssynergia ADautonomic dysreflexia. DESSDetrusor external sphincteric dyssynergia ADautonomic dysreflexia. DESSDetrusor external sphincteric dyssynergia ADautonomic dysreflexia. DESSDetrusor external sphincteric dyssynergia ADautonomic dysreflexia.
8
Major concern in managing SCI

• Preservation of renal function
• Free of symptomatic urinary tract infection
• Efficient bladder emptying
• Freedom of catheter
• Continence

9
High risk SCI Patients

• Complete neurological lesion
• Cervical SCI with quadriplegia
• Prolonged indwelling catheter
• High detrusor leak-point pressure
• Presence of DESD and AD
• Large residual urine
• Presence of vesicoureteral reflux

10
Detrusor leak-point pressure

• The intravesical pressure (detrusor pressure) at
  the end of filling or urinary incontinence
• A detrusor LPP of over 40cm water will endanger
  the upper tract in meningomyelocele
• Reduction of detrusor LPP can improve renal
  function, reduce the risk of UTI, decrease the
  degree of hydronephrosis, improve vesicoureteral
  reflux and restore continence

11
Hydronephrosis in SCI

• Hydronephrosis is a sign of upper tract
  deterioration after SCI
• In 251 SCI patients, 24 (9.6) had
  hydronephrosis, including
• Cervical SCI 7 (5.9 of 118), 7 4 (3-15)
  years
• Thorac lumb 8 (8.6 of 93), 9.9 6.5 (3-22)
• Sacral 9 (22.5 of 40), 17 6.1
  (8-26)

12
Autonomic dysreflexia

• Spinal cord lesion above T6
• Hypertension and increased sympathetic outflow,
  flushing, sweating above dermatome during
  increased visceral input (bladder
  over-distension,urination, rectal distension,
  surgery, UTI)
• Risk of heart failure and stroke
• Bladder neck contraction during voiding

13
Cervical SCI autonomic dysreflexia and BN
dysfunction
14
Detrusor external sphincter dyssynergia (DESD)

• Spinal cord lesion above micturition reflex
  center
• Lack of coordination in the micturition center
• External sphincter contrction during detrusor
  contractions
• Dysuria, difficult to initiate voiding, high
  voiding pressure, large residual urine
• Result in frequent UTI and upper tract damage

15
Grades of DESD

• Grade 0- 3 according to the sphincteric activity
• Grade 0 normal or synergia
• Grade 1 DH high Pves, hyerreflexic sphincter
  at initiation, voiding with mild residual urine
• Grade 2 DH or hyporeflexic detrusor,
  intermittent hyperreflexic sphincter, large
  residual urine
• Grade 3 DH, closed hyperreflexic sphincter, no
  spontaneous voiding

16
Grade 1 DESD
17
Grade 2 DESD- High voiding pressure and increased
EMG
18
Gr 2 DESD with low voiding pressure and no flow
19
Grade 3 DESD
20
Recovery from spinal shock in Cervical SCI
21
Late Urological Complications in Spinal cord
injury

• Urinary tract infection induced sepsis
• Hydronephrosis and uremia
• Stone formation (renal bladder stone)
• Contracted bladder VU reflux
• Incontinence and associated complications
• Bladder tumor formation (chronic indwelling
  catheter)

22
Hydronephrosis in chronic SCI
23
Bladder stones in chronic SCI
24
Vesicoureteral reflux in chronic SCI
25
Analysis of LUTS in 704 SCI
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??? 14 5 12 3 3 3 0 2
???(???) 50 18 92 14 31 13 2 3
???(???) 27 32 24 12 14 14 2 1
?????? 8 17 16 11 2 20 0 2
???? 13 21 12 16 4 16 0 10
???? 2 24 4 9 0 17 0 5
???? 8 32 5 7 7 21 1 3
? ? 122 149 165 72 61 104 5 26
26
Analysis of UTI in 704 chronic SCI
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?? ??? ?? ??? ?? ??? ?? ???
????UTI 31 56 32 21 19 41 4 5 209 (29.7)
lt1 / year UTI 45 46 66 19 17 22 0 3 218 (31)
? 1 / year UTI 38 15 57 12 14 14 1 4 155 (22)
??? 8 32 10 18 11 24 0 3 122 (17.3)
27
Late complications in 704 SCI
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?? ??? ?? ??? ?? ??? ?? ???
???? 44 60 43 16 18 44 3 3 231 (32.8)
?????? 51 37 78 24 27 22 0 4 243 (34.5)
???? 11 10 38 15 10 5 0 1 90 (12.8)
???? 16 6 21 5 2 8 0 4 62 (8.8)
????? 14 7 19 6 8 0 0 1 55 (7.8)
??? 6 5 8 2 2 1 1 0 25 (3.6)
28
Management of voiding in 704 SCI in Taiwan
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?? ??? ?? ??? ?? ??? ?? ???
?????? 23 10 14 7 7 4 2 -
???? 13 5 16 1 2 1 - -
???? 14 17 39 19 17 28 - 11
???? 17 29 24 12 4 10 - 4
???? 39 27 55 13 21 11 3 4
???? 3 1 10 6 4 7 - 1
???? 11 57 7 12 6 40 - 6
? ? 2 3 - 2 - 3 - -
? ? 122 149 165 72 61 104 5 26
29
The relationship of UTI frequency and SCI level
and voiding management
r UTI Fequency UTI Fequency UTI Fequency UTI Fequency UTI Fequency
0/year 1/year 2/year 3/year sepsis
Level of SCI
Cervical SCI 41(34.7) 20 (16.9) 15 (12.7) 42 (35.6) 7
Thoracic or lumbar SCI 17 (18.3) 21 (22..6) 17 (18.3) 38 (40.9) 4
Sacral or infrasacral SCI 2 (5) 9 (22.5) 7 (17.5) 22 (55)
Complete lesion 15 30 28 51 9
Incomplete lesion 45 20 11 51 2
Initial management
Urethral Foley catheter 12 11 10 16 6
Suprapubic cystostomy 3 6 14 16 1
Crede maneuver 13 16 4 65 4
Abdominal tapping,reflex 7 5 - 1
CISC 11 - - 3
Normal 14 12 11 1
CISCClean intermittent self-catheterization. CISCClean intermittent self-catheterization. CISCClean intermittent self-catheterization.
30
Considerations in management of LUTD in chronic
SCI

• Correct complications
• Treat hydronephrosis, treat UTI, treat
  vesicoureteral reflux
• Improve quality of life
• Treat incontinence, convenience of bladder
  emptying, free of catheter,free of medication
• Individual treatment strategy for each SCI patient

31
Medical Treatment for LUTD in chronic SCI

• To reduce detrusor hyperreflexia
  anticholinergics (oxybutynin,imipramine)
• To reduce bladder neck hyperreflexia
  alpha-blocker (tamsulosin, terazosin, prazosin)
• To reduce striated sphincter spasticity
  skeletal muscle relaxant (baclofen, diazepam)
• To increase detrusor muscle tone cholinergic
  agent (urecholine)

32
Combination of medication for LUTS in Chronic SCI

• To treat incontinence anticholinergics and
  adrenergic agnist (methylephedrine) CISC is
  needed, residual urine, UTI should be monitored
• To facilitate voiding cholinergic agent and
  alpha-blocker and skeletal muscle relaxant
  incontinence exacerbates, upper tract
  deterioration if detrusor LPP is high

33
Side effects of Medical Treatment in chronic SCI

• Constipation -- anticholinergics
• Hypotension alpha-blocker
• Nasal congestion adrenergic agonist
• General weakness skeletal muscle relaxant
• Side effects increase as combination of
  medication
• Cost benefit should be considered

34
Intravesical therapy for SCI

• Detrusor hyperreflexia oxybutynin, capsaicin,
  resiniferatoxin, botulinum injection
• Reversible response
• Periodic instillation or injection

35
Capsaicin and resiniferatoxin

• Intravesical agents for overactive bladder have
  been mostly been used in neurogenic bladder
  disorders
• Capsaicin and resiniferatoxin have been
  successfully used intravesically to reduce
  urinary incontinence in neurogenic detrusor
  hyperreflexia
• Resiniferatoxin has less acute side effect and
  similar efficacy as capsaicin
• Resiniferatoxin is effective in treating detrusor
  hyperreflexia refractory to capsaicin treatment

36
Therapeutic effects of resiniferatoxin

• 10 -5 to 10 -7 M RTX is effective for DH of SCI
• 10 -8 M RTX can significantly improve voiding
  pattern and pain score in hypersensitive
  disorders and bladder pain
• RTX is safe for application in humans
• Is RTX effective for DESD through inhibition of
  DH in SCI patients?

37
Successful Therapeutic Effects

• Patient became dry
• Increase in 50 of maximal cystometric capacity
• Subjective improvement rate by gt50 in
  incontinence or dysuria
• Significant change in quality of life in
  urination subjectively

38
Side Effects of RTX Treatment

• Autonomic responses
• Elevated blood pressure
• Headache
• Bradycardia
• General malaise
• RTX was drained out and bladder irrigation was
  performed if systolic BP gt200mmHg

39
Results of resiniferatoxin therapy

• 20 patients (7 women and 13 men)
• Mean age 42.2 13.2 (24 66) years
• 10 cervical, 10 thoracic SC lesion
• 18 traumatic SCI, 2 multiple sclerosis
• All had DESD, 9 had autonomic dysreflexia
• 18 incontinence, 13 dysuria, 8 recurrent UTI

40
Responses of RTX instillation

• Initial excitatory response at 1-5 min
• Four types of initial responses
• Type 1 A sustained high pressure followed by
  complete detrusor non-contraction
  Type 2 A high pressure
  contraction followed by progressively lower
  amplitude contractions Type
  3 Intermittent high pressure contractions
  Type 4
  Intermittent low pressure contractions

41
Initial CMG Tracing after RTX
42
Therapeutic Results of RTX

• 4/20 became dry during the daytime but
  incontinent at night time
• 8/20 had increased in frequency interval and
  voided volume
• 8/20 had no significant improvement
• 8/13 with dysuria had improvement in spontaneous
  voiding (5) or on Crede maneuver (3)

43
Urodynamic Changes after RTX
Baseline Post-RTX Stastistics
Cystometric capacity(ml) 102.131.5 236.688.6 Plt0.001
Bladder compliance (ml/cmH2O) 23.712.1 25.915.3 Pgt0.05
Voiding pressure (Pdet, cmH2O) 55.923.2 47.528.1 Pgt0.05
Presence of DESD 100 100
44
Side Effects and QOL after RTX

• Dizziness and headache with high BP and
  bradycardia (4/20)
• Initial gross hematuria (5/20)
• Bladder irritation and frequency in all patients
• 7/20 responded that quality o life improved after
  RTX
• 13/20 did not notice any significant change in
  QOL although objective data showed improved

45
Correlation of RTX Responses with Therapeutic
Results

• A good response was noted in 12 patients
• Type 1 5 (100)
• Type 2 4 (80)
• Type 3 2 (40)
• Type 4 1 (25)
• Duration of RTX responses 1 (6m), 6 (3m), 3
  (2m), 2 (1m), repeat instillation in 7/12

46
Urodynamic tracings before, during and after
resiniferatoxin
47
Botulinum toxin injection

• Botlinum toxin has been used to inject striated
  urethral sphincter for grade 3 DESD
• Refractory detrusor hyperreflexia can be
  eradicated by intra-detrusor injection of botox
• Reversible effect and possibilty of antibody
  formation after repeated injection
• Cost-benefit should be weighed

48
Reduction of Voiding pressure after Botulinum
toxin in DA
49
Rhythmic detrusor contractions in SCI with DESD
after Botox
50
Botulinum A Toxin Detrusor Injection for Detrusor
Hyperreflexia

• 5 IU/Kg Botox (Botulinum A toxin) was injected to
  30 sites into detrusor muscle
• Decreased detrusor pressure and increased
  cystometric capacity after Botox
• Increased residual urine and CISC is needed
• Abdominal tapping to void
• Indicated in refractory detrusor hyperreflexia

51
Botulinum A toxin 250 U Detrusor Injection for
Detrusor Hyperreflexia
52
Cauda equina lesion andDetrusor areflexia
53
Grade 1 DESD in a SCI Women
54
Grade 1 DESD in Cervical SCI
55
Failure of Pharmacological Mx

• Presence of vesicoureteral reflux
• Severe bladder fibrosis and trabeculation
• Presence of severe bladder outlet obstruction
• Severe outlet incompetence
• Azotemia or renal failure
• No improvement in quality of life

56
Surgical treatment for complications of chronic
SCI

• External sphincterotomy and urethral stent
• Augmentation cystoplasty
• Bladder autoaugmentation
• Continent urinary reservoir formation (Kock
  pouch)
• Pubovaginal sling procedure
• Continent cystostomy
• Ureteral reimplantation

57
External Sphincterotomy

• Indicated in quadriplegic patients with DESD
• Potentially not result in total incontinence
• Urinary tract infection can be eliminated
• Free of catheterization
• Re-do is possible in 25 patients with inadequate
  sphincter relaxation or scarring
• 25- 30 may have persistent hydronephrosis

58
Technique of Sphincterotomy

• 12 oclock position
• Incision from BN to bulbous
• Cutting deep to fat vessel
• Bleeding can be controlled
• Avoid diffused coagulation
• On Foley catheter for 2 days

59
Intravesical pressure after external
sphincterotomy
60
Reduction in MUCP afterExternal sphincterotomy
61
Urethral Stent

• Indwelling a distensible urethral stent for
  scarred membranous or severe DESD refractory to
  sphincterotomy
• Complication should be weighed stone formation,
  stent erosion, persistent UTI, total incontinence
• Only 2/11 longer follow-up patients needed to be
  removed

62
Implantation of a urethral stent
63
Augmentation cystoplasty

• A bladder capacity of less than 250ml
• Overflow incontinence and large residual urine
• Presence of hydronephrosis
• Azotemia and frequent pyelonephritis
• Patient is able to catheterize by himself
• Side effect or refractory to pharmacological
  therapy

64
Technique of augmentation cystoplasty
65
Surgical results after augmentation cystoplasty
66
Bladder autoaugmentation

• Partial myomectomy of bladder wall
• Increase bladder compliance and capacity by
  distensible bladder mucosa
• Less surgical morbidity and complication
• Secondary fibrosis and reduced capacity after
  long-term follow-up
• Serve as first line surgical procedure for SCI

67
Bladder autoaugmenttion
68
Ureteral reimplantation

• Not suitable in trabeculated bladder
• High failure rate after ureteral reimplantation
  or collagen injection
• Contraindicated in SCI patients with DESD AD
• Combined augmentation and anti-reflux procedure
  is a better way

69
Anti-reflux afferent nipple valve
70
Continent Reservoir (Kock pouch)

• Creation of a continent reservoir by a 40-cm
  segment of ileum
• Detubularization and double folded ileum can have
  a volume of 600ml
• Anti-reflux and anti-incontinence nipple valves
• Self-catheterization is needed
• Suitable for female SCI with good hand function

71
Sonography of Kock pouch
72
Degeneration of intestinal wall in Urinary
reservoir
73
Transurethral injection

• Transurethral injection of botulinum toxin may
  reduce sphincteric tone and facilitate voiding in
  SCI with DESD or detrusor areflexia
• Transurethral injection of collagen or Teflon
  paste may bulk sphincter and increase urethral
  tone, eliminate incontinence in lower level SCI
• Other new devices implant into bladder neck or
  sphincteric urethra to combat incontinence

74
Artificial Urethral Sphincter
75
Artificial Urethral Sphincter

• 95 in the NVD patients (half of 250) receiving
  AUS implantation became continent, 78 at the
  first AUS attempt
• Revision rate in neurogenic voiding dysfunction
  is 33
• Annual incidence of erosion was 5
• Overall success rate was 77,revision rate 59 in
  107 children