经神经途径重建脊髓损伤后膀胱功能新进展

神经源性膀胱引起的严重的尿潴留和尿路感染甚至慢性肾功能衰竭严重影响患者生活质量以及生命,其治疗有多种方法,本文从经神经途径重建脊髓损伤后膀胱功能的方法作一综述,同时对膀胱神经再支配治疗神经源性膀胱的新进展进行文献复习.     

脊髓损伤后弛缓性膀胱的治疗

目的探讨脊髓损伤后弛缓性膀胱的治疗方法。方法广泛查阅国内外相关文献，介绍几种弛缓性膀胱的治疗方法。结果脊髓损伤后弛缓性膀胱尚缺乏有效的治疗方法，与清洁间断导尿、加压排尿、药物治疗及重建逼尿肌功能等治疗方法相比，建立人工反射弧能实现膀胱的可控性排尿。结论人工反射弧的建立为脊髓损伤所致的弛缓性膀胱提供了一种新的膀胱功能重建方法。     

脊髓损伤后膀胱人工反射弧建立的实验研究

目的 通过建立家犬人工膀胱反射孤,以恢复脊髓损伤后的膀胱功能。它包含一个体反射孤,并将体反射运动冲动经异化的运动传出支传入膀胱,引起膀胱的自主性收缩．方法 将右Ｌ５前根近端与右Ｓ２前根远端在硬膜囊内行显微吻合,保持Ｌ５后根完整,经轴突再生后,建立膝腱－脊髓中枢－膀胱这一新人工反射通路,通过刺激右侧膝腱激发排尿。神经根吻合术后６个月和１８个月,分别进行神经电生理、膀胱测压、膀胱逼尿肌肌电图等早期和远     

脊髓损伤后膀胱功能的评价与修复

脊髓损伤后膀胱功能的评价与修复刘智胥少汀脊髓损伤后的膀胱功能障碍称为神经原性膀胱，可引起尿毒症和慢性肾功能衰竭，这是脊髓损伤患者晚期死亡的主要原因。随着对这一问题认识的不断深入，许多治疗方法，包括清洁间歇性导尿术、药物治疗和尿道外括约肌切开术等，取得...     

脊髓损伤后膀胱尿流动力学检查及分类

目的：检测脊髓损伤患者膀胱功能并分类。探讨并发症与膀胱功能的关系。方法：采用尿流动力学四导程测压仪对３６例脊髓损伤患者进行下尿路功能分组检测。结果：各组患者因脊髓损伤节段及程度的不同，会有不同的尿流动力学表现及不同的膀胱功能，而且有相应的并发症发生，这之间有一定的规律及内在联系，并据此将膀胱分为三类。结论：根据尿流动力学表现对脊髓损伤后膀胱进行分类，对临床有一定的指导意义。     

经神经途径重建脊髓损伤后膀胱排尿功能

本文系统综述了通过神经途径重建脊髓损伤后膀胱功能的各种治疗方法及研究进展,并对各种不同方法的重建方式、治疗效果以及存在的问题进行了探讨。对膀胱神经再支配和骶神经前根电刺激重建膀胱排尿功能研究进展的论述,反映了当前脊髓损伤后膀胱功能重建的研究方向。     

脊髓损伤患者上尿路损伤风险预测的膀胱内压临界值研究

目的探讨对脊髓损伤患者预测上尿路损伤风险的膀胱内压临界值。方法回顾性分析97例脊髓损伤患者的病历资料,根据诊断标准分为上尿路功能损害组和无上尿路功能损害组,比较两组的基线资料,进行膀胱内压诊断上尿路损伤的ROC曲线分析。结果上尿路损伤组年龄显著大于无上尿路损伤组,病程显著短于无上尿路损伤组(均P0.01),根据ROC曲线计算得到膀胱内压最佳临界值为33.25cmH2O。结论可将33.25cmH2O作为预测上尿路损伤的膀胱内压力临界值。     

Baclofen对脊髓损伤后痉挛性膀胱的疗效观察

Ｂａｃｌｏｆｅｎ对脊髓损伤后痉挛性膀胱的疗效观察侯春林１刘明轩１包聚良１巴氯酚（Ｂａｃｌｏｆｅｎ），商品名称是力奥来素（Ｌｉｏｒｅｓａｌ），是目前最有效、副作用最小的肌肉松弛剂〔１〕。自７０年代以来，国外一直广泛应用于脊髓损伤性痉挛患者的治疗，但对于...     

脊髓损伤后血流改变

选用成年狗１０只，于胸９－０给以２０ｇ×２５ｃｍ打击量，应用氢清除法于伤后１５ｍｉｎ～４ｂ测定脊髓血流量（ＳＣＢＦ）。结果显示伤后不同时期灰质血流量均较白质血流量（ｗＳＣＢＦ）为高，近侧节较远侧节亦高，伤后２ｈ，ｗＳＣＢＦ稍升高，但４ｈ恢复正常。作者认为，伤后头几个小时为关键时刻，此时如能采用有效措施，对不全瘫还能逆转。本文结果与文献相比有些差异，可能与实验条件不同及观察时间较短有关。     

Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury

AIMS: The vast majority of spinal cord lesions cause neurogenic bladder disorders. Detrusor hyperreflexia presents a major risk factor for renal damage in these patients. We evaluated the long-term results of patients with spinal cord injury treated at our institution. METHODS: Eighty spinal cord injury patients (60 male, 20 female; mean age 29.6 years) with at least one follow-up visit a year for a minimum of five consecutive years, were included in this retrospective analysis. Follow-up included urodynamic evaluation, sonography of the upper and lower urinary tract, urine examination, and evaluation of renal function. Treatment modifications were based on the urodynamic findings. RESULTS: Mean follow-up was 67.3 months (range 60-103 months). At initial presentation, 51 patients performed intermittent catheterization, 7 had indwelling catheters, 10 utilized reflex voiding, 2 patients presented with a Brindley stimulator, 10 patients used abdominal straining. At the end of our study, no patient had signs of renal damage. To achieve that goal, 8 patients underwent sphincterotomy, 3 received a Brindley stimulator, 3 underwent bladder augmentation, one Kock pouch was performed, and 12 patients were treated with botulinum-A-toxin injections in the detrusor. Twenty-two patients received intravesical anticholinergic therapy. In merely three patients, treatment was not modified during the entire follow-up. CONCLUSIONS: In the long term, treatment strategy of neurogenic bladder dysfunction in patients with spinal cord injury had to be modified in almost all patients. 18.8% underwent surgery. For protection of the upper urinary tract and maintenance of continence, regular urodynamic follow-up is warranted.     

多节段脊髓平面损伤后大鼠神经源性膀胱模型的制备

目的研制一种具有临床相似性、可调控性、可重复性的脊髓损伤后神经源性膀胱尿道功能障碍动物模型的制模方法。方法采用改良Allen法,将10g重的柯氏针从20cm高以自由落体落下,撞击在动物脊柱背侧的垫片上,造成一定程度的脊髓损伤。结果在脊髓休克期,骶上脊髓损伤(胸腰段)组和骶髓损伤组动物平均每次挤压膀胱排尿量差异无统计学意义(P>0.05),在脊髓休克期后,两组之间差异有统计学意义(P<0.001)。结论改良Allen法具有临床相似性等优点,能为脊髓损伤后神经源性膀胱尿道功能障碍的研究提供理想的动物模型。     

Early sacral neuromodulation ameliorates urinary bladder function and structure in complete spinal cord injury minipigs

Aims

To determine the effects of early sacral neuromodulation (SNM) and pudendal neuromodulation (PNM) on lower urinary tract (LUT) function, minipigs with complete spinal cord injury (cSCI) were analyzed. SNM and PNM have been proposed as therapeutic approaches to improve bladder function, for example after cSCI. However, further evidence on efficacy is required before these methods can become clinical practice.

Methods

Eleven adults, female Göttingen minipigs with cSCI at vertebral level T11-T12 were included: SNM (n = 4), PNM (n = 4), and SCI control (SCIC: n = 3). Tissue from six healthy minipigs was used for structural comparisons. Stimulation was started 1 week after cSCI. Awake urodynamics was performed on a weekly basis. After 16 weeks follow-up, samples from the urinary bladder were taken for analyses.

Results

SNM improved bladder function with better capacities and lower detrusor pressures at voiding and avoided the emergence of detrusor sphincter dyssynergia (DSD). PNM and untreated SCI minipigs had less favorable outcomes with either DSD or constant urinary retention. Structural results revealed SCI-typical fibrotic alterations in all cSCI minipigs. However, SNM showed a better-balanced distribution of smooth muscle to connective tissue with a trend towards the reduced progression of bladder wall scarring.

Conclusion

Early SNM led to an avoidance of the emergence of DSD showing a more physiological bladder function during a 4 month follow-up period after cSCI. This study might pave the way for the clinical continuation of early SNM for the treatment of neurogenic LUT dysfunction after SCI.

     

Early predictors of bladder recovery and urodynamics after spinal cord injury

Our purpose was to determine if intact perianal (S4–5) pin sensation (PPS) and bulbocavernosus (S2–4) reflex (BCR) shortly after spinal cord injury (SCI) are predictive of bladder function recovery. Twenty-eight SCI patients (aged 18–68 years, Frankel Classification A–D, spinal injury level C4–T12), admitted within 72 hours of injury, underwent evaluation of initial PPS and BCR. The presence of intact PPS and BCR were correlated with the patient's voiding function and urodynamic evaluation results 1 year postinjury. Of the 28 patients within 72 hours of SCI, PPS was intact in 17 (60%) and absent in 11 (40%), while 15 patients (54%) demonstrated a positive BCR and 13 (46%) did not. One year after SCI, no patient with absent PPS voided unassisted, while of the 17 patients with preserved PPS, 11 (65%) were voiding spontaneously. Of these 11 patients, urodynamic evaluation revealed detrusor areflexia in 1 (9%), normal detrusor function in 2 (18%), and detrusor hyperreflexia in 8 (73%), with 3 of these 8 patients (38%) also demonstrating detrusor-sphincter dyssynergia. At 1 year postinjury, only 2 of 13 patients (15%) with an absent BCR voided spontaneously, while 9 of 15 patients (60%) with an intact BCR were able to void. Although PPS and BCR are moderately sensitive in predicting the return of spontaneous voiding, they cannot predict detrusor hyperreflexia and sphincter dyssynergia. Therefore, urodynamic study remains an essential component of initial urologic evaluation after SCI. Neurourol. Urodynam. 17:25–29, 1998. © 1998 Wiley-Liss, Inc.