Sacral Nerve Root Stimulation for the Treatment of Urge Incontinence and Detrusor Dysfunction Utilizing a Cephalocaudal Intraspinal Method of Lead Insertion: A Case Report

Sacral nerve root stimulation (SNRS) is known to be effective in the treatment of pelvic motor dysfunction( 1 - 4 ). Bladder and urethral motor disorders commonly treated include urinary urge incontinence, voiding/detrusor dysfunction, and urgency/frequency syndromes. To date, neurostimulation specific to bladder and urethral dysfunction has applied a unilateral, trans‐sacral approach. (Interstim, Medtronic, Minneapolis, MN) Despite some success, this method has been associated with technical failures in maintaining electrode position( 5 , 6 ). As an alternative, this case report describes the selective epidural application of a cephalocaudal (“retrograde”) lead insertion method in a patient with severe detrusor dysfunction and urinary urge incontinence( 7 ).     

Sacral nerve stimulation in fecal incontinence; efficacy and safety

Fecal incontinence is common due to various reasons. Conservative therapy of fecal incontinence may sometimes be effective in improving function, but usually many patients require surgery. Sacral nerve stimulation is another treatment modality which gained interest, and appears to be an alternative method that is successful with low morbidity. With the approval of the local ethical committee a total of 14 patients with rectal incontinence had undergone trial stimulation of sacral neuromodulation after failure of conservative treatment modalities. The implantations were performed under surgical sterile conditions with fluoroscopic guidance through the S3 foramen. After correct placement 0.5-2 V, 15 /min, pulse width 210 micro s stimulus was given. The patients had trial period longer than 6 weeks; 9 of 14 patients responded positively to the trial period. Of these 1 had permanent implantation, 3 were booked for permanent implantation, and 2 of the patients had complete incontinence relief from the trial period. Evaluating the data and the results of our study we may conclude that sacral nerve stimulation is an emerging surgical technique to produce a clinically beneficial physiological effect on the lower bowel, pelvic floor and anal canal.     

Sacral Nerve Stimulation With Percutaneous Dorsal Transforamenal Approach in Treatment of Isolated Pelvic Pain Syndromes

Objectives. The aim of the study was to test the effectiveness of sacral nerve stimulation (SNS) performed by a transforamenal approach in patients with isolated chronic intractable pelvic pain. Materials. Sevenpatients with intractable pelvic pain underwent implantation of self‐anchoring leads by way of the dorsal S3 foramen in four cases and of the dorsal S4 foramen in three cases. Patients with pain improvement > 50% underwent sacral nerve root stimulation device implantation. SNS therapeutic efficacy was measured using a visual analog scale (VAS) and its effects on quality of life (QoL) using the SF‐36 scale. Results. During test stimulation five patients had significant and permanent pain relief and subsequently underwent implantation of a permanent device. VAS score improvement was evident in these patients and remained unchanged at 3, 6, and 12 months (median 8 months); SF‐36 QoL questionnaire also revealed significant improvement in many domains of QoL including all the four physical domains and three of the four mental domains. There were three complications in our seven patients: one lead fracture, one lead displacement in the presacral space, and one patient who developed pain at the implantable pulse generator site. Conclusions. Transforamenal SNS is effective in relieving isolated pelvic pain but a high complication rate was found.     

Principles of Sacral Nerve Stimulation (SNS) for the Treatment of Bladder and Urethral Sphincter Dysfunctions

Objectives. Sacral nerve stimulation (SNS) (Medtronic, Inc., Minneapolis, MN) is an exciting new treatment for refractory voiding disorders including urinary incontinence, retention, and voiding dysfunction. It is known that both voiding and continence reflex mechanisms are organized in the sacral spinal cord and that pathologic conditions can alter the balance between these two opposing mechanisms. Methods. The background and surgical technique of SNS will be presented. This will be followed by a discussion of hypotheses on how SNS works. Results. The beneficial effects of SNS are most reasonably attributed to activation of somatic afferent axons in the sacral spinal roots. This evoked afferent activity in turn modulates sensory processing and micturition reflex pathways in the spinal cord. Hyperactive voiding can be suppressed by direct inhibition of bladder preganglionic neurons as well as inhibition of interneuroneal transmission in the afferent limb of the micturition reflex. On the other hand, voiding in patients with urinary retention can be facilitated by inhibition of reflex pathways to the urethral outlet (guarding reflexes). Conclusions. SNS, a nonablative, minimally invasive technique for urologists, holds great promise for a large number of patients who suffer debilitating and refractory urinary symptoms.     

神经束膜囊肿的显微外科治疗

目的研究神经束膜囊肿的临床表现及影像学特点,确定适宜的治疗方法.方法对6例神经束膜囊肿患者的临床特点、治疗方法进行回顾性分析.结果6例患者,其中3例术后骶神经疼痛症状消失,2例明显减轻,1例以麻木表现者无明显变化,憋气及改变体位时无明显疼痛.3例2～3个月恢复.随访2个月～5年,未见囊肿复发.结论神经束膜囊肿临床少见,MRI仍是最灵敏、最有效的诊断方法.对于有典型骶神经根症状的患者,采用显微外科技术,行囊肿切除或部分切除、囊肿内减压术,可显著改善临床症状.     

The laparoscopic implantation of neuroprothesis to the sacral plexus for therapy of neurogenic bladder dysfunctions after failure of percutaneous sacral nerve stimulation

Objectives: To report about our first short series of laparoscopic implantation of neuroprothesis—LION procedure—to the sacral plexus for treatment of different neurogenic bladder dysfunctions in patients in whom percutaneous sacral nerve stimulation (SNS) failed. Material and Methods: A unilateral sacral LION procedure was performed in four patients with a refractary interstitial cystitis, in 13 patients with refractory bladder overactivity (multiple sclerosis N= 8, spina bifida N= 1, incomplete paraplegia N= 2, diabetic cystopathy N= 1), one patient with a neurogenic bladder incontinence by Parkinson syndrome, and in four patients for treatment for bladder atonia (Fowler's syndrome). In all patients, not only previous medical treatments but also SNS by transforaminal implantation had failed. Laparoscopic exposure of the sacral nerves roots S2 to S4/5 is performed by a transperitoneal approach and a quad electrode is placed perpendicular to the sacral nerve roots for postoperative global stimulation of these sacral nerve roots. Results: All procedures were performed successfully by laparoscopy without any complications. The mean operative time for such a procedure was 34 min. In two patients of the series postoperative neuromodulation failed. In all further 19 patients with an actual follow‐up varying between three months and three years, neuromodulation is still working successfully. Conclusions: Our results underscore that the sacral LION procedure to the sacral plexus is effective and safe for treatment divers neurogenic bladder dysfunctions even after failure of the classical percutaneous technique of implantation.     

扩大胼胝体离断术治疗难治性癫痫

目的探讨扩大胼胝体离断术治疗难治性癫痫的手术疗效和并发症的发生。方法回顾性分析58例扩大胼胝体离断术患者,分析术后的急慢性并发症和手术对癫痫发作的控制。结果术后随访13～48个月,所有患者术后仍然继续术前抗癫痫药物治疗,6.9%(4例)的患者术后发作消失,术后发作频率减少大于75%的患者为55.2%(32例),29.3%(17例)的患者发作频率减少50%以上,8.6%(5例)的患者无明显改善。51例患者术后发生缄默症状,47例在术后2周内恢复,4例3周后恢复;11例出现右侧肢体轻偏瘫,均在2周内症状消失;6例术后3～6天出现小便失禁,均在2周内恢复;未见长期并发症患者。结论对于癫痫灶定位困难的难治性癫痫患者,扩大胼胝体离断术能够较好的缓解患者的发作,尽管急性并发症发生率较高,但通常恢复良好,远期并发症发生率低,是一种有效和安全的手术。     

The influence of sacral nerve stimulation on gastrointestinal motor function in patients with fecal incontinence

Background Sacral nerve stimulation (SNS) is a well‐established treatment for fecal incontinence of various etiologies. However, the mechanism of action remains unclear. The aim of the present study was to determine whether SNS affects gastric emptying, small intestinal transit or colonic transit times. Methods Seven patients with a permanently implanted sacral nerve stimulator participated in a double‐blind randomized cross‐over study. The patients were allocated to stimulation ON or OFF for two 7‐day periods separated by at least 1 week. On days 4–7 of each 7‐day period, the patients were examined by gamma camera imaging to measure gastric emptying, small intestinal transit and colonic transit parameters of a radiolabeled, 1600 kJ mixed solid and liquid meal ingested on day 4. Key Results Sacral nerve stimulation did not change gastric retention at 15 min, gastric mean emptying time, gastric half emptying time, small intestinal mean transit time or colonic geometric center after 24, 48 and 72 h. Conclusions & Inferences Sacral nerve stimulation does not induce major changes in the propulsive capacity of the gastrointestinal tract in patients successfully treated for fecal incontinence with permanent sacral nerve stimulator.     

骶神经刺激治疗神经源性膀胱的疗效观察

目的 观察骶神经刺激(SNS)治疗神经源性膀胱的疗效.方法 使用SNS治疗94例神经源性膀胱患者,观察SNS治疗前和治疗1周后的尿失禁症状简易评分(ICI-Q-SF评分)、排尿日记(包括尿失禁次数、尿垫试验、排尿次数、夜尿次数、排尿量等)和尿动力学检查指标(包括膀胱容量、逼尿肌压、最大尿流率、平均尿流率、膀胱颈压、最大尿道压、功能性尿道长度和残余尿量等),并对所得数据进行统计学分析.结果 治疗前ICI-Q-SF评分为(17.2±1.8)分,治疗后为(8.3±1.6)分,差异有统计学意义(P<0.05).与治疗前比较,尿失禁次数、排尿次数和夜尿次数显著减少(P<0.05),尿垫显著减轻(P<0.05),排尿量显著增加(P<0.05);膀胱容量、最大尿流率和平均尿流率显著增加(P<0.05),残余尿量显著减少(P<0.05),而逼尿肌压、膀胱颈压、最大尿道压和功能性尿道长度等无显著性改变(P＞0.05).本组总有效率为75.5%,无一例并发症发生.结论 SNS治疗神经源性膀胱的效果确切,症状改善明显,并发症少且发生率低,是值得临床推广的治疗方法.     

Cauda equina syndrome due to disk herniation: Long-term functional prognosis

ObjectiveCauda equina syndrome (CES) caused by lumbar disk extrusion is classically considered an indication of urgent surgery. CES can be subdivided into CESI (incomplete CES) and CESR (complete CES with urinary retention and incontinence). This paper evaluates the long-term functional outcome of a CES cohort operated on due to disk herniation.MethodsSingle-center retrospective observational study. CES patients due to disk herniation that underwent surgery between 2000 and 2016 were included in the study. Demographic data, time intervals to diagnosis and surgery, preoperative neurologic status and outcome at the end of follow up were recorded.ResultsTwenty-two patients were included (median age 44 years). Eight patients were CESR and 14 CESI. Median time from symptom onset to diagnosis was 78 h (range, 12–720 h), and from diagnosis to surgery 24 h (range, 5–120 h). Median follow up was 75 months (range, 20–195 months). At the end of follow up, in the CESR group (median time from diagnosis to surgery, 23 h) only pain significantly improved after surgery (p = 0.007). In the CESI group (median time from diagnosis to surgery 23 h) low back pain, sciatica and urinary sphincter function significantly improved (p < 0.001). There were no significant differences between early (<48 h) operation (n = 4) and late (n = 18) in terms of sphincter recovery (Fisher's Exact Test, p = 0.076).ConclusionPain associated to CES improved both in the CESI and CESR groups. However, urinary sphincter impairment significantly improved only in the CESI group. No significant differences were found regarding long-term functional outcome between early and late surgery.     

Selective Nerve Root Stimulation (SNRS) for the Treatment of Intractable Pelvic Pain and Motor Dysfunction: A Case Report

Interstitial cystitis is the most disabling nonmalignant disorder seen by urologists. Chronic debilitating urinary bladder symptoms (severe pain and pelvic floor muscular dysfunction) often progress despite maximal medical attempts at management. Although the exact cause remains unknown, a neuropathic etiology has recently been suggested( 1 , 2 ). This case report describes the use of Selective Nerve Root Stimulation (SNRS) for the treatment of intractable pelvic pain and motor dysfunction in a patient with Interstitial cystitis (IC).     

Existing and emerging applications for the neuromodulation of nerve activity through targeted delivery of electric stimuli

Abstract

The effective treatment of many diseases requires the use of multiple treatment strategies among which neuromodulation is playing an increasingly important role. Neuromodulation devices that act to normalize or modulate nerve activity through the targeted delivery of electrical stimuli will be the focus of this review. These devices encompass deep brain stimulators, vagus nerve stimulators, spinal cord simulators and sacral nerve stimulators. Already neuromodulation has proven successful in the treatment of a broad range of conditions from Parkinson’s disease to chronic pain and urinary incontinence. Many of these approaches seek to exploit the activities of the autonomic nervous system, which influences organ function through the release of neurotransmitters and associated signalling cascades. This review will outline existing and emerging applications for each of these neuromodulation devices, proposed mechanisms of action and clinical studies evaluating both their safety and therapeutic efficacy.     

Spinal‐Peripheral Neurostimulation (SPN) for Bilateral Postherniorrhaphy Pain: A Case Report

Objective: Postherniorrhaphy pain is a not uncommon, and difficult to treat, pain condition. Success with different methods of neurostimulation has been reported in the literature in the last decade. We assess the use of a new modality of neuromodulation—spinal‐peripheral neurostimulation (SPN). Materials and Methods: We report the results of treatment of a patient with bilateral, intractable postherniorrhaphy pain with SPN. Results: Significant reduction in pain and decrease in opioid consumption have been achieved. Conclusion: SPN can be an effective treatment for postherniorrhaphy pain resistant to conservative management.     

Cauda Equina Syndrome Associated with Dural Ectasia in Chronic Anlylosing Spondylitis

Cauda equina syndrome (CES) associated with dural ectasia is a rare neurologic complication in patients with longstanding ankylosing spondylitis (AS). We report a 68-year-old male with a 30-year history of AS who presented a typical symptom and signs of progressive CES, urinary incontinence and neuropathic pain of the lumbosacral radiculopathy. Computed tomography (CT) and magnetic resonance imaging (MRI) findings showed the unique appearances of dural ectasia, multiple dural diverticula, erosion of posterior element of the lumbar spine, tethering of the conus medullaris and adhesion of the lumbosacral nerve roots to the posterior aspect of the dural ectasia. Considering the progressive worsening of the clinical signs, detethering of the conus medullaris through resection of the filum terminale was performed through a limited laminectomy. However, the urinary incontinence did not improve and there was a partial relief of the neuropathic leg pain only. The possible pathogenetic mechanism of CES-AS and the dural ectasia in this patient with longstanding AS are discussed with a literature review.     

Neuromodulation of the Pudendal,Hypogastric, and Tibial Nerves With Pelvic Floor Muscle Rehabilitation in the Treatment of Urinary Urge Incontinence

ObjectivesThe hypothesis of the study is that adding percutaneous tibial nerve neuromodulation (Urgent PC, Uroplasty Inc., Minneapolis, MN, USA) with pelvic floor muscle rehabilitation (Evadri System, Hollister Inc., Libertyville, IL, USA) is safe, and more successful than either therapy alone for the treatment of urge incontinence.Material and MethodsTwo hundred and fifty-six female patients with urge incontinence or mixed incontinence were included in this investigation. Patients were treated sequentially (on the same day) with both pelvic floor muscle rehabilitation and percutaneous tibial nerve neuromodulation twice per week at the Southern Arizona Urogynecology Center, Tucson, Arizona.ResultsAt three months 93% of the patients were dry. The remaining 7% of patients had a mean improvement of 84% in their incontinence episodes. The median follow-up is now 19 months. There were no adverse side events.ConclusionsNeuromodulation of the pudendal, hypogastric, and tibial nerves is a highly effective treatment for urge incontinence, and superior to either treatment alone by a factor of greater than two times (see Table 1).     

The Laparoscopic Implantation of Neuroprothesis (LION) Procedure to Control Intractable Abdomino‐Pelvic Neuralgia

Objective. To present different aspects and advantages of the laparoscopic implantation of a peripheral nerve stimulator adjacent to the pelvic nerves, aimed at treating intractable pelvic neuralgia by means of neuromodulation—the laparoscopic implantation of neuroprothesis (LION) procedure. Materials and Methods. We report here a series of three patients with different types and etiologies of chronic pelvic neuralgia who underwent laparoscopy for implantation of a peripheral nerve stimulator for neuromodulation, the first for neuromodulation of the ilioinguinal and pudendal nerves, the second for neuromodulation of the sciatic nerve, and the third for neuromodulation of the sacral nerve roots. In all three patients, the neuralgia was refractory to medical management and had profound socioeconomic consequences for the patients. Results. Laparoscopic implantation of neuroelectrodes was successfully performed in all three patients and resulted significant diminution of pain without need for further medical treatment. Conclusions. Laparoscopy allows optimal implantation of electrodes on all pelvic nerves through a minimally invasive approach. In addition, it permits new applications of neuromodulation for pelvic polyneuropathies or mononeuropathy, not covered by classical spinal cord or transcutaneous techniques.     

Rectal motility after sacral nerve stimulation for faecal incontinence

Abstract  Sacral nerve stimulation (SNS) is effective against faecal incontinence, but the mode of action is obscure. The aim of this study was to describe the effects of SNS on fasting and postprandial rectal motility. Sixteen patients, 14 women age 33–73 (mean 58), with faecal incontinence of various aetiologies were examined. Before and during SNS, rectal cross-sectional area (CSA) and ano-rectal pressures were determined with impedance planimetry and manometry for 1 h during fast and 1 h postprandially. Neither in the fasting state nor postprandially did SNS affect the number of single rectal contractions, total time with cyclic rectal contractions, the number of aborally and orally propagating contractions, the number of anal sampling reflexes or rectal wall tension during contractions. Postprandial changes in rectal tone were significantly reduced during SNS ( P  < 0.02). Before SNS, median rectal CSA was 2999 mm² (range: 1481–3822) during fast and 2697 mm² (range: 1227–3310) postprandially ( P  < 0.01). During SNS, median rectal CSA was 2990 mm² (1823–3678) during fast and 2547 mm² (1831–3468) postprandially ( P  = 0.22). SNS for faecal incontinence does not affect phasic rectal motility but it impairs postprandial changes in rectal tone.     

Improved Sexual and Urinary Function in Women with Sacral Nerve Stimulation

Objectives: Urinary and sexual function improve following sacral nerve stimulation (SNS) for refractory overactive bladder. No significant associations between these changes have been found. Whether improvements in sexual function are independent of or secondary to improvements in urinary function remains unclear. The aim of this study was to analyze changes in urinary and sexual function in a homogeneous sample of patients undergoing SNS for urge urinary incontinence and subsequently identify associations between the two. Materials and Methods: A prospective database was created. Enrollees underwent a full history and physical examination at the first office visit. Multiple‐day voiding diaries with validated and investigator‐designed questionnaires were administered at baseline and follow‐up as standard implantation procedures and to assess changes in urinary and sexual function, respectively. Analyses were completed using data from patients who were sexually active at baseline and follow‐up. Results: Statistically significant improvements in urinary and sexual function occurred according to multiple metrics. Patient global impression scales categorized all patients' urinary conditions as improved, with most being less severe. Validated urinary symptom and quality of life scores improved significantly. After treatment, most patients were incontinent less often with sexual activity and felt less restricted from sexual activity by fear of incontinence. Validated quantification of sexual function demonstrated significant improvements in overall sexual function, arousal, and satisfaction. No significant associations between changes in urinary and sexual function were noted; however, trends appeared to exist between the two. Conclusions: Improved sexual function was not significantly associated with improved urinary function after SNS despite apparent trends between the two. Larger samples are required to definitively demonstrate this conclusion.     

Percutaneous Implantation of a Brachial Plexus Electrode for Management of Pain Syndrome Caused by a Traction Injury

Introduction. Intractable pain in the affected arm is a common sequel to severe traction lesions of the brachial plexus. Its management presents a challenge. Existing interventional therapies are not effective for the intractable pain from brachial plexus traction lesions, in the long term. Spinal cord stimulation is indicated for the relief of pain following peripheral nerve injury, but has its limitations and, in the UK, is restricted only to specialized centers. Peripheral neuromodulation is widely practiced noninvasively as transcutaneous electrical nerve stimulation and more recently, both as external neuromodulation and, invasively, using a surgical procedure with restricted indications. Methods. We report here a single case report of the successful management of intractable pain of uncertain pathology following traction injury of the shoulder and brachial plexus with the percutaneous implantation of a permanent stimulating electrode via a stimulating needle to the brachial plexus using the posterior route at the interscalene level. Results. Stimulation of the brachial plexus in this one patient has resulted in excellent pain control and unexpected beneficial sensory and motor changes in the arm of the patient. Conclusions. We cautiously conclude that percutaneous implantation of a stimulating electrode to the brachial plexus via a stimulating needle is a relatively simple procedure when compared to surgical implantation and, as shown in our case, very effective.