Spinal Cord Injury R Hamid Consultant Neuro-Urologist London Spinal Injuries Unit, Stanmore & National Hospital for Neurology & Neurosurgery, UCLH
SCI 800 1000 new cases per year in UK Car accidents 35% Violence 30% Falls 20% Sports related 7% Surgery & Misc 8% Males 70-80% Average age 31 years
SCI Incomplete quadriplegics 28% Complete paraplegics 26% Complete quadriplegics 24% Incomplete paraplegics 18% Paraplegics: 6% reduction in life expectancy Tetraplegics: 20%
SCI 1970 s major cause of death Renal Failure Late 80 s onwards pneumonia, accidents, suicide
SCI Nomenclature Orthopaedic: relates to bone injury eg C5/6 dislocation Neurological: last fully functioning root level Complete OR Incomplete (ASIA) score Injury is complete if there is: No voluntary anal contraction S4-5 sensory scores = 0 no anal sensation = No Otherwise injury is incomplete Typical complete SCI Above lesion = normal Lesion = flaccid Below = hyperreflexic autonomous distal cord
SCI Cord ends at L1 Cervical roots come out above vertebral body, rest below Symp: T1 L2 Parasymp: Vagus, S2,3,4
Before Injury The bladder is normal or has function consistent with age, gender, habit etc
The Normal Bladder Stores Empties
Storage Volume normal should be 500ml or less Pressure is low (15cmH20) or less
Emptying Speed Fast Volume Up to 500ml Residual Should be 0
The Normal Bladder Conscious Control Voiding is at a socially convenient time CC CC Pontine micturition centre Cortical connections PMC Learnt from the the age of 3yrs onwards Sacral micturition centre SMC
How do we pass urine?
All you need to know Onuf s nucleus: Somatic Ant horn S2,3,4 Continence Sacral micturition Centre Parasymp Interomediolateral grey Receptive relaxation Voiding Talk to each other via Pontine Micturition Centre
What happens after SCI? Loss of control of the reflex in lesions above the sacral reflex arc with reflex bladder behaviour NDO No control of the bladder with no ability to empty in lesions of the sacral nerves and below the sacral reflex arc - acontractile bladder
Spinal Shock Period of excitability at & below SCI Absent somatic reflexes & flaccid muscle paralysis Autonomic activity Acontractile, areflexic bladder Sphincter = functioning retention (catheter / SPC / CISC) Lasts days to months
Bladder Recovery Last to recover Majority of recovery in 1st 6 months More subtle changes up to 2-5 years
Spinal Shock - recovery Reflex recovery 1 st = striated muscle of pelvic floor Return of Bulbocavernosus reflex S3,4: pinch glans/clitoris or pull catheter and anal sphincter contracts on your finger If BCR present: sacral micturition centre = intact
Types of bladder dysfunction Acontractile NDO xxxxxxxxxx
SCI UMN above T10 spastic DANGEROUS BLADDER LMN below L1 areflexic SAFE BLADDER Mixed T10 L1 mixed picture
Supra Pontine Injury Neurogenic Detrusor Overactivity (Hyperreflexia) Overactive bladder muscle Incontinence Urgency Frequency Inappropriate bladder emptying Sensory urgency
Lower Motor Neuron SCI Acontractile Detrusor (Areflexia) Flaccid bladder muscle that does not contract?some sensory urge but unable to instruct bladder to empty Weakened sphincters and pelvic floor muscle causing genuine stress incontinence
Upper Motor Neuron SCI Autonomous distal cord Spastic / hyperreflexic bladder Neurogenic detrusor overactivity Decreased compliance No communication between SMC & Onuf Unco-ordinated sphincter Bladder and sphincter contract together Detrusor sphincter dyssynergia (70-100% pts)
Supra-sacral spinal injury Intraurethral Pressure Sphincter EMG Detrusor Pressure Urine Flow
Detrusor sphincter dyssynergia Problems: Large PVR UTI High Pdet Hydronephrosis Autonomic dysreflexia Worsens with UTI, fissure, constipation
Detrusor Hyperreflexia with DSD The Pressures are high The Bladder is obstructed by external sphincter dyssynergia The Duration of contraction is long
CMG demonstrating poor bladder compliance
Autonomic Dysreflexia Injury above T6 Exaggerated sympathetic response to afferent visceral stimulation Nociceptive stimulation of afferent impulses ascend through the cord and elicit reflex motor outflow Bladder >90% Symptoms sweating, headache, flushing Signs bradycardia, hypertension Treatment Identify and treat cause Nifedipine 10-20 mgs
Philosophy of Bladder Management Preservation of Renal Function Promotion of Continence achievable goal Dept of Health Report on Continence July 2001 Patients Perspective Socially acceptable Simple Avoids drainage device Personal control Medical Perspective Low pressure storage Complete & efficient emptying Preservation of renal function
Aims of Bladder Management after SCI Should be to Maintain capacity Maintain low pressure Prevent incontinence Achieve complete bladder emptying Avoid complications
Acute Management IDUC Intermittent catheterization SPC Anticholenergics Conveen sheath Temporary stents
Treatment (summary) 1 Preserve renal function 2 Continence Suprasacral SCI If bladder is safe - CSIC If not safe paralyse the bladder (anticholinergic, botox, capsaicin, RFX, post rhizotomy) Or Augment Then empty it: CISC, mitroffanof, SARS, catheter Or Divert
Treatment (summary) Conus SCI If bladder safe: CISC / strain voiding? Tx GSI AUS, colpo, inject, urethral closure, divert If unsafe: augment
Thank you