Epidural spinal cord stimulation affects bladder and bowel function â A Case report
1Walter M, 1Lee A, 2Kavanagh A, 3Phillips A, 1Krassioukov A
1International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; 2Department of Urologic Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; 3Physiology and Pharmacology, Cumming School of Medicine, Libin Cardiovascular Institute, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
Epidural spinal cord stimulation (ESCS) in humans with chronic spinal cord injury (SCI) is associated with ameliorated motor dysfunction. In addition to sensorimotor impairment, urinary bladder and bowel function are among the primary priorities for patients with SCI. However, the effect of ESCS on neurogenic lower urinary tract dysfunction (NLUTD) and neurogenic bowel dysfunction (NBD) has yet to be revealed. Therefore, we are presenting a case report on evaluation of short-term ESCS on bladder and bowel function in man with SCI.
A 33-year-old man was involved in a motor vehicle accident in 2012 and sustained C5, AIS B SCI. After standard rehabilitation within a tertiary hospital, he was discharged into the community. He presented with following conditions: orthostatic hypotension (OH), autonomic dysreflexia (AD), NLUTD, NBD and neuropathic pain. In May 2016, he underwent a L2 laminectomy and implantation of a 16-electrode array [RestoreAdvanced SureScan MRI neurostimulator (Medtronic)]. The neurostimulator was pre-set with 9 different configurations, focused on improving motor functions.
As a consequence of NLUTD, the patient underwent intradetrusor onabotulinumtoxinA injections (200 IE Botox) in March 2017, which effectively ameliorates neurogenic detrusor overactivity (NDO) for six months. His preferred method for bladder emptying is intermittent catheterization. In July 2017, we assessed the acute effect of ESCS on bladder function by performing urodynamic studies with and without all 9 stimulation configurations while measuring intravesical and abdominal pressure (urethral and rectal catheter), as well as muscle activity of the sphincter/pelvic floor (surface electromyography). Simultaneously, we continuous measured blood pressure (BP), heart rate (HR) and cerebral blood flow (CBF). Furthermore, we assessed the acute effect of ESCS on bowel function by recording the time necessary to facilitate bowel management.
First, we established that without ESCS, AD occurred at a cystometric volume of 415mL. However, NDO did not occur. After draining the bladder completely, BP and HR returned to baseline values. Next, we prefilled the bladder to a volume of 250mL, so as to fill the bladder with enough volume to measure intravesical and abdonominal pressure but not to elicit NDO or AD. We then applied all 9 stimulation configurations in consequent order for a period of at least one minute. ESCS resulted in an increase of intravesical pressure and sphincter/pelvic floor activity. However, sphincter and pelvic floor muscles activity as well as intravesical pressure were mainly affected with ESCS configurations involved activation of middle and caudal electrodes of the implanted 16-electrode array. Furthermore, acute ESCS reduced the time required for bowel management from 2 hours to only 45 minutes.
This preliminary data demonstrates that ESCS may have the capacity to modulate autonomic bladder and bowel function after SCI, furthering our previous work demonstrating this possibility in autonomic cardiovascular function. However, further evaluations are necessary to investigate whether ESCS can result in coordinated voiding, bowel evacuation, and improved continence in individuals with SCI.
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