Reinnervation of the neurogenic bladder in the late period of the spinal cord trauma

Study design: Intercostal nerve to spinal nerve root anastomosis in chronic spine-injured patients. Objectives: To analyze the effectiveness of neurogenic bladder reinnervation in spinal cord-injured patients through artificial creation of sprouting (intercostal nerve to spinal nerve root anastomosis). Setting: Center of Neurosurgery, Moscow, Russia. Operations were performed by Professor A Livshits. (At present, Professor A Livshits is working at the Spinal Care Unit, Meir General Hospital, Kfar Saba, Israel.) Methods: A total of 11 patients with spinal cord injury of the L1 level were operated on in the late (chronic) stage. The neurological status and urodynamics were investigated before and 12 months after operation. A laminectomy from T11 to L3 was performed. Next, a neurolysis of the 11th and 12th intercostal nerves was carried out, at a distance of 20-21 cm, and transferred to the vertebral canal. The S2-S3 roots were then cut in their proximal portion and anastomosed end-to-end to the intercostal nerves. The results of urodynamic studies were calculated by the Wilcoxon signed rank test for comparison before and 12 months after operation. Results of urodynamic studies: Bladder capacity (ml) before operation - 489±79, after operation - 350±39, urine volume (ml) before - 18.2±17, after - 306.4±39.8, residual urine (ml) before - 459±99.4, after - 50±11.8. Detrusor tone (rel. units) before - 0.6±1.5, after 1.2±0.2; voiding pressure (cmH₂O) before - 4.4±5.2, after - 30.5±4.9. Force of detrusor contraction before -5±5.8, after - 32.8±5.5. Sphincter resistance (cmH₂O) before -6.5±3.8, after - 21.1±4.2. Significant improvements in bladder function were observed during the 10th to 12th postoperative months. Restoration of reflex voiding occurred in all patients; in eight of the 11 paresthesic in the groin and scrotum and reappearance of the bulbocavernous, anal and cremasteric reflexes were noted. Conclusion: These results suggest that a restitutive process occurs in the bladder under novel conditions of its nerve supply provided by the intercostal nerve and by new connections established between it and the bladder nerves. Spinal cord lesions that might benefit from nerve crossover surgery would be located at the conus, so functional intercostal nerves could be connected to sacral roots to bypass the injury in an attempt to restore central connections to the bladder.