Acute, severe traumatic spinal cord injury: improving urinary bladder function by optimizing spinal cord perfusion

Abstract

OBJECTIVE The authors sought to investigate the effect of acute, severe traumatic spinal cord injury on the urinary bladder and the hypothesis that increasing the spinal cord perfusion pressure improves bladder function. METHODS In 13 adults with traumatic spinal cord injury (American Spinal Injury Association Impairment Scale grades A–C), a pressure probe and a microdialysis catheter were placed intradurally at the injury site. We varied the spinal cord perfusion pressure and performed filling cystometry. Patients were followed up for 12 months on average. RESULTS The 13 patients had 63 fill cycles; 38 cycles had unfavorable urodynamics, i.e., dangerously low compliance (< 20 mL/cmH2O), detrusor overactivity, or dangerously high end-fill pressure (> 40 cmH2O). Unfavorable urodynamics correlated with periods of injury site hypoperfusion (spinal cord perfusion pressure < 60 mm Hg), hyperperfusion (spinal cord perfusion pressure > 100 mm Hg), tissue glucose < 3 mM, and tissue lactate to pyruvate ratio > 30. Increasing spinal cord perfusion pressure from 67.0 ± 2.3 mm Hg (average ± SE) to 92.1 ± 3.0 mm Hg significantly reduced, from 534 to 365 mL, the median bladder volume at which the desire to void was first experienced. All patients with dangerously low average initial bladder compliance (< 20 mL/cmH2O) maintained low compliance at follow-up, whereas all patients with high average initial bladder compliance (> 100 mL/cmH2O) maintained high compliance at follow-up. CONCLUSIONS We conclude that unfavorable urodynamics develop within days of traumatic spinal cord injury, thus challenging the prevailing notion that the detrusor is initially acontractile. Urodynamic studies performed acutely identify patients with dangerously low bladder compliance likely to benefit from early intervention. At this early stage, bladder function is dynamic and is influenced by fluctuations in the physiology and metabolism at the injury site; therefore, optimizing spinal cord perfusion is likely to improve urological outcome in patients with acute severe traumatic spinal cord injury.

Significance of spinal cord perfusion pressure following spinal cord injury: A systematic scoping review

“…The full data extraction table for all 73 included articles is provided on the Open Science Framework. These articles consisted 34 original research articles, 6 , 8 , 9 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 13 conference abstracts, 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 13 literature reviews, 24 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 4 systematic reviews, 5 , 13 , 14 , 15 4 letters to the editor, 76 , 77 , ...…”

“…Phang and colleagues concluded that monitoring from the injury site is safe and this was concurred by the systematic review of Menacho & Floyd (2021). 14 More recent studies have reported the incidence of pseudomeningocele to be as high as 54% (7/13) 24 and CSF leak in 19% of patients (5/26). 44 Only two original research articles have addressed adverse events related to lumbar ITP monitoring.…”

Interventions to Optimize Spinal Cord Perfusion in Patients With Acute Traumatic Spinal Cord Injury: An Updated Systematic Review

“…The Effects of SCPP Support on Adverse Events. This update included four new studies, [28][29][30]46 which were considered in addition to four from the prior review. 32,36,42,45 According to…”

“…Asymptomatic pseudomeningocele occurred in 7/13 (54%) ISCoPE patients where the intrathecal catheter was inserted intra-operatively at the site of the SCI. 29 The quality of the evidence was rated down due to study design, risk of bias, indirectness, and inconsistency, and imprecision.…”

Monitoring Spinal Cord Tissue Oxygen in Patients With Acute, Severe Traumatic Spinal Cord Injuries

“…Intraspinal pressure and spinal cord perfusion pressure are clinically important parameters that correlate with injury site metabolism (8) and long-term outcome (9). Interventions to increase spinal cord perfusion pressure improve somatosensory (10) and motor-evoked (11) responses at the injury site, increase limb motor score (11, 12), lower the sensory level (13), and improve urinary (14) and anal sphincter (15) functions.…”