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

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  • 1 Academic Neurosurgery Unit, St. George’s, University of London;
  • | 2 Department of Urology, Guy's and St. Thomas’ NHS Foundation Trust; and
  • | 3 Neuro-Intensive Care Unit, St. George’s Hospital, London, United Kingdom
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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.

ABBREVIATIONS

AIS = American Spinal Injury Association (ASIA) Impairment Scale; DO = detrusor overactivity; ICU = intensive care unit; ISCoPE = Injured Spinal Cord Pressure Evaluation; ISP = intraspinal pressure; LPR = lactate to pyruvate ratio; MAP = mean arterial pressure; MD = microdialysis; Pabd = abdominal (rectal) pressure; Pana = anal sphincter pressure; Pdet = detrusor pressure (Pves − Pabd); Pves = intravesical pressure; SCIM III = Spinal Cord Independence Measure version III; SCPP = spinal cord perfusion pressure; TSCI = traumatic spinal cord injury; Vmax = volume drained from the bladder at end-fill; ΔV/ΔPdet = bladder compliance.

Supplementary Materials

    • Supplements 1-6 (PDF 803 KB)

Illustrations from Hubbe et al. (pp 160–163). Copyright Ioannis Vasilikos and Roberto Ferrarese. Published with permission.

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