RU2481869C1 - Method of treating neurogenic bladder in patients with traumatic spinal disease - Google Patents

Abstract

FIELD: medicine, pharmaceutics.

SUBSTANCE: invention refers to medicine, namely, urology, neurosurgery and vertebrology. Two temporary electrodes are intraoperatively inserted into the epidural space of the spinal cord under X-ray control. The first epidural electrode anode is inserted at the level of the segments L1-L2, and the second electrode cathode - at the level of the roots S2-S4. That is followed by postoperative electric neurostimulation by weak electric current for 10 minutes, 10 days every day.

EFFECT: method extends the range of products for treating neurogenic bladder in the patients with traumatic spinal disease.

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Description

The invention relates to medicine, namely to urology, neurosurgery, vertebrology, and is used to treat neurogenic bladder in patients with traumatic spinal cord disease.

There is also a method of treating neurogenic bladder dysfunction. This method is used to treat neurogenic bladder dysfunction of the hyperreflex type in adults, regardless of gender and age. The method consists in sacred neuromodulation, including the search and puncture of sacred holes using injection needles, while the right and left S3 sacral holes are punctured with the introduction of an alloplant solution into them. The amount of alloplant solution introduced is 2 ml in each hole. The course of treatment consists of 3 injections with a frequency of 1 time in 3 days (Sacral neuromodulation using Alloplant for acupuncture administration of intensive action "in the treatment of patients with hyperactive bladder / V.N. Pavlov [et al.] // Healthcare of Bashkortostan Special issue: scientific and practical journal. - 2005. - No. 3. - P.84-85. - ISSN 0869-6306).

However, this method of neuromodulation also allows you to stimulate only parasympathetic centers of urination, which is not effective enough for patients with traumatic spinal cord disease.

The closest way to treat neurogenic bladder dysfunction to the claimed is sacred electrical stimulation using a temporary implantable electrode. Stimulation is carried out by a weak electric current of the nerve root of the third sacral segment (S 3), which affects the detrusor activity of the bladder. In this method, the formation of the urge occurs by increasing afferentation from the bladder receptors. First, bone landmarks are determined and search punctures of sacred holes are made. To do this, use needles No. 18 G with a special insulating coating. After punctures, a passive electrode is placed in the gluteal region from the side of the proposed electrical stimulation, and the active electrode is alternately connected to a neurostimulator. For electrical stimulation, single-phase rectangular pulses with a duration of 210 μs and a repetition rate of 25 Hz are used. After the acute sacral stimulation test and the selection of the sacred hole by the needle, an electrode is inserted into the sacred hole. After installation, the electrode is fixed to the skin and connected to a portable device for neural electrical stimulation (E.B. Mazo, G.G. Krivoborodov. Overactive bladder. M: Veche, 2003, p. 121-132, Fig. 14- 17).

However, in this method, only the spinal root of one segment of the sacral parasympathetic afferent center most responsive to the electric pulse was stimulated. The sympathetic center of regulation was not stimulated.

The objective of the invention is to develop a method for the treatment of neurogenic bladder in patients with traumatic disease of the spinal cord by stimulating the sympathetic and parasympathetic centers of urination, providing the formation of urge to urinate and self-urination.

The specified technical result is achieved by the fact that in the method of treating a neurogenic bladder in patients with traumatic disease of the spinal cord, including intraoperative installation of electrodes followed by electroneurostimulation of sacred roots, namely, two temporary electrodes are installed under x-ray control, the first epidural electrode (anode) - at the level of the segments L1-L2 of the spinal cord, the second (cathode) - in the projection of the roots S2-S4, after which they produce electrical neurostimulation with a weak electric eye for 10 minutes for 10 days on a daily basis.

The invention is illustrated by a detailed description, a clinical example and illustrative material, which shows:

Figure 1 - installation of the epidural electrode in the projection of the segments of the spinal cord L1-L2 (sympathetic center of urination);

a - insertion of a Tuoha needle into the interspinous space of the Th10-Th11 vertebrae through the interspinous and yellow ligament;

b - insertion of an electrode through a Tuohe needle into the epidural space (in the projection of the segment L1-L2);

c - radiological control of the introduction of the electrode into the epidural space;

d is an x-ray reflecting the location of the epidural electrode and the Tuohe needle; the black arrow indicates the location of the epidural electrode, the white arrow indicates the location of the Tuohe needle;

d - fixation of the epidural electrode to the skin with a capron suture.

Figure 2 - installation of the epidural electrode in the projection S2-S4 of the roots of the segments of the spinal cord (parasympathetic center of urination);

a - introduction of the Tuoha needle into hiatus sacralis;

b - insertion of the electrode through the Tuohe needle into the projection S2-3 of the vertebrae;

c - X-ray control of the introduction of the electrode using a Tuohe needle into the space of the sacral canal through hiatus sacralis in the projection S2-3 of the vertebrae; a solid black arrow indicates the location of the epidural electrode; dotted black arrow - the location of the Tuohe needle;

g - fixation of the epidural electrode to the skin with a nylon seam.

Figure 3 - electrical stimulation process: 1 - the device "Miorhythm 021", 2 - the anode, 3 - the cathode.

The method is as follows.

In the operating room, local anesthesia (0.5% novocaine solution) of soft tissues and ligaments is performed in the area of installation of two temporary epidural electrodes.

The first electrode is placed in the epidural space in the projection of the segments of the spinal cord L1-L2 (sympathetic center of urination). The introduction of the electrode is carried out using a Tuohe needle, which is installed under x-ray control, in the interspinous gap Th10-Th11 of the vertebrae, through the interspinous and yellow ligament (Figa). Then, an epidural electrode is inserted through the needle and placed at the level of L1-L2 segments of the spinal cord (Fig.1b, c, d). After x-ray control of the location of the electrode, the electrode is fixed to the skin with a nylon seam (Fig.1d).

The second epidural electrode is installed in the projection S2-S4 of the roots (parasympathetic center of urination). The introduction of the electrode is carried out using a Tuohe needle, which is installed under x-ray control, into the sacral canal through the hiatus sacralis (Fig. 2a), and then the epidural electrode is inserted through the needle into the projection S2-3 of the vertebrae (Fig. 2b). After x-ray control (Figv), the epidural electrode was fixed to the skin with a nylon seam (Figv).

For the procedure of stimulation of the structures of the spinal cord used the device (Figure 3) "Miorhythm - 021" (1). Electroneurostimulation is carried out in a ward. A trial procedure is carried out on the first day after the installation of the electrodes, for 10 minutes. The parameters of the stimulating signal are selected individually according to the patient's feelings. As the anode (2) using an electrode located in the interspinous gap Th10-Th11 vertebrae (in the projection of the segments of the spinal cord L1-2) (Figure 3). The electrode located in the projection S2-4 of the roots is the cathode (3) (Figure 3). The parameters of the stimulating signal are selected individually according to the patient’s sensations and range from: current strength from 3 to 5 mA, pulse frequency from 10 to 20 Hz. The pulse duration is 0.3 m / s, the stimulation time is 10-15 minutes. The electrical stimulation procedure is carried out for 10 days (daily).

Evaluation of the effectiveness of neurostimulation is carried out according to the clinical manifestations of the urinary system, the patient's sensations, and urination diaries.

The practical use of the method is illustrated by the following clinical observation.

Patient B., 29 years old. Diagnosis: TBSM, acute period. Compression-comminuted fracture of the Th9 vertebral body of the II-III degree with contusion and compression of the dural sac and spinal cord. Lower moderate spastic paraparesis. Dysfunction of the pelvic organs by the type of urinary retention and fecal incontinence. Neurogenic bladder. Chronic pyelonephritis.

Hospitalized with complaints of pain in the thoracic spine, decreased muscle strength and sensitivity in the lower extremities, impaired voluntary urination.

Given the presence of continued compression of the spinal cord, an unstable fracture of the Th9 vertebral body, the patient underwent an emergency operation for the patient: Laminectomy Th8, Th9 vertebra. Anterior decompression of the spinal cord at TP8-9 level. Removing the wedge of Urban. Interbody fusion Th8-9 with PLIF implant made of porous TiNi. Revision of the spinal cord. Osteosynthesis of Th7-8-10-11 segments by USS Fracture Synthes, an internal transpedicular fixation system. Installation of epidural electrodes (above and below the level of injury).

In the postoperative period, a comprehensive conservative treatment was carried out, including: vascular drugs, nootropics, antihistamines, analgesics, NSAIDs, antispasmodics, muscle relaxants, antibiotics.

Despite the powerful surgical and conservative treatment in the postoperative period, urinary retention remained.

To improve the function of the urinary system, the patient underwent surgery: a closed puncture installation of two epidural electrodes in the projection of the segments of the spinal cord L1-L2 and S2-S4 roots. On the first day after the installation of the electrodes, test electrostimulation was performed as usual. During the stimulation, there was a urge to urinate. After a stimulation session, the patient noted a feeling of fullness of the bladder. During the third session of neurostimulation, pronounced active urge to urinate appeared, which remained in the subsequent period, and then the phenomena of the neurogenic bladder stopped. After performing 10 neurostimulation procedures, complete stopping of urination disorders was observed.

Assessment of the neurological status of patient B. showed the presence of positive dynamics. So, before stimulation in a patient, reflexes from the lower extremities were increased (knee and Achilles D = S), movements in the lower extremities were preserved in full, but the muscle strength of the left lower limb was reduced to 2-2.5 points, the right - to 3 points, sensitive disorders were observed in the form of segmental hypesthesia, from the level of Th9 dermatome, disorders of the pelvic organs by type of urinary retention, neurogenic bladder were recorded.

During stimulation, active visible contractions of the muscles of both lower extremities were noted, larger than the posterior group of the leg muscles. The patient noted periodic active urination. After the end of the electrostimulation session, the patient also felt for some time a persistent urge to urinate. After three sessions of electroneurostimulation, urinary retention is stopped, the act of urination is fully restored.

After the end of the neurostimulation procedure (10 sessions), reflexes from the lower extremities are slightly enlivened (knee and Achilles D = S). Active movements in the lower extremities were in full. The muscle strength of the left lower limb increased to 3 points, the right to 4 points. Sensitive disorders were stopped. There were no dysfunctions of the pelvic organs.

Using the proposed method in the clinic FSBI "RRC" WTO "them. Acad. G.A. Ilizarova »The Ministry of Health and Social Development of Russia has shown that its use makes it possible to partially or completely stop the phenomenon of urination disorders in persistently formed disorders of the neurogenic bladder in patients with traumatic spinal cord disease, which significantly improves the quality of life of this category of patients.

Claims (1)

A method for treating a neurogenic bladder in patients with traumatic spinal cord disease, including intraoperative installation of electrodes followed by electroneurostimulation of sacred roots, characterized in that two temporary electrodes are installed under the radiological control in the epidural space of the spinal cord, the first epidural electrode-anode at the level of segments L1 -L2, the second electrode-cathode is at the level of the roots S2-S4, after which they perform electrical neurostimulation with a weak electric current for 10 min, in ix 10 days daily.

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