Chunlin Hou

Clinical study of reconstructed bladder innervation below the level of spinal cord injury to produce urination by Achilles tendon-to-bladder reflex contractions.

OBJECT Neurogenic bladder dysfunction following spinal cord injury (SCI) is a major medical and social problem for which there is no ideal treatment strategy. In the present study, the authors analyze the effectiveness of neurogenic bladder reinnervation in patients with SCIs by using Achilles tendon reflexes below the paraplegic level. METHODS Spinal root anastomoses were performed in 12 paraplegic patients with hyperreflexic neurogenic bladder and detrusor external sphincter dyssynergia (DESD) caused by complete suprasacral SCI, in an attempt to reinnervate the bladder. The surgery anastomosed the unilateral proximal end of the S-1 ventral root and the distal end of the S-2 and/or S-3 ventral roots to build the Achilles tendon-to-bladder reflex, while the S-1 dorsal root was kept intact as the trigger for micturition after axonal regeneration. All patients underwent urodynamic evaluation before surgery and at follow-up. RESULTS The mean follow-up duration was 3 years. Of the 12 patients, 9 (75%) regained satisfactory bladder control within 6 to 12 months after ventral root microanastomosis. In these 9 patients, urodynamic studies revealed a change from detrusor hyperreflexia with DESD and high detrusor pressure to almost normal storage and synergic voiding without DESD. The average bladder capacity increased from 258 +/- 33 ml to 350 +/- 49 ml, residual urine decreased from 214 +/- 36 ml to 45 +/- 11 ml, and urinary infections were not observed. Patients with impaired renal function experienced a full recovery. Three patients failed to show any improvement after the operation. CONCLUSIONS These results suggest the effectiveness of bladder innervation below the level of SCI to produce urination by Achilles tendon-to-bladder reflex contractions, and might therefore provide a new clinical approach to reconstructing spasmodic bladder urination function.

Transfer of the phrenic nerve to the posterior division of the lower trunk to recover thumb and finger extension in brachial plexus palsy.

OBJECT Hand function is severely impaired in cases of lower root avulsion. In the present study, the authors investigated the clinical effectiveness and safety of phrenic nerve transfer to the posterior division of the lower trunk of the brachial plexus to recover thumb and finger extension. METHODS Between 2004 and 2006, 10 patients with brachial plexus palsy underwent phrenic nerve transfer as part of a strategy for surgical reconstruction of their plexuses. The mean patient age of was 27.2 years (range 18-44 years), and the mean interval from injury to surgery was 5.7 months (range 3-9 months). The phrenic nerve was always transferred to the posterior division of the lower trunk. RESULTS The follow-up of the patients ranged from 2.5 to 4.4 years, with an average follow-up length of 3.5 years. There were no major complications related to the surgery. Eight patients recovered to Grade 3 or better (Medical Research Council grade) in extensor digitorum strength, and 7 patients recovered to Grade 3 or better in extensor pollicis strength. None of the patients had any clinical signs or symptoms of respiratory insufficiency. CONCLUSIONS Satisfactory thumb and finger extension can be achieved by phrenic nerve transfer to the posterior division of the lower trunk of the brachial plexus. This procedure is simple and less traumatic than that of transferring the phrenic nerve to the radial nerve. It is indicated in cases in which the brachial plexus is relatively intact at the division level.

Innervation of reconstructed bladder above the level of spinal cord injury for inducing micturition by contractions of the abdomen-to-bladder reflex arc.

Medical management is often the initial management of cervical spondylitic syndromes, including radiculopathy, myelopathy, and neck pain. This includes pharmacological and rehabilitation treatment. Prospective studies comparing the efficacy of surgical versus medical management are lacking. The indications and efficacy of pharmacological and rehabilitative treatments are reviewed. The use of anti-inflammatory drugs, muscle relaxants, analgesics, antidepressants, anticonvulsants, steroids, facet joint ablation, and physical therapy are reviewed. A rationale for the medical management of acute neck pain, chronic neck pain, radiculopathy, and myelopathy is presented.

Long-term Outcome of Using Posterior-thigh Fasciocutaneous Flaps for the Treatment of Ischial Pressure Sores

Among the many difficult problems presented by patients with spinal cord injuries, management of ischial pressure ulcers remains challenging for reconstructive surgeons. This study describes the long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores. Between January 1999 and June 2003, 12 patients with ischial sores were enrolled in this study. All the patients underwent early aggressive surgical debridement followed by surgical reconstruction with a laterally based posterior-thigh fasciocutaneous flap. The follow-up period ranged from 24 months to 97 months (mean, 62 months). All the flaps survived, and there were no partial flap losses. Primary-wound healing occurred in all the cases. In two patients, Grade II ischial pressure sores recurred 24 months and 27 months after the operation. There was no recurrence in the other 10 patients. The posterior-thigh fasciocutaneous pedicled flap was a good method for treating ischial bed sores. This flap could be used to treat recurrences observed after primary bed-sore treatment with other methods. The flap was easy to raise, and it did not cause any donor-site morbidity. The long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores was generally good.

Reconstructed Bladder Innervation Below the Level of Spinal Cord Injury: The Knee-Tendon to Bladder Artificial Reflex Arc

Abstract Background/Objective: To study the effectiveness of knee-tendon to bladder artificial reflex arc in dogs. Methods: In 6 beagles, the proximal end of the right L5 anterior motor root and the distal end of the right S2 anterior root were anastomosed to build a knee-tendon to bladder reflex, whereas the right L5 posterior sensory root was kept intact. Action potential (AP) curves and electromyograms (EMGs) of the detrusor muscle, the intravesical pressure, horseradish peroxidase (HRP)-labeled neurons, and the passing rates of myelinic nerve fibers were calculated to evaluate its feasibility. Results: AP curves and EMG detected in all 6 dogs were similar to those of the control. Six and 18 months after surgery, the means for bladder contraction induced by percussion of the right knee-tendon were 38 ± 27% and 62 ± 5% that of the normal control, respectively. The mean duration times induced by percussion of the right knee-tendon at 6 and 18 months after surgery were 51 ± 37% and 84 ± 12% that of the normal control, respectively. HRP retrograde tracing and neurohistologic observation indicated the feasibility of the artificial reflex arc. Conclusions: Our data showed the effectiveness of bladder innervation below the level of spinal cord injury producing urination by knee-tendon to bladder reflex contractions, and therefore, might provide a new clinical approach for restoring bladder function in individuals with paraplegia.

Transfer of the superior portion of the pectoralis major flap for restoration of shoulder abduction.

Shoulder function is frequently impaired or lost following brachial plexus injuries. We introduce a novel method of restoring shoulder abduction by transferring the superior portion of the major flap of the pectoralis. Between March 1998 and June 2003, eight patients with insufficient abduction of the shoulder joint were treated with transfer of the superior portion of the pectoralis major flap. The mean follow-up period was 6 years. In all cases, shoulder mobility was improved. The mean increase in active abduction was from 6 degrees to 74 degrees. The mean forward flexion increased from 10 degrees to 75 degrees, and subluxation was abolished. All patients were satisfied with their improvement in function. Transfer of the superior portion of the pectoralis major flap is an easy and practicable method to restore abduction without serious complications. The patients achieved good stability and functionality of the shoulder.

Design and Evaluation of a New Bladder Volume Monitor

OBJECTIVE To introduce and evaluate a new implantable bladder volume monitor. DESIGN Experimental study. SETTING Animal laboratory. ANIMALS Eight dogs. INTERVENTIONS A coin-shaped permanent magnet was stitched onto the anterior bladder wall and a magnetic field sensor was fixed onto the lower abdominal external wall in 8 male dogs. The bladder was filled with sterile normal saline in consecutive steps of 25 mL each from 0 to 200 mL by a transurethral catheter. MAIN OUTCOME MEASURE Sensor readings were recorded after each step of bladder filling. RESULTS The sensor baseline was set at 70 degrees when the bladder was empty. After filling the bladders with 25, 50, 75, 100, 125, 150, 175, and 200 mL saline water, the sensor readings were 74.6+/-0.9 degrees , 79.6+/-1.2 degrees , 84.5+/-0.9 degrees , 90.1+/-0.8 degrees , 95.5+/-1.1 degrees , 101.8+/-2.1 degrees , 110.5+/-2.9 degrees , and 121.9+/-3.5 degrees , respectively. Sensor readings were positively correlated with bladder volume (r=1; P<.01). CONCLUSIONS The design of a new bladder volume monitor that is made up of an external magnetic field sensor and an internal permanent magnet is reasonable and feasible. The new bladder volume monitor is simple in structure.

Contralateral L-6 nerve root transfer to repair lumbosacral plexus root avulsion: experimental study in rhesus monkeys.

OBJECT Nerve transfer is used for brachial plexus injuries but has rarely been applied to repairs in the lower extremities. The aim of this study was to evaluate the feasibility and effectiveness of using the contralateral L-6 nerve root to repair lumbosacral plexus root avulsions. METHODS Eighteen rhesus monkeys were randomized into 3 groups. In the experimental group, the left L4-7 and S-1 nerve roots were avulsed and the right L-6 nerve root was transferred to the left inferior gluteal nerve and the sciatic nerve branch innervating the hamstrings. In the control group, the left L4-7 and S-1 nerve roots were avulsed and nerve transfer was not performed. In the sham operation group, the animals underwent a procedure that did not involve nerve avulsion and nerve transfer. Functional outcomes were measured by electrophysiological study, muscle mass investigation, and histological study. RESULTS The mean amplitudes of the compound muscle action potentials from the gluteus maximus and biceps femoris in the experimental group were higher than those in the control group but lower than those in the sham group (p < 0.05). The muscle mass and myofiber cross-sectional area of these muscles were heavier and larger than those in the control group (p < 0.05). The number of myelinated nerve fibers of the inferior gluteal nerve and the branch of the sciatic nerve innervating the hamstrings in the control group was significantly smaller than the number in the experimental and sham groups (p < 0.01). CONCLUSIONS In this animal model, the contralateral L-6 (analogous to S-1 in humans) nerve root can be used to repair lumbosacral plexus root avulsion.

Influence of Different Urination Methods on the Urinary Systems of Patients with Spinal Cord Injury

Objective: This study evaluated the influence of different urination methods on the urinary systems of patients with spinal cord injury. Methods: Patients with spinal cord injury were grouped according to their usual voiding method: clean intermittent catheterization (CIC); Credé manoeuvre/reflex voiding; indwelling catheterization; normal voiding. Urinary tract infections (UTIs) were monitored and type B-ultra -sonography (B-USG) scans, renal function tests and urodynamic studies were performed in all patients over a 2-year period. Results: Compared with the normal voiding group (n = 14), incidence rates of UTIs were significantly different in the Credé manoeuvre/reflex voiding (n = 26) and indwelling catheterization (n = 12) groups but not in the CIC group (n = 15). All intervention groups had a significantly higher rate of positive findings on B-USG scan and a significantly increased residual urine volume, compared with the normal voiding group. In addition, residual urine volume was significantly lower in the CIC group compared with the Credé manoeuvre/reflex voiding and indwelling catheterization groups. Conclusion: CIC was shown to be the optimal method for assisted bladder voiding after spinal cord injury.

Treatment of Ischial Pressure Sores Using a Modified Gracilis Myofasciocutaneous Flap

Despite the availability of a variety of flap reconstruction options, ischial pressure sores continue to be the most difficult pressure sores to treat. This article describes a successful surgical procedure for the coverage of ischial ulcers using a modified gracilis myofasciocutaneous flap. From August 2000 to April 2004, 12 patients with ischial sores were enrolled in the study. All patients underwent early aggressive surgical debridement followed by surgical reconstruction with a modified gracilis myofasciocutaneous flap. The follow-up period ranged from 13 to 86 months, with a mean of 44 months. Overall, 91.7% of the flaps (11 of 12) survived primarily. Partial flap necrosis occurred in one patient. Primary wound healing occurred without complications at both the donor and recipient sites in all cases. In one patient, grade II ischial pressure sores recurred 13 months after the operation. There was no recurrence in other 11 patients. A modified gracilis myofasciocutaneous flap provides a good cover for ischial pressure sores. Because it is easy to use and has favorable results, it can be used in the primary treatment for large and deep ischial pressure sores.