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Эберхард Фетц (Eberhard Fetz) и его коллеги из университета Вашингтона (University of Washington) построили систему, при помощи которой обезьяна научилась управлять мышцами своей руки, не имевшей прямой связи с головным мозгом. Опыт открывает заманчивые перспективы для парализованных пациентов с повреждениями позвоночного столба.

Ранее некоторые научные группы показывали возможность снятия сигналов с моторной коры головного мозга, которые затем управляли манипулятором робота. Другие демонстрировали возможность функциональной электростимуляции определённых мышц, под управлением компьютера (без участия мозга). Но впервые, как сообщает PhysOrg.com, оба этих подхода были совмещены.

Treatment of Urinary Voiding Dysfunction Syndromes With Spinal Cord Stimulation

Alexander E. Yakovlev, MD and Beth E. Resch, APNP


This case report presents the use of spinal cord stimulation (SCS) in a patient with urinary
incontinence who had previously undergone trial and implantation of InterStim therapy
(Medtronic Neurological. Minneapolis, MN). The patient also experienced bilateral lower
extremity pain and low back pain related to post-laminectomy syndrome. Having failed all
conservative treatment, the patient underwent SCS trial and subsequent implantation. In the
postoperative period using SCS therapy, the patient had excellent relief of urinary incontinence
symptoms, along with relief of low back pain and bilateral lower extremity pain and was able
to discontinue use of InterStim therapy. For this patient, SCS was effective in controlling
the urinary voiding dysfunction symptoms, bilateral lower extremity pain and back pain.
The use of SCS to treat urinary incontinence problems deserves further study to explore its
therapeutic potentials.


Urinary voiding dysfunction syndromes, including urge incontinence,
urinary frequency and urinary retention, affect more than 33 million people in the
United States.’ Clinical presentation includes irritative symptoms of frequency
and urgency with urge incontinence, obstructive symptoms including difficulty
initiating and sense of incomplete emptying of the bladder, and urinary retention.-
Sacral neuromodulation is a well-established treatment option for voiding
dysfunction refractory to conservative therapies, including behavioral, medical,
and uro-surgical treatment.^** This case report presents a single patient with
urinary incontinence who had previously undergone trial and implantation of
InterStim therapy (Medtronic Neurological. Minneapolis, MN) {figure 1). The
patient also had post-laminectomy syndrome with bilateral lower extremity pain
and low back pain. Having failed all conservative treatment, she underwent spinal
cord stimulation (SCS) trial and subsequent implantation. While using the SCS
therapy, the patient had excellent relief of urinary incontinence symptoms and
was able to discontinue use of InterStim therapy. We present the case of effective
treatment of urinary voiding dysfunction symptoms, bilateral lower extremity
pain and back pain with SCS.

Figure 1. InterStim electrode with generator positioned over right supragluteal region.

Figure 2. Lumbar epidural placement of two 8-electrode epidural leads showing the electrodes positioned at T8-T9-T10.

Case Report

The patient was a 58-year-old woman (63 kg, 159 cm) with a history of postlaminectomy
syndrome with intractable bilateral lower extremity pain and low
back pain refractory to conservative therapies including caudal epidural injections.
opioid and non-opioid pain medications, behavior
modification therapy and physical therapy. The patient’s
medical history was significant for post-laminectomy
syndrome lumbar spine, chronic low back pain, left lower
extremity radicular pain, hypertension, hyperlipidemia,
abdominal aortic aneurysm, and urinary frequency status
post-IntcrStim implant.


According to the patient’s urology medical records and
voiding diary, her urinary voiding dysfunction symptoms
improved following InterStim implant as follows: urinary
frequency decreased from every 1 to 2 hours to every 3 to 4
hours; pads per day decreased from 3 to 4 pads to 1 to 2 pads;
nocturia episodes decreased from 4 to 5 episodes per night to
zero to 1 episodes per night. She also reported a 50%
improvement in symptoms of pain and urgency with voiding.
According to the urologist who implanted the InterStim, she
had a greater than 50% improvement in voiding parameters
after implant.


The patient was on a chronic pain medication regimen.,
including pregablin 75 mg every 8 hours, oxycodone/
acetaminophen 10/325 mg up to 8 tablets per day. She was
offered placement of SCS, and she decided to proceed with
this procedure. In January 2009, the patient underwent SCS
placement. The patient underwent successful trial of
percutaneous placement of two 8-electrode epidural leads
(Medtronic Inc. Minneapolis. MN). Epidural access was
gained at the L1/L2 interspace with final leads positioned at
T8-T9-T10 {figure 2). During the two day SCS trial, the
patient reported a greater than 50% improvement in bilateral
lower extremity and low back pain. Two weeks later the
patient underwent implantation with permanent leads and a
RestoreULTRA (Medtronic Inc, Minneapolis, MN) rechargeable generator. The procedure was done in ambulatory
surgery, and her postoperative course was uneventful.

Results

After final implantation of SCS, the patient reported
significant relief of bilateral lower extremity pain and low
back pain (>80% reduction in visual analog score [VAS]) and
was able to decrease her use of pain medications. At her
2-month follow-up, the patient reported improvement in
urinary incontinence symptoms equal to results she had
experienced with the implanted InterStim therapy sacral
nerve stimulation. Post-operative stimulation parameters were
amplitude of 3.2 volts, pulse width of 450 microseconds, and
frequency of 50 Hz. The patient used the SCS continuously
and reported 100% pain relief both at rest and with activity.
After implantation of SCS, the patient reported improvement
in voiding dysfunction similar to that experienced with the
InterStim. The patient tried using the SCS and the InterStim
systems together and then each system alone over the 2-month
post-op
period. She experienced the same improvement in
urinary voiding dysfunction symptoms whether the InterStim
was on or off. She was able to discontinue use of the InterStim,
and exclusively uses the SCS for effective treatment of
urinary incontinence symptoms and chronic pain in the
bilateral lower extremities and low baek.


Other positive outcomes after SCS implant included the
ability to return to social and educational activities and
improved family relationships. At 6-month post-implant, the
patient continues to report good pain control (VAS scores 1-3
out
of 10) and improved functional status. Last SCS parameters
were amplitude of 3.6 volts, pulse width of 450 microseconds,
and frequency of 60 Hz.

Discussion

Spinal cord stimulation was first used for pain control in 1967
by neurosurgeon Dr. Norman Shealy and his colleagues.^
Spinal cord stimulation is based on the principles enunciated
in the “gate-control theory” of pain proposed by Melzack and
Wall in 1965.’’ This theory postulates that SCS activates largediameter
afferent fibers via application of an externally
applied electric field that “closes the gate” to pain transmission.
Spinal cord stimulation blocks pain by stimulating the dorsal
columns, which inhibits transmission through the painconducting
spinothalamic tract. Since its first use over three
decades ago, in which electrodes were placed epidurally over
the dorsal columns of the spinal cord, SCS has been further
refined, and multiple studies have demonstrated its efficacy in
the treatment of intractable, chronic pain with a variety of
causes.^ Spinal cord stimulation has been used to successfully
treat chronic pain in patients with failed back syndrome,^-^
ischйmie limb pain,’" angina pectoris," painful peripheral
neuropathies,’2-’3 and cancer related
Spinal cord stimulation may be a therapeutic alternative for
patients with combined urinary dysfunction symptoms and
radicular low back pain who, in the past, exhausted all
available treatments or failed test stimulation before the
placement of the device for InterStim therapy. Spinal cord
stimulation and InterStim therapy are considered to be
minimally invasive surgical interventions that have successfully
positioned themselves between more conservative medical
treatments and more invasive surgical procedures which may
have mixed results."’’’^ Spinal cord stimulation may be
included in the future in the treatment algorithm of patients
with complex disorders which include pain syndromes and
urinary dysfunction disorders. The use of SCS to treat urinary
incontinence problems deserves further study to explore its
therapeutic potentials. Spinal cord stimulation is a relatively
easy to perform, effective, and safe procedure. Knowledge of
potential benefits of SCS can enrich the armamentarium of
not just pain physicians, but also specialists who treat patients
with voiding dysfunctions. It is also an excellent option for
patients with co-morbidities that make them less than ideal
candidates for more invasive interventions. The therapy is
reversible should the voiding dysfunction alleviating effect or
pain relieving effect be lost, or if voiding dysfunction
symptoms resolve. For this patient, SCS is an effective
treatment modality for her urinary voiding dysfunction
symptoms, bilateral lower extremity pain, and back pain.

References

  1. Stewart WF, Van Rooyen JB. CundiiTGW, Abranis P, Herzog AR, Corey R, Hunt TL. Wein AJ. Prevalence and burden of overactive bladder in the UnitedStates. World J Uro! 2OO3;2O:327-336.
  2. Abrams P. Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A. Wein A; Standardisation Subcommittee of the International Continence Society. The standardisation of terminology of lower urinary tractfunction: report from the Standardisation Sub-committee of the InternationalContinence Society. Neurourol Urodyn 2002;21:I67-I78.
  3. Hassouna MM. Siegel SW, Nyeholt AA, Elhilali MM. van Kerrebroeck PE, Da.s AK. Gajewski JB. Janknegt RA, Rivas DA, Dijkema H. Milam DF. Oleson KA, Schmidt RA. Sacral neuromodulation in the treatment of urgency-frequency symptoms: a multi-center study on efficacy and safety. J Urol2000;l63:I849-1854.
  4. Weil EH. Ruiz-Ccrdб JL, Eerdmans PH, Janknegt RA, van Kerrebroeck PE. Clinical result of sacral neumiodulation for chronic voiding dysfunction using unilateral sacral foramen electrodes. World J Urol 1998:16:313-321.
  5. Shealy CN. Dorsal column stimulation. Surg Neurol I977;7:192.
  6. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965:150:971-979.
  7. Cameron T Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. J Neurosurg 2004:100 (3 Suppl Spine):254-267.
  8. Striiijk JJ. Holsheimer J, Spineemaille GH, Gielen FL, Hoekema R. Theoretical performance and clinical evaluation of transverse tripolar spinal cord stimulation. IEEE Trans Rehabil Eng 1998:6:277-285.
  9. Ohnmeiss DD, Rashbaum RF, Bogdanfпy GM. Prospective outcome evaluation of spinal cord stimulation in patients with intractable leg pain. Spine (Phila Pa 1976) I996;2l: 1344-1350.
  10. Ghajar AW, Miles JB. The differential effect of the level of spinal cord stimulation on patients with advanced peripheral vascular disease in the lower limbs, Br J Neurosurg 1998; 12:402-408. Hautvast RW, DeJongste MJ, Staal MJ, van Gilst WH, Lie KI. Spinal cord stimulation in chronic intractable angina pectoris: a randomized, controlled efficacy study. Am Heart J 1998:136:1114-1120.
  11. Kumar K. Toth C, Nath RK. Spinal cord stimulation for chronic pain in peripheral neuropathy. Surg Neurol 1996;46:363-369.
  12. Tesfaye S. Watt J. Benbow SJ, Pang KA, Miles J, MacFarlane IA. Electrical spinal-cord stimulation for painful diabetic peripheral neuropathy. Lancet I996;348:I698-I7O1.
  13. Cata JP. Cordelia JV. Burton AW. Hassenbusch SJ, Weng HR. Dougherty PM. Spinal cord stimulation relieves chemotherapy-induced pain: a clinical case report. J Pain Symptom Manage 2004:27:72-78.
  14. Yakovlev AE. Ellias Y. Spinal cord stimulation as a treatment option for intractable neuropathic cancer pain. Clin Med Res 2OO8;6:IO3-tO6. Hohenfellner M. Linn J, Hampel C, Thuroff JW. Surgical treatment of interstitial cystitis. In: Sant GR, ed. Interstitial cystitis. Philadelphia. PA: Lippincott-Raven;1997. 223-233.
  15. Baskin LS, Tanagho EA. Pelvic pain without pelvic organs. J Urol 1992;I47:683-686.

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