Sacral Denervation
When detrusor hyperreflexia post SCI does not respond to conservative treatment, and patients are not eligible for ventral sacral root stimulation for electrically induced micturition, sacral bladder denervation may be considered as a stand-alone procedure to treat urinary incontinence and AD.
| Author Year; Country Score Research Design Sample Size |
Methods | Outcome |
|---|---|---|
| Kutzenberger 2007; Germany
Case series Initial N=464 Final N=440 |
Population: 440 (190 tetra, 274 para) SCI patients ranging from 0.5 to 46 years since injury.
Treatment: Sacral deafferentation and implantation of a sacral anterior root stimulator. Outcome Measures: Presence of AD. |
1. Autonomic dysreflexia disappeared in all cases with the exception of two. In these individuals, blood pressure was maintained at less dangerous levels. |
| Hohenfellner et al. 2001;
Germany Pre-post N=9 (with AD=5) |
Population: detrusor hyperreflexia.
Treatment: sacral bladder denervation. Outcome Measures: bladder capacity, blood pressure, symptomatic AD. |
1. Episodes of detrusor hyperreflexia and AD were eliminated in all cases.
2. In the 5 patients with AD, both SBP and DBP were reduced 196(16.9) to 124(9.3) mmHg and 114(5.1) to 76(5.1) mmHg, respectively. |
| Schurch et al. 1998; Switzerland
Case series N=10 |
Population: 10 SCI patients with AD.
Treatment: sacral deafferentation. Outcome measures: continuous non-invasive recordings of BP and HR during urodynamic recordings, pre- and post-operative data. |
1. There was a marked elevation in systolic and diastolic BP with bradycardia during the urodynamic examination in all eight patients, despite complete intra-operative deafferentation of the bladder in five.
2. AD persisted in patients with SCI even post complete sacral deafferentation, consistently occurring during the stimulation-induced voiding phase. |
Discussion
Three level 4 studies (aggregate n=459) (Schurch et al. 1998; Hohenfellner et al. 2001; Kutzenberger 2007) examining sacral denervation have reported conflicting results in response to this procedure. Hohenfellner et al. (2001) reported that sacral bladder denervation is a valuable treatment option for eliminating detrusor hyperreflexia and AD in all 9 of their participants. However, in Schurch et al.’s 10 participants, it was shown that complete bladder deafferentation does not abolish AD during bladder urodynamic investigations. In a review of 440 patients, Kutzenberger saw sacral deafferentation eliminate AD in 438 of them.
Conclusion
There is level 4 evidence (from one pre-post study and one case series study: Hohenfellner et al. 2001; Kutzenberger 2007) that sacral deafferentation may be effective in preventing AD.
