脊髓损伤后的排尿功能重建

介绍２种恢复脊髓损伤后控制性排尿的新方法及其临床经验。方法：（１）总结国内第１例Ｂｒｉｎｄｌｅｙ骶神经前根电刺激器埋置术的手术方法和经验。（２）在成功建立犬膝腱－脊髓－膀胱人工反射孤的基础上,对３例圆锥上ＳＣＩ痉挛性膀胱的病人,进行肌腱－脊髓－膀胱人工反射孤建立术。     

脊髓损伤后重建膀胱功能:犬腹壁膀胱人工反射弧实验

目的:试通过在健存连续的脊髓上建立犬腹壁人工膀胱反射弧,从而使脊髓损伤后的膀胱功能得到恢复。方法:实验在第三军医大学大坪医院野战外科研究所第三实验室完成。将犬的右胸12肋间神经前根近端与右骶2神经前根远端在硬膜囊内行显微吻合,将骶2神经后根远端与胸12后根进行端侧显微吻合,经轴突再生后,建立腹壁—脊髓中枢—膀胱这一新的人工反射通路,通过刺激右侧腹壁激发排尿。神经根吻合术后9个月,分别进行神经电生理、膀胱测压、膀胱逼尿肌肌电图等早期功能观察。结果:胸12椎管平面下截瘫前后,单相方波(115mV,1.0ms)刺激右胸12神经后根,所有7犬均可在吻合口远端记录到动作电位,其形态和波幅与对照组相似;截瘫48h后,串刺激(1000mV,10Hz,2s)右胸12神经后根,经新建的反射弧引出的膀胱收缩平均可达正常对照组的61%,刺激右侧腹壁引出的膀胱收缩平均达正常的51%。结论:体神经的运动传出支通过轴突再生能够长入自主神经的副交感性纤维,并具有良好的传导运动兴奋的功能;利用健存连续的脊髓上的体反射,通过硬膜囊内神经根吻合的方法,建立人工膀胱反射弧实现患者的可控制性排尿;同时也为患者建立了自主性膀胱反射通路,通过训练后以期待能达到患者的自主性排尿。     

脊髓损伤后重建膀胱功能：犬腹壁膀胱人工反射弧实验

目的:试通过在健存连续的脊髓上建立犬腹壁人工膀胱反射弧,从而使脊髓损伤后的膀胱功能得到恢复.方法:实验在第三军医大学大坪医院野战外科研究所第三实验室完成.将犬的右胸12肋间神经前根近端与右骶2神经前根远端在硬膜囊内行显微吻合,将骶2神经后根远端与胸12后根进行端侧显微吻合,经轴突再生后,建立腹壁-脊髓中枢-膀胱这一新的人工反射通路,通过刺激右侧腹壁激发排尿.神经根吻合术后9个月,分别进行神经电生理、膀胱测压、膀胱逼尿肌肌电图等早期功能观察.结果:胸12椎管平面下截瘫前后,单相方波(115 mV,1.0 ms)刺激右胸12神经后根,所有7犬均可在吻合口远端记录到动作电位,其形态和波幅与对照组相似;截瘫48h后,串刺激(1000 mV,10 Hz,2 s)右胸12神经后根,经新建的反射弧引出的膀胱收缩平均可达正常对照组的61%,刺激右侧腹壁引出的膀胱收缩平均达正常的51%.结论:体神经的运动传出支通过轴突再生能够长入自主神经的副交感性纤维,并具有良好的传导运动兴奋的功能;利用健存连续的脊髓上的体反射,通过硬膜囊内神经根吻合的方法,建立人工膀胱反射弧实现患者的可控制性排尿;同时也为患者建立了自主性膀胱反射通路,通过训练后以期待能达到患者的自主性排尿.     

建立脊髓损伤犬腹壁膀胱人工反射弧的实验

背景：利用截瘫平面下健存的体反射建立膀胱人工反射弧，是否可实现可控制性排尿？目的：通过在健存连续的脊髓上建立犬腹壁人工膀胱反射弧，恢复脊髓损伤后的膀胱功能。设计：以实验动物为对象的自身左、右侧对照观察实验。单位：解放军第三军医大学大坪医院野战外科研究所。材料：实验于2002-04／2004-11在第三军医大学大坪医院野战外科研究所完成。成年雄性实验家犬6只，体质量10～12 kg。干预：将犬的右T2肋间神经前根近端与右S2神经前根远端在硬膜囊内行显微吻合，将S2神经后根远端与T12后根进行端侧显微吻合，经轴突再生后，建立腹壁-脊髓中枢-膀胱这一新的人工反射通路，通过刺激右侧腹壁激发排尿。神经根吻合术后9个月，分别进行神经电生理观察及根据膀胱压力增加值计算膀胱收缩功能并与左侧进行对照。主要观察指标：①神经电生理观察。②膀胱收缩功能。结果：6只犬均进入结果分析。①T12椎管平面下截瘫前后，单相方波（115mV，1．0ms）刺激右T12神经后根，所有6只犬均可在吻合口远端记录到动作电位，其形态和波幅与左侧相似。②截瘫48h后，串刺激（1000mV，10Hz，2s）右T12神经后根，经新建的反射弧引出的膀胱收缩平均可达左侧的61％，刺激右侧腹壁引出的膀胱收缩平均达正常的51％。结论：利用脊髓损伤平面以上的体反射建立新的人工膀胱反射通路为膀胱感觉的脊髓上传通路建立了神经通道，并具有良好的传导运动兴奋的功能；新建立的人工膀胱反射弧可以产生膀胱收缩，实现犬可控制性排尿。     

建立脊髓损伤犬腹壁膀胱人工反射弧的实验

背景利用截瘫平面下健存的体反射建立膀胱人工反射弧,是否可实现可控制性排尿?目的通过在健存连续的脊髓上建立犬腹壁人工膀胱反射弧,恢复脊髓损伤后的膀胱功能.设计以实验动物为对象的自身左、右侧对照观察实验.单位解放军第三军医大学大坪医院野战外科研究所.材料实验于2002-04/2004-11在第三军医大学大坪医院野战外科研究所完成.成年雄性实验家犬6只,体质量10～12 kg.干预将犬的右T12肋间神经前根近端与右S2神经前根远端在硬膜囊内行显微吻合,将S2神经后根远端与T12后根进行端侧显微吻合,经轴突再生后,建立腹壁-脊髓中枢-膀胱这一新的人工反射通路,通过刺激右侧腹壁激发排尿.神经根吻合术后9个月,分别进行神经电生理观察及根据膀胱压力增加值计算膀胱收缩功能并与左侧进行对照.主要观察指标①神经电生理观察.②膀胱收缩功能.结果6只犬均进入结果分析.①T12椎管平面下截瘫前后,单相方波(115 mV,1.0 ms)刺激右T12神经后根,所有6只犬均可在吻合口远端记录到动作电位,其形态和波幅与左侧相似.②截瘫48 h后,串刺激(1000 mV,10 Hz,2 s)右T12神经后根,经新建的反射弧引出的膀胱收缩平均可达左侧的61%,刺激右侧腹壁引出的膀胱收缩平均达正常的51%.结论利用脊髓损伤平面以上的体反射建立新的人工膀胱反射通路为膀胱感觉的脊髓上传通路建立了神经通道,并具有良好的传导运动兴奋的功能;新建立的人工膀胱反射弧可以产生膀胱收缩,实现犬可控制性排尿.     

骶神经前根电刺激排尿的研究进展

圆锥上脊髓损伤绝大多数将并发高张力、高反射的痉挛性膀胱,膀胱的贮尿与排尿功能双重障碍,尿失禁与尿潴留并存,尿路感染和高压性膀胱-输尿管返流引起的肾脏损害,是SCI病人晚期死亡的第一位原因。本文介绍了国外开展S_(2～4)骶神经前根电刺激配合后根完全切断去传入,恢复脊髓损伤病人可控制性排尿的理论、适应证、手术方法和治疗效果。     

人工体神经-内脏神经反射弧恢复脊髓损伤致神经源性膀胱病人的护理

外伤后脊髓横断损伤或马尾神经损伤引起的神经源性膀胱所致膀胱排尿功能障碍是医学上的一大难题。我科肖传国教授创建肖氏手术方法 ,人工建立体神经 -内脏神经反射弧控制排尿 ,获得成功。通过对 31例脊髓神经损伤病人利用脊髓损伤平面以下的躯体神经与骶神经吻合 ,重建膀胱功能[1 ] ,经过 1ａ～3ａ随访 ,取得了满意效果。现将护理报告如下。1　临床资料　　 1 998年— 2 0 0 0年 ,我科共收治外伤引起的神经源性膀胱病人 31例。男 2 7例 ,女 4例 ;年龄最大的 60岁 ,最小的 2 2岁 ,平均 36岁。受伤时间最长 2 0ａ ,最短 6个月 ,平均 5 .5ａ。…     

构建犬"腹壁反射-脊髓中枢-膀胱"人工反射弧功能基础的实验研究

目的:探讨构建犬"腹壁反射-脊髓中枢-膀胱"人工反射弧,以恢复脊髓损伤后的膀胱功能.方法:对6只雄性犬麻醉后进行T12和S2神经的解剖,将T12前根近端与S2前根远端通过一段尾神经在硬膜囊内行显微缝合,保持T12后根完整,经过一段时间轴突再生后,建立"腹壁反射-脊髓中枢-膀胱"人工膀胱反射弧.神经根吻合术后6个月和18个月,分别在破坏L5～S2脊髓节段前后进行膀胱神经电生理、膀胱测压、膀胱逼尿肌肌电图等早期和远期功能观察.结果:实验侧膀胱神经动作电位和膀胱逼尿肌肌电图,其形态与波幅与对照侧相似.1、2、4号犬术后6个月截瘫48 h后,电刺激经新建的反射弧引出的膀胱收缩平均可达正常对照组71.80%.5、6号犬术后18个月,相同电流刺激引出的膀胱收缩平均达正常的84.42%.结论:体神经的运动传出支经自体神经移植,其轴突能再生长入膀胱平滑肌内副交感神经节细胞.并具有良好的传导运动兴奋的功能;构建犬"腹壁反射-脊髓中枢-膀胱"人工反射弧,可望实现脊髓损伤患者膀胱可控性排尿功能.     

经神经途径重建脊髓损伤后膀胱功能术患者的护理

经神经途径重建脊髓损伤后膀胱功能包括3种术式,即骶神经前根电刺激术、选择性骶神经根切断术和腱-脊髓-膀胱人工反射弧重建术,可在一定程度上重建脊髓损伤后痉挛性膀胱患者的排尿功能.总结了对16例行该3种术式患者的护理,即做好心理护理、术前禁用阿托品、术后4d保持平俯卧位等;详细介绍了3种不同术式患者康复训练的方法,包括正确设置排尿程序、指导患者正确使用和保护膀胱刺激器、加压排尿、间歇性清洁导尿、扳机点排尿、敲击跟腱或扳动踝关节引发排尿等.本组术后膀胱容量增大,尿失禁明显减轻或消失,排尿次数从术前的每日7～15次减少为每日4～6次.     

骶神经根电刺激治疗圆锥上脊髓损伤后排泄功能障碍

圆锥上脊髓损伤导致的痉挛性膀胱，贮尿与排尿功能双重障碍，对患的生活质量和生存寿命影响最大。在这类患植入骶神经根(S2-4)排泄神经假体，通过电刺激能恢复控制性的排尿、排便和阴茎勃起功能，配合完全性骶神经后根(S2—4)切断去传入，能恢复良好的贮尿功能。目前该方法已临床应用2000多例，效果优良。章介绍了排泄神经假体的组成、临床适应证、植入方法、治疗效果、手术并发症和术后故障的判断与处理。     

直流电场与甲基强的松龙联合应用促进脊髓再生的实验研究

背景直流电场能促进脊髓再生,但伤后6 h置入电刺激器的疗效比伤后立即置入电刺激器的疗效为差,可能于脊髓损伤后出现脊髓水肿有关.目的探讨直流电场与大剂量甲基强的松龙联合应用治疗完全性脊髓损伤的疗效.设计随机对照实验.地点和对象实验在海南省人民医院完成.对象为33只中国家犬,体质量10～12kg,犬龄1.5～2岁,由海南省动物中心提供.干预将33只家犬随机分成3组,用AllenWD法致脊髓完全损伤.A组为对照组;B组脊髓损伤6 h时置入电刺激器组;C组脊髓损伤2 h静滴大剂量甲基强的松龙,脊髓损伤6 h再置入电刺激器组.主要观察指标伤后各组1,2,3个月神经功能、皮层体感诱发电位、神经元数量、神经元截面积和内氏体密度恢复情况.结果神经功能评分A组伤后1～3个月均为1分;B组伤后1个月3分,伤后2,3个月均为4分;C组伤后1个月4分,伤后2,3个月均为5分.B,C组1,2,3个月神经功能、皮层体感诱发电位、神经元数量、神经元截面积和尼氏体密度恢复均优于同时期A组(P＜0.05或P＜0.01).此外,C组优于B组,差异有显著性意义.结论直流电场能有效地促进脊髓再生,直流电场与大剂量甲基强的松龙联合应用能有效地协同治疗脊髓损伤,特别是促进神经功能早期更好的恢复.     

膀胱神经支配重建的研究

脊髓损伤后膀胱神经支配重建是膀胱功能重建的方法之一。理想上的神经病理性膀胱功能障碍的治疗是通过恢复中枢控制而康复功能性排尿 ,这需要彻底了解影响轴突再生和平滑肌神经重支配的因素。有关膀胱神经重支配的研究报道首于1907年发表 ,此后相关的实验研究及临床手术报道并不多。最近 ,有关膀胱人工反射弧建立的实验研究可能具有良好的临床应用前景。本文献综述对历史上膀胱神经支配重建的研究报道进行总结和提练 ,着重说明不同研究的技术方法。     

Altered glutamate receptor function during recovery of bladder detrusor-external urethral sphincter coordination in a rat model of spinal cord injury.

Coordination of the bladder detrusor and the external urethral sphincter is a supraspinally controlled reflex that is essential for efficient micturition. This coordination is permanently lost after spinal cord transection but can recover chronically after incomplete spinal cord injury (SCI). As glutamatergic transmission plays a key role in all levels of detrusor-external urethral sphincter coordination, we examined the role of potential alterations in glutamatergic control in its recovery after SCI. Rats were subjected to standardized incomplete contusion injury. Detrusor-external urethral sphincter coordination was evaluated urodynamically at 5 days (subacute) and 8 weeks (chronic) after SCI. Sensitivity of coordinated activation of the external urethral sphincter in response to bladder distension to the alpha -amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid/kainate antagonist 1,2,3,4-tetrahydro-6-nitro-2,3-dioxo-benzo(f)quinoxaline-7-sulfonamide disodium (NBQX) and to the N-methyl-D-aspartate (NMDA) antagonist R(--3-(2-carboxypiperazine-4-yl)-propyl-1-phosphonic acid (CPP) was determined by intrathecal application at the L6 spinal cord level during urodynamic recordings. We found that while detrusor contractions recovered at 5 days after SCI, coordinated activation of the external urethral sphincter was significantly impaired at 5 days and recovered only by 8 weeks. There was no difference in sensitivity of detrusor-external urethral sphincter coordination to NBQX at the subacute or chronic time points. However, external urethral sphincter response to bladder distension was sensitive to a 50% lower dose of CPP at 5 days compared with uninjured rats or chronic recovered SCI rats. Thus, alterations in NMDA receptor function appeared to be involved in recovery of detrusor-external urethral sphincter coordination after incomplete SCI.     

Effect of neuromuscular electrical stimulation on cough capacity and pulmonary function in patients with acute cervical cord injury.

OBJECTIVE: To assess the effectiveness of neuromuscular electrical stimulation (NMES) on cough capacity and prevention of pulmonary complication in patients with acute cervical cord injury. DESIGN: A randomized controlled trial. SUBJECTS: Twenty-six tetraplegic patients with cervical spinal cord injury, 13 in the NMES therapy group and 13 in the control group. METHODS: NMES was applied to the clavicular portion of the pectoralis major and abdominal muscle. Pulmonary function tests were performed before and after therapy, and at 3 months and 6 months follow-up. The pulmonary complications in this 6-month follow-up period were also recorded. RESULTS: After the 4-week therapy, and at 3 months and 6 months follow-up testing, patients in the NMES therapy group displayed significant improvement in their peak expiratory flow, forced expiratory volume in 1 second, forced vital capacity, maximal expiratory pressure and maximal inspiratory pressure, compared with those in the control group (p<0.05). Patients in the NMES therapy group also had fewer pulmonary complications in the follow-up period. CONCLUSION: NMES over the pectoralis and abdominal muscles might improve cough capacity and pulmonary function in cervical spinal cord injury with tetraplegia. This improvement might last for 6 months. With this improvement, pulmonary complications were reduced.     

Decrease of hypertonia after continuous passive motion treatment in individuals with spinal cord injury

OBJECTIVE: To examine the effect of ankle continuous passive motion on the reflex excitability and overall hypertonia of calf muscles in individuals with chronic spinal cord injury and without physical disabilities. DESIGN: Two-way repeated measure experimental design. SETTING: Inpatient rehabilitation department in general hospital. SUBJECTS: The spinal cord injury group comprised eight individuals with chronic complete spinal cord injury and the control group comprised eight healthy people without physical disabilities. An additional eight healthy people were recruited as the sham group. INTERVENTIONS: Each subject received 60 min of continuous passive motion on the ankle joint. MAIN MEASURES: The H-reflex of the soleus muscle was elicited by tibia nerve stimulation just before, immediately after, and 10 min after continuous passive motion. The Modified Ashworth Scale (MAS) score at the ankle joint was recorded for the spinal cord injury group just before and 10 min after continuous passive motion therapy. RESULTS. After 60 min of continuous passive motion of the ankle joint, the H-reflex amplitude at the soleus muscle was depressed in individuals with and without spinal cord injury (77.46 +/- 32.64%, P = 0.047 and 51.76 +/- 26.74% of initial, P<0.0001, respectively). This depression persisted up to 10 min after continuous passive motion only in individuals without spinal cord injury. In individuals with spinal cord injury, the median of MAS scores decreased from 2 to 1.25 after continuous passive motion. CONCLUSION: Sixty minutes of continuous passive motion of the ankle joint decreased reflex excitability and overall hypertonia in people with or without spinal cord injury. The depression of overall hypertonia persisted longer than the reflex excitability in people with spinal cord injury.     

脊神经前根吻合重建脊髓损伤大鼠的股四头肌功能

背景：如何重建脊髓损伤肢体运动功能对截瘫患者具有重要的意义。目的：探索利用脊髓损伤平面以上健存的脊神经前根与支配股四头肌的腰神经建立神经通路,恢复脊髓损伤后股四头肌的神经支配和肌收缩功能。方法：对清洁级SD大鼠L1神经根的前根与L3神经根的前根进行显微吻合。经一段时间（6个月）的轴突再生后,期望建立新的肌肉收缩功能。神经缝合后6个月,在破坏L2脊髓节段前后,分别进行神经电生理检测,观察股四头肌神经支配情况。结果与结论：在同侧L2半切脊髓前后,电刺激移植神经干时可记录到股四头肌的收缩肌电图。在同侧L2半切脊髓前后,电刺激L1感觉根时可同样在股四头肌记录到肌电图。说明利用脊髓损伤平面以上健存的L1神经根前根与L3神经前根移植吻合能重建新的股四头肌神经支配反射通路,并使股四头肌低级反射中枢上移。     

Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia

Patients with chronic pain after whiplash injury and fibromyalgia patients display exaggerated pain after sensory stimulation. Because evident tissue damage is usually lacking, this exaggerated pain perception could be explained by hyperexcitability of the central nervous system. The nociceptive withdrawal reflex (a spinal reflex) may be used to study the excitability state of spinal cord neurons. We tested the hypothesis that patients with chronic whiplash pain and fibromyalgia display facilitated withdrawal reflex and therefore spinal cord hypersensitivity. Three groups were studied: whiplash (n=27), fibromyalgia (n=22) and healthy controls (n=29). Two types of transcutaneous electrical stimulation of the sural nerve were applied: single stimulus and five repeated stimuli at 2 Hz. Electromyography was recorded from the biceps femoris muscle. The main outcome measurement was the minimum current intensity eliciting a spinal reflex (reflex threshold). Reflex thresholds were significantly lower in the whiplash compared with the control group, after both single (P=0.024) and repeated (P=0.035) stimulation. The same was observed for the fibromyalgia group, after both stimulation modalities (P=0.001 and 0.046, respectively). We provide evidence for spinal cord hyperexcitability in patients with chronic pain after whiplash injury and in fibromyalgia patients. This can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain, at least in part, pain in the absence of detectable tissue damage.     

以弛缓性瘫痪为特点的高位置脊髓损伤临床特征探讨

目的分析以弛缓性瘫痪为特点的高位置脊髓损伤发生原因。方法在1014例创伤性脊髓损伤患者中对以弛缓性瘫痪为特点的高位置脊髓损伤（骨折水平在T₁₀或以上）患者进行分析。结果6例患者被确认为以弛缓性瘫痪为特点的高位置脊髓损伤,其中男性5例,女性1例,平均年龄（42±12）岁。脊髓损伤水平分布在C₇～T₈水平,脊柱骨折水平在T₃～T₁₀。参考骨折水平,4例脊髓损伤水平上升超过3个脊髓节段,其中3例脊髓损伤水平上升出现在外科手术后;1例无明显诱因,伤后48 h出现神经损伤平面进行性上升至C₇水平,伴随胸部严重疼痛。伤后6个月MRI检查,5例患者显示广泛胸段脊髓萎缩变细。结论以弛缓性瘫痪为特点的高位置脊髓损伤非常罕见。其重要特点是病理上存在广泛胸段脊髓萎缩变细。发生原因尚不清楚。     

Incomplete spinal cord injury: neuronal mechanisms of motor recovery and hyperreflexia.

OBJECTIVE: To understand neuronal mechanisms of motor recovery and hyperreflexia after incomplete spinal cord injury (SCI), and their role in rehabilitation. DESIGN: Reviewed and compared clinical, neurophysiologic, and neuropathologic data from human SCI patients with behavioral, neurophysiologic, and neuroanatomic data from animals to postulate underlying neuronal mechanisms. OUTCOME: A postulation that two neuronal mechanisms-receptor up-regulation and synapse growth-act sequentially, to explain the gradual appearance of motor recovery after incomplete SCI. These same mechanisms may also act in spinal reflex pathways to mediate hyperreflexia caudal to SCI. RESULTS: After incomplete SCI, walking ability and hyperreflexia often develop. Initially, cord neurons are hyperpolarized and less excitable because of loss of normal descending facilitation; this is spinal shock. Then, gradually, voluntary movement recovers and hyperreflexia develops. Early (hours to days), these changes develop simultaneously, suggesting a common postsynaptic mechanism-likely, an increase in postsynaptic receptor excitability, possibly receptor up-regulation. Late (weeks to months), recovery and reflex changes occur at a slow rate, are no longer simultaneous, and are long-lasting, which suggests a presynaptic mechanism, such as local synapse growth in spared descending pathways and in reflex pathways. This presumed synapse growth is seemingly enhanced by active use of the growing pathway. Also, developing hyperreflexia appears to limit motor recovery. CONCLUSIONS: These observations suggest that rehabilitation for incomplete SCI should (1) increase activity in spared descending motor pathways, (2) initially use reflex facilitation or central nervous system stimulants to assist spared descending inputs in depolarizing cord neurons, and (3) later minimize reflex input, when spared descending inputs can depolarize cord neurons without reflex facilitation. Better understanding of neuronal mechanisms that underlie motor recovery after incomplete SCI promises better outcomes from rehabilitation.