SCI Care: What Really Matters
SCI Care: What Really Matters
The importance of sensory afferent pathways in the assessment and management of the neurogenic bladder after spinal cord injury: A conversation with Professor JJ Wyndaele
Key points:
- Key sensory afferent pathways from the urinary bladder to the spinal cord often remain intact in spinal cord injuries above the level of the conus medullaris.
b) The urinary bladder wall urothelial cells, sensory nerves, interstitial cells, smooth muscle cells and the chemo/mechanosensors in the urethral paraneurons or “brush cells” play a key role in bladder neurophysiology.
c) Knowledge regarding the sensory afferent pathways from the bladder could guide future neuromodulation therapeutic options for the neurogenic bladder after SCI.
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The SCI Care: What Really Matters podcast aims to provide valuable insights and the most up-to-date information for those providing care to people with spinal cord injury (SCI) worldwide. The vision of the International Spinal Cord Society (ISCoS) is to "facilitate healthy and inclusive lives for people with spinal cord injury or dysfunction globally".
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Hello, I'm Michael Failings, professor of Neurosurgery at the University of Toronto and the Editor-in-Chief of Spinal Cord, and welcome to our regular ISCOT podcast series in which, in my role as Editor-Jacques Windel, who is Professor Emeritus at Amherst Antwerp University in Belgium and has many distinguished past roles, including past president of ISCOS. He was actually previously in my role as editor-in-chief of Spinal of Cord and last year Professor Windell was honored with giving the Sir Ludwig Gutmann lecture at the ISCOSS meeting and, at my request, wrote a very nice review article summarizing his lecture, which dealt with the focus on the afferent sensory nervous system pathways of the lower urinary tract after spinal cord injury Very important issue because of the frequency of neurogenic bladder in individuals with spinal cord injury. So, jj, thank you so much for joining us on today's podcast. For us, the key features of the lecture that you gave at the ISCOS meeting and is summarized in your excellent article.
Speaker 2:Thank you very much.
Speaker 2:Good morning and good morning Michael and good morning people who are listening. I would consider what was presented and what was published afterwards in this article as quite important, because fairly new, not really got much attention before and still it is worthwhile having it. That and I'm talking about the sensory innovation of the lobodurum and head tract, and that goes for the pelvic organs also it's not about efferent, no, it's about the effort that you feel, which is a smaller part but which is much easier to sort of investigate and then find out. And the main point that I wanted to make there is that after spinal cord injury, a majority of patients has these sensations. A majority of patients has these sensations, one of them there is a list of sensations that are possible out of the Lao Yunner track but the majority has them and they are not really taken much care of, and this is a pity because it can also be used for treatment purposes, and I think this is the main point. So don't underestimate the presence of these afferent nervous systems, both diagnostic but also therapeutic.
Speaker 1:Thank you but also therapeutic, thank you. And the article in some of the tables summarizes the afferent sensory innervation that's preserved in the lower urinary tract, which I think is quite important and quite interesting. So you were mentioning that this can be a potential value from a therapeutic perspective. Could you give us one or two examples of where this could be applied from a therapeutic perspective?
Speaker 2:One might be, but it needs to be explored more. Is that spinal cord injury individuals are trained to feel when their bladder is full, so that they come not with machinery or technology determined if the time has come to categorize reasons, but that they can feel it themselves if. If this sensation is present, of course, the other part is that it will be the key factor in an evolution which has become quite popular neuromodulation and neurostimulation, because neuromodulation, as we all well know, for these organs is mainly based, a starting starting point, in the sensory system. So if you know about the sensory system, you can better judge what chance of success you might have with these techniques, which are not cheap I.
Speaker 1:You brought up a very interesting point which relates to the whole concept of neuromodulation. Where would you say that we are currently in the state of management of the neurogenic bladder related to neuromodulation? What do you see as a current state of the art? What do you see in the future?
Speaker 2:Well, what sort of frightens me a little bit is that, of course, when this technique started to be developed, it was quite pushed by the people who developed them.
Speaker 2:It was quite pushed by the people who developed them and the studies that have been done when neuromodulation was given during the shock phase in both sides of the body, and that better results were found finally in the outcome of bladder function. I think this needs much more study. I think it's a sort of perhaps one step too far, but on the other hand, without any doubt, the neuromodulation not directly the stimulation, because the stimulation is, for an autonomic organ, not really what you want, but the neuromotivation can help. This has been well demonstrated and I am pleased but also a little bit surprised, because there is a lot of study that should still happen to find out which parameters are the best, where the position is the best, and so on. Now this all has been overruled just to be put in to the advantage of a number of individuals with spinal cord injury, but it's perhaps a step that still has to be done.
Speaker 1:I see, you see that, apart from neuromodulation, you see other areas of potential research in the future related to the understanding of the neurogenic bladder and the management of the neurogenic bladder.
Speaker 2:Well, the paper that came out of the Goodman lecture is actually completely focused on the sensory nervous system, not on the other part. Lot of evolution possible in motor function, um, which is not minor, which is major, but are the sensor is now are something that is definitely worth looking at better. Um, and one of the points is how can you diagnose it? Okay, um, to diagnose it can be done clinically and can be done with other techniques, like uh urodynamic testing with feeling sensation, uh sensation during, uh voiding in the urethra, which is a different system, and then then, of course, by electrical stimulation. And electrical stimulation, the determination of EPT in different parts of the lower urinary tract gives information which, neurologically, is wonderful. Okay, because it gives you parts of the innovation, of the lower innovation, that you can um divide in in different fields, and one field can be heard and the other not. So, but that is then looking into it very in detail.
Speaker 2:In general practice, I would say um, ask for it. Okay, ask for it. Do you feel if your blood was filling? If you're doing a urodynamic test, always do it, asking if they feel what is happening in the blood or not, and try to repeat it and um, and then the, the and try to repeat it, and then the other information, like if an endoscopy is done or catarization is done, if the feel of the passage of the cadaver that brings you already far and can guide you to where you go further.
Speaker 1:Very good. So we've had a discussion with Professor JJ Windhill, professor Emma Reedus at Antwerp University. We've had a discussion on Professor Windale's recent review article in spinal cord on a focus on afferent sensory nervous pathways with lower urinary tract after spinal cord injury, and some of the key summary points that Professor Windale has articulated in this article relates to the preservation of a number of these critical sensory-acquirent pathways after spinal cord injury and how these can be applied diagnostically and potentially therapeutically in the future. So that concludes our podcast session. Professor Wendell, thank you again for joining us and I would welcome all of you to have a look each month at our issues of spiral cord, have a look each month at our issues of spiral cord and we look forward to seeing many of you at the ISCOS meeting in Gothenburg this October.