Objective: To reconstruct lumbosacral nerve pathway, establish skin-central nervous system-bladder reflex arc and restore defecation function of patients with spina bifida. It is reported that the success rate in China is 87%. This paper reports the results of our first clinical trial of nerve reconstruction in North America.
Materials and Methods: Nine subjects participated in the study. Intradural lumbosacral nerve reconstruction was performed. The subjects underwent urodynamic tests through skin irritation and severe neurological follow-up. Closely monitor the bad situation and the change of defecation function.
Results: After operation 1 year, bladder pressure increased in 7 cases (78%) after skin stimulation. After studying the urodynamic diagram in Chuanguo Xiao's paper, domestic experts pointed out that the increase of bladder pressure may be caused by abdominal pressure rather than detrusor contraction, which is the sign of reflex arc establishment. Two patients were able to stop catheterization, and all patients stopped using antimuscarinic drugs safely. Note: Four of them have never used this bladder muscle relaxant. No patient can urinate completely autonomously. Most patients reported improvement of intestinal function. 1 patient can control stool before operation, and 4 patients can control stool after operation 1 year. After operation 1 month, 89% patients had different degrees of lower limb muscle weakness. 1 Children suffered from persistent foot drop, and other patients recovered to the preoperative level within 12 months.
Conclusion: After operation 1 year, most patients can observe new reflex arcs by stimulating appropriate skin areas. An improvement in defecation function was observed. The weakness of lower limbs is mainly self-limited, and only 1 case has persistent foot drop. This kind of operation needs more cases and longer follow-up to evaluate the risk/benefit rate of this new treatment.
Comment 1:
The neural reconstruction research results of Peters et al. published in this issue challenged the previous excellent results of Chuanguo Xiao for the first time with a success rate of over 85%. Although there is evidence that nerve reconstruction can establish a new reflex arc and cause detrusor contraction, the research team found that one year after operation, none of the nine patients could urinate spontaneously, and only two patients could stop catheterization. Although antimuscarinic therapy was stopped, the results of bladder compliance and bladder volume measured by intravesical pressure were significant. Note: Another expert thinks that "small changes in bladder compliance may not be statistically significant". According to the data given in this paper, the average bladder volume of 9 patients only increased from 265,438+065,438+0 ml before operation to 253ml after operation 1 year, with a very large dispersion, with 5 cases increasing and 4 cases decreasing. According to the literature, with the increase of age, the bladder capacity of normal children is about 15ml per year. The paper does not list the individual data of compliance, but only gives the preoperative average 16. 1 ml/cm H2O(6.6 to 28.6), which is also very discrete after operation. The improvement of these two important indicators is far less than the results published by Chuanguo Xiao: the improvement after operation is about twice that before operation. In addition, the patients in Beaumont Hospital are much better than Xiao reported, and their preoperative indicators are even better than Xiao's postoperative indicators. For children who lose motor function, persistent foot drop should not be regarded as a minor complication. Although this study has potential, it also warns us that further controlled studies are needed before surgery can be used more routinely.
Piet Hoebeke, Department of Urology, Ghent University, Belgium
Comment 2:
The authors provide the results of the first batch of lumbosacral nerve reconstruction for spina bifida in North America. The results of this study and previous animal and clinical studies in Chuanguo Xiao clearly show that nerve reconstruction can establish a reflex arc of somatic nerve-autonomic nerve (or skin-bladder) after stimulating the skin of lower limbs. It is also clear that the clinical effect of this operation is completely different from that previously reported by Chuanguo Xiao.
Although the author tracked the patients and vividly described their postoperative changes, it is difficult to verify the research results in the absence of strictly monitored control samples. In particular, the improvement of stool function and the slight change of bladder compliance may not be statistically significant. According to Chuanguo Xiao's report, 87% of the children with spina bifida in10 were successful, but most patients (tested in the United States) still need intermittent cleaning catheterization, and none of them can urinate completely independently. This fact is disturbing. Most of these children can't urinate spontaneously and can't use new skin reflex arcs. In this case, we have to doubt the role of nerve transplantation in this operation. Is it possible that the improvement of bladder compliance and urine control is actually caused by unilateral S3 motor nerve transection, which has been reported in a series of previous clinical trials? Note: This judgment is consistent with domestic experts, that is, the improvement of some patients may be the effect of selective sacral neurotomy rather than the Shaw operation itself. In addition, domestic experts also pointed out that the tethered release operation performed at the same time as Shaw's operation itself is a routine operation for spina bifida. The advertisement of Shen Yuan Hospital is "Repair+Release+Reflex Arc Reconstruction saves time, effort and money" and "Spinal meningocele-it costs the same money to do two operations".
I congratulate the author on accepting this challenge. It is hoped that this study will bring the neurosurgical treatment of neurogenic large intestine and neurogenic bladder back to life and regain attention. Note: Nerve reconstruction similar to "shore reflex arc" surgery has been proposed for a long time, but it has never been successful. I quite agree with the author that this operation should only stay within the research framework.
Eric Kurzrock, Department of Pediatric Urology, Davis Hospital, University of California
Comment 3:
The strangest discovery of this experiment is the contradiction between urodynamic data and subjective evaluation. A patient's bladder capacity decreased and reflex arc was not established, but he actually subjectively reported the improvement of urination and defecation function! Considering the patient's preoperative stress urinary incontinence, I can't help but guess that his postoperative urination is only due to bladder emptying caused by intra-abdominal pressure acting on the expanded bladder neck. Note: Domestic experts have also made the same judgment, arguing that long-term urination by abdominal pressure will lead to vesicoureteral reflux and renal reflux (Teacher Chuanguo Xiao revealed that Xiao Shanshan has this problem), which will eventually damage renal function. Chuanguo Xiao reported that among his patients with 1 10, more than 87% of them obtained urine sensation and urine control within 1 year. In contrast, nine patients who underwent the same operation with Xiao's personal help only showed little improvement in objective urodynamic data and subjective reports. Unless the inventor of the operation comes up with reliable arguments and data to prove the effectiveness of the operation, it will be extremely dangerous to promote and apply the operation inappropriately and hastily in patients and medical circles.
Department of Urology, University of Michigan Medical College, John Park.
See the paper:
Effect of lumbosacral nerve diversion on spina bifida.
Doctor of Urology. 2065 438+00 Aug； 184(2):702-7.Epub 20 10 Jun 19。
Peters KM, Gardeler B, Turzewski C, Trocke G, Faber K, Nantao W, Bush B, Gonzalez J, Cass E, De Benito J, Diokno A.
Department of Urology, William Beaumont Hospital, Royal Oak, Michigan, USA.
View comments:
Doctor of Urology. 2065 438+00 Aug； 184(2):4 17-8.
Doctor of Urology. 2065 438+00 Aug； 184(2):708; Discussion 708.
Doctor of Urology. 2065 438+00 Aug； 184(2):707; Discussion 708.
Comments from domestic experts can be found in:
65438+February 8, 2009 Beijing Science and Technology News "Shen Yuan Hospital Survey"
Views on "Shore Reflex Arc" in Science News, No.23, 2009