Christopher S. Elliott MD, PhD Dimitar Zlatev MD James Crew MD Kazuko Shem MD
Wiley Online Library Published online Feb 22, 2019. doi:10.1002/nau.23943
Bladder dysfunction after spinal cord injury (SCI) often requires clean intermittent catheterization (CIC) or other management strategies. A common dilemma in those desiring to perform CIC independently but lacking the appropriate upper extremity (UE) motor function is the timing of reconstructive surgery.
We assessed the National Spinal Cord Injury Data Set for the years 2000‐2016. Our cohort consisted of persons with cervical SCI, who underwent complete motor examination upon discharge from rehabilitation and at 1‐year follow‐up. Using a previously published algorithm, UE motor scores were transformed to predict a patient's ability to independently perform CIC. Improvements in the predicted ability to self‐catheterize were evaluated.
Of the 1428 individuals meeting the inclusion criteria, improvements in the predicted UE motor function necessary to independently self‐catheterize were observed in 39%, 42%, and 38% of those deemed possibly able, only able with surgical assistance, or unable to self‐catheterize at rehabilitation discharge, respectively. On multivariate analysis, only increasing Association Impairment Scale (AIS) classification and AIS classification improvement over the first year were associated with an increased odds of improving predicted CIC ability (odds ratio [OR] = 1.44 for AIS C and 1.97 for AIS D compared with AIS A, and OR = 1.90 for AIS classification improvement versus stable AIS classification, P < 0.05 for each).
Improvements in UE motor function to independently perform CIC occur in approximately 40% of persons with cervical SCI in the first year after rehabilitation discharge. Those with incomplete injuries are more likely to improve. These findings should enhance patient bladder management counseling and guide surgeons in determining an appropriate timeline for offering reconstruction.
Comment by Howard Goldman:
Bladder management is one of the key concerns after a patient has suffered a spinal injury. If reasonable spontaneous voiding is not possible, clean intermittent catheterization is the preferred avenue of management when possible. Upper extremity (UE) functional capacity is critical in determining if a patient will be able to do CIC and this can be an issue in those with cervical spine injuries. Ultimately, some of these patients may require reconstructive bladder surgery/diversion or UE surgery (tendon transfer) to facilitate either CIC or another method of baldder emptying.
Elliot et al, in an interesting article recently published in Neurourology and Urodynamics, evaluated the likelihood of improvement in UE function over the first year after rehabilitation in such patients. They reviewed the United States National Spinal Cord Injury Database and pulled information on UE function at rehabilitation discharge and compared it to that at one-year follow-up. Based on the data pulled they characterized each patient on their ability to perform CIC based on UE function alone. Patients were divided into groups such as able to do CIC, possibly able to do CIC, able to do CIC with surgical reconstruction and unable to catheterize even with surgical reconstruction. They then compared their characterizations between rehabilitation discharge and one year later.
Ultimately, they demonstrated that improvements in UE motor function to allow the patient to independently perform CIC occur in 40% of patients with cervical spinal cord injury in the first year after rehabilitation. Even 38% of those deemed completely unable to successfully catheterize at rehab discharge had improvements sufficient to allow for independent CIC at follow-up. Those with incomplete injuries had a higher rate of improvement.
These findings should provide guidance to clinicians who care for these patients and suggest reconstructive procedures be delayed at least a year in many as they may have functional UE improvement sufficient to independently do CIC without any reconstructive procedures. This would potentially avoid the morbidity and cost that comes with many of these procedures.
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