创伤性脊髓损伤患者影像尿流动力学特征分析

Video-urodynamics features of traumatic spinal cord injury

目的观察创伤性脊髓损伤(traumatic spinal cord injury,TSCI)患者影像尿流动力学特征,探讨其与损伤程度、损伤水平及治疗方案制订的关系。方法103例TSCI患者均行躯体神经系统检查,损伤水平为颈髓损伤31例,胸腰髓损伤26例,骶髓下损伤46例;根据美国脊髓损伤协会分级标准进行分类,损伤程度为完全性脊髓损伤39例,不完全性脊髓损伤64例。103例患者均行影像尿流动力学检查,记录逼尿肌过度活动(detrusor overactivity,DO)/逼尿肌-括约肌协同失调(detrusor-sphincter dyssynergia,DSD)、逼尿肌无反射、逼尿肌有收缩、低顺应性膀胱、膀胱感觉缺失、肾积水发生情况及最大逼尿肌压力、最大膀胱容量。比较不同损伤程度和损伤水平TSCI患者影像尿流动力学特征,根据检查结果给予相应治疗,1年后复查影像尿流动力学,比较治疗前、后影像尿流动力学参数变化。结果103例TSCI患者中,DO/DSD 48例(46.6%),逼尿肌无反射51例(49.5%),逼尿肌有收缩4例(3.9%),低顺应性膀胱40例(38.8%),膀胱感觉缺失58例(56.3%),肾积水7例(6.8%),最大逼尿肌压力为(39.6±23.2)cm H_(2)O,最大膀胱容量为(316.4±101.7)mL。完全性脊髓损伤患者膀胱感觉缺失发生率(76.9%)高于不完全性脊髓损伤患者(43.8%)(χ^(2)=10.840,P=0.001),DO/DSD(51.3%)、逼尿肌无反射(48.7%)发生率与不完全性脊髓损伤患者(43.8%、50.0%)比较差异均无统计学意义(P>0.05)。颈髓损伤和胸腰髓损伤患者DO/DSD发生率(71.0%、61.5%)、最大逼尿肌压力[(47.4±26.1)、(49.5±28.2)cm H_(2)O]均高于骶髓下损伤患者[21.7%、(25.2±13.5)cm H_(2)O](P<0.05),逼尿肌无反射发生率(19.4%、38.5%)、最大膀胱容量[(281.7±118.3)、(279.1±117.4)mL]均低于骶髓下损伤患者[76.1%、(362.8±70.3)mL](P<0.05);胸腰髓损伤患者低顺应性膀胱发生率(57.7%)高于骶髓下损伤患者(26.1%)(P<0.05);颈髓损伤患者DO/DSD、逼尿肌无反射、低顺应性膀胱发生率及最大逼尿肌压力、最大膀胱容量与胸腰髓损伤患者比较差异均无统计学意义(P>0.05)。103例患者随访至2021年6月,随访完成97例,失访6例。抗胆碱能药物联合间歇性清洁导尿39例,其中1例因治疗效果不佳改为骶神经调节术联合间歇性清洁导尿;膀胱壁A型肉毒毒素注射联合间歇性清洁导尿2例;骶神经调节术联合间歇性清洁导尿4例;单纯间歇性清洁导尿27例;手法辅助排尿或叩击排尿14例;留置导尿11例。36例患者治疗1年后复查影像尿流动力学,膀胱感觉缺失发生率(33.3%)低于治疗前(58.3%)(χ^(2)=4.531,P=0.033),低顺应性膀胱发生率(63.9%)高于治疗前(38.9%)(χ^(2)=4.503,P=0.034)。结论骶髓上损伤患者主要表现为DO/DSD,膀胱顺应性降低,最大逼尿肌压力增高和最大膀胱容量减小,依据影像尿流动力学检查结果选择治疗方法可有效保护上尿路功能。

Objective To observe the video-urodynamics(VUDS)features of traumatic spinal cord injury(TSCI)patients,and to investigate the relationships of the VUDS features with TSCI degrees,TSCI levels and therapeutic regime.Methods A total of 103 patients were divided into 31 patients with cervical TSCI,26 with thoracolumbar TSCI,and 46 with infra-sacral TSCI according to somatic neurological examination,and also divided into 39 with complete TSCI and 64 with incomplete TSCI according to ASIA Impairment Scale.All 103 patients underwent VUDS to record the incidences of detrusor overactivity(DO)/detrusor-sphincter dyssynergia(DSD),detrusor no-reflex,detrusor contraction,low compliance bladder,bladder sensory loss and hydronephrosis,as well as the maximum detrusor pressure and maximum bladder volume.The VUDS features of TSCI patients with different TSCI degrees and levels were compared,and the corresponding treatment was given according to the examination results.One year later,VUDS was repeated to compare the changes of VUDS parameters before and after treatment.Results Among 103 TSCI patients,48patients(46.6%)had DO/DSD,51(49.5%)had detrusor no-reflex,4(3.9%)had detrusor contraction,40(38.8%)had low compliance bladder,58(56.3%)had bladder paresthesia,and 7(6.8%)had hydronephrosis.The maximum detrusor pressure was(39.6±23.2)cm H_(2)O,and the maximum bladder volume was(316.4±101.7)mL.The incidence of bladder sensory loss was higher in patients with complete TSCI(76.9%)than that in patients with incomplete TSCI(43.8%)(χ^(2)=10.840,P=0.001),and there were no significant differences in the incidences of DO/DSD and detrusor no-reflex between patients with complete TSCI(51.3%,48.7%)and patients with incomplete TSCI(43.8%,50.0%)(P>0.05).The incidence of DO/DSD and maximum detrusor pressure were higher in patients with cervical TSCI[71.0%,(47.4±26.1)cm H_(2)O]and in patients with thoracolumbar TSCI[61.5%,(49.5±28.2)cm H_(2)O]than those in patients with infra-sacral TSCI[21.7%,(25.2±13.5)cm H_(2)O](P<0.05),and the incidence of detrusor no-reflex was lower and maximum bladder volume was smaller in patients with cervical TSCI[19.4%,(281.7±118.3)mL]and in patients with thoracolumbar TSCI[38.5%,(279.1±117.4)mL]than those in patients with infra-sacral TSCI[76.1%,(362.8±70.3)mL](P<0.05).The incidence of low compliance bladder was higher in patients with thoracolumbar TSCI(57.7%)than that in patients with infra-sacral TSCI(26.1%)(P<0.05).There were no significant differences in the incidences of DO/DSD,detrusor no-reflex,low compliance bladder,maximum detrusor pressure,and maximum bladder volume between patients with cervical TSCI and patients with thoracolumbar TSCI(P>0.05).Till June,2021,97 were followed up and 6 were lost follow-up.In 103 patients,39 were treated with anticholinergic drugs combined with clean intermittent urethral catheterization(CIC)including 1 patient who changed to sacral neuromodulation combined with CIC due to poor therapeutic effect,2 were treated with bladder wall botulinum toxin A injection combined with CIC,4 were treated with sacral neuromodulation combined with CIC,27 were treated with simple CIC,14 were treated with manual assisted urination or tapping urination,and 11 were treated with indwelling urethral catheterization.One year after treatment,36 patients were repeated VUDS,showing a lower incidence of bladder sensory loss and a higher incidence of low compliance bladder(33.3%,63.9%)compared with those before treatment(58.3%,38.9%)(χ^(2)=4.531,P=0.033;χ^(2)=4.503,P=0.034).Conclusions Patients with infra-sacral TSCI is mainly presented with DO/DSD,low bladder compliance,high maximum detrusor pressure and small maximum bladder volume.To select therapeutic methods based on the results of VUDS can effectively protect the upper urinary tract function.