The Initial Clinical Application Of Intercostal Nerve Transfer To Reconstruct The Flaccid Bladder Function

Objective:To study the impacts of the urinary system and the anatomical characteristics of nerves after the thoracic and lumbar spinal cord injury.Using of the vascularized intercostal nerves of the normal plane superior to the paraplegia plane and the vascularized sural nerves to anastomose sacral nerve to reconstruct the control bladder voiding function after spinal cord injury.Through summarize the materials by rehabilitation exercises, further observation and tracking follow-up to explore a simple and effective method for flaccid bladder function reconstruction after the cone spinal cord injury.Methods:1 Select Objects:Bladder dysfunction patients after thoracic and lumbar spinal cord injury within six months. The age of them younger than 45 years.2 Surgical Procedures:Lateral position, intraoperative lateral upward with intubation anesthesia.Selected the recent two plane normal intercostal nerves superior than the paraplegia plane , made a incision from beside of the sacral spine muscle to adjacent to the subclavian central line,fully freed two groups vascularized intercostal nerves,to cut off and ligate the blood vessels in the remote of the subclavian central line ,removed the nerve through the tunnel below sacral spine muscles to the near of the tubus vertebralis, fixed by small incision marker.Did a median incision between the L5 and S2 , fenestration were in S1 to S3. Exposed S2-S3 spinal nerve roots and cut off the start of the nerve bundles of each nerve root most electively, taken the bilateral vascularized sural nerveside with the same length.Grafted two nerves by cable type which bridged the proximal of the intercostal nerve and the distal of the S2 and S3 nerve root.Anastomosis was did in intercostal blood vessels and sural nerve blood vessels,also in blood vessels and sural nerve inferior gluteal artery。Imposed muscle flap filling the spinal canal fenestration and act as a nerve bed.Results:Operative time was 150 minutes (range of 120-180 minutes).The blood lost was 400ml (range of 350～550ml).Hospitalization was 12 days (range of 10 to 14 days). Follow-up time was of 9 months(range of 8 to 12 months). One case had urination after 12 months,recovered the defecation reflex,perineum S1-2 level feeling and the right cremaster reflex active of urinary function.However, there were still mild urinary incontinence.Two cases intended to improve the voiding after 10 months ,one case perineal S1-2 level feeling recovered after 9 months ,one case without significant improvements after 6 months.Conclusions:This method proved that part of the mixed nerve fibers from human body (intercostal nerve) could through sacral nerve roots and pelvic nerve plexus to reach the establishment of autonomic nervous system control of bladder reflex again.And reconstructed some of the sphincter functions and sensory function.Sacral nerve roots regeneration abilities after intradural spinal cord injury below the waist needed to be further studied.However, the normal peripheral nerves and peripheral nerves anastomosis between the receptor nerves restored some functions had been proved for many years by experimental and clinical validation.The patients confirmed that the autonomy of such surgical methods could obtain their self-sensations and external sphincter of contractile function recovery.So that paraplegic patients are expected to resume high-quality and near-physiological functions of urination.