Balasubramaniam, A.V.; (2008) A neurophysiological assessment of the bladder guarding response in spinal cord injury. Doctoral thesis , University of London.

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Abstract

Neuroregeneration and repair of the spinal cord following traumatic injury (SCI) provide the ultimate goal in the treatment of this patient group and in the challenge to end the permanence of paralysis. To assess the effectiveness of these techniques as they are developed it is important to have sensitive functional assessment tools capable of detecting the repair of damaged pathways. Routine assessment of SCI subjects currently relies on subjective clinical measurement using the ASIA classification and Impairment Score, which is not always consistently rated and excludes autonomic function. In eight chapters this thesis describes work executed to fill this niche by, optimising and standardizing a somatovisceral neurophysiological tool that combines the evoked potential of the sacral somatic pudendo-anal reflex response (PAR) (as a surrogate marker of the pudendo-urethral reflex) with bladder function as a measure of the integrity of the guarding response (GR) for assessing residual supra-sacral bladder and sphincter function in SCI subjects. Presented is the confirmation of the predominant absence of the GR in complete SCI and its preservation, variability and inverse correlation with the degree of impairment in iSCI. Normally suppressed during voiding, the GR is enhanced in SCI, due to aberrant sacral reflexes leading to overactivity of the bladder and dyssynergia of the sphincters. For the first time shown is the residual control of the sphincter in SCI by facilitation of the PAR that gives the best systematic correlation with ASIA grading. And the localised cortical stimulation with TMS facilitates the PAR and may provide an additional means to test the precise integrity and timing of residual cerebro-spinal pathways facilitating the guarding response and pelvic floor muscles. The relationship of this somatovisceral measure with the ASIA/IMSOP scale has been confirmed and finally discussed is how the GR, through neurophysiological testing of somatovisceral reflexes could potentially present an assessment tool for those with SCI.

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