Editing Functional: Neuromodulation (section)

== Electrical Stimulation for Storage Disorders ==

* '''Criteria for Selection of Patients'''
** '''Sacral neuromodulation is frequently attempted in patients in whom traditional conservative measures (e.g., bladder retraining, pelvic floor biofeedback, and medications) have failed and before more invasive surgical procedures (e.g., enterocystoplasty and urinary diversion)'''
** '''There are no defined preclinical factors, such as urodynamic findings, that can predict which patients will or will not respond to sacral neuromodulation.'''
** '''Contraindications:'''
*** '''Absolute (4):'''
***# '''Significant anatomic abnormalities''' in the spine or sacrum that may present challenges to gaining access
***# '''Cognitive dysfunction in patients who cannot manage their device or judge the clinical outcome'''
***# '''Physical limitations that prevent the patient from achieving normal pelvic organ function, such as functional urinary incontinence'''
***# '''Non-compliance'''
*** '''Relative (2):'''
***# '''Pregnancy'''
***#* Potential for teratogenicity or abortion from the effect of electrical stimulation is not known; no adverse effects of electrical stimulation on pregnant rats
***#* '''Termination of pregnancy is not advised for prospective mothers when electrical stimulation has been performed unknowingly in early pregnancy.'''
***#* '''Females with electrical stimulation devices for pelvic health conditions who become pregnant may simply turn off their devices during pregnancy.'''
***# '''MRI'''
***#* '''At present, contraindicated to perform MRI of a patient with an implantable neurostimulator system, if the MRI is looking at spinal cord segments or anything below the head'''
***#* '''Recent changes in the manufacturer recommendations do allow for head MRI to be performed with an InterStim in situ,''' but clearance requires several factors including having the device turned off and use of a 1.5-Tesla magnet or lower
***#* '''For patients who have InterStim devices in place, we advocate removal of the device in preparation for elective MRI based on current manufacturer recommendations. After the MRI procedure, a new neuroelectrode and generator may be placed.'''
***#* Anecdotal reports of patients safely undergoing the study (MRI) with the InterStim implant in place have occurred, but patients should have the devices turned off in anticipation.
* Electrical Stimulation of the Bladder
* '''Sacral Rhizotomy'''
** '''In most cases, bilateral anterior and posterior sacral rhizotomy or conusectomy converts an overactive detrusor to an areflexic one.'''
*** '''This alone may be inappropriate therapy because it also adversely affects the rectum, anal and urethral sphincters, sexual function, and the lower extremities.'''
*** '''In an attempt to leave sphincter and sexual function intact, selective motor nerve section can increase bladder capacity by abolishing only the motor supply responsible for involuntary contractions'''
**** '''Partial or selective procedures are considered only in such patients who retain some sensation or have excellent reflex erections.'''
***** '''To enhance the clinical response and minimize side effects, differential sacral rhizotomy always should be preceded by stimulation and blockade of the individual sacral roots with cystometric and sphincterometric control.'''
**** '''Posterior rhizotomy decreases the reflex activity of the detrusor and improves bladder compliance'''
**** '''There is still controversy about the role of anterior rhizotomy for treatment of DO;''' unintended effects on pelvic and lower extremity sensory or motor functions may occur with disastrous medical and legal sequelae.
*** '''Advantages of bilateral posterior sacral rhizotomy in treatment of voiding dysfunction after SCI:'''
***# '''Abolishing reflex incontinence'''
***# '''Improving compliance'''
***# '''Abolishing striated sphincter dyssynergia without altering resting tone'''
*** '''For optimal bladder emptying to be achieved, sacral anterior root stimulation with posterior rhizotomies of S2, S3, and S4 would be required.'''
**** '''The S3 anterior (ventral) root provides the dominant motor innervation of the human bladder.'''