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Urologic complications after surgery on lumbosacral spine
URODYNAMICS
UROLOGIC
COMPLICATIONS
ON LUMBOSACRAL MOSHE ELYAKIM MATITYAHU AM1 SIDI,
SPINE
BROOKS,
MORENO,
AFTER SURGERY
M.D
M.D.
M.D.
ZVI F. BRAF, M.D. From the Neurologic Clinic, Department of Rehabilitation Medicine, and Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
ABSTRACT-Forty-five of 74 patients (60%) postsurgery for disk disease showed findings of neurogenic bladders. Sixty-nine of these patients had no complaints before surgery and presented with complaints only after surgery. We believe this is a high surgical morbidity, and all patients should have a presurgical urodynamic diagnostic evaluation to aid in selection of patients in whom surgery will be most helpful and to establish a presurgical baseline for further postsurgical UTOdynamic comparison.
The surgical treatment of the prolapsed lumbar and/or sacral disk is a recognized therapeutic approach to relieving pain symptoms and reversing the neurologic signs occurring from compression of the nerve root and/or spinal cord.’ Much has been written concerning the use of presurgical diagnosis of the neurogenic bladder in disk disease as evidence of neurologic involvement from disk protrusion, and as an additional indication for surgical intervention.2’3 However, very little follow-up is cited concerning postsurgical complaints. Among the numerous complications of post-disk surgery are those involving urinary complaints in patients whose presurgical course was conspicuously free of urinary tract symptoms. We present a series of 74 patients, 69 of whom had the onset of their urinary problems in the postoperative period. Material and Methods Seventy-four patients, 57 men and 17 women, complaining of urination difficulty af-
202
ter laminectomy, diskectomy, or both, were examined. Patients ranged in age from eighteen to seventy-eight years (mean 55.5 + 15.1 years). Complaints included urgency, frequency, nocturia, and loss of urine. All patients were referred from either the departments of orthopedics or neurosurgery immediately after spinal surgery for investigation of these postsurgical complaints. Only 5 of these 74 patients had symptoms prior to or accompanying the operative interlude. Two of these 5 suffered from benign prostatic hypertrophy. One patient was a T9 paraplegic secondary to tuberculosis spondylosis. In these 5 patients complaints intensified after surgery. No attempt was made to correlate patients’ complaints with pathologic findings, nor was any correlation attempted between surgical procedures or anatomic locations and pathologic findings. Table I summarizes the distribution of surgical procedure. In all patients, all medications were withdrawn prior to urodynamic examination. All examinations were performed with a carbon-dioxide
UROLOGY
/
AUGUST
1985
/)
VOI,UME
XXVI.
NUMBER
2
TABLEI. L2 to Sl D8 Dll, D12. Ll Ll
TOTALS
Summary
Comment
of operative procedures
Laminectomy
Diskectomy
Both
43
21
5
1
. .
. .
1 1
1 1
. . . . -
-
-
46
23
5
cystometer. Patients were then catheterized using sterile techniques. 4 Residual urines were drained and measured, and then CO, was introduced at a rate of 120 ml/minute. Patients were told to report the first urge to void which was recorded as the first sensation of filling (FSF). They were then instructed to tolerate the increasing feeling of fullness and urgency until absolutely unable and then to urinate. With a rise in intrabladder pressure 30 cm Hz0 above the initial resting bladder pressure, either voluntary or involuntary, the examination was terminated. This point was used to determine the total bladder capacity volume. Results are reported as follows: residual urine greater than 50 ml or greater than 10 per cent of volume is considered pathologic, FSF less than 100 ml is considered hyperesthetic. FSF greater than 200 ml is considered hypoesthetic. Volume less than 200 ml or greater than 500 ml is considered pathologic.5 Results Of the 74 patients examined, 45 (60%) had pathologic urodynamic findings in one or more parameters tested. Seven patients had indwelling catheters after surgery, 18 patients had residual urines with no abnormal cystometric findings. Ten patients had a sole finding of sensory disturbances, 2 of whom had FSF greater than 200 ml and 8 had FSF less than 100 ml. Another 20 patients had sensory disturbances combined with other pathologic findings. Thus, a total of 30 patients (40%) had sensory disturbances (Table II). Ten patients had a sole pathologic finding of disturbances of volume. Six patients had a small-capacity bladder (less than 200 ml) and 4 patients had a largecapacity bladder (greater than 500 ml). Another 10 patients had volume changes associated with residual urines or indwelling catheters. Thus a total of 20 patients had disturbances in bladder capacity or, expressed neurologically, detrusor dysfunction (Table II).
I_ROI,OGY
AUGUST1985
/ VOLUMEXXVI,NUMBER2
Much of the investigational efforts in patients with low-back pain are directed at localizing the presence and level of the lesion. Rosomoff et aLB showed the presence of detrusor areflexia prior to surgery in 41 of 50 patients with no urinary complaints. Since their article concerned diagnosis, no follow-up is reported. Andersen and Bradley2 also showed the presence of detrusor areflexia with some patients having no urologic recovery postsurgery. From their data, it appears as if all patients have urologic complaints prior to surgery. Sharr, Carfield, and Jenkins3 had a 75 per cent rate of symptom relief and bladder function improvement in 73 patients. These patients all had their complaints prior to surgery with 62 per cent of the patients showing a return-to-normal function after surgery and another 15 per cent showing some improvement. Nielsen et ~1.~ reported that surgical treatment within two days of the appearance of urologic symptoms and finding of areflexia detrusor in patients with lumbar disk herniation can reverse these complaints. Again, the urologic symptoms were present prior to surgery. In our series of 74 patients, 69 presented with their urinary complaints after surgery. With no presurgical studies, obviously we cannot determine how many of our 49 patients with pathologic urodynamic findings had presurgical neurogenic bladders. However, in none was the operative decision based on urologic complaints or findings. Ravichanran and Franke18 stated in a review of 57 operated cases of disk lesions that patients who have had laminectomies for lumbar disk protrusions generally had a disturbance of micturition. They claim improvement in most cases after a short period of bladder training in their center. They do not describe symptoms, and TABLEII.
Sensory and bladder capacity disturbances
-----FSFPatients Sole finding Combined with residual urine Catheter Volume decrease TOTALS
>200
-VolumeMl. < 100 Ml. <200 Ml. >500 Ml. -2 8 6 4
8 2
2 3
12
2 2
5 1
10
10
5 18
203
make no mention of pre- or postsurgical urologic status; they also do not describe diagnostic methods nor define what is meant by improvement. We believe that the 60 per cent of our patients with diagnostic findings of neurogenic bladders whose complaints were first made after surgery is an extremely high surgical morbidity. Possible explanations for this include: (1) unmasking of pre-existing urologic findings with pain relief after surgery, (2) iatrogenic exacerbation of a pre-existing condition, (3) reoccurrence of compression in the postsurgical period from scar formation of disk protrusion, (4) further extension of the basic disease process, reflecting a new unaccommodated and uncompensated anatomic situation, and (5) direct iatrogenic etiology. We believe that all patients with lumbosacral disk disease deserve a presurgical urodynamic diagnostic evaluation to aid in selecting those patients in whom surgery will be most helpful, and to establish a presurgical baseline for further postsurgical urodynamic comparison.
204
Department of Rehabilitation Medicine Chaim Sheba Medical Center Tel Hashomer, 52621 Israel (DR. BROOKS) References 1. Mixter WJ, and Barr JS: Rupture of the intervertebral disc with involvement of the spinal cord, N Engl Surg Sot 211: 210 (1934). 2. Andersen JT, and Bradley WE: Neurogenic bladder dysfunction in protruded lumbar disk and after laminectomy, Urology 8: 94 (1976). 3. Sharr MM, Carfield JC, and Jenkins JD: Lumbar spondylosis and neuropathic bladder investigations of 73 patients with chronic urinary symptoms, Br Med J 1: 645 (1976). 4. Guttmann L: Spinal Cord Injuries, Comprehensive Management and Research, Oxford, Blackwell Scientific Publications Ltd., 1973, pp 345-350. 5. Bates P. et al: The standardization of terminologv of lower “’ urinary tract function, J Urol 121: 551 (1974). 6. Rosomoff HL, et al: Cystometry in the evaluation of nerve root compression in the lumbar spine, Surg Gynecol Obstet 117: 263 (1963). 7. Nielsen B, de Nully M, Schmidt K, and Hansen RI: A urodvnamic study of cauda equina syndrome due to lumbar disc herniation, Urol Int 35: 167 (1980). 8. Ravichanran G, and Frankel HL: Paraplegia due to intervertebral disc lesions, a review of 57 operated cases, Paraplegia 19: 133 (1980).
UROLOGY
AUGUST
198.5
VOLUME
XXVI.
SUMBER
2
UROLOGIC
COMPLICATIONS
ON LUMBOSACRAL MOSHE ELYAKIM MATITYAHU AM1 SIDI,
SPINE
BROOKS,
MORENO,
AFTER SURGERY
M.D
M.D.
M.D.
ZVI F. BRAF, M.D. From the Neurologic Clinic, Department of Rehabilitation Medicine, and Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
ABSTRACT-Forty-five of 74 patients (60%) postsurgery for disk disease showed findings of neurogenic bladders. Sixty-nine of these patients had no complaints before surgery and presented with complaints only after surgery. We believe this is a high surgical morbidity, and all patients should have a presurgical urodynamic diagnostic evaluation to aid in selection of patients in whom surgery will be most helpful and to establish a presurgical baseline for further postsurgical UTOdynamic comparison.
The surgical treatment of the prolapsed lumbar and/or sacral disk is a recognized therapeutic approach to relieving pain symptoms and reversing the neurologic signs occurring from compression of the nerve root and/or spinal cord.’ Much has been written concerning the use of presurgical diagnosis of the neurogenic bladder in disk disease as evidence of neurologic involvement from disk protrusion, and as an additional indication for surgical intervention.2’3 However, very little follow-up is cited concerning postsurgical complaints. Among the numerous complications of post-disk surgery are those involving urinary complaints in patients whose presurgical course was conspicuously free of urinary tract symptoms. We present a series of 74 patients, 69 of whom had the onset of their urinary problems in the postoperative period. Material and Methods Seventy-four patients, 57 men and 17 women, complaining of urination difficulty af-
202
ter laminectomy, diskectomy, or both, were examined. Patients ranged in age from eighteen to seventy-eight years (mean 55.5 + 15.1 years). Complaints included urgency, frequency, nocturia, and loss of urine. All patients were referred from either the departments of orthopedics or neurosurgery immediately after spinal surgery for investigation of these postsurgical complaints. Only 5 of these 74 patients had symptoms prior to or accompanying the operative interlude. Two of these 5 suffered from benign prostatic hypertrophy. One patient was a T9 paraplegic secondary to tuberculosis spondylosis. In these 5 patients complaints intensified after surgery. No attempt was made to correlate patients’ complaints with pathologic findings, nor was any correlation attempted between surgical procedures or anatomic locations and pathologic findings. Table I summarizes the distribution of surgical procedure. In all patients, all medications were withdrawn prior to urodynamic examination. All examinations were performed with a carbon-dioxide
UROLOGY
/
AUGUST
1985
/)
VOI,UME
XXVI.
NUMBER
2
TABLEI. L2 to Sl D8 Dll, D12. Ll Ll
TOTALS
Summary
Comment
of operative procedures
Laminectomy
Diskectomy
Both
43
21
5
1
. .
. .
1 1
1 1
. . . . -
-
-
46
23
5
cystometer. Patients were then catheterized using sterile techniques. 4 Residual urines were drained and measured, and then CO, was introduced at a rate of 120 ml/minute. Patients were told to report the first urge to void which was recorded as the first sensation of filling (FSF). They were then instructed to tolerate the increasing feeling of fullness and urgency until absolutely unable and then to urinate. With a rise in intrabladder pressure 30 cm Hz0 above the initial resting bladder pressure, either voluntary or involuntary, the examination was terminated. This point was used to determine the total bladder capacity volume. Results are reported as follows: residual urine greater than 50 ml or greater than 10 per cent of volume is considered pathologic, FSF less than 100 ml is considered hyperesthetic. FSF greater than 200 ml is considered hypoesthetic. Volume less than 200 ml or greater than 500 ml is considered pathologic.5 Results Of the 74 patients examined, 45 (60%) had pathologic urodynamic findings in one or more parameters tested. Seven patients had indwelling catheters after surgery, 18 patients had residual urines with no abnormal cystometric findings. Ten patients had a sole finding of sensory disturbances, 2 of whom had FSF greater than 200 ml and 8 had FSF less than 100 ml. Another 20 patients had sensory disturbances combined with other pathologic findings. Thus, a total of 30 patients (40%) had sensory disturbances (Table II). Ten patients had a sole pathologic finding of disturbances of volume. Six patients had a small-capacity bladder (less than 200 ml) and 4 patients had a largecapacity bladder (greater than 500 ml). Another 10 patients had volume changes associated with residual urines or indwelling catheters. Thus a total of 20 patients had disturbances in bladder capacity or, expressed neurologically, detrusor dysfunction (Table II).
I_ROI,OGY
AUGUST1985
/ VOLUMEXXVI,NUMBER2
Much of the investigational efforts in patients with low-back pain are directed at localizing the presence and level of the lesion. Rosomoff et aLB showed the presence of detrusor areflexia prior to surgery in 41 of 50 patients with no urinary complaints. Since their article concerned diagnosis, no follow-up is reported. Andersen and Bradley2 also showed the presence of detrusor areflexia with some patients having no urologic recovery postsurgery. From their data, it appears as if all patients have urologic complaints prior to surgery. Sharr, Carfield, and Jenkins3 had a 75 per cent rate of symptom relief and bladder function improvement in 73 patients. These patients all had their complaints prior to surgery with 62 per cent of the patients showing a return-to-normal function after surgery and another 15 per cent showing some improvement. Nielsen et ~1.~ reported that surgical treatment within two days of the appearance of urologic symptoms and finding of areflexia detrusor in patients with lumbar disk herniation can reverse these complaints. Again, the urologic symptoms were present prior to surgery. In our series of 74 patients, 69 presented with their urinary complaints after surgery. With no presurgical studies, obviously we cannot determine how many of our 49 patients with pathologic urodynamic findings had presurgical neurogenic bladders. However, in none was the operative decision based on urologic complaints or findings. Ravichanran and Franke18 stated in a review of 57 operated cases of disk lesions that patients who have had laminectomies for lumbar disk protrusions generally had a disturbance of micturition. They claim improvement in most cases after a short period of bladder training in their center. They do not describe symptoms, and TABLEII.
Sensory and bladder capacity disturbances
-----FSFPatients Sole finding Combined with residual urine Catheter Volume decrease TOTALS
>200
-VolumeMl. < 100 Ml. <200 Ml. >500 Ml. -2 8 6 4
8 2
2 3
12
2 2
5 1
10
10
5 18
203
make no mention of pre- or postsurgical urologic status; they also do not describe diagnostic methods nor define what is meant by improvement. We believe that the 60 per cent of our patients with diagnostic findings of neurogenic bladders whose complaints were first made after surgery is an extremely high surgical morbidity. Possible explanations for this include: (1) unmasking of pre-existing urologic findings with pain relief after surgery, (2) iatrogenic exacerbation of a pre-existing condition, (3) reoccurrence of compression in the postsurgical period from scar formation of disk protrusion, (4) further extension of the basic disease process, reflecting a new unaccommodated and uncompensated anatomic situation, and (5) direct iatrogenic etiology. We believe that all patients with lumbosacral disk disease deserve a presurgical urodynamic diagnostic evaluation to aid in selecting those patients in whom surgery will be most helpful, and to establish a presurgical baseline for further postsurgical urodynamic comparison.
204
Department of Rehabilitation Medicine Chaim Sheba Medical Center Tel Hashomer, 52621 Israel (DR. BROOKS) References 1. Mixter WJ, and Barr JS: Rupture of the intervertebral disc with involvement of the spinal cord, N Engl Surg Sot 211: 210 (1934). 2. Andersen JT, and Bradley WE: Neurogenic bladder dysfunction in protruded lumbar disk and after laminectomy, Urology 8: 94 (1976). 3. Sharr MM, Carfield JC, and Jenkins JD: Lumbar spondylosis and neuropathic bladder investigations of 73 patients with chronic urinary symptoms, Br Med J 1: 645 (1976). 4. Guttmann L: Spinal Cord Injuries, Comprehensive Management and Research, Oxford, Blackwell Scientific Publications Ltd., 1973, pp 345-350. 5. Bates P. et al: The standardization of terminologv of lower “’ urinary tract function, J Urol 121: 551 (1974). 6. Rosomoff HL, et al: Cystometry in the evaluation of nerve root compression in the lumbar spine, Surg Gynecol Obstet 117: 263 (1963). 7. Nielsen B, de Nully M, Schmidt K, and Hansen RI: A urodvnamic study of cauda equina syndrome due to lumbar disc herniation, Urol Int 35: 167 (1980). 8. Ravichanran G, and Frankel HL: Paraplegia due to intervertebral disc lesions, a review of 57 operated cases, Paraplegia 19: 133 (1980).
UROLOGY
AUGUST
198.5
VOLUME
XXVI.
SUMBER
2