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Vesical Dysfunction Caused by Protruded Lumbar Disk
Vol. 105, Jan. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK JOHN L. EMMETT
AND
J. GRAFTON LOVE
From the Sections of Urology and Neurosurgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
we have found that the condition includes many parameters of vesical dysfunction, not just the end stage of complete retention. In other words, we have learned to recognize the problem in the pre-retention stage of the disease. Therefore, we have substituted the term "vesical dysfunction" for "urinary retention". Third, as we suspected, we have also encountered the problem in patients with "symptomatic" disk protrusions (back and leg pain and signs of radiculopathy). In fact, 9 of 35 patients in the series were in this category. However, in most of these the pain was relatively mild, vesical dysfunction being the primary complaint.
We presented 2 previous reports on urinary retention in women caused by asymptomatic protruded lumbar disk. The first report concerned 3 cases1 while the second presented 5 cases2 in detail with an addendum concerning 6 more, or a total of 11 cases. As of December 31, 1968 the series had increased to 35 cases. Herein we will study in depth these 35 patients, the first of whom was operated upon in June 1966 and the last in December 1968. All have been followed carefully and we have complete information on all cases as of May 15, 1969. In our 2 original reports we stressed the finding of urinary retention, the asymptomatic nature of the protruded disk and its apparent predilection for women. By asymptomatic we meant the absence of the characteristic pain of radiculopathy and its accompanying neurologic deficits. We were in effect asserting that the bladder can be an isolated target in spinal cord disease. It early became apparent that the problem involved more than just total urine retention. For instance, in our first 2 cases the history revealed that intermittent episodes of vesical irritability (urgency, frequency, difficulty voiding) had been present several years before culminating in total urinary retention.1. 2 Careful questioning after successful operation disclosed that these episodes began shortly after forgotten injuries which could have caused the disk protrusion. The study has therefore outgrown the original title. First, there are now 5 men in the series which was formerly confined to women patients. Second,
SELECTION OF PATIENTS
Inasmuch as either a diagnostic myelogram or an operation on the lower part of the spinal column is not without risk and postoperative complications, neither should be performed indiscriminately. Because of negative neurolo!2;IC findings in most cases and either negative or equivocal myelograms in many, accurate diagnosis is difficult. It is ironic that although the etiology of the disease is neurologic and the treatment is neurosurgical, diagnosis and selection of patients remain almost exclusively a urologic problem. In our experience a painstaking cystoscopic examination performed without general or topical anesthesia and with or without cystometrography coupled with careful appraisal of the distinctive urologic symptom complexes provides the best method of diagnosis and selection of patients.
Accepted for publication February 7, 1970. Abridgment of a paper read at meeting of Canadian Urological Association, Toronto, Canada, June 16-19, 1969. A copy of the complete paper may be obtained from the authors on request. 1 Love, J. G. and Emmett, J. L.: "Asymptomatic" protruded lumbar disk as a cause of urinary retention: preliminary report. Mayo Clin. Proc., 42: 249, 1967. 2 Emmett, J. L. and Love, J. G.: Urinary retention in women caused by asymptomatic protruded lumbar disk: report of 5 cases. J. Urol., 99: 597, 1968.
UROLOGIC DIAG.'!OSIS
Cystoscopy. We have learned to recognize a group of typical cystoscopic findings characteristic of this disease and referred to hereafter as "classic cystoscopic findings". Cystoscopy should be done preferably without anesthesia; at most a little topical anesthesia confined to the urethral meatus and terminal urethra should suffice. Findings are: 1) Vesical sensation is reduced or absent. The 86
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK
is aware that the cystoscope has been introduced and has little or no sensation of distress or pain when the vesical neck and trigone are or nrcv!rinrl with the heel of the direct Braasch cystoscope. 2) the most rn,nAPT•.rnT observation is that the patient has no normal desire to void. As the bladder is distended there is an awareness of only a sensation of "fullness"; as distention is increased the complains of discomfort and pain in the lower part of the abdodesire to men but still. does not v~•Jr,''""'V a void. This examination care and patience on the part of the ; he must obtain the confidence of the patient and the meaning of various terms such as "normal de~ire to void". In some excitable, nervous cystoscopy may have to be on another day to obtain accurate information. 3) There is no trabeculation of the bladder. 4) There appears to be normal force as water is evacuated through the cystoscope. 5) The c:1rmcn,y of the bladder is increased. In all cases the bladder will accommodate a minimum of 500 ml. In some cases the bladder may hold as much as ml. (average about 350 ml. for the normal In a few cv,stc,sc,cm:Lcfindings. However, we believe that we have been able to obtain as much or more information careful cystoscopy. should probably be used in addition to cystoscopy, since it a more objective and permanent record of the exami1mtion. UROLOGIC SYNDROMES THAT SUGGEST PROTRUDED DISK
or more, overflow incontinence (contindribbling of are the first 2 series 1 • 2 who were women in their The first had been an indwelling catheter for several monthH. The second patient had been diapers because of constant overflow-urine leaked from a bladder distended to 850 ml. Neither could initiate
87
urination. Both had associated bowel tion, having bowel movements only once in 3 to 5 day~. Results of removal of a protruded lumbar disk were immediately dramatic, both vesical and bowel function returning to normal. Syndrome 2. Chronic long-standing retention. This syndrome is characterized the patient (usually a woman) who is able to void but constantly has large amounts of residual urine with accompanying urinary infection. results of operation have been less dramatic than in other groups, most patients have been definitely benefited operation, and substantial reduction in the (so-called preretention phase). This syndrome is characterized by symptoms of frequency, urgency, difficulty in initiating and maintaining the urinary strean1 and straining to void. It may or may not be associated with flank, inguinal or lower quadrant abdominal pain, which can be a dramatic manifestation of this cmnJJlex Of diagnostic importance is the fact that this pain can be reproduced tion of the bladder during cystoscopy, or both. Syndrome 4. Loss of desire to void and unawareness of need to void often associated with micturition. This can best be described with an illustrative case. A high school football player, 6 feet 4 inches tall and weighing 250 pounds, 4 years previously had had fever and inability to void which continued for 18 hours. He had no particular distress and no feeling of a need to urinate, but catheterization evacuated ml. urine. For the last few months he had lost the desire to void and went long intervals (12 to 24 hours) between At times he could void a liter or more at one time. At other times he had been unable to initiate micturition and cathcterization would evacuate a similar amount of urine. The cystoscopic findings were classic but the patient had no residual urine. N eurologic findings were There wa.s no sign of radiculoA rnyelogram was disclosed a midline protrusion of the L4 disk which was removed. There was an immediate dramatic return of a normal desire to void. :\Iicturition could easily be initiated and frequency was normal-every 2 to 3 hours with no residual urine.
88
EMMETT AND LOVE OTHER FINDINGS
Bowel symptoms. Approximately one-third of the patients have had bowel symptoms. These symptoms consisted essentially of inability to have a bowel movement more often than every 3 to 5 days. Sexual symptoms. Sexual difficulty associated with both vesical and bowel dysfunction was observed in a 36-year-old man. All symptoms were eliminated following removal of the L4 disk. N eurologic evaluation. The neurologic examination-sensory, motor, reflexes-has been of little or no diagnostic value because it has given negative results in practically all cases. Examination for evidence of radiculopathy (such as positive Lasegue sign, spasm of erector spinae muscles) may be helpful if the findings are definitely positive. However, it has been of limited usefulness since 1) it so often gives negative results (because most the disk protrusions have been midline with minimal compression of the nerve roots* and 2) because the results of examination depend too much on the opinion of the examiner. For instance, one examiner may make a negative diagnosis whereas another may elicit minor alteration in the examination and call it positive. Objectivity in this examination may be difficult to achieve. Myelography. The myelogram often has been disappointing. If it is grossly positive, demonstrating a large defect due to the disk, it is helpful. However, often the defect is difficult to demonstrate so that the radiologist may call it negative whereas we (J.G.L.) may regard it as positive. It must not be forgotten, however, that symptomatic disk protrusion with typical pain, radiculopathy and so forth has never been primarily a roentgenologic diagnosis. Diagnosis has been made chiefly from clinical data; negative myelographic findings have not precluded surgical exploration if clinical data were definite. Indeed, myelography is not done routinely by some workers in this field. Estimates of the percentage of surgically proved symptomatic disks in which the preoperative myelogram has been negative vary but that it occurs in a substantial number of cases is not questioned. It is the opinion of one of us (J.G.L.)
* The low incidence of typical disk-type (sciatic) pain in this series of patients is believed to be due to the midline location of the disk which causes minimal pressure on the nerve roots as they leave the spinal column.
that the incidence of positive myelographic findings would definitely increase if air were used instead of opaque contrast medium. Not only may opaque contrast medium obscure the disk but its use gives a definitely higher incidence of post-myelographic complications (such as arachnoiditis). We have classified the myelograms as positive, equivocal and negative. If one of us (J.G.L.) and the radiologists agree that it is positive, it is so classified. If there is disagreement (between one of us [J.G.L.] and the radiologist or between individual radiologists), it is classified as equivocal; if all concerned call it negative it is so classified. On this basis in the 35 cases, myelograms were posiitive in 14 (40 per cent), equivocal in 19 (54 per cent) and negative in 2 (6 per cent). ANALYSIS OF DIAGNOSTIC DATA AND LATE RESULTS OF OPERATION ON
35
CASES
Evaluation of late results is important because, as mentioned previously, either diagnostic myelography or an operation on the lower part of the spinal column can involve risk, complications and postoperative morbidity. Length of followup. The first patient in this series was operated upon in June 1966, the last in December 1968. Duration of followup was 1 to 3 years for 27 patients and 6 to 10 months for 8 patients. Aye, sex and site of protruded disk. There were 30 women and 5 men in the group. Their ages varied from 15 to 72 years. The site of the protruded disk was L4, 29 cases (83 per cent); L3, 2 cases; L5, 2 cases and L4 and L5, 1 case. No protruded disk was found in 1 case. Classification of results. The condition of the patient has been classified as good, improved or unimproved (poor). Good means that vesical symptoms and residual urine (if present) have been completely eliminated and disk pain (if present) has been completely relieved. Improved signifies 1) vesical dysfunction has been corrected but the patient now has some disk-type pain which was not present preoperatively, 2) vesical function has been improved and residual urine has been reduced in amount but not completely eliminated or 3) disk pain present before operation is less severe and vesical function is improved but not entirely normal. Unimproved signifies 1) vesical function has not improved, 2) immediate results were good
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK
(vesical function returned to normal) but the condition later regressed or 3) the condition definitely has been worse since operation; for instance, vesical dysfunction has increased and the patient now has disk-type pain that was not present before operation or if disk-type pain was present before operation, it has increased. According to this classification, the condition of the patient on followup was good in 17 cases (49 per cent), improved in 7 (20 per cent) and unimproved in 11 (31 per cent). Correlation of results with preoperative and operative findings. Hoping to elicit information that might assist in a more accurate selection of patients for operation we attempted to correlate preoperative and operative data with results. Findings that seemed to have no influence on results were 1) age and sex; 2) site of protruded disk; 3) weight of disk material removed which varied from 0.05 to 3.1 gm. (lack of correlation of weight of disk with results of operation is illustrated by our most dramatic results which were obtained in 2 patients whose disk weights differed 0.5 and 3.1 gm., respectively) and 4) quantity of residual urine (lack of correlation of this factor with results of operation is indicated by the fact that large residuals of 150 to 3,000 ml. were present in the same percentage, 53 per cent, of patients with good results as in those with poor results; similarly no residual urine was present in essentially the same percentage, 17 per cent, of patients with good results as in those with poor results). Findings that seemed to predispose to a good result included 1) preoperative typical disk-type pain (sciatica); 2) evidence of radiculopathy; 3) preoperative flank, lower quadrant abdominal or inguinal pain, or a combination of these, reproducible by bladder distention; 4) a large vesical capacity (500 ml. or more); 5) classic cystoscopic findings and 6) either a positive or equivocal myelogram. Postoperative complications and morbidity; patients requiring re-operation. Four patients have undergone re-operation. One was operated upon 5 months after her first operation for recurrence of preoperative disk pain. She had had no recurrence of vesical dysfunction. At operation (done elsewhere), recurring protrusion of disk material at the same site (14) with some scarring was found. This operation was successful and the pain was relieved. The patient was well at followup more than 18 months after the second operation.
89
Three other patients required re-operation because of subsequent accidents. The most unusual patient was the one reported in detail as case 2 previously. 1 • 2 This was an obese 23-year-old nurse who arrived at the ::viayo Clinic wearing diapers because of overflow in" continence and 850 ml. residual urine. She was entirely free of symptoms following removal of protruded disks at L4 and L5 interspaces until 6 months later when her large dog accidentally knocked her over backward. She struck the lower part of her back upon falling and typical disk pain (with sciatica) developed which was not present before the original operation. However, vesical dysfunction did not recur. A myelogram made with opaque contrast medium by an orthopedist showed recurrence of protruded disk material at L5 which he removed; symptoms were relieved. Four months later (10 months after the original operation at the Mayo Clinic) this patient fell down stairs, landing hard on her buttocks and suffering a recurrence of the disk and sciatic pain. She still had no recurrence of vesical dysfunction. She was again operated on by her local orthopedist who reported finding more protruded disk material. However, the operation did not relieve the pain. Four months later (14 months after the original operation) the patient returned to the Mayo Clinic with disk pain, numbness in left foot, limp and list of the trunk with spasm of the erector spinae muscles. Two weeks previously the vesical dysfunction had recurred; she again had 850 ml. residual urine but had no recurrence of the overflow incontinence. She could void small amounts of urine with abdominal straining Crede expression. She had no desire to void. An air myelogram showed a defect from the disk at the L4 space. Operation (J.G.L.) revealed recurring protruded disk material which was removed. Fifteen months later (2~-:i years after the original operation) the pain, numbness, list, limp and spasm of the erector spinae had been eliminated but vesical dysfunction persisted. We have classified this patient's condition as unimproved. The third patient was the 19-year-old high school football player who illustrated syndrome 4. Five months after operation he lifted a heavy sack of sand, something "snapped" in his back, typical disk pain developed and vesical dysfunction recurred. The fourth patient was a woman (original case
90
EMMETT AND LOVE
Lar e anterior meningocele in 33-year-old woman. Meningocele has e~panded a~d eroded sacral c~nal and sa~ral foramina and has extended up into 1umbar spinal canal. A, pl_am film (residual opaqud. medmm is from previous myelography done elsewhere). B, myelogram made with opaque contrast me mm. 3) 1 • 2 who was well for 1 year until she fell on the stairs and typical disk pain and a recurrence of vesical dysfunction developed. Patients whose postoperative condition was classified as unimproved (poor result). Of the 11 patients in this classification, 1 patient (case 4 reported previously) 2 had, in addition to protrusion of the L3 disk, a tumor (ependymoma) of the conus and cauda equina. The tumor was so extensive and removal so difficult that it was considered unwise to prolong the operation to remove the disk. In 1 patient (case 2 in previous reports),1· 2 multiple postoperative accidents with trauma to the back were the cause of the final poor result. (This patient's course has been described in the section on postoperative complications, morbidity and re-operation.) Two patients probably should not have been operated upon because preoperative findings were not sufficiently typical of the disease complex. One case was classic. Immediate results were excellent. Complete retention was eliminated and normal desire and ability to urinate returned. However, 4 to 6 weeks later retention recurred. We suspect that more disk material has extruded and the patient probably needs re-operation. Another case was classic but the results were disappointing. Vesical dysfunction continues. We have no explanation for this failure. In 1 case no disk was found. In the remaining cases we have no explanation for the poor results.
DISCUSSION
Physiopathologic mechanism of vesical dysfunction in cases of "silent" protruded disk. There has been considerable criticism of the concept that vesical dysfunction can result from a protruded disk in which no other neurologic deficits or radicular pain can be demonstrated, that is that the bladder can be an isolated target in spinal cord disease. We admit that the cause-and-effect relationship is difficult to explain. At present we believe that the chief factor is a deficit in the sensory nerve pathways from the bladder to the spinal cord. Certainly the most prominent single finding is the absence or decrease of vesical sensation, with loss of normal desire for micturition, which is associated with a great increase in ve.3ical capacity. These findings are easily demonstrated by either cystoscopy or cystometry. Rosomoff and associates demonstrated the frequency of abnormal cystometrograms in patients with protruded lumbar disks. 3 Robson 4 and Constantian 5 now have had a fairly substantial and favorable experience with operation; both have relied heavily on cystometry for diagnosis and selection of cases. It seems likely that the sensory fibers from the 3 Rosomoff, H. L., Johnston, J.D.~., Gallo, A. E., Givens, F. and Kuehn, C. A.: Routme cystometry in evaluation of lumbar disk syndromes. Surg. Forum, 13: 442, 1962. . . 4 Robson C. J.: Personal commumcat10n. 6 Consta~tian, H. M.: Personal communication.
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK
bladder (which run via the sacral roots and cauda equina to the reflex center for micturition in the sacral portion of the cord) may be more susceptible to damage by minimal degrees of stretching or pressure from a midline protrusion of a disk than are somatic sensory and motor fibers. It is significant that in many of these cases it has been possible at operation (J.G.L.) to demonstrate hyperirritability of the cauda equina. Since the early days of operations for protruded disks we have known that compressed nerve roots are usually swollen and unless severely damaged from longstanding pressure are hyper-irritable. That is, when the involved nerve root is stroked or touched with a bayonet forceps the muscles supplied by that root contract violently and often the patient's respirations change audibly. Evidence that extensive disease of the cauda equina may disturb only the nerve pathways to the bladder is provided by the following case. A 33-year-old woman came to the Mayo Clinic because of complete "bladder paralysis", which had necessitated an indwelling catheter constantly for the past 10 years. If the catheter was removed the bladder would distend to 3,000 ml. or more and overflow dribbling incontinence would ensue. Aside from the bladder trouble she complained of no symptoms. She had had 3 children with entirely normal pregnancies and deliveries. There was no bowel difficulty. N eurologic findings were normal. There was no weakness of the lower extremities. Plain films and a myelogram revealed a huge anterior sacral meningocele which expanded the sacral canal and sacral foramina and extended into the lumbar spinal canal (see figure). There was such extensive
91
erosion of the walls of the sacrum that pressure over this area with the hand would cause the patient to complain of pressure in the head and headaches. Surgical exploration revealed erosion of the sacrum on the right side. The huge meningocele extended well up into the lumbar canal. The anterior body of the sacrum had been completely destroyed in this area and the rectum had herniated through this and was distorting the meningocele. The sacral roots (except SI) were lying within the defect. Accuracy in diagnosis; difficulty in selection of patients for operation. Selection of patients for operation continues to be difficult. Conventional neurologic examination is of little or no help, as it almost always gives negative results. :\Iyelography has also been disappointing; a definitely positive myelogram is helpful but an equivocal or negative one does not exclude protrusion of a disk as the cause of the vesical dysfunction. Urologic examination (cystoscopy, cystometry or both) and a careful history and clinical evaluation continue to be the most significant diagnostic modalities. Postoperative complications; recurrence of protruded disk. That recurrence of protruded disk material is a not uncommon and important postoperative complication is substantiated by the 4 patients in this series who required re-operation. Increased susceptibility to injury (from falls, lifting and so forth) must be carefully explained to the patient. Possible revisions of surgical technique to minimize this complication must be entertained.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK JOHN L. EMMETT
AND
J. GRAFTON LOVE
From the Sections of Urology and Neurosurgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
we have found that the condition includes many parameters of vesical dysfunction, not just the end stage of complete retention. In other words, we have learned to recognize the problem in the pre-retention stage of the disease. Therefore, we have substituted the term "vesical dysfunction" for "urinary retention". Third, as we suspected, we have also encountered the problem in patients with "symptomatic" disk protrusions (back and leg pain and signs of radiculopathy). In fact, 9 of 35 patients in the series were in this category. However, in most of these the pain was relatively mild, vesical dysfunction being the primary complaint.
We presented 2 previous reports on urinary retention in women caused by asymptomatic protruded lumbar disk. The first report concerned 3 cases1 while the second presented 5 cases2 in detail with an addendum concerning 6 more, or a total of 11 cases. As of December 31, 1968 the series had increased to 35 cases. Herein we will study in depth these 35 patients, the first of whom was operated upon in June 1966 and the last in December 1968. All have been followed carefully and we have complete information on all cases as of May 15, 1969. In our 2 original reports we stressed the finding of urinary retention, the asymptomatic nature of the protruded disk and its apparent predilection for women. By asymptomatic we meant the absence of the characteristic pain of radiculopathy and its accompanying neurologic deficits. We were in effect asserting that the bladder can be an isolated target in spinal cord disease. It early became apparent that the problem involved more than just total urine retention. For instance, in our first 2 cases the history revealed that intermittent episodes of vesical irritability (urgency, frequency, difficulty voiding) had been present several years before culminating in total urinary retention.1. 2 Careful questioning after successful operation disclosed that these episodes began shortly after forgotten injuries which could have caused the disk protrusion. The study has therefore outgrown the original title. First, there are now 5 men in the series which was formerly confined to women patients. Second,
SELECTION OF PATIENTS
Inasmuch as either a diagnostic myelogram or an operation on the lower part of the spinal column is not without risk and postoperative complications, neither should be performed indiscriminately. Because of negative neurolo!2;IC findings in most cases and either negative or equivocal myelograms in many, accurate diagnosis is difficult. It is ironic that although the etiology of the disease is neurologic and the treatment is neurosurgical, diagnosis and selection of patients remain almost exclusively a urologic problem. In our experience a painstaking cystoscopic examination performed without general or topical anesthesia and with or without cystometrography coupled with careful appraisal of the distinctive urologic symptom complexes provides the best method of diagnosis and selection of patients.
Accepted for publication February 7, 1970. Abridgment of a paper read at meeting of Canadian Urological Association, Toronto, Canada, June 16-19, 1969. A copy of the complete paper may be obtained from the authors on request. 1 Love, J. G. and Emmett, J. L.: "Asymptomatic" protruded lumbar disk as a cause of urinary retention: preliminary report. Mayo Clin. Proc., 42: 249, 1967. 2 Emmett, J. L. and Love, J. G.: Urinary retention in women caused by asymptomatic protruded lumbar disk: report of 5 cases. J. Urol., 99: 597, 1968.
UROLOGIC DIAG.'!OSIS
Cystoscopy. We have learned to recognize a group of typical cystoscopic findings characteristic of this disease and referred to hereafter as "classic cystoscopic findings". Cystoscopy should be done preferably without anesthesia; at most a little topical anesthesia confined to the urethral meatus and terminal urethra should suffice. Findings are: 1) Vesical sensation is reduced or absent. The 86
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK
is aware that the cystoscope has been introduced and has little or no sensation of distress or pain when the vesical neck and trigone are or nrcv!rinrl with the heel of the direct Braasch cystoscope. 2) the most rn,nAPT•.rnT observation is that the patient has no normal desire to void. As the bladder is distended there is an awareness of only a sensation of "fullness"; as distention is increased the complains of discomfort and pain in the lower part of the abdodesire to men but still. does not v~•Jr,''""'V a void. This examination care and patience on the part of the ; he must obtain the confidence of the patient and the meaning of various terms such as "normal de~ire to void". In some excitable, nervous cystoscopy may have to be on another day to obtain accurate information. 3) There is no trabeculation of the bladder. 4) There appears to be normal force as water is evacuated through the cystoscope. 5) The c:1rmcn,y of the bladder is increased. In all cases the bladder will accommodate a minimum of 500 ml. In some cases the bladder may hold as much as ml. (average about 350 ml. for the normal In a few cv,stc,sc,cm:Lcfindings. However, we believe that we have been able to obtain as much or more information careful cystoscopy. should probably be used in addition to cystoscopy, since it a more objective and permanent record of the exami1mtion. UROLOGIC SYNDROMES THAT SUGGEST PROTRUDED DISK
or more, overflow incontinence (contindribbling of are the first 2 series 1 • 2 who were women in their The first had been an indwelling catheter for several monthH. The second patient had been diapers because of constant overflow-urine leaked from a bladder distended to 850 ml. Neither could initiate
87
urination. Both had associated bowel tion, having bowel movements only once in 3 to 5 day~. Results of removal of a protruded lumbar disk were immediately dramatic, both vesical and bowel function returning to normal. Syndrome 2. Chronic long-standing retention. This syndrome is characterized the patient (usually a woman) who is able to void but constantly has large amounts of residual urine with accompanying urinary infection. results of operation have been less dramatic than in other groups, most patients have been definitely benefited operation, and substantial reduction in the (so-called preretention phase). This syndrome is characterized by symptoms of frequency, urgency, difficulty in initiating and maintaining the urinary strean1 and straining to void. It may or may not be associated with flank, inguinal or lower quadrant abdominal pain, which can be a dramatic manifestation of this cmnJJlex Of diagnostic importance is the fact that this pain can be reproduced tion of the bladder during cystoscopy, or both. Syndrome 4. Loss of desire to void and unawareness of need to void often associated with micturition. This can best be described with an illustrative case. A high school football player, 6 feet 4 inches tall and weighing 250 pounds, 4 years previously had had fever and inability to void which continued for 18 hours. He had no particular distress and no feeling of a need to urinate, but catheterization evacuated ml. urine. For the last few months he had lost the desire to void and went long intervals (12 to 24 hours) between At times he could void a liter or more at one time. At other times he had been unable to initiate micturition and cathcterization would evacuate a similar amount of urine. The cystoscopic findings were classic but the patient had no residual urine. N eurologic findings were There wa.s no sign of radiculoA rnyelogram was disclosed a midline protrusion of the L4 disk which was removed. There was an immediate dramatic return of a normal desire to void. :\Iicturition could easily be initiated and frequency was normal-every 2 to 3 hours with no residual urine.
88
EMMETT AND LOVE OTHER FINDINGS
Bowel symptoms. Approximately one-third of the patients have had bowel symptoms. These symptoms consisted essentially of inability to have a bowel movement more often than every 3 to 5 days. Sexual symptoms. Sexual difficulty associated with both vesical and bowel dysfunction was observed in a 36-year-old man. All symptoms were eliminated following removal of the L4 disk. N eurologic evaluation. The neurologic examination-sensory, motor, reflexes-has been of little or no diagnostic value because it has given negative results in practically all cases. Examination for evidence of radiculopathy (such as positive Lasegue sign, spasm of erector spinae muscles) may be helpful if the findings are definitely positive. However, it has been of limited usefulness since 1) it so often gives negative results (because most the disk protrusions have been midline with minimal compression of the nerve roots* and 2) because the results of examination depend too much on the opinion of the examiner. For instance, one examiner may make a negative diagnosis whereas another may elicit minor alteration in the examination and call it positive. Objectivity in this examination may be difficult to achieve. Myelography. The myelogram often has been disappointing. If it is grossly positive, demonstrating a large defect due to the disk, it is helpful. However, often the defect is difficult to demonstrate so that the radiologist may call it negative whereas we (J.G.L.) may regard it as positive. It must not be forgotten, however, that symptomatic disk protrusion with typical pain, radiculopathy and so forth has never been primarily a roentgenologic diagnosis. Diagnosis has been made chiefly from clinical data; negative myelographic findings have not precluded surgical exploration if clinical data were definite. Indeed, myelography is not done routinely by some workers in this field. Estimates of the percentage of surgically proved symptomatic disks in which the preoperative myelogram has been negative vary but that it occurs in a substantial number of cases is not questioned. It is the opinion of one of us (J.G.L.)
* The low incidence of typical disk-type (sciatic) pain in this series of patients is believed to be due to the midline location of the disk which causes minimal pressure on the nerve roots as they leave the spinal column.
that the incidence of positive myelographic findings would definitely increase if air were used instead of opaque contrast medium. Not only may opaque contrast medium obscure the disk but its use gives a definitely higher incidence of post-myelographic complications (such as arachnoiditis). We have classified the myelograms as positive, equivocal and negative. If one of us (J.G.L.) and the radiologists agree that it is positive, it is so classified. If there is disagreement (between one of us [J.G.L.] and the radiologist or between individual radiologists), it is classified as equivocal; if all concerned call it negative it is so classified. On this basis in the 35 cases, myelograms were posiitive in 14 (40 per cent), equivocal in 19 (54 per cent) and negative in 2 (6 per cent). ANALYSIS OF DIAGNOSTIC DATA AND LATE RESULTS OF OPERATION ON
35
CASES
Evaluation of late results is important because, as mentioned previously, either diagnostic myelography or an operation on the lower part of the spinal column can involve risk, complications and postoperative morbidity. Length of followup. The first patient in this series was operated upon in June 1966, the last in December 1968. Duration of followup was 1 to 3 years for 27 patients and 6 to 10 months for 8 patients. Aye, sex and site of protruded disk. There were 30 women and 5 men in the group. Their ages varied from 15 to 72 years. The site of the protruded disk was L4, 29 cases (83 per cent); L3, 2 cases; L5, 2 cases and L4 and L5, 1 case. No protruded disk was found in 1 case. Classification of results. The condition of the patient has been classified as good, improved or unimproved (poor). Good means that vesical symptoms and residual urine (if present) have been completely eliminated and disk pain (if present) has been completely relieved. Improved signifies 1) vesical dysfunction has been corrected but the patient now has some disk-type pain which was not present preoperatively, 2) vesical function has been improved and residual urine has been reduced in amount but not completely eliminated or 3) disk pain present before operation is less severe and vesical function is improved but not entirely normal. Unimproved signifies 1) vesical function has not improved, 2) immediate results were good
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK
(vesical function returned to normal) but the condition later regressed or 3) the condition definitely has been worse since operation; for instance, vesical dysfunction has increased and the patient now has disk-type pain that was not present before operation or if disk-type pain was present before operation, it has increased. According to this classification, the condition of the patient on followup was good in 17 cases (49 per cent), improved in 7 (20 per cent) and unimproved in 11 (31 per cent). Correlation of results with preoperative and operative findings. Hoping to elicit information that might assist in a more accurate selection of patients for operation we attempted to correlate preoperative and operative data with results. Findings that seemed to have no influence on results were 1) age and sex; 2) site of protruded disk; 3) weight of disk material removed which varied from 0.05 to 3.1 gm. (lack of correlation of weight of disk with results of operation is illustrated by our most dramatic results which were obtained in 2 patients whose disk weights differed 0.5 and 3.1 gm., respectively) and 4) quantity of residual urine (lack of correlation of this factor with results of operation is indicated by the fact that large residuals of 150 to 3,000 ml. were present in the same percentage, 53 per cent, of patients with good results as in those with poor results; similarly no residual urine was present in essentially the same percentage, 17 per cent, of patients with good results as in those with poor results). Findings that seemed to predispose to a good result included 1) preoperative typical disk-type pain (sciatica); 2) evidence of radiculopathy; 3) preoperative flank, lower quadrant abdominal or inguinal pain, or a combination of these, reproducible by bladder distention; 4) a large vesical capacity (500 ml. or more); 5) classic cystoscopic findings and 6) either a positive or equivocal myelogram. Postoperative complications and morbidity; patients requiring re-operation. Four patients have undergone re-operation. One was operated upon 5 months after her first operation for recurrence of preoperative disk pain. She had had no recurrence of vesical dysfunction. At operation (done elsewhere), recurring protrusion of disk material at the same site (14) with some scarring was found. This operation was successful and the pain was relieved. The patient was well at followup more than 18 months after the second operation.
89
Three other patients required re-operation because of subsequent accidents. The most unusual patient was the one reported in detail as case 2 previously. 1 • 2 This was an obese 23-year-old nurse who arrived at the ::viayo Clinic wearing diapers because of overflow in" continence and 850 ml. residual urine. She was entirely free of symptoms following removal of protruded disks at L4 and L5 interspaces until 6 months later when her large dog accidentally knocked her over backward. She struck the lower part of her back upon falling and typical disk pain (with sciatica) developed which was not present before the original operation. However, vesical dysfunction did not recur. A myelogram made with opaque contrast medium by an orthopedist showed recurrence of protruded disk material at L5 which he removed; symptoms were relieved. Four months later (10 months after the original operation at the Mayo Clinic) this patient fell down stairs, landing hard on her buttocks and suffering a recurrence of the disk and sciatic pain. She still had no recurrence of vesical dysfunction. She was again operated on by her local orthopedist who reported finding more protruded disk material. However, the operation did not relieve the pain. Four months later (14 months after the original operation) the patient returned to the Mayo Clinic with disk pain, numbness in left foot, limp and list of the trunk with spasm of the erector spinae muscles. Two weeks previously the vesical dysfunction had recurred; she again had 850 ml. residual urine but had no recurrence of the overflow incontinence. She could void small amounts of urine with abdominal straining Crede expression. She had no desire to void. An air myelogram showed a defect from the disk at the L4 space. Operation (J.G.L.) revealed recurring protruded disk material which was removed. Fifteen months later (2~-:i years after the original operation) the pain, numbness, list, limp and spasm of the erector spinae had been eliminated but vesical dysfunction persisted. We have classified this patient's condition as unimproved. The third patient was the 19-year-old high school football player who illustrated syndrome 4. Five months after operation he lifted a heavy sack of sand, something "snapped" in his back, typical disk pain developed and vesical dysfunction recurred. The fourth patient was a woman (original case
90
EMMETT AND LOVE
Lar e anterior meningocele in 33-year-old woman. Meningocele has e~panded a~d eroded sacral c~nal and sa~ral foramina and has extended up into 1umbar spinal canal. A, pl_am film (residual opaqud. medmm is from previous myelography done elsewhere). B, myelogram made with opaque contrast me mm. 3) 1 • 2 who was well for 1 year until she fell on the stairs and typical disk pain and a recurrence of vesical dysfunction developed. Patients whose postoperative condition was classified as unimproved (poor result). Of the 11 patients in this classification, 1 patient (case 4 reported previously) 2 had, in addition to protrusion of the L3 disk, a tumor (ependymoma) of the conus and cauda equina. The tumor was so extensive and removal so difficult that it was considered unwise to prolong the operation to remove the disk. In 1 patient (case 2 in previous reports),1· 2 multiple postoperative accidents with trauma to the back were the cause of the final poor result. (This patient's course has been described in the section on postoperative complications, morbidity and re-operation.) Two patients probably should not have been operated upon because preoperative findings were not sufficiently typical of the disease complex. One case was classic. Immediate results were excellent. Complete retention was eliminated and normal desire and ability to urinate returned. However, 4 to 6 weeks later retention recurred. We suspect that more disk material has extruded and the patient probably needs re-operation. Another case was classic but the results were disappointing. Vesical dysfunction continues. We have no explanation for this failure. In 1 case no disk was found. In the remaining cases we have no explanation for the poor results.
DISCUSSION
Physiopathologic mechanism of vesical dysfunction in cases of "silent" protruded disk. There has been considerable criticism of the concept that vesical dysfunction can result from a protruded disk in which no other neurologic deficits or radicular pain can be demonstrated, that is that the bladder can be an isolated target in spinal cord disease. We admit that the cause-and-effect relationship is difficult to explain. At present we believe that the chief factor is a deficit in the sensory nerve pathways from the bladder to the spinal cord. Certainly the most prominent single finding is the absence or decrease of vesical sensation, with loss of normal desire for micturition, which is associated with a great increase in ve.3ical capacity. These findings are easily demonstrated by either cystoscopy or cystometry. Rosomoff and associates demonstrated the frequency of abnormal cystometrograms in patients with protruded lumbar disks. 3 Robson 4 and Constantian 5 now have had a fairly substantial and favorable experience with operation; both have relied heavily on cystometry for diagnosis and selection of cases. It seems likely that the sensory fibers from the 3 Rosomoff, H. L., Johnston, J.D.~., Gallo, A. E., Givens, F. and Kuehn, C. A.: Routme cystometry in evaluation of lumbar disk syndromes. Surg. Forum, 13: 442, 1962. . . 4 Robson C. J.: Personal commumcat10n. 6 Consta~tian, H. M.: Personal communication.
VESICAL DYSFUNCTION CAUSED BY PROTRUDED LUMBAR DISK
bladder (which run via the sacral roots and cauda equina to the reflex center for micturition in the sacral portion of the cord) may be more susceptible to damage by minimal degrees of stretching or pressure from a midline protrusion of a disk than are somatic sensory and motor fibers. It is significant that in many of these cases it has been possible at operation (J.G.L.) to demonstrate hyperirritability of the cauda equina. Since the early days of operations for protruded disks we have known that compressed nerve roots are usually swollen and unless severely damaged from longstanding pressure are hyper-irritable. That is, when the involved nerve root is stroked or touched with a bayonet forceps the muscles supplied by that root contract violently and often the patient's respirations change audibly. Evidence that extensive disease of the cauda equina may disturb only the nerve pathways to the bladder is provided by the following case. A 33-year-old woman came to the Mayo Clinic because of complete "bladder paralysis", which had necessitated an indwelling catheter constantly for the past 10 years. If the catheter was removed the bladder would distend to 3,000 ml. or more and overflow dribbling incontinence would ensue. Aside from the bladder trouble she complained of no symptoms. She had had 3 children with entirely normal pregnancies and deliveries. There was no bowel difficulty. N eurologic findings were normal. There was no weakness of the lower extremities. Plain films and a myelogram revealed a huge anterior sacral meningocele which expanded the sacral canal and sacral foramina and extended into the lumbar spinal canal (see figure). There was such extensive
91
erosion of the walls of the sacrum that pressure over this area with the hand would cause the patient to complain of pressure in the head and headaches. Surgical exploration revealed erosion of the sacrum on the right side. The huge meningocele extended well up into the lumbar canal. The anterior body of the sacrum had been completely destroyed in this area and the rectum had herniated through this and was distorting the meningocele. The sacral roots (except SI) were lying within the defect. Accuracy in diagnosis; difficulty in selection of patients for operation. Selection of patients for operation continues to be difficult. Conventional neurologic examination is of little or no help, as it almost always gives negative results. :\Iyelography has also been disappointing; a definitely positive myelogram is helpful but an equivocal or negative one does not exclude protrusion of a disk as the cause of the vesical dysfunction. Urologic examination (cystoscopy, cystometry or both) and a careful history and clinical evaluation continue to be the most significant diagnostic modalities. Postoperative complications; recurrence of protruded disk. That recurrence of protruded disk material is a not uncommon and important postoperative complication is substantiated by the 4 patients in this series who required re-operation. Increased susceptibility to injury (from falls, lifting and so forth) must be carefully explained to the patient. Possible revisions of surgical technique to minimize this complication must be entertained.