Selective sacral rootlet rhizotomy for hypertonic neurogenic bladder.

The authors describe a highly selective transsacral microsurgical procedure for sacral nerve rootlet interruption in five patients with hypertonic neurogenic bladder. Magnification and systematic stimulation of sacral roots provided accurate identification of motor fibers supplying bladder detrusor muscle and differentiation of efferent components to the legs and anal sphincter. Although the technique prevented incontinence and adverse effects of nerve section on rectal and lower extremity function improvement in voiding patterns and diminution of urinary sepsis was of brief duration in three of the five patients. Physiological data from these procedures reaffirms the importance of S-3 and S-4 motor roots in detrusor innervation, but clinical responses bring into question the possibility of sustained improvement from such a highly selective procedure at the sacral level. The authors suggest that alternative pathways, not apparent on initial stimulation, may develop after section of sacral root components, and that dissection and stimulation of fibers at the level of the conus medullaris should be investigated as an alternative procedure.