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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.

Three patients with spastic neurogenic bladder underwent sacral root stimulation and appropriate section of motor rootlets to the detrusor at the levels of the conus medullaris. Compared to the results obtained with rhizotomies at the sacral levels in a previous series of patients, urinary frequency and infection were inhibited for longer periods of time, but some uninhibited bladder activity recurred in all three patients. Analysis of anatomical and electrophysiological data serves to emphasize the complexity and asymmetry of efferent supply to detrusor muscle. The authors conclude that the role of selective rhizotomy for inhibition of the spastic bladder is inconclusive, and perhaps a combination of surgery and medications that inhibit smooth-muscle contraction may be required for long-term protection of urinary collection systems.

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✓ In 10 dogs, identifiable bundles of motor rootlets were stimulated as they left the conus medullaris at various levels. It is concluded that the bladder musculature is supplied by individual rootlets in variable combinations or patterns, originating from S-1 to S-4, with negligible overlapping innervation of the rectum and lower extremities. This experimental verification of clinical results suggests the possible value of a highly selective rhizotomy in humans with spastic neurogenic bladders (a procedure the authors term “selective sacral rhizidionotomy” from the Greek word rhizidion, meaning rootlet).