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CHAPTER 26
This was followed by a film taken during bladder pressure raised by straining either
voluntarily or passively, or by provoking reflex detrusor function (micturating film).
Reflux was found in 75 out of the 343 cases (22 per cent). Of these, 221 had upper
motor neuron lesions with more or less marked spasticity, and the incidence of reflux
was 43 (19 per cent), while 122 cases had lower motor neuron lesions with flaccidity, and
amongst these 32 (26 per cent) had reflux. These findings confirmed previous views
(Guttmann, 1953) tnat there was no evidence to assume a particular neurogenic lesion of
the ureter as a direct aetiological factor of reflux, as far as type, degree and level of the
cord lesion was concerned. This was not in accordance with the view expressed by Bors &
Comarr (1955) and Damanski & Gibbon (1960), who considered reflux occurring more
frequently in upper motor neuron lesions than in lower motor neuron lesions. Bors
suggested as explanation, that the preservation of the sympathetic innervation of the
trigone in low-cord lesions may have some protective effect upon the ureteric orifice
which accounts for the low incidence of reflux in lower motor neuron lesions. However,
there is no proof that cord lesions at and above T5, including cervical lesions, where the
whole splanchnic control is crippled, show a higher incidence of reflux than cord lesions
below that level. The arbitrary classification of cord lesions described by Damanski &
Gibbon, dividing their cases into those above T9, T9~Tn and Tn, is not acceptable
as a proof of their theory from a neuro-physiological point of view that reflux is prevalent
in upper motor neuron lesions. Actually, Bors & Comarr (1971) in a recent statistic of
Long Beach V.A. Hospital on 866 patients, in contrast to their data given in 1955, also
found, in confirmation of my own observations, a higher percentage of reflux in lower
motor neuron lesions (38-6 per cent) than in upper motor neuron lesions (27 per cent).
The concept that the cord lesion itself has a direct effect on the incidence of reflux
has led workers in this field to carry out neurosurgical procedures, such as pudental
neurectomy, sacral neurectomy, anterior or posterior rhizotomy, or intrathecal alcohol
block. However, from the results described it cannot be concluded that these operations
had any therapeutic effect on the reflux.
It is worthwhile mentioning that of my 122 patients who had a cystogram within the
first 12 months following paraplegia and tetraplegia 34 had a sterile urine and there was
no reflux. Of the 85 patients with infected urine only two had reflux. Moreover, it may
TABLE 21. Time between injury and first diagnosis of reflux
Time after injury
Reflux
Less than 3 months
2
3 to 6 months
8
Over 6 to 12 months
5
Over i to 2 years
3
Over 2 to 3 years
I
Over 3 to 4 years
o
Over 4 to 5 years
I
Over 5 to 6 years
I
Total
21
