Sacral Selective Dorsal Rhizotomy for the Treatment of Neurogenic Bladder: Surgical Technique

Selective dorsal root rhizotomy (SDR) has been traditionally used to alleviate spasticity in patients with cerebral palsy. Its application to modulate bladder dysfunction in neurogenic spastic bladder, however, remains underexplored. We present single-level conus medullaris approach for sacral SDR as a technically feasible and potentially effective strategy for treating neurogenic bladder in a selected patient with neurogenic spastic bladder.

This instrumentation report details the surgical technique of sacral SDR targeting the S2-S5 dorsal rootlets by a minimally invasive single-level laminotomy at L1. Conus localization was guided by preoperative MRI and intraoperative neurophysiological monitoring-including electromyography and low-frequency radicular stimulation-was used to identify and selectively section hyperactive sensory fibers contributing to bladder overactivity. Intraoperative illustrations, photographs, and video are provided to enhance technical reproducibility.

Preoperatively, the patient demonstrated significant bladder dysfunction, with a maximum cystometric capacity of 181 mL and detrusor pressure of 85 cm H 2 O. Bladder compliance was severely impaired at 2 mL/cm H 2 O, with sustained involuntary detrusor contractions. Postoperatively, urodynamic studies revealed significant improvements: Maximum cystometric capacity was stable (173 mL), detrusor pressure decreased to 26 cm H 2 O (69.4% reduction), and bladder compliance improved to 7 mL/cm H 2 O. Notably, involuntary detrusor contractions were no longer detected.

Sacral SDR seems to be a feasible and safe procedure when performed at the conus medullaris level using a single-level approach. It may represent a potential therapeutic option for selected patients with neurogenic bladder who are refractory to conventional medical treatment. Nevertheless, further studies with large cohorts and longer follow-up are necessary to better assess the safety, efficacy, and appropriate indications of this technique before it can be considered for broader clinical application.