Sacral anterior root stimulation: Prerequisites and indications

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Abstract
An intact sacral reflex arc, or at least an intact second motor‐neuron and a detrusor being able to contract, are the two prerequisites for implanting an anterior sacral root stimulator. Transrectal electrostimulation or direct needle stimulation of the sacral roots may reveal if patients despite absent or only weak detrusor contractions on routine investigation are suitable. Patients with a complete midthoracic paraplegia are the ideal candidates, but tetraplegics also benefit. Patients with incomplete lesions and preserved pain sensations are suitable provided that they can undergo posterior sacral root rhizotomy. Non‐traumatic spinal cord lesions follow the same rules, provided that the type of lesion does not allow recovery and is not progressive. Myelomeningocele patients may be suitable provided that the pathoanatomy of the sacral roots permits the operation (may be possible only in thoracolumbar myelomeningocele). Vesico‐uretero‐renal reflux is no contraindication; it may even be a strong indication, if a low compliance bladder or high detrusor contractions are the main reasons for it. In most patients the procedure should or must be combined with posterior sacral root rhizotomy in order to normalize a low compliance, to abolish spontaneous reflex contractions, and to achieve continence. The benefit of following these rules is reflected in our own series of 30 patients. In all of them the operation has improved considerably the quality of life and no patient so far has regretted the operation.