Neurourology and Urodynamics 25:788^791 (2006)

External Anal Sphincter Responses After S3 Spinal

Root Surface Electrical Stimulation
Giuseppe Pelliccioni* and Osvaldo Scarpino
Neurology Unit, Geriatric Hospital, INRCA, Ancona, Italy
Aims: The aim of this study is to present the normative data of direct and re£ex motor anal
sphincter responses, simultaneously evoked by S3 surface electrical stimulation. By this method,
it is possible to test the functional integrity of the nervous pathways activated during sacral neu-
romodulation (SNM). Methods: Twenty healthy subjects were studied. Motor-evoked potentials
(MEPs) were recorded by concentric needle electrode from external anal sphincter (EAS). Electrical
stimulation was applied by means of a bipolar surface electrode over the S3 right or left sacral
foramina. Results: Direct (R1) and re£ex responses (R2 and R3) were found at latencies of 6.98,
25.12, and 50.31 msec, respectively. The two ¢rst responses were recorded in all the cases; the last
response is steadily recorded in 17 out of 20 subjects. Conclusions: Our data can serve as reference
values for future study in patients with pelvic £oor dysfunction. EAS responses following S3 percu-
taneous electrical stimulation can represent a useful aid in the selection of candidates to SNM.
Neurourol. Urodynam. 25:788 ^791, 2006. ß 2006 Wiley-Liss, Inc.

Key words: electric stimulation; motor-evoked potentials; neurophysiology; pelvic £oor

INTRODUCTION cedures that require introducing wire electrode close to S3

Sacral neuromodulation (SNM) was introduced by Tanagho
and Schmidt [1982] for voiding dysfunction and has been
reported to be useful in detrusor overactivity and urinary reten-
tion [Bosch and Groen, 1998; Hassouna et al., 2000; Siegel et al.,
2000; Abrams et al., 2003; Dasgupta et al., 2004]. More recently, it
has gained increasing use for the treatment of fecal incontinence
[Matzel et al., 1995; Vaizey et al., 1999, 2000; Malouf et al., 2000;
Jarrett et al., 2004]. SNM involves applying a low voltage electri-
cal current to S3 root via an electrode placed through the corre-
sponding sacral foramen. During SNM, both the e¡erent and
a¡erent ¢bers in the sacral nerve are stimulated.
The e⁄cacy of the treatment may depend from the func-
tional integrity of the motor pathways and the status of the
whole re£ex arc subserving the lower sacral segments.
Di¡erent neurophysiological tests have been proposed in
order to assess the direct and re£ex responses to the pelvic
£oor [Opsomer et al., 1989a; Vodusek, 1996; Uher and Swash,
1998; Podnar and Vodusek, 2001]. Among these, the more fre-
quently used are the pudendoanal re£ex, the bulbocavernosus
re£ex, the pudendal nerve terminal motor latency (PNTML).
The cutaneoanal re£ex and other somatosomatic and viscero-
somatic re£exes have limited usefulness in pelvic £oor investi-
gations due to a large variability in the latency of these
responses [Swash, 1982; Bartolo et al., 1983; Uher and Swash,
1998]. More recently, Fowler et al. [2000] and Vodusek [2001]
described direct and re£ex responses after S3 root stimulation,
to demonstrate the exact placement of the wire electrodes
close to S3 root, while Schurch et al. [2003] recorded
only re£ex responses of early and late latencies by a similar
stimulation protocol. All these studies used invasive pro-
sacral root.
The aim of our study was to settle experimental protocol
and to present normative data of direct and re£ex motor anal
sphincter responses, simultaneously evoked by S3 surface,
non-invasive, electrical stimulation, in a group of 20 healthy
subjects.
PATIENTS AND METHODS
Subjects
The study included 20 normal subjects, 11 males and
9 females of varying parity (0 ^3). Mean age was 47 years
(range 15 ^ 76 years). Neurological, gastroenterological, and
urological clinical examinations were performed and only
subjects without any neurological, gastroenterological, or
urological disorders were included. All subjects gave their
informed consent to the study.
Protocol
The subject reclined comfortably in the right-lateral position
and appropriate sacral landmarks were identi¢ed by palpation.
This paper was received, reviewed, and accepted by the previous editorial
board under the leadership of the past editor, Dr. Jerry Blaivas.
No con£ict of interest reported by the author(s).
*Correspondence to: Giuseppe Pelliccioni, MD, Neurology Unit, Geriatric
Hospital, INRCA, via della Montagnola 81, 60100 Ancona, Italy.
E-mail: g.pelliccioni@inrca.it
Received 28 April 2005; Accepted 7 November 2005
Published online 29 August 2006 in Wiley InterScience
(www.interscience.wiley.com)
DOI 10.1002/nau.20215

ß 2006 Wiley-Liss, Inc.

 Anal Sphincter Responses After S3 Electrical Surface Stimulation 789

The technique used to identify the sacral foramina, in which the

sacral nerves are located, has been previously described by others
[Schmidt et al., 1990]. Each foraminal canal lies in a vertical line
about 2 cm from the midline.The S2 foramen lies about1cm med-
ial and 1cm below the posterior superior iliac spine, while the for-
amina of S3 lie 2 cm vertically below the landmark of S2.
Motor-evoked potentials (MEPs) from external anal
sphincter (EAS) were elicited by means of a bipolar surface
electrode (Medtronic Neurodiagnostics, hand-held stimulat-
ing electrode with intensity control, #9031E0152) with the
cathode over the S3 posterior right or left sacral foramina.
Random square wave stimuli of 0.4 msec duration were used.
An average number of 5 ^ 8 electrical shocks per session were
delivered to each subject. Care was taken to stimulate with
supramaximal stimuli, never described as painful.
MEPs from EAS were recorded by concentric needle elec-
trode using an EMG-EP equipment (Keypoint; Medtronic
Functional Diagnostics, Skovlunde, Denmark). Disposable
26 G concentric needle electrodes (0.45  40 mm) with a
recording surface of 0.07 mm2 (Medtronic) were used. The
EAS insertion was guided by digital palpation of the muscle
under direct visual inspection. Correct placement was con-
¢rmed by the audiovisual output of the spontaneous EMG
signal. The ground electrode was located around the upper
portion of the leg. The EMG-EP equipment was set to allow a
bandpass of 2 Hz ^ 20 kHz. Di¡erent sweep-times of 1, 3, and
5 msec/division were simultaneously used. Ampli¢cation was
50 mV/division. Fig. 1. External anal sphyncter responses following electrical
Evoked responses were distinguished from random basal stimulation of S3 spinal root. Simultaneous recordings with different
action potentials by its larger size, de¢nite morphology, and sweep times. Two traces are superimposed to demonstrate the
reproducibility of the responses.
approximately constant latency. Measurements of MEP
latency were performed at the onset of the ¢rst de£ection.
Among the shortest latencies obtained, the most reproducible Vodusek et al., 1983; Vodusek and Janko, 1990; Yang and
was used to calculate the mean value of the group. Bradley, 2000], or magnetic [Opsomer et al., 1989b; Loening-
Baucke et al., 1994] stimulation and involve the whole re£ex
arc, but do not di¡erentiate the a¡erent and e¡erent branch
RESULTS
of the re£ex. Conversely, the PNTML only explores the more
Stable and reproducible direct (R1) and re£ex responses distal portion of pudendal nerve, not looking at the portion of
(R2 and R3) were recorded in all but three of the subjects the nerve proximal to the site of the stimulation induced by
investigated, using a stimulation strength up to 50 mA. These the St. Mark’s electrode [Ki¡ and Swash, 1984; Lefaucheur
three last subjects had preserved R1and R2 responses, whereas et al., 2001].
the long latency R3 re£ex responses could not be obtained. Direct motor and re£ex responses from the EAS by S3
Examples of direct and re£ex responses from EAS after S3 electrical stimulation can provide valuable information on
root stimulation are shown in Figure 1. Mean values of MEP the functional integrity of the sacral re£ex pathway, but di¡er-
latencies are reported inTable I. ently from the pudendoanal and bulbocavernosus re£exes, can
distinguish the e¡erent limb of the re£ex pathway from the
whole arc.
DISCUSSION
In the present study, we obtained three consecutive
We report an electrophysiological technique able to investi- responses at di¡erent latencies, in nearly all the subjects inves-
gate the integrity of the nervous tract distal to S3 root and of tigated.The ¢rst motor response, which we labeled R1, at mean
the whole sacral re£ex arc supplying pelvic £oor muscle func- latency of 6.98 msec is analogous in latency and morphology
tion. To this purpose, the more commonly used electrophysio- to the intraoperative selective direct response following S3
logical investigations are the PNTML and the sacral re£exes. root stimulation obtained with hand-held hook electrodes by
These last tests can be elicited by mechanical [Amarenco et al., Vodusek [2001]. This early evoked muscle response in EAS,
2002], electrical [Ertekin and Reel, 1976; Siroky et al., 1979; according to previous studies [Jelasic et al., 1975; Vodusek
Neurourology and Urodynamics DOI 10.1002/nau
790 Pelliccioni and Scarpino
TABLE I. MEP Latencies at the External Anal Sphincter branch of pudendal nerve and to exclude lesions at the sacral
After S3 Spinal Root Electrical Stimulation S2 ^S4 central cord levels. Further studies should be per-
Subject no. Age (years) Gender R1 (msec) R2 (msec) R3 (msec) formed in subjects submitted to PNE and SNM to clarify the
possible predictive role of this technique. In fact, our data only
1 47 Female 6.9 29.7 58.2 provide a baseline for additional studies to be carried out to
2 37 Female 7.9 24.4 58.6 demonstrate the prognostic relevance of this electrophysiolo-
3 44 Male 7.1 26.4 46.2
gical method.
4 48 Female 8.4 25.8 48.4
5 39 Female 6.7 29.3

The electrical percutaneous S3 stimulation, which had been
6 39 Male 6.9 31.2 50.2 ¢rstly applied by Jelasic et al. [1975], could gain new increased
7 57 Female 6.4 27.6
interest. We demonstrated that EAS responses during S3
8 35 Male 8.2 28.8 50.8 percutaneous electrical stimulation are stable, easy to
9 57 Male 5.7 24
perform, not invasive neither too painful and we think that
10 15 Female 9 24.4 52.4 this electrophysiological technique could represent a useful
11 57 Male 9.4 28.5 50.4 aid in the selection of candidates to SNM.
12 35 Male 8.8 21.8 41.6
13 66 Male 5.6 17.2 50.8
14 54 Female 6.4 25.5 60.6 ACKNOWLEDGMENTS
15 54 Male 8.4 29.6 53
16 66 Male 7.3 26.4 68.6 The authors thank Luana Rosa, Rosanna Pierpaoli, and
17 30 Female 4.9 26.1 48.6 Rita Magnaterra for their skilful collaboration in technical
18 76 Male 6.1 21 39.5 assistance.
19 47 Female 6 19 35.9
20 37 Male 3.5 15.6 41.5
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