Letter to the Editor, Re: Lavelle J, Hornberger J. No Cystometrogram Among Veterans With Spinal Cord Injury Results in Adverse Urinary System Outcomes. Neurourol Urodyn. 2026 Mar;45(3):494–502: The Heterogeneity of 'Suprasacral' Lesions

We read the recent article by Lavelle and Hornberger 1 with great interest. We commend the authors for their valuable study utilizing a large cohort to demonstrate the positive impact of cystometrography on urinary system outcomes. However, we would like to highlight a literature-wide homogeneity issue regarding the definition of “suprasacral” spinal cord injury (SCI), stemming from varying methodological choices in patient selection, which is also reflected in this study. In the neuro-urology literature, the “suprasacral SCI” patient cohort is widely selected as the primary target group to define the high-risk cohort for detrusor overactivity and detrusor sphincter dyssynergia 2. However, the neurological ASIA Impairment Scale (AIS) boundary of this suprasacral umbrella term is so ambiguous that perhaps even sacral profiles get mixed into it. A critical review of the literature reveals that the lower boundary of a suprasacral lesion exhibits significant heterogeneity. Based on the AIS neurological level, some study designs strictly set the cut-off above the T12 level 3, while others choose to broadly include L1 or general “lumbar” level patients in the suprasacral group 4, 5. Furthermore, some studies rely on the vertebral fracture level rather than the neurological level and classify the L1 level entirely within the sacral cohort 6. Moreover, the occasional use of alternative terminologies, such as the “supraconal” cohort, also contributes to this ambiguity, with definitions ranging strictly from above the L1 level 7 to broadly including lumbar spinal cord segments 8. This methodological inconsistency further deepens the confusion in the literature. This methodological choice is also present in the current study 1. Specifically, patients with “Thoracic-Low” and “Lumbar” neurological levels were included in the analysis under the suprasacral definition. However, existing evidence indicates that such broad grouping choices may introduce concealed clinical variations. For instance, Yalçın et al. 9 demonstrated distinct differences in urodynamic findings and treatment approaches between upper lumbar and lower lumbar-sacral injuries. Similarly, Erden et al. 10 found significant differences even within thoracic levels, specifically between T1-T10 and T11-T12 injuries. From our perspective, it is evident that the neurological level significantly influences outcomes within the critical ‘gray zone’ (T11-L2), where suprasacral and sacral lesions diverge clinically and urodynamically. Therefore, to achieve a more homogeneous structure in the literature, we believe that a segmental-based classification would yield more reliable results. Alternatively, in cases where the “suprasacral” umbrella term is preferred, we strongly suggest that the specific cut-off level should be explicitly defined in the inclusion criteria. Furthermore, as an initial step toward resolving this ambiguity, systematically comparing the urodynamic profiles of patients across the individual neurological levels between AIS T11 and L2 could provide crucial clinical insights into where the true functional boundary lies. Given these varying definitions and choices in the literature regarding the “suprasacral” SCI cohort, we would highly appreciate hearing the authors' and the Editor's thoughts, their specific rationales for their selections, and their perspectives on this terminological ambiguity. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.